The Southeast Florida Association for Psychoanalytic Psychology
A Local Chapter of Division 39 of the American Psychological Association

Psyche & Sol - Winter 2009, Issue 16, Volume 2

President’s Message - Richard Steinberg, Ph.D.

PROGRESS

In the1980’s, the renowned cellist and conductor Pablo Casals was known to practice the cello seven hours per day. A friend of his commented to him, “Maestro, you are a celebrated musician, known around the world. Why do you spend so much time practicing?” Casals reportedly replied “I think I’m making progress”.

How do we define progress as a psychoanalytic organization and, how do we measure it? Even more importantly, what promotes progress for each of us as psychoanalytic psychotherapists?

Since we are a number society, let’s begin by looking at the number of members. We have had fairly stable membership throughout the year with an encouraging spurt of growth within the last month. The total paid membership is now at 120, up about 10% from last Spring.

Most new members have come as a result of people signing up as volunteers for the Veterans Project of South Florida-Strategic Outreach to Families of All Reservists (VPOSF-SOFAR), our community service project, which offers pro bono mental health services for veterans and families of the Iraq and Afghan wars. This is most beneficial as the additional growth enables us to offer more programs and to enrich the variety and personality of our membership.

Another number that matters is attendance at educational meetings. Our Scientific Meetings usually feature recognized figures in the field from “out of town”. This year featured local members of SEFAPP and SEFIPP. In October, 2009 Antonio R. Virsida, Ph,D., A.B.P.P, Stefan Pasternack, M.D. and Michelle Channing, Psy.D. presented “The Conflict of Money in Psychotherapy and Practice Building Methods in Today’s Economy”. The final Scientific Meeting of 2009 was on December 5th, “Fostering Mentalization in Child Patients: An Integration of Structural, Object Relations and Attachment Theories in Psychotherapy with Children” by Alan Sugarman, Ph.D. Dr. Sugarman presented two separate events on the same day. Both well attended and well received.

It is so important to hear from outstanding people in our field from other parts of the country and the world to keep us current and to stimulate our community. We have made an effort this year to attempt to target professional organizations who might have a particular interest in our programs. For example, we reached out to the Broward County Chapter of the Marriage, Family Therapy and Mental Health Counseling Association, to help us promote Dr. Glenn Good’s presentation on couple therapy. At the suggestion of Larry Kaufman, L.M.F.T. and former President of SEFAPP, we contacted the Chapter President, Sloane Veshinski, L.M.F.T., who was kind enough to place the program on their web site. This led to several new registrants. If all our members would assist us in networking, we could both increase membership and attendance at our educational meetings. We would appreciate your feedback about this. You can reach me at rstein1426@aol.com. Our Liaison Committee chair Larry Levy, Psy.D. would also like to hear from you at drlevy@levyypsychology.com.

Turning to personal/professional development, how do we define the impact of SEFAPP’s educational programs on us? Here, there are so many variables to consider, like theoretical orientation, years of experience, post-graduate training, personal therapy or analysis. SEFAPP is a ‘Big Tent’ and our only requirement for membership is an “interest” in psychoanalysis. For me, I learned something from each presentation that I later thought about in my office with patients. From Donna Bentolila, L.C.S.W, I became more sensitive to the depth of early childhood wounds that underlie severe depression and violence. There was also Dr. Salman Akhtar’s utilization of a physical representational metaphor by

cradling his left arm to symbolize the holding environment, and simultaneously bending the right arm toward the cradling left and wiggling his fingers of the right hand towards the imagined cradled patient. I doubt that my description, which may conjure up more an image of martial arts than the functions of a therapist, conveys as did Dr. Akhtar, the powerful and dynamic dual functions of the therapist, simultaneous holding and engaging.

Dr. Glenn Good’s way of beginning each session with in his work with couples, “It’s All Yours”, helped me to solve the problem with a particular couple who often attempted to talk to me individually, thereby short-circuiting interaction with one another. The ‘Money” conference was helpful in so many ways, through Dr. Virsida’s forthright approach to direct discussion about financial matters and his skillful handling of deception regarding money; and through Dr. Pasternack’s rescue from intense countertransference , through his recognition of a process of projective identification. These papers helped me to understand and feel freer to address similar problems with my patients. The afternoon section on Practice Management, Practice Building and Investment was especially helpful to a business-phobic therapist like myself and prompted me to institute some new systems of billing and to consider legal incorporation of my practice. Our own Michelle Channing, Psy.D. brought home the crucial importance of systems regarding billing and other aspects of practice management. I’m sure each of you has been affected in different ways by the presentations and, as I noted, I believe they do have an impact on our actual work.

To go a little further, I believe it is essential to open ourselves up to, and learn more about, other points of view and new ideas in the field. I had two experiences this past year that have had a significant effect.

The first was participating in a study group on Self-Psychology led by Stefan Pasternack, M. D. I trained (and I am still a candidate) at the Institute for Psychoanalytic Training and Research (IPTAR), a Freudian grounded institute in New York City, where self-psychology wasn’t emphasized. Reading Frank Lachman’s (2008) “Transforming Narcissism: Reflections on Empathy, Humor, and Expectations” revealed an original thinker and challenged me to re-examine and consider additional points of view. While my general theoretical approach has not changed markedly, I have a much greater appreciation for the self-psychological viewpoint and have become more attuned to the patient’s subjective experience as a starting point for deeper feelings and a wider exploration.

Another important experience for me was participating in a telephone study group with Norbert Freedman, Ph, D, and Rhonda Ward, Ph. D. on the Symbolization Process. The fascinating research based on transcribed sessions of an analysis re-connected me to my institute, reawakened an interest in psychoanalytic research, sharpened theoretical concepts and focused attention on actual clinical process. I recommend the Freedman, Lasky and Ward (2009) article cited below.

I think each of us decides what we need to continue to grow professionally. Both the SEFAPP continuing education programs and the study group experiences this past year were, for me, an antidote to becoming ‘encrusted’ in my theoretical and technical stances. These programs led me to really examine and sharpen my understanding of what “I thought I knew” and hopefully, enabled me learn something’ new’ which is so essential to remaining a vital ‘Self’ and vital ‘Object’ to our patients.

And so, by the numbers, and considering my personal experiences with SEFAPP

and beyond this year: “I THINK WE’RE MAKING PROGRESS”.

Finally, my heartfelt thanks to all the members of the board who have worked so tirelessly and creatively to support SEFAPP and to make this such a rewarding year for me and, I hope, our membership.

All of My Best Wishes for a healthy, happy and prosperous 2010, and good luck to Marshall Fenster, Psy.D. in his presidency.

References:

Freedman, N., Lasky, R., Ward, R., (2009) The Upward Slope: A Study o Psychoanalytic Transformations, Psychoanalytic Q., 78:202-231

Lachman, Frank, (2008). Transforming Narcissism: Reflections on Empathy, Humor and Expectations. Psychoanalytic Inquiry Book Series, Volume 28, Analytic Press, N.J.

Editor's Column - Antonio R. Virsida, Ph.D., ABPP

This issue of Psyche & Sol reflects SEFAPP's increasing vitality. The amount of work done by our board and committee members is impressive, and is reflective of their commitment to psychoanalytic perspectives and to SEFAPP. Richard Steinberg, Ph.D, in his presidential column portrays not only some of the work done by board and committee members, but the success and “progress” of our scientific programs, symposium brunches, outreach and “in-reach” efforts.

Our membership has increased to over one hundred twenty members, in significant part owing to our collaborative endeavor with the Florida Psychoanalytic Society in which we developed the Veterans Project of South Florida-Strategic Outreach to Families of All reservists (VPOSF-SOFAR). Frederic J. Levine, Ph.D., who is the Co-Chair, along with our President, Richard Steinberg, Ph.D. of the VPOSF-SOFAR, reports on recent activities, outreach and impressive future programs. Aaryn Gottesfeld, M.A., SEFAPP's treasurer reports that we are in sound financial shape, even with our $500 contribution of seed money to the VPOSF-SOFAR. In this regard, SEFAPP has received considerable financial support from the Ticho Foundation Administrator and SEFAPP member, Stefan Pasternack, M.D.

Leonard J. Ferrante, Psy.D., Membership Committee Chair reports on the efforts to recruit new members and to expand our attendance at our events, including our upcoming March, 2010 New Members Brunch. Emily Krestow, Ph.D. summarizes our October,24, 2009 Annual All Day Conference, held at Florida Atlantic University's, Bio-Medical Department, which was arranged by Stefan Pasternack, M.D., and I summarize the November 22nd, 2009 Symposium Brunch Event with Dr. Siv Boalt Boethius.

In this issue of Psyche & Sol we continue with Linda Sherby, Ph.D., A.B.P.P. and her Clinical Vignettes article, “Another Voice”, in which she illustrates the various roads to emotional meanings and unconscious processes. The addition of Transference Countertransference Corner by Shirley Malove, L.C.S.W. adds another interesting and illuminating clinical article.

Several Special Reports enrich this issue. My SEFIPP News and Update reports on SEFIPP's faculty growth, curriculum and training requirements revisions, program additions and the Special Seminar which was held on November 15, 2009. Re-printed from the newsletter of Psychoanalyst Practitioners, Section I of Division 39, the Round Robin is an article by Jack Novick, Ph.D. and Kerry Kelly Novick, entitled, “The Rat Man and Two Systems of Self-Regulation”. The Novicks use Freud's paper on the Rat Man to elaborate their incisive perspectives on the Rat Man's pathological, closed, sadomasochistic and omnipotent system of self regulation, as distinguished from an open system which is attuned to inner and outer reality, a range of emotions and is organized by competence, creativity and love.

William A. MacGillivray, Ph.D., A.B.P.P., Division 39, President-Elect and Editor of Division 39's and the Appalachian Psychoanalytic Society's newsletter gave us permission to reprint the article, “Psychodynamic Psychotherapy: In the News!”, in which he reviews a recent important research comparing outcome effectiveness of Long Term Psychodynamic Psychotherapy (LTPP) with short-term interventions.

Along similar lines, an article by Oliver James, Ph.D., re-printed from the Guardian UK.Org, an online newsletter, reports a study which concludes that psychodynamic psychotherapy was superior to either medical or cognitive behavioral interventions with women suffering with postnatal depression. Mary Beth Cresci, Ph.D., A.B.P.P., Division 39 President gave us permission to reprint an email she sent to Division 39 members, reporting on, and providing an abstract of an important meta-analytic study of the efficacy of psychoanalytic psychotherapy by Jonathan Shedler, Ph.D. of the University of Colorado's Department of Psychiatry and the Health Sciences Center.

Closing out this issue are two book reviews. James E. Gorney, Ph.D. of the Appalachian Psychoanalytic Society, and a previous SEFAPP presenter and a friend of many of us in SEFAPP, gave us permission to reprint his 2004 book review of Francoise Davoine's and Jean-Max Gaudilliere's profound book, History Beyond Trauma. This book review gives us an excellent glimpse of what we'll hear, particularly about war trauma and the intergenerational transmission of trauma when they present at the VPOSF-SOFAR and Miami VA Medical Center co-sponsored conference, which will be held at the Miami VA Medical Center on March 20, 2010. They will be presenting along with Jonathan Shay, M.D., Ph.D., who is a consultant to the Department of Defense and the military and the world renowned author of Achilles in Vietnam: Combat Trauma and the Undoing of Character and Odysseus in America: Also on that panel will be Daniella David, M.D., PTSD expert of the Miami VA Medical Center and Professor at the University of Miami's Medical School, Department of Psychiatry.

Morris N. Eagle, Ph.D. Professor of Psychology at Adelphi University's, Gordon Derner Institute of Advance Psychological Studies in Garden City, N.Y. and former president of Division 39, reviews William Borden's book, entitled, Contemporary Psychodynamic Theory and Practice: Toward a Critical Pluralism, which is reprinted here with Dr. Eagles' permission.

The sun is shining ever more brightly in and on SEFAPP and the south Florida psychoanalytic weather is indeed great.

As always your comments to the Editor and Contributors are welcome. I also invite readers to submit 500 to 1,000 word articles for consideration of inclusion in Psyche & Sol via email to myself at arvirsida@aol.com.

Transference/Countertransference Corner - Shirley Malove, LCSW

Editor’s Note:

With the addition of Ms. Malove’s regular column, Psyche & Sol adds a second piece that offers readers rich and informative opportunities to reflect on clinical work. In the last twenty years, there has been a sea change in how the clinical situation and mutative action is conceptualized, which has profound impacts on the way we understand patients and ourselves.

Ms. Malove offers us an opportunity to re-think, explore and have a conversation about, a wide variety of clinical concepts; to mention a few, insight, the therapeutic relation-ship, neutrality, abstinence, anonymity, mutuality, enactment and the mutative action of psychoanalytic psycho-therapies.

In the infancy of psychoanalytic thought, many psychoanalysts considered countertransference to be an indication that the clinician had unresolved conflicts that needed to be further analyzed. Fortunately, as psychoanalysis developed over time, most psychoanalytically-oriented psychotherapists and psychoanalysts learned to appreciate and utilize their countertransference reactions to better understand themselves, their patients, and the “pair” within the context of the therapeutic relationship.

Countertransference is now considered a useful tool which, when used properly, informs and deepens the treatment. The decision to share certain countertransference feelings and thoughts with a patient must be based upon its ability to facilitate the treatment. Such candidness can demonstrate a deep understanding of a patient’s struggle - an understanding which they probably never experienced in other relationships. This is not to suggest, however, that every thought and feeling is to be shared with the patient.

The purpose of this column is to provide a forum for discussing and thinking about one of the most challenging aspects of psychoanalytic treatment. The format is flexible and I am open to suggestions about the way in which this column may be most helpful.

I encourage you to send in questions, commentary, review a book or article on the topic or share your own countertransference experiences. Our work is as challenging as it is rewarding. Colleagues provide valuable clarity, support and insight by sharing clinical perspectives and experiences.

The following case vignette illustrates my use of countertransference and the way in which it deepened the treatment with a patient. As with any clinical writing, identifying information has been disguised to protect confidentiality.

Sophie began psychotherapy with me when my theoretical perspective was primarily through an ego psychology lens. During the time she was in therapy, however, I began advanced training, which focused on more contemporary (e.g. relational, intersubjective) psychoanalytic theories. As a result, my clinical views began to shift as I integrated these approaches into my practice.

Sophie, a 34-year-old woman presented as clean and well groomed. Her manner of interacting was guarded and detached. She sought treatment for depressive symptoms intensified by a rapidly deteriorating marriage, which ended in divorce shortly after therapy began. Throughout childhood Sophie was victim and witness to extreme domestic violence at the hands of her father. A victim herself, Sophie’s mother was unable to provide protection. Consequently, Sophie withdrew into her own world. She recalled not fitting in with peers and feeling like an outsider in her family. It appeared that her entire life, she longed for inclusion, yet greatly feared intimacy and therefore, “hid” in relationships.

From the beginning, Sophie had a propensity for intellectualizing by digressing into lengthy, abstract topics. I originally viewed this as defensive. Most of the time, I attempted to explore or interpret her need to avoid uncomfortable topics. We never seemed to get very far with this approach. In retrospect, maybe I too was intellectualizing, which perpetuated the enacted mutual detachment. At times, I noticed myself becoming bored and “zoning out.” Before and during her sessions, I frequently became so sleepy that I could hardly keep my eyes open which was uncharacteristic for me. Perhaps I feared what was underlying the superficial dialogue and “checked out” in order to protect myself, just as Sophie did her entire life.

Sophie distanced from others and me by being vague, abstract and sometimes silent. This adaptive measure served Sophie well in her youth. She stated, “I became invisible in a room full of people. If they don’t see you, you can’t be a target.” In the therapy, I responded in kind by not seeing her, not connecting with her; even unconsciously colluding with her by remaining too intellectual and removed in the way I interpreted her behavior. Thus, Sophie hid from me right in front of my eyes and I allowed it.

Fortunately, as my countertransference became apparent to me, I began to pay closer attention to what was occurring between us in the treatment room. When she became abstract and I noticed myself drifting, I shared these observations, as I believed this provided information which was important for us to understand together. Sophie recalled dissociating when she needed to escape the abuse in childhood. In therapy, she believed her tangents were efforts to avoid subjects she didn’t want to discuss. Slowly, however, she began to recognize that she was avoiding connecting with me. Eventually, Sophie began to understand the way in which she used intellectualization and unconventional ‘shocking’ statements to distance from others. These breakthroughs allowed Sophie and me to relate and connect on a much deeper level.

As a result of this shift in our therapeutic work, Sophie came alive to me. I looked forward to her sessions and listened intently. Shortly thereafter, I was required to be away for an extended period during which time Sophie continued her sessions over the phone. She began one of these sessions stating that she had a difficult week and called her sister to talk. Sophie explained, “I had to leave a message on her machine which really pisses me off because her son erases them and doesn’t tell her. She never called back. I’m tired of being the one always calling my family.” I was struck by the parallel quality here as I was away for the summer, which required Sophie to call me; however, any anger toward me was conspicuously missing. I asked her about this and she quickly defended, “No. It’s not any different calling you on the phone than going to your office.” I persisted. She stated that it was “safer to practice (her anger) on them,” but more difficult with me because “I still need you.” At that point, I began to delve into an interpretation in which I suddenly lost my train of thought. I disclosed this to Sophie. She laughed and said, “Maybe you lost your train of thought because you knew I wasn’t ready to go where you were going.” I was impressed and encouraged her to continue. She went on, “(w)ell, I don’t think after spending so much time together that my thoughts can’t help but influence you because you know me.” Clearly, Sophie and I were deeply connected. From a relational view point, Irwin Hoffman (1983) addresses this point specifically:

(E)very patient knows that he is influencing the analyst’s experience and that the freedom the analyst has to resist this influence is limited. Patients create atmosphere…(which) include the therapist’s personal reaction to the patient, the patient guessing what the reaction is partly on the basis of what he thinks his own behavior is likely to have elicited, the analyst guessing what the patient is guessing, and so on. (p. 410)

Sophie’s observation of me expressed our mutual understanding and recognition of each other. She was known to me and I was known to her. My countertransference experiences gave me an invaluable insight into Sophie’s internal struggles and ultimately demonstrated our deep understanding and connection.

References:

Hoffman, I., (1983). The patient as interpreter of the analyst’s experience. Contemporary Psychoanalysis, 19:389-422.

Conference Summary - Emily Krestow, Ph.D.

SEFAPP Annual All Day Conference:

October 24, 2009

The Conflict of Money in Psychotherapy and Practice-Building Methods in Today’s Economy

Held at Florida Atlantic University, this conference provided a “wealth” of information dedicated to examining the usually taboo subject of money: the meaning of money as an expression of the patient/therapist interaction, the therapist’s own self-worth, development as a business person, and need to plan long term personal goals such as retirement. What might have been expected to be dry was anything but dry.

The morning presentations by Antonio R. Virsida, Ph.D., A.B.P.P. and Stefan Pasternack M.D. gave us richly theoretical and clinical presentations. Both spoke to the evolution of psychoanalytic theory in relation to money from Freud on, and gave patient-therapist scenarios illustrating the wide range of meaning of money to both therapist and patient.

Both underlined the importance of using the fee to deepen the understanding of the patient. Their willingness to be fully open, to discuss the patient/therapist interaction and their own countertransferences was a great learning experience for those attending.

Dr. Virsida presented cases in which money issues presented difficulties in the treatment. One particularly meaningful clinical example was the patient who hid money from his wife, while exhibiting similar behavior in the consulting room by deceiving Dr. Virsida into giving him a lower fee.

Through exploration, multiple meanings were uncovered. Reducing fees meant the therapist loved him, yet the patient experienced guilt about the deception. At the same time, Dr. Virsida was seen as a “prostitute” for charging a fee at all. The dynamic of who was in control, i.e.., who wins, who loses became available for exploration. And don’t forget the therapist’s own feeling about being deceived. The exploration of the fee alone unearthed condensed inter-connected issues specific for this patient.

Dr. Pasternack also demonstrated the complex meanings of fees in his case examples. One woman intensely needed to bargain. After back and forth negotiating, Dr. Pasternack said, “Clearly you have enough money. What is driving you to bargain?” The meaning was ultimately revealed. Her deceased husband had taught her how to negotiate, and if her negotiation failed, she would lose the love and financial security that his money represented. Money was all she had left of him. She had to fight, then, to keep every dollar, for every drop of money spent was a drop of his blood.

Thus, if the bargaining had remained on the level of simply determining the fee, if the therapist had allowed his exasperation to prevail, lost would be the possibility for insight and growth.

At the end of the morning, open discussion ranged from the issue of whether an enormously wealthy person should be charged more than the regular fee, to what we should do with cash payments and insider information such as stock tips.   This is a slippery slope and seductive, but with learning opportunities such as were offered at this conference, participants learned that barriers can be broken down that inhibit therapists from confronting money matters, and assist in facilitating the therapeutic process.

The afternoon presentations by Steve Werble, CPA, CVA, Michelle Channing, Psy.D, and Steven Hein, CPA, J.D., MBA, LLM   had us shift gears to the business aspect of psychotherapy practice and financial planning.

Steven Werble spoke to the practical aspects of building a practice. Mr. Werble gave many valuable pointers for practice building and development.   Among them were:

	Build a relationship with a bank, perhaps through a lawyer or CPA who has a relationship with a bank. One benefit relates to the potential need for a line of credit.
	Incorporate! This lowers auditing chances, and it provides liability protection.
	Those of us who have employees or consultants must be careful in the designation of independent contractors. Differentiate the employee whom you direct, from someone who manages his/her own time. It is a touchy area with the IRS and the “employee” can be re-classified by IRS as an independent contractor - with penalties.

Dr. Michelle Channing was enormously helpful for those who are building a group practice and her knowledge and expertise was applicable to solo mental health practitioners as well.

Information on how to run a business included the patient flow from call to appointment to initial visit, highlighting the importance of scheduling as soon as possible, along with the importance of researching in advance the fee schedule of insurance companies. She gave insurance tips, collection tips, the benefits of using CAQH to help with getting on insurance panels, when it is legally required to collect co-pay and when it is not. Hint: Out of network provider is not required to collect co-pay. Another hint: electronic billing gets quicker results than paper.

The last speaker of the day, but not least, was Steven Hein who addressed investment strategies and the different ways to manage money: the importance of asset allocation; enough money in a “safe bucket;” long term investments; Simple, Roth and Sep IRAs.

An analysis of current financial circumstances must include defining future goals, such as the need for a plan for doubling one’s income in twenty years, building in health care and long-term care costs. And he enumerated optimal ways to save for retirement: Roth IRA conversions; long term care, and awareness of retirement risks. In regards to retirement, he cautions that your investment philosophy must match your life expectancy.

“Kudos” to all our presenters. What a rich, diversified presentation by highly skilled, experienced clinicians and business people!

Symposium Summary - “Psychotherapist to Supervisor: Supervisees’ and Supervisors’ Experiences of a Group Supervision Training Program”, November 22, 2009

By Antonio R. Virsida, Ph.D., A.B.P.P.

“Tell a Story in Only Six Words.”

From Psychotherapist to Supervisor:

Supervisees’ and Supervisors’ Experiences of a Group Supervision Training Program

Presented by Siv Boalt Boethius, Ph.D.

Ernest Hemmingway was once challenged to tell a story in only six words. Papa came back with, “For Sale: Baby Shoes, Never Worn.” Good stuff, good stuff indeed.

Dr. Siv Boalt Boethius, Professor of Psychology, Emerita at the University of Stockholm, Sweden, Member, Swedish Psychoanalytic Institute/International Psychoanalytical Association, trained psychoanalyst and Director of the Erica Institute was SEFAPP’s Symposium Brunch presenter on November, 22, 2009.

She told a story of her training program at the Erica Institute that, while using more than six words, was eloquently clear, and as simple, profound and capturing in its precision as was Ernest Hemmingway’s retort to the above challenge.

Mrs. Kerstin Kupferman, friend and colleague of Dr. Boalt Boethius, and also a psychologist/ psychoanalyst, was the hostess of this Symposium Brunch. Dr. Boalt Boethius described a training program, complex in its conception and execution as any that can be imagined. It was intended to train, from psychodynamic perspectives, psychotherapists who worked in organizational/agency settings to be supervisors.

The content was compelling and instructive, and to the great delight and inspiration of attendees, Dr. Boalt Boethius brilliantly talked about her training program, its processes and outcomes in ordinary language, which, in my view, reflected her capacity to optimally teach and communicate with others. She relied on background complex theoretical concepts to inform the structure and processes of the training program, but discussed it in everyday language, which captured the essence of how to teach and how to optimize learning among diverse trainees.

Dr. Boalt Boethius’s presentation made clear the basic utility and different but unique benefits of supervision in a group setting. Contrary to the usual psychotherapy and psychoanalysis supervision utilized in most graduate programs and psychoanalytic institutes, Dr. Boalt Boethius’ group supervision program detailed the concepts of “holding,” “containment,” timing and the important dimension of learning “from one another” inherent in the group supervisory process.

While not ignoring the complexity of individual conflicts and group processes, the basic idea was to keep, as background, individual “countertransferences” (not her way of talking about personal idiosyncrasies) and group psychodynamics until they became interferences to learning among the students.

Groups of four supervisees were supervised by a supervisor, matched to the supervisees on a number of variables. Each supervisor was supervised by a “super” (again, not her word) supervisor, which complicated and enriched the processes of learning at all levels. Learning was enhanced by an accepting, exploratory and reflective attitude of supervisors.

The specific results and outcomes of her program are far too detailed and complex to discuss here. Suffice it to say, Dr. Boalt Boethius told a story “in more than six words,” but rivaled Papa in her ability to express and explicate complex human dynamics, emotions and conflicts in simple terms.

If only, we all had Dr. Boalt Boethius’ ability to communicate, we would be able to teach theoretical, clinical and listening concepts that would capture our students’ imaginations, and their desires to learn, unencumbered by allegiances to any particular model of the mind.

Diversity and complexity indeed reign in Stockholm, Sweden.

P.S.— Dr. Boalt Boethius’ husband, Jorgen, is a neuroscientist and neurosurgeon who enlivened and enriched our post presentation brunch with his understanding and knowledge of neuroscience and European history. An unexpected treat and good stuff, good stuff indeed.

Committee Report: Treasurer’s Report - Aaryn Gottesfeld, M.A.

SEFAPP has remained financially stable in the last several months, and we anticipate increased profitability as we progress through the 2009-2010 season. Since September, we have hosted two events which were both profitable. The Board of Directors puts a great deal of effort into promoting events, as well as keeping costs down, both of which have a direct impact on the financial health of the organization.

Our Freud Amongst the Arts fundraiser which was held last May raised $2215.00. While this profit is considerably less than what we had originally estimated, it is still an impressive amount considering the current economic climate. This money will be divided between SEFAPP and SEFIPP. In addition, SEFAPP received a generous donation of $2,000 from the Ticho Foundation, an organization that supports psychoanalytic endeavors.

SEFAPP currently has a balance of $9,653.00, and the chart below illustrates the stability of our account. While stability is sufficient for the start of 2010, our financial goal for the rest of the season is to increase our reserve funds.

	Income	Expenditures	End of Month Balance
April '09 - June '09	$4584.89	$9966.45	$9006.49
June '09 - September '09	$5463.00	$5337.47	$9132.02
September '09 - October '09	$3413.72	$3078.71	$9467.03

Membership Committee Report: Leonard J. Ferrante, Psy.D.

SEFAPP has entered another year, continuing our tradition of offering our members an exciting agenda of new presentations. In 2009, we increased our membership by 20%, notwithstanding such difficult economic times. The increase in our membership is not only a testimony to the resilience of our professional organization, but it also underscores the relevance and clinical efficacy of our psychoanalytic ideas and methods.

You have received an application to renew your membership, so return it as quickly as possible so that you can to take advantage of the reduced membership fees for the next round of clinical presentations.

Once again please join me in welcoming our newest members:

Glenda Bates

Robin Benjamin, LCSW

Pamela Garber, LMHC

Patricia Jaegerman, Psy.D.

Rebecca Klasfeld

Laura Kreiger

Roslyn Malmaud, Ph.D.

Ann Toback-Bair, LCSW

Susan Turner, LMHC

Special Report: The Southeast Florida Institute for Psychoanalysis & Psychotherapy (SEFIPP) Status and Update - By Antonio R. Virsida, Ph.D., ABPP, President

SEFIPP is continuing to work on developing innovative training and education programs, and toward that objective we held a special seminar/meeting for faculty and candidates on November 15, 2009, entitled, Psychoanalytic Training and Becoming a Psychoanalyst at Imperial Point Medical Center.

Attended by SEFIPP faculty and candidates, the seminar was organized around three readings: an interview by Jeremy Safan of Lewis Aron published in Psychoanalytic Psychology about the history of psychoanalytic training, politics, trends, old ideas and new perspectives that may have a salutary impact on the structuring of training by institutes, a letter from Daniel Terman, President of the Chicago Psychoanalytic Institute, the second oldest psychoanalytic training institute in the U.S. Published in the International Journal of Psychoanalysis (IJP), the letter outlined their modestly successful, innovative attempts to re-structure their training requirements, training and educational programs in order to attract candidates. The third article was an IJP paper by Thomas Ogden and Glenn Gabbard, entitled, On Becoming a Psychoanalyst.

The authors discussed their personal development as psychoanalysts, including their conflicts, identifications with personal analysts, supervisors and various theoreticians, culminating in finding their own visions and voices as psychoanalysts. Our discussion was lively and animated and yielded some interesting innovative ideas.

The SEFIPP curriculum committee, Helen Banta, Ph.D., Chair, Jane Hall, L.C.S.W., Max Harris, Ph.D., Linda Sherby, Ph.D., A.B.P.P., Arnold Schneider, Ph.D., A.B.P.P., Richard Steinberg, Ph.D. and Scott Winfield, L.C.S.W. is working on a curriculum for a one year introductory program, which is designed to stand alone or serve as the first year of a four year training program in psychoanalysis. The introductory course includes weekly contemporary theoretical and clinical/technical courses, as well as monthly clinical case process seminars. We plan to offer this program in the Fall of 2010.

SEFIPP just completed the first year of the Contemporary Psychodynamic Case Seminar (CPCS), which met for nine months, once per month for two hours. The twelve participants enjoyed the course and reported that they learned a great deal in the seminars.

The nine seminars were divided into three segments, each led by different SEFIPP faculty members, Richard Steinberg, Ph.D., Antonio R. Virsida, Ph.D., A.B.P.P. and Donna Bentolila, L.C.S.W. The focus of the seminars was clinical, with theory serving as a background for understanding patients’ communications. As part of the CPCS series, the participants were also offered three supervision sessions which were included in the registration fee with any of the three faculty members of their choosing.

The second in the CPCS series begins in March 2010, and will be led by three different faculty members, Max Harris, Ph.D., Emily Krestow, Ph.D. and Linda Sherby, Ph.D., A.B.P.P. The focus of each of the three segments will again be clinical and take up psychoanalytic listening, dynamic understanding of symptoms and the patient/therapist relationship.

SEFIPP has recruited twenty-five faculty members from the tri-county area, as well as from around the state, including Clearwater, Sarasota and Tampa.

In addition, we are pleased that we have recruited thirty visiting faculty members from around the country. Many of these visiting faculty members are nationally and internationally known for their publications and all have made important and significant contributions to psychoanalytic training, education and organizations.

We have assembled an outstanding faculty with wide ranging theoretical and clinical interests, and are continuing with our tradition of offering comprehensive and diverse training and education programs.

Please feel free to contact me at (561) 338-0902 or at arvirsida@aol.com if you have any questions about SEFIPP.

Special Report: Veteran’s Project of South Florida Update - Frederic J. Levine, Ph.D.

Upcoming Events Update:

We have some exciting upcoming programs scheduled in the next few months. All events offer Continuing Education Units and are free of charge.

January 30, 2010 - “Citizen Solidiers and the National Guard: The Conscience of a Nation and the Citizens who Serve Them”, presented by Christopher Davenport of the Washington Post, a reporter who embedded with a National Guard unit and documented their difficulties with re-entry to civilian life. He will be joined by a panel including a SOFAR Boston Volunteer and Florida National Guard personnel, who can help familiarize participants with the special needs and problems of National Guard personnel. The location of this event is the Westin Colonnade Hotel, Coral Gables.

March 20, 2010 - Jonathan Shay, M.D., Ph.D., author of Achilles in Vietnam and Odysseus in America, will present a full-day conference on combat trauma at the Miami VA Hospital. Additional participants will be Francoise Davoine, Jean-Max Gaudillere (Trauma Experts) and Daniella David, M.D. of the Miami VA hospital).

Consider Volunteering:

Florida is third-highest among all states in number of military personnel deployed and in the number of troops and veterans living here. Its needs are among the highest, and resources are limited. At this writing, the entire Florida National Guard is in the process of being deployed.

20% of soldiers returning from Iraq and Afghanistan have shown symptoms of PTSD, substance abuse problems, depression, and family problems. Many more suffer from these problems but do not seek treatment because of stigmatization. Reservists and National Guard personnel often have particular difficulty in obtaining treatment because – unlike regular military members – they go directly back to civilian life after discharge and don’t have access to the psychiatric services provided on military bases. Their spouses and family members, who suffer greatly from the “collateral damage” of military life, are usually not eligible for VA services. For more information on forms and other documents necessary, please contact our Administrator, Cristina Virsida via phone at (877) 783-2748 or via e-mail at veteransprojectfl@gmail.com.

2009 Project Overview:

In summary, this has been an exciting experience for all of us in the Veterans Project of South Florida – SOFAR, in which we feel we have been increasingly able to integrate the contributions of psychoanalytic clinicians with those of other service providers in the community in a way that makes clear that psychoanalysts can be very valuable and productive contributors to joint community projects. We have received grant funding from the Florida BrAIve fund and the American Psychoanalytic Foundation that has made it possible for us to develop as an important community resource in South Florida, and are very grateful to them for that. Through BrAIve, we are linked with a large number of other agencies and groups that provide services to veterans, and serve as an educational and consultation resource for them as well as providing direct services to troops and their families.

We are enormously grateful to BrAIve and the APF for their critical roles in making it possible for us to develop as a community resource in South Florida, and we are hopeful that psychoanalysis in Florida – as well as veterans and their families – will benefit from our work.

Steering Committee Members:

Frederic J. Levine, Ph.D and Richard Steinberg, Ph.D. as Co-Chairs, Ana Eriksen, M.D., Emily Krestow, Ph.D., Cathy Stamm-Kaufman, LCSW, Jill Hartog, LCSW, Antonio Virsida, Ph.D., ABPP and Karen Dainer-Best, Ph.D. We welcome your participation and invite you to join us!

Special Article - "Family Under the Microscope"

Author: Oliver James

Originally published by The Guardian, 10/3/09. Reprinted with permission

Four in five mothers suffer some sort of "baby blues" in the first months after giving birth, but 10% develop a full-blown depression. If this hits, it has massive implications for the whole family, as well as you. Assuming you have a choice, which therapy should you opt for?

The main alternatives are antidepressants, cognitive behavioural therapy (CBT) and psychodynamic psychotherapy. The pills rule out breastfeeding, and in the great majority of cases, even if they do have an effect it is a placebo – people given chalk pills but told they are antidepressants are almost as likely to claim to feel better as people given the real thing.

Regarding the talking therapies, in one study depressed new mothers were randomly assigned to eight sessions of CBT, or to counseling, or to psychodynamic psychotherapy. Eighteen weeks later, the ones given dynamic therapy were most likely to have recovered (71%, versus 57% for CBT, 54% counseling).

For many years, psychoanalysis was written off as unscientific because it was untestable as a theory, but studies done in the last 15 years have largely confirmed Freud's basic theories. Dreams have been proven to contain meaning. Early childhood experience has been shown to be a major determinant of adult character. And it is now accepted by almost all psychologists that we do have an unconscious and that it can contain material that has been repressed because it is unacceptable to the conscious mind.

The treatment Freud's theory gave rise to entailed patients attending 50-minute sessions for up to five times a week, lying on a couch and speaking whatever entered their mind. Childhood relations with parents were used to interpret dreams and their relationship to the analyst.

Although slow to be tested, the clinical technique has now also been demonstrated to work. The strongest evidence for its superiority over cognitive, short-term treatments was published last year. Initially, eight to 20 sessions of short-term therapy reduced depression and anxiety, more so than going two to three times a week for psychoanalytic therapy. However, after three years, those receiving the long-term psychoanalytic treatment were dramatically better off: less likely to be depressed and four times more likely to have recovered from anxiety. A recent survey of 23 other studies had similar findings.

Many studies show that the sort of person a therapist is – especially whether they are warm – is more important than their orientation. There are undoubtedly some very good CBT therapists (despite, rather than because of, their training) and some appallingly bad psychoanalysts (some of whom I have had the misfortune to visit myself).

But a "campaign for real therapy" would insist on systematic scrutiny of how parental care in the early years affected you and close attention to the relationship between therapist and client. Since hardcore CBT rejects both these, it will never be of enduring value. If it's all that's on offer, hold out for one who is warm and prepared to deviate from strict CBT manuals – willing to provide more than a handful of sessions and to talk about childhood causes of problems.

I realise this is a tall order if you are depressed with a newborn. That makes it vital that partners take a big interest in what kind of care is being offered and don't just go along with the tendency of GPs to dole out pills or CBT.

Postnatal depression therapy study: Cooper, PJ et al, 2003, British Journal of Psychiatry, 182, 412-9. Strongest evidence for Psychoanalysis: Knekt, P et al, 2008, Psychological Medicine, vol 38, 689-703. Review of 23 long-term therapies: Leichsenring, DSc et al, 2008, JAMA, 300, 13, 1551-65. More Oliver James at selfishcapitalist.com

Special Article - "Psychoanalytic Psychotherapy: In the News!"

By William A. MacGillivray, Ph.D., A.B.P.P.

Psychoanalysis and psychoanalytic psychotherapy have been "under the gun" for many years. Having ridden the wave of public acceptance for many years, psychoanalysis has been increasingly criticized as a treatment modality that is too expensive, too lengthy, too elitist, and so on. Researchers and clinicians have rejected psychoanalytic therapy as being sexist (and heterosexist as well) and out of touch with the diverse array of emotional and psychiatric difficulties that people face. Finally, it has been critiqued for not having real data to show that actually works!

Many of the criticisms listed above readily applied (and in some cases still apply). Psychoanalytic theorists tended to see psychoanalysis as working for every problem in every situation, and it if did not help the person, they were dismissed as "unanalyzable." Although some of the early psychoanalysts, such as Karl Abraham, actually did outcome studies, there has been a dearth of data supporting psychoanalytic psychotherapy as effective, or as effective as alternatives.

A surprising dose of favorable publicity arrived in October 2008 with the publication of a meta-analytic study of the effectiveness of Long Term Psychodynamic Psychotherapy (LTPP) in the Journal of the American Medical Association. The study, conducted by Falk Leichsenring and Sven Rabung (2008) concluded,

In this meta-analysis, LTPP was significantly superior to shorter-term methods of psychotherapy with regard to overall outcome, target problems, and personality functioning. Long-term psychodynamic psychotherapy yielded large and stable effect sizes in the treatment of patients with personality disorders, multiple mental disorders and chronic mental disorders. The effect sizes for overall outcome increased significantly between end of therapy and follow-up. (p. 1563)

In addition to the remarkable fact that the study was published in the prestigious medical journal was an accompanying editorial by the Deputy Editor of JAMA, Richard Glass (2008), cautiously endorsing the results of the study and noting that evidence for efficacy of LTPP comes at a time when psychiatrists are receiving minimal training in any form of psychotherapy, let alone long-term treatment. He concluded,
“Even with the necessary qualifications, the meta-analysis . . . provides evidence about the effectiveness of long-term dynamic psychotherapy for patients with complex mental disorders who often do not respond adequately to short-term interventions. It is ironic and disturbing that this occurs at a time when provision of psychotherapy by psychiatrists in the United States is declining significantly. The reasons for this merit careful evaluation. To some extent this may reflect the cost-efficacy of treatments for some mental disorders with medications and brief supportive visits. However, this trend appears to be strongly related to financial incentives and other pressures to minimize costs. Is that what is really wanted for patients with disabling disorders that could respond to more intensive treatment?”

To fill out the week of pleasant surprises, Benedict Carey of the New York Times reviewed the study and reported on its positive message that psychoanalytic psychotherapy is at least as effective as other forms of therapy, and with certain conditions, such as borderline personality disorder, LTPP may be superior to shorter-term treatments. The article goes on to note the furor these findings are already receiving in certain academic circles:

“Experts cautioned that the evidence cited in the new research was still too meager to claim clear superiority for psychoanalytic therapy over different treatments, like cognitive behavior therapy, a shorter-term approach. The studies that the authors reviewed are simply not strong enough, these experts said.”

The reporter also noted that concerns about research findings related to psychoanalytic treatment are not limited to researchers, but that practitioners as well have raised objections to these kinds of studies,

The field has resisted scientific scrutiny for years, arguing that the process of treatment is highly individualized and so does not easily lend itself to such study. It is based on Freud’s idea that symptoms are rooted in underlying, often long-standing psychological conflicts that can be discovered in part through close examination of the patient-therapist relationship.

For now, however, we can be pleased that the efficacy of long-term treatment can be cited as having the same kind of backing that other forms of treatment have claimed as the "gold standard."

Finally, the article cites one of our members, Andrew Gerber, on implications of this study,
"If you define borderline personality broadly as an inability to regulate emotions, it characterizes a lot of people who show up in clinics, whether their given diagnosis is depression, pediatric bipolar or substance abuse, This paper suggests that you’ve got to get into longer-term therapy to make improvements last."

I will not attempt to summarize the discussion of the study among our colleagues on a psychodynamic research e-mail group except to note that the study does stand up under further scrutiny, although the limitations of the study are also important to note. While results cited appear vigorous, the authors only found 23 studies that met their criteria for inclusion in the study, and these studies were typically based on modest numbers of subjects (number of patients ranged from 129 down to 14). It is also notable that the authors of the study were not Americans, and this speaks to the lack of support in this country for the kind of research into psychodynamic therapy that can demonstrate the efficacy of our approach to treatment.

There was one criticism of the study that I found particularly curious. One researcher chided the authors for failing to include studies of long-term treatment with cognitive behavior techniques. Since this was not the purpose of the study, the criticism seems a way to dismiss the results without having to actually challenge the findings directly. What seems amusing, however, is the insistence that maybe people require longer term treatment, regardless of the treatment modality, a position that would seem to undermine a central claim of many cognitive behaviorists.

There are many in the psychoanalytic community who have been opposed, sometimes vociferously opposed, to research into psychoanalytic process and outcome, taking the position that research design and conclusions drawn from such research are either trivial or fail to capture the essence of our craft. For these clinicians the results of this study will likely be seen as irrelevant or a "sellout." Most of out psychoanalytic colleagues, however, have been troubled by the seeming lack of evidence for the value of our work. Despite knowing that psychoanalytic psychotherapy has helped countless individuals, the relentless drumbeat from the "evidence-based" crowd has tended to have the effect of placing us on the defensive, or simply avoiding the topic altogether.

Drew Westen (Westen and Bradley, 2005) and others have helped bring about a critical perspective on the concept of "evidence-based" and the problematic assumptions of this prevailing model of research, but there remains the task of having the positive evidence for the efficacy of our work. The Psychodynamic Diagnostic Manual (2006) and the PowerPoint presentation by Greg Lowder (2007) have gone a long way toward educating our membership and the public concerning the research basis of the value of psychoanalytic work.

Leichsenring and Rabung’s article and its attendant publicity should certainly help further this important task of informing our colleagues in the larger psychology and medical community that psychoanalytic psychotherapy can demonstrate its effectiveness even on terms laid down by the "evidence-based" paradigm. I hope it will also encourage our colleagues to take the time and effort to become more informed by psychoanalytic research.

William A. MacGillivray, Ph.D., A.B.P.P. is President-Elect, the Division of Psychoanalysis (39) of the American Psychological Association, the Editor, Psychologist-Psychoanalyst, the newsletter of Division 39 and the Editor, Viewpoints, the newsletter of the Appalachian Psychoanalytic Society (APS), a local chapter of Division 39.

References:
Carey, Benedict (2008). Psychoanalytic therapy wins backing, New York Times, 10/1/2008.

Glass, Richard M. (2008). Bambi survives Godzilla? Psychodynamic psychotherapy and research evidence. Journal of the American Medical Association, 300, 1587-1589)

Leichsenring, Falk and Rabung, Sven (2008). Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. Journal of the American Medical Association, 300, 1551-1555.

Lowder, Greg (2007) The enduring significance of psychoanalytic theory and practice.

PDM Task Force (2006). Psychodynamic diagnostic manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations.

Westen, Drew and Bradley, Rebekah (2005). Empirically supported complexity: Rethinking evidence-based practice in psychotherapy. Current Directions in Psychological Science. 14, 266-271.

Special Article - “The Rat Man and Two Systems of Self-Regulation”

Authors: Jack Novick, Ph.D, Kerry Kelly Novick

From Presentation given to Division 39, San Antonio, TX, April 24, 2009

It has been 100 years since the publication of Freud’s “ Notes upon a case of obsessional neurosis” (Freud, 1909) and here we are, discussing again a case treated in the early years of Freud’s theory and technique. Why are we doing so? In most scientific disciplines, anything published 10 years earlier is out of date and seldom referred to. Even in the softer sciences like psychology, it is rare to find a reference to articles more than 20 years old. In a 2008 article on OCD in children and adults only 10 of the 320 references were dated earlier than 1983 (Maia et al, 2008). What can we gain from rereading this case? Few analysts refer to it. When it is taught to analytic candidates the “Rat Man” case is often used to illustrate errors in technique, a “misalliance,” an avoidance of transference interpretations; the course often ends with a patronizing list of all of Freud’s “non-analytic” interventions, including feeding the patient herring. Freud’s theoretical formulations are used to demonstrate how psychoanalytic theory at that time lacked the power and complexity of the later structural model and second theory of anxiety.

There is a further reason for avoiding this paper as many analysts are somewhat cowed by the supposed efficacy of CBT and clomipramine in treating OCD. So why are we spending this lovely day sitting here discussing an outdated theory and technique for the treatment of OCD? Well, before you rush for the exits, let me share why I think that the study of this case remains rewarding and continues to stimulate ideas that are relevant to our current work.

In 1909 Freud wrote to Jung, “In my practice, I am chiefly concerned with the problem of repressed sadism in my patients. I regard it as the most frequent cause of failure of therapy. Revenge against the doctor combined with self-punishment. In general, sadism is becoming more and more important to me” (cited in J. Novick and K.K. Novick, 2007 [1996], p.42). Freud wrote this letter while preparing the “Rat Man” case for publication; surely that case reinforced his life-long engagement with the topic of sadomasochism. Freud remained intrigued by the complexity of sadomasochism; each major shift in psychoanalytic theory stemmed directly from his clinical experience with cases like the “Rat Man.” Freud and his followers were challenged by the complexity and counter-intuitiveness of sadomasochism. The overarching regulatory principle was the “pleasure principle” so how and why did patients do things that were so obviously self-destructive?

If we think of the “Rat Man” paper not only as a study of the treatment of an obsessional neurosis but as an illustration of an underlying life-long sadomasochistic adaptation to trauma then this paper comes to life with insights which remain relevant. We can also reclaim forgotten or discarded ideas to enhance our understanding of the treatment of severely neurotic patients. This case remains one of the best descriptions of what we have called a closed, sadomasochistic, omnipotent system of self-regulation (J. Novick and K.K. Novick, 2001).

Sadomasochism is a perversion and Freud was not the first or foremost Victorian to explore human sexuality and the perversions in particular. His unique contribution was to use a developmental perspective to understand the childhood antecedents to the adult perversion. The Rat Man, or more respectfully, Dr. Lorenz, as we know from Freud’s daily case notes, began treatment in 1907 at the age of 29. He had suffered, during the prior four years, from obsessive thoughts that something might happen to the woman he loved and to his father. He also had compulsions, such as the impulse to cut his throat with a razor, and had produced many prohibitions to fend off these obsessions and compulsions. He had, he said, wasted years fighting against these ideas.

If he were to be seen today he would meet all the criteria for DSM 1V, 300.3 -- Obsessive Compulsive Disorder -- and he would be referred for medication and CBT. But he had been through various forms of treatment, all aimed at symptom removal, to no avail. From the very beginning psychoanalysis was a tertiary treatment, a last resort after all other efforts of self-cure and all the available physical and psychological forms of treatment had failed. I have seen many patients who call me after having tried a series of other treatments. What is striking is that often no prior psychiatrist or psychologist had asked about their history, their personal story, their feelings and relationships, their loves and hates. The focus had been on the symptoms and the application of standardized psychological or medical procedures for treating such a condition. A few years ago I saw a 10-year-old boy who had been treated at the psychiatry department since the age of 4 for ADHD and more recently for OCD. The treatment consisted of a range of medications coupled with behavioral modification therapy. There were few changes and the parents came to me for a consultation. At our first meeting I said to the boy. “You’ve seen so many doctors, you must have told your story over and over again.” “No,” he said, “Nobody asked. Do want to hear?” “Absolutely!” I exclaimed and he then launched into a lengthy story about his fear of freshwater sharks. His family had a summer home on Lake Michigan and as long as he could remember he had been terrified of going into the water. We have come full circle and, as for Freud, our modern psychoanalytic developmental focus has once again become unique.

At Dr. Lorenz’ first session Freud encourages and allows for the emergence of a developmental story. Lorenz first talks about the history of his obsessional symptoms as he probably had done with all his previous doctors. But then he turns to his adolescent struggle over masturbation and sexuality. In the course of the first three meetings he had memories of his religiosity as a school child and then memories from his fourth year referring to the illness and death of his older sister. Freud was, at first, not sure if Lorenz or another patient had talked of the death of a sibling and his countertransference confusion underscores the affective intensity of these memories. So within three sessions Freud and the patient had begun to share a developmental story that moved from the current and recent past, back to his adolescence, to his school years and then into the recesses of early childhood. This developmental thrust, the complex interweaving of past and present, is the unique contribution of psychoanalysis as a theory and as a treatment.

For many years we have studied and written about destructive and self-destructive sadomasochistic behavior in failure-to-thrive infants, violent children, and murderous or suicidal adolescents and adults. In ordinary clinical work, all patients present with some degree of sadomasochistic functioning no matter what the diagnosis. We used Freud’s developmental strategy to trace the epigenesis of sadomasochistic functioning. We soon found that sadism and masochism always go together as they do in Lorenz’s painful masochistic obsession that something will happen to his girl friend and father, a worry driven by his sadistic wishes.

Increasingly our studies led us to posit an intimate circular relationship between sadomasochism and omnipotence. At each point in the development of sadomasochistic functioning we discerned an underlying omnipotent belief in the power to exert magical, hostile control over others, maintained when validated by external events. Freud talks about the patient’s omnipotent beliefs as early as in his notes to the second session. In relation to

the Lorenz’s attempt to control his prayers Freud states, “All this was strengthened by a certain amount of superstition, a trace of omnipotence, as though his evil wishes possessed power, and this was confirmed by real experiences” (1909, p. 260).

Freud saw the core of Lorenz’ neurosis as the conflict between the patient’s erotic desires and his father’s angry opposition. This would repeat the patient’s childhood rage at his father and he would wish him dead. This is the source of the Lorenz’s “oldest and favorite obsessions” -- “if I marry the lady, some misfortune will befall my father.” But why, we may ask, should a little child’s death wish have such a devastating impact and lead to a life of crippling protective thoughts and compulsions? Every parent has experienced the intensity of a toddler’s anger -- it is not unusual for a child to say ‘I wish you would die” (usually meaning go away); a child’s oedipal passion is equally intense. Freud’s insight is that these childhood wishes were and remain charged with the omnipotent belief that wishing makes it so. In his original record of the case, Freud hypothesizes that Lorenz is guilty for assaulting the sister who died. Father chastises him, he flies into a rage at father and then the patient believes that “this would cause his death, since [my] his affects are omnipotent” (ibid. p.279).

Is this what most analysts of all persuasions now refer to as “normal infantile omnipotence?” In the evolution of our thinking we have taken a position that differs from that. In our view omnipotent beliefs (in contrast to wishes) are magical hostile delusions created in response to reality failures in order to protect the individual from overwhelming experiences of helplessness. Omnipotent beliefs are constructed and maintained in order to protect the child or adult from further trauma. We distinguish omnipotent wishes, which everyone has throughout life, from omnipotent delusions -- beliefs that present as convictions or assumptions that organize an individual’s thinking and actions. We have said that omnipotent beliefs arise as one of the ways of dealing with real or anticipated helplessness (i.e trauma) and then become consolidated when external reality validates those magical convictions.

In Freud’s paper he does not say that Lorenz’s omnipotence is a normal developmental phase he had not outgrown but links it, as we do, to external events which validated his omnipotence, primarily the death of his sister when he was three. Various other events had coincided, like being beaten by his father for biting a sibling (perhaps his sister), having flown into a rage at his father who then said, “the child will be either a great man or a criminal,” and then the overwhelming experience of ongoing sexual activity with his governess coincident with the death of his sister.

We said earlier that Freud’s description of his patient is a vivid presentation of someone living in a closed, hostile, omnipotent sadomasochistic system of self-regulation. Omnipotent beliefs are a defining characteristic of the closed system; another is the life-long attachment to pain. The case is painful to read, was painful to work with and in fact pain is the predominant affect infusing a closed system of self-regulation. Pain pervades Lorenz’s life and soon we realize that he actively creates situations of pain. We have said that “pain is the affect which triggers the defense of omnipotence, pain is the magical means by which all wishes are gratified and pain justifies the omnipotent hostility and revenge contained in the sadomasochistic fantasy” (J. Novick and K.K. Novick, 2007, p. 64). The patient has many of the features we have described in our studies of sadomasochism. The addiction to pain is foremost and in this case we see that Lorenz chooses a woman who has twice rejected him. He likes children, but she is medically incapable of having children. He listens to and then internalizes the sadistic account of the rat torture described by his captain. He imagines this torture being applied to his lady and to his father. The rat torture in fact comes from a pornographic novel very popular at that time and it is likely that he knew about it. But hearing it from the captain allows him to externalize responsibility: in the fantasy he is not doing it, some vague other person is applying rats in a pot boring into the anuses of his lady and father.

Externalization is a major defense mechanism of the closed system, allowing the person to be a victim or an innocent bystander to the sadistic activities of others. All of Freud’s published cases, except little Hans, are suicidal and we have demonstrated the links among suicide, beating fantasies and sadomasochism. Freud called the beating fantasy “the essence of masochism.” Dr. Lorenz has a beating fantasy and is suicidal. The patient tells Freud that he has come because he had read one of Freud’s books. But he doesn’t tell Freud until later that he has been told that Freud’s brother was a murderer, and that he thinks Freud will jump on him and kill him for his wishes. This may explain why he called Freud “Captain.” He keeps talking of himself as a criminal, especially in relation to his father. Freud finds this “nonsensical” since he has never done anything bad to his father and, besides, his father died many years previously. Of course Lorenz’ captain had said that the rat torture is the way the Turks punished criminals. He imagines that Freud is setting up his own brother to marry his lady and develops the fantasy that Freud wants him to marry his daughter whom he had passed on his way to his session. He then describes Freud’s daughter as having dung on her eyes and in general is demeaning and vicious in ways quite extreme, but all in the context of cringing fear that he will be beaten and thrown out by Freud.

We have called this way of functioning a closed system of self-regulation because the legitimate basic needs for safety, control, predictability, satisfaction, aliveness, attachment, power and self-esteem are served by mechanisms which are divorced from reality, are circular, self-reinforcing and impervious to change. The system operates on the basis of a magical omnipotent belief in the power to control others and force them to do one’s bidding. Ultimately it is a derivative of the defensive belief that one can change one’s mother into a “good enough,” competent, loving person rather than the traumatogenic mother of infancy and childhood.

Freud has little to say about infancy, a phase he tended to relegate to inherited or constitutional tendencies. He suggested that his patient had an inherited disposition to excessive sadism. Our own studies, starting with the study of beating fantasies in children (J. Novick and K.K. Novick, 2007 [1972/1996]), see the origins of the closed system in the pleasure/pain economy of the parent-infant relationship. In all our cases of severe sadomasochistic disorders we found that infancy was marked by an excess of pain due to various causes. Constant in their lives was the predominant experience of a range of dysphoric feelings and difficulty in eliciting gratification of ordinary needs from the caregiving person.

Lorenz’s mother is hardly discussed in the published case but in the daily notes a picture begins to emerge of a loveless marriage, an overburdened and unavailable mother, a woman who was married for her money rather than for love. The patient was the fourth of seven children, four sisters born before him. Although no mention is made of the fact that this was a Jewish family, he was the first son so, initially, very special. But he was damaged, he had an undescended testicle, and within nine months mother was pregnant again and gave birth to a son who was handsome, stronger and the favorite of the parents and other caregivers. His mother had some undisclosed medical condition which made her smell and the patient said that everything bad about him came from his mother.

His brother was born when he was eighteen months old and the patient became, in his words, a pig. He had worms, played with his feces and was probably encopretic. The fact that he could have years of infantile sexual activity with his governess, without anyone noticing, only underscores the unavailability and “soul blindness” of his mother (J. Novick and K.K.Novick, 2005; Wurmser, 2007).

We noted that his lady friend had twice rejected him, but this was not his first sadomasochistic object choice. At the start of his adolescence he had fallen in love with the sister of a friend. He imagined that she did not reciprocate his feelings and he created a fantasy that if something terrible happened to him, like the death of his father, she would return his affections. We could speculate that these unavailable women represented the unavailable, soul blind mother, with whom he could remain attached only through pain. The closed system evolves through development, shapes and is shaped by subsequent phases and is consolidated in late adolescence. Omnipotent beliefs are active constructions providing a defense against helplessness and overwhelming rage or excitement. Given the security, safety and gratification the omnipotent delusion provides it is indeed questionable why anyone would give it up.

Hegel, the 19th century German philosopher, said that the recognition of the self/other occurs only through situations of “lordship/bondage.” In Rathbone’s (2001) empirical study of self-styled masochists, she quotes a prolific writer of S and M stories as claiming that “...sadomasochism is not a perversion but a normal part of human behavior” (pp 245 -246). The world indeed often seems to confirm the view that “lordship/bondage” is normal and life revolves around dominance or submission, kill or be killed, abuse or be abused. Is there no way out and, if not, how can we hope to help our patients who have adapted to this sadomasochistic world better than we have?

Freud’s patient provides a vivid example of how powerful and gratifying the closed system of self-regulation can be. Lorenz is a 29-year-old student who has wasted many years in nonsensical thoughts and prayers to protect others from his omnipotent rage. He can’t get the woman he loves to marry him, he feels ashamed of his parents, feels damaged, feels he has wasted his life and, in general, presents as a pathetic, helpless loser. Yet he can get the eminent Dr. Freud to enact a sadistic fantasy of penetration with an interpretation. Lorenz gets Freud to force him to tell the story of the rat punishment. Freud validates the patient’s omnipotent belief in his power to make people do what he wants, his defensive conviction that he is an exception to the rules of reality, both social and natural laws, and entitled because of his suffering to force others to meet his needs. We will recall that Freud had introduced the fundamental rule at the second session. “The next day I made him pledge himself to submit to the one and only condition of treatment –namely, to say everything that came into his head, even if it was unpleasant to him…” (Freud, 1909, p.159). Lorenz does not submit to this one rule, he is an exception, and he gets Freud to guess and articulate “the great obsessive fear,” i.e., that rats bored their way into his anus.

Is there an alternative to the closed system or do we expect a magical cure through sublimation, the undefined resolution of all conflicts? Our work on sadomasochism and its organizing omnipotent beliefs has led us to posit two systems of self-regulation (J. Novick and K.K. Novick, 2000, 2001). The closed system, so vividly illustrated by Lorenz’s material, is the system generally studied by all analysts of all theoretical persuasions. But what remains unexplored is what we have called the “open system” of self-regulation. Our two-system model of development describes two alternative ways to respond to the challenges of life. In our model, one system is attuned to inner and outer reality, has access to the full range of feelings and is characterized by competence, creativity and love. We call this the “open system.” The closed system with its core omnipotent beliefs avoids reality, is caught in vicious circles and is resistant to change. The open-system aim is to transform the self; the closed-system aim is to control, force and change others. The open system generates and is fueled by love and joy; the closed system depends on victimization and anger.

The two systems describe potential responses in everyone, but at the beginning of treatment they often exist only in the mind of the therapist. The knowledge of the open system, manifested in the tasks of the therapeutic alliance that the analyst initiates with the patient, is what lends the analyst courage and hope to venture into the patient’s borderland to guide both to the possibility of choice. From the beginning of therapy, the analyst keeps in mind the treatment goal of greater open-system functioning, and this is part of what moves the treatment along toward a good ending. We can assess interventions throughout treatment in terms of whether and how they give the patient expanded, open-system, real possibilities of choice and change (J. Novick and K.K. Novick, 2006).

The two-system model emerged from our years of study and writing about the development of omnipotent, sadomasochistic modes of mastery and control. The closed system is so fast, efficient, gratifying, and self-protective that most patients cannot even contemplate changing for fear that the alternative would be a return to the traumatic experiences of helplessness, guilt, rage and shame that gave rise to it in the first place. We have suggested that it is helpful to clinicians to keep in mind the alternative possibilities in development, different choices for self-protection and basic needs available to the patient as treatment proceeds. This two-system model has profound implications for technique.

Freud tells us that, after eleven months of psychoanalytic treatment, “the patient’s mental health was restored.” How did this happen? He also tells us that he can’t take leave of his patient without conveying that he had disintegrated into two preconscious states between which his consciousness could oscillate. “In his normal state he was kind, cheerful, and sensible –an enlightened and superior kind of person.” In his other state, “he paid homage to superstition and asceticism. Thus he was able to have two different creeds and two different outlooks on life” (Freud, 1909, p.248). Here, in an early and often neglected or criticized work, Freud presents a version of our two-system model of self regulation.

The two-system model is embedded in our proposition that the core of psychoanalysis is the metapsychological, multi-dimensional approach to all psychological phenomena. By “metapsychology” we do not mean the abstract theories so cogently criticized as outmoded nineteenth-century science. We understand it to mean Freud’s emphasis on psychoanalysis as the only complete, multi-dimensional approach to all psychic phenomena. Anna Freud called metapsychology the “language of psychoanalysis” (1966, p. 70). We have argued that reclaiming this meaning of metapsychology allows us to regain the richness of psychoanalysis as the most comprehensive theory of human development and functioning (K.K. Novick and J. Novick, 2002). Importantly, it defines psychoanalysis as a multi-modal therapeutic technique. A two-system model adds movement from closed- to open-system functioning to the goals of analysis. Therefore any intervention that facilitates such movement can be considered analytic.

From the very beginning of contact with the patient the two-system model includes as analytic a range of interventions which are generally not discussed, or are excluded from usual practice, or are included only as “parameters” when justified by the excessive pathology of the patient. The idea of two systems of conflict-resolution and self-regulation can lead to a conceptualization of two kinds of technique, one that elucidates closed-system functioning, another that enhances open-system functioning. Conflicts over open-system functioning usually are expressed in reversion to closed-system omnipotent beliefs, efforts at creating sadomasochistic interactions, and externalization of impulses or ego and superego functions on to the analyst (J. Novick and K.K. Novick 2003).

Technical interventions have differing impacts on phenomena relating to the two systems. Closed-system phenomena require the drive/defense, classical approach of transference and resistance analysis, with the aim of putting the patient in the active center of his pathology while the analyst remains relatively receptive and neutral. But defense and transference interpretations of open-system functioning can pathologize and drive away competence. Mirroring, empathy, reconstruction, validation, support, and developmental education, to list but a few of the more active analytic interventions, link open-system phenomena with the analyst’s functions beyond serving only as a transference object. These techniques applied to closed-system functioning, however, may be at best a palliative waste of time, at worst, may serve to reinforce a passive, helpless, victimized stance on the part of the patient. Thus, we have to think in terms of expanded and alternative technical options to encompass the open-system dimensions of our patients’ personalities and the opportunities of the treatment situation.

Freud’s work with Lorenz has been criticized by Kanzer (1980), Weiss (1980), Langs (1980) and others for deviations from technique, the use of non-analytic interventions, his limited use of transference, avoidance of negative transference, and stumbling toward the seminal idea of the transference neurosis emerging in the treatment and resolved through interpretation. Psychoanalytic treatment would evolve to this third phase in 1914 with the publication of Freud’s paper “Remembering, repeating and working through.” These criticisms are valid, especially in relation to closed-system phenomena and Freud himself was critical of some of these earlier psychoanalytic techniques (Freud, 1920). However, if we think of these interventions in relation to open-system phenomena we might be able to reclaim and reaffirm the value of the techniques which Freud used in this second phase in the evolution of psychoanalytic theory and technique. He called it the use of “human influence” (ibid. p.18). We suggest that, rather than a technique to be criticized, this is in fact the sine qua non of successful analytic work.

A central contribution of psychoanalysis has been the concept of the therapeutic alliance. Freud describes the concept in his technique papers (1912, 1913). There he emphasizes the need to establish rapport with the patient before interpretation, develops the idea of a friendly affectionate part of the transference, and describes empathic understanding as “everything an analyst should do in a positive sense” (Freud, 1913, p. 252). We can see these ideas in action in his work with Lorenz, especially in Freud’s capacity to empathize with the patient. Sometimes, as when he hears about the death of Lorenz’ sister, his empathic listening becomes too acute, as when it touches off his own experience of sibling loss. Freud recovers and his understanding of the impact of sibling loss plays a crucial role in creating an alliance with Lorenz.

Since the 1970’s analysts have tended to dismiss the concept of the therapeutic alliance, only to have it claimed by adjoining fields of psychology and psychiatry (K.K. Novick and J. Novick, 1998; 2002). In our view this has been a grievous loss to psychoanalytic theory and technique. A rereading of Freud’s work with Lorenz reminds us that the therapeutic alliance held a central place from very early in our history; the collaborative alliance, based on an empathic, two-person relationship, was crucial to the Rat Man’s analysis.

In the few moments remaining, let’s look at some of Freud’s interventions that, in our view, serve to strengthen and consolidate open-system functioning. It has been noted that analysts have difficulty with reality (Friedman, 1999), love (J. Novick and K.K. Novick, 2000), and joy (Heisterkamp, 2001). But these dimensions of mental functioning are all contained in the case of the Rat Man. Perhaps a two-systems model of a multi-modal psychoanalytic technique can allow us to reclaim interventions relating to these dimensions of experience and treatment.

Let us look first at what Winnicott (1949) called “objective love” and we have referred to as “open-system love” (J. Novick and K.K. Novick 2000). In the first page of his report Freud describes the young man as “…being a clear headed and shrewd person” (1909, p.158). At the end of the report he describes him as kind, cheerful, sensible, “an enlightened and superior kind of person...”(ibid p.248). In the report, and even more so in the daily notes, it is clear that Freud likes and admires this young man. He comes in fact to love him, and there is a very moving, sorrowful tone to the footnote with which Freud ends his report, “…like so many other young men of value and promise, he perished in the Great War” (ibid p.259). We have written about open-system objective love, in contrast to closed-system enthrallment (J. Novick and K.K. Novick, 2000); to us open-system respect, admiration and love, evident in Freud’s work with Lorenz, is essential for creating a safe context for reliving and analyzing the borderland phenomena of the closed system. Open-system respect and admiration are also essential first steps in the analyst’s work to establish a therapeutic alliance.

How does Freud deal with reality? Lorenz tells Freud that he has heard that Freud comes from a family of murderers. This material represents his wish that Freud, as the externalized closed-system superego figure, would beat him or kill him for no reason other than the fact that, like “Budapest Freud,” he too is a killer. Freud does not take this up as a transference and he has been roundly criticized for that. Instead he laughs and reassures Lorenz that he has never been to Budapest, he is not related to that other Freud, and he was only four when that widely publicized event occurred.

The next day Lorenz is “quite gay and cheerful,” and follows up Freud’s reassurance with a different image of Freud. He says that if there were murderous impulses in Freud’s family he would have fallen on Lorenz like a beast of prey. He then tells Freud about his own jealousy and murderous rage at Freud. From a two-systems, multi-modal technique perspective we would say that Freud first used reality reassurance to help consolidate Lorenz’s open-system reality testing and support his feeling safe in the analytic situation. The patient then feels safe enough to share his closed-system irrational transference rage.

Freud’s name means “joy” and it is ironic how little attention analysts give to patients’ experiences of reality-based, open-system joy and pleasure. In contrast to closed-system triumph and sadistic glee at the misfortune of others, the open system allows for exploration and expansion of real experiences of pleasure and joy in competent and effective functioning. As noted earlier, young Lorenz lived a constricted life of self-inflicted pain to control his omnipotent murderous impulses. But there were isolated areas of pleasure and Freud notes and comments on them. He says a number of times that Lorenz is potent and seems to present a running account of the patient’s various successful sexual encounters.

He also records the patient’s sadomasochistic association of pleasure, especially sexual pleasure, with loss and death. At the time of his first copulation Lorenz had the thought: “ This is a glorious feeling! One might do anything for this – murder one’s father for instance.” Freud goes on to describe the patient’s memories of having been beaten by father. Pleasure and joy are open-system affects that can become corrupted and linked with pain. Freud used this case ten years later to describe the link between pain and pleasure as he wrote about a series of cases to demonstrate that the beating fantasy is the essence of masochism (Freud, 1919). It is possible that Freud’s warmth and pleasure at Lorenz’s pleasure, the positive alliance created by Freud through his “human influence,” helped the patient delink pain and pleasure, and so consolidate an open system of self-regulation where pleasure and joy are the motivation for and result of competent, respectful and loving relationships with others.

To us, and we hope that now to you also, the 1909 case is not a paper to be ignored as representing an outmoded phase of psychoanalytic theory and technique. Rather it remains a vivid illustration of psychoanalysis as a multi-modal technique capable of engaging with the patient’s pain-filled closed sadomasochistic world and enhancing or consolidating open-system reality-testing, love, joy and pleasure.

References:

Friedman, L. (1999). Why is reality a troubling concept? J. Amer. Psychoanal. Assn. 47: 401-425.

Freud, A. (1966). Some thoughts about the place of psychoanalytic theory in the training of psychiatrists. In: The Writings of Anna Freud, vol.7. New York: International Universities Press, 1971, pp. 59-72.

Freud, S. (1909). Notes upon a case of obsessional neurosis. S.E. 10: 153-320.

----------- (1912). The dynamics of transference. S.E.12: 97-108.

----------- (1913). On beginning the treatment. S.E. 13: 123-44.

----------- (1914). Remembering, repeating and working through: further recommendations on the technique of psychoanalysis II. S.E. 12: 145-56.

----------- (1919). A child is being beaten. S.E. 17: 175-204

----------- (1920). Beyond the pleasure principle. S.E. 18: 3-64.

Heisterkamp, G. (2001). Is Psychoanalysis a Cheerless (Freud-Less) Profession?: Toward a Psychoanalysis of Joy. Psychoanal Q., 70:839-870.

Kanzer, M. (1980). The transference neurosis of the Rat Man. In: Freud and His Patients, eds. Mark Kanzer and Jules Glenn. Jason Aronson: New York. pp. 137-143.

Langs. R.J. (1980). The misalliance dimension in the case of the Rat Man. In: Freud and His Patients, eds. Mark Kanzer and Jules Glenn. Jason Aronson: New York. pp. 215-231.

Maia, Tiago V., Cooney, Rebecca E., and Peterson, Bradley S. (2008). The neural bases of obsessive-compulsive disorder in children and adults. Development and Psychopathology 20: 1251-1283.

Novick, J. and Novick, K.K. (2000). Love in the therapeutic alliance. J. Amer. Psychoanal. Assn. 48: 189-218.

---------------------------------- (2001). Two systems of self-regulation: psychoanalytic approaches to the treatment of children and adolescents. Special issue, Journal of Psychoanalytic Social Work 8: 95-122.

---------------------------------- (2003). Two systems of self-regulation and the differential application of psychoanalytic technique. American Journal of Psychoanalysis 63: 1-19.

---------------------------------- (2005). Soul blindness: a child must be seen to be heard. In: A Handbook of Divorce and Custody, Eds. L. Gunsberg and P. Hymowitz. Analytic Press: Hillsdale NJ. Chapter 7, pp. 81-90.

---------------------------------- (2006). Good Goodbyes: Knowing How to End in Psychotherapy and Psychoanalysis. Jason Aronson: New York.

---------------------------------- (2007 [1996]). Fearful Symmetry: The Development and Treatment of Sadomasochism. Jason Aronson: New Jersey.

Novick, K.K. and Novick, J. (1998). An application of the concept of the therapeutic alliance to sadomasochistic pathology. J. Amer. Psychoanal. Assoc. 46: 813-46.

----------------------------------- (2002). Reclaiming the land. Psychoanalytic Psychology 19: 2, 348-77.

Rathbone, J. (2001). Anatomy of Masochism. New York: Kluwer Academic/Plenum Publishers.

Weiss, S.S. (1980) Reflections and speculations on the psychoanalysis of the Rat Man. In: Freud and His Patients, eds. Mark Kanzer and Jules Glenn. Jason Aronson: New York. pp. 203-214.

Winnicott, D.W. (1949). Hate in the Countertransference. In: In One’s Bones: The Clinical Genius of Winnicott. ed. D. Goldman. Northvale, NJ: Aronson, 1993, pp. 15-24.

Wurmser, L. (2007). Torment Me, But Don’t Abandon Me. Jason Aronson: New York.

Special E-mail to Division 39 Members from Marybeth Cresci, Division 39 President, Take Heart: More Research, "Evidence Based" Support for Psychoanalytic Psychotherapy

Editor’s Note:

The following email and research abstract were sent to Division 39 members by President, Mary Beth Cresci, Ph.D., A.B.P.P. I reprint it here for your information and suggest you go to the website of the author Jonathan Shedler, Ph.D., www.psysystems.net/shedler.html.

On his website, Dr. Shedler has another excellent, well written and concise paper he has written entitled, That Was Then, This is Now: Psychoanalytic Psychotherapy for the Rest of Us.

Dear Division 39 Members:
I am sure that you have read the many recent critiques in the popular press claiming that psychology is not taught from a scientific, evidence-based foundation. These articles are using material from an article by Baker et al. published in the journal of APS, an organization that wants to supersede APA as the accrediting body for psychology doctoral programs. Baker et al. claim that CBT is one of the few evidence-based therapies and that doctoral programs should be teaching its students to practice from this perspective.

By fortuitous circumstance, American Psychologist has recently accepted an article by Jonathan Shedler that presents the considerable scientific evidence for the effectiveness of psychodynamic psychotherapy. I have summarized Jonathan's article and some of the arguments that counter Baker's claims in a soon-to-be-published issue of the Division 39 newsletter, Psychologist-Psychoanalyst. However, that newsletter will be some weeks in reaching you via snail mail.

In the meantime, Jonathan has graciously offered to send his article to the Division 39 membership via our LISTSERV. It is available through the attachment to this email or on Jonathan's website. The link to his website is www.psychsystems.net/shedler.html.

In addition, I am posting the abstract from his article below: The Efficacy of Psychodynamic Psychotherapy by Jonathan Shedler, PhD

Abstract
Empirical evidence supports the efficacy of psychodynamic psychotherapy. Effect sizes for psychodynamic psychotherapy are as large as those reported for other therapies that have been actively promoted as “empirically supported” and “evidence based.” Additionally, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, non-psychodynamic therapies may be effective in part because the more skilled practitioners utilize techniques that have long been central to psychodynamic theory and practice. The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings.

I know that we don't ordinarily send announcements like this on our LIST-SERV. However, I believe that you will be heartened to see that psychoanalytic psychotherapy has a strong scientific base for its effectiveness and efficacy.

My thanks to Jonathan and the researchers he references for providing the evidence we need to counter the damning press that psychoanalytic psychology and psychotherapy is receiving.

Best regards,
Mary Beth M. Cresci, Ph.D., ABPP
President, Division 39

Book Review - History Beyond Trauma, Fall 2004

Title: History Beyond Trauma

Authors: Francoise Davoine and Jean Max Gaudilliere (Translated by Susan Fairfield)

Publisher: OTHER PRESS,NEW YORK

2004; 282 PP., $30.00.

Reviewed By: James E. Gorney, Ph.D.

Reprinted with permission from Division 39 Publications: Book Reviews, Fall 2004

In History Beyond Trauma Françoise Davoine and Jean-Max Gaudillière have provided the social sciences, and in particular psychoanalysis, with a profound and original illumination of the theory and treatment of psychosis. Over the course of this ambitious, encyclopedic volume, the authors summarize and integrate thirty years of their collaborative clinical and theoretical investigation of psychotic phenomena. This is an essential book for all interested in the psychoanalytic understanding of madness and trauma.

Drawing upon their early studies in philosophy and classics, subsequent academic experience as professors of sociology, and eventual psychoanalytic training in the school of Lacan, Davoine and Gaudillière approach madness not as a symptom, pathology or structure in the DSM, but rather as a Place. This is the place where the symbolic order, which guarantees an individual’s connection to language, history and social relations, has ruptured, exploded or disappeared. Consequently, one of the most original and important insights to be found in this work is that the psychotic is engaged in a form of research investigation into the nature and history of this place; he or she is a seeker.

In the clinical situation, the therapist is second in command to the patient—the Principal Investigator—who desperately attempts to articulate an unspeakable dimension of trauma and catastrophe, which has come to be foreclosed in individual or social history. Within this context, Davoine and Gaudillière draw upon numerous other powerful traditions to inform this non-reductionistic formulation of the psychotic experience. From their many years of contact with clinicians associated with the Austen Riggs Center they have assimilated the work of Sullivan, Fromm-Reichman, Searles and Otto Will. They also have been significantly influenced by the texts of Winnicott, Bion and Gaetano Benedetti. Within History Beyond Trauma the authors weave multiple strands of the many French and non-French masters from whom they have learned; yet, as they themselves are quick to point out, their most profound teachers have been those psychotic patients with whom they have engaged in psychoanalytic exploration over the years.

As Gerard Fromm notes in his forward to this volume, History Beyond Trauma is written in a literary, philosophical, non-linear and somewhat elliptical style. In other words, it is at times very French. For those not used to this manner of discourse it may take some getting used to, but patience and perseverance will provide considerable rewards to the reader. Indeed, as the book unfolds, an overarching polyphonic structure emerges, as in a complex musical score, in which theoretical, philosophical, literary and clinical perspectives upon psychosis begin to synergize each other in surprising ways. The book is divided into two sections: Part I–Lessons of Madness, and Part II–Lessons from the Front. Broadly speaking, Part I develops a philosophic and psychoanalytic theoretical model of psychosis and Part II develops a framework for the psychoanalytic treatment of psychosis by drawing upon principles derived from war psychiatry. The theoretical and clinical sections of the book dovetail; they mutually enrich and inform each other.

The essential insight which is developed with great nuance and complexity in Part I is that the psychotic symptom is a marker pointing toward a Place; a place of unspeakable catastrophe, destruction and horror once inhabited in the past, and now still relived in the present. The symptom both masks and begins to communicate the madness, mute pain and terror of this as-yet-unsymbolized location. The un-symbolized trauma comes to haunt the subject, while at the same time foreclosing free access to individual, familial, or social history. It is only when this place of trauma can be named and inserted into the symbolic order of language that the horror can be remembered, and not just re-lived repetitively as if it is branded or carved into one’s very being. When the catastrophe inhabiting the place of the Real (the unsymbolized) can be brought into a “social link” through the dialectic of symbolic speech in a human relationship, then the trauma can be remembered, spoken, eventually integrated, and even, for long periods, usefully repressed or forgotten. This field of symbolic language is entered through the inscription of a name or a word that functions as a signifier. How to facilitate the emergence of such a signifier, in word or perhaps, at first, in gesture, within the psychoanalytic situation is at the center of Davoine and Gaudillière’s clinical concern. A general framework for clinical praxis with psychotic patients eventually comes to center stage within Part II.

The authors radically locate psychosis within a social and historical field of investigation. In regard to “madness,” they assert; “we never use this word to describe the structure of an individual but instead to characterize a form of social link in an extreme situation” (p. xxii). It is precisely the unsymbolized and unremembered trauma of such “extreme situations” that come to haunt the psychotic subject. Within psychosis there is a collapse of time as well as personal identity. The individual is inhabited in the present not only by ghosts from his own earlier life experience, but also those of preceding generations. The authors draw upon their own personal history, as well as their French and European identities, to develop a model of trauma based upon the paradigm of war. Davoine and Gaudillière were literally born into a war zone in the early 1940’s. They and their patients had parents and grandparents who were directly affected by both of the world wars fought on their native soil. In toto, the carnage, brutality and social disruptions of war lead to breakdowns in the symbolic order, the rule of law and the predictability of social relations. This collapse becomes for the authors the basis of a powerfully illuminating model of trauma. They go on to illustrate their concept of trauma as a war zone with vivid clinical material. From this perspective, they take particular care in asserting, “the connection between madness and trauma is not a causal one. For there can be no transition from the past to the present when the impact of disaster has immobilized time” (p. xxx). Thus, the psychotic patient transmits from generation to generation “pieces of frozen time,” eventually bringing a war zone into the analyst’s consulting room.

Davoine and Gaudillière examine this zone of collapsed time through multiple lenses. First and foremost it is a place where conventional, reliable rules and norms of symbolic

speech have been exploded; in their place the psychotic individual engages in Wittgensteinian language games. The patient in the place of madness initially comes to the therapist in a state of “rupture, departure and confrontation,” thereby thrusting the therapist into a battle scene. This war zone becomes an empty possibility within which the first beginnings of symbolic exchange may be inscribed. This would constitute a first step away from madness, toward the horizon of the symbolic. At this juncture, the authors provide a rich metaphor for the entire therapeutic process via elaborating the etymological metaphor of the ancient Greek word Symbalon:

“Symbolon emphasizes the signifying gesture in which two new allies exchange the two pieces of a broken shard, in such a way that their being fitted together later on is a pledge of mutual hospitality for them and their descendants. These humble bits and pieces, broken for the occasion, take the place of one’s word given as a guarantee. Of no intrinsic value, they are the basis of value and the foundation of the social tie, at the same time as they are the possibility of language itself. (p. 66).”

Thus, to restore the place of language is to restore the place of the symbolic order itself. This is the task of the analyst, who must now approach the patient in madness upon the battlefield, carrying the broken shards of his own humanity and history. Within the book, this now shifts the focus to the nature of the therapeutic relationship in the field of madness.

Part II of History Beyond Trauma delineates the conditions necessary for a psychoanalytic investigation into trauma and madness that can facilitate symbolic exchange and activate therapeutic transformation. Toward this end, Davoine and Gaudillière, remaining within their model of war trauma, recount research that led them to uncover the first principles of war psychiatry. These were developed by Thomas W. Salmon in 1917 to deal with shell-shocked soldiers returning traumatized from the front. The so-called “Salmon Principles” are elaborated upon in Part II by the authors and the implications of each of these principles for establishing the possibility of psychoanalytic work with traumatized, psychotic individuals is developed in detail. Thus, the second half of the book is particularly rich in clinical wisdom and insight. For Davoine and Gaudillière the Salmon Principles become broad technical guidelines for transforming standard psychoanalytic technique and the therapeutic frame for work with those who are psychotic.

The principles and their functions are:

• Proximity opens up a new space of trustworthiness amid chaos.

• Immediacy creates a living temporality in contact with urgency.

• Expectancy constructs a welcome to the return from hell.

• Simplicity emphasizes the obligation to speak without jargon.

Modifying traditional psychoanalytic practice in light of these principles may at first, to some, seem radical and controversial, yet they are consistent with modifications proposed by many other important psychoanalytic researchers into madness, e.g., Fromm-Reichman, Searles, Otto Will, Winnicott, Margaret Little and Benedetti.

Davoine and Gaudillière contend that Proximity not only refers to the actual physical encounter within the consulting room, it also involves a willingness to engage face to face upon the battlefield of a traumatic place; a taking up the gauntlet and a determination to survive the patient’s destructiveness without undue retaliation. From this distinctly Winnicottian position, the authors assert that the details of the real trauma will eventually become revealed within the specifics of the transference relationship.

Through the unfolding of the transference, a significant relational bond develops: “Combat evokes in those who are fighting side by side a passion for taking care of the other physically and psychically, equivalent to the earliest and deepest family relationships” (p. 154). Thus, referencing the etymology of the ancient Greek term Therapôn, meaning a second in combat and ritual double, the therapist is understood as a comrade in arms. Together confronting trauma, the therapeutic dyad engaged in the psychoanalysis of madness create “a psychoanalysis upside down. Far from lifting a repression it becomes the tool that makes repression possible and puts an end to the catastrophic effects of the Real” (p. 158).

For Davoine and Gaudillière, the principle of Immediacy opens up the possibility of establishing contact with the patient at the maximal locus of urgency. When they contend that “It is better to conceive of all crises of madness as beginnings” (p. 168), the authors follow in a long tradition, beginning with Sullivan in his early work Conceptions of Modern Psychiatry (1940) which postulated that the moment of madness creates the potential for hope and re-integration. Within psychoanalysis, psychosis cannot be approached at a distance. Immediacy implies active engagement, and that may engender risk, uncertainty and confusion in the analyst. Again, Davoine and Gaudillière turn conventional psychoanalysis on its head when they propose that upon entering this field of madness, “transferentially the response comes first, then the formulation of the problem of which the analyst will come to be part once he has become confused” (p. 169). It is the gradual working out of this confusion via the identification and naming of ghosts that comes to constitute the fabric of the treatment. Efforts to reduce the immediacy of this encounter by primary recourse to psychotropic medication or behavioral interventions are understood by the authors to be most often a countertransferential backing away by the analyst from the dangerous urgency of the battle scene. In the face of contemporary prevailing modes of treatment offered to psychotic individuals in America and Europe, the authors’ point of view in this regard is unsparing, controversial and ultimately courageous.

The principle of Expectancy references the realm of the interpersonal, of alterity, the place of relying on a trustworthy other. It conjures images of wounded buddies forging a bond in the trenches and implies a form of mutuality in which both participants in the analytic situation bring shards of their own traumas and histories with them (the Symbolon) into the evolving relationship. Davoine and Gaudillière are not thereby proposing a boundaryless, mutual confessional, but rather they recognize that upon entering a zone of trauma, two histories converge in analytic space. Put another way, they assert that when analyst and patient encounter each other in the war zone, all of both of their relatives and ancestors also enter this space. The past is also in the present. Therefore, there are critical moments when the analyst’s own life, memories, experiences and history must be articulated to initiate symbolic exchange. It is possible for this then to be experienced by the psychotic patient as a trustworthy affirmation. Yet, the affirmation of expectancy begins with the very first word uttered by the analyst at the very beginning of the first session. The authors put it very clearly: “This first “Yes” from the analyst is a primal affirmation that in fact presides over the judgment of existence we have spoken of and opens out the field of speech:

“Yes, something happened, something happed to you; it’s not all in your head, and what you’re showing is the only way you could bear witness to it. No, these events are not the cause of your condition but the object of your investigation. (p. 221)”

The principle of Simplicity can best be illustrated through a consideration of the many generous clinical accounts offered throughout the book. The authors believe that psychoanalysis is within an ancient and long tradition of oral history and their stories of transformative clinical encounters with psychotic patients are masterfully realized and beautifully presented. Within these accounts both analysts are heard to speak simply, directly, and above all, with profound honesty to their mad patients. They make creative use of found objects to initiate symbolic exchange when speech fails

or is not yet possible. They utilize aspects of their own (sometimes traumatic) histories in order to make points of connection with patients who have disappeared, exploded or evaporated.

Davoine and Gaudillière are true masters of their craft and it is mesmerizing, and a rare privilege, to observe them help create small (and sometimes large) miracles within the

consulting room. Often these clinicians appear more related to shamans or medicine men than to scientists or doctors. Yet, within the arena of madness, this is exactly the direction to which a radical trust in unconscious processes inexorably leads. Shamans and medicine men are also fundamental exemplars of an ancient oral tradition.

In summary, History Beyond Trauma is a singularly important contribution to psychoanalysis in general, and the theory and treatment of psychosis in particular. It rests on the shoulders of giants from the past while it simultaneously charts radically creative new directions for the future. For those of us engaged in the ongoing work of undertaking psychoanalytic exploration with traumatized and psychotic patients, this is an indispensable volume. Particularly in this age of managed care, antipsychotic medication and DSM driven psychiatry, History Beyond Trauma offers hope for the healing power of symbolic exchange within a human relationship. Beyond the dilemma of psychosis, Davoine and Gaudillière deserve to be read by all who believe in the transformative potential of the psychoanalytic relationship. In my judgment, this magnificent book is likely to become an essential part of the psychoanalytic canon for generations to come. It deserves the widest possible readership.

Jim Gorney is a member of the Appalachian Psychoanalytic Society and in independent practice in Knoxville, Tennessee.

Book Review - Contemporary Psychodynamic Theory & Practice: Toward a Critical Pluralism, Fall 2008

Title: Contemporary Psychodynamic Theory & Practice: Toward a Critical Pluralism

Author: William Borden.

Publisher: Lyceum Books, Chicago, 2008; 185 pp., $29.95.

Reprinted with permission from Psychoanalytic-Psychologist, Fall 2008, Vol. XXVIII, No. 4

I begin this review with a piece of self-disclosure. Because I have been working on a book that also deals with contemporary psychoanalytic theories, I thought it might be useful for me to review a book on Contemporary Psychodynamic Theory and Practice. However, it soon became clear that the author, William Borden, and I had very different projects in mind.

Borden’s book is a primer, directed primarily to social workers as well as other mental health professionals and “seeks to deepen readers’ understanding of psychoanalytic thought in contemporary psychoanalysis and to demonstrate the relevance of relational perspectives and recent developments in psychodynamic studies for psychosocial interventions” (p. xii). The book covers in 13 chapters of 167 pages of text the work of Freud, Adler, Jung, Ferenczi, Suttie, Klein, Fairbairn, Winnicott, Bowlby, Sullivan, Kohut, and the relational paradigm (mainly the work of Mitchell). Quite a feat! Given the sheer amount of material covered in a modest sized volume, for the most part, the author does an excellent job in providing the reader with a clear and intelligent summary of complex ideas. He does an especially good job on the ideas of Winnicott and Suttie. For those who want to get a broad introduction to some central psychoanalytic ideas and who do not want to grapple with the extensive, complex, and variegated primary sources, this book will serve them well.

The author also manages in this slim volume to present not only a summary of others’ ideas, but also something of his own point of view. He is clearly sympathetic to a “relational paradigm” and adopts a perspective that he labels “critical pluralism.” More about that later.

I could end the review here by simply recommending this book as an excellent choice for an undergraduate and early graduate survey course on basic psychoanalytic ideas. However, I have some concerns about some aspects of the content of the book that go beyond a summary of the work of various theorists.

According to Borden, because “much of Freud’s work is flawed and out of date” and because “very little of what Freud understood as psychoanalysis has remained intact,” critics of psychoanalysis “remain behind the times” (p.xii). I must confess that I always react negatively to this familiar defense of psychoanalysis because it suggests that if critics were aware of contemporary psychoanalytic formulations, they would learn that their criticisms have been adequately addressed or no longer apply. However, if this kind of defense of psychoanalysis is to be taken seriously, one is obligated to a) identify just which aspects of and in which ways

Freud’s work is flawed and out of date; b) describe the nature of the criticisms directed to Freudian theory; and c) most important, delineate precisely how contemporary psychoanalytic theories address (and overcome or ameliorate) these criticisms. The author does not tackle any of these tasks.

After telling the reader that “much of Freud’s work is flawed and that “very little of what Freud understood as psychoanalysis has remained intact,” one is then also told some twenty odd pages later that “empirical study in the behavioral and social sciences increasingly provides support for a series of core propositions that Freud advanced in his theoretical systems, including assumptions about the nature of unconscious motivational, affective, and cognitive processes; defensive strategies and self-deception; the origins of personality and social dispositions in childhood; developmental dynamics; and the nature of “psychic reality” and subjectivity” (p. 24). This seems like an awful lot that has remained intact. How does one reconcile these very disparate assessments of the standing of Freud’s ideas?

In citing Greenberg and Mitchell’s (1983) distinction between a drive paradigm and a relational paradigm approvingly, the author contrasts a perspective “which takes relational elements, rather than (my emphasis) biological drives, as the core constituents of human experience” (p. 2). Although I understand the distinction drawn, it would be useful to be reminded that if we have learned anything about human nature, we have learned that “relational elements” are as biologically rooted (e.g., the attachment system) as sexual and aggressive drives.

In adopting James’ pragmatism, the author writes that “what matters is what works, and the practitioner determines the validity of theoretical formulations on the basis of their effectiveness in the particular clinical situation” (p. 9). The relationship among validity, veridicality, and effectiveness is complex, as is the question of whether the practitioner can truly determine the validity of theoretical formulations on the basis of their effectiveness in the particular clinical situation. If one is to do justice to these complex issues, one needs to tackle them in a sustained and serious way. But that is not going to happen in a primer. Perhaps, then, one ought to leave these issues alone in this kind of book. And here is one of the problems with the book. So long as it remains a primer, it does an excellent job. When, however, it goes beyond this limit and attempts to deal with more complex issues, given the nature of the book, it cannot help but deal with them in a superficial way.

Before concluding this review, I want to raise what may seem to be a strange question, namely, what do books like this tell us about the state of our field? What I mean by “books like this” are ones that typically devote a chapter each to the “usual suspects”—Freud, Adler, Jung, Sullivan, Klein, and so on, and also include additional theorists who are current at the time the book is published. Books like this have been around for a while. I am reminded of Ruth Munroe’s Schools of Psychoanalysis, a book widely used during my graduate school days and also of Hall & Lindzey”s Theories of Personality, a book not limited to, but including different psychoanalytic theories.

As I suggested earlier, books of this kind can be useful for teaching purposes. And, as I also indicated, Borden does an excellent job in providing such a book. But the question I raise is: What is the image of psychoanalysis that emerges from books of this kind? We get a picture of successive charismatic figures, each one proposing a presumably comprehensive theory to replace previous theories, each figure with a loyal band of followers, and each theory associated with its own training institute. The presentation of psychoanalysis as a succession of different and often warring theorists and theories, followers, and institutes may well be historically accurate. But is this the most useful way to present our discipline, particularly, in a book entitled, Contemporary Psychodynamic Theory and Practice? This sort of presentation does not include much of anything about the evidential base for each theory or any systematic evidence on whether it is associated with greater therapeutic effectiveness. Nor is there much discussion of such issues as possible contradictions among theories, different language for similar constructs, possible differential applicability, or areas of possible convergence and integration.

The above state of affairs is frequently hailed as pluralism, in Borden’s case “critical pluralism.” According to his modest and defensible version of critical pluralism,

“we must master multiple theoretical models, therapeutic languages, and methods of intervention, sorting out the strength and limits of various perspectives. In doing so, we locate ourselves in the broader therapeutic landscape and establish a clinical sensibility that is distinctly our own. (p. 167)”

At another point in the book, however, Borden’s “critical pluralism” seems to entail the position, which he attributes to James, that “there are equally valid descriptions of phenomena that contradict each other . . .”(p. 8). It is difficult to believe that this is an accurate attribution. I suspect the author is confusing different or disjunctive descriptions that may be equally valid with contradictory ones that, insofar as they contradict each other, cannot be equally valid. In any case, the question with which I want to end this review is whether the state of affairs described in Borden’s book should be viewed as a happy pluralism—let a thousand flowers bloom—or whether it urgently suggests that it is time for serious attempts at integration, even if partial integration, and for the careful assessment of the array of different psychoanalytic theories in terms of systematic evidence and therapeutic effectiveness.

Morris Eagle, Ph.D.

The Southeast Florida Association for Psychoanalytic Psychology ♦ Email: sefapp@gmail.com
Phone/Fax: (954) 597-0820 ♦ Administrative Office: 101 Mint Hill Drive, Cary, NC 27519

The Southeast Florida Association for Psychoanalytic PsychologyA Local Chapter of Division 39 of the American Psychological Association

Book Review - History Beyond Trauma, Fall 2004

Book Review - Contemporary Psychodynamic Theory & Practice: Toward a Critical Pluralism, Fall 2008

The Southeast Florida Association for Psychoanalytic Psychology
A Local Chapter of Division 39 of the American Psychological Association