The Theory and Practice of Psychoanalytic Therapy

Listening for the Subtext

Siri Gullestad, Bjørn Killingmo

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429775932
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

The Theory and Practice of Psychoanalytic Therapy: Listening for the Subtext outlines the core concepts that frame the reciprocal encounter between psychoanalytic therapist and patient, taking the reader into the psychoanalytic therapy room and giving detailed examples of how the interaction between patient and therapist takes place.

The book argues that the therapist must capture both nonverbal affects and unsymbolized experiences, proposing a distinction between structuralized and actualized affects, and covering key topics such as transference, countertransference and enactment. It emphasizes the unconscious meaning in the here-and-now, as well as the need for affirmation to support more classical styles of intervention. The book integrates object relational and structural perspectives, in a theoretical position called relational oriented character analysis. It argues the patient's ways-of-being constitute relational strategies carrying implicit messages – a "subtext" – and provides detailed examples of how to capture this underlying dialogue.

Packed with detailed clinical examples and displaying a unique interplay between clinical observation and theory, this wide-ranging book will appeal to psychotherapists, psychoanalysts and clinical psychologists in practice and in training.

Part I

Theoretical foundation

Chapter 1

Key concepts

In clinical practice, some concepts will always be close to hand. We call them “front concepts”. In psychoanalytic psychotherapy transference and countertransference are examples of such concepts. They are closely aligned with the clinical material, and thus situated on a lower level of abstraction than other concepts. The front concepts are the ones that first come into play in the therapeutic interaction. They capture prioritized signals and contribute to the therapist’s immediate understanding of the relevant material. We will describe these concepts in the clinical part of the book. Behind the clinical front line, a network of more general concepts is operative, one that supports the front concepts. We call these concepts the “key concepts”. This term means that clinical practice would rest on a shaky theoretical foundation without these concepts. In what follows we will explain some selected key concepts. The aim is not to discuss them in full, but to mark our position in relation to these concepts. Taken together, they form the main components of the theory of personality that founds the clinical practice described in the book.

Before we present the key concepts, it is necessary to clarify briefly what we understand by the term “clinical material”. In a historical sense a psychoanalytic treatment consists of a linguistic discourse. The patient’s spoken – and unspoken – words and their contents are simultaneously both the analytical material and the medium in which the analytic process unfolds. Classical psychoanalysis has rightly been called a “talking cure” (Breuer & Freud, 1895). Some therapists still hold the opinion that unconscious fantasies, as they are expressed symbolically in semantic language, is the “real” clinical material in an analytic therapy. An example of this position is Ricœur (1977), who argues that the facts or data of psychoanalysis are those parts of experience (1) which can be verbalized and (2) which are communications to an other, concerning (3) the patient’s psychic reality and (4) which are communicated in the form of a narrative. ¹ In our opinion this definition is too narrow. The therapist’s listening perspective is not just aimed at the conscious and unconscious contents of the patient’s words. It is also directed towards the language structure, tone of voice, mimicry, gaze, breathing, and not least the patient’s general “style” and manner of being, often expressed in a characteristic bodily posture. If, however, we take language to mean all the unconscious communication that takes place in the analytic session, we may still speak of psychoanalytic therapy as a “talking cure”. A person is always “speaking” with an other, external or internal, consciously or unconsciously. The therapeutic dialogue is an exchange of signs that communicates a message between the parties. In the therapeutic space this exchange happens at many levels and takes many different forms. On this background, the therapist’s listening perspective in the clinical situation can be formulated as follows: “Who is speaking to whom, about what, in which form and on which stage?” (Killingmo, 2001b).

Unconscious processes

The assumption that there are unconscious mental processes, the recognition of the theory of resistance and repression, the appreciation of the importance of sexuality and of the Oedipus complex—these constitute the principal subject-matter of psycho-analysis and the foundations of its theory. No one who cannot accept them all should count himself a psycho-analyst.

(Freud 1923a, p. 247)

Although psychoanalysis finds itself in a pluralistic phase, there is reason to believe that psychoanalysts still generally endorse the assumptions that Freud asserts here. Still, it cannot be taken for granted that the elements Freud lists are of equal importance. None of the other elements would maintain their specific connotations in the absence of the first premise, namely the assumption of unconscious emotional processes. This idea – that a person’s thoughts, emotions and actions can be governed by unconscious intentions (that is to say, by wishes and intentions of which the individual is unaware and incapable of revealing by her own efforts) – this idea precedes all others in psychoanalytic understanding of humankind. In general, the assumption of unconscious psychic processes involves an enormous expansion of the psychological field the therapist is to relate to. Everything the patient consciously brings to the therapy session is linked with emotions, ideas and fantasies, which are unconscious. The subtext is hidden to the patient himself and needs to be interpreted in order to become accessible. Thus regarded, we may say that the idea of the unconscious has priority over and above all others when we are to describe the process of psychoanalytic therapy. Like a compass, it is always there while, consciously or unconsciously, guiding the directions of the therapist’s interventions.

Psychoanalytic theory of the unconscious should be distinguished from what we may call the descriptive unconscious. The latter simply means that there is psychic activity that takes place outside of the consciousness of the individual. Psychoanalysis is concerned with intentional psychic processes, hence the term dynamic unconscious. Several ideas are included in the concept of the dynamic unconscious. First, humans both feel and think intentionally without being aware of the fact that such processes take place. Second, the unconscious psychic activity may access, or is connected with, all the accumulated events and experiences in the previous life of the individual. Third, what functions as dynamically unconscious, whether we are concerned with wishes or mechanisms of defence, actively resists becoming conscious. Fourth, dynamically unconscious psychic contents are continuously active – round the clock – and exercise a constant influence on the psychic processes that are consciously accessible to us. Fifth, dynamically unconscious processes operate in a “language” of their own, so-called primary processes. This language may be studied in its purest form in the dream work, that is, in how the dream’s latent content is processed and expressed in the manifest dream, in a masked and symbolized form. Through concepts such as condensation, symbolization and displacement, the theory may explain how latent dream thoughts are transformed into pictorial representations in the manifest dream. The concepts of primary and secondary process enable one to describe and classify cognitive products by their level of psychic functioning, and they contain an implied theory of thinking (Hilgard, 1962; Holt, 1956: Gill, 1967). These ideas are necessary in order to conduct psychoanalytic therapy, and they are taken as premises in this book. We should specify that we will not be using the term “the unconscious”. We use “unconscious” as an adjective, that is to say, as a characteristic of psychological processes, emotions and ideational contents.

To Freud himself, however, the substantival formulation Das Unbevußte stood for a more comprehensive content than the one we have referred to here. The unconscious holds the position of a separate “province” in the psyche that collects the most primitive and archaic parts of a person’s psychic life. Freud for instance assumed that the unconscious contains a number of universal fantasies. These fantasies have not been formed through the experiences of the singular individual; they are found a priori in the unconscious as part of human nature. One of these is “the primal scene” which refers to an innate “knowledge” in the child of intercourse between the parents and fantasies surrounding this theme. A discussion of this hypothesis and of Freud’s other hypotheses about the contents of the unconscious are beyond the scope of this book. We would still like to point to the fact that fantasies about the parents’ erotic relation, which frequently occur in analytical material, can be explained on the basis of experience, as similar individual experiences. There is no need to turn to a speculative hypothesis about phylogenetic “inheritance” to explain this clinical phenomenon.

In the topographical theory, which is Freud’s (1900) first account of how the psychical processes are organized, the unconscious holds the position as one out of three psychical systems. The theory presents the psyche as layered. The unconscious represents the part of the psyche that is the furthest from consciousness, while the preconscious is a level in between the conscious and the unconscious. In the topographical theory the qualities of the psychical phenomena are determined based on where they belong within these layers. There is a principled distinction between the system unconscious and the two other systems. This distinction marks the very special position of the unconscious. It manages the central drive wishes, wishes with an inherent tendency to strive to be realized in the conscious system. A barrier (censorship) between the preconscious and the unconscious system prevents the drive wishes from reaching consciousness. A strained field between two sets of forces arises on the boundary between the two systems, on the one hand the drive wishes, on the other hand the censorship. This force field is the source of the dynamic in human psychic life, a source that never withers.

In 1923 Freud changed his theory of the organization of the psychic processes. In the new structural theory (Freud, 1923b, 1926) the decisive element is no longer where the phenomena belong within the three systems, but which “instance” they belong to; the id, the ego or the superego. Id represents the forces of the drives, the ego stands for the relation to reality, and the superego represents moral prohibitions and ideals. In the new theory the drive wishes are no longer the only unconscious elements; the counter-forces, that is to say the defence against them, function on an unconscious level. The unconscious-conscious dimension, which previously held the position of a system variable, has now moved down so that it becomes a descriptive clinical variable. The earlier force field between conscious and unconscious (drive wishes and censorship) has moved to an intrapsychic conflict between id on the one hand and ego and superego on the other. The structural theory and its concepts enable a far more complex and nuanced description of the total tension dynamic in the personality than what the topographical theory allows for. This theory, with the additions and nuances that have been added since Freud’s version of it, forms a main theoretical frame for our understanding of pathological phenomena as well as of therapeutic technique.²

This does not mean, however, that the topographical way of thinking is completely outdated. Like many other outdated psychoanalytic views, it has not been discarded. It has rather been incorporated among the range of concepts whose golden age has passed and that have been set aside in favour of more recent views. At the same time, they represent a part of psychoanalytic culture and may still influence contemporary thinking. If we study more closely what takes place in the therapy room, we are made aware of the fact that a shared feature of many of the therapist’s interventions is precisely that of being aimed at the patient’s resistance to take in and accept parts of herself that have previously been denied or rejected. As Svalheim (1993) puts it: “In everyday clinical work, I believe by far the most psychotherapists think within the frame of the topographical model. They strive, together with the patients, to make the unconscious conscious” (pp. 69–70).

Motivation

We have used the term “dynamic” above to refer to intentionality in unconscious processes. In a wider sense, dynamic refers to the concept of motive, that is to say to the question of why humans experience and act the way they do. The word “dynamic” is derived from the Greek dynamikos (moving force). The psychoanalytic theory of the personality is a dynamic theory. In classical psychoanalysis the analyst’s task was to trace the unconscious forces as they expressed themselves in free associations, dreams, fantasies and symptoms – to thereafter, via interpretation, unmask them so that the unconscious meaning content became available to the consciousness of the analysand. The analytic work focused the dynamic between the systems id, ego, and superego (intersystemic perspective) The motives were the drive wishes, the unit of analysis was the id/ego conflict, and the effective principle of the therapy was summed up in the concept of insight. The aim of the therapy was expressed in Freud’s familiar formulation: “Where id was, there ego shall be” (Freud, 1933, p. 80).

When we adopt a dynamic point of view in clinical practice, it implies that we seek the answers to two questions:

1. What content in terms of conscious or unconscious meaning governs a given psychic phenomenon?
2. What is the psychological driving force behind the manifestation of the phenomenon?

On a deeper level these two questions are expressive of the same problem, though formulated in two different languages. The classical theory postulates that the experience and behaviour that is of psychological interest – normal as well as pathological – may be traced back to two drives, sexuality and aggression. The concept of drives is Freud’s answer to the two questions we posed above. A drive is to begin with a physiological event that is conveyed in the mental apparatus through representations, that is to say, patterns of meaningful ideas and emotions. Such a pattern is called a drive wish. Freud (1905a), to begin with, referred to one single drive, namely sexuality. Later on, aggression too was assigned the status of being a dive, like sexuality (Freud, 1920), therefore the term the dual drive theory.

The term drive does not refer to an observable phenomenon, but a hypothetical construction which points towards an inherent psychological force or impulse in the organism. A drive may be described from three angles: source, aim and object. The first one refers to the drive’s biological basis, the second to the drive’s purpose, and the third to the kind of object capable of satisfying the drive (Freud, 1905a). What criteria would need to be satisfied in order for a given psychological phenomenon to be named a drive? We will list five fundamental characteristics:

1. an experienced pressure, something dire;
2. relief at release;
3. discomfort when release or abreaction is blocked;
4. cyclical tension-discharge; and
5. attachment to a bodily zone.

Additionally, a physiological source must be determinable. Sexuality can be said to fulfil these criteria. The same thing cannot be said of aggression. In this case it is not a matter of a cyclical phenomenon. Nor can we say that aggression is tied to a particular bodily zone in the way sexuality in tied to so-called erogenous zones, and we have no good reasons to state that aggression has a specific physiological source in the way sexuality does. We are therefore of the opinion that aggression is not a drive on an equal footing with sexuality, and we do not follow Freud’s assumption of a separate “death drive”. What seems clear, however, is that an aggressive “impulse” often satisfies the three first criteria we have mentioned above. Aggression thereby presents itself as a drive-like phenomenon that may, on a clinical level, be seen as a separate motivating force, alongside sexuality.

When we refer to “drive” or to “drive theory” in this book, what we have got in mind is sexuality. Even though sexuality fulfils fundamental drive characteristics, sexuality as a phenomenon is first and foremost characterized by plasticity and volatility. This applies both to its expressions and to object choices. Sexual excitement may occur in numerous displaced and masked ways. Pleasurable sensations may for instance be achieved through masochistic self-torment and sadistic torment. The variability of sexuality’s forms of expression may be linked with the psychosexual development of the child. Sexuality passes through three stages (the oral, the anal and the phallic stage) before it reaches adult genitality, and it is localized in different bodily zones. If the child’s pleasure seeking comes to a halt, is fixated in one of these stages, it may influence both its sexual search for pleasure and choice of a partner later in life. Aggression too may be tied to the psychosexual phases and lend an aggressive taint to sexuality. With some patients the fixation in a particular sexual/aggressive pattern may become so dominant that it puts its stamp on the entire character development, both with regards to intensity and manner, for instance as oral/aggressive greed, anal/stubborn persistence or phallic/narcissistic need to dominate.

In classical analysis clinical symptoms and character traits were commonly understood on the basis of fixation and regression to psychosexual stages.³ This perspective has taken a back seat today. It may seem as if the object relational perspective has entailed a downgrading of the significance of sexuality as an etiological factor (Green, 1995). In presenting an overview over the state of psychoanalytic theory by the end of the 20th century, Holt concludes:

It is clinically obvious that sexuality and aggression, in their multifarious manifestations, are of overriding importance, but fear, anxiety, dependence, self-esteem, curiosity and group belonging (to name just a handful) cannot in any valid way be reduced to sexuality and aggression. They are emotional themes the therapist may not legitimately disregard.

(Holt, 1989, p. 179)

Along the lines of Holt, our view is that the psychosex...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Introduction
• PART I: Theoretical foundation
• PART II: The clinic
• PART III: Theory of change
• References
• Index