Psychoanalysis: Clinical and Theoretical

I approached this book, the second published volume of Wallerstein’s selected papers, with trepidation. I had read most of these papers when they were originally published over the years and experienced his sometimes tedious and convoluted prose style (e.g., first full paragraph on page 10), his tendency to quote long passages from his previous papers (e.g., pp. 44, 76, 87–88), and his self-congratulatory tone (e.g., informing us that certain papers were given “by invitation”). As I read through the book, however, I grudgingly had to admit that this series of papers is outstanding and demonstrates a thorough knowledge of the history of psychoanalysis as well as of the current issues and problems in the field. It is almost a textbook of psychoanalysis and will be of very great interest to practicing psychoanalysts and anyone interested in the situation of the discipline today. This is true even though some sections seem to be almost medieval disputation (e.g., chapter 3), but if one is willing to wade through some of the longeurs, one will be richly rewarded by Wallerstein’s erudition and capacity to state fairly both sides of various current controversies.

The overall text consists of a collection of 15 previously published papers scanning the period from 1981 through 1997. It is divided into three parts: Clinical Papers; Theory: Critiques of Alexander, Anna Freud, Gill, Kohut; and The Psychoanalyses and the Psychotherapies. As is unavoidably the case in such collections, there is some repetition of material. Each of the three sections offers a brief introduction.

The first part contains six papers from 1981 through 1992. The first of these deals with the “psychoanalyst’s life.” Wallerstein tells us,

This is a remarkable statement for an authority in the field, and the general thrust of Wallerstein’s book is an admission that psychoanalysis in the middle of the twentieth century was somewhat oversold and is now coming to terms with its realities and limitations, a salutary development for which Wallerstein himself gets considerable credit.

Wallerstein remarks on the fact that psychoanalysis was originally a radical and antiestablishment doctrine but became transformed in our American society, some critics say, “into an arm of the conservative establishment purveying adjustment to a coercive and repressive social order, with modern day ego psychology made into the expression of a reactionary psychology of adjustment to evil with Hartmann its chief architect” (p. 19). The result of this is that psychoanalysis is under attack from the left because of the interpretation (or misinterpretation) of Hartmann’s doctrine and also from the right based on a misinterpretation of psychoanalysis as encouraging permissiveness and sexual freedom and immorality. It is also under attack from the medical profession, as it more or less has always been, for being out of touch with current developments in the neurobiological sciences, a situation recognized by several leaders in our field such as Gedo (1), who also attempted to alleviate the situation. Wallerstein reports that diverse elements tell us that we are suffering from “an unquestioning allegiance to what is declared to be an outmoded psychology rooted in a nineteenth century mechanistic, biological, and patriarchal world conception totally unsuited to current realities and unresponsive to the social, the economic, and the political aspects of human disease and suffering” (p. 19). He is correct, although this seems incredible to me in my functioning as the co-vice-chairperson of the active and busy committee on human rights and social issues of the American Academy of Psychoanalysis.

Our beleaguered discipline is in the process of correcting itself, although I doubt this will reduce the vehemence and multiplicity of the attacks on it, which have continued since its inception. Wallerstein decries “the timidity and conservatism with which we so characteristically face the social-political surround that impinges upon us.…We are very widely seen as members of a self-serving guild, set self-contentedly within the heart of the conservative social and political establishment” (p. 23). He does not address the fact that psychoanalysts in the mid-twentieth century made a great deal of money, and wealthy individuals are not usually known for their interest in changing their social surround. One might argue that the onset of (mis)managed care along with the revolutionary findings of biological psychiatry, having substantially reduced the incomes of most psychoanalysts, may have introduced an important initiating factor toward both the revision and the improved reality testing regarding outcomes in the field, as well as an increasing tolerance of each other’s disagreements about theoretical matters.

Wallerstein concludes in a 1981 paper that “psychoanalysis is in increasing trouble as…an intellectual discipline in today’s world” (p. 25). In a sense, the rest of the book attempts to outline the difficulties from a historical point of view that have led to this increasing trouble and to offer worthwhile and reasonable solutions. Whether they will be implemented in time to save the discipline remains to be seen. As he states, in a Proustian sentence more than 10 lines long, psychoanalysis has now been able to recognize itself at least in some quarters as having “a now tempered, realistically much more modest assessment of realizable expectations “ (p. 88), the same conclusion Freud came to in his famous paper written near the end of his life (2). Wallerstein’s solution includes the building of systematic planned patient follow-up with clinical and research activities if at all possible; this, he says, will be consistent with the

This is not an attack on psychoanalysis; when psychoanalysis does what it can do, it often still means all the difference between a psychological life and a psychological death for an individual human being!

The second part of the book consists of five papers from 1981 through 1997 in which the works of Franz Alexander, Anna Freud, Merton Gill, and Heinz Kohut are examined. In his criticism of Alexander’s much maligned “corrective emotional experience,” Wallerstein argues that the boundaries between psychoanalysis and psychotherapy are fluid and shifting, and that “psychoanalytic psychotherapy is neither a more nor a less honorable—or effective—enterprise than psychoanalysis proper” (p. 156). The chapter on Anna Freud, cleverly portraying her as a radical innovator and a staunch conservative at the same time, is one of the most interesting in the book. Her famous work on the ego and the mechanisms of defense was certainly revolutionary, but she was a staunch conservative, he says, in opposing the so-called widening scope of psychoanalysis and its application to narcissistic and borderline conditions. Wallerstein says that his research findings tend to support Anna Freud’s conservative stance.

Wallerstein, like Gedo, argues that psychoanalysis, although it is a clinical discipline devoted to the study of complex subjective mental states, “can at the same time be studied in ways loyal to the proper requirements of appropriate science, and building bridges to cognate social and behavioral sciences as well” (p. 167). The papers reviewing the work of Gill and Kohut are interesting and polemical; the bottom line of Wallerstein’s critique of their work is in his concern that they have overemphasized one or the other aspect of the psychoanalytic process at the expense of ignoring other factors of equal importance. The reader will have to judge for himself or herself, but to ignore the views of Gill or Kohut would be a tremendous mistake, as I am sure Wallerstein would agree.

The paper on Kohut is largely a review of criticisms that had been made to the date of Wallerstein’s 1983 paper; elsewhere (3) I have reviewed these criticisms and the whole field of self psychology. One of the curious omissions in this group of papers is that of any discussion of the relationship between mental illness and creativity and the role psychoanalysis can play in releasing stultified or restricted creative potential (see, for example, recent books by Gedo [4] and myself [5]). Kohut had a great deal to say about the selfobject function of creativity and its importance, and this is not addressed by Wallerstein.

The third part of the book contains four papers from 1988 through 1990, and it is the most repetitious but also offers what I consider to be the most au courant presentation in the book, “One Psychoanalysis or Many?” The other papers essentially summarize Wallerstein’s well-known research at the Menninger Foundation, which he has described in various books and journal publications. This research showed that treatment results tended to be the same for psychoanalysis and “various mixes of expressive-supportive” psychotherapy; there were plenty of supportive elements in the psychoanalytic treatments and the changes brought about “often seemed quite indistinguishable from each other, in terms of being so-called real or structural changes in personality functioning” (p. 289). But it should be kept in mind that these treatments were carried out on sicker patients than psychoanalysts usually see. Wallerstein views psychoanalysis as an unparalleled research instrument into the depths of human mental functioning, saying—psychiatric residency training directors please note—“It is a still unquestioned central aspect of the educational and training process by which individuals become proficient theoretically and clinically so that they will be maximally able to deploy knowledgeably the whole range of psychoanalytically conceptualized therapeutic approaches” (p. 290).

Wallerstein emphasizes the transition of psychoanalysis into worldwide theoretical diversity and the dependence of theoretical orientations on local social and cultural factors, a fact that I have repeatedly referred to in my publications calling for a Nietzschean style genealogical study of what is considered “truth” and choice of theories among psychoanalysts in various countries. Steiner is quoted as saying, “Despite the universality of the process of the unconscious, psychoanalysis is considerably influenced by the historical, cultural and social context in which it is developing” (p. 345 in Wallerstein from p. 233 in Steiner [6]). These differing and conflicting schools of thought, says Wallerstein, are gradually learning to live with each other without producing unfortunate schisms and civil wars, so that psychoanalysis today “consists of multiple (and divergent) theories of mental functioning, of development, of pathogenesis, of treatment, and of cure” (p. 351).

Wallerstein believes that there are certain fundamentally shared assumptions in psychoanalysis and that these rest on Freud’s concepts of the unconscious, transference, and resistance. He argues that the various theoretical explanations of our clinical material represent “explanatory metaphors, heuristically useful to us…in explaining, i.e., making sense of the primary clinical data of our consulting rooms” (p. 358). This does not mean that these overarching theoretical perspectives have equal status, however, because they are not equal in ultimate explanatory power. In fact, Wallerstein hopes that eventually there will be “greater correspondences between the constructs of the theory and relationships between the observables in our consulting rooms” (p. 369) that will allow us eventually to assert the ultimate superiority and truth of any one of these theoretical perspectives over the other.

He does not really explain in detail how this will come about, and in fairness he also quotes the views of Rangell, who claims that the American mainstream ego psychology orientation has the most direct line from Freud and can be accepted as the comprehensive psychoanalytic theory, and who complains that the other alternative theories tend to discard various aspects of the central Freudian corpus. Although Rangell’s view is at the present time a minority one, that does not mean it is necessarily wrong. In the current fashion of postmodernism there is a deep suspicion of any overarching meta-theory and encouragement for a whole variety of conflicting differing theories to flourish and abound (7). Postmodernism produces the ambiance in which, for example, “Latin American analysts attribute to their open receptivity to the confrontation and the clash of every psychoanalytic theoretical perspective, originating from wherever around the world, all hungrily imported and debated in their psychoanalytic discourse” (p. 372) the fact that there has been a recent explosive growth of psychoanalytic interest, training, and practice throughout Latin America. Wallerstein worries that “this debate—in these terms of debating these general theoretical perspectives—may be chimerical and irresolvable, i.e., ultimately sterile” (p. 372).

The twenty-first century will bring the answer to some of the salient issues so eruditely described in Wallerstein’s book. He concludes, “The central problem…is that these comparable observational data get ‘explained’ by us ultimately through widely differing theoretical explanatory frameworks, and that this is possible just because these overarching theoretical systems (that I have called our encompassing metaphoric systems) do not depend upon, i.e., are not tightly linked to, our data” (p. 380). I believe that the solution of this problem remains for the future and for genealogical and cultural study, and I highly recommend this not-easy-to-read book for anyone interested in the current status of psychoanalysis and its unresolved problems as we go into the twenty-first century.