Process Facilitation in Psychoanalysis, Psychotherapy and Social Work

Sylvia O'Neill

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781138591097
• eBook ISBN: 9780429955549
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Process Facilitation in Psychoanalysis, Psychotherapy and Social Work elaborates a differential theory of therapeutic engagement with full reference not only to psychoanalysis and to psychotherapy but also – surprisingly – to social work. When contemporary social work with the marginalised achieves mutual constructive collaboration, social workers characteristically notice an unfolding process. Could this correspond to the 'analytic process' of psychoanalysis?

Sylvia O'Neill seeks to explain theoretically, and to illustrate clearly in practice, just how a quasi-autonomous therapeutic process becomes established. The theory underpinning the book is Jean-Luc Donnet's conceptualisation of the establishment of the analytic process in psychoanalysis through introjection of the analytic setting. Donnet designates the psychoanalytic setting as the analytic 'site'. O'Neill proceeds to trace, by means of detailed clinical discussion, the analogous process by which a viable therapeutic process can become established through created/found discovery and introjection of the relevant 'site' or setting in psychoanalytic psychotherapy and in social work. Amongst the most important elements are the practitioner's internalised theoretical principles.

The book demonstrates that unconscious introjection figures more importantly in effective therapeutic engagement than a conscious therapeutic alliance. An important corollary for social work is that, contrary to popular myth, no prior psychological-mindedness is required. The differential theory of Process Facilitation in Psychoanalysis, Psychotherapy and Social Work is equally relevant to psychodynamic counselling.

Part I

‘Lines of advance in psychoanalytic therapies’

Chapter 1

Lines of advance, then and now

Continuum, or radical break?

Freud addresses an international congress

The Fifth Congress of the International Psycho-Analytical Association was held in Budapest on 28th and 29th September 1918. Many psychoanalysts who would otherwise have attended (such as Freud’s future biographer, Ernest Jones from England), faced insurmountable barriers to international travel because the world was still at war. Consequently, of the 42 delegates, almost all (the exceptions being two Dutch, one Polish and three German participants) came from the Austro-Hungarian Empire (Jones, 1974). Many of them had enlisted as army psychiatrists and wore their army uniform to the conference. In an unprecedented act of recognition of psychoanalysis within official channels, the representatives of three governments – Austria, Germany and Hungary – attended this conference, attracted ironically enough by the promise of contributions on the subject of ‘war neuroses’. The traditional attitude to shell-shocked soldiers had been to regard them as malingerers, but official interest had been growing in the work done by Ernst Simmel in a German military hospital using psychoanalytically derived ideas to treat war-traumatised soldiers, and as a part of the Congress there was a symposium on the subject of war neurosis for which Simmel, Karl Abraham and Sándor Ferenczi had all prepared papers (Gay, 1988). Simmel explained that, pragmatically, he did his best to reduce the number of treatment sessions to two or three. Ferenczi had meanwhile written a paper on his development of an ‘active technique’ in the treatment of a female patient for which he had solicited Freud’s keen attention and to which Freud’s speech to the Congress would refer (Ferenczi, 1919; Freud, 1919). Evidently, the adaptation of psychoanalytic treatment to meet the exigencies of circumstance and of time, cost and manpower had already begun (as had also the potential threat of its being harnessed for exploitative purposes, exemplified by the official interest in making soldiers well enough for return to the battlefront).

Freud’s choice of a subject for his own address to the Congress concerned the lines along which he thought that psychoanalysis, from that juncture, should progress and develop. In a departure from his usual practice of speaking without notes, and to the disapproval of his son Ernst and daughter Anna, who were guests at the Congress, he read the paper – which suggests that he had considered very carefully indeed what he had chosen to say (Jones, 1974). The paper bore the title ‘Lines of advance in psycho-analytic therapy’, and would be published the following year (Freud, 1919).

The Congress paper contained Freud’s famous remark that, in the modified psychoanalytic therapy that he was proposing, the ‘gold’ of analysis would have to be alloyed freely with the ‘copper’ of direct suggestion. That observation has often been quoted in discussions that juxtapose psychotherapy with psychoanalysis. However, it was not until well into the 21st century that attention was drawn to history’s surprising neglect of Freud’s bold claim on that occasion – Max Eitington was to call it half prophecy and half challenge – that psychoanalysis could in future be extended on a large scale to the mass of the people too poor to be able to afford to pay a fee for psychoanalysis. In Freud’s Free Clinics, Elizabeth Danto has documented in detail the way that several of the members of Freud’s audience rose to that challenge during the 1920s and 1930s and established clinics offering free psychoanalytic treatment in several European cities (Danto, 2005). Thus, Eitington and Simmel opened the Berlin Poliklinik in 1920, Eduard Hitschmann started the Vienna Ambulatorium in 1922 and Ferenczi established a free clinic in Budapest in 1929. Four other members of the audience – Melanie Klein, Hanns Sachs, Sándor Radó and Karl Abraham – were all to play an important part in the work of the Berlin Poliklinik. Jones, not present, would open the London Clinic of Psycho-Analysis in 1926. Danto has restored a chapter that had gone missing from the history of psychoanalysis, and her book’s point of departure is Freud’s address to the 1918 Congress in Budapest.

Yet an important if subtle feature of Freud’s Congress paper remains overlooked. The paper oscillates, implicitly, between two basic standpoints. There is a discernible antinomy in it that suggests Freud’s intuitive sense of an inherent and problematic tension between two ways of conceiving of the potential future practice that he was sketching. One conception is that of psychoanalysis (albeit with some modification) extended to the poor. The other conception is that of the poor having extended to them a practice so far modified in its essentials that it amounts to something fundamentally different in kind from the psychoanalysis inspiring it – so different as to constitute not psychotherapy but something that would come to be called psychodynamic social work, a practice comparable with psychoanalysis only by way of analogy.

A close reading of Freud’s Congress paper reveals the antinomy at its heart.

A reading of ‘Lines of advance in psycho-analytic therapy’: the prominence of analogy

New influences were in the air when Freud wrote ‘Lines of advance in psycho-analytic therapy’. Particular pathologies were posing challenges in the consulting-room, notably phobias, obsessional neuroses and certain kinds of treatment-resistant hysteria, and in the light of this challenge Freud was interested in weighing up the merits of the ‘active technique’ about which Ferenczi had recently written a paper which would be published the following year (Ferenczi, 1919; Freud, 1919). Strachey’s editorial commentary on Freud’s Congress paper states that it consists chiefly of a discussion of Ferenczi’s active technique (Strachey, 1955). Certainly, that is a central part of Freud’s paper.

However, the other major ‘line of advance’ proposed by Freud in his Congress address was that psychotherapy, as a modified version of psychoanalysis, might make a psychoanalytic therapy available to whole populations then excluded from it by poverty, social class and associated deprivations. A second influence was at work here. Freud wrote the paper in July 1918 while he was a guest in the house of Anton von Freund (Strachey, 1955). Von Freund had been in analysis with Freud the previous year after consulting him about post-operative depression following apparently successful surgery for testicular cancer, and was now himself training to be a psychoanalyst. The son of a wealthy industrialist, von Freund had obtained a PhD but had then laid aside his wish to become a teacher and had instead entered the family brewing business. This however left unsatisfied his wish to advance knowledge and social justice (Freud, 1920). After his analysis with Freud he not only set himself to train as a psychoanalyst – Freud would refer to him after his untimely death from the cancer, which returned and killed him in 1920, as one of the brightest hopes of psychoanalysis – but he also believed passionately that psychoanalysis should be far more widely available than just to those who like himself could afford to pay for it. He conceived a plan not only to endow a psychoanalytic publishing house but also to set up outpatient clinics, funded by his private fortune, which would train a large number of personnel in psychoanalysis and in which psychoanalysis would be freely available to the poor (Freud, 1920). He handed over a substantial sum of money to the municipal authorities in Budapest for this purpose. This project of making analysis as freely available to the poor as to the wealthy was something he valued very highly and was very near to von Freund’s heart. It was also one with which the political landscape would soon be in tune, in cities like Vienna (to be declared a republic on 11th November), after the imminent end of the First World War and with it the collapse of the Austro-Hungarian Empire and a move in some of its former cities towards social democracy (Clark, 1980; Danto, 2005). Freud, who had previously recorded his belief that psychoanalytic treatment does not work if a fee is not charged, evidently listened keenly to von Freund’s ideas about making psychoanalysis freely available to the people (Freud, 1913). The Congress paper demonstrates that, characteristically, he also went on thinking.

In the context of Freud’s call at the end of his Congress address for a psychotherapy for the mass of the people, the opening of the paper shows itself to be part of a fascinating sub-text. Freud’s opening point comprises a systematic discussion of the use and limitations of analogy. He first points out that the term ‘analysis’ in psycho-analysis refers to the psychoanalyst’s work of identifying the particular constituent elements of compound mental manifestations, and that the analogy is, in that sense, to chemical analysis – that is, to the laboratory chemist’s work of separating out the constituent elements of chemical compounds. He then takes issue with those who were proceeding to advocate that the new lines of advance in psychoanalysis should entail a shift at a certain point in the treatment from psycho-analysis to psycho-synthesis, just as the chemist sets out to synthesise, in new ways, the elements that he has isolated. According to Jones, the chief advocate of this idea was one Bezzola (Jones, 1974). Freud had also taken issue with Pfister concerning the same idea in a letter to him the previous year: ‘In the technique of psycho-analysis there is no need of any special synthetic work; the individual does that for himself better than we can’ (Meng & Freud, 1963, p. 62). Freud reasons in his Congress paper that the idea of psycho-synthesis is based on a false analogy. He spells out the nature and limitations of analogy: ‘the two objects compared need only coincide at a single point and may be entirely different from each other in everything else’ (Freud, 1919, p. 161). It is utterly meaningless to push a comparison beyond such a point of coincidence. ‘What is psychical is something so unique and peculiar to itself that no one comparison can reflect its nature’ (Freud, 1919, p. 161). With regard to the particular point in dispute, Freud points out that the neurotic patient’s mind is actually torn, divided by resistances, and as the resistances are analysed the ego itself achieves a psycho-synthesis during analytic treatment ‘without the analyst’s intervention, automatically and inevitably’ (Freud, 1919, p. 161). In a footnote, Freud adds that a more apt analogy than to the chemist’s labour of synthesis is to the kind of chemical synthesis that comes about not through the chemist’s intentional manipulation but spontaneously:

After all, something very similar occurs in chemical analysis. Simultaneously with the isolation of the various elements induced by the chemist, syntheses which are no part of his intention come about, owing to the liberation of the elective affinities of the substances concerned.

(Freud, 1919, footnote, p. 161)

Now, this discussion of analogy takes up fully three pages of a paper that is only nine pages long and that ends with Freud’s thoughts about the desirability of establishing institutions and clinics offering free psychoanalytic therapy to the poor. Immediately after this last suggestion, the final paragraph of the paper begins: ‘We shall then be faced by the task of adapting our technique to the new conditions’ (Freud, 1919, p. 167). This suggests that even at this point of simply sketching the outlines of a bold new idea, Freud may have had an intuition that such a therapy might sometimes turn out to be so unlike the psychoanalysis inspiring it that it might qualify for a definition as a clinical activity merely analogous to psychoanalysis – in short, a species of what nowadays we call psychoanalytic application – rather than being even the modified version of psychoanalysis that we call psychotherapy.

For what are the modifications that Freud proposes? Explicitly or implicitly, there are five; four of them entail fundamental variations of the parameters of psychoanalysis. The one that does not is simply sensible advice that, in working with uneducated patients, ‘we shall need to look for the simplest and most easily intelligible ways of expressing our theoretical doctrines’ (Freud, 1919, p. 167). A second explicit suggestion, however, is the oft-quoted variation prompted by the sheer scale of what Freud is envisaging: ‘the large-scale application of our therapy will compel us to alloy the pure gold of analysis freely with the copper of direct suggestion’ (Freud, 1919, p. 168). This is usually understood to distinguish from psychoanalysis proper Freud’s concept of psychotherapy, envisaged as potentially less time-consuming, from psychoanalysis. The third of Freud’s explicit proposals, however, is rarely cited by psychoanalysts, yet it is highly significant: ‘Often, perhaps, we may only be able to achieve anything by combining mental assistance with some material support, in the manner of the Emperor Joseph’ (Freud, 1919, p. 167; italics mine). Here we might begin to suspect that we have left the realm of psychoanalysis far behind and have entered a quite different one, that of the ‘applied’ sphere of what was to become psychodynamic or relationship-based social work. Indeed, after the establishment of the Berlin Poliklinik two years later, members of the new profession of social work along with others in psychiatry and child guidance were to flock to the Poliklinik from a number of countries – the USA, France and Egypt among them – for training purposes (Danto, 2005). What is more, we might notice how Freud’s appreciation that the work might need to begin with material support accords with the most enlightened 21st century social work approaches to helping multiply burdened families (Knei-Paz, 2009; Mason, 2012; Charles, Jones & Guo, 2014).

Two additional fundamental variations were already implicit in Freud’s very suggestion of free clinics. The first of these is the absence of the fee. Only five years earlier, in ‘On beginning the treatment’ (1913), Freud had explicitly declared the requirement of the payment of a fee to be in itself an essential feature of the psychoanalytic treatment set-up. Danto suggests that this earlier attitude to the fee constitutes a view of the psychoanalyst as medical entrepreneur, an attitude from which she regards Freud as having been converted (Danto, 2005). I think we need, rather, to be careful to note the reason why Freud had stated, in 1913, that he regarded the fee as essential. This was on the basis of the disappointing failure of his own experimental attempts, over a ten year period, to conduct certain psychoanalyses in which he waived the fee: and he concluded that the fee functioned to ground the analysis in the world of reality, and thereby performed an important regulating function (Freud, 1913). It was an astute observation, and since history and contemporary experience demonstrate that free psychoanalytic psychotherapy can work very well, it raises the interesting question of what it might be in successful non-fee paying treatments that performs a regulating function corresponding to that of the fee. That question will be explored in Chapter 3 of this book.

The second variation implicit in the idea of a free clinic is that the treatment would be conducted not in a private practice setting, but within an institution, eventually to be established and funded, Freud suggested, by the state. This raises the issue of whether an institutional or agency setting, in itself, marks a fundamental difference in kind between the clinical practice of psychoanalysis and that of social work. Richard Titmuss would certainly think so: in years to come he was to argue that the institutional setting is one of the irreducibly defining features of social work practice, because social work is a societal concern (Titmuss, 1954).

Could Freud’s creative intuition have bee...

Table of contents

• Cover Page
• Process Facilitation in Psychoanalysis, Psychotherapy and Social Work
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• Introduction
• Part I ‘Lines of Advance in Psychoanalytic Therapies’
• Part II the Site in Psychoanalytic Psychotherapy
• Part III the Site in Social Work
• Part IV Conclusion
• Index