Specialty competencies in psychoanalysis in psychology 9780190210922, 0190210923

Table of contents :
Machine generated contents note: --
Section I Introduction to Psychoanalysis --
Chapter 1 --
On Defining Psychoanalysis in Psychology Practice --
Rafael Art. Javier --
Chapter 2 --
Conceptual and Scientific Foundations --
Rafael Art. Javier and William G. Herron --
Section II Functional Competency --
Assessment --
Chapter 3 --
Assessment Strategies --
Rafael Art. Javier --
Chapter 4 --
Psychodynamic Case Formulation --
Dolores O. Morris --
Section III Functional Competency --
Intervention --
Chapter 5 --
Beginning Treatment --
William G. Herron --
Chapter 6 --
Transference, Countertransference and Resistance --
William G. Herron --
Chapter 7 --
Therapeutic Effect --
William G. Herron --
Section IV Other Functional Competencies --
Chapter 8 --
Supervision --
William G. Herron --
Section V Foundational Competencies --
Chapter 9 --
Common Ethical and Legal Challenges --
Dolores O. Morris --
Chapter 10 --
Considerations Concerning Individuals and Cultural Diversity --
Rafael Art. Javier and Dolores O. Morris --
Chapter 11 --
Professional Identity --
Dolores O. Morris --
Key Terms --
Index --
About the Authors --
About the Series Editors.

Citation preview

Specialty Competencies in Psychoanalysis in Psychology

Series in Specialty Competencies in Professional Psychology SERI ES ED ITO RS

Arthur M. Nezu, PhD, ABPP, and Christine Maguth Nezu, PhD, ABPP SERI ES A DVIS O RY BOA R D

David Barlow, PhD, ABPP

William Parham, PhD, ABPP

Jon Carlson, PsyD, EdD, ABPP

Michael G. Perri, PhD, ABPP

Kirk Heilbrun, PhD, ABPP

C. Steven Richards, PhD

Nadine J. Kaslow, PhD, ABPP

Norma P. Simon, EdD, ABPP

Robert Klepac, PhD TITL ES I N TH E SERI ES

Specialty Competencies in School Psychology, Rosemary Flanagan and Jeffrey A. Miller Specialty Competencies in Organizational and Business Consulting Psychology, Jay C. Thomas Specialty Competencies in Geropsychology, Victor Molinari (Editor) Specialty Competencies in Forensic Psychology, Ira K. Packer and Thomas Grisso Specialty Competencies in Couple and Family Psychology, Mark Stanton and Robert Welsh Specialty Competencies in Clinical Child and Adolescent Psychology, Alfred J. Finch, Jr., John E. Lochman, W. Michael Nelson III, and Michael C. Roberts Specialty Competencies in Clinical Neuropsychology, Greg J. Lamberty and Nathaniel W. Nelson Specialty Competencies in Counseling Psychology, Jairo N. Fuertes, Arnold Spokane, and Elizabeth Holloway

Specialty Competencies in Group Psychology, Sally Barlow Specialty Competencies in Clinical Psychology, Robert A. DiTomasso, Stacey C. Cahn, Susan M. Panichelli-Mindel, and Roger K. McFillin Specialty Competencies in Rehabilitation Psychology, David R. Cox, Richard H. Cox, and Bruce Caplan Specialty Competencies in Cognitive and Behavioral Psychology, Christine Maguth Nezu, Christopher R. Martell, and Arthur M. Nezu Specialty Competencies in Clinical Health Psychology, Kevin T. Larkin and Elizabeth A. Klonoff Specialty Competencies in Psychoanalysis in Psychology, Dolores O. Morris, Rafael Art. Javier, and William G. Herron

DOLORES O. MORRIS R AFAEL ART. JAVIER WILLIA M G. HERRON

Specialty Competencies in Psychoanalysis in Psychology

1

3 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford New York Auckland  Cape Town  Dar es Salaam  Hong Kong  Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trademark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016

© Oxford University Press 2015 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. CIP data is on file at the Library of Congress. ISBN 978–0–19–976647–5

9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper

S E L E C T E D E V E N T S I N T H E H I S T O R Y O F P S YC H O A N A LY S I S 1859

Publication of On the Origin of Species by Means of Natural Selection by Charles Darwin.

1872

Publication of Expression of the Emotions in Man and Animals by Charles Darwin.

1883

Emil Kraepelin proposes the first classification of mental disorders.

1883

Publication of Inquiries into Human Faculty and Its Development, a study of memory in the real world by Sir Francis Galton.

1885

Study of human memory by Herman Ebbinghaus.

1885–1886 Sigmund Freud studies at the Salpêtriére School of Hypnosis under Jean-Martin Charcot. 1890

Publication of The Principles of Psychology by William James.

1891

Publication of Diseases of Personality by Théodule Ribot.

1892

Establishment of the American Psychological Association.

1893–1895 Publication of Studies on Hysteria by Josef Breuer and Sigmund Freud. 1894

Publication of Diseases of the Will by Théodule Ribot.

1894–1896 Publication of the Neuropsychosis of defense and Further Remarks on the Neuropsychosis of Defense by Sigmund Freud. 1896

Publication of Diseases of Memory An Essay in Positive psychology by Théodule Ribot.

1990–1901 Publication of The Interpretation of Dreams by Sigmund Freud. 1901

Publication of The Development of Sexual Instinct by Havelock Ellis.

1901–1905 Publication of Three Essays on Sexuality and other works by Sigmund Freud. 1907

Publication of Study of Organ Inferiority and Its Psychical Compensation by Alfred Adler.

1909

The Clark University Conference is attended by Sigmund Freud, G.  Stanley Hall, Carl Jung, Abraham Brill, Ernest Jones, and Sándor Ferenczi.

1911

The American Psychoanalytic Association is founded; the first accrediting national psychoanalytic organization in the nation.

1911

Publication of Symbols of Transformation by Carl Jung, which begins his breaking away from Freud’s basic theories, with the final break to come in 1913.

1914–1918 World War I, which is followed by the 1929 financial collapse, prompts the emigration of prominent psychoanalysts to the United States in the 1930s, such as Otto Rank, Otto Fenichel, Erich Fromm, Karen Horney, Ernest Simmell, and Helene Deutsch. 1918

Freud establishes the Institutes for Psychoanalytic Education and Training in Berlin, immediately followed by similar establishments in Vienna and London. In America, New York is the first, followed by Chicago, Boston, and Baltimore–Washington.

1920

The Tavistock Clinic is founded by Dr. Hugh Crichton Miller.

1923–1925 Publication of The Ego and the Id, and other works by Sigmund Freud. 1924

Otto Rank breaks from Freud with the publication of Rank’s book The Trauma of Birth.

1924

The American Psychoanalytic Association, under the influence of the New York Psychoanalytic Society, adopts the requirement that members be physicians. This decision is based on the fear or concern that opening it up would dilute the exclusiveness and the conviction that physicians were better prepared to provide psychoanalysis.

1926

Publication of On Inhibitions, Symptoms, and Anxiety by Sigmund Freud.

1928–1971 Publication of Judgement and Reasoning in the Child, Construction of Reality in the Child, On the Development of Memory and Identity, and other works by Jean Piaget. 1932–1957 Publication of The Psychoanalysis of Children, Envy and Gratitude, and other works by Melanie Klein. 1932

Sigmund Freud breaks with Sándor Ferenczi.

1933

Publication of Confusion of Tongues between Adults and the Child The Language of Tenderness and of Passion by Sándor Ferenczi, which represents a departure from his previous Freudian view.

1934

Otto Rank moves permanently to the United States and becomes an influential force for prominent psychoanalysts such as Carl Rogers, Franz Alexander, Rollo May, Robert Lifton, and Irvin Yalom.

1935

Publication of Konrad Lorenz’s observation on “imprinting” in ducklings, also relevant to understand the crucial importance of the critical period in human.

1936

Publication of The Ego and the Mechanism of Defense by Anna Freud.

1940

Publication of The Influence of Early Environment in the Development of Neurosis by John Bowlby.

1946

Publication of The Observation of Anaclitic Depression in Orphaned and Neglected Children by René A. Spitz.

1947

The Hempstead Child Therapy Course is established by Anna Freud; and the Hempstead Child Therapy Course and Clinic is established by Anna Freud, Dorothy Burlingham, and Helen Ross in 1952.

1948

Establishment of the Postgraduate Center for Mental Health in New York by Louis Wolberg.

1950–1969 Publication of Childhood and Society, Identity and the Life Cycle, and Identity Youth and Crisis by Erik Erickson. 1951

Publication of Maternal Care and Mental Health by John Bowlby.

1952

Publication of An Object Relations Theory of the Personality by William Ronald Fairbairn.

1953

Publication of The interpersonal Theory of Psychiatry by Harry Stack Sullivan.

1958

Publication of Ego Psychology and the Problem with Adaptation by Heinz Hartman.

1959

Publication of Separation Anxiety by John Bowlby.

1959–1994 Publication of Introspection, Empathy, and Psychoanalysis; The Analysis of the Self; The Restoration of the Self, and other works by Heinz Kohut. 1961

Creation of the New  York University postdoctoral program in psychotherapy and psychoanalysis by Bernard Kalinkowitz.

1963

Establishment of the Adelphi postdoctoral program (the Derner Institute) by Gordon Derner.

1963–1977 Publication of Separation and Individuation by Margaret Mahler. 1965

Publication of Research on the effect of maternal deprivation in infant monkeys by Harlow and Associates.

1969–1980 Publication of Attachment and Loss by John Bowlby. 1972

Creation of the San Francisco Psychotherapy Research Group, founded by Joseph Weiss and Harold Sampson.

1972

The National Association for the Advancement of Psychoanalysis (NAAP) is founded, a group of psychoanalytic practitioners whose affiliated institutes do not require candidates to have a graduate degree in a healthcare profession before undertaking psychoanalytic training. Toward the end of establishing psychoanalysis as a separate discipline, the NAAP has worked not only to establish accreditation standards for psychoanalytic institutes, but to establish state licensure for individual psychoanalysts. Their lobbying has been credited with successfully establishing licensing for individuals under the title of “psychoanalyst” in the states of New York, Vermont, and New Jersey.

1974

Publication of The Holding Environment by Donald Winnicott.

1975

Publication of Borderline Conditions and Pathological Narcissism by Otto Kernberg.

1977–1988 Publication of Ecrits A  Selection; Four Fundamental Concepts of Psychoanalysis, and other works by Jacques Laçan. 1978

Theodor Reik founds the National Psychological Association for Psychoanalysis (NPAP) to educate non-medical psychoanalysts in New York City, with an affiliate in California. (There were other institutes outside of the American Psychoanalytic Association available before NPAP that did not subscribe to the classic Freudian doctrine.)

1978

Publication of Patterns of Attachment by Mary Ainsworth and associates.

1979

The Division of Psychoanalysis (Div. 39)  is established within the American Psychological Association.

1979

Publication of Faces in a Cloud Subjectivity in Personality Theory by Robert Stolorow and George Atwood.

1982

Establishment of The Journal of Psychoanalytic Psychology, for the APA Division of Psychoanalysis, with Helen Lewis as its first editor.

1984

Publication of Structures of Subjectivity Explorations in psychoanalytic phenomenology by George Atwood and Robert Stolorow.

1985

Publication of The interpersonal World of the Infant by Daniel Stern.

1985

A  federal anti-trust class action lawsuit is brought about by four psychologist plaintiffs against the American Psychoanalytic Association (APsaA), the International Psychoanalytical Association, and two institutes that were affiliated with these associations.

1986

The Clark Conference on Psychoanalytic Training for Psychologists is sponsored by Division 39.

1988

APsaA modifies its by-laws to eliminate its “waiver process“ for full clinical psychoanalytic training for doctoral level psychologists and social workers.

1988

The Psychoanalytic Consortium is formed by Division 39 (Psychoanalysis) of the American Psychological Association, The American Academy of Psychoanalysis and Dynamic Psychiatry, the American Psychoanalytic Association, and the American Association for Psychoanalysis in Clinical Social Work—in opposition to the NAAP’s efforts. They believe that divorcing psychoanalysis from the established healthcare professions would lower standards by essentially turning psychoanalytic institutes into master’s programs rather than a postdoctoral requirement, which could potentially damage the reputation of psychoanalysis in the public mind.

1988

Publication of Relational Concepts in Psychoanalysis by Stephen Mitchell.

1989

Settlement of the anti-trust class action lawsuit is reached (April 17), opening the door for non-medical training in psychoanalysis.

1995

Creation of the Boston Change Process Study Group by Louis Sander, Daniel Sterns, Karen Lyons-Ruth, Nadia Bruschweiler-Stern, Jeremy Nahum, and Alexander Morgan.

1995

The American Psychological Association (APA) establishes the Commission for the Recognition of Specialties and Proficiencies in Professional Psychology (CRSPPP) to identify, codify, and clarify the distinctive patterns of professional education, training, and practice that exist among the specialties of professional psychologists. Psychoanalysis in psychology is one of the specialties, as are all specialties that must go through a renewal process every seven years; which is affirmed by the APA Council of Representatives.

1996

The American Board of Professional Psychology establishes the Speciality Board of Psychoanalysis to certify psychologists in psychoanalysis.

2001

Accreditation Council for Psychoanalytic Education, Inc. (ACPEInc) is established to evaluate and accredit educational institutions that train and graduate practitioners of psychoanalysis. Its evaluation and accreditation criteria are based on the standards developed by the Psychoanalytic Consortium.

CONTENTS

About the Series in Specialty Competencies in Professional Psychology

xiii

Preface

xvii

SECTION I

Introduction to Psychoanalysis

1

ON E

On Defining Psychoanalysis in Psychology Practice Rafael Art. Javier

3

T WO

Conceptual and Scientific Foundations Rafael Art. Javier and William G. Herron

18

SECTION II

Functional Competency—Assessment

41

THREE

Assessment Strategies Rafael Art. Javier

43

FOU R

Psychodynamic Case Formulation Dolores O. Morris

66

SECTION III

Functional Competency—Intervention

81

FIVE

Beginning Treatment William G. Herron

83

SI X

Transference, Countertransference, and Resistance William G. Herron

101

SE V E N

Therapeutic Effect William G. Herron

124

SECTION IV

Other Functional Competencies

135

E IGH T

Supervision William G. Herron

137

xii

Contents SECTION V

Foundational Competencies

151

NINE

Common Ethical and Legal Challenges in the Practice of Psychoanalysis in Psychology Dolores O. Morris

153

TEN

Considerations Concerning Individuals and Cultural Diversity Rafael Art. Javier and Dolores O. Morris

166

ELEVEN

Professional Identity Dolores O. Morris

187

Key Terms

201

Index

207

About the Authors

221

About the Series Editors

223

ABOUT THE SERIES IN SPECIALT Y COMPETENCIES IN PROFESSIONAL PSYCHOLOGY

This series is intended to describe state-of-the-art functional and foundational competencies in professional psychology across extant and emerging specialty areas. Each book in this series provides a guide to best practices across both core and specialty competencies as defined by a given professional psychology specialty. The impetus for this series was created by various growing movements in professional psychology during the past 15 years. First, as an applied discipline, psychology is increasingly recognizing the unique and distinct natures of a variety of orientations, modalities, and approaches with regard to professional practice. These specialty areas represent distinct ways of practicing one’s profession in various domains of activities that are based on distinct bodies of literature and often address differing populations or problems. For example, the APA, in 1995, established the Commission on the Recognition of Specialties and Proficiencies in Professional Psychology (CRSPPP) in order to define criteria by which a given specialty could be recognized. The Council of Credentialing Organizations in Professional Psychology (CCOPP), an inter-organizational entity, was formed in reaction to the need to establish criteria and principles regarding the types of training programs related to the education, training, and professional development of individuals seeking such specialization. In addition, the Council on Specialties in Professional Psychology (COS) was formed in 1997, independently of APA, to foster communication among the established specialties, in order to offer a unified position to the public regarding specialty education and training, credentialing, and practice standards across specialty areas. Simultaneously, efforts to actually define professional competence regarding psychological practice have also been growing significantly. For example, the APA-sponsored Task Force on Assessment of Competence in Professional Psychology put forth a series of guiding principles for the

xiv

About the Series in Specialty Competencies in Professional Psychology

assessment of competence within professional psychology, based in part on a review of competency assessment models developed both within (e.g., Assessment of Competence Workgroup from Competencies Conference— Roberts et al., 2005) and outside (e.g., Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties, 2000) the profession of psychology (Kaslow et al., 2007). Moreover, additional professional organizations in psychology have provided valuable input into this discussion, including various associations primarily interested in the credentialing of professional psychologists, such as the American Board of Professional Psychology (ABPP), the Association of State and Provincial Psychology Boards (ASPBB), and the National Register of Health Service Providers in Psychology. This widespread interest and the importance of the issue of competency in professional psychology can be especially appreciated given the attention and collaboration afforded to this effort by international groups, including the Canadian Psychological Association and the International Congress on Licensure, Certification, and Credentialing in Professional Psychology. Each volume in the series is devoted to a specific specialty and provides a definition, description, and development timeline of that specialty, including its essential and characteristic pattern of activities, as well as its distinctive and unique features. Each set of authors—long-term experts and veterans of a given specialty—was asked to describe that specialty along the lines of both functional and foundational competencies. “Functional competencies” are the common practice activities provided at the specialty level of practice that include, for example, the application of its science base, assessment, intervention, consultation, and (where relevant) supervision, management, and teaching. “Foundational competencies” represent core knowledge areas, which are integrated and cut across all functional competencies to varying degrees, and depending upon the specialty, in various ways. These include ethical and legal issues, individual and cultural-diversity considerations, interpersonal interactions, and professional identification. Although we realize that each specialty is likely to undergo changes in the future, we wanted to establish a baseline of basic knowledge and principles that compose a specialty, highlighting both its commonalities with other areas of professional psychology, as well as its distinctiveness. We look forward to seeing the dynamics of such changes, as well as the emergence of new specialties in the future. In this volume, Morris, Javier, and Herron describe the foundational and functional competencies of psychoanalysis. The authors have

About the Series in Specialty Competencies in Professional Psychology

delivered an exceptionally interesting book that provides a thorough recapitulation of the field and will be very helpful to psychologists seeking to strengthen their background in psychoanalytic theory or treatment. Additionally, individuals who aspire to specialize in this area of professional psychology will find it invaluable. Because the authors describe these complex theoretical ideas in terms of practical competencies, this book would make an especially useful guide for teaching students. The chapters focused on assessment and interventions are extremely enlightening in that they provide the reader with the opportunity to learn how psychoanalysis uniquely addresses these functional competencies. The chapters concerning how to begin treatment, and those illustrating concepts such as transference, countertransference, and resistance, are particularly informative, and help readers better understand these important concepts and how they impact treatment. Although the authors’ expertise and knowledge is revealed throughout the different chapters, concerning individual and cultural diversity as well as the professional identity of the psychoanalyst are particularly instructive.

xv

PREFACE

This book is one in a series designed to describe current foundational and functional competencies across specialties in professional psychology. Foundational competencies include basic knowledge, which, in some fashion, is common to all competent practices. The functional competencies occur in the specialization of practice, which in this case is psychoanalysis. In its evolution, psychoanalysis has now become a broad term that includes all therapies making use of an approach that can be considered “psychoanalytic” in that it is based on the existence and importance of unconscious (out of awareness) motivation. This book uses the concept of psychoanalysis in that manner, without emphasizing distinctions between psychoanalysis, psychoanalytic therapy, psychoanalytically oriented psychotherapy, psychodynamic psychotherapy, and so forth. The particular emphasis of the book is on the discussion and delineation of the functional competencies, which include their scientific basis, and assessment, intervention, supervision, and consultation: four pillars of psychoanalytic practice. Similarly, the book covers discussions of the foundational competencies, which involve issues related to professional identification, ethical and legal issues, interpersonal interactions, and diversity, as they relate to the theory and practice of psychoanalytically oriented psychotherapies. The book is designed for all mental health professionals and is expected to serve as a guide to train specialists in a particular area of theory and practice, which is psychoanalysis. Although psychologists-psychoanalysts are exemplified in our discussions and examples, the foundations and competencies discussed in the book are applicable to all who are interested in and/or wish to practice as psychoanalysts or psychoanalytically oriented psychotherapists. This is a book about the totality of psychoanalysis. It is written in relatively broad strokes aimed both at the sophisticated and the merely interested readers, for whom understanding the working of psychoanalysis in both its theories and its practices is an ongoing curiosity and desire.

xviii

Preface

The book has 11 chapters, divided into five sections. Section I  is the Introduction and includes two chapters, beginning with defining psychoanalysis (Chapter 1), followed by its conceptual and scientific foundations (Chapter 2). Section II deals with one group of functional competencies, namely assessment, involving two chapters:  the first on making assessments of patients for appropriate treatment (Chapter 3), and the second on developing psychodynamic case formulations (Chapter  4). Section III is concerned with another group of functional competencies, namely interventions, and discusses issues related to beginning treatment, transference, countertransference and resistance, and the therapeutic effect. The ultimate goal of this section, which includes three chapters, is delineating the components that create therapeutic effects normally associated with psychoanalytic treatment. The remaining chapters, which make up the remaining two sections, are concerned with foundational conceptions related to the development of the required professional identity, and issues related to training, supervision, consulting, and legal and ethical considerations. An extensive discussion on issues of diversity is also included here, to highlight the kinds of issues likely to emerge in the assessment and treatment of patients from diverse populations. Chapter 1 is designed to provide a general introduction to psychoanalysis, starting with a definition of the specialty, and tracing the theoretical foundations guiding the practice of psychoanalysis from Freud to more current developments in contemporary psychoanalysis. Also noted are the basic competencies of the specialty and its basic training requirements. The essential characteristics of psychodynamic interventions and specific differentiating characteristics of psychoanalysis are identified, as well as psychological disorders that have been found to benefit from the psychoanalytic approach. Chapter  2 is concerned with scientific foundations, and starts with describing the conceptual basis of the specialty. This is intertwined with its scientific foundation. The chapter concludes with a discussion of psychoanalytic research methods and the empirical evidence of the viability of the specialty. Recommendations are made for future investigations that could answer what kinds of changes occur in specific patients treated with specific interventions, and in turn the changes that may be expected in personality structures that differ from those of other therapies. Chapter 3 describes the assessment process, with clinical examples, and includes expectations and assumptions that both patient and therapist bring to the process. It is vital for the assessor to have a sufficient knowledge base for the assessment and an awareness of any personal biases that

Preface

could influence the result. A determination needs to be made regarding the appropriateness of each therapist to work with a particular patient. Chapter 4, on psychodynamic formulation, illustrates how the assessment information is put to use before formal treatment begins. The formulation can be viewed as “genetic-dynamic,” the former word referring to its origins, while the latter refers to subsequent interactive development throughout life, and up to the point of creating the formulation. This serves as a guide for the interventions that can follow, suggesting what will be most effective for each patient. Chapter 5, on beginning treatment, discusses developing one of most important ingredients in psychoanalytic practice; that is, the development of empathy with the patient. The chapter also provides a detailed explanation of the therapeutic process. There is a focus on working together in a manner both patient and therapist agree is acceptable and potentially effective. This requires establishing a therapeutic alliance in which the patient understands the psychoanalytic techniques of listening, relating, exploring, and interpreting, with the goal of bringing about positive changes. Chapter 6 concerns transference, countertransference, and resistance. All analytic work involves these components to varying degrees. Although patients are seeking change, they also fear being different, so they resist, often working against the alliance by using avoidance, distrust, dismissal of interpretations, and so forth, all of which require discussion with the analyst. An integral part of the process is transference, wherein the patient views the therapist as a projected (imagined) figure, and attributes feelings and impressions to the therapist that are created by the patient and often reveal unconscious material. Working through transference material is meant to facilitate the progression of understanding, relating, and interpreting, and ultimately, creating the opportunity for positive changes. In addition, since there are two individuals’ psychology involved, and although the therapist strives to maintain a certain objectivity, the likelihood that he has a transference to the patient—namely, a countertransference— also needs to be examined, particularly to see how it may be affecting the process. Chapter 7, on therapeutic effect, considers the culmination of analytical efforts in a discussion of “working through,” which is the therapeutic effect designed to complete an analysis. This can be viewed as a translation of insight into action through the two major interventions used by analysts:  the therapeutic relationship and interpretations. Employed in varying degrees around the fulcrum of transference, resistance, and

xix

xx

Preface

countertransference, they make up the analytic process that has been demonstrated to be therapeutic. Chapter 8 is devoted to supervision, a key aspect of training psychoanalysts. Analytic supervision is defined, and the competencies required for a successful supervisor are described. Supervision is primarily a teaching process, but the relationship between supervisor and supervisee contains transference, countertransference, and resistance, so it also has therapeutic elements that need to be integrated and resolved. Examples are given of interactions providing a reflective atmosphere of learning where the supervisor is an empathic and knowledgeable helper. Chapter 9, concerning the common ethical and legal challenges in the practice of psychoanalysis in psychology, discusses the ethics codes that psychologists-psychoanalysts are expected to follow in different settings, by exploring practice competencies that require introspectiveness while following the requirements of laws and regulations. A table that compares and examines the codes of ethics of two major organizations is presented, as well as some common questions based on a code of ethics. The reader will have a better understanding of the underpinnings that provide the solution to ethical dilemmas. Chapter  10, on diversity, emphasizes the development of conditions contributing to our difficulty in dealing with diverse factors in psychoanalytic theory and practice. These concepts help the specialist determine the direction of inquiry, and make decisions about necessary interventions and the rendering of appropriate services. These concepts also enhance the provider’s knowledge about and comfort with diversity, thereby increasing the possibility of understanding the particular needs of the patient. In particular, application of psychoanalytic formulations to culturally diverse patients has to be individualized and requires an understanding of their sociopolitical context and the total life experiences brought to the treatment. Analysts use this orientation to navigate the unconscious motivations emerging in the interpersonal space of the analytic situation. The last chapter, Chapter  11, is dedicated to issues related to professional identity. The purpose of this chapter is to discuss how the psychologist-psychoanalyst identity is formed or emerges. Psychoanalytic education and professional organizations play an integral role in the developmental process of the specialist. In this context, the requirements for the specialty are addressed, followed by a description of the demographic characteristics of psychologists- psychoanalysts and their professional attitudes. The variety of roles that allows for their creativity and leadership, as well as their interface with professional organizations, are

Preface

covered. The conclusion speculates about the future of the specialty. The professional and personal identities of the psychologist-psychoanalyst blend to create the container that molds and discerns the experience of the psychoanalytic process. This identity is at the crux of psychoanalytic therapy and practice and permeates every aspect of functional and foundational competencies. At this point, we want to make some personal observations. First, we are in awe of the amount of material and effort that has been involved in psychoanalysis. It is indeed both an evolving culture of its own and an integral part of the culture of the world. Then, as its founder intended, it never stands still. New developments constantly take place: some subtle, others radical, yet all in the service of the best therapeutic effort, for there is more to be accomplished. Also, this book took a number of years to write, and there were many discussions as to how it would be written. This book has involved three analysts with a powerful belief in the value of psychoanalysis, but with different predilections for its ingredients. Despite our differences, our aim has been to speak in a voice that will be clear and of value to the reader.

xxi

SECT IO N I

Introduction to Psychoanalysis

ON E

On Defining Psychoanalysis in Psychology Practice RAFAEL ART. JAVIER

This is the first of 11 chapters in a volume dedicated to specialty competencies in psychoanalytic psychology. This chapter begins by defining psychoanalysis and psychoanalytic practice, with a special emphasis on describing clinical evidence and empirical research support for its effectiveness. The first two sections in this chapter illustrate the conceptual evolution of analysis that results in its current definition. The next sections are devoted to its history. These are followed by descriptions of areas of proven psychoanalytic competence, particular requirements of the specialty, and a summary. Although clinical material and research data appear throughout the book, we dedicate Chapter 2 more specifically to a discussion of the research evidence and scientific foundations of the specialty. Finally, for stylistic convenience and in keeping with American Psychological Association (APA) standards, we will use “he” or “she,” “him” or “her,” and “his” or “hers” throughout the book in equal quantity when appropriate, rather than “he/she,” “him/her,” and “his/hers” to refer to the gender of the patient or therapist. An important aspect of psychoanalysis since its inception in late 1800s in Europe is its concern with finding an effective method to treat psychological conditions whose causes are not always evident to those suffering from the impact of mental illness, or to the practitioners treating these conditions. Psychoanalysis became separate from other methods of treating mental conditions at the time because it developed a new method

4

Introduction to Psychoanalysis

to explain psychological illness that focused less on neurological causes, and emphasized instead “the role of the unconscious,” or material out of awareness, in the development of these conditions. In its evolution, psychoanalysis has become an umbrella term for therapies that emphasize unconscious motivations. These include traditional psychoanalysis, psychoanalytic psychotherapy, psychodynamic therapy, dynamic psychotherapy, and the like. These therapies vary in methods, but all share a focus on the unconscious; specifically, desires and unformulated material, all of which have been excluded from consciousness because of their anxiety-arousing potential. Such exclusion results in pathogenic beliefs, wishes, and relationships. Some component may be anchored and organized at a prelinguistic and sensory level, but all are imbued with a great deal of affective meaning for the individual. The nature and quality of the content of the unconscious are not considered components of a “cognitive construct” as traditionally defined in what is involved in “implicit cognition” (defined as a process that cannot be directly inferred through introspective awareness) and “explicit cognition” (defined as a process that can be consciously detected and reported) (Amodio & Mendoza, 2010; Greenwald & Banaji, 1995). This is the case because the unconscious incorporates a range of complicated and conflicting emotions (not only cognitions) for the individual that then become part of his motivational forces in dealing with the world. Psychoanalysis aims at the patient’s emancipation from maladaptive schemes acquired primarily in the past. Although there is controversy regarding specific therapeutic interventions (discussed in subsequent chapters), self-understanding (insight) and feeling understood (intersubjectivity) are most transformative for the patient. They are most often acquired through interpretation (understanding) and corrective (therapeutic) relationships developed in the analytic process.

Definition of Psychoanalysis as Practiced Today Psychoanalysis is a theory and practice that continues to evolve through dialogue with the needs of society, for which it offers a distinctive opportunity to understand that is different from other therapeutic approaches. It is a treatment approach that is based on the systematic observation that individuals are often unaware of many of the factors (forces) that influence and determine their emotions and behaviors. These unconscious factors may be the source of considerable distress and unhappiness. This distress and unhappiness may develop

Defining Psychoanalysis in Psychology Practice

as symptoms or troubling personality traits, with resulting difficulties in love, work, and play. These difficulties can result in disturbances in mood and self-esteem. Because the individual is not sufficiently aware, these determining forces are not discerned by the conscious awareness of the individual, the advice of friends and family, or self-help books, and even the most determined efforts of will often fail to provide significant relief. Psychoanalysis is operationally defined by the American Board of Psychoanalysis as .  .  .  a means of understanding human motivation and behavior based upon an understanding of factors outside of a person’s awareness. It informs both scholarly study and practice. . . . Technical facets such as working with dreams, slips of the tongue, fantasies and other symbolic material, frequency of sessions per week, use or non-use of the couch, or such issues as the neutrality of the analyst . . . may not be regarded as requirements common to all approaches to psychoanalysis. What distinguishes psychoanalysis is bringing the analysand in touch with motivations and wishes of which s/he is only partially aware or completely unaware before treatment. (American Board of Professional Psychology, www.abpp.org) Although the definition includes technical factors, such as free association by the patient and interpretation by the analyst, the key feature is the emphasis on unconscious motivation. The patient discovers hidden meanings, and the analyst is the facilitator of that discovery. Their joint venture is what we call the “psychoanalytic process.” Part of that process involves the exploration of the source of whatever may be distressing the individual. This exploration may involve the therapist asking questions about early experiences when the problems may have started. It may also involve (and these are less intrinsic to the psychoanalytic process) seeing the patient more than once a week or less, the use (or not) of the couch, and treating the patient individually or in group therapy, depending upon the circumstances of the patient (such as willingness, availability, financial condition, personal interest and preference, etc.) and the therapist (such as style of practice and personal preference) (Gill, 1954). What becomes most important for the psychoanalytic process is the focus on helping the patient become more aware of unconscious motivations and wishes that may be affecting her overall function and causing psychological distress.

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Historical Evolution: Structural and Technical Development There are numerous important developments in the medical field that provided the necessary foundation for the development of psychoanalysis as we know it today (Breger, 2000). In the latter part of 1800s, when the medical establishment was confronted with a clinical syndrome (“hysteria”) that challenged the preconceived notions about causation of mental disorders, the prevailing view was that abnormal behavior was rooted in diseases of the brain (Nevid, Rathus, & Greene, 2013). Kraepelin (1883) proposed the first classification of mental disorders in his influential textbook of psychiatry, which provided the medical profession with a way to classify mental conditions according to their distinctive causes and symptoms. Charcot (Makari, 2008), a respected French neurologist, was the first to recognize that organic factors alone could not explain all the types of symptoms seen in his patients suffering from hysteria. He used hypnosis to demonstrate how symptoms could be removed in his patients suffering from hysterical conditions. Around the same time, a Viennese physician, Joseph Breuer, not only used hypnosis to treat the crippling effect of hysterical symptoms suffered by one of his patients (Breger, 2000), but also encouraged his patients to talk, sometimes under hypnosis. His view was that recalling and talking (which was known as the “talking cure”) about events surrounding the emergence of the symptoms helped the patient connect with the appearance of the symptoms, especially with events that evoked distressing feelings (such as fear, anxiety, or guilt). This procedure often resulted in symptom relief. The emotional connections with these feelings and the resulting discharge of emotions are called “catharsis,” which continues to be an important part of the psychoanalytic process. This new discovery created tremendous excitement in the scientific medical community at the time, and it caused a change in their understanding of causality and treatment. Factors other than physical had to be considered when dealing with mental disorders. This is the historical context that influenced the development of psychoanalysis and Sigmund Freud as the “father of psychoanalysis.” In fact, Freud was influenced by Breuer, and while working closely with him, Freud developed his theoretical model, which provided explanations not only about hysteria, but about a variety of other psychological disorders (Freud, 1894, 1896). Others who followed him (as interpersonal psychologists, ego psychologists, self psychologists, humanistic psychologists, object relations psychologists, and relational psychologists) also provided important insights into the same questions that propelled Freud to develop his theory

Defining Psychoanalysis in Psychology Practice

and contributed to the further development of the specialty of psychoanalysis as we know it today. E A RLY A PPL I C ATI O N S O F PSYCH OA N A LYSIS

At first, psychoanalysts discovered that most mental problems resulted from an unconscious conflict. This conflict was between wishes and desires that were considered inappropriate, unacceptable, and forbidden by the individual, and the (unconscious) realization that the fact that these wishes and desires emerged in him revealed something about the individual that he did not want to face. This realization often resulted in the emergence of feelings that remained rejected by the individual and repressed (shame, guilt, etc.), producing the range of psychological disturbances that is often seen in patients (anxiety, depression, phobia, unexplained headaches, etc.). Emphasis on the role of the unconscious led Freud and early psychoanalysts to realize that the person’s personality is the result of how the individual is able to negotiate unconscious demands to allow expression of certain needs, wishes, and desires in ways that produce the least possible psychological distress. They understood that the individual is progressively equipped with internal agencies (id, ego and superego) that help her organize and negotiate the demands and expectations of the outside environment in ways that allow personal satisfaction of her basic needs and survival, while preserving her psychological health. These three agencies represent three different levels of psychological organization and experience formation. The id represents and encapsulates the most primitive, animalistic, and biologically based experience of the most basic needs, the satisfaction of which ensures the biological survival of the individual as an organism. The ego encapsulates the most coherent organization of psychic functioning and is responsible for negotiating with the real world. The superego then encapsulates all the necessary rules and moral standards that guide our relationship with ourselves, one another, and the society at large. Defining further the role of these internal agencies in mental health became the main focus of a number of influential psychoanalysts who followed Freud, with particular emphasis on the description of the specific conditions that contributed to their development. The role of the parents, particularly the nature and quality of the early mother–child interaction, became a crucial component of future psychoanalytic theories. Important

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research emerged in this context, such as attachment theory (Ainsworth, 1982; Bowlby, 1969, 1973, 1980)  and the description of how the child develops from a biological entity into a psychological one (Mahler, 1979). Findings from these research studies, as well as from Stern (1985), provided documented developmental progressions. TH E E VO LU TI O N O F PSYCH OA N A LYSIS AS A SPECI A LT Y I N T H E U N ITED S TATES

The evolution of psychoanalysis in the United States developed in the context of historical conditions in the world. Part of that development was precipitated by the political deterioration in Europe and the subsequent eruption of World War I, and particularly World War II, which displaced a number of individuals from these countries and forced immigrations into other countries, particularly the United States. Many of the individuals who immigrated were part of the group of analysts who had been influenced by the work of Freud and in turn influenced the theories and practice of psychoanalysis that now characterize the psychoanalytic practice in the United States. These refugees included Otto Rank, Hans Sachs, Otto Fenichel, Erich Fromm, Ernest Simmel, Karen Horney, and Helene Deutsch (Breger, 2000; Makari, 2008). Another important development that helped psychoanalysis in the United States was the fact that the American society was at that time becoming more interested in developing accreditation standards and establishing training requirements for many professions that, up to that point, had been without requirements. For instance, prior to the First World War, no single state required lawyers to have attended law school, and two-thirds of the medical schools did not require their candidates to have attended a high school before admission (Spezzano, 1990). By the end of the First World War, psychology became an important discipline with the development of testing procedures to evaluate soldiers, and by the Second World War, clinical psychology began to emerge as a discipline in the American professional landscape. Gradually, clinical psychologists became interested in psychotherapy, which was dominated by psychoanalysis as the only respectable and viable model for psychotherapy at that time (Spezzano, 1990). This was the (propitious) environment found by the early psychoanalysts who immigrated to the United States. In keeping with the basic thrust of the unique American fabric and personal philosophy, these early psychoanalysts found a fertile reception for their views of the

Defining Psychoanalysis in Psychology Practice

determining importance of internal factors and interpersonal environments on the individual’s psychological health and the development of mental illness. Thus, these early psychoanalysts became more interested in describing the central functions of the “ego” in the mental life of the individual, as well as describing the specific qualities of the interpersonal environment that were more conducive to psychological health, and those more conducive to the development of psychological distress. In this context, the work of Anna Freud (1936) and Heinz Hartman (Blanck & Blanck, 1974) became very influential in the development of psychoanalysis in the United States with more of an emphasis on the “ego” as the agency (or internal organization/mechanism) responsible for ensuring the protection of the psychic life of the individual through its defense (coping) mechanisms (Freud, 1936). Ego was described by these individuals as the agency responsible for higher functioning, for keeping a sense of reality, for developing appropriate judgement, and for the development of appropriate adaptive functions and a sense of mastery and competence. These qualities were considered essential for forging the proper mental conditions to succeed in the society and be able to respond to the challenges of reality (Bellak & Faithorn, 1981; Hartmann, 1958). E A RLY O RGA N IZ ATI O N O F T H E SPECI A LT Y I N T H E U N ITED S TATES

As psychoanalysis took hold in the United States, it became essential to consider the necessary educational structures that could facilitate the training of future psychoanalysts. In this context, a number of important and influential psychoanalytic schools emerged in the United States, many of which clearly departed from some aspects of the Freudian thinking, but all of which retained their basic emphasis on the role of the unconscious. A  brief discussion of some of these schools is found in Greenberg and Mitchell’s book, Object Relations in Psychoanalytic Theory (1983). Some psychoanalytic training programs were set up as postdoctoral fellowships in university settings (e.g., Duke University, Yale University, New  York University, Adelphi University, and Columbia University). Others were psychoanalytic institutes not directly associated with universities but usually with faculty who also held positions with psychology doctoral programs and/or with medical school psychiatry residency programs. The development of many of the early schools of psychoanalysis and their training curricula were initially guided by a central organization, originally

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developed by Freud and his earlier disciples, which he called “Congresses” and which became known as the International Psychoanalytical Association (IPA). The American Psychoanalytic Association (APsaA) was then established in the United States and was later approved by the IPA as an arm of the international group. As such, the APsaA was then given the authority to offer accreditation to institutes that provided training in the United States following the IPA’s basic curriculum. Also, a number of independent institutes began to emerge throughout the United States, not all directly connected to the IPA or APsaA, both of which had a policy of mainly providing training to physicians and banning psychoanalytic training of non-physicians (Spezzano, 1990). The 1940s to the 1960s were a period of rapid growth in the United States, with the emergence of institutes founded by psychologists with the primary purpose of providing psychoanalytic training to psychologists and other mental health professions. Currently, there are approximately 100 independent institutes, such as the American Institute for Psychoanalysis founded by Karen Horney, and the William Alanson White Institute founded by Harry Stack Sullivan and Clara Thompson. Also, two university-affiliated institutes appeared, namely the New York University Postdoctoral Program founded in 1961 by Bernie Kalinkowitz (a White Institute graduate) and the Adelphi Postdoctoral Program (the Derner Institute) founded in 1963 by Gordon Derner. In 1948, the Postgraduate Center for Mental Health was founded by Louis Wolberg, and was opened to psychiatrists, psychologists, and social workers (Spezzano, 1990). An important development is that, until the establishment of the Division of Psychoanalysis (Division 39) of the APA in 1979, psychoanalysis had no national organizational or academic home where professional concerns and issues could be addressed in a variety of venues and professional forums, something that the American Psychoanalytic Association provided for its medical members. Now, continuing education programs covering discussions on theory, research, and clinical techniques can be routinely presented under the Division 39 umbrella, including in its affiliated local chapters (Spezzano, 1990). The Division has approximately 3,000 members and 30 local chapters in the United States. The membership reflects a wide diversity of views, including training in different types of psychoanalysis such as Freudian, object relations, interpersonal psychoanalysis, self psychology, intersubjectivity, humanistic, relational, and so forth. Over time, pluralism in technique and theory has evolved, but the discipline is always true to the

Defining Psychoanalysis in Psychology Practice

idea of unconscious motivation. The primary areas of therapeutic effect are the interpretation of the unconscious and the development of appropriate ways of relating to other people. Finally, another important development for the establishment of psychoanalysis as a specialty in the United States was the decision in 1985 by the APA, with the impetus from Division 39, to sue the American Psychoanalytic Association, the Columbia University Center for Psychoanalytic Training and Research, and the International Psychoanalytical Association—that resulted in the favorable adjudication of the antitrust lawsuit in 1989 against these institutions. The outcome of that lawsuit was the APsaA was forced to abandon a policy that they had established in 1924 that restricted membership to physicians, who were thought to be better prepared to provide psychoanalysis. This policy allowed the acceptance of psychologists into their institutes, but only as “researchers” as part of a “waiver process,” with an agreement that those trained in institutes approved by the APsaA would never practice psychoanalysis. Beginning in 1986, the APsaA modified its by-laws to eliminate its “waiver process” and began accepting doctoral-level psychologists and social workers into clinical psychoanalytic training with all the rights and responsibilities accorded to other members. This opened opportunities for collaborative competition between APsaA and non-APsaA institutes and the expansion of psychoanalytic thought (Schneider & Desmond, 1994).

Areas of Psychoanalytic Competence Treatment of a specific condition occurs in the context of very clearly defined structure, or what is called a “psychoanalytic frame” (or guiding principles that instruct the psychoanalytic work with the patient), from which the information elicited from the patient can be more clearly understood and explained; where interventions emerging in this context are carefully designed to produce maximum effect; and where the analyst’s personal psychology is carefully monitored so as to ensure his relative objectivity in the nature and quality of the intervention. Because of this carefully designed “frame,” the material that emerges from the patient is viewed as a “reenactment” of the patient’s experience and hence as having the same quality of experiences that the patient had or has in his interactions with others in the outside world. The feelings, thoughts, and memories emerging from the patient under these conditions are forms of communication of material that he finds difficult to verbalize

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(due to a problem with mentation) through the normal process of communication, and thus find expression in these indirect forms. It is this quality of the communication that makes it relevant to the focus of the psychoanalytic intervention. Another important component of the way the patient communicates this type of material is when these feelings, thoughts, and memories are transferred to the person of the analyst as if she were indeed responsible for them. This is called the “transference” or “projection” of internal contents onto the person of the therapist/analyst. The analysis of these transference materials is a way to unlock (reveal) important information that could help the patient get to the sources of the problems that may have brought her to seek treatment. Other tools used by the analyst to reach contents that are unconscious (or out of awareness) are the analysis of “slips of the tongue” (or missteps in communication) and dream contents. Also, the analyst–patient relationship is significantly involved as a potential therapeutic factor. W H AT D O PSYCH OA N A LYS TS D O?

Psychoanalysis helps patients become aware of the unconscious causes of disruptive experiences that negatively infiltrate their overall functioning. Psychoanalysts strive to reverse the effects of such experiences. Such efforts include the exploration of the different strategies the person uses in the present or used in the past in attempts to deal with the effect of noxious experiences. Also involved are the analyst–patient relationship; the person’s history of relationships; educational and work experiences; his capacity to enjoy what life has to offer; and his capacity for adaptive engagements with the self and the world. Origins of psychopathologies can be found in unconscious conflicts between and among different psychic structures (id, ego, and superego) as they are in operation in his modes of relating, adapting to the environment, and self-development. The goal of the psychoanalytic work is to identify not only the areas of conflicts but also the mechanisms that have been helpful to keep the individual from falling into a state of dysfunction and despair (components of resilience and personal identity), and to help the patient use acquired insights and corrective emotional experiences for behavioral changes. The best way to accomplish this work is by meeting the individual regularly so as to allow for more intense work on the issues of concern and thus foster the development of stability and trust in the relationship, while

Defining Psychoanalysis in Psychology Practice

minimizing the power of “the resistance to change” that often emerges in these types of treatment; this notwithstanding, the psychoanalytic approach (process) can still be used effectively, regardless of session frequency. The process involves a careful and systematic exploration of the person’s motives that emerge in the context of her interactions with others in the world; and analysis of dreams, transference, and areas of conflicts that are assumed to be involved in maintaining her dysfunctional conditions (symptoms) (Gill, 1954). The analysis of dreams is viewed as a window to the internal world that can provide important information about the nature of the problem(s) the individual is facing. Transference is treated in a similar manner. (Psychoanalytic interventions are discussed more in detail in subsequent chapters.) T YPI C A L PRO BL E MS A D D RES SED BY T H E SPECI A LT Y A N D T H E T YPE O F I N D IVI D UA L S A N D SYM P TOM ATO LO GY M OS T L I K ELY TO BEN EFIT FROM T H IS A PPROACH

Psychoanalysis was originally developed to deal with neurotic symptoms (anxiety, phobias, etc.). These symptoms were viewed as the results of inner conflicts that were not contained by defenses, such as repression (motivated forgetting). Analysis is most effective with these disorders. However, it has also been found to be effective with personality disorders where disturbed behavioral patterns (narcissism, paranoia, etc.) are experienced by the patient as acceptable parts of the self, but cause problems with adaptation in reality. Psychoanalysis can also be used to deal with psychosis (a break with reality). Basically, psychoanalytic intervention is most productive with all psychopathologies that are considered to be the result of people’s inadequately internalizing self-regulation (or where their capacity to negotiate and regulate the variety of personal urges, conflicting emotions, and internal tensions did not totally develop and become integral parts of the self), generally due to inadequate caregiving, leaving a person unprepared to lead a productive life. (More specific discussions on this issue is found in the next chapter on scientific foundations.) REQ U I RE M EN TS O F T H E SPECI A LT Y

The specialty in psychoanalysis is differentiated from other specialties by the theoretical framework that guides the practice, particularly the emphasis on the unconscious motivation, and by sets of training requirements that are meant to prepare those interested in the specialty. These

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can be summarized in three different components (to be discussed more fully later in this volume): 1. It requires the psychologist and other mental health professionals to complete all requirements pertaining to the profession of psychology or mental health, before engaging in psychoanalytic training. 2. It requires the candidate to engage in a rigorous training that includes specific content and practice, as delineated by the American Board of Professional Psychology or similar institutions. This training involves the recognition of the role played by the psychoanalyst’s own psychology and the crucial importance of the personal awareness of the psychoanalyst’s own unconscious material that emerges in the context of the personal analysis. 3. It involves the maintaining of the specific components of the psychoanalytic frame, including, but not limited to: • the establishment of a therapeutic relationship; • the establishment of a working alliance; • the recognition of the importance of unconscious material in all aspects of the individual’s life; • the recognition that the key to patient’s improvement is the proper resolution (working through) of issues that emerge from unconscious material; • the establishment of the proper conditions to minimize external distractions and to encourage exploration of material coming from the patient’s internal world; • regularly established sessions and frequency of the sessions (which can be more than once or twice a week); • encourage the working through of the resistance (which could manifest itself in missing sessions, not remembering dreams, becoming more interested in continuing involvement in risky and destructive behaviors rather than exploration in treatment, etc.); and • the use of analysis of transference as an important tool that helps unlock the patient’s unconscious material and facilitate the therapeutic relationship. The tools listed above are different from what is required from other training in psychology and related disciplines, where the emphasis could

Defining Psychoanalysis in Psychology Practice

be primarily on the study and analysis of behavior, emotions, cognitive development, personality characteristics, factors involved in psychopathological formation, and the role of biology and neurology in determining psychological processes, and so on; or where the emphasis is on utilizing the latest empirical findings from physiology, neurology, and other related sciences as the basis for treatment intervention. In contrast, psychoanalytic training schools assume those interested in specializing in psychoanalysis to have this type of training as a foundation, before venturing into analysis of other factors that have been found to have an impact on how the individual develops in general, and of factors involved in the development of psychological disorders (Shedler, 2010). That is, psychoanalysis is involved in the meticulous analysis of material that is not easily quantifiable (which is referred to as “psychoanalytic data”), but not less important for that. It requires the psychoanalyst to maintain the same scientific openness, or suspension of all preconceived notions about the nature of the psychological condition and its etiology, with the additional components of recognizing also the importance of other sources of evidence not often considered in the “empirically” driven approach of behavioral sciences. There are other therapies influenced by psychoanalysis in various degrees, such as Yalom’s (1977) dynamic interactional group therapy; play therapy based on psychodynamic principles, particularly used with children of alcoholics (Hammond, 1985; Robinson, 1989; Vannicelli, 1989); and family therapy, such as Minuchin’s structural family therapy model (1978), which makes use of psychoanalytic principles.

Conclusion In conclusion, our goal in this chapter was to provide a general introduction to a basic definition of the specialty, the theoretical foundations guiding the practice of psychoanalysis from Freud to more current developments, the basic competences required for the proper practice of the specialty, and the basic training requirements to ensure these competences. We identified the basic characteristics of psychodynamic interventions and what specific characteristics differentiate the specialty, and identified a number of psychological disorders (anxiety, depression, somatic disorders, and personality disorders, including borderlines, and psychosis) that have been found to benefit from this form of treatment– intervention. These issues will be discussed more fully in the rest of the volume.

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References Ainsworth, M. (1982). Attachment:  Retrospective and prospective. In C. M.  Parkes & J. Stevenson-Hinde (Eds.), The Place of Attachment in Human Behavior (pp. 3–30). New York: Basic Books. Amodio, D.  M., & Mendoza, S.A. (2010). Implicit intergroup bias:  Cognitive, affective, and motivational underpinnings. In B. Gawronski & B. K. Payne (Eds.), Handbook of Implicit Social Cognition (pp. 353–374). New York: Guilford. Bellak, L., & Faithorn, P. (1981). Crisis and Special Problems in Psychoanalysis and Psychotherapy. New York: Brunner/Mazel. Blanck, G., & Blanck, R. (1974). Ego Psychology: Theory and Practice. New York: Columbia University Press. Bowlby, J. (1969). Attachment and Loss, Vol. 1. New York: Basic Books. Bowlby, J. (1973). Attachment and Loss, Vol. 2. New York: Basic Books. Bowlby, J. (1980). Attachment and Loss, Vol. 3. New York: Basic Books. Breger, L. (2000). Freud: Darkness in the Midst of Vision. New York: John Wiley & Sons. Freud, A. (1936). Ego and the Mechanism of Defense. New York: International University Press. Freud, S. (1894). The Neuropsychosis of Defense. Standard Edition, vol. 3:45–68. Freud, S. (1896). Further Remarks on the Neuropsychosis of Defense. Standard Edition, vol. 3:162–185. Gill, M. M. (1954). Psychoanalysis and exploratory psychotherapy. Journal of the American Psychoanalytic Association, 2, 771–797. Greenberg, J.  R., & Mitchell, S.  A. (1983). Object Relations in Psychoanalytic Theory. Cambridge, MA; London: Harvard University Press. Greenwald, A. G., & Banaji, M. R. (1995). Implicit social cognition. Psychological Review, 102, 4–27. Hammond, M. (1985). Children of Alcoholics in Play Therapy. Pompano Beach, FL: Health Communications. Hartmann, H. (1958). Ego Psychology and the Problem with Adaptation. New York: International Universities Press. Kraepelin, E. (1883). Psychiatrie (8th ed.). Leipzig, Germany: J. A. Barth. Mahler, M.  S. (1979). Selected Papers of Margaret S.  Mahler, vols. 1/2. New  York; London: Jason Aronson. Makari, G. (2008). Revolution in Mind:  The Creation of Psychoanalysis. New York: HarperCollins Publishers. Minuchin, S. (1978). Families and Family Therapy. Cambridge, MA: Harvard University Press. Nevid, J. S., Rathus, S. A., & Greene, B. (2013). Abnormal Psychology in a Changing World (9th ed.). Englewood Cliffs, NJ: Pearson Prentice Hall. Robinson, B. (1989). Working with Children of Alcoholics:  The Practitioner’s Handbook. Lexington, MA: Lexington Books. Schneider, A., & Desmond, H. (1994). The psychoanalytic lawsuit:  Expanding opportunities for psychoanalytic training and practice. In R. G. Lane & M. Meisels (Eds.), A History of the Division of Psychoanalysis of the American Psychological Association (pp. 313–335). Hillsdale, NJ: Lawrence Erlbaum Associates.

Defining Psychoanalysis in Psychology Practice Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. doi: 10.1037/a0018378, PMID 20141265 Spezzano, C. (1990). A history of psychoanalytic training for psychologists in the United States. In M. Meisels & E. R. Shapiro (Eds.), Tradition and Innovation in Psychoanalytic Education (pp. 63–75). Mahwah, NJ: Lawrence Erlbaum Associates. Stern, D. N. (1985). The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology. New York: Basic Books, Publishers. Vannicelli, M. (1989). Group Psychotherapy with Adult Children of Alcoholics: Treatment Techniques and Countertransference Considerations. New  York; London:  The Guildford Press. Yalom, I.  D. (1977). The Theory and Practice of Group Psychotherapy (2nd ed.). New York: Basic Books.

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Conceptual and Scientific Foundations RAFAEL ART. JAVIER AND WILLIAM G. HERRON

The previous chapter was an overview of psychoanalysis that describes its historical progress and its definition. In this chapter, the initial section is concerned with the conceptual basis for psychoanalysis. This is intertwined with discussing its scientific basis. The chapter concludes with a discussion of psychoanalytic research methods and the results of this research, which provide evidence of the viability of the specialty. N E W U N D ERS TA N D I N G O F H UM A N D E VELO PM EN T

A major reason for the development and progression of psychoanalysis was the existence of mental disorders that were not responsive to the medical treatments that were prevalent when Freud was beginning his practice of medicine. The prevailing view was that heredity and biology should be able to explain these disorders, but while these could not be discounted as contributors, it became clear that conventional medicine by itself was not a cure. The issues of heredity and biology were front and center in the scientific discourse in Europe when Freud decided to join Charcot’s laboratory in 1885. This discourse was being influenced by the seminal work of Charles Darwin, the leading force in scientific inquiry, which was percolating all throughout Europe during this time, with his publications On the Origin of Species by Means of Natural Selection; or, The Preservation of Favoured Races in the Struggle for Life (1859) and then his Expression of the Emotions in Man and Animals (1872). The study of psychology was

Conceptual and Scientific Foundations

also being influenced by the work of Théodule Ribot, who engaged in the development of the psychologie nouvelle in France with his unwavering emphasis on the need to use methods of natural science to investigate psychological phenomena. Among the phenomena occupying the interest of the scientific community of the time were somnambulism, multiple personalities, double consciousness, demonic possession, fugue states, faith cures, and so on, which were thought to escape the scientific rigor of the natural science due to their unique mental qualities. Ribot favored associational psychology and believed that inner experience could be studied by how perceptions, ideas, and feelings are linked, synthesized, and brought into consciousness (Makari, 2008). He also suggested that psychology would have to include the study of heredity, an idea he put forward in his book Heredity: A Psychological Study of Its Phenomena, Laws, Causes, and Consequences (in English in 1895; in French in 1873). He saw the study of mental disease or “the morbid derangements of the organism” as the optimal experimental laboratory condition that could provide the necessary scientific foundation for studying the complex phenomena of the mind. He then published three important works to further cement his claims; namely, The Diseases of Personality (1891), Diseases of the Will (1894), and Diseases of Memory:  An Essay in the Positive Psychology (1896; in their English translations—published earlier in French in 1885, 1883, and 1882, respectively) (Makari, 2008). These were the historical and scientific movements that Freud found in France in 1885 when he arrived in Paris in search of a better understanding of what caused hysterical symptoms. He was quite eager to insert himself in the cradle of the most important scientific movements of the time going on in France. He came to France already partly dissatisfied with the outcome of his early research in biology, histology, physiology, and cocaine while in Vienna, working in Ernest Wilhelm von Brücke’s lab (resulting in some minor discoveries and a number of publications). But the scientific enterprise that Freud was now entering was more in keeping with the line of questions that was to occupy the rest of his professional life; that is, “investigating associations and dissociations, the role of heredity, and the light that psychopathology might throw on normal mental functioning” (Makari, 2008, p. 20). Charcot was spearheading this effort at the time, and he provided important insights into the role of the unconscious psychic state in psychopathology, particularly in hysteria, dual consciousness, multiple personality, fugue states, and so on, which were to provide the necessary framework and foundation for Freud’s own venture into explaining these psychic phenomena. Totally taken by Charcot’s

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convincing demonstration of how hysterical symptomatology could be removed or induced by hypnosis, Freud embraced Charcot’s theories of hysteria, trauma, and hypnotism, and even his emphasis on the role of heredity in the development of mental conditions (Maraki, 2008). The importance of Charcot’s influence was that he was able to control and recreate the hysterical condition under hypnosis, and demonstrated that these symptoms could be removed or induced through the use of suggestions during hypnosis. Such findings provided an important method for the study of the mind and forced the scientific community to consider a different methodology for the study of mental illness involving the determining power of the mind in causing psychopathology. This was considered a paradigm shift that set the stage for the development of psychoanalysis. The realization that whatever psychological factors that give rise to hysteria must lie outside the range of consciousness provided the foundation of psychoanalysis as the first psychological model that provided an explanation for the emergence of abnormal behavior. It was on that foundation that Sigmund Freud and his followers continued the exploration of these processes, leading to the elucidation of the work of the unconscious and the dynamic formulation of the work of the mind that we referred to in Chapter 1 (Makari, 2008; Nevid, Rathus, & Greene, 2008). Freud and his early followers turned their attention to the intricate workings of the mind and saw less need to consider the role of heredity in explaining psychic phenomena. Thus, understanding how trauma and traumatic events in their patients’ lives could have a determining effect on the production of their symptoms became more important. Freud believed in this context that normal functioning in hysteria could be altered by a pathogenic idea, and he postulated the central role of an inner battle of ideas or mental conflict as the cause of mental illness. He delineated this explanation very clearly in two early publications, On the Neuropsychosis of Defense (1894) and Further Remarks on the Neuropsychosis of Defense (1896), where he described how symptoms can develop from neurosis to phobia, to obsession, and to psychosis, and how these symptoms can be maintained by complicated mental (unconsciously driven) structures that cripple and derail the individual’s capacity to function adequately in the world and maintain a relatively happy and fulfilling life. M OTIVATI O N A N D PSYCH O LO G I C A L C AUSA L IT Y

Understanding what motivates individuals and what mechanisms are involved became another important focus for early psychoanalysts and

Conceptual and Scientific Foundations

has continued for contemporary psychoanalysts (to be discussed later). Freud saw human motivation as having its very foundation in the basic forces that guide the organism as a biological entity, as described by Darwin (1859, 1872), and that are transformed through the individual’s life, reaching the most refined manifestation in the creative process (or what he called sublimation) and the operation of high mental processes. It was an interesting paradox of relying on biology and hereditary to provide the necessary source that explains human motivation while at the same recognizing how that source becomes less relevant as the explanation for conditions such as aesthetic and other sublimatory states. He explained the role of instincts in mental life as follows, in keeping with an evolutionary view: It is his basic tenet that the individual is driven initially by biologically based forces (instincts) to ensure the survival of the organism (primary motivation). These motivational forces are organized around what he called the life and the death instincts, or biological forces, that drive toward the integration or disintegration of the organism. Being able to satisfy one’s basic needs (for food, shelter) and becoming actively involved with the environment in securing their satisfaction (crying when hungry, smiling when satisfied, etc.) become essential components of thriving. Inactivity (or inability of the organism to evolve or respond to the challenges of the environment) can lead to the destruction of the organism. It is in this context that he speaks of the libidinal and death instincts and instinct derivatives as motivational forces and as essential aspects of his description of normal and abnormal behavior, from neurosis, to narcissism, to masochism and sadism, to psychopathic organization, to schizophrenia, and character pathology, and so forth. This biologically based motivational system has been challenged by the contemporary psychoanalytic view, which, influenced by findings from attachment research (Ainsworth, Blehar, Waters, & Wall, 1978; Bowlby, 1940, 1951, 1959, 1969), sees the interaction with the environment as a much more powerful motivational force in both normal and abnormal conditions. CRITI C A L PERI O DS I N H UM A N D E VELO PM EN T

Related to the issue of causality is the issue of understanding and identifying the specific conditions under which a traumatic event could have a deleterious effect on a person’s function. When looking at the role of trauma in the development of pathological formations, it became clear to Freud that trauma or a traumatic moment had most impact on

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an individual’s mental life when it occurred at a particular moment in that person’s development. Here again, we find Freud’s view to be influenced by the findings in biology and ethology that found that the organism is most susceptible to influence at a critical period. The criticalness of the early period was demonstrated later by Lorenz in his 1935 manuscript, Der Kumpan in der Umwelt des Vogels or The companion in the bird’s world (Bretherton, 1995), when he observed “imprinting” in birds. In keeping with that view, Freud refers to the “critical period” as the time when the child is most susceptible to the impact of the environment in all its aspects, including traumatic events, due to its vulnerable and susceptible psychic stage. By traumatic, he refers to a condition that is unexpected and for which the individual is not prepared, producing a kind of a jolt to the system, resulting in a temporary or more lasting disorganization in the individual’s normal functioning. He felt that once trauma occurs, it reverberates throughout the psychic life of the individual, forcing a development of defensive maneuvering in the organism to protect it against future recurrences. As part of this defensive maneuvering, the organism develops ways to remember these events: first through sensory memory (particularly early in development), and then in more complex memories when the individual acquires a more complex capacity for organizing her experiences. These memory organizations or schemes become a reference point for future exchanges with the environment. The issue of the “critical period” in development was more systematically studied and formulated by René Spitz, John Bowlby, and Mary Ainsworth (Goldberg, Muir, & Kerr, 1995), with their work on the importance of secure attachment to the parent for the development of a healthy psychological condition. It is during this critical period when the infant (and its developing brain) must interact with a responsive environment (or the “average respectable environment” of Hartmann [1958]; “the holding environment” of Winnicott [1974]; or “the empathic/mothering environment” of Sullivan [1953]), if the development of the brain and the personality is to proceed satisfactorily. Bowlby formulated the notion that the defenseless infant maintains closeness to its caretaker by means of a system of emotive and behavioral response patterns, or “attachment system.” According to him, this is “an inborn instinctual or motivational system, much like hunger or thirst, that organizes the memory processes of the infant and directs it to seek proximity to and communication with the mother” (Goldberg et  al., 1995; Kandel, 1999, p.  513). Attachment has a tremendous evolutionary importance for the survival of the infant, as the

Conceptual and Scientific Foundations

parental responses serve both to soothe and to help the infant tolerate his negative emotional states by giving him secure protection when upset or when in need of refuge. M E M O RY

A core component of the psychoanalytic exploration involves the recovery of memories assumed to be repressed and not easily accessible to conscious awareness. According to psychoanalytic formulations, a great deal of what we experience (what we perceive, think, dream, and fantasize) or what often motivates our actions, is not easily accessible to our conscious thoughts (Kandel, 1999). Most of the research on human memories during the early years of psychoanalysis was guided by the work of a German scholar, Hermann Ebbinghaus (1885), who decided to apply the experimental methods that had recently been developed for the study of perception, to the study of human memory (Baddeley, 1991; Cohen, 1991). His focus was on investigating in the laboratory the conditions for learning and recalling information (e.g., lists of nonsense syllables), or the process of forgetting, by simplifying a very complicated process into experimentally controlled conditions. Unlike this approach to the study of memory, Sir Frances Galton (1883) was also studying memory at the time, but he was most interested in focusing on the study of memory in the real world. He was particularly interested in emphasizing the rich and complex functioning of memory in the natural context. The complex nature of memory was also being highlighted at the time by one the great minds of the time, William James (1890), although from a more philosophical perspective. Freud was also interested in providing an understanding of the very nature of memory, particularly the psychological factors and mechanisms that make some memories inaccessible to conscious awareness. He discovered with Breuer that at the front and center of the development of psychopathology were repressed memories of traumatic events that threatened the integrity of the individual’s psychological life. These memories are kept out of conscious awareness by the mechanism of repression, which is put in place by the ego for the protection of the individual’s mental life. He was able to distinguish between unconscious material that is repressed and unconscious material that is not repressed but will never become accessible to conscious awareness. This latter condition includes the unconscious, which is concerned with habits and perceptual and motor skills, closer to

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the most primitive organization of our experience. Kandel (1999) refers to this type of unconscious information as the procedural unconscious, which can be considered biological, given that it results from the operation of the somatic nervous system and the autonomic nervous system, which are also present in other animals (Nevid et al., 2013). Current findings in neuroscience have been able to define further this type of memory organization as part of the procedural memory structure that characterizes the organization of most of the information that is acquired early in infancy (Javier, 2007; Kandel, 1999). This explains further why children tend to have difficulty remembering events (even non-traumatic events) that occur early in their development and may be able to remember them only as a sensory memory. There are other types of unconscious (repressed) memories that can become conscious through the links to words and images and by an effort of attention. For Freud, “the power of words” or the development of language provides inaccessible material a link to conscious recollection. So the introduction of the methods of free association and dream interpretation became paramount in getting access to this repressed material, and these were incorporated into the psychoanalytic technique as a clever way to access unconsciously laden and emotionally loaded material. An important contribution of psychoanalysis to the understanding of memory is not only the recognition of different memories that are in various degrees of conscious accessibility, beginning with early memories that are organized at a prelinguistic or sensory level, but also the realization that memories are not only a cognitive organization but also have an affective component. This fact was essential in understanding how conflictual emotional components associated with traumatic events are what make a memory problematic for the individual and likely to become repressed, resulting in the formation of abnormal behavior. Psychoanalysis is interested in the exploration of the internal organization of these experiences, or what is called the inner reality, as the key to symptom relief. This view of repressed memory has been challenged and expanded (guided by more recent research findings) by contemporary psychoanalytic theories to refer to formulated and non-formulated experiences or contents of experience that, although not accessible, are not necessarily “repressed” in the dynamic sense referred to by Freud (Eagle, 2011). From this perspective, there are out-of-awareness memories and processes that do not ever need to become conscious in order to have a positive impact on the person’s overall functioning.

Conceptual and Scientific Foundations T H E M E A N I N G A N D RO L E O F A N XI E T Y I N PSYCH O PAT H O LO GY

In the early months of 1900, a number of scientists began to focus on elucidating empirically the essential features of how learning is acquired. Pavlov (1849–1936) was able to illustrate how fear or adverse conditioning affected behavior, producing defensive conditioning that is generalized to other situations or conditions not directly related to the original situation (unconditioned situation), but that signal the approach of the noxious conditions (Nevid et al., 2013). This is what is referred to as a signal or anticipatory anxiety, which, according to Pavlov, is biologically adaptive and allows the individual to respond to danger before the real danger is present (Kandel, 1999). Freud was also interested in this phenomenon as it relates to the relationship between the experience of anxiety and the development of defensive or protective reactions. So the issue here was not only what causes anxiety but what role anxiety plays in the overall functioning of the individual, the effect that the feeling of anxiety has on the individual, and finally, the coping or defense mechanism that may be available to the individual to handle the feeling of discomfort normally associated with the experience of anxiety. In his 1926 publication On Inhibitions, Symptoms, and Anxiety, Freud described different types of anxieties:  One where there is a clearly identified condition causing the anxiety reaction (actual anxiety); and the other, a condition whose origin is more obscured (neurotic anxiety). The presence of a condition experienced by the individual as “dangerous” and the subsequent defensive reaction is seen as paralleling similar conditions caused by the “traumatic moments” that Freud described beginning in 1894. According to this model of psychopathology, when faced with a threatening condition (traumatic moment), the individual first attempts to protect the self by an act of forgetting or trying to trick the mind into believing that the event did not occur. This does not work when the threatening condition is traumatic (or is a condition of sufficient importance for the individual to trigger intense anxiety). If not successfully addressed and resolved, the traumatic condition will be transformed into symptoms. These symptoms serve as continuing reminders (albeit unconscious) of the traumatic conditions. Once the individual is able to work through the source(s) of the symptoms, these are expected to disappear. The method through which this work is done is free association in the therapeutic context, where the individual is given the opportunity to gain awareness and insight as to the content responsible for producing the anxiety. This work involves the progressive acquisition of what Sanders, Sterns, and others refer to as moments of meaning about the person’s condition that eventually produce behavioral changes (Kandel, 1999).

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Finally, Freud’s investigation on the effect of traumatic events revealed another important complexity in understanding the trajectory of trauma. The effect of trauma is not necessarily instantaneous, and often a period of time elapses before any evidence of trauma is observed. This is referred to as a “delayed reaction,” which we see often in police officers, soldiers, and other individuals exposed to life-threatening conditions, where their post-traumatic stress disorder (PTSD) may appear at a later point and in response to a seemingly neutral cue from their environment. Part of the reason is that the meaning of the trauma does not always emerge in a linear fashion, but rather follows a very complex trajectory that does not solely depend on the severity of the condition, the individual’s personality characteristics, developmental factors, environmental characteristics, resiliency, and so forth. In the case of children, the meaning and effect of the trauma depend on the developmental period when the traumatic event takes place. When the trauma occurs too early in life, its meaning tends to become clearer later in life (retroactively) when the organism has developed sufficient capacity (neurological maturity) for memory formation and linguistic organization that provide the necessary links for conscious awareness. SE XUA L IT Y

The role of sexuality in the development of normal and abnormal conditions is a cornerstone of psychoanalysis, because it is in relation to sex and conflict around sexual desire that major psychopathology emerges. Freud anchored his view within the scientific questions of the time by clarifying that he recognized the importance of heredity and genetics in the biology of gender and gender orientation, but that his concern was to elucidate the conditions that result in a pathological development of sexual behavior, or sexual aberrations. His concept of sadism and masochism in relationship to sexual activities was clearly influenced by the work of Krafft-Ebing and the work of Havelock Ellis, who in 1901 published an important article entitled “The Development of Sexual Instinct” (Freud, 1905). He learned from biology that the distinction between genders is not that clear initially, as early embryonic development of the gonads is the same for both genders. A single gene determines the male phenotype, and that gene is responsible for initiating the development of early gonads into testis, which are responsible for the production of testosterone, or into ovaries responsible for the production of estrogen. These hormones are ultimately responsible for all the phenotypical sexual characteristics in males and females (Kandel, 1999). From this, he postulated that both genders are inherently bisexual, as “in

Conceptual and Scientific Foundations

every normal male or female individual, traces are found of the apparatus of the opposite sex” (Freud, 1905, p.  141). He was interested in elucidating the nature and conditions that lead to sexual inversions, described by his contemporaries Lydston (1889), Kiernan (1888), Chevalier (1893), and Havelock Ellis (1915) (as cited by Freud, 1905), and the conditions that result from the directions taken by the libido. Following the view of biology, he saw drives as what moves the organism forward and provides the necessary energy to act and respond to the environment. An innate drive becomes transformed through its interaction with the “object” and the ultimate “aim” of the sexual activity. In fact, according to Freud, the most primitive drive (libido) becomes transformed into the “sexual drive” once the organism is able to identify the “object” and the “aim” of the sexual attraction. In his investigation as to how this drive operates, he was able to identify early manifestations of sexual drive in childhood related to feeling pleasure resulting from the satisfaction of basic biological needs. In this context, he delineated the vicissitudes of the sexual libido through the developmental history of the individual (psychosexual stages), where the highest biological level is reached when the individual is able to procreate and so continue the preservation of the species. So any conditions that disturb this natural trajectory are considered sexual deviations or aberrations and perversions (e.g., fetishism, voyeurism, and exhibitionism, etc.) of the natural process, which only become pathological if they become exclusive, but not if they are at the service of the ultimate aim of heterosexual copulation. He saw this sexual drive as being involved as well in creativity and high cognitive processes through a process he called “sublimation.” The most fundamental psychoanalytic contribution in understanding sexual desires is the recognition that psychoanalysis is concerned with all sexual preferences, particularly the ways sexual activities are processed in the mind. In this context, Freud elucidated how a homosexual activity may fulfill all the necessary requirements for a heterosexual relationship in the mind and vice-versa. He also emphasized that sexual interests only become problematic when the overall capacity to function normally in the world is affected, as is the case with the development of serious mental disorders.

Scientific Foundations of Contemporary Views of Psychoanalysis Following this early period of tremendous advances in our understanding of the nature and work of the mind, the origin of thinking and perception,

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the nature of memory and the mechanism involved in forgetting, and so forth, psychoanalysis entered a period mostly guided by its practical application. The primary concern was then with developing treatment conditions where it was more likely that more creative and unconscious processes could emerge. The result was a more intuitive and less structured approach in psychoanalytic practice which was considered to provide the best conditions for the work of unconscious motivations to become apparent in the course of the treatment. This new approach was considered the best condition for studying complex phenomena of the mind. This basic approach to the study and exploration of the interior characterized the work of early and future psychoanalysts. However, validation was limited to individual case studies, or anecdotal evidence, rather than by becoming part of major research studies and collaborating with other disciplines. The consequence was that the practice of psychoanalysis and the psychoanalytic data which emerged from this approach focused more on a single-subject design, with an assumption of generalizability and replicability. Training of future psychoanalysts became the responsibility of private institutes, with only a few being housed at academic institutions. Helen Block Lewis (1990) saw this isolation from the scientific community by the psychoanalytic community as problematic for the future of psychoanalysis as a scientific enterprise. Nevertheless, a number of important developments occurred through “specialty groups” whose emphasis was on the investigation of the process of psychotherapy, the identification of the specific components involved in changes in the clinical picture of the patients, the identification of the aspects of the transference that are most conducive to change, the identification of the types of symptomatology that are more conducive to psychoanalytic treatment, and the duration of the effect. Among these groups we find the Hampstead Child Therapy Clinic, the Boston Change Process Study Group, and the San Francisco Psychotherapy Research Group. One of the concerns of these groups was how to find a methodology that allows for standardized observation and recording of clinical data in ways that respect the complexity and richness of the material. The emphasis on studying the process of psychotherapy, the nature of the transference, the quality of the therapist, and the way that changes take place in the context of the interpersonal relationship between the patient and therapist was guided by important findings coming from attachment research, neuroscience, and cognitive psychology. One of the earliest organizations that sought to provide free psychoanalytic treatment and promote research was the Tavistock Clinic, which was

Conceptual and Scientific Foundations

founded in 1920 by Dr. Hugh Crichton Miller. Bowlby was one of the scholars involved in this project, and he became interested in studying the individual in the natural environment, as Konrad Lorenz demonstrated in geese and precocial birds using ethological methods. James Robertson, who was trained by Anna Freud in naturalistic child observation, joined Bowlby in his work, providing him with experience in the application of naturalistic observational methodology that was to guide all the research on attachment (Bretherton, 1995). This methodology provided a great deal of information about the conditions necessary to develop a healthy and thriving child. Bowlby, for instance, was able to observe that the formation of a social bond does not need to be tied to feeding. While he recognized the importance of instincts and biologically based motivations (e.g., sucking, clinging, following, crying, smiling, etc.) that guide the relationship between the child and the mother, he viewed these as bonding opportunities (Bretherton, 1995). According to Bowlby, it is these aspects of the early experience that are intimately involved in the development of attachment in the infant. The methodology employed by Bowlby, Robertson and later by Ainsworth revolutionized research on infant development in years to come (Holmes, 1995). It was a solid methodology with a great many controlled conditions, and with a very clearly delineated standard for data collection and data analysis. Ainsworth had already observed in the laboratory children’s reaction to a strange situation, demonstrating that the child’s behavior in a strange situation was a good reflection of what the child experienced at home during the first year (Ainsworth & Bell, 1970). She felt that such a reaction serves as a marker for future responses to the environment. In her Ganda Project (1963, as cited by Bretherton, 1995) she took her research questions to the next level and found attachment quality to be significantly correlated with maternal sensitivity. Three different attachment patterns were identified from the observation of mothers’ involvement with their children. The fundamental points derived from the attachment observations are as follows (Holmes, 1995): 1. That there is a primary attachment bond between mother and child. 2. That this bond is there from birth and does not depend on an “oral drive,” as affirmed by Freud, or reward by feeding, as affirmed by the conditioning paradigm. 3. This has a fundamental evolutionary function—protection from predation.

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4. The attachment assumes a harmonious mother–child interaction, which only becomes disturbed by external difficulty, not by internal conflict, which is a deficiency model. 5. The role of sex in the child’s life is downplayed, with pleasure related to proximity to the object, play, and nurturance rather than orgasmic discharge. 6. The key issue in infantile experience is space—that is, the concern of “who I am in relation to my loved one.” 7. The unconscious is seen as containing a representation of the interpersonal world rather than as a “cauldron of fantasy.” 8. Attachment theory sees the infant and parent as psychologically separate and interacting from birth. 9. It sees abnormality in the context of normal development and postulates nurturance as fundamental for sanity to occur. It considers psychological disturbances as responses to loss and environmental failure. These findings provided scientific support to a number of important theoretical developments, particularly the fundamental tenets of the object-relations and interpersonal and relational theories that were being developed at the time. Winnicott coined the term “holding environment” and saw “the capacity to be alone” as directly emerging from a successful attachment experience. Sullivan used the concept of “empathic linkage” to refer to the special connection that exists between a mother and child so as to secure timely responses to the child’s basic needs. Stern’s research (Stern is a member of the Boston Change Process Study Group) provided additional support to the importance of the mother– child relationship (1985). He refers to the mother’s affective attunement as the mother’s capacity to zoom in and modulate minute-by-minute the child’s moods, stimulating when activities drop, or calming when the child becomes too excited. Another important contribution by Stern (1989, 1998, and 2003) is the elucidation of the nature of experience and how it becomes organized in the mind. In this context, he makes the distinction between formulated and unformulated experiences that are part of the human’s interaction with her environment. “Unformulated” refers to experiences that are still in a state of fluidity and not clearly defined (through language), although the person may be aware of its presence as a sensory experience. The formulated experiences are unformulated experiences that are

Conceptual and Scientific Foundations

changed through the involvement of language. The presence of anxiety and fear (rejection, criticism, etc.) interferes with the process by which an unformulated content is allowed to become formulated. If registered as a critical or threatening condition, it is more likely that the unformulated content will remain such. This description of formulate and unformulated experience makes the content of the unconscious to be a cognitive process where the work of psychoanalysis is more “a matter of constructing than uncovering or discovering preexisting meaning . . . there is nothing to be uncovered or discovered, only something . . . to be completed and coconstructed in interaction with another” (Eagle, 2011, p. 114). According to Eagle, such a description of the nature of experience gives support to the major tenets of the relational and interpersonal approaches to psychoanalysis. The failure to formulate that which is not yet formulated (unformulated) is seen as the primary defense against the experience of anxiety. Thus, using an “attempt to forget” to push a conflictual content out of consciousness (Freud, 1894) may mean that it remains an unformulated experience in the mind, so the content is unattended to by the “selective inattention” of Sullivan (1953) (or the mechanism by which an individual keeps his conscious attention away from contents of experience that are considered emotionally problematic). This attempt to forget may also be seen as a preventive maneuver by the self-system (or the internal structure responsible for guiding and protecting the individual from internal and external threat) to prevent certain mental content from reaching consciousness because of its threatening nature. Research coming from the Boston Process of Change Study Group (1998) has been particularly interested in looking at how changes occur in the therapeutic process. This group was created in 1995, and its members include infant-researchers, developmentalists, and practicing analysts such as Sander, Sterns, Lyons-Ruth, Bruschweiler-Stern, Nahum, and Morgan. As mentioned earlier, this group identified what they called moments of meaning, or moments in the interaction between patient and therapist that reflect changes in the patient’s behavior. According to this group, many of the changes that occur in therapy and that advance the therapeutic process are not within the conscious awareness of the patient, but are organized at unconscious “procedural” (nonverbal) levels or as implicit knowledge and behavior that permit the patient to progress to the next level. This process develops in the context of the therapeutic interaction in transference and is guided by the careful intervention of the therapist. As Kandel summarizes the findings, “This progression does not depend on conscious insights; it does not require . . . the unconscious

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becoming conscious. Rather, moments of meaning are thought to lead to changes in behavior that increase the patient’s range of procedural strategies for being and doing . . . including in ways that contribute to transference” (1999, p. 509). The San Francisco Psychotherapy Research Group, cofounded by Weiss and Sampson in 1972 with the specific goal of studying the psychoanalytic process, also found that the nature and quality of the therapeutic environment was important to encourage change in the patient and that patients unconsciously monitor their therapists’ attitudes toward their conflictual beliefs for signs of approval or disapproval. They found, for instance, that patients often made significant progress without any preceding interpretation by the analyst, but that the most important component is the feeling that the therapy context makes one feel safe and encourages personal exploration without restriction (Weiss, Sampson, & Mount Zion Psychotherapy Research Group, 1986; Weiss, Sampson, & O’Connor, 1995). The tremendous importance of the early mother–child interaction systematically highlighted by the various findings of attachment research, as well as research emerging from animal experiments (e.g., Harlow and associates’ research on the effects of maternal deprivation in infant monkeys [1965]) and Spitz’s observation of anaclitic depression in orphaned and neglected children (1946) forced a new look at the role of the environment and the quality of the early experience in the development of psychopathology. Contemporary psychoanalytic theories include these scientific findings to support the extent to which one’s mind is socially constructed, where the nature of the mind fluctuates depending on the nature and quality of the individual’s interpersonal interactions. There is a reduced emphasis on the importance of the recovery of repressed memories, and an increase in looking at the contents of unconscious processes as composed of the self, self-representation, object, and interactional representations (as well as beliefs, expectations, and affects associated with these experiences) that developed in early interactions with parental figures (Eagle, 2011). The object-relations theorists, particularly represented by Fairbairn and Winnicott, also placed a great deal of emphasis on the importance of the early environment and the quality of the mother’s attentiveness as crucial in the development of good mental health. It is in this context that Fairbairn refers to internalized objects and internalized object relations. This is what Sullivan refers to as the interpersonal field, with his view that “there is no such a thing as an individual personality,

Conceptual and Scientific Foundations

only an interactional field” (Eagle, 2011, p. 140). For Mitchell, the basic unit of study is also the “interactional field,” and the individual is only of concern in that context, not as a separate entity (1988). He sees the mind as fluid and a socially constructed product of ever-shifting social interactions. The contemporary unconscious is cognitive, rational, and reality-oriented as unconscious representations that truly reflect actual events. Finally, the intersubjective perspective also sees the importance of the early environment, and sees psychoanalysis as a science concerned with exploring the interplay between the “differently organized subjective worlds of the observer and the observed” (Atwood & Stolorow, 1984, p. 41). This concept of “the mind” is of an “intersubjective system” that incorporates principles and rules of behavior learned in the context of a relational field and in the context of the early interactions with caregivers, determining what contents or regions the individual will be capable of experiencing, or will be encouraged to exclude from conscious experience by a critical and unsupported environment (Eagle, 2011).

Evidence of the Therapeutic Effect of Psychoanalytic Treatment We focused in the previous sections on the description of the scientific foundations that influenced and provided support for the development of key concepts in the psychoanalytic theories, from the early years of psychoanalytic development to contemporary perspectives. Now we will address the issue of evidence for the effectiveness of psychoanalytic treatment. There is research evidence that psychoanalytic formulations and treatments have the most effect on individuals who are interested in seeking a more profound understanding of their conditions and are able to postpone immediate relief of their symptoms. This is particularly important because the emphasis of the specialty is on gaining understanding and helping the individual (through his awareness of the source of the underlining conflict) become more actively involved in finding solutions to his personal dilemma. It has been found to be very effective in treating the following conditions: • Individuals with non-psychotic character disorders • Individuals with major deficits in working effectively or maintaining satisfactory relationships

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• Individuals suffering from phobia, conversions, compulsions, obsessions, sexual dysfunctions, and a wide variety of character problems (i.e., hyperemotionality, workaholism) • Individuals suffering with a variety of anxiety disorders, depressive symptomatology (Abbas, Hancock, Henderson, & Kisely, 2006; Kandel, 1999) Shedler (2010) also discussed the work of Abbas, Kisely, and Kroenske (2009), who found psychodynamic psychotherapy to be effective in treating patients with a variety of somatic conditions (e.g., dermatological, neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal, genitourinary, and immunological). Psychodynamic psychotherapy has also been found to be effective in treating personality disorders and borderline personality disorders (Leichsenring & Rabung, 2008, as cited by Shedler, 2010). It was found to be effective in helping adolescents with an uncontrolled diabetic condition to significantly improve their medical condition, compared with a comparison group (Moran, Fonagy, Kurtz, Bolton, & Brook, 1991). Finally, it has been found that the effect of psychoanalytic intervention tends to hold better over time than other interventions, producing changes in underlying psychological mechanisms (or intrapsychic processes) (Muratori, Picchi, Bruni, Patarnello & Romagnoli, 2003; Shedler, 2010).

The Future of Psychoanalytic Research It is clear that we need to continue to investigate all aspects of psychoanalytic processes and their outcomes regarding the nature and extent of change in targeted conditions. Researchers involved with the Boston Change Process Study Group and the San Francisco Psychotherapy Research Group (previously “the Mount Zion Psychotherapy Research Group”) have already provided important understanding of change processes, but there is a need for systematic exploration in terms of the therapeutic process itself and in terms of how change occurs and to what extent, and what psychological conditions are more amenable to psychoanalytic treatment. Wallerstein (2005) provides a useful overview, primarily of outcome research, but inclusive of process issues as well. He makes a distinction between supportive and expressive psychoanalytic therapies, as well as the issue of outcome (namely, therapeutic effect and process) and how do changes occur. According to his review, outcome study remains the

Conceptual and Scientific Foundations

clinicians’ favorite because it is a very practical and tangible concern with major implications for insurance coverage for the conditions under consideration. Additionally, expressive therapy was found to be more fascinating than supportive therapy, where there is less emphasis on exploration, because the former appears to be more “psychoanalytic.” This notwithstanding, it is clear that we should be involved in developing more refined improvement criteria and the elaboration of their conceptual foundations (such as etiology, symptoms, change processes, and sustainability) for both of these types of psychotherapies. Wallerstein also describes a number of studies in which attempts were made to overcome the previous methodological limitations. A significant finding was the predictive value of the “patient–therapist match;” namely, the greater the degree of compatibility, the more likely the therapy would result in improvement. However, other predictor variables did not tend to correlate highly with successful outcomes, nor were assessments at termination particularly valuable in predicting subsequent follow-up status. This points to the limits of expected predictors and the need for greater knowledge of what in the therapeutic process is primarily responsible for therapeutic effects. It also suggests that the value of predictors varies, depending on when the predictions are made. Addressing these concerns in future psychoanalytic investigations will go a long way toward shedding some important light on our understanding of the change processes in psychoanalytic treatment. Additionally, we need to look more carefully at the expectations for different approaches to therapy (supportive vs. expressive), as well as process variables (such as patient type) that are likely to be involved; in many investigations, the therapeutic value of support appears to be underestimated. The idea that attempting to bring about structural change is more likely to lead to greater improvement is not necessarily valid. In fact, changes associated with support often appear to be similar to changes associated primarily with insight. Thus, it is clear that there are numerous intervening variables and process factors that require consideration in estimating the likelihood of improvement based on particular techniques. We are now experiencing a large increase in research on the process by which change takes place. Improvements in technology are making this possible and allow for combining sophisticated process and outcome measures. Accuracy in describing what psychoanalytic work can accomplish as well as in predicting what it will do requires integration of descriptive representations of patients’ problems, treatment procedures, and outcome assessments, including follow-up studies in a variety of settings.

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Another development has been the so-called offset studies, which illustrate the value of mental health treatment in decreasing the need for, and in turn the cost of, other medical services, like Moran and colleagues’ (1991) study with adolescents with diabetes. Also, outcome measures have been significantly improved in order to evaluate changes in personality structure. These measures are in various stages of establishing validity and reliability, and they appear promising (Wallerstein, 2005). Recently, Levy and Ablon (2009) compiled a significant number of studies that support the value of psychoanalytic psychotherapy. The limitation is that most of the evidence is for short-term treatment, although the existing evidence indicates that the effects of long-term work can be considered similar to the therapeutic effects of other therapies (Fonagy, Roth, & Higgit, 2005). A major point that is made in terms of both the outcome and the process research is the need for pluralism, or customizing interventions to fit different patients. The research evidence base both provides an imperative to make use of pluralism as well as indicates the paths to follow in creating successful matches (Jimenez, 2007). Siefert, Defife, and Baity (2009) provide a useful summary of ten process measures that can be used to understand the effects of psychodynamic therapy. They note that empirical research is unlikely to be able to cover the totality of what happens in psychoanalytic therapies. However, this is not an acceptable reason to dismiss existing evidence or shirk the need for further studies. This work needs to be understood and enhanced by clinicians because the refinements in both process and outcome research make it possible to build a useful and credible foundation of empirical research for psychoanalysis that has been lacking. That limitation has become increasingly costly, both in practical and prominence terms, to the practice of psychoanalysis and its ability to maintain or increase interest in the specialty. Furthermore, the possible aims of psychoanalysis remain more extensive than those of other forms of treatment focusing on symptom reduction. It is now possible to learn from, and use in practice, process measures that involve specific psychodynamic constructs, as the Analytic Process Scale (Waldron, Scharf, Hurst, Firestein, & Burton, 2004) and the Countertransference Questionnaire (Betan, Heim, Conklin, & Westin, 2005). The same assets are available for outcome measures (Blatt & Auerbach, 2003; Leichsenring, 2005). In summary, future investigations of psychoanalytic treatment should answer the questions of what kind of changes occur in specific patients treated with specific techniques, and in turn, to what degree can

Conceptual and Scientific Foundations

psychoanalytic therapies result in changes in personality structure that go beyond those claimed by other therapies. The last issue is a key one for psychoanalysis, because for patients to be motivated to use the treatment, and for people to want to learn to practice it, psychoanalysis needs to reestablish its value. It can sound just fine, and even feel that way to a number of practitioners and their patients, but to regain its prominence, or (in the opinion of a number of people) to survive as a viable therapy, it is going to have to become evidence-based in regard to being able to fulfill its ambitions.

References Abbas, A. A., Hancock, J. T., Henderson, J., & Kisely, S. (2006). Short-term psychodynamic psychotherapies for common mental disorders. The Cochrane Database of Systematic Reviews, Issue 4, Art. No. CD 004687. Abbas, A. A., Kisely, S., & Kroenske, K. (2009). Short-term psychodynamic psychotherapy for somatic disorders:  Systematic review and meta-analysis of clinical trials. Psychotherapy and Psychosomatics, 78, 265–274. Ainsworth, M. D., & Bell, S. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41, 49–67. Ainsworth, M.  D., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of Attachment. Hillsdale, NJ: Lawrence Erlbaum Associates. Atwood, G.  E., & Stolorow, R.  D. (1984). Structures of Subjectivity:  Explorations in Psychoanalytic Phenomenology. Hillsdale, NJ: Analytic Press. Baddeley, A. (1991). Human Memory:  Theory and Practice. Hove; London:  Lawrence Erlbaum Associates. Betan, E., Heim, A.  K., Conklin, C.  Z., & Westin, D. (2005). Countertransference phenomenon and personality in clinical practice. An empirical investigation. American Journal of Psychiatry, 162, 980–898. Blatt, S.  J., & Auerbach, J.  S. (2003). Psychodynamic measures of therapeutic change. Psychoanalytic Inquiry, 23, 268–397. Boston Process of Change Group (1998). Interventions that effect change in psychotherapy: A model based on infant research. Infant Mental Health Journal, 19, 277–353. Bowlby, J. (1940). The influence of early environment in the development of neurosis and neurotic character. International Journal of Psycho-Analysis, 21, 1–25. Bowlby, J. (1951). Maternal care and mental health. World Health Organization Monograph (serial no. 2), 3:355–534. Bowlby, J. (1959). Separation anxiety. International Journal of Psycho-Analysis, 41, 1–25. Bowlby, J. (1969). Attachment and Loss, Vol 1. New York: Basic Books. Bretherton, I. (1995). The origins of attachment theory—John Bowlby and Mary Ainsworth. In S. Goldberg, R. Muir, & J. Kerr (Eds.), Attachment Theory: Social, Developmental and Clinical Perspectives (pp. 45–84). Hillsdale, NJ: Academic Press. Cohen, G. (1991). Memory in the Real World. Hove; London: Lawrence Erlbaum Associates, Publishers.

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Introduction to Psychoanalysis Darwin, C. (1859). On the Origin of Species by Means of Natural Selection; or, The Preservation of Favoured Races in the Struggle for Life. London: John Murray. Darwin, C. (1872). The Expression of the Emotions in Man and Animals. London:  John Murray. Ebbinghaus, H.  E. (1885). Memory:  A  Contribution to Experimental Psychology. (Republished 1964). New York: Dover. Eagle, M.  N. (2011). From Clinical to Contemporary Psychoanalysis:  A  Critique and Integration. Psychological Issues Book Series, Vol. 70. New York: Routledge. Fonagy, P., Roth, A., & Higgit, A. (2005). Psychodynamic psychotherapies: Evidenced-based practice and clinical wisdom. Bulletin of the Menninger Clinic, 69, 1–58. Freud, S. (1894). The Neuropsychosis of Defense. Standard Edition (S.E.) 3:45–68. Freud, S. (1896). Further Remarks on the Neuropsychosis of Defense. S.E. 3:162–185. Freud, S. (1905). Three Essays on the Theory of Sexuality. S.E. 7:130–254. Freud, S. (1926). Inhibitions, Symptoms and Anxiety. S.E. 20:77–175. Galton, F. (1883). Inquiries into Human Faculty and Its Development. London: McMillan. Goldberg, S., Muir, R., & Kerr, J. (Eds.) (1995). Attachment Theory: Social, Developmental and Clinical Perspectives. Hillsdale, NJ: Academic Press. Harlow, H. F., Dodsworth, R. O., & Harlow, M. K. (1965). Total social isolation in monkeys. Proceedings of the National Academy of Sciences, 54, 90–97. Hartmann, H. (1958). Ego Psychology and the Problem with Adaptation. New York: International Universities Press. Holmes, J. (1995). “Something there is that doesn’t love a wall”: John Bowlby, attachment theory and psychoanalysis. In S. Goldberg, R. Muir, & J. Kerr (Eds.), Attachment Theory:  Social, Developmental and Clinical Perspectives (pp. 19–43). Hillsdale, NJ: Academic Press. James, W. (1890). The Principles of Psychology. New York: Holt. Javier, R. A. (2007). The Bilingual Mind: Thinking, Speaking and Feeling in Two Languages. New York: Springer. Jimenez, J.  P. (2007). Can research influence clinical practice? International Journal of Psychoanalysis, 88, 661–679. Kandel, E.  R. (1999). Biology and the future of psychoanalysis:  A  new intellectual framework for psychiatry revisited. American Journal of Psychiatry, 156, 505–524. Leichsenring, F. (2009). Psychodynamic psychotherapy:  A  review of efficacy and effectiveness studies. In. R. A. Levy & J. S. Ablon (Eds.), Handbook of Evidence-Based Psychodynamic Psychotherapy (pp. 3–27). New York: Human Press. Levy, R.  A., & Ablon, J.  S. (Eds.) (2009). Handbook of Evidence-Based Psychodynamic Psychotherapy. New York: Human Press. Lewis, H.  B. (1990). Some thoughts on becoming a psychoanalyst:  Anno 1985. In M. Meisels & E. R.  Shapiro (Eds.), Tradition and Innovation in Psychoanalytic Education (pp. 19–27). Hillsdale, NJ: Lawrence Erlbaum Associates. Makari, G. (2008). Revolution in the Mind:  The Creation of Psychoanalysis. New York: Harper Collins Publishers. Mitchell, S. A. (1988). Relational Concepts in Psychoanalysis. Cambridge, MA: Harvard University Press. Moran, G., Fonagy, P., Kurtz, A., Bolton, A., & Brook, C. (1991). A controlled study of the psychoanalytic treatment of brittle diabetes. Journal of the American Academy of Child & Adolescent Psychiatry, 30, 926–935.

Conceptual and Scientific Foundations Muratori, F., Picchi, I., Bruni, G., Patarnello, M., & Romagnoli, G. (2003). A two-year follow up of psychodynamic psychotherapy for internalizing disorders in children. Journal of the American Academic of Child & Adolescent Psychiatry, 42, 331–339. Nevid, J. S., Rathus, S. A., & Greene, B. (2013). Abnormal Psychology in a Changing World (9th ed.). Englewood Cliffs, NJ: Pearson Prentice Hall. Pavlov, I. (1927). Conditioned Reflexes: An Investigation of the Physiological Activity of the Cerebral Cortex. London: Oxford University Press. Ribot, T. (1891). The Diseases of Personality. Chicago: The O pen Court Publishing. Ribot, T.(1894). Diseases of the Will. Chicago: The Open Court Publishing Company. Ribot, T. (1895). Heredity:  A  Psychological Study of Its Phenomena, Laws, Causes, and Consequences. New York: D. Appleton-Century Company. Ribot, T. (1896). Diseases of Memory:  An Essay in the Positive Psychology. New  York:  D. Appleton-Century Company. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. doi: 10.1037/a0018378, PMID 20141265 Spitz, R. A. (1946). Analytic depression. In A. Freud et al. (Eds.), The Psychoanalytic Study of the Child, vol. 2 (pp. 313–342). New York: International University Press. Stern, D. N. (1985). The Interpersonal World of the Infant. New York: Basic Books. Stern, D. N. (1989). The analyst’s unformulated experience of the patient. Contemporary Psychoanalysis, 25(1), 1–33. Stern, D. N. (1998). The process of therapeutic change involving implicit knowledge: Some implications for developmental observations for adult psychotherapy. Infant Mental Health Journal, 19(3), 300–308. Stern, D.  N. (2003). Unformulated Experience:  From Dissociation to Imagination in Psychoanalysis. Hillsdale, NJ: The Analytic Press. Siefert, C.  J., Defife, J.  A., & Baity, M.  R. (2009). Process measures for psychodynamic psychotherapy. In. R. A.  Levy & J. S.  Ablon (Eds.), Handbook of Evidence-Based Psychodynamic Psychotherapy (pp. 157–178). New York: Human Press. Sullivan, H. S. (1953). The Interpersonal Theory of Psychiatry. New York: W.W. Norton & Company. Waldron, R. S., Scharf, R., Hurst, D., Firestein, S. K., & Burton, A. (2004). What happens in psychoanalysis: A view through the lens of Analytic Process Scale (APS). International Journal of Psychoanalysis, 85, 443–466. Wallerstein, R.  S. (2005). Outcome research. In E. S.  Person, A. M.  Cooper, & G. O.  Gabbard (Eds.), Textbook of Psychoanalysis (pp. 301–315). Arlington, VA: American Psychiatric Publishing. Weiss, J., Sampson, H., & O’Connor, L. E. (Spring, 1995). How psychotherapy works: The research findings of the San Francisco Psychotherapy Research Group. Bulletin of the Psychoanalytic Society, 4, 1–5. Retrieved Aug. 19, 2012, from http://www.behavior.net/​ orgs/sfprg/research.html. Weiss, J., Sampson, H., & Mount Zion Psychotherapy Research Group (1986). The Psychoanalytic Process:  Theory, Clinical Observation, and Empirical Research. New York: Guilford Press. Winnicott, D.  W. (1974). The Maturational Processes and the Facilitating Environment. New York: International University Press.

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SECT IO N II

Functional Competency—Assessment

TH REE

Assessment Strategies RAFAEL ART. JAVIER

Now that we have provided a brief description of the history of psychoanalysis, its theoretical and scientific foundations, and the core issues of interest to psychoanalytic work, we explore who can benefit from such an endeavor, to what extent, under what conditions, for what kinds of difficulties—and most important, how the therapist makes such a determination. As noted by various prominent psychoanalysts, answers to these questions can only be found through a serious assessment process prior to a determination about treatment (Akhtar, 2009; Sullivan, 1970). In principle, psychoanalytic formulations and treatment should be applicable to a variety of situations and individuals, including the poor and disenfranchised. This is the case because the unconscious operates in everyone (Brenner, 1987). So the answer to the question of how applicable and useful psychoanalytic intervention will be is one of the most challenging aspects of the psychoanalytic work, because it requires a serious consideration and examination of the personal psychology of the one making the assessment, her personal history and biases, and the extent of her meaningful exposure to the experience of individuals whose intrapsychic content may have developed in different cultural, linguistic, ecological, socio-political, and socioeconomic contexts (Javier & Herron, 2002). The serious examination of the extent of disparity in personal experience between the psychoanalyst and the potential patient is particularly relevant because a determination of appropriateness for treatment could be strongly influenced by negative countertransference about the patient, triggered for the

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most part by unfamiliarity with the potential patient’s background and circumstances. These are the conditions that have been found to result in what Tuch referred to as “emphatic failure” on part of the therapist (1997), and that negatively affects patients’ compliance with treatment (Mehra, 2013; Sharf, Primavera, & Diener, 2010). In fact, in a most recent study, empathy (empathic concern) was found to be the single most important factor predicting patient compliance with treatment (Mehra, 2013).

Critical Challenges in the Assessment Process We recognize that, although psychoanalytic formulations may be able to provide rich explanations for most psychological difficulties, the fact is that not everyone is attracted to such treatment and ready, able, or willing to engage initially in psychoanalysis with the kind of dedication (of time and money) to personal exploration that such a treatment requires; hence the need to make a proper assessment to determine what would be helpful to a patient at a particular time without prejudice that the patient may be getting inferior treatment if, say, a brief and targeted approach is determined to be most appropriate. Individuals come to our offices with different degrees of awareness and psychological sophistication about their reason(s) for seeking treatment; some even acknowledging that they are there only because their employers have threatened to terminate their employment, or their spouses may have given them an ultimatum, and so on. Moreover, some patients also come to our office with assumptions as to how the process should work and expecting a quick solution to their difficulties, much as when they go for a medical consultation or treatment. Additional assumptions may be in operation when we are dealing with members of disfranchised groups who, by virtue of their cultural, socioeconomic, socio-political, and linguistic experience, may be expecting and requiring different types of initial interventions that are meaningful to them and that reflect to them a true understanding by the therapist of their personal dilemma. This job is particularly challenging because we are not only dealing with manifest content and material easily available to conscious recollection, but also and most particularly with unconscious material associated with the reason(s) why the individual may be seeking treatment at this time. As delineated in the previous chapters, psychoanalysis emerges from the discovery that symptoms come from unresolved unconscious conflicts whose origin is usually found during early childhood; depending on the severity of these unresolved conflicts, they tend to create a great deal of

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psychological discomfort (anxiety, panic, irritability, inability to sleep and concentrate, etc.), that impact the individual’s ability to relate well with others, to be productive at work, and to function generally, in ways that suppress his capacity for a relatively fulfilled and happy life. So there are major consequences to the person’s overall functioning if these conflicts are not addressed and worked through. Analysis is a delicate and complicated process because it requires the therapist to suspend judgement and create a therapeutic environment that provides the patient various opportunities to get in touch with uncomfortable material (such as personal vulnerabilities and deep-seated psychological memories with different degrees of painful affects, etc.), even if a patient’s appearance, viewpoints, lifestyle, language, are so foreign that the therapist may feel that he (the therapist) is more in the grip of “a strange anxiety” reaction in need of a personal exploration (Bach, 1988; Javier & Herron, 2002). So it is clear that from the initial contact we are engaged in an important process with those seeking our services and that much is required from us to ensure that the process is effective. A patient may initially be unable to be specific about the reason(s) for seeking treatment; only providing a vague description of her goal and requiring a great deal of patience from the therapist to clarify the patient’s questions. This was the case of Blanca, a 27-year-old single woman, who came to treatment with a goal of “self-improving” but was reluctant or unable to speak about any experiences other than those she felt were directly related to her treatment goals, as unclear as they were. She was seeking assistance with coping better in order to “operate optimally,” but questions raised by the therapist to get further clarification about what she meant by “coping better” only increased her level of discomfort. She described herself as “not particularly outgoing” or “particularly shy” and said that she was “comfortable by herself.” She requested specific tools to apply in certain situations where she felt she was not operating optimally, but could not specify what situations. By the third session, the therapist felt the need to press the patient to become clear about her presentation and to decide whether or not she was ready to engage in treatment at this time. The patient reported becoming very confused about what the therapist was asking of her and responded by cancelling the following session and then asking to reduce the session frequency to perhaps once a month, “when I have things to talk about.” Our ultimate responsibility is to be able to understand the reason(s) why the patient is seeking treatment, for what condition, what is bringing the individual to seek treatment now, and with this specific professional,

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and so forth. With patients like the one described above, it may take more time to help them get to a place where they feel less defensive. For instance, it is important to recognize with regard to Blanca that the fact that she was the one who initiated the treatment, even if she was unable to provide clarity initially, meant that she had taken an important step. The goal of this initial stage is helping her become more actively involved in being specific about her dilemma.

Developing the Frame We will now focus on describing in more detail what is involved in a proper psychoanalytic assessment of the patient’s condition and the important components to consider in this assessment process, from the initial contact to the final determination and recommendations. Throughout the chapter, we will refer to those making the assessment as the analyst, psychoanalyst, psychotherapist, or therapist interchangeably, in keeping with the usage throughout most of the current psychoanalytic literature. We will address the issue of assessment in the most general way, highlighting the most important aspects and becoming more specific when required by the content under discussion. For more discussions of questions to ask patients and tips to follow in the process of psychoanalytic assessment and treatment with specific clinical examples, the books Turning Points in Dynamic Psychotherapy by Akhtar (2009), The How-To Book by Bach (2011), and Guide to Assessment for Psychoanalytic Psychotherapists by Cooper and Alfillé (2011) provide invaluable resources in this regard, with the understanding that additional issues should be considered, particularly those related to the therapist’s personal psychology, when dealing with members from groups unfamiliar to the therapist (by virtue of their different social class, culturally and linguistically diverse groups, and different gender, religious orientations, etc.). D ECI D I N G H OW TO REFER TO TH OSE SEEK I N G SERVI CES

There are a number of questions and assumptions that will be crucial for the psychotherapist to clarify from the very beginning, and perhaps before receiving a referral or having the first contact with a prospective patient or client. It is important for the psychotherapist to have a clear framework within which to interact and process what will emerge in the context of the assessment. As we stated earlier, this is particularly the case because individuals seeking treatment are not always aware of

Assessment Strategies

how the psychoanalytic process works and what is expected of them, and most importantly, how this particular psychotherapist works. Issues such as whether the therapist will refer to those seeking his professional services as “patients,” “clients,” or any other variations on that theme, can affect the therapeutic enterprise in terms of how the therapist may behave toward these individuals. The early psychoanalysts (see previous chapters in this book) referred to those seeking treatments as “patients” in keeping with the medical model of treatment, where the role of the psychoanalyst was considered the same as that of any other medical doctor. A  patient comes with an illness (symptom), seeking a treatment (solution) that, in the patient’s mind, can be obtained from the psychoanalyst, who has special expertise. The difference is that the illness is more psychological in nature, and a number of unconscious motivations are usually in play, requiring the expert intervention of the psychoanalyst. As we described in the previous chapter, recent movements in psychoanalytic theories (Eagle, 2011) tend to emphasize more the relational aspects of the therapeutic transaction and hence tend to see those seeking treatment as “collaborators,” where the therapist is more likely to be actively involved with those seeking treatment. Finally, the use of “client” to refer to those seeking treatment tends to emphasize more the business aspect of the transaction, with the client in the role of consumer. In that context, development of a treatment contract with clearly delineated expectations about payment, the nature and quantity of involvement, measurable goals to be achieved, and so forth, is an important component of being a “client.” It is clear that, regardless of where one falls within the spectrum “patient—collaborator-client,” a psychoanalytic treatment requires the exploration of unconscious material that is considered the source of the individual’s psychological difficulties. Because of this unique quality, “true” collaboration from those seeking our services can be problematic, as this collaboration is a function of several factors: (a) The quality of the patient’s inner life, which includes the health and strength of his defenses (coping mechanism); his capacity to keep the destructive forces at bay, where the ego capacity for self exploration and determination to seek a cure takes precedence (b) The quality of the empathic connection between the therapist and patient (c) The therapist’s openness and capacity to listen fully to the narrative of the patient’s dilemma

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So, it is not so common that the patient openly refuses to cooperate and instead becomes engaged in behaviors that are counterproductive to the resolution of her difficulties; what we see more often is that the extent and quality of personal assumptions by the patient and the therapist, the nature of the patient’s pathology, and her desperate need to protect herself against the emergence of painful material may make the development of the working alliance more challenging. Paradoxically, a patient who does not feel connected to his therapist for whatever reason(s) and feels the need to be cautious about “what,” “when” and “how” to reveal painful affects associated with discussions of painful events in his life tends to make things worse rather than better, leading to an intensification of the symptoms the person is attempting to address. Such a development could be quite confusing for someone not familiar with how the psychoanalytic process works and is likely to result in the abrupt abortion of the process, like the case of Blanca, the patient described above. It is as if the empathic failure may be experienced by the patient as a confirmation of the more general emphatic failure related to this patient’s experience, and thus providing the necessary environment for a reenactment of a trauma when she was expecting to find relief in the treatment situation but did not. Russell (1998) speaks clearly about this paradox when referring to how the very trauma suffered by the patient that resulted in the psychological difficulties now being presented for assessment makes the patient particularly sensitive to situations that have qualities similar to those of the traumatic experience. According to Russell, it is the presence of this condition that propels the patient to engage (compulsively) in a reenactment in an attempt to heal. As Russell puts it, “the more painful the experience, the more we were injured by it, the more likely . . . we find ourselves compulsively repeating” (p. 2) as an attempt to not feel the pain associated with the trauma. So the repetition is in lieu of being able to feel (i.e., what he calls “affective incompetence” or a “dysfunctional feeling system”). No healing is forthcoming, because the patient finds himself wrapped up in the parts of his behavior that he wants to change but cannot, partly resulting from the empathic failure by the therapist. In this book, we will continue to use “patient” to refer to those seeking treatment, as in our experience, those suffering psychological pain tend to interact with the therapist in a deferential and respectful manner and tend to place all their expectations on the expertise of the therapist as responsible for their healing. Although the patient’s active engagement in her treatment is crucial, it is ultimately the responsibility of the therapist to help move the treatment forward with interventions and timely interpretation, the establishment of the therapeutic frame, the sensitive and timely analysis of

Assessment Strategies

resistance to change, the timely use of the material that emerges in the transference and what transpires in the countertransference, and so on. Thus, the psychotherapist has an important self-monitoring function to play throughout the process and particularly at this junction, in terms of the following (Akhtar, 2009): • The therapist’s capacity to connect emotionally with the specific patient. • His ability and readiness to understand the patient’s difficulties and to remain as faithful as possible to the analytic frame of neutrality. • The level of personal genuineness and like and dislike of the patient’s personal qualities. • His readiness to deal with the range of transference and countertransference feelings likely to emerge in the treatment process, particularly with patients coming from different cultural, linguistic, socioeconomic, religious experiences, and so forth. • The level of personal comfort in dealing with material that may be quite alien to the therapist’s personal psychology (i.e., experience of racism and prejudice, ethnic tension, religious experience, gender/ sexual orientation, etc.) and likely to trigger intense anxiety. • The level of awareness of the therapist’s financial needs and the extent to which it may affect the therapist’s capacity to address fee issues and schedule flexibility with patients within the therapeutic frame. As indicated earlier, the patient may decide to seek treatment from a specific individual based on a recommendation by other patients, professionals, or by getting to know the reputation of the therapist through literature, professional presentations, or being part of the patient’s insurance panel, and the like. But now the patient has to make a determination (consciously or unconsciously) as to whether or not he feels that this is a good fit. This assessment is continuous, and the patient’s behavior throughout the process may communicate to an attuned professional the level of comfort the patient may be experiencing and his ambivalence, which, if not addressed, could prove to be fatal for the continuation of the analytic process. D ECI D I N G W H AT WI L L BE T H E N AT U RE O F TH E I N ITI A L EN CO U N TER

Another important clarification is whether the first encounter with a patient should be considered a consultation, or the first stage of treatment.

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This initial process, which includes the initial interview and recommendations, can be summarized as follows (see Figure 3.1). Some therapists consider that the treatment process begins at the first contact at the time of the referral, when making the first and subsequent appointments. A  lot can be derived from these exchanges that can then be the source of important diagnostic information. In this context, what is communicated as to the reason(s) for the referral question(s), and the nature and quality of the first telephone contact with the patient, become important sources of information regarding the evaluation of the patient’s condition. It is important to communicate clearly to the patient F I GU R E   3. 1  

Decision Tree in the Assessment process Assessment Process Initial Contact: Telephone contact, setting up first appointment or decision of inappropriate referral.

Referral to another professional and/or discontinuation of contact

Traditional psychoanalytic interview Initial Interview period: 2–3 sessions, sometimes consecutively, to assess the issues of concern for the patient. Decision on treatment recommendations.

Psycho-diagnostic testing Psychoanalysis: Individual treatmentat least twice a week meetings but likely more frequently and intense exploration-May or may not include the use of the couch.

Possible Treatment Recommendations:

Psychoanalytic informed/psychodynamic psychotherapy: Individual and or group treatment- usually at least once a week-less intense but still involving explorations of emotions and motivations.

Supportive psychotherapy: Less intense and tends to address concrete issues in the patient’s life.

Assessment Strategies

at the very beginning how the initial sessions (normally two or three encounters or longer) will be utilized (i.e., will be dedicated to assessing a number of important questions raised by the patient and will culminate with making a diagnostic and treatment determination) (Akhtar, 2009; Sullivan, 1970). Considering that this initial contact may be fraught with anxiety for the patient, it is important to provide the patient with clear and specific directions to the therapist’s office and the waiting room, and to answer the patient’s question about the fee directly and other questions related to what is expected of him (Akhtar, 2009). One should remain faithful to the therapeutic frame in terms of refraining from any interventions, making treatment recommendations, or engaging in situations or specific requests made by patients at this time that could compromise the treatment situation at a later point. However, there are situations where a more direct intervention is called for, such as when there is a serious risk of suicide or homicide, or issues related to child abuse and domestic violence. Take, for instance, the case of a 29-year-old patient who called a therapist with an intense and urgent voice and a request to be seen right away. He indicated that he was unable to travel to the therapist’s office and that he had arranged for a space at the local church not far from his house for the purpose of the session. The patient spoke about his inability to go beyond a six-block radius, within which he also worked. “You are not going to be sorry, I am an interesting patient that you will write about some day,” he said while trying to plead his case. The patient made no mention about payment concerns, focusing only on being seen. He reported having been in other treatments, including behavioral, but said that he had derived little benefit from these interventions. He had refused recommendations from other professionals to seek psychiatric consultation because he was adamantly opposed to medication for fear of “contaminating” and “poisoning” his mind. This concern was again raised at this time. The therapist agreed to see the patient for an evaluation, provided that the patient found a way to come to his office. He was given a specific day and time with a request to confirm if he was able to keep the appointment. The patient called to confirm it later that day, although his appointment was for later that week. He came a few minutes early to the session, and when asked to come into the office from the waiting room, he came in accompanied by his sister. They both sat on the couch, she sitting almost behind him, as if wanting to stay in the background. He was a married man and the father of a two-year-old boy. Taking advantage of the situation, the therapist asked about his condition, the history, and so on, but

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also asked whether there was something that patient felt only his sister could provide. The patient was quite loquacious in his presentation, and it was clear that his sister was there to help him deal with the anxiety (as a “container”) and that he felt he may have developed a full-blown panic attack otherwise. The therapist learned, among other things, that the patient functions by relying on his sister and his wife, both of whom were required to wear a “beeper” whenever they had to travel beyond his comfort zone (a six-block radius). Such demands had created a tremendous tension between the patient and each of them, but his wife was the one most reluctant to function in that capacity. The symbolic meaning of “six” in terms of his radius of comfort or discomfort could not be overlooked in relationship to the possible age of his trauma when examining his condition, as well as his suggestion to use a place at a church nearby his house for his treatment and the use of the “beeper” with his sister and wife whenever they were to travel outside his comfort zone. The initial hypothesis generated at that visit was that the patient was dealing with issues related to a serious condition of separation anxiety, and that the beeper was an attempt to recreate the umbilical connection with the sister and then with his wife, and ultimately with his primary object (his mother). The sister was more willing to provide that for him because she was part of the dynamic that he was attempting to work through, but he found himself engaged in a repetition compulsion. The patient was also dealing with intense guilt feelings, the source of which only became clear later. (The patient slept in the same bedroom as his mother until her death, when the patient was in his late teens or early twenties. He also kept his mother’s undergarments in a drawer in the mother’s bedroom that he was now occupying with his wife.) His concern was that these unacceptable feelings of a sexual nature likely to emerge in the context of treatment were going to consume him (hence the church site), giving the therapist a warning to proceed cautiously with the treatment. The patient stayed in treatment for about six or seven years, with excellent results in terms of the resolution of his phobia, being able, toward the latter part of the treatment, to come by himself and able to travel way beyond the initial restriction. There were a number of opportunities to work through his various reenactments, including full manifestations of severe panic attacks in the office, and analyses of dreams, whose contents revealed the patient’s primitive and sexually loaded material involving his mother, rage against his father, and so on, which ultimately made it possible for him to give up these types of internal relationships that were

Assessment Strategies

consuming him. Eventually he got rid of all the mother’s garments and moved to a different apartment with his wife and child. At this point, we will not enter into a complete description of the treatment of this patient. We only want to emphasize the importance of keeping the analytic frame, to allow more aspects of the patient to be revealed, particularly as part of the assessment stage. In the case of this patient, had we agreed to the patient’s request to use the church as part of the consultation, the intensity and complexity of the patient’s dilemma may not have emerged in the same manner, probably resulting in delaying the resolution of the patient’s problems. AS SES SM EN T AS A PRO CES S?

The American Psychoanalytic Association (APsaA) views assessment as a “process” and suggests that a complete assessment process may require a trial period of several months or even a year to determine the patient’s capacity to benefit from insight-seeking treatment (APsaA Practice Bulletin 7, 2013). However, the reality in the mental health field today is that a determination of treatment may need to occur after only a couple of sessions, because many patients coming to us may need to use their insurance coverage to pay for our services, in conjunction with their taking financial responsibility for the fees once the insurance coverage has run out. Once a third party is involved, it is likely that these companies will require a treatment decision to be made in a few initial sessions (including a diagnosis), where a treatment plan has to be agreed upon by the patient. Hence the therapist will need to be prepared to provide a very specific diagnostic picture and treatment recommendations quickly (but only preliminarily from the psychoanalytic perspective) to respond to the reality of the situation. The benefit of seeing the assessment period as a process that extends beyond the initial few sessions is that it allows subsequent new information that emerges from the patient in the course of the therapeutic work to still impact on new ways of assessing the patient’s difficulties. This “open-mindedness” is suggested in the very framework required for analytic work, which was already discussed in prominent psychoanalytic writings related to neutrality (Freud, 1936), in which the therapist’s mind is expected to remain open to receiving information from the patient, without prejudgement, in the manner described by Freedman (1983) in his article on psychoanalytic listening. This capacity to listen is a crucial skill to develop if one is to be a successful

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analyst or psychotherapist. According to Freedman, this listening process involves a sequence of the rhythmic alternation of a phase where the mode is on receiving information and a phase of restructuring that information. During the receiving phase, there is “an openness to the intent of the other . . . a tolerance for multiple alternatives . . . an emphasis on subjectivity. . . . It is a suspension of the need to objectify or symbolize” (p.  409). In terms of the restructuring phase, Freedman sees that phase as “a narrowing of attention, a reduction of the possibilities aiming toward consolidation and synthesis, and emphasis on objectification and symbolic representation” (p. 409). For psychoanalysts who follow a more traditional or “classical” approach, the line between the assessment and treatment period may be intentionally blurred, and they may conduct the assessment as if it were a regular session. In this context, allowing the patient to speak freely about her difficulties without much interruption, and venturing some questions here and there to clarify what is emerging in the patient’s communication, is seen as the best method to appreciate the very nature of the patient’s level of difficulties. The rationale is the belief that a lot can be learned from a patient’s free communication about the nature and urgency of the presenting problems, her overall personality function, character pathology, way of dealing with anxiety, ability to communicate her difficulties clearly, ability to relate to the person of the psychoanalyst, and so forth. So the assessment is done as part of “submerging” the prospective patient in the actual treatment process and seeing how the patient would function in that context. Some trial interpretations may be offered, only to assess the extent to which our way of interacting and processing the patient’s information is meaningful for this patient and to determine how to structure our future interventions with this patient so to enhance the working alliance. An assessment process that only seeks to determine the patient’s level of “psychological-mindedness” (to be discussed later in this chapter) places the emphasis primarily on the patient’s degree of psychological capacity to engage in psychoanalytic work and less on the examination of the therapist’s contribution and role in being able to develop an understanding of the patient’s presenting problem and an empathetic connection with the patient, perhaps due to the therapist’s personal psychology. So if the patient is unable to use the lack of clear direction and directness by the therapist, the ambiguity created in the treatment situation, or is too anxious, is unable to articulate clearly his difficulties with a sense of personal curiosity as to the cause behind the difficulties, may

Assessment Strategies

be viewed as evidence that such a patient may not be able to benefit from psychoanalytic intervention. In fact, it may be viewed as showing signs of cognitive disorganization, because the therapist may be unable to follow the patient’s narrative. The potential damage for a patient already dealing with a sense of insecurity, with the experience of multiple rejections, confusion about how psychoanalytic intervention works, a sense of inadequacy, and feeling like a failure is ever so great. This condition may result in a premature termination of the contact with this psychoanalyst, and perhaps relinquishing all attempts for treatment in the future. In essence, greater flexibility and involvement by the analyst is a better approach. D ECI D I N G W H AT WI L L BE I NVO LVED I N T H E AS SES SM EN T PRO CES S

Another important consideration is determining what the initial assessment period will entail, so that such information is communicated to the patient at the time of the first appointment. Depending upon one’s practice, assessment includes not only regular interviews, but diagnostic tests as well (see Figure 3.1). Such a practice is endorsed by Holt in his “Editor’s Foreword” of a book by Rapaport, Gill, and Schafer (1974). According to Holt: while the total case history based largely on the diagnostic and therapeutic interview is an unexcelled way of learning about the larger sweep of personality development and the patterning of life’s events, diagnostic tests are the best way of learning about microstructure of personality, the patterning of defenses, and the interpretations of motives and thought and affects. (p. 38) The APsaA (Practice Bulletin 7, 2013)  also endorses the use of psychoanalytically oriented psychological testing for three major purposes: (1) to assess the degree of the patient’s analyzability, (2) to enhance the prediction of treatment outcome, and (3) to delineate the dimensions of changes (variables) by which treatment outcome may be measured. We also suggest that such testing should include the degree of empathy or empathic concern by the therapist, as the presence of such empathy has been found to predict treatment compliance and outcome (Mehra, 2013; Sharf, Primavera, & Diener, 2010). If one decides to include testing as part of the assessment process, it is necessary to make sure that the tests are valid and reliable for the variety of the patient population likely to

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come to our offices, and to have the testing performed by someone else so that the two functions remain separate. Testing normally requires the psychoanalyst to relate with the patient differently than what is expected in the psychoanalytic interview. In fact, some analysts are quite clear that knowing about diagnostic categories is not as important (and is less reliable) in determining a person’s suitability and capacity to benefit from psychoanalytic treatment, because the discernment of suitable traits takes place in the context of the process of the clinical interview (Bach, 2011; Rueve & Correll, 2006) and should also consider personal traits of the therapist. FO CUS O F TH E AS SES SM EN T

There seem to be a consensus in the psychoanalytic literature regarding the importance of the initial contact with the patients, the role of the psychotherapist, how questions are to be asked, the importance of inquiring about how the referral came about, and so on (i.e., whether the referral came from another colleague, another professional or whether the patient found out about the therapist through the Internet, through the therapist’s publications, etc.) (Akhtar, 2009; Bach, 2011; Cooper & Alfillé, 2011). The therapist should take advantage of all aspects of the interaction with the patient in order to gather information about what may be going on with the patient beyond what the patient is verbalizing, as well as the level of urgency of the patient’s situation. Thus, the focus is not just on gathering data for diagnostic purposes as one does in any other interview, but particular attention is placed on how that information is delivered. The main role for the psychoanalyst is to listen to what the patient is or is not communicating verbally and nonverbally (Bach, 2011) and to keep his personal biases in check. At the end, the therapist is trying to determine not only what are the nature and extent of the patient’s difficulties, but how and the extent to which psychoanalytic intervention can benefit this patient and whether or not he will be able to work with this patient. These questions need to be answered because the question as to whether or not the specific patient is “treatable” or “analyzable” can only be known by assessing those involved in the transaction (the patient and the therapist). This point was made quite succinctly by Bach (2011), when he said that “analyzability does not reside within the patient: It is a function of a particular patient working with a particular analyst at a particular time . . .” (p. 4).

Assessment Strategies

We are reminded of a 54-year-old patient who came to see a therapist several years ago with the complaint of a serious fear of traveling, particularly by plane, which he only endured after numbing or anesthetizing himself with a few shots of whisky, waking up when he was already at the destination. The therapist mainly listened to the description of his difficulties. He asked a few questions, trying to get a sense of how the patient saw his difficulties. These were answered with “I don’t know.” The patient made a comment that he did not know “how this is supposed to work” but that he was speaking a lot and the therapist was just sitting in his chair, quiet. He informed the therapist that he had come to see him because he was referred by his brother, who had been in treatment with this analyst for several years many years ago, “and he said that you helped him a lot.” It was clear from the beginning that he wanted some immediate relief because he was traveling soon (although he had not yet bought his ticket) and was having a panic attack at the thought of it. The therapist recommended taking more time to assess his condition before making any recommendations as to how to proceed. He was a business man, and there was a sense that he could not commit the time to a long process. He promptly paid for the consultation in cash and agreed to set up another appointment, pending his travel plan, something that he did not keep because apparently it conflicted with his time to travel. The patient disappeared, only to return about six years later. He returned this time “ready to face” what was causing his condition. In his earlier visit, it was clear that this patient was having a hard time understanding the therapist’s analytic listening stance and came with an assumption and expectation of immediate cure or the cure that the therapist supposedly had provided for his brother. This time around, he was still resistant to entering into some of the reasons for his difficulty, and his reluctance and fear to face difficult memories became evident. This patient spoke in a very loud voice even though the therapist was only a few feet away from him. He reported that he had not heard well for many years and thus tended to miss most of the things said to him by others, and he depended on his brothers to repeat and translate to him what was said at meetings. He never thought about seeking a medical opinion for his condition, because, as reported, he has lost faith in the seriousness and qualifications of various doctors. It was clear that his condition was affecting his day-to-day functioning at his business and with his family. He was highly distrustful of the medical profession and, by extension, of the psychological/psychoanalytic profession (the therapist). However, his

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decision to return suggests that he was at an important juncture to determine whether or not to give the treatment a chance. It was evident that the patient was as much evaluating the therapist as the therapist was evaluating the patient, suggesting that it was important to inquire about the patient’s view of the process and how he was reacting to the therapist in the context of the initial interview so as to have an opportunity to address those issues early in the process. Obviously, the patient’s urgency and lack of availability at that initial visit did not provide the therapist with any opportunity to complete the evaluation, and even less to initiate treatment. The fact that the patient returned six years later suggests that something about the interaction provided him with some hope and personal comfort, sufficient to give himself another opportunity. In terms of the importance of assessing the patient’s situation, Akhtar (2009) summarizes that the focus should include three main areas, in addition to the personal examination required in the therapist:  (1)  the patient’s need for deep psychotherapy, (2) the patient’s suitability for such, and (3) the actual feasibility of undertaking a long procedure. To answer these questions requires the assessment of the patient’s unique characteristics (or ideal traits), strengths, and deficiencies in terms of her (a) motivation, (b)  potential for self-observation, (c)  potential to withstand the tensions likely to emerge in the course of treatment, and (d) her potential to work analytically (APsaA Practice Bulletin 7, 2013). Greenspan (1977), Akhtar (2009), and Rueve and Correll (2006) suggest that the assessment should then include an evaluation of the following: 1. The patients’ capacity to distinguish between internal and external realities. 2. Their degree of psychological suffering and motivation for treatment, as well as the extent to which they show an “internal sense of personal responsibility for their lives with some ability to control their circumstances” (Rueve & Correll, 2006, p. 45). 3. Their level of cohesiveness of the internal organization and self/object representations, even in the context of stressful conditions. 4. The level and quality of their defenses. 5. Their capacities to experience, perceive, and recognize in others a full range of affective states (including love and hate) without compromising their personal integration.

Assessment Strategies

6. Their capacity for appropriately modulating and keeping impulses under control in dealing with external situations. 7. Their capacity for developing genuine and lasting connections (attachments) with others. In terms of assessing these qualities in the patient more concretely, the therapist is encouraged to inquire about the following issues in the course of the initial assessment. This can serve as a rough guide for the kinds of questions to pursue with patients: • What is bringing the patient to seek treatment at this point in time? How clearly and seriously does the patient view his level of difficulties, and how determined is he to work actively toward a solution in a psychoanalytic exploration at this point? To what extent is the patient’s current life situation (family responsibility, financial condition, etc.) likely to impact in the patient’s conscious decision to enter into psychoanalytic treatment? • What is the true extent of the patient’s capacity for personal introspection, his level of personal curiosity, and a genuine capacity for self-reflection? Does the patient have an active dream life and communicate such to the therapist? Does the patient show good verbal skills and the capacity to deal with fantasy, symbolism, metaphor, and a range of different feeling states? Does the patient show a capacity for psychological mindedness? (or a “capacity for objectivity, for reflecting on his/her own emotions and related behaviors, and for handling new awareness of his or her faults” (Rueve & Correll, 2006, p. 46). • What is the quality of the patient’s ego and superego functions and the extent of the patient’s cohesive sense of identity? What is the extent of the patient’s capacity for impulse control, self-containment of strong affects, and his capacity to tolerate intense frustrations? What is the patient’s history of losing control, how, in what way, under what situations, for how long, in reference to whom, and with what consequences? • Does the patient show ability to look at her contribution to a situation, abilities for adaptive conf lict resolution; or is the patient prone to blaming others and other conditions for her misfortune?

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• What is the pattern and strength of defensive maneuvering likely to be utilized by the patient (denial, repression, splitting, projection, projective identification, intellectualization, sublimation, etc.) when confronted with strong conflictual situations? Is there a history of somatic complaints or oscillations and disruptions of relationships after a period of blissful/idealized connection following intense emotional conflicts? What are the specific contents of the conflict that result in these intense reactions? Although the need to make a formal diagnostic determination before treatment is not endorsed by all psychoanalysts (Bach, 2011), most are very interested in information about patterns of defense and ego function to determine the kind of personality organization likely to impact on the treatment process and outcome. If a patient is showing a borderline constellation or one where a depressive, psychopathic, or primarily narcissistic personality predominates, it is likely that he will develop different types of transference, and make different demands on the therapist (Kernberg, 1975). • What is the history of his connections and attachments to others, including spouses, girlfriends/boyfriends, friendships, and relationships with his immediate family as well as earlier relationships? In this connection, Akhtar suggests inquiring about “the patient’s feelings of ethnicity and of belonging to his communal group and continuity of contact with friends and associates from earlier periods of life” (2009, p. 24). D E TER M I N ATI O N F O R TRE ATM EN T

After gathering all information about the patient and his circumstances, as well as assessing her own reactions regarding the patient and the material that emerged from the interaction, the therapist should be ready to make recommendations. It will be important for the therapist to inquire about the patient’s understanding of what transpired over the few sessions prior to communicating her recommendations. These recommendations should be preceded also by providing a summary of the major issues that emerged during the meetings, restating the patient’s referral complaints, and providing a psychological explanation (formulation) of the major issues that may be causing the troubles and symptoms in the patient. The recommendation for an intense psychoanalysis, psychodynamic psychotherapy, or supportive psychotherapy (see Figure 3.1) has to derive directly from that formulation in ways that make sense to the patient and that also take into consideration the patient’s specific financial situation and

Assessment Strategies

cultural requirements at the time. For some patients, more frequent meetings may be viewed as reflecting a more serious condition rather than reflecting more opportunity to work more intensely in the resolution of what is impacting on their functioning. The patient should be encouraged to verbalize her reactions to the recommendations and, if these are agreed upon, a determination as to the time and frequency of the sessions is mutually made. It is at this point that the therapist reaffirms the expectation/policy on missed sessions, vacation, fee, and payment schedule, with the understanding that some patients may have great difficulty processing this new framework and may require a period of adjustment and leeway. The therapist should communicate from the very beginning any planned absences for vacation, illness, professional meetings, and the like, and ask the patient if she has any planned absences in the near future. Some therapists may agree to see the patient at a different time and or date to accommodate planned absences in order to ensure minimum disruption to the process. The patient should be reminded that the treatment works best when he comes to the session regularly, particularly if he does not feel like coming, and that his role is to communicate what comes to mind without prejudgement and to avoid making major decisions in his life without giving himself an opportunity to understand the possible reason(s). Reaffirmation of the importance of dreams should also be made, with an encouragement to bring all dreams to the session. Hopefully, this assessment process will end with a specific time for the beginning of treatment, but one has to be prepared to accept a patient’s decision to take more time to make her decision or decline to proceed altogether. How this transaction is handled may provide the additional information that the patient requires to make the final determination. AS SES SM EN T T H RO U G H O U T T H E T H ER A PEU TI C PRO CES S

It is now more likely that the assessment process will extend to the period of treatment so as to assess various aspects of the patient’s improvement over time. The nature of this assessment and instruments to be used for this purpose are to be directly related to the specific focus of the treatment. Although it is not traditionally the case, psychoanalysts, particularly those who are accepting insurance fees and those involved in therapy outcome research, are engaged in establishing specific protocols that include various measures to assess short- and long-term improvement in their patients. In this context, it is not unusual to give their patients a set of objective measures and questionnaires at the beginning of treatment and three, six,

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and twelve months later and beyond, to measure changes over time as a function of the psychoanalytic intervention. Thus measures of changes in anxiety, depression, fears, aggression, self-esteem, intimacy, alcoholism and other substance abuse, ability to concentrate, extent and intensity of eating disorders, and so forth, are frequently found in the literature to address the symptoms often reported by patients suffering from a variety of psychological disorders (Abbas, et al., 2006, 2009; Leichsenring, 2009; Shedler, 2010). Because psychoanalytic intervention is particularly interested in working toward structural changes in the person’s internal structure, measures that are more likely to reflect structural changes in personality should also be considered. Thus, measures of changes in self-perception and self-concept, object relations, overall improvement and life satisfaction, management of affects, capacity for mentation, perceived guilt, interpersonal dependency, capacity for intimacy, resilience, locus of control, tendency toward magical ideation, capacity for impulse control, cognitive flexibility, self-understanding, and the nature of attachments are some of the areas to consider in assessing long-term effects of psychoanalytic intervention. Examples of specific measures are found in Blatt and colleagues’ work over a period of several decades (Blatt & Auerbach, 2003; Blatt, Auerbach, Zuroff, & Shahar, 2006; Porcerelli et  al., 2006; Blatt, Auerbach, & Behrends, 2008), as well as the list of measures for clinical practice included in the source book by Corcoran and Fischer (1987) and Fischer and Corcoran (2007). Personality inventories like the Sixteen Personality Factor Questionnaire (or 16PF) and the Minnesota Multiphasic Personality Inventory (or MMPIs), as well as the data that are elicited by projective texts such as the Rorschach can be quite instructive. Finally, the Analytic Process Scale (Waldron et al., 2004), has been found to be a promising measure of specific psychodynamic constructs when dealing with the psychoanalytic process.

Conclusion In this chapter, we attempted to describe the assessment process, which includes aspects related to assumptions and expectations that both the patient and the psychotherapist bring to the process. We emphasized in this context the importance of the therapist’s taking charge of her own psychology with regard to any personal biases and prejudices likely to emerge in the context of the therapeutic situation. An important decision

Assessment Strategies

to be made in this regard is a determination of whether or not the therapist would feel comfortable enough and has the necessary expertise to work with a specific patient effectively, and with the specific issues brought by the patient. Regarding the patient, we emphasized the need to elicit detailed information not only about the specific complaints (such as a description of the complaints and difficulties, the degree of urgency and intensity, the areas of functioning being affected, under what situation and in reference to whom, etc.), as well as the history of these difficulties, and how the patient has attempted to address them in the past (previous treatment attempts), with what outcome. Other areas to be covered in the initial assessment should also include: • Patient’s readiness to embark on what is required to address the patient’s complaints. • Psychological mindedness (e.g., a level of personal curiosity about the true nature of his difficulties and the nature of his internal life, ability to withstand ambiguity and capacity for regression, ability to relinquish control and to allow the therapist to guide the therapeutic process; and finally, capacity, willingness, and comfort in allowing himself to become dependent on the therapist, etc.). • Readiness and ability to dedicate the necessary time and financial resources to secure the integrity of the work of psychoanalysis. Finally, we emphasize the value of using the therapeutic frame, being vigilant about one’s own personal biases, and maintaining active listening to everything our patients are attempting to communicate, verbally and nonverbally. Only then will we be providing our patients the best opportunity for healing. In the end, only through a careful assessment, which also includes making sure that the possibility of empathic failure due to the disparity of our personal experience with that of our patients is kept under control, can we be relatively certain that a proper decision has been made as to what would be best for the patient. We say “relatively,” because the complexity of what a patient presents as her reason for treatment is not always easy to discern at the beginning, only becoming clearer in the context of the progression of the treatment, where the task remains the “discovery of patients’ basic psychic struggles and the uncertainties of their origins, and facilitating of the alleviation of psychic pain” (Javier & Herron, 2002, p. 165).

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References Abbas, A. A., Hancock, J. T., Henderson, J., & Kisely, S. (2006). Short-term psychodynamic psychotherapies for common disorders. The Cochrane Database of Systematic Reviews, 4, CD 004687. Abbas, A. A., Kisely, S. & Kroenske, K. (2009). Short-term psychodynamic psychotherapy for somatic disorders:  Systemic review and meta-analysis of clinical trials. Psychotherapy and Psychosomatics, 78, 265–274. Akhtar, S. (2009). Turning Points in Dynamic Psychotherapy—Initial Assessment, Boundaries, Money, Disruption and Suicidal Crises. London: Karnac Books, Ltd. Bach, S. (2011). The How-To Book—For Students of Psychoanalysis and Psychotherapy. London: Karnac Books, Ltd. Blatt, S.  J., & Auerbach, J.  S. (2003). Psychodynamic measures of therapeutic change. Psychoanalytic Inquiry, 23, 268–397. Blatt, S.  J., Auerbach, J.  S., & Behrends, R.  S. (2008). Changes in representation of self and significant others in the therapeutic process:  Links among representation, internalization and mentation. In A. Slade, E. Jurist, & S. Bergner (Eds.), Mind to Mind: Infant Research, Neuroscience and Psychoanalysis (pp. 225–253). New York: Other Press. Blatt, S. J., Auerbach, J. S., Zuroff, D., & Shahar, G. (2006). Evaluating efficacy, effectiveness and mutative factors in psychodynamic psychotherapies. In Psychodynamic Diagnostic Manual (pp. 537–572). Silver Springs, MD: Alliance of Psychoanalytic Organizations. Cooper, J., & Alfillé, H. (2011). A Guide to Assessment for Psychoanalytic Psychotherapists. London: Karnac Books, Ltd. Corcoran, K., & Fischer, J. (1987). Measures for Clinical Practice:  A  Sources Book. London: The Free Press. Eagle, M.  N. (2011). From Classical to Contemporary Psychoanalysis—A Critique and Integration. New York; London: Routledge, Taylor & Francis Group. Fischer, J., & Corcoran, K. (2007). Measures for Clinical Practice (4th ed.). New York: Oxford University Press. Freud, A. (1936). The ego and the mechanism of defense. In The Writings of Anna Freud, Vol. II. New York: International University Press, 1966. Freedman, N. (1983). On psychoanalytic listening:  The construction, paralysis, and reconstruction of meaning. Psychoanalysis and Contemporary Thought, 6, 405–434. Greenspan, S. (1977). The oedipal-preoedipal dilemma:  A  reformulation in the light of object relations theory. International Review of Psychoanalysis, 4, 381–391. Holt, R. R. (1974). Editor’s Foreword. In D. Rapaport, M. M. Gill, & R. Schafer, Diagnostic Psychological Testing (pp. 1–44). New York: International University Press. Javier, R.  A., & Herron, W.  G. (2002). Psychoanalysis and the disenfranchised:  Countertransference issues. Psychoanalytic Psychology, 19(1), 149–166. Kernberg, O. F. (1975). Borderline Conditions and Pathological Narcissism. New York: Jason Aronson. Leichsenring, F. (2009). Psychodynamic psychotherapy:  A  review of efficacy and effectiveness studies. In R. A. Levy & J. S. Ablon (Eds.), Handbook of Evidence-Based Psychodynamic Psychotherapy (pp. 3–27). New York: Human Press.

Assessment Strategies Mehra, A. (April, 2013). Therapist empathy mediation in treatment orientation effects on dosage non-compliance. Doctoral dissertation, St. John’s University, New York. Porcerelli, J. H., Shahar, G., Blatt, S. J., Ford, R. Q., Mazza, J. A., & Greenlee, L. (2006). Change in object relations following intensive psychoanalytically oriented inpatient treatment. Journal of American Psychoanalytic Association, 53, 1323–1325. Practice Bulletin 7 (2006)—Psychoanalytic Clinical Assessment. Published by the American Psychoanalytic Association—Retrieved on Jan. 18, 2013, from http://apsa.​ org/About_APsaA/Practice_Bulletins. Rueve, M.  E., & Correll, T.  L. (2006). The art of psychotherapy:  Selecting patients for psychodynamic psychotherapy. Psychiatry (Edgmond), 3(11), 44–50. Russell, P. (1998). The role of paradox in the repetition compulsion. In J. G. Teicholz & D. Kriegman (Eds.), Trauma, Repetition, and Affect Regulation—The Work of Paul Russell (pp. 1–22). New York: The Other Press. Sharf, J., Primavera, L.  H., & Diener, M.  J. (2010). Dropout and therapeutic alliance:  A  meta-analysis of adult individual psychotherapy. Psychotherapy:  Theory, Research & Practice, 47, 637–645. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. doi: 10.1037/a0018378, PMID 20141265. Sullivan, H. S. (1970). The Psychiatric Interview. New York: W.W. Norton & Company. Tuch, R. M. (1997). Beyond empathy: Confronting certain complexities in self psychology theory. Psychoanalytic Quarterly, 66, 259–282. Waldron, R. S., Scharf, R., Hurst, D., Firestein, S. K., & Burton, A. (2004). What happens in psychoanalysis:  A  view through the lens of the Analytic Process Scale (APS). International Journal of Psychoanalysis, 85, 443–466.

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Psychodynamic Case Formulation DOLORES O. MORRIS

Chapter 3 covered assessment strategies such as psychoanalytic psychology. The plan of this chapter is to define psychodynamic case formulation, a vital component to intervention, followed by its history, relevant research, application, a description of a case formulation model with its components, and finally, a case example and conclusion.

Definition of Case Formulation Psychodynamic case formulation is used clinically in conjunction with treatment. It is a working hypothesis of a person’s psychological function. Below is one of several definitions that incorporate the best practices involved when a psychoanalytically informed clinician does a diagnostic assessment and develops a treatment or invention plan. It is representative of the case example that will be presented later in the chapter. The psychodynamic formulation is a concise conceptualization of the patient’s problem that begins with the core psychodynamic problem and illustrates the connections between the patient’s symptoms, key childhood experiences, seminal life events, and current life issues. A comprehensive formulation combines psychodynamic with nondynamic factors in understanding the patient’s life course. The formulation allows the therapist to anticipate the unfolding of the treatment, including the opportunities for change, obstacles and

Psychodynamic Case Formulation

resistances and emerging themes in the therapeutic relationship. (Summers & Barber, 2010, p. 175) Case formulation is a systematic approach with defined domains of data that provide an accurate and comprehensive picture of the person at the time. It is a clinical tool that provides data that are unique to the individual’s history and dynamics: the person is involved in the process. The term “psychodynamic case formulation” was created in an attempt to distinguish the concept from the more general biopsychosocial formulations that are usually limited in their focus on psychological conflict. Previous chapters cover the theoretical foundation for psychoanalytic psychology and its principal therapeutic techniques, which provide the knowledge base for psychodynamic case formulation. The clinical case history method originated with Freud, and his early case studies continue to be taught as models of psychoanalytic thinking. Freud used the term “formulation” to refer to a general theoretical statement. His narratives of each of his extended seminal cases—Dora, Little Hans, the Wolf Man, and the Rat Man—might be considered psychoanalytic formulations, though he did not call them that (Friedman & Lister, 1987). Freud tried to present plausible accounts of why and how the patients’ symptoms developed and were relieved. Faced with a stream of seemingly disconnected, often bizarre sequences of verbal associations, he wanted to construct a meaningful explanation of the patients’ often irrational behavior. He was particularly struck by the gaps in the patients’ memory, by the patients’ tendency to avoid certain material, and by the inexplicable nature of their symptoms. The subsequent development of psychoanalytic theory shows an increasingly complex and subtle understanding of human experience, particularly from the perspective of unconscious, intrapsychic conflict, a core notion of Freudian theory. Since Freud, many writers of various views have contributed to an understanding of the theoretical foundations of psychodynamic therapies with their techniques and terms such as establishing an alliance, transference, countertransference, negative transference, self-awareness of the analyst, and skill in listening, all of which set the frame for treatment. This knowledge base can be daunting for the analyst or therapist to use to formulate and write a treatment plan for the patient. MacKinnon and Michels (1971) provide a guide to the psychiatric interview focused on the psychodynamics of a wide range of psychopathological entities, with a clear delineation of each dynamic constellation. MacKinnon later worked with Yudofsky (1986, 1991)  to develop guidelines for psychodynamic

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formulation that included the patient’s present illness, psychopathology, developmental data, diagnostic classification, and prognosis. The misconception was that the construction must be elaborate, time-consuming, and reserved for psychiatrists in training and not necessarily put in written form (Perry, Cooper, & Michels, 1987). It was Perry and colleagues’ (1987) concise, short formulation that provided the concept of “dynamic and nondynamic factors.” During this period, Friedman and Lister (1987) also developed a systematic approach that examined structural, dynamic, and genetic factors with an outline for the case formulation that was less structured and more “intuitive.” They believed that their approach increased clinicians’ empathy or understanding of the patient and facilitated the selection of appropriate treatments, and further research. Summers (2003) updated Perry and colleagues’ work to include new areas of knowledge, in a description of core psychodynamics using the ego psychology, object relations, or self psychology mode. They all share the core concept of dynamic unconscious mental activity; that is, they assume that human behavior is constantly influenced by unconscious thoughts, wishes, and mental representations. They agree that it should be written and concise. Summers (2003) observes that while Perry and colleagues recognized the importance of including neurobiological factors in the formulation, they did not provide a systematic format for including these elements. He updates their thinking and the format of the traditional psychodynamic formulation to include new areas of knowledge. McWilliams’s thorough treatment of the subject incorporates new domains of data into the traditional formulation, including temperamental and organic factors, and includes other paradigms, such as cognitive and relational models. However, she is not specific about the format for written formulations, and unfortunately provides few complete examples. McWilliams (1999) and Summers (2003) continued the refinement of the psychodynamic formulation begun by Perry and his colleagues. Their contribution further emphasizes the integration of nondynamic factors into the formulation that is used by Perry and colleagues and elaborated by Summers. McWilliams does not use the Perry and associates’ structural format, nor the term “nondynamic.” She does incorporate new, important domains of data. Whereas both Summers and Perry use ego psychology, self psychology, and object relations, McWillieams and Perry both attempt to integrate new areas of knowledge by considering more deeply the specific interactions of dynamic and nondynamic factors in understanding the development, maintenance, and resolution of the patient’s difficulties.

Psychodynamic Case Formulation

The integration of temperament, genetics, attachment, and psychopathology with psychodynamics results in a contemporary psychodynamic formulation: a formulation that allows the integration of the developmental lines of psychological and neurobiological factors that determine how someone develops into a person—a complex combination of vulnerabilities and strengths. Inferences and hypotheses about the interaction of nature and nurture as biologically determined factors are integrated with the patient’s core conflicts, attachment history, pattern of loving, personality organization, and resultant core conflicts that influence love, work, and play. This contemporary view may serve as an impetus for more accurate understanding of individual patients, and may raise questions that can continue to stimulate research. While it is recognized that the clinically derived individual case formulations do not demonstrate scientific reliability and validity, the approach is systematic and has defined domains of data that must be gathered and included. As a consequence, the expanded psychodynamic formulation provides a more accurate and comprehensive picture of the patient.

Review of Psychodynamic Case Formulation Research Psychotherapy case formulations have been influenced in significant ways by psychoanalytic, humanistic, behavioral, and cognitive psychology. These diverse influences have motivated research efforts to identify areas of consistency and variation. Psychotherapy case formulation has also been influenced by how psychopathology is understood, by the development of psychometric assessments, and by recent research in which the reliability and validity of case formulations have been examined. Seitz’s (1966) seminal study has made significant contributions to fostering agreement between clinicians about the structure and content of the case formulation, by identifying these variations and providing the impetus for research to enhance the reliability and validity of case formulations. This research has addressed the fundamental skills required to develop a comprehensive formulation. It has influenced educators to include it in the curriculum to develop this knowledge and skill as learning objectives for practitioners in training. Eels cited various theoretical orientations—psychodynamic, Curtis and Silberschatz (1997), Horowitz (1997), Levenson and Strupp (1997), Luborsky (1997), and Perry (1997); cognitive-behavioral, Persons and Tompkins (1997); interpersonal, Markowitz and Swartz (1997); behavioral, Nezu, Friedman, and colleagues (1997), and Koerner and Lineman (1997);

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and blends of orientations, Caspar (1995), and Ryle and Bennett (1997)— that have examined case formulation construction. Eels’s (2001) review of the newer psychodynamic case formulation methods cites Luborsky’s Core Conflictual Relationship Theme (CCRT) as a way to formulate and formalize core conflicts or central issues methods (see Luborsky, 1997). This instrument is an example of one with good reliability and validity. Its ease of application for empirical research enables the evaluation of outcomes. Validity studies have focused on how well adherence to a case formulation predicts the psychotherapy process and outcome. In another study, they showed that the accuracy of therapist interventions, as defined by adherence to reliable, constructed CCRTs, correlated with outcome of patients undergoing psychodynamic psychotherapy. Similarly, Siblerschatz, Fetter, and Curtis (1986), and Siblerschatz and Curtis (1993) demonstrated that formulation-consistent interventions are associated with a deeper level of experience in patients than interventions that do not adhere to a formulation. In retrospect, the empirical research on case formulations has continued to refine its methods and enhance the value of the evidence it provides regarding efficacy and variation across theoretical orientations and patient populations (Eels et  al., 1998). A  salient contribution that Eels made in his review (2001) is that there are four broad categories of information that are contained in most methods, regardless of orientation. These are: (1) symptoms and problems, (2) precipitating stressors or events, (3) predisposing life events or stressors, and (4) a mechanism that links the preceding categories and explains the precipitants and maintaining influences of the individual’s problems. In summary, psychodynamic case formulation has also been influenced by how psychopathology is understood, by the development of psychometric assessments, and by recent research in which the reliability and validity of case formulations have been examined.

Case Formulation Approaches While there are other approaches noted earlier, Perry and colleagues (1987), McWilliams (1994, 1999, 2004), and Summers (2003) all have in common their contemporary understanding of the generic assessment components cited with a difference in theoretical approach that informs their understanding of psychopathology and personality development, which in turn influences the inferences that are generated. They agree that the patient is a collaborator in the formulation process. Progressive

Psychodynamic Case Formulation

adjustments and multicultural considerations should be incorporated in the formulation. They each describe, to a greater or lesser degree, a systematic format with a rationale for collecting data for the formulation. Whereas Williams (1999) leaves the structure of the case formulation to the clinician, Summers provides a concise four-step method for a traditional and updated psychodynamic formulation, with a detailed description that clearly guides the clinician through the process. He expands Perry and colleagues’ original format and case example that illustrates the inferences that ego psychology, self psychology, and object relations theory might make with the same case. Summers’s approach more closely adheres to psychiatric disorders and the Diagnostic and Statistical Manual of Mental Disorders (DSM) than McWilliams. McWilliams (1999) observed that the DSM minimizes the subjective and inferential aspects, which are multiple and overlapping causation on diagnosis upon which most clinicians depend. She discusses how the DSM may be successful in the identification or classification of a disorder, but points out that it does not get at the internal subjective world of the patient. She provides a good synopsis of the literature that speaks to defenses associated with these internal subjective states. Similarly, she acknowledges that her approach is subject to the same criticisms about “labeling” and “pathologizing” as are the DSM and other descriptive psychiatric diagnoses. She believes that a diagnosis associated with a sophisticated understanding of defenses is a superior construct supported by extensive clinical literature. She has examined the process of diagnosis rather than the outcome, and focuses on the questions that experienced clinicians might ask themselves. Her treatment of case formulation incorporates new domains of data into the traditional formulation by incorporating temperamental and organic factors, and includes other paradigms, such as cognitive and relational models. However, McWilliams does not provide, as noted earlier, a specific structure for written formulations. She is one of the collaborators on the Psychodynamic diagnostic manual (PDM) Task Force (2006), which is based on current neuroscience and treatment outcome studies; many of its concepts are adapted from the classical psychoanalytic tradition of psychotherapy, which is a desirable feature for psychodynamic therapists. The PDM diagnostic framework describes both the deeper and the surface levels of an individual’s personality, emotional and social functioning, and symptom patterns. All of them make bold attempts to integrate the knowledge and skill sets into a contemporary psychoanalytic perspective that informs a comprehensive psychoanalytic formulation. These models were selected for the vast amount of knowledge, scholarship, and expertise

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regarding theory, psychopathology, and personality development that they bring to psychodynamic case formulation methodology. Most case formulation methods cited share three features:  (1)  they emphasize levels of inference that can readily be supported by a patient’s statements in therapy, (2)  the information that they contain is based largely on clinical judgement rather than patient self-report, and (3) the case formulation is compartmentalized into preset components that are addressed individually in the formulation process and then assembled into a comprehensive formulation.

Application of the Psychodynamic Case Formulation Model The foregoing discussion of how a psychodynamic case formulation is developed has reviewed the evolution of the clinical concept in the psychoanalytic and psychodynamic psychotherapy literature. It traced the influence of the concept on empirical research, and finally, provides a summary of contemporary models to illustrate the impact of this clinical and research activity. This leads to an examination of the clinical application of the psychodynamic formulation. CO RE COM PE TEN CI ES

The three core competencies—knowledge, skill, and attitude—have been identified and delineated by Gabbard (2010), employing American Psychoanalytic Association’s core competencies in psychiatric training. These core competencies will be applied for their comprehensiveness and general applicability to psychodynamic case formulation. Specific descriptors have been incorporated under each of the core competencies. For this discussion, the descriptors have been collapsed into to a broader spectrum that should encompass all theoretical approaches. The content of these competencies follows. Knowledge “Knowledge” is the acquisition and integration of fundamental information that is critical to understanding the patient, and that can be subsumed under three categories. The first is a basic foundation, which includes developmental theories, personality development, defense mechanisms, ego organization, difference between neurotic and borderline levels, and psychiatric disorders (diagnosis), which may determine suitability for treatment. The second category is an understanding of unconscious mechanisms, which include transference resistance and countertransference,

Psychodynamic Case Formulation

forms of resistance and manifestations, working with dreams, basic mechanisms of disguise in dreams, function of fantasy (free association), impasse phenomena, and negative therapeutic reaction. The third and final category under knowledge is treatment, which involves the processes of psychodynamic psychotherapy, such as developing diverse goals, different modes of therapeutic action, working with mentalization, a range of expressive-supportive continuums of interventions, the process of working through, and finally, the use of a variety of termination strategies and their management. Skill “Skill” is the ability or capacity to use oneself in the service of the patient. Communications is the first category under skill, and includes listening empathically to the patient’s account, forming a therapeutic alliance, and engaging the patient’s collaboration in understanding symptoms and problems. Skill identifies the patient’s defense mechanisms and incorporates observations about the patient’s nonverbal communications into assessment and treatment. This understanding is integrated into a written psychodynamic formulation within the context of a biopsychosocial model. The ability to shift between empathic immersion in the patient’s point of view and an outside observer’s perspective is an additional critical skill. The second category is the use of unconscious mechanisms, which includes the ability to identify, interpret, and confront resistances; the capacity to collaborate with the patient in understanding a dream; and the ability to identify and work with fantasies. The third and final skill category is treatment, which is the capacity to use countertransference to advance an understanding of the patient and the therapeutic process. It establishes and maintains professional boundaries, and sets appropriate therapeutic goals with the patient. The assessment of the patient’s suitability for long-term psychodynamic treatment and lastly the ability to manage the termination process. Attitude “Attitude,” the third of the core competencies, defines the therapist’s professional role. The first category under attitude is rapport, which includes empathy and compassion; curiosity about the patient’s inner experience and fantasy life (unconscious); restraint in passing judgement about the patient’s thoughts, feelings, and behavior; and, lastly, honesty and receptivity in supervision. The second category is treatment, which is a firm setting of limits and adhering to the therapeutic frame. It also involves

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ethical commitment to putting patient’s needs before one’s own and a sensitivity to gender and cross-cultural issues. The third category is counter-transference, which involves an openness to counter-transferential feelings that may involve the patient’s sexual orientation and sexual behavior; as well as persistence in the pursuit of understanding, even in the face of a multitude of resistances. Psychodynamic case formulation is a consequence of the data collected in the interview, applying the three core competencies as a guide. Once it has been accomplished, the formulation will provide a description of the clinical picture of the patient and her associated stressor(s). The therapist will then generate hypotheses or inferences that may address the question of how biological, intrapsychic, and sociocultural factors contribute and interact with one another. The final and ongoing question is how the formulation informs the treatment and prognosis. Preparing for treatment is the assessment of transference and countertransference. Transference resistance in the context of the personality organization of the patient to determines the suitability and capacity of the patient to respond to treatment. It informs the therapist’s strategy and tactics to make predictions about prognosis. The primary use of the case formulation is to guide and shape the therapist’s decision-making in determining the suitability of a particular type of therapy for a patient; to choose problem areas to focus on, and types of interventions. It is expected that the formulation would be shared with the patient in a face-to-face context to the extent appropriate, with revisions to the formulation occurring during the course of treatment. The psychodynamic interview involves both the therapist and the patient as collaborators, and is a competency (as stated earlier) that drives the case formulation process. The technique or form of an interview is usually determined by the theoretical orientation preferred by the clinician. The literature has a host of references for the interview, such as Sullivan (1956). This section concentrates on the information that is collected in the psychodynamic interview. The seminal work of McKinnon and his colleagues as well as the work of Friedman and Lister were mentioned earlier as a systematic guide to collecting data. McWilliams (1990, 1994), Gabbard (2010), and Kassaw and Gabbard (2002) are others who provide guidelines. Finally, Summers and Barber (2010) describe a schema or grid to keep track of the essential domains over the longitudinal course of the patient’s life that parallels psychodynamic and nondynamic information required in Summers’s (2003) expansion of Perry and colleagues’ work. Starting with the top row, in descending order, are:

Psychodynamic Case Formulation

• Seminal life events, including major family changes or disruptions, traumatic events, life-changing developmental events, and occupational or relationship events; • Key subjective experiences, such as the patient’s description of psychiatric symptoms like anxiety, depression, or obsessional behavior; which includes how the patient feels and felt and how the symptoms developed, as well as the role of trauma, single or recurrent (which could also be included in the first row); • Neurobiological factors, which are nondynamic and include the role of temperament; • Psychodynamic themes, and finally; • Treatments and response. Process of Case Formulation For concision, the following case example uses the traditional psychodynamic case formulation created by Perry and colleagues and expanded by Summers (2003). As conceived by them, a psychodynamic formulation may take from four to six initial sessions to gather the information, is relatively brief (500–750 words), and has four parts: 1. Summary of the case that describes the patient’s current problems and places her in the context of her current life situation and developmental history. It outlines why this particular patient presents with this diagnosis and these particular problems at this particular time. The patient, the precipitating events, the extent and quality of her interpersonal relationships, the most salient predisposing features of her past history, and the prominent behaviors that the formulation will attempt to explain psychodynamically are described. 2. A description of nondynamic factors that may have contributed to the psychiatric disorder. This may include genetic predisposition, mental retardation, social deprivation, overwhelming trauma, and drugs or any physical illness affecting the brain. 3. A psychodynamic explanation of the central conflicts, describing their role in the current situation and their genetic origins in the developmental history. This is an integrative inference based on psychoanalytic principles that considers unconscious fantasies and motives. The focuses is on the central conflicts and uses prototypical psychodynamic models to explain how these conflicts are being resolved.

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4. Predicting responses to the therapeutic situation. This final section of the formulation is related to the prognosis, but rather than predicting the overall course of the patient’s disorder, it focuses on the meaning and use that the patient will make of treatment. Particular emphasis is placed on understanding the probable manifestations of transference (both positive and negative) and the forms and modes of resistance.

Case Example This formulation is written from an ego psychology orientation perspective:  one of the three (the others being object relations and self psychology) that Perry and colleagues used. As indicated earlier, there are other structures that may be used in a psychodynamic case formulation. Part 1: Summarizing Statement Ms. B.  was a 29-year-old, single, elementary school teacher of Jewish background with a history of obsessive-compulsive ritualistic behavior, social anxiety, and generalized anxiety. She had an obsessive preoccupation with body image and eating. She presented two years after moving from her parents’ home because of feelings of extreme anxiety and increased ritualistic behavior and a sense of stagnation. She frequently took Valium, prescribed by her primary physician for her anxiety disorder. She was unable to complete tasks and slept for over 12 hours at a time over the weekends. Ms. B.’s parents married in their late thirties, and she was their only child. Her father, a sales representative, was an over-indulgent and stimulating caretaker. She frequently slept in his twin bed, and he held her tightly, arousing warm sensations. Ms. B.’s mother, a homemaker who had aspired to be a performing artist, was intrusive, controlling, critical, and extremely possessive. They did everything together, excluding her peers. Her mother would confuse her by insisting that she establish friendships, while at the same time criticizing the attempts she made. Ms. B.’s maternal grandparents, survivors of the Holocaust, were primary caretakers until she was four years old. They accepted her unconditionally until their death in her late adolescence. Her mother did not tell her when either one of them died, saying that she did not want to distract her from her studies. Each time she was told, she was devastated and overcome with grief.

Psychodynamic Case Formulation

Part 2: Description of Nondynamic Factors Ms. B. was markedly obese and had attempted numerous diets with the advice and encouragement of her primary care physician. Ms. B.’s mother was an anxious child with close attachments to her parents and difficulty establishing friendships, suggesting the predisposition for a failed compromise formation, resulting in an anxiety-spectrum disorder. Part 3: Psychodynamic Explanation of Central Conflicts Ms. B.’s core conflict involved the issue of separation and individuation. The wish to be autonomous was inhibited by a powerful fear of separation. The comprise formation from this core conflict was a compulsive need to maintain sameness and orderliness. Her obsessive-compulsiveness was a source of ego strength and intactness. Her single-mindedness and attention to detail, as well as intellectualization, had enabled her to complete a master’s degree and sustain a responsible position in education and a profitable business. Failure of this compromise formation occurred when Ms. B.’s superego overwhelmed her ego, resulting in features of an anxiety-spectrum disorder. This was manifested by generalized anxiety, obsessions and compulsions, body dysmorphic preoccupation with her breasts, and episodic impulsive self-destructive indulgence in excessive eating. The onset of this eating disorder was in preadolescence and represented her rebellious effort to establish psychological boundaries. It increased when she went away to college and was no longer under the constant supervision of her mother. She stated that she gained over 100 pounds during that time. Part 4: Predicting Response to the Therapeutic Situation Ms. B. is likely to view treatment as another challenge to her wish to be separate. She will be solicitous and intellectual in her approach, avoiding emotion and feelings. The initial transference/countertransference paradigm will be reflected as a bridge relationship between her mother and the therapist. Ms. B.’s obsessive-compulsive tendencies will emerge in the treatment as compulsive list-making regarding questions she wants to ask, and other anxiety-binding behaviors to maintain control of her boundaries and reverse the roles. This may elicit in the therapist a reaction of anxiety and powerlessness, which represents the feelings the patient struggled with in her relationship with her controlling mother. The transference resistance will be encapsulated in her compartmentalization and preoccupation with her weight,

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dieting, and body image. The prognosis will depend on the therapist’s ability to engage the patient in understanding how this constellation of symptoms emerged from her desire and fear of separating from her mother.

Summary and Conclusions The foregoing discussion has defined the psychodynamic case formulation. In addition it has reviewed the evolution of the concept in the psychoanalytic and psychodynamic psychotherapy literature that has stimulated research over the last 40 years regarding clinician agreement, needs assessment, and more recently, issues of reliability, validity, and prediction of treatment. This review illustrates how the psychodynamic formulation has evolved to its contemporary form, as illustrated by Summers and others. The use of the psychodynamic formulation is illustrated in the above case. The essential features of the psychodynamic formulation include data collection and organization, guided by the core competencies in the psychodynamic interview described in this volume.

References American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., rev.). Washington, DC: APA. Caspar, F. (1995). Plan Analysis: Toward Optimizing Psychotherapy. Seattle, WA: Hogrefe and Huber. Curtis, J. L., & Silberschatz, G. (1997). The plan formulation method. In T. D. Eels (Ed.), Handbook of Psychotherapy Case Formulation (pp. 116–136). New York: Guilford. Eels, T.  D. (2001). Update on psychotherapy case formulation research. Journal of Psychotherapy Practice Research, 10, 277–281. Eels, T. D., Kendjelic, E. M., & Lucas, C. L. (1998). What’s in a case formulation? Development and use of a content coding manual. Journal of Psychotherapy Research, 7, 144–153. Friedman, R.  S., & Lister, P. (1987). The current status of psychodynamic formulation. Psychiatry, 50, 126–141. Gabbard, G.  O. (2010). Long-Term Psychodynamic Psychotherapy:  A  Basic Text. Washington, DC: American Psychiatric Publisher. Horowitz, M.  J. (1997). Formulation as a basis for planning psychotherapy treatment. Washington, DC: American Psychiatric Press. Kassaw, K., & Gabbard, G.  P. (2002). Creating a psychodynamic formulation from the clinical evaluation. American Journal of Psychiatry, 159, 721–726. Koerner, K., Lineman, M. M. (1997). Case formulation in dialectical behavior therapy for borderline personality disorder. In T. D. Eels (Ed.), Handbook of Psychotherapy Case Formulation (pp. 340–368). New York: Guilford Press. Levenson, H., & Strupp, H. H. (1997). Cyclical maladaptive patterns: Case formulation in time-limited dynamic psychotherapy. In T. D. Eels (Ed.), Handbook of Psychotherapy Case Formulation (pp. 84–115). New York: Guilford Press.

Psychodynamic Case Formulation Luborsky, L. (1997). The core conflictual relationship theme:  A  basic case formulation method. In T. D. Eels (Ed.), Handbook of Psychotherapy Case Formulation (pp. 58–83). New York: Guilford Press. Mackinnon, R.  A., & Michels, R. (1971). The psychiatric interview in clinical practice. Philadelphia, PA: Saunders. MacKinnon, R. A., & Yudofsky, S. C. (1986). DSM-III diagnosis and the psychodynamic case formulation. In The Psychiatric Evaluation in Clinical Practice. Philadelphia: Lippincott. MacKinnon, R.  A., & Yudofsky, S. (1991). Principles of psychiatric evaluation. New York: Lippincott, Williams & Wilkins. Markowitz, J. C., &, Swartz, H. (1997). A case formulation in interpersonal psychotherapy of depression. In T. D.  Eels (Ed.), Handbook of Psychotherapy Case Formulation (pp. 192–222). New York: Guilford Press. McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York: Guilford Press. McWilliams, N. (1999). Psychoanalytic case Formulation. New York: Guilford Press. McWilliams, N. (2004). Psychoanalytic psychotherapy:  A  practitioner’s guide. New York: Guilford Press. Nezu, A. M., Nezu, C. M., Friedman, S. H., et al. (1997). Case formulation in behavior therapy:  Problem-solving and functional-analytic strategies. In T. D.  Eels (Ed.), Handbook of Psychotherapy Case Formulation (pp. 368–40). New York: Guilford Press. PDM Task Force. (2006). Psychodynamic diagnostic manual (PDM). Silver Spring, MD: Alliance of Psychoanalytic Organizations. Perry, J.  C. (1997). The idiographic conflict formulation method. In T. D.  Eels (Ed.), Handbook of Psychotherapy Case Formulation (pp. 137–165). New York: Guilford Press. Perry, S., Cooper, A.  M., & Michels, R. (1987). The psychodynamic formulation:  Its purpose, structure and clinical application. American Journal of Psychiatry, 144, 543–550. Persons, J. B., & Tompkins, M. (1997). Cognitive-behavioral case formulation. In T. D. Eels (Ed.), Handbook of Psychotherapy Case Formulation (pp. 314–339). New York: Guilford Press. Ryle, A., & Bennett, A. (1997). Case formulation in cognitive analytic therapy. In T. D. Eels (Ed.), Handbook of Psychotherapy Case Formulation (pp. 289–313). New York: Guilford Press. Seitz, P.  F. (1966). Census problem in psychoanalytic research. In L. Gottschalk and L. R.  Auerbach (Eds.), Methods of Research and Psychotherapy (pp. 209–225). New York: Appleton-Century Crofts. Silberschatz, G., & Curtis, J. T. (1993). Measuring the therapist’s impact on the patient’s therapeutic progress. Journal of Consulting and Clinical Psychology, 61, 403–411. Silberschatz, G., Fretter, P. B., & Curtis, J. T. (1986). How do interpretations influence the process of psychotherapy? Journal of Consulting and Clinical Psychology, 54, 646–652. Summers, R.  F. (2003). The psychodynamic formulation updated. American Journal of Psychotherapy, 57, 39–51. Summers, R. F., & Barber, J. P. (2010). Psychodynamic therapy: A guide to evidence-based practice. New York: Guilford Press.

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FIVE

Beginning Treatment WILLIAM G. HERRON

This is the first of three interconnected chapters on psychoanalytic interventions. All represent ingredients of the analytic process; namely, what goes on in the sessions that is specifically designed to help patients. The first chapter focuses on beginning treatment, and the second on transference, countertransference, and resistance. The third chapter deals with specific interventions, such as interpretation and developing the therapeutic relationship. The first of these three chapters is divided into nine sections, each describing what the analyst needs to know and to do in order to successfully initiate psychoanalytic psychotherapy. These sections describe the initial encounter, the analyst–patient dialogue, the explanation of the psychoanalytic process, the fit and the tilt between analyst and patients, the spectrum of analytic treatment, patients’ questions, and the distinction between psychoanalytic and other psychotherapies. The final section summarizes the analytic work in the early sessions of treatment.

Initial Encounters Psychoanalytic therapists begin treatment by presenting an atmosphere of empathic understanding. This requires a partial identification with the patient on both an intellectual and an emotional level. The analyst understands what the patient is describing and feeling and makes this clear to

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the patient. The patient has the opportunity to feel understood as well as to develop an emotional connection with the therapist. For this match to work and have vitality, the therapist has to want to hear the patient and do his best to have this happen. The patient, in turn, needs to find the analyst to be someone with whom she feels she wants to speak. The necessity of such a listening environment, and the complexity of both parties’ getting immersed in it, as well as the analyst’s being able to move in and out of it in service of therapeutic progress, has been well documented (Kaner & Prelinger, 2005; McWilliams, 2004). It is the “basic intervention” that promotes entry into the subsequent intricate therapeutic relationship. Within this shared sensibility, the analyst is going to both develop a psychodynamic formulation and actually begin the psychoanalytic process. The formulation has been discussed in previous chapters, but a concise summation is useful here for purposes of continuity. It involves the analyst’s placing the patient on a developmental continuum of personality organization that includes identity, object relations, affect tolerance and regulation, reality testing, ego strength, and superego functioning (Psychodynamic Diagnostic Manual [PDM] Task Force, 2006). The analyst needs to be aware of the correspondence between the levels of functioning and the types of dysfunction that are likely to be displayed, both in the patient’s life and in therapy. For example, dividing the levels according to ego structure, the level of least disturbance (neurotic) is likely to show relatively well-contained pathology that is ego-dystonic, manifested as the person suffering loss and displaying dejected affect, essentially a neurotic depression that goes beyond normal mourning. The middle, more severe level (personality disorder) represents a more fixed and pervasive ego-syntonic dysfunction, manifesting as repeated relational difficulties that have become rather entrenched patterns of behavior. Finally, the most severe level of dysfunction (psychosis) involves frequent breaks with reality, manifesting as delusions and hallucinations. This awareness of the patient’s personality structure provides valuable clues for the analyst about what to expect from the patient as well as what interventions are likely to be successful.

Dialogue In order to facilitate both assessment and therapeutic action, the patient is encouraged to speak as openly as possible in regard to her thoughts and feelings as they occur to her. At the same time, the analyst indicates to her that he is aware that at times she may be uncomfortable talking about

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particular issues and want to refrain from discussing, or even mentioning them. He suggests that it would be helpful for the progress of the therapy if, when these obstacles to personal revelation occur, she would let the analyst know what is happening. The suggestion is not a guarantee that the patient will follow it, and particularly at the start of therapy, material may be both suppressed and repressed, but if the patient accedes, a discussion can occur regarding what the patient is feeling that seems like a reason not to speak about a particular thought or feeling. Even if it does not, it does make apparent the patient’s feelings in that situation. The analyst is aiming for “free” association, but will probably have to settle for less. As therapy progresses and the patient becomes more trusting of the analytic situation, she is likely to speak with greater freedom. Also, and ideally, from the analyst’s viewpoint, psychoanalytic psychotherapy would involve frequent sessions over a lengthy duration. This desire is prompted by a belief that long-term therapy provides the best opportunity for the patient to explore feelings and access unconscious material, thereby offering the most complete view of the patient’s motivations. It also provides for the deepest and most intensive patient–therapist relationship. The result is viewed as the greatest provision of a therapeutic effect through both insight via interpretation of unconscious material, as well as the learning that takes place through the therapeutic relationship. In fact, as Freud (1937) pointed out, in terms of learning about the self and thereby increasing the possibility of personality changes and the modification of dysfunctions, analysis could be “interminable,” but practical reasons often dictate its point of termination. This is poignantly true at present, when the norm has become once-a-week meetings for a limited time. Such a situation is due to a number of factors. Socioeconomic changes have altered the face of psychoanalysis, and analytic therapists have had to adjust to this changed environment. Basically, the changes involve pressure for short-term, apparently predictable, evidence-based changes—not the slower-paced flow that analysis has favored. In addition, as psychoanalysis has evolved, so has its theoretical and technical pluralism. This has altered motivational theories and behavioral procedures, such as the interventions discussed in this and the following two chapters. At the moment, within this pluralism, two trends are prominent as the most likely therapeutic factors. These are the gaining of insight through interpretation, and the shifts in relations developed through the therapeutic relationship. As a result, in the initial sessions, analysts tend to be particularly interested in the apparent capacities of the patient for both

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insight and relating. These capacities overlap, in that understanding and relating are interconnected and can facilitate each other. The initial dialogue between analyst and patient usually consists of the analyst’s doing more listening than talking, given that there is much to find out about the patient, so the patient needs to talk and the analyst needs to listen and conjecture. The patient’s conversation emphasizes what is bothering her, such as anxiety and depression, ways in which symptoms appear, how much they disrupt her life, and how she wants to be free of her problems. The analyst’s comments vary, sometimes being encouraging, such as “Tell me more about how you are feeling,” or empathic, such as “That must be very uncomfortable for you,” or somewhat probing, such as “Did you ever have this feeling before?” The analyst is striving to both gain information and be therapeutic. At times the analyst may go further, exploring the possible sources of the symptoms, or the depth of discomfort. The analyst is both attempting attunement with the patient to try to assure her that she is being understood, as well as getting an idea of the pyschodynamics that may be involved. Also, the way in which the analyst’s comments are received, as well as how freely the patient communicates and interacts, are indicators of the way the patient relates. Gabbard describes it succinctly. “The first task, is to convey that the patient is accepted, valued, and validated as a unique person with unique problems” (2005, p. 70). While a tentative psychodynamic formulation is coming about even in the first interview, and certain concerns have to be addressed, like diagnosis and basic treatment formulations, the rest can evolve over time. The initial sessions are evaluative, but the discussion here is concerned primarily with treatment, which is the main reason for the patient’s presence. Of course, there is no guarantee that any treatment will continue, an issue that has to be considered, For example, Barrett and colleagues (2008) have reported that reviewing the literature on continuation indicates that the majority of people do not come to more than six to eight sessions, with 35% ending after a single session. Consequently, the importance of the beginning sessions is striking. While some of the lack of continuation can be attributed to limited motivation, the very fact that a person comes to an analyst’s office indicates some problem is present, so it is crucial that an analyst make a connection with the patient as quickly as possible. This means having an awareness of the “discontinuation factor” on the analyst’s part. The initial dialogue facilitates that, as well nonverbal cues that support the patient’s feelings of “safe understanding” as well as the “possibility of help.”

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Explaining the Process The initial dialogue confirms the presence of a problem, such as the patient’s stating, “I feel down about my work, overwhelmed,” and the therapist’s confirming the feeling as well as trying to expand upon it so that both of them fully understand the problem. The therapist might say, “It feels too much for you and it depresses you,” thereby showing some understanding of the problem. Then, the therapist could add, “That must be difficult for you,” showing empathy. Following this, the analyst could ask, “Are you concerned you won’t be able to do the job?” This expands the conception of the patient’s concerns and can further the discussion. After the problems have been described in some detail, and the analyst has some tentative conceptions of what is bothering the patient and the probable psychodynamic cause of the psychopathology, it is useful to explain to the patient how analytic therapy will proceed and what will be the likely results. That patient not only wants his stated problem to be understood, but he also wants to know that the analyst has something to offer that can help alleviate the problem (Renik, 2007). It is useful to take a few sessions to clarify the psychopathology and the psychodynamics, to get a “feel” for the patient as to the probability of a therapeutic relationship, and any possible resistances. In these early sessions, although therapy has begun to some extent, a firm therapeutic commitment is not made by either person. Both are getting a sense of each other and how it will be as they continue to engage each other. The therapist needs to estimate if this person will be open to a relationship in which the focus is on the patient, both in terms of revelation and exploration, as well as in actually carrying out changes. At the same time, the analyst is a definite participant, observer, and commentator. By the end of the first session, the analyst needs to explain the process, including the possible outcome. For example, the analyst could say: From what you have told me, you are feeling depressed, and you feel it is due to the stress of your job, but you are also concerned about your feelings of inability and helplessness. I can definitely understand that your job has become stressful, which is certainly uncomfortable for you. Many times, when something happens to upset a person’s feeling of well-being, this can also be a useful signal that concerns may be operating that you are unaware of, and they may actually interfere with your ability in dealing with the stress. Psychoanalytic psychotherapy offers a relationship in which you can freely explore your life with another person who

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is particularly interested in you. In the process of exploration, you can make discoveries that will aid your overall functioning. The probability is that your insight will improve, as well as your relational skills, and you will feel better. That last phrase, “you will feel better,” is a relatively safe bet, because most people do feel better talking about themselves to someone who is truly listening. At the very least, there is generally cathartic relief, even if the analyst and the patient have not connected that well. However, the first session is not the time to explain the details of the frame of the analysis; namely, its rules and the constraints of the relationship, which is both unusual and tilted, given that the focus is on the patient’s issues. One detail in the frame does have to be established, however; namely, the fee, which is up to the analyst, even when it is negotiated. The fee is frequently connected to the patient’s circumstances, as well as to the analyst’s. The best approach is to create a fee situation in which both parties are relatively comfortable. Managed-care patients as well as Medicare and Medicaid patients have set fees, and analysts who participate in these programs are aware of this in advance, as are the patients. With other people, there is more room for variability. Countertransference, broadly defined as the analyst’s feelings about the patient, is usually an issue here. It needs to be recognized in order to avoid having analysts attempt to work with people where either party resents the payment, despite having agreed to it. Economic issues certainly have to play a role, but it is a difficult balancing act to achieve an equilibrium of satisfaction for both parties. Can the analyst make enough to support his desired lifestyle? Can his patients value the therapy enough, and have the resources, to pay his fee? How much fee variability can the analyst accept and feel satisfied with the total result? There is no easily determined answer to the fee issue, so it often begins at one place and ends at another, but it is definitely an issue from the start of analysis. Also, the analyst needs to be aware that, although the patient may agree to a certain fee arrangement, the patient may alter it, either because he did not understand it in the first place, but was hesitant to ask enough questions, or because he was being resistive. When fee problems first occur, the analyst should both clear away any misunderstanding and explore the possible motivation for these problems with the patient. Repeated “misunderstandings” usually represent resisting the relationship or doing the same with interpretations, and then it is unlikely progress will be made.

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The Fit Both of these issues, if experienced as potential perpetual resistances, indicate a bad fit. Some hints of this appear in patients who seem to reject attempts at empathy by the analyst (McWilliams, 2004). At the same time, it should be kept in mind that, for some patients, empathy in the early stages of analysis is disturbing, or what Maroda describes as “a spear rather than a baton (2010, p. 20).” Regardless of their accuracy, too many “spears” of empathy can be overwhelming. The issue is not so much that the patient is giving signs of being difficult, but the degree of that difficulty. The patient may feel too resistive for the analyst, and consequently not workable. The lack of fit can also come about because the patient creates feelings of anxiety, or other discomforts in the analyst, to the point that the analyst is likely to always be on edge with this patient. If these issues cannot be worked out rather quickly for the analyst, then the patient needs to be referred. This can be accomplished by stating, “Given what you have told me. I feel you would gain more by working with someone who works with these issues more than I do.” It is possible the patient may react negatively, but the analyst needs to emphasize that effectiveness is the issue here. There is no value in taking on people if you feel it will result in a pointless struggle. Another issue that does have to be addressed is the duration of the session. This is usually 45 to 50 minutes. A few more sessions can result in both the analyst and the patient concluding they want to work together. The patient makes this decision based on deciding that this person, and the analytic process described, is likely to be of help, and the patient feels she can do it. The analyst makes this decision based on a belief that he, and the analytic work, can be helpful, and that he wants to work with this person. This highlights the issue of the “fit” between analyst and patient. Also, before the therapeutic contract is agreed upon, the analyst explains the frame of the analysis that is needed for the work to be successful. Generally, analysts prefer to see people frequently because the contact allows greater focus on the the transference–countertransference matrix, as well as the form and nature of resistances. A subsequent chapter will be devoted to these three phenomena. It is sufficient for the analyst to tell the patient that the intensity created in sessions is useful for both the relationship and interpretation, potential sources of connecting with unconscious motivation. However, as noted earlier, patients are often reluctant to come more than once a week, and at times may want less frequency, like every

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other week, or once a month. Given that it is possible to work analytically with less frequency, and without the couch, if the analyst believes something useful can be accomplished, the analyst can meet the patient’s needs to the extent allowed, but will indicate that more frequent sessions could be helpful. In the current environment, analysts do what they can with what they are given, provided that it appears to be enough to see some signs of progress. Also, the analyst needs to describe basic ground rules regarding cancellations, missed sessions, lateness, vacations, and the timing of payment. The specifics of these issues are up to the analyst, and are designed both to facilitate the process, particularly its consistency, as well as to accommodate the analyst’s schedule, but the patient’s concerns about these issues also must be considered. Flexibility is necessary, but the basic configuration has to fit for both parties.

The Tilt When the therapist is offering a special relationship, very likely different from anything previously experienced by the patient, this needs to be explained. Broadly speaking, it will be a mutual relationship (Aron, 1996), but restricted to the analytic process. Neither analyst nor patient is a social object for the other in a total context. They come to work together, and although a certain amount of socialization may occur in sessions, it is secondary to the analytic work. A session can have a playful aspect (Winnicott, 1905), but the focus is on the analysis of the patient. Freud (1912) suggested a triad of neutrality, anonymity, and abstinence on the analyst’s part, although he did not really practice that way. Given the analyst’s subjectivity, such an approach is not possible. Attempts to do this have not proven helpful. As a result, the triad concepts have been reinterpreted (Gabbard, 2005). Neutrality is an attempt to be nonjudgemental to facilitate the free flow of the patient’s material. The analyst wants the patient to express as many of her thoughts and feelings as she can, particularly those that patients are prone to keep secret. The analyst will have feelings about the material, including exchanges between analyst and patient that may result in the analyst’s unconsciously acting like a patient’s internal object. The analyst needs to be alert to this possibility in terms of its effects on the transference and the therapeutic relationship. Greenberg (1986) redefined neutrality as taking a position between a past object and a present one. The analyst moves into the inner world of

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the patient, but also moves out in understanding what is going on between the analyst and the patient. This is where the analyst’s objectivity comes into play. Early sessions involve a limited amount of engagement and disengagement, marking the beginnings of the analytic process. Anonymity also has come to be viewed differently from its original interpretation. There is relative anonymity, the original idea being the fostering of projection and the viewing of the analyst primarily as a transferential figure, thereby providing greater insight into the unconscious. The need for fostering the transference has been questioned, however, particularly by the relational movement, where a greater emphasis has been placed on the authenticity of the relationship, with transference occurring nonetheless. This is a different way of reaching the unconscious, with more of the analyst’s feelings revealed, though it is not meant as a disclosure of the analyst’s life. It does raise the possibility of slanting the transference, meaning that the more projection is limited by reality, the more likely it is that certain material may not emerge, so this possibility needs to be kept in mind. The advantage lies in that, by not keeping the analyst such a transference figure, intersubjectivity may be increased. Thus, the relational model, akin to the original conflict model, has advantages and disadvantages, and it is up to each analyst to decide what is more appropriate for each patient. The fact that choices can be made illustrates the pluralism available in the field. There are now many possibilities, more than in the past. Also, no matter what the analyst does, there is always transference, countertransference, and resistance. In addition, the patient–analyst relationship creates its own version of transference, based on what seems to be happening between them, but at the same time, tinged by the past. What is also reflected in a more open model of exchange is how the patient and analyst are presently reacting to each other by increasing the mutuality of the exchange. In this fashion, a “new–old” transference is created. Now the analyst has a number of pathways to unconscious material. The method chosen, which can be broadly described as primarily instinctual or primarily relational, often depends on the analyst’s belief regarding which approach is usually more effective. However, there is no hard evidence to suggest that one is better than another, although at present, relational approaches tend to be more popular. Ideally, the method should be customized to the patient. This can be carried out by assessing motivational levels in each patient, as first suggested by Pine (1990) and recently further elaborated by Lichtenberg, Lachmann, and Fosshage (2011). Such methodology will be taken up in detail later. At this point we

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want to complete the redefinition of Freud’s triad of neutrality, anonymity, and abstinence. Abstinence was first suggested in terms of withholding gratification of the patient’s desires so that transference would be more available for analysis, but it became apparent that transference gratifications happened to varying degrees anyway, due to the analyst’s subjective reactions. It also became clear that the gratification of a wish does not preclude its analysis. Also, deprivation of desires of people whose pathology usually includes a history of deprivations appears to be an inappropriate therapeutic technique if broadly applied. At the same time, gratification needs to be selective. First, analysis is not aimed at the gratification of the analyst through the apparent gratification of the patient, so exploitation has to be avoided. This rules out activities such as sexual contact and socialization. The patient is certainly someone toward whom the analyst can feel and act in a friendly manner, but such an approach is limited to what is deemed therapeutic. Boundaries have loosened in recognition of the analyst’s inevitable subjectivity and the potential value of authenticity (Maroda, 1991)  and emotional engagement (Mitchell, 1997). Gratification is usually given to relieve debilitating symptoms or excessive defensiveness, but as Gabbard and Lester (2003) point out, the analytic process itself results in boundary-crossing through introjection, projective identification, and empathy. Basically, without necessarily harming the patient, the analytic process, or putting themselves in jeopardy, analysts can feel comfortable being more authentic, which promotes the initial engagement that is so useful in an early understanding of the patient as well as promoting the continuation of analysis.

The Treatment Spectrum Analytic therapy was originally designed both for rather specific disorders and to be carried out in specific ways, primarily using free association to analyze transference and resistance as pathways to the unconscious. This would involve interpretation (making conscious the unconscious), leading to insight, resulting in behavioral change. However, resistances proved to be recurring forces: in essence, primarily reluctance or refusals, or inability to translate insight into action. Furthermore, as a positive result, analytic methodology proved useful with most disorders, rather than with just the original group. Analysts began to work with a diverse group of patients, and this continues today. For example, Marcus (2003) has recently demonstrated that

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psychotic patients can recover with psychoanalytic treatment. In so doing, analysts have also become well aware that resistances are recurring issues and that many different analytic procedures may have to be involved to provide consistent relief. Analysts need to be continually aware of this and be able to work along a supportive–explorative range. Understanding who will benefit from what technique and when is a complex issue, as is the balance of subjectivity and objectivity. With all this in mind, the analyst needs to be alert to the importance of the early sessions in the formation of an effective therapeutic alliance. Such an alliance has served as the most effective predictor of eventual outcome (Martin, Groske, & Davis, 2000). As Gabbard (2005) has pointed out, in the beginning sessions, the analyst needs to understand patients well enough to see any warning signs of a need for supportive interventions. Some examples of these are a limited tolerance for anxiety and/or frustration; limited psychological-mindedness and capacity for self-observation; significant ego-defects, including difficulty with object relations, reality testing, and impulse control: and a severe life crisis. In contrast, the absence of these difficulties, coupled with significant emotional distress, a desire to relate, and a capacity as well as motivation for insight; and reflective responses to some interpretations, suggests the value of an exploratory approach. Also, although the relationship is a mutual one in terms of respect for each other and both parties’ sharing the goal of improving the patient’s situation, it begins as a tilted, or unequal, situation and remains that way throughout the analysis. The analyst is expected to know more than the patient about psychopathology, psychodynamics, interventions, and how an analysis ought to be conducted. In that sense, the patient expects the analyst to be the “expert,” and by definition the analyst should expect that of herself and strive to fill that role. Of course, in many other ways they are equals, and the analyst should always view the patient as a person who deserves her full attention. Furthermore, there may well be areas of life where the patient is superior to the analyst, which can bring into play feelings of envy and jealousy on the part of the analyst. Distinct inferiority of the patient can do something similar, except the analyst may have feelings of contempt and disregard. In either instance, these are feelings that would need to be resolved by the analyst. The analyst makes it clear from the start that analysis is a collaborative effort. This means that both the patient’s story, and reactions to the analyst’s comments, are expected from the patient. Maroda (2010) points out that enactments are common for both the patient and the analyst, and that

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some patients become attuned very quickly to what is going on in the analyst’s life. The degree to which this affects the analysis is certainly a matter for consideration, starting with the initial session. At the same time, even if the patient correctly senses depression in the analyst (as an example), the tilt remains, because the patient is paying the analyst to be the expert, and by accepting the payment, the analyst seals the deal. It also means that the depression noted by the patient is a reality; it has to be given consideration by the analyst. Does this mean the analyst cannot be objective? As previously noted, the analyst tries to be as objective as he can, given that he is a subject and reactive in both subjective and objective ways.

Questions The patient has a right to know certain details about the analyst, such as the analyst’s training and depth of experience. Details about the analyst’s personal life fall in another category, primarily a transferential one, so they are better left to be imagined and projected. This does not impinge on the authenticity of the analyst, because that refers to the analyst’s feelings and reactions. Also, personal details can be revealed, such as the analyst’s marital status, but the patient’s conception is best explored before the revelation, even if the answer is relatively obvious, such as signified by a ring on the analyst’s finger. The focus is on what the patient feels and thinks, more than on the realities of the analyst’s life. Although analysts bring their past and present circumstances into the analytic session, both parties are there to focus on the patient’s life, not on the analyst’s. The patient has goals in the therapy, and these need to be made explicit. What seems to be desired in the beginning may well shift over time, but the analyst has to decide in the early sessions if this is a workable situation for him. The question is, can analytic therapy meet the desired goals? Symptom relief is the most obvious and frequent request, and is usually desired as quickly as possible. Another possibility that the patient may think could be solved rather quickly is a relationship problem with friends, family members, or co-workers. Analysts are trained to look beyond the presenting problem and investigate the underlying dynamics. However, analysts are certainly capable of doing supportive and educational work as well, so the possible brevity and targeted alleviation suggested by the patient is not automatically a problem. Analysts can verbally alleviate some anxiety or depression, offer some suggestions about relationships, and perform other, relatively brief assistances, but these are not the main aims of analytic therapy. The value of more investigation has to

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be explained to the patient, and if understood and accepted, then psychoanalytic therapy would be put into place. Either way, the analyst can be helpful, and, as noted, just the interaction can be of assistance. It is the analyst’s prerogative to suggest what would be the most beneficial possibility for the patient to follow in terms of alleviation. Also, even if the treatment is brief and supportive, it has a dynamic characteristic to it, with some observations being offered that have to do with the possible meanings involved in the symptoms.

Distinctions What distinguishes psychoanalytic treatment from any other possible therapy? This is clearly an obvious question for the potential consumer in the early stages of treatment. The consumer is going to wonder, is this treatment going to help? The analyst has to consider her ability to help this particular patient. In this era of pluralism, the answer does not legitimately turn on having the “correct” theory, though if the analyst is wedded to a particular theory, it may. However, the most appropriate procedure is to customize the process to the needs of this patient. As a result, analysts can be more effective if they are able to be pluralistic, both in theoretical conceptualization and application. What makes the therapy both psychoanalytic and distinctive, as well as being the common thread in pluralism, is the search and discovery of unconscious meanings, as well as being able to translate the discovery into behavioral change. It is that inexorable link to the unconscious that highlights the identity of the analyst and the treatment. It is true that analysts of different persuasions (meaning that they favor one theory of unconscious motivation over another, as well as the techniques that accompany each theory) are likely to approach the uncovering of unconscious meanings and their operationalization in different ways. For example, conflict theory has one emphasis (drive gratification); relational theory has another (object relations). The proliferation has led to some pessimism. For example, “Our common identity is a remnant of the past, and possibly a hope for the future” (Eisold, 2003, p. 304). Such a statement is a reaction to the complexities of pluralism, but it is also a reaction to theories and techniques that have to be part of an evolving process that at the same time remains true to its essence. Our singular mission remains. Furthermore, focusing on “hope for the future,” Tuckett (2005) points out the need for a disciplined pluralism. In response to Eisold, Tuckett bases the possibilities for disciplined pluralism on competence in

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three areas. These can represent the present and provide a common ground for what Wallerstein (1990) described as the experience-near clinical level. These are, first, to develop a setting to sense the relevant data coming from a patient, particularly affects and unconscious meanings. Both the patient and the analyst gain an impression of the analyst’s abilities in terms of listening, observing, reflecting, and responding. The analyst needs to be aware of both personal and patient perceptions. Some examples (given by Tuckett) include the following: Waiting for material to be understandable; reflecting when presented with a difficult situation; hearing at a level other than the manifest; noticing and reflecting on mistakes; being aware of the effect of each intervention. In addition, for a connection to be made, empathy has to be established, and a working alliance (agreement on the philosophy of analytic therapy) has to be created. The alliance is an agreement by both the analyst and the patient that they are going to work in a psychoanalytic mode; that is, involving free expression by the patient, the development of a relationship, the use of interpretation, and basically the search for unconscious meanings and their use in the alleviation of distress. It is an acceptance by the patient of the psychoanalytic way of working so that the patient is interested in being cooperative, as the two parties have a similar goal: the patient’s improvement through the method offered by the analyst. It is an acceptance by the patient of the role of an analytic patient: that is, not continually disputing the analyst s’ interpretations, or the understanding and establishment of a relationship, or continuing to deny that any particular behavior is a resistance. On the analyst’s part, he is making a commitment to work with the transference–countertransference–resistance triangle, which will be discussed in detail in the next chapter. In this regard, Tuckett has also suggested that, from the start, the analyst needs to conceptualize the psychoanalytic process in theoretical terms. A psychoanalytic model needs to be put into place that fits with the hierarchy of the patient’s desires and concerns. This is where pluralism plays a major role, because now there are many theoretical psychoanalytic models from which to choose. Based on specific institute training, as well as personal preferences, any analyst may be inclined to use the model that is most familiar, rather than the one best suited to meet the patient’s needs. Today’s analysts need to versed in a number of possible models and their application, either to the point of being able to customize analysis to the patients’ motivational structures, or at least, to be able to discern whether the model they prefer to use is likely to be effective with a

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particular patient. If they do not see their preferred model as a good fit, yet the analyst is taken with the model, then a referral is in order. Disciplined pluralism requires the possible application of a variety of theories, and in turn, competencies in each of the theories, all of which are psychoanalytic. Clearly, this requires a belief in the value of more than one theory and its applications, which is a challenging task, but certainly not impossible (Pine, 1990; Renik, 2003; Wallerstein, 1990). Then there are interventions that should follow from both the observational level and the theoretical stance. These tend to be primarily interpretive and relational, and will also be discussed in more detail in a subsequent chapter. These may also consist of non-intervening moments and silences. Although they are technical procedures, the manner in which they occur, as well as words that are chosen, represent an art form that is unique to each analyst. Also, the analyst’s theoretical preference is likely to be apparent in the initial sessions, although the direction of the interventions is always connected to an interest in unconscious meanings and motivations, whether they are supportive or explorative. For example, Maroda (2010), using a relational approach, sees repetitive patterns as both repeating the past, as well as coming from precipitating stimuli appearing in the present. She views analysis as an ongoing interaction between the analyst’s and the patient’s established ways of relating, resulting in emotional encounters that eventuate in change for the patient (and, at times, for the analyst as well). The unconscious is revealed in the evolving encounter. In contrast, an analyst using a conflict model will focus on the interpretation of the unconscious as revealed in the transference as the subsequent path to change. Both models are the analytic process at work, but the first emphasizes relational motivation (interpersonal connection), while the second is more concerned with drive motivation (satisfaction of desire). Both are nonetheless aiming at producing enduring changes in patients.

Conclusions This chapter emphasizes the procedures involved in the early stages of analysis, usually the first three to four sessions, as the analyst and patient agree to work together or part company. The focus is on a desired outcome: continuation of the work. It takes into account the principles indicated in the preceding chapters on psychoanalytic assessment and case formulation. The analytic encounter begins with the development of empathic understanding. An exploratory discussion takes place between

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the analyst and the patient. The patient is encouraged to speak as openly as he can, while the analyst listens carefully, asks pertinent questions, works to begin developing a therapeutic relationship, and may make some interpretations. This is followed by a more detailed description of how psychoanalytic work proceeds. Basically, this involves the description of unconscious motivations and their discovery, as well as the development of a therapeutic relationship, both of which facilitate change in the patient. A fee has to be established that is satisfactory for both parties, and the duration of the relationship has to be established. Within the first three sessions, it is useful to describe the general framework of analysis, the specifics being up to each analyst–patient pair. A major consideration is the “fit” between the analyst and the patient. This means that both subjectivities are in play, as each party brings their own transference, and resistance, to the encounter. The fit needs to be “good enough” so that a therapeutic alliance can develop where both parties want to be together as part of a psychoanalytic process. It is particularly helpful in the early sessions to establish an impression as to whether or not a therapeutic alliance is likely to take place. Part of the match between the therapist and the patient is the understanding that, although there is considerable mutuality in the relationship, it is tilted in favor of the analyst as the “expert.” Despite the presence of the analyst’s subjectivity, she strives to be as objective as possible (Eagle, 2003). The patient comes to her because she is supposed to be “more knowing,” and although she can and does make mistakes, and the patient may even be more accurate on some points, in the main the analyst should know more than the patient about the unfolding analytic process The establishment of boundaries and the analytic frame are depicted as a subjective–objective mixture on the analyst’s part, and as her responsibility. Then the treatment spectrum is described, stressing the need for variations in both support and dynamic exploration. The point is made that analytic approaches have been proven useful with a wide range of disorders. Indications for each emphasis are suggested, as is the value of establishing an early therapeutic alliance. Then questions the patient may legitimately have about the process and the relationship are considered, with an emphasis placed on the purpose being to examine the patient’s life. Finally, the point is made as to the distinctiveness of psychoanalysis from other therapies, including the value of its current pluralism of approaches. Examples are given to illustrate how unconscious motivation

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may be approached from at least two major motivations, relational and conflictual—both analytic, both designed to effect changes, each with a somewhat different flavor to the process.

References Aron, L. (1996). A meeting of minds: Mutuality in psychoanalysis. Hillsdale, NJ: Analytic Press. Barrett, M.  S., Wee-Jhong, C., Cris-Cristoph, P., & Gibbons, M.  B. (2008). Early withdrawal from mental health treatment. Implications for psychotherapy practice. Psychotherapy: Theory, Research, Practice, Training, 45, 247–267. Eagle, M. N. (2003). The postmodern turn in psychoanalysis. Psychoanalytic Psychology, 20, 411–424. Eisold, K. (2003). Towards a psychoanalytic politics. Journal of the American Psychoanalytic Association, 51(Suppl.): 301–323. Freud, S. (1912). Recommendations to physicians practicing psychoanalysis. The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 12, pp. 109–120. London: Hogarth Press. Freud, S. (1937). Analysis terminable and interminable. The Standard Edition . . ., vol. 23, pp. 209–253. London: Hogarth Press. Gabbard, G.  O. (2005). Psychodynamic psychotherapy in clinical practice (4th ed.). Arlington, VA: American Psychiatric Publishing. Gabbard, G.  O., & Lester, E.  P. (2003). Boundaries and boundary violations in psychoanalysis. Washington, DC: American Psychiatric Publishing. Greenberg, J.  R. (1986). Theoretical models and the analyst’s neutrality. Contemporary Psychoanalysis, 22, 87–106. Kaner, A., & Prelinger, E. (2005). The craft of psychodynamic psychotherapy. Lanham, MD: Aronson. Lichtenberg, J.  D., Lachmann, F.  M., & Fosshage, J.  L. (2011). Psychoanalysis and motivational systems. A new look. New York: Routledge. Marcus, E.  R. (2003). Psychosis and near psychosis:  Ego functions, symbol structure, treatment. Madison, CT: International Universities Press. Maroda, K. A. (1991). The power of countertransference. Chichester, UK: Wiley. Maroda, K. A. (2010). Psychodynamic techniques. Working with emotion in the therapeutic relationship. New York: Guilford Press. Martin, D.  J., Graske, J.  P., & Davis, K.  K. (2000). Relation of the therapeutic alliance with outcome and other variables. Journal of Consulting and Clinical Psychology, 68, 438–450. McWilliams, N. (2004). Psychoanalytic psychotherapy. A  practitioner’s guide. New York: Guilford Press. Mitchell, S. (1997). Influence and autonomy in psychoanalysis. Mahwah, NJ: Analytic Press. PDM Task Force (2006). Psychodynamic diagnostic manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations. Pine, F. (1990). Drive, ego, object, and self. A synthesis for clinical work. New York: Basic Books.

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Functional Competency—Intervention Renik, O. (2007). Intersubjectivity, therapeutic action, and analytic technique. Psychoanalytic Quarterly, 76, 1547–1562. Renik, O. (2003). Standards and standardization. Plenary address, American Psychoanalytic Association. Journal of the American Psychoanalytic Association, 51(Suppl), 43–55. Tuckett, D. (2005). Does anything go? Towards a framework for more transparent assessment of psychoanalytic competence. International Journal of Psychoanalysis, 86, 31–49. Wallerstein, R.W. (1990). Psychoanalysis: The common ground. International Journal of Psychoanalysis, 71, 3–20. Winnicott, D.W. (1965). The maturational process and the facilitating Environment:  Studies in the theory of emotional development. London: Hogarth Press.

SIX

Transference, Countertransference, and Resistance WILLIAM G. HERRON

Once the patient and the analyst have agreed to work together, they begin what is called the psychoanalytic process. We will explore this first, then examine its three essential elements of transference, countertransference, and resistance. We will show how these develop as ingredients of all psychoanalytic therapies, and how they are used to develop therapeutic effects.

Psychoanalytic Process “The analytic process” is an intriguing term because it both defies consensual definition and has almost universal usage. Samberg and Marcus recently endorsed its employment as a term that is appropriate to the common elements appearing in all psychoanalytic approaches. They state, “Process is what happens in an analysis and how what happens comes to happen” (2005, p. 230). They also note that in the analytic work itself, different analytic schools will emphasize different parts of the process, thus causing some confusion over just what is the “process.” Controversies about the process, starting with an acceptable definition, have been present since the inception of psychoanalysis (Abrams, 1987; Boesky, 1990; Freud, 1913). These have revolved around what are the essential parts of the process. The current thinking is seen in a definition suggested by Samberg and Marcus: “Process refers to the progressive

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unfolding of the psychoanalytic treatment in which more and more the patient’s unconscious, dynamic psychology, and its organization are revealed, elaborated and explored” (205, p. 229). This process includes transference, countertransference, and resistance. These are co-created to varying degrees by analyst and patient. The degree of the analyst’s involvement in creation depends heavily on his subjectivity–objectivity balance. Also included are “other relationships” between analyst and patient:  the therapeutic alliance, the therapeutic relationship, and the “real” relationship, though some analysts view these other relationships as distinct from transference or countertransference. We will consider all of these, along with resistance, in detail, starting with transference.

Transference The patient’s relationship with the analyst is generally viewed as transference, but qualifications of this concept are necessary. As indicated, some analysts see other components. Also, different schools of analytic thought make different uses of transference: some focusing on interpretation of it, and others on the qualities of the relationship itself, including the feelings of both parties. There are many different ways to categorize transference, as well as differences of opinion regarding the analyst’s role in the creation and development of transference. The origins and content of transference are also subject to dispute. However, there is general agreement that all psychoanalytic therapies contain transference.

Freud’s Concept of Transference The original conception of transference (Freud, 1912)  was that patients have unsatisfied unconscious desires that in analysis are directed at the analyst, despite his attempts at neutrality and objectivity. For the patient, the analyst becomes someone separated from the analyst’s personal reality and turned into a person for whom the patient already has an instinctual drive. The patient develops a relationship with the analyst because potential drive satisfaction requires it, but in this early view, Freud did not see transference as motivated by relational needs (Herron, 1999). For analysts, starting with Freud, the patients’ reactions (transference) were inappropriate, a point reiterated by Greenson (1967) many years later. However, for patients, their responses felt appropriate because they came with an unconscious plan to react in a way that would satisfy their existing

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desires, regardless of the analyst’s behavior. Analysts were attempting to be objective, via neutrality, anonymity, and abstinence, trying to give few cues to their feelings and reactions in order to encourage patients’ projections (transference). Although Freud initially saw transference as a fixation blocking free association, he subsequently changed his view to regard the interpretation of transference as a key feature in analysis. Despite the attempted objectivity, it has subsequently become apparent that analysts are subjective to a greater extent than first imagined. As a result, co-construction of transference appears to be the current understanding of the process (Maroda, 2004). At the same time, the degree of co-construction is in dispute.

The Expansion of Transference Contemporary concepts of transference involve two general types— those close to Freud’s view, and those departing significantly from it. An example of the former is statement that “The client’s experience of the therapist is shaped by his or her own psychological structures and past, and involves displacement onto the therapist of feelings, attitudes and behavior belonging rightfully in earlier significant relationships” (Gelso & Hayes, 1998, p. 11). The drift away from Freud’s conception appears in the work of Melanie Klein, whose attention centered on early mother–child relationship conflicts and the emotional experiences accompanying these conflicts (Likierman, 2001). Blanck and Blanck (1991) view transference as a distortion, but also as a pattern of object relations. Another expansion of the concept highlights the idea that transference becomes more than a replay of the child-parent relationship by adding fantasies and internal representations projected onto the therapist (Blum & Fonagy, 2003). Joseph (1985) comments that transference is a way for patients to demonstrate that their behaviors originate in past relationships with internal objects and involve ways of functioning, including impulses, fantasies, conflicts, and defenses. Such a concept includes a history of growth that fosters a broad description of the patient’s entire therapeutic relationship. Transference was originally intended to be a template for the transfer of desire, but has shifted and expanded into much more of a relational issue. At times it has been viewed as the entire patient–therapist relationship. For example, Maroda describes transference as “the conscious and unconscious responses—both affective and cognitive—of the patient to the therapist” (2004, p. 66). While this expansion has become popular, it

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is by no means universal (Eagle, 2000), so consideration also has continued to be given to analyst–patient relationships that could be viewed as non-transferential and/or not co-constructed.

Transference Distinctions Because transference was originally viewed as a patient distortion, there was also interest in forms of the patient–analyst relationship that appeared to be appropriate, i.e., not distorted. This resulted in distinguishing reactions such as the “therapeutic alliance” (Zetzel, 1956)  or “working alliance” (Greenson, 1967). These were names for the collaborative agreement of patient and analyst to work together within the analytic frame using free association, thereby sharing a philosophy of how analysis was conducted. Such an alliance is needed for an analysis to proceed, and is viewed as an appropriate reaction to the analyst’s expectations, given that these are the basic rules for analytic therapy. However, such an alliance may not be as appropriate as it looks, and may subsequently founder, if it is primarily a transferential desire to try to please the analyst rather than being motivated by the patient’s grasp of reality. To further complicate distinguishing what is “real” in the relationship, Greenson added the possibility of a patient’s realistic perception of the analyst. Also, he admits these reactions can overlap, stating, “There is no transference reaction . . . , without a germ of truth, and there is no realistic relationship without a trace of transference fantasy” (1967, p. 219). At best, relative distinctions can be made that remain open to dispute. What has become more apparent over time is the potential influence of the analyst in shaping the transference, which had been downplayed in earlier views of transference. The analyst is a partner, through interpretations and personal reactions, in developing, resetting, or dissolving aspects of the transference, as well as intensifying some relatively fixed existing patterns or creating new ones. However, in some instances, the transference can seem intractable, no matter what the analyst does. The analyst is always a participant in the transference, but either party in the interaction may appear to be in control at various times, both having to operate within their respective roles. The patient has a need for help, which colors his perception of the analyst’s reactions, and the analyst needs to provide help, which affects her perceptions of the patient’s reactions. Currently, transference is most often viewed as the manner in which the patient relates to the analyst. This is determined by what each person does as the therapy proceeds, particularly as the patient’s issues are

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presented in the therapeutic relationship, which can also provide possible exposure of the analyst’s conflicts. Competencies required for the analyst are an ability to provide a therapeutic environment enabling the patient to be expressive, followed by an ability to understand the patient’s conflicts and assist in their resolution. This includes the ability to distinguish transference reactions from appropriate reactions to the therapist. This means the analyst concludes that certain patient reactions are not engendered by the therapist, in contrast to viewing all patient reactions as co-constructed transference. Eagle notes, “The whole point about the concept of transference is that it points to a ‘stickiness’ of mental structures and patterns” (2003, p. 420). In this view, transference can be considered to be pre-formed patient sensitivities that are activated in the therapeutic setting. The analyst needs to be aware of these sensitivities, their potential for expression, and his possible contribution to their activation, as well as making therapeutic use of the reactions. Furthermore, the analyst needs to be aware of the more comprehensive use of transference as the totality of patient reactions, and to decide which view of transference is the most effective.

Working with Transference Transferences are considered to be negative when they are obstacles to therapeutic progress. These are usually interpreted as they occur, to reduce the blockage. In contrast, positive transferences are in line with the therapeutic alliance and are generally not interpreted until the transference is sufficiently developed to allow an interpretation to be useful. Whether negative or positive, transferences provide access to unconscious content that otherwise might not be revealed. A contemporary synthesis of the value of transference is provided by Grant and Crawley (2002). It provides an understanding of the origin of conflicts and shows how they persist in current difficulties. Transference also makes it possible to highlight current relational patterns as they appear between therapist and patient, with the potential of leading to changes for the patient. Added to this is taking into account the therapist’s possible contributions and the probable intersubjectivity. Gill (1994) suggests three ways of interpreting transference. The first uses a here-and-now focus. The second links the current patient–analyst relationship to other people in the patient’s life. The third establishes connections to the past and the probable causes of present disruptive patterns.

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It is the analyst’s choice as to what approach, or mixture of approaches, will be most helpful. Kohut (1984) linked the development of the self to the type of transference needed by the patient. Patient needs center around requiring others to serve as “selfobjects” fueling the growth of self-structure. Three types of transferences are involved: grandiose, idealizing, and twinship. Grandiose transference requires confirming responses from the analyst. Idealizing transference requires that the analyst be viewed as a source of stability. In twinship transference, the patient’s perception needs to be that he is not alone. The analyst needs to be attuned to the desired transference, adapt to it, and be able to interpret it in terms of the patient’s deficits arising from unmet selfobject needs. In addition, the analyst needs to provide empathic reactions that include acknowledgement and exploration of failures in attunement to the patient’s needs. Akin to this is the intersubjective approach to transference. Distinctions lie primarily in the view of transference as a continuing organizing principle for the patient, and a stronger focus on the therapist’s subjectivity (Stolorow, Atwood, & Brandchaft, 1994). These varied approaches to transference emphasize both pluralism (more than one analytic theory) and the subjective role of the analyst. The original approach to transference was to encourage it as a pathway to unconscious repressed material. The validity of this idea remains. However, the major approach to facilitate this was to have the analyst present a picture of neutrality, anonymity, and abstinence, thereby promoting the patients’ projections constituting transference (Weiner, 2009). Now, all schools of psychoanalysis appear to recognize that the subjectivity of analysts limits such an approach. A  distinction is drawn between analysts’ attempting neutrality and anonymity, thus limiting co-construction in favor of encouraging patients’ projections, and analysts using their subjectivity to open certain psychic space for analyst–patient interaction containing its own transference. The latter approach may slant the transference by limiting other psychic space available for projection, but the first method could limit a useful analyst–patient interaction. The focus point is essentially going to be determined by the analyst’s theoretical beliefs about which is the more effective approach. Weiner notes that therapists are always working with patents’ transference, but have a choice about the manner they are going to work in the patients’ transference. Two inevitables are apparent. The therapist contributes to the construction and development of transference, and at the same time, transference occurs in some fashion regardless of what the therapist does. At issue is

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what the therapist is attempting to do with transference as a therapeutic tool. Negative transference that is limiting therapy needs to be resolved. Positive transference needs to be encouraged. Relative neutrality is the most likely procedure. The analyst in many ways has to be an authority, but as far back as Jung, there was an awareness that the analyst always adds a subjective element to transference and interpretation (Weiner, 2009). Subjectivity means more opportunities for mistakes. If they are detected, the tolerance of these mistakes will depend heavily on the transference. The “fixed transference,” relatively uninfluenced by the analyst’s behavior, is not much of an issue, but the “fluid transference,” influenced significantly by the analyst, will be affected. The analyst has to determine the type and extent of the fluid transference as well as the impact of “mistakes” on it. The question is, how impervious is the transference overall in terms of the analyst’s behavior? Weiner notes that because analysts can influence transference, and often do, greater awareness of such influence is valuable; so is greater flexibility in meeting different transference needs. Authenticity is important, but she believes it needs to be contained in such a way that patients are protected against unwanted intrusions or enactments by analysts. The value in striving for objectivity, although it will be relative, is that it provides more psychic space overall for patients to explore, imagine, and gain independence from conflicts. Whether the focus is on interpretation of the transference, or on understanding and using transference in a relationship, transference is a central feature of the progression of the patient’s self-understanding as well as a byproduct for the analyst’s development of greater therapeutic skill. In terms of elucidating analysts’ competencies in regard to transference, Maroda puts it aptly when she suggests, “Focus on the nature of the interaction and the emotional state of the therapist and patient at the moment. . . . The patient will tell you everything that you need to know, if you will only listen to him and consult with him” (2004, pp. 21–22).

Clinical Example The following is a brief description of a transference interaction. Patient: “I got a promotion today.” The patient uses a moderate tone. Therapist: “You did?” The therapist sounds interested. Patient: “Yes.” Therapist: “Congratulations. I am happy for you.”

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Patient: “Thanks.” The tone is moderate again. Therapist: “You don’t sound enthused.” Patient: “You seem to be implying I should be. That is just what my mother would do, tell me how to react without knowing how it actually feels.” The transference from the mother provides the analyst with a number of possibilities. She could begin an interpretation, stating, “It sounds like you felt misunderstood by your mother.” Or she could focus on the patient–analyst relationship, as, “I realize now that I did not ask you about your feelings.” Both could be avenues to therapeutic progress.

Countertransference Transference has a partner, countertransference: the analyst’s relationship with the patient during the analytic process. As with transference, qualifications of its meaning are needed. Some analysts see the relationship having other components, while others see it as completely countertransferential for the analyst. In addition, different schools of analytic thought use countertransference in different ways, usually emphasizing either containment of the analyst’s feelings, or disclosure. Countertransference can be categorized in different ways, with opinions differing as to the creation, development, and content of countertransference. However, consensus exists in regard to its consistent existence, so competency is required in being aware of it and understanding its various possibilities.

Freud’s Concept of Countertransference Originally Freud (1910) had a similar reaction to countertransference as he had to transference—that it was a problem. In this case, he believed it diminished the analyst’s objectivity. His solution was to get rid of it, or, if that was not possible, to keep it to a minimum. This required the analyst to be continually aware of his own “return of the repressed,” which then would have to be eradicated as much as possible. Additional analysis, supervision, and continual personal scrutiny were recommended to do this. In contrast to Freud’s changing view on transference, he remained convinced of the negative impact of countertransference. As a result, for some time, there was little discussion regarding countertransference. Although it does interfere with objectivity, it turns out to provide other useful possibilities, so his view did not prevail.

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Expansion of Countertransference Gelso and Hayes suggest three other views of countertransference. The first is the “totalistic” position, articulated by Little (1951), further articulated by Epstein and Feiner (1988), and recently detailed by Maroda (2004). All of the analyst’s reactions to the patient are viewed as countertransference and are part of the therapy to be used for interpretation and/or in a relational manner, rather than having to be eliminated. Countertransference is moved into the same position as broadly defined transference—with both regarded as basic, active components of therapeutic interaction. However, this position does seem to deplete the utility and distinctiveness of the terms. The second view is described as “complementary,” emphasizing the continual influence of analyst and patient on each other’s responses, although the patient is considered the originator of the therapist’s responses. Projective identification, where the patient temporarily disowns an affect by projecting it into the analyst who becomes its container (Ogden, 1994), is an example of this. The totalistic and complementary views both view countertransference as a useful part of the analytic process. Both see the therapist’s reactions as derived primarily from the patient’s pathology, but take note of the therapist’s conflicts that may be involved as well. The complementary view approaches co-construction by stressing the patient–therapist interaction. The last approach, “relational,” is the most contemporary, viewing the patient–therapist interaction as jointly developed through the intersection of the psychodynamics of both people. In this approach, the analyst’s countertransferential reactions are more likely to be disclosed to the patient as part of the therapeutic effort (Maroda). Each person is seen as capable of eliciting reactions from the other, so there is considerable mutuality, but the analyst’s authority may move the transference in a particular direction. The patient might react positively to please the analyst, or negatively to preserve the self against a perceived attack, thereby limiting mutuality and the scope of the process. As with transference, some countertransference is likely to persist, regardless of what the analyst attempts. Also, countertransference appears not to be just a reaction to the patient’s transference, so again we have the issue of the “real” relationship compared to the projected one. There is the issue of the therapeutic alliance, more positive with some patients than with others, resulting in a corresponding effect on countertransference. There is a lack of consensus about what projection is, and what is an appropriate reaction on the analyst’s part. Current usage leans toward

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a subjectivity that leaves little psychic space for objectivity. As Weiner points out, analysts need to be able to discern projections, appraise their meaning, make interpretations, and relate therapeutically. This requires psychic space for the analyst’s thoughts that are not automatically and entirely projections, but contain both an awareness of his own subjectivity and the ability to convey accurately what is happening. Competencies required are awareness of countertransference and the ability to use it to facilitate the patient’s understanding and relational capacities.

Countertransference Distinctions Countertransference can be divided into “negative” and “positive” based on the analyst’s feelings about the patient, as well as whether it impedes or facilitates the analysis, the latter grouping being more vital. This is because an analyst could like a patient who was not really progressing, and dislike one who was, although both distinctions are of interest in understanding the analyst’s feelings and their impact on the relationship. Another possibility is to look at “counter-” as an oppositional reaction, or as “complementary,” and in turn a counterpart to the transference (Sandler, Dare, Holder, & Dreher, 2002). Freud (1915) did indicate that some of the analyst’s feelings for the patient are not countertransferential, but instead, appropriate. Weiner points out that a number of analysts, such as Winnicott, Little, Sharpe, and Heinmann, stressed the inevitability and possible value of countertransference. Weiner views it as a joint creation of the analyst and patient, including both the analyst’s subjective responses and the patient’s projections. She emphasizes its value for understanding both patient and analyst in the relationship. Racker (1968) was particularly influential in developing the idea of different types of countertransference. He distinguished “neurotic countertransference,” an over-identification with personal feelings, from “true countertransference,” a reaction to the patient’s transference. He subdivided the latter into “concordant identification,” or empathy based on the analyst’s identifying with the structure of the patient’s personality, and “complementary identification” with the patient’s internal objects so that the analyst takes on the role given by the patient. However, Grinberg (1970) suggested this may be “projective counteridentification,” the analyst’s transference to his own internal objects rather than identifying with the patient’s objects.

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Eagle (2000) has further reservations, suggesting it is more likely that the analyst is reacting to how he is being treated by the patient, rather than identifying with the patient’s internal objects. Eagle consider the analyst’s feelings to be natural ones, and suggests there are no complementary identifications, only concordant ones. Gelso and Hayes offer an integrative view of countertransference, which they see as originating in the analyst’s inner conflicts, but they also believe analysts’ reactions can be engendered by non-transference patient behavior. They see patients exerting an unconscious “pull” on therapists to act as the patients wish, a tendency noted by Strupp and Binder (1989) as well, but it is not to be equated with an automatic complementary response from the analyst. They support the idea of joint patient–therapist construction of countertransference, but with the analyst as the main agent, so the patient’s role needs amplification. Particularly useful is their sharpening of the countertransference concept. They state, “Each of us has experienced intense feelings in psychotherapy that are not connected to unresolved issues, but instead are natural (at times useful) responses to the patient’s material and personhood” (2007, p. 38). Considering the distinctions noted in regard to countertransference, it is clear that, as with transference, limited consensus exists regarding the details of the concepts. At the same time, it is agreed that countertransference is inevitable and multifaceted, and that opinion has shifted from eradicating it to using it. The basic competency to work for is its recognition and differentiation from “natural” analyst’s responses.

The Uses of Countertransference Gelso and Hayes suggest five ways to use countertransference constructively. These begin with self-insight, which for analysts involves personal analysis while training, as well as Supervision, and more of both is useful throughout an analyst’s career. These are necessary competencies, but there is no way to permanently remove conflicts from an analyst’s life, as Freud (1937) noted in his paper “Analysis terminable and interminable.” Changing life circumstances, the shifting rhythm of living, and the temporary de-centering of analytic work (Celenza, 2010)  can revive old conflicts as well as instigate new ones. The analyst needs to be continually aware of his feelings about his patients, the role his own issues are playing in these feelings, and how these feelings are involved in the analyst’s therapeutic reactions to patients.

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This is not an easy task. Weiner noted that anxiety is the constant companion of unconscious countertransference. Furthermore, Gelso and Hayes have reported that self-insight resulting in awareness of countertransference feelings is not sufficiently helpful in a therapy session unless it is accompanied by conceptualization. Thus psychoanalytic theory is a required competency to understand patients’ issues that are connected to the therapist’s reactions. Theory provides an opportunity to use understanding to interpret and/or pursue the therapeutic relationship in depth. A third factor is empathy, requiring varying degrees of identification with patients so that it is apparent that there is attunement to the patients’ needs. At the same time, the analyst has to avoid over-identification and has to maintain a clear sense of self. This introduces the fourth factor, self-integration. This refers to the analyst’s having a firm identity and relatively sound psychological health, as she needs to be more emotionally healthy than ill, and if wounded, rather well-healed. The factors mentioned are valuable competencies for every analyst, but attainable only to a certain degree and requiring continual attention. The inevitability of some countertransference is noted by most analysts (Gabbard, 2001). The question is, what to do about it? There are numerous possibilities, none of which is agreed upon as a universal solution. Eagle (2000) has pointed out that a classical view of countertransference requires awareness and attempts at resolution that are in service of understanding the patient and using interpretation to impart that understanding. He supports the value of the analyst’s doing this (Eagle, 2003)  because, although this involves a personal opinion, it is a knowledgeable one based on the analyst’s store of information about the patient and the patient’s type of disorder, and it is aimed at understanding the patient’s psychic reality. It is a chance to be as objective as possible, and as Nagel put it, “one can increase one’s objective understanding by trying to transcend one’s particular viewpoint” (1986, p. 5). A more contemporary view sees countertransference as a subjective reflection of the analyst–patient relationship that, through identification, becomes a joint creation of the patient’s psychic state. The analyst’s reactions are more indicative of the patient’s inner state than they are of the analyst’s, so they can be used to form an interpretive construction of the patient’s inner world (Eagle, 2003). The first approach is more likely to process the countertransference to interpret the patient’s unconscious, while the second features a jointly constructed relationship

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involving construction of the patient’s unconscious. Both approaches are useful in understanding the patient.

Disclosure The approaches discussed are interpretive rather than directly self-revealing for the analyst, although the “exchanges” in the relational approach create a greater possibility of disclosure of countertransference. Tansey and Burke (1989) divided analysts into conservative, moderate, and radical in regard to disclosure. Most fall within the first two categories. Conservatives see self-disclosure as a definite negative, while moderates do it under special circumstances. The arguments against disclosure are that it burdens the patient, slants the transference, and is basically self-serving. Little (1951) appears to be a major originator of the radicals’ approach. Gorkin (1987) suggested five positive reasons for analyst disclosure; namely, confirming reality, establishing the therapist’s humanity and authenticity, clarifying the impact of the patient on the therapist, and breaking a blockage in the treatment. Maroda (2004) is a major advocate of disclosure. She believes that whatever is necessary to help patients discover the truth must be disclosed, though the disclosure is restricted to the analyst’s affective responses to patients. Once again, there are plenty of opinions, but no consensus on this issue. Personal analysis, self-analysis, and appropriate “defensiveness” are not guarantees against mistakes, but neither are shared vulnerabilities, empathy, and mutual feelings. Gelso and Hayes suggest that once the source of countertransference is understood, analysts consider the basis for possible disclosure, but add, “if they think such a disclosure will be beneficial to the patient” (p. 102). This suggests that the benefit of disclosure is not automatic. Meyers and Hayes (2006) found that if the therapeutic alliance is weak, countertransference disclosure will not be productive. They add that the value of analyst disclosure depends on “the patient’s ability to process interpersonal material, the strength of the alliance, the phase of therapy, and other factors” (p. 103). The add-on of “other factors” signifies that more problems are to be considered. The majority opinion is that disclosure is often more disruptive than helpful, although selective disclosure can be effective.

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Clinical Example In this example, countertransference is viewed as the analyst’s unconscious feelings that surface and are expressed to the patient and subsequently recognized by the analyst as a reaction to the patient’s transference that stimulated an unconscious conflict of the analyst. The patient had called the analyst prior to the session and told her he would be ten minutes late, due to having to deal with some matters with his cleaning lady. When he arrived, he immediately began discussing the cleaning problems and his need to settle them before he could feel comfortable coming to the session. After the analyst listened for a few moments, the patient paused, and she asked “Do you always need to be in control?” A look of dismay passed over the patient’s face; he was silent for a moment, then put his head down. He said, “I feel like you are trying to hurt me.” Although she asked him why he felt that way, and they subsequently discussed his reaction in terms of control issues that were pertinent, she quickly realized she had been angry with him. In retrospect, her phrasing of her initial comment seemed harsh and inappropriate to her. She had many better alternatives. She realized she had felt dismissed in favor of the cleaning lady, reminding her of how her mother would promise to take her some place, but at the last minute, delay their leaving to perform some household chore, or make a phone call that would seem to last forever. He had diminished the importance of their time together, a transference reaction that needed to be explored, just as her mother had done. Indeed, she had attacked him for it. Her recognition of her countertransference alerted her to a subsequent exploration of dimensions of his transference, such as the possibility that he was feeling uncomfortable about a growing attachment to her, so he needed to limit their time, or that he was testing the extent of her connection to him by being late and seeing if she would give him extra time, or other possibilities regarding his transference and her reactions to it.

Resistance Thus far the psychoanalytic process has been described as involving the broad categories of transference and countertransference, with interpretation and the therapeutic relationship exemplified within these categories. Now we come to a third category, resistance, considered by Samberg and Marcus to be one of the fundamental concepts of psychoanalysis. Weinshel (1984) considers resistance “the clinical unit of the psychoanalytic process” (p. 69). Boesky

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notes wryly, “So one can define the process of successful analysis as just one damned resistance after another” (p. 4). The management of resistance is crucial for effective analytic work, and now will be explored in some detail. VI E WS O F RESIS TA N CE

At first, Freud (1912) considered resistance as anything that limited free association, but later expanded his understanding to the many possible sources and results of resistance. It is an inevitable part of psychoanalytic therapy, and its management is an essential competency for the analytic therapist. Such management was originally thought to be accomplished primarily by interpretation, but expanded with the recognition that resistance is both a dynamic and an interpersonal concept, so the analyst– patient relationship is a vital management tool as well. Samberg and Marcus describe resistance as “all those mental processes, fantasies, memories, reactions, and mechanisms that serve to defend against the progress of the analytic process . . . resistance is often a demonstration of basic character and its reaction to defenses” (p. 233). Resistance covers a lot of ground, including defenses and character, but in particular it poses the conundrum of patients’ fearing change while also desiring it, essentially trying to move forward while also trying to stand still or step backward. Although resistance is often oppositional, its most-noted feature, it also can be useful because it highlights the gratification of holding onto the past; as, for example, maintaining what is known to feel comfortable based on familiarity, even if such behavior is ineffective for the patient in many other crucial ways. Maroda provides a helpful view of what appears to be patients’ rather universal fear of change, regardless of the psychic pain in embeddedness. She suggests it is not so much the concept of change that is resisted, as it is the meaning of change, which she considers inclusive of vulnerability. She believes resistance indicates that the patient is indeed alive emotionally, while its absence could imply a type of psychic death. “They fear, and resist, not change, but the death of the person they have managed to salvage over the years. . . . Resistance is a matter of survival, not self-sabotage” (2004, p. 34). A more traditional view (Greenson, 1967)  describes resistance as opposition to the analytic procedures. He describes a number of clinical examples of such a defense, as silence, feeling like not talking, inappropriate affect, position, time fixation, trivia, avoidance, missing sessions, fee issues, boredom, acting out, and transference resistance. The enduring

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nature and types of resistances are seen in a more current list (Thompson & Cotlove, 2005) that includes those already mentioned, as well as talkativeness, excessive descriptions, and lying. These authors also view resistance primarily in terms of defenses, divided into primitive, like splitting; mid-level, like denial, and mature, like humor. A  hierarchy of defenses is consistent with Greenson’s view, but he described different resistances pertaining primarily to different developmental phases, defenses, and disorders, as well character resistances, considered as habitual ego patterns. The more contemporary approach is similar in noting the clinical possibilities. It is less concerned with locating resistances in structures, or creating categories, but more concerned with issues such as the relative contributions of analyst and patient to the presence and use of resistance. The difference between what was—the need for resistance analysis, and what is—differences of opinion about the important of resistance, has been described by Samberg (2004). Busch (1992) and Gray (1996) focus on the defensive activity of the ego as a contemporary version of ego psychology. The analysis of resistance is seen as therapeutic in itself. Outside of this structural theory approach, there is a shift to viewing resistance less as an intrapsychic process primarily created by the patient. Instead, resistance is seen more as the co-creation of analyst and patient. A key issue is trying to understand patients’ resistance to change. Patients emphasize fear about what happens if the “old me” is left behind, the possibilities being losses of safety, pleasure, and positions already attained. As a result, the idea of resistance as an ongoing, ever-present phenomenon remains very much alive. Samberg sums up the results of a panel on current uses of resistance. Of four opinions, three considered the term as having clinical utility. The prevailing views were that resistance is part of the transference–countertransference situation, that there always seems to be resistance regardless of patients’ expressed desires to change, and that resistance is related to defending against affects, especially as they appear in the transference. WO RK I N G WIT H RESIS TA N CE

Greenson suggested six steps in managing resistance. These were recognition, demonstration, clarification, interpretation of the cause, interpretation of the manner of resistance, and working through. The motive for resistance was avoidance of painful affects, but conceptualized in the intrapsychic realm, particularly a repetition of the past in the transference, but without the interpersonal connection that would be more in

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accord with current approaches. Working through emphasizes the value of interpretations, often revisited and reworked, that provide new ways of looking at established patterns of behavior. To translate insight into change, patients have to be motivated. This means that patients have developed consistent “change functions,” such as an observational stance in regard to self-functioning, as well as abilities to both analyze and soothe the self in ways not previously in awareness or utilized. There is resistance to doing this, and even if it is being carried out, resistance remains. This is also true for the more contemporary view that the therapist–patient relationship is the facilitator of change. Neither insight nor relating brings automatic, consistent change. Instead, relative consistency is certainly possible, but there will be regression in service of resistance, whatever the mode of therapy. Wallin (2007) offers a possible antidote to the “inconsistency” effect. People have the capacity to understand behavior in terms of internal mental states that are the foundation for their behavior. Such a reflective view is called “mentalizing,” and it provides for re-description of the past, current circumstances, and the future. The analyst’s mentalizing within a secure patient–therapist relationship facilitates this in patients as well. This is accomplished by “mindfulness,” or focusing on what is being experienced at the moment. Mentalizing explains behavior in terms of meaning, and mindfulness increases receptiveness to what is emotionally important to the patient and therapist as they relate. This approach is a combination of interpretation leading to insight and a path that can lead to a new receptivity to previously unacceptable thoughts and desires so that resistance can become unnecessary. What had appeared as inevitable emotional pain can now be seen in a new perspective that is less threatening. However, there is also a relationship that co-constructs reactions that may appear to be resistance, but the patient at the time sees these reactions as appropriate responses to the analyst’s degree of attunement to the patient’s concerns. Once this is discovered by the analyst, and recalibrated for a better fit, the relationship allows for a new perspective and a diminishing of resistance. Would that this were always so; but whatever the relationship, the level of awareness, and the insights developed, patients continue to resist what is being offered and learned. The importance of repeatedly “melting” resistance is always there. As Maroda notes, “Resistance is born out of fear and distrust, both of self and other” (2004, pp. 34–35). All the methods described treat resistance as a phenomenon that needs to be explained, meaning that unconscious causes are to be explored and

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understood through interpretation or relating, or some combination of both. However, because these approaches are not always sufficiently successful in resolving resistance, the next issue to be considered is managing and using resistance in other ways. M A N AG I N G RESIS TA N CE

Despite his emphasis on resistance as an obstacle, Sigmund Freud (1895) also expressed the value of resistance as a clue to a person’s psychic functioning. He indicated the importance of uncovering the reason for the resistance, which he saw as a defense against a psychic threat. Anna Freud (1936) viewed resistance as a sign of a competent ego using signal anxiety to recognize the need to resist. Within structural theory, Blanck and Blanck (1994) described resistance as a diagnostic indicator, dividing patients into “structured” and “unstructured,” an approach reminiscent of Greenson’s hierarchy of defenses. Defenses have the adaptive quality of seeking psychic equilibrium, and that includes resistance and is applicable in relational theory as well as structural. The major problem for analysts is patients’ fear and distrust of what analysis (including the analyst) will do to them if patients drop their guard, so resistance appears to be a necessity. However, on the positive side, it can be an assertion of autonomy that provides an opportunity for growth. Of course, patients need encouragement to use their autonomy constructively, which means making a reasonable judgement that a therapeutic alliance is more likely to help than to harm them. Such encouragement involves resistance analysis, which opens both patients and therapists to what could be experienced as an attack. The patient’s material is being given the most scrutiny, so it can appear as the most “attacked,” but the analyst’s comments regarding resistance are the stimuli for the perceived attack, so the analyst may be attacked for making the comments. Such a potential at times may cause analysts to avoid resistance analysis, keeping the resistance alive as a possible obstacle. Another possibility is that resistance analysis becomes a sadomasochistic exercise for both parties, without recognition of the motivation, and not making the best use of the resistance. Another possibility is that what seems like a fine therapeutic alliance may actually be limiting resistance analysis unconsciously, so that the gratification of positive transference can prevail, with just enough negative transference to mask certain resistances that will never be exposed. Thus, understanding and using resistance therapeutically is a complicated process requiring considerable attention and skill on the part of the analyst.

Transference, Countertransference, and Resistance

The work of Gray (1994, 1996) provides some ways to assist patients to be motivated to attempt changes despite resistances. These ways are described in terms of structural theory, emphasizing ego functioning, but are applicable to other psychoanalytic theories. Gray points out that we are asking patients to speak freely, and to pay attention to what is being spoken and felt in the dyad. We want them to acknowledge what goes on in the interactions between analyst and patient, whether it is a thought, feeling, or desire; in essence, what Wallin has described as “mindfulness.” Unfortunately, the presence of autonomous motivation by the patient has too often been assumed from the apparent existence of positive transference and the formation of a therapeutic alliance, without complete understanding of the reasons for the motivation. Gray notes that motivation based on the authority of transference is “a form of suggestion . . . widely used to overcome resistance, and more accepted in practice than acknowledged in theory” (1994, p.  68). The result is a “good” patient whose negative transference is minimally exposed. When that happens, a “successful” analysis lacks authenticity. To avoid this, analysts have to stay focused on getting the complete picture of the patient. Patient education is necessary to help them deal with resistance in adaptive ways. This requires explaining that analytic therapy is designed to identify, discuss, explore, and resolve unconscious conflicts that are being handled unsuccessfully by patients, but are clung to, due to a familiarity that represents imagined safety. Patients resist the dangers they associate with the degree of self-observation that would be most helpful in identifying and resolving their difficulties. It is useful to point out that a lack of participation in the process is connected to the reason the problems have never been resolved. Basic conflicts can and will be resolved, provided patients allow access to their existence. For psychoanalysts, the required competencies are the awareness and understanding of resistances, as well as explanation, and its reiterations, to foster motivation. Gray describes this work as “a rational basis for the motivation to develop the ability for self-observation” (1994, p. 70). The analyst needs to show patients the ways they are resisting. This has to be carried out in a way that seems helpful from the patients’ perspective, rather than appearing critical, punishing, provocative, or some other form of disruption in the analytic relationship. Resistances need to be documented, and the value in their recognition needs to be demonstrated by the analyst.

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For example, the analyst indicates that he observed that the patient became quiet when a particular topic, the patient’s mother, was being discussed. The possible reasons for that happening need to be explored, such as the extent of the mother’s influence, the anxiety that awareness aroused, and the further exploration that was avoided by the patient’s silence. The value of the patient’s continuing to talk is illustrated by analyzing the inhibiting anxiety. The analyst makes the point that the fear can be worked through to an understanding of the underlying conflict— punishment for divergence from the mother’s wishes—that can now be seen and acted upon in a constructive way. The basic approach is to diminish anxiety in favor of demonstrable gain, repeating the process whenever resistance arises. This does need to be carried out within the context of the patient’s ability to comprehend the point the analyst is making. Just as the analyst can fail the patient by inappropriate avoidance of resistance analysis, she can overburden with interpreting resistances when a patient is not ready to take in the analyst’s remarks. Resistance analysis is selective. As a guide for choosing possibilities for interpreting, Gray suggests “a selection of those elements in the material that successfully illustrate . . . they encountered a conflict . . . which caused them . . . to react in identifiably defensive ways. By ‘successfully illustrate’ I mean to succeed in directing analysands’ attention to things they can grasp in spite of never ceasing resistance” (1994, p. 76). The pace and degree of building such a viewpoint in each patient will vary. Nonetheless, by creating an interest and desire in patients to be aware of and analyze resistances, the therapeutic alliance becomes stronger and more authentic. The process is a more cooperative, mutual one, and defensive activity can be exchanged for more realistic and adaptive ways for patients to live.

Conclusions The work of the psychoanalytic psychotherapist involves knowledge of the effects of analysis, along with the capability to participate in the use of transference, countertransference, and management of resistance. The ultimate aim of this work is to resolve or ameliorate psychic conflict and produce therapeutic effects. Core competencies for an American Board of Professional Psychology (ABPP) specialist were designated earlier in this book as knowledge, skill, and attitude. The specialist, wherever possible, should have evidence-based

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current information regarding effectiveness of the interventions, the skill to apply them appropriately, and a professional attitude in the acquisition of knowledge and its application. In psychoanalytic therapy, the interventions tend to involve complex processes where definitions are often in dispute. This reflects that psychoanalysis is a fluid, evolving field where analysts currently work in diverse conceptual realms. However, there is agreement as to the presence of the concepts we have discussed, as well as their utility. Two of them, transference and resistance, were present in Freud’s original description of psychoanalysis. Other basics include the unconscious, psychic conflict, and countertransference. Greenson’s list of fundamental psychoanalytic techniques; namely, clarification (understanding what is being said), confrontation (noting contradictions), interpretation (explaining unconscious material), and working through (creating therapeutic effects) remain valid as interventions, although there are controversies about their meaning and the weight attached to each. These concerns are connected to the motivational conceptualization underlying development that is considered primary in fostering the analytic process. For example, it makes a difference whether an analyst considers people to be motivated primarily by instinctual drives, like libido and aggression, or by relational and attachment needs. In the former scenario, the focus will be on interpretation of these drives as the major therapeutic force, whereas in the latter, the analyst–patient relationship is the major therapeutic tool. However, the aim is always the same—producing a therapeutic effect, which is the purpose of working through. How to achieve the most potent therapeutic effect remains a major concern in regard to interventions, and is essentially an open question in our field. The next and last chapter, on intervention, explores this issue through a consideration of the two major possibilities:  interpretation leading to insight, and relating leading to new experience. In the material discussed up to this point, as well as in the next chapter, it is clear that analysts have choices regarding interventions. These choices are made based on their belief in what is likely to be the most effective intervention, so that issue requires further exploration.

References Abrams, S. (1987). The psychoanalytic process: A schematic model. International Journal of Psychoanalysis, 68, 441–452.

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Functional Competency—Intervention Blanck, G., & Blanck, R. (1994). Ego psychology:  Theory and practice (2nd ed.). New York: Columbia University Press. Blum, H. P., & Fonagy, P. (2003). Psychoanalytic controversies. International Journal of Psychoanalysis, 84, 497–515. Boesky, D. (1990). The psychoanalytic structure and its components, Psychoanalytic Quarterly, 59, 550–584. Bush, F. (1992). Recurring thoughts on unconscious ego resistances. Journal of the American Psychoanalytic Association, 40, 1089–1115. Celenza, A. (2010). The analyst’s need and desire. Psychoanalytic Dialogues, 30, 60–69. Eagle, M.  N. (2000). A  critical evaluation of current concepts of transference and countertransference. Psychoanalytic Psychology, 17, 24–37. Eagle, M. N. (2003). The postmodern turn in psychoanalysis: A critique. Psychoanalytic Psychology, 20, 411–424. Epstein, L., & Feiner, A. H. (1988). Countertransference: The therapist’s contribution to treatment. In B. Wolstein (Ed.), Essential papers on countertransference (pp. 282–303). New York: New York University Press. Freud, A. (1936). The ego and the mechanisms of defense. New  York:  International Universities Press. Freud, S. (1895). Studies on hysteria. The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 2, pp. 135–151. London: Hogarth Press. Freud, S. (1910). The future prospects of psycho-analytic therapy. The Standard Edition . . ., vol. 11, pp. 139–151. London: Hogarth Press. Freud, S. (1912). The dynamics of transference. The Standard Edition . . ., vol. 12, pp. 99–108. London: Hogarth Press. Freud, S. (1913). On beginning treatment (Further recommendations on the technique of psychoanalysis). The Standard Edition . . ., vol. 12, pp. 121–149. London: Hogarth Press. Freud, S. (1915). Observations on transference love. The Standard Edition . . ., vol. 12, pp. 157–171. London: Hogarth Press. Freud, S. (1937). Analysis terminable and interminable. The Standard Edition . . ., vol. 23, pp. 209–253. London: Hogarth Press. Gabbard, G. O. (2001). A contemporary model of countertransference. Journal of Clinical Psychiatry, 58, 861–867. Gelso, C. T., & Hayes, J. A. (2007). Countertransference and the therapist’s inner experience. Mahwah, NJ: Lawrence Erlbaum Associates. Gill, M. M. (1994). Psychoanalysis in transition. Hillsdale, NJ: Analytic Press. Gorkin, M. (1987). The uses of countertransference. Northvale, NJ: Aronson. Grant, J., & Crawley, J. (2002). Transference and projection. New York: Open University Press. Gray, P. (1994). The ego and analysis of defense. Northvale, NJ: Aronson. Gray, P. (1996). Undoing the lag in the technique of conflict and defense analysis. Psychoanalytic study of the child, 51, 87–101. Greenson, R. (1967). The technique and practice of psychoanalysis. Vol. 1. New York: International Universities Press. Grinberg, L. (1970). The problems of supervision in psychoanalytic education. International Journal of Psychoanalysis, 51, 371–374.

Transference, Countertransference, and Resistance Herron, W. G. (1999). Narcissism and the relational world. Lanham, MD: University Press of America. Joseph, B. (1985). Transference: The total situation. International Journal of Psychoanalysis, 66, 447–455. Kohut, H. (1984). How does analysis cure? Chicago: University of Chicago Press. Likierman, M. (2001). Melanie Klein. Her work in context. London: Continuum. Little, M. (1951). Countertransference and the patient’s response to it. International Journal of Psychoanalysis, 32, 320–340. Maroda, K. J. (2004). The power of countertransference. 2nd ed. New York: Routledge. Meyers, D., & Hayes, J.  A. (2006). Effects of general self-disclosure and counter­ transference disclosure on ratings of the therapist and the session. Psychotherapy, 43, 247–262. Nagel, T. (1986). The view from nowhere. New York: Oxford University Press. Ogden, T. H. (1994). Subjects of analysis. New York: Aronson. Racker, H. (1968). Transference and countertransference. Madison, CT:  International Universities Press. Samberg, E. (2004). Resistance: How do we think of it in the twenty-first century? Journal of the American Psychoanalytic Association, 52, 243–253. Samberg, E., & Marcus, E.  R. (2005). Process, resistance, and interpretation. In E. S.  Person, A. M.  Cooper, & G. O.  Gabbard (Eds.), Textbook of psychoanalysis, pp. 229–240. Washington, DC: American Psychiatric Publications. Sandler, J., Dare, R., Holder, A., & Dreher, A. (2002). The patient and the analyst: The Basis of the psychoanalytic process. New York: Kanac. Stolorow, R.  D., Atwood, G.  E., & Brandchaft, B. (Eds.) (1994). The intersubjective perspective. Northvale, NJ: Aronson. Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in a low key. New York: Basic Books. Tansey, M. J., & Burke, W. F. (1989). Understanding countertransference: From projective identification to empathy. Hillsdale, NJ: Analytic Press. Thompson, J. M., & Cotlove, C. (2005). The therapeutic process. Lanham, MD: Aronson. Wallin, D. G. (2007). Attachment psychotherapy. New York: Guilford Press. Weiner, J. (2009). The therapeutic relationship. College Station, TX: University of Texas A&M Press. Weinshel, E. M. (1984). Some observations on the psychoanalytic process. Psychoanalytic Quarterly, 53, 63–92. Zetzel, E.  R. (1956). Current concepts of transference. International Journal of Psychoanalysis, 37, 369–375.

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Therapeutic Effect WILLIAM G. HERRON

A distinguishing feature of psychoanalysis that often gets limited notice in terms of its therapeutic effect is the emphasis by some analysts on the process itself. This consideration differs from the strong emphasis on the impact of unconscious motivation to create therapeutic action. However, what most directly aims at therapeutic action has to get first notice. For example, Renik states, “The author [Renik] defines the therapeutic action of psychoanalysis as the patient’s increased capacity to make changes in his/her attitudes or behavior in order to achieve greater well-being and satisfaction in life” (Renik, 2007, p. 1547). Kernberg sums up the direct therapeutic effect that can be considered an “up-front” aim of all psychoanalytic methods by stating, “The objective of all psychoanalytic approaches is to feel better” (2007, p. 1707). It is, after all, a therapy (among other possibilities), so the patients expect such results, and it is on this basis that comparisons with other psychotherapies are usually made. The basic practical question is, how well does it work? This has been substantially addressed in terms of research, and case material, in other chapters. Our current concern is, how does it work? The answer is that two factors—namely, specific interventions and the analytic work itself (as the sum of interventions, interactions, and interpretations)—are the contributors. Interpretation is primarily a subjective experience that may be only incidentally concerned with symptoms. As Freud commented, “The removal of the symptom of the illness . . . is achieved . . . as a byproduct of the analysis” (1923, p. 251). Aisenstein (2007)

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notes that Lacan takes this view further, putting the purpose of analysis as undergoing the process for its inherent value. Aisenstein states, “I see therapeutic action as an indisputable truth . . .” (p.  1458). She continues, “Analysis . . . alone aims . . . at aiding patients to become . . . the principal agents in their own history and thought” (p. 1460). She states that, in 1933, Freud insisted on the truth value of psychoanalysis, which included the possibility of improvement. This means that psychoanalysis offers two intertwined possibilities, the experience of analysis, and the therapeutic effect, which is usually derived from the experience, yet the experience can be distinctive because its purpose is to unfold the truth of the patient’s life: not necessarily to be equated with being curative. The experience, however, has become a “something else” conceptually; namely, a therapeutic method with its success in that regard moved to the forefront, reversing the original emphasis on the analytic procedure itself. The reversal has occurred for practical sociocultural reasons, and as a result, our discussion will focus on the therapeutic factors of analysis. We will explore the merits of the two prime interventions in the analytic process, interpretation and relating, as therapeutic factors.

Interpretation A basic premise of psychoanalysis is that patients are not sufficiently aware of the motivations for their actions. They have a “blind side,” which causes them to persist in living limited lives. The “real reasons” for their behavior are hidden, disguised by “assigned conscious reasons.” Interpretation is a psychoanalytic intervention that provides the revelation of the real (unconscious) reasons. The idea that people are unaware of much of what goes on in their minds, and that they may have many reasons for wanting to remain unaware, is not new. However, psychoanalysis powered the focus on unconscious desires that were leading to a set of conflicts that resulted in seemingly inexplicable symptoms. The unconscious mind was a morass of conflicting desires over which the conscious mind had limited control. Various defense mechanisms, particularly repression, were unconsciously employed to protect patients against psychic pain, like anxiety and depression, but such defenses were often unsuccessful. The result was a variety of mental disorders that combined unresolved conflicts with constitutional predispositions to result in neuroses, character disorders, or psychoses. These were mystery diseases that defied customary medical explanations and treatments. Psychoanalysis originally concentrated on the neuroses, where the lifting of repression appeared to have the greatest

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chance of success; but in time, analysis spread to the other disorders as well. The path to solving the mystery disorders seemed to have opened. Using patients’ associations, analysts would discover and explain alternatives to the patients’ assumed explanations that were restricting their lives and resulting in their bewilderment at what was happening to them. Analysts, with the assistance of patients’ associations and psychoanalytic theorizing, now appeared able to reveal the actual behavioral motivations, the nature of the conflict of desires, the defenses against “knowing,” and the ongoing resistance to using the interpreted knowledge. Certainly this can happen, and is accomplished most easily with neurotic patients because their reality testing is relatively intact, resulting in a greater willingness to understand unconscious motivations and use the insights being offered. However, character disorders are more difficult because of the relative unacceptability by the patient of hidden motivations, and psychoses are particularly difficult because of the patients’ breaks with reality. Also, in practice, many pathologies contain a variety of disturbances, bringing a mixture of motives and defenses. Also, resistance is an issue in all disorders. While evidence accumulates that psychoanalytic approaches can be useful in all disorders, modifications are required, and there always seem to be some patients who do not change, despite the accuracy of interpretations. The insight provided through interpretations seems as if it should lead to greater motivational understanding that would translate into behavioral change. In many cases, that does happen, but such change is not guaranteed. It is the “failures” of interpretations that are of interest; namely, resistances to change that are variable, in turn limiting the power of interpretation. For interpretation to be effective, resistances have to be depleted, or at least mitigated. The management of resistance has been discussed in the previous chapter. Here, our particular interest is focused on resistance to using insight to make behavioral changes. Freud suggested a number of ways to facilitate the value of interpretation. All involved the elusive “working through” process to actualize change. He emphasized the analysis of resistance and transference where working through appears to be repetitive analysis of this material (1912). Added to essentially learning through elaborated insights was the therapeutic alliance (Greenson, 1965), also described in the previous chapter. Also, positive transference is valuable in aiding the patient’s desire to accept and act upon interpretations. Such transference is a large part of the patient–therapist relationship, but,

Therapeutic Effect

as Eagle (2011b) points out, this does not mean that the relationship itself is the therapeutic agent. Moreover, “Love the analyst, so love the analyst’s interpretation” goes only so far. A number of limitations are involved. First of all, the analyst’s interpretations are not always correct. They are subjective, so they are open to the influence of the analyst’s personal feelings. Also, every analyst has limitations in both knowledge and technique, so mistakes are made. Beyond that, Freud (1914) noted that patients need time to work through resistances, and so do analysts. The question often posed is, how much time? The answer is, whatever time it takes, meaning the working through is potentially open-ended, and that kind of time is usually not available. Eagle also notes that Freud appeared to believe that the “working-through time” consisted of the patient’s continuing to free-associate, with the result being that the resistances would melt away, but this has not proven effective. Working through is a more complex process. In the previous chapter, we discussed resistance analysis (Gray, 1994), which is a large issue in working through. Waelder (1960) has described working through as similar to the process of mourning. Insight offers some unwelcome realizations, such as becoming aware that certain personal desires will remain unfulfilled. However, akin to the desire to have a loved one who has died, the desire for the lost object returns. This serves as a resistance to acting on an insight, such as the need for a new object, which is being overshadowed by the desire for the lost object. Waelder believed that the repetition of the desire arising from repeated interpretations would make it clear that the original desire had to be given up, and given time, that would happen. In essence, the possible would replace the impossible, but time again weighs in as the improbable factor. The process of working through highlights a conflict. The aim is to have the patient both become willing to act, and then act, but part of the resistance of the patient to doing this is not wanting to give up a way of being that the patient has come to consider necessary for his well- being, such as dependency. Greenberg (1991) highlights this danger for the patient in changing, as he notes, “We do not move forward without relinquishing something valued” (p. 141). Greenberg describes the interpretive process as constituting five steps. The first is that the patient talks freely, attempting to avoid self-censorship. Nonverbal communication can also be part of this openness to the analyst. The analyst both observes and listens, considering where the focus of the work is best applied, as well as what the most effective interventions will be. The result is a framework developed by the analyst that is based

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on the listening-observational process. This provides a direction to the patient’s data that is to be interpreted as well as how it is to be interpreted. The result is that what was previously unconscious for the patient is now displayed, putting a new and different perspective on the patient’s behavior. The analyst provides an impression of the patient’s actions, thoughts, and feelings that differs from the patient’s conscious experience. Analysts carry out these basics in different ways, but in essence, the guides for interpretation are the material produced by the patient and the analyst’s theoretical deconstruction of it so that hidden motives can be seen, considered, understood, and if so desired, altered or used. The patient is given chances to change with every interpretation, but the exposed motives create a conflict with the life already being lived. The logic of change beckons, but the safety of familiarity remains tempting, just as the mourner keeps remembering and wishing there was no need to change. At times, change will appeal to the point of prevailing, resulting in a therapeutic effect, but at other times it will not. Despite an awareness of the latter possibility, Kernberg believes that interpretation of the patient’s unconscious is the key to a therapeutic effect, with working through involving persistent interpretation of the transference, which facilitates the patient’s positive experience of the analyst. At the same time, there appears to be more to this process than interpretation, yet without interpretation there would be no analysis, and in turn, no opportunity for new perspectives. Eagle (2011b) summarizes the trajectory of interpretation. Its value tended to be relatively unquestioned from Freud’s original proposal and as long as the culture valued the belief that self-knowledge was the most effective way of freeing the personality from destructive conceptions and behaviors. Because true self-knowledge was not available due to personal defenses, interpretation provided a way to create transparency and was viewed as curative. Interpretation aimed at congruence with “real” reality for the patient. Given that interpretation by itself has not been as effective as desired, attempts have been made to elaborate and enhance interpretation. Greater notice was taken of resistance, countertransference, the need for a therapeutic alliance and working through, but doubts remained that the “blank screen” analyst relying mainly on interpreting the transference was the answer to developing a therapeutic effect. What resurfaced was the possibility that the therapeutic relationship was also a curative factor, rather than primarily a background for interpretation of transference. Instead, the relationship itself came to be

Therapeutic Effect

considered a “corrective emotional experience,” which in turn was viewed as the major therapeutic ingredient. Unfortunately, this led to a division between emphasizing the use of interpretation and the analyst–patient relationship. “Self-understanding is replaced by feeling understood by the other, . . . and insight is replaced by corrective emotional experience” (Eagle, 2011a, p. 105). This development is the reason we are discussing “interpreting” and “relating” separately. However, as Eagle (2011b) points out, this is an unnecessary division. One is usually contained in, or accompanies the other. A supportive relationship aids the effectiveness of an interpretation, which in turn embodies an emotional experience. Both approaches are potentially change factors, and each one always has at least a little bit of the other. Also, the process of interpretation has undergone modifications. These reflect shifts in emphasis, such as the defense analysis described previously. There is also a movement that is less concerned with discovering repressions, and is rather focused on the workings of the mind and the idea that reason serves the appropriate meeting of desires and needs. All of these modifications retain the importance of the self-knowledge that involves interpretation. However, there is a limit to the scope of interpretation—analysts being more “mind-guessers” than “mind readers,” thereby undercutting the accuracy of interpretation. Also, there are relationship factors involved in interpreting that may produce therapeutic effects. The result of these observations is an increased awareness of the contextual value of insight, and, as previously noted, the need for the analyst to manage the repeated resistance by patients to the use of insight. Working through is a process in which only some of the parts have been clearly delineated, so there is a lack of clarity about actualizing the concept in practice. Providing insight still can leave the patient with a wish for the pleasant part of the past, the known gratification. To avoid the possibility of pain that may exist in being different, the insight can be understood but subsequent action deferred, or the interpretation can be rejected so that nothing has to change. However, if insight occurs and a patient “works on it,” then goes a step further and “works it through” to the point that change is now attractive, possibilities emerge as the past recedes and new possibilities appear. There is empirical evidence that accurate interpretations are related to good outcomes (Crits-Cristoph, Cooper, & Luborsky, 1988). At the same time, there is the persistence of states of being, feeling, relatedness, whatever it is a patient thinks and feels creates the strongest

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tug to avoid or not use insight, so we are always confronted with the need for the management of resistance with an appropriate mixture of safety and effectiveness (primary patient motivations suggested by Greenberg). This is essentially a trial-and-error process requiring time and patience for interpretations to become effective. It is here that patients and analysts stumble, struggle, and search for the motivational keys to a better life. It is clear that the semantic content of interpretation, by itself, is not a guarantee of therapeutic effect. It is also clear that dichotomizing curative factors is not necessary or particularly useful, given that psychoanalysis today often engages in pluralism involving both insight and corrective emotional experience.

Motivation There has always been a tendency toward reductionism in psychoanalysis. Interpretation as the major therapeutic factor (including working through) is part of the reductionism of the earlier (classical) approach emphasizing two motivational drives (biological urges), libido (sexually powered) and aggression (destructive as well as assertive). All behavior was seen as derivatives of these drives involving behavioral transformations. The result was the absence of an obvious relationship between current behavior and its unconscious origins. Relationships with others were a secondary motivation, a means to provide drive gratification. In relational theory, the reverse is postulated. Fairbairn (1952) suggested that there is one major motivation—seeking contact with others (which includes objects-seeking as well as attachment). Self-psychology can also be seen as under this rubric, as individuals throughout their lives are in need of “selfobjects” (empathic others) in order to feel understood and have a cohesive self. Connection to others is the primary motivation, while libido and aggression are the tools of socialization. As a result, in this theory, positive emotional experiences with others (including self-assertion) are seen as the major therapeutic ingredient, rather than self-understanding through interpretation. The analyst is primarily a “relator” rather than an “interpreter.” The traditional analytic stance of maintaining anonymity, abstinence, and neutrality is mitigated because the focus is on engagement rather than transference. The therapeutic aim is to develop a relatively real connection in the therapy sessions, rather than a transferential one, although transference occurs and is available for analysis.

Therapeutic Effect

Relationships The basic divide in psychoanalytic theory and practice rests on what is to be the primary focus of the analysis, but relating and interpreting are intertwined. Greenson’s (1967) early mention of the therapeutic alliance as well as the “real relationship,” with both distinct from the transference, indicated his awareness of the complexity of the analyst–patient relationship. However, his comments were not at that time designed to emphasize the therapeutic effect of the person’s relating to the analyst. That emphasis was brought into play with a book by Greenberg and Mitchell (1983) and has continued to become the relatively dominant approach in contemporary psychoanalysis. The therapeutic relationship tends to be viewed in a number of different ways. The most prominent is that the patient has a relationship with the analyst that is different from most, if not all, of the patient’s other relationships. The difference is primarily in the analyst’s nonjudgemental acceptance of the patient’s thoughts and feelings. Glickhauf-Hughes and Wells (1997) point out that the analyst provides a corrective emotional experience for the patient, but they see this as an additive to interpretation. Other variations play down the role of interpretation. Of course, in this model, it is most helpful to get the accurate corrective experience, meaning that it is properly attuned to the patient’s difficulties and capabilities to master emotional dysfunctions and deficits. Self-psychology promotes this attunement through an analyst–patient dialogue that aims for an effective response to a variety of transferences. Glickhauf-Hughes and Wells indicate that the aim is not that the analyst manipulate, or assume a role, but that the relationship be a genuine relationship. The analyst makes up for a developmental deficit or continuing relational trauma by behaving and responding in an authentic and empathic way that differs from the way significant others have treated the patient. Mitchell (1988) offers a somewhat different view of the experience: the key feature is the building of experience within the relationship. Eagle (2011a) notes that the therapist’s acceptance of the expression of desire is a different reaction from what most patients received in preceding relational experiences, particularly with their parents. This supports generalization of possible relationships with significant others.

Transference and Countertransference As the analyst becomes more “real,” the probability of patient projections becomes more limited, and countertransferential responses are likely to

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be more apparent. However, as indicated earlier, some transference always seems to exist. What may be gained via warmth and empathy can make establishing appropriate boundaries more difficult. The distinction needs to remain that the analyst can be friendly and caring, yet is not a social friend.

Convergence While hard research evidence to support the best technique to maximize therapeutic effect is not currently available, it is clear that insight and relating are always involved. It is possible to stress one more than the other, with each having its technical risks, as loosening or tightening boundaries can create a negative effect on patients, really “making matters worse,” so these factors have to be kept in mind. The goal is to be therapeutic, with insight and corrective emotional experiences able to be employed together as well. Also, while considerable attention has been appropriately given to the impossibility of maintaining strict objectivity in a human encounter such as analysis, attention must also remain on the analyst’s objective knowledge base and the need to attempt objective understanding. It is a false dichotomy to insist that either insight or the therapeutic relationship is the main therapeutic agent, because one is not automatically given without including the other, even if so intended. The patient actually decides what brought about any change. Analysis is the carrier of the possibilities, and the analyst is the one making the offerings. Analysis is certainly a relationship, but its ingredients are not readily transparent. It is important that the analyst understand the patient as thoroughly as possible and form relatively objective conclusions. It is also vital that the patient feel understood and supported. Regardless of the analyst’s emphasis, the patient is there to be analyzed. This means that unconscious motivation needs to be recognized in consciousness, that there be ongoing, implicit, relational knowing (Lyons-Ruth, 1999), and that insight, whether relational or interpretive, leads to change, Analysts, like all therapists, are agents of change.

Resistance A final word needs to be said about patients’ adhesion to what was and is, and their opposition to an embrace of what could be. Change, like growth, is a process that has its own timetable. In psychoanalytic work, the analyst’s expectations are that it is most likely to occur slowly. Resistance is the

Therapeutic Effect

obstacle, and resistance in varying degrees remains after the patient has terminated with the analyst. However, the more complete the analysis, the more likely it is that resistance will be substantially decreased. Analysts want time for the process to work, which means a high frequency of sessions and a lengthy duration. As previously noted, contemporary culture does not support taking the desired time. Psychoanalysis is adapting to this restriction by using a more targeted approach to patients’ problems, but this compromises therapeutic effects because of the lessened opportunity to mitigate resistance. In essence, currently, the therapeutic effect of the process is limited in favor of more direct therapeutic action in regard to patients’ stated complaints.

Conclusions Interpretation and a therapeutic relationship have become the main agents of therapeutic effects. Although some analysts and analytic schools of thought tend to favor one agent rather than the other, they are always partners in some fashion. Interpretation has always been set in a relational context of empathy, and relationships are set in a context of explanation. Also, although the analyst may focus on one factor, the patient may view the other as more important. The evidence for the value of each point of view at this juncture rests on clinical experience. The fact that interpretation and emotional-relational experience are both used as major therapeutic interventions points to a trend already mentioned in this book; namely, pluralism. This extends to analytic schools, theories, and methods, and indicates the need for recognition of multiple motivations (Lichtenberg, Lachmann, & Fossaghe, 2011; Pine, 1990)  rather than reductionism. As Eagle states, “Self-knowledge that leads to therapeutic change, emerges in the context not only of interacting with the other but also of reflecting on and trying to understand how one construes the other . . . ” (2011a, p. 293).

References Aisenstein, M. (2007). On therapeutic action. Psychoanalytic Quarterly, 76, 1443–1461. Crits-Cristoph, P., Cooper, P., & Luborsky, L. (1988). The accuracy of therapists’ interpretations and the outcome of dynamic psychotherapy. Journal of Consulting and Clinical Psychology, 54, 490–495. Eagle, M. N. (2011a). From classical to contemporary psychoanalysis. New York: Routledge. Eagle, M.  N. (2011b). Psychoanalysis and the Enlightenment vision. Journal of the American Psychoanalytic Association, 59, 1099–1118.

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Functional Competency—Intervention Fairbairn, W. R. D. (1952). Psychoanalytic studies of the personality. London: Tavistock. Freud, S. (1912). The dynamics of transference. The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 12, pp. 97–108. London: Hogarth Press. Freud, S. (1914). Remembering, repeating, and working through. Standard Edition . . . , vol. 12, pp. 145–158. London: Hogarth Press. Freud, S. (1923). Two encyclopedia articles. Standard Edition . . . , vol. 18, pp. 235–259. London: Hogarth Press. Glickhauf-Hughes, C., & Wells, M. (1997). Object-Relations psychotherapy. Northvale, NJ: Aronson. Gray, P. (1994). The ego and analysis of defense. Lanham, MD: Aronson. Greenberg, J. (1991). Oedipus and beyond. Cambridge, MA: Harvard University Press. Greenberg, J., & Mitchell, S. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press. Greenson, R. (1965). The working alliance and the transference neurosis. Psychoanalytic Quarterly, 34, 155–181. Greenson, R. (1967). The technique and practice of psychoanalysis. New York: International Universities Press. Kernberg, O.  F. (2007). The therapeutic action of psychoanalysis:  Controversies and challenges. Psychoanalytic Quarterly, 76, 1689–1723. Lichtenberg, J. D., Lachmann, F. M., & Fossaghe, F. (2011). Psychoanalysis and motivational systems. New York: Routledge. Lyons-Ruth, K. (1999). The two-person unconscious. Intersubjective dialogue, implicit relational knowing, and the articulation of meaning. Psychoanalytic Inquiry, 16, 257–264. Mitchell, S. (1988). Relational concepts in psychoanalysis. Cambridge, MA:  Harvard University Press. Pine, F. (1990). Drive, ego, object, and self. New York: Basic Books. Renik, O. (2007). Intersubjectivity, therapeutic action, and analytic technique. Psychoanalytic Quarterly, 76, 1547–1562. Waelder, R. (1960). Basic theory of psychoanalysis. New York: International Universities Press.

SECT IO N IV

Other Functional Competencies

EI GHT

Supervision WILLIAM G. HERRON

Given the importance of supervision in training psychoanalysts, noted in Chapter  9, we will now examine the competencies needed to be a psychoanalytic supervisor. A succinct description is provided by Kernberg; namely, “to transmit to the supervisee knowledge of the application of psychoanalytic theory to psychoanalytic technique, with particular reference to the skills required to carry out the technical requirements of the supervised case” (2010, p. 61). A competent supervisor needs to know psychoanalytic theories as well as how to apply them to psychoanalytic techniques, which requires knowledge of the techniques, which we described previously as interventions under the general headings of transference, countertransference, and resistance. The supervisor also must be able to create an environment where the knowledge can be transmitted to the supervisee. This is a complex process that we will examine here in more detail, beginning with an understanding of the supervisory process. Included in this process are the supervisor–supervisee interactions that involve the development of a reflective atmosphere, as well as the reported analyst–patient interactions that are the raw material for supervision.

Defining “Supervision” “Supervision” is a term used in the mental health field as though its meaning was universally understood and the process was carried out in

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a relatively universal manner. In practice, supervision shifts significantly with the setting and the competence of both supervisor and therapist. There is also a variety of definitions in the literature accompanied by many suggested ways to supervise, along with the numerous ways that are actually practiced All this rests side by side with universal agreement about the need for supervision to adequately train therapists and ensure the safety of patients (Bernard & Goodyear, 2004). Add to this mix the fact that theories of psychotherapy inform and essentially constitute theories of supervision (Weiner, Mizen, & Duckham, 2003), which in turn creates further diversity of viewpoints, even within a particular school of therapy such as psychoanalysis. At the same time, there is sufficient universality to the concept of supervision to provide useful common ground. This includes its potential for teaching and learning psychoanalytic theories and skills; for improving the progress of therapies practiced by the supervisees, and in turn the lives of their patients; as well as emotional and behavioral changes that can be endemic to the teaching-learning process. All parties involved have affective reactions to what is taught and what is learned, as well as the manner of presentation and subsequent reconstruction. A  circular process is in uneven motion wherein time has both horizontal and vertical dimensions (Mander, 2002b; Weinstein, Winer, & Ornstein, 2009). What is offered by the parties involved is influenced by their feelings about the material as well as their responses to the offerings. The result is the potential for emotional experiences that can be enhancing and therapeutic, or disruptive and discouraging. Supervision is a cognitive-emotional experience akin to psychotherapy, but with a greater emphasis on teaching-learning than on feeling-expressing. The two modes are inextricably linked, but the reflective space created during the process of supervision is expected to be slanted in the direction of thinking about the case being examined, rather than being filled with the emotional issues of either the supervisee or the supervisor. These issues are considered, but to the degree and manner in which they affect the patient involved in the supervisee–supervisor interaction. The primary thrust of the supervisory process is intended to be the education of the supervisee working as an analyst. The supervisee provides a major point of entry by presenting material from the therapist–patient session. This is mainly verbal, described customarily to the supervisor in face-to-face sessions. Variations are possible, like recording, viewing the action, or reporting in group meetings. We here discuss supervision as

Supervision

an exchange between supervisor and supervisee in traditional one-to-one fashion, but that approach can be modified to other formats while the same dynamic could be employed. It is the actual revelation of the conduct of the analysis as described by the supervisee that keys the supervisor to explore the progression of the treatment. The supervisor aims to teach things about the case that are unknown to the supervisee, who in turn has the desire to learn so that the information can be used to help the patient. The interest in learning from the supervisor is fundamental to the value of supervision as an essential part of a broad therapeutic endeavor to improve patients’ functioning. The concept seems clear and straightforward, given the intellectual and emotional capacities that supervisors and supervisees have already demonstrated to achieve their respective roles, but the practice of supervision is markedly complex. The expectations that a supervisor can fill a knowledge gap for the supervisee are not always met, or admitted, if such is the case. Also, the supervisee does not always present material in a way that is indicative of a desire to learn the unknown, or even admit the existence of unknowns. These problems, as well as other disconnections from the probability of actualizing the ideals of supervision, arise from motivational and affective distortions of supervisors and supervisees. They are what Szecsody (1990, p.  250) refers to as “blind spots”; namely, “defensive avoidance of certain information,” and “dumb spots,” which are “lack of knowledge, information, and skill.” In essence, there are realistic questions about how much “super vision” supervisors make sure they have, and how open and interested supervisees are willing to be or capable of being. Supervision is evaluative—often formally, because most supervision takes place during training. Even when evaluation is not formalized, a certain amount of feedback is likely to occur for both parties. That feedback provides impressions of the value of supervision and the expertise of each person, and it influences both parties. Each wants to be seen as good at the job, and probably better than good, which can cause their dialogue to be slanted in the direction of approval or disdain, depending on their manner of relating. As a result, it is difficult to “purify” supervision to meet its best actualization. However, there are two mitigating possibilities for achieving this. One is that supervisees accept the probability that supervisors will have a more favorable view if it is made clear that the supervisee wants to learn from them. The other is that supervisors realize that being a psychotherapist, even with considerable experience, does not automatically make them effective supervisors.

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Formal training in supervision is the ideal, but at the very least, supervisors need to have a fundamental approach that is familiar to them and congruent with their knowledge base, and then learn to stretch into the unfamiliar and give it some consideration. As Clemens (2006, p. 35) notes, “The hallmark of psychodynamic psychotherapy is individualization of the therapy to the uniqueness of each patient.” The same individualization applies to supervision. In addition to supervisory training and adaptability, the logical extension of adaptation is pluralism. The specificity of effectiveness must be considered. Goldberg (2007) indicates some of the many interventions that can be of help, such as the patient–analyst relationship, or insights, or developmental progression, so a single theory is not going to fit the needs of all supervisees. Goldberg also points out that, as we have indicated throughout, psychoanalytic theory is most appropriately viewed as being in evolution and varying in its applications. A utilitarian acquaintance with the many psychologies that can be categorized under the “psychoanalytic” rubric, and corresponding competencies, is particularly helpful, with a practical compromise being found in the awareness of the value of pluralism in theory and application. In developing a definition of supervision, it becomes clear that, despite variability in preparation, theoretical underpinning, and methods of execution, supervisors have certain common goals. These are developing a learning environment, discovering methods to facilitate knowledge and growth, and attending to the work of the supervisee with patients. The learning environment is the next area of exploration.

The Learning Environment The supervisor has a responsibility for creating a favorable learning environment, but there are contextual limits, in that the framework for supervision usually has its own boundaries, such as time, psychical surroundings, matching of supervisors and supervisees, and treatment goals. Supervision may often be carried out within situations created and enforced by policies that are less than ideal, thereby necessitating flexibility. Training institutions generally provide a model that can be used to illustrate a “good enough” arrangement. For example, a psychoanalytic institute will require its candidates to have a set number of hours of supervision, spread over a number of supervisors, with minimums and maximums for any one supervisor. The supervisors are part of the institute’s faculty and usually qualify for their role based on their experience. Supervisors need a

Supervision

comprehensive knowledge base that indicates to supervisees that they are working with people who know enough to teach them what they do not know. Essentials for psychodynamic supervisors are to have formulated, and to be able to articulate, theories of mental structure, theories of pathogenesis related to theories of the mind, and treatment procedures linked to the preceding theoretical developments (Abend, 2007). Also, sufficient familiarity with a variety of psychoanalytic theories is important, as well as an awareness of other therapeutic modalities if psychodynamic work is not feasible. Supervisors need to be at least familiar with two primary modes of interaction—insight through interpretation, and the transference–countertransference experience—and they need to be aware that consensus does not yet exist on the effects of therapy. They also need to be attuned to the needs of supervisees. As noted, supervision tends to be evaluative, which tends to cause supervisees to feel vulnerable. In turn, supervisors have to think of supervision as partially a clinical encounter. The atmosphere of trust that therapists work to accomplish in therapy situations must be established in the supervisory relationship as well. The focus is on the supervisee’s work with patients, rather than on her personal problems, but they are interrelated. The supervisor is seeking as much disclosure as possible regarding the supervisee’s work with the patient. The degree of disclosure depends on the degree of trust experienced by the supervisee, which depends on the type of supervisor– supervisee relationship that is established. Using the fundamentals of psychoanalytic theory—transference, resistance, countertransference, and unconscious communication—the supervisor can fashion and refashion the learning environment so it facilitates the supervisee’s ability to make effective interventions. There are numerous useful organizers that can serve as aids in understanding what Mander (2002a, p.  38) has described as the supervisory activity of “thinking about thinking.” One is the distinction between conceptualization and execution by the supervisee. This is illustrated in the following material from a supervisory session with a female supervisor and a male supervisee. He: “Whatever interpretations I  make, she rejects. I  know I  could be wrong about my impression, my explanation, but I don’t believe I am always wrong.” She: “From what you have described, I do not think your interpretations are wrong.” He: “Then you think it is resistance on her part?”

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She: “Not exactly. I think this is an instance of projective identification.” He: “I am not sure what you mean.” She: “Your interpretations have been about her anger, which seems to intensify as you interpret. I get the impression she is trying to get you to be the container for her anger.” He: “That’s projective identification?” She: “No, that is one way of dealing with projected anger. The projective identification is the patient finding her anger unbearable for her, yet considering it as an essential part of her. She is trying to project that anger, trying to give it to you to hold for her, lend it, because she believes you can contain what she cannot, even to transform it, so she can have it back without it being dangerous to her.” He: “You mean she splits it off from herself, but it still belongs to her. I am just the safe keeper.” She: “Yes, that is a good way to describe what she could want.” He: “I don’t know, it seems fanciful, and I don’t really know what it means to contain it.” She: “I think you could, or certainly you have an inkling. Being a container is in many ways difficult to describe.” He: “You want me to take in her feelings?” She: “Instead of trying to interpret her anger, yes, that would be a possibility, to see if that works.” He: “I don’t know whether I can do that. I am not sure what it means.” It appears as if the supervisee is trying to use the claim of a lack of conceptual knowledge to avoid dealing with his discomfort at being a “container” of the patient’s angry feelings. The supervisor seems to be aware of this and is slowly moving on this issue. She has the option of being more explicit about both projective identification and containment, although she could be limited by the controversial elements of both concepts, as well as the fact that they are both difficult to explain with precision. However, his responses suggest he has some understanding of both concepts, but is uncomfortable with the role he would be carrying out once he acknowledges his comprehension. He seems close to such an acknowledgement, so it is likely they will discuss his role as a container and how that can be resolved. In this example the supervisor is working towards identifying the supervisee’s stated difficulty in grasping concepts and being aware of their relevance. She is also aware that the purported problem may mask the supervisee’s resistance to actualizing the concepts. She wants him to

Supervision

understand the theory and be able to apply it so it can become an assimilated way of proceeding with patients. Accomplishing this requires taking into account the different learning styles of supervisees. Jacobs and colleagues (1995) have suggested a schema with four primary ways of thinking; inductive, associative, creative, and reflective. “Inductive” stresses drawing inferences from specifics in accordance with a general principle. In the case described, the supervisor wants the supervisee to sort through the possibilities that are suggested by the patient’s repeated rejections of interpretations. These could include incorrect interpretations, overwhelming anxiety by the patient in response to accurate interpretations, or a lack of recognition by the therapist that the patient may be using projective identification of hostility by disagreeing with the analyst. If the supervisee is a strong inductive thinker, he will be able to get past his anxiety and comprehend the supervisor’s formulation of projective identification. In “associative” thinking, the supervisee may arrive at the same understanding through a different route; namely, assembling and linking associations from what at first appears to be a random process. This is akin to the analytic method of free association, which gives rise to an awareness and understanding of thematic content. “Creative” thinking is a more imaginative process, in which many meanings and reconstructions are “played with.” The result may be the same as with the other modes of thinking, but the construction process differs. This is also true for “reflection,” where the supervisee can self-reflect to better understand interventions and to process material. There is overlap among these styles, and they are only some of the ways of looking at modes of thinking and the learning process. Other effective possibilities certainly exist. The point is that the supervisor can help the supervisee learn by making use of his perceived strengths in learning modes, and can also assist the supervisee in exploring alternative ways of thinking that may be unfamiliar and less developed, but could be useful. Another major issue is the degree of collaboration taking place. Psychoanalytic supervision has moved from an origin that included supervision as part of an analyst’s personal analysis, to the concept of a separate training analysis, and from there to the current state of a separate process of supervision. During most of this evolution, the supervision had an authoritarian cast where the supervisor, a trained analyst, was viewed as the expert, with an emphasis on the idea that the supervisee was the one who was there to learn. However, Teitelbaum (2001) points out that the process has been increasingly democratized with a growing awareness of mutual learning. The result is a greater concern with the intricacies of the

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supervisory relationship and an interest in developing a more collaborative model of supervision (Orlans & Edwards, 2001). This collaboration involves active participation in the supervisory relationship by both parties in the supervisory process, but a tilt in the relationship is still expected in that the supervisor needs to be more knowledgeable than the supervisee, particularly in areas such as theory and technical experience, and needs to be able to transmit knowledge in an effective way. The supervisor’s responsibility to be a knowing observer of both the interaction with the supervisee and the progress of the therapy conducted by the supervisee always exists, regardless of co-constructions and mutual learning. This is largely a function of triangulation in supervision, which increases in complexity because it takes place in dyadic relationships, like supervisor–supervisee, or therapist–patient.

Triangulation “Triangulation” refers to the “creation” by two people, in this case the supervisor and the supervisee, of another, a third, either the patient of the supervisee or a conception about the process of therapy or of supervision, but always including the patient in some fashion. For example, when the supervisor’s impression of material about the patient results in a new interpretive reconstruction, then this forms the completion of a triangle. The supervision at times may shift from an apparent focus on work with the patient to the relationship between the supervisor and the supervisee, but the patient is the progenitor of the supervision and the one who is the background of tension between the supervisor and the supervisee. Triangulation can also result when the supervisee is working with the patient, in the form of internalizing the supervisor as part of the therapeutic process. Another possibility is that, if the patient is aware that the therapist is under supervision, the patient may triangulate by internalizing a projected image of the supervisor. Internalization and types of projective identification of all parties are possible for everybody concerned. For example, the supervisor usually has to imagine the patient and co-construct an object representation of the supervisee. Although the members of the triad and their constructions have concrete reality that can be observable, the process of observation by the triad of themselves, each other, and the material produced results in personal creations’ forming a significant part of supervision. There is an ongoing process in triangulation of developing representations that become internalized.

Supervision

The triangulation possibilities are summarized by Marshall (1997) as six possible interactional triads: patient–analyst–supervisor, patient– supervisor–analyst, analyst–patient–supervisor, analyst–supervisor– patient, supervisor–analyst–patient, and supervisor–patient–analyst. The first of these, patient–analyst–supervisor, is considered the most effective.

The Supervisor’s Role Expectations for supervisors have already been described in a number of ways. The viewpoints can now be sharpened by comparing these with some other recent formal descriptions. For example, The supervisor then, functions as the “third eye” who sees things from a different perspective and, as such, can ensure that the patient has an advocate if the supervisee fails to hear or understand. . . . It is the supervisor’s role to facilitate understanding in the supervisee . . . a container who enables the supervisee to think and cope with the primitive defenses against anxiety and to recover to the learning position. (Stewart, 2002, pp. 81–82) In this instance, the supervisor completes the triangle that began with the therapist and the patient, and brings another perspective that can differ from that of the therapy dyad and enhance the work of the analyst and the patient. The supervisor can also serve as an advocate by offering a possible patient perspective that may be eluding the therapist, and can protect the therapist by assisting him in avoiding mistakes and crafting interventions. The containment aspect of supervision provides a space for thought and reflection. The supervisee can use this space to both engage in speculation and deal with any anxiety generated by the analytic encounter. It is also a time for the exploration of countertransferences. Of particular interest is the occurrence of a parallel process in which the supervisee identifies unconsciously with the resistances of the patient being discussed in supervision and acts out these resistances with the supervisor. What is happening in therapy is now also happening in supervision, with the supervisor put in the role of the analyst who is being supervised. The supervisor’s awareness of this increases the possibility of resolution in which countertransferential feelings can be utilized in service of therapeutic progress. A  parallel process appears in the previous example of supervisor–supervisee interaction.

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A supervisory session has space and time in the description cited as depicted in terms of Kleinian theory. The learning situation is seen as a reaction to uncertainty, where the supervisee’s anxiety results in regression to a paranoid-schizoid position inhibiting understanding. The supervisory space provides an opportunity for reconstituting and returning to a depressive, or learning, position in which the ambivalence associated with doubt about operating effectively can be tolerated. Another possibility is to see anxiety about a problem in learning as activating the ego to defend the supervisee through regression to a different level of learning, where the supervisee feels unable to cope with the patient without the assistance of the supervisor, who can operate in the restoration of ego functioning. The ability to use ego psychology illustrates the adaptability of psychoanalytic conceptualizations. Other theoretical formulations, such as relational or self, can be used like frameworks to inform and essentially expand a working theory of supervision. Also possible, but not present in the description of supervision quoted earlier, is that the supervisor may see the supervisee’s work from a similar or allied perspective. This alliance can support the analyst’s efforts to move forward, given the “holding environment” where understanding is facilitated by a separate, but congruent, perspective supporting the supervisee’s functioning, which may have become temporarily frozen in doubt. The emphasis on “the third” is on an additional perspective rather than its difference from or sameness relative to the supervisee’s, given that either can be used to aid the supervisee. Also, Stewart (2002) seems to be downplaying the teaching function of supervision, or at least altering the usual meaning of “teaching.” The expanding knowledge base that is needed for supervision seems to be shifted from content to technique; namely, the facilitation of understanding. However, content is the foundation for technique. Understanding will be limited if the supervisor does not “know” enough to provide enough possibilities for examination and comprehension of the material provided about the therapy sessions. The supervisor still “needs to know,” more now than in the past, and to integrate this with the competency for intersubjectivity in the supervisory process (Herron & Teitelbaum, 2001). Supervision uses the goals of both teaching and psychotherapy. In the former case, the supervisee has to acquire knowledge of content, particularly theory that enables therapeutic effects. In the latter case, self-knowledge is necessary for one to work effectively as an analyst. However, the focus in supervision is on one aspect of personal development, the facilitation of the abilities required of the supervisee to be effective, and the knowledge

Supervision

to be imparted by the supervisor is dedicated to the supervisee’s development as an analyst. That development includes the improvement of the supervisee’s patients, the supervisee’s knowledge base, and the emotional health of the supervisee. At the same time, the main function of supervision is teaching the supervisee. The specific methods of doing this vary, and are designed to fit the specific situations of each supervisee as well the competencies of each supervisor. For example, Teitelbaum (2001) points out that the shifting environment of increased “managed care” alters the type of analytic therapy the supervisees are likely to be doing. In particular, he notes the probability of brief therapies and active therapeutic interventions. These limit the time and effort that could be used for transference interpretations and working through, while highlighting the therapeutic alliance, resistance, and termination issues. The spread of short-term work also increases the need for supervision, because the time frame restricts opportunities to discover and correct errors. Consequently, case management has become more complex, requiring more flexibility and breadth of knowledge from supervisors. A final concern is depicting the supervisor as a “container,” the general implication being the creation of a holding environment for the supervisee. This could also be interpreted as a more active process by which the supervisor and supervisee are able to discover and consider levels of meaning. It also could be thought of as a way to foster an engagement of the unconscious, or it could viewed primarily as a listening process. The concept of containment is in line with the finding that the most effective supervisors are actively engaged with their supervisees (Rock, 1997). These supervisors were found to have commitments to the process of supervision, to the supervisee, and to the well-being of the patient. In addition, they have sufficient knowledge to be helpful, and they are focused on the work at hand. A supervisory relationship in which teaching is a significant partnership allows for the possibilities of identification, guidance, and the encouragement of autonomy that can also recognize the need for counsel. For a good fit to take place on a consistent basis, the supervisor has to pay attention to the triangulation found in the relationships between all parties involved. Such attention is a very active, involving process. In contemporary analytic supervision, the container can also be the contained as part of a reciprocal discussion between supervisors and supervisees. Mutuality is more apparent today, but with the expectation by both parties that the supervisor is more of an expert than the supervisee. It is not just a matter of a different voice, a different viewpoint, or the existence of

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a “third party.” It is a matter of a voice that, through training and experience, is in a position to “know better” (without “knowing everything”). Finding the appropriate teacher–relator mix remains a work in progress. This can be seen in contrasting definitions offered by Gold (2006), and Frawley-O’Dea and Sarnat (2001). Gold chooses as her version of supervision a description by Alonso: The supervisor is focused primarily on the clinical and professional development of the supervisee . . . always perched on the border between teaching the student and therapeutically addressing the implicit developmental impediments in the student’s learning . . . must listen with a clinician’s ear and speak with a teacher’s mouth. (Alonso, 2005, p. 55) In contrast, Frawley-O’Dea and Sarnat suggest, “The supervisory relationship, in fact, is second only to the therapist’s own analytic relationship in potentiating the supervisee’s development as an analytically informed clinician” (2001, p. 70). The former definition resonates with the approach we have taken, but it does not go far enough in considering the role of the supervisor–supervisee relationship, while the latter appears to go too far in emphasizing the power of the relationship. However, it is clear that supervisors need competencies in both knowledge and relating to the supervisee.

Conclusions Supervision is not easily defined, despite many attempts to do so. Our impression is that supervision can best be seen as a reflective space or time for cognitive-emotional experience aimed at increasing the therapist’s effectiveness. It is primarily a learning experience for both supervisor and supervisee, which includes a mutual relationship in which the supervisor is expected to be the teacher and the supervisee is the student. The complexity appears because the supervisory relationship involves transference, resistance, countertransference, and a learning alliance. These factors play a role in the interactive learning that is designed to take place and that usually occurs in an evaluative context; namely, the degree of effectiveness of the therapy that is the basic concern of the supervision. Although supervisors are in their role usually because of their experience, formal training in supervision should also be acquired. Supervision should be approached with an interest in adapting and an ability to

Supervision

adapt to varying supervisory situations, because flexibility is necessary in order to meet the broad demand. In this context, a case is made for the value of theoretical and technical pluralism. Psychoanalysis as a work in evolution provides that possibility. At the same time, there are common tasks of supervision: developing the space for learning, facilitating knowledge acquisition as well as personal growth, and enhancing the supervisee’s work with patients. All supervisors need to develop the competency to carry out these endeavors, and that includes supervisors’ ability to be attuned to supervisees’ needs in order to foster a learning alliance, Although supervision is generally viewed as a training activity designed to eventually replace the external supervisor with an internal one, formal supervision is useful for analysts throughout the existence of their practices. The task for the contemporary psychoanalytic supervisor is to offer a mixture of teaching and relating that results in more effective work by the supervisee. This requires a combination of supervisory skills that are sufficiently grounded in proven tradition as well as in enlightened contemporary modification so that supervisors can learn to be “ahead of the curve” in meeting an increasingly demanding treatment environment.

References Abend, S.  M. (2007). Therapeutic action in modern conflict theory. Psychoanalytic Quarterly, 76, 1417–1442. Alonso, A. (2000). On being skilled and deskilled as a psychotherapy supervisor. Journal of Psychotherapy Practice and Research, 9, 55–61. Bernard, J. M., & Goodyear, R. K. (2004). Fundamentals of Clinical Supervision (3rd ed.). Boston: Allyn and Bacon. Clemens, N.  A. (2006). Supervising psychodynamic psychotherapy. In J. Gold (Ed.), Psychotherapy Supervision and Consultation in Clinical Practice (pp. 35–58). Lanham, MD: Aronson. Frawley-O’Dea, M. G., & Sarnat, J. (2001). The Supervisory Relationship. New York: Guilford Press. Gold, J. H. (Ed.) (2006). Psychotherapy Supervision and Consultation in Clinical Practice. Lanham, MD: Aronson. Goldberg, A. (2007). Pity the poor pluralist. Psychoanalytic Quarterly, 76, 1663–1674. Herron, W. G., & Teitelbaum, S. (2001). Traditional and intersubjective supervision. The Clinical Supervisor, 20, 145–159. Jacobs, D., David, P., & Meyer, D. (1995). The Supervisory Encounter. New Haven, CT: Yale University Press. Kernberg, O. F. (2010). Psychoanalytic supervision: The supervisor’s tasks. Psychoanalytic Quarterly, 79, 605–621. Mander, G. (2002a). Supervision: Between control and collusion. In C. Driver & E. Martin (Eds.), Supervising Psychotherapy (pp. 38–50). Thousand Oaks, CA: Sage.

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Other Functional Competencies Mander. G. (2002b). Timing and ending in supervision. In C. Driver & E. Martin (Eds.), Supervising Psychotherapy (pp. 140–152). Thousand Oaks, CA: Sage. Marshall, R.  J. (1997). The interactional triad in supervision. In M. H.  Rock (Ed.), Psychodynamic Supervision (pp. 77–101). Northvale, NJ: Aronson. Orlans, V., & Edwards, D. (2001). A collaborative model of supervision. In M. Carroll & M. Tholstrup (Eds.), Integrative Approaches to Supervision. (pp. 42–49). London: Jessica Kingsley. Rock, M. H. (1997). Effective supervision. In M. H. Rock (Ed.), Psychodynamic Supervision (pp. 107–134). Northvale, NJ: Aronson. Stewart, J. (2002). The interface between teaching and supervision. In C. Driver & E. Martin (Eds.), Supervising Psychotherapy (pp. 64–83). Thousand Oaks, CA: Sage. Szecsody, I. (1990). Supervision:  A  didactic or mutative situation. Psychoanalytic Psychotherapy, 4, 245–264. Teitelbaum, S. (2001). The changing scene in supervision. In S. Gill (Ed.), The Supervisory Alliance (pp. 3–18). Northvale, NJ: Aronson. Weiner, J., Mizen, R., & Duckham, J. (Eds.) (2003). Supervising and Being Supervised. A Practice in Search of a Theory. New York: Palgrave Macmillan. Weinstein, L. S., Winer, J. A., & Ornstein, E. (2009). Supervision and self-disclosure: Modes of supervisor interaction. Journal of the American Psychoanalytic Association, 57, 1379–1400.

SECT IO N V

Foundational Competencies

N IN E

Common Ethical and Legal Challenges in the Practice of Psychoanalysis in Psychology DOLORES O. MORRIS

The purpose of this chapter is to discuss the ethics codes that psychologists are expected to follow in different settings; also to explore practice competencies that require introspectiveness while following the requirements of law and regulations. At the very least, the psychoanalyst–patient relationship is complicated and sometimes conflicting. Ethical dilemmas arising out of this context require a careful weighing of the conflicting principles to resolve the resulting tension produced by a dilemma. This process provides the building blocks for the foundation of our ethics codes.

Ethics Codes Ethics codes establish educational and disciplinary standards for a profession and reflect its consensual values. Ethics deals with personal values, moral dilemmas, and high ideals, analyzing moral problems. The ethical values of the individual are reflected in the attitude of the professional. On the other hand, the ethics code of the profession deals only with a limited set of standards to follow in the role of a psychologist (Knapp & VandeCreek, 2003). Codes of ethics cannot anticipate all the situations in which psychologists may confront ethical dilemmas, nor can they specify concrete actions for psychologists to follow in all situations. Some of the possible ethical conflicts faced by psychologists have no clear solution and require

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psychologists to engage in an ethical decision-making process involving the balancing of competing ethical standards (Bersoff, 2008). Common ethical dilemmas and problems that are experienced by psychologists across rural and urban communities are multiple relationships, competency, burnout, confidentiality, and visibility l (Helbok et al., 2006). There are numerous case books that could be informative, such as Campbell and colleagues (2009), Dewald and Clark (2008), and Koocher and Keith-Spiegel (2007). In addition, Nagy (2010), Bersoff (2008), Knapp and VandeCreek (2005), and Pomeratz (2005) are a few examples of references that provide a comprehensive understanding of the APA code. Ethics codes are periodically updated and revised to reflect best practices and relevant current thinking. Knapp and VandeCreek (2003) noted in their review of the changes to the APA Ethics Code (2002) that there was no loss in protection of the public and that many of the changes were designed to keep the ethics code from being unnecessarily punitive for psychologists. The revisions enhanced sensitivity to the needs of cultural and linguistic minorities and students. TH E A PA E T H I CS CO D E A N D PSYCH O LO G IS TS-PSYCH OA N A LYS TS FO L LOW T WO E TH I C A L CO D ES

There are two major organizations that represent the professional interests of psychologists. Each organization has its own set of professional ethics that set standards for professional behavior and decision making (see Table 9.1 below). The APA code was developed to guide the practice and behavior of a variety of professional psychologists, such as clinic, behavioral, school, and forensic psychologists as well as psychologists in academic and research settings. In addition to its use by the APA Ethics Office, the APA Ethics Code, or a variation of it, has been applied by state psychological associations, licensing boards, malpractice courts, and institutional employers to evaluate the conduct of psychologists. Knapp and VandeCreek (2003) recognized that the standards in the ethics code are designed only to address cases of clear misconduct. Psychologists who wish to perform at a higher level of skill may want to supplement their ethics education with sources beyond the APA Ethics Code. Similarly, the ethics code contains no special section for practice in any special area of professional psychology. On the other hand, the American Psychoanalytic Association’s Principles and Standards

TA B L E   9.1  

Comparison of Ethic Codes Applicable to Psychoanalysis Psychology Practice

P R I N C I P L E S A N D S TA N DA R DS O F E T H I C S F O R P S YC H OA N A LYS T S ( A P S A A , 2 0 0 8)

E T H I C A L P R I N C I P L E S O F P S YC H O L O G I S T S A N D C O D E O F C O N D U C T ( A PA , 2 0 0 2 )

Introduction

Introduction and Applicability

Guiding General Principles: Professional Competence; General Principles: Beneficence and Non-maleficence; Fidelity Respect for Persons; Mutuality and Informed Consent; and Responsibility; Integrity; Justice; Respect for People’s Confidentiality; Truthfulness; Avoidance of Exploration; Rights and Dignity Scientific Responsibility; Safeguarding the Public and the Profession; Social Responsibility; Personal Integrity Preamble

Preamble

Ethical Standards

Ethical Standards (1, 2, 3, 4, 5, 6, 7, 8, 10)

I. Professional Competence

Standard 2.01 Boundaries of Competence, 2.03 Maintaining Competence, 2.06 Personal Problems and Conflicts Standard 7.01 Design of Education and Training Programs? Standard 7.03 Accuracy in Teaching

II. Respect for Persons

Standard 1. Resolving Ethical Issues Standard 3.01 Unfair Discrimination; Standards 3.02 and 3.03 Sexual and Other Harassments

III. Mutuality and Informed Consent

Standard 3.10 Informed Consent Standard 6.0 Record-Keeping and Fees Standard 10.09

IV. Confidentiality

Standard 4 Privacy and Confidentiality

V. Truthfulness

Standard 5.01 Advertising and Other Public Statements, 5.02 Standard 7.04 Education and Training

VI. Avoidance of Exploitation

Standard 3.02 to 3.05 Human Relations Standard 5.06 Advertising and Other Public Statements Standard 7.07 Sexual Relationships with Students and Supervisees Standard 10.01 Informed Consent to Therapy,10.04 Providing Therapy to Those Served by Others, 10.5 Sexual Intimacies with Current Therapy Clients/Patients, 10.06 Sexual Partners, 10.07 Therapy with Former Sexual Partners, 10.08 Sexual Intimacies with Former Therapy Clients/Patients*, 10.10 Terminating Therapy

VII. Scientific Responsibility

Standard 4.04 Minimizing Intrusion; Standard 4.05 Disclosures; Standard 4.07 Didactic Use of Material

VIII. Protection of the Public and the Profession

Standard 2.06 Personal Problems and Conflicts; Standard 4.02 Limits of Confidentiality; Standard 4.05 Disclosures Standard 10 Therapy

IX. Social Responsibility

Standard 4.01 Privacy and Confidentiality

X. Personal Integrity

General Principles Standard 1 Resolving Ethical Issues Standard 7 Education and Training

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(2008) was developed specifically for psychoanalysts and addresses practice issues that are more specific regarding expectations and behavior. Both sets of standards are designed to provide guidance and promote best practices. The American Psychoanalytic Association’s Principles and Standards of Ethics for Psychoanalysts (APsaA, 2008) and the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (APA, 2002)  have differences and points in common. Both codes effectively codify standards for practice and professional behavior. Psychologists should be completely familiar with the ethics code of both organizations, regardless of their own membership. Knowledge of both codes may be expected in the work setting, in order to function as a competent practitioner. Table 9.1 provides a side by side comparison of the two codes. COM PE TEN T E TH I C A L PR AC TI CE

The ethics codes and principles apply to psychologist-psychoanalysts working in a variety of settings, such as independent practice, training institutes, clinics, hospitals, and universities. in addition to the APA and the APsaA codes, licensed professionals need to be familiar with the ethics codes in state licensing law (which, as noted, are not always the same as APA’s); institutional ethics codes, such as in analytic institutes, but also in places of employment like hospitals or clinics, such as the Health Insurance Portability and Accountability Act (HIPAA, 1996), state statutes for reporting child abuse and neglect (Child Welfare Information Gateway 2011), and state license codes. The ability to negotiate this complex array of regulatory and legal expectations is an important component of competent ethical practice. TH E A PA E T H I CS CO D E A N D PSYCH O LO G IS TS-PSYCH OA N A LYS TS

The following discussion will show how the APA Ethics Code applies to psychology-psychoanalysis and will clarify the issues important to ethical decision-making and practice behaviors of competent psychologists. APA principles will be included where relevant (see APA Ethics Code, 2010, 2002; and APsaA, 2008, for more details). I N TRO D U C TI O N A N D A PPL I C A BI L IT Y

An ethics code is applicable to psychologists in many situations and contexts. Domains included are private practice, teaching, supervision,

Common Ethical and Legal Challenges

research, consultation, administration, and policy development. Many psychologists can be competent in some of these wide-ranging potential activities; however, it is an unrealistic task to maintain up-to-date knowledge and skills in all the domains simultaneously. Some specialists may be capable of functioning in many of these domains over the course of their careers; being a psychologist-psychoanalyst who functions in this broad manner would be a lifelong learning endeavor, associated with competency. The ethics codes apply in a variety of contexts, such as in-person, or via postal, telephone, Internet, and other electronic transmissions. PRE A M BL E

Psychologists are committed to increasing scientific knowledge of behavior and people’s understanding of themselves and others. They should integrate new knowledge in the best interest of their clients and the profession. Psychologists are expected to respect and protect civil and human rights as well as encourage freedom of inquiry and expression. G EN ER A L PRI N CI PL ES

The five general principles (stated as A to E) as guide and inspire psychologists to the highest ethical ideals of the profession and do not determine the basis for imposing sanctions as do the ethical standards. The first principle—A. beneficence and non-malfeasance—is demonstrated by psychologists’ striving to benefit patients and avoid doing harm to those; they attempt to resolve conflict responsibly, minimizing harm. Psychologists must recognize the vulnerability of their clients, supervisees, and others, by not misusing their position for their personal interests. They must also be aware of the effect of their own physical and mental health on their competency by seeking appropriate intervention when indicated. B. Fidelity and responsibility, the second principle, is based on trust and the psychologist’s acting in the best interests of the patient. There are times when following the standards of conduct can be complex. In ranking ethical obligations, the psychologist’s duty is to the patient directly, or indirectly through supervision or consultation with the treating psychologist. In the case of patients who are minors, there are also ethical obligations to the minor’s parent(s) or guardian(s). In descending order, the therapist has ethical obligations to the profession, to students and colleagues, and to society.

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C. Integrity, the third principle in psychoanalytic psychology practice, means that the psychologist will promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology. D. Justice, the fourth principle, is when the psychologist recognizes that fairness and justice is the right of all individuals to equal access to and quality of services provided, while respecting the patient’s rights to privacy, confidentiality, and individual choice. Psychologists should attend to their potential biases, the boundaries of their competence, and their expertise in the scope of their practice. E. The fifth and last principle is respect for people’s rights and dignity. The practice of psychoanalytic psychology should demonstrate this principle by being “.  .  .  aware of and respect[ing] cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language and socioeconomic status; these differences are considered when working with individuals from such groups” (APA 2002, p. 1063). Similarly APsaA principle II. Respect for Persons expresses the same sentiment. E TH I C A L S TA N DA R DS

The APA Ethics Code establishes minimum standards for the conduct of psychologists and is composed of ten standards, with subsections for each standard as does APsaA under Principles (depicted on Table 9.1). They are:   1. Resolving ethical issues   2. Competence   3. Human relations   4. Privacy and confidentiality   5. Advertising and public statements   6. Record-keeping and fees   7. Education and training   8. Research and publication  9. Assessment 10. Therapy

Common Ethical and Legal Challenges

The reader is referred to the source document for a full description (APA, 2002). The areas covered by the standards are delineated in Table 9.1. This table compares the APA and APsaA codes side by side. As noted earlier, the APA code of ethics is generic and addresses a broader audience of psychologists that includes professional as well as academic and research psychologists. The American Psychoanalytic Association’s audience, however, is the psychoanalytic practitioner. Both are valuable in providing a guide for ethical practice. It should be noted that the core values of both organizations are similar, but the sequence and emphasis of the standards may be different. As indicated earlier APA presents 5 general principles from A to E followed by ten Ethical Standards whereas APsaA’s 10 general principles are presented followed by their standards. This discussion will focus on the APA code and contrasting it with the APsaA code. APA Ethical Standards are: 1. Resolving ethical issues: The first standard requires that psychologists resolve conflicts between ethical standards and expectations in other settings. They should refuse to observe organizational policies that violate the rights of individuals, such as discrimination by age, disability, ethnicity, religion, sexual orientation, or socioeconomic status. The psychologist should work to reconcile such differences between ethical principles and organizational policies. 2. Competence: Psychologists are expected to work within the scope of their education and training and should strive to keep up to date with changes in theories and techniques, as well as make appropriate use of professional consultations with colleagues in allied fields such as psychopharmacology. Psychologists should take steps to correct any impairment in their analyzing capacities and do whatever is necessary to protect patients from such impairment. Awareness of professional judgements and personal problems and conflicts is a factor that requires introspectiveness. For example, an area of importance is the sensitive management of cultural diversity. This may present psychologists with the task of making a decision regarding their cultural competence. Recognizing transference and countertransference issues and the lack of sufficient information or understanding of cultural difference may be a subtle and challenging task when working with patients for

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whom English is a second language. This applies similarly to a patient who comes from a culture or subculture that is unfamiliar to the analyst. 3. Human relations: The first principle, of beneficence and non-malfeasance (that is, benefiting and avoid doing harm), is an important part of human relations. Psychoanalysts-psychologists do not knowingly engage in harassment or discrimination and should recognize the considerable power they may have in their relationships by avoiding potential exploitation of individuals who are patients and supervisees in any way related to the psychoanalyst-psychologist. Obtaining informed consent for psychoanalytic psychological treatment is essential to best practice: all aspects of the treatment should be discussed with the patient during the initial consultation. Psychoanalysts-psychologists delivering psychotherapy through institutes or hospitals should provide relevant information beforehand to the client/patient. The application of practice to third-party payment should be discussed and agreed upon by the patient. Psychologists should guard against entering into relationships that limit objectivity. Careful attention should be given to the process of referral to avoid conflicts of interest with other patients and colleagues. Referrals between members of the same family, including spouses, and significant others, should be carefully scrutinized, with disclosure being made early in the initial stages of referral so that preferable alternatives may be considered. The psychoanalyst should not unilaterally discontinue treatment without adequate notification and discussion with the patient, and if the patient is a minor, without notifying the parent(s) or guardian(s) and making an offer of referral for further treatment. 4. Privacy and confidentiality: Psychoanalysts-psychologists’ relationship with the patient is built on trust, a fundamental principle. They respect the right of the patient to privacy, and the maintenance of confidentiality of the patient should be discussed with the patient at the beginning of treatment and thereafter as new circumstances may warrant, as well as confidentiality’s limits, such as the involvement of third parties in billing and the transmission of electronic data. In these instances, disclosures should be done with the permission of the patient. Psychologist should minimize the intrusion on the patient’s privacy by only providing information that is relevant to the purpose for which the communication is made. The specifics of a patient’s life

Common Ethical and Legal Challenges

are confidential, including the name of the patient and the fact of treatment, and disclosing confidential information should be resisted to the full extent permitted by law. Psychologists-psychoanalyst do not disclose in consultation with colleagues, their writings, lectures, or other public media any confidential, personally identifiable information concerning patients, students, or supervisees. Candidate psychoanalysts-in-training obtain the patient’s informed consent pertaining to disclosures of confidential information before beginning treatment. (APsaA, 2008) 5. Advertising and other public statements: Psychoanalysts-psychologists do not knowingly make public statements that are false, deceptive, or fraudulent about their practice, research, or persons or organizations with which they are affiliated. They do not make false, deceptive or fraudulent statement concerning their degrees, training, experience or competence. Psychoanalysts-psychologists avoid misleading patients, parents or guardians of minor patients, or the public with statements that are knowingly false, deceptive, or misleading. Psychologists who engage others to create or place public statements to promote their professional practice have a professional responsibility for such statements. Statements made to the media are based on professional knowledge and represent current practice standards. Testimonials are not permitted from current or prior patients. Solicitation of patients for service is not permitted, as this again is a misuse of one’s role with vulnerable patients. However, contacts that provide additional appropriate services for those already in treatment or provide for those in disaster situations are appropriate. The faculty of an institute that offers continuing education workshops must present accurate, truthful information. 6. Record-keeping and fees: Psychoanalyst-psychologist in independent practice ensure that professional services are properly documented, billing records are accurate, and treatment records are protected for confidentiality. An agreement should be reached specifying compensation and billing arrangements early in the initial stages of the referral, and fees should be consistent with the law. Third-party payment for sessions should be discussed and agreed upon by the patient. In an institute setting, candidates’ records are created, maintained, and disposed of in conformity with local, state, and federal laws. Only the candidate and other authorized persons have access to these records.

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  7. Education and training: Psychoanalysts-psychologists responsible for education and training programs ensure that the programs meet current standards and are designed to provide the appropriate knowledge and proper experiences to meet the requirements for certification in psychoanalysis or other goals claimed by the program. A current and accurate description of the program content with training goals and objectives, benefits, and requirements that must be met for satisfactory completion of the program must be available. Reasonable steps must be taken to ensure the accuracy of the syllabi and psychological information. A new addition to the current code is that candidates are not required to disclose personal information unless it is a written program requirement that was made known as part of the administration requirement. An exception occurs when it is clearly necessary to determine whether personal issues are negatively affecting the candidate’s ability to meet requirement (Knapp & VandeCreek, 2003).   8. Research and publication: Most psychoanalysis-psychologists are practitioners, and some may conduct research. In these instances, it is conducted under conditions of institutional approval and informed consent from participants. Data are reported accurately, and publication credit is in proportion to the individual’s contribution to the effort. Similar standards apply for articles and other publication materials that may be produced.   9. Assessment: This standard, as indicated above, is not included in the ApsaA code. The standards for this principle apply to psychoanalysts-psychologists who are engaged in research and those who may use tests in their practice. They ensure that the tests are used for the purposes and population they were developed for, with consideration given to their reliability and validity. When psychologists provide consultation or supervision, the sources of information conclusions and recommendation are provided to the client, This is also true in case formulation, which is structured by the psychodynamic interview to assess a patient and develop a treatment plan (see Chapter 4, Case Formulation). 10. Therapy: Last, but not least, we turn to the standard of utmost interest to psychoanalysts-psychologists, for a major portion of their practice is devoted to it, and there has been some controversy about the sexual intimacy code. The practitioner informs the patient as early as possible about the nature and anticipated course of the

Common Ethical and Legal Challenges

therapy and provides an opportunity for answers to any questions. This may be an ongoing process. For candidates in training, the name of the candidate’s supervisor is provided as part of the informed consent procedure. When couples or family members are a part of the therapy, clarification is made at the beginning about who is the patient and what relationship the therapist will have with each person. Conflicting roles may become apparent, and the psychologist will take steps to clarify, modify, or withdraw appropriately. When group therapy is provided, the roles and responsibilities and the limits of confidentiality are described. Psychoanalysts-psychologists should not engage in sexual intimacies with current patients, relatives, or significant others of therapy patients or with their former sexual partners. Knapp and VandeCreek (2003) make the important observation that some wanted the Ethics Code to make unethical all sexual contact between former patients and psychologists, and that some wanted the Ethics Code to completely prohibit sexual contact between former patients and psychologists and remove the current “almost never” two-year rule in keeping with Gabbard’s (1994) compelling argument against it. The American Psychoanalytic Association Code, “VI: Avoiding Exploitation” makes the explicit statement that “sexual activity between the psychoanalyst and a current or former patient, or any member of the patient’s immediate family whether initiated by the patient, the parent or guardian or family member or by the treating psychoanalyst, is unethical” (Dewald & Clark, 2008, p. 7). The ethics committees for each association has procedures for dealing with complaints made against members that are carried out by their respective committees. This chapter has discussed the ethics codes that psychologists are expected to follow in different settings, while exploring practice competencies that require introspectiveness for following the requirements of law and regulation. There are some common questions that may have some simple answers, and there are those that are more complex and pose an ethical dilemma. A few selected questions and answers from the Committee on Professional Practice and Standards (2003) are presented below: Q: What is informed consent? A: In general, informed consent is the concept of gaining a patient’s consent to treatment or release of records after the patient has been given necessary and appropriate information.

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Q: What is privilege? A:  It is a legal concept that generally bars the disclosure of confidential communications in a legal proceeding. Q: What is confidentiality? A: Confidentiality is the ethical, and in most states, the legal duty of psychologists to not disclose information about a client. Q:  Am I  violating client confidentiality simply by acknowledging that someone is a client? A: Likely yes. Q: If my client dies, must I continue to treat the records as confidential? A: Generally yes. Commonly, there are state laws that delineate the duration that information about a deceased client must be kept confidential. Q: Can I make as a condition of treatment a requirement that my clients will not solicit my involvement in any type of legal proceeding? A: Such a condition probably could not be enforced. While these questions and answers may seem simple, they are each based on a code of ethics. It is hoped that the reader now has a better understanding of the underpinnings that provide the solutions to ethical dilemmas.

References American Psychological Association (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060–1073. American Psychological Association (2010). 2010 Amendments to the 2002 Ethical Principles of Psychologists and Code of Conduct. American Psychologist, 65, 493. Bersoff, D.  N. (1976). Therapists as protectors and policemen:  New roles as a result of Tarasoff? Professional Psychology, 7, 267–273. Bersoff, D.  N. (2008). Ethical Conflicts in Psychology. Washington, DC:  American Psychological Association. Campbell, L., Vasquez, M., Behnke, S., & Kinscherff, R. (2009). APA Ethics Code: Commentary and Case Illustrations. Washington, DC: American Psychological Association Child Welfare Information Gateway. (2011). Definitions of Child Abuse and Neglect. Washington, DC:  U.S. Department of Health and Human Services, Children’s Bureau. Committee on Professional Practice and Standards (2003). Legal issues in the professional practice of psychology. Professional Psychology: Research and Practice, 34, 595–560. Dewald, P. A., & Clark, R. W. (Eds.) (2008). Ethics Case Book of the American Psychoanalytic Association. New York: American Psychoanalytic Association. Gabbard, G.  O., & Lester, E.  P. (1995). Boundaries and Boundary Violations in Psychoanalysis. Washington, DC: American Psychiatric Publishers.

Common Ethical and Legal Challenges Health Insurance Portability and Accountability Act of 1996 (HIPAA), Publ. l, No. 104–191. Helbok, C. M., Mariner, P., & Walls, R. (2006). National survey of ethical practices across rural and urban communities. Professional Psychology:  Research and Practice, 37, 36–44. Knapp, S., & VandeCreek, L. (2003). An overview of the major changes in the 2002 APA Ethics Code. Professional Psychology: Research and Practice, 34, 301–308. Knapp, S., & VandeCreek, L. (2005). Practical Ethics for Psychologists: A Positive Approach. Washington, DC: American Psychological Association. Koocher, G.  P., & Spiegel, P.  K. (2009). Ethics in Psychology and the Mental Health Professions: Standards and Cases. Oxford, UK: Oxford University Press. Nagy, T.  F. (2010). Essential Ethics for Psychologists:  A  Primer for Understanding and Mastering Core Issues. Washington, DC: American Psychological Association. Pomeratz, A. (2005). Increasingly informed consent:  Discussing distinct aspects of psychotherapy at different points in time. Ethics & Behavior, 15, 351–360.

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Considerations Concerning Individuals and Cultural Diversity RAFAEL ART. JAVIER AND DOLORES O. MORRIS

This chapter will discuss the factors that require awareness and sensitivity to work professionally with diverse individuals. Attention will be given to the controversy related to intrapsychic and social political forces that influence self-esteem and identity, both in the patient and in the therapist. This is particularly important because we recognize that both patients and therapists can be equally caught in their cultures, which may lead to “mutual enactment of conscious and unconscious feelings, attitudes, values, morals, biases, and prejudices that each party brings to the relationship,” or what Morris referred to as “cultural countertransference” (Morris, 1998, pp. 579–80). In this chapter we will refer to this process as “cultural transference and countertransference” to highlight the role that both patients and therapists play in this transaction. In this context, we will look at issues of cultural differences within research and practice, particularly in those that relate to culturally based personal characteristics, sexual orientation, ethnic/cultural background, and spirituality. We will begin by defining the landscape of diversity as used in this chapter and will include a brief examination of the current and projected diversity demographics as provided by the U.S. Census Bureau. Finally, we will also elaborate on assessment and intervention strategies that are important to consider when working with a diverse population.

Considerations Concerning Individuals and Cultural Diversity

Defining Culturally Diverse Individuals and Their Needs Following the most recent U.S. Census, minorities or diverse individuals are defined as “Hispanic,” “Black,” “Asian,” “American Indian,” and “Alaska Native.” The Census also includes “Hawaiian and Other Pacific Islanders” and people who identify themselves as being of two or more races. Currently, minorities are 30% of the U.S. population and are projected to be 57% in 2060 (US Census, 2013). Consequently, the United States is projected to become a majority-minority nation for the first time in 2043. While the non-Hispanic white population will remain the largest single group, no one group will make up a majority. In fact, the immigrant population reached 40 million in 2010, making it the highest number in American history, with nearly 14 million of them being new immigrants. In view of these statistics, it is clear, as we delineate below, that there will be a further increase of diversity in language, sexual orientation, religious beliefs, and so on, as immigration and birthrates among immigrants increase, with the subsequent challenges to psychotherapists involved in delivering psychoanalytic treatment to this population. L A N G UAG E

The recent Census reports of languages spoken in the home for individuals five years or older are 79.4% English-only and 20.6% a language other than English. This percentage includes Spanish (12.8%), other Indo-European languages (3.7%), Asian and Pacific Islander languages (3.2%), and other languages (.09%) (Fact Finder 2, U.S. Census, 2010). Since language is an important vehicle in psychoanalytic treatment because of its involvement in all aspects of cognitive and emotional processes (Javier, 2007), psychoanalysts make particular use of the analysis of patients’ use of their languages when assessing and treating their psychological problems. SE XUA L O RI EN TATI O N

It should be noted that sexual orientation is delineated as “same-sex head of household” in the Census, which is not specific enough for this discussion. For our purpose, “sexual orientation” will refer to a variety of sexual preferences, including lesbian, gay, bisexual, and transgendered (LGBT). The Demographic Characteristics of APA Members report (2010) showed that members reported their sexual orientation as heterosexual 88%, while others indicated their sexual orientation as gay (2.1%), lesbian

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(2.2%), bisexual (1.4%), transgender (0.0%), other (0.1%), and 6.5% with no response. Because gender and sexual orientations are intimately involved in one’s self-definition and orientation to the world, the recognition and analysis of the vicissitude and diversity of these factors in the individuals’ normal and pathological organizations become an important focus of the psychoanalytic work. REL I G I O US BEL I EFS

The recognition in psychology that cultural belief systems and traditions are intrinsic aspects of human behavior is an important factor in understanding diversity and promoting cultural sensitivity as a critical component of clinical competence (Nelson, 2009). American religious diversity has increased remarkably since the founding of this country. The Pew survey found that, among American adults 18 years old and older, 83.1% are affiliated with a religion, and 16.1% are not. Of the latter group, 1.6% are atheist, 2.4% agnostic, 12.1% reported no particular religion, and 0.8% no response (U.S. Religious Landscape Survey—Pew Forum, 2008). By contrast, when psychologists were asked on a survey of the American Board of Professional Psychology (ABPP) in 2010 regarding what best represents their beliefs, 35% reported being “religious or spiritual,” 29% “spiritual but not religious,” 17% agnostic, 13% atheist, and 6% gave no response (Morris et al., 2012). Though using different categories to survey religious affiliation, there is a striking difference between the general population reported in the Pew survey and the findings in the ABPP survey, with the latter reporting higher levels of agnosticism and atheism. This finding highlights the difference between ABPP’s members’ belief systems, or lack of, and those of the general population. This could have serious implications if the difference in belief systems is ignored or not properly addressed as a crucial factor in the treatment process, particularly for patients who prefer to use religiosity and spirituality to process their experiences with the world around them.

On the Role of Multicultural Education in Psychoanalytic Practice: The Controversy The recognition of the physical and linguistic presence of these diverse groups has opened an awareness of the different sets of values, beliefs, and cultural expectations that they bring to the therapeutic process. While there has been substantial progress in raising awareness about diversity

Considerations Concerning Individuals and Cultural Diversity

and developing cultural competency guidelines within professional organizations, such as the American Psychological Association (1990, 2000, and 2003) and the American Psychoanalytic Association (2012), many clinicians still struggle with the implementation of cultural competency in their practices. Tummala’s review (2004) of the empirical and clinical literature on multicultural education shows that, despite positive outcomes in the knowledge base and the relationship between analyst and patient, there is broad variability in the ways these factors are considered. This suggests a need for a deeper discussion of these issues to increase more sophisticated understanding of its interpersonal aspect. The emphasis has been on knowledge acquisition and on self-reported multicultural competence rather than on skill development, which is at the core of the quality of the client–therapist relationship. The American Psychological Association accreditation requirement that graduate psychology programs demonstrate sensitivity to diverse populations has increased scholarship in this area with the examination of skill development and the application to service delivery (Smith et al., 2006). Training institutes are no exception, as pointed out by Holmes (2005) when she boldly calls for attention to be paid to issues of race and social class in institutes’ hierarchy of training, staffing, and reward systems, as well as recruitment. She believes cultural diversity should be established with systematic and intentional plans. McWilliams (2003) speaks to the delicacy of the learning and socialization process with the patient, especially when there may be a conflict with beliefs and conventional ideas in our society. As indicated earlier, race/ethnicity, class, gender preference, and language differences permeate our society and influence the participants in the analytic process and shape their identity and attitudes (Altman, 2007; Dalal, 2006; Holmes, 2006). This is the case because the history of race relations in America is an important aspect of its culture and tends to guide our psychic organization and behavioral repertoire. In fact, black women and men in America inevitably feel torn between accepting a deeply conflicted, often devalued sense of self, absorbed from generations of ambivalent relations with white America, and a more valued individual identity that embraces self-acceptance, a celebration of their racial identity, and a pride in their heritage as African Americans. Holmes (2006) observes in this context that all transactions in our culture regarding race and social class are premised on the views that non-dominant races and the poor are inferior, and that European-Americans and the rich are superior. Wealth, health, and human services are distributed accordingly. The consequence is the

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likelihood of the presence of disparities in the treatment of culturally diverse persons. Yet there is a controversy as to the best and most effective way that multicultural awareness should be included in psychoanalytic training. Part of the reason for the controversy is the belief that, under the best of circumstances, consideration of the importance of cultural diversity, race, and class in the psychological development of the individual should be inherent to any discussion related to the human condition. That is, that it should be intertwined with and organic to any discussion of human motivation, the nature of conflict, normal and pathological development, the development of the self and self-identity, the nature and quality of relationships, and, more specifically, the very nature and quality of the unconscious and unconscious processes. It is believed that by giving diversity a separate focus, the subject matter is artificially separated from its meaningful place in discussions about the vicissitudes of the human condition and its consequences. The problem has been, however, that discussions of the factors related to diversity in psychology following this line of thinking have paradoxically resulted in the same predicament that they were trying to avoid; that is, in the treatment of the subject matter as something additional to the human condition and external to its circumstances. Thus we find ourselves in various ways looking at diversity factors as external to the individual and as something that only applies to certain individuals and conditions, mostly individuals from “minority” populations. Altman (1996, 2007), Holmes (1992, 1999, 2006), Bonovitz (2005), and Morgan (2009) recognize that the relationship between culture, the unconscious, and the interpersonal field is an essential aspect of the transference-countertransference experience and is deeply embedded in the psyche. Cultural transference-countertransference is constructed by patient and analyst together, and reflects interpersonal relations as well as internalized self-object representations. These and other observations have changed, not only the way we think of transference, but the nature of the analyst’s participation. These changes, in turn, have affected our understanding of the influence of the social and historical contexts on individual lives. The divide between mind and culture has narrowed to the point that each creates and defines the other. Analysts use this orientation to navigate the unconscious motivations emerging in the interpersonal space of the analytic situation. We will find, however, that our greatest difficulty in dealing effectively with diversity issues is to be found in our need to organize and codify our experiences

Considerations Concerning Individuals and Cultural Diversity

into discrete categories where issues related to the diverse community are categorized as belonging to the “other.” Once our view of others is established, it functions as a rigid cognitive structure that influences our way of perceiving, thinking, and acting toward the world around us. A Clinical Case To appreciate the various ways distortions in perceptions resulting from one’s experience can seriously compromise and confuse our relationship with others, let us consider the case of a patient who, from the very beginning, felt that the owner of a dry cleaning establishment was dismissive of him and acted with an air of superiority toward him. The owner was a French citizen who spoke with a strong accent and always referred to the patient as “Sir,” which sounded to the patient as the owner’s attempt to keep him at a distance. The patient was from Algeria and had immigrated to the United States several years ago and was now an established professional. The patient found that he was accumulating a great deal of ill feelings and secretly harboring strong hatred toward the owner, but could not explain the sources. He would bring his clothes to the store, always feeling that the owner would mess up his clothes and would not do as good a job as he would with his other clients. So he would always check and count his shirts, always returning to the dry cleaners with questions about spots not removed, buttons crushed or missing, or items lost. “I will do my best,” the dry cleaner owner would say with what the patient felt was an air of disgust for having even been questioned. “I could do it again, but no guarantee that it will be any better,” the owner proceeded. “And what about my black suit and blue jacket I brought in for cleaning?” the patient quickly retorted to demonstrate that the issue was greater than the spots in his clothes and crushed buttons. Without blinking an eye and without checking to see if the patient was correct, the owner responded with a definite pronouncement, “If it is not in the computer, you did not bring them here,” a statement that enraged the patient at the moment. There were several of these exchanges, after which the patient invariably would find the items at home tucked in a corner of his bedroom, resulting in intense feelings of shame and embarrassment at having doubted the owner and harbored such strong feelings. But one day, the patient felt that he finally caught the owner with a mistake, as he was missing his gray suit and was sure that it was in the dry cleaners. In one of his visits to the dry cleaners he was sure that a gray suit that was hanging from a rack by the window at the entrance of the store was his. He ruminated for a while but finally got enough courage to confront the

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owner by showing the suit hanging on the rack. “This is my suit that I was missing,” he said to the owner with certainty. The owner now looked indignant, but the patient did not care as he was determined “not to let this guy take advantage of me again.” “That item belongs to another store, another dry cleaner. It is not yours, sir,” the owner said emphasizing the “SIR,” which further infuriated the patient. He was quite surprised to find the suit a couple of days later at a place he had searched several days earlier. He again felt quite confused and ashamed about the whole incident. He had felt that this man was continuing to denying him his “rightful place” by the way the patient felt he was being treated, but this time he felt that he had given the owner ample justification. He has now given the owner reasons to question him, and the owner now knew his true nature, which was revealed and uncovered through the patient’s actions. He was concerned that his reputation as a person of respect and prestige in the community that he had so carefully cultivated was being eroded by these exchanges with the dry cleaner owner. The patient referred to this experience with a great deal of anxiety as if being tortured by a deep feeling of “not belonging” that he had inexplicably twisted as one of being “rejected” by this dry cleaner owner, a rejection that he could not clearly prove but that he continued to harbor. His view of the dry cleaner owner, which could be connected to the French colonial history in his country, was also the way he saw other people in authority, including the therapist. But the fact that the owner was French was a particular trigger for this patient’s internal struggle, related to his attempt at a new self-definition and his struggle with the development of a new self-identity that could override the old one that was associated with so much pain from his terrible history of poverty and socioeconomic and sociopolitical alienation.

Stubborn Factors in the Emergence of Our View of the “Other” There are numerous examples of culture-bound syndromes (such as “Amok,” or sudden change where an otherwise normal individual will become berserk, goes into rage and strikes others, sometimes with deadly consequences; “Dhat syndrome,” or intense fear or anxiety over the loss of semen; “Koro,” a condition described as intense anxiety involving fear that one’s genitals are retracting into the body, resulting in death; and “Ataque de nervios,” a condition characterized by uncontrollable shouting, attacks of crying, trembling, psychomotor and epileptic-like behavior,

Considerations Concerning Individuals and Cultural Diversity

culminating in a temporary loss of consciousness) that are often given as evidence that culture-specific conditions can only be understood within the culture (Nevid, Rathus, & Greene, 2013). Such a position sounds reasonable when it refers to the need to contextualize a phenomenon in order to derive its most appropriate meaning. The other implication, however, is that such phenomena only impact specific individuals and that they are not to be considered psychological processes generalizable to other individuals. There are other culturally specific behaviors and preferences also found in religious belief systems (i.e., Voodoo, Santería, brujería or witchcraft, Espiritismo, etc.), in dress styles and colors, in food, and in music preferences, and so forth. All these preferences represent a particular worldview, including the view of the role of supernatural etiology or misfortune in mental illness, which can clash with the more traditional perspectives and practices of the dominant society. Once this clash happens, it creates a sense of cognitive dissonance when professionals from this dominant society attempt to assess degrees of disturbance with regard to these practices. The possibility for construing these preferences as “weird” and pathological formations is ever so great, due to the influence of the therapist’s different belief and value systems on the evaluation and treatment of individuals coming from these diverse communities. One of the first attempts to address the feeling of discomfort and cognitive dissonance triggered by these preferences is to categorize them as “something in need of explanation.” When these preferences are seen as evidence of “weirdness” and out-of-the-ordinary practices, and as belonging to the realm of the “not acceptable,” the society has a way of curtailing these practices, at least in the public arena. Such is the intent of the 2010 law in France prohibiting the use of the “burqa” (burka) or any garment that covers a woman’s face in public places, such as streets, shops, museums, public transportation, and parks (Turkey also has similar law banning the use of these garments in private and state universities and schools:  Rainsford, 2007). These prohibitions have been explained in terms of the need for national security, which is greatly compromised by not having access to information that can be derived from the individual’s face and facial expressions. In the United States, we have also seen a number of corrected laws enacted (e.g., enactment of laws such as the equal marriage act, equal opportunity employment, racial equality, etc.), emerging from a recognition that, in spite of one’s personal view about the other, society needs to be governed by principles and aspirations that attempt to ensure the well-being of all its citizens (e.g., the U.S. Declaration of Independence

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and the Bill of Rights), although not always able to reinforce fair practice of these principles. An example of that is the emergence of the English-only movement meant to require the use of English in public spaces, as well as the termination of bilingual programs in an effort to expedite and encourage cultural and linguistic assimilation on part of the immigrants (Javier, 2007). This mindset is fed by a view of the “other” through a very specific lens, contaminated by a personal psychology with strong bias against the “other.” We see that this is the same position that has permeated the history of civilizations and has given justification to the history of colonialism and its catastrophic practices that required from those colonized complete renunciation of that which, up to that point, had defined them and their experiences; it is the story of colonialism that has required from those being colonized complete renunciation of their past, and assimilation and faithful adherence to rules of conduct imposed by the dominant group, which considers the “other” “primitive,” “savage,” and “in need of being civilized” (Gutierrez, 1991; McCullough, 2012). This is the same position that found justification for the history of discrimination and slavery in many parts of the world and that has resulted in socioeconomic, political, and religious-based positions that have become the source of frictions and divisiveness over many centuries, most recently in the Middle East. So, it is an old way of thinking that is stubbornly engrained in our cognitive fabric and that is applied unconsciously, affecting the ways we experience ourselves and the world around us. Since these same factors have also influenced the mental health field, including psychoanalytic conceptualizations and practice, particularly in the tendency to treat patients’ behaviors as psychologically abnormal or unhealthy, it is crucial for those interested in the practice of psychoanalytic and psychodynamic treatment to become aware of these tendencies and to examine the extent to which their own way of relating may also be affected by these tendencies. It is in this context that we are encouraging an examination of the assumptions underlining our view of the “other,” because this is more likely to affect our ability to adequately address psychological issues affecting patients coming from diverse communities. In the end, what we are looking for is to establish the necessary conditions that will allow all information emerging from the patient (whatever the sources, including sources related to culture, race, class, sexual orientations, linguistic difference, physical handicap, immigration experience, etc.) to emerge unobtrusively and meaningfully in the context of the therapeutic transaction, and to allow this formation to guide our understanding and

Considerations Concerning Individuals and Cultural Diversity

treatment of the patient’s specific dilemmas. Being able to listen for these types of information is an essential part of becoming an effective psychoanalyst, as described by Freedman (1983). T H E I N FLU EN CE O F E VO LU TI O N A RY T H I N K I N G I N TH E SCI EN TI FI C EN TERPRISE A N D O U R VI E W O F T H E “OTH ER ”

The first assumption that has become engrained in our way of thinking is the one inherent in the evolutionary theory of the preservation of the species that we discussed in earlier chapters. In this context, by necessity, the initial organization of the experience is guided by the extent to which basic biological needs are properly responded to by the environment, out of which emerge organizations of experience that are categorized as “good” or “bad,” depending on whether or not they adequately address the resulting physiological urgency and reduce the tension associated with the biological demands (e.g., the need for food and shelter). The outcome of this development is that we find ourselves organizing experiences with ourselves and the world around us along “dichotomous dimensions,” which includes establishing parameters that, at a more personal level, allow us to distinguish areas to avoid and/or approach, depending on their level of personal threat or comfort. Once we are involved in dichotomizing ourselves and the world around as “us” and “them,” as “good” or “bad,” “acceptable” or “unacceptable,” and “normal” or “abnormal,” it forces a categorization of our experience where the “others” and the “unknown” by necessity and de facto are relegated to one pole of the categorization opposite to the one reserved for the “self.” So, there is an inherently antagonistic position that then contaminates everything we see and experience about the “other” to some degree. The “other” and its content can then become subject to rejection and disallowance on our part if it cannot be understood or processed through our cognitive structure, or if it is too anxiety-provoking (when too different from our own experience). So, anything and anyone who is unfamiliar and unknown to us (e.g., culturally, racially, and linguistically different groups; differences in sexual orientations; differences in religious beliefs and practices; the physically handicapped and the immigrant; etc.) become part of that “other.” Our greatest problem is that this “other” is seen as not part of the “US,” and not integrated into the very fabric of the human endeavor, but as something that has to be explained. This dichotomous organization is inherent in our scientific endeavors, where the purest form of knowledge of the truth of a particular

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phenomenon can only be established through an objective proof of such a phenomenon. That is, the establishment of the truthfulness of a particular phenomenon is guided by specific standards of validity (criteria for evidentiary truth), which require the individual to ascertain as valid only information (data) that can be independently corroborated and replicated (through a control condition) by others; the scientific standard requires that findings obtained in this manner are proven only through statistically significant validation (Hayes, Follette, Dawes, & Grady, 2007). This empirical method of finding the truth (logical empiricism), which has produced so many important findings for humanity, considers acceptable only knowledge that is directly derived in this manner with minimal personal involvement (bias), and hence “assumed” to be independent from personal and subjective beliefs: that is, independent from personal values, attitudes, opinions, sensations, impressions, feelings (Moncayo, 1998). From that perspective, anything that cannot be explained in this manner is considered “unscientific” and relegated to less desirable components of the scientific enterprise (as “not acceptable,” “not valid,” etc.). When these principles are rigidly applied to the study and understanding of complex factors affecting human motivations and human endeavors (such as cultural and diverse factors) that are not easily amenable to such rigid a methodology, we are left with the condition we have today, where studies of these complex factors are reduced (by the law of parsimony) to their simplest form in order to establish less complicated conditions so as to enhance replicability and generalizability. Thus, there is no room to include as part of the scientific paradigm meaningful discussions of cultural, racial, and ethnic factors, unless there is a realignment of the parameters that guide the scientific enterprise. Without that, these factors are relegated to the “other” “the subjective” and “less desirable” factors and thus not an essential part of the scientific inquiry and, by extension, not relevant to explaining the complexity inherent in the human condition. PSYCH O LO G I C A L M ECH A N ISM T H AT K EEPS TH E “OTH ER ” AT A D IS TA N CE

This way of “knowing” that characterizes the thinking patterns in Western civilization is very dangerous because the “other” not only becomes the repository of what is not acceptable and is unfamiliar/unknown to the scientific and professional community but also of all things that are disallowed and rejected by the individual related to his personal psychology and unconscious processes; that includes content of unconscious material

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related to the forbidden (unresolved and unneutralized aggression) which can be experienced as too cognitively disorganizing if consciously recognized by the individual as content of the self; all of this disallowed material is then projected onto the “other” who is imbued with all these undesirable qualities. As Javier and Herron (2002) stated in this regard, it is “the content of the introjects and the nature of the repressed material influenced by these dynamics [that] become the driving force for . . . the control and often the domination of others” (p. 157). It is this mechanism of projection and its unconscious operation that has been associated with the development of prejudice, bias, and bigotry (Lichtenberg, Beusekom, & Gibbons, 1997) and that tends to complicate the therapeutic transaction, particularly when patients from the diverse communities are involved. Laҫan’s view of the unconscious is quite instructive in this regard. According to Moncayo (1998), for Laçan, the very definition of “the unconscious” already encapsulates “the other,” where the otherness “encompasses the subject of the unconscious and the presence of a different social other” (p. 276) (i.e., an ethnic, racial, and linguistic-minority individual or group, physically handicapped, etc.). He went on to explain that “the unconscious as the Other encompasses the place of a repressed symbolic drive and the psychosocial space of the socially different  .  .  .  the place of minorities, of the socially different by virtue of race and class, symbolically represents the place of forbidden satisfaction (jouissance), the natural jouissance, the place of the lack of discipline that the laws demand. Thus, minorities, the masses, people of color, and the lower classes have been classically perceived and defined as representing the other of the primitive mentality found in nature, passion, and drive.” (Moncayo, 1998, pp. 276–277) In this context, we can say that the “other” has the effect of serving as a reminder to members of the ruling class of what they cannot do or have (the forbidden) (Moncayo, 1998). So the “other” and what it has and wants is viewed as something exotic and unusual that can trigger in those in power a secret admiration and desire, and thus represent what those in power cannot allow themselves to have or do openly, unless it is incorporated into their behavioral repertoire and preferences (Moncayo, 1998). So it is both a repudiation and a reflection of envy of the “other” that create a tremendous psychological tension that requires some other resolutions when enactment of laws alone prohibiting the behavior does not work.

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That was the case with the Tango in Argentina, which was incorporated into the high-society dance repertoire after being considered the dance of the depraved and less desirable members of Argentine society. In the United States and in other parts of the world, we have witnessed subgroups of immigrants who also have managed to develop their own culturally driven neighborhoods with businesses of various kinds (e.g., Chinatown, Little Italy, Harlem, and Spanish Harlem, etc.) that then become desirable attractions for the locals and visitors alike.

Implications of Dichotomous Thinking for Psychoanalytic Formulations on Diversity In psychoanalytic thinking, we have also seen this same evolutionary mechanism in operation as described above, although Freud’s original idea was to provide “extensive and relatively noncategorical personality profiles” (Herron, Ramirez, Javier, & Warner, 1997, p. 177). He was looking for a psychological model that can explain a range of behavioral conditions, including normal developments, and a description of conditions likely to produce pathological formations as seen in symptoms. It was his contention that it was possible to explain through universal principles of mental function a person’s cognitive and emotional experiences in all their complexity, and regardless of cultural, ethnic, racial, socioeconomic, and sociopolitical conditions (Javier & Yussef, 1995, 1998). The impact of cultural influence found its most distinct reference in Freud only when discussing the development of the superego, which he defined as “the representative of the id and the external world.” The superego is said to include the idea of “right” and “wrong” encoded in our conscience related to specific prohibitions associated with unacceptable feelings toward the primary relationships in the oedipal configuration. The psychoanalytic formulation that created the greatest challenge to the meaningful and fair incorporation of issues related to the “other” was the development of ego psychology with its emphasis on adaption, ego strength and ego deficit, autonomous functions, the importance of self-reliance, mastery-competence related to environmental demands, capacity for insight, and so on (Bellak & Faithhon, 1981; Moncayo, 1998). Such a development was heralded as an important accomplishment toward allowing psychoanalytic formulations to be more amenable to scientific investigations, resulting in the creation of a number of instruments to measure ego functions and related constructs, such as locus of control, ego identity, and so on (Bellak & Faithhon, 1981; Corcoran & Fischer,

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1987; Fischer & Corcoran, 2007). The problem is that ego psychology also resulted in a consolidation of dichotomous judgements about what constitutes normal behavior, whereas issues related to the “other” were often associated with the abnormal and undesirable. For instance, it was more likely for the poor to be considered as having a problem with mentation, delayed gratification, compromised ego function, and so on (Javier, 1990; Javier & Herron, 2002). With this development, the areas of demarcation became quite clear as to what constituted acceptable/desirable behavior related to cultural bounds, norms, and expectations. The result is that members of the poor community, individuals whose culture and language are not familiar to the ruling class, and those whose sexual orientations do not follow the traditional view of gender behavior are likely to be given the most severe diagnoses (such as sexual perversion). We see this in operation in the number of linguistically minority children who are improperly diagnosed as learning disabled (Javier, 2007) and in the number of members of the minority communities who are likely to receive more severe psychiatric diagnoses and be incarcerated (Guerino, Harrison, & Sabol, 2012; Scherer & Diaz, 2013; Whaley & Geller, 2003). A similar phenomenon is seen in the educational system, where children whose culture and outlook are congruent with those in authority are more likely to have their playing and rough behaviors with one another be seen as just child’s play; similar rough behavior observed in children from the “other” community is more likely to be judged as aggressive and inappropriate (Javier & Herron, 1998), resulting in suspensions. In psychoanalytic practice, this dichotomous thinking resulted in a group of individuals’ being considered as not having the necessary prerequisites to benefit from psychoanalytic treatment, resulting in the description of the ideal patient for analyzability (i.e., verbal, bright, highly educated, able to pay for treatment, ability to postpone gratification, with capacity for insight, strong impulse control, capacity to withstand ambiguity, capacity for mentation and symbolism, etc.). The work of Roland (1988), Altman (1995), Perez Foster (with Moskowitz & Javier, 1996), Javier and Herron (1998), Wachtel (1999), Comas-Diaz (2000), Holmes (2005, 2006), Greene (2007), Muran (2007), Wong (2007), Tummala-Narra (2007, 2013), Gentile (2013), and many others has demonstrated that psychoanalytic intervention can be very effectively applied to members of diverse communities, provided that countertransference issues are adequately addressed. Most recently, Gentile (2013) provided us with an unusual and courageous view of the nature of the complex and

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multifaceted work that is required from the therapist working psychoanalytically with a patient from a diverse community. As she said, “Neither participant can come out intact, nor can our tools of analysis, meaning making, or engagement”(p. 463). What was required of her was the difficult task of relinquishing her cognitive structure, of renouncing the way of knowing that has characterized her way of processing experience in a dichotomous fashion, renouncing the attitude associated with a sense of power and privilege given to her by virtue of her education, social class, race, ethnicity (the therapist was white and the patient was Latino), and professional accomplishment, and most importantly, “to renounce being a representative of the ego ideals of the ruling classes” (Moncayo, 1998, p. 275). All of that was done to provide the patient with an opportunity and the space to heal. This is the prescription given by Anna Freud (1936) and later further delineated by Freedman (1983) as the ideal quality of a good therapist. Included in such a prescription is the importance that the therapist remains neutral, equidistant from all sources of information coming from id, ego, and superego material; able to listen to the patient’s information with suspension of preconceived ideas and judgements, and able to operate from a position of “not knowing” so as to allow the “culturally and linguistically ciphered unconscious” of the diverse patient “speak in its own true voice” (Moncayo, 1998, p. 275). This will remain only an ideal for as long as we do not take an active control of the sources of our own prejudices against the “other” emerging from our personal psychology.

Conclusion The takeaway from this chapter is that those interested in becoming involved in psychoanalytic practice have a particular obligation and responsibility to become aware of and examine the personal factors likely to affect negatively their ability to work effectively with issues affecting patients from diverse communities. There are too many possibilities for mishaps when working with the diverse population by virtue of the different experiences that may have shaped the psychic structure of both the patient and the therapist. It would be the best circumstance for these types of patients if the therapist is able to suspend in some way any judgements and preconceived notions about the “other” (which can only be an aspiration) and operate from the perspective of not-knowing, while allowing the patient’s information to guide both the assessment of the conditions under consideration and the treatment.

Considerations Concerning Individuals and Cultural Diversity

As psychotherapists we are called upon to help our patients rid themselves from the distortions in perceptions that may have developed in the context of their experiences of categorizing the “other.” This is not an easy task, as shown in the treatment of the dry cleaner patient. But if the therapist’s own distortions about the “other” are not also actively addressed, the therapeutic transaction can become quite a messy and deplorable collusion of distortions coming from the patient and the therapist, with dire consequences for the course of treatment of the patient. To curtail the possibility of such an eventuality, we are suggesting that therapists consider the following recommendations: 1. The patient’s problems should be viewed first from the patient’s personal perspective and cultural background in terms of how “normal” and “abnormal” behaviors are defined and understood. That is, it is the patient’s personal context that should guide the assessment of and intervention in the patient’s unique dilemma. In that context, it is important to be aware that what appears as a patient’s cautiousness toward the therapist and a tendency to see the therapist as a potential adversary could be adaptive and self-protective, expected from someone for whom authority figures have not always been fair but rather abusive and punitive. 2. It is important to recognize the differential impact of cultural, linguistic, and ethnic influences on the individual’s personality development and the degree and extent to which such influences may be affecting the individual’s specific behavioral repertoire. The challenge is to avoid using this awareness to stereotype the patient. 3. Recognize that not all members of diverse groups are the same, and that cultural, ethnic, and linguistic characteristics are differentially embraced; so it is important to evaluate individually the extent to which diverse values are incorporated in this patient’s psychological repertoire. 4. Recognize that the quality of the unconscious for members of the diverse community also has additional components associated with their ethnic and cultural qualities. In this context, we can then point to the quality of what Herron (1998) refers to as the “ethnic unconscious,” and that includes belief systems of a supernatural nature and other culturally specific ways that are used to process and deal with life’s challenges.

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5. It is important to recognize the role of multiple identifications (e.g., being a black man, homosexual, parent of an adopted child, living in a dilapidated and poor section of the city, going to graduate school in a predominantly white university, etc.) and related oppressions that members from diverse communities have to negotiate (Greene, 2007) and that could have an impact on their overall psychological functioning. 6. It is important for the therapist to be aware of his countertransference (defined as a failure of the therapist to be in touch with his own urgency) and that can result in compromising and derailing the containment function of the therapeutic situation (Russell, 1998a, 1998b). So, being aware of the therapist’s reaction to the patient in reference to accent, appearance, sexual and religious preferences, racial characteristics, weight and height, color of hair, physical handicaps, and so on, may provide important information about the therapist’s own personal psychology, including any biases and prejudice about the “other.” 7. It is important to acknowledge the challenge of being able to identify with the patient’s personal plight whose preferences are so different from ours. This is particularly the case in reference to economic and class issues where the therapist’s aspiration (whether one is white/ black/Latino/Asian, etc.) is more likely to emulate that of the middle class and always searching for improving her lot in this regard, rather than being able to truly and empathically connect with the disadvantaged patient (Javier & Herron, 2002). 8. It is also important to keep in mind that countertransference reactions toward the “other” occur even in therapists coming from diverse communities, and hence the tremendous importance of examining one’s own reactions to patients’ appearance, class, linguistic characteristics, mannerisms, issues raised in treatment, and so on, and to assess one’s personal prejudice and bias in this regard, regardless of one’s cultural background. 9. The main goal of the therapeutic situation is to work toward a decrease in the patient’s feeling of vulnerability. This work requires the therapist to be able to establish an empathic connection with the patient. Paradoxically, however, when the therapist is trying too hard to establish such a connection, it can have the opposite effect, or what Tuch (1997) refers to as “empathic failure.” According to him, “One

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of the greatest sources of emphatic failure is the analyst’s tendency to rely too heavily upon his/her own experience in order to understand the patient’s” (p. 266). 10. Working to help our patients rid themselves of negative assumptions about others is a complicated and delicate process that may result in an exacerbation of symptoms and deterioration of functions. This is the case because it requires the patient to become aware that these assumptions have developed from projections of content coming from the inside of oneself (herself), which the patient is actively rejecting and disavowing.

References Altman, N. (1995). The analyst in the inner city:  Race, class, and culture through a psychoanalytic lens. Hillsdale, NJ: Analytic Press. Altman, N. (1996). The accommodation of diversity in psychoanalysis. In R. M. P. Foster, M. Moskowitz, & R. A.  Javier (Eds.), Reaching across boundaries of culture and class: Widening the scope of psychotherapy (pp. 195–209). Northvale, NJ: Jason Aronson. Altman, N. (2007). Toward the acceptance of human similarity and difference. In C. Muran (Ed.), Dialogues on difference—Studies on diversity in the therapeutic relationship (pp. 15–25). Washington, DC: American Psychological Association. American Psychoanalytic Association (2012). Impact of immigration policy on children, individuals, and families. Available at the American Psychological Association website, http://www.apsa.org/About_APsaA/Position_Statements/Impact_of_​Immigration_ Policy.aspx. American Psychological Association (1990). Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. Washington, DC: APA. American Psychological Association. (2000). Guidelines for psychotherapy with lesbian, gay, and bisexual clients. American Psychologist, 55, 1440–1451. American Psychological Association (2003). Guidelines on multicultural education, training, research, practice and organizational change for psychologists. American Psychologist, 58, 377–402. Available at the American Psychological Association website, http://www.apa.org/pi/oema/resources/policy/provider-guidelines.aspx. Bellak, L., & Faithorn, P. (1981). Crisis and special problems in psychoanalysis and psychotherapy. New York: Brunner/Mazel. Bonovitz, C. (2005). Locating culture in the psychic field:  Transference and countertransference. Contemporary Psychoanalysis, 41, 55–76. Comas-Diaz, L. (2000). An ethnopolitical approach to working with people of color. American Psychologist, 10, 1319–1325. Comas-Diaz, L., & Jacobsen, F.  M. (1991). An ethnocultural transference and counter­ transference in the therapeutic dyad. American Journal of Orthopsychiatry, 61, 392–402. Corcoran, K., & Fischer, J. (1987). Measures for clinical practice: A sourcebook. London: The Free Press.

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Foundational Competencies Dalal, F. (2006). Racism:  Processes of detachment, dehumanization, and hatred. Psychoanalytic Quarterly, 75, 131–161. Fischer, J., & Corcoran, K. (2007). Measures for clinical practice (4th ed.). New York: Oxford University Press. Freedman, N. (1983). On psychoanalytic listening:  The construction, paralysis and reconstruction of meaning. Psychoanalysis and Contemporary Thought, 6, 405–434. French Senate approves ‘Burka ban’ (2010). Available at the Telegraph website, http://​ www.telegraph.co.uk/news/worldnews/europe/france/8002914/French-Senate-aprov. Retrieved June 8, 2014. Freud, A. (1936). The ego and the mechanism of defense. New  York:  International University Press (1966). Gentile, K. (2013). Bearing the cultural in order to engage in a process of witnessing. Psychoanalytic Psychology, 30(3), 456–470. Greene, B. (2007). How difference makes a difference. In C. Muran (Ed.), Dialogues on difference—Studies on diversity in the therapeutic relationship (pp. 47–63). Washington, DC: American Psychological Association. Guerino, P. L., Harrison, P. M., & Sabol, M. J. (2012). Prisoners in 2010. U.S. Department of Justice Bulletin: The Bureau of Justice Statistics. Available at the Bureau of Justice Statistics website, www.bjs.gov; retrieved Aug. 4, 2013. Gutierrez, R. A. (1991). When Jesus came, the Corn Mother went away: Marriage, sexuality, and power in New Mexico, 1500–1845. Stanford, CA: Stanford University Press. Hayes, S. C., Follette, V. M., Dawes, R. M., & Grady, K. E. (2007). Scientist standards of psychological practice: Issues and recommendations. Reno, NV: Context Press. Herron, W.  G. (1998). The development of the ethnic unconscious. In R.A. Javier & W. G.  Herron (Eds.), Personality development and psychotherapy in a diverse society: A sourcebook (pp. 343–355). Northvale, NJ: Jason Aronson. Herron, W. G., Ramirez, S. M., Javier, R. A., & Warner, L. K. (1997). Cultural attunement and personality assessment. Journal of Social Distress and the Homeless, 6, 175–193. Holmes, D. (1992). Race and transference in psychoanalysis and psychotherapy. International Journal of Psychoanalysis, 73, 1–11. Holmes, D. (1999). Race and countertransference:  Two “blind spots” in psychoanalytic perception. Journal of Applied Psychoanalytic Studies, 1, 319–332. Holmes, D. (2005). Psychoanalysis, theory, and practice: Ensuring relevance to minority communities. American Psychoanalyst, 39, 8–11. Holmes, D. E. (2006). The wrecking effects of race and social class on self and success. Psychoanalytic Quarterly, 75, 215–235. Javier, R.  A. (1990). The suitability of insight-oriented therapy for the Hispanic poor. American Journal of Psychoanalysis, 40(4), 305–318. Javier, R. A. (2007). The Bilingual Mind: Thinking, Feeling and Speaking in Two Languages. New York: Springer. Javier, R. A., & Herron, W. G. (Eds.) (1998). Personality development and psychotherapy in a diverse society: A source book. Northvale, NJ: Jason Aronson. Javier, R.  A., & Herron, W.  G. (2002). Psychoanalysis and the disfranchised:  Countertransference issues. Psychoanalytic Psychology, 19(1), 149–166. Javier, R. A., & Yussef, M. B. (1995). A Latino perspective on the role of ethnicity in the development of moral values:  Implications for psychoanalytic theory and practice. Journal of the American Academy of Psychoanalysis, 23(1), 79–97.

Considerations Concerning Individuals and Cultural Diversity Javier, R. A., & Yussef, M. B. (1998). A Latino perspective on the role of ethnicity in the development of moral values: Implications for psychoanalytic theory and practice. In R. A. Javier, & W. G. Herron (Eds.), Personality development and psychotherapy in a diverse society: A source book (pp. 366–382). Northvale, NJ: Jason Aronson. Lichtenberg, P., Beusekom, N. V., & Gibbons, D. (1997). Encountering bigotry—Befriending projecting persons in everyday life. Northvale, NJ: Jason Aronson Inc. McCullough, M. (2012). Vertical orientalism. The colonial disjuncture and the transnational child. Journal of Social Distress and the Homeless, 21(1& 2), 257–274. McWilliams, N. (2003). The educative aspects of psychoanalysis. Psychoanalytic Psychology, 20, 245–260. Moncayo, R. (1998). Cultural diversity and the cultural epistemological structure of psychoanalysis—Implications for psychotherapy with Latinos and other minorities. Psychoanalytic Psychology, 15(2), 262–286. Morgan, H. (2009). Issues of “race” in psychoanalytic psychotherapy: Whose problem is it anyway? Research digest. Journal of Child Psychotherapy, 35, 315–321. Morris, D. (1998). The supervision of psychotherapy for culturally diverse patients. In R. A.  Javier & W. G.  Herron (Eds.), Personality development and psychotherapy in our diverse society: A source book (pp. 567–595). Northvale, NJ: Jason Aronson. Morris, D., Tansey, M., Cox, D., Nezu, A., Kendall, P., & Kaslow, N. (Winter 2012). BOT Diversity Committee Report for 2012. The Specialist, 31(1), 34–39. Muran, C. (Ed.) (2007). Dialogues on difference:  Studies on diversity in the therapeutic relationship. Washington, DC: American Psychological Association. Nelson, J. M. (2009). Psychology, religion, and spirituality. New York: Springer. Nevid, J. S., Rathus, S. A., & Greene, B. (2013). Abnormal psychology in a changing world. Upper Saddle River, NJ: Pearson Prentice Hall. Perez Foster, R.  M., Moskowitz, M., & Javier, R.  A. (Eds.) (1996). Reaching across boundaries of culture and class—Widening the scope of psychotherapy. Northvale, NJ: Jason Aronson. Pew Forum (2008). See U.S. Religious Landscape Survey, below. Rainsford, S. (2007). Women condemn Turkey constitution. Available at BBC News website, http//news.bbc.co.uk/2/hi/Europe/7025294.stm. Retrieved July 4, 2013. Roland, A. (1988). In search of self in India and Japan: Toward a cross-Cultural psychology. Princeton, NJ: Princeton University Press. Russell, P. L. (1998a). The role of paradox in the repetition compulsion. In J. G. Teicholz & D. Kriegman (Eds.), Trauma, repetition compulsion and affect regulation: The work of Paul Russell (pp. 1–22). New York: The Other Press. Russell, P. L. (1998b). Trauma and the cognitive function of affects. In J. G. Teicholz & D. Kriegman (Eds.), Trauma, repetition compulsion and affect regulation: The work of Paul Russell (pp. 23–47). New York: The Other Press. Scherer, M., & Diaz, E. (June 29, 2013). After Trayvon. Time, 182(5), 28–35. Smith, T. B., Constantine, M. G., Dunn, T. W., Dinehart, J. M., & Montoya, J. A. (2006). Multicultural education in the mental health professions:  A  meta-analytic review. Journal of Counseling Psychology, 53, 132–145. Tuch, R. M. (1997). Beyond empathy: Confronting certain complexities in self psychology theory. Psychoanalytic Quarterly, 66, 259–282. Tummala-Narra, P. (2004). Dynamics of race and culture in the supervisory encounter. Psychoanalytic Psychology, 21, 300–311.

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Foundational Competencies Tummala-Narra, P. (2007). Skin color and the therapeutic relationship. Psychoanalytic Psychology, 24, 255–270. Tummala-Narra, P. (2013). Psychoanalytic applications in a diverse society. Psychoanalytic Psychology, 30(3), 471–485. U.S. Census Bureau, Public Information Office, website [email protected]. Last revised: January 29, 2013 (U.S. Religious Landscape Survey—Pew Forum, 2008). U.S. Religious Landscape Survey—Pew Forum (2008). Religious affiliation:  Diverse and dynamic. Retrieved on June 8, 2014 from Pew Forum on Religion and Public Life, available at http://religions.pewforum.org/pdf/report-religious-landscape-st udy-full.​pdf. Wachtel, P.  L. (1999). Race in the mind of America:  Breaking the vicious circle between Blacks and Whites. New York: Routledge. Whaley, A.  L., & Geller, P.  A. (2003). Ethnic/racial differences in psychiatric disorders: A test of four hypotheses. Ethnicity & Disease, 13, 499–512. Wong, P. (2007). The inscrutable Doctor Wu. In C. Muran (Ed.), Dialogues on difference— Studies on diversity in the therapeutic relationship (pp. 187–202). Washington, DC: American Psychological Association.

ELEVEN

Professional Identity DOLORES O. MORRIS

The purpose of this chapter is to discuss how the identity of the psychologist-psychoanalyst’s is developed. First the requirements are addressed, including how they are derived. This is followed by a description of the demographic characteristics of psychologist-psychoanalysts and their professional attitude. The variety of roles that allows for their creativity and leadership as well as the interface with professional organizations will be covered. The conclusion speculates about the future of the specialty.

Education Psychologists begin by having a doctoral degree from a professional program, usually clinical, counseling or school psychology. Currently most doctoral programs approved by the American Psychological Association (APA) do not provide a significant amount of course work in psychoanalysis. This appears to be due to the emphasis on evidence-based therapies (EBT), the “evidence” being research studies in contrast to the traditional case studies of psychoanalysis. Recently, psychoanalysis has also begun to provide research evidence of its effectiveness. The result was that, for a time, APA did not include analysis as an EBT, but now it does. Nonetheless, doctoral students continue to get limited exposure to psychoanalysis.

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Psychoanalytic Education Training in psychoanalysis usually takes place in an institute and occurs after the psychologist has acquired a doctorate. The training involves didactic course work, supervision of psychoanalytic work with patients, and personal analysis (Accreditation Council for Psychoanalytic Education, Inc. (ACPEinc [ACPE, Standards].) Although the specifics of didactic material in particular vary with the interest and beliefs of the institute, a typical program involves 300 hours of thrice-weekly personal analysis, a minimum of four years of course work, and supervision of two to three cases of patients’ being analyzed by the candidate. Supervisors are experienced analysts approved by each institute. Approval is also required for the candidate’s personal analyst. Supervision will consist of a minimum 150–200 hours; 150 hours when the institute or program requires two cases, and 200 hours when the institute or program requires three cases. It is expected that one case will be supervised through termination; this may occur before or after graduation. It is recommended that, when possible, candidates receive supervision from supervisors of different theoretical orientations and of both sexes. (A more detailed account of the supervisory process is contained in Chapter 8.) In the earlier days of psychoanalysis in this country, psychiatrists restricted psychoanalytic training in institutes to medical doctors, so other institutes were created by psychologists to provide the training. The practice of psychoanalysis was not regulated by law, nor licensed, but most analysts were graduates of institutes and had doctorates in their specialty, such as medicine, psychology, or social work. Because there are different theories within psychoanalysis, institutes vary in their primary emphasis, but all adhere to the core principles of psychoanalysis. There has been an ongoing debate in the psychoanalytic community about the definition of “psychoanalysis,” theoretical orientations, and frequency and duration of sessions (Aron, 2009; Goldberg, 2009; Stern, 2009a; Stern, 2009b; and Wallerstein, 2009). While there was not a consensus in the debate, they agreed that psychoanalytic education was essential for the preparation of an analyst. The Psychoanalytic Consortium is made up of four major psychoanalytic organizations: Division 39 (Psychoanalysis, APA), the American Psychoanalytic Association (APsaA), the American Academy of Psychoanalysis and Dynamic Psychiatry (AAPDP), and the American Association for Psychoanalysis in Clinical Social Work (AAPCSW). This interdisciplinary consortium is committed to psychoanalytic teaching and education and have collaborated for 18 years to develop

Professional Identity

common standards for psychoanalytic education. The outcome was the formation of the Accreditation Council for Psychoanalytic Education (ACPEinc) in 2001. ACPEinc is an autonomous agency that accredits psychoanalytic institutes and training programs that are authorized to provide an educational program by the states in which they are located. The next step for institute-trained psychologists or those with equivalent training is board certification, which comes through the American Board of Professional Psychology (ABPP), the primary organization for specialty board certification in psychology. The examination given by board-certified specialists of the American Board and Academy of Psychoanalysis (ABAPsa) is designed to assess core competencies, and requires educational standards, experience, and passing its oral examination. It is the national board providing competency-based examination for psychologists practicing psychoanalysis in North America, similar to national certification boards for specialties in the practices of law and medicine, and it is the highest standard for a psychologist-psychoanalyst to attain, indicating a significant degree of expertise and acceptance by fellow specialists. Psychoanalysis is a specialty recognized by the American Psychological Associaiton and its Committee on Specialities (COS). In summary, the training or educational requisites for a psychologist-psychoanalyst are a doctoral degree from a program in professional psychology, postdoctoral training in psychoanalysis, a state license, and finally, board certification. Thus, there are two main groups that are invested in the preparation to practice psychoanalysis. The first is the profession, which establishes its own standards, and the second is governmental agencies that establish entry-level standards that all psychoanalysts must meet to be licensed in a jurisdiction. Both are ethically and morally responsible to serve the best interest of the student or practitioner and the public. There are many analytic institutes that have their own codes of ethics, in addition to the APA and the APsaA codes. Licensed professionals should be familiar with the ethics code in state licensing law, and institutional ethics codes, as well as the codes in their places of employment such as hospitals or clinics.

Demographic Characteristics of Psychologists-Psychoanalysts Demographic characteristics of psychologist-psychoanalysts include type of job preparation, job satisfaction level, practice patterns and finances,

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gender, and ethnicity. The specialist has a dual identity: one rooted in psychology, and the other in psychoanalysis. It is complicated to ascertain the number of psychologists who are estimated to work in the profession, and some of their basic demographic characteristics, including gender and ethnicity, for there is no single list or registry that provides this information. The most direct way to make inferences regarding practitioners’ basic characteristics is to examine available data from national organizations. However, even this method is fraught with challenges, because accurate statistics for those who join professional organizations are unknown, and many psychologist-psychoanalysts may belong to two or more professional organizations that represent the specialty. There are two primary organizations that psychologist-psychoanalysts may join: APA Division 39 and the American Psychoanalytic Association (APsaA). The APA is a primary source of data. It may be assumed that the majority of psychologists are APA members, but the APA does not report specific data pertaining to postdoctoral institute training or its equivalent. However, the APA does report information from the American Board of Professional Psychology (ABPP), which certifies specialties. Unfortunately, it is difficult to identify the significant number of psychologists who have completed psychoanalytic institute training or its equivalent but did not choose to apply for ABPP certification. The purpose of certification is to affirm that the specialist has met the criteria defining the specialty; and has successfully completed the education, training, experience, and professional standing requirements of the specialty; including a comprehensive examination developed and administered by ones’ peers certified in the specialty to evaluate the competencies required to provide quality service in the specialty of psychoanalysis. Division 39, Psychoanalysis, of the APA represents l psychologists that identify themselves as having a major commitment to the study, practice, and development of psychoanalysis and psychoanalytic psychotherapy. A  demographic snapshot of the professional identity of a psychoanalyst will be illustrated by his/her job preparation, professional degree, license, and the aspects of practice that represent job satisfaction, practice patterns and finances, gender, and ethnic representation. These data can be obtained from workforce data of APA and Division 39 (2010).1 1

The Division 39 and APA comparison tables were adopted by using only members, and fellows from each group.

Professional Identity J O B PREPA R ATI O N

The Ph.D. is the degree that the majority of members of Division 39 and APA have earned: 81% and 96%, respectively. Thirteen percent of Division 39 members have Psy.D. degrees, and similarly, the Ed.D. for APA members. It is also noteworthy that 58% of Division 39 members have had their degrees for 25  years or more, and 38% of APA, indicating Division 39 members are an older population. Licensure status for Division 39 members is 89% licensed and/or certified, compared to 63% of APA members (APA Table 2, 2010 adopted). Members come from all regions in the United States, Canada, and other countries, with the middle Atlantic region having the highest representation for both groups, at 45% for Division 39 and 19% for APA (Table 1 APA Work Force Study 2010 Regional Representation adopted Table 3). The Division 39 survey (2008), Division 39 Practice Survey: A Guide to the Main Results, provides the practice patterns, practice finances, attitudes toward practice, and practice development of its members. The average age of the membership is 60, ten years older than the average APA members, with the men being marginally older than women. This is not surprising, since many of its members are on the postdoctoral level and may have joined the division later. As mentioned earlier, females outnumber men both in APA and Division 39 membership. However, males are older and have been in practice longer. Twenty-one percent is the mean number of years in practice for the survey respondents, with males being in practice significantly longer than females. The respondents in independent practice have an average of 18 different patients per week, with males seeing significantly more patients than do females. Respondents in practice longer reported seeing significantly more patients per week. Seventy percent of patients are seen for once-weekly therapy, with approximately 46% of the average respondent’s caseload having been in treatment for one to five years, and 22% being seen for more than five years. Female patients in treatment outnumber males by 61%. Patient age is fairly evenly distributed across decades, with almost half being between 30 and 49. The practice finances category showed that 63% of practitioners are not managed-care providers and that 68% of their income is from patient self-pay. Patients are most commonly charged in the range of $100 to $150 per session; 65% of patients are charged between $100 and $199 per session, and approximately 25% are charged less than $100 per session. The positive degree of satisfaction of practitioners with their practice seems to be reflected by the size and scope of their practice, the mix of

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patients, and their income from the practice. Most of them seemed relatively satisfied with their practices. Overall satisfaction correlates with income level with males, who are earning more than females and are more satisfied overall with their practices. Male respondents have been in practice longer, see more patients, earn higher incomes, and overall are more satisfied with their practices and report being more satisfied. Although it is difficult to provide an exact count of practitioners of psychoanalysis in psychology, Division 39 has approximately 4,000 members, most of whom identify themselves as psychologist-psychoanalysts. There are currently more than 125 ABPP board-certified psychoanalysts, and over 2,000 certified graduates of postdoctoral training programs in psychoanalysis. There are approximately 85,000 licensed psychologists in the United States, many of whom have indicated in surveys that they have been significantly influenced during training by psychoanalysis. Postdoctoral education and training in the specialty of psychoanalysis is currently available in most North American states and Canadian provinces, as well as Mexico. Psychologist-psychoanalysts practice in all states and provinces. The Psychoanalysis Synarchy Group represents the postdoctoral specialty of psychoanalysis. The psychologist-psychoanalysts represented by the Synarchy include the members and governance of the APA Division 39, the board-certified Fellows of the ABPP Academy of Psychoanalysis, the Directors of the ABPP Specialty Board of Psychoanalysis and representatives of postdoctoral psychoanalytic training programs throughout North America. The total number of psychologist-psychoanalysts and postdoctoral psychoanalytic candidates represented by the Synarchy is estimated to be 6,570 practitioners. Females represent 59% and 55% of Division 39 and APA, compared to males 41% and 44% respectively. Females outnumber males in Division 39 and APA by 18% and 11%. Whites outnumber other groups in the first number represents Division 39 and second APA, 85% and 68%, respectively, with 11% and 25% not specified, respectively. Hispanics are represented by 3% in both groups, whereas in Division 39, only 1% of blacks and Asians are represented, with the percentage of Asians, Hispanics, and blacks being about the same in APA (APA, 2010 Adopted Tables 1 and 2). This demographic snapshot of psychologists committed to the practice of psychoanalysis is set against the background of the demographics of the parent APA. It identifies an older core group who are largely Ph.D.’s, majority female, predominately white. These professionals tend to be quite enthusiastic about the practice of psychoanalysis. Their enthusiasm is

Professional Identity

illustrated in their organizational membership, reflected by the fact that Division 39 has one of the largest memberships among the 56 divisions in APA. Their vigorous advocacy for psychoanalysis is manifested in their robust identification with and activities in the broader psychoanalytic community, ranging from the academy to the consultation room. PRO FES SI O N A L AT TIT U D E A N D I D EN TIT Y

There are many facets of a professional identity. Becoming a competent psychologist-psychoanalyst is a lifelong journey and is integrally related to one’s personal and professional identity, which may be expressed in many ways. The interrelatedness of the two informs the many ways that psychologist-psychoanalysts use their training or expertise and understanding of self, that ranges from independent practice, institution affiliations such as hospitals, training institutes, university teaching, consultation, and creative leadership roles in the public and private sectors. Studies in a variety of fields demonstrate that personal and professional identity are integrally related (Clarke et al., 2009; Pratt et al., 2006; Miehls & Moffatt, 2000; Billett & Somerville, 2004), validating that this is an attitude that all professionals experience, no matter the profession. Thoma (2004) says that the professional self is closely connected to the personal self, and it is important to distinguish between the professional self and the person. He suggests that we speak of a psychoanalytic attitude, which is an integration of the two, as do Schafer (1983, 1992)  and Peterfreud (1975). This Psychoanalytic attitude includes analysts’ sense of self and affiliation as a professional. The tension of the conflicts between personal and professional self is a critical determinant of identity formation. The exchange of experiences within the professional community is essential for the ongoing education of analysts and the development of their professional identity as well as for the profession of psychology-psychoanalysis. This exchange provides the opportunity to share with the psychoanalytic community one’s thinking, feelings, and sensibilities through case presentation, formulation, and the exploration of an understanding of clinical practice and theory development. Participation in this psychoanalytic forum validates and strengthens the professional identity of the individual as well as the profession (Thoma, 2004). For example, Division 39 provides continuing education in theory, research, and clinical technique for its members during its annual conference, and its affiliate chapters provide the same. These continuing educational experiences provide a nurturing milieu for sustaining a competent professional identity.

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Personal analysis is a critical part of the process of developing a mature professional identity. A  primary goal of a personal analysis is to assist the analyst in avoiding the pitfalls of over-identifying with the patient. Another, equally important, goal of the personal analysis is to cultivate the analyst’s awareness of the power gradient that renders the patient vulnerable to the vicissitudes of enactments. Personal analysis humbles the analyst, reducing and heightening his/her awareness of the narcissistic need to be attributed a special identity that subordinates the patient. Nevertheless, the analyst’s membership in the larger professional community reinforces his/her professional identity by belonging to a group whose identity is based on the assumptions regarding the unconscious and how unconscious processes are to be understood. This membership creates a rich diversity of investigation and theory development that strengthens both professional and organizational identity. Consequently, the active participation in organizations of psychoanalytic-psychologists on a local, state, national, and international level provides continuing support for maintaining a competent professional identity. The maturational experiences that define an analyst have been identified by Gabbard and Odgen (2009). They observe that the vicissitudes of the life experiences of analysts determines who they become. For the authors, the most important element in the maturational process of analysts is the development of the capacity to make use of what is unique and idiosyncratic to them in a way that reflects their own analytic style. This integration of personal and clinical styles, reflecting a way of being with and talking with patients in the psychoanalytic situation, is the essence of the practice of psychoanalytic psychology. E X A M PL ES O F PR AC TI CE

As there are developmental levels for becoming a psychologistpsychoanalyst, there are myriad ways of integrating a professional self into the day-to-day practice; that is expressed in the roles that are undertaken. For the purposes of this discussion, categories of independent practice, governance, and the creative use of the self will be used to illustrate various activities and interests. A distinction between fee-paid services and volunteer or pro bono services will be made. It is startling to see the amount of time that is devoted to leadership roles in professional organizations that is uncompensated and based on the personal satisfaction that the specialist receives. It demonstrates the commitment

Professional Identity

to the profession and the deep connection between self and professional identity. There is a delicate balance between voluntarism, the practice, and one’s personal responsibilities. Each of these three categories will overlap to varying degrees, depending upon the individual and the circumstances. There are three basic levels of years in practice: early entry, middle, and later years. I N D EPEN D EN T PR AC TI CE

Independent practice may be the most common form of practice, as noted in the demographic data discussed earlier. These specialists may spend their full time in practice, which may include supervision of new analysts; working in residential or hospital settings; consultation; and volunteering for local, national, and international professional organizations on graduate and postgraduate levels. The demographic data demonstrate that Division 39 members are older than the APA membership. Examples of volunteer governance are in professional organizations such as APA, Division 39 of APA, APsaP, and the International Psychoanalytic Association. G OVER N A N CE O F O RGA N IZ ATI O NS FO R COM PENSATI O N

Directors of institutes usually are compensated minimally, for these are not-for-profit organizations. It is not unusual for these specialists to devote half of their time to these responsibilities with the remaining time given to independent practice, consultation, and supervision. However, institutes and other academic institutions are also placement opportunities for those interested in teaching and research. Teaching may not be compensated. CRE ATIVE USE O F SEL F

Creative use of the self is a category for the specialist that can be applied in a number of circumstances. Psychoanalytically informed consultation takes a variety of forms, from a simple conversation with a colleague for clarification about a case, a patient in crisis referral, another professional, or an organization, each requiring a different perspective on the problem in question. There are psychoanalytically trained analysts who enter the court system as expert witnesses, for a host of reasons. The psychological strategy of

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the overall case or deciding the proper approach to the cross-examination of a witness are areas requiring additional skill and training. Opportunities for collaboration are often present, even in legal conflicts that never go to trial. The decision to work together may present opportunities like those in a psychoanalytic session: unexpected, or vaguely hinted at, yet vitally important (Shopper and Gunsberg, 2009). There are psychoanalysts that utilize their knowledge and expertise to assist communities stricken by trauma and violence such as rescue and recovery workers at Ground Zero, September 2001 in New York; a hotel occupied by internally displaced people within the Republic of Georgia; the city of Topeka, Kansas; the inner city schools of Washington, D.C.; and post-conflict Angola from community-based policing program and a number of school based settings that gives psychoanalysts access to people at a point when early interventions may prevent the long-term consequences of the traumas that may occur. The psychoanalyst in the work place or organization is yet another form of consultation. An organization must be receptive to change and to appropriate assimilation if the organization is to remain healthy and functional. Reciniello (1999) illustrated how the growth in the number of women in any given organization and the overall emergence of a more powerful female workforce can function as a threat to an organization’s identity. She observes that many corporations and institutions struggled to confront this threat and to assimilate this change, some more successfully than others. She raises questions such as: what are the unconscious elements of the organizational identity that are threatened by this change; is the organization flexible and open enough to confront these elements to eventually accommodate this change; what are the unconscious fantasies about women in the workplace and about women becoming more powerful with earned promotions and equal salaries. She also cites targets for intervention such as senior management, managers and other key individuals, and work groups, male and female alike, who may be troubled by several unconscious issues and emotions that will require interpretation and guidance. Similarly, Eisold (2005) observes that the problems facing training institutes and professional associations today require a sophistication about groups and systems that are not provided by them. Consequently, institutes are increasing seeking consultation to understand their difficulties, by bringing in outsiders with more knowledge about management as well as a greater detachment from the specific issues affecting them. Consultants can offer not only insights and observations to clarify disputed issues, but

Professional Identity

also help to create a reflective space allowing them to step back from their own internal conflicts. Another role for creative uses of self lies in how the separate processes of psychoanalysis and negotiation might inform the other. Leary and Wheeler (2003) explored the commonalities between psychoanalysis and negotiation. Although the goals of these processes are different, and each is based on different practice domains and theoretical orientations, both rely upon dialogue to reach an end. Thus, the role of first impressions in these human relational processes is important. Because first impressions in both psychoanalysis and negotiation differ, these differences within their particular contexts may be mutually beneficial to both sets of practitioners. For example, social roles can shape first impressions, which are interactive processes. Yet, first impressions can be correct or incorrect. Because first impressions likely shape the interactions that follow, it is important for psychoanalysts and negotiators to recognize subtleties, be self-aware and to be able to recognize that others may see the world differently than they do. This is a social process in which people shape the nature of a dispute according to their understanding of it and by the process of relating one another. There are others, Strategic Outreach to Families of All Reservists (SOFAR) is another example of creative use of self that is a pro bono project in collaboration with the Psychoanalytic Couples and Family Institute of New England and the Division of Psychoanalysis (Division 39) of the American Psychological Association (APA). This consultation and outreach project challenges the idea that psychoanalysis and psychodynamic ideas pertain only to long-term psychotherapy with the worried well. The project demonstrates that both psychoanalytic and psychodynamic ideas reflect a way of understanding development and the interaction between a person’s inner life and the person’s ability to adapt to stress. (Darwin & Reich, 2006). FU T U RE CH A L L EN G ES

The loss of many board-certified specialists through retirement is growing as they approach age 60 (Bent, Packard, & Goldberg, 1999; Robinson & Habben, 2003). Demographic data show that psychologist-psychoanalysts are older when they enter their specialty, creating an additional challenge to recruitment and retention necessitating strategies that attend to this issue. The good news is that postdoctoral accreditation of education and training programs in psychoanalysis will greatly affect a significant

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number of future psychoanalytic-training candidates, as well as many current practitioners in the specialty of psychoanalysis. This will raise the profile of the specialty. The proliferation of ideas in postmodern psychoanalysis and the variety of educational opportunities have made the future challenging. Specifically, when one considers the advancements made by theorists in contemporary Freudian, intersubjective, and relational psychoanalysis, the scope and breadth of the fundamental assumption of psychoanalytic theory is promising and challenging. This proleration of ideas must also be considered in parallel with the advancements being made in the neurosciences and its cross-fertilization with psychoanalytic theory and practice. Psychoanalysis must publicize the unique and attractive features we have described throughout this book.

Summary Psychoanalytic education and professional organizations play integral roles in the development of the specialist. Their professional identity is shaped by their specific training, their demographic characteristics and the scope and range of their practice. Moreover, there are a variety of roles that allows for creativity and leadership within psychoanalysis. This confluence of variables is the unique professional identity for this specialty area of practice.

References Accreditation Council for Psychoanalytic Education, Inc. (ACPEinc). https://www.​ acpeinc.org (2014). American Psychological Association (B). Table 1: Demographic Characteristics of APA Members; Table  2:  Educational Characteristics of APA Members; Table  3:  Current Major Field of APA Members; and Table  5:  Membership Characteristics of APA Members, Compiled by Work Force Studies. Available at http://www.apa.org/​ workforce/publications/10-member/index.aspx (2011). American Psychological Association Division 39 Table  1:  Demographic Characteristics of Division 39 Members; Table 2 Educational Characteristics of Division 39 Members; Table  3 Current Major Field of Division 39 Members and Table  5 Membership Characteristics of Division 39 Members, Complied by Work Force Studies. Available at: http://www.apa.org/about/division/div39-2010.aspx American Psychological Association (APA) (2007). Renewal petition for the recognition of the specialty of psychoanalysis:  Document 11, revised, 04-07-07. http://www.​apadivisions.org/division-39/leadership/committees/education/ renewal-petition.pdf

Professional Identity Aron, L. (2009). Day, night, or dawn: Commentary on paper by Steven Stern. Psychoanalytic Dialogues, 19, 656–668. Bent, R.  J., Packard, R.  E., & Goldberg, R.W. (1999). The American Board of Professional Psychology, 1947 to 1997. Professional Psychology:  Research and Practice, 30, 65–73. Billett, S., Somerville, M. (2004). Transformations at work: Identity and learning. Studies in Continuing Education, 26, 309–326. Clarke, C.  A., Brown, C.  D., & Hailey, V.  H. (2009). Working identities? Antagonistic discursive resources and managerial identity. Human Relations, 62, 323. Darwin, J. L., & Reich, K. I. (2006). Reaching out to the families of those who serve: The SOFAR project. Professional Psychology: Research and Practice, 37(5), 481–484. Division 39 practice survey:  A  guide to the main results http://www.apadivisions.org/​ division-39/publications/review/2012/07/practice-survey-guide.aspx Eisold, K. (2005). Psychoanalysis and psychotherapy: A long and troubled relationship. International Journal of Psychoanalysis, 86, 1175–1195. Gabbard, G.  O., & Ogden, T.  H. (2009). On becoming a psychoanalyst. International Journal of Psychoanalysis, 90, 311–327. Goldberg, P. (2009). With respect to the analytic frame: Commentary on paper by Steven Stern. Psychoanalytic Dialogues, 19, 669–674. Katz, C.L. (2006). Analysts in the Trenches, Edited by Bruce Sklarew, Stuart Twemlow, and Sallye Wilkinson, The Analytic Press, Hillsdale, NJ, 2004, 331 pp. Journal of American Academy Psychoanalysis. Dynamic Psychiatry, 34, 394–397. Leary, K. (2003). A special section negotiating and psychoanalysis: Some common aspects of practice. Negotiation Journal, 19, 311–313. Miehls, D., & Moffatt, K. (2000). Constructing social work identity based on the reflexive self. British Journal of Social Work, 30, 339–348. Peterfreund, E. (1975). How does the analyst listen? On models and strategies in the psychoanalytic process. Psychoanalysis and Contemporary Science, 4, 59–101. Pratt, M.  G., Rockman, K.  W., & Kaufman, J.  B. (2006). Constructing professional identity: The role of work and identity learning cycles in the customization of identity among medical residents. Academy of Management Journal, 49, 235–262. The Psychoanalytic Consortium and the ACPE March 13, 2011 http://www.apadivisions.​ org/division-39/news-events/news/psychoanalytic-consortium.aspx?_ Reciniello, S. (1999). The emergence of a powerful female workforce as a threat to organizational identity:  What psychoanalysis can offer. The American Behavioral Scientist, 43, 301–323. Robinson, J.  D., & Habben, C.  J. (2003). The role of American Board of Professional Psychology in professional mobility. Professional Psychology: Research and Practice, 34, 474–447. Schafer, R. (1983). Analytic Attitude. New York: Basic Books. Schafer, R. (1992). Retelling a Life:  Narration and Dialogue in Psychoanalysis. New York: Basic Books. Shopper, M., & Gunsberg, L. (2009). Living and working in two worlds: The psychoanalyst in the office, and the psychoanalyst as forensic expert in the courtroom. Psychoanalytic Inquiry, 29, 441. Standards of Psychoanalytic Education https://www.acpeinc.org/standards/ (2014).

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KEY TER MS

Chapter 1 Adaptation: The act of adapting or adjusting to a new situation or condition. It requires some modification by the individual. Analyst:  The professional engaged in providing psychoanalysis and/or psychoanalytic treatment. Attachment theory:  A  theory developed by John Bowlby that explains the conditions under which the child develops bonds with primary people in their lives and that are affected by the nature and quality of the early mother–child interaction. Catharsis: Refers to the feeling of relief the patient experiences once pent-up emotions are allowed to be discharged normally. Clinical syndrome: Range of psychological disorders. Conscious awareness: refers to the knowledge (motivations) of oneself and the world that the individual has conscious access to and is able to use to navigate through life and is able to communicate to others. See also explicit cognition. Content of the unconscious: Refers to thoughts, feelings, fantasy, etc., which are part of the individual’s unconscious repertoire and whose origins are related to repressed parts of the personality. It includes id derivatives and conflictual superego-derivative material. Defense mechanism: Refers to the different coping mechanisms that the individual uses to protect himself against anxiety and other negative emotions, such as projection, denial, rationalization, etc. Dysfunctional conditions:  Psychological disorders that affect the overall capacity to function. Ego:  Encapsulates the most coherent organization of the psychic functioning and is responsible for negotiating with the real world and responding to its demands. Explicit cognition: Refers to a cognition or knowledge that can be consciously detected and reported. See also conscious awareness. Free association: Method developed by early psychoanalysts to help the patients become aware of unconscious material that was producing psychological disturbances of various kinds. Hypnosis: Method characterized by putting the individual in trance that allows the communication of unconscious material that the individual is not consciously aware of and that he would not have communicated if wide awake and alert. Id: Represents and encapsulates the most primitive, animalistic, and biologically based experience of one’s most basic needs. Implicit cognition: Refers to a cognition or knowledge that cannot be directly inferred through introspective awareness.

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Key Terms Intersubjectivity: Refers to the capacity for sharing experience between two individuals that allows the experience to be understood without much explanation. It refers to internal synchronicity of the experience between two individuals. Mental illness: A disorder of the mind that characterizes various psychological conditions, such schizophrenia, depression, etc. Neurotic symptoms: Psychological disorders or psychogenic affections that result from unresolved psychic conflicts from childhood. Personality disorders: Psychological disorders that affect a large portion of the individual and are chronic in nature. Examples of these are borderline personality disorder, psychopathic personality disorder, etc. Psychoanalysis: Discipline founded by Freud that follows established methods to examine human consciousness and unconscious motivations in all their complexity and permutations so as to elucidate the reasons why individuals feel and behave the way they do, with themselves and with others. Psychoanalytic competence: Refers to the ability of the professional to utilize a range of psychoanalytically informed formulations and treatment strategies to treat a patient’s condition. Psychoanalytic data:  The material that emerges and is derived from the treatment process. Psychoanalytic frame:  Guiding principles that instruct the psychoanalytic work with the patient, by which the information elicited from the patient can be more clearly understood and explained. Psychoanalytic or psychodynamic psychotherapy: A treatment intervention informed by the psychoanalytic principles in terms of the role of the unconscious in human behavior, but that follows less restricted methods than the more traditional psychoanalysis, such as meeting once or twice a week, face-to-face and using the chair rather than the couch. Psychoanalytic process: Refers to the joint venture of the patient with the therapist in the context of psychoanalytic treatment, by which hidden and conflictual meanings in the patient’s functioning are revealed and worked through, resulting in an improvement of the patient’s functioning. Psychological conditions:  Refers to psychological disturbances that tend to have an impact on the individual’s functioning in general or more specifically. Reenactment:  The act of repeating an earlier experience or event. An example of that process is transference. Repression: The process or operation by which material that is unacceptable to the individual is confined to the unconscious. Sense of reality: Refers to a general sense of connectedness with the world. The capacity of the person to see things in the world the way they are and as shared by others. Superego: Encapsulates all the necessary rules and moral standards that guide our relationship ourselves, one another, and the society at large. Therapeutic relationship: Refers to the quality and nature of the relationship between a patient and the therapist that allows treatment to occur. This relationship is guided by the specific theoretical principles guiding treatment intervention. Therapist: The professional engaged in providing psychotherapeutic treatment. It is often used to refer to the person of the analyst. See also analyst. Transference material: The content of the unconscious material that is redirected toward the person of the psychoanalyst in the transference.

Key Terms Transference:  The process by which feelings and desires from childhood are unconsciously redirected toward new objects, particularly the treating psychotherapist. See also reenactment. Transformative: That which produces changes. Unconscious motivations: Motives of behavior whose origin is not clear to the individual but nevertheless can still influence the overall function of the individual. Unformulated material: Refers to material that is basically unconscious and without sufficient clarity in the individual’s mind for her to be able to provide a clear description, but nevertheless can be experienced. Usually refers to experiences that have not yet become part of the conscious discourse. Working alliance:  Conscious and/or unconscious agreement made by the patient and the therapist to be actively engaged in the therapeutic process, and that permits the accomplishment of the treatment goals. Working through: Capacity to remain engaged in the treatment even when confronted with strong resistance, until the resolution of the conflict.

Chapter 2 Critical period: An early period when the organism is most receptive to being impacted by its environment. See imprinting. Empathic linkage:  Special connection of the mother with her child that allows her to predict his basic needs and enables him to secure timely response to these needs. Formulated experience:  Experience that is clearly established in our cognitive system and that becomes part of our conscious discourse. Holding environment: Term used by D. W. Winnicott to refer to the best environmental condition for the infant to develop, where a feeling of security and protection are primary. It also refers to the therapeutic environment created by the therapist where the patient feels sufficiently secure to explore the most difficult content of her internal life. Imprinting: Learning process that occurs early in life, usually with birds, and that results in the development of behavioral patterns (e.g., attraction or recognition of the first thing/object/person seen at birth) that affect the early functioning. Internalized object relations:  The relationship the individual maintains with intrasubjective relations that have been transformed from real ones through the process of introjection. Paradigm shift: A radically new way of looking at a condition/situation that results in new insight and treatment approaches. Procedural unconscious: Unconscious material not considered repressed, such as habits and perceptual or motor skills that allow us to function without the involvement of consciousness. They are considered biological, given that they are part of the procedural memory structure resulting from the operation of the somatic nervous system and the autonomic nervous system. Repressed memories: Memories that are lodged in the unconscious. Selective inattention: A term used by Harry Stack Sullivan to refer to a condition where an individual, consciously or unconsciously, moves his focus of attention away from what is considered unattainable: ignoring things that do not matter, excluding them from awareness.

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Key Terms Sublimation:  Process of redirecting the expression of primitive material to a more socially/culturally acceptable form. An example of this process could be of a person with serious problem with aggression becoming a crime writer. It requires a transformation of the original impulses. Unformulated experience: Content of experiences not accessible to conscious discourse because they are not yet fully organized, developed, or processed in our cognitive system, but nevertheless, not considered repressed in the dynamic sense of Freud.

Chapter 3 Affective incompetence: Inability of the individual to process range of positive or negative feelings, particularly when they are too intense in nature and quality. Analyzability: The extent to which an individual has the necessary qualities to be able to make full use of the psychoanalytic method to engage in the exploration of the sources of her conflicts that are bringing her to treatment. Countertransference: The unconscious positive or negative reaction of the therapist to the patient and to the patient’s transference. Empathic failure: Rupture in the connection or bond of the therapist with the patient as a result of the therapist’s inability to understand and appreciate fully his patient’s dilemma.

Chapter 4 DSM: The Diagnostic and Statistical Manual of Mental Disorders (APA). Nondynamic factors: may include genetic predisposition, intellectual functioning, social deprivation, overwhelming trauma, and drugs or any physical illness affecting the brain. PDM: Psychodynamic Diagnostic Manual. Psychodynamic case formulation: A brief written description of the person’s psychological function that predicts treatment derived from a psychodynamic interview. Psychodynamic factors: explanation of person’s central conflicts that considers their role in the current situation and genetic origins in the developmental history.

Chapter 5 Beginning treatment: the first phase in the psychoanalytic process. Psychoanalytic treatment: psychotherapy identified as psychoanalytic. Therapeutic alliance: an agreement between analyst and patient to adhere to a jointly accepted mode of treatment.

Chapter 6 Countertransference: the analyst’s unconscious reactions to the patient’s transference. Resistance: behavior interfering with the psychoanalytic process. Transference: unconscious feelings projected onto the analyst.

Chapter 7 Interpretation: bringing unconscious material into consciousness.

Key Terms Relationship: Interaction between the analyst and the patient. Therapeutic effect: Result of the analytic process that is therapeutic for the patient. Working through: What is learned in the psychoanalytic process that has a therapeutic effect.

Chapter 8 Parallel process:  Supervisor–supervisee relationship that parallels the supervisee– patient relationship. Supervisee: Recipient of learning about an ongoing case from another analyst. Supervisor: Enabler of learning for another analyst in regard to a case in progress. Supervisory relationship: interaction between the supervisor and the supervisee.

Chapter 9 APA Code: American Psychological Association’s ethics code. APsaA Code: American Psychoanalytic Association’s ethics code. Ethics codes: established educational and disciplinary standards for a profession, which apply across a variety of contexts such in person, on the telephone, internet, and other electronic transmissions.

Chapter 10 Cultural countertransference: both patient and therapist can be equally caught in their cultures, which may lead to mutual enactment of conscious and unconscious feelings, attitudes, values, morals, biases, and prejudices that each party brings to the relationship. Cultural transference: The process by which feelings and desires from specific cultural components of the patient’s childhood and that now guide and define his basic view of the world are unconsciously redirected toward person of the therapist. See also reenactment. Culturally bound syndromes: Syndromes that are found in a specific cultural environment and rarely found outside of such an environment, such as Amok, Dhat, Koro, Ataque de nervios, etc. Ethnic unconscious: Includes belief system about supernatural nature and other culturally specific ways that are used to process and deal with life’s challenges. Multiple identifications: All the ways in which an individual is forced to deal with the life’s challenges, forcing her to organize her functions in distinct fashion “as a mother,” “member of a minority group,” “a woman,” etc. “Other”: that which is culturally different, or the outsider.

Chapter 11 ACPEinc: Accreditation Council for Psychoanalytic Education, Incorporated. Professional identity:  Interrelationship between personal and professional identities, or shaped by the development of professional and personal experiences, formal and informal. Psychoanalytic Consortium: consists of four major psychoanalytic organizations: Division 39 (Psychoanalysis, APA); the American Psychoanalytic Association (APsaA); the

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Key Terms American Academy of Psychoanalysis and Dynamic Psychiatry (AAPDP); and the American Association for Psychoanalysis in Clinical Social Work (AAPCSW). Psychoanalytic education:  Involves didactic course work, supervision of psychoanalytic work with patients, and personal analysis in a psychoanalytic institute or its equivalent.

INDEX

Abbas, A. A., 34 Ablon, J. S., 37 abstinence transference and, 106 triad of neutrality, anonymity and abstinence and, 90–92 Accreditation Council for Psychoanalytic Education, Inc. (ACPEinc), 188, 189 actual anxiety, 25 adaptation, cultural diversity and, 178–180 adolescent diabetics, psychoanalysis of, 31, 36 adverse conditioning, behavior and, 25 advertising, ethics and standards concering, 161 affective attunement, 30 transference and, 103–104 aggression, motivation and, 130 Ainsworth, Mary, 22, 29 Aisenstein, M., 124–125 Akhtar, S., 58–60 Alonso, A., 149 Altman, N., 170, 179 American Academy of Psychoanalysis and Dynamic Psychiatry (AAPDP), 188 American Association for Psychoanalysis in Clinical Social Work (AAPCSW), 188 American Board and Academy of Psychoanalysis (ABAPsa), 189 American Board of Professional Psychology (ABPP), 189, 190, 192–193

American Board of Psychoanalysis, psychoanalysis defined by, 5 American Institute for Psychoanalysis, 10 American Psychoanalytic Association (APsaA), 9, 11 assessment process and, 53–55 core competencies and, 72–76 cultural competency guidelines, 169–172 membership in, 190 Principles and Standards, 154–164 Psychoanalytic Consortium and, 188 psychological testing guidelines of, 55–56 American Psychological Association (APA) Code of Conduct, 154–164 Committee on Specialties (COS), 189 cultural competency guidelines, 169–172 Division of Psychoanalysis in, 10, 187– 193, 197–198 educational programs approved by, 187–189 Ethical Principles of Psychologists, 154–164 membership demographics, 191–193 Psychoanalytic Consortium and, 188 suit against American Psychoanalytic Association, 11 “Amok” syndrome, 172 analyst-patient relationship, 12–15. See also therapeutic alliance/contract countertransference and, 112–113

208

Index analyst-patient relationship (cont.) interpretation and, 126–130 management of resistance in, 118–120 professional attitude and identity and, 193–194 supervisor’s role in, 145–148 therapists’ distortion of “other” and, 181–183 transference and, 102–104, 106–107, 116–117 triangulation in, 144–145 Analytic Process Scale, 36–37, 62 anonymity transference and, 106 triad of neutrality, anonymity and abstinence and, 90–92 anticipatory anxiety, 25 anxiety countertransference, 112–113 initial patient contact and, 51–53 psychopathology and, 25–26 supervision and, 146–148 areas of psychoanalytic competence, 11–15 Aron, L., 112, 121, 188, 210, 221 assessment process, 43–63 components of, 55–56 critical challenges in, 44–46 decision tree for, 50f determination for treatment and, 60–61 focus of, 56–60 framework for, 46–53 in initial encounter, 49–53 procedural guidelines, 53–55 referral decisions and, 46–49 during therapeutic process, 61–62 treatment linked to, 54–55 associational psychology, 19 associative thinking, supervision and, 143–144 “Ataque de nervios” syndrome, 172 attachment theory environment and, 22–23 historical evolution of, 8, 29–37 naturalistic observational methodology, 29 attitude

as core competency, 73–75 for interventions, 120–121 authenticity, in therapy, 92 autonomic nervous system, memory and, 24 autonomous motivation, resistance management and, 119–120 Bach, S., 56 Baity, M. R., 36 behavioral psychology cultural diversity and, 179–180 psychodynamic case formulation and, 69–70 behavior change interpretations and, 126–127 psychopathology and, 25–26 beneficence, principle of, 157, 160 Bennett, A., 70 Bersoff, D. N., 154 Binder, J. L., 111 biology early research in, 18 human development and, 22 sexuality, 26 bisexuality, Freud’s research on, 26–27 Blanck, G., 103–104 Blanck, R., 103–104 Blatt, S. J., 62 blind spots, supervision and, 139–140 board certification future challenges in, 197–198 professionalization of psychology and, 189–193 Bonovitz, C., 170 borderline personality disorders, psychodynamic psychotherapy and, 34–35 Boston Change Process Study Group, 28, 30–32, 35 Bowlby, John, 22–23, 29 Breuer, Joseph, 6 Bruschweiler-Stern, Nadia, 31 Burke, W. F., 113 burqa (burka) laws, 173 Bush, F., 116

Index Campbell, L., 154 case formulation process, 75–76 case study approach in psychoanalysis, 28 Caspar, F., 70 catharsis, psychoanalytic process and, 6 change, resistance to, 115–116 change functions, development of, 117 character disorders, interpretation, 126–127 Charcot, Jean-Martin, 6, 18–21 child development, early research on, 28–37 Clark, R. W., 164 Clemens, N. A., 138–140 client framework in psychoanalytic assessment, 47–49 clinical case history, development of, 67–68 co-construction, transference and, 103, 106–107 codes of ethics, 153–164 comparisons of, 155 general principles, 157–158 introduction and applicability, 156–157 preamble, 157 cognitive-behavioral theory, psychodynamic case formulation and, 69–70 cognitive construct defined, 5 supervision, 138–140 transference and, 103–104 cognitive disorganization, assessment and, 54–55 collaboration, supervision and, 143–144 colonialism, cultural diversity and legacy of, 174 Columbia Center for Psychoanalytic Training and Research, 11 Comas-Diaz, L., 179 commitment to therapy by patient, 63 patient-therapist dialogue concerning, 87–88 communications, skill in, 73 compensation of psychiatrists and psychologists

governance of organizations and, 195 practice finances for psychoanalysts and psychologists, 191–193 competence, ethics and standards concerning, 159–160 complementary countertransference, 109–110 conceptualization, supervision and, 141–144 concordant identification, countertransference and, 110–111 confidentiality, 164 ethics and standards concerning, 160–161 conflict analysis, psychodynamic case formulation, 77 conflict theory, in early psychoanalysis, 7 conscious response, transference and, 103–104 continuing education programs in psychoanalysis, 10–11 convergence, 132 Corcoran, K., 62 core competencies ethical practice, 154–164 interventions and, 120–121 pluralism and, 96–97 psychodynamic case formulation, 72–76 Core Conflictual Relationship Theme (CCRT), 70 corrective emotional experience, 129–130 countertransference, 101–121 applications of, 111–113 attitude concerning, 74 basic principles, 108 clinical example, 114 cultural countertransference, 166–183, 182–183 disclosure and, 113 distinctions of, 110–111 expansion of, 109–110 Freud’s concept of, 108–109 supervision and, 141–144 therapeutic effect, 131–132 understanding of, 72–73

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210

Index Countertransference Questionnaire, 36–37 Crawley, J., 105 creative thinking, supervision and, 143–144 “critical period” in human development, 22 cultural diversity issues, 166–183 clincal case example, 171–172 dichotomous thinking and, 178–180 emergence of the "other," 172–178 individuals and needs, 167–168 language issues, 167 multicultural education controversy and, 168–172 religious beliefs, 168 sexual orientation, 167–168 cultural transference-countertransference, 166–167, 170–172 culture-bound syndromes, 172–178 Curtis, J. L., 69–70 Darwin, Charles, 18–19, 21 death instinct, Freud’s research on, 21 defense mechanisms patient’s pattern of, 60 therapeutic effect and, 125–130 defensive conditioning and, 25–26 Defife, J. A., 36 delayed reaction, 26 Demographic Characteristics of APA Members report, 167–168 Der Kumpan in der Umweld des Vogels (The companion in the bird’s world) (Lorenz), 22 Derner, Gordon, 10 Derner Institute, 10 Deutsch, Helene, 8 “The Development of Sexual Instinct” (Ellis), 26 Dewald, P. A., 154 “Dhat” syndrome, 172 Diagnostic and Statistical Manual of Mental Disorders (DSM), 71 diagnostic testing, assessment and, 55–56 dialogue, during treatment, 84–86

dichotomous dimensions, of cultural diversity, 175–176, 178–180 disclosure, countertransference and, 113 Diseases of Memory: An Essay in the Positive Psychology (Ribot), 19 Diseases of the Will (Ribot), 19 The Diseases of Personality (Ribot), 19 distinctions in transference, 104–105 distortion, transference as, 103–104 Division 39 Practice Survey: A Guide to the Main Results, 191–193 dreams, analysis of, 12–13 in case study, 51–53 memory and, 24 drives, Freud’s theory on, 27 dumb spots, supervision and, 139–140 duration of treatment sessions, initial establishment of, 89–90 dysfunction, initial encounters and assessment of, 84 Eagle, M. N., 31, 105, 111–113, 127–129 Ebbinghaus, Hermann, 23 education data on psychoanalyst training, 189–193 ethics and standards concering, 162 job preparation in psychoanalysis and, 191–193 professional identity and, 187–189 Eels, T. D., 69–70 ego assessment in patient of, 59–60 conflicts and, 12 defensive activity of, 116 psychodynamic case example and, 76–78 psychology of, 6–8, 178–180 supervision and, 146–148 in United States, 9 Eisold, K., 96–97, 196–197 Ellis, Havelock, 26 emotional engagement supervision, 138–140 in therapy, 92 empathy

Index countertransference and, 112–113 failure of therapists and, 44 initial treatment phase and, 89–90 linkage theory concerning, 30, 44 environment cultural diversity and, 178–180 individual in, 29 in object-relations theory, 32–33 in psychoanalysis, 22 Epstein, L., 109 ethical challenges in psychoanalysis, 153–164 ethics codes. See codes of ethics ethnic unconsciousness, 181–183 ethology, human development and, 22 evaluation, supervision and, 139–140 evidence-based therapy, 187–189 evolutionary theory, cultural diversity and, 175–176 execution, supervision and, 141–144 experience-near clinical level of treatment, 96–97 exploitation, avoidance of, 163 Expression of the Emotions in Man and Animals (Freud), 18–19 expressive psychotherapy, 35–36 Fairbairn, W. R. D., 32, 130 fees, ethics and standards concerning, 161 Feiner, A. H., 109 Fenichel, Otto, 8 fidelity, principles of, 157 Fischer, J., 62 focus of assessment, guidelines and case study concerning, 56–60 formulated experience, 30–31 memory and, 24 Fosshage, J. L., 91 foundational knowledge, 72–73 framework for assessment strategies, 46–53 for treatment, 88 Frawley-O’Dea, M. G., 148 free association anxiety and, 25–26 defined, 24

transference and, 103 Freedman, A., 53–55, 180 Fretter, P. B., 70 Freud, Anna, 9, 29 ego psychology and, 180 on resistance, 118–120 Freud, Sigmund on anxiety, 25–26 clinical case history method and, 68 countertransference of, 108–109 on cultural influences, 178–180 on dialogue with patients, 85–86 on interpretation, 126–130 on memory, 23–24, 311 neutrality, anonymity and abstinence triad and, 90–92 personality profiles of, 178 psychoanalytic theory and, 6–8, 10 research on human development and, 18–22 on resistance, 115–116 resistance management and, 118–120 on sexuality, 26–27 therapeutic effect and, 124–125 transference concept of, 102–103 Friedman, R. S., 68, 69–70 Fromm, Erich, 8 Further Remarks on the Neuropsychosis of Defense (Freud), 20 Gabbard, G. O., 72, 93, 194 Galton, Frances (Sir), 23 Ganda Project, 29 Gelso, C. T., 109, 111–113 Gentile, K., 179–180 Gill, M. M., 105–106 Glickhauf-Hughes, C., 131 Gold, J. H., 148 Goldberg, A., 140 Gorkin, M., 113 governance of organizations, examples of practice, 194-195 grandiose transference, 106 Grant, J., 105 gratification, in therapy, 92 Gray, P., 116, 119–120

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212

Index Greenberg, J., 127–128, 131 Greenberg, J. R., 90–91 Greene, B., 179 Greenson, R., 102–104, 116–117, 131 Grinberg, L., 110–111 Guide to Assessment for Psychoanalytic Psychotherapists (Cooper and Alfillé), 46 Hampstead Child Therapy Clinic, 28 Hartman, Heinz, 9 Hartmann, H., 22 Hayes, J. A., 109, 111–113 here-and-now interpretation, of transference, 105–106 heredity, early research in, 18–21 Heredity: A Psychological Study of Its Phenomena, Laws, Causes, and Consequences (Ribot), 19 Herron, William G., 18–37, 83–99, 101– 121, 124–133, 137–149, 177 holding environment, 30 supervisor’s role in, 147–148 Holmes, D., 169–172, 179 Holt, R. R., 55–56 Horney, Karen, 8, 10 Horowitz, M. L., 69–70 The How-To Book (Bach), 46 human development critical periods in, 21–22 early research in, 18–21 humanistic psychology, 6 human relations, ethics and standards concerning, 160 hypnosis early use of, 6 psychoanalysis and, 20 hysteria as clinical syndrome, 6 early research on, 19–21 id

conflicts and, 12 role of, in early psychoanalysis, 7–8 idealizing transference, 106 identity

assessment in patient of sense of, 59–60 professional identity of psychoanalysts and, 193–194 implicit cognition, defined, 5 inconsistency effect, resistance and, 117 independent practice, demographics on, 195 individual diversity issues, 166–183 inductive thinking, supervision and, 143–144 information attention to delivery of, 56–60 defensive avoidance of, 139–140 receiving and restructuring of, during assessment, 54–55 informed consent, ethics and standards concerning, 163–164 initial encounter in psychotherapy questions during, 94–95 strategies for, 49–53 tilt in, 90–92 treatment procedures and, 83–84 innate drive, Freud’s theory on, 27 insight, resistance to, 126–130 instincts, Freud’s research on, 21 insurance coverage for psychotherapy assessment process and issue of, 53–55 outcomes research and, 36–37 integrity, in codes of ethics, 158 interactional field in psychoanalysis, 33 internalized object relations, 32–33 International Psychoanalytical Association (IPA), 9, 11 interpersonal psychology, 6, 32–33 cultural diversity and, 170–172 development of, 30 psychodynamic case formulation and, 69–70 interpretation supervision and, 141–144 therapeutic effect and, 125–130 intersubjective perspective, 33 transference and, 106 intervention initial encounters in, 83–84

Index psychodynamic case formulation, 69–78 supervisor’s role in, 145–148 therapeutic effect of, 124–125 introspection, patient’s capacity for, 58–60 Jacobs, D., 143 Javier, Rafael Art., 3–15, 18–37, 166–183 Jung, Karl, 107 justice, in codes of ethics, 158 Kalinkowitz, Bernie, 10 Kandel, E. R., 24, 31–32 Kernberg, O., 124, 128, 137 Klein, Melanie, 103–104, 146 Knapp, S., 154–155, 163 knowledge as core competency, 72–73 interventions and, 120–121 of the "other," 176–177 Koerner, K., 69–70 Kohut, H., 106 Koocher, G. P., 154 “Koro” syndrome, 172 Kraepelin, E., 6 Kroenske, K., 34 Lachmann, F. M., 91 language, cultural diversity and, 167 Laҫan, Jacques, 125, 199–200 learning disability, cultural diversity and misdiagnosis of, 179–180 learning environment multicultural education and, 169–172 supervision in, 140–144 supervisor’s role in, 147–149 learning styles, supervision and, 143–144 Leary, K., 197 legal challenges in psychoanalysis, 153–164 lesbian, gay, bisexual, and transgendered (LGBT), 167–168 Levenson, H., 69–70 Levy, R. A., 37 Lewis, Helen Block, 28 libido

Freud’s research on, 21 motivation and, 130 sexuality and, 27 Lichtenberg, J. D., 91 Lineman, M. M., 69–70 listening in patient-therapist dialogue, 85 in psychoanalysis, 53–55 Lister, P., 68 Little, M., 109–110, 113 Lorenz, Konrad, 22, 29 Luborsky, L., 69–70 Lyons-Ruth, Karen, 31 MacKinnon, R. A., 67 managed care environment, supervisor’s role in, 147–148 Mander, G., 141–144 Marcus, E. R., 92–93, 101–102, 115–116 Markowitz, J. C., 69–70 Maroda, K. J., 93–94, 103–104, 107, 109, 113, 115, 117 masochism, 26–27 McWilliams, N., 68–72, 169 memory interpretations of transference, 105–106 psychoanalysis and role of, 23–24 mental health, internal agencies in, 7–8 mental illness concepts and scientific research in, 18–19 early classification of, 6 psychoanalysis and treatment of, 3 mentalizing, resistance and, 117 Meyers, D., 113 Michels, R., 67 Miller, Hugh Crichton (Dr.), 28–29 mindfulness, resistance and, 117, 119 Minnesota Multiphasic Personality Inventory (MMPI), 62 minority population in U.S., 167 Mitchell, S. A., 33, 131 moments of meaning, 3111 anxiety and, 25–26 Moncayo, R., 199–200 Moran, G., 31, 36

213

214

Index Morgan, H., 170 Morris, Dolores O., 66–78, 153–164, 166–183, 187–198 mother-child interaction attachment research and, 29–37 in early psychoanalysis, 7–8 in object-relations theory, 32–33 transference and, 103–104 motivation cultural diversity and, 175–176 early research on, 20–21 interpretation and, 130 of patient, assessment of, 58–60 therapeutic effect and, 125–130 therapist’s motivation of patient, 61 Mount Zion Psychotherapy Research Group. See San Francisco Psychotherapy Research Group multicultural education, psychoanalytic practice and, 168–172 multiple identifications, 182–183 Muran, C., 179 mutual learning, supervision and, 143–144 Nagel, T., 112–113 Nagy, T. F., 154 Nahum, Jeremy, 31 naturalistic observational methodology, 29 negative countertransference, 110 negative transference, 107 negotiation, psychoanalysis and, 197 neurobiology, psychodynamic case formulation and, 68 neurosis early research on, 20–21 initial assessment, 84 interpretation of, 125–130 neurotic anxiety, 25 neurotic countertransference, 110–111 neutrality in assessment process, 53–55 transference and, 106 triad of neutrality, anonymity and abstinence and, 90–92

New York University Postdoctoral Program, 10 Nezu, A. M., 69–70 nondynamic factors, psychodynamic case formulation, 77 non-formulated experience, memory and, 24 non-malfeasance principle of, 157, 160 objectivity, transference and, 107 Object Relations in Psychoanalytic Theory (Greenberg and Mitchell), 9–11 object-relations theory, 6, 30, 32 transference and, 103–104 obsession, early research on, 20–21 offset studies, 37 On Inhibitions, Symptoms, and Anxiety (Freud), 25–26 On the Neuropsychosis of Defense (Freud), 20 On the Origin of Species by Means of Natural Selection: or, The Preservation of Favoured Races in the Struggle for Life (Darwin), 18–19 open-mindedness, in assessment process, 53–55 organic factors in mental illness, 6 organizational psychology, specialists training and practice in, 196 "other" cultural diversity and emergence of, 172–178 psychological distancing of, 176–177 therapists’ distortion of, 181–183 outcome research, 35–37 interpretations and, 129–130 paradigm shift, in psychoanalysis, 20 parallel process, supervision and, 145–148 parenting, in early psychoanalysis, 7–8 patient commitment to therapy of, 63 defined, 48–49 dialogue during treatment of, 84–86 education concerning resistance and, 119

Index management of resistance in, 118–120 reaction to therapist’s recommendations by, 61 resistance to change in, 116 therapist evaluation by, 57–60 “patient-collaborator” client, 47–49 patient framework in psychoanalytic assessment, 47–49 patient-therapist match initial treatment phase and, 89–90 research on, 36 spectrum of treatment and, 93–94 tilt in, 90–92, 98–99 Pavlov, I., 25 Perez Foster, R. M., 179 Perry, J. C., 68–71, 75–76 personal analysis, professional attitude and identity and, 194 personality focus of assessment and, 58–60 role of, in early psychoanalysis, 7–8 personality disorders initial assessment, 84 psychodynamic psychotherapy and, 34–35 personality inventories, 62 Persons, J. B., 69–70 Peterfreund, E., 193 phobia in case study, 51–53 early research on, 20–21 Pine, F., 91 pluralism, in psychotherapy, 36, 96–97 Pomeratz, A., 154 positive countertransference, 110 positive transference, 107, 126–127 Postgraduate Center for Mental Health, 10 post-traumatic stress disorder (PTSD), 26 practice finances for psychoanalysts and psychologists, 191–193 practice guidelines, professionalization of psychoanalysis and, 194–195 primarily instinctual pathway, 91–92 primarily relational pathway, 91–92 privacy, ethics and standards concerning, 160–161

privilege, ethics and standards concerning, 164 procedural memory structure, 24 professionalization of psychology, 8–11 data on practitioners of, 191–193 demographic characteristics of analysts, 189–198 development of, 187–198 education and, 187–189 future challenges in, 197–198 governance of organizations for compensation, 195 independent practice, 195 professional attitudes and identity, 193–194 self-development and, 195–197 projection countertransference, 109–110 defined, 12 psychoanalysis areas of competence in, 11–15 conceptual foundations of, 18–37 contemporary views in, 27–34 countertransference and, 112–113 debate over definitions of, 188–189 definitions of, 4–5 demographic characteristics of analysts, 189–198 dichotomous thinking and diversity issues in, 178–180 early applications, 7–8 educational training for, 188–189 ethical and legal challenges in, 153–164 future of research in, 35–37 historical evolution of, 3–4, 6–11 job preparation for, 191–193 memory and, 23–24 multicultural education and, 168–172 process of, 12–15, 101–102 scientific foundations of, 18–37 sexuality and, 26–27 specialty requirements of, 13–15 structural and technical development of, 6–11 supervision in, 137–149 therapeutic effect of, 33–34, 124–133

215

216

Index psychoanalysis (cont.) training programs developed for, 9–11 in United States, 8–11 Psychoanalysis Synarchy Group, 192–193 Psychoanalytic Consortium, 188 Psychoanalytic Couples and Family Institute of New England, 197 psychoanalytic data, 15 psychoanalytic frame, 11–12 psychodynamic case formulation application of, 72–76 approaches in, 70–72 core competencies and, 72–76 defined, 66–69 dialogue with patient and, 85–86 ego psychology orientation and, 76–78 example, 76–78 initial encounters, 83–84 research review, 69–70 psychodynamic interview, 74–75 psychodynamic psychotherapy, 34–37 case formulation in, 66–78 supervision in, 140 psychological causality, early research on, 20–21 psychological-mindedness of patient, 54–55, 63 psychological testing, assessment and, 55–56 psychologie nouvelle, 19 psychologists, demographic characteristics of analysts, 189–198 psychology early research in, 18–21 ethical and legal challenges in, 153–164 professionalization of, 8–11 psychopathology, anxiety and, 25–26 psychosis, early research on, 20–21 psychotherapy assessment challenges in, 44–46 dialogue during, 84–86 ethics and standards concerning ethics and standards concerning, 162–163 explanation to patient of, 87–88 historical evolution of, 8–11 initial encounter in, 49–53

process of, 28–37 psychodynamic psychotherapy, 34–35 supervision in, 146–148 publication, ethics and standards concerning, 162 public statements, ethics and standards concerning, 161 questions, during initial treatment encounter, 94–95 race relations multicultural education and, 169–172 psychoanalysis of the “other” and, 177–178 Racker, H., 110–111 Rank, Otto, 8 rapport, as core competency, 73–75 reality testing, 126–127 Reciniello, S., 196 record-keeping, ethics and standards concerning, 161 referral strategies, 46–49 reflective thinking, supervision and, 143–144 relational psychology, 6 development of, 30 motivation in, 130 transference and, 103–104 relationships assessment of patient’s attachments, 60 interpretations, 131 transference and, 105–106 religious beliefs, cultural diversity and, 168 Renik, O., 124 repressed memory, 24 transference and, 105–106 research, ethics and standards concerning, 162 resistance applications of, 116–118 to change, 101–121 interpretation and, 126–130 management of, 118–120 in psychoanalysis, 12–13, 114–121

Index supervision and, 141–144 therapeutic effect, 132–133 resistance analysis, 118–120 responsibility, principle of, 157 Ribot, Théodule, 19 rights and dignity, respect for, 158 Robertson, James, 29 Roland, A., 179 Rorschach test, 62 Russell, P., 48 Ryle, A., 70 Sachs, Hans, 8 sadism, 26 Samberg, E., 101–102, 115–116 Sampson, H., 32 Sander, Louis, 25, 31 San Francisco Psychotherapy Research Group, 28, 32, 35 Sarnat, J., 148 Schafer, R., 193 science, cultural diversity and, 175–176 Seitz, P. F., 69 selective inattention theory, 31 self-development cultural diversity and, 178–180 professional identity and, 195–197 transference and, 106 self psychology, 6 relationships and, 131 self-reflection countertransference and, 111–113 interpretation and, 129–130 patient’s capacity for, 58–60 in supervisors, 146–148 sexuality, psychoanalysis and, 26–27 sexual orientation issues and definitions involving, 167–168 psychoanalysis and, 179–180 Shedler, J., 34 short-term treatment options prevalence of, 85–86 supervisor’s role in, 147–148 Siblerschatz, G., 70 Siefert, C. J., 36

signal anxiety, 25 Silberschagz, G., 69–70 Simmel, Ernest, 8 Sixteen Personality Factor Questionnaire (16PF), 62 skill for interventions, 120–121 in psychodynamic case formulation, 73 slips of the tongue, 12 socialization, multicultural education and, 169–172 socioeconomic changes, psychoanalysis and, 85–86 somatic nervous system, memory and, 24 Spitz, René, 22, 32 standards, ethical standards, 158–159 Stern, D. N., 25, 30–31 Stewart, J., 146 Strategic Outreach to Families of All Reservists (SOFAR), 197 structural change, assessment of, 62 Strupp, H. H., 69–70, 111 subjectivity countertransference and, 109–110 transference and, 107 subjectivity-objectivity balance, of therapist, 102 sublimation, 21 Sullivan, Harry Stack, 10, 22, 30–33 Summers, R. F., 68, 70–72, 75–76 superego assessment in patient of, 59–60 conflicts and, 12 Freud’s discussion of, 178 role of, in early psychoanalysis, 7–8 supervision, 137–149 defined, 137–140 educational training, 188–189 in learning environment, 140–144 supervisor’s role in, 145–148 triangulation and, 144–145 supportive psychotherapy, 35–37 Swartz, H., 69–70 symptom reduction, psychotherapy focus on, 36–37 Szecsody, I., 139

217

218

Index talking cure, early use of, 6 Tansey, M. J., 113 Tavistock Clinic, 28–29 teaching, supervision as, 146–148 technology, psychotherapy and, 36–37 Teitelbaum, S., 143–144, 147 therapeutic alliance/contract distinctions in, 95–97 ethics and standards concerning, 162–163 initial dialogue concerning, 89–90 interpretation and, 126–130 relationship analysis and, 131 spectrum of treatment and, 93–94 supervisor’s role in, 145–148 therapists’ distortion of “other” and, 181–183 transference distinctions in, 104–105 triangulation and, 144–145 therapeutic effect convergence and, 132 defined, 124 interpretation of, 125–130 resistance, 132–133 transference and countertransferences, 131–132 therapeutic process prediction of response, 77–78 “thinking about thinking,” supervision and, 141–144 third party, supervisor’s role as, 144–148 Thomä, H., 193 Thompson, Clara, 10 Tompkins, M., 69–70 totalistic countertransference, 109–110 training ethics and standards concerning, 162 in supervision, 138–140 supervision and, 140–144 transference abstinence and, 92 applications of, 105–107 categorization of, 102 clinical example of, 107–108 defined, 12 distinctions in, 104–105

expansion of, 103–104 Freud’s concept of, 102–103 overview of, 101–121 patient-analyst relationship ad, 102 self psychology and, 131 supervision and, 141–144 therapeutic effect, 131–132 understanding of, 72–73 trauma anxiety and, 25–26 assessment challenges in clients with, 48–49 early psychoanalytic research on, 20–22 specialists training and practice in, 196 treatment assessment and, 54–55 attitude concerning, 73–75 determination for, 60–61 dialogue during, 84–86 distinctions in, 95–97 ethics and standards, 154–164 explanation of process in, 87–88 initial encounters in, 83–84 initial procedures, 83–99 knowledge of, 73 preparation for, 74 psychodynamic case formulation, 69–70 spectrum of, 92–94 triad of neutrality, anonymity and abstinence, initial treatment process and, 90–92 triangulation, supervision and, 144–145 true countertransference, 110–111 Tuch, R. M., 44 Tuckett, D., 96–97 Tummala-Narra, P., 169, 179 Turning Points in Dynamic Psychotherapy (Akhtar), 46 twinship transference, 106 unconscious cultural diversity and, 170–172, 181–183 knowledge of the “other” and, 177–178 memory and, 23–24 patient awareness of, 12–15

Index role of, in psychoanalysis, 7, 10–11 supervision and, 141–144 transference and, 102–103 understanding of, 72–73 unformulated experience, 30–31 United States cultural diversity issues in, 173–178 evolution of psychoanalysis in, 8–9 immigrant identity in, 178 specialization of psychology in, 9–11 university-affiliated psychological institutes, 10 U.S. Census, minority population data, 167 VandeCreek, L., 154–155, 163 Von Brücke, Ernest Wilhelm, 19

Wachtel, P. L., 179 Waelder, R., 127 Wallerstein, R. S., 35–36, 96–97 Wallin, D. G., 117 Weiner, J., 107, 108–110, 112 Weiss, J., 32 Wells, M., 131 William Alanson White Institute, 10 Winnicot, D., 22, 30, 32, 110 Wolberg, Louis, 10 women in workforce, organizational psychology and, 196 Wong, P., 179 workplace psychology, specialists training and practice in, 196 Yudofsky, 67–68

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ABOUT THE AUTHORS

Dolores O.  Morris, Ph.D., ABPP, is a Clinical Consultant, NYU Postdoctoral Program in Psychotherapy and Psychoanalysis. She received her certification in psychoanalysis from the American Board of Professional Psychology (ABPP). She has served ABPP in numerous capacities, having been president of the speciality board of psychoanalysis in psychology and a member of the Board of Trustees representing the speciality. She received the first Diversity Award from Division 39 of the American Psychological Association in 2014. She is a fellow of the American Psychological Association. She has published and presented in the area of race, culture, supervision with special interest in the interface of professional and personal identity. She maintains an independent practice. Rafael Art. Javier, Ph.D., ABPP, is a professor of psychology, the Director of Inter-agencies Training and Research Initiatives and the Post-Graduate Professional Development Programs and of the Postdoctoral Certificate Programs in Forensic Psychology at St. John’s University. He was the founding and first director of the Center for Psychological Services and Clinical Studies at St. John’s University for almost 20  years. He was on the faculty and a supervisor at New  York University Medical Center’s Department of Psychiatry. He is currently on the faculty and supervisor at the Object Relations Institute. Prior to joining St. John’s University, he held the Chair of Psychology at Kingsboro Psychiatric Center and was on the faculty at Downstate Medical Center. William G. Herron, Ph.D., ABPP, practices psychoanalysis and psychotherapy, and trains in Woodcliff Lake, New Jersey. He also trains psychiatric residents at Bergen Regional Hospital in Paramus, New Jersey. He has lectured on psychoanalytic topics, taught psychology for over 40 years, published extensively on psychoanalytic topics, and written numerous books on psychoanalysis and psychotherapy.

ABOUT THE SERIES EDITORS

Arthur M. Nezu, Ph.D., ABPP, is Professor of Psychology, Medicine, and Public Health at Drexel University, and Special Professor of Forensic Mental Health and Psychiatry at the University at Nottingham in the United Kingdom. He is a fellow of multiple professional associations, including the American Psychological Association, and is board-certified by the American Board of Professional Psychology in Cognitive and Behavioral Psychology, Clinical Psychology, and Clinical Health Psychology. Dr. Nezu is widely published, is incoming editor of the Journal of Consulting and Clinical Psychology, and has maintained a practice for three decades. Christine Maguth Nezu, Ph.D., ABPP, is Professor of Psychology and Medicine at Drexel University, and Special Professor of Forensic Mental Health and Psychiatry at the University at Nottingham in the United Kingdom. With over 25  years of experience in clinical private practice, consultation/liaison, research, and teaching, Dr.  Maguth Nezu is board-certified by the American Board of Professional Psychology (ABPP) in cognitive and behavioral psychology and clinical psychology. She is also a past president of the ABPP. Her research has been supported by federal, private, and state-funded agencies, and she has served as a grant reviewer for the National Institutes of Health.