What Do Psychoanalysts Want?

The Problem of Aims in Psychoanalytic Therapy

Anna Ursula Dreher, Joseph Sandler

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781134780259
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Defining the aims of psychoanalysis was not initially a serious complex problem. However, when Freud began to think of the aim as being one of scientific research, and added the different formulations of aim (for example, that the aim was to make the patient's unconscious conscious) it became an area of tension which affected the subsequent development of psychoanalysis and the resolution of which has profound implications for the future of psychoanalysis.

In What Do Psychoanalysts Want? the authors look at the way psychoanalysts have defined analysis both here and in America, from Freud down to the present day. From this basis they set out a theory about aims which is extremely relevant to clinical practice today, discussing the issues from the point of view of the conscious and unconscious processes in the psychoanalyst's mind.

Besides presenting a concise history of psychoanalysis, its conflicts and developments, which will be of interest to a wide audience of those interested in analysis, this book makes important points for the clinician interested in researching his or her practice.

1

Freud’s views on aims

Before devising the method of free association, Freud had made use of hypnosis and other techniques of suggestion in order to retrieve memories which he regarded as having been repressed as a consequence of trauma; but such methods were given up because he had found them to be therapeutically ineffective. These earlier forms of treatment had involved different attempts on the part of the physician, essentially based on suggestion, to force repressed memories into consciousness, with a resulting catharsis, a ‘discharge’ of affect; but the procedure of suggestion, Freud pointed out later, is like painting in which particles of colour are applied to the canvas – per via di porre, as Leonardo da Vinci had put it. Analytic therapy, as it was conceived by the turn of the century, proceeds, on the other hand, per via di levare, ‘since it takes away from the block of stone all that hides the surface of the statue contained in it’ (1905, p. 260).

In The Interpretation of Dreams (1900), Freud spelled out his ‘topographical’ theory of the mind, which involved a division of the ‘mental apparatus’ into the systems Perceptual-Conscious, Preconscious and Unconscious. The psychoanalytic ‘cure’ was not now achieved through catharsis, but rather by the interpretation of instinctual wishes and phantasies that had been repressed into the system Unconscious, and the conflicts with which they were associated. The approach to dream interpretation taken in 1900 had become the basis for the whole method of analysis. Ten years later, in speaking of a ‘general effect’ of psychoanalysis, Freud says, ‘the psychoneuroses are substitutive satisfactions of some instincts the presence of which one is obliged to deny to oneself and others. Their capacity to exist depends on this distortion and lack of recognition. When the riddle they present is solved and the solution is accepted by the patients these diseases cease to be able to exist’ (1910, p. 148). Freud’s view at that time was that the illness was a disguised expression of the instinct (drive) so that the underlying wish was not recognised. This formulation paralleled his views about the formation of the dream as a concealed expression of an unconscious instinctual wish. The aim of the analytic method was to bring the ‘latent’ instinctual wish to consciousness and to overcome the resistance to its acceptance.¹

It is important to note that Freud’s orientation was consistently that of a physician and scientist, who had fully internalised the empirical approach and medical model of the late nineteenth century. Certainly there were many streams of influence, beside the scientific perspective of the time, that affected the development of Freud’s thinking. He was in many ways a child of his time, affected by the changing attitudes towards late nineteenth-century Victorian values, by his mixed liberal and orthodox Jewish background, and by his enormous interest in literature and in philosophical ideas (see, for example, Jones, 1957; Gay, 1988; Ellenberger, 1970; Sulloway, 1979). But it was essentially his objectivist scientific approach that led him, in the course of developing the psychoanalytic method, to emphasise that it was not only a therapy but equally a method of research – a dual perspective reflected in his famous ‘conjunction’ statement that

In psychoanalysis there has existed from the very first an inseparable bond between cure and research. Knowledge brought therapeutic success. It was impossible to treat a patient without learning something new; it was impossible to gain fresh insight without perceiving its beneficent results. Our analytic procedure is the only one in which this precious conjunction is assured. It is only by carrying on our analytic pastoral work that we can deepen our dawning comprehension of the human mind.

(1927, p. 256)²

Freud gave equal weight to cure and research in the ‘conjunction’ statement of 1927, but there is evidence that the two aims were not in fact evenly balanced in his mind, and that this was a source of a conflict for analysts which remains to this day. Psychoanalytic research was the gaining of knowledge through analysing, and the problem of the ‘aim to cure’ as opposed to the aim to conduct research (that is, the aim to analyse) was, as we shall see, to run like a thread through subsequent discussions of analytic aims, during Freud’s lifetime and afterwards.

In 1909, Freud stated clearly that ‘therapeutic success, however, is not our primary aim; we endeavour rather to enable the patient to obtain a conscious grasp of his unconscious wishes’ (1909, p. 120). Implicit in this is Freud’s view that the successful application of the psychoanalytic method would inevitably lead to beneficial therapeutic results in the patient. The analyst’s task is to analyse, and if he is preoccupied with achieving a cure rather than confining himself to analysing the patient, this is inimical to the psychoanalytic process. Freud was quite outspoken in condemning the physician who was possessed by the furor sanandi – the passionate obsession to cure: ‘As a doctor, one must above all be tolerant to the weakness of a patient, and must be content if one has won back some degree of capacity for work and enjoyment ³for a person even of only moderate worth. Educative ambition is of as little use as therapeutic ambition’ (1912, p. 119).

Freud was not entirely comfortable with the idea that the analytic method, strictly applied, should divest itself of therapeutic aims. In a paper entitled ‘Recommendations to physicians practising psychoanalysis’ (one of a series of writings on technique published between 1910 and 1915) he voiced concern about the antithetical properties of the therapeutic and research orientations. The aim of undertaking research on a patient’s material during the analysis can, Freud said, interfere with the proper conduct of the treatment: ‘One of the claims of psychoanalysis to distinction is, no doubt, that in its execution research and treatment coincide; nevertheless, after a certain point, the technique required for the one opposes that required for the other. It is not a good thing to work on a case scientifically while treatment is still proceeding’ (1912, p. 114).

We have indicated that Freud must have experienced a conflict between his therapeutic aims, on the one hand, and the aims of research and the application of the psychoanalytic method, on the other. There was the natural wish of the physician to heal, yet there was the knowledge that a preoccupation on the part of the analyst with curing the patient of his ills could hinder the effectiveness of the analytic method. The way out of this dilemma was provided by the ‘conjunction’ notion and the belief that cure could only come about through the application of what Freud called ‘strict and untendentious psychoanalysis’ (1919, p. 168). This approach to psychoanalytic therapy reflected a slight shift of emphasis in Freud’s formulation of analytic aims which had been evident from early on. Less and less importance had been placed on the notion of ‘cure’, more on the process of analysis per se and on the aim of making what is unconscious conscious. In an article entitled ‘Freud’s psychoanalytic procedure’ (1904) he had said,

The task which the psychoanalytic method seeks to perform may be formulated in different ways, which are, however, in their essence equivalent. It may, for instance, be stated thus: the task of the treatment is to remove the amnesias…. Or the formula may be expressed in this fashion: all repressions must be undone. The mental condition is then the same as one in which all amnesias have been removed. Another formulation reaches further: the task consists in making the unconscious accessible to consciousness, which is done by overcoming the resistances.

(1904, pp. 252–253)

Having stated the analytic task in this way, Freud nevertheless goes on to indicate his concern for the patient’s recovery from his illness. So, a few lines further, we read that

the aim of the treatment will never be anything else but the practical recovery of the patient, the restoration of his ability to lead an active life and of his capacity for enjoyment. In a treatment which is incomplete or in which success is not perfect, one may at any rate achieve a considerable improvement in the general mental condition, while the symptoms (though now of smaller importance to the patient) may continue to exist without stamping him as a sick man.

(1904, p. 253)

The aim of making the unconscious conscious was not without obstacles. The analyst needs ‘to recognise the resistance with which the patient clings to his disease and thus even fights against his own recovery; yet it is this phenomenon of resistance which alone makes it possible to understand his behaviour in daily life’ (1905, p. 261). As Freud elaborated his theories of mental functioning (metapsychology), the idea of ‘making the unconscious conscious’ by overcoming the patient’s resistance, as an aim of the method, was amplified. In 1906 he remarks: ‘The aim of psychoanalysis is absolutely uniform in every case: complexes have to be uncovered which have been repressed because of feelings of unpleasure and which produce signs of resistance if an attempt is made to bring them into consciousness’ (p. 112). Some years later Freud points out that the resistance ‘accompanies the treatment step by step. Every single association, every act of the person under treatment must reckon with the resistance and represents a compromise between the forces that are striving towards recovery and the opposing ones …’ (1912, p. 103).⁴

Interestingly, Freud’s writings made much use of metaphors of this sort, which were based on a military model; inevitably these had a bearing on the ways in which the aims of psychoanalysis were conceived. Not only did the patient show ‘resistance’ and have to ‘fight against his own recovery’, but he experienced ‘conflict’, made use of ‘defences’, needed to be ‘better armed against unhappiness’, and so on. The idea that the patient has to fight against a sort of ‘enemy within’ seems to have influenced some psychoanalysts to see their work with their patients as a sort of battle in which the analyst has to fight with the enemy in the patient. In spite of the military metaphors, Freud was careful to avoid being tempted towards a moralistic criminalisation of the patient, but some of his followers have not managed to do this. Consequently Freud’s liberal attitude towards such issues as homosexuality (Freud, 1935, p. 195–196) was not followed by those analysts who were determined to cure it in their patients (R. Steiner, personal communication).

The publication of the Introductory Lectures on Psychoanalysis (1916–17) marked an important step in Freud’s thinking. The lectures were composed at a time when his theoretical views were undergoing significant development, as witnessed in his papers on narcissism (1914), on meta psychology (1915a, 1915b, 1915c) and in ‘Mourning and melancholia’ (1917). In his Introductory Lectures Freud provides the reader with an overview of psychoanalytic theory as he had developed it over two decades. In numerous comments on the aim of the method he amplified, restated, and in some instances modified many of his previous formulations.

Freud now takes the idea of making the unconscious conscious further, and notes that the outcome of this process is the transformation of the pathogenic conflict into a normal one ‘for which it must be possible somehow to find a solution’ (p. 435). He remarks that the patient, as a consequence of analysis,

has rather less that is unconscious and rather more that is conscious in him than he had before. The fact is that [one is] … probably underestimating the importance of an internal change of this kind. The neurotic who is cured has really become another man, though at bottom, of course, he has remained the same; that is to say, he has become what he might have become at best under the most favourable conditions … the ego was feeble, infantile, and may perhaps have had grounds for banning the demands of the libido as a danger. Today it has grown strong and experienced, and moreover has a helper at hand in the shape of the doctor. Thus we may expect to lead the revived conflict to a better outcome than that which ended in repression.

(1916–17, pp. 435, 438)

Although Freud had often insisted that the aim of psychoanalysis was to make the unconscious conscious, he went on to qualify this view in a way that had the greatest significance for the psychoanalytic method. He pointed out that the idea that translation by the analyst of what is unconscious can by itself bring about psychic change and result in cure is a shortsighted error. If the analyst simply conveys his understanding of what is unconscious to the patient, the new knowledge does not replace the unconscious material in the mind of the patient, but comes to exist beside it, with very little change resulting. So the analyst must look for the unconscious material in the patient’s memory ‘at the place where it became unconscious owing to a repression’ (p. 436). What has become important is the removal of the resistance consequent on the repression, and this removal occurs by discovering the resistance and showing it to the patient. This resistance to conscious awareness was regarded by Freud as identical with one that took place earlier as a result of conflict, and the analyst now has to discover, understand and communicate it to the patient. Nevertheless he has to do it in the right place, and in his interpretations has to get back to the point in development at which the conflict arose. He has to work on the resistance which is now aroused because of the repetition of the unconscious conflictual wish in the present (particularly in the patient’s relation to the analyst) and of the repression which has been directed against this wish.

An important conceptual step in the Introductory Lectures is the elaboration of Freud’s idea of the transference neurosis. In the course of treatment ‘we are no longer concerned with the patient’s earlier illness but with a newly created and transformed neurosis which has taken the former’s place’ (p. 444). There is a transferring of the patient’s essential neurotic conflict to the arena of the analysis, the analyst becoming the centre of the patient’s preoccupations. It is a ‘new edition of the old disorder’, and the overcoming of this new and artificial (transference) neurosis coincides with cure. ‘A person who has become normal and free from the operation of repressed instinctual impulses in his relation to the doctor will remain so in his own life after the doctor has once more withdrawn from it’ (pp. 444–445). We can see, reflected in Freud’s concern with the need for the development and overcoming of the transference neurosis, his concern with analysis as a procedure with therapeutic aims; and a central aim in this connection was the resolution of the neurotic conflict which had brought the patient to analysis.

It was clear that while Freud had retained the aim of analysis as being to make the unconscious conscious, in his Introductory Lectures he refined his views on what was necessary to achieve this aim. There he began to give more attention to the details of the intrapsychic alterations that occur in the patient as a consequence of analysis. This is evident in his comment that one cannot account for the therapeutic effect of psychoanalysis by its having made a full sexual life possible for the patient. Rather ‘we accustom [the patients] … to giving unprejudiced consideration to sexual matters no less than to any others; and if, having grown independent after the completion of their treatment, they decide on their own judgement in favour of some midway position between living a full life and absolute asceticism, we feel our conscience clear whatever their choice’ (p. 434). Freud then remarks that people who know the truth about themselves are permanently protected from the dangers of immorality even though their moral standards are different from the customary ones in society. Freud relates the widening of the intellectual horizons of the patient to ‘the surprising and liberating enlightenment the treatment brings with it’ (p. 440), which also increases the patient’s capacity to make choices.

In the course of the last of the Introductory Lectures (Lecture 28) Freud sums up the nature of the therapeutic work which, he says, falls into two phases. The steps described for each of the phases can be considered to reflect aims of the psychoanalytic method as seen at that time.

In the first [phase], all the libido is forced from the symptoms into the transference and concentrated there; in the second, the struggle is waged around this new object and the libido is liberated from it. The change which is decisive for a favourable outcome is the elimination of repression in this renewed conflict, so that the libido cannot withdraw once more from the ego by flight into the unconscious. This is made possible by the alteration of the ego⁵ which is accomplished under the influence of the doctor’s suggestion. By means of the work of interpretation, which transforms what is unconscious into what is conscious, the e...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Foreword
• Preface
• Introduction
• 1 Freud’s views on aims
• 2 The early Freudians in the 1920s
• 3 Consolidation in the pre-war decade
• 4 The emigration of analysts and a period of transition
• 5 The 1950s and the widening-scope discussions
• 6 Heightening tensions
• 7 The 1970s and the flowering of pluralism
• 8 Pragmatism and integration in contemporary psychoanalysis
• 9 A framework for thinking about aims
• References
• Name index
• Subject index