Standing Firmly On All Sides of the Issues

by Marvin Hyman, Ph.D. 

When an analyst and an analysand collaborate in psychoanalytically investigating unconscious mental life, they discover that one of the ubiquitous components of that life is the presence of unconscious conflict and conflict resolution.   They discover further that the means by which conflict is resolved entails the formation of compromises which permit the expression, in disguised form, of unconscious motives and defenses while simultaneously maintaining the repression of the unconscious dynamic.  Such resolutions of conflict are not, however, complete; residuals of the repressed motives remain to press for expression and thus defenses are required to oppose such expression.   We conclude, therefore, and to no one's surprise, that life in the unconscious is not perfect.

It is equally unsurprising that conscious mental life is also imperfect.  This is in contrast to the fantasy that each of us may have had, at one time or another, that there is an analyst out there who leads a perfect professional and personal life, presumably because that person has been perfectly analyzed.  I regret to inform you that there ain't no such analyst.  That person cannot exist because the professional life of the analyst has inherent in it conflicting points of view relating to matters of theory, of technique, of education, and of the professional situation.  And, frequently, the analyst's professional conflicts do not lend themselves to compromise; rather they require the analyst to remain the repository of two or more incompatible positions and to live his or her professional life accordingly.

 In this presentation, I would like to list some of those conflictual issues and discuss the nature of the experience (at least as it exists for me), how I perceive the analysand is affected by them, and how the issues impact the psychoanalytic work and other psychodynamic sequelae. 

PSYCHOANALYST VERSUS PSYCHOLOGIST (OR PHYSICIAN, HISTORIAN, OR WHATEVER)

STUDENT OF UNCONSCIOUS PROCESS VERSUS HEALTHCARE PROVIDER

In the United States, it is extremely rare for psychoanalysis to be recognized as an independent profession.  As a consequence, most American psychoanalysts come to the enterprise from other, perhaps related, professions, e.g., psychology, medicine, social work, or nursing.  In many instances, those related professions designate psychoanalysis as one of their specialties.   In addition, these professions have been labeled as "health care" professions, which designation includes, by default, any psychoanalytic component they may have.  Although there is an increasing tendency for psychoanalysts to come from back-grounds in the arts and humanities, e.g., philosophy, English, music, etc., those who do so are usually designated as health care professionals when they function as analysts. 

Since each profession is defined in part by its philosophical and ethical foundations, being a psychoanalyst by profession while also being, for example, a psychologist, means that one is placed in two camps which do not necessarily have compatible principles. (Since I was initially educated and trained as a psychologist, I will use that disciplinary status as illustrative of my discussion.)

Some Ethical Issues

 Everyday that I go to work as a psychoanalyst, I am in violation of the codified Ethical Principles of Psychologists in several different ways.  In the first place, as a psychoanalyst, I consider it incumbent upon me to follow a strict adherence to the requirements of confidentiality.  This puts me in violation of those laws which require mental health practitioners (a group of which I do not consider myself a member) to warn, to protect, and to report.  And, since I am violating several laws, I am at odds with the code of ethics which does not condone lawbreaking.

 As a psychoanalyst, I do not perceive analysands as sick, disordered, or incapacitated in any way.  If I did, I would not be able to maintain psychoanalytic neutrality since I would have taken a judgmental position.  Being motivated by unconscious forces is not a state of incapacity or disorder; it is a given of the human condition.  Further, as an analyst, I listen to reports of so-called "reportable" behaviors as thoughts that have come to mind rather than as events or "symptoms" or statements of fact.  I do this in order to accomplish the work of elucidating the unconscious dynamics, which is the central and only purpose of the analysis as that is agreed to by the analysand and myself.  It is for these reasons that I cannot be in a position to know if an analysand is a "danger to himself or others", I cannot make a "diagnosis", and I cannot guard the analysand or others from the consequences of the analysand's intrapsychic processes; all of which are expected of me by the code of ethics of psychologists.

 Psychoanalytic ethics are, at the present time consensual but not codified.  If there were a code of psychoanalytic ethics it would be substantially different from those of other disciplines.  Nonetheless, when we try to abide by the codes of those other disciplines in professional life interesting results occur.

I am a card-carrying member of the American Psychological Association the organizational parent of the Code of Ethics of Psychologists; I have a Ph.D. in Psychology; I carry malpractice insurance as a psychologist, not as a psychoanalyst; I am licensed as a psychologist in Michigan; I have a diploma from the American Board of Professional Psychology; I am a faculty member in the Department of Psychiatry and Behavioral Neurosciences; and for more than two decades I had a day job as Director of Psychological Services in a psychiatric hospital.  If I want to argue that psychoanalysis is not a mental health profession or a specialty of psychology and that, therefore, as a psychoanalyst, I am not bound by those ethical codes, then I will be hard put to do so in the face of all the contradictory evidence I just cited which defines me as a psychologist bound by those codes.  If I want to assert that I am also not subject to the regulations, guidelines, rules, prohibitions, laws, standards, evaluations, intrusions, and so on which seek to govern the behavior and functioning of the health care profession, then I have to be prepared to defend myself against the inevitable assault from governmental and organizational regulatory agencies, professional organizations and their ethics committees, tort attorneys, and myriad such agencies, all of which want either to declare me a psychologist, and therefore, ipso facto, a health care professional, subject to their ethical constraints and in violation of them.  Moreover, if I want to forego those diplomas, licenses, and certificates which define me as a psychologist, then I risk being prosecuted for quackery and practicing without a license, as was Theodore Reik. 

Given my reluctance to subject myself to the risk of being prosecuted, I remain a psychologist with little, if anything, in common with modem day psychology.  And, as a psychoanalyst, I am a member of a community whose adherents still are defined by whatever other profession or discipline they belong to.  Sometimes one might feel oneself living in a Lewis Carroll world.

Some Organizational Issues 

With very few exceptions, psychoanalytic associations require their members to be qualified both as psychoanalysts and in some other health care profession such as medicine, psychology, social work, etc.  Simultaneously, these same organizations recruit as members and candidates individuals with no mental health background or interests.  All of us, I am sure, have gifted psychoanalytic colleagues who come from backgrounds in the arts, the humanities, and the sciences.  Although the fiction is maintained that by virtue of their training as psychoanalysts such individuals have become mental health practitioners, they are nonetheless a problem for most of the existing psychoanalytic organizations

to which they apply for or are admitted membership.  The difficulty is that when such individuals function successfully as analysts despite their lack of membership in a qualifying health care profession, it can be argued that such success is proof that psychoanalysis is not health care.

 Different psychoanalytic organizations have devised different solutions to this dilemma: some have limited their memberships to individuals who are qualified as analysts and also are qualified members of a health profession, e.g., physicians (even though they train others who can never be members of their organization); some organizations accept qualified analysts as members who are also qualified in any one of the health professions; some organizations accept qualified analysts who are not health professionals, but consider them as somehow special (sometimes according them a sort of second class membership); and some organizations, eschew identification as a health care group and accept any individual who meets their definition of psychoanalyst.

I am a member of a number of psychoanalytic organizations, each with different definitions of a psychoanalyst as implied by their membership requirements.  I find myself implicitly supporting, by my memberships, two or more competing and incompatible definitions of who is a psychoanalyst, none of which accords with my views of what the membership requirements should be.  The situation become even more complicated if one is part of the governance of an organization and obliged, therefore, to implement membership policies with which one might not agree.  Of course, one could choose not to be part of an organization, but then one might have to forgo furthering those policies which one finds compatible and deserving of support.  Besides, turning off and dropping out risks subjecting oneself to a kind of professional isolation, an experience particularly onerous for a psychoanalyst whose professional life outside of organizations is isolated enough. 

 ANONYMOUS, ABSTINENT, NEUTRAL CONSULTANT WITHIN AN
ARTIFICIAL PSYCHOANALYTIC SITUATION VERSUS APPROPRIATELY
SELF-DISCLOSING, CARE TAKING AND CARING, INVOLVED PARTNER IN A
NATURALISTIC HUMAN RELATIONSHIP 

Many individuals, when they first consult an analyst, perceive themselves like the gang members in West Side Story who seek to have the police recognize them as victims who are "depraved because they were deprived".  To no small degree, psychoanalysis has supported such a viewpoint in its conception of deficit, deprivation, and other such traumas as antecedent events which constitute the etiological basis for the so-called psychopathology which is discovered in the initial, diagnostic interviews that many analysts consider a requisite of psychoanalytic practice.  In this model, the interviewee (perhaps later to become an analysand) has become the victim of forces beyond her control and is in need of some sort of rescue from them.  Often, the analysis is expected, by both participants, to be the place in which the antecedent events are rectified and erased.   In various ways, psychoanalysis of one kind or another has been conceptualized as a sort of "corrective emotional experience" which is effected by the analytic demeanor within the relationship.  A mentor of mine, Richard Sterba, has argued that the humane actions of the analyst constitute the central curative agency of the analysis and that the analyzing activities are simply the background or context in and against which the humane could appear.  Examples of such humane activity included feeding the analysand, finding jobs for them, showing slides of trips to Vienna, and being a solicitous and caring individual.  Sterba maintained that the analyst must always be friendly, and that ahead of doing the work of analyzing.  To criticisms that the humane actions might make it more difficult for transference reactions to be perceived, understood, and interpreted, Sterba's answer was, "transference is transference and reality is reality and the participants know the difference on and off the couch".

 A different and opposite conceptualization of that which the analysand presents as psychopathology is that the model is inappropriate, and that that which we call psychopathology might better be named psychodynamics.  Thus, the analysand is understood to be presenting what Brenner would call a "mind in conflict", a mind in which can be discerned, through the methodology of psychoanalysis, conflicts between the psychic forces of unconscious motives which press for expression and the repressive forces which seek to keep them from awareness.  The compromises between these forces are the solutions at which the analysand has unconsciously arrived, such solutions consisting of disguised and derivative expressions of the unconscious motives which enable the individual to remain unaware of them.  Moreover, the resolutions of the psychic conflicts are problems only in that they supercede the conscious intentions of the individual and result in experiences which are seemingly without reason and are therefore distressful, upsetting, and sometimes psychically painful.  When analysands discover that they have been pursuing alternative agendas to those of which they were aware and learn the nature of those agendas, the discovery itself of the existence of such agendas is as important to the analysand as the knowledge about the specific conflicts. 

The conceptualization just described has significant implications for the conduct of the analysis and the nature of the relationship which is perceived to exist.  The first, and perhaps most important, characteristic of the relationship is that it is an artificial one.  It has none of the attributes of the other relationships the participants have and exists solely for the purpose of accomplishing the task of analyzing the unconscious conflicts of the relationship.  The conduct of the analyst is artificially restrained in the service of facilitating the associative communications through which the analysand will provide information representationally about ongoing unconscious processes, including highly charged and dramatic affective experiences of that part of the analysand's mind called the analyst. 

In order for the agreement between the collaborators to be valid, it must be assumed that the analysand has the full capacity to live his or her life in the way he says he consciously desires and that he is not doing so only because of the existing unconscious conflicts.  Reciprocally, the analyst must respect that capacity and must avoid demeaning the analysand by gratuitously providing fulfillment of the analysand's needs as they exist in the mind of the analyst.  It might be considered the epitome of humane respect to accord the analysand full responsibility for his or her life as well as full responsibility for the use that the analysand does or does not make of the analysis.  The relationship between analyst and analysand is perceived to be based only on the needs of the analyzing work. 

I am not ignoring the experience of transference and the transference determined perceptions of the analyst.   Nor do I ignore the significant of what has been called the “evocative" aspects of the transference which is perceived by the analyst through her untoward experiences of and reactions to the analysand.  Finally, I am not eliminating the importance of the countertransference.  The conception of analysis which I am describing perceives these phenomena as something to be analyzed rather than acted upon, notwithstanding that such action may be appropriate and respectful of the boundaries imposed by professional integrity and responsibility. 

Many analysts see the relationship I have just described as sterile, rigid, unfriendly, and cold.  Others see it as the only kind of relationship in which the analyzing work can be accomplished.  In reversal, some analysts see the emphasis on relationship as a central curative factor (as Strachey described it) as effusive, intrusive, demeaning, and infantilizing.  Others see it as the only kind of relationship that can rectify the developmental insults which have psychically been imposed upon the analysand. 

Certainly, it is clear that communication about these alternative views of the psychoanalytic endeavor is at best difficult since they seem so different in regards to theory, practice, philosophy, and epistemology.   To some the views are at war with each other.   If they are, I think we had better get a quick armistice or else there will be nothing left but the field of battle soon to be taken over by entities who have declared a plague on both houses of the warriors. 

THE EDUCATION OF THE ANALYST
DEVELOPMENT THROUGH INSTITUTE TRAINING
VERSUS SELF-DIRECTED DEVELOPMENT 

Some years ago, at a conference on psychoanalytic training I presented a paper in which I argued that the system of training analysts in institute had become so flawed and, perhaps, corrupt, that we would do well to substitute for it the model proposed by Sigfried Bernfeld.   The essence of Bernfeld's model entailed the potential analyst conducting his or her own training, aided, if desired, by the advice and assistance of a mentor.  I do not intend to argue that proposition in this presentation.  Rather, I would like to address an issue that very much relates to it.

 I think that all of us would agree that being a psychoanalyst requires an unusual degree of skill, of knowledge, of experience, and, perhaps, innate ability.  We would agree further, I believe, that the acquisition of those attributes and the fulfillment of the potential requires, above all, an extraordinary degree of commitment to the educational enterprise.  It has been my experience that such commitment can be found both in candidates at psychoanalytic institutes and in persons who have chosen to become analysts through assiduously pursued educational and experiential activities.  It is not individuals of that sort about whom I am concerned.  Rather, I want to comment on some anomalies which I have observed regarding both those training models. 

One perversion of the model of self-directed development I have encountered consists of individuals, who, because of the freedom inherent in the model, declare after having spent two or three months in analysis.   To my mind, such persons show little understanding, respect, or appreciation of the nature of the psychoanalytic enterprise and provide justification for those who hold psychoanalysis in disrepute.  They are the individuals to whom I would not refer, even a person whom I did not like.

 Another difficulty with this model is the sometimes glacial pace at which the program proceeds for those individuals who, regardless of their potential, delay fulfilling it because they lack, not commitment, but discipline; something which they have to provide themselves in this model of training.  Such persons might do well, as many have, by submitting themselves to the externally imposed discipline of the organized educational program of an institute.  Of course, they will have to compromise, to some degree, their freedom to direct their own development, but the tradeoff might be worth it.  An additional price that might have to be paid is the experience imposed when the educational process is institution-centered rather than student-centered.  This, of course, is not a matter of proclamation, no training program would believe that it was not student centered.  It is, rather, the nature of the beast.  It is in the sociology of institutions that the first order of business is the preservation of the entity and that gives first priority whatever accomplishes that.   Too often, the program loses sight of its educational objectives as it attempts to deal with the entrepreneurial costs and pressures it faces. 

And so, how does one advise a prospective analyst which program to adopt.  Often it winds up that, depending upon the individual, one chooses one and the other and both. 

A SUMMARY 

I can think of a couple of other dilemmas and conflictual issues with which the analyst of our time is confronted.  Because of time limitations, I can only name those conflicts and leave an exploration of them for another time.

 The thought I hope you will take away with you from this presentation is that it is not necessary to value a single, linear, cause and effect solution to the myriad conflicts we face in our professional lives.  Just as all in our universe is relative, changing, and infinitely modifiable, so to is the mental life of our analysands as well as the lives of our analysts.   Uncertainty is the hallmark of our profession.  I think we ought to let ourselves find satisfaction and gratification in it.