Psychoanalysis - today

It is common to imagine a psychoanalyst as a serious-looking person who listens to patients lying on a couch and carefully interprets their dreams and fantasies. The film industry, however, has long since done away with this cliché. In the cinema, Freud's grandchildren are often portrayed as ridiculous, dangerous or pitiable figures. Just think of Hannibal Lecter, the snarling psychopath from The Silence of the Lambs, or Dr. Fritz Fassbender from the Woody Allen film What's New, Pussy? who likes to chase female patients around the treatment room.

The most recent example is Dr. Henry Carter from the film Shrink, which was released in summer 2009. The shrink, played by Kevin Spacey, doesn't shave, sleeps in his clothes and is befuddled by hash most of the time. The blank stare with which he observes his patients is not a therapeutic technique, not an expression of professional neutrality, but a genuine indifference that has afflicted the celebrity therapist after the death of his wife. As a result, the patients seem to benefit little from his half-hearted attempts at interpretation. But in a city like Los Angeles, the psychiatrist's peculiarity is hardly noticeable. To his clients, he is an eccentric genius who uses his own emotional confusion and inner emptiness as a radical technique to cure their neuroses.

No one would suggest that a movie like Shrink paints a realistic picture of today's psychoanalytic practice. There is no doubt that techniques and approaches have changed enormously since Freud's day. But what really goes on in psychoanalysts' practices? How does treatment today differ from treatment 20, 50 or even 100 years ago? Does psychoanalytic therapy still exist at all? These are questions that analysts also ask themselves. The International Psychoanalytical Association (IPA), the world association of the profession with 12,000 members around the world, has therefore chosen "Convergences and divergences in psychoanalytic practice" as the theme of this year's congress. Around 2000 representatives of the profession gathered in Chicago at the end of July 2009.

COMMUNICATION PROBLEMS

Surprisingly, communication about psychoanalytic work does not seem to be so easy. In the opening lectures, there was initially a lot of talk about communication problems and other hurdles. Juan Pablo Jiménez, psychoanalyst and professor of psychiatry at the University of Chile, emphasized the difficulties of gaining reliable access to what psychoanalysts actually do in the intimacy of the therapeutic relationship. In his experience, many analysts prefer to talk about theoretical rather than practical issues and like to present their practice in an idealized way so that it fits into predetermined categories, preferred theories or the thinking of the fashionable author.

The American analyst and psychiatrist Warren Poland painted an even more critical picture of the psychoanalytic culture of conversation: "As clinicians, we spend a lifetime listening to our patients. It's all the more shocking how badly we listen to each other." According to Poland, this is partly due to human weaknesses that can be observed in all professional and academic circles: Rivalry, vanity, the desire to distinguish oneself. In addition, the exchange between analysts is made more difficult by the unusual nature of the work. All too easily, analysts forget to leave the asymmetry of the analytical partnership behind in the treatment room and, in discussions with colleagues, retreat to "that feeling of superiority that can be associated with the interpretative position".

THE "BALKANIZATION" OF PSYCHOANALYSIS

In addition, there is the notorious fragmentation into numerous schools, which began in the early days of psychoanalysis and has not abated to this day. This shows how lively the discipline still is, but also brings with it difficulties in the form of misunderstandings and hostility, as Poland emphasized: "Fortunately, despite our difficulties, analytical thinking is flourishing; new ideas are making a name for themselves and psychoanalytical journals are flourishing. But although there is a certain amount of cross-fertilization, it cannot be denied that the diversity brings with it a 'Balkanization', a division into ever smaller and even hostile sects."

Different schools mean specialized journals - which publish articles by members of one group but not those of other groups - different vocabularies and definitions, which leads to a "degeneration of the common language into provincial dialects" (Poland) and also to conflicting ideas about what an analytical session should look like.

Even if not everyone shared Poland's pessimistic view, there could be no doubt about psychoanalytic plurality itself at the Chicago congress. A glance at the program shows how diversified the field is. One panel compared the clinical approaches of Sigmund Freud and C.G. Jung; another discussed the problem of narcissism in Kleinian thinking. There were sessions on the application of Bion's ideas in the treatment of patients as well as on Lacan and Winnicott. One group dealt with object relations in clinical work; another reflected on the extent to which Ferenczi's idea of the clinical diary plays a role in today's practice.

WHAT CONSTITUTES PSYCHOANALYSIS?

So what constitutes psychoanalytic treatment today? Two of the traditional cornerstones of psychoanalytic treatment are largely undisputed among analysts: firstly, the belief in the existence of the unconscious (although there are differing views on what the unconscious is) and secondly, the postulate of asymmetry in the relationship with the patient, with the analyst taking primary responsibility for what happens in the treatment room. But beyond this, very different ideas have developed about what is important in a session. In Chicago, the Italian analyst Antonino Ferro provided an overview of the spectrum of approaches practiced. According to this, there are differences in terms of

• whether the emphasis is on reconstructing the life story or on making the unconscious conscious,
• the importance attached to the dreamlike in a session (e.g. interpretation of the analysand's dreams using strictly prescribed procedures, concentration on the analyst's fantasies in relation to the events in the analytic relationship, interpretation of the entire session as a dream),
• what reality content is attributed to the patient's messages and what importance is attached to the poles of truth and lies (factual versus inner reality, historical versus "narrative" truth),
• which concept of transference is used (transference as a repetition of what cannot be remembered or as a projection of fantasies into the outside world),
• the level at which interpretations are located and who provides them (reconstructive interpretations of the life story, interpretations of the transference and/or the relationship between analyst and patient, interpretations by the analyst or jointly constructed interpretations).
• Even in the external aspects of the psychoanalytic setting that were once considered almost sacrosanct - the couch and the high frequency of sessions - diversity exists today. While some analysts continue to adhere to recumbent treatment and a four-times-a-week rhythm, others emphasize that even once or twice weekly meetings and a vis-à -vis conversation can provide the depth necessary for analysis.

In view of such a list of different ideas, one can hardly speak of unity in psychoanalytic practice. Almost every analyst seems to have his own style, his own approach and his own ideas. In fact, studies in the 1960s already showed that even experienced psychoanalysts hardly ever reach a reliable agreement regarding the interpretation of complex inner states. These results have been confirmed by more recent studies.

Is this a reason for pessimism or a sign of fruitful change? Should we support or counteract this development? Is it even possible? For Juan Pablo Jiménez, the exuberant diversity of treatment models is the inevitable result of clinical practice itself. In his efforts to maintain the vitality of the analytic situation, the analyst will inevitably modify his technique in an individual way, sometimes deviating considerably from his "standard theory", i.e. from the technique he has internalized as "correct analysis", according to Jiménez' argument: "A lot is practised in the treatment rooms today that does not conform to psychoanalytic rules and standards." From the Chilean's point of view, this is an extremely positive development. He really encouraged his colleagues to separate theory and practice: "Theories often hold us captive and tie us to a certain point of view. We then put patients in shoes that they don't fit into. That's why we have to put the theories aside and open up our practice."

A feeling for the individuality of the patient, their particularities and idiosyncrasies therefore seems to be more important nowadays than adhering to any kind of officially recognized theory. This also includes taking a client's cultural and ethnic background into account. For example, it makes a considerable difference in which country a psychoanalytic couch is located.

CULTURAL ADAPTATIONS

Robert Paul, Dean at Emory University (Atlanta), who is not only an analyst but also a cultural anthropologist, provided vivid examples of how differently psychoanalytic treatment has developed in different countries.

Classical Freudian analytic technique, according to Paul's starting point, is based on the idea of the patient as an autonomous individual whose orientation towards reality must be in tact to such an extent that he can enter into an alliance with the analyst against the neurotic part of his personality. In this concept, healing means the restoration of the analysand as a fully independent person who is able to control impulses and fears so that functioning in the social world can succeed. In order to achieve this, the initially rational, business-like relationship between analyst and client must be allowed to develop into a kind of psychodrama in which the patient's repressed, infantile desires and fears determine what happens and he enters into a confrontation with the analyst about love, rejection, authority and disregard. One of Freud's simplest but most effective techniques for achieving this effect is the use of the couch, on which the patient lies like a helpless, beloved baby on the mother's lap. However, this mother-child-like relationship is not created with the aim of keeping it alive in the long term, Paul emphasized, but rather with the intention of criticizing it through interpretation and thus ultimately strengthening the powers of reason within the patient.

This treatment model - designed for a clientele in a specific social and historical context - cannot be easily transferred to other cultures. Paul drew particular attention to the Asian region:

• In India, for example, the idea of psychoanalysis as a relationship between two independent people with different thoughts, desires and experiences is not easy to convey. Indians generally show a strong bond within the family and other social groups, which is accompanied by a constant exchange of warmth, care and encouragement and an almost symbiotic way of thinking and feeling. In comparison, the interaction of people from Western countries seems to be characterized by a downright lack of closeness, sensitivity, intimacy and emotional exchange. For example, the idea of freeing oneself from the symbiotic entanglement in a family through psychoanalytic treatment, which probably arouses predominantly positive feelings in "Westerners", is likely to cause fear and rejection in Indians.
• In Taiwan, on the other hand, psychoanalysts are confronted with a completely different understanding of authority compared to the West. Paul told of a Western colleague who, while setting up a psychoanalytic training program, repeatedly had to deal with the problem that Taiwanese students insisted that the Western teacher or training analyst should impart his analytic knowledge to them directly and without detours.

The idea that an analysand would associate freely, make discoveries about himself, contradict the analyst or even meet him with hostility made no sense to them. "The high positive value placed on legitimate authority in Chinese-influenced societies," says Paul, "means that Chinese students or analysands tend to revere the teacher or analyst in a way that makes confrontation of the kind expected in a typical Western analysis impossible."

A NEW VIEW OF ROLES

The "export" of psychoanalytic treatment to other cultures was and is therefore accompanied by considerable modifications. But even within the West it is anything but static. Perhaps the most important change is the great importance attached today to the relationship between analyst and client. The shift from a "one-person psychology", in which the analyst's interpretations are central, to a "two-person psychology", in which the interaction and exchange between patient and therapist is the focus, was a recurring theme in Chicago.

"The analyst is no longer seen as the all-knowing therapist, as the one who alone provides the interpretations, while the patient remains uninvolved in the interpretation," explained Gertraud Schlesinger-Kipp, former chair of the German Psychoanalytical Association and now European representative on the IPV Board, in a conversation on the fringes of the conference. "Today, analysis is understood as a joint exploration of the problem, as a reciprocal process." Jiménez also emphasized how much the role of the patient used to be underestimated: "Today, we are much more reserved towards clients and offer our interpretations rather than suggestions. And very often it is the patient who provides new and important interpretations."

The change in understanding also means that the analyst has to bring in their personal experiences and feelings in a completely different way than before. "It doesn't go as far as revealing details from your own life to the patient," says Schlesinger-Kipp. "But if a patient tells me something and a situation with my own daughter comes to mind, for example, then I would ask myself why I have these thoughts, what my feelings have to do with the patient. And I wouldn't communicate the thoughts themselves, but the result of my reflection on them to the patient." Such an approach, she says, would have been unthinkable 20 years ago: "People would have said that it contradicted the analyst's demand for neutrality and abstinence."

PSYCHOANALYSIS UNDER CHANGED CIRCUMSTANCES

What are the triggers for changes like these? On the one hand, they can be understood as a response to social change. At a time when economic restrictions play a major role in the healthcare system and many people are under great time pressure, a long-term and complex treatment approach such as psychoanalysis naturally has a difficult time.

"There is a lively controversial discussion among analysts about the extent to which we need to adapt to these changes and open up our forms of application," says Schlesinger-Kipp. The softening of the postulate of almost daily treatment, for example, represents such an opening.

However, research findings have also contributed to the further development of the discipline. Numerous studies have shown, for example, that the quality of the therapeutic relationship is the most powerful factor for change in all types of therapy. This also applies to psychoanalysis. "From a clinical point of view," says Jiménez, "this means that the techniques and interventions are not effective in and of themselves. Everything we do takes place in relationship and must be seen in relationship."

Psychoanalytic practice is changing and will probably continue to do so in the future. The congress made this impressively clear. There are plenty of interesting opportunities for development. How must psychoanalysis change in order to be compatible with new findings in biology and neuroscience? Is psychoanalytic treatment really so different from what behavioral or cognitive therapists do, for example, and how can the therapeutic approaches be meaningfully combined? Questions such as these, discussed in Chicago in discussion groups and in the corridors, could, for example, lead to a clear opening of psychoanalysis to the outside world.

However the discipline develops, one thing is certain: the typical cliché image of the psychoanalyst has survived once and for all.