I'm a psychoanalyst. So it was with great interest that I read Daphne Merkin's New York Times Magazine article about her forty-year history of psychoanalysis and psychoanalytic psychotherapy. Merkin is a terrific writer, a brave observer of her inner life, and a lively critic of the professional cultures devoted to studying and healing inner lives. She found the New York psychoanalytic culture reassuring, even if not always helpful. She says:
"...aside from the fact that the unconscious plays strange tricks and that the past stalks the present.....[there is] a certain language, a certain style of thinking that, in its capacity to reframe your life story, becomes--how should I put this?--addictive....Whether [it does] so rightly or wrongly is almost besides the point."
For decades I've heard that it doesn't matter what theory a therapist holds, what his or her formulation about the patient might be. What matters, the cliché goes, is simply the presence of an attentive relationship. Merkin's variation on this theme is that her idealization of her analysts' wisdom and the rhythms and imagery of a psychoanalytic conversation have been more comforting than anything she's been offered in the way of interpretation and insight. The process, in other words, was more important than the content or outcome.
Now, my psychoanalyst colleagues certainly don't think this is true. It's important to them -- to us -- that our very extensive training (6 - 8 years after we get our professional degrees) has given us access to a special knowledge (transference, unconscious conflict, defenses, primitive mental states, etc.) about the human psyche that is vital to the success of our treatment. Unfortunately, psychoanalysis has unwittingly colluded with the caricature that its practitioners don't really help their patients, but instead foster 40-year treatments more akin to addictions than cures. I thought that Merkin's essay hoisted us on our own petard. And this petard is a big reason why I left organized psychoanalysis.
When I read Merkin's essay, I thought back to Janet Malcolm's New Yorker articles, often biting accounts of psychoanalytic politics and the insularity of the analytic establishment. Perhaps the most embarrassing story in Malcolm's articles was the description by a young analyst, Dr. Aaron Green, of his own 15-year analysis in which he described uncovering the core of his psyche, namely his secret wish to be a beautiful woman. Whether or not Green was any healthier at the end of his treatment was apparently beside the point.
Since the days of Freud, psychoanalysts have been ambivalent about helping people, or at least about defining their treatment as primarily designed to relieve patients' suffering. Too often my colleagues have privileged understanding over curing. They have historically shunned or attempted to excommunicate practitioners and theorists (e.g. Franz Alexander, Joseph Weiss) who have advocated more activist techniques (e.g. "corrective emotional experiences") that might promise more effectiveness. They have denounced analysts who show too much explicit desire to help patients cure their symptoms, pathologizing such desire as an unfortunate "therapeutic zeal."
In case conference after case conference, analysts still tend to focus on the vicissitudes of technique and rarely query the presenters about whether their patient is getting better or not. In fact, analysts often question treatments in which patients get better too quickly, suggesting that the patient might be "fleeing" into health, complying with the analyst, or simply building better defenses. In recent decades many analysts have embraced the work of the British analyst, Wilfred Bion, who once said that the analyst should approach each session "without memory or desire," the most problematic desire being the wish to help or cure the patient.
I suppose that I'm one of those culprits with too much "therapeutic zeal." It was a passion that was consistently devalued in the psychoanalytic culture in which I was raised. If, as Merkin says, she could never bring herself to view analysts as service providers -- to be evaluated, therefore, on the basis of results -- it was and is equally true of many psychoanalysts. This reluctance not only makes us vulnerable to all of the Woody Allen-esque caricatures of our work, it is also corrupt, self-deceiving, and unethical. With all the hubbub at psychoanalytic institutes about "boundary violations," analysts sleeping with their patients, the most profound and dangerous ethical violation psychoanalysts routinely commit is their inability to sufficiently help their patients and their almost-principled denial of the harm inherent in this fact.
My own experience is that when theory is divorced from practice, or, in this case, divorced from therapeutic outcome, that theory becomes either more obtuse or self-referential. Either way it fails to serve the patient. I repeatedly saw and experienced both of these tendencies. First, during the 1990s there was a turn toward philosophy, with analysts galore getting on the post-modern bandwagon arguing that there is no such thing as "truth" in analysis, that interpretations can't be judged right or wrong, but instead somehow emerge from the mysterious ether of co-construction. And second, I've witnessed a growing theoretical turn in analysis toward a search for inspiration from colleagues in Europe and South America -- Italian post-modernists, Argentine Kleinians, and British middle-school'ers and Bionians. A key emphasis within these traditions is the notion that the analyst understands what's most important about a patient through his or her (the analyst's) own self-reflection, that the analyst reads the counter-transference as a text in which he finds the most vital meanings and communications of the patient.
These were just a couple of the trends that led me to leave the organized psychoanalytic community in which I trained and practiced. The post-modern philosophical tendency seems to me to glamorize not-knowing, while its nod to philosophy reinstates us as intellectuals. It is certainly something that you certainly couldn't reveal to your patients who are spending a lot of money and effort to get the benefits of your expertise. And the move toward making the analyst's own psyche so important takes us further away from a focus on the patient's welfare. I'm sometimes tempted to sarcastically ask: Doesn't the real patient occasionally get in the way of your self-examination?
Post-modern uncertainty undermines the legitimate authority of the analyst as a healer who knows what he or she is doing and in whom the patient legitimately invests money and hope. The argument that we don't know if we're "right" or "wrong" is silly to me. If we're on the right track, the patient generally improves, either symptomatically or in his or her ability to take on certain emotional and developmental challenges. To ignore therapeutic improvement as the one relevant barometer of the validity of our theories is nihilistic and self-paralyzing. Furthermore, while self-reflection and the counter-transference is important in what we know about the patient, it is not the Rosetta stone. It may or may not have anything to do with the patient. It can take us further away from studying the actual observable markers in the patient's behavior, affect, and speech that are usually more reliable guides to the accuracy of our hypotheses. And it mystifies the nature of the mind and the process of change by wrapping us and the job we do in a false and narcissistic flag of intellectual complexity.
As a mentor of mine, Owen Renik, has written, we need a "practical psychoanalysis." We need one focused primarily and consistently on helping the patient get better. And our efforts ought to be oriented to clarifying and simplifying this process, not making it more arcane. Some treatments might take a long time, but there has to be an end point. Without it, psychoanalysis becomes either a church or a foil for a New York Times Magazine article.
When someone says: "I want results" I ask the definition of "results". If it means, quick reduction in symptoms, generally less anxiety/depression, in the short-term, then "evidence-based treatments" (medications, CBT, etc.) are generally quite successful. But it is relatively "provider-driven" (ie, the doctor/therapist gives meds, homework assignments, gives the structure, and helps the client/patient define clear goals, generally behavioral goals). If one wants a more open-ended, exploratory and informed "conversational" type of therapy where the client takes more of a lead, then psychoanalysis is more appropriate. Interestingly, there is much current research that psychoanalysis also gives concrete "results."
HOWEVER, it is rare to see anyone asking the client/pt/"consumer" what they want, what they mean by results, and what methods they prefer, since so many other parties (insurance, psychotherapists themselves, training programs, etc.)have a financial, ideological and emotional stake in the process.
There is no reason to make black and white distinctions between "psychoanalysis" and CBT/evidenced based, etc. This is more a political issue than a scientific one. Good therapists generally combine approaches and tailor the therapy to the pt/client/customer.
I wonder in the original NYTimes article, what the client "wanted" rather than a discussion of what she "got."
The problem I see, however, is that the dichotomy he draws between insight/understanding on the one hand and clinical practice on the other strikes me as false. I am a psychoanalyst who routinely uses countertransference, notions of intersubjectivity and relationality, and so forth, not to be smart (although that's nice if it happens), but because my training and personality resonate with them in the service of the patient. I suspect other practitioners feel similarly.
Too often postmodernism is used to discredit a truth that is far older than that movement: that subjective experience is "impossible" for the other to fully know. Freud knew this, as did Kant. I don't need external authority to confirm anything right or wrong. All that matters to me is that my patients and I get it mostly right. And whether that means understanding something or relieving symptoms doesn't really matter. Analysis can handle both as the need arises.
Regarding training, there are probably no mental health practitioners available with as much training and supervised clinical work as psychoanalysts. The strongest argument for this training is that these psychoanalytic clinicians are less likely to make the common mistakes that occur in clinical treatments--mistakes that cost patients time or result in avoidable complications. Interested individuals would can find accurate information about the indications for and availability of psychoanalytic treatments at the web site of the American Psychoanalytic Association, http://www.apsa.org/.
---
The whole point of Merkin's article is that taking the psychoanalytic road has apparently cost her all kinds of time - time she might have saved using some other approaches to deal with her very real suffering.
It makes sense to put some sort of a time limit on any modality. If there's no real change in some reasonable period of time, then try something else - something different.
But to continue trudging on an interminable road for 40 years? What a waste of time and money that would be for anyone!
Recently I lost my son, my only child. Since I am battling with overwhelming, yet normal, grief I set out to find help. There is no cure for what ails me, except time (I hope!). I was shocked by the 5 therapists I saw for 2 to 10 times. Each one of them focussed on my childhood! My childhood had nothing to do with the accidental death of my 32 year old son! If I hadn't seen 5 different therapists I would have said this stupidity was an exception. Sadly, it has only proven your point: their process was more important than my content.
www.bruisedandbattered.com
If there is no cure, it's just self-absorbed navel-gazing.
And I can do that for nothing at home over a glass (or two) of red.
Someone didn't do their homework it seems...
For the one I'm referring to, google "Le Chatlier Principle Systemantics".
I could not afford many sessions with a psychoanalyst, but these few sessions made me aware of Carl Jung and through reading him I was enabled to pursue self-analysis ... which is surely the crux of the matter, because an analyst can only be a facilitator for an analysand, who cannot be passively healed like someone with a broken leg, for instance. He or she must actively participate.
In any event there is no question of it that the self-understandings I developed have got me through some very bad times and, in complementary fashion, have enabled me to recognize harmful people, notably through understanding "the psychology of the tranference" and projection (the common ascription of faults in someone else to oneself).
A problem is that - especially those with paranoid tendencies - people with manifest destructive traits will never go near a psychoanalyst, let alone self-examination ... well can you imagine GWB and Cheney delving within?
I'll leave it a that and let the article speak for itself ... just thought I'd add some personal experience, including that I didn't just rely on Jung and I am not a "Jungian". But to explain further would run way overlength.
generalizations. Then i decided, what's the point; no doubt doctors in NY will write to the NYT
and set it all right. Then, along you come. I think you are about as all-wet as Ms. Merkin is
neurotic -- i. e. very much! Her article is shot through with unattended acting out and signifiers
of neurotic mis-perception that you do not mention at all or even hint at. I think it is just fine that
you have "left the psychoanalytic community" -- possibly a wise move before they kicked you out?
Most people expect too much of psychoanalysis, and yes the analysts themselves contribute to this, very often. Conventional psychoanalytic theory has been proven very wrong about homosexuality,
for example, and has never quite come clean after their position was shown to be inaccurate and bad medicine. There are many other examples -- but for you, with all your knowledge and qualifications, to hold up Ms Merkin as a paradigm is very bad work indeed!
Even some people with severe mental illness can be better handled if they have people around them who accept who they are and help them to mitigate the damage when the mental illness gets out of control.
You can't "fix" someone who is troubled mentally (anyone who says differently is selling snake oil). You can help them know that at least here is someone who accepts them for who they are and will help them figure out ways to deal with the "Real World".
Our diagnostic culture makes having a "diagnosis" more important than quality of life, because first you MUST have a "diagnosis" before you are allowed to get assistance of any kind.
Helping people feel "better" is fine, be it through a compassionate relationship with an understanding listener and wise counselor, or pharmaceuticals, etc. But how can a psychoanalyst who is true to herself help someone who is seemingly hardwired to avoid philosophical pessimism and nihilism at all costs, no matter how warranted such views may be, get "better"?