Interpretation and Interaction

Psychoanalysis or Psychotherapy?

Jerome D. Oremland, Merton M. Gill, Jerome D. Oremland, Merton M. Gill

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134884179
• Edition: 1
• Topic: Psychology
• Subtopic: Interpersonal Relations in Psychology
• Index: Psychology

In recent decades the relationship between psychoanalysis and psychotherapy has been a focal point for debate about the distinctiveness of analysis as a particular kind of therapeutic enterprise. In Interpretation and Interaction, Jerome Oremland invokes the interventions of"interpretation" and "interaction, " rooted in the values of understanding and amelioration, respectively, as a conceptual basis for reappraising these important issues.In place of the commonly accepted triadic division among psychoanalysis, exploratory psychotherapy, and supportive psychotherapy, he proposes a new triad: psychoanalysis, psychoanalytically-oriented psychotherapy, and interactive psychotherapy. Anchoring his classification in what he terms the "orientation of the therapy" rather than the "orientation of the therapist, " Oremland submits that analysis and psychoanalytically-orientedpsychotherapy strive systematically to interpret the therapeutic interaction as expressed in the transference. Interactive psychotherapy, on the other hand, uses the transference selectively to ameliorate psychic stress.

Interpretation and Interaction is enriched by a concluding chapter from Merton Gill, a preeminent authority on the therapeutic process. Gill's critical appreciation of Oremland's proposals amounts to an illuminating refinement of his own position on the relationship between psychoanalysis and psychotherapy.

Scholarly in conception, thoughtful in tone, and pragmatic in yield, Interpretation and Interaction is a clarifying addition to the psychoanalytic theory of psychotherapy. It will have the practical consequence, in Gill's words, of "aiding clinicians in retaining their analytic identities and their analytic orientation across the spectrum of their therapeutic work."

CHAPTER 1

Psychotherapy

The concept of mental illness was a mid-18th-century attempt to make mental aberration parallel to physical dysfunction. Viewing mental aberration as parallel to physical illness was a part of the epistemological evolution that, since the Renaissance, had defined a physical, as opposed to a spiritual, world. This liberal humanistic movement, itself derived from many philosophical roots, used a medical model and gave rise to the concepts of mental illness, the mentally ill, the mental patient, and mental treatment. Developing a medical lexicon for mental disturbance was part of the freeing of mental aberration from spiritual connotations. Just as the medical hegemony steadily replaced the religious influence in the study, care, and treatment of physical dysfunction, medical interests replaced the religious influence in the study, care, and treatment of people with mental aberrations. By the early 18th century, physicians were specializing in the mental illnesses. In fact, the first medical “specialist” was the alienist, the forerunner of the modern psychiatrist.

An early systematic attempt to provide rational treatment in this newly defined area of “illness” was the development in the mid-18th century, particularly in the United States, of moral treatment. Proceeding on the simple principles of “knowing the patients well and working closely with them,” as part of an emerging mental health movement, these proto-mental health professionals, some of whom were physicians, “were confident that the insane could be cured” (McGovern, 1985, p. 10). Moral treatment emphasized the “role of the environment in the cause and treatment of the mentally ill” and advocated “kind treatment to gain the confidence of the patient,” regularity in the patient's life, manual labor, constructive activities, and most important, “breaking] up the ‘wrong association of ideas’ of the patients and help[ing] them to form ‘correct habits of thinking as well as acting’ ... to direct the patients’ minds along new and healthy avenues of thought” (pp. 10–12). Essentially a rational kind of psychotherapy was born.

For many reasons, the confusion and lack of clarity about what constitutes psychotherapy continues to exist. The term itself entered the English language in 1901 (Oxford English Dictionary) with the founding of the London Psycho-Therapeutic Society. Psychotherapy originally was used to describe the psychological prevention and cure of physical disease. The broad hope of the London Psycho-Therapeutic Society reflected the wide interest at the turn of the century in suggestion and hypnosis and in the rudimentary but beginning scientific base for understanding physical disease.¹

Although the term psychotherapy came into being shortly following the publication in 1900 of Sigmund Freud's The Interpretation of Dreams, an association between psychotherapy and psychoanalysis did not flourish until the 1950s. Because psychoanalysis had evolved from hypnosis, understandably the early polemics regarding psychoanalysis as a treatment quickly concerned the distinctions between psychoanalysis and hypnosis (Freud, 1905a, c, 1912, 1916–1917; Ferenczi, 1919, 1923).

Interest in psychotherapy reached an apogee in the 1950s in the United States. This interest arose largely from the desire to expand the therapeutic scope of psychoanalysis, especially with regard to borderlines and schizophrenics, and in response to the theoretical and operational rigidity that progressively characterized psychoanalysis (Fromm-Reichmann, 1950; Sullivan, 1953; Stone, 1954). The most important figure in this expansion was Harry Stack Sullivan, an American, who with his colleagues launched the study of interaction (Sullivan, 1953). Sullivan phrased his observations and theories in terms quite different from the closed-system, energic, psychoanalytic formulations epitomized in the metapsychological writings of Heinz Hartmann, Ernst Kris, and Rudolph Loe-wenstein, which dominated psychoanalytic thought (Hartmann, 1939, 1950; Hartmann, Kris, and Loewenstein, 1946; Kris, 1951). Sullivan's group became known as the Interpersonal School of Psychiatry because of its emphasis on interpersonal processes in development, psychopathology, and psychotherapy.

Although the center of psychoanalytic theory building, training, and practice had shifted from central Europe to the United States after World War II, in an inconsistent way by the early 1950s interpersonal theory had become the theoretical infrastructure of the emerging psychoanalytic psychotherapy, particularly for nonmedical psychotherapists, among whom psychiatric social workers predominated. Traditional psychoanalytic theory continued as the foundation of the increasingly more standardized psychoanalytic procedure, psychoanalysis proper. Psychoanalytic psychotherapy was a particularly American invention.

With the development of ego psychology, spearheaded by Hartmann (1939, 1950), and the expanding recognition of the importance of understanding the development of object relatedness, which came from several sources, particularly Melanie Klein (1932; Klein, Isaacs, and Riviere, 1952; Harry Guntrip (1961), Donald Winnicott (1965, 1971), and W. R. D. Fairbairn (1954), and as psychoanalysis incorporated and systematized an observational base of development (Mahler, 1968; Mahler, Pine, and Bergman, 1975), the dichotomy between interpersonal and psychoanalytic theory began to disappear. This trend toward integration of psychoanalysis as a theory of development, psychopathology, and treatment has somewhat been reversed by Heinz Kohut's (1971, 1977, 1984) self psychology. Although different from interpersonal theory and object relations theory, Kohut attempted to address issues and deficiencies in general psychoanalytic theory similar to the issues that give impetus to interpersonal theory (Oremland, 1985).

With increasing numbers of mental health professionals being trained as psychotherapists in the United States, many of whom received unsystematic, partial, and frequently erroneous psychoanalytic information, the theoretical base for psychoanalytic psychotherapy became a mixture of concepts and descriptions derived from interpersonal theory, object relation views, behaviorial observations, and psychoanalytic developmental formulations. This potpourri of theories and practices applied by the melange of practitioners of highly varying training, especially in the fields of psychiatry and social work, had as its lingua franca the developmental, energic, and structural lexicon of psychoanalysis.

This compote of theories and practitioners was matched by the array of people and mental conditions to which it was applied, people ranging from the most regressed, nonverbal, posturing schizophrenics to those suffering the lightest situational disturbances of adolescent or adult life. Psychoanalysis had arrived at its Golden Age. In fact, the Golden Age of psychoanalysis rested more on the widespread application of this melange of theories and styles of practice than it did on psychoanalysis proper. Psychoanalysis, which had successfully freed itself from hypnosis, had a stepchild of unclear dimensions called psychoanalytic psychotherapy, with the psychoanalysts as the theoretical and clinical leaders (Berliner, 1941).

Within the psychotherapeutic enterprise, a rigid hierarchy of disciplines was soon established with institute-trained psychoanalysts, a small and select group of psychiatrists, at the top. Beneath this elite group were the “dynamic” or “psychoanalytic” psychiatrists, who were partially trained in, or at least considered knowledgeable about, psychoanalysis. This larger group of physicians was followed by a much larger group, the social workers, who, abandoning their traditional guidance and case-oriented helping roles, adopted the nonintervening, nondirective, cathartic model that was being touted as psychoanalytic. Operationally, to a large extent the social workers did the clinical work, generally in institutional settings, under the supervision of psychoanalytic psychiatrists, who themselves had been taught, supervised, and treated by the elite psychoanalysts.

Although schematically appealing, such a hierarchical system could not be maintained because of the varying degrees of training and abilities in each of the disciplines. Moreover, the system began to face difficulties because of the dissatisfaction and disillusionment that inevitably came from the nonspecific application of nonspecific theories to overwhelming problems. It is little wonder that the Golden Age of psychoanalysis was to dissolve into the interactive excesses and emphasis on spontaneity, intuition, and absence of training that characterized the “psychotherapeutic” scene in the late 1960s and early 1970s.

Until the 1970s, the role of the psychologist was yet to be strongly felt in the psychotherapeutic community, although within psychoanalysis there was from the beginning a small group of academically trained psychologists with strong clinical interests. These psychologists called basic psychoanalytic formulations into question and asked for systematization and empirical testing of the widely accepted psychoanalytic propositions (Klein, 1973; Schafer, 1964, 1976; Holt, 1965). Aside from this group of academically trained psychologists, clinically trained psychologists, largely because of their exclusion from the psychoanalytic training institutes, gravitated toward the scholastically acceptable and empirically testable learning theories, even though their influence on psychotherapy was minimal. With time, the psychotherapeutic application of learning theory insinuated itself into the hodgepodge of psychotherapeutic techniques as various conditioning techniques. Suggestion was again gaining favor in the psychotherapeutic community. Somewhat bridging both trends, and of singular importance, was Carl Rogers (1942), who developed a highly nondirective technique that gained wide favor because of its easily demonstrable and taught technique.

The most important early attempt within psychoanalysis to bring order to the chaos created by wide and indiscriminate application of psychoanalytic principles to psychotherapy was the American Psychoanalytic Association's 1953 panel, “Psychoanalysis and Dynamic Psychotherapy—Similarities and Differences,” reported by Leo Rangell (1954a).

The International Psychoanalytic Association was not to have a major discussion on psychotherapy until 1970 at the Rome meeting at which a panel was presented on “Psychoanalysis and Psychotherapy,” chaired by Robert Wallerstein (Adler, 1970). The Journal of the American Psychoanalytic Association (Rangell, 1954a), published the panel reports with sections on the Widening Scope of Indications for Psychoanalysis, the Traditional Psychoanalytic Technique and Its Variations, and Psychoanalysis and Dynamic Psychotherapy—Similarities and Differences. Obviously psychoanalysis was searching its boundaries.

The section on Psychoanalysis and Dynamic Psychotherapy—Similarities and Differences (Rangell, 1954a) carried elaborated versions of the 1953 panel presentations by Franz Alexander, Edward Bibring, Freida Fromm-Reichmann, and Rangell and a new paper by Merton Gill, “Psychoanalysis and Exploratory Psychotherapy.’’ In these papers the wide range of terms used to refer to psychoanalytic psychotherapy reflected the groping for a central theoretical structure to organize the thoughts. Rangell (1954b) wrote,

the experience of the Committee on Evaluation of Psychoanalytic Therapy, set up within the American Psychoanalytic Association in 1947, . . . was never able to pass the initial and vexatious point of trying to arrive at some modicum of agreement to exactly what constitutes psychoanalysis, psychoanalytic psychotherapy, and possibly transitional forms [p. 734].

Gill's (1954) paper was written without his knowing of the 1953 panel and was a response to a variety of publications attempting to define psychotherapy, particularly Alexander's (1927, 1946; Alexander and French, 1946) bold and widely popular departure from psychoanalysis and Fromm-Reichmann's (1950) attempt to place psychotherapy and psychoanalysis on a continuum. Alexander advocated contrived “corrective” interactions by psychotherapists and actively downplayed psychoanalysis as the premier psychotherapy. Fromm-Reichmann saw “free association, recumbency, and similar measures ... [as not only] not necessary in psychoanalysis . . . but [a] waste [of] time” (p. 795).

Gill's (1954) paper immediately became a classic because of its succinctness, simplicity, and applicability. He began his clarification by pointing out that confusion exists because

psychotherapy is often discussed without clearly defining whether one is talking about cases in which psychoanalysis would have been theoretically applicable, but could not be used because of external reasons such as a lack of time or money so that psychotherapy with lesser goals is employed, and those in which psychoanalysis is regarded as contraindicated whether because of temporary reasons ... or more permanent reasons . . .[p. 773].

Of paradigmatic importance was a conceptual advance in which Gill acknowledged that psychotherapy was generic, and psychoanalysis, a subset. According to Gill,

The word “psychotherapy” is used in two main senses, first as a broad term to include all types of therapy by psychological means, under which psychoanalysis is included, and second in a narrow sense to designate methods of psychological therapy which are not psychoanalysis, even if they are grounded in the theory of psychoanalysis [p. 772].

Gill's paper marked another important advance. Traditionally, psychoanalysis technically was largely defined in terms of differences from suggestion and hypnosis (Freud, 1905a, c; 1916–1917). In Gill's paper, psychotherapy was defined by contrasting it with psychoanalysis. To do so, Gill had to arrive at an operational definition of psychoanalysis, a refinement of Freud's (1916–1917) description of the shibboleth of psychoanalysis, interpretation of resistance and transference. Gill wrote,

By putting together a number of attempts at definition which have been made, I believe that the essence of the psychoanalytic technique is stated in the following formula: Psychoanalysis is that technique which, employed by a neutral analyst, results in the development of a regressive transference neurosis and the ultimate resolution of this neurosis by techniques of interpretation alone” [p. 775].

Psychoanalysis, or at least Gill's definition of psychoanalysis, became the standard against which other psychotherapies were measured and defined.

With regard to the generic concept of psychotherapy, Gill maintained a triadic distinction: supportive psychotherapy, exploratory psychotherapy, and psychoanalysis. Gill differentiated his triad along an axis of predominate intervention. Supportive psychotherapy was defined by its predominance of counseling, suggestion, and advice-giving interventions. Exploratory psychotherapy included vaguely defined explorations of causal factors largely in developmental, that is, personal, historical terms. Psychoanalysis was defined by the primacy of interpretation of the transference neurosis. In a general way, supportive and explorative psychotherapies involved lesser frequency of sessions (once or twice a week) and face-to-face positioning; psychoanalysis required greater frequency (three to five times a week) and recumbency of the patient.

To clarify exploratory psychotherapy, Gill introduced a new term, the intermediate form. In this expanded concept of what was generally held to be “exploratory,” Gill, more than previous writers, blurred the distinctions between psychotherapy and psychoanalysis proper, placing the psychotherapies on a continuum— “primarily supportive or primarily exploratory, with all grades in between” (p. 772). Gill's unclearly formulated “intermediate” form characterized a genre of psychotherapy. Although solving some terminological problems, Gill's proposal raised many theoretical issues. This intermediate form (generally called exploratory psychotherapy) became the overall rubric for the most widely applied form of psychotherapy in America and became synonymous with psychoanalytic psychotherapy (Berliner, 1941). Although Gill (1982) currently and in important ways is assailing his own definition of psychoanalysis and his continuum, his 1954 paper remains a watershed definition of these procedures.

Somewhat later and working within a research framewor...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Contents
• Preface
• Chapter 1 Psychotherapy
• Chapter 2 Psychoanalytically Oriented Psychotherapy
• Chapter 3 Transference, Resistance, and Interpretation
• Chapter 4 Neutrality, Countertransference, and Abstinence
• Chapter 5 Phases in Psychoanalytically Oriented Psychotherapy
• Chapter 6 The Dream in Psychoanalytically Oriented Psychotherapy
• Chapter 7 Some Specific Interaction Situations
• Chatper 8 Psychoanalytically Oriented Psychotherapy and Psychoanalysis: A Double Helix
• Chapter 9 In Summary
• Chapter 10 Indirect Suggestion: A Response to Oremland’s Interpretation and Interaction
• References
• Index