Directions in psychoanalysis

Clinical Psychology Review, Vol. 18, No. 7, pp. 857–883, 1998 Copyright © 1998 Elsevier Science Ltd Printed in the USA. All rights reserved 0272-7358/98 $19.00 ⫹ .00

PII S0272-7358(98)00020-8

DIRECTIONS IN PSYCHOANALYSIS Robert C. Lane, Bady Quintar, and W. Bradley Goeltz Nova Southeastern University

ABSTRACT. This article is intended to familiarize the general practitioner with the important concepts in the practice of psychoanalysis. It provides an overview of the development of the field of psychoanalysis, considering it as a theory of personality, as an explanation of psychopathology, and as a research procedure. It also explores psychoanalysis as a method of treatment and presents an outline of the knowledge and training necessary to become a psychoanalyst. A consideration of the analytic process includes a review of the postulates that govern its application—the analytic process, the therapeutic dyad, and psychodynamic interventions. Historical and political issues are examined, including the spread of psychoanalytic theory, the various contributions of important psychoanalytic thinkers, a review of the struggle of nonmedical psychoanalysts to break the one-time monopoly held by medical psychoanalysts, and the ongoing love-hate relationship between clinical practitioners and academic psychologists. In addition to providing this background material, this article explores the issues currently facing the field of psychoanalytic thought—the need for integration of the structural and relational perspectives and the outlook for the future of the discipline. © 1998 Elsevier Science Ltd

INTRODUCTION THE TERM psychoanalysis introduced by Freud is stated by Fine (1982) to be an abbreviation of psychological analysis, an expression used by Janet in the 1890’s. From the beginning of his explorations into the mind, Freud saw psychoanalysis as a system and discipline of psychology and not of medicine. This led to bitter infighting, which continues to this day, as to which profession would be permitted to study and practice psychoanalysis. The details of this struggle and the effects of World Wars I and II, as well as other significant events and times, on the development of psychoanalysis are described in the American Psychoanalyst, a publication of the American Psychoanalytic Association (APsaA); Fine’s (1979) History of Psychoanalysis; and Lane and Meisels’s (1994) A History of the Division of Psychoanalysis of the American Psychological Association. This article constitutes the opinions of the authors, and history as they perceive it, and does not necessarily reflect the point of view of the editors or the publisher. Correspondence should be addressed to Dr. Robert C. Lane, Nova Southeastern University, Center for Psychological Studies, Maltz Psychology Building, 3301 College Avenue, Fort Lauderdale, FL 33314-7796.

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THERAPEUTIC DYAD The psychoanalytic dyad consists of a patient (the analysand) and a therapist (the analyst) engaged in an intensive interpersonal relationship in which both parties agree to certain terms referred to as the frame, or ground rules of psychotherapy. This frame, the basic therapeutic contract, includes the relative neutrality and anonymity of the analyst, the establishment of the fee and the time and place of meeting, the use of a neutral and private setting and a fixed physical arrangement of the office, the frequency of sessions, the method of free association (i.e., the verbalization of whatever comes to mind without censorship), the agreement to attend sessions consistently and until both parties agree to terminate, and the agreement that therapeutic material will remain private and confidential within the bounds of law. A “secure frame” leads to safety and trust for both patient and therapist and clears the way for the pursuit of insight, understanding, growth, and autonomy. Personal opinions, nonneutral interventions, and self-revelations by the analyst disrupt the treatment by contaminating the transference, which may be understood as the influence of the patient’s unconscious feelings and desires that have been retained from infancy and childhood and are presently directed toward the analyst. In other words, the individual’s perception of the world around him or her is determined by early relationships—Every person to whom one relates is perceived on an unconscious level as being in some way like one’s earliest love objects (most often the infant’s parents). The analytic frame seeks to preserve and intensify these unconsciously transferred feelings and desires in the hope of resolving poorly negotiated conflicts between internal needs and external reality. Langs (1982) pointed out that the neutrality of the frame, which is intended to intensify the transference, is “not indifference or lack of concern, coldness and distance or unavailability,” but a unique type of holding and warmth. The analyst strives to provide and maintain maximum privacy and security. This facilitates a collaborative experience that is designed to discover the nature of the patient’s wishes, fantasies, and problems with the purpose of relieving the suffering of the patient. There is currently a significant debate being waged over the degree to which the frame must be preserved and protected in its ideal state. Relational psychotherapists, for example, contend that the ideal of anonymity and neutrality is unnecessary and that the transference is a universal phenomenon that will remain relatively undamaged by what a more classical analyst would regard as a damaging frame break. Although the more classical psychoanalytic position would concede that transference is indeed a universal phenomenon, it would also caution that frame breaks (such as self-revelation or nonneutrality by the analyst) complicate the infinitely complex web of mutual influences that exist in every relationship. It is also proposed that the frame exists to help the analyst ensure that he or she is using the setting to help the client rather than as a means of satisfying his or her own unconscious desires or needs. Ultimately, the frame exists to simplify and isolate the relational process to such a degree that the analyst may reasonably pursue an understanding of the client and help the client understand himself or herself.

ANALYTIC POSTULATES Psychoanalysis proposes a number of postulates. First, there is an unconscious that influences all behavior and human experience. Second, the specific life experience, history, and psychic needs of the individual powerfully influence perception and behav-

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ior (this is called psychic determinism). Third, it posits a genetic orientation in which the adult dysfunction is determined by the individual’s developmental history, the person’s early life experiences, and relationships. The fourth postulate is that pathology exists on a continuum, that mental illness is a matter of degree, with all persons susceptible to pathology under certain conditions. The fifth and last major proposal is that all individuals are unique—The etiology of every symptom is unique to the individual in whom it is demonstrated. The psychoanalytic goal of self-awareness, insight, and understanding is achieved by working with the patient’s free associations, memories, derivatives, fantasies, slips of the tongue, and other symbolic material to discover the analysand’s unconscious wishes and the motivation that causes the disturbed affects of anxiety, depression, shame, guilt, and rage.

THE ANALYTIC PROCESS Fully cognizant of the developmental, relational, interpersonal, and structural influences on behavior, the analyst attempts to bring the unconscious into conscious awareness and help the analysand reach his or her optimal potential. The psychoanalytic process is often treated as if it has three stages of treatment: the beginning, the middle, and the end (termination). The setting of the frame and the establishment of the therapeutic alliance, the working relationship between the analysand and the analyst, are part of the initial phase. The development of the transference neurosis (or the bringing of the neurosis into the analytic situation and living it out with the analyst) is part of the middle phase, and the working through of the major resistances and the transference is part of the final phase. As noted before, the mechanism with which the analyst works is transference. The patient relates to the analyst as if he or she were someone from the patient’s past or reverses the situation by placing the analyst in their position while the analysand assumes the position of some important figure from personal history. Thus, through the displacement and projection of the past situation into the present, the patient relives earlier experiences but with someone who is not personally involved and can therefore interpret the affects of the involved parties as well as the intrapsychic and interpersonal conflicts. The analyst must keep his or her finger on the pulse of the transference and always be aware of the adaptive context (Langs, 1982). That is, he or she must be aware of the central unconscious theme that the client presents in the session, repeatedly and in disguised (derivative) form. It is important that he or she be aware of the significance of the situation that is being displaced or projected onto the therapeutic situation at any particular moment in therapy. Resistance constitutes all of the patient’s attempts to defend against disclosure of problems and is still operative at the end of treatment. Recently, the importance of countertransference has become a focus of much discussion in analytic circles. The one-person psychology of Freud has given way to a twoperson understanding in which both the analysand and the analyst contribute to the ongoing intrapsychic, interpersonal, and intersubjective interaction. Racker (1968), for example, regarded the therapist as engaging in roles similar to the patient’s role in the transference situation. In complementary countertransference, the analyst, influenced by the analysand’s transference and by his or her own intrapsychic conflicts, takes on qualities of the person to whom the patient is relating through the transference; he or she “becomes,” and therefore acts and feels like, the hated sibling or beloved father or

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idealized mother. The concordant countertransference establishes a situation in which the patient adopts the role of an important figure from his or her past, and the analyst “becomes,” acts and feels like, the patient. If the analyst is unappreciative of this phenomenon or is unequipped to manage it, the countertransference may indeed become, as Freud understood it, a hindrance. On the other hand, the well-managed concordant or complementary countertransference can be an invaluable tool for understanding the affective position of the patient.

INTERVENTION The method of promoting understanding that leads to insight is known as intervention. Interventions—the means by which the analyst helps the client move toward insight— may deal with the manifest, which is conscious, or the latent, which is unconscious. Silence on the part of the analyst can be used as a nonverbal intervention, whereas questions and clarifications are two forms of verbal interventions dealing with conscious material, which function to expand the knowledge and awareness of both the patient and the therapist. A fourth form of intervention is confrontation, which also deals with conscious material and is intended to “direct the patient’s attention to surface resistance” and to the defense mechanisms that are demonstrated during session with the expectation that follow-up will eventually get to fantasy and unconscious material (Langs, 1973). The only type of intervention that directly attempts to make conscious the unconscious is the interpretation, in which the analyst attempts to bring into the patient’s awareness the unconscious meaning and origin of a significant psychic event. The threepronged interpretation brings together the present effects of the unconscious psychic event, the past history or origin of the current psychic situation, and the manner in which the unconscious meanings are currently revealed in the transference; this is perhaps the clearest and deepest type of intervention. Errors in interpretation may derive from the analyst’s countertransference and are, according to Langs (1973), the result of his or her unresolved intrapsychic conflicts, disruptive fantasies, instinctual drive needs, superego pathology, “defenses and other disturbed ego functions, including at times, gross distortions of perception, reality testing, and relating” (p. 511). Langs feels that inappropriate uses of interpretation include premature interpretation; under- and overuse of interpretation; “too-deep” interpretations (i.e., of a psychic depth for which the patient is unprepared); and incomplete, inexact, or missed interpretations. These errors can lead to excessive intellectualization or defensive rumination by the analysand.

THE SPREAD OF ANALYTIC THINKING Aspects of psychoanalytic theory (e.g., defense mechanisms) have found their way into many different theories of personality and mental health in general. Although Freud first utilized psychoanalysis in the treatment of neuroses, his methods were soon applied to nearly all psychopathological conditions, as well as the study of literature, art, history, biography, and culture. Different forms of psychodynamic psychotherapy regard psychoanalysis as the treatment of choice—Kohutian therapy in the treatment of narcissistic disorders, object relations therapy in the treatment of psychoses, and contemporary structural therapy in the treatment of neuroses.

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Psychoanalysis has been particularly helpful in treating patients with longstanding intrapsychic conflict; characterological difficulties; neuroses; perversions; inhibitions of intellect, work, and love; problems of early childhood; failure with other forms of therapy; the need for a deep insightful experience; and disturbances that block the reaching of one’s potential. Psychoanalytic language such as the unconscious, defense mechanism, free association, transference, resistance, and many other terms have become common not only in general professional usage but also in everyday vocabulary.

KNOWLEDGE AND TRAINING The first question to be asked concerns what types of knowledge and characteristics are necessary for the applicant to psychoanalytic training. It has been found that the same qualifications as those for analyzability appear to be necessary to become a successful psychoanalytic candidate. These include good intellectual ability, the capacity for sustained inquiry, curiosity, insight, good communication skills, a relatively welldeveloped capacity for self-observation, awareness and reflection, the possession of significant sophistication and psychological mindedness, a degree of maturity, and a willingness to express affect and empathy. Two factors are absolutely essential in the budding psychoanalytic therapist or researcher—a knowledge of the therapeutic field (including personality development, psychopathology, and psychoanalytic technique) and a certain degree of self-awareness. The psychoanalyst receives the first factor in his or her training via course work and supervision and the second factor in his or her personal analysis. Today, training is available at the 29 training institutes of the APsaA, at a large number of independent institutes in cities such as New York and Los Angeles, and at approximately 10 training institutes sponsored by the Division of Psychoanalysis (39) of the American Psychological Association (APA). Two events in particular opened the door in America to psychoanalytic training for psychologists. First, there was the formation of the Division of Psychoanalysis and its local chapters; second, there was the successful antitrust suit against the APsaA. The lawsuit opened the institutes of the APsaA to nonmedical personnel and permitted the APsaA members to teach in nonmedical institutes. Now let us consider the training model that was made available. The model of training for most of the institutes of the International Psychoanalytical Association (IPA) has been, and continues to be, that of the Berlin Institute established in 1920 by Max Eitingon (Fine, 1979). It has been known as the “traditional” model, the “closed” model, and the “lock-step” model and has, since the 1920s, consisted of personal analysis, theoretical courses, supervision, and societal control of training. Far-reaching and important decisions regarding training included the ruling that every prospective psychoanalyst should have a training analysis, should be supervised on several cases by an experienced senior (“control”) analyst, and should have a series of courses in psychoanalytic theory over a period of time. Societal control over training has further led to a host of difficulties, particularly splits in institutes and societies. Charismatic leaders who would break away or were expelled from a society would form new institutes and take their followers, often “generations” of their analysands and supervisees, with them. Battles for institute control as well as control over the training committee would ensue. Who is on the faculty, who are the directors, who are the training and control analysts become crucial problems related to who is in control. Rifts occur along with many abuses. When training analysts are on the institute faculty,

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other problems occur, and when training analysts are “reporting” analysts, still other problems result. Often, institutes insist that training and control analysts must be selected from their acceptable list of analysts. Leaders may mislead candidates regarding the position of their opponents. Charismatic leaders tend to be idealized. Agreement with someone (e.g., Freud) may lead to expulsion from one institute, whereas disagreement with the same figure may lead to the same fate in another institute. As mentioned, institutes can present a rigidity and intimidation concerning their philosophy and may present an atmosphere of paranoia. Course work has remained practically the same for many years and includes the following: (a) introduction to psychoanalysis; (b) dreams, libido theory, and infantile sexuality; (c) technique of psychoanalysis; (d) psychopathology—special theory and characteristics of neuroses, perversions, and character disturbances; (e) theoretical problems; (f) seminar on psychoanalytic history and literature; (g) colloquium on novelties in psychoanalysis and its allied fields; (h) psychoanalysis and the practicing psychoanalyst; (I) course for practical-theoretical development; (j) special themes; and (k) reading and seminars on the extratherapeutic application of psychoanalysis. This last course includes the following areas of study: general, literature and art, psychoanalysis and sociology, law and criminality, philosophy, religion, and education. Lectures for the public were also offered (Fine, 1979). Case presentation has always been part of the course work, and additional courses generally include the following topics: the first year of life, comparative psychoanalysis, cultural influences, women’s issues, and gender issues. Although this training model has withstood the test of time, the Clark Conference of the Division of Psychoanalysis (Meisels & Shapiro, 1990) on tradition and innovation in psychoanalytic education highlighted the open model of training as well as discussing the traditional model. Anne Marie Sandler (1990) in her presentation contrasted the British and French institutes. The latter’s open model is not lock-step, but it is candidate centered, self-directed, and more creative, and candidates move through the program at their own pace. Regarding the closed model, Sandler (1982) had this to say: “The danger now is towards a tendency to unhealthy conservatism which may result in rigidity, in a kind of ossification and a lack of openness to adaptive change” (p. 280). Hyman (1990) stressed “independent study without allegiance to any particular institute.” He feels that timing and sequence of courses should be determined by each individual’s unique educational needs. To Hyman, such an approach provides a climate of creativity, challenges authoritarianism in education, and is part of the educational revolution. Others (Gourevitch, 1990) feel that giving the candidate too much responsibility may prove to produce too loose a system, in which standards may not be maintained. Gourevitch (1990) stressed a “relational” climate of “mutual acceptance . . . without dominance or rigid hierarchies.” Suggestions were also made at the Clark Conference concerning the components of psychoanalytic training, personal analysis, and supervision. For a fuller description of tradition versus innovation, see Meisels and Shapiro (1990). Knowledge has been disseminated at the many psychoanalytic meetings that are held annually. The Division of Psychoanalysis holds a midwinter and an annual meeting at the APA’s convention. The APsaA also holds two annual meetings as well as a number of annual meetings at the local level throughout the country. Psychoanalytic Abstracts, a publication of Division 39, surveys and abstracts nearly 50 journals in addition to having an annual issue on psychoanalytic topics and another on books and book chapters. Continuing education courses are offered at meetings to furnish the latest psychoanalytic information and to provide a forum for the free exchange of ideas and knowledge.

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PSYCHOANALYSIS AS A THEORY OF PERSONALITY Psychoanalysis began in the 1890’s as an explanation of neuroses. Freudian theory placed the emphasis on lack of resolution of the Oedipal conflict. One hundred years later, although the Oedipal conflict is still central, the importance of the pre-Oedipal period, or the dyadic period of exclusivity between mother and infant (Brunswick, 1940/1950), and the widening scope of indications for psychoanalysis (Stone, 1954) have received increased attention. Klein (1946/1964) and her co-workers extended psychoanalytic treatment after World War I to both the more severely disturbed and to children. New theoretical models crop up, establishing themselves as separate models of the mind rather than permitting their incorporation into a broader contemporary structural viewpoint (e.g., Kohut, 1971). Self psychology highlights its treatment of disorders of the self and the narcissistic disorders. Object relations theory stresses its handling of schizoid and borderline disorders. Stone (1954) “recommended modifications in treatment for people with more primitive mental organizations who have difficulty abstracting and generalizing. Alterations in treatment broadened the scope of psychoanalysis by accommodating a wider range of patients” (Lane, 1995). Mahler, Pine, and Bergman (1975) emphasized the importance of the pre-Oedipal phase of development in psychopathology in delineating the stages of separation individuation. For example, pathology involving separation-abandonment (i.e., the borderline diagnosis) was related to the rapprochement crisis. Herman and Lane (1995) had this to say: Beginning around sixteen months, the average child undergoes a vulnerable, stressful, conflictual period called the “rapprochement crisis.” In libidinal and aggressive terms, oral, anal and phallic conflicts coalesce. As a now more cognitively, motorically and linguistically advanced senior toddler, the child becomes more acutely aware of his separateness, as if he had omnipotently moved out too far during the practicing subphase. Separation anxiety flares up, stimulating an urge for rapprochement seen in “wooing” mother, “shadowing” her, and wanting her to share experiences and discoveries. (pp. 22–23)

Freud felt that the narcissistic neuroses (psychoses) were not amenable to treatment by the psychoanalytic method, as patients were too much “into themselves” to relate to others or to form a working alliance. It was Stone’s (1954) work that opened up a wider scope of treatment for the extremely borderline personality disorder and narcissistic patients who demonstrated a weakened ego functioning and feelings of omnipotence. Bellak and his colleagues (Bellak & Hurvich, 1969; Bellak, Hurvich, & Gediman, 1973; Bellak & Meyers, 1975), for example, did research on ego strength, treatability, and analyzability. Frieda Fromm-Reichmann (1960), Harold Searles (1965), and Harry Stack Sullivan (1947) established that schizophrenics could be treated, and other schools of thought (e.g., self psychology and object relations) appeared to specialize in the treatment of the difficult patient (Fairbairn, 1940/1952; Klein, 1946/1964; Rosenfeld, 1952).

PSYCHOANALYSIS AS A METHOD OF TREATMENT Psychoanalysis advocates that pathology is the result of conflict. This conflict may be intrapsychic (“within the psyche”) or intrasystemic—a conflict contained within a particular psychic structure, such as the ego. Alternatively, the conflict might be interpsy-

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chic (“between psyches”) or intersystemic—as demonstrated by id wishes versus superego prohibitions. Conflict is represented by symptoms that are the result of compromise formations. These are unconscious and constitute a combination of instinctual material, defenses, affect (e.g., anxiety or depression rooted in the “calamities of childhood” or dangers children experience), and some aspect of superego functioning (Brenner, 1973, 1982). One goal of psychoanalysis is to make the unconscious conscious through the process of free association and the abreaction of traumatic material. Disturbing thoughts, feelings, memories, fantasies, dreams, and daydreams are guarded against via a series of defense mechanisms (A. Freud, 1936) that function to prevent the conscious awareness of disturbing material. Toward the end of his life, S. Freud (1923/1961) shifted his focus from the id to the ego when he introduced both structural theory (delineating the id, ego, and superego) and the adaptive functions of the ego. Psychoanalytic theory follows the genetic model that states in essence that the pathological behavior of the patient in the here-and-now (i.e., present conflict) is a repetition of some unresolved maladaptive behavior, lack of attunement, or misalliance of childhood, and an attempt to master through the repetition compulsion some traumatic event or cumulative series of traumatic events. When these traumas occur at specific crucial developmental stages, arrest or fixation at the corresponding points of development can occur. Certain schools of psychoanalysis (e.g., the Kohutians) believe in deficit theory, in which the cause of pathology is understood as an underdevelopment of intrapsychic structure rather than conflict. Contemporary structural psychoanalysts believe that past experiences and relationships, repressed but not forgotten, are recapitulated in the present through the process of repetition compulsion. These conflicts may break through in the form of a dream, fantasy, slips of the tongue, wit, or some form of parapraxes in general. Psychoanalytic therapy uses the couch, relatively frequent sessions, a secure frame, and the establishment of a therapeutic alliance to encourage the transference relationship. Transference is the displacement and/or projection of feelings for a significant other (often from childhood or infancy) onto the therapist; it may be positive or negative, dependent, eroticized, homosexual, idealized, or any of a number of other types as proposed by different theories. As the transference intensifies, the patient’s conflict with the significant other is relived in the analysis, and this is referred to as transference neurosis. Through the process of free association, the analysis of resistance, and the appropriate use of interventions, the analyst attempts to help the patient work through or “get at” the causes of symptoms, repair deficit, and resolve conflict. The positive therapeutic movement elicited by these methods is often resisted by the patient for a variety of conscious and unconscious reasons. Resistance is the patient’s manner of retaining or preserving symptomatology, “all those forces within the patient that oppose the treatment process” (Milman & Goldman, 1986, p. 3). It may be classified according to source, fixation point, type of defense, diagnostic category, and degree of ego syntonicity (Greenson, 1967). S. Freud (1926a) classified resistance according to its source when he described five types of resistance—three associated with the ego, one from the superego, and one from the id. The ego resistances are repression resistance (use of repression, projection, denial, and other defenses to prevent knowing), transference resistance (due to displacements from past to present objects), and epinosic resistance (due to secondary gains from illness which produce too much pleasure). Superego resistance occurs where the superego needs to punish the ego—the negative therapeutic reaction being one way in which progress is sabotaged

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(Etchegoyen, 1991; Lane, 1985; Lane, Monaco, & Gregson, 1997). Id resistance occurs when the patient continues to gratify needs and to seek pleasure through maintenance of symptoms and unrestrained discharge of drives. An important rule in psychoanalysis is that resistances should be handled before content is addressed. When resistances are connected to disturbing fantasies, it may be necessary for the analyst to wait until the analysand presents the fantasy on his own before tackling the resistance. Countertransference pertains to the therapist’s displacement of feelings and thoughts, both conscious and unconscious, onto the patient, and counterresistance refers to the therapist’s resistance to curing the patient. It must be noted that psychoanalysis is the only form of therapy in which by definition the therapist has not only spent many years in course work and supervision but has also had a personal psychoanalysis. This suggests that the psychoanalyst, through insight and self-knowledge, will arrive at a greater awareness of countertransference (and counterresistance) issues. The fact is, interestingly, many other modes of therapy generally disregard the importance, or even the presence, of countertransference in the therapeutic situation. The most important therapeutic skill is the ability to listen; the analyst spends years learning what to listen for and how to listen with what Freud called an evenly hovering attention. One of the most profound explanations of listening belongs to Kavanaugh (1995a): One “listens” to all communications from the patient as being part of the associative process and as being brought to mind for the purpose of communicating something about the individual’s understanding and experience of “self”, of “others”, of their world, and of their relationship to that world. One “listens” with and through all of their perceptual senses and systems as these communicative aspects of behavior are conceptualized as being expressed through the verbal language of speech, the visual language of dreams, and the iconic language of the body and somatic expressions, experiences, and processes. All of these communicative aspects of the individual join together in the “choreographed conversation” during the analytic hour reflecting the assumption of a monistic view of mind and body. (p. 13)

PSYCHOANALYSIS AS AN EXPLANATION OF PATHOLOGY In the beginning of psychoanalysis, Freud concentrated on the understanding and treatment of the neuroses. His first explanation of anxiety concerned it being the result of a transformation of undischarged libido. This first explanation (S. Freud, 1895) placed emphasis on a biological component, the principle of constancy, and dammed up libido that led to or was transformed into anxiety. Freud then made reference in his writings to an anticipatory warning or signal of anxiety with the purpose of avoiding still greater anxiety or displeasure. S. Freud (1926a) in “Inhibitions, Symptoms and Anxiety” described signal anxiety, his second theory of anxiety. The aim of signal anxiety was to prevent the ego from being overwhelmed by stimulation resulting in feelings of helplessness. Thus, signal anxiety was to trigger the defense system before anxiety reached the traumatic or panic level. In S. Freud’s (1933) third phase of anxiety, he dropped his transformation theory, completely accepted the theory of signal anxiety, and recognized that anxiety was the cause of repression rather than repression being the cause of anxiety. Freud felt (Lane & Foehrenbach, 1994), “a number of different developmental events including birth, specific early traumas, separation anxiety, loss

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of the object, loss of love and protection of the object, led to loss of self-esteem, castration, masturbation, and superego anxiety” (p. 108). For a brief history of the contributing psychoanalysts to the theory of anxiety, particularly annihilation anxiety, see Bowlby (1973) and Lane and Foehrenbach (1994). Freud felt that pathology was a question of intensity or degree. Thus, viewing pathology on a continuum, the psychotic patient demonstrates a greater degree of pathology (not necessarily greater suffering) and fewer methods of coping or adapting than does the neurotic. S. Freud (1916–1917) postulated predestined erotogenic zones and stages of libidinal development which he termed psychosexual stages (e.g., oral, anal, phallic, and genital). S. Freud (1916–1917) said: Certain zones or areas of the body are in effect predestined by their anatomical juxtaposition to vital organs as to receive stimuli. These erotogenic zones are the oral, anal, urethral, clitoral, and genital zones. These predestined zones of erotization are linked to “great organic needs” such that the satisfaction of the related biological drives produces the concomitant effect of stimulating the erotogenic zone. (p. 315)

Psychoanalytic theorists have long associated severity of pathology with fixation at earlier stages of development. Freud offered a series of character traits he felt represented fixations on and residuals of the psychosexual stages; for example, anal character traits such as parsimony, obstinacy, and orderliness were the result of a degree of fixation at the anal stage. Freud first felt the roots of neuroses could be attributed to libidinal disturbances. Abraham (1924/1953) developed a table of psychopathology based on the psychosexual stages, in which he understood hysteria as a fixation on the phallic level, obsessive-compulsive neurosis as a fixation on the late anal level (retentiveness), paranoia as a fixation on the early anal level (expulsiveness), melancholia as a fixation on the late oral level (biting, incorporating), and schizophrenia as a fixation on the early oral level (sucking). Spitz (1965) proposed three organizers of the psyche in the first year of life—the smiling response, stranger anxiety, and the development of language (the origin of human speech and communication). There have been a number of developmental tables constructed around Freud’s psychosexual stages. Perhaps the three most popular tables are Fliess’s (1950) ontogenetic table in The Psychoanalytic Reader (pp. 254–255), which concerns the basic data of the ontogenesis of the psychic apparatus presented chronologically; the Blanck (1968, pp. 176–177; 1974, pp. 114–118) “Developmental Psychogram;” and Siegel’s (1984, pp. 41–51) “Developmental Outline.” This last table offers an overview of the differentiation of drives, defense mechanisms, and levels of anxiety. Stern (1985) in his well-received book on the interpersonal world of the infant “discards either explicitly or implicitly, most of the metapsychological constructs which have been built up over the past century” (Hull & Lane, 1996). Gone are the Freudian concepts such as the metapsychological approaches, energic concepts such as cathexis, the binding of excitation, the stimulus barrier, the repetition compulsion, normal autism, the concepts of fixation and regression, intrapsychic structure, and the psychosexual stages. Mahler’s stages of separation individuation, Erikson’s psychosocial stages, Spitz’s sequence of ego precursors, and all the developmental tables we have just discussed are also gone by the wayside for Stern. Stern conceptualizes pathology from an interactional-intersubjective Kohutian perspective that focuses primarily on the sense of self (Stern, 1985). He relates pathology to various deficits in the emergent self, core self, subjective self, and verbal self and

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suggests that a psychotic level of disturbance may originate from a failure of developmental processes at the level of core self-experience. Personality disorders, on the other hand, are understood as originating from disturbances of intersubjectivity, and neurotic disturbances may have their origins at the point where a verbal self develops (Hull & Lane, 1996).

CONTRIBUTIONS OF OTHER PSYCHOANALYSTS TO PSYCHOANALYTIC THEORY Through the years, there have been literally hundreds of contributors to psychoanalytic theory. Foremost among these have been a number of Freud’s contemporaries. Alfred Adler (1927), founder of the School of Individual Psychology, suggested that feelings of inferiority (with regard to organs or to the person), along with a quest for power and a striving for superiority, was the cause of the neuroses. He also postulated the importance of birth order, attributing personality characteristics to the order of birth, and felt that early memories were the key to understanding a person’s dynamics. He felt neurotic symptoms were a bid for attention, and the greater the sense of organ inferiority, the greater the need for attention. Carl Jung (1917), founder of the School of Analytical Psychology, stressed the importance of the individual and his or her racial and phylogenetic history in determining personality. He postulated the importance of the collective unconscious or the “storehouse of latent memory traces inhibited from the past” (Strean, 1994), the personal unconscious (experiences once repressed or too weak to make a conscious impression upon the person), complexes (organized groups of feelings, thoughts, perceptions, and memories existing in the personal unconscious), the concept of archetypes, introversion-extroversion, and the use of the word association test (Jung, 1918). Otto Rank (1924) is credited with contributing the importance of birth trauma as a cause of anxiety. Neurotics were thus those individuals who never succeeded in overcoming the anxiety of birth and are fixated on mother who offers protection from pain. He saw neurotics as people who had broken with society’s dictates and were attempting to exert their will in an attempt at self-realization. Wilhelm Reich (1948) contributed the importance of character and character defenses. To him, illness implied the inability to utilize character defenses in the service of one’s health (Strean, 1994). Two of the giants among the contemporary structural theorists are Arlow and Brenner (1964), who together wrote a book on structural theory and psychoanalytic concepts. Some prominent ego psychologists are Gertrude Blanck, Erik Erikson, Anna Freud, Heinz Hartmann, Ernst Kris, and R. M. Lowenstein. Associated with the interpersonal relations and object relations school are Eric Fromm, Karen Horney, Harry Stack Sullivan, and Clara Thompson from the interpersonal and W. R. D. Fairbairn, John D. Sutherland, and Donald W. Winnicott from the British school of object relations. The American object relations school is represented by Edith Jacobson, Otto Kernberg, and Margaret Mahler. For an excellent description of the structural, selfpsychological, and object relational approaches, see Lerner and Ehrlich (1994) and McWilliams (1994). Among those analysts who work with infants and children are Beatrice Beebe, Anna Freud, Melanie Klein, Margaret Mahler, and Daniel Stern. Currently popular self psychologists are Arnold Goldberg, Heinz Kohut, and Robert

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Stolorow. Stephen A. Mitchell and Jay Greenberg are the outstanding names in relational theory.

PSYCHOANALYSIS AS A RESEARCH PROCEDURE Because psychoanalysis and psychodynamic therapy are built on the foundation of the patient’s narrative, psychoanalytic research differs from research in other areas of psychology. The experimental and scientific method, which is embraced by academic psychology, is generally ineffective in evaluating the nuances in the complex interpersonal relationship between the therapist and patient, and it is the special nature of this relationship that is the curative factor in psychoanalytic treatment. The introduction of audio and video recording can artificially influence the behavior of both the therapist and the patient (leading to an exhibitionistic or superficial session), thereby contaminating both the transference reaction and the degree of neutrality and “evenly hovering attention” so valued by psychoanalysts. The interjection of an empirically acceptable means of recording would generally be expected to alter fundamentally the nuances that lie at the heart of the process being measured. Additionally, it must be noted that the spoken interchange between the analyst and his or her patient is only inadequately preserved no matter what means of recording is utilized; it has been estimated that approximately 50% of human communication is nonverbal in nature. Similarly, note-taking during the session and process notes written at the conclusion of the session are too subjective to be of much empirical value, although they may be clinically helpful to the therapist. The following statement by Luborsky and Spence (1978) captures the stated difficulties: Thus the issue is no longer whether process notes are sufficient—it has moved to the question of whether even audio recordings capture enough of the hour to be representative specimens of the analytic reality. The problem can be illustrated by looking at the issue of intention. The statement, “You have been silent now for some time,” when made by the analyst, is more than an observation; it is usually spoken with the aim of prompting the patient to speak. A full specification of that intention will not appear in the transcript, and although it may be supplied by the sophisticated reader, it may not occur to all readers with the same degree of force. Thus different readings of the same text are more than likely to occur, increasing the unreliability of ratings and adding noise to any study of process. . . . If full transcripts are fallible, process notes are even more defective. (p. 359)

In addition to these complications in measurement, the nature of treatment also makes translation of psychoanalytic data for research purposes exceedingly difficult. The rigorous training necessary to prepare an analyst for practice, the need for selfawareness, the focus on unconscious motivations and psychic determinism, the underlying subjectivity of the participants’ experience of the therapeutic relationship, and the importance of confidentiality all create difficulties for the individual seeking to quantify the psychoanalytic process. For example, the unconscious (one of psychoanalytic theory’s most fundamental and important concepts) is, by its very nature, unavailable to conscious observation. Clinical practitioners and empirical researchers alike must content themselves with inferring its existence and structure from subtleties in the patient’s behavior—Although acceptable within the analytic frame, inference of this nature is anathema to empirical science. The number of variables within the analytic hour is immense. The subtlety and sub-

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jectivity of the analytic variables create a practical measurement problem. Because psychoanalysis utilizes subtle, nonstandardized interventions, and because the primary goal of psychoanalytic therapy is insight and self-awareness rather than specific symptom alleviation, it is exceedingly difficult to define and delineate the exact nature of the variables to an extent that would satisfy the prototypical empiricist. Because of this difficulty, researchers in the field have traditionally utilized individual case reports, a practice that is criticized by empiricists as lacking in scientific rigor. The immense complexity that distinguishes each patient as an individual and marks his or her interactions with the therapist is the very means by which that person may be understood. By attempting to quantify isolated aspects of the therapeutic relationship (or of the individual) and thereby artificially removing them from the context of the relationship (or the individual) as a whole, one ignores the strength of the psychoanalytic method—the pursuit of an appreciation of the personhood of the individual, the very thing that makes him or her a unique being. Quantification and inclusion in outcome research often results in an abandonment of any consideration of the subjects as individuals, a practice that is anathema to psychoanalytic thinkers. The pooling of subjects into large groups (“pursuit of a large N”) is, in fact, intended to minimize the influence of extraneous individual differences on the dependent variable. Psychoanalytic theorists and clinicians would argue that it is with these very extraneous individual differences that we should be most concerned. To coin a phrase, “God is in the details”; the mystery and magic of personhood will seldom be discovered in the clean variables of “large N” experiments. It is only by getting one’s emotional and intellectual hands dirty in the mud of the therapeutic relationship itself that one can appreciate the nuances of how people act in terms of interpersonal and intrapsychic relationality. Research in psychoanalysis has focused less on quantitative studies and more on important theoretical and clinical issues that contribute to increasing understanding of the analytic process. Only a few journal articles devoted to the study of psychoanalysis or psychoanalytically oriented psychotherapy have relied strictly on quantitative research to demonstrate their effectiveness. In all scientific fields, research has become increasingly controlled and more quantitative in nature. The very nature of psychoanalytic clinical research often precludes the quantification preferred by empiricists, and if that quantification is the standard by which outcome studies are measured as being scientific, psychoanalysis cannot and will not qualify as pure or hard science. Despite the myriad of complications, there are a number of psychoanalytic researchers who are attempting to demonstrate to the empirical community that psychoanalysis is indeed an effective means of understanding and treating people, and it seems that, fortunately, research in psychoanalysis is beginning to gain momentum. Following the comprehensive review of research on psychoanalytic treatment by Wallerstein and Sampson (1971), evidence of greater interest in quantitative research has made its appearance in various journals. The most ambitious, largest, and distinguished of the quantitative therapy projects was conducted at the Menninger Foundation. Such well-documented research began in its present form in 1954 from the work of a multidisciplinary group of gifted professionals such as Sargent, Horowitz, Wallerstein, and Applebaum (1968), Kernberg et al. (1972), and Voth and Orth (1973). They attempted to investigate, in a naturalistic setting, the effectiveness of a variety of psychodynamic treatment modalities, including supportive and expressive psychotherapies as well as psychoanalysis. Other research studies have centered on the area of psychodynamic formulation,

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selection criteria, psychotherapeutic techniques, psychodiagnoses, and the like. Research on the efficacy of interpretation, particularly transference interpretation (Bibring, 1954; Luborsky & Spence, 1978), suggests that the results, although promising, lack definitive answers as to its efficacy. It appears that, when transference interpretations are made frequently, they tend to have some detrimental effect on the working alliance, as patients feel unduly criticized (Piper, Azim, Joyce, & McCallum, 1991). The therapeutic alliance has become an area of particular concern, especially over the course of the last 2 decades. Several rating scales were designed to study the importance of the alliance on the therapeutic process. The best known of these studies include the development of the Vanderbilt Therapeutic Alliance Scale (Hartley & Strupp, 1983), the Penn Helping Alliance Rating Scale (Morgan, Luborsky, CritsChristopher, Curtis, & Solomon, 1982), and the Therapeutic Alliance Rating System (Marmar, Weiss, & Gaston, 1989). These and other contributions tended to confirm the prognostic value of the working alliance in predicting the outcome of psychodynamic therapy. Recently, the fruitful and seminal work of Sidney Blatt (Blatt, 1992; Blatt, Cornell, & Eshkol, 1993) has contributed substantially to our understanding of the process of therapeutic change, the validation of certain psychoanalytic concepts, and the efficacy of a psychodynamic treatment modality. Having committed himself to the exploration of the benefits and validation of psychodynamic therapy, Blatt’s work sets a high standard for current research into the depth psychologies. In considering the role of individual differences in therapeutic change, he has identified two general personality types—the introjective and the anaclitic. The introjective personality style is marked by a strong sense of identity; these individuals tend to be interpersonally aggressive and self-assertive, valuing power, achievement, and prestige. Being perfectionistic, they tend to be self-critical and ruminative and demonstrate a preference for counteractive defense mechanisms such as intellectualization and projection. Good candidates for psychoanalysis, they tend to be logical, introspective patients. On the other hand, the anaclitic patient tends to be dependent, fearing abandonment, and wishing to be loved, nurtured, and cared for. Often reporting subjective feelings of loneliness and helplessness, they tend to seek fusion and sameness in an attempt to avoid the conflicts and danger of genuine interpersonal relationships. As one might expect, these individuals are generally quite focused on their environment, and they defend themselves via avoidant mechanisms such as denial and repression. Psychotherapy is the preferred means of treating these people, as opposed to psychoanalysis which is more appropriate for the introjective personality. As might be expected, Blatt has found that each of these two personality types engages therapy and the therapist in characteristically different manners. Although the clinical usefulness of Blatt’s findings is readily apparent, he had to overcome a myriad of operational difficulties in designing his studies, due to the concepts with which he was working. For example, it could be argued that the most valuable contribution of psychoanalytic theory is the concept of the unconscious; however, requests for analysands to provide responses or to provide self-reports still leave the researcher with the (disreputable) task of inferring the influence of unconscious processes. Additionally, the psychoanalytic explanation of symptoms is that they are metaphors for, or symbols of, unconscious material that is unacceptable to the patient. As such, the significance or the meaning of a symptom may be understood only when one considers the entire presenting picture of the client (including the personal history, the nature of the object relationships, etc.). Obviously, the amount of

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detailed information needed to gain an appreciation of the purpose and meaning of the symptom precludes the likelihood of effective empirical work with large subject pools. Current areas of concern and research in psychoanalysis include an exploration of the nature of the differences between conscious and unconscious feeling and thought, a consideration of symptom picture as a metaphor for core conflicts or deficits, and the nature of maladaptive behavior. Further concerns include the investigation of reporter bias regarding the nature of the presenting problem and examination of the difficulties faced in accumulating an adequate and representative sample of any diagnostic category, an issue complicated by each subject’s unique symptom picture, symptom meanings, and subjective perception of his or her presenting problems. An interesting recent development in the field of empirical psychoanalytic research is the realization that, “A great deal of cutting-edge research in cognitive, social, personality, and developmental psychology today is based on psychoanalytic theory” (Bornstein, 1996). It is not unusual, however, for the contributions of psychoanalysts whose work has not been subjected to rigorous empirical verification to be overlooked or ignored. Greenberg and Mitchell’s (1983) conceptualization of object representation is an example of an idea that has held a place of importance in psychoanalytic theory for almost 100 years. As Bornstein (1996) pointed out, however, “Variations on this concept have been ‘discovered’ independently by developmental, cognitive and social psychologists [who have] invented their own terms [such as] schema, self-representation, and internalized working model, all of which describe similar (though not identical) theoretical constructs.” Despite the complications that arise from the very nature of psychoanalytic theory, current researchers must endeavor to explore empirically the assumptions and constructs on which the theory rests. If psychoanalysis hopes to live up to the expectations of its creator, Sigmund Freud, it must make concessions to the rigorous demands made of other scientific disciplines and subjugate itself to the rules and regulations of empiricism; it is imperative, however, that its strengths—as an art and a philosophy— not be abandoned in pursuit of empirical verification and acceptance.

A BIT OF HISTORY AND POLITICS S. Freud’s (1926b, 1927) position on the subject of lay analysis (i.e., analysis by other than medical analysts) was always very strong. In his writings, he reiterated that opposition to lay analysis was opposition to analysis itself. Despite the history of psychoanalysis demonstrating the powerful influence of nonmedical analysts, very few nonmedical analysts were accepted into American psychoanalytic societies during and following World War II. The most famous of these people, Theodore Reik, was never accepted into the New York Psychoanalytic Society despite pressure to do so from Freud himself. This rejection stimulated Reik, along with a number of psychologists, to found the National Psychological Association for Psychoanalysis in 1948, the first psychological psychoanalytic institute. The influence of medicine in psychoanalysis was to be clearly stated in the Oberndorf Resolution in 1928 (Fine, 1982; Oberndorf, 1927–1928), declaring the necessity of full medical training for psychoanalysts. The influence of the APsaA on the IPA was demonstrated by the APsaA having complete control over membership from the United States in the IPA.

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Two developments greatly influenced the relationship between medical and nonmedical analysts. The first event was Reuben Fine’s founding of the Division of Psychoanalysis of the APA in 1979. Reuben Fine along with George D. Goldman, Samuel Kutash, and Robert C. Lane (Lane, 1994), associated with The New York Center for Psychoanalytic Training, constituted a founding group that spearheaded the formation of the Division 39 (Psychoanalysis) of the APA. The New York Center for Psychoanalytic Training became the first of four central offices for the Division. It was the formation of the Division that gave a home and an identity to America’s psychologist psychoanalysts. Dr. Fine’s vision and hope that the Division’s practitioners would form a Section with IPA standards and could eventually be accepted as a provisional institute of the IPA seemed a possibility. Division 39 of the APA was to become the third largest vote getter in the November APA Apportionment Ballot and has four council representatives on the APA Council at the time of this writing. For a complete history of the development and struggles of the Division of Psychoanalysis, see Lane (1994) and Lane and Meisels (1994). The fighting among medical analysts (psychiatrists) and nonmedical analysts (psychologists and others) eventually led to a court case, the second development that has influenced the relationship between medical and nonmedical analysts. Three psychologists, Reuben Fine (president pro tem and president, 1979–1980), Robert C. Lane (vice-president pro tem and president, 1981–1982), and Gertrude Blanck (distinguished author and theoretician), met with three members of the IPA, Adam Limentani (IPA, president), Moses Laufer (distinguished nonmedical member of IPA), and Irene Auletta (IPA secretary) at the Waldorf Astoria meeting of the IPA in the early 1980s to discuss how members of Section I (the Section of Psychologist-Psychoanalyst Practitioners) could become members of the IPA. The psychologists were told in very clear terms that the IPA in America is the APsaA, and there was no way of joining the IPA without first becoming an APsaA member. Dr. Fine, at that time, decided to discuss with the APA bringing antitrust and monopoly charges against the APsaA and the IPA. Shortly thereafter on March 1, 1985, four plaintiffs (Toni Bernay, Helen Desmond, Arnold Z. Schneider, and Bryant Welch), all members of the Division of Psychoanalysis, along with the legal firm of Clifford Stromberg, brought a Federal Antitrust Class Action lawsuit against the APsaA, the IPA, the New York Psychoanalytic Institute, and the Columbia University Center for Psychoanalytic Training and Research for restraint of trade and monopoly. For a history of the legal action, see Schneider and Desmond (1994) on the psychoanalytic lawsuit. The terms of the settlement (April 17, 1989) allowed psychologists (and other qualified nonmedical clinicians) to train in APsaA Institutes, permitted members of the APsaA to teach in non-American-affiliated institutes, opened membership in the IPA to all qualified psychologists and nonmedical institutes, and the defendants were ordered to pay $650,000 to the plaintiff class for costs and legal fees. It should be mentioned that it took considerable time and negotiations following the settlement to see that the provisions of the settlement were implemented. A major step was the formation of the “Committee On Settlement Enforcement” with Arnold Z. Schneider and Helen Desmond as co-directors to serve as a clearing house and information source and to monitor happenings and ensure that the settlement was being satisfactorily implemented. Since the settlement, four institutes in the United States with a large percentage of psychologists (two each in California and New York City) have been accepted for IPA membership. These include the New York Freudian Society, the Institute for Psycho-

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analytic Training and Research, the Psychoanalytic Center of California in Los Angeles, and the Los Angeles Institute and Society for Psychoanalytic Studies. One of these institutes had considerable difficulty, and another institute decided to withdraw their application after a number of on-site visits. These four American institutes accepted by the IPA formed the Independent Psychoanalytic Societies, and they have concentrated their work on three areas: (a) stressing the importance of the IPA and the maintenance of its standards; (b) attempting to join the Consortium—a group of representatives from four psychoanalytic organizations including the APsaA, the Academy of Psychoanalysis, the Division of Psychoanalysis of the APA, and the National Committee on Psychoanalysis in Clinical Social Work; and (c) getting involved in the process of accreditation. The Consortium has provided strong opposition to any one organization’s petition to the Committee on Higher Education Accreditation to be an accrediting agency for psychoanalysis. The Independent Psychoanalytic Societies filed a letter of intent with the Committee on Higher Education Accreditation, thus upsetting members of the Consortium, and has contacted institutes that formed from local chapters of the Division of Psychoanalysis (39) with invitations to join them as Study Groups of the IPA. It appears that there is strength in numbers and that, if the institutes formed from Division 39 join with the Independent Psychoanalytic Societies, which then gains membership in the Consortium and is supported by the APsaA, an external credentialing board in psychoanalysis seems possible and might emerge. The fourth concern involves scientific meetings and forums with topics of common interest. The Consortium just published their proposed set of recommended standards for becoming a psychoanalyst, with Nathan Stockhamer serving as a representative of Division 39 and Marvin Hyman (president of the Division) present as an observer. Among other standards, an analysand-contact frequency of a minimum of three times per week was proposed, although four or five times per week was recommended. These standards were to continue for a period of 3 years or more during the period of training and to begin prior to or concurrent with the beginning of classes, unless there are special circumstances. However, in the past, the issue of frequency has led to heated debate in the Division, and it is doubtful whether the proposed recommendations would pass a vote by the membership of Division 39. Candidates are recommended to have three adult cases, or a minimum of two, at an expected frequency of four or five times a week, with a minimum of three times a week. Supervision is to be conducted by accredited supervising or control analysts for 200 hr, with a required minimum of 150 hr. Further recommendations are that supervisors be of different theoretical orientations, that one case be supervised through the termination process before or after graduation, and that the training analysis and the supervision be concurrent. It is further recommended that patients be of both genders, except in cases of special circumstances, and that at least one patient be in analysis for a minimum of 2 years, whereas another patient must be seen for at least 1 year. Other significant items in the report of the Committee on Accreditation of the Psychoanalytic Consortium concern eligibility (i.e., highest degree in the field of licensure), suitability (e.g., character, maturity, analyzability, clinical aptitude, etc.), criteria for practice, curriculum (4 to 5 years with a minimum of 3 years at 30 or more weeks a year of classes for a minimum of 3 hr a week or a total minimum of 380 hr), evaluation, records, ethics, and appointment as a training analyst (5 years of postgraduation experience and 20 hr per week of analytic work). At the time of this writing, it appears that the medical institutes have benefited from the lawsuit in that they are receiving psychologists, social workers, and other mental

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health workers as applicants during a period of dwindling medical or psychiatric applicants. The issue of waivers has been reviewed and revised, thus opening up the medical institutes to nonmedical applicants. This has, however, resulted in competition between medical and nonmedical (Division 39) institutes in the same community. However, general relations between psychologist and psychiatrist analysts have improved considerably. At the time of submission of this article, some good news is that psychoanalysis has just been approved as a specialty area by the Commission for the Recognition of Specialties and Proficiencies in Professional Psychology and awaits approval of the APA Council. The American Board of Psychoanalysis in Psychology, which is in charge of the examination process, was established in 1983 as Division 39’s liaison to the American Board of Professional Psychology. They report that there are currently 65 Diplomates in Psychoanalysis, with 16 or so on the waiting list to be examined.

PEDAGOGICAL STRUGGLE WITHIN PSYCHOLOGY Although the struggle between psychologist psychoanalysts and psychiatrist psychoanalysts appears to have quieted down as a result of the lawsuit settlement and the working through of a number of problems, the major source of opposition to psychoanalysis appears to come from academic psychology (Eysenck, 1985). Many schools do not offer psychoanalytic courses, engage in what is commonly known in psychoanalytic circles as “Freud bashing,” and their psychodynamic programs attempt to avoid actual psychoanalysis. Few universities appear to be friendly to psychoanalysis, and many universities do not acknowledge contributions made by psychoanalysis or acknowledge that it is a serious body of knowledge. Students have distorted ideas and hold misconceptions about Freud and psychoanalysis. Authors of textbooks or chapters in textbooks that have positive things to say about psychoanalysis have their books or chapters rejected or their titles changed (to omit any mention of psychoanalysis) by publishers, who encourage them to remove positive comments or tone them down. Burstein (1995), a Tennessee psychologist, talks about the recent difficulties within the domain of academia: Interest of graduate programs in clinical psychology in students with psychoanalytic interest is on the decline and I would predict that the difficulty that psychoanalytic institutes are experiencing in recruiting top quality physician candidates will soon be or is already mirrored in a decline in the numbers and quality of clinical psychology candidates. . . . Further, despite the increased openness by some psychoanalytic institutes to the training of individuals who are not physicians, my informal contacts with students give me the impression that fewer and fewer of them are considering institute training.

He offers four reasons for the lack of growth of psychoanalytic models in American universities: the antipathy of academic psychology, the valorization of the experimental model, changes in the mental health market place, and the political climate in academic psychology. What Burstein (1995) had to say is interesting in light of the recommendation of many psychoanalysts that psychoanalysis should be taught in the universities. It is difficult enough to get a university to offer an unbiased course in psychoanalysis, so the prospect of a department of psychoanalysis appears to be, at this time, a fantasy. London College and Hebrew University have had professors of psychoanalysis (Joseph Sandler and Sidney Blatt), and the University of Tennessee and Nova

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Southeastern University have had psychoanalytic scholars in residence (Harold Fine and Robert C. Lane). In addition, three schools have postdoctoral institutes in psychoanalysis (Adelphi University, New York University, and Nova Southeastern University), and two centers have postdoctoral programs in psychoanalytic psychology (Austin Riggs, located in Stockbridge, MA, and The Traumatic Stress Institute for Adult and Adolescent Psychotherapy in South Windsor, CT). The University of Southern California offered a PhD in Mental Health (a degree with a psychoanalytic emphasis), but this degree was discontinued after 13 years. A proposed PhD in Psychoanalysis at the University of Chicago offered by the Chicago Psychoanalytic Institute was vetoed by the APsaA; however, the Southern California Psychoanalytic Institute and the Newport Psychoanalytic Institute offer a PhD in Psychoanalysis. Several additional institutes have entertained discussion of offering a PhD in Psychoanalysis, and it is hoped that these will become a reality in the near future. Although the universities have not been very active in encouraging psychoanalysis, the APsaA’s institutes in California have been and are training researchers from the universities. Psychoanalysis was legitimized by the State of California in 1977 with the passage of the state’s Research Psychoanalyst’s Law (Research Psychoanalysts, California Business and Professions Code, Division 2, Chapter 5.1., Sections 2529–2530). This law permits the APsaA’s four California Institutes (Los Angeles, San Diego, San Francisco, and Southern California) to train analysts for the purposes of “teaching, training or research.” The research graduates of these institutes are then permitted to call themselves psychoanalysts and to practice the profession of psychoanalysis (Loewenberg, 1996). The four California institutes, particularly the Southern California Psychoanalytic Institute, have been most active in training university research scholars. The Southern California Psychoanalytic Institute, supported by the Eisenstein/ Gabe Research Training Fellowship Fund, has had a very successful research training program for over 30 years and has trained some 32 academic researchers from University of California at Los Angeles (UCLA), University of Southern California (USC), and Cal Tech who have completed or are in the process of completing their psychoanalytic training. The Los Angeles Psychoanalytic Society and Institute has graduated or is currently training more than a dozen researchers from UCLA and USC, and the San Francisco Institute has trained or is training at least 10 researchers. The San Diego Institute is also training a number of researchers. These research graduates with clinical experience teach in the humanities, social sciences, and other areas; at California universities and other universities; participate in conferences; and spread positive thinking about psychoanalysis (Loewenberg, 1996).

THE NEED FOR INTEGRATION: STRUCTURAL AND RELATIONAL THEORIES Psychoanalytic models of the mind and theories of personality can be classified into two main groups: those that emphasize nature as the primary influence on behavior and those that emphasize nurture. Those theories that regard the role of the innate and personal history as being of primary importance in an understanding of the human condition are traditional Freudian theory, id and ego psychology, developmental theory, and contemporary structural theory. The object relational, interpersonal, self psychological, and contemporary relational theories posit that the role of environmental influences, and current patterns of interaction, are the fundamental means by which one may understand the human experience.

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The current debate between structural and relational psychoanalytic thinkers is a volatile and important one. Its resolution is necessary for psychoanalytic theory to advance as a (relatively) unified field of thought, and it will provide for practitioners a much richer and more deeply explanatory working hypothesis. To date, the controversy has been largely polarizing, with the relational theorists minimizing the importance of classical Freudian drive theory. They propose that it places too great an emphasis on biology, natural science, bodily urges, internal structures and the intrapsychic, past relationships, fantasy, conflict, defense mechanisms, and resistance. The relationists generally regard classical psychoanalytic theory as a positivistic, asocial, one-person psychology. They feel that this viewpoint neglects the transferencecountertransference relationship and, by virtue of its focus on conflict, neglects the importance of understanding pathology in terms of deficit, the underdevelopment of psychic structure. The structuralists, on the other hand, argue that the relational theorists have minimized the relevance of Freud’s ideas without having studied the original papers. This, they posit, leads to inaccurate interpretation of Freudian, and therefore structural, theory. These classical theorists also regard the relationists’ emphasis on current reality and on the immediate patient-therapist relationship as distracting from the transference neurosis. They argue that neglecting the importance of the patient’s personal history puts the therapist in danger of ignoring events of subjective significance, which must be worked through if lasting change is to occur. In truth, there are a wide variety of ways in which these two theories legitimately differ on important philosophical points. The relational model emphasizes the interpersonal, the experiential, intersubjectivity, object relations and interaction with the external world, reality and the here-and-now, constructivism, the social environment, and a two-person psychology. Alternatively, the structural theory is based primarily on the Freudian drive model, which concerns itself with the influence of the intrapsychic, the internal determinants, and the role of instinctual drives in the psychology of the individual. In short, the classical theory is generally regarded as a psychology of the private, autonomous self, whereas relational psychology is a more interpersonally focused theory that emphasizes the role of external forces. The basis for the disagreement between these two schools of thought may be traced to fundamental philosophical differences in the ways that the theorists understand human existence. Structural theory proposes that one’s experiential interaction with the world is determined by predisposing innate factors such as the drives, abilities, and shortcomings with which one is born. The relationists, on the other hand, feel that it is the individual’s necessary participation in his or her environment that is responsible for the development of those qualities that are so closely identified with the individual that they appear to be innate (Gill, 1995). It is also important to note that contemporary structuralists understand human experience as a deterministic phenomenon—They perceive the present as being the only possible outcome of the complex web of events that makes up history. As such, they understand behavior and development as being “determined” as the only possible outcome resulting from an infinitely complex variety of causal events. The relationists, on the other hand, argue that humans possess a degree of freedom and that, although the individual’s past is a powerful influence on his or her present condition, it does not exert absolute power over the here-and-now. They value the past for the light that it reflects on the nature of current events in the patient’s life. They contend that the individual is much more independent of the past than the deterministic philosophy of the structuralists will allow. Not surprisingly, the relationists emphasize the current nature of the pa-

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tient’s interpersonal relationships as being the primary agent of therapeutic change, whereas the structuralists emphasize the importance of insight and the understanding of the relationship between past experience and current perception (Gill, 1995). The importance of an awareness of the philosophical differences between the relationists and the structuralists lies not in determining who is right or wrong but in appreciating the contributions of each perspective. These two dichotomous models of the mind are sometimes seen as mutually exclusive, and this attitude discourages movement toward an integrated and complementary perspective with the goal of understanding the human condition. To function effectively as a clinician, one must accept that the dichotomy presently apparent in psychoanalytic theory is a reflection of a dichotomy that exists among all humans. Any theory, be it psychological, psychoanalytic, or otherwise, represents humanity’s attempt to understand an infinitely complicated universe by virtue of our finite minds. To propose that the interpersonal and the intrapsychic are both of momentous value in understanding the human being is no more paradoxical than the proposition that, to develop appropriately, the individual must experience both differentiation and identification. Ideas that seem at first glance to be diametrically opposed are not necessarily mutually exclusive within the realm of the paradox of human experience.

THE FUTURE OF PSYCHOANALYSIS1 The most dangerous threat to any philosophical system is that it will become rigid, static, and reactionary—an ideology. In an attempt to avert the withering of the vine of psychoanalytic thought, there are a significant number of theorists who propose to prune the branches that remain distinctly Freudian. In this case, Freud’s ideas are the very soil in which psychoanalysis grows—To abandon Freud would be to unearth psychoanalysis and leave it fallow. Freud exists as the eternal father for psychoanalysis. His theories changed the way a world thought about itself. As is the case with all humans, Freud was fallible and finite; he was subject to many of the prejudices of the epoch in which he lived and to the limits of his gender, his social caste, and his religion. Just as children must come to accept the mortality of their parents, modern-day thinkers face the task of accepting the reality of Freud’s personal and philosophical imperfections. The healthy adult child does not reject his or her parents but has separated and differentiated with an appreciation of his or her parents’ profound influence on his or her identity. Psychoanalytic theorists have, over the past 50 years or so, become increasingly reluctant to acknowledge their “father,” instead preferring to put him aside, relegate his influence to history, and establish separate schools of thought that, they purport, are effectually independent of Freudian influence. This phenomenon is, again, analogous to the rebellion of a child against his or her parents as he or she seeks an identity; complete rejection and attempted negation of the influence of the parents is, by definition, delusional—Even if all ties are severed, their influence is immutably interwoven into their offspring’s psyche. A healthy, mature identity is established via incorporation as well as differentiation, and intellectual independence cannot be achieved by denying the foundation of one’s philosophy. Abandoning and ignoring the past seldom induces

1We

extend thanks to Jacob Gelles for contributing several points to this section.

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growth; it merely ensures that the contributions of our forefathers (and foremothers) will have to be rediscovered and that mistakes previously made will be repeated. Although psychoanalysis is a philosophical system that has a life of its own, and is not Freud’s child, his thinking forms the basis for current and future exploration (in its current state, the field might more aptly be considered his great grandchild). The contention that Freud’s ideas are no longer of significance is a call for the removal of the cornerstone of psychoanalytic thought—Without it, the whole edifice is weakened, perhaps fatally. Further weakening the psychoanalytic structure is the widespread tendency of professionals to demonstrate a primary loyalty to their particular subdivision of psychoanalytic theory but only a secondary allegiance to the field itself (Richards, 1990). Drive theorists, structuralists, ego psychologists, object relations theorists, relationists, interpersonal psychologists, self psychologists, and Lacanians will debate vehemently amongst themselves the question of psychoanalytic truth. The infighting that currently exists within the field of psychoanalysis seems to have more to do with a need for identity and individuality than intellectual idealism. In actuality, the apparently irreconcilable differences between, for example, self psychology and object relations psychology may be more semantic than theoretical. This is not to suggest that genuine controversy does not exist between perspectives; it does indeed exist and is necessary for the health of the field. Nevertheless, the passion with which subtle theoretical differences are defended and attacked, and the stubborn allegiance to subdisciplines, suggests an emotional basis (rather than a theoretical or intellectual one) for the behavior. Indeed, the fact is that both the field of psychoanalysis in general and our patients in particular stand to profit more from healthy debate within an integrated discipline than from bitter and divisive infighting between estranged intellectual camps. Related to the need to pursue theory integration is the ever-increasing necessity of establishing empirical evidence of the effectiveness of psychoanalysis, both as a method of treatment and as a means of understanding human development and behavior. The animosity suffered at the hands of much of academia is perhaps well deserved; we, as a field, profess to be a science rather than a philosophy, and as such we must endeavor to provide empirical support for our ideas (Kernberg, 1993). Although this issue has long been an important theoretical one, the recent proliferation of managed care has made it a practical issue as well. If we as psychoanalysts or psychodynamic practitioners hope to maintain a productive relationship with clients who are represented by their respective managed care organizations, the necessity of proof of the effectiveness of our method is appropriately thrust upon us. Another important issue facing the field is whether there will be enough future interest in psychoanalysis to accommodate all the training institutes that are cropping up. Where there is a choice of institute, APsaA or Division 39, psychologists may favor the medical institute over the psychologically operated institute, although the reverse may also become the case. Whereas gatekeeping and control of the psychoanalytic turf for more than 50 years by the APsaA seems to have come to an end, medical analysts fear that there will be a dilution of purity in the field, an elimination of standards, and an erosion of excellence accompanying the loss of the medical identity and model (Kirsner, 1990, p. 176). There is a fear that, with the drop in medical enrollment and the admission of nonmedical applicants, the field will eventually become a nonmedical specialty (Cooper, 1990, p. 185). Cooper pointed out that the demedicalization of psychoanalysis has led to a significant decline in medical applications to psychoanalytic institutes.

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The APsaA is already offering membership to qualified Consortium members of the four American institutes accepted by the IPA. Cooper, as well as other medical analysts, is concerned with a loss in status and prestige. The decline in referrals to medical analysts (Kirsner, 1990, p. 184) is attributed to the economic conditions, the prospect of managed care, and the increase in health maintenance organizations with their limited sessions. Alternative therapies, psychopharmacological advances, a greater number of nonmedical analysts willing to see patients at lower fees, and an increase in analytic practitioners without a corresponding increase in the patient pool also contribute to a decline in medical referrals. Among the internal factors, Kirsner (1990, p. 185) included an erosion in the excellence of instructors, a lack of follow-up on research studies, and poor affiliation and interaction with universities and medical schools. Others emphasize too great an obsession with the ceremonious, ritualistic, and the orthodox; a poor image; and difficulty in differentiating psychoanalysis from psychotherapy. Margolis (1997), the president of the APsaA, told us that there has been a steady decline in analytic patients with a general decrease of 1% yearly. Later in his paper, he spoke specifically about psychoanalysis in Michigan and outlined steps that have not only maintained patient loads but have actually increased their numbers (yielding an average of 6.5 patients and two thirds of clinical time spent on analysis, as opposed to 4 patients and less than half of the time spent in analytic work). The mean of 4 analytic patients is influenced by the 5.5 patients and 24 hr of analysis performed by training analysts; without including these figures, the averages drop significantly. Psychoanalysis seems to be moving toward becoming a part-time vocation. The number of child analytic cases has dropped to less than one per week. These factors add up to demoralization, decreased attractiveness, and general disillusionment with the field. Margolis referred to analysts as having been aloof, elitist, rigid, and not open to contemporary thinking as well as being members of a guild that has attempted to control the market. This perception of psychoanalysis has not increased acceptance of psychoanalysis on the local, community level. There is also concern that, with the loss of status, outstanding young medical students will not choose to pursue psychoanalysis (Cooper, 1990). Those medical analysts who feel that traditional analysis is on its way out point out the need for the emergence of new forms of analysis. The increased importance of the IPA brings the fear that there will be increased interest in Kleinian models of the mind (the Europeanization of American psychoanalysis; Cooper, 1990). Another concern of American medical analysts is that deviations from the classical model will lead away from psychoanalysis and toward psychotherapy. Still another fear concerns the “feminization of psychoanalysis” (Cooper, 1990, p. 185; Lax, 1993). As the potential applicant pool is “significantly more female,” and “women do not receive equal pay or equal rewards” (p. 185), there is concern over a diminution of status. Already, the ratio of female to male applicants in psychology doctoral programs is running greater than 3 to 1. Sometimes, advanced psychology classes consist of only women. With the number of men entering doctoral programs decreasing at the present rate, some understanding of what is happening in the field appears necessary. Michels (1988) predicted the emergence of new methods allowing us to progress well beyond current knowledge in the next era of psychoanalysis; the development of new ideas and knowledge certainly appears to be in order. Michels (1988, pp. 177– 178) pointed out that the profession places greater emphasis on “preserving knowl-

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edge and training practitioners” than in developing new ideas. Kirsner (1990, p. 187) said, “Now is a good time for analysts in America to look afresh at what is special to their science, at what goes beyond the epiphenomena—the setting, the trappings and the external paraphernalia.” With managed care hanging over our heads and health maintenance organizations and preferred provider organizations limiting visitations and refusing to pay for analysis, we must concern ourselves with things other than differentiating psychoanalysis from psychotherapy—whether or not the couch should be used, the frequency of visits, how much the analyst says during an hour, or whether he or she should be a blank screen or a mirror? Margolis (1997) pointed out the need for change in the APsaA in the direction of becoming more credible and improving its image. He recommended the participation of all APsaA members in discussion and decision making, that candidates should be empowered in governance, the taking in of students as society members, and that evaluation should be constantly monitored. Greater participation on the candidates’ part promotes deidealization, discourages infantilization, and encourages growth and maturity in general. Margolis recommended more scientific programs and programs for the general public, a marked effort to work with the local community, and participation on the health-care front, particularly in debates over the role of managed care. In an attempt at democratization at a national level, the APsaA, with its 41 societies and 29 institutes, has appointed 70 committees with the intention of studying all psychoanalytic concerns and interactions with the community. As previously mentioned, the APsaA has opened it ranks to members of the IPA, invited others to join, and is negotiating with different societies for forums intended to foster the appreciation of differences. In general, the APsaA is working toward becoming less exclusive and is striving to welcome more diverse, nonmedical candidates to study at their institutes. Margolis addressed our need to move from an avoidance of a prominent profile in the interest of analytic anonymity to actively reaching out to all elements and joining in community improvement. He also recommended the establishment of centers, clinics, homes for institutes, and societal and candidate organizations as forums for education and the fostering of independence and creativity. These sites would encourage joint efforts with the local community to address major issues such as problems of addiction, sexual abuse, and violence. Margolis concluded that the community, on a local as well as a national level, must be convinced that the profession of psychoanalysis represents an ally rather than an enemy; that we can work as partners in cooperative community endeavors to improve mental health; and that we are approachable, interested, and cooperative. Innovations in training have been influenced by new schools of thought, new ways of looking at education, the economic situation, what insurance companies and thirdparty payers are willing to consider (Meisels & Shapiro, 1990), and the postmodern era. With the advent of managed care, the entire concept of treatment will have to be restudied and re-evaluated. Kavanaugh (1995b), from whom we have taken the liberty to quote frequently in this work, had the following to say: The monolithic view of psychoanalysis . . . has been disappearing, if not disintegrating, as a plurality of heterogenous theories have been making their appearance in contemporary psychoanalytic thinking. Theoretical pluralism at least for the time being has been accommodated, if not appropriated, through innovations within the traditional institutional structure and educational curriculum. Clearly, it would seem, the re-thinking of what is meant by “psychoanalytic education,” itself, as process, as method, and as objective would constitute a major and ongoing postmodern project. (p. 14)

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Ester Shapiro (1990), in her concluding chapter on the future of psychoanalytic education, had the following to say: The future of psychoanalytic education will best be served by the exploration of varieties of educational alternatives, rather than rigid reliance on one particular training format. In spite of very different institutional forms, each psychoanalytic educational community has to struggle to arrive at its own balance between structural requirements and the flexibility of independent study, between adherence to existing traditions and creation of new apparatus. (p. 283)

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