The Texture of Treatment: On the Matter of Psychoanalytic Technique (Book Review)

Author:  Schlesinger, Herbert J.
Publisher: Hillsdale, NJ: Analytic Press, 2003
Reviewed By: Edwin Fancher, Spring 2005, pp. 50-52

For years I have made it a practice to give my supervisees a copy of a paper on interpretation by Herbert Schlesinger (1995). So, I looked forward to reading this treatise on psychoanalytic technique with great expectation. I was not disappointed. Schlesinger has spent over forty years teaching and supervising psychoanalysis and psychotherapy at such places as the Menninger Clinic, the New School University and he is presently Clinical Professor of Psychiatry in Psychiatry, College of Physicians and Surgeons, Columbia University, and Supervising Analyst, Columbia University Center for Psychoanalytic Training and Research.

In the first chapter of this book, Schlesinger states: " While I may seem to be offering a textbook of psychoanalysis (and secretly I hope to have filled the need for one), I have adapted by ambition to a less formal and less demanding and perhaps less off-putting style of simply thinking aloud.” Yes, he has produced a textbook (in spite of two limitations I will discuss later) and it probably is the best such text on psychoanalytic technique since Fenichel (1941) or Glover (1971). But it is not based just on "simply thinking aloud," but rather on thinking deeply about the complicated issues of treatment and training.

His ambitious goal is to "Present the technique of psychoanalysis and psychotherapy in a way that is both more systematic and simpler than I recall it being taught to me." He will put his ideas "In the same simple, everyday language we use when talking to patients." He tries to avoid professional jargon as much as possible, and hopes to demystify the topic of technique. He accomplishes this by showing that traditional psychoanalytic clinical theory can be reformulated in terms of modern systems theory based on the simple concepts that "The society, the organism, or the personality can be viewed as a system, that is, as a self-regulating organization that is purposive and adaptive and also is open and able to make use of the information it trades with its environment." (p.15). He re-frames traditional psychoanalytic concepts such as interpretation, resistance, regression, transference, and countertransference in terms of systems theory and processes, and shows how they conform with clinical evidence as illustrated by numerous case examples.

Schlesinger applies systems theory to psychopathology: “A neurosis can be viewed as a set of internal operating conditions that were imposed on the personality, or better yet, created by the personality during early development. These conditions are in the nature of fixed, erroneous, and conflicting assumptions about the nature of the self, the nature of the object world and the contingencies that relate them to each other. In analytic terms these fixed assumptions are not independent but are embedded in unconscious fantasies that originated in efforts to solve an unconscious conflict” (p. 20).

At one time the neurotic behavior was the best possible compromise among the various forces represented in unconscious conflict. Like all systems, neuroses tend to become stable compromise formations which, when disturbed, return to a previous state of stability.

On the basis of this model of neurosis Schlesinger formulates a specific approach to treatment framed in terms of "process." Thus, "The ultimate aim of psychoanalysis is to promote the patient's activity to promote the patient’s living in the real world rather than in fantasy." (p. 28). The therapeutic task is to disrupt the rigid structure of the neurosis and help retard reversion to stasis by follow-up interventions. Schlesinger regards interpretation as "the defining act" of psychoanalysis, but disputes the conventional view that interpretation is defined by the intention of the analyst. Rather,

Whether an intervention is an interpretation, a suggestion, a confrontation, or a dud depends on how the patient takes it. And how the patient takes it is what the analyst should be listening for so he can include the patient's judgment in his next intervention. (p. 7)

If it has been effective, "The interpretation will have rattled the system, sending it into a self-protective spasm. But, if the analyst relaxes at that point and allows time for the system to recover, it will revert as closely as possible to its previous state. The analyst must understand the effect his interpretation has had and be prepared to follow up, guided, of course by the principles of tact, dosage, and timing." (p. 16)

The view that interpretation is a process "conflicts with the older view of interpretation as a construction that has arisen in the analyst's mind and delivered as a package to the patient" (p. 41). It means that interpretation is often offered to the patient in bits at a time over many sessions in the process of building an interpretation or construction linking events in the session with those in the past and in current life situations. In this way interpretations are constantly corrected and deepened by both the analyst and the patient.

Schelsinger presents us with three principles of psychoanalytic technique, and begs us not to think of them as frivolous. He wants us to take them seriously:
1. The patient is always right
2. Analysts don't analyze, patients do.
3. The patient is doing the best he can.

The notion that "the patient is always right" may be used against the overly ambitious analyst who may tend to think that he knows better then the patient what the patient needs.. That "analysts don't analyze, patients do," is his way of saying that analysis requires participation and activity on the part of the patient, not just from the analyst. "The patient is doing the best he can" Is an admonition to attend and respect the limitations of the defensive functions of the patient. Resistance is regarded as "defense expressed in the transference." The technique of analysis is not seen as an attempt to "undermine or breakdown" resistance, as in the past, but rather to repeatedly interfere with the patient's efforts to recreate the neurosis in the analytic situation. Above all, the patient is always the focus of technique, and the interpretation is defined by how the patient reacts to it:

[W]hatever the analyst might have intended, the patient always takes an interpretation as a suggestion; at the very least he assumes that the analyst wants him to think in a new way about the matter. (p. 20)

The analysis of transference, conceived of as a process, is central to Schlesinger's philosophy of psychoanalytic treatment. He defines transference analysis as "the remodeling of patient and therapist role definitions." (p. 51). "The analyst is required to submit to being cast in a series of specific roles in the reenactment of the patient's unconscious fantasy." (p.73). But, transference is seen as having a function in the adaptive and defensive points of view as well as being a mode of communication with the analyst. To Schlesinger, "The overall 'purpose' of the transference is conservative, to preserve the neurosis, to protect the unconscious fantasy from the intrusion of reality, to bar disconfirming information, in short to resist change" (p. 55).

Schlesinger rejects the popular concept of countertransference as referring to everything the analyst feels about the patient. He proposes that the analyst has two kinds of transference to patients. One kind is the analyst's transference to the patient which is based on general character traits like "overly nurturing attitude, a strong distaste for the direct expression of hostility, and the inability to witness another's pain." These trends he calls "transference to the patient." Such feelings are differentiated from reactions in the analyst evoked by specific elements of the patient's transference to the analyst, which are usually destructive. Only these are labeled countertransference by Schlesinger.

Schlesinger was trained as an ego psychologist, and though he avoids the murky metapsychology of the earlier ego psychologists, his approach to technique remains close to theirs. Psychoanalysis should promote ego autonomy. He refers to Sterba's therapeutic split, where the patient learns to experience his feeling at the same time that another part of the ego is observing what is going on. He prefers the metaphor that the analyst's position is more like that of the midwife than that of Freud's surgeon: "The patient analyzes himself, with the occasional assistance of the analyst" (p. 32). The goal is to promote freely chosen activity of the patient. "Interpretation is not something that the analyst does to or for the patient but, rather, something he does with the patient." (p. 106). He does not believe that neutrality means that the analyst should not encourage the patient.

Discussion of Freud's theories of neutrality, anonymity and abstinence aren't reviewed until Chapter 10, although everything before had reflected his views, including the three principles already mentioned. Neutrality implies objectivity, which is necessary, but must also be "in the context of deep concern for the patient." (p. 50). Anonymity is relative at best these days. Abstinence does not mean that the analyst does not provide support to the patient, but for most patients the best support is provided by accurate and timely interpretations.

In a very practical chapter, “Severe Regression,” Schlesinger shows that many episodes of severe regression are precipitated by a combination of unrecognized vulnerability in the patient and analyst mismanagement, often related to countertransference. (p. 207). The combination of support and understanding due to interpretation of the need for defense in the transference can reduce the anxiety significantly in many cases. But, "Paradoxically, offering support through reassurance but without interpretation tends to deepen regression and invites the very trouble one hopes to avoid" (p. 212).

Chapter 11, “Questioning, Con and Pro,” may stir up some controversy. He discusses particularly the dilemmas of the beginning therapist who, due to his anxiety, starts the treatment with a series of questions: "Whenever the therapist interrupts the patient to ask a question he should be aware that he has "changed the rules' and has assigned new status to himself and the patient. In effect, he is saying 'I know that I asked you to say whatever might come into your mind, I want to interrupt you now because I'm more interested in what came into my mind and I can't wait to find out what your response to that might be." Thus, questioning the patient undermines the analytic situation. To the related issue of how to respond to the patient's question to the analyst, Schlesinger advises focusing on the act of questioning itself and recommends responding to it as to any other association. However, he recognizes that flexibility is often necessary: "The analyst may answer any time he believes it would advance the analytic purpose, or at least not interfere with it" (p. 177).

Schlesinger doesn't get to the problems of how to start a treatment until Chapter 18, “Whether and How to Begin a Psychoanalysis.” He asserts, "Beginning is not for beginners" (p. 231), a way of saying that it requires broad knowledge and great clinical skill to decide whether to start a treatment, and, if so, how to go about it. He compares starting a treatment to a "blink date" and discusses the anxieties and temptations of the candidate facing his first case. In advising on how to structure the first interview, he argues that we do not sell "time" as a landlord sells room space, but instead we provide a valuable clinical service. He takes the unusual point of view that by not charging for missed appointments, it "frees both analyst and patient to inquire into the meaning of absences." He denies that this policy has ever affected his income.

Schlesinger wrestles with the thorny issue of the difference between psychoanalysis and psychoanalytic psychotherapy, and confesses that he has deliberately used psychoanalysis and psychotherapy because most of what he has had to say applied to both. But he does make a distinction. He feels that at times most psychotherapy patients slip into a state comparable to psychoanalysis, at least for a brief time, but it is not usually sustained. To him, “T]he major difference between psychoanalysis and psychoanalytic psychotherapy is that, when conducting any of the psychoanalytic psychotherapies, unlike when conducting psychoanalysis “proper,” the analyst or therapist will (that is should) attempt to preclude the development of a transference neurosis”(p. 262).

Perhaps this stipulation would be better put as, “the therapist should avoid encouraging more regression than the treatment requires and that the patient can stand." (p. 262). The analysis of the transference neurosis is, then for him, the defining element in psychoanalysis, although he recognizes that the very concept of the "transference neurosis" is disputed by Brenner and many others. However, it is one of his favorite concepts. He sees it as a state where the various infantile relationships reflected in the transferences have coalesced around the person of the analyst. Interpretation of this system increases defensiveness, which must then be loosened by successive interpretations that gradually loosen the hold of the unconscious fantasy that generates the neurotic conflicts.

Near the end of his book, Schlesinger reports that in more than 40 years of supervising and consulting two common problems stand out with both beginners and experienced practitioners:

The first has to do with translating insight into action within the analysis. This means: Does the patient take an active stance toward an interpretation? Does he test it against experience? Does he weigh his emotional reaction to it? Does he challenge it perhaps? And, finally does he take ownership of it by having worked through his objections to it. (p. 275)

The second problem is that the analyst does not recognize that resistance is not just against the analysis, but is also for some position of safety in the patient's complicated pattern of conflicts. It usually indicates that both sides of a conflict have not been analyzed.

I mentioned at the beginning of this review that there were two limitations to this book. One limitation is that there is no chapter on termination, although Schlesinger has announced that he is writing a book on termination, which I assume will be an extension or completion of this book, and is to be looked forward to. The other limitation is the price of this 300-page book. At $55.00, it is outside the budget of many students and may delay its inclusion into the curriculum of schools and institutes. It is hoped that the publishers will issue a paper back edition at a reasonable price soon.

It is impossible to do justice to this book in a brief review. It is an elementary textbook for institute candidates and beginning psychotherapists. It is also a challenge for experienced analysts and therapists to rethink and retest their technique in their clinical practices. The book will also prove invaluable to supervisors training the next generation of analysts and psychoanalytic psychotherapists.

References

Brenner, C. (1976). Psychoanalytic technique and psychic conflict. New York: International Universities Press
Glover, E., (1955). The technique of psychoanalysis. New York: International Universities Press.
Schlesinger, H. J., (1995). The process of interpretation and the moment of change. Journal of the American Psychoanalytic Association, 43, 662-685.

Reviewer Note

Edwin Fancher is a member, training analyst and faculty member of the New York Freudian Society and the New York School for Psychoanalytic Psychotherapy and Psychoanalysis, where he is also president. He is also a member of the International Psychoanalytical Association

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