Harvard Review of Psychiatry

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Recent Developments in Psychoanalytic

Technique: A Review

Jonathan Kolb, Steven Cooper & George Fishman

To cite this article: Jonathan Kolb, Steven Cooper & George Fishman (1995) Recent
Developments in Psychoanalytic Technique: A Review, Harvard Review of Psychiatry, 3:2, 65-74

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 Recent Developments in Psychoanalytic
Technique: A Review
Jonathan Kolb, MD, Steven Cooper, PhD, and George Fishman, MD zyx
This article provides an update on recent trends in psychoanalytic theory, particularly the
theory of technique. It discusses several trends that have coalesced into a major shift in

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emphasis. Psychoanalysis is moving to embrace a two-person psychology, focused on the

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relations between patient and analyst. In this new perspective the analyst is no longer seen
as an objective observer, even potentially free from unconscious influences. These trends
are discussed in terms of their origins in analytic experience, contemporary science, and
philosophy. The struggle within psychoanalysis to deal with these new views is examined,
and some implications for the practice of psychotherapy are offered. (HARVARD REV PSYCHIATRY
1995;3:65-74.)

The study of human subjectivity, of what is literally on a Similarly, modern psychoanalysis has traversed a difficult
person’s mind, has been prone to fractionation in psychia- path to maturity and is replete with efforts to create newer
try. The empirical approach has selectively studied that and more precise languages with which to understand a
which is most capable of being defined and quantified. Many patient’s report of his or her affective experience. The
clinicians fault this approach for avoiding what is most moment has never been more opportune for a bridging of
uniquely human. In contrast to the empirical approach, various partial approaches to the study of the human
psychoanalysis has embraced the metaphors a person uses subject.

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to describe the complexities of emotional experience. This Psychiatry continues to nudge psychoanalytic knowledge
approach runs the risk of reification. into the corner because it still harbors the misconception
At present, contemporary neuroscience has moved be- that dynamic therapists are indelibly wedded to the meta-
yond behavioral reductionism toward a much richer concep- physics of Freud’s original drive theory. This review is an
tual framework that allows for the study of subjectivity.’ attempt to open a window onto contemporary psychody-
namic thinking to counter this stereotype. We believe that
psychoanalysis still provides a uniquely helpful context for
understanding a patient’s suffering and for understanding
From the Department of Psychiatry, Harvard Medical School (Drs. what happens between doctor and patient. The discoveries
Kolb, Cooper, and Fishman), the Boston Psychoanalytic Society and
Institute (Drs. Kolb, Cooper, and Fishman), and the Department o f of familial/genetic factors in the mood and anxiety disorders
Ps-ychiatry, Beth Israel Hospital (Drs. Cooper and Fishman), Bos- and the prevalent use of psychotropic drugs do not mean the
ton, Mass., and the Department of Psychiatry, McLean Hospital, end of the need for an understanding of the whole person.
Belmont, Mass. (Dr. Kolbi. Clinical practice is a humbling testimony to the necessity for
a balance between medication and psychotherapy. The phy-
Original manuscript received 17 January 1995, accepted for publi-
cation 27 February 1995; revised manuscript received 9 March sician’s initial euphoria at the relief of target symptoms by

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1995. a selective serotonin-reuptake inhibitor is often followed by

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Reprint requests: Jonathan Kolb, MD, 214 Buckminster Rd.,

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Brookline. M A 02146.

Copyright 0 1995 by Harvard Medical School.

1067-3229/95/$3.00 +0 3911164963
disappointment at the presence of “leftover” problems. A
psychopharmacologist must often explain to a patient edu-
cated solely by Kramerz that fluoxetine talks back effectively
to depressive symptoms but is mostly mute when it comes to
issues of character, finding satisfaction in work, and under-
standing persistent barriers to intimacy. This paper is of-
65
 zyx
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66 Kolb, Cooper, and Fishman
Harvard Rev Psychiatry
July/August 1995

fered in the hope of fostering a renewed understanding of patient and analyst will contribute to the organizing prin-
and interest in the possibilities for integrating biological and ciples in the transference.” Thus, this shift in our concep-
psychodynamic insight. tion of what is “internalized” has moved our focus on
We will focus primarily on how the evolution of psycho- transference beyond what is repetitive to what is uniquely
analysis has transformed clinical practice. The paper is not created by patient and therapist.
based on an exhaustive, systematic rereading of the litera- Third, a profound change has occurred in the way
ture but instead represents our synthetic attempt to isolate we think about knowledge and clinical evidence. As in
one set of themes from our own unique readings of the related sciences and other academic disciplines, the naive
literature, as clinicians and teachers, over many years. By nineteenth-century concept of objectivity is outmoded. How-
concentrating primarily on technique, we do not mean to ever, the hypothesis of the existence of an archaic uncon-
downplay the importance of other changes in psychoanaly- scious working within the closed system of the patient’s
sis. The growing feminist critique of traditional theories of psyche has been indelibly linked to the notion of the analyst
development and psychopathology, for example, has led to who stands outside that system and can objectively decode
an enormously altered and enriched view of these areas. But its transmission through the patient’s free association. Our
that is the subject of a different, future review. As an recognition of the mutual participation of therapist and
orientation to the various subtopics that will be discussed patient in everything that occurs in the patient’s psychic
here, we will first provide an overview of the basic evolution reality has required a major shift in viewpoint. We now
of the theory and methodology of psychoanalysis. recognize the fallibility of the analyst, and accordingly, we
have turned to a more circumscribed, focused view of what
TRENDS IN METHODOLOGY constitutes analytic data, evidence, and inference. In a later
section, we will provide a sketch of a contemporary psycho-
Three trends in methodology have been key to bringing analytic epistemology.
about the changes we are reporting here. First, therapists In the next seven sections of this review, we will flesh out
have tried to stretch their understanding beyond the classic a few of these new developments in analysis, in broadly
neuroses in order to be able to treat the greatest variety of separate but overlapping categories. Finally, in a last sec-
problems. This openness to the widening scope of practice tion, we will return to the interface with psychiatry, drawing

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has brought about an interest in developmental disorders together some of the threads we have spun, in an effort to
affecting or affected by attachment, trauma, temperament, indicate how this changed psychoanalysis remains essential
and cognition. As we broaden our formulations to meet such to a changing psychiatry.
“new” patients, we also apply the broadened formulations
to our “old” patients. Efforts are continually being made to THE RELATIONSHIP IN THE THEORY OF
understand how severe early circumstances, environmental PSYCHOANALYTIC ACTION
and congenital, skew development and the eventual form of
an adult’s psychodynamics. For example, the narcissistic From the prehistory of psychoanalysis, when Anna 0. fell in
issues of a person who grew up with the shame of a learning love with Breuer and experienced a fantasy of pregnancy
or attention disorder must be distinguished from those of a and delivery, there has been controversy about the role of
person who was continually forced to defend against an the relationship in treatment, both in the collection of data
unloving or hypercritical environment. and in the production of change. Early psychoanalysts were
Second, the burgeoning of infant psychiatry has nurtured united in agreeing that the relationship was important, as a
contemporary dynamic thinking. Many researchers (for ex- background, to the success of the enterprise, but that the
ample, Stern,3 Beebe et al.,“ Li~htenberg,~and Emde“) have cure was effected by insight, making that which was uncon-
begun to study the subtle ways in which the mother-infant scious, conscious. This formulation prevailed for many
dyad structures what the infant takes in. The basic synchro- years. Analytic thinkers who suggested otherwise, such as
nies and patterns of interaction between mother and infant Ferenczi and Alexander, were firmly Not until
cannot be explained by the characteristics of either mother around 1960 did analysts began to insist on the more
or infant alone. This body of work has had profound impli- curative role of the analytic relationship in a way that could
cations for adult therapy. It suggests that transference is be at least tolerated within the main body of psychoanalytic
not a stack of slides of disconnected earlier experiences ego psychology, the dominant theory in this c o ~ n t r y . ~ . ’ ~ *
ready to be projected. Instead, what is stored seems to be
“interactional representations” -the sense of what it was
like to be with person A or B. Beebe and colleagues* spoke
*The situation was somewhat different in England and especially
for many psychodynamically oriented infant researchers in South America, where the theories of Melanie Klein had a much
stating, “the ‘rules’ that the patient has internalized greater impact on practice. This review would be impossibly complex
through the experiences of the joint constructions between if we tried to tell more than the North American version of events.
Volume 3, Number 2 zyxwvutsrqponml
Harvard Rev Psychiatry
Kolb, Cooper, and Fishman 67

Winnicott’s idea of the holding environment’’ analogized widening-scope patients. As a result, he articulated a major
the patient’s use of the analyst to the baby’s use of its change in the job description of the analyst: he or she was to
mother. Loewald’ elegantly propounded his idea that the regard the giving of interpretations as secondary to the
analyst filled a quasi-parental role in the development of the “holding” of the patient’s attempts to become whole and to
patient, holding in safekeeping some idea of the future the survival of the patient’s angry attacks. In Winnicott’s
potential growth of the analysand. Loewald cloaked radical work the relative importance of interpretation and relation-
propositions in traditional language, and his ideas gained ship began to shift, with the relationship moving to the
wide acceptance. The concept of the therapeutic or working fore.
alliance was another acceptable way to talk about an aspect Kohut provided a variation on this theme. Instead of
of the analytic relationship that was functionally, if not stressing the parents’ holding function, he1’ chose to em-
theoretically, more than transference. By 1960 more than phasize their role in maintaining the child’s self-esteem and
the camel’s nose was in the tent, and the question of what self-cohesion. For emphasis, he13 proposed that we give up
was curative in psychoanalysis had become a legitimate the “health and maturity morality” that prevailed in anal-
subject of controversy, debate, speculation, and even re- ysis and prevented the emergence and resolution of the
search. transferences appropriate to a certain type of patient. In

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Technique is inextricably linked to the theory of cure. In relation to mainstream technique and conceptions of the
the late 1940s and early 1950s, Ferenczi in Europe and analytic relationship, this was a further shift. The analyst
Alexander in the United States had begun the debate about now had a more intimate role in the patient’s psychic life,
altering “standard” technique to fit their proposed alter- providing not just a forum or opportunity for further
ations in the notion of cure.’.’ But each attempt was, in its learning, but responsivity, the “gleam in the parent’s eye”
own way, too radical a departure. Alexander’s “corrective that had been missing.
emotional experience”8 proposed that the analyst act in
specific ways to counteract aspects of parental character or THE USE OF THE THERAPIST: TRANSFERENCE
action that the analyst decides have been harmful. This OBJECT, DEVELOPMENTAL FACILITATOR,
seemed too contrived and aberrant for mainstream analysis, OR NEW OBJECT
and the concept not only died an ignominious death but
continues to be used as a pejorative way to brand new Along with changes in our ideas about the role of the
departures as heresies. Ferenczi’s entire project, which in- relationship in psychoanalytic treatment, there has been
cluded “mutual analysis” as a technique to work with vigorous debate about the nature and extent of the trans-

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patients who are survivors of early traumas such as incest, ference and its relevance for therapeutic change. Main-
was deemed too radicaL7 He also came into direct confron- stream ego psychology, attempting to perpetuate the possi-
tation with Freud in believing that “a large part of chil- bility that the analyst could be objective, partitioned the
dren’s sexuality is not spontaneous, but is artificially grafted treatment relationship into transference-dominated and
on by adults, through overpassionate tenderness and se- transference-spared domains. Generally speaking, among
duction. ” 7 ego psychologists and therapists who have worked with
Ferenczi’s ideas have recently enjoyed a revival. Analysts more-seriously-ill patients, the notions of therapeutic alli-
have acknowledged that we treat many such survivors, and ance, real relationship, and new-object experience have been
their needs for safety and a containing presence are differ- viewed as helpful for understanding aspects of the thera-
ent from the needs of a traditionally neurotic patient. But peutic relationship. Many of these psychoanalysts might
until this revival, Ferenczi’s proposals were considered far agree with Brenner’s position“ that all aspects of the rela-
outside the mainstream of developing thought about the tionship are usefully understood as a part of the transfer-
analytic relationship. ence. The therapeutic alliance concept was an attempt to
Object-relations theorists, exemplified by Fairbairn” and concretize and name the inchoate experience of somehow, in
Winnicott,” developed ideas that enlarged and modified our the midst of transference heat, being able to talk to the
notions about the nature of the therapeutic relationship, patient about that very heat. It is as though the patient can
and they did so in a way that proved acceptable within the see beyond the intense love for or anger at the therapist in
general framework of North American analysis. Winnicott, the moment to the more reasonable person that he or she
especially, emphasized the critical role of the “good enough actually is. This does and must happen for a treatment to be
mother” in helping an infant to enter the relational world viable. However, the debate remains as to whether the
with his maximal creative potential (a true self) rather than patient’s capacity to acknowledge the existence of a “rea-
reactive compliance (a false self). He created his theories by sonable” side of the therapist should be viewed as reality
moving fluidly between the world of mother-child interac- testing or another layer of transference. Ironically, contem-
tion that he saw as a pediatrician, and the world of patient- porary analysts, in order to avoid judging the reality of their
analyst interaction that he observed in analyzing so-called patients’ perceptions of them, have returned from an un-
68 zyxwvutsr
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Kolb, Cooper, and Fishman

tenable position of self-pronounced objectivity to a position

that resembles the classical one -that all of the patient’s
Harvard Rev Psychiatry
July/August 1995

experience as attempts by the therapist to avoid the mag-

nitude and refractory qualities of the transference. Thus the
experience of the analyst, including what we like to call the very existence of these concepts and their heuristic value
alliance, should be viewed as potentially imbued with trans- in describing the nature of therapeutic action have become

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ference.15

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Another difficulty inherent in the idea of therapeutic
alliance derives from the fact that it deemphasizes the
intrinsically subjective nature of the analyst’s interpretive
discipline. It is as though the concept spares one sector of
the analytic relationship, the cooperative feelings, from the
universal need to question and analyze what goes on be-
tween the two participants. As psychoanalysis comes to
terms with the indivisibility of a person’s subjectivity, both
a source of debate. We would explain this debate as
reflecting, at least in part, variations in the kinds of patients
treated by the different analysts who take part in it. The
more seriously disturbed the patient, the more active the
therapist must be at times to facilitate the exploration of
repetition and transference experience.

OBSERVER AND OBSERVED BECOME

INTERACTING SUBJECTlVlTlES
analyst and patient are faced with the fact that the only
observing lens for each of them is constantly filtered by Harry Stack Sullivan’s interpersonal psychiatry, like
their respective transferences. Freud’s psychoanalysis, was philosophically rooted in
A related question involves the degree to which thera- nineteenth-century scientific positivism, with a firm belief
peutic action revolves solely around the repetition and in the distinction between the observer and the observed.
working-through of transference paradigms. All psychoana- But while Freud postulated a psyche filled with inner
lytic theories have some way to describe how the therapist conflicts, agencies, drives, and defenses, Sullivan concen-
functions as a “new object” to the patient. The notion of the trated on the adaptive nature of the developing person in
new object was used initially by Strachey“ in 1934 to his social context. His “security operations,” as opposed to
describe how the patient was able to internalize a new, more Freud’s ego defenses, deal with danger not from within but
benign object. Loewald’ similarly referred to the ways in from without.” Instead of a theory of a mind in conflict,
which the analyst, through systematic analysis of the trans- Sullivan conceptualized a person in conflict with the people
ference distortions, was gradually experienced and observed around him. From his contribution, then, have followed a
as a helpful and therapeutic agent of change for the patient. number of searching looks at the interactions that char-
For Loewald the analyst was conceptualized as a new object acterize a person’s essence, especially as seen in the in-
to the extent that he or she offers the opportunity for a teractions of therapy. Dissonance between the interpersonal
rediscovery of the early pathways and patterns of object school and classical psychoanalysis was inevitable. Even
relations, leading to “a new way of relating to objects and of when Freud at times acknowledged an important role for
being oneself.” the relatedness to objects, he steadfastly maintained that
In more recent years analysts such as M ~ e r s o n ,Green-
’~ they became significant only after they had been internal-
berg,’’ Killingm~,’~ and McLaughlin’’ have used the concept ized in the psyche. In other words, the object is borrowed
of the new object to refer to more than the patient’s given and molded for its major use as a medium for the elabo-
and evolving experience of how the analyst as a transference ration of intrinsically programmed drive conflict. Sullivan,
object differs from past objects. Some theorists (e.g., Green- on the other hand, insisted that the opposite obtained: the
berg) have proposed specific techniques that the analyst individual was motivated only to remember how to get basic
may use to differentiate himself or herself from the pa- needs met, and at the same time to stay clear of actual
tient’s experience of past objects. These departures from vulnerabilities of the parents. Once this expectation of
traditional “neutrality” are proposed as being useful in the similar vulnerabilities in others repeatedly proved unnec-
face of impasse or stalemate. Greenberg has noted that an essary, in Sullivan’s view of treatment the patient had the
analyst’s usual level of reserve may repeat, for a particu- intrinsic fluidity to change.
lar patient, a parental injunction against all affective Other factors conspired to keep the interpersonal
expression; he advocates altering one’s technique with a perspective marginalized. Sullivan was an eccentric
view toward helping the patient distinguish old experience outsider; he developed his own language of psychiatry, based
from new. For many analysts conceptualizing what the term largely on interviews with schizophrenic patients, which he
“new experience” or “new object” could mean has been taught in seminars. His methods and data were different
difficult. After all, they believed experience to be determined enough from mainstream analysis that he was easy to
by the past, and repetition in the form of the regressive ignore, despite the richness and vibrancy of some of his
transference is an axiomatic feature of the therapeutic ideas.
situation and therapeutic action. These analysts viewed the Recently, the focus on the interactional nature of analytic
evocation of concepts of therapeutic alliance and new-object data, described as “participant-observation,’’ has had an
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Harvard Rev Psychiatry
Volume 3, Number 2 Kolb, Cooper, and Fishman 69

increasing influence. For example, within the mainstream analysis-a regrettable fact of life. By contrast, 0gden3’ has
of current psychoanalytic thought, Merton Gill stressed the given a picture of how changed analysis becomes when it
importance of the analyst’s contribution to the formation is predominantly viewed through the lens of intersubjec-
and manifestations of the transference. He propounded the tivity. In his description of a patient with whom he felt
idea that transference is not the patient’s wholly made-up deadened, the report of the analytic experience becomes a
distortion of the blank-screen analyst, but a unique inte- crisscrossing between the private worlds of patient and
gration of past representations of objects with the actions analyst, detouring through the complex histories and de-
of the analyst in order to form a plausible, rather than a vious tendencies of each, looking for the correspondences
distorted, version of reality.””~“ Thus the angry patient’s that will illuminate the patient’s state so that it can be more
exhortation, “Stop yelling at me,” which the classical fully articulated and known. Ogden spoke of three
analyst who has not raised his voice views as a distor- subjectivities: that of the patient, that of the analyst, and
tion and failure of reality-te~ting,’~ would prompt from a third that is a unique creation between the analyst and
Gill an inquiry into what action (or silence) of the analyst
the patient had experienced as the equivalent of a raised
voice.
Hoffman has provided both a rationale for this more
egalitarian approach and a model of technique that goes
with it. His provocatively titled paper “The Patient as
Interpreter of the Analyst’s Ex~erience’’’~ has taken this
development to its logical extreme, where the therapist has
the analysand.

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Two more points on the spectrum of response to the
analyst’s subjectivity can be identified. McLaughlid’ has
accepted this subjectivity with equanimity, while Renik33
has reveled in it, declaring that “unconscious personal
motivations expressed in action by the analyst are necessary
for the analysis.” He proposed to reverse the familiar Freud-
ian dictum and declare that action is trial thought - that the
no more access to the truth of the interaction than the analyst discovers an interpretation of a transference-
patient: each has a plausible view, colored by past templates countertransference situation by reading his or her own
and present exigencies. As a result, the therapist’s authority action tendency.
has been greatly curbed as he or she embraces more fully
the role of participant-observer. SUBJECTIVITY RAMPANT: THE RISE OF
Other analysts have come to the interactional perspective COUNTERTRANSFERENCE AND ENACTMENT
from a different direction. Greenberg, for example, has
suggested a new definition of analytic neutrality that ac- The realization that the subjectivity of the analyst so
cepts as a starting point the proposition that the analyst critically influences the treatment has brought a renewed
inevitably acts in ways to provide substrate to which the intensity of interest in the study of countertransference.
patient’s transference experiences attach. He“ noted, “The The very history of the concept of countertransference helps
neutral analyst occupies a position that maintains an opti- to clarify one of the basic paradoxes of the psychoanalytic
mal tension between the patient’s tendency to see him as a method: how does one create a science of subjectivity when
dangerous object and the capacity to see him as a safe one.” the observer is beset by the very subjectivities under study?
If we contrast this neutrality with Anna Freud’s familiar Within the analytic endeavor, the concept of countertrans-
adviceg6that the analyst should maintain a position equi- ference evolved from an obstacle that stands in the way of
distant from the three mental agencies (id, ego, and super- the analyst’s understanding to an internal source of in-
ego), we can see how far the view of analysis has moved. In formation that the analyst can use reliably.
Greenberg’s reformulation a two-person field is assumed to Originally, Freud’s hope was that a kind of purification
be operating all the time. The therapist cannot possibly through personal analysis would place the analyst in a
avoid behaving in a way that is experienced by the patient as position to more objectively understand, formulate, and
either dangerous or safe. The technical goal is to keep a interpret the unconscious productions of the patient. Ini-
balance between these two poles. tially, Freud34sparingly defined the concept of countertrans-
The implication of the foregoing is that the analyst’s ference as the analyst’s reactions to the patient’s conflicts.
subjectivity precludes neutrality. Analysts have met this He abandoned the position that the analyst could ever be

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finding with varying degrees of enthusiasm. SchwaberZ7has completely free of the influence of countertransference.
tended to advocate a listening stance inside the patient’s What remained, however, was an ongoing conflict between
subjectivity, implicitly regarding the analyst’s subjectivity as his positivist predilections and his clinical awareness that
an interference that needs to be constantly discovered and the analyst was always vulnerable to the intrusion of his
worked around. Similarly, Kantrowitz, beginning with her subjectivity. By 1937 FreudJ5had suggested that the analyst
research exploring the patient-analyst match,” has written return to the couch at 5-year intervals, reasoning that the
a series of paper^^^.^^ in which she acknowledges that the constant experience of being exposed to his patient’s uncon-
character of the analyst will inevitably impinge on the scious, primary process productions might activate “all the
70 Kolb, Cooper, and Fishman
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July/August 1995

instinctual demands which he would otherwise keep under and patient does it become possible to construct what is
suppression.” being repeated from an individual’s childhood. Enactment,
In part, experience with more-seriously-ill patients has like countertransference, has been greeted with reactions

z
stimulated interest in countertransference. Many analysts
(e.g., Little,”“Gabbard,37Adler and Buie,”’R a ~ k e r ,Searles,“’
~”
and Kernberg4l) have noted that the countertransference is
relatively more intense and early in its appearance in work
with patients with more severe disturbance. Kernberg”l re-
introduced Melanie Klein’s conception of projective identifi-
cation to describe how the therapist is sometimes the recipi-
ent of unwanted, expelled instinctual urges of the patient. In
ranging from distaste to embrace, the latter exemplified by
Levine’s recent c~ntribution.“~ From the perspective of the
analyst and the analyst’s participation in the analytic pro-
cess, one cannot distinguish an “emotional reaction” from a
“proper interpretation” because a proper interpretation is
an emotional reaction.

PSYCHIC REALITY RECONSIDERED

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this model the therapist is called upon to contain these primi-
tive aspects of the psyche and to reintroduce them carefullyto “Psychic reality” refers to Freud’s initial solution to the
the patient in a less toxic form. problem of the unreliability of memories of childhood events.
It is important to note, however, that the theoretical In a crucial decision that marked the creation of psychoanaly-
basis for interpretations of projective identification has sis as a new endeavor, Freud“’ decided that it was not the
largely revolved around a closed-system model in which truth - or untruth- of childhood memories of seduction that
theorists have regarded the analyst as a receptacle for the mattered. Whether the memories depicted real events, a
patient’s encapsulated conflicts. But other perspectives, child’s fantasied constructions or reconstructions of other
such as those articulated by Sandler,“”Guntrip,“”H ~ f f m a n , “ ~ events, or fantasies based on purely internal considera-
A. Cooper,45and Tansey and B ~ r k e ,acknowledge
“~ the role tions, it was their importance to the growing child, their
of the therapist’s conscious and unconscious motivations in psychic reality, that made them important in development.
both evoking and understanding these communications and McLaughlin””returned to this concept in 1981in his seminal
affects. Sandler,“”for instance, has coined the idea of role- paper that has provided language for an approach to tech-
responsiveness to emphasize his view that the therapist is nique. He examined the interplay between transference and
neither a simple receptacle nor a blank screen for the countertransference, in light of Freud’s concept of psychic
projective identifications of the patient. reality.* He argued that the standard practice of viewing
McLaughlin””has questioned the utility of the counter- transference as distortion, and countertransference as a rare
transference concept. He located its origins in a longstand- and problematic occurrence -or as a common, secondary re-
ing struggle for psychoanalysis to acknowledge the human- action to the patient’s transference-did not do justice to the
ness and vulnerabilities of the analyst at work. He argued facts of clinical encounters or to our theories of the function-
that the prefix “counter” in “countertran~ference”is a kind ing of minds. He pushed for a more open, unbiased inquiry, on

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of a linguistic cover-up performed on the transference of the
therapist, who by this device is “claiming rationality, de-
tachment, and imperturbability in the presence of the all-
too-humanness of his patient.”
McLaughlin’s work may be seen as a part of a general
trend toward viewing the therapist’s subjective reactions as
intrinsic to the process of psychotherapy. This has also
included a greater awareness of the possibility or, in many
quarters, the inevitability that aspects of transference will
the part of the analyst, to the patient’s experience, including
the patient’s experience of the analyst.
McLaughlin was influenced by S~hwaber,~~*“’~“’
series of papers has explored what she calls a unique
listening stance. As opposed to Langs? whose examples
were all drawn from psychotherapy sessions of students
who in a

(often residents), Schwaber increasingly reported her own

analytic material. She sought to ascertain exactly what the
patient was experiencing and perceiving at moments of
be enacted between the therapist and the patient. In “Re- disruption in the connection between analyst and patient.
membering, Repeating and Working Through,” pos- Through this exquisitely focused lens, she has explored a
ited that the transference was always enacted before being number of issues, including the primacy of psychic reality.
expressed in verbal terms by the patient. The concept of While explicitly denying that she seeks to overturn any
enactment involves an extension of this basic insight into classical theory, she has expounded a listening stance that
the two-person field and is related to Sandler’s idea of pays scrupulous attention to the patient’s perceptions, in-
role-responsiveness.An enactment is a sequence of interac- tentions, and conscious experiences. These data would have
tions between analyst and patient, within the new situation been brushed aside as defenses and rationalizations in an
of the treatment, that can be understood as a dramatization
of the crucial story of the patient’s childhood. As a concept
or clinical phenomenon, enactment suggests that often only *McLaughlin elevated psychic reality as a concept to a level of
after a period of repetitive interactions between therapist importance that Freud never gave it.
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Harvard Rev Psychiatry
Volume 3, Number 2 Kolb, Cooper, and Fishman 71

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era when analysts were searching for truths that were he stressed looking for moments when the patient cannot
unconscious and not reachable through introspection alone, continue a line of thought that would express anger or other
without interpretation. Schwaber” has written: “Real is aggressive thoughts toward the analyst, at least in the
how things are felt to be and how they are perceived-how presence of the analyst. The analyst’s focus, according to
feelings and perceptions, wishes and defences, interdigitate. Gray, should be on these moments, so as to improve the
Real is what each of us experiences as true -the correctness analysand’s capacity to observe why and how he or she is
of which no other one of us can be the arbiter. Real, as it is defending himself or herself. Gray stressed the benefits of
felt by another, must include ourselves, the observers, as its the repetitive cognitive learning that accrues from these
participants.” moments.* For his part, Gray asserted that most of what is

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Schwaber’s insistence that the analyst remain firmly being celebrated by modern interpersonal and intersubjec-
committed to understanding the integrity of the patient’s tive approaches, namely immersion in mutual affective ex-
subjective reactions has made her work controversial. Oth- change, is an arena for the free play of the therapist’s
ers, such as ModelP and Meis~ner,~‘ have echoed this shift resistances. Conventional attitudes, such as the idea that
in listening stance without arguing for its hegemony over the analyst might be proud of the patient or want him or her
other ways of hearing any given sample of process. to Gray debunked as ways to rationalize not
addressing the analytic task at hand. For Gray, the analytic
RESISTANCE RECONSIDERED task at hand has often involved recognizing the vicissitudes
of human aggression.
While various innovators have been suggesting approaches
to technique that may profoundly alter the paradigm of the KNOWING BY DOING
analytic interaction, other contributors to current thinking
on technique have been busy elaborating and revising As already illustrated in earlier sections of this review, the
within a more traditional framework. Of these, two of the dialectic between clinical experience and technique has in-
most influential, Anton Kris and Paul Gray, are worth evitably led to a changing epistemological basis for psycho-
discussing. analysis. Freud’s original dictum, to make the unconscious
K r i P described his effort to reformulate technique on conscious, was predicated on several assumptions. First, it
the basis of as few theoretical and metapsychological beliefs was assumed that the unconscious was a fairly fixed struc-
as possible. He detailed a method of careful attunement to ture. Freud’s metaphors implied that the unconscious was
the process of free association, listening for discontinuities, like a buried text. This buried text, however, courted a
for patterns of failures of the patient to adhere to the task. mystique because it could never be known in its own tongue.
He described reluctances (conscious evasions) and resis- Archaic unconscious fantasies, as long as they were re-
tances (unconscious blockades) to free association and for- pressed, persisted unchanged in a primary form that was
mulated an expanded list of the kinds of conflicts his inaccessible to human introspection. They became knowable
patients were exhibiting, based on their pattern of associa- only when they cloaked themselves in the ego’s present-day
tions. His reemphasis on listening to associations, on choos- events, images, and language in order to appear incognito in
ing when to intervene based on breaks in the associative manifest consciousness. Second, these fantasies were fueled
chain, and his attempt to place theory in a secondary role in by the id and were therefore in conflict with most of the
clinical analytic work, subordinate to observation, have been manifest goals of the self. Third, the basic vehicle for cure
received gratefully by a generation of younger analysts was restoration of knowledge, or recovery of what had been
looking for a method that is more science friendly and less repressed.
theory bound. With his emphasis on the satisfaction inher- Major shifts have occurred in all three assumptions. The
ent in free-associating, Kris introduced a more permissive unconscious is no longer referred to by the analogy of a
tone to an enterprise that had become identified with absti- fixed, embedded text. Freud himself actually unwittingly
nence and deprivation. dismantled this premier concept when he speculated on the
Gray,24.86,87 on the other hand, beginning with his im- effects that current experience could have on the form of a
mensely influential 1981 paper, has propounded a technical person’s memories. The major example was the acquisition
approach marked by an exquisite attention to a certain kind
of analytic surface. He proposed following the associations
for evidence of the patient’s “change of voice,” a subtle shift
in tone or content that is hypothesized to represent a *What is revolutionary about this approach is that, in contrast to
the tradition of an analyst’s revealing deep unconscious contents on
resistance in the moment. He emphasized the turnings the basis of cues that he or she alone can read, Gray favored the
away from further expressions of aggressive drive deriva- patient’s being able to participate actively in developing the data
tives, in the context of the analytic relationship. Basically, out of which the insight emerges.
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72 Kolb, Cooper, and Fishman
Halvard Rev Psychiatry
July/August 1995

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of sexual knowledge in adole~cence.~~ At that point, earlier
fantasies from the phallic oedipal stage were transformed
retrospectively by the sexual awareness attained at puberty.
He called this process nachtruglichkeit. Contemporary neu-
roscience lends support to his idea. For example, Edelman’
has speculated that human “memory” is a dynamic system
with few similarities to computer memory (a static system
and sexual fantasy. Freud and several succeeding genera-
tions of analysts concluded that this primary process was
generated by primal instincts that immutably struggled
with the dictates of the mature ego/superego. The newer
view, articulated by M ~ d e l l ,among
”~ others, is that primary
process is a developmental relic. It captures the cognition
of certain early periods of childhood. This recasting need
of fixed representations comparable to the model of the not do away with the central importance of intrapsychic
“repressed” in early psychoanalysis). In other words, it now conflict. However, it helps to refine one major tension
appears that the memories regularly evoked by daily expe- between content organized in the primary mode and that
rience are not intact files but rather variations on a familiar organized in the mature secondary mode of cognition. The
remembrance that are constantly reedited and recon- tension again revolves around nachtraglichkeit: the adult
structed in accord with new experience. This alteration is patient is constantly in a push-pull around allowing mature
not frank distortion, but an attunement of “memory” so affective awareness to fill in the blanks of more-primitive
that it can be maximally informative to the current experi- recollections. For example, the patient who is surprised by
ence that has evoked it. feeling devastated over a therapist’s brief absence is dan-
A current analogy to the functioning of unconscious gerously close to becoming aware of why particular crea-
memory might be the reciprocity between a “story” and its tures haunted his or her dreams in childhood at a time when
embodiment as a play, novel, folktale, or screenplay. It is he or she was unaware of any conscious reaction to a
clear that in this sense, a story is not a substantive thing, mother’s absence. Therapy, in other words, cannot help but
but rather a set of narrative principles that can generate dare a patient implicitly: “are you ready to use what
many possible stories and, in turn, itself be regenerated by you know now to see more fully what you experienced
feedback from any current product of itself. Many contem- then?”
porary theorists, including Spence5’ and Schafer,“’ have The change in the third assumption follows from the
taken this view of memory as embodied in the new creation changes in the other two: knowledge of the unconscious is
called the transference. neither simple nor automatically curative. As already stated,
Clinically, transference has been the window on re- what a patient needs to know is not the text of his or her
pressed memory. Therefore, its conceptualization has been unconscious drives, but the way in which he or she uncon-
changed to fit this newer understanding. Stolorow and sciously organizes interpersonal experience. The guide is the
colleaguesG1have suggested that the unconscious linkage of emergence of affect^.'^.^^,^^ Emergence is used in two senses.
current situations with the therapist to similar experiences First, as noted earlier, the patient and therapist necessarily
with figures from the past does not occur by a cue sorting of fall into the enactments that generated genuine feeling.
stored “slides” or “film clips.” Instead, the identification of This can never be contrived; it must emerge. Second, as
present with past occurs by dint of a hierarchy of organizing noted above, the patient must be ready to feel what he or
principles similar to the narrative principles in the analogy she has never exactly felt before. The lifting of repression
above. This new epistemology supports views like that of has always evoked the idea of a fully formed affective beast
Gill,” who asserted that transference is a person’s attempt ready to spring from the id once defenses had been removed.
based on the past to construct a plausible, not a distorted, Now it is clear that the cognitive-emotional reckonings of
version of present reality. The therapist is no longer on a the past, stored in the primary process, were anlagen (an-
mission to disabuse a patient of his or her distortions of tecedents) awaiting later experience in order to be com-
interpersonal reality. Instead, the goal is a respectful exami- pleted. The animals in a childhood phobia do not have
nation of the patient’s transferences (defined as the pa- well-developed referents -they are not true symbols. They
tient’s experience of the analyst) as attempts to master and are better viewed as markers of a primitive distress that, if
adapt to reality. The hope is that the patient will become unaddressed at the time, must reemerge in adulthood when
increasingly willing to look at the strengths and liabilities of there is the capacity to feel more fully and specifically what
the organizing principle generating his or her reality. could not be felt then.
The second assumption, namely that repressed id content In summary, psychoanalysis has undergone a major shift
is always in opposition to the rest of the mind’s workings, in its underlying epistemological assumptions. It no longer
has also been challenged. Loewald6’ and his later interpret- assumes that there is an embedded, unconscious text that
e r have~ suggested
~ ~ that the “id” is really the record of past can be precisely translated as repressions are lifted. Instead,
attempts to wrestle with charged affective experiences. it regards the patient as having a set of organizing principles
What gave the id its proper name was the primitive form it that exist outside of awareness and that have been variably
assumed, namely the often-surreal visual condensations of influenced by feedback from later development. The goal of
dreams, or the wildly fantastic excesses of waking reveries therapy is to understand the principles that generate the
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Haward Rev Psychiatry
Volume 3, Number 2 Kolb, Cooper, and Fishman 73

greatest liability for the patient and to restore their acces- selected papers of Franz Alexander. New York: Basic Books,
sibility to the forward pull of emotional development. 1961:261-75.
9. Loewald H. On the therapeutic action of psychoanalysis. Int J
PSYCHOANALYSIS AND PSYCHIATRY Psychoanal 1960;41:16-33.
10. Fairbairn WRD. Psychoanalytic studies of the personality.
London: Routledge and Kegan Paul, 1952.
Having taken our readers on this tour of three decades of 11. Winnicott DW. Ego distortion in terms of true and false self. In:
development in analytic thinking, we must now return Maturational processes and the facilitating environment. New
briefly to contemporary psychiatry. York: International Universities Press, 1965:140-52.
Psychiatry has traditionally been the locus, within medi- 12. Kohut H. The two analyses of Mr Z. Int J Psychoanal 1979;60:
cal education, for teaching of and research on the human 3-27.
encounter that forms the basis of all healing relationships. 13. Kohut H. The restoration of the self. New York: International
As modern psychiatry adopts a posture that is ever more Universities Press, 1977.
scientific and medical, it risks separating itself altogether 14. Brenner C. Working alliance, therapeutic alliance, and trans-
from this area of acknowledged expertise. ference. J Am Psychoanal Assoc 1979;27(suppl):S137-57.
15. Cooper A. Changes in psychoanalytic ideas: transference inter-
Our impression has been that psychiatric residents expe-
pretation. J Am Psychoanal Assoc 1987;35:77-98.
rience a dampening of enthusiasm as they become more
16. Strachey J. The nature of the therapeutic action of psycho-

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experienced with clinical practice. The excitement that they analysis. Int J Psychoanal 1934;15:127-59.
feel when they first realize that they can actually affect 17. Myerson P. The nature of the transactions that occur in other
symptoms and help patients owes a great deal to modern than classical analysis. Int J Psychoanal 1981;62:91-103.
developments in pharmacotherapy. The disappointment oc- 18. Greenberg J. Oedipus and beyond. Cambridge, Massachusetts:
curs when they begin to tangle with the character resis- Harvard University Press, 1991.
tances and relational difficulties -the transferences - in 19. Killingmo B. Conflict and deficit: implications for technique. Int
their patients, difficulties that may affect medication com- J Psychoanal 1989;70:65-80.
pliance and often persist even after medications have had 20. McLaughlin JT. Clinical and theoretical aspects of enactment.
their maximum effect. At this point, they need and want to J Am Psychoanal Assoc 1991;39:595-614.
21. Sullivan HS. The interpersonal theory of psychiatry. New York:
learn how to think about doctor-patient relationships.
Norton, 1953.
As this review shows, the psychoanalytic view of what
22. Gill M. Analysis of transference; vol 1. Psychological issues,
happens in therapy has evolved and deepened. Originally monograph 53. New York: International Universities Press,
conceived as the study of the individual mind, psychoanaly- 1982.
sis is well embarked upon a new project - the study of the 23. Gill M, Hoffman I. Analysis of transference, vol 2. New York:
doctor-patient relationship. We believe that both projects International Universities Press, 1982.
remain of central importance to psychiatry. 24. Gray P. On the technique of the analysis of the superego-an
introduction. Psychoanal Q 1987;56:130-54.
25. Hoffman I. The patient as interpreter of the analyst’s experi-
ence. Contemp Psychoanal 1983;19:389422.

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REFERENCES 26. Freud A. The ego and the mechanisms of defense. New York:

zyx
International Universities Press, 1966.
1. Edelman G. Bright air, brilliant fire. New York Basic Books, 27. Schwaber EA. Countertransference: the analyst’s retreat from
1992. the patient’s vantage point. Int J Psychoanal 1992;73:349-61.
2. Kramer P. Listening to Prozac. New York: Viking Press, 1993. 28. Kantrowitz JL, Katz AL, Greenman DA, Morris H, Paolitto F,
3. Stern D. The interpersonal world of the infant. New York: Basic Sashin J, et al. The patient-analyst match and the outcome of
Books, 1985. psychoanalysis: a pilot study. J Am Psychoanal Assoc 1989;37:
4. Beebe B, Jaffe J, Lachmann FM. A dyadic systems view of 893-919.
communication. In: Skolnick NJ, Warshaw SC, eds. Relational 29. Kantrowitz JL. The analyst’s style and its impact on the
perspectives in psychoanalysis. Hillsdale, New Jersey: Analytic analytic process: overcoming a patient-analyst stalemate. J Am
Press, 1992:61-82. Psychoanal Assoc 1992;40:169-94.
5. Lichtenberg JD. Infant studies and clinical work with adults. 30. Kantrowitz JL. Impasses in psychoanalysis: overcoming resis-
Psychoanal Inquiry 1987;7:311-30. tance in situations of stalemate. J Am Psychoanal Assoc 1993;
6. Emde RN. Positive emotions for psychoanalytic theory: sur- 41: 1021-50.
prises from infancy research and new directions. J Am Psycho- 31. Ogden TH. The analytic third: working with intersubjective
anal Assoc 1991;39(suppl):5-44. clinical facts. Int J Psychoanal 1994;75:3-20.
7. Dupont J. The clinical diary of Sandor Ferenczi. Balint M, 32. McLaughlin JT. Transference, psychic reality, and counter-
Zarday N, transl. Cambridge, Massachusetts: Harvard Univer- transference. Psychoanal Q 1981;50:639-64.
sity Press, 1988. 33. Renik 0. Analytic interaction: conceptualizing technique in
8. Alexander F. Analysis of the therapeutic factors in psychoana- light of the analyst’s irreducible subjectivity. Psychoanal Q
lytic treatment. In: The scope of psychoanalysis 1921-1961; 1993;62:553-71.
 zyx
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zyxwvutsrq
Harvard Rev Psychiatry
74 Kolb, Cooper, and Fishman July/August 1995

34. Freud S.The future prospects of psychoanalytic therapy. In: 50. Schwaber E. Psychoanalytic listening and psychic reality. Int
Strachey J, ed. The standard edition of the complete psycho- Rev Psychoanal 1983;10:379-92.
logical works of Sigmund Freud, vol 11. London: Hogarth 51. Schwaber E. Interpretation and the therapeutic action of psy-
Press, 1910:141-5 1. choanalysis. Int J Psychoanal 1990;71:22940.
35. Freud S. Analysis terminable and interminable. In: Strachey J, 52. Langs R. The bipersonal field. New York Jason Aronson, 1976.
ed. The standard edition of the complete psychological works of 53. Modell A. Other times, other realities. Cambridge, Massa-
Sigmund Freud, vol 23. London: Hogarth Press, 1937:211-53. chusetts: Harvard University Press, 1990.
36. Little M. Countertransference and the patient’s response to it. 54. Meissner WW. What is effective in psychoanalytic therapy: the
Int J Psychoanal 1951;32:32-40. move from interpretation to relation. New York: Jason Aron-

zyx
37. Gabbard G. Technical approaches to transference hate in the son, 1992.
analysis of borderline patients. Int J Psychoanal 1991;72:625- 55. &is AO. Free association. New Haven: Yale University Press,
37. 1982.

zyxwvutsrq
38. Adler G, Buie DH J r . Aloneness and borderline psycho- 56. Gray P. Psychoanalytic technique and the ego’s capacity for
pathology: the possible relevance of child development issues. viewing intrapsychic activity. J Am Psychoanal Assoc 1973;21:
Int J Psychoanal 1979;60:83-96. 474-94.
39. Racker H. The meanings and uses of countertransference. 57. Gray P. On transferred permissive or approving superego
Psychoanal Q 1957;26:303-57. functions: the analysis of the ego’s superego activities; part 11.
40. Searles HF. The effort to drive the other person crazy-an Psychoanal Q 1991;60:1-21.
element in the aetiology and psychotherapy of schizophrenia. 58. Freud S. Letter of November 14, 1897. In: Masson JM, ed. The
Br J Med Psycho1 1959;32:1-18. complete letters of Sigmund Freud to Wilhelm Fliess, 1887-
41. Kernberg 0.Borderline conditions and pathological narcissism. 1904. Cambridge, Massachusetts: Harvard University Press,
New York Jason Aronson, 1975. 1985:281.
42. Sandler J . Countertransference and role-responsiveness. Int 59. Spence D.Narrative truth and historical truth: meaning and
Rev Psychoanal 1971;3:43-8. interpretation in psychoanalysis. New York: Norton, 1982.
43. Guntrip H. Psychoanalytic theory, therapy, and the self. New 60. Schafer R. Retelling a life: narrative and dialogue in psycho-
York: Basic Books, 1971. analysis. New York: Basic Books, 1992.

zy
44. Hoffman I. Dialectical thinking and therapeutic action in the 61. Stolorow R, Branchaft B, Atwood G. Psychoanalytic treatment:
psychoanalytic process. Psychoanal Q 1994;63:187-218. an intersubjective approach. New York Analytic Press, 1987.
45. Cooper A. Changes in psychoanalytic ideas: transference inter- 62. Loewald H.Papers on psychoanalysis. New Haven: Yale Uni-
pretation. J Am Psychoanal Assoc 1987;35:77-98. versity Press, 1980.
46. Tansey MJ, Burke WF. Understanding countertransference: 63. Lear J. Love and its place in nature: a philosophical interpre-
from projective identification to empathy. Hillsdale, New tation of Freudian psychoanalysis. New York Farrar, Strauss,
Jersey: Analytic Press, 1989. & Giroux, 1990.
47. Freud S. Remembering, repeating and working through. In: 64. Modell A. The private self. Cambridge, Massachusetts: Harvard
Strachey J, ed. The standard edition of the complete psycho- University Press, 1993.
logical works of Sigmund Freud, vol 12. London: Hogarth 65. Margulies A. Empathy, virtuality, and the birth of complex
Press, 1914:147-56. emotional states. In: Ablon SL, Brown D, Khantzian EJ, Mack
48. Levine H. The analyst’s participation in the analytic process. JE, eds. Human feelings: explorations in affect development
Int J Psychoanal 1994;75:665-76. and meaning. Hillsdale, New Jersey: Analytic Press, 1992:181-
49. Freud S. The interpretation of dreams. In: Strachey J, ed. The 202.
standard edition of the complete psychological works of Sig- 66. Mitchell S. Relational concepts in psychoanalysis. Cambridge,
mund Freud, vols 4 and 5. London: Hogarth Press, 19OO:l-627. Massachusetts: Harvard University Press, 1988.