An Extended Practice of Psychoanalysis
Expanding the scope of psychoanalysis broadens and deepens the range of phenomena we can consider psychoanalytic.
In narrative fashion, the author gives an account of an essentially psychoanalytic practice, employing analytic group interventions (analytic family, group, and therapeutic community), illustrating it with the therapy of a severely depressed and character disordered individual.
The initial positive relationship formed with this patient was not sufficient to contain the disruptive affects attendant on the profoundly disordered form of transference induced, or to carry it forward without severe perverse and regressive cycles. therapeutic alliance was then sought and obtained with his marital partner, then in analytic group therapy, with his family, then in the context of an analytically oriented therapeutic community. Each rendered him more capable of sustaining the analytic position and its attendant functioning. He struggled with and mourned his alienating identifications, first towards heroic addiction, exceptional and mythic relationship roles, self immolation in favour of his dead father, and last, an incestuous relationship with his mother. These were manifested in serial order of the transference. The phenomenon of revenant, then of vivid dreams announced progressive deepening of this man’s intra-psychic capacity to experience the transference that centered about his father’s death.
In this report, I shall sketch the main features of a clinical practice that, while not generally acknowledged as psychoanalysis per se, is present in varying degrees in contemporaneous practices. I address the issue of what is essential to psychoanalysis and I call it an extended practice. From the first, I have broadened the range of patients beyond those who can be worked with by the standard method--narcissistic, character disordered, and actively psychotic--and have developed new treatment methods to engage those difficult-to-reach patients into a psychoanalytic treatment course. Expanding the scope of psychoanalysis has broadened and deepened the range and nature of phenomena we can consider psychoanalytic.
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I had considerable experience prior to my psychoanalytic training, in the use of the group method to treat character disordered and psychotic individuals. The work there was done jointly with sociologists, psychologists, educators and other allied professionals and succeeded in reversing the course of alienation of individuals in prison and hospital settings. However, I realized that a thorough individuated treatment called for a psychoanalytic approach. When I combined the two approaches, after eight years of psychoanalytic training, I found, to my gratification, that the psychoanalytic and group processes were basically identical. Transference would appear regularly in the groups when I took the analytic position, exercising the combination of activity and abstinence particular to psychoanalysis.
I discerned that the analytic experience focused on the inner life and relations of the individual, and that such study, while usually conducted in a group of two, analyst and analysand, also was possible in larger group formations. Freud had noted that in Group Psychology and Analysis of the Ego (Freud, Standard Edition, 1955):
- Rarely and under certain exceptional conditions is individual psychology in a position to disregard the relation of this individual to others...So from the very first individual psychology, in this extended but entirely justifiable sense of the words, is at the same time social psychology as well. (p. 69)
Lessons I had learned in my previous groups enabled me to continue the work with the severely disordered in private practice. I had learned the necessity of close and scrupulous attention to the treatment alliance, to the evocation and enactment of a state of mutual enterprise and confidence, much of this centred on a union in the ego ideal, analogous to the tie Freud described in his Group Psychology as existing in the Army and Church.
In addition, I found that the group method could be extended from institution to private practice. For those who needed something more than the standard method, I assembled a variety of populations--a group for unaffiliated individuals, troubled couples, and troubled families. At intervals, my office was transmuted into a lively clinic. As a consultant, I participated in the development of a therapeutic community in a general hospital context to tide my patients through their periods of decompensation.
In the five-plus decades of this practice, my patient population was rather stable in composition. It was made up of about 20 individuals; I had generally one family and 2-4 troubled couples going at any one time. Their diagnoses ranged from neurosis through borderline, to character disordered and actively psychotic. About a third of these were in standard analysis, half of them starting as such. Another third were in a combined group and individual course. The rest came as troubled couples and families, whom I saw as such and in groups. Groups were formed for the individuals, and were in constant flux, although paradoxically a relatively steady feature in my practice.
My practice was skewed towards work with the more difficult patient because of my interest and reputation among my colleagues and patients. Colleagues and patients were about equal in referring patients. I have worked with other psychoanalysts in tandem and conjointly with difficult patients, as well as with allied professionals, in work with families and couples groups.
I worked towards a therapeutic encounter with the individual patient in which (1) a working alliance was obtained (with evocation of, and engagement with, the observing ego); (2) constructive regression initiated; (3) the resistances to transference and transference resistances interpreted and worked through; (4) the infantile neurosis experienced; (5) and on termination, largely resolved. Dream analysis played an essential part in the work. I found the couch almost essential at some point in the process, that of the phase of free-associative analysis.
Illustrative Case History
Obviously, operation of a practice of this sort was highly complex, at least administratively so. I would like to cut through those complexities by presenting just one case which illustrates my employment of group formations to enable the psychoanalytic relationship and process to emerge and be carried through to a relatively successful outcome. The presentation will of necessity be in a rough sketch, skewed in favour of specifics of the therapeutic alliance with difficult patients, the occasion for use of parameters, and their relinquishment as the analytic process took hold.
The treatment lasted ten years. It began for this then 38-year-old pathologist when he attempted suicide with the morphine to which he was addicted. He was referred by his friend, a colleague of mine, as a last resort. Because of exigencies in my practice, I asked another colleague to be the principal therapist, intending to utilize my analytic group to help stabilize the treatment.
The patient's illness had begun at age 26, soon after the death of his father which just preceded his graduation from medical school. He "saw" his father sitting ominously in his burial suit in the back seat of the car on the way from the funeral. He could not sleep thereafter, was agitated, medicated himself with hypnotics, then stimulants, and began the psychotherapeutic course which ultimately lasted twenty-two years. There were numerous suicidal attempts, a self-inflicted gunshot wound to the leg, a number of hospitalisations (one lasting for a year and a half at a psychoanalytic hospital), and treatment by another psychoanalyst for five years, one of the five psychiatrists who attempted to work with him.
I agreed to see him in consultation with a view towards including him in my analytic group therapy. In the first hour, he expressed a monumental sense of failure in all dimensions of his life, especially in his relations with other men. He reported alternating between high idealism to black disillusionment. Aware of being driven--he had to climb the mast of a boat he and his colleagues had sailed, to cap the experience--he was helpless to alter his course.
The picture emerged of an individual who pursued quixotic dreams and who had been struggling with himself since early childhood. He had kept his family and friends engaged in wrestling for his soul, and in a state between despair and hope. His wife and three children (female, teenage) were, at this point, verging on alienation, because of his preoccupation with his careers in addiction and self-destructiveness, which kept him away on the streets, in hospitals and doctors' offices.
He reported that he had been restless and "psychopathic" since earliest childhood, taking after his father with whom he had a "weird" empathy and exquisite awareness of his hurts. He greeted his sister's birth at first with murderous intentions, bringing on scenes where both he and his mother, previously "fast friends," went at each other literally tooth and nail. He turned protector and exemplary brother upon the birth. He was aware that this sort of rivalry was going on now with his daughter's boyfriends, in contrast to the warm, loving and understanding man he would like to be.
In the next hour, he reported a recurring dream of lying in a Chinese junk, in a coffin, with everything black and peaceful. He awoke with a strong impulse to cut his throat. Associations were to murderous rage towards his mother and female surrogates; men calmed him.
A number of psychiatrists had tried tranquillizers and antidepressants to help him fight this "terrible depression," to no avail. I asked if he had developed any therapeutic relationship where he had encountered some trust and mutuality. He replied he had, for several years, and he "had not lied." He had broken faith when the analyst had confronted him, asking him to "stand things" without the drugs. At that point he had become outraged, alienated and alienating; only one person, a friend, who believed that his drugs kept him alive, could help him out of his extreme self-destructiveness. This friend had referred him to me.
To my surprise, during this exchange, I experienced empathy with him. I felt his depressive affect, which seemed to centre about his father's death and the ideals they had both held. He went on to tell how he had recently broken with this friend. It was over their psychic impotence; my patient refused to blame his wife even though she was calling him a "eunuch." It turned out that in the break from his friend, he had completed the break from the network of relationships in his life. In his alienation from his previous analysts, he had reassumed the ambience of an addict, pursuing his perversity with characteristic assiduity and compulsivity.
Paradoxically, in the midst of this, when assigned the role of the acting head of a large hospital on overnight or "weekend duty," he became a veritable Osler. In the meanwhile, in his current course, he had several treatment hours with the colleague who had agreed to be his principal therapist. Then, over the weekend, he made another suicidal attempt, leaving clues by which his wife saved and hospitalised him. Because of the manifest negativity of this patient, my colleague bowed out of the case as principal therapist.
Simultaneously, the patient's wife asked for counselling. I agreed to see her in marital counselling. I focused on their desperate situation and her conception of her part in it. She responded eloquently that they were unable to live their lives or help each other to do so, despite their immense efforts. She realized that she had lived through the marriage and her efforts to save him, but did not know what to do otherwise. She was aware that not following the lead he had left to the place of his suicide would have resulted in his death. She went on to disclose her mother's self-immolation in her marriage, and she ended with, "If I would just disappear, no one would ever know I was there."
In the second hour, she revealed that they had "found" each other when quite young and formed an extremely idealistic union, some 16 years previously. It was marked immediately by profound jealousy on his part and obdurate devotion to her. While they were alienated, they were closely tied through their ideals. It became even more apparent that their morale was at the moment very low, and they were looking for relief from their martyrdom through death.
She reported that they were able to perceive the ego deficits of the other with great clarity, and expressed a deep disappointment in the other, self, and the marriage. It was apparent that both, while disavowing such, assumed the authoritarian and preemptive roles of their families of origin, which happened to be Jewish, and rebelled against one another, and self. In addition, they exhibited, because of their internal conflicts and ego deficits, an inability to be consistent. They were obtusely enmeshed in a web of principles and ideals.
The task of analytic marital counselling was to deal with the nadir status of their morale and the despair that accompanied it, then mobilize their capacity to take counsel about their marital union, firstly on whether they wanted to stay together long enough to resolve their impasse, to resume their marital course, or part. They were capable of taking counsel with one another only to the extent of deciding on a moratorium on that decision, sufficient to work their way through this crisis.
Despite their profound ego deficits, we were able to form an alliance in the ego ideal sufficient to serve as a mandate for me to work with them individually. Collectively, we would be responsible for one another as we proceeded in the mutual enterprise.
Parenthetically, I had learned the necessity for such an engagement in my previous work in therapeutic community, to form a therapeutic symbiosis first, as part of the therapeutic alliance. I have learned subsequently to attend as scrupulously and systematically to that aspect of the individual therapeutic relationship. In this instance, I would have followed this patient to the hospital and engaged in an intensive and prolonged encounter until the alliance in the ego ideal we had formed at the inception was reconstituted. I estimate that the clinical course would have been much less stormy and prolonged.
He succeeded in alienating hospital personnel during subsequent hospitalisations, six in number, occasioned by either suicide or its threat, or severely obtuse and addictive behaviour. On his seventh, however, he was admitted to a therapeutic community I had started, but in which I did not directly participate. There he immediately changed from Hyde to Jekyll, "adopting" another patient, an old man he sensed to be like his father, and participated with warmth and vigour in the doings of the therapeutic community. On discharge, he resumed his therapeutic regimen with me in a more analytic manner, abstained from drugs, reconciled with his wife and family, and engaged in productive work for the first time in five years.
The marital counselling in the inceptive phase of the treatment succeeded in so altering their way of transacting that both parties began to let go of their locked-in idealistic union, and to mourn its loss – a welcome change from their previously impotent, perverse rage. After hospitalisation, the patient entered formal therapy with me. In his version of free-association, he revealed evidence of his desperate and important ties to his family of origin; dreams of compulsive, violent intercourse with his mother, and fantasies of Don Juan-like ventures in the world of women, plus accounts of his failures in his work and marriage.
However, having once "hooked" me and then been "hooked" into our idealistic enterprise, he seemed to cleave to a separate world; he resisted coming to the hours on time or at all. It became apparent that in tendering me material he was patronizing this "bourgeois, straight" analyst who was going to convert him to his enslaving values, away from the freedom of alienation. This superior position, narcissistic in nature, had enabled him to resist the efforts of his previous therapists, despite his and their long efforts. On an intrapsychic level, it involved a self-transcendence, in which he was above, and below, and outside of being human. Later in the therapy, he cited his own and his wife's expectations that he be superhuman.
It was in his human situation that the transference lay. Relinquishment of his narcissistic position brought him to the edge of grief and rage concerning his father's death, his life course, and the immediacy of an incestuous tie to his mother and her surrogate, his wife. He had developed an automatic response to the emotions inherent in those aspects of his life -- "I've got to die!"
From the first, we experienced relationship cycles, in which he broke from treatment and family to repair to the world of an addict (morphine, dexamyl, phenobarbital, and Ritalin), and also to the hospital for treatment of his many physical disabilities, such as pneumonia, broken ribs, and traumatic arthritis. Sometimes the cycles were preceded by dreams or fantasy-urges relative to his home or work situation ("I dreamt of my daughter being hurt and awoke to pop a dexamyl.") Mostly they were obscure in origin, "I couldn't stand it." It became even more apparent that the journey back to his premorbid personality, away from his profound self- alienation, sufficient for analysis to take place, called for further structuring of his therapeutic experience so that it rather than drugs would sustain him. The optimal situation would have been a live-in therapeutic community in a half-way situation. Such was not available. I, therefore, soon after the inception of treatment, put him in my analytic therapy group which met for an hour and a half, plus two individual sessions, and a marital counselling session every week or every other week.
In the analytic group, during the turns of the cycle when he attended, he reported a deep sense of difference from the others there. He was sicker, more perverse, beyond help, the slowest of the group in conceiving of his selfhood, for all of his pronounced messianism and grandiose ambitions. At the same time, he was the most impatient and ardent in supporting the group as an instrument of hope for the others and, in exemplification of what they should be doing, reported on his internal states and dream life, in a manner approximating free association. In experiencing his internal states for the group (as a hero, climbing this mast), he felt a deep malaise, that he was dying. This marked the transition from narcissistic resistance to the appearance of the transference itself. He then began dreaming of his dead father's return. In one dream his dead father came to live in his basement. Then, subsequent to an encounter with the patient in a therapeutic community who resembled his father, he dreamt that he had his father's rotting corpse within him. He convulsively attempted to jump out of his very skin. In his explosive flight from self, he crippled his knee. Thereupon ensued another long absence from therapy, for physical treatment.
On return to his hours, after some resistance, he went into frank mourning for his father, with prolonged sobbing, allowing me to be empathetic with him. A flood of memories of life with his father accompanied this, and awareness of a terrible inability to feel compassion towards women, in loyalty to his father's code. This was accompanied by awareness of enormous pressure to "knock over the king," and to be knocked over. This led to a further awareness of the lack of constancy and life within himself, and of an internal incapacity to reward himself for constructive behaviour. He later wished to destroy himself to reproach his wife for his failures. He would awake from dreams of killing her for her compulsive intrusion on his person. She at the same time had a dream of breaking off his penis diagonally and keeping the piece alive inside her, for him. They were able to discuss their contributions to each other's impotence, a far cry from their mutual self-immolation at the beginning of the therapy.
He proceeded in therapy with infinite slowness through a complex of individual hours (which would number from zero to three per week), a group session (of an hour and a half), a family session (with his wife and one to three daughters present), plus individual counseling with the wife and daughters. After the first year of alarms and emergencies, his pathologic regressions grew less dangerous, and in accordance with the thesis of medical parsimony, I moved to associating with the family only on demand and during crises, attempting nevertheless to maintain a state of mutual enterprise and confidence. I had become a relatively steady fixture in their lives, much like the family doctor of yore.
As the family moved from its nadir status, the children made representations about their parents' enmeshment, asking them to assume their proper roles, and helping each other to avoid their parents' rebelliousness, bossiness, and self-sacrifice. The patient increasingly found himself accepted as the father in the family, occasions marked often by tears – his and theirs. They were relinquishing the past, moving into reconciliation in the present.
My patient would then come to the hours in position to work in the analytic mode. However, much of it was still for the benefit of his family and the group. It is of interest that this advance followed lead from his dream life, leads that preceded the appearance of the transference by several weeks. He relinquished his special, narcissistic role and capacity in the treatment group. This development happened in the groups before occurring in his individual treatment.
Summary of the Treatment
This patient called for the maximum extension of my practice at the time. I have of necessity presented only enough material to indicate his passage from a state of utter nadir hood and alienation to one of renewed selfhood, after a period of mourning centred chiefly about his paternal introjection, and reconciliation, internal and external. I have noted the role the psychoanalytic method played in both the administration of his therapy and the analysis proper, to enable him to work through his profound problems in individuation. His first problem centred on the formation of an alliance and working arrangement with me. He had ended his previous analytic work in a negative therapeutic reaction, intent on suicide as his ultimate solution.
Our alliance was achieved chiefly through special attention to a messianic aspect of his ego ideal and the establishment of an effective dialogue. As important was the relationship I established with his family, especially his wife. He exhibited profound ego deficits and modification of developmental nature, plus alienation attendant on mounting failures in his profession and therapy. This alienation made it impossible to participate in the therapeutic work, much less engage in free association. I had to utilize my analytic therapy group and his family group; while I could not entirely contain his cycles of alienation, as would have been possible had there been a therapeutic community at the inception of treatment. He was able to assume a special place in the analytic group as devoted leader and an exemplification of resistance. In that context, he began to relinquish his narcissistic defences. In entering the transaction with the other human beings in the group he established an external platform for the analytic relationship and for free association which he gradually internalized. Dream analysis, begun in his individual hours and continued in the group, enabled him to engage and mobilize the aspect of his ego he in his survivor's guilt had no right to have--having been caught in and preempted by an autistic sacrificial compact with his dead father.
Work on his maternal identification followed on the heels of a growing capacity to experience himself as a full member of the group and as an analysand in his hours, both in dream material and transference in the group. This coincided with further pressure by the children in his family to bring their parents into their proper roles. There also were useful exchanges about the repetition of the family’s difficulties in the three generations of the family, on both sides of the family tree.
Finally, the patient responded spectacularly to participation in a therapeutic community, which would have been maximally useful earlier in treatment. Readied by his previous therapeutic work, it enabled him to form a messianic relationship with a patient resembling his father, a relationship that opened him to the transference of the mourning he had failed to experience on his death. That mourning took full expression in his individual, group, and marital counselling hours. Concomitantly he returned to his premorbid personality. He was almost literally Dr. Jekyll again. From that vantage point, he required no further structuring of his treatment situation to deal with his alienation. He proceeded to analyze the narcissism of that character defence to termination of therapy.
Discussion
I chose this case as the focus for my thesis concerning the extended practice of psychoanalysis because of the extraordinary difficulty in structuring his treatment. I wanted to ensure that he could go through the process of personal change along analytic lines. This was supported through the inception of three groups: an analytic family group, an analytic therapy group, and an analytically oriented therapeutic community. The establishment of an effective therapeutic alliance called for the establishment of a state of mutual confidence and enterprise with his family, especially his wife, alongside the special one necessary with narcissistic and alienated individuals.
He was most able to relate in a free-associative manner in the group analysis, in conjunction with his individual work with me, despite the use of the couch, and frequent hours. In the individual work, despite his best intentions, he resisted the transference through living in the alien world of the addict, or an obsessive-compulsive compliance. When he did come into the transference, he had a direct, very vivid, and quite traumatic experience in mourning his dead father. Then he mourned the losses he sustained in his developmental eras, centring around his maternal object and the transference to his wife and myself.
As he worked through the alienation incurred in his previous treatment and life experiences as an addict and failures in his careers in marriage and profession, his cycles of alienation and rapprochement in the treatment became less dangerous, calling for a decrease in his need for administrative management. Though he tended to act out in the treatment group, the availability of his unconscious was of great help to the highly repressed neurotics there.
It is one of my contentions that the massive investment of time and concern extended to this patient was necessary to bring him into the mode of treatment necessary for work on his alienation and his narcissistic defences so that the transference and the inception of analysis proper could occur. Not only was it indicated on that count, but it comported with the principle of therapeutic parsimony. Beyond that, this patient could have been considered a candidate for chronic individualism and hospitalisation, a most costly outcome.
Conclusions
I have presented the outlines of a practice in psychoanalysis in which I extend the nature of its population to the actively psychotic, narcissistic, and character disordered; and of the modes of treatment beyond standard psychoanalysis -- group analysis, family analysis, and analytic therapeutic community. These considerations are exemplified in a case of a depressed individual, also addicted, whose treatment called for extensive structuring of the treatment situation, involving his family, an analytic group, individual psychoanalysis, and therapeutic community.
At first alienated and suicidal, the patient I have chosen to illustrate this practice formed a therapeutic alliance in which, after work on his narcissistic defences against the transference, he began free association and dreaming indicative of a mourning process which continued through much of his treatment. This process involved transaction and a working through of pre and post-oedipal issues about his paternal and maternal introjects. Issues of acting out because of the character disordered aspect of his personality were dealt with only with partial success until he participated in a therapeutic community towards the end of his therapeutic course.
Dr Joseph Abrahams is a psychoanalyst of deep distinction. Born in 1916, and with ¾ of a century of work as a psychoanalyst under his belt, we are immensely privileged to have had the honour of presenting his work. Dr has retired from professional life to write, and has now completed five books and a number of essays. He is a Distinguished Fellow of the
American Psychiatric Association
and a member of both the San Diego and Washington Psychoanalytic Societies. He lives in San Luis Obispo with his wife of many years, Elisabeth Galloway Abrahams.
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