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Book Forum: PSYCHOANALYSIS   |    
The Modern Freudians: Contemporary Psychoanalytic Technique
RICHARD D. CHESSICK, M.D., PH.D.
Am J Psychiatry 2000;157:301-302. doi:10.1176/appi.ajp.157.2.301
View Author and Article Information
Evanston, Ill.

edited by Carolyn S. Ellman, Stanley Grand, Mark Silvan, Steven J. Ellman. Northvale, N.J., Jason Aronson, 1998, 306 pp., $40.00 (paper).

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This book comes from a conference presented at New York University in 1996 by the "Freudian faculty of the NYU Post-doctoral Program in Psychotherapy and Psychoanalysis" (p. ix) and is composed of a series of essays by psychologists (and one physician) on various current controversies in psychoanalysis. The stated purpose of the book is to address the fact that "psychoanalysis had changed so much in the last fifty years that members of the faculty had not really defined for themselves or others why they still considered themselves ‘Freudian’ " (p. ix). The lone physician contributor, Dr. Arnold Richards, is the editor of the Journal of the American Psychoanalytic Association and is not a member of the New York University faculty; the chapter titled "From Ego Psychology to Contemporary Conflict Theory: An Historical Overview" by Richards and Arthur Lynch contains some genuinely new material and is the best in the book.

Most of the other chapters go over ground that has been covered extensively in the literature before, but they do it in a way that may be of interest to readers not familiar with contemporary Freudian psychoanalysis. Although all of the contributors identify themselves as Freudians (p. xviii), this should not put off the reader because "modern" Freudian psychoanalysis has evolved a long distance from many of the original concepts of Freudian technique. This is a salutary evolution and indicates that at least in the hands of the psychologists, psychoanalysis is progressing and developing a better and better understanding of its own process and curative factors at work.

The first chapter (by Richards and Lynch) outlines the development of ego psychology and its evolution into conflict theory. Chapter 2 is a review of object relations theory. The final chapter (chapter 13) is a personal note by Martin Bergmann, a rather well-known author, and includes a nice summary of what Freud discovered that is still valid today. The book is divided into five parts, The Evolution of Freudian Thought, The Enduring Legacies, Changing Perspectives on the Therapeutic Relationship, The Difficult Patient, and What Is Unique About Freudian Technique? Summary and Conclusions.

Part 2 (chapters 3, 4, and 5) illustrates the contemporary importance of Freud’s original concepts, including the unconscious, id, ego, transference, resistance, free association, and Oedipus complex, all "still considered crucial by the NYU contemporary Freudians" (p. xxvi). Part 3 (chapters 6, 7, and 8) deals with the thorny contemporary problems involved in separating the transference from the "real relationship" and examines the current movement known as "intersubjectivity." Part 4 (chapters 9, 10, and 11) is clinical and deals with the treatment of the difficult patient. These three chapters will be of special interest to psychiatrists who still practice psychodynamic psychotherapy.

There are clinical pearls scattered throughout the book that will reward the psychodynamic psychiatrist for struggling with some of the more difficult theoretical concepts that are considered. For example, we are reminded of Kris’s claim of "how a person’s unique history infuses the self-image with the important early fantasy. The personal myth is preserved as a ‘treasured possession’ and the person reenacts the repressed fantasy in various aspects of life" (p. 11). More generally, we see how unacceptable wishes of childhood, woven into unconscious fantasies, seek resolution in the present through compromise formations. These fantasies shape our special interests and character traits. So, as Richards and Lynch put it, "Contemporary conflict theory approaches mental life and all psychic phenomena as the expression of intrapsychic forces in conflict and the resulting compromises" (pp. 14–15).

The debate between those analysts who maintain that the interpretation of these conflicts is the main curative factor in psychoanalytic treatment and proponents of the view that the relationship between patient and analyst is the crucial therapeutic factor runs throughout this book and of course is not resolved. However, "There is a central core of theory from Freud to the present with many diverse elaborations. Often, seemingly radical differences among theories diminish in their clinical presentation" (p. 17). The distinction between psychoanalysis and psychoanalytically oriented psychotherapy is not treated as a major one in this book, another reason it will be of interest to psychiatrists who do not practice psychoanalysis but who are psychoanalytically oriented in their therapeutic work. For example, chapter 3 presents a patient who has been seen in "one-and-a-half years of once- and twice-weekly treatment" (p. 53).

Probably the most difficult chapter in the book is that on psychoanalysis and symbolization (chapter 4). Readers unfamiliar with the work of Lacan will have special hardship with this chapter and with some of the prose contained within it, e.g., "Symbolization is a network of self-reflective mediation, and in desymbolization this network has collapsed to a zero point" (p. 93). The author ends the chapter with a summary of Plato’s dialogue Cratylus that he feels is relevant "to the psychoanalytic understanding of symbolization" (p. 95 note), but I think this may lead to even greater confusion because the dialogue is taken out of the context of Plato’s philosophy and placed in an entirely different context.

Among the nice features of the book are the brief overview essays that introduce parts 2, 3, and 4; these help to orient the reader to some rather difficult and controversial material. In chapter 7, Helen Gediman points out that "our present understanding of the therapeutic action of psychoanalysis has evolved significantly into a more broadly based, multiperspectival approach to the psychoanalytic treatment of a widening scope of patients" (p. 141). In chapter 9, Sheldon Bach reminds us, "If we are only able to listen carefully enough, patients will usually prescribe exactly what is necessary for their healing to begin" (p. 191), and he maintains that the Freudian classical method is "the paradigm we strive for with the ideal analytic patient" (p. 194). This is consistent with Kuhn’s well-known view of the necessity for a basic paradigm in any science. Bach correctly adds that the modifications that have evolved in Freudian technique "were introduced as it became clear that classical technique didn’t always work well enough for patients with severe problems of trust, of self-regulation, of self-reflexivity, and of symbolization" (p. 194). Of course, that would include the majority of patients that psychiatrists have to struggle with today.

Richard Lasky, in chapter 10, an especially valuable chapter for the practicing psychiatrist, points out there is a difference of opinion as to whether, as Freudians insist, the relationship with the analyst determines only the shape of the transference or whether, as the relational view suggests, "each individual’s personality contributes not only to the shape the transference eventually takes but also creates the contents of the transference itself" (p. 201). This is a hotly debated topic in current psychoanalysis. Lasky adds, "For Freudians…behavior in analysis…as it may exist in any patient—behavior that is repeatedly acted out in many different settings with many different people, behavior that repetitively enacts a particular, an often complex fantasy constellation—is an important part of the patient’s psychology that is not thought to be dependent on the actual behavior of the analyst" (p. 203). For Freudians, transference has to do with the expression of deep fantasy constellations in the patient’s mind, and analysts do not "initiate either the need or the stereotypic manner in which they eventually become used" (p. 203). For Freudians, intrapsychic processes determine how the patient experiences the psychotherapeutic situation and the vicissitudes of the transference. Freudians also are committed to try to get as reasonably close to the conditions of objectivity, neutrality, and abstinence as is possible, while at the same time knowing this can never be achieved to perfection. As Lasky puts it, the issue is whether the characteristics and behavior of the analyst are to be treated as a foreground issue or background issue:

If the analyst’s characteristics and behavior are treated as a foreground issue (as in the relational models), then transference itself is a joint production of the analyst and the patient, and the problem that Freudians have with conceptualizing the transference in this way is that the concept of intrapsychic process is essentially jettisoned. When the characteristics and behavior of the analyst are treated as a background issue (as one finds in the Freudian model), intrapsychic processes are seen as superordinate and transference is seen as a compulsive kind of repetition, where the characteristics and behavior of the analyst (whatever they are) are being used—bent by unconscious processes—to give what are actually fantasy-dominated events the superficial appearance of perceived reality. (pp. 205–206)

Lasky adds, and I agree, that attempting to do psychoanalytic therapy with difficult and disturbed patients forces us to examine some of the basic assumptions that are unique to the Freudian psychodynamic orientation: "This is because the exaggerated nature of both their needs and their experience of us helps us to see these phenomena, in sharp relief, as psychological rather than reality factors" (p. 207). It is actually in work with patients who have a terrible time using the relationship that the psychiatrist offers to them in therapy to their benefit that we can see most effectively "how intrapsychic processes can come to dominate and dictate the patient’s experience of reality" (p. 208). Lasky warns us that in such cases the therapist is also "most vulnerable to extreme countertransference reactions and enactments" (p. 208).

The final chapter in part 4 deals with the current controversy about the role of deficit and the role of conflict in pathology formation. This chapter lends itself well to a discussion of the differences between supportive psychotherapy and uncovering psychotherapy.

I recommend The Modern Freudians to any psychiatrist who is interested in psychoanalytic psychotherapy. It will be of special value to those who have already studied an introductory textbook on the subject, because some of the terminology used and the concepts discussed may be unfamiliar to the beginner.

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