Crises and Special Problems in Psychoanalysis and Psychotherapy (Book Review)

Author:  Bellak, Leopold and Peri Faithorn
Publisher:  Northvale, N.J.: Jason Aronson Press, 1981/1994
Reviewed By:  David Downing, Winter 2004, 64-67

In 1979, I purchased Emergency Psychotherapy & Brief Psychotherapy, by Leopold Bellak and Leonard Small. The first edition was published in 1965, and the second one, in 1978. This earlier book is largely incorporated into the volume that is the subject of this review. I mention it to underscore what my Statistics and Experimental Design professor had noted at the outset of his class in 1979: “There is nothing new.” I think that it is important to note this well; particularly at this juncture in our history, replete with the woes related to so-called empirically supported treatments, or the recently valorized phrase “evidence-based practice.” Naturally, we must also fold into the current admixture of angst, pessimism, and nostalgic yearnings the corporatist dream-come-true/psychotherapeutic nightmare of so-called managed care.

I emphatically do not believe in “the good old days.” These challenges are intimately linked to a variety of social, political, and economical forces, and enfold more than the professional practice of clinical psychology, psychoanalytical psychotherapy, and psychoanalysis. Indeed, they can be understood, in many respects, as outgrowths of the successes of professional psychology and psychoanalysis. These successes also include the ascendancy of the Division of Psychoanalysis within the American Psychological Association, the lawsuit brought against the American Psychoanalytic Association et al, and the veritable renaissance within psychoanalytical theorizing, writing (as evidenced by the plethora of books, journals, professional conferences), clinical applications (for example, to the psychoses and severe characterological organizations), and extension to cross-cultural populations, with a re-emergence of concern with respect to matters of class, race, gender, and more. Armed with a more internationalist perspective, and the assistance of post-modernistic discourses such as deconstructionism; some of the old, divisive, barriers separating and isolating psychoanalysts from one camp to another began to lose their relevance, and there has been ushered in a new era of ecumenical, multi-disciplinary discourse. Additionally, if traditional scientist-clinician, Boulder-Model Programs in clinical psychology (typically university-based PhD programs) have become more entrenched within a behavioral, cognitive, experimentalist framework; the rise of scholar-practitioner, Vail-Model Programs in clinical psychology (university-based and free-standing programs, generally offering the PsyD), have been able to maintain a space for psychoanalytically-oriented courses, and an emphasis on training in psycho-diagnostic assessment, including a respectable position for projective measures.

While not ignoring the unique nature of contemporary derivatives nor denying the especially venal tone of the public and private debates that are shaping contemporary practice and the options available for such practice; nor styling myself as some sage old-timer, who has seen it all, I will now deign to put some much-needed perspective on the face of things to quell the furor for all of the poor, benighted souls out there: I do believe that the life-span of this book by the late Dr Leopold Bellak: psychiatrist, psychologist, and psychoanalyst—with the assistance of Dr Peri Faithorn—communicates a great deal.

We have now been under the sway of a hyper-conservative, rightist political economy for some twenty-three solid years, relentlessly shaping political and public debates, and eroding the socially-conscious, politically liberal discourse and institutional pockets that were always, with respect to certain European counterparts, fairly diluted in the USA. Community mental health centers were already contending with federal funding cut-backs; the impingements of health maintenance organizations and other third-party payors; the rise of various forms of intra- and extra-agency utilization and quality assurance reviews; and so forth, by the late 1970s. These trends were already in full-swing by the early 1980s. Public and private institutions offering psychiatric and clinical psychological care were, accordingly, re-examining their own policies and procedures around matters such as length-of-stay, reimbursement for services, the sanctity of the entitlement programs such as Social Security, Medicare, and so forth.

Bellak wrote his books when he did because psychoanalysts were always, from the outset of psychoanalysis, practicing in short-term and time-limited ways. They had always had to contend with crises: There is nothing new. Bellak briefly notes some of his own experience with the Veterans Administration after World War II, when crisis intervention (“trouble-shooting clinics”), short-term treatments, and associated clinical/technical interventions/techniques were quite literally born of necessity, given the great influx of traumatized war veterans and a limited pool of trained, experienced clinical professionals available to assess and treat these individuals.

This book was written before the frenzied, tail-wagging-the-dog rush to “validate” the superiority of short-term treatments over long-term treatments, and the cooptation of such models by cognitive-behavioral clinicians as their unique invention and property. The “fashion” for short-term treatments has arisen less from clinical concerns a third-party payor mandated restrictions in the types of practice that would be reimbursed. This makes a bit of a lie out of the notion of a neutral, objective, value-free “science” of psychology.

The multifaceted problem and contradiction that is managed care has been amply documented and written about. Miller (1996), in a series of evocative articles, underscores that it actually constitutes a form of health-care access and treatment “rationing.” He also helpfully underscores the peremptory and unethical nature of dictating to qualified and duly-trained professionals (co-opted and de-professionalized into corporatist structures as proletarianized workers, or, as we are popularly and alarmingly termed, “providers”) exactly what they may or may not do; along with suspect reporting and documenting policies that impinge upon the psychotherapeutic space already frayed with the increasing domain of exceptions following upon the Tarasoff decision. Miller (1996a,b,c) sagely reminds us to maintain a professional identity and render clinically determined decisions regarding length of stay, treatment approaches, etc.

This is, it should go without saying, and most certainly what Bellak and Faithorn support. How contemporary the book reads. I will quote from the Introduction:

“Psychoanalysis as practiced today addresses itself not only to psycho-neuroses, but also, and in fact increasingly, to character disorders, borderline conditions, and psychoses...[Perhaps] the evolution of our culture, with its greater mobility, faster pace, less traditional concepts of family (“alternative life-styles”) and consequently more frequently interrupted or disrupted human relationships, contributes to producing more of these varied types of emotional disturbances. Matters of a political, social, and professional natures, for example, patients brought to us by third-party payors, or the flood of recent publications on “borderlines,” also undoubtedly have their influence on psychoanalytic practice, both in terms of whom we see and how we view them... Psychiatry, like every other field, has its fads (page xi).”

Bellak and Faithorn’s work is a solid piece of clinical theorizing and incorporates Bellak’s well-known, extensive researches into ego functions. This is used to great effect in underscoring his adherence to a quintessentially psychoanalytic ethos: securing the psychotherapeutic frame, with a focus on the relationship; an understanding and judicious use of the transference that is mobilized in nascent form; and maintaining an interpretative mode. Moreover, given the modification of parameters that is part and parcel of the new wave of psychoanalytic treatments, Bellak underscores his awareness that “some of my suggested stratagems could be misunderstood or misused, especially by the relatively inexperienced—namely, as inappropriate intrusions into the therapeutic process and the rights of our patients” (page xiv). He goes on to “make clear...that all other things being equal, the most appropriate and useful attitude of the psychoanalytic therapist...is to observe therapeutic neutrality” (page xiv), while at the same stroke recommending a non-dogmatic openness to active intervention under appropriate circumstances. All of this, he asserts, will be possible to leverage, if one follows his recommendations and takes exquisite care with respect to the gathering of the patient’s history or life-narrative; and out of this, develops a fulsome, multi-layered assessment and conceptualization of the patient.

In this respect, Bellak offers his work on Ego Function Assessment (refer to Sharp, V & Bellak, L, 1978). The twelve ego functions he articulates for assessment are: (1) Reality testing; (2) Judgment; (3) Sense of reality; (4) Regulation & control of drives; (5) Object relations; (6) Thought processes; (7) ARISE (Adaptive Regression In Service of the Ego); (8) Defensive functions; (9) Stimulus barrier; (10) Autonomous functions; (11) Synthetic functions; and (12) Mastery-competence (Bellak and Faithorn, 1981/1994). The fact that this work was based on empirical research adds a certain cachet—then, as well as now; and also puts to the lie, once again, that psychoanalytic theory and technique has not been based on research. This helpful conceptual frame has also found some resonance, however, with audiences of younger generations of graduate students who are skeptical and questioning; but, unfortunately, tend to be poisoned against all things psychoanalytic; and all-too-often steeped in a concretized, logical positivist, technique-based, objectification of a highly personal, potentially fragile encounter, that does not take into full recognition and account for the centrality of the relationship between the psychotherapeutic pair of patient and psychotherapist.

Bellak and Faithorn (1981/1994) also articulate their mode for working within multi-disciplinary treatment teams. The selective and judicious employment of psychopharmacological adjuncts (used sparingly, to assist in the reintegration of the patient to the extent that a psychotherapeutic process can obtain), the helpfulness of short-term respite or hospital care, environmental supports/interventions (again looking at the unique contributions of constituents of an interdisciplinary team that accrues to the totalistic and coordinated psychological treatment of the patient) are delineated. Such matters scarcely can be stressed enough, especially in the contemporary milieu wherein medications are given hegemonic sway over the talking cure.

Bellak and Faithorn (1981/1994) cover a considerable field of potential difficulties or special situations that can befall the generalist as well as the specialist in their clinical (agency or private) practice. Matters such as treating and managing in a crisis mode clinical issues including panic, acting-out, transference difficulties, counter-transference dilemmas, a treatment that has become stalemated, dissociative phenomena, suicidal and psychotic processes, are instructively covered. The impact of the patient’s facing major surgery, having been a victim of crime (rape, mugging, etc), dynamics related to pregnancy and abortion, losses of various kinds, e.g., lay-offs at work, divorce, bereavement and threat of death, and managing third-party involvement, are also discussed.

It has been my experience that these pithy, yet fulsome chapters can be quite helpful, instructive, and containing to students who are learning about short-term and crisis psychotherapy. In this book, they scarcely become some damnable, reductive cookbook that absolves the clinician from relating to his or her patient, as well as registering and managing their own internal reactions. Toward that end, the book itself ends with Part IV: “Problems of the Therapist,” including the occurrence of events that impinge upon our personal lives and associated professional lives as well, drawing our attention to the need to be aware of the impact upon the patient the potential meanings of the psychotherapist’s pregnancy, divorce, illness, and so forth. Especially instructive for students, as well as being a fine booster shot for more experienced clinicians, is the chapter on “Problems of Psychotherapy as a Profession.” As someone once noted, they go well beyond hemorrhoids, and this chapter manages to auger for the psychotherapist to recognize the peculiarities of a life in this “impossible” profession, so as to be well prepared to manage its vicissitudes, and thus manage to be a sound clinician. Again, it is most helpful for students to read that periodic returns to psychoanalysis or psychotherapy is helpful, as well as taking part in study/professional groups, attending conferences, and receiving consultations about one’s work. In short, students need to learn to become part of a professional community, yet also maintain a life independent from the voracious grasp of the profession.

In closing, I will note that I continue to use this book in courses that I have taught across time on short-term and crisis psychotherapy. While I obviously sprinkle the course with current journal articles, or chapters of books that may deal with certain issues such as managed care more pointedly, this book tends to occupy a center place in the course. I would also recommend the book by Coren (2001), for some non-psychoanalytic approaches, as well as its excellent appraisal of the contexts and impacts of managed care. Messer’s and Warren’s (1995) exhaustive compilation and analysis of various strains of short-term psychoanalytic approaches is also a veritable must. Here, students get a thorough-going history of short-term treatments and are disabused of many of the fallacies regarding psychoanalysis as well as psychoanalysis and its relation to shorter-term treatments. They also receive detailed, careful expositions on the many systematizers within the field, including Davanloo, Sifneos, Mann, Luborsky, the research supporting their work, outcome studies, and critiques. Finally, in deepening the work of Bellak and Faithorn (1981/1994) with respect to hospitalization, especially given the extreme brevity of stay at this time, I make use of the book by Oldham and Russakoff (1987) that is wholly devoted to the integration of psychoanalytic treatment into hospital wards that are difficult to constitute as true “milieus” owing to the constant admission and discharge (and often readmission) of patients. They elucidate helpful guidelines for structuralizing groups of various kinds and managing, psychotherapeutically, a host of problematic situations and clinical issues, with often highly resistant patients; within an environment that may be ignorant of, or hostile to, a psychotherapeutic ethos, let alone a psychoanalytic one.

References

Sharp, V. & Bellak, L. (1978). Ego function assessment of the psychoanalytic process. Psychoanalytic Quarterly, 47: 52-72.
Bellak, L. & Small, L. (1978). Emergency Psychotherapy & Brief Psychotherapy. New York: Grune & Stratton.
Coren, A. (2001). Short-Term Psychotherapy. New York: Karnac Books.
Messer, S.B. and Warren, C.S. (1995). Models of Brief Psycho-Dynamic Therapy: A Comparative Approach. New York: Guilford Press.
Miller, I.J. (1996a). Time-limited brief therapy has gone too far: The result is invisible rationing. Professional Psychology: Research and Practice, 27, 567-576.
Miller, I.J. (1996b). Some ‘short-term therapy values’ are a formula for invisible rationing. Professional Psychology: Research & Practice, 27, 577-582.
Miller, I.J. (1996c). Ethical & liability issues concerning invisible rationing. Professional Psychology: Research & Practice, 27, 583-587.
Oldham, J.M. & Russakoff, L.M. (1987). Dynamic Therapy in Brief Hospitalization. New York: Jason Aronson Publishers. 

Reviewer Note

David L. Downing is Director of Graduate Programs in Psychology and Associate Professor at the University of Indianapolis. He is the Treasurer of the International Federation for Psychoanalytic Education, and is the President of Section IV (Local Chapters) of Division 39. He maintains a private practice in psychoanalysis and psychoanalytical psychotherapy in Chicago and Indianapolis.

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