"In the neighborhood": aspects of a good interpretation and a "developmental lag" in ego psychology

The significance of the ego in "The Ego and the Id" and its unfulfilled promise

It is not well known that The Ego and the Id, where Freud presented his second model of the mind, and introduced a new role for the Ego, was ignored by many of the major theorists that followed. I will attempt to demonstrate the importance of this new view of the ego for clinical psychoanalysis, and what has been lost by its being ignored.

Mentalization, insightfulness, and therapeutic action: The importance of mental organization

Continuing debates over the relative importance of the role of interpretation leading to insight versus the relationship with the analyst as contributing to structural change are based on traditional definitions of insight as gaining knowledge of unconscious content. This definition inevitably privileges verbal interpretation as self-knowledge becomes equated with understanding the contents of the mind. It is suggested that a way out of this debate is to redefine insight as a process, one that is called insightfulness. This term builds on concepts such as mentalization, or theory of mind, and suggests that patients present with difficulties being able to fully mentalize. Awareness of repudiated content will usually accompany the attainment of insightfulness. But the point of insightfulness is to regain access to inhibited or repudiated mentalization, not to specific content, per se. Emphasizing the process of insightfulness integrates the importance of the relationship with the analyst with the facilitation of insightfulness. A variety of interventions help patients gain the capacity to reflect upon and become aware of the intricate workings of their minds, of which verbal interpretation is only one. For example, often it seems less important to focus on a particular conflict than to show interest in our patients' minds. Furthermore, analysands develop insightfulness by becoming interested in and observing our minds in action. Because the mind originates in bodily experience, mental functioning will always fluctuate between action modes of experiencing and expressing and verbal, symbolic modes. The analyst's role becomes making the patient aware of regressions to action modes, understanding the reasons for doing so, and subordinating this tendency to the verbal, symbolic mode. All mental functions work better and facilitate greater self-regulation when they work in abstract, symbolic ways. Psychopathology can be understood as failing to develop or losing the symbolic level of organization, either in circumscribed areas or more ubiquitously. And mutative action occurs through helping our patients attain or regain the symbolic level in regard to all mental functions. Such work is best accomplished in the transference. The concept of transference of defense is expanded to all mental structure, so that transference is seen as the interpersonalization of mental structure. That is, patients transfer their mental structure, including their various levels of mentalizing, into the analytic interaction. The analyst observes all levels of the patient's mental functioning and intervenes to raise them to a symbolic one. At times, this will require action interpretations, allowing oneself to be pulled into an enactment with the patient that is then reprocessed at a verbal, symbolic level. Such actions are not corrective emotional experiences but are interpretations and confrontations of the patient's transferred mental organization at a level affectively and cognitively consistent with the level of communication. Nonetheless, the goal becomes raising the communication to a symbolic level as being able to reflect symbolically on all aspects of one's mind with a minimum of restriction is the greatest guarantee of mental health.

Questioning Authority in the Psychoanalytic Classroom

Psychoanalytic educators today, like their predecessors who trained them, struggle to maintain respect for and make use of candidates' various kinds of professional expertise while offering instruction in "the subject." But unlike their predecessors, today's educators teach in the wake of various challenges to authority and knowledge in recent decades from across the disciplines. Some of the most important work of teaching in this context begins when teachers recognize that they have assumed the position of objectivity in the classroom--that they have closed down the possibilities for open discussion--and figure out (with and in front of their students) what to do next.

On learning to inquire: Revisiting the detailed inquiry

This paper describes the author's experience of initial disorientation when encountering for the first time in supervision an interpersonal analytic approach with an emphasis on active questioning of the patient through the use of a detailed inquiry. This initial disorientation is linked to a predominant trend in psychoanalysis that generally opposes the use of questions as a significant means of analytic interaction. In contrast, Interpersonal approaches that make free use of inquiry are discussed in light of the author's clinical experience that learning to inquire contributed to a more finely tuned awareness of the analytic process.

Child versus adult psychoanalysis: two processes or one?

Child analysis continues to be seen as a different technique from adult analysis because children are still involved in a developmental process and because the primary objects continue to play active roles in their lives. This paper argues that this is a false dichotomy. An extended vignette of the analysis of a latency-aged girl is used to demonstrate that the psychoanalytic process that develops in child analysis is structurally the same as that in adult analysis. Both revolve around the analysis of resistance and transference and use both to promote knowledge of the patient's mind at work. And both techniques formulate interventions based on the analyst's appraisal of the patient's mental organization. It is hoped that stressing the essential commonality of both techniques will promote the development of an overarching theory of psychoanalytic technique.

The contribution of the analyst's actions to mutative action: a developmental perspective

The concept of action has evolved since Freud's initial attempts to adticdress the topic. It is no longer viewed as just serving a defensive function. Instead it is increasingly seen as a mode of experiencing and n, communicating, one that is less developmentally advanced than the verbal one usually emphasized in psychoanalysis. Research from many fields documents the view that experiencing, thinking, and communicating originate in bodily action. Hence psychoanalysts have learned to use the patient's actions to broaden their understanding of the patient and to deepen the analytic process. But they have been slower to apply this understanding to their own actions. This paper uses an extended clinical vignette of an action intervention by the analyst to demonstrate its importance in maintaining and deepening an analytic process. It then suggests a theoretical and clinical rationale that such action interventions are a common and necessary aspect of most analyses. Finally it raises the question of whether such interventions can be regarded as interpretations offered at the developmental level being used by the patient to communicate at particular moments in analysis. Can they be viewed as the initial interpretation in the process of interpretation?

A shadow concept

The author focuses on the significance of preconscious thinking, and its relationship to what we think of as unconscious fantasies. He reopens Freud's forgotten struggle with preconscious thinking, while he explores preconscious thinking as the basis for thinking about psychoanalytic treatment. This includes our goals in bringing an idea to the analysand's attention, and the role of transitional space where thoughts and feelings can be played with.

Analyst as teacher / teacher as analyst: a confusion of tongues?

An ad hoc volunteer force, psychoanalytic educators must make do with little formal preparation in teaching methods before they enter the classroom. When they inevitably encounter common pedagogical problems, they often attribute their difficulty to a personal failure or the recalcitrance of candidates, but rarely to a lack of instruction in the craft of teaching. Given this situation, how can analysts who spend most of their time with patients learn to lead productive classroom discussions? How can they enhance participation when discussions become stale and strained? Most important, how can they determine whether candidates actually learn something in their classes? It is only slight exaggeration to say that the answers to these questions cannot be found in the thousands of pages that the profession has devoted to the subject of psychoanalytic education. A supplementary literature of psychoanalytic education is proposed that would directly address pedagogical issues through close attention to the goals and outcomes of courses and through case studies of moment-to-moment interactions in the classroom.

Paul Gray's narrowing scope: a "developmental lag" in his theory and technique

A cental thesis of Paul Gray's work is that a "developmental lag" pervades modern psychoanalysis in its failure to assimilate and apply knowledge gained about the role of the unconscious ego in intrapsychic life. But Gray himself, it is proposed, has become a victim of a new "developmental lag," of his own construction. As he somewhat single-mindedly pursued the ramifications of his "developmental lag" concept, Gray may have foreclosed on some noteworthy ideas developing around him. The most important example is his claim--herein refuted--that proper interpretive technique can avoid being infused with transference. He also seems to have rejected the theoretical importance of the internalization of the analyst and the clinical usefulness of countertransference. While emphasizing defense analysis, he ignores defenses such as splitting, denial, and disavowal as substantive problems for his technique of close-process attention. Gray's "undoing" of the rapprochement between "ego analysis" and "id analysis" by viewing the matter as an either-or proposition undermines the very real value of his contribution to the field.

How can we know what we need to know? Reflections on clinical judgment formation

What distinguishes a psychoanalyst from any other psychologically minded, empathic human being? This seemingly simple question goes to the heart of our profession, the way we see ourselves as competent clinicians. To understand a patient's material beyond ordinary empathy--that is, to come to a clinical judgment--we need to step out of the dyadic, countertransference situation and reflect what we've experienced in reference to our clinical theories. An analytic vignette shows how a theoretical background can be used to understand and interpret to a patient in a way that is deeply meaningful.

A new model for conceptualizing insightfulness in the psychoanalysis of young children

Traditional definitions of insight fail to take into account the cognitive and developmental limitations of young analysands, who lack the capacity to mentalize. It is suggested that insightfulness be redefined as promoting mentalization in young children. Gaining this key psychological function furthers the internal integration and self-regulation necessary to regain developmental momentum. The central importance of promoting such development in child psychoanalysis suggests that the facilitation of a mechanism for self-understanding, not the interpretation of content, is essential. Insightfulness is facilitated by employing a range of interventions beyond the interpretation of resistance and content, rendering meaningless the distinction between interpretive and relational aspects of the analyst's role.

Back to the future

Significant components of psychoanalytic technique, and the theory that underlies it, seem to remain buried in our past, but are central to the growth of psychoanalysis as a treatment method based on understanding a patient's mind. By updating technique based on a theory of mind with structure, the author views the increasing freedom of the patient's mind as central to the curative process, and takes the position that in interpretive work, the analyst needs to pay more attention to the patient's capacity to meaningfully receive and integrate the analyst's interventions.

Conceptions of conflict in psychoanalytic theory and practice

There are many different views of conflict in contemporary psychoanalysis, each with its own technical implications. After reviewing the psychoanalytic origins of the concept of conflict, the author discusses the diverse positions of four North American conflict theorists, each of whom offers a different view of the location of conflict both in the mind of the patient and in the material of the clinical hour. The role of conflict in the work of several relational psychoanalysts is then examined. A tentative approach toward integration is proposed.

Telling stories

Patients need to tell their stories. One of our primary tasks as analysts is to help patients tell their stories and own them. The freedom of mind to think, to feel, and to know are dependent on the ongoing capacity for storytelling. The analyst's stance plays a major role in the development of the analysand's storytelling capacities.

On trying something new: effort and practice in psychoanalytic change

This paper describes one of the ingredients of successful psychoanalytic change: the necessity for the analysand to actively attempt altered patterns of thinking, behaving, feeling, and relating outside of the analytic relationship. When successful, such self-initiated attempts at change are founded on insight and experience gained in the transference and constitute a crucial step in the consolidation and transfer of therapeutic gains. The analytic literature related to this aspect of therapeutic action is reviewed, including the work of Freud, Bader, Rangell, Renik, Valenstein, and Wheelis. Recent interest in the complex and complementary relationship between action and increased self-understanding as it unfolds in the analytic setting is extended beyond the consulting room to include the analysand's extra-analytic attempts to initiate change. Contemporary views of the relationship between praxis and self-knowledge are discussed and offered as theoretical support for broadening analytic technique to include greater attention to the analysand's efforts at implementing therapeutic gains. Case vignettes are presented.

What is a deep interpretation?

Important differences are emerging regarding the place where analysts believe the most meaningful analytic work takes place. One area that highlights these distinct ways of working is the analyst's view of deep interpretations. Models underlying the differing perspectives on this issue are presented, along with an extended clinical example that illustrates the importance of considering, in formulating analytic interventions, the concept of a structured mind. A view of the analytic process that accords the patient's perspective greater privilege is introduced.

Superego defense analysis in the termination phase

This paper is a contribution to recent efforts to identify areas in clinical theory and practice in which the analyst's authority is used, rather than analyzed, to achieve therapeutic results. In the termination phase there may occur an intensification of transferences of authority (superego transferences) in response to the aggression inherent in termination. Analysts may develop counterresistances to analyzing these defense transferences, since their analysis exposes the analyst to the patient's heightened aggression at termination. The literature on termination may have contributed to analysts' falling short in analyzing these transferences, by its having accorded internalizing mechanisms a prominence in the therapeutic action of termination that they otherwise lack in contemporary ego psychological theories of therapeutic action. Gray's formulation of the superego as an analyzable defensive activity is applied to events in the termination period, thereby bringing into focus conflicts over aggressive impulses defended against by superego forces. Clinical vignettes from the termination phase of an analysis are presented.

Understanding the patient's use of the method of free association: an ego psychological approach

While most of our methods of listening have been geared toward unearthing unconscious fantasies, those directed toward the ego's all-inclusive role in effecting the associative process have lagged far behind. It is the thesis of this paper that listening from the perspective of the ego allows the analyst to work more closely with what the patient is ready to understand. Clinical technique, using an ego psychological view, is elaborated, demonstrated, and compared to technique dependent on the reading of signs and symbols of the unconscious.

The ego and its significance in analytic interventions

Freud's view of the ego as Januslike, the one component of the psychic system turned toward the external world yet partly unconscious, should have insured its centrality in clinical interventions. However, history and experience do not bear this out. It is argued that a core part of the change process in analysis lies in the modifications that occur in ego functioning, making it necessary to carefully consider the role of the ego in clinical technique. Numerous clinical examples are presented to show the manner and significance of such an approach.

Beginning a psychoanalytic treatment: establishing an analytic frame

The opening phase of analysis has received scant attention. Freud initially included, as essential, the establishment of an analytic process via the method of free association in the opening phase. However, his stance in relation to this process we can now characterize as authoritarian, and as influenced by suggestion and manipulation. Recent literature, while contributing to the understanding of the range of dynamics possible when beginning an analysis, continues to ignore the manner in which the method of free association may be used by both participants in establishing an analytic frame. Two clinical examples of how this latter process may be inaugurated are given, and reasons for the drift away from it are suggested.

On focused association and the analytic surface: clinical opportunities in resolving analytic stalemate

Focused association is a technique for exploring repetitive noncommunicative phenomena, especially those which occupy center stage during periods of analytic stalemate. This psychological content is studied by a two-part investigation of the particulars of the presenting "surface," involving (1) focusing and (2) association. The technique was originally devised by Freud to access the latent meanings of dreams. The effort departs from free association, calling upon more active analytic teamwork within a transference-countertransference context that is steadily considered and analyzed. The key "unverbal" material arising from this dyadic flux is descriptively preconscious, multimodal, widely variable in form, and not primarily lexical. A frequent finding is that these repeating ad hoc clinical phenomena, often categorized as resistance (especially transference resistance), are highly condensed and defensively rearranged compositions, like dreams, that have been internally structured by processes akin to dreamwork. Approached by focused association, such content yields unconscious derivatives that previously had been sequestered in repetitious, noncommunicative forms. This work allows the analyst to follow Freud's clinical maxim to "start with the surface" and provides relief for the analyst from the temptation to invoke global resistance interpretations when derivative communication and analytic movement have lapsed.

Do actions speak louder than words? A query into an enigma in analytic theory and technique

While action is increasingly viewed as ubiquitous throughout psychoanalytic treatment, our understanding of why it occurs is limited by rudimentary views of verbalization and action. Dynamic and genetic interpretations of action, usually given at a time of resistance impasse, give only a partial explanation of the phenomenon. The question is explored of why the behavior may appear in the form of action, as well as its implication for interpretive strategies. A major premise is that the role of the ego has been overlooked, especially modes of thinking associated with earlier developmental levels.

Some ambiguities in the method of free association and their implications for technique

The method of free association, rooted in the topographic model, has not been clearly defined in structural terms. Little changed since Freud; the method is geared toward overcoming rather than investigating resistances. Furthermore, it is designed to discourage rather than encourage self-analysis. This seems to be another example of a "developmental lag" in adapting the psychology of the ego to clinical technique.

Recurring thoughts on unconscious ego resistances

Analysis of the unconscious ego resistances is one of those clinical concepts more honored in the breach than in the observance. This same point has been made periodically over the past fifty years. It has not been sufficiently realized that a true psychoanalytic understanding of resistance analysis could only begin with Freud's second theory of anxiety. Freud himself never fully embraced this theory, and clinical contributions since then have varied in their ability to use the techniques inherent in the second theory of anxiety. Recent contributions to the literature have not eliminated the espousal of theories of resistance based on earlier views of anxiety. Reasons cited for this include: the ambiguities in Freud's writing, the direction of the early ego theorists, and proclivities toward deeper interpretations.