Why We Need a "Practical Psychoanalysis"

Since Freud, psychoanalysts have been ambivalent about defining their treatment as primarily designed to relieve patients' suffering. Too often my colleagues have privileged understanding over curing.
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I'm a psychoanalyst. So it was with great interest that I read Daphne Merkin's New York Times Magazine article about her forty-year history of psychoanalysis and psychoanalytic psychotherapy. Merkin is a terrific writer, a brave observer of her inner life, and a lively critic of the professional cultures devoted to studying and healing inner lives. She found the New York psychoanalytic culture reassuring, even if not always helpful. She says:

"...aside from the fact that the unconscious plays strange tricks and that the past stalks the present.....[there is] a certain language, a certain style of thinking that, in its capacity to reframe your life story, becomes--how should I put this?--addictive....Whether [it does] so rightly or wrongly is almost besides the point."

For decades I've heard that it doesn't matter what theory a therapist holds, what his or her formulation about the patient might be. What matters, the cliché goes, is simply the presence of an attentive relationship. Merkin's variation on this theme is that her idealization of her analysts' wisdom and the rhythms and imagery of a psychoanalytic conversation have been more comforting than anything she's been offered in the way of interpretation and insight. The process, in other words, was more important than the content or outcome.

Now, my psychoanalyst colleagues certainly don't think this is true. It's important to them -- to us -- that our very extensive training (6 - 8 years after we get our professional degrees) has given us access to a special knowledge (transference, unconscious conflict, defenses, primitive mental states, etc.) about the human psyche that is vital to the success of our treatment. Unfortunately, psychoanalysis has unwittingly colluded with the caricature that its practitioners don't really help their patients, but instead foster 40-year treatments more akin to addictions than cures. I thought that Merkin's essay hoisted us on our own petard. And this petard is a big reason why I left organized psychoanalysis.

When I read Merkin's essay, I thought back to Janet Malcolm's New Yorker articles, often biting accounts of psychoanalytic politics and the insularity of the analytic establishment. Perhaps the most embarrassing story in Malcolm's articles was the description by a young analyst, Dr. Aaron Green, of his own 15-year analysis in which he described uncovering the core of his psyche, namely his secret wish to be a beautiful woman. Whether or not Green was any healthier at the end of his treatment was apparently beside the point.

Since the days of Freud, psychoanalysts have been ambivalent about helping people, or at least about defining their treatment as primarily designed to relieve patients' suffering. Too often my colleagues have privileged understanding over curing. They have historically shunned or attempted to excommunicate practitioners and theorists (e.g. Franz Alexander, Joseph Weiss) who have advocated more activist techniques (e.g. "corrective emotional experiences") that might promise more effectiveness. They have denounced analysts who show too much explicit desire to help patients cure their symptoms, pathologizing such desire as an unfortunate "therapeutic zeal."

In case conference after case conference, analysts still tend to focus on the vicissitudes of technique and rarely query the presenters about whether their patient is getting better or not. In fact, analysts often question treatments in which patients get better too quickly, suggesting that the patient might be "fleeing" into health, complying with the analyst, or simply building better defenses. In recent decades many analysts have embraced the work of the British analyst, Wilfred Bion, who once said that the analyst should approach each session "without memory or desire," the most problematic desire being the wish to help or cure the patient.

I suppose that I'm one of those culprits with too much "therapeutic zeal." It was a passion that was consistently devalued in the psychoanalytic culture in which I was raised. If, as Merkin says, she could never bring herself to view analysts as service providers -- to be evaluated, therefore, on the basis of results -- it was and is equally true of many psychoanalysts. This reluctance not only makes us vulnerable to all of the Woody Allen-esque caricatures of our work, it is also corrupt, self-deceiving, and unethical. With all the hubbub at psychoanalytic institutes about "boundary violations," analysts sleeping with their patients, the most profound and dangerous ethical violation psychoanalysts routinely commit is their inability to sufficiently help their patients and their almost-principled denial of the harm inherent in this fact.

My own experience is that when theory is divorced from practice, or, in this case, divorced from therapeutic outcome, that theory becomes either more obtuse or self-referential. Either way it fails to serve the patient. I repeatedly saw and experienced both of these tendencies. First, during the 1990s there was a turn toward philosophy, with analysts galore getting on the post-modern bandwagon arguing that there is no such thing as "truth" in analysis, that interpretations can't be judged right or wrong, but instead somehow emerge from the mysterious ether of co-construction. And second, I've witnessed a growing theoretical turn in analysis toward a search for inspiration from colleagues in Europe and South America -- Italian post-modernists, Argentine Kleinians, and British middle-school'ers and Bionians. A key emphasis within these traditions is the notion that the analyst understands what's most important about a patient through his or her (the analyst's) own self-reflection, that the analyst reads the counter-transference as a text in which he finds the most vital meanings and communications of the patient.

These were just a couple of the trends that led me to leave the organized psychoanalytic community in which I trained and practiced. The post-modern philosophical tendency seems to me to glamorize not-knowing, while its nod to philosophy reinstates us as intellectuals. It is certainly something that you certainly couldn't reveal to your patients who are spending a lot of money and effort to get the benefits of your expertise. And the move toward making the analyst's own psyche so important takes us further away from a focus on the patient's welfare. I'm sometimes tempted to sarcastically ask: Doesn't the real patient occasionally get in the way of your self-examination?

Post-modern uncertainty undermines the legitimate authority of the analyst as a healer who knows what he or she is doing and in whom the patient legitimately invests money and hope. The argument that we don't know if we're "right" or "wrong" is silly to me. If we're on the right track, the patient generally improves, either symptomatically or in his or her ability to take on certain emotional and developmental challenges. To ignore therapeutic improvement as the one relevant barometer of the validity of our theories is nihilistic and self-paralyzing. Furthermore, while self-reflection and the counter-transference is important in what we know about the patient, it is not the Rosetta stone. It may or may not have anything to do with the patient. It can take us further away from studying the actual observable markers in the patient's behavior, affect, and speech that are usually more reliable guides to the accuracy of our hypotheses. And it mystifies the nature of the mind and the process of change by wrapping us and the job we do in a false and narcissistic flag of intellectual complexity.

As a mentor of mine, Owen Renik, has written, we need a "practical psychoanalysis." We need one focused primarily and consistently on helping the patient get better. And our efforts ought to be oriented to clarifying and simplifying this process, not making it more arcane. Some treatments might take a long time, but there has to be an end point. Without it, psychoanalysis becomes either a church or a foil for a New York Times Magazine article.