Notes from Professor Edward Lichtenstein

Introduction

Psychoanalysis is at least three things: A theory of behavior, a theory of psychopathology, and a theory and technique of psychotherapy. The theory and techniques of therapy are inextricably tied to the notions of psychopathology. This is true of any form of treatment; all treatments make assumptions about the nature, origin or maintenance of deviant behavior and this directly implies the necessary remedies. For example, Wolpe, believes deviant behavior largely to be conditioned anxiety responses. The treatment that naturally follows from this formulation is one relying on counter-conditioning. Similarly, the Skinnerian who believes deviant behavior to be die to a faulty reinforcement history, naturally believes the required course is to alter the nature of the individual's reinforcements. (It should be noted, however, that the success of the treatment does not prove the theory of etiology.)

I will assume some familiarity with psychoanalytic theory and therefore not go in to the notions of psychopathology. (For those not having any background here, I would suggest a book by Charles Brenner, An Elementary Textbook of Psychoanalysis; or alternately the first 100 pages or so of Otto Fenichel's Psychoanalytic Theory of Neurosis.)

Briefly, psychoanalytic concept of psychopathology is focused around three concepts: conflict, anxiety, and defense or as Colby puts it, wish - defense conflicts. Analytic therapists assume as follows:

(1) Mental illness derived from otherwise insoluble intrapsychic conflicts.

(2) These intrapsychic conflicts are largely unconscious.

(3) The unconscious intrapsychic conflicts are related to early childhood experiences and represent inadequately resolved infantile conflicts. Psychoanalytic techniques are derived from or based upon these fundamental assumptions.

Number of analysts:

Some statistics are helpful in putting psychoanalysis in perspective. Schofield stated there was slightly over 1000 members of the American Psychiatric Association with 50 to 75 additional members joining each year. He noted that the average year upon completing training, was 35 and that an analyst might see 200 patients in his lifetime if he specialized in analytic therapy. Schofield noted that analysts played a significant role as teachers (especially in medical school) and to a lesser extent as researchers but commented "their direct contribution to the care of the mentally ill has been insignificant and will probably continue to be so." Hunt presented slightly different but not really incompatible figures. He stated there were 1700 medical analysts and 700 to 1000 lay analyst totalling 2500 to 3000 working analysts. He estimated that with this work force there were no more than 20,000 to 24,000 persons getting analyzed at the current time. Hunt also acknowledged the limited role of analysts in curing mental illness but stressed more than Schofield the intellectual influence of psychoanalytic thinking. It is true that psychoanalytic psychodynamics have been exceedingly influential in the mental health field and that countless thousands of therapists in various professional allegiances utilized these concepts in their therapeutic work, and this continues to be true and this is the major justification for devoting considerable time to this course.

Helpful here is the distinction between psychoanalysts and psychoanalytically oriented therapy. Psychoanalysis is used here to refer to the pure thing: three to five times a week on the couch for three to five years. Greenson's book concerns this form of treatment. Colby is talking more about psychoanalytically oriented psychotherapy. That is, there are many therapists who utilize similar theories of neurotic conflicts and defense but modify psychoanalytic threat considerably. Their treatment is shorter, they make less use of free association, focus less on childhood experiences, and dreams, often set more modest treatment goals. In these lectures I will speak more about pure psychoanalysis but sometimes switch back and forth hopefully making explicit when I do so. The reason for the emphasis on "pure" psychoanalytic theory is again because of its intellectual influence.

Who should be accepted for treatment? (Pure psychoanalysis:)

The analytic patient should be not psychotic, because uncovering therapy requires considerable ego strength and flexibility and the capacity to form a stable transference. He should be between the ages of 16 and 50. He should be old enough to have formed a very stable personality pattern and defenses and yet not so old so as to have become to rigid and inflexible in his defenses. He should be fairly intelligent and verbal because of the requirements for verbal expression required by the treatment. He should not be sociopathic because the treatment requires a control of impulses not acting them out but rather expressing them in words in the confines of treatment situations. He should be relatively independent in the sense of both "financially and psychically," so that the course of the analysis will not be buffeted by external forces (such as the parents suddenly refusing to pay the bills any more). He should be experiencing considerable stress in order to motivate him for the work of treatment. Indeed this is a very important requirement because analysis is an exceedingly difficult and expensive undertaking and requires a highly motivated patient. Moreover, the illness or the symptoms should have relatively little secondary gain value accruing to the patient. For if his symptoms or distress are winning him reinforcements, he will be unmotivated or less motivated to change. The analytic patient must be willing and able to observe himself. A certain amount of psychological mindedness is necessary. He must be able to pay and indeed it is preferable that the payment not be dependent on current income. Otherwise treatment is likely to be interrupted if current income is affected by some external circumstance. He should not be a friend or colleague because this would foul up the transference, and although he must be subjectively distressed and uncomfortable to motivate him, he should be able to forego immediate systematic relief because analysis will not necessarily bring him this. In effect, he must be able to accept the idea that his symptoms of distress are due to internal conflicts of long standing duration which are tenacious and will change slowly, and that he must be willing to tolerate his symptomatic distress for as long as is necessary to bring about a more fundamental changes in psychic structure.

A frequent critical response to the above listed criteria is something like "so who needs treatment." This is the accusation that analysts see relatively normal persons. This is a somewhat controversial issue - the question of whether analysts see more difficult cases or less difficult cases. Analysts reply that persons only undertake the arduous task a last resort when they have tried everything else. Therefore their patients are quite difficult to treat. This kind of explanation is often invoked to explain relatively modest success rates. Critics counter with the criteria that analysts use in their careful selection procedure. It does seem to be true that many persons undertake analysis for relatively less severe problems (for example, candidates in the analytic institutes must get analyzed). However, my own impression is that analysts do indeed see very troubled persons often with character disorders many of whom could be justifiably labeled as severely neurotic. It might be noted that there is no mention of the overt attitude of the patient as a criteria. This is because of the theories emphasis on unconscious motives.

Aspects of the Psychotherapeutic Contract:

In therapy the client pays his money and agrees to certain conditions in return for professional help (not a cure or necessarily the promises of a cure). The details of the contract or what the client agrees to are very important and often neglected in discussions of therapeutic principles and techniques. For example, analysts typically take a careful history including much developmental information in order to get information to determine whether analysis is a suitable treatment. The therapeutic contract is, I think, a very general phenomena and it is to the analysts credit that he is often more explicit about it than other therapists.

Freud, and many current analysts advocate the "leased-time" procedure wherein the patient pays for the analysts time so many days per week whether he comes in or not. Three reasons can be cited for this: (a) self-interest of the analyst, he has to make a living; (b) the deterministic assumption of analysis and the emphasis on unconscious motivation lead to the assumption that all missed meetings are in one sense or another due to resistance; (c) and relatedly, the leased-time procedure will help reduce such resistances. Analysis also requires frequent sessions. Six days a week was customary among early analysts, four is more common now. Such frequent sessions are necessary to maintain continuity, to help overcome resistances, and the patients willingness to meet such a schedule assures that he is likely to have the necessary motivation. An analyst in a sense assumes that the analysis will become the most important thing in the patient's life.

Fees:

A high fee coming out of the patient's own pocket is believed essential for analysts. Again this derives from the emphasis on unconscious processes and unconscious resistances. To insure the necessary motivation to overcome such resistances the analysis must hurt the patient financially if possible. Analysts are very artful in erecting theoretical justifications and rationales for fees. Some of these make sense, some of these may seem a bit forced. They assert that the analyst is unafraid to cast aside false shame and take a sure and honest position about his need for money. It is also asserted that the analyst conveys that he is an open mature person with appropriate self-esteem by asking for and demanding a high fee. I urge you to read Carl Menninger's book pages 33 to 35 for an excellent summary of the psychoanalytic reasoning about fees.

Several other matters are usually discussed in the contracts or negotiation stage. The probable time or length of treatment is usually communicated to the patient. Whereas many of Freud's analysis were conducted in six months or a year, the custom now is three to five years. The patient is also forewarned about some of the difficulties or traumas of treatment: that he may get worse before he gets better and that he can expect some upsets. Related to this he is told that he should not make any important decisions or major changes in his life (e.g., getting a divorce, changing jobs) without first discussing the issue in analysis. He is warned that under stress of intensively examining himself he may feel impulses to make such changes or decisions and he must guard against this. Finally, there is the somewhat controversial issue of the "trial period." Some analysts advocate telling the patient very clearly that he can stop any time because they want to place the motivation and responsibility on him. Others feel that a trial period is appropriate from the analysts point of view in order to determine whether the patient is really suitable. On the other hand, it may be undesirable to warn the patient of this since it may make him overly defensive and self-conscious. The general consensus does seem to be that the first several months of the analysis do constitute a kind of trial on the basis of which both patient and doctor decide whether to go further. Some patient behaviors during this trial period that would cause the analyst concern would be: great difficulty or blocking in free associating, acting out behavior outside the therapeutic sessions.

Requirements for the analyst:

The analysts must have a thorough knowledge of psychoanalytic theory, have undergone his own personal analysis, and have completed the successful analysis of the patient under the supervision of a analytic teacher. He should have a sharp memory and be able to comply with Freud's instructions about maintaining an evenly distributed free-floating attention as he listens to his patient's productions. Menninger offers an interesting requirement in addition. He states that the analysts must have a kind of restraint, a freedom from the "desire to cure." He must somehow communicate to the patient the attitude that "I don't want you to do anything, rather it is you that must decide whether you want to do the necessary work in order to get well." Greenson places great emphasis on the importance of the analyst understanding and being sensitive to the unconscious, both his own and the patients.

Goals:

In looking at the various therapies we shall be concerned with what their goals are and who chooses them. Colby states the goals of psychoanalytic therapy as "Relieve the patient of distressing neurotic symptoms or discordant personality characteristics which interfere with his satisfactory adaptation to the world of people and events." Elsewhere Colby talks about modifying wish-defense systems. Another analytic writer states that the goal is "the correction of Psychopathology - of the pathological area of the dynamics - the pathodynamics which consists primarily of disordered emotional patterns of reactions to other persons formed especially prior to about age 6" (really around ages 4-6, oedipal issues). Essential feature of these goal statements is the emphasis on internal states and the rearrangement of or altering of internal states as the fundamental goal.

In a general way all therapies have the foal of relieving suffering or symptoms. Analysis assumes that symptoms are functions of unconscious conflicts or wish-defense conflicts that have infantile origins.

The essential goal of psychoanalytic treatment is to uncover and understand the infantile origins of the unconscious conflicts or to produce insight because that is their definition of insight. In a sense, this is the goal of all psychoanalytic treatments-that is, it applies to all analytic patients - and is chosen by the therapist because it is dictated by the analysis theory. However, analysts would argue that the patient then has the choice of what new behaviors or new ways of responding he wishes to substitute for the maladaptive behavior that is now understood and hopefully dispensed with. Thus, in another sense, it is also the goal of analysis to change behavior but analysts are reluctant to use behavior change as a fundamental criteria because of some of the considerations just mentioned, and also because they would argue that overt behavior may be subject to various situational influences and may not be a direct or valid reflector of the brought about changes in intrapsychic states.

Having conducted a diagnostic interview or set of interviews agreed on analysis and worked out details of the contract, the analyst and patient are ready to begin. The analysis proper begins with the patient assuming his place on the couch and beginning to free associate.

The Couch:

Use of the couch is one of the defining characteristics of analysis. Freud noted that he resorted to this techniques because he could not bear to be looked at for many hours a day. However, the couch can be construed to serve some useful functions in the treatment.

1. The couch helps accentuate the uniqueness of the analytic situation where his old ways of responding are not very adaptive and he must use different resources.

2. The couch may be said to represent a mild or moderate stimulus deprivation situation since it reduces the input to the patient. Because the ego is receiving less external stimulation and therefore will be more sensitive to internal stimulation, that is, unconscious impulses and fantasies which are at the heart of the analytic work.

3. Both of these, in turn, help to facilitate regression. Regression may be defined as the "emergence of more primitive, varied wishes in the employment of techniques that once applied to expectations of other kinds from other persons for whom the therapist is substituted." Remember that infantile conflicts and coping mechanisms are the crucial concern. The patient is talking to an invisible, relatively non-responding person. This is inevitably a frustrating situation which as Menninger terms it as "unfavorable balance of trade." Thus the patient is thrown back on more primitive ways of coping, ergo the term regression.

4. And related to 3 above, the use of the couch facilitates the development of the necessary transference neurosis. Since the analyst is our of sight and admits relatively few cues about himself, the way is paved for him to fantasy about the analyst and he is less able to reality test his fantasies and projections. To put in another way, the more ambiguous the therapist remains, the easier it is for a transference relationship to develop.

Finally a possible disadvantage of the couch may be mentioned. This is the problem of the patient isolating the analytic hour as some kind of magic ceremony or ritual that is cut off from life. This possibility is beautifully caricatured in a novel by Lillian Ross titled Vertical and Horizontal.

Free Association:

This is the primary technique for eliciting responses and is the primary task of the patient. It is a technique for getting at (but indirectly) unconscious processes which are the focus of treatment. Note that Freud had earlier used other techniques for getting at repressed material: hypnosis and what might be termed pressure techniques wherein he would hold or rub the patient's head and command him to remember. These earlier techniques were associated with earlier versions of psychoanalytic treatment which focused on the id and getting material our of the id into consciousness. As psychoanalysis became more of an ego psychology, and focussed more on resistances, the free association became increasingly more important.

Bordin describes the function of free association as follows: "The intent of the basic rules is to provide a situation maximally conducive to laying bare these internally organized systems by minimizing the influence of external (situational) determinants."

The basic rule and the physical setting (the couch, etc.) reduce censorship by the ego but do not completely remove it. It is assumed that the content of the patient's speech will mirror the ebb and flow of the wish-defense (or one might term them approach-avoidance) conflicts. The patient's unconscious conflicts are assumed to produce derivatives in his talk. Derivatives occur when repressed impulses push toward consciousness and displace their cathexis on to associatively connected ideas that are less objectionable to the conscious ego. According to ideas that are less objectionable to the conscious ego. According to Fenichel, in analysis these pre-conscious derivatives are encouraged and caught by the observing ego and thus the repressed becomes known.

An interesting paradox. The basic rule (free association) is made to be broken. If one followed it perfectly it would be an indicator that one had no conflicts. The analysts doesn't expect that free association will lead to unconscious material directly but rather that free association will lead to defenses or resistance, that these will be interpreted, and give clue to more material, more defenses, and so it goes. Put another way, the patient's difficulties in free associating, blocking, etc. are extremely important clues and material in and of themselves.

Research on Free Association:

Relatively little empirical research has been done on free association, somewhat surprising in view of its importance in psychoanalytic therapy. However, some of the data are relevant to the "blank screen" issue. Analysts use their patient's behavior as the primary data for theory construction. They act as if they are observing "emitted behavior." That is, organismically produced behavior that is not affected by the situation. Evidence that the verbal behavior of analytic patients is indeed influenced by situational variables therefore has important theoretical implications.

I shall briefly describe three studies on free association: Temerlin (Journal of Abnormal and Social Psychology about 1956) tried to predict individual differences in the ability to free associate. He had therapists rate how variable, flexible, and productive was the free association of their patients during the first 20 sessions. The patients were then placed in the autokinetic affect situation. He found that good associaters (as nominated by their therapist) were more variable (i.e. flexible) in their autokinetic affect reports.

A study by Colby (Behavioral Science, 1960, 5, 195-210) is of interest. He hypothesized that free association would be affected by the two person relationship. Eleven paid subjects between the ages of 23 and 30 with no previous analysis were studied for four sessions a week for three weeks. During week one the subjects were given free association instructions and free associated with only a tape recorded present. During week two, the experimenter entered the room and silently sat down after 15 minutes. Week three was a repeat of week one (so we have an analyst carrying our an ABA design). The basic data analysis compares the two halves of the week two (experimenter absent - experimenter present) and compares these different scores to comparable different scores from week one and three where the experimenter was present during both halves. He found that in the second half of week two there was a significant increase in "personyms" (his term for the names of significant figures in the subject's life). Such an increase in week two-second half for talk about the observer of the experimenter but this occurred only during the first session of week two. When this was controlled for it did not affect the presence of an observer was sufficient to activate "imago" systems was confirmed. Imago is his term for intrapsychic representations of important figures.

The third study on free association is one by Bordin and since this is out of the reading list it will not be described here. You should read it and I will hand out in class some materials relevant to this study. Resistance:

As the patient tries to free associate the analyst remains neutral, a blank screen and gives the patient's productions "evenly divided attention". Inevitably resistance emerges. Resistance represents avoidances or defenses. Resistance may be defined as "a defense operating against, the efforts of therapy" or as whatever disturbs "the progress of the work" or as the patient's failure to comply with an agreed upon rule of the game.

Resistances permit the patient and therapist to observe in situ the patient's defensive or avoidance behaviors. Examples or resisted behavior would be: difficulty in free associating, quarreling about the rules of the game (e.g. scheduling), lateness or absence, avoiding certain topics. The occurrence of resistances gives the analyst clues to sources of the patient's anxiety, that is what produces the resistance. However, the analyst is cautious in approaching these sources of the resistance and first focuses on and interprets the resistance itself. This is a fundamental rule of analysis: Interpret resistances first, content later.

The occurrences of resistances is facilitated by the therapeutic regression noted earlier which in itself is facilitated by the "control frustration" in the analytic situation. As noted, this frustration arises because the patient experiences "unfavorable balance of trade". He cooperated, gives of himself and gets back very little. As Menninger puts it: "Attention, audience, toleration, yes - but no response, no reaction, no advice, no explanation, no solution, no help, no love," Freud put it in this way (and I paraphrase): the patient's frustrations are what made him ill and his symptoms are substitute gratifications. Therefore Freud concluded that "it is expedient to deny him precisely those satisfactions which he desires most intensely and experiences most importunately."

Menninger put it thusly: "the analyst must abstain from responding to the patient's pleas, charges, maneuvers, requests and demands in the way he would were this a social relationship and the patient must experience the denied satisfaction. For so far we have come upon no better method for allowing the patient to discover is style of and his conditions for "loving and hating."

Note that it was stated earlier that the frustration is controlled (analysts like to use the term titrated). The extent to which the analyst responds to some of the patient's demands is a function of his judgement of the patient's ego strength and his judgments about issues of timing in the therapy. The analyst recognizes that to be too depriving and frustrating could produce excessive anxiety and hostility and prevent the development of the appropriate working alliance. On the other hand, if he gratifies the patient too much, he will defeat the ultimate purpose of the analysis and mess up the transference. On pages 58 and 59 of his book (Theory of Psychoanalytic Techniques), Menninger gives a good patient view of the regression frustrations situation in the analysis. Menninger also provides a nice schematic outline of kinds of resistances that are encountered along the course of analysis and this will be given to the class as a hand-out.

Transference:

"The unrealistic roles or identities unconsciously ascribed to a therapist in the regression of psychoanalysis and the patient's reactions to this representation derived from earlier experience." Transference is one kind of resistance and one aspect of the regression. They are reactions or feelings that the therapist has not ilicited (remember E is to be a neutral blank-screen) but rather that are learned early in life particularly toward ones parents and are unconscious and irrational. that is, the patient transfers to the therapist, feelings, reactions etc., that were appropriate to a previous time and a previous place. The analyst recognizes that the patient's responses to him are partly determined by realistic perceptions of him and his professional role. However, he tries to avoid giving the patient more cues than these. Two major kinds of transference are generally recognized: positive and negative.

The transference neurosis refers to the situation where the patient's conflicts become centered on situational events in therapy and the therapist. That is, the patient manifests in situ his maladaptive modes of behavior, defenses, wishes, etc., and manifests them toward the therapist. The patient's ability to develop and tolerate such a transference is highly important because transference reactions give the analyst important information or clues to conflicts impulses and defenses. And most importantly, the interpretations of the transference are usually viewed as the most crucial. As Colby puts it "of all the interpretation made in therapy, none carries greater weight in modifying defenses." This is so because of the intensity of the feelings and the fact that the feelings, inappropriate ways of responding are right there in the office and can be observed by both patient and therapist. As Freud put it, you can't slay the enemy in abstentia. One should note here and throughout the discussion of analysis, the emphasis that analysts play on experiential learning. Defenses, transferences, etc., are not really talked about in the abstract, they are as far as possible to be experienced at the moment and thereby examined, understood and modified.

When is the transference used? Generally analysts are cautious in approaching the transference and do so when strong resistances develop such that the analysis seems to be faltering. Another general rule of thumb in analysis is to interpret resistances at the point of least resistance so to speak. That is to chip away at the most accessible resistances first. Since transference is the most loaded of the resistances, it is approached more cautiously. As long as the analysis seems to be progressing, the therapist is not likely to focus on the transference even though he will be aware of its development. One must keep in mind here, the long haul of analysis and remember that the therapist can assume that he has a great deal of time.

Why does the transference develop? For the large part we have already answered that by describing the ambiguity, frustration, and inevitable push of infantile conflicts that occur in analytic therapy. That is, the same reasoning that was used to explain the role of frustration and the inevitable development of regression in analysis also explains the emergence of transference. Typically, the patient develops a mildly positive transference in the early stages of analysis (there is the expectancy of help and the optimism that one usually sees in the beginning of projects), this then turns into a negative, often strongly, so transference toward the middle of the analysis (one gets discouraged that the analyst is so unresponsive, etc.), and hopefully evolves back toward a more realistic and somewhat positive attitude toward the therapist at the end of the analysis. In terms of the ebb and flow of positive and negative feelings, I would suggest there are some similarities between analysis and the student-adviser relationship in thesis or dissertation research.

A term sometimes used by analysts is, transference cure. This refers to rapid symptomatic improvement due to the particular nature of intensity of a transference conflict. It is seen as a resistance and is frequently used to explain sudden symptomatic improvements during the early stages of treatment and also sometimes used to account for spontaneous remissions. That is, it is assumed that the patient has lost his sym as a defensive maneuver to avoid the painful work of analysis and to justify his terminating treatment. The concept of transference cure nicely points up the analytic emphasis on intrapsychic change rather than a automatic change. Transference cure is also a concept used by analysts to explain the apparent success of other shorter term therapies quite frequently.

Finally one must mention the concepts of counter transference. These are unconscious inappropriate feelings transferred to directed to the patient by the therapist. They too are derived from infantile unconscious conflicts and can also be said to represent unanalyzed or unsolved hang-ups of the therapist. It should be emphasized that the therapist does and must use his reactions to the patient as an important source of data. Indeed, the therapist should let his unconscious and preconscious resonate to the patient's productions as a means of better understanding them. As long as this activity is reasonably well under the analyst's conscious control, it is not counter transference. Counter transference is an unconscious reaction elicited by the patient determined by the he analyst's own blind spots. The personal analysis undergone by the analyst as well as occasional supervision helped guard against this. Some signs of counter transference are: Inability to understand the patient, carelessness in regard to arrangements and appointments, drowsiness, being too afraid of losing the case, arguing with the patient and dreaming about the patient.

Counter transference notions have generated a fair amount of empirical research and this would be an appropriate subject for one of the research papers.

Interpretation:

This is the principle intervention and primary technique for changing intrapsychic structure and thus behavior. Interpretation is any therapist's statement which has the intent or function of confronting the patient with something new about himself. Psychoanalysis and client-centered therapy disagree most sharply (at least the older client-centered therapy) over the question of whether interpretation is of positive or negative benefit. The purpose of interpretations are to make unconscious material more conscious, to make the patient more aware of his defenses or warded off instincts.

Interpretation has had much written about and several ways of classifying interpretations have been offered. One scheme would be in interpretations, transference interpretations, content interpretations, or dream interpretations. Al of these kinds of interpretations are of course utilized in analysis or psychoanalytic therapy. Another scheme would be to classify them in terms of the style of the interpretation as Colby does.

1) clarification (interpretation): This is when the therapist helps the client focus on a theme, or sort out a theme or helps him crystalize a thought or idea that he has been speaking around. You should consider possible similarities and differences between clarification interpretation and the client-centered technique of reflection.

2) Comparison interpretation: When the therapist places two thoughts or two events or two feelings side by side and invites the patient to compare them.

3) Wish-defense interpretation: These are assumed to be the most potent interpretations although again the emphasis is on the defense part.

It is my impression that there is much misconception about psychoanalytic interpretation. The flashy deeper interpretation concerning some infantile experience is seldom used. As has been emphasized before, the analyst starts interpreting defenses and only cautiously approaches content and transference. As one writer says " instead of rubbing his nose in it, so to speak (which he will find ways to avoid) one proceeds then to the interpretation of the resistance." The general sequence would be something like this: First, pointing out to the patient that the resistance exists; second, pointing our how it is manifested; and third, pointing out its purpose. The purpose is first pointed out in a rather general way; that is, that the resistance serves to avoid anxiety or something like that. The content that is causing anxiety is approached even more slowly.

Among the most written about technical problems in analysis are issues concerning the depth, timing or dosage, and wording of interpretations, Much of the supervision and training that an analysts does through is focused on giving him experience concerning these issues. Only some general statements can be made about them. In terms of depth, the ideal interpretation is not a deep on but is also not trivial. As Fenichel put it, and I paraphrase, the analyst interprets what is already at the surface and just a little bit more. In terms of timing or dosage, the general rule is to offer interpretations when the patient is ready to accept them. Obviously, this is a matter of clinical judgement. In terms of wording, interpretations should be simple and offered tentatively. The analyst does not want to sound like an authority, indeed he tries to minimize the transference implications of this role. How does the analyst judge the effects of his interpretations? In general he does this by observing the subsequent productions of the patient. Passive acceptance of an interpretation is likely to mean defensiveness (or the analyst could be wrong.) In any event the analyst is likely to back off and assume that he has either mistimed or misdirected his interpretation. If the interpretation subsequently leads to further productive explorations on the part of the patient, then it can be judged to have been an apt one.

The following quote from Fenichel: "To name unconscious contents that are not yet represented by preconscious derivatives, and therefore cannot be recognized as such by the patient merely by turning his attention to them, is no interpretation." Instead, says Fenichel, the analyst's objective should be to illuminated the unconscious contents "by naming it at the moment it is striving to break through to consciousness."

Some of the analytic notions about interpretation and resistance are nicely illustrated by Spiesman's study which is assigned on the reading list. You should all read this. I will hand out materials from this study that we will use in making ratings of therapy tapes that we will listen to.

Working through:

The patient has free associated, manifested resistances and developed a transference which has been interpreted. Now what? What remains is the process of working through which is in a sense repeated interpretations. One interpretation doesn't undo a defense. Rather the interpretation must be repeated in many situations. Again I have the impression that there are misconceptions about the nature of insight in psychoanalytic treatment. One may believe that the analyst strives to produce the "big insight" which will lead to all manner of change. Instead the analyst (as the behaviorist) realizes that insight and change are fairly situational. He recognizes the need to point out defenses in many different contexts and situations. Indeed, insight develops cumulatively as a product of many small interpretations rather than working the other way around.

Menninger offers eloquent definition of insight which follows: This definition nicely illustrates the ambitious goals that the analyst sets for himself and his patient.

"I define insight as the recognition by the patient (1) that this or that aspect of his feelings and attitudes, this or that technique of behavior, that or that role in which he casts other people, is of a pattern; (2) that this pattern, like the footprints of a bear which has lost certain toes in a trap, originated long ago and stamps itself on every step of his life journey; it is present in his contemporary reality and situational relationships, and it is present in his analytic relationships; (3) that this pattern originated for a reason which was valid at the time, and persisted despite changes in some of the circumstances which originally determineed it; (4) That this pattern contains elements which are offensive and injurious to others as well as expensive and troublesome to the patient."

"... insight is the simultaneous identification of the characteristic behavior pattern in all three (childhood, analysis, reality) of these situations, together with an understanding of why they were and are used as the were and are."

Dream Interpretation:

This is another relatively unique focus in analytic treatment and is a particularly important part of psychoanalysis proper. Freud termed dreams the royal road to the unconscious.

A brief bit of dream theory is necessary; hopefully, many of you will have or will read in this area. Analysts distinguish the manifest dream or manifest dream content which is the consciously remembered dream; the latent dream content which is the unconscious dream content which threaten to wake the dreamer; and the dream work, the unconscious mental operations that transform the latent dream content into manifest content. The dream work employs primary process mechanism in this translation including condensation, symbolism, and displacement. Secondary elaboration refers to the egos efforts to mold the dream recall into some kind of logical coherent hold.

While sleeping the dreamer's conflicts strive for expression (the return of the repressed). This is striving conflictual material is a combination of id drives and current concerns. The egos guard is lessened but not absent. The result is a compromise formation such that enough energy is discharged to let the sleeper sleep, yet is is sufficiently disguised to "hide" the conflict. Anxiety dreams- that is, dreams in which are consciously highly distressful - represent the failure of ego defenses. Since the dreams are compromise conflict expressions they can be construed as wishful fulfillments. You may be familiar with Freud's dictum that all dreams are wishful fulfillments in one sense or another. Since the analyst is highly concerned about wish-defense systems the wish fulfilling nature of dreams makes them considerable interest.

How are dreams handled in therapy? Freud's paper is very clear and informative. In essence they are handled like any other bit of material. They are not pursued ad nauseum; the therapist does not tell the patient what it means, they are interpreted gradually.

. First, of course, the patient must be taught to attend to and report his dreams. This is part of the socialization process that takes part in any kind of therapeutic endeavor wherein the therapist teaches a client to do what the client must do in order for the therapist to do what he must do. Freud emphasized that the focus of analysis should always be on what is currently on the patient's mind. Thus, he advised against carrying dream interpretations over from one hour to the next unless the patient initiated this. If a fresh dream occurred before an old one was completely analyzed, attend to the new one. The analyst should not be concerned with milking or completing the analysis of any one dream. This is impossible and the themes will come up again. (remember the analyst has plenty of time). Freud also cautioned against giving deep interpretations of dreams early in treatment pointing out that early dreams are more "naive". Later dreams are more disguised as the patient's ego defenses become more sophisticated under the onslaught of the analysis.

The primary technique in dream interpretation is to ask the patient for his reactions or associations to various elements in the dream. The choice of what elements and in what order is a matter of clinical judgement. How much of the dream is to be interpreted heavily depends on the focus of the therapy whether it is uncovering or supportive therapy. It is also recognized that the analyst interest in dreams is going to reinforce the patient's recovery in report of them. Psychoanalytic notions about symbolism are particularly important in helping the analyst to decode the dream. For example, basements, downstairs, upstairs, attics, front porches and alike are considered to symbolize anatomy or anatomical parts of the body.

You are all urged (required) to read Freud's paper on dream interpretation and you are urged to compare his precepts in this paper with what he reports he does with the dreams in the case of Dora. We will also see an example of dream interpretation in a tape of a therapy excerpt conducted by Franz Alexander. We should also compare Alexander's behavior with dream interpretation theory.

Evaluation of Psychoanalytic Therapy:

Kneight many years ago offered five criteria for evaluating the effectiveness of treatment which have been quite influential. These are: (1) symptomatic improvement, (2) increased productiveness, (3) improved adjustment and pleasure in sex, (4) improved interpersonal relations, and (5) ability to handle ordinary psychological conflicts and reasonable reality stress. These concepts are often difficult to measure. It must be admitted that analysts have done relatively little research.

There are some clinical reports of outcome data but they don't employ control groups. Five of these reports are summarized by Eysenck, who summarizes them by observing that approximately one-third of the patients broke off treatment and 66% success rate is reported for the remainder (success being patients rated as cured, much improved or improved). Eysenck,as you know, or soon will know, is a controversial figure in the psychotherapy outcome research area. Strupp has disputed Eysenck's computations after re-examining the original sources. He Strupp, does not understand how Eysenck arrived at his conclusions. Strupp further notes that "it is also abundantly clear from the reports that exceedingly stringent criteria were employed in classifying outcomes."

There are no good studies evaluating psychoanalysis or even psychoanalytically oriented therapy. This is, or course, unfortunate Analysis purports to do much, sets high goals for itself and argues that its criteria are more stringent. Analysts get disturbed at criticisms of some of the reports they have published arguing that the critics have been unfair. Possibly because of this, it is rumored that the American Psychoanalytic Association chose not to publish a recently compiled survey of the success or outcome of psychoanalytic treatment. This too is unfortunate. Frankly analyst being what they are and psychoanalysis being what it is, I am doubtful that we will ever see a good outcome study of analysis. Probably the best we can hope for is the project currently nearing completion conducted at the Menninger Clinic.

Remember that psychoanalysis does not promise cure or behavior change but rather increase self-understanding. Given the nature of man and the current human condition it is likely that there will always be considerable number of people who are willing to pay high prices for such increased self-understanding. Indeed, are we all not curious about ourselves and our origins?