A border dispute between parent and child

Review of: S. Frisch (ed.) (2001). Psychoanalysis and psychotherapy. The controversies and the future. London: Karnac, ISBN 1-8555-266-2, 154 pages, price: £19.99

Eddy de Klerk

When I was asked to review the book Psychoanalysis and psychotherapy I hoped that the dispute between psychoanalysis and psychoanalytic psychotherapy would not be battled out exclusively on the basis of Freud's 'gold' versus 'brass' metaphor. From this compilation by ten well-known authors it is evident that there is far more to be said on the matter.
In his foreword Wallerstein maps out the post-war history of the relationship between psychoanalysis and psychoanalytic psychotherapy in the United States. This history can be traced in terms of the rise and fall of the ego-psychological paradigm put forward by Hartmann cum suis. Its rise resulted in the so-called 'classical' analysis model, which was the sole norm for a long time. This paradigm started to waver when work by authors like Sullivan, Klein, Kohut and Kernberg was published. Furthermore, it was influenced by the application of psychoanalytical therapy. Wallerstein's publications (Forty-two lives in treatment, 1986; The talking cures, 1995) played an important role in the discussion as well. Similar streams arose in North-West Europe at the same time as in the United States. The present collection, with six of the ten contributions by writers from the Romanic language area, illustrates that reflecting on the relationship between psychoanalysis and psychoanalytical psychotherapy has filtered through to Southern Europe and to Latin America.
Frisch (Luxemburg) points out in his introduction that a number of psychoanalysts showed an interest in psychotherapy from the very start, namely Adler, Stekel, Jung, Rank, Ferenczi, Alexander and Fromm-Reichmann. They were usually interested in using it for patients who, in psychoanalysis, ran the risk of falling into a deep regression. The demand for psychoanalytical psychotherapy, or modified versions of it, increased enormously in the period running from the end of the second World War to the oil crisis in the seventies. This development got underway because medical insurance policies started to include psychotherapy in their cover; and because the first psychoanalytic psychotherapy associations were founded, making it possible to be trained elsewhere instead of only at recognised psychoanalytical training institutes. Since the oil crisis the controversy has acquired an institutional, political and financial dimension in addition to the initial scholarly debate.
Bell (Germany) devotes a large part of her contribution to this side of matters. She describes the situation in Germany, where the insurance cover - an extrinsic factor - has a decisive influence on how psychoanalysts and psychoanalytic psychotherapists work in their practices. As an introduction to this, she outlines the historical debate in the United States using the insight/affect (Freud/Ferenczi) dichotomy as a basis for her argument. She cites Gill, who mainly attributes the distinction between psychoanalysis and psychoanalytical psychotherapy to extrinsic factors like lying down/sitting up, frequency, well/not well integrated patient and completely/incompletely trained analyst. In Gill's view, apart from the external setting, it is a question of actively promoting - through interpretation - transference into the here and now, whereby the analyst - as a real person - has a personal contribution to make not only to the relationship but also to the transference. Bell finishes her essay by expressing her desire to be in a position to carry out an objective evaluation of all forms of psychoanalytical therapy, including the influence of external factors.
The essay by Aisenstein (France) has the no-nonsense title: Psychoanalytic psychotherapy does not exist. Her arguments are cogent and logical. In her view only a complete course of training to become a psychoanalyst provides an adequate basis for carrying out psychoanalytic psychotherapy. She gives a convincing account of this type of therapy which takes place once a week for an unlimited period, using as an example an ice-dancer whose emotional life was frozen but which gradually thawed after years of treatment. She poses the question as to whether it is ethically justifiable that psychoanalysts should offer their services to train aspirant psychotherapists who have been rejected for the psychoanalyst course. Thus the students with the least training are often faced with the most severe pathology. Frisch, however, states in his introduction that she is ignoring the reality of the growing number of practitioners. A large group of psychoanalytic psychotherapists has been trained in this manner; the longer established psychoanalysts will have to find a way to relate to this reality.
Gauthier (French-speaking Belgium) in his philosophically-tinged essay looks into the implicit assumptions made about the time dimension involved. Often the distinction between psychoanalysis and psychoanalytic psychotherapy is brought about by the pressures of time. He wonders whether the principle of an unlimited period of time for psychoanalysis is not based on unfounded idealism. Gauthier fears that the debate about psychoanalysis versus psychotherapy is more like a crusade than a scholarly exchange. For him empirical research is the only solution.
The contribution made by Coles (England), traces her own development as a psychoanalytic psychotherapist. It is a factual account of trial and error, of persevering despite the low status this work has in the psychoanalytical community. She reverses the order of 'gold' and 'brass'. Brass is stronger and can be used in a greater number of ways than gold. There are practical reasons for opting for greater frequency. Who, for example, can keep track of thirty-five patients when they only see them once a week? Psychoanalytical psychotherapy once a week feels different from more intensive therapy: more outside events are brought in. At the start of her career she dearly missed separate training in this sort of therapy and makes a powerful case for its introduction. In so doing she offers a counterbalance to Aisenstein's arguments.
Resnick, in his contribution On madness: a psychotherapeutic approach gives superb examples of his method of work with psychotics. He makes use of his own creativity during the sessions to find, with the aid of the patient, instruments which make joint work possible.
When reading Golse's contribution I thought about the fact that the historical marginalisation of child analysis is somewhat reminiscent of the harsh way in which psychoanalytic psychotherapy has been treated. Golse thinks that the problems child analysis are wrestling with may generate new and fruitful developments for psychoanalysis in general. In answer to the question as to who should be trained to become a child therapist, he opts for a pragmatic approach: the need for good therapists must be met, even if they are not completely trained psychoanalysts. Suman and Brignone (Italy) attempt to understand why the demand for psychoanalytical psychotherapy is so much greater than for psychoanalysis. In a postmodern culture people put absolute truths, ideology and religion into perspective. Scientific theories can also be added to this list. There are a great number of meaningful stories and truths all vying with one another for precedence. The postmodern man is frightened lest the psychoanalyst should be given too much influence and finds a single weekly session more democratic. If psychoanalysis can be characterised as 'free-floating' then psychoanalytical psychotherapy is more selective in its choice of focus - which may in fact change at each session. This satisfies the expectations of the present-day patient.
Kirsner (Australia) describes in his contribution how psychoanalytic psychotherapists who have not be trained to IPA standards are ignored by this organisation, despite the fact that they represent an important part of daily reality in terms of manpower, talent and availability on the market. He stresses the fact that psychoanalysis has become to much of a 'movement' instead of a science, with all the inherent hazards, and he makes a plea for a scholarly approach embracing more openness.
Hinselword in his concluding words shows that the task Freud set himself in the past - making a demarcation line between psychoanalysis and suggestion - has evolved over the years. The problem is not so much that psychoanalysis and psychoanalytical psychotherapy are on opposite sides of the fence, but rather that they resemble each other. The long search for one distinguishing characteristic has been in vain. The more difficult it became to find it, the harder it was pursued. He compares it to a situation which arose during the evolutionary process: the difference between two practically identical populations only becomes clear over a long period of time. In the early stages there is a great deal of overlap between individuals from both populations. The motivation to search for one distinguishing feature is not driven by scientific interest alone. Other motives are equally important: group identity, status and income.
I greatly enjoyed reading this interesting book in which a topical theme has been approached from many angles. The contributions are accessible and clearly written. The fact that they sometimes overlap and are based on identical sources in no way detracts from their quality, as this makes it all the more clear to what extent viewpoints converge and diverge. It struck me that characteristic new developments within psychoanalysis, like validation of the support factor, the influence of the analyst as a real-life person, the interactive character of two-person psychology, the active emphasis on the importance of affect, are all elements that have been a matter of course in psychoanalytical psychotherapy practice for quite some time!
Certainly for those involved with setting up joint courses for the various psychoanalytical associations this book is to be highly recommended.

A. de Klerk, is a clinical psychologist and psychoanalyst with his own practice.

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