Difficulties with Psychoanalysis Case Conceptualization

Originally I was interested in psychoanalysis as a form of socio-cultural critique, something like what Ricoeur did in his work “Freud and Philosophy.” I wrote a lengthy article about this (published elsewhere in this journal), but hadn’t really conceived of it as something that actually could be used to treat persons with psychiatric disorders. I recently took a course in psychoanalysis from Colin Vogel. Dr. Vogel is a passionate and committed advocate for psychoanalysis and an excellent teacher. Particularly useful was the way he brought in outside speakers to expound various psychoanalytic doctrines and case supervise. The class clarified and refined for me some of the issues it presents. I will summarize these as ecumenically as possible, particularly given my strong CBT orientation.

Generally, my theme is that once one starts peeling back the layers of psychodynamic theory, several seemingly-intractable problems become apparent. They make it hard to determine whether there’s a difference between psychoanalysis and simple attention-and-contact therapy (i.e. the therapeutic effect of seeing somebody who’s interested in your problems, or who at least appears to be).

1. Psychoanalysis has evolved a vocabulary that’s specialized to the point where few key words or phrases have an intuitive meaning. It’s hard to translate them into operational terms. One can understand the words individually, but not in the context of their broader semantics. Klein, for example, refers to the “paranoid/schizoid position” and the “depressive position” but her use of these phrases is so arcane that it’s difficult to interpret them. The paranoid/schizoid position has nothing to do with schizophrenia, nor does the depressive position have anything to do with depression, conventionally understood. Use of words isn’t like with Heidegger, who just makes up complex but eventually-comprehensible phrases. Rather it’s deceptive because one thinks one knows what’s being said but one really doesn’t. There’s tremendous phase shift as one attempts to understand words’ technical meaning versus their ordinary meaning.

2. Psychoanalysts are under a peculiar compulsion to trace their lineage back to Sigmund Freud, the founder of the discipline. This typically takes the form of “I was analyzed by so and so” who was “analyzed by so and so” who “was a student of Freud’s and then analyzed by so and so.” No other psychology discipline has this peculiar emphasis on pedigree. It’s almost like the vampires on “True Blood” constantly invoking their “maker.”

3. Psychoanalysts must be a quarrelsome group as they’re constantly splitting off to found their own schools and “institutes” based on various dogmatic and somewhat obscure feuds they’ve engaged in over the years. There are a half dozen in Los Angeles alone, each adhering to its own set of tenets, varying from the others primarily in emphasis. It would be a difficult but entertaining exercise to trace their provenance, which surely intersects at some point (see #2 above).

4. Psychoanalysis insist it’s necessary to meet for therapy no less than four times per week for a lengthy period of time. In principle it’s possible for one to be “in analysis” for one’s entire life. Anything less than that runs a grave risk that therapy will be ineffective. This is a huge commitment in time and money. As a result psychoanalysis is for the wealthy only. This inevitably skews its orientation towards psychological disorders (they’re pervasive aspects of one’s personality and difficult to overcome) and the best way to treat them (as leisurely as possible). Even if my mother killed my father when I was a baby, I’m not sure I’d have that much to talk about. It makes me wonder how much psychoanalysts are interested in preserving revenue sources, versus helping people to get better. One thing’s for sure, it’s inconsistent with managed care.

5. The raw material of psychoanalysis is precisely these neonate experiences, occurring when one is less than six months old (even continuing back, most likely, to when one still is in one’s mother’s womb). At this time in one’s life, one isn’t “conscious” in any meaningful sense of the word, so it’s difficult to see how one could form the complex ideations psychoanalysis hypothesizes. Psychoanalysis attempts to skirt this issue by calling it “feeling in memory,” i.e. that one develops pre-conscious attitudes, orientations or outlooks towards people and objects. I’m dubious about this and doubt it occurs. Recent research has pushed consciousness back possibly even to the fifth month of life (Koider et al., “A Neural Marker of Perceptual Consciousness in Infants,” Science 340, 376-380 (2013), doi: 10.1126/science.1232509). But nobody actually can conceptualize, much less remember, what happened during this critical period (because of infantile amnesia).

6. Psychoanalysis insists all therapy involves the phenomenon of “transference,” that is, a person projecting onto the personage of the psychoanalyst certain attributes or ascriptive predicates of a person with whom one interacted during this crucial early period, for example, one’s father or mother. One literally has to pretend the psychoanalyst is, or becomes, that person, and then enact, or reenact, the earlier relationships upon which this impression is based. While this might be fun for a day or two, I fail to see how it is productive and leads to therapeutic change, especially if it’s supposed to be the primary motivation. One can adopt a stance towards one’s past history and come to regard it as such to minimize its interference effect with one’s present life. However one can’t magically eliminate what happened in the past by pretending the main characters in the drama are somebody else.

7. As a discipline, psychoanalysis is insecure. Practitioners seem as though they’re constantly (but perhaps unknowingly) trying to elevate the status of the discipline to something more empirical or scientific. For example, they insist the people who see them are “patients,” not “clients.” They’re always “doctors.” The only persons who are patients are those who are seeing a medical doctor in a clinic or hospital. Everybody else is a client.

8. What happened to formerly-pervasive but now-vanished psychoanalytic diagnoses such as “hysteria?” They vanished because there either wasn’t an underlying psychological disturbance to treat, or because it was misapprehended. Why is it that most psychoanalysts seem to be older, if not downright elderly? It’s because the discipline addressed needs (or pseudo-needs) that prevailed during a particular space-time interval, itself culturally mediated. Since that particular culture and its artifacts have vanished, there’s no further need for a therapeutic technology to address them.

9. The entire project of psychoanalysis is self-referential. Because it always can say: “well, if you don’t get it, that just illustrates you don’t have insight into what your mother did to your father when you were three months old.” The answer to objections isn’t to confront them, or revise premises, it’s just to say you need more of what the discipline offers. This is reminiscent of a brand that eschews substantive change to its product, believing all it has to do in order to induce broader consumer acceptance simply is to reformulate its marketing package. Another example is a politician who doesn’t really change her/his views but simply says, “we need to refine our message.” But it isn’t the way the message is presented that people disagree with, it’s the substantive propositional content of the message itself.

I am not saying these difficulties are insurmountable, only that they require explanation. I will endeavor in a subsequent post to set forth a case conceptualization from an object relations perspective.