Practical Psychoanalysis for Therapists and Patients
by Owen Renik
Renik argues that psychoanalysis must move beyond theory and focus instead on effectiveness
The Stuff of New Yorker Cartoons
By now, the term practical psychoanalysis has become an oxymoron. The way psychoanalytic treatment is generally conducted, it is extremely impractical: it doesn't serve the needs of the vast majority of potential patients. Understandably, people who seek the help of mental health caregivers want a therapy that will provide maximum relief from emotional distress as quickly as possible. Most clinical psychoanalysts offer instead a lengthy journey of self-discovery during which too much concern with symptom relief is considered counterproductive. "Self-awareness" is the main goal; symptom relief is of secondary importance and is expected to arrive, if at all, only after a while.
No surprise, then, that psychoanalysis has come to be regarded by the public at large as an esoteric practice which promotes a self-involved escape from real life, rather than a treatment method that helps the patient live real life more happily. No surprise, either, that all over the world fewer and fewer patients seek psychoanalytic treatment, and that those who do are for the most part people who want to become psychoanalysts themselves or fellow travelers who have an intellectual interest in the field. Clinical psychoanalysis has become, deservedly, the stuff of New Yorker cartoons.
This unfortunate state of affairs is ironic, considering that psychoanalysis got its start on the basis of its therapeutic efficacy. In the course of their researches, Breuer and Freud stumbled upon a method for relieving notoriously difficult to treat hysterical symptoms. Though Freud was a fascinating and imaginative writer who developed far-reaching ideas about culture and society, as well as about individual psychology, the world originally paid attention to him because of the extraordinary cures he and Breuer achieved—and achieved very rapidly, too, in contrast to the expectations of contemporary psychoanalysts.
Over the years, psychoanalysis drifted away from its original orientation toward symptom relief as the desired outcome of treatment and became increasingly preoccupied with a special, specifically psychoanalytic goal: the achievement of "insight" for its own sake. In the process, psychoanalysts not only made themselves irrelevant to most peoples' needs, but, as many critics have pointed out, also compromised clinical psychoanalysis as a scientific investigative tool. How can the validity of insight be assessed? Insights reached by analyst and patient together about the latter's psychology are inevitably influenced by the former's theory. Therefore, unless insights are validated by correlation with symptom relief (an outcome criterion that is not theory driven) a closed system is set up in which successful clinical analysis consists of analyst and patient discovering what the analyst assumed a priori to exist. Impractical psychoanalysis is also unscientific psychoanalysis.
Clinical psychoanalysis has become impractical, but it does not have to be impractical. In order to offer patients practical psychoanalysis, however, clinicians cannot conduct treatment on the basis of received wisdom. To begin with, psychoanalysts cannot assume the virtue of any particular set of procedures—use of the couch, frequency of sessions, even the method of free association. These are techniques, and in the progressive development of any scientifically based clinical practice, techniques will alter, even alter dramatically, as empirical evidence accumulates; some prove valuable and are retained, others are discarded. Only two hundred years ago, for example, the best available medical science indicated that bleeding the patient through use of leeches or by venicotomy was part of the responsible standard of care for most illnesses. Almost every patient who consulted a physician was bled. We now know that this technique, which was practiced as state of the art by the best physicians for centuries, was useless in almost all cases and dangerously detrimental in many.
Similarly, we have every reason to expect that the techniques of a scientifically based clinical psychoanalysis will alter over time. Therefore, it makes no sense to define clinical psychoanalysis as a particular set of techniques. Nor does it make sense to define clinical psychoanalysis as a particular set of theories, for these, too, will alter as science progresses. Even the most fundamental psychoanalytic concepts and principles should be critically reviewed at every turn, and we can anticipate that most will eventually be found obsolete. That's what happens in science. Practical psychoanalysis means remaining open-minded with regard to theory, holding nothing as axiomatic; and it means retaining an experimental approach to technique—i.e., searching for whatever way of working together with a given patient seems to make progress toward the desired goals of treatment.
If practical psychoanalysis cannot be defined in terms of any particular theory or technique, how can it be defined? The sensible way to define practical psychoanalysis is in terms of its area of study and its objectives. Sciences are usually defined in terms of their subject areas and applied sciences in terms of their objectives (e.g., chemistry is the study of compounds and pharmaceutics is the creation of useful drugs by applying chemical knowledge). Psychoanalysis is a scientific study of the mind, and clinical psychoanalysis an application of psychoanalytic science to therapy. Practical clinical psychoanalysis is a treatment that aims to help the patient feel less distress and more satisfaction in daily life through improved understanding of how his or her mind works. Another way to put this is to say that in a successful practical analysis the patient is able to revise various aspects of the way he or she constructs reality, with the result that the patient feels better.
We might even take a traditional view, following Freud, and add that practical analysis brings the unconscious into consciousness. However, if we want to continue to use that conception, we must be prepared to update our definition of "the unconscious." It was Freud's idea that clinical psychoanalysis brings into conscious awareness certain thoughts that are available to consciousness but remain unconscious because the patient is motivated not to be aware of them—what Freud termed repressed thoughts or the dynamic unconscious. And it is true that successful practical analysis usually does, to a certain extent, involve the patient identifying ideas, feelings, memories, etc. that he or she has been holding out of conscious awareness for one reason or another. But it is also true that a very significant part of what happens in practical analysis consists of the patient becoming conscious of thoughts that have never been repressed, thoughts that the patient simply never had the opportunity to think before. These thoughts arise from novel perspectives provided by the analyst—explicitly or implicitly, intentionally or unintentionally—in the course of an intimate, mutually engaged exploration with the patient of his or her difficulties.
Doing What Works
In every professional community, there are some psychoanalysts who treat patients practically. These clinicians help their patients achieve therapeutic benefits as rapidly as possible. The patients feel better, the quality of their lives improves, and their friends and families can see it. For that reason, practical psychoanalysts, contrary to the general trend, have more referrals than they can handle—and their practices are filled with patients who are neither analysts in training, nor hapless souls who are encouraged to remain for many years in treatments that produce no significant symptom relief.
Unfortunately, practical psychoanalysts tend not to publicize what they do with patients; instead, they quietly set many traditional psychoanalytic theories and techniques aside and go about doing what works. Good for practical psychoanalysts and for their patients! But not good for the field. There are many clinicians who would like to learn more about how to conduct a practical psychoanalytic treatment, and many patients who would like to know how to recognize one. This book is addressed to readers in both categories.
In the chapters that follow, I will discuss what I have found to be basic principles of practical psychoanalytic treatment. I will use a casebook format, presenting concepts via illustrative clinical examples. I do that for two reasons: first, because I find that abstract formulations about psychoanalytic theory and technique, by themselves, are difficult to understand, let alone apply on the line in work with patients; and second, because my recommendations are not based upon findings from systematic, controlled empirical research (nobody's recommendations are, in psychoanalysis, since adequate research methods have not yet been developed) and I want to share with readers, as best I can, the clinical experiences that have led me to reach my conclusions.
This is not intended as a scholarly volume. I haven't presented a survey of the literature, noting whose ideas have been the same or similar to mine and whose have been different. No background in psychoanalysis is required to understand what I have written. When I speak of an "analyst," I do not refer to someone who has attended an official psychoanalytic training program; I only mean a psychoanalytically informed psychotherapist—and since most of Freud's important ideas have long since percolated into the cultural surround, any contemporary psychotherapist who is at all eclectic in his or her orientation will inevitably be psychoanalytically informed. My aim is to discuss in a down-to-earth way what, in my experience, can be useful for both analyst and patient to keep in mind when collaborating in an effort to help the latter feel better; and I think the best way for me to do that is to offer a collection of anecdotes, together with my thoughts about them.
Excerpted and adapted from Practical Psychoanalysis for Therapists and Patients by Owen Renik, MD. Published on Psychotherapy.net with written permission from the author.