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Blog entry for September 17, 2005
We want to support candidates in getting ready to accept their first patients into analysis. In keeping with this goal for the first several weeks, we will continue to examine the question, for whom is psychoanalysis the most efficacious treatment?" And, as importantly, if you feel that analysis is the optimal treatment - how does one make an effective recommendation. Both this week's reading and next week's reflect this focus. In the first reading, Psychoanalysis, Psychoanalytic therapy and Supportive Psychotherapy, Kernberg examines the question of, "what psychoanalytic treatments are appropriate for whom"? In next week's reading, "A perspective on doing a consultation and making the recommendation of the Recommendation of Analysis to a Prospective Analysand", Rothstein renders an alternate viewpoint.
According to Kernberg there are a myriad of conceptual, clinical, educational and political controversies as to how one might differentiate between psychoanalysis, psychoanalytic therapy and supportive therapy. He confines his focus to the first three concerns.
Kernberg asserts that there are commonalities across the ego-psychological, Kleinian, British independent and French Schools approaches. These include: a primary focus on the analysis of transference, being aware of pathological character formations and focusing on unconscious meanings in the "here and now". Beyond this, he feels that there is an increasing emphasis on countertransference analysis and on the patient's affective or emotional state as a portal of entry to exploring unconscious meanings. Also, he adds the intersubjective and interpersonal psychoanalytic approaches, including self psychology, have had an impact, noting that they require a focus on the relationship between patient and analyst. In these approaches, the patient's growth is contingent on the integration of new affective or emotional interpersonal experiences.
He seems to be saying that there are a diversity of psychoanalytic theories. And, while they share some commonalities - because of their differences, it's extremely difficult to differentiate between psychoanalysis, psychoanalytic therapy and supportive therapy. He seems to imply that he views some of the modern day psychoanalytic theories as more "psychotherapy-like" than psychoanalysis-like.
And so, with a nod to the North, a nod to the East, a nod to the South and a nod to the West, he dispenses with the preamble and gets to the fundamental purpose of his paper - which is, difficult as these differentiations may be, he believes that they should be made - and, he's going to make them. So, here he goes. Let's see what he has to say.
According to Kernberg, in order to differentiate these three modalities one distinguish theory of treatment from the objectives of treatment. Also, one must separate the techniques used from the "resulting process". Regarding objectives he distinguishes between the three modalities.
The aim of psychoanalysis, he tells us, is to "structural change". The goal is to make the unconscious conscious and to alter the relationship between the psychic structures (id, ego, superego). The individual is helped to become aware of those warded off parts of himself so that they can be successfully reintegrated into a more, mature, adult ego.
Undoubtedly, this sounds familiar. It harkens us back to the Jacobs article from last week. These sound like the very traditional analytic goals that Jacobs describes. Jacobs as you recall, thought that these goals were necessary but not sufficient. Jacobs expanded these goals to include what he thought to be - the very important goal - of helping the patient to make significant life changes. When you read the Rothstein article, note too, that Rothstein has a broader view of what constitutes psychoanalysis, and, as we shall come to read, who can be analyzed. But, I am getting a bit ahead of myself.
For Kernberg, the objective of expressive or psychoanalytic psychotherapy is "partial reorganization of the psychic structure" in tandem with symptom belief.
Finally, the objective of supportive therapy is symptomatic relief along with some altering in what he calls "defense/impulse" configurations.
For Kernberg, because these modalities overlap they can not be differentiated based on their objectives. Instead, he differentiates them based on their technical approaches. For Kernberg psychoanalysis is distinguished by three features: interpretation, analysis of the transference and technical neutrality. He says that these are the three essential ingredients of the psychoanalytic method. Before addressing these three critical ingredients, he proposes that these three features bring about a regressive transference neurosis - which, in turn, "reproduces in the psychoanalytic situation the pathogenic, unconscious impulse - defense configurations dominant in the patient's psychopathology". Beyond this, in an effort to be inclusive he talks about internalized object relations, unconscious, infantile, sexual and aggressive conflicts, oedipal dynamics, castration anxiety, not to mention, (with a nod to the French) the linking of archaic Oedipal and preoedipal issues
Next, he describes these three ingredients.
Interpretation
For him, interpretation includes three features: clarification, confrontation and interpretation. First, he clarifies the patient's conscious and preconscious experience. Next, he confronts, tactfully focusing on the verbal and non-verbal behavior Ð that goes in tandem with the free association. Then, he interprets the unconscious meaning of what has been said and understood in "the here and now" linking it to "there and then".
Transference analysis
For Kernberg, the analysis of the transference is a cardinal feature by which he differentiates analysis from psychoanalytic and supportive psychotherapy. Analysis of the transference must systematically be carried out. He notes that the idea developmental conflicts will emerge in a linear fashion is antiquated.
Technical neutrality
For him, this means that in making interpretations, the analyst remains equidistant from the id, the ego and the superego, not privileging one over the other. Transference is highlighted so that the patient can experience the gap between the straightforward initial treatment arrangement and the maelstrom of chaotic feelings that they are now experiencing.
He notes that "free association" is a crucial feature in both psychoanalysis and psychoanalytic psychotherapy. And, he adds that most analysts think that analysis should be carried out at a frequency of at least three or four times a week, though he doesn't agree that frequency is a defining feature of psychoanalysis. Similarly, he asserts that many see the couch as a sine qua non of analysis; but, he does not.
Transference analysis
In psychotherapy (with more troubled patients - whom he would not treat in analysis), transference analysis plays an important role from the outset of treatment. But, it must be done in tandem with an in depth exploration of the patient's daily life situation. He feels that this is essential in order to address the propensity for splitting and acting-out inside and outside of the treatment situation.
Technical neutrality
Although he feels this is essential to the work, he recognizes that with severely characterologically impaired patients - it must be abandonned in the service of the patient's safety. Limits must be set. However, subsequently the analyst must analyze the situation that precipitated the need to set limits. Next, the analyst must analyze the impact of the limit setting on the patient's experience. Ideally, over time, (as the patient gets healthier), it is optimal to use interpretation rather than limit-setting.
He feels that a frequency of two to four sessions is essential. Otherwise, one onlly hears the weekly accounting of daily events or the analysis of the transference. But, the two are not integrated and this can lead to the splitting off of important events in the patient's life - and, can lead to acting-out. He feels that sessions should be face-to-face so that the patient's non-verbal behavior (which is a significant feature in more disturbed patients) can be highlighted. For him, treatment should focus on three things: (1) free association; (2) non-verbal communication; (3) the therapist's countertransference reaction. The analyst should use these three sources of information to corroborate each other - and, should make his interpretation based on this information.
For Kernberg, psychotherapy uses analytic technique to modify unconscious conflicts, with some modifications that are spelled out in advance. Importantly, therapy attends to the patients day to day relationships. Also, the analyst attends to the vulnerability of these patients to use treatment as a way to avoid life.
Interpretation
According to Kernberg, supportive therapy, does not use interpretation. Rather, it uses clarification and confrontation with the aim of supportive more adaptive compromise formations. It entails support, reassurance, and working with relatives and other supportive agencies.
Transference
Transference is not interpreted. But, it is not ignored. Rather, the analyst attends to the transference, using it to point out and confront pathological behavior in the hour, and, to relate this behavior to the patient's behavior in the world.
Technical Neutrality
Technical neutrality is abandonned.
He sees psychoanalysis as the treatment of choice for neurotics and for some kinds of character pathology. For those with more severe character pathology, particularly those prone to acting-out, he sees psychoanalytic psychotherapy as the appropriate treatment. When these treatments are contra-indicated, supportive therapy is the treatment of choice.
He argues that while some will say that conducting a structural interview and making a psychiatric diagnosis limits exploration, he feels that it provides the analyst with a richer more in depth picture of the patient's pathology. This knowledge can be quite useful later in analysis when the analyst attempts to relate the unconscious present to the unconscious past.
He raises the question as to whether psychoanalytic psychotherapy should be taught to candidates and/or to non-candidates.
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