The Texture of Treatment

On the Matter of Psychoanalytic Technique

Herbert J. Schlesinger

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134910496
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

In simple, jargon-free language, Herbert Schlesinger sets out to demystify technique, to show how it is based on basic principles that are applicable both to psychoanalysis and to the psychotherapies that derive from it. He has little need for conventional theory; rather, he reframes essential analytic notions - transference, resistance, interpretation, regression, empathy - as processes and assigns technique the goal of promoting the patient's activity within the treatment situation. The aim of the analytic therapist is to restore to the patient active control of his own life.Utilizing basic premises of systems theory, Schlesinger approaches personality and neurosis alike as self-stabilizing systems that can be changed only with persistent effort. Follow-up interpretations that address the patient's responses to previous interpretations are crucial. Similarly, the analyst views the transference as "rules of behavior" the patient has created that limit the freedom of both parties in the treatment. Interpretation speaks to the patient's inability to make full use of the freedom the analytic situation affords to explore how his mind works. Viewing neuroses as what the patient does, rather than what he has, the analyst sees the "resisting" patient not as opposing the treatment but rather doing what the patient feels he must do both to accommodate to the demands of the script of an unconscious fantasy and to provide for his own sense of safety.Beautifully illustrated with clinical vignettes and everyday social experiences, The Texture of Treatment is a lucid and engaging presentation of the principles Schlesinger has taught to successive generations of psychiatric residents, clinical psychology interns, clinical social work students, and psychoanalytic candidates. Taking up elementary matters from an advanced point of view, he has produced a contemporary text whose appeal to seasoned clinicians will be no less that its usefulness to beginning therapists.

1

In the Beginning … Was Technique

In Defense of Technique

Perhaps most analysts were introduced to the mysteries of psychoanalytic technique as I was: that it was not so much a cohesive body of structured knowledge and practice as a loose collection of do’s and don’ts. A chill in the heart warned me that to violate any one of them would ruin the analysis. Cowering before gray eminences, I and my fellow candidates had a bad case of transference to the Institute, for none of our teachers had literally laid down any such doctrine. It was more that no one troubled to disabuse us of the idea that, if somehow we were lucky enough to avoid all the pitfalls set by our natural enemy, the patients, the residue of our avoidance would be pure essence of psychoanalysis. We feared analysis was a fragile flower, one easily crushed in the hands of clumsy beginners. And the patients, we feared, were secretly out to do us in, to abort our nascent careers. Simply through recalcitrance, they could keep us from graduating. It took a while to discover that our patients were even more frightened than we were. It took more time to discover that analysis is not a fragile flower, but a sturdy affair. What we once regarded as fatal mistakes turned out mostly not to matter that much; sins of omission—what we failed to do—proved much more harmful.

It also seems to me, after later reflection, that we were working with more than a collection of rules of thumb, that there was a structure to the knowledge we use when analyzing patients and that it would be useful to spell out this structure. Karl Menninger and Philip Holzman (1973) have offered us a systematic theory of technique, one that makes great sense to me. The reader will find resonance of this approach in what follows. But their overall approach seems to me too heavily committed to the model of a rational “compact” between analyst and patient, an idea that does not fit with my experiences in the analytic situation.

I am not offering here an altogether new view of psychoanalytic technique. Rather I am attempting to make explicit that there is a logic to the way we go about analyzing as we listen to our patients and follow their associations. We generally do not pay attention to that logic while analyzing any more than we think about the physics of keeping the bicycle upright while riding (Schlesinger, 1994). But one needs to pay attention to the science when designing a bicycle or when designing a treatment for a particular patient, which after all is what one does when one analyzes. In this book I will present the technique of psychoanalysis and psychotherapy in a way that is both more systematic and simpler than I recall it being taught to me.

The very term technique strikes some clinicians as repellant when applied to psychotherapy or psychoanalysis; it seems to signify a manipulative intent rather than a collaboration and tends to substitute a mechanistic approach for intuitive and empathic understanding. But the term has other implications that are inescapable for a clinician. Psychoanalysis certainly ought to be collaborative: to rest on the analyst’s intuitive and empathic understanding of the experience of the patient and to encourage the patient in intuitive self-understanding. But the analyst or therapist is more responsible for the conduct of the treatment than the patient is, and the analyst is expected to know what she is doing and why and what to expect when she intervenes. “Technique” refers to this responsibility of the clinician to conduct a rational treatment.

“Technique” has a politicized history. Almost from the beginning of the psychoanalytic era, the field has been marked by fervent arguments about preserving the integrity of the method. Self-appointed custodians of the field have worried that any deviation from received wisdom would spoil what was truly psychoanalytic, would dilute the purity of its technique and lead inevitably to seduction of the innocents. The debate has taken different forms and has used different terms across the generations but always within the general concern that, on one hand, ill-considered modifications would impair the integrity of Freud’s legacy and, on the other, hide-bound adherence to outmoded doctrine would make the field irrelevant.

The struggle has often had the character of a religious war with clinching arguments based on quotation from authoritative texts rather than experiment and data. The crowning denunciation from the right has been “But that’s not analysis,” and, on the left, “But it works.” Neither charge is apposite. Both are flawed, logically and psychologically—and also analytically.

To pursue this discussion of technique with less heat it is necessary to clarify the operative terms and to set down some ground rules: I do not use the word analysis to describe the process under consideration. Processes must be described with verbs, and, as I consider “analysis” to be a noun, a process, the appropriate verb is “to analyze.”¹ Rather than permitting the wholesale derogation of a clinician’s work with the denunciation, “That’s not analysis,” or, in its ultimate form, “We all know he doesn’t do analysis, and between us, neither did his analyst,” we require that objectors specify at what point(s) they believe the clinician under observation failed to analyze, either by not attending to something at all or by attending to it in some way the objector considers “unanalytic.”

Not everything an analyst does, or a clinician of any stripe does, has “technical” intent. After all, the analytic situation is a subset of the larger social situation and is, to a considerable degree, governed by the customs, manners, and expectations prevalent in the culture at large as well as the social subcontext of the doctor-patient relationship. The expectations of these larger contexts may, but do not inevitably, conflict with those of the analytic situation. It becomes a matter to be determined, at the moment under review, if these expectations conflict, and if they do, which context should govern.

I reserve the term technique for those actions (including withholding intervention, or silence) the analyst undertakes with specific analytic intent. For these actions, the analyst should be able to state what he believes the effect ought to be, how he would know if his action had had the intended effect, and what ought to happen next. Much of what the analyst does is not technical in this sense but is either nonspecifically facilitative or, more generally, in the service of preserving the analytic situation or not offending the expectations of the larger social context (Schlesinger, 1995a).

I avoid professional jargon unless the descriptive powers of ordinary English prove insufficient. It has been my experience that jargon often is used to conceal a lack of clarity, and it is my purpose to expose that lack rather than conceal it. I have tried to write in such a way as to demystify the topic of technique. Though my topic is serious, I see no reason to be solemn about it or to affect the dense style that announces itself as scholarly and pretends to profundity. My goal has been to write so that an intelligent layman interested in this topic could understand all of it.

I mean to show that both psychoanalysis and the dynamic psychotherapies derived from it are governed by the same technical principles. I deal with the differences and similarities between them in a chapter that, logically, ought to appear early. But in that position it would interrupt the general argument and so it appears closer to the end.

I discuss psychoanalysis as a process. In common usage within the profession, the term process is often employed as an intensifier, when the user means to invoke the ineffable essence of psychoanalysis, as in, “I guess he does all right clinically, but he doesn’t grasp the psychoanalytic process.” I intend to show that the term process has much more specific meaning, and that viewing such standard topics as resistance, regression, transference, and interpretation as processes promotes clarity and adds power to our understanding of technique.

Since my view of psychoanalytic technique is based on “system” and “process,” the organization of this book is necessarily recursive; these key ideas reappear in different contexts. While I may seem to be offering a textbook of psychoanalysis (and secretly I hope to have filled the need for one), I have adapted my ambition to the less formal and less demanding and perhaps less off-putting style of simply thinking aloud.

What Do We Mean by “Technique?”

Technique is a term used in many fields of practice. Freud (1912a) liked to draw an analogy between the position of the analyst at work to that of the surgeon (Stepansky, 1999). But, for a surgeon, technique has several important implications that analysts tend to ignore. For instance, a surgeon will choose the point of incision depending on his purpose in undertaking the operation. When he opens the abdomen he will have a clear expectation of what he ought to find. He will also have a clear idea about what should not be present, and how and with what instruments he will undertake to correct matters.

The general term I use for the “instrument” of the psychoanalyst is technical intervention. The term analyzing instrument was used by Isakower (1957) for processes in the mind of the analyst that lead to interpretation. I have no quarrel with his usage, but prefer to focus on the outcome of that process, that is, what the analyst does or refrains from doing. Among the various technical interventions, analysts favor particularly interpretation. Compared with the surgeon’s scalpel, interpretation must seem a blunt instrument. But an analyst can aspire to something like surgical precision if he holds the same attitudes of purposefulness and expectancy as the surgeon. Like Fenichel (1941, p. 52) I believe the analyst should accept analogous responsibilities to direct an interpretation toward an issue of immediate analytic significance and to have an idea of what the patient’s response might be if the interpretation is correct. The analyst should also have an idea of what ought not to happen in response to an intervention.

It might be objected that even in ordinary conversation, one making any comment will have an expectation of what the response is likely to be inasmuch as the context in which the parties are conversing sets the bounds of appropriateness of response. But interpretation is the kind of intervention that seldom occurs in ordinary conversation, a context in which we, of course, are not privileged to offer interpretations. By interpreting we intend to disturb the expectation of the other; by changing the meaning of an idea in play, we violate the apparent context in which it was offered originally. It is, therefore, incumbent on the analyst to anticipate how the patient will respond to a disturbing, if enlightening, message.

Although the analogy to the surgeon has much to teach analysts with regard to intentionality, it is too limited in other important respects to serve as a general guide. It could be taken to imply that an analyst must always know precisely what is going on and make no utterance without both a specific purpose and a clear idea about what ought to ensue. To the contrary, one of the main lessons an analyst must learn is to be comfortable with ambiguity, with not knowing instantly where he is. And much of what the analyst does is in the interest of expectancy, of allowing matters to develop.

Classifying Interventions

The activities of the analyst in the analytic situation can be arrayed in a simple table (see Table 1). The headings “Technical” and “Nontechnical” imply that some interventions may not have technical intent; the labels “Specific” and “Nonspecific” refer to the extent to which the analyst’s activity is planned and deliberate, rather than casual. Table 1 represents systematically our general awareness that the analytic situation includes more than the purely technical activity of the analyst. While it oversimplifies matters, this matrix does permit organizing some of the familiar terms with which the analytic situation has been described (Schlesinger, 1995a).

For instance, “Technical and Specific” includes the named, planned interventions that particularly characterize analysis. They have been categorized by Bibring (1954) and others. While these activities may define psychoanalysis, I do not believe anyone would claim today that, if only these activities were carried out, an analysis would occur. Obviously, more than strictly technical activities are necessary.

Table 1. The Activities of the Analyst

	Technical	Nontechnical
Specific	Interpretation, clarification, etc.	Suggestions, prohibitions, ultimatums, etc.
Nonspecific	Facilitating comments intended to build toward interpretation.	Socially appropriate comments intended to promote relationship

“Nontechnical and Specific” is also easy to characterize. It includes all those things that analysts do, with plan in mind or not, that are not engraved in the canon of technique but generally have a considerable influence on the analytic situation. Over the years, these interventions have been given various names—blunders by some, parameters by others; they may include orders, ultimatums, advice, and other therapeutically intended interventions that are not, strictly speaking, analytic.

“Nonspecific and Nontechnical” encompasses all those aspects of the human relationship between analyst and patient that promote its continuance, whether that continuance has the form of a therapeutic or working alliance, or a stalemate, or a transference-countertransference bind sustained by mutual acting out. Friendliness, attentiveness, and more could be included.

“Technical and Nonspecific” might seem at first glance to be a puzzling, even confusing designation. But, if one thinks of interpretation as a process, one could define its vector with increasing specificity—in its earliest phase as largely nonspecific and facilitative (perhaps merely encouraging grunts) as the analyst attempts to determine the readiness of the patient to explore, analyze, absorb, or otherwise get into the conflict that is at the root of the disturbance of the moment. Later, the interpretive process becomes more specific and focal. At all times, however specific or nonspecific, the intent of the analyst is to build toward interpretation and hence is technical.

My purpose in organizing interventions in this way is to support the idea that the effectiveness of an interpretation depends not only on its correctness, its “truth value,” but also on a number of other variables. This idea is of course not new. Supervisors constantly stress in their teaching the importance of timing, tact, and dosage, along with the empathic quality and the accuracy of the interpretation. Notice that I did not include tact, dosage, timing, or empathy in this matrix of technique, even though we talk about them repeatedly in seminars on technique. But, if I may anticipate the end of this argument, tact, dosage, and the rest are desirable attributes of all the interactions in the analytic situation and elsewhere (Loewenstein, 1958; Poland, 1975). They are, after all, basic to our code of social manners. If we were to include them in the matrix, perhaps they would fit best among the nonspecific aspects of technique rather than among such specific aspects as interpretation, clarification and confrontation (Schlesinger, 1995a).

Intervention versus Interpretation?

I have used the term intervention to cover the analyst’s deliberate activity without distinguishing the various forms that intervention can take. A comprehensive discussion of analytic technique certainly seems to need to address these distinctions inasmuch as so much has been made of them in the literature. In particular, I must deal with the defining act of psychoanalysis, the interpretation. I have left unchallenged the implicit notion that it is sensible to label an intervention as an interpretation or as something else on the basis of formal definitions. But I believe much too much importance has been given to categorizing interventions and to rating their presumed analytic value. According to convention, one decides if an intervention was an interpretation from the way it was phrased and from the intention of the analyst. I do not believe this approach is useful. An old story may make my point clear:

Three aging baseball umpires were bragging about their exploits at judging on the field and compared their sense of conviction about calling balls and strikes. One declared, “I call them the way I see them.” The second umpire averred, “I see them the way I call them.” The third, most senior, umpire quietly ended the discussion by saying, “They ain’t nothing until I call them.”

In analysis the patient, not the analyst, is the umpire. Wh...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Acknowledgements
• Contents
• Introduction
• Chapter 1 In the Beginning … Was Technique
• Chapter 2 The Systems Approach
• Chapter 3 Working Principles of Technique
• Chapter 4 Transference and the Process of Interpretation
• Chapter 5 Transference and Countertransference
• Chapter 6 Resistance
• Chapter 7 Dreams: Royal Road or Scenic Route?
• Chapter 8 From Listening to Interpretation
• Chapter 9 The Process of Defense
• Chapter 10 On Therapeutic Activity
• Chapter 11 Questioning, Con and Pro
• Chapter 12 Responding to Patients’ Questions
• Chapter 13 The Process Point of View
• Chapter 14 The Place of Regression in Psychoanalysis
• Chapter 15 The Challenge of Regression
• Chapter 16 Severe Regression
• Chapter 17 Analyzing in the Middle Phase
• Chapter 18 Whether and How to Begin a Psychoanalysis
• Chapter 19 The Optimal Therapeutic Relationship
• Chapter 20 Psychoanalysis and Psychoanalytic Psychotherapy
• Chapter 21 Analyzing and Life Change
• Chapter 22 Conclusion: Interpretation and Change
• References
• Index