Relational Psychoanalysis and Psychotherapy Integration

An evolving synergy

Jill Bresler, Karen E. Starr, Jill Bresler, Karen E. Starr

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317601265
• Edition: 1
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

Relational Psychoanalysis and Psychotherapy Integration traces the history of efforts to integrate psychoanalysis with other psychotherapeutic modalities, beginning with the early analysts, including Ferenczi and Rank, and continuing on to the present day. It explores the potential for integration made possible by contemporary developments in theory and technique that are fundamental to a relational psychoanalytic approach.

Editors Jill Bresler and Karen Starr bring together an array of valuable theoretical and clinical contributions by relationally oriented psychoanalysts who identify their work as integrative. The book is organized in four segments: theoretical frameworks of psychotherapy integration; integrating multiple models of psychotherapy into a psychoanalytically informed treatment; working with specific populations; the future of integration, exploring the issues involved in educating clinicians in integrative practice.

The contributions in this volume demonstrate that integrating techniques from a variety of psychotherapies outside of psychoanalysis can enrich and enhance psychoanalytic practice. It will be an invaluable resource for all practicing psychoanalysts, psychotherapists, and psychoanalysts and psychotherapists in training, particularly those with an interest in relational psychoanalysis and psychotherapy integration.

Part I
A Conceptual Framework for Integration

1
Introduction

Jill Bresler and Karen Starr

This book is about the integration, in theory and practice, of relational psychoanalysis with a variety of psychotherapeutic approaches that have traditionally been considered “nonanalytic.” Its aim is to offer a perspective on psychoanalytically informed clinical work that is inclusive rather than polarizing. We believe that this is a book whose time has come. The contemporary relational turn in psychoanalysis, with its increasing interest in attachment theory, infant research, embodied experience, dynamic systems theory, cognitive science, and neuroscience, makes possible a more open dialogue with therapeutic approaches that have traditionally remained outside the psychoanalytic sphere than was feasible within the more inward-focused classical psychoanalytic framework.

The attempt at integration is not a new phenomenon. Throughout its history, psychoanalysis has been characterized by a fundamental tension between creativity and constraint, progressiveness and orthodoxy. While Freud himself was continually reworking his theories in light of new discoveries, he was also careful to maintain tight control over the direction of psychoanalysis. Challenging Freud could be a complicated and at times, costly act, resulting in the expulsion of some of the most creative psychoanalytic thinkers from Freud’s inner circle.

One of the most creative of these early psychoanalytic thinkers was Sandor Ferenczi, who was one of the first analysts to consider the impact of the analyst’s subjectivity in the psychoanalytic situation (Ferenczi, 1932). Aron (1991) traces the origins of relational theory to Ferenczi’s contributions and to his differences with Freud. Known as the analyst of “last resort” (Ferenczi, 1932, p. xix), Ferenczi was deeply concerned about helping his patients, many of whom were “hopeless cases” referred to him by other analysts from all over the world. Describing himself as an “empiricist” (Ferenczi, 1931, p. 419), Ferenczi believed it was the analyst’s responsibility to devise a treatment that would most effectively treat the patient’s problems. In the service of this goal, he conducted numerous experiments with technique.

In the history of the link between relational psychoanalysis and psychotherapy integration, the original effort to integrate psychoanalysis with other therapeutic approaches can be located in Ferenczi’s technical experiments. Prior to becoming an analyst, Ferenczi had earned his medical degree in Vienna in 1894 and interned at various hospitals in Budapest, where he specialized in neurology and neuro-pathology. He also developed his skill in hypnotism and published numerous short papers on hypnosis. After becoming an analyst, Ferenczi continued to use a variety of relaxation and meditation exercises with his patients. Calling for the occasional need for “active interference in the patient’s psychic activities to help over dead points in the work of the analysis” (Ferenczi, 1919, p. 196), Ferenczi’s technical experiments in what he called his “active technique” involved hypnotic, relaxation, and behavioral suggestions. He wrote,

I have … learnt that it is sometimes useful to advise relaxation exercises, and that with this kind of relaxation one can overcome the psychical inhibitions and resistances to association. I need hardly assure you that this advice is only put to the service of analysis, and only concerns the bodily self-control and relaxation exercises of the yogi in that we hope to learn from it something of the psychology of these adepts.

(Ferenczi, 1925, p. 226)

Aware that his experiments were likely to arouse criticism from the more conservative psychoanalysts in Freud’s circle and most importantly, from Freud himself, Ferenczi was careful to emphasize that his interventions were purely for the purpose of furthering the psychoanalytic process, and further, made a point of explicitly tracing the origins of his active technique back to Freud.

Freud had advocated that in cases of anxiety hysterias, or phobias, it was often necessary to encourage the patient to engage in the very anxiety-arousing behaviors he had been avoiding—a directive that in a contemporary cognitive behavioral framework might be termed exposure. Advocating for the necessity of active intervention in cases where the treatment appeared to be stalled, Ferenczi (1919) wrote,

We owe the prototype of this “active technique” to Freud himself. In the analysis of anxiety hysterias on the occurrence of a similar stagnation—he had recourse to the method of directing the patients to seek just those critical situations which usually caused them an attack of anxiety; not with the idea of “accustoming” them to these situations, but in order to free the wrongly anchored affects from their connections.

(p. 196)

In collaboration with Otto Rank, Ferenczi further elaborated on his ideas in their jointly authored The Development of Psycho-analysis (Ferenczi & Rank, 1925). In this work, Ferenczi and Rank outlined their proposal for modifying psychoanalytic technique—when indicated by the specific needs of the case—by introducing active intervention, setting a date for the end of treatment, and potentially even reincorporating hypnosis into psychoanalysis. They suggested that at some point integrating psychoanalysis with other therapeutic techniques would offer clinical advantages, writing,

From this point of view of the practical application the splendid isolation which was indispensable to the creation and development of psychoanalysis need then no longer be strictly adhered to: indeed, we should not wonder, if the point were finally reached when other psycho-therapeutic methods which had proven themselves useful according to analytic understanding (as we tried to show, for example, in hypnosis) were legitimately combined with psycho-analysis.

(Ferenczi & Rank, 1925, p. 64)

Again, they were careful to trace their proposal back to Freud, continuing,

Freud himself had such future possibility of the mass application of psycho-analytic therapy in mind when he expressed the opinion that it was very probable that “the pure gold of analysis might be freely alloyed with the copper of direct suggestion and that the hypnotic means of influence might again find its place.”

(p. 64)

Despite their efforts to demonstrate to Freud and his adherents that their ideas were a natural extension of Freud’s own, Ferenczi and Rank came under criticism from Freud and his more conservative followers.

In the history of relational psychoanalytic ideas, Ferenczi is probably best known for his controversial experiments with mutual analysis, in which he and his patient Elizabeth Severn (at her insistence) took turns analyzing one another (Ferenczi, 1932). Ferenczi ultimately abandoned this technique, deeming it unworkable and concluding that a better solution to unresolved issues in the analyst is a better analyzed analyst. However, in times of emotional turmoil, Ferenczi himself often turned to his friend and colleague, Georg Groddeck, with whom he engaged in a sort of mutual analysis for most of his life. In fact, we contend that Ferenczi’s analysis with Groddeck can itself be considered an “integrative” relationally oriented psychoanalytic treatment! Groddeck, the self-proclaimed “wild analyst” (Groddeck, 1977, p. 7), was a pioneer in psychosomatic medicine, practicing as a spa physician at Baden-Baden, where he incorporated psychoanalysis, hydrotherapy, massage, suggestion, hypnosis, and dietary restrictions into his talk therapy treatments of primarily chronically ill patients. After Freud introduced Ferenczi to Groddeck in 1917, Ferenczi spent many summers at Groddeck’s sanatorium, where, while undertaking spa treatments, he and Groddeck analyzed one another (Rudnytsky, 2002). Following Will (1994), Rudnytsky (2002) identifies Groddeck’s experiments with mutual analysis as a precursor to Ferenczi’s.

While for 20 years Otto Rank had been a member of Freud’s closest circle, the publication of The Development of Psycho-analysis (1925) and The Trauma of Birth (1924), which challenged the centrality of the Oedipal complex as the nucleus of neurosis, ultimately led to his break with Freud. Rank’s own work led to the development of brief therapy, a modality that was adopted and further developed by Alexander and French (1946), who described their modifications to psychoanalytic technique as a continuation and realization of ideas first proposed by Ferenczi and Rank. Like Ferenczi and Rank, Alexander and French (1946) advocated for adapting psychoanalytic technique to fit the specific needs of the patient. Their recommendations for modifications included adjusting session frequency, giving directives to the patient concerning his daily life, interrupting the treatment for a particular period of time in preparation for termination, regulating the transference relationship to meet the specific needs of the case, and making use of real-life experiences as an integral part of the therapy. They emphasized the importance of taking into account the external events in a patient’s life and giving the patient active direction and help when indicated. Further, they proposed models of brief psychotherapy, even going so far as to contend that some patients might be helped in just one session.

Many of these threads of innovation in psychoanalysis were adopted and further developed by psychoanalytic schools of thought that remained outside the psychoanalytic mainstream. Unfortunately, the conservative turn of American psychoanalysis in the 1950s brought with it a narrow definition of psychoanalysis that characterized it as an elite, pure, scientific treatment suitable only for an elite group of patients—and specifically, not as psychotherapy. For a thorough historical review of how psychoanalysis came to define itself so narrowly, we direct the reader to A Psychotherapy for the People: Toward a Progressive Psychoanalysis (Aron & Starr, 2013). The authors identify a series of binaries in which psychoanalysis has been situated, and trace the history of how psychoanalysis came to define itself as distinct from and in opposition to psychotherapy. Documenting the focal debates of the 1950s among mainstream analysts in the United States, Aron and Starr (2013) demonstrate how this “definition via binary opposition” created a hierarchy in which psychoanalysis was both distinguished from and valued over psychotherapy, with the consequence that psychoanalysis has dangerously contributed to its own marginalization within the field of psychology. They call for a broader and more flexible definition of psychoanalysis, one that has wider applicability and that includes the potential for integration with other therapeutic approaches.

The relational paradigm, itself an integrative school within the discipline of psychoanalysis, provides a fertile base for explorations in psychotherapy integration. Since its inception, relational psychoanalysis has radically reconceptualized and integrated ideas from classical psychoanalysis, interpersonal theory, ego psychology, and object relations theory. As it continues to evolve, relational thinking has increasingly incorporated findings from developmental research, attachment theory, systems theory, and neuroscience. At a time when the psychoanalytic world is shrinking, interest in relational psychoanalysis continues to grow, attesting to its vitality and accessibility. In connecting psychoanalysis to current research and contemporary cultural ideas, relational writers form a bridge to the larger world of modern psychology. This development has the potential to play a critical role in the future of psychoanalysis, which has become increasingly marginalized in today’s society. While diversity of approach as well as theoretical perspective is increasingly becoming the norm, in the popular imagination the stereotype of the silent analyst behind the couch still prevails.

Many alternative therapies still define themselves in opposition to psychoanalysis, reacting to a static and misleading impression of how contemporary psychoanalysts think and work that is, to some degree, created by psychoanalytic writers themselves. We believe that this written focus is misleading, and that in fact, most psychoanalytic practitioners are more flexible in their actual practice than is apparent from the literature. Many psychoanalysts have followed in Freud’s footsteps, continually reworking their understanding of theory and practice, while behaving in the clinical setting in ways that are not conveyed in written accounts. Practicing psychoanalysts are increasingly moving toward psychotherapy integration, incorporating therapeutic techniques developed outside of psychoanalysis into their clinical work. Although psychotherapy integration has not yet been widely discussed in the relational literature, there are signs of an increasing tendency toward integration among psychoanalysts who work within a relational framework. Clinical conversation, attendance at conference presentations on psychotherapy integration, and enthusiasm among many analysts for training in cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), dialectical behavior therapy (DBT), and other modalities all point to this trend. In practice, many trained analysts, like the majority of psychotherapists (Norcross, 2005), frequently draw upon techniques associated with therapies developed outside of their home school, without necessarily consciously considering their work integrative.

The relational movement and the modern-day psychotherapy integration movement (“movement” may be an exaggerated term for the small group of analysts investigating integration at the time) developed concurrently, in the late 1970s to early 1980s, and in close proximity to one another. Key theorists of the two groups were affiliated with the same New York universities and training institutes. This proximity facilitated an increasingly popular cross-fertilization of ideas that have their roots in psychoanalytic thinking and other diverse perspectives. While these two groups had different aims and developed somewhat independently, both were responses to a psychoanalysis that had, by the force of its complex history, become rigid, exclusive, and overly conservative (Aron & Starr, 2013).

Relational psychoanalysis developed through selectively integrating across psychoanalytic models. Considered by the psychoanalytic mainstream to be a diluted, if not utterly bastardized, version of psychoanalysis, the relational paradigm triggered heated debates within the psychoanalytic establishment about how to define the limits of psychoanalysis. These debates were the focal point of many conversations among relational theorists in the emergent years of its history. In contrast, psychodynamically oriented therapists developing an integrative perspective were less interested in the question of analytic authenticity. Those who strongly identified with the integrative movement were, by definition, open to incorporating the perspectives and technical innovations of nonpsychoanalytic schools of psychotherapy.

The publication of Paul Wachtel’s Psychoanalysis and Behavior Therapy (1977) is considered by some to mark the beginning of the contemporary psychotherapy integration movement. Integration was not an entirely new concept; theorists from earlier decades had argued on behalf of therapeutic flexibility (see Goldfried et al., 2005 for a comprehensive history of integrative thought). Writing before the relational school had formed, and anticipating many of its concerns, Wachtel addressed the limits of the classical analytic approach that dominated psychoanalytic practice at the time. An analyst by training, Wachtel inveighed against many of the older psychoanalytic tropes, including the vertical model of mind and analytic neutrality. He argued that insights emerging from a behavioral paradigm of the nature of human experience and the change process could complement psychoanalysis, leading to a more comprehensive theory and more effective practice.

Although Wachtel positioned behavioral thinking as his ideological counterpoint to traditional psychoanalysis, in doing so he presented concepts that are at the heart of relational thinking. Among them are the notion that the patient’s relationships and other aspects of lived experience are data equal in importance to that of the patient’s inner life; that it is essential to examine the relationship between inner and outer life; and that it may be fruitful at times for the analyst to actively intervene with the patient. Wachtel’s book was followed by other integrative texts, some of which also examined psychoanalysis in relation to other psychotherapies. For example, Wachtel and Wachtel (1986) and Gerson (1996) wrote about t...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• CONTENTS
• Contributors
• Acknowledgments
• PART I A Conceptual Framework for Integration
• PART II Integrating Multiple Models of Psychotherapy
• PART III Working With Specific Populations
• PART IV The Future of Integration
• Index