The Patient and the Analyst

The Basis of the Psychoanalytic Process

Christopher Dare, Anna Ursula Dreher, Alex Holder, Joseph Sandler, Anna Ursula Dreher, Christopher Dare, Anna Ursula Dreher, Alex Holder, Joseph Sandler

• Editorial: Routledge
• Año: 2018
• ISBN:
  9780429921681
• Edición: 1
• Categoría: Psychologie
• Categoría: Geschichte & Theorie in der Psychologie

This is a completely revised and enlarged edition of the well-known classic. In the twenty years since the previous edition was published much progress has been made in regard to the clinical concept of psychoanalysis, and this new edition brings the subject completely up to date. New knowledge of the psychoanalytic process has been added, together with advances in understanding the clinical situation, the treatment alliance, transference, countertransference, resistance, the negative therapeutic reaction, acting out, interpretations and other interventions, insight, and working through. The book is both a readable introduction to the subject and an authorities work of reference.

Chapter One
Introduction

This book is about basic psychoanalytic clinical concepts and their meanings. Many concepts that have developed within psychoanalysis, in particular those dealt with in this book, have been extended in their meaning, and it is one of the purposes of this work to examine some fundamental concepts from the point of view of the changes in meaning and usage that have occurred over time. The book is not, however, intended to be a sort of dictionary or glossary, although we believe that our discussion of basic psychoanalytic clinical concepts will lead to a better understanding of the role they play in present-day psychoanalysis.

The first two chapters introduce the discussion of specific terms. The philosophical implications of change of meaning when concepts are transferred from their original context have been discussed by a number of writers (e.g. Kaplan, 1964; Sandler, 1983; Schafer, 1976; Schon, 1963), and in this connection psychoanalytic theory presents special problems of its own. It is often regarded as being a completely integrated and consistent system of thought, but this is far from being the case. Psychoanalytic concepts are not all well defined, and changes in their meanings have occurred as psychoanalysis has developed and aspects of its theory have changed. Moreover, in some cases a given term has been used with different meanings even at the same point in the historical development of psychoanalysis. Prime examples of this are the multiple meanings of such terms as ego (Hartmann, 1956), and of identification and introjection (Sandler, 1960b). It will be seen how strikingly the problems engendered by this enter into the concepts considered in this book. We find a situation within psychoanalysis in which the meaning of a concept is only fully discernible from an examination of the context in which it is used. The situation is complicated further by the fact that different schools of psychodynamic thought have inherited, and then modified for their own use, much of the same basic terminology (for example, the meanings given to ego, self, and libido in Jungian psychology are different from those in the Freudian literature). The overall purpose of the present work can be regarded as an attempt to facilitate communication, not only within the realm of clinical psychoanalysis itself, but also where situations other than the classical psychoanalytic treatment situation (such as psychotherapy and some forms of casework) need to be conceptualized in appropriate psychodynamic terms (see Sandler, 1969). This need is all the greater in view of the emphasis placed on training in psychotherapy as part of general psychiatric education.

In this context it is worth remembering that psychoanalysis refers not only to a specific treatment method but also to a body of theory which aspires to be a general psychology. Some of its concepts can be regarded as predominantly technical or clinical and do not form part of the general psychological model of psychoanalysis; it is these with which we are concerned in this book. Clinical concepts of this sort include, for example, resistance, a concept that refers to a set of clinical phenomena but can also be seen as a specific manifestation of the operation of the mechanisms of defence (part of general psychoanalytic psychology and regarded as existing in 'normal' as well as in disturbed persons). The distinction between clinical psychoanalytic concepts and those of general psychoanalytic psychology ('metapsychology') is important to bear in mind.

While the clinical concepts of psychoanalysis can be extended outside the psychoanalytic consulting room and may be capable of application in some degree to any therapeutic situation, such use may necessitate some re-evaluation and possible redefinition of the concepts. Thus, if we refer again to resistance, which was first defined in psychoanalysis as resistance to free association, there is no doubt that essentially the same phenomenon may show itself even in pharmacotherapy in the form of a patient's failure to take helpful medication. While this may reflect a process of resistance similar to that seen by the psychoanalyst, its definition in terms of free association cannot be sustained. All psychiatrists and social caseworkers are familiar with the phenomenon of resistance, even though forms of communication other than free association are involved.

The wish to give a precise definition of a concept, particularly a clinical one, cannot be entirely fulfilled if it is to be used in a variety of situations. The attempt to formulate precise definitions has led to difficulties and inconsistencies in the presentation of psychoanalytic concepts in the increasingly available psychoanalytic glossaries and dictionaries (e.g. Eidelberg, 1968; Hinshelwood, 1989; Laplanche & Pontalis, 1973; Moore & Fine, 1967, 1990; Rycroft, 1968). It is clear from both the virtues and the shortcomings of all these dictionaries that a historical approach is a sine qua non for the understanding of any psychoanalytic concept. For this reason, therefore, we will proceed more or less chronologically.

Psychoanalysis developed to a very great extent in and through the work of Freud, but during the course of its evolution Freud himself modified his formulations many times, revising concepts and adding new dimensions to technical procedures. This has also been true of psychoanalysis after Freud. Thus when one talks of one or other aspect of psychoanalysis, one has to stamp it with a date and also, for convenience, to divide the history of psychoanalysis into a number of phases (after Rapaport, 1959), beginning with Freud's early work.

After qualifying in medicine in Vienna in 1881 and working for a while as a physiologist in Meynert's laboratory, Freud journeyed to France to study with the eminent neurologist, Charcot. There he was impressed by the parallel drawn by Charcot between the phenomenon of mental dissociation that could be induced by hypnosis and the dissociation between a conscious and an unconscious part of the mind that appeared to occur in patients with gross hysterical symptoms. This dissociation was regarded by Charcot and by other French psychiatrists, notably Janet, as being due to some acquired or inherited fault in the nervous system, which also prevented the mind being held together in one piece, so to speak. On returning to Vienna, Freud began his collaboration with Josef Breuer, a physician who some years previously had found that a patient (the famous Anna O) suffering from hysterical symptoms experienced relief if allowed to talk freely under hypnosis. During and following his work with Breuer, Freud became convinced that the process of dissociation into conscious and unconscious regions of the mind was not specific to the psychoneuroses, but occurred in everyone. The appearance of neurotic symptoms was regarded as being due to the breaking through of pent-up unconscious forces that could not find adequate expression in some other way. He now saw this dissociation as active, as a process of defence whereby consciousness was protected from being overwhelmed by feelings and memories that were unpleasant or threatening. This belief in a process of active dissociation is one that has remained, in one form or another, as a central viewpoint in psychoanalytic writings, although at different times Freud and others have emphasized different aspects of the content of the dissociated and unconscious part of the mind. Initially, particularly during the course of his early work with Breuer, the unconscious content which was being defended against was regarded as consisting of emotionally charged memories of a real traumatic event. In the book which they published jointly, the well-known Studies on Hysteria (1895), real traumatic events were thought to lie behind the symptoms of the neurotic patient. Such traumatic experiences were postulated as having given rise to a 'charge of affect'. This, together with the memories of the traumatic event, was actively dissociated from consciousness and could find expression by being converted into symptoms. Based on this view, treatment consisted of a variety of attempts to force the forgotten memories into consciousness, thus simultaneously bringing about a discharge of affect in the form of'catharsis' or 'abreaction'.

The first phase of psychoanalysis can be taken to include Freud's work with Breuer and lasted till 1897, when Freud discovered that many of the 'memories' of traumatic experiences, especially seductions, given to him by his hysterical patients were not in fact memories of real events at all, but rather accounts of fantasies (Freud, 1950a [1887-1902]).

The second phase can be regarded as having lasted from the point at which Freud rejected the trauma theory of neurosis until the early 1920s, when he introduced the so-called structural model of psychoanalysis (Freud, 1923). The second phase reflected a change from the early emphasis on external events (the traumatic situation) to an emphasis on unconscious wishes, promptings, and drives, and to the way in which these impulses manifested themselves on the surface. At this time the unconscious wishes came to be seen as largely sexual in nature. It was the phase in which attention was shifted predominantly to what came from within, to the way in which childhood reactions were repeated over and over again in the present. Attention was also directed to the study of what we might call the analyst's translation of the patient's conscious productions into their unconscious meaning. Indeed, the aim of psychoanalysis was seen by Freud as being 'to make what is unconscious conscious'. In this phase, as we might expect when we consider the inevitable to and fro of theory development, there was a radical swing from the consideration of the person's relation to external reality to the study of his relation to his unconscious wishes and impulses. Most of the clinical concepts that we consider in detail in this book had, as we shall see, their original elaborations in the second phase of psychoanalysis.

In 1900 Freud published The Interpretation of Dreams (1900a). His study of dreams provided an example of the way in which unconscious wishes were thought to find their way to the surface. The urge for direct expression of these wishes created a situation of conflict with the individual's assessment of reality and with his ideals. This conflict, between instinctual forces on the one hand and repressive or defensive forces on the other, resulted in the construction of compromise formations which represented attempts at obtaining fulfilment of the unconscious wishes in disguised form. Thus the manifest dream content could be considered to be a 'censored' or disguised fulfilment of an unconscious wish. Similarly, the free associations of the patient in analysis were also regarded as disguised derivatives of unconscious wishes.

In the second phase, as in the first, Freud assumed that there was a part of the mind or 'mental apparatus' which was conscious and a further, substantial, unconscious part. In this connection, Freud distinguished between two sorts of unconsciousness. One, represented by a 'system', the Unconscious, contained instinctual drives and wishes, which, if they were to be allowed to emerge into consciousness, would constitute a threat and would give rise to anxiety or other unpleasant feelings. The strivings in the Unconscious were seen as being constantly propelled towards discharge, but they could only be allowed expression in a distorted or censored form. The other sort of unconsciousness was that attributed to the Preconscious system, which contained knowledge and thoughts that were outside consciousness but not held back by the counterforces of repression, as were contents relegated to the Unconscious. Preconscious mental content could enter into consciousness at the appropriate time and could not only be utilized by the individual for rational tasks but could also be seized upon by wishes from the Unconscious in their attempts to force a passage through to consciousness—i.e. they could be used to represent these wishes. The model of the mental apparatus in the second phase is generally known as the 'topographical' model, and in it the Preconscious system was thought of as lying between the Unconscious and consciousness (the latter being the quality of the system Conscious).

Freud saw the instinctual drives as 'energies' which could be invested in different mental contents. (In English translations of Freud, the German word for 'investment' [Besetzung] has been rendered, in our view unfortunately, as 'cathexis'.) He made use of the term libido for the sexual energy of the instinctual drives, but, although aggression was later given a status equal in importance to sexuality, he coined no corresponding term for 'aggressive energy'. In the Unconscious these drive energies were regarded as being freely displaceable from one content to another and functioned according to the so-called primary process. Logical and formal relations between the elements in the Unconscious were regarded as absent: there was no awareness of time, and only simple and primitive rules of association applied. Drives and wishes in the Unconscious functioned according to the 'pleasure-principle', i.e. they were regarded as seeking discharge, gratification, and relief of painful tension at all costs. The systems Preconscious and Conscious could be considered as being in direct opposition to this. In them, logic, reason (secondary process), and the knowledge of external reality and of ideals and standards of conduct predominate. Unlike the Unconscious, the Preconscious and Conscious systems take (or attempt to take) external reality into account, to follow what Freud called the 'reality-principle'. Thus situations of conflict, for example between sexual wishes of a primitive sort which had been repressed into the Unconscious and the person's moral and ethical standards, must inevitably arise and some sort of solution sought which would take the opposing forces into account.

Thus far we have referred to the instinctual drives and instinctual wishes as if they were regarded as existing somewhat in isolation. In Freud's view this was far from being the case, as from early in the child's development the instinctual urges were seen as having become attached to important figures in the child's world, or objects, to use the unfortunately impersonal term employed by psychoanalysts to describe these emotionally significant figures. Every unconscious wish was regarded as having an object, and the same object could be the recipient of quite opposing wishes manifested typically in feelings of both love and hate for the same person. This ambivalence is in itself a most potent source of mental conflict. Freud took the view that people, in their adult relationships to others, repeated (often in a very disguised way) their infantile attachments and conflicts, and that this tendency to repetition was often at the root of a great many of the difficulties that his patients brought.

Among the early conflicts of the child reconstructed through analysis, one constellation—the Oedipus complex, in which the child, at about the age of four or five, has to deal with a conflict of the most intense sort in regard to his wishes and object relationships—was thought to be universal. Essentially Freud regarded it as the wish of the little boy to have intercourse with his mother, to possess her completely, and to get rid of father in some way, not the most uncommon being to have him die. These wishes were seen by Freud as being in conflict with the little boy's love for his father, and also with his fear of rejection or bodily damage at his hands, in particular the fear of father's retaliatory damage to his genitals, the so-called 'castration anxiety'. The picture in regard to the little girl is somewhat similar, the roles of the parents being reversed, although in both boys and girls the two opposing constellations are also thought to exist. Thus we find in the boy a wish to be possessed by the father and to be rid of mother, a consequence of the innate bisexuality in everyone, male or female.

These views of mental functioning and infantile sexuality were the product of the second phase, a period of intense study of the vicissitudes of unconscious instinctual drives, particularly sexual drives (Freud, 1905d), and their derivatives. It has been described here at some length because of its importance for the more detailed consideration of the clinical concepts discussed in the chapters that follow. In the context of the psychological model of the second phase, these concepts can be regarded as relatively simple and straightforward. However, as we shall show, developments in Freud's thinking caused complications to appear.

The third phase can be dated from 1923, when a decisive change occurred in Freud's conceptualization of mental functioning. Freud had been deeply impressed by the operation in his patients of what he could only conceive of as an unconscious sense of guilt. In addition, a number of inconsistencies and contradictions were emerging in the detailed application of the 'topographical' division of the mental apparatus into the systems Unconscious, Preconscious and Conscious, and this led Freud to put forward a revised theoretical model. Perhaps it would be more appropriate to say that he introduced a further point of view, for his new formulations did not entirely replace the former ones but rather existed alongside them. It was such a situation we had in mind when we referred earlier to the fact that psychoanalysis, as a developing body of thought, does not have a fully consistent and integrated theoretical model. In 1923 Freud formulated, in The Ego and the Id (1923b), the 'structural' model, or what has been called the 'second topography'—the three-fold division of the mental apparatus into what he referred to as id, ego, and superego.

The id was seen as corresponding roughly to much of what had been encompassed by the concept of the Unconscious. It can be regarded as that area of the mind containing the primitive instinctual drives, with all their hereditary and constitutional elements. It is dominated by the pleasure principle, and it functions according to the primary process. During maturation and development and as a consequence of the interaction with the external world, a portion of the id undergoes modification to become the ego. The primary function of the ego was seen as the task of self-preservation and the acquisition of means whereby a simultaneous adaptation to the pressures of the id and the demands of reality can be brought about. It gains the capacity to delay instinctual discharge, or to control it by means of a variety of mechanisms, including the mechanisms of defence. The third agency, the superego, was seen as developing as a sort of internal precipitate or residue of the child's early conflicts, particularly in relation to his parents or other figures of authority and his identifications with them. The superego is the vehicle of the conscience, including that part of the conscience which is regarded as unconscious; for large parts of the superego, as well as of the ego, and all of the id, were seen as functioning outside consciousness.

It is worth mentioning that in this structural theory there is again a change of emphasis from that which dominated the previous phase. The ego's role was seen to be that of a mediator, a problem-solver, having at each and every moment to meet the demands arising from the id, from the superego, and from the external world. In order to resolve these often conflicting demands, the ego has at times to create the most complicated compromises, and in the last resort these compromises may result in the symptoms which, although painful and distressing to the individual who experiences them, represent the best possible adaptation that he can bring about in the particular circumstances. Such compromises are regarded as entering into the formation of character and personality, into choice of career and love-objects, and into all those things which go into making any one person a unique individual.

This particular phase in the development of psychoanalysis lasted till Freud's death in 1939. This is a rather arbitrary dating, for what we can refer to as the fourth phase represents the contributions of psychoanalysts other than Freud. Thus there were important additions to theory and practice from the time that colleagues first came to be associat...