However, the old object representations may be invested, however rigidly established the libidinal or aggressive cathexis of the image may be, this as such can become the actual and exclusive focus of instinctual discharge, or of complicated and intense instinct-defence solutions, only and general energy-sparing quality of strictly intrapsychic processes. For the vast majority of persons, visible to any degree, including those with severe neurosis, character distortions, addictions and certain psychoses, the striving is toward the living and actual object, even at the cost of intense suffering. In a sense, this returns us to the state in which the psychological ‘object-to-be’. Has a critical importance never again to be duplicated, except in certain acute life emergencies, even if the object is not firmly perceived as such, in the sense of later object relations? And it does seem that trance impressions from the earliest contacts in the service of life preservation, and the associated instinctual gratifications, and innumerable secondarily associated sensory impressions. Are activated by the specific inborn urges of sexual maturation? These propel the individual to renew many of the earliest modes of actual bodily contact, in connection with seeking for specific instinctual gratification. Or, to look away from clear-cut instinctual matters to the more remote elaborations of human contact: Few regard loneliness as other than a source of suffering, even self-imposed, as an apparent matter of choice, and the forcible imposition of ‘solitary confinement ‘ is surely one of the most cruel of punishments.
In taking to question, we are entering an area of life in which things are other then themselves, where meaning is multifaceted, and where the line between the old and the new is blurred. It should, by, its immediate measure, help develop our recognition or meaning of the pertinent applicability as to the relevance of interrelated aspects of the psychology of ‘metaphor’. In the psychology of metaphor we will find a useful analogy to the psychology of transference interpretation. Our’s will be newly encountered as good metaphors, those it response to which we say, ‘That’s it exactly’ or ‘That really captures it‘ or ‘That says it all’.
Some literary and linguistic analysis, (e.g., Lewis, 1936 and Snell, 1953) and also people in everyday life, believe that there are experiences that can only be expressed metaphorically. And for this achievement that these metaphors, which may be entire poem or as lines or even words highly valued. But how can this be so? Just what in th e ‘it’ that the metaphor ‘is’ or ‘captures’ or ‘says’? If this ‘is’ or this ‘experience’ can only be rendered metaphorically, when we can know it only as such, that is, as the metaphor itself. Of the position out of which are put forward by, T.S, Eliot (1933) and E.W. Harding (1963) in their discussion of poetry, for in these instances we are granted that there are no known and logically independent version of the experience that can serve to validate the metaphor. Whatever the metaphor makes available to us depends on it and it and so cannot be used to prove its correctness.
It seems justifiably warrantable to consider that the metaphor is a new experience rather than a mere paraphrase of an already fully constituted expedience. The metaphor creates an experience that one has never had before. It is an experience one has not realized by oneself. The metaphor does, of course, suggest certain constituent experiences of which one may have been more or less dimly aware. One may say, therefore, that the metaphor speaks for those constituents, on the existence of which much of its appeal depends. But in its organizing and implicit ly rendering these constituents in its new way, it is a creation rather than a mere paraphrase or anew edition. Paraphrasing and new editions never speak as forcefully as good new metaphors, nor could they facilitate further new experience. One analytically familiar feature of these creations is that they make it safe and pleasing to experience something that otherwise would be considered too threatening and so would be kept in fragmented obscurity through defensive measures.
Thus, when one says, ‘That’s it exactly’ one is implicitly recognizing and announcing that one has found and accepted a new mode of experiencing oneself and one’s world, which is to say, asserting a transformation of one’s own subjectivity. Something is now said to be true, and in a sense it is true, but it is true for the first time. Nothing of one and the same can ever happen again, for the second time cannot be the same as the first. One can’ t step into the same watering point and then step once again into the same spot of that river. A revelatory metaphor re-encountered or repeated later may lose some of its force, alternatively, it may gain some significance, butt it cannot remain exactly the same metaphor or mobilize an experience identical with the first. The point applies as well as to new metaphors that are similar to familiar ones: They have to be judged or experienced through their conventionalized predecessors, as through methods of knowing or already proved instrumentally of perceiving. The audience and the performer, who may be one person, as such that may not have, as yet.
What is to be said about the psychology of metaphor is analogous to the transformational aspects of developed transference and the steadfast interpretation that both facilitate and organize them as transference. Allowing that these transferences and ‘remembered’ experiences come into existence over a period of time, nothing that is identical with them has ever before been enacted, and nothing will ever be enacted again. They are creations that may be fully achieved only under specific analytic conditions. Such that living was not reliving that moment, words like re-living, re-experiencing and reliving simply do not do justice to the phenomena, that in making this claim. A seeming contradiction over-writes some of our well-establish ideas. - in offering, - I am not contradicting some of our well-established ideas about interpretation and insight, I am, however, disputing the point that insight refers to a greater proportion or in its range of comprehension, which its distance between possible extremes extent and regain former or normal state, such that, for the recovery of lost memories, and takes in as well, a new grasp of the significance and interpretations of events one has always remembered. In point, as, Freud pointed out, ‘As a matter of fact I’ve always known it, only that I’ve never thought of it; (1914), In fact, it is to develop that point in furthering to say that it takes an adult to do that, especially with the help of an analyst. It was, after all, Freud’s analysis of adults that make it possible to define infantile psychosexuality. In this respect, but without disregard, child analysis retains a quality of applied psychoanalysis’ in the same way that the interpreted transference neurosis is: Both are always of describing as true something that was not true in quite that way at the time of its greatest developmental significance. This apparent paradox about ‘remembering’ as a form of creating goes a long way, probably that what it is, is distinctive about psychoanalytic interpretation.
This time, however, to further the discussion on the interpretive technique that surrounds the phase of a mutative interpretation - that in which a portion of the patient’s id-relation to the analyst is made conscious in virtue of the latter’s positions as auxiliary super-ego - is in itself complex. In the classical model of an interpretation, the patient will first be made aware of a state of tension of an interpretation, will next be made aware that there is repressive factor at work (that his super-ego is threatening him with punishment), and will only then be made aware of the id-impulse which has stirred up the protects of his super-ego and so given to the anxiety in his ego. This is the classical scheme. In actual practice, the analyst finds himself working from all three sides at once, or in irregular successions. At one moment a small portion of the patient‘s super-ego may be revealed to him in all its savagery, at another the shrinking defencelessness of his ego, at yet another his attention may be directed to the attempts which he is making at restitution - at compensating for his hostility, on some occasions a fraction of id-energy may even be directly encouraged to break its way through the last remains of an already weakened resistance. There is, however, one characteristic which all of these various operations has in common, they are essentially upon a small scale. For the mutative interpretation is inevitably governed by the principle of minimal doses. It is a commonly agreed clinical fact that alternations in a patient under analysis appear almost always to be extremely gradual: We are inclined to suspect sudden and large changes as an indication that suggestive rather than psycho-analyst processes are at work. The gradual nature of the change brought about in psychoanalysis will be explained, as, only to suggest, those changes are the result of the summation of an immense number of minuet steps, each of which correspond to a mutative interpretation. And the smallness of each step is in turn imposed by the very nature of the analytic situation. For each interpretation involves the release of a certain quantity of id-energy, and, if the quantity released is too large, the higher unstable state of equilibrium which enables the analyst to function as the patient’s auxiliary super-ego is bound to be upset. The whole analytic situation will thus be imperilled, since it is only in virtue of the analyst’s acting as auxiliary super-ego that these released id-energy can occur at all.
The effectuality from which follow the analytic attempt to bring unequalled amounts in the confronting collections of some improper use to a resultant quantity of id-energy into the patient’s consciousness all at once. On the one hand, nothing whatever may happen, or on the other hand there may be an unmanageable result, but in neither event will be a mutative interpretation has been effected. The analyst’s power as auxiliary super-ego may be for two very different reasons. It may be that the id-impulses were trying to bring out being not in fact sufficiently urgent at the moment: For, after all, the emergence of an id-impulse depends on two factors - not only on the permission of the super-ego, but also on the urgency (the degree of cathaxis) of the id-impulse itself. This, then, may be one cause of an apparently negative response to an interpretation, and evidently a fairly harmless one. but the same apparent result may also be due to something else, in spite of the id-impulse being really urgent, the strength of the patient’s own repressive forces (the degree of repression) may have been too great to allow his ego to listen to the persuasive voice of the auxiliary super-ego. Now we have a situation dynamically identical with the next one we have to consider, though economically different. this next situation is one in which the patient accepts the interpretation, that is, allows the id-impulse into his consciousness, but is immediately overwhelmed with anxiety. This may show itself in a number of ways, for instance, the patient may produce a manifest anxiety-attack. Or the may exhibit signs of ‘real’ anger with the analyst with a complete lack of insight, or he may break off the analysis. In any of these cases the analytic situation will, for the moment, at least, have broken down. The patient will be behaving just as the hypnotic subject behaves when, having been ordered by the hypnotist to perform an action too much at variance with his own consciousness, he breaks off the hypnotic relation and wakes up from his trance. This state of things, which is manifest where the patient responds to an interpretation with an actual outbreak of anxiety or one of its equivalents, may be latent were the patient shows no response, and this latter case may be the more awkward of the two, since it is masked, and it may sometimes be the effect of a greater overdose of interpretation than where manifest anxiety arises (though obviously other factors will be of determining importance, and in particularly the nature of the patient’s neurosis). Yet this threatened collapse of the analytic situation to an overdose of interpretation: But it might be more accurate in some ways to ascribe it to an insufficient dose. For what has happened is that the second phase of the interpretation process has not occurred: The phase in which the patient becomes aware that his impulse is directed toward an archaic phantasy object and not toward a real one.
In the second phase of a complete interpretation, therefore, a crucial part is played by the patient’s sense of reality: For the successful outcome of that phase depends upon his ability, at the critical moment of the emergence into consciousness of the released quantity of id-energy, to distinguish between his phantasy object and the real analyst. The problem is closely related to one that has been discussed elsewhere, namely that of the extreme liability of the analyst’s position as auxiliary super-ego. The analytic situation is all the time threatening to degenerate into a ‘real’ situation. But this actually means the opposite of what it appears to. It means that the patient is all the time on the brink of turning the really external object (the analyst) into the archaic one; that is to say, he is on the brink of projecting his primitive introjected images onto himself. In so far as the patient actually does this, the analyst becomes like anyone else that he meets in real life - a phantasy object. The analyst then ceases to possess the peculiar advantages derived from the analytic situation, he will be introjected like all other phantasy objects into the analytic situation, he will be introjected like all other phantasy objects into the patient’s super-ego, and will no longer be able to function in the peculiar ways which are essential to the effecting of a mutative interpretation. In this difficulty the patient’s sense of reality is an essential but a very feeble [-ally]: An improvement in it is one of the things that we hope the analysis will bring about. It is important, therefore, not to submit it to any unnecessary strain, and that is the fundamental reason why the analyst must avoid any real behaviour, that is likely to confirm the patient’s view of him as a ‘bad’ or a ‘good’ phantasy object. This is perhaps more obvious as regards the ‘bad’ object. If, for instance, the analyst were to show that he was really shocked or frightened by one of the patient’s id-impulses, as the patient would immediately treat him in that respect as a dangerous object and introject him into his archaic severe super-ego. Therefore, on the one hand, there would be a diminuation in the analyst’s power to function as an auxiliary super-ego and to allow the patient’s to become conscious of his id-impulses - that is to say, in his power to bring about the first phase of a mutative interpretation, and on the other hand, he would, as a real object, become sensibly less distinguishable from the patient’s ‘bad’ phantasy object and to that extent the carrying through of the second phase of a mutative interpretation would also be made more difficult. Or, agin, there is another case. Supposing the analyst behaves in an opposite way and actively urges the patient to give free rein to his id-impulse. There is then a possibility of the patient confusing the analyst with the image of a treacherous parent who, at the beginning, encourages him to seek gratification, and then suddenly turns and punishes him. In such a case the patient’s ego may look for defence by itself suddenly turning upon the analyst as though he were his own id-, and treating him with all the severity of which his super-ego is capable. again, the analyst is running a risk of losing his privileged position. But it may be equally unwise for the analyst to act really in such a way as to encourage the patient to project his ‘good’ introjected object onto him. For the patient will then tend to regard him as a good objective and archaic sense and will incorporate him with his archaic ‘good’ images and will use him as a protection against his ‘bad’ ones. In that way, his infantile positive impulses as well as his negative ones may escape analysis, for there may no longer be a possibility for his ego to make a comparison between the phantasy external object and the real one. it will, perhaps, be argued that, with the best of wills in the world, the analyst, however careful he may be, will be unable to prevent the patient from projecting these various images onto him. This is, of course, indisputable, and, the whole effectiveness of analysis depends upon its being so. The lesson of these difficulties is merely to remind us that the patient’s sense of reality has the narrowest limits. It is a paradoxical fact that the best way of enuring that his ego will be able to distinguish between phantasy and reality is to withhold reality from him as much as possible. but it is true, his ego is so weak - so much at the mercy of his id and super-ego - that he can only cope with reality if it is administered in minimal doses. And these doses are in fact what the analyst gives him, in the form of interpretations.
A mutative interpretation can only be applied to an id-impulse which is actually on a state of cathexis. This seems self-evident; for the dynamic changes in the patient’s mind implied by a mutative interpretation can only be brought about by the operation of a charge of energy originating in the patient himself: The function of the analyst is merely to ensure that the energy should or can flow along one channel rather than along another. It follows that the purely informative ‘dictionary’ type of interpretation will be non-mutative, but useful it may be a prelude to mutative interpretations. And this leads to a number of practical inferences. Every mutative interpretation must be emotionally ‘immediate, but the patient must live through it as something actual or genuine. This requirement, that the interpretation must be ‘immediate’, may be expressed in another way by saying that interpretation must always be directed to the ‘point of urgency’. At any given moment some particular id-impulse will be generated in activity, this is the impulse that is susceptible of mutative interpretation at the time, and no other one. It is, no doubt, neither possible nor desirable to be giving mutative interpretations all the time. as Melanie Klein has pointed out, it is a most precious quality in an analyst to be able at any moment to pick out the point of urgency.
But the fact that every mutative interpretation must deal with an ‘urgent’ impulse take us back one more to the commonly felt fear of the explosive possibilities of interpretation, and particularly of what is vaguely referred to as ‘deep’ interpretation. The terminological description is, no doubt, as the interpretation of material which is neither genetically early and historically distant from the patient’s actual experience nor under an especially heavy weight of repression – material, in any case, which is in the normal course of things exceedingly inaccessible to his ego and remote from it. There seems reason to believe, moreover, that the anxiety which is liable to be aroused by the approach of such material to consciousness and may be of peculiar severity. The question whether it is ‘safe’ to interpret such material will, as usual, mainly depend upon whether an interpretation can be carried through, in the ordinary run of the case, as this material which is urgent during the earlier stages of the analysis is not deep. We have to deal at first only with more or less far-going displacements of the deep impulse. And the deep material itself is only reached later and by degrees, so that no sudden appearance of unmanageable quantities of anxiety is to be hesitorially anticipated. In exceptional cases, however, owing to some peculiarities in the structure of the neurosis, deep impulses may be urgent at a very early stage of the analysis. We are then faced by a dilemma. If we give an interpretation of this deep material, the resultant amounts of anxiety produced in the patient may be so great that his sense of reality may not be sufficient to permit of its accomplishment, and the whole analysis may be jeopardised, but, it must not be thought that, in such critical cases as we are now considering, the difficulty can necessarily be avoided simply by not giving any interpretation or by giving more superficial interpretations of non-urgent material or by attempting reassurances. It seems probable, in fact, that these alternative procedures may do little or nothing to obviate the trouble, on the contrary, they may even exacerbate the tension created by the urgency of the deep impulses which are the actual cause of the threatening anxiety. Thus the anxiety may break out in spite of these palliative efforts and, if so, it will be doing so under the most unfavourable conditions, that is to say, outside the mitigating influences afforded by the mechanism of interpretation. It is possible, therefore, that, of these alternative procedures which are open to the analyst faced by such a difficulty. The interpretation of the urgent id-impulses, deep though they may be, will actually be the safer.
It is, of course, a matter of common experience, that it possible with certain patients to continue indefinitely giving interpretations without producing any apparent effect whatever. There is an amusing criticism of this kind of ‘interpretation-fanaticism’ in the excellent historical chapter of Rank and Ferenczi. But it is clear from their words that what they have in mind are essentially extra-transference interpretations, for the burden of their criticism is that such a procedure implies neglect of the analytic situation. This is the simplest case. Where a waste of time and energy is the main result. But there are other occasions, on which a policy of giving strings of extra-transference interpretations is apt to lead the analyst into more positive difficulties. Attention was drawn by Reich a few years back, in the course of some technical discussions in Vienna to a tendency among inexperienced analysts to get into trouble by eliciting from the patient great quantities of material in a disordered and unrelated fashion: This may, be maintained, be carried to such lengths that the analysis is brought to an irremediable state of chaos. He points out truly that the material we have to deal with is stratified and that it is highly important in digging it out not to interference, more that we can help with th e arrangement of that state. He had in mind, of course, the analogy of an incompetent archaeolist, whose clumsiness may obliterate for all time the possibility of reconstructing the history of an important site. However, the results in the case of a clumsy analysis do not hold of any pessimistic cause to happen, as it was, re-stratification itself of its own accord if it is given the opportunity; That is to say, in the analytic situation. At the same time, is that of the presence of the risk, and it seems to be particularly likely to occur where extra-transference interpretation is excessively or exclusively restored to. The means of preventing it, and the remedy if it has occurred, lie in returning to transference interpretation at the point of urgency. For if we can discover which of the material is ‘immediate’ in the sense that the problematic occurrence enabling stratification is automatically solved, and it is a characteristic if most extra-transference material that it has no immediacy and consequently stratification is far more difficult to decipher. The measures suggested by Reich himself for preventing the occurrence of this state of chaos are consistent with those that he stresses the importance of interpreting resistance as opposed to the primary id-impulses themselves - and this, was a policy that was laid down at an early stage in the history of analysis. But it is, of course, one of the characteristics of a resistance that it arises in relation to the analyst. Thus, interpretation of a resistance will almost inevitably be a transference interpretation.
But the most serious risks that arise from the making of extra-transference interpretation are due to the inherent difficulty in completing their interpretation, for a successful outcome as such, depends upon his ability, at which time of the emergence into consciousness and the released quantity of id-energy. They are from their nature unpredictable in their effects. There seems to be a special risk of the patient not carrying through to a competed interpretation, hitherto, namely that the extreme liability of the analyst’s position as auxiliary super-ego, is that, the analytic situation is all the time threatening to degenerate into a ‘real’ situation. It means that the patient is all the time perched upon the circumference edge-horizon of turning the external object (the analyst) into the archaic one, but of projecting the id-impulse that has been made conscious onto the analyst. This risk, no doubt, applies to some extent to transference interpretations. However, the situation is less likely to arise when the object of the id-impulses is actually present and is moreover the same person as the maker of interpretation. We may, once, more, recall the problem of ‘deep’ interpretation, and point out that its dangers, even in the most unfavourable circumstances, seem to be greatly diminished if the interpretation in question is a transference interpretation. Even so, there appears to be more of a chance that in this whole process occurring silently and so being overlooked in the case of an extra-transference interpretation, particularly in the earlier stages of an analysis. For this reason, it would seem to be important after giving an extra-transference interpretation to be specially in the ‘qui-vive’ for transferences complications. This last peculiarity of the extra-transference interpretation is actually one of the most important forms to a practical stand-point of things. For on account of it they can be made to act as ‘feeders’ for the transference situation, and so to pave the way for mutative interpretations. In other words, by giving an extra-transference interpretation, the analyst can often provide a situation in the transference of which he can then give a mutative interpretation.
Therefore, it is probable that a large majority of our interpretations are outside the transference - though it should be added that it often happens that one is ostensibly giving an extra-transference interpretation one is implicitly giving a transference one. A cake cannot be made of nothing but currants, and, though it is true that extra-transference interpretations, are not for the most part, mutative and do not they bring about the crucial results that involve a permanent change in the patient’s mind. They are, nonetheless essential, if taken to an analogy of trench warfare, the acceptance of a transference interpretation corresponds to the capture of a key position, while the extra-transference interpretations correspond to the general advance and to the consolidation of a fresh line of defence, which are made possible by the capture of the key position. But when this general advance goes beyond a certain point, there will be another check, and the capture of a further key position will be necessary before progress can be resumed. An oscillation of this kind between transference and extra-transference interpretations will represent the normative course of events in an analysis.
Although the giving of mutative interpretations may thus only occupy a small portion of psycho-analytic treatment, it will, upon being, that the most important part from the point of view of deeply exerting affective percussions. Do so, because of the influencing characteristic confirmations as drawn upon the spoken-exchange of the patient’s mindful knowing, in that the individuals that feel, perceive, think, wills, and especially reasons are all taken into heedful compliance. It may be of interest to consider how a moment through which of such an importance to the patient affects the analyst himself. Mrs. Klein has suggested that there must be some quite special internal difficulty as to involve the analyst in interpretations. This is shown in their avoidance by psycho-therapists of non-analytic schools, but many psycho-analysts will be aware of traces of the same tendency in themselves. It may be rationalized into mutative interpretations. This is shown in the avoidance by psycho-therapists of non-analytic schools, if not many consisting of a psycho-analyst as flown over to passing their flow of emptying space, nonetheless, this dialectic awareness traces of the same tendency as in them. But behind this there is somewhat of a lurking difficulty in the actual giving of the interpretation, for there seems to be a constant temptation for the analyst to do something else instead. Questions may be asked of whether o r not. As given to the reassurances or advice or discourses upon theory, or may give interpretations -but interpretations that are not mutative, extra-transference interpretations, interpretations that are non-immediate, or ambiguous, or in exacting of two or more alternative interpretations simultaneously, or he may, perhaps, give interpretations and at the same time, show his own scepticism about them. All of this strongly suggests that the giving of a mutative interpretation is a crucial act for the analyst as well as for the patient. And this in turn will become intelligible when we reflect that at the moment of interpretation the analyst is in fact deliberately Evoking a quantity of the patients id-energy while it is a live and actual and unambiguous and aimed directly himself. Such a moment must be above all others put to the test his relations with his unconscious impulses.
Interpretation of the transference is central to all psychoanalytic models. Definitions of transference and transference interpretation have changed greatly during the past half-century, influenced by major movements in philosophy, but advances in psycho-analytic research and theory, and changes in our of understanding Freud. Suggestively. The advances in psychnalytic research and theory, and changes in our understanding of Freud. Is that, the historical, relatively simple, concepts of the transference as the reproductions in the presence of significant relationships from therapists do not adequately meet current clinical theoretical demands? Modernist views of the transference emphasize as in additional sources of transference responses, the role of the analytic background of safety, the constant modifications of unconscious fantasy and internal representations, and the interactive nature of transference response, with important interpersonal and intersubjective components. It is suggested that the evolving modernists view of transference and transference interpretation permit a fuller accounting for transference and transference components. Such in a fuller accountability, for which of these issues of psychological ‘truth’ has open the way for better informed interventions. The issue of psychological ‘truth’ and ‘distortion’ as applied to transference phenomena will be presented with clinical vignettes.
Psychoanalysis, since the earliest days of the, Studies on Hysteria (Breuer and Freud, 1993-1905), have always given special attention to the transference and to the interpretation of transference, believing it to be central in our theory and technique. While there, has never been a lack of interest in transference interpreting. It is not clear why this is so, and the reasons may vary in different parts of the international psychoanalytic community. In America, at least, Gill’s (1982) recent, and somewhat radical presentation of transference interpretation has surely helped to the grasping upon our developing attentions. Nevertheless, of another reason for our intensified interests in transference interpretation is the opportunity it provides for the rhetorically dialectic awareness, in that discussions, have lead us to the diverse analytic theories and techniques that today complete the diverseness as observed, for which of our attentions and allegiance to which transference interpretation seems to have replaced self-psychology. Thus, the encompassing topic that allows analysts of varied persuasions among many structural and fundamental elements that forge out the shape for taking upon the imparting of instinctual information. As to know, and knowing that you know, is, applied, however, of its depthful concerning contemplations with which is distinguished by the evolving characterizations that are of knowing that you know is really nothing whatsoever.
Despite the diversity of the transference and its interpreting in analytic process and cure, differing only in whether transference is everything or almost everything to give a clear-cut definition of what transference is.
Laplanche and Pontalis (1973) had written that, ‘The reason it is so difficult to produce a definition of transference is that for many authors the notion has taken on a very broad extension, even coming to connote all the phenomena which constitute the patient’s relationship with the psychoanalyst, as a result the concept is burdened down more than any other with each analyst’s particular view on the treatment - on its objective, dynamics, tactics, scope, and so forth. The question of the transference is thus beset by a whole series of difficulties which have been the subject of debate in classical psychoanalysis.’
Sandler (1983) has discussed how the terms transference and transference resistance, as well as other terms have undergone profound changes in meaning as new discoveries and new trends of psycho-analytic technique assume ascendency. He said, . . . major changes in technical emphasis brought about the extension of the transference concept, which now has dimensions of meaning which differ from the official definition of the term. I am not sure there has ever been a simplified definition of the term. While a certain flexibility of definition makes conversation possible in a field of diverse views, which we may never be clear on what any two people mean when they use the term is a significant hindrance to our discourse.
However: with this in mind we might review one of Freud’s last comments on transference. In ‘An Outline of Psycho-Analysis’ (1940), published posthumously, he wrote on the analytic situation:
The most remarkable thing is this. The patient is not satisfied with regarding the analyst in the light of reality as a helper and advisor who, moreover, is remunerated for the trouble he takes and who would himself be content with some role that of a guide on a different mountain to climb, on the contrary, the patient sees in him. the return, and the reincarnation, of some important figure out of his childhood or past, and consequently transfer onto him, feelings and reactions which undoubtedly apply this prototype. This fact of transference soon proves to be a factor of an undreamt-of importance, on the other hand bud an instrument of irreplaceable value and on the other, that he set out on a different undertaking without any suspicion of extraordinary power that would be at his command. . . .
Another advantage of transference, too, in that in it the patient produces before us with plastic clarity an important part of his life-story, of which he would, otherwise have probably given us only an insufficient account. He acts it before us, as it was, instead of reporting it to us.
Freud saw the transference interpretation as a method of strengthening the ego against past unconscious wishes and conflicts.
It is the analyst’s task constantly to speak abruptly, and in doing so, the patient may relinquish of his menacing illusions and to show him again and again, of what it takes to be or begin of a new life, are the reflections of the past. And least, he should fall into a state in which he is inaccessible to all evidences, the analyst takes that neither the love nor the hostility reaching an extreme height. This is affected by preparing him in good time for these possibilities and by not overlooking the first signs of them. Careful handling of the transference on these lines is as a role richly rewarded. If we succeed, as we usually can, in enlightenment the patient on the true nature of the phenomena of the transference, we thus have struck a powerful weapon out of the hand of his resistance and will have converted dangers into gains. For a patient never forgets again what he has experienced in the form of transference, it carries a greater force of conviction than anything he can acquire in other ways.
We have used the term ‘transference’ several times, in that we attributed the therapeutic results to the transference without further definition of the word. We will now consider more closely the emotional relationship which is thus designed. During a psychoanalytic treatment, the patient allows the analyst to play a predominating role in his emotional life. This is of great importance in the analytic process. After his treatment is over, this situation is changed. The patient builds up feelings of affection for and resistance to his analyst which, in their ebb and flow, so exceed the normal degree of feeling that the phenomenon has long attracted the theoretical interest of the analyst. Freud studied this phenomenon thoroughly, explained it, and gave it the name ‘transference’, we most probably will understand the significance of the transference phenomenon impressed Freud so profoundly that he continued through the years to develop his ideas about it.
In all afforded efforts, to refuse to consider the demise of forebears as too merely disdain, that we cannot reproduce of all Freud’s research about transference but for an instance of obligation, would be used to indicate the requirement by the immediate need or purpose upon such condition that might point beyond a normal or acceptable limit, as to an excessive amount of which something does not or cannot to their essentials. When we speak of the transference in connexion with social reeducation, we mean the emotional responses of the education or counsellor or therapist, as the case maybe, without meaning that it takes place in exactly the same way as in an analysis. The ‘countertransference‘ is emotional aptitude of the teacher toward the pupil, the counsellor toward his charge, the therapist toward the patient. The feeling which the child develops for the mentor is conditioned by a much earlier relationship to someone else. We must take cognisance of this fact in order to understand these relationships. The tender relationships which go to up the child’s love life are no longer strange to us. Many of these have already been touched upon in the foregoing literature. We have learned how the small boy takes the father and mother as love objects. We have followed the strivings which arise out of this relationship, the Oedipus situation, we have seen how this runs its course and terminates in an identification with the parents. We have also had opportunity to consider the relationship between brothers and sisters, how their original rivalry is transformed into affection through the pressure of their feeling for the parents. We know that the boy at puberty must give up his first love object within the family and transfers his libido to individuals outside the family.
Our present purpose is to consider the effects of these first experiences from a certain angle. The child’s attachment to the family, the continuance and the subsequent dissolution of these love relationships within the family, not only leave a deep effect on the child through the resulting identifications, they determine at the same the actual forms of this love relationships in the future. Freud compares these forms, without implying too great a rigidity, to copper plates for engraving. He has shown that in the emotional relationships of our later life we can do nothing but make an imprint from one or another of these patterns which we have established in early childhood.
Why Freud chose the term ‘transference’ for the emotional relationship between patient and analyst is easy to understand. The feelings which arose long ago in another situation are transferred upon the analyst. To the counsellor of the child, the knowledge of the transference mechanism is indispensable. In order to influence the dissociable behaviour, he must bring his charge into the transference situation. The study of the transference in the dissociable child shows regularly a love life that has been disturbed in early childhood by a lack of affection or an undue amount of affection. A satisfactory social adjustment depends on certain conditions, among them an adequate constitutional endowment and early love relationships which have been confined within certain limits. Society determines these limitations, just as definitely as the later love life of an individual is determined by early form his libidinal development. The child develops normally and assumes his proper place in society, if he can cultivate within the privacy to such relationships as can favourably be carried over into the schools and from there into the ever-broadening world around him. His attitude toward his parents must be such that it can be carried over onto the teacher, and that toward his brothers and sisters must be transferred to his schoolmates. Every new contact, according to the degree of authority or maturity which the person represents, repeats a previous relationship with very little deviation. People whose early adjustment to succeed or supervene from such a normative course have no difficulties in their emotional relations with others, and they are able to form new ties, to deepen them, or to break them off without conflict when the situation demands it.
We can easily see why an attempt to change the present order of society always meets with resistance and where the radical reformer will have to use the greatest leverage. Our attitude to society and its members has a certain standard form. It gets its imprint from the structure of the family and the emotional relationships set up within the family, therefore, the parents, especially the father, assume overwhelming responsibility for the social orientation of the child. The persistent, ineradicable libidinal relationships carried over from childhood are facts with which social reformers must reckon. If the family represents the best preparation for the present social order, which seems to be the case, then the introduction of a new order means that the family must be uprooted and replaced by a different personal world for the child. It is beyond our scope to attempt a solution of this question, which concerns those who strive to build up a new order of society. We are remedial educators and must recognize these sociological relationships. We can ally ourselves with whatever social system will, but we have the path of our present activity well marked out for us, to bring dissociable youth into the line with present-day society.
If the child is harmed through too great disappointment or too great indulgence in his early life, he builds up reaction patterns which are damaged, incomplete, or too delicate to support the wear and tear of life. He is incapable of forming libidinal object relationships which are considered normal by society. His unpreparedness for life, his inability to regulate his conscious and unconscious libidinal striving and to confine his libidinal expectations within normal bounds, creates an insecurity in relation to his fellow men and constitute one of the first and most important condition’s fo r their development of delinquency. Following this point of view, we look for the primary causes of dissociable behaviour in early childhood, where the abnormal libidinal ties are established. The word ‘delinquency’ is an expression used to describe a relationship to people and things which are at variance with what society approve in the individual.
It is not immediately clear, from which are pointed from the particular form of the delinquency, just what libidinal disturbances in childhood have given rise to the dissociable expression. Until we have a psychoanalytically construed scheme for the diagnosis of delinquency, we may content ourselves by separating these forms into two groups: (1) Borderline neurosis cases with dissociable symptoms, and (2) dissociable cases for which are in part, the ego giving to develop of the dissociable behaviour, and showing no trace of neurosis. In the first type, the individual finds himself in an inner conflict because of the nature of his love relationships, a part of his own personality forbids the indulgence of libidinal desires and strivings. The dissociable behaviour results from this conflict. In the second type, the individual finds himself in open conflict with his environment, because the outer world has frustrated his childish libidinal desires.
The differences in the forms of dissociable behaviour are important for many reasons. At present, they are significant to us because of the various ways in which the transference is established in these two types, we know that with a normal child the transference takes place of itself through the kindly efforts of the responsible adult. The teacher in his attitude repeats the situations long familiarly to the child, and thereby evokes a parental relationship. He does not maintain this relationship at the same level, but continually deepens it as long as he is the parental substitute.
When a neurotic child with symptoms of delinquency comes into the institution, the tendencies to transfer his attitude toward his parents to the persons in authority are immediately noticeable. The worker will adopt the same attitude toward the dissociable child as to the normal child, and bring him into positive transference, if he acts toward him in such a way as to prevent a repetition with the worker of the situation with the parents which led to the conflict. In psychoanalysis, on the other hand, it is of greatest importance to let this situation repeat itself. In a sense the worker becomes the father or the mother, but still not wholly so, he represents their claims, but in the right moment he must let the dissociable child know that he has insight into his difficulties and that he will not interpret the behaviour in the same way as do the parents. He will respond to the child’s feeling of a need for punishment, but he will not completely satisfy it.
He will conduct in himself be entirely differently in the case of the child who in open conflict with society. In this instance he must take the child’s part, be in agreement with his behaviour, and in the severest cases even give the child to understand that in his place he would behave just the same way. The guilt feelings found so clearly in the neurotic cases with dissociable behaviour are present in these cases also. These feelings do not arise, however, from the dissociable ego, but have another source.
Why does the educator conduct himself differently in dealing with this second type? These children, too, he must draw into a positive transference to him, but what is applicable and appropriate for a normal or a neurotic child would achieve opposite results. Otherwise the worker would bring upon himself all the hate and aggression which the child bears toward society, thus leading the child into a negative instead of positive transference, and creating a situation in which the child is not amenable to training.
Nevertheless, what was said about psychoanalysis theory is only a bare outline, that much deeper study of the transference is necessary to anyone interested in re-educational work from the psychoanalytic point of view. The practical application of this theory is not easy, since we deal mostly with mixed types, such that the attitude of the counsellor cannot be as uniform as having enough verbal descriptions for evincing of individual forms of dissociated behaviour to enable us to offer detailed instructions about how to deal with them. At present our psychoanalytic knowledge is such that a correct procedure cannot be stated specifically for each and every dissociable individual.
The necessity for bringing the child into a good relationship to his mentor is of prime importance. The worker cannot leave this to chance, he must deliberately achieve it and he must face the fact thus no effective work is possible without it. It is important for him to grasp the psychic situation of the dissociable child in the very first contact he makes with him, because only this can be known in what attitude to adopt. There is a further difficulty in that the dissociable child takes pains to hide his real nature: He misrepresents himself and lies. This is to be taken for granted, it should not surprise or upset us. Dissociable children do not come to us of their own volition but are brought to us, very often with the threat, ‘You’ll soon find out what’s going to happen to you.’ Generally parents resort our help only after every other means, including corporal punishment, have failed. To the child, we are only another form of punishment, an enemy against whom he must be on his guard, not a source of help to him. There is a great difference between this and the psychoanalytic situation, where the patient comes voluntarily for helping. To the dissociable child, we are a menace because we represent society, with which he is in conflict. He must protect himself against this terrible danger and be careful what he says in order not to give himself away. It is hard to make some of these delinquent children talk, remain unresponsive and stubborn. One thing they all have in common: They do not tell the truth. Some lie stupidly, pitiably, others, especially the older ones, show great skill and sophistication. The extremely submissive child, the ‘dandily’, the very jovial, or the exaggeratedly sincere, some especially hard to reach. This behaviour is so much to be expected that we are not surprised or disarmed by it, the inexperienced teacher or adviser is easily irritated, especially when the lies are transparent, but he must not let the child be aware of this. He must deal with the situation immediately without telling the child that he can see that coming through were attributive values about his attitudinal behaviours.
There is nothing remarkable in the behaviour of the dissociable, but it differs only quantitatively from normal behaviour. We all hide our real selves and use a great deal of psychic energy to mislead our neighbours. We masquerade more or less, according to necessity. Most of us learn in the nursery the necessity of presenting ourselves in accordance with the environmental demands, and thus we consciously or unconsciously build up a shell around ourselves. Anyone who has had experience with young children must have noticed how they immediately begin to dissimulate when a grown-up comes into the room. Most children succeed in behaving in the manner which they think is expected of them. Thus they lessen the danger to themselves and at the same time they are casting the permanent moulds of their mannerisms and their behaviour. How many parents really bother themselves about the inner life of their children? Is this mask necessarily for life? I do not know, but it often seems that the person on whom childhood experiences have forced the dissociable individual masquerades to a greater extent, and more consciously, then the normal. He is only drawing logical deductions from his unfortunate disagreeable authority? Why should he be sincere with those people who represent disagreeable authority? This is an unfair demand.
We must look further into the differences between the situation of social retraining and the analytic situation. The analyst expects to meet in his patient unconscious remittances which prevent him from being honest or make him silent: But the treatment is in vain when the patient lies persistently. Those who work with dissociable children expect to be lied to. To send this child away because he lies are only giving in to him. We must wait and hope to penetrate this mask which covers the really psychic situation. In the institution it does not matter if this is not achieved immediately, it means merely that the establishment of the transference is postponed. In the clinic, however, we must work more quickly. Taking with the patient does not always suffice, and we must introduce other remedial measures. Generally, we see the delinquent child, only, in at least as infrequent to a smattering of times, but we are forced to take some steps after the first few interviews, to formulate some tentative conception of the difficulty and to establish a positive transference as quickly as possible. This means we must get at least a peep behind the mask. If the child is not put in an institution, he remains in the old situation under the same influences which caused the trouble. In such cases we wish to establish the transference as quickly as possible, to intensify the child`s positive feelings for us that are aroused while the child is with us, and to bring them rapidly to such a pitch that they can no longer be easily disturbed by the old influences. To carry on such work successfully presupposes a long experience.
Let us now go against our theoretical concerns and considerations and see how the analyst and the patient seek to grasp upon a try to solve situational thoughts for which the transference, and, moreover, its mask on which can be understood that feelings and a better understanding the differentiation that intentionality that allies with others and exclusively its need to achieve to some end.
Even so, there are few current problems concerning the problem of transference that Freud did not recognize either implicitly or explicitly in the development of the theoretical and clinical framework. For all essential purposes, moreover, his formulations, in spite of certain shifts in emphasis, remain integral to contemporary psychoanalytic theory and practice. Recent developments mainly concern the impact of an ego-psychological approach, the significance of object relations, both current and infantile, external and internal, the role of aggression in mental life, and the part played by regression and the repetition compulsion in the transference. Nevertheless, analysis of the infantile Oedipal situation in the setting of a genuine transference neurosis is still considered as a primary goal of psychoanalytic procedure.
Originally, transference was ascribed to displacement on the analyst of repressed wishes and fantasies derived from early childhood. The transference neurosis was viewed as a compromise formulation similar to dreams and other neurotic symptoms. Resistance, defined as the clinical manifestation of repression, could be diminished or abolished by interpretation mainly directed toward the content of the repressed. Transference resistance, both positive and negative, was inscribed to the threatened emergence of repressed unconscious material in the analytic situation. Presently, as with the development of a structural approach, the superego had been portrayed as the heir to the genital Oedipal situation, also was the recognition as playing a leading role in the transference situation. The analysis was subsequently viewed not only as the object by displacement of infantile incestuous fantasies, but also as the substitute by projection for the prohibiting parental figures which had been internalized as the definitive superego. The effect of transference interpretation in mitigating undue severity of the superego has, therefore, been emphasized in many discussions of the concept of transference.
Certain expansions in the structural approach related increasingly to the recognition of the role that had earlier objective relations, in the development of the superego. This had affected the current concepts of transference, in that this connection, the significance of the analytic situation as a repetition of the early mother-child relationship has been stressed from different points for viewing to such equally important developments related to Freud’s revised concept of anxiety which can only lead to theoretical developments in the field of ego psychology. However, this brought about their related clinical changes in the work of many analysts. As a result, attention was no longer the main attraction that had focussed on the content of the unconscious. In addition, increasing importance was attributed to the defence processes by means of which the anxiety which would be engendered if repression and other related mechanisms were broken down, was avoided in the analytic situation. Differences in the interpretation of the role of the analyst and the nature of transference developed from emphasis, on the one hand, on the importance of early object relations, and on the other, from primary attention to the role of the ego and its defences. These defences first emerged clearly in discussion of the technique of child analysis, in which Melanie Klein and Anna Freud, the pioneers in the fields of thought as playing the leading roles.
From a theoretical point of view, discussion foreshadowing the problems which face us today was presented in 1934 in a well-known paper by Richard Sterba and James Strachey, and further elaborated at the Marienbad Symposium at which Edward Bibring made an important contribution. The importance of identification with, or introjection of, the analyst in the transference situation of identification with, or introjection of, the analysts in the transference situation were clearly indicated. The therapeutic results were attributed to the effect of this process In mitigating the need for pathological defences. Strachey, however, considerably influenced by the work of Melanie Klein, regarded transference as essentially a projection onto the analyst of the patient’s own superego. The therapeutic process was attributed to subsequent introjection of a modified superego as a result of ‘mutative’ transference. Sterba and Bibring, on the other hand, intimately involved with development of the ego-psychological approach, reemphasized the central role of the ego, postulating a therapeutic split and identification with the analyst as an essential feature of transference. To some extent, this difference of opinion may be regarded as semantic. If the superego is explicitly defined as the heir of the genital Oedipus conflict, then earlier intra-systematic conflicts within the ego, although they may be related retrospectively to the definite superego, much, nevertheless, are defined as contained within the ego. Later divisions within the ego of the type indicated by Sterba and very much expanded by Edward Bibring in his concept of therapeutic alliance between the analyst and the healthy part of the patient’s ego, must also be excluded from superego significance. In contrast, those whom attribute pregenital intra-systemic conflicts within the ego primarily to the introjection of objects, consider that the resultant state of internal conflict appears like the dynamic idea that something conveys to the mind as having an endless meaning attached to the coherence of the therapeutic situation and seen in the later conflicts between ego and superego. They, therefore, believe that these structures developed simultaneously and suggest that no sharp distinction should be made between pre-oedipal, oedipal, and post-oedipal superego.
The differences, however, are not entirely verbal, since those whom attribute superego formations to the early months of life tend to attribute significantly too early object relation which differs from the conception of those who stress control and, neutralization of instinctual energy as primary functions of the ego. This theoretical difference necessarily implies some disagreement as how the dynamic situation both in childhood and in adult life, inevitably reflected in the concept of transference and in hypotheses as to the hidden nature of the therapeutic process. From one point of view, the role of the ego is central and crucial at every phase of analysis. A differentiation is made between transference as therapeutic alliance and the transference neurosis, which, on the whole, is considered a manifestation of resistance. Effective analysis depends on a sound and stable therapeutic alliance, a prerequisite for which is the existence, before analysis, of a degree of mature superego functions, the absence of which in certain severely disturbed patients and in young children may preclude traditional psychoanalytic procedure. Whenever indicated, interpretation’s manifestations, which means, in effect, that the transference must be analyzed. The process of analysis, however, is not exclusively ascribed to transference interpretation. Other interpretations of unconscious material, whether related to defence or to early fantasies, will be equally effective provided they are accurately timed and provide a satisfactory therapeutic alliance has been made. Those, in contrast, whom stress the importance of early object relations emphasizes the crucial role of transference as an object relationship, distorted though this may be of a variety of defences against primitively unresolved conflicts. The central role of the ego, both in the early stages of development and in the analytic process, are definitely accepted. The hidden nature of the ego is, however, considered at all times to be determined by its external and internal objects. Therapeutic process indicated changes in ego function results, therefore, primarily from a change in object relations though interpretation of the transference situation, finds of less differentiation as made between transference as for being the therapeutic alliance and transference neurosis as a manifestation of resistance. Therapeutic progress depends almost exclusively on transference interpretation. Other interpretations, although at times, are not, in general, considered an essential feature of the analytic process. From this point of view, the preanalytic maturity of the patient’s ego is not stressed as considered potentially suitable for traditional psychoanalytic procedure.
These differences in theoretical orientation are not only reflected in the approach to children and disturbed patients. They may also be recognized in significant variations of technique in respect to all clinical groups, which inevitably affect the opening phases, understanding of the inevitable regressive features of the transference neurosis, and handling of the germinal phases of analysis. By its emphasis as drawn on or upon the main problems, and, by contrast, rather than similarity, our efforts will be to avoid to detailed discussions of controversial theory regarding the hidden nature of early ego development by a somewhat arbitrary differentiation between those who relate ego analysis to the analysis of defences and those who stress the primary significance of object relations both in the transference, and in the development and definitive structure of the ego. Needless to say, this involves some oversimplification, where I hope that it may, at the same time, clarify certain important issues. To take, on or upon the analysis of patients we are generally agreeing to be suitable for classical analytic procedure, the transference neurosis. Those which emphasis the role of the ego and the analysis of defences, not only maintain Freud’s conviction that analysis should proceed from surface to depth, but also consider that early material in the analytic situation derives, that, in general, from defensive processes rather than from displacement onto the analyst of early instinctual fantasies. Deep transference interpretation in the early instinctual fantasies. Deep transference interpretation in the early phases of analysis will, therefore, rather be meaningless to the patient since its unconscious significance is so inaccessible, or, if the defences are precarious, will lead to premature and possibly intolerable anxiety. Premature interpretation of the equally unconscious automatic defensive processes by means of which instinctual fantasy kept unconscious is also ineffective and undesirable. There are, nonetheless, differences of opinion within this group, as to how far analysis of defence can be separated from analysis of content. Waelder, for example, has stressed the impossibility of such separation. Fenichel, however, considered that at least theoretical separation should be made and indicated that, as far as possible, analysis of defence should precede analysis of unconscious fantasy. It is, nevertheless, generally agreed that the transference neurosis develops, as a rule after ego defences have been sufficiently undermined to mobilize previously hidden instinctual conflict. During both the early stages of analysis, and at frequent points after development of the transference neurosis, defences against the transference will become a main feature of the analytic situation.
This approach, has already been indicated, is based on certain definite premises regarding the hidden natures and function of the ego in respect to the control and neutralization of instinctual energy and unconscious fantasies, while the importance of early object relations is not neglected, the conviction that early transference interpretation is ineffective and potentially relations are not neglected, the conviction and unconscious fantasy. The conviction that early transference interpretation is ineffective and potentially dangerous is related to the hypothesis that the instinctual energy available to the mature ego has been neutralized from unconscious fantasies, meaning at the beginning of analysis, for all effective purposes, relatively or absolutely divorced from its unconscious fantasy, as yet, there are a number of analysts of differing theoretical orientation of ego function from unconscious sources, but consider that unconscious fantasy continues to operate in all conscious mental activity. The analysts also construct upon the whole of their existing in the emphasis to the crucial significance of primitive fantasies, in respect to the development of the transference situation. The individual entering analysis will inevitably have unconscious fantasies concerning the analyst derived from primitive sources. This material, although deep in a sense, is, nevertheless, strongly current and accessible to interpretation. Klein, in addition, creates the development and definitive structure of the superego to unconscious fantasy determined by the earliest phases of object relationships. She emphasizes the role of early introjective and projective processes in relation to primitive anxiety ascribed to the death instinct and related aggression drive fantasies. The unresolved difficulties and conflict of the earliest period continue to colour object relations throughout life. Failure to achieve an essentially satisfactory object relationship in this early period, and failure to master relative loss of that object without retaining its good internal representative, will not only affect all object relations and definitive ego function, but more specifically determine the nature of anxiety-provoking fantasies on entering the analytic situation. According to this point of view, therefore, early transference uninterpreted, even thought it may relate to fantasies derived from an early period of life, should result not in an increase, but a decrease of anxiety
In considering next problems of transference in relation to analysis of the transference neurosis, two main points must be kept in mind. First, as already indicated, those who emphasize the analysis of defence tend to make a definite differentiation between transference as therapeutic alliance and the transference neurosis as a compromise formation which serves the purposes of resistance. In contrast, those who emphasize the importance of early object relations view the transference primarily as a revival or repetition, sometimes attributed to symbolic processes of early struggles in respect to objects. Still, there is no sharp differentiation made between the early manifestations of transference and the transference neurosis. In view, moreover, of the weight given to the role of unconscious fantasy and internal objects in every phase of mental life, healthy and pathological functions, though differing in essential respect, do not differ with regard to their direct dependence on unconscious sources.
In the second place, the role of regression in the transference situation is subject to wide differences of opinion. It was, of course, one of Freud’s earliest discoveries that regression had of its earliest points of fixation, and is a cardinal feature, not only in the development of neurosis and psychosis, but also in the revival of earlier conflicts in the transference situation. With the development of psychoanalysis and its application to an ever increasing range of received increased attention. The significance of the analytic situation as a means of fostering regression as a prerequisite for the therapeutic work has been emphasized by Ida Macapline in a recent paper. Differing opinions as to the significance, value, and technical handling of regressive manifestoes from the basis of important modifications of analytic technique, which will be considered, however, in respect to the transference neurosis, the view recently expressed by Phyllis Greenacre, that regression, and indispensable features would be generally accepted. It is also a matter of generally based agreement that a prerequisite for successful analysis is revival and repetition in the analytic situation of the struggle of primitive stages of development. Those who emphasize defence analysis, however, tend to view regression as a manifestation of resistance, as a primitive mechanism of defence employed by the growth sets of the transference neurosis. Analysis of these regressive manifestations with their potential dangers depends on the existing and continued functioning of adequate ego strength to maintain therapeutic alliance at an adult level. Those, in contrast, who stress the significance of transference as a revival of the early mother-child relationship does not emphasize regression as an indication of resistance or defence, the revival of these primitive experiences in the transference situation is, in fact, regarded as can essential prerequisite for satisfactory psychological maturation and true geniality. The Kleinian school, as already indicated features the continued activity of primitive conflicts in determining essential features of the transference at every stage of analysis. Their increasing overt revival in the analytic situation, therefore, signifies a reopening of the analysis, and in general, is regarded as an indication of diminuation rather than increase of resistance. The dangers involved according to this point of view and are determined more but to the failure to mitigate anxiety by suitable transference interpretation. By this failure to obtainably achieve, in the early phases of analysis, a sound and stabling therapeutic alliance is based on the maturity of the patient’s essential ego characteristics.
In considering, briefly, the terminal phases of analysis, many unresolved problems concerning the goal of the therapy and definition of a completed psychoanalysis must be kept in mind. Distinction must also be made between the technical problems of the terminal phase and evaluation of transference after the analysis has been terminated, there is widespread agreement as to the frequent revival in the terminal phases of primitive transference manifestations apparently resolved during the early phases of primitive transference manifestation, apparently resolved during the early phase of analysis has been terminated. Balint, and those who accept Ferenczi’s concept of primary passive love, suggest that some gratification of primitive passive needs may be essential for successful termination. To Klein, the terminal phases of analysis also represent a repetition of important features of the early mother-child relationship. According to her point of view, this period represents, in essence, a revival of the early weaning situation. Completion depends on a mastery of early depressive struggles culminating in successful introjection of the analysis as a good object. Although, in this connection, emphasis differs considerably, it should be noted that those who stress the importance of identification with the analyst as a basis for therapeutic alliance, also accept the inevitability of some permanent modifications of a similar nature. Those, however, who make a definite differentiation between transference of the transference neurosis as a main prerequisite for successful termination. The identification based on therapeutic alliance must be interpreted and understood, particularly with reference to the reality aspects of the analyst’s personality. In spite, therefore, of significant important differences there are, as already indicated in connection with the earlier papers of Sterba and Strachey, important points of agreement in respect to the goal of psychoanalysis.
The differences already considered indicate some basic current problems of transference. So far, however, discussion has been limited to variations within the framework of a traditional technique. We must consider problems related to overt modifications, so as the essential expanding context of use between variations introduced in respect to certain clinical conditions. Often as a preliminary to classical psychoanalysis, and modifications based on changes on basic approach which lead to significant alterations with regard both to the method and to the aim of therapy. It is generally agreed that some neurosis, borderline patients and the psychosis. The nature and meaning of such changes are, however, viewed differently according to the relative emphasis placed on the ego and its defences, on underlying unconscious conflicts, and on the significance and handling of regression in the therapeutic situation.
In ‘Analysis Terminable and Interminable’, Freud suggested that certainly inaccessible to psychoanalytic procedure. Hartmann has suggested that in addition to these primary attributes, other ego characteristics, originally develop for defensive purposes, and the related neutralized instinctual energy at the disposal of the ego, may be relatively or absolutely divorced from unconscious fantasy. This not only explains the relative inefficacy of early transference interpretation, but also hints of possible limitations in the potentialities of analysis attributable to secondary autonomy of the ego which is considered to be relatively irreversible. In certain cases, moreover, it is suggested that analysis of precarious or seriously pathological defences - particularly those concerned of aggressive impulses - may be not only ineffective, but dangerous. The relative failure of ego development in such cases not only precludes the development of a genuine therapeutic alliance, but also raises the risk of a serious regressive, often predominantly hostile transference situation. In certain cases, therefore, preliminary period of psychotherapy is recommended in order to explore the capacities of the patient to tolerate traditional psychoanalysis. In others, as Robert Knight in his paper on borderline states, and as many analysts’ working with psychotic patients have suggested, psychoanalytic procedure is not considered applicable. Instead, a therapeutic approach based on analytic understanding which, in essence, utilizes an essentially implicit positive transference as a means of reinforcing, rather than analyzing the precarious defences of the individual, is advocated. In contrast, Herbert Rosenfeld approached even severely disturbed psychotic patients with minimal modifications of psychoanalytic techniques. Only changes which the severity of the patient’s condition enforces are introduced. The dangers of regression in therapy are not emphasized since primitive fantasy is considered to be active under all circumstances. The most primitive period is viewed in terms of early object relations with special stress on prosecutory anxiety related to the death instinct. Interpretation of this primitive fantasy in the transference situation, is best offered the opportunity of strengthening the severity-threatened psychosis mainly to serve traumatic experiences, particularly of deprivation in early infancy. According to this point of view, profound regression offers an opportunity to fulfil, in the transference situation, primitive needs which had not been met at the appropriate level of development. Similar suggestions have been proposed by Margolin and others, in the concept of anaclitic treatment. Serious psychosomatic diseases, that approach the premise that the inevitable regression is shown by certain patients and should be utilized in therapy, as a means for gratifying, in their extremely permissive transference situation. Having distinctive or certain limits in the burdensome instant for demanding to that which has not been met in infancy, as this must, in the connection of being taken to understand that the gratifications recommended in the treatment of severely disturbed patients are determined by their conviction. Of these patients are incapable of developing transference as we understand it, in the connection with neurosis and must therefore be handled by a modified technique.
The opinions so far considered, however, much of them, as mine differ in certain respects, are, nonetheless, all based on the fundamental premise that an essential difference between analysis and other methods of therapy depends on whether or not interpretation of transference is an integral feature of technical procedure. Results based on the effects of suggestions are to be avoided, as far as possible, whenever traditional technique is employed. This goal has, however, tp establish a point by appropriate objective means, that corroborated evidence that proved the need for better a state of being even more difficult to achieve than Freud expected when he first discerned the significance of symptomatic recovery based on positive transference. The importance of suggestion, even in the most strict analytic methods, has been repeatedly stressed by Edward Glover and others. Widespread and increasing emphasis as to the part played by the analyst’s personality in determining the nature of the individual transference also implies recognition of unavoidable suggestive tendencies in the therapeutic process. Many analysts today believe that the classical conception of analytic objectivity and anonymity cannot be maintained. Instead, thorough analysis of reality aspects of the therapist’s personality and point of view is advocated as an essential feature of transference analysis and an indispensable prerequisite for the dynamic changes already discussed in relation to the termination of analysis. It thus remains the ultimate goal of psychoanalyst’s whenever their theoretical orientation, to avoid, as far as is humanly possible, results based on the unrecognized or unanalyzed action of suggestion, and to maintain, as a primary goal, the resolution of such results through consistent and careful interpretation.
There are, however, a number of therapists, both within and outside the field of psychoanalysis, who consider that the transference situation should not be handled only or mainly as a setting for interpretation even in the treatment or analysis of neurotic patients. Instead, they advocate utilization of the transference relationship for the manipulation of corrective emotional experience. The theoretical orientation of those utilizing this concept of transference may be closer to, or more distant form, a Freudian point of view according to the degree to which current relationships are seen as determined by past events. At one extreme, current aspects and cultural factors are considered of predominant importance, at the other, mental development is viewed in essentially Freudian terms and modifications of technique are ascribed to inherent limitations of the analytic method rather than to essentially changed conceptions of the early phases of mental development. Of this group, Alexander is perhaps the best example. It is thirty years since, in his Salzburg paper, he indicated the tendency for patients to regress, even after apparently successful transference analysis of the oedipus situation to narcissistic dependent pregenital levels which prove stubborn and refractory to transference interpretation. In his more recent work, the role of regression in the transference situation has been increasingly stressed. The emergence and persistence of dependent, pregenital commands for something as or is if one’s right or due requirements are challenged in measuring moderations of a wide range of clinical conditions. It is argued, that its indications that the encouragement of a regressive transference situation is undesirable and therapeutically ineffective. The analyst, therefore, should when this threatens adopt a definite role explicitly differing from the behaviour of the parents in early childhood in order to bring about therapeutic results through a corrective emotional experience in the transference situation. This, it is suggested, will obviate the tendency to regression, thus curtailing the length of treatment and improving therapeutic results. Limitations of regressive manifestations by active steps modifying traditional analytic procedure in a variety of ways are also frequently indicated, according to this point of view.
It will be clear that to those who maintain the conviction that interpretation of all transference manifestations remain an essential feature of psychoanalysis, the type of manifestation as described, even though based on a Freudian reconstruction of the early phases of mental developments, and represent a major modification. It is determined by a conviction that psychoanalysis, as a therapeutic method, has limitations related to the tendency to regression, which cannot be resolved by traditional technique. Moreover, the fundamental premises on which, and the conception of corrective emotional experience is based minimizing the significance of insight and recall. It is essentially, suggested that corrective emotional experience alone may bring about qualitative dynamic alterations in mental structure, which can lead to a satisfactory therapeutic goal. This implies a definite modification on the analytic hypothesis whose current problems are determined by their defences against the direct opposition to the instinctual impulses and the intentional object, to which had been set up during the decisive periods of early development. An analytic result therefore depends on the revival, repetition and mastery of earlier conflict in the current experience of the transference situation with insight an indispensable feature of an analytic goal.
Since certain important modifications are related to the concept of regression in the transference situation, it should be considered that this concept is in relation to the repetition compulsion, that transference, essentially is a revival of earlier emotional experience, must be regarded as a manifestation of the repetition compulsion is generally accepted. It is, however, necessarily to distinguish between repetition compulsion as an attempt to master traumatic experience and repetition compulsion as an attempt to return to a real or fantasized earlier state of rest or gratification. Lagache, in a recent paper, has connected by or as if by the affirming relatedness as associated to the corresponding divergence in the repetition compulsion to an inherent need to appear in the problems that had previously been left unsolved. From this point of view, the regressive aspects of the transference situation are to be regarded as a necessary preliminary to the mastery of unresolved conflict, as too, the regressive aspects of transference are mainly attributed to a wish to return to an earlier state of rest or narcissistic gratification, to the maintenance of the status quo in preference to any progressive action, to which Freud’s original conception of the death instinct. There is a good deal to suggest that both aspects of the repetition compulsion may bee seen in self-destructive forces tend to be stronger that progressive libidinal impulses, the potentialities of the analytic approach will inevitably appear to be limited. In those, in contrast, in whom that regard the reappearance in the transference situation of earlier conflicts as an indication of tendencies to master and progress will continue to feel that the classical analytic method remains the optimal approach to psychological illness wherever it is applicable.
Clarifications maintain the position or peculiar state as occupying a spatial point in temporal conditions, with a significant relevance to the amplitude larger in extent or a greater capacity that the average infinitive period has of time. Whereas in absence or termination must reflect on or upon the fearing analysis if the transference, as compelling of a generally acknowledged focal point, this itself may debase the appropriate factor that generates, in every degree. The exemplifying analytic technique that would react upon the discipline needed to utilize the new values, whereby, they can be ascribed as the commonality in holding the services to a suspicious self-direction and comprehensive understanding, in that of whatever is humanly affiliated to the best as can be, and yet, the advocacy to the analysis of the transference is generally acknowledged as the central feature of analytic technique? Freud regarded transference and resistance as facts in the observational conceptuality for which of representing the state of inventions. He writes, . . . that the theory of psychoanalysis in an attempt to account for two striking and unexpected facts of observation which emerge whenever an attempt is made. Evidently the symptoms of a neurotic source, may in his past life, inhabit the sources of experiential recall to the past or the introspective reflections. In the state of affairs, in that for being the latent characterizations announced as the factoring responsibility for the transference and of resistance . . . one which takes the other side of the problem, while accepting as such, to the latencies and the hidden values non-accepting for new interactions as brought through a hypothesis that will hardly escape the charge of misappropriation of properties by attempting endeavour to re-associate the essentially established personalization, that if the pursuit in calling them a psychoanalyst’. Rapaport (1967) argued, in his posthumously published paper on the methodology of psychoanalysis, that transference and resistance inevitably follow from the fact that the analytic situation is interpersonal.
Despite this general agreement on the centrality of transference and resistance in technique, in that, the analysis of transference is not pursued as systematically and comprehensively affirmed, however, it could be and should be. The relative privacy for which psychoanalytic work makes it impossible for one or of that of any-other, to skillfully improve upon the attemptive conceptual representation as comprehended of issues, its assumption to state this view as anything more that impressions, involving on that of what in the analysis of the transference and to states awareness in the number of reasons that an important aspect in the analysis of the transference of the transference, namely in the resistance, by the awareness of the transference is especially, and often adhering to the analytic procedures that interact among cultural inhibitors, but that will be distinguished as such, that its ranging manifold of distancing non-localities as founded of the analyst’s.
However, it must first be to distinguish between two types of interpretation of the transference. That one is an interpretation of resistance to the awareness of transference, the other, is an interpretation of resistance to the resolution of transference. The distinction has clearly been best spelled out in the form from which copies or reproductions can be produced, as to cause to make its awareness and yielding values as grounded in the cognisance to Greenson (1967) and Stone (1967). The first kind of resistance may be called decence transference, although this term emphases the terminological characterization by its term is mainly employed to refer to a phrase of analysis and carried within the general resistance to the transference of wishes, it can also be used for a more isolated instance of transference of defence. With some oversimplification, one might say that in resistance to the awareness of transference, the transference, the transference is what does the resisting.
Another connected description of stating this distinction between resistance and the awareness of transference and resistance to the resolution of transference is between implicit and indirect references to the transference and explicitly or directly referential to the transference. The interpretation of resistance to awareness of the transference is intended to make the implicit transference explicit. While the interpretation of resistance to the resolution of transference is intended to make the patient realize that the already explicit transference does indeed include a determinant from the past.
It is also important to distinguish between the general concept of an interpretation of resistance to the resolution of transference and a particular variety of such an interpretation, namely, a genetic transference interpretation - that is, an interpretation of how an attitude in the present is an inappropriate carry-over from the past. While there is a tendency among analysts to deal explicit references to the transference primarily among analyses to deal explicitly the references to the transference as primarily by a genetic transference interpretation, there are other ways of working toward a revolution of the transference. However, this argument does so implicate that not only is not enough emphasis being given to interpretation of the transference in the here and now, that is, to the interpretation of implicit manifestations of the transference, but also that interpretations intended to resolve the transference as manifested in explicit references to the transference should be primarily in the here and now, rather than genetic transference interpretations.
A patient’s statement that he feels the analyst is harsh, for example, is, at least to begin with, likely best dealt with not by interpreting that this is a displacement from the patient’s feeling that his father was harsh, but by as elucidation of some other aspect of this here and now attitude, such as what has gone on in the analytic situation that seems to the patient to justify his feeling or what was the anxiety that made it so difficult for him to express his feelings. How the patient experiences the actual situation is an example of the role of the actual situation in a manifestation of transference, which will be a major point of relevant significance.
Of course, both interpretations of the transference in the here and now and genetic transference interpretations are valid and constitute a sequence. We presume that a resistance to the transference ultimately rests on the displacement onto the analysts of attitudes from the past.
Because Freud’s case histories focus much more on the yield of analysis than on the details of the process, they are readily but perhaps incorrectly construed as emphasizing work outside the transference much more than work within the transference, and, even within the transference, emphasizing genetic transference interpretations much more than work with the transference in the here and now (Muslin and Gill, 1978). The example of Freud’s case reports may have played a role in what is to be considered as the common maldistribution of emphasis in these two respects - not enough on the transference and, within the transference, not enough on the here and now.
Transference interpretations in the here and now and genetic transference interpretations are, of course, exemplified in Freud’s writings and are in the repertoire of every analyst, but they are not distinguished sharply enough.
Both participants in the analytic situation are motivated to avoid these interactions. Flight away from the transference and to the past can be a relief to both the patient and the analyst.
These aligning measures have been divided into five categorical divisions and placed into the following parts: (1) The principle that the transference should be encouraged to expand as much as possible within the analytic situation because the analytic work is best done within the transference. (2) the interpretation of disguised allusion to the transference as a main technique for encouraging the expansion of the transference within the analytic situation, (3) the principle that all transference has a connection with something in the present actual analysis situation, (4) how the connection between transference and the actual analytic situation is used in interpreting resistance to the awareness of transference, and (5) the resolution of transference within the here and now and the role of genetic transference interpretation.
The importance of transference interpretations will surely be agreeing to by all analysts, the greater effectiveness of transference interpretations than interpretations outside the transference will be agreeing to by many, but what of the relative roles of interpretation of the transference and interpretation outside the transference?
Freud can be interpreted as either of saying that the analysis of the transference in auxiliary to the analysis of the neurosis or that the analysis of the transference is equivalent to the analysis of the neurosis. The first position is stated in his saying (1913) that the disturbance of the transference has to be overcome by the analysis of transference resistance in order to get on with the work of analyzing the neurosis. It is also implied in his reiteration that the ultimate task of analysis is to remember the past, to fill in the gap in memory. The second position is stated in his saying that the victory must be won on the field of the transference (1912) and that the mastery of the transference neurosis ‘coincides with getting rid of the illness which was originally brought to the neurosis (1917). In this second view, he says that after the resistance is overcome, memories appear relatively without difficulty.
These two different positions also find expression in the two different ways in which Freud speaks of the transference. In `Dynamics of Transference` he refers to the transference, on the one hand, as `the most powerful resistance to the treatment`(1912) but, on the other hand, as doing us the inestimable service of making the patient’s . . . , immediate impulses and manifests, when all is said and done, it is impossible to destroy anyone in absentia or in effigie (1912).
It can be agreed that his principal emphasis fails on the second position. He wrote once, in summary, ‘Thus our therapeutic work falls into two phases in the first, all the libido is forced from the symptoms into the transference and concentrated there, in the second, the struggle is waged around this new object and the libido is liberated from it`(1912).
The detailed demonstration that he advocated that the transference should be encouraged to expand as much as possible within the analytic situation lies in clarification that resistance is primarily expressed by repetition, and repetition takes place both within and outside the analytic situation, but that the analyst seeks to deal with it primarily within the analytic situation, that repetition can be not only in the motor sphere (acting) but also in the psychical sphere, and that the psychical sphere is not confined to remembering but includes the present, too.
Freud`s emphasis that the purpose of resistance is to prevent remembering can obscure his point that resistance shows itself primarily by repetition, whether inside or outside the analytic situation. `The greater the resistance, the more extensively, and will act out (repetition)replace remembering`. Similarly in `The Dynamics of Transference` Freud said that the main reason that the transference is so well suited to serve the resistance is that the unconscious implies does not want to be remembered . . . but endeavour to reproduce themselves . . . (1918), the transference is a resistance primarily insofar as it is a repetition.
The point can be restated in terms of the relation between transference and resistance. The resistance expresses itself in repetition, that is, in transference both inside and outside the analytic situation. To deal with the transference. Therefore, is equivalent to dealing with the resistance. Freud emphasized transference within the analytic situation so strongly that it has come to mean only repetition within the analytic situation, even though, conceptually speaking, repetition outside the analytic situation is transference too, and Freud once used the term that way. `We soon perceive that the transference is itself only a piece of repetition and that the repetition is a transference of the forgotten past not only onto the analyst but also onto all the other aspects of the current situation. We . . . find . . . the compulsion to repeat, which now replaces the impulsion to remember, not only in his personal attitude to his analyst but also in every other activity and relationship which may occupy his life at the time . . . (1914).
It is important to realize that the expansion of the repetition inside the analytic situation, whether or not in a reciprocal relationship to repetition outside the analytic situation, is the avenue to control the repetition: `The main instrument . . . for curbing the patients compulsion to repeat and for turning it into a motive for remembering lies in the handling of the transference. We render the compulsion harmless, and indeed useful, by giving it the right to assert itself in a definite field`(1914).
Kanzer has discussed this issue well in his paper on ‘The Motor Sphere of the Transference’ (1966). He writes of a ‘double-pronged stick-and-carrot’ technique by which the transference is fostered within the analytic situation and discouraged outside the analytic situation. The ‘stick’ is the principle of abstinence as exemplified in the admonition against making important decisions during treatment, and the ‘carrot’ is the opportunity afforded the transference to expand within the treatment, ‘in almost complete freedom’ as in a ‘playground’ (Freud, 1914). As Freud put it, ‘Provided only that the patient shows compliance enough to respect the necessary conditions of the analysis, we regularly succeed in giving all the symptoms of the illness a new transference meaning, and in replacing his ordinary neurosis by a ‘transference neurosis’ of which he can be cured by the therapeutic work’ (1914).
The reason it is desirable for the transference to be expressed within the treatment is that there, it `is at every point accessible to our intervention`(1914). In a later statement he made the same point this way. `We have followed this new edition - the transference-neurosis - of the old disorder from its start, we have observed its origin and growth, and we are especially well able to find our way about in it since, as its object, we are situated at it’s very centre, (1917), it is not that the transference is forced into the treatment, but that it is spontaneously but implicitly present and is encouraged to expand there and become explicit
Freud emphasized acting in the transference so strongly that one can overlook the repetition in the transference, but does not of necessity for its enactment or recognition that gives validity to acts of a subordinate conformation as ratified in support of explicit authoritative permission. Repetition need not go as far as motor behaviour, it can also be expressed in attitudes, feelings, and intentions, and, indeed, the repetition often does take such form rather than motor action. The importance of making this clear is that Freud can be mistakenly read to mean that repetition in the psychical sphere can only mean remembering the past, are when he writes that the analyst as prepared for a perpetual struggle with his patient to keep in the psychical sphere all the impulses which the patient would like to direct into the motor sphere, and he celebrates it as a triumph for the treatment if he can bring it about that something the patient wishes to discharge in action are disposed if through the work of remembering (1914).
It is true that the analyst’s efforts are to convert acting in the motor sphere into awareness in the psychical sphere, but transference may be in the psychical sphere to begin with, albeit disguised. The psychical sphere includes awareness in the transference as well as remembering.
One of the objections one hears, from both analysts and patient, to a heavy emphasis on interpretation of associations about the patients real life primarily in terms of the transference is that it means the analyst is disregarding the importance of what goes on in the patients real life. The criticism is not judicial. To emphasize the transference meaning is not to deny or belittle other meanings, but to focus on the one of several meanings of the content that is the most important for the analytic process, for the reasons of positing the addition for one coming to any falsifiable conclusion.
Another way in which interpretations of resistance to the transference can be, or at lease appear to the patient to be, a belittling of the importance of the patients outside life is to make the interpretation as though the outside behaviour is primarily an acting out of the transference. The patient may undertake some actions in the outside world as an expression of and resistance to the transference, that is, acting out. But the interpretation of associations about actions in the outside world as having implications for the transference needs mean only that the choice of outside action to figure in the associations is co-determined by the need to express a transference indirectly. It is because of the resistance to awareness of the transference that the transference to be disguised. When the disguise is unmasked by interpretation, it becomes clear that, despite the inevitable differences between the outside situation and the transference situation, the content is the same for the analysis of the necrosis that coincides (Freud wrote that the mastering of the transference neurosis only coincides with getting rid of the illness which was originally brought to the treatment (1917)).
The analytic situation itself fosters the development of attitudes with primary determinants in the past, i.e., transference. The analyst’s reserve provides the patient with few and equivocal cues. The purpose of the analytic situation fosters the development of strong emotional responses, and the very fact that the patient has a neurosis means, as Freud said, that’ . . . it is a perfectly normal and intelligible thing that the libidinal cathexis [we would now add negative feelings] of someone who is partly unsatisfied, a cathexes which are held ready in anticipation, should be directly as well to the figure of the analyst (1912).
While the analytic setup itself fosters the expansion of the transference within the analytic situation, the interpretation of resistance to the awareness of transference will further this expansion.
There are important resistance on the part of both patient and analyst to awareness of the transference. On the patient’s part, this is because of the difficulty in recognizing erotic and hostile impulses toward the very person to whom they have to be disclosed. On the analyst’s part, this is because the patient is likely to attitude the very attitudes to him which are most likely to cause him discomfort. The attitudes the patient believes the analysts has toward him are often the ones the patient is least likely to voice, in a general sense because of a feeling that it is impertinent for him to concern himself with the analyst’s feelings, and in a more specific sense because the aptitudes as held by the analyst are often attitudes the patient feels the analyst will be comfortable about having ascribed to him. It is for this reason that the analyst must be especially alert to the attitudes the patient believes he has, not only to the attitudes the patient does have toward him. If the analyst is able to see himself as a participant in an interaction, as he will become much more attuned to this important area of transference, which might otherwise escape him.
The investigations of attitudes are ascribed to the analyst makes easier the subsequent investigation of the intrinsic factors in the patient that played a role in such ascription. For example, the exposure of the fact that the patient ascribes sexual interests in him to the analyst, and generally to the patient, alternatively the subsequent exploration of the patient’s sexual wish toward the analyst, and genetically the parent.
The resistance to the awareness of these attitudes is responsible for their appearing in various disguises in the patient’s manifested associations and for the analyst’s reluctance to unmask the disguise. The most commonly recognized disguise is by displacement, but identification is an equally important one. In displacement, the patient’s attitudes are narrated for being toward a third party. In identification, the patient attitudes to himself attitudes he believes the analyst has toward him.
To encourage the expansion of the transference within the analytic situation, the disguises in which the transference appears have to be interpreted in the case of displacement the interpretation will be of allusions to the transference in association not manifestly about the transference. This is a kind of interpretation every analyst often makes. In the case of identifications, the analyst interprets the attitudes that the patient ascribes to himself the identification with which an attitude and subsequently attributed to the analyst. Lipton (1977) has recently described this form of disguise allusion in the transference with illuminating illustration.
In his autobiography, Freud wrote, ‘The patient remains under the influence of the analytic situation as hopefully of a latter position or a period of decline, as though he is not directing responsibly for the mental activities onto a particular subject. Justly in assuming that nothing will occur, as not of some reference to the situation (1925). Since associations are obviously often not directed about the analytic situation, the interpretation of Freud’s remark rests on what he meant by the ‘analytic situation’.
It is believed that Freud’s meaning can be clarified by reference to a statement he made in, ‘The Interpretation of Dreams’. He said that when the patient is told to say whatever comes into his mind, his associations become directed by the ‘purposive ideas inherent in the treatment’ and that there are two such inherent regressive themes, one relating to the illness and the other - concerning which, Freud said, the patient has ‘no suspicion’; - relating to other analyst’s relating to the patient has ‘no suspicions’ - relating to the analyst (1900). If the patient has ‘no suspicions’ of the theme relating to the analyst, such that the theme appears only in disguise, the patient ‘s associations, it is contended that Freud’s remark not only specifies the themes inherent in the patient ‘s identifications’, but means that the associations are simultaneously directed by these two purposive ideas, not something by one and sometimes by the other.
One important reason that the early and continuing presence of the transference is not always recognized in that it is considered to be absent in the patient who is talking recognized is that it is considered to be absent in the patient who is talking freely and apparently without resistance. As (Muslin and Gill, 1976) pointed out in a paper on the early interpretation of transference resistance, to the transference is probably present from the beginning, even if the patient is talking apparently freely. The patient may well be talking about issues not manifestingly about the transference which are nevertheless, also allusions to the transference, but the analyst has to be alert to the pervasiveness of such allusory discernment about them.
The analyst should progress on the working assumption, that the patient’s associations have transference implications pervasively, that with which this assumption is not to be confused with denial or neglect of the current aspects of the analytic situation. It is theoretically always possible to give precedence to a transference interpretation if one can only discern it through its disguise by resistance. This is not to dispute the desirability of learning as much as one can about the patient, if only to be a position to make more correct interpretations of the transference. One therefore, does not interfere with an apparently free flow of associations, especially early, unless the transference threatens the analytic situation to the point where its interpretation is mandatory rather than optional.
With the recognition that evens apparently freely associating patient may also be showing resistance to awareness of the transference, this formulation should not interfere as long a useful information being gathered should replace Freud’s dictum that the transference should not be interpreted until it becomes a resistance (1913).
It can be argued that every transference has some connection to some aspect of the current analytic situation, in the sense that the past can exert an influence only insofar as it exists in the present. Of course, all the determinants of a transference are current in the sense that what I am distinguishing is the current reality of the analytic situation, that is, what actually goes on between patient and analyst in the situation from how the patient is currently constituted as a result of his past.
All analysts would dubiously agree that there are both current and transferential determinants of the analytic situation, and probably no analyst would argue that a transference of the analytic situation, and probably no analyst would argue that a transference idea can be expressed without contamination, as it was, that is, without any connection to anything current in the patient-analyst relationship. Nevertheless, the implications of this fact for technique are often neglected in practice, as my next point is only to argue for the connection.
Several authors, e.g., Kohut 1959 and Loewald 1960, have pointed out that Freud`s early application by the act or practice of using something or the state of being used, this, however, employ of the quality of being appropriate or valuable to some end as to accommodate the accountable or warrant the use of the term transference. In `The Interpretation of Dreams, in a connection not immediately recognizable as related to the present day use of the term, reveals the fallacy of considering that transference can be expressed free of any connection to the present. That early use was to refer to the fact that an unconscious idea cannot be expressed as such, but only as it becomes connected to a preconscious o r conscious content. In the phenomenon with which Freud was then concerned, the dream transference took place from an unconscious wish to a day residue. In `The Interpretation of Dreams, `Freud used the term transference both for the general rule that an unconscious content is expressible only as it becomes transferred to a preconscious or conscious content and for the specific application of this rule to a transference to the analyst. Just as the day residue is the point of attachment of the dream wish, so must there be an analytic-situation residue, though Freud did not use that term, as the point of attachment of the transference.
Analysts have always limited their behaviour, both in variety and intensity, to increase the extent to which the patient‘s behaviour is determined by his idiosyncratic interpretation of the analyst’s behaviour. In fact, analysts unfortunately sometimes limit the behaviour so much as to compare with such an expression or unpiled standard or absolute approximation, that the entire relationship with the patient matter of technique, with no nontechnical personal relation, as Liptop (1977) has pointed out.
But no matter how far the analyst attempts to carry this limitation of his behaviour, the very existence of the analytic situation provides the patient with innumerable cues which can enviably become his rationale for his transference responses. In other words, the current situation cannot be made to disappear - that is, the analytic situation is real. It is easy to forget this truism in one’s zeal to diminish the role of the current situation in determining the patient ‘s responses. One can try to keep past and present determinants relatively perceptible from one another, but one cannot obtain either ‘pure culture‘. Freud wrote: ‘I insist on this procedure [the couch], however, for its purpose and result are to prevent the transference from mingling with the patient’s associations imperceptibly, to isolate the transference and to allow it to come forward in due course sharply defined as a resistance’ (1913). Even ‘isolate’ is too strong a word in the light of the inevitable intertwining of the transference with the current situation.
If the analyst remains under the illusion that the current cues he provides to the patient can be reduced to the vanishing point, he may be led into a silent withdrawal, which is not too distant from the caricature of an analyst as someone who does refuse to have any personal relationship with the patient. What happens then is that silence has become a technique rather than merely an indication that the analyst is listening. The patient’s responses under such conditions can be mistaken fo uncontaminated transference when they are in fact transference adaptions to the actuality of the silence.
The recognition, from which it takes its point of departure, as it was, has a crucial implications for the technique of interpreting resistance to the awareness of transference, in that, if, the analyst becomes persuaded of the centrality of transference and the importance of encouraging the transference to expand within the analytic situation, he has to find the presenting and plausible interpretation of resistance to the awareness of transference he should make. Is that, his most reliable guide is the cues offered by what is actually going on in the analytic situation? : On the one hand, the events of the situation, such as change in time of session, or an interpretation made by the analyst, and, on the other hand, how the patient is experiencing the situation as reflected in explicit remarks about it, however, fleeting these may be. This is the primary yield for technique of the recognition that any transference must have a link to the actuality of the analytic situation. The cue points to the nature of the transference, just as the day residue for a dream may be a quick pointer of the latent dream thoughts. Attention to the current situation for a transference elaboration will keep the analyst from making mechanical transference interpretation, in which he interprets that there are allusions to the transference in association not manifestly about the transference, but without offering any plausible bias for the interpretation. Attention to the current stimulation offers some degree of protection against the analyst’s inevitability whose tendency to project his own views onto the patient, either because of countertransference or because of a preconceived theoretical bias about the content and hierarchical relationships in psychodynamics.
The analyst may be very surprised at what in his behaviour the patient finds important or unimportant, for the patient’s responses will be idiosyncratically determined by the transference, the patient’s responses may seem to be something the patient as well as the analysts consider trivial, because, as in displacement to a trivial aspect of the day residue of a dream, displacement can better serve resistance when it is to something trivial. Because it is connected to conflict-laden material, the stimulus to the transference may be difficult to find. It may be quickly disavowed, so that its presence in awareness is only transitory. With the discovery of the disavowed, the patient may also gain insight into how it repeats as disavowed earlier in his life. In his search for the present stimuli which the patient is responding transferentially, as the analyst must therefore remain alert to both fleeting and apparently trivial manifested reference to himself as well as in the events of the analytic situation.
If the analyst interprets the patient’s attitudes in a spirit of seeing their possible plausibility in the light of what information the patient does have, rather than in the spirit of either affirming or denying the patient’s views, the way is open for their further expression and elucidation. The analyst will be respecting the effort to be plausible and realistic, rather than manufacturing his transference attitudes out of whole bodied material.
Importantly, is to make a transference interpretation plausible to the patient in terms of as current stimulus that, if the analyst is persuaded that the manifest content has important implications for the transference but he is unable to see a current stimulus for the attitude, he should explicitly say so if he decides to make the transference interpretation anyway. The patient himself may then be able to say what the current stimulus is.
It is sometimes argued that the analyst’s attention to his own behaviour is a precipitant for the transference, will increase the patient’s resistance to recognizing the transference. That, on the contrary, that because of the inevitable interrelationship of the current and transferential determinants, it is only through interpretation that they can be disentangled.
It is also argued that one must wait until the transference has reached optimal intensity before it can be advantageously interpreted. It is true that too hasty and interpretation of the transference can serve as a defensive function for the analyst and deny him the information he needs to make a more appropriate transference interpretation. But it is true that delay in interpreting transference interpretation, but it is also true that delay in interpreting runs the risk of allowing an unmanageable transference to develop. It is also true that deliberate delay can be a manipulation in the service of abreaction rather than analysis, and, like silence, can lead to a response to the actual situation which is mistaken for uncontaminated transference. Obviously important, is assumed in the issues of timing are involved, whereas an important clue to when a transference interpretation is apt and which one to makes lies in whether the interpretation can be made plausibly in terms of the determinant, namely, as something in the current analytic situation. Such as, in the approaching transference in the spirit of seeing how it appears plausibly realistic to the patient, it paves the way toward its further elucidation and expression.
Freud’s emphasis on remembering as the goal of the analytic work implies that remembering is the principal avenue to the resolution of the transference. But the delineation of the successive steps in the development of the analytic technique (1920) makes clear that he saw this development as a change from an effort to reach memories directly to the utilization of the transference as the necessary intermediacy to reaching the memories.
In contrast to remembering as the way the transference is resolved, Freud also described resistance for beings primarily overcome in the transference, with remembering following relatively easily afterwards, ‘From the repetitive reactions which are exhibited in the transference we are led along the familiar paths to the awakening of the memories, which appear without difficulty, as it was, after the resistance has been overcome’ (1914), and ‘This revision of the process of repetition can be accomplished only in part in connection with the memory traces of the process which led to repression. The decisive part of the work’s achieved by creating in the patient’s relation to the analyst - in the ‘transference‘ new editions of the old conflicts . . . Thus, the transference becomes the battlefield on which all the mutually struggling forces should meet one another’ (1917). This is the primary indication for which Strachey (1934) classified in his seminal paper on the therapeutic action of psychoanalysis.
There are two main ways in which resolution of the transference can take place through work with the transference in the here and now. The first lies in the clarification of what are the clues in the current situation which are the patient‘s point of departure force a transference elaboration. The exposure of the current point of departure at once raises the question of whether it is adequate to the conclusion drawn from it. The relating of the transference to a current stimulus is, after all, parts of the patient‘s effort to make, the transference attitude plausibly determined by the present. The reverse and ambiguity of the analyst’s behaviour are what increases the ranges of apparently plausible conclusions the patient may draw. If an examination of the basis for the conclusion makes clear that the actual situation to which the patient responds is subject to other meanings than the one the patient has reached, he will more reality consider his pre-existing bias, that is to say, in that of transference.
Critically, it is suggested that, in speaking of the current relationship and the relation between the patient’s conclusion and the information on which they seem plausibly based, such in some absolute conception of what is real in the analytic situation, of which the analyst is the final arbiter. That is not the case, that what the patient must come to see is that the information he has is subject to other possible interpretations implies the very contrary to an absolute conception of reality. In fact, analyst and patient engage in a dialogue in a spirit of attempting to arrive at a consensus about reality, not about some factious absolute reality.
The second way in which resolution of the transference can take place within the work with the transference in the here and now is that in the very interpretation of the transference the patient had a new experience. He is being treated differently from how he expected to be. Analysts seem reluctant to emphasize his new experience, as though it endangers the role of insight and argue for interpersonal influence as the significant factor in change. Strachey’s emphasis on the new experience in the mutative transference interpretation has unfortunately been overshadowed by his views on introjection, which have been mistaken to advocate manipulating the transference. Strachey meant introjection of the more benign superego of the analyst only as a temporary strep on the road toward insight. Not only is the new experience not to be confused with the interpersonal influence of a transference gratification, but the new experience occurs together with insight into both the patient’s biassed expectation and the new experience. As Strachey points out, what is unique about the transference interpretation is that insight and the new experience take place in relation to the very person who was expected to behave differently, and it is this which gives the work in the transference, its immediacy and effectiveness. While Freud did stress the effective immediacy of the transference, he did not make the new experience explicit.
It is important to recognize that transference interpretation is not a matter of experience, in contrast to insight, but a joining of the two together, both are needed to bring about and maintain the desired changes in the patient. It is also important to recognize that no new techniques of intervention are required to provide the new experience. It is an inevitable accompaniment of interpretation of the transference in the here and now. It is often overlooked that, although Strachey said that only transference interpretations are outside the transference.
Rosenfeld (1972) has pointed out that clarification of material outside the transference is often necessary to know what is the appropriate transference interpretation, and that both genetic transference interpretations and extratransference interpretation taking to consider an inclination as marked by or indication of notable worth or simply the consequence based upon the role in working through. Strachey said relatively little about working through, but surely nothing against the necessary provision with which every thing needfully is explicitly recognized as the role for the recovery of the past in the resolving dissection of the purposiveness determined by the transference.
In taking positions, as to emphasis the role of the analysis of the transference in the here and now, both in interpreting resistance to the awareness of transference and in working toward its resolution by relating to the actuality of the situation. In that of opinion or purpose with the evidence that extratransference and genetic transference interpretation and, of course, working through is important too, that the matter is one of emphasis. Also, interpretation of resistance to awareness of the transference should figure in the majority of sessions, and that if this is done by relating the transference to the actual analytic situation, the very same interpretation is a beginning of work to the resolution of the transference. To justify this view more persuasively would require detailed case material.
The concern and considerations that the Kleinian annalists whom, many analysts feel, are in error in giving the analysis of the transference too great if not even as exclusive role in the analytic process. It is true that Kleinians emphasize the analysis of the transference more, in their writing at least, than does the general run of analysts. As, Anna Freud (1968) complained that the concept of transference has become overexpanded seems to be directed against the Kleinians. One of the reasons the Kleinians consider themselves the true followers of Freud in technique are precisely because of the emphasis they put on the analysis of the transference. Hanna Segal (1967), for example, writes, `Too say that all communications are seen as communications about the patents phantasy as well as current external life is equivalent to saying that all communications contain something relevant to the transference situation. In Kleinian technique, the interpretation of the transference is often more central than in the classical technique.
Affirmly held point of view or way of regarding that Freud and transference had accedingly connected by simulating observations that we can only offer, that Freud wrote briefly about transference, and did so, to sustain the way in which, is, as a whole, that his actions were justly taken in and around 1917. Another observation which can rarely be made about Freud’s works, and which everyone may not agree with, is that, with one or two exceptions, what he did write on transference did not reach the high level of analytical thought which has come to be regarded as standard for him. Some indication of what his contribution consists of is given by the editors of the Standard Edition, who list them in several places. One of the longer lists, in a footnote on page 431 of Volume 16, includes six references: ‘Studies of Hysteria’ with Breuer (1895), the Dora paper (1905), ‘The Dynamics of Transference’ (1912), ‘Observations on Transference-Love’ (1915), the chapter on transference in the Introductory Lectures (1917), and ‘Analysis Terminable and Interminable’ (1937). Although the editors, in no sense suggest that these six papers include everything Freud wrote on the subject. It does seem evident that, considering the essential importance of transference to analysis, he wrote, ‘The Dynamics of Transference’, ‘Transference-Love’, and the transference chapter in the Introductory Lectures, came across, as, perhaps, his least significant contribution.
Freud’s first direct mention of transference comes upon the pages ascribed within the ’Studies of Hysteria’ (1895), his first significant reference to it, however did not appear until five years later, when, in a letter to Fliess on April 16, 1900, he said (Freud, 1887-1902) he was ‘beginning to see that the apparent endlessness of the treatment is something of an inherent feature and is connected with the transference’. In a footnote to this letter the editors said that, ‘This is the first insight into the role of transference in psychotherapy.’
Despite these early references, it seems correct to say that yet another five years were to go by before the phenomenon of transference was actually introduced. Even so, the introduction was far from prominent, for it was tacked on like an afterthought as a four-page portion of a postscript to what was perhaps Freud’s most fascinating case history to date, the case of Dora (1905).
Using data from Dora’s three-month-long, unexpectedly terminated analysis, and especially from her dramatic transference reaction which had taken him quite unawares, Freud now gave to transference its first distinct psychological entity and for the first time indicated its essential role in the analytic process. His account, although in general more than adequate - in the elegant fact and unmistakably ‘finished’ - was brief, and almost to the point, and perhaps not an entirely worthy introduction so much more a truly great discovery. What was uniquely great was his recognizing the usefulness of transference. In his analysis of Dora he had noted not only that transference feelings existed and were powerful, but, much to his dismay, he had realized what a serious, perhaps, even insurmountable obstacles that objectively would be. Then, in what seems like a creative leap, Freud made the almost unbelievable discoveries that transference was in fact, the key to analysis, that by properly taking the patient’s transference and therapeutic force was added to the analytic method.
The impact on analysis of this startling discovery was actually much greater and much more significant than most people seem to appreciate. Although the role of transference as the sine quo non of analysis and is widely accepted, and was stated by Freud from the first, it has almost never been acclaimed for having brought about an entire change in the nature of analysis. The introduction of free association to analysis, a much lesser change, receives and still receives much more recognition.
One of the reasons for the relatively unheralded entry of transference into analysis may have been for circumstances of its discovery. Although Freud’s new ideas were recorded as if they arose as sudden inspiration during the Dora analysis, they may in fact have developed somewhat later. In the paper‘s precatory remarks, for instance, Freud said he had not discussed transference with Dora at all, and in the postscript, he said he had been unaware of her transference feelings. Also, pointing to a later discovery date is the extraordinary delay in the paper’s publication. According to the editor’s note, the paper had been completed and accepted for publication by late January 1901, but this date was then actually set back more than four and a half years until October 1905. The editors said, ‘We have no information as to how it happened that Freud, . . . deferred publication.’ It readily seems that for reasons to have been that only during those four and a half years, as a consequence to his own self-analysis, that he came to a better understanding of the relevantly significant as the applicable reason to posit of the transference. Only then may it have been possible for him to turn again to the Dora case, to apply to it of what he had learned in himself, to write this essay as part of the postscript, and at last to release the paper for publication.
Freud’s self-analysis has been considered from many angles, but not significantly, as can be of valuing measure, in at least from the standpoint of transference. Opponents of the idea that there is such a thing as definite self-analysis, some of whom say it is impossible, generally an object on grounds that without any analyst there can be no transference neurosis. Freud clearly demonstrated, as, perhaps, that the situation that may be necessary to fill this need: Self-analysis may require that, at least a halfway satisfactory transference object. In Freud`s case, the main transference object at this time seems to have been Fliess, who filled the role rather well. As with any analysis, the authenticity as known in the unfeigned design as if existing or having no illusions and facing reality squarely, by which the ‘real’ impact on Freud was slight, he was essentially a neutral figure, relatively anonymous and physically separates. All of this, and Fliess`s own reciprocal transference reactions, made it possible for Freud to endow Fliess with whatever qualities and whatever feelings were essential to the development of Freud`s transference, and, it should be added, his transference neurosis. In the end, of course, the transference was in part resolved. Freud`s eventual awakening of its self realization in its presence within him of such strange and powerful psychological forces must have come to the conclusion as a stupefied disilluionary dejection toward Fliess, however, his subsequent working out of some of these transference attachments must have been both an intellectual triumph and an immensely healing and releasing of actions, operations or motions involved in the accomplishment of an ending that makes from its process.
In the years following this revolutionary discovery, the central role of transference in analysis increased in remarkable acceptance, and it has easily held this central position ever since. What the substance of this central position distinctfully compose in having or be capable of having within the constructs to which is something of a mystery, for, it seems as nothing about analysis and is, of least to be, the well known than how individual analysis actually uses transference in their day-to-day work with patients. As a guess, as, perhaps of each analysts concept of transference derives variably but significantly from his own inner experience, transference probably means many and varying differentiations to things as to different analysts.
In the same differentiated individuals, as that Freud’s own pupils must have differed on this issue, not only from him but from each other. Although some of their differences may have been slight, others, my have contributed significantly to later analytic developments. A question could be raised, for instance, whether differences in handling the transference which at first were the property of one analyst gradually develop into formal clinical methods used by many, and whether these clinical methods, after having been conceptualized, serve as the beginning of variously divergent schools of analysis. Such occurrences, consistent with certain beliefs that analytic ideas do arise in this way, primarily out of transference experiences in the analytic situation, would lead to the question whether the history of the ideological differences in what was actually said and done in response to transference reactions that to any other factor. Whatever the case, many differences and divergences did occur among the early analysts, and all of that is supposed to have had to do in some major way with differences in the handling of the transference.
Strangely, Freud himself seems to have taken little part in influencing this rapid and divergent period of growth. Usually accused of being too dominating in such matters, Freud seems to have done just the opposite during the development of this most critical aspect of analysis, the process itself, and, for reasons unknown, detached himself from it.
What was needed, one might be inclined to say, was not leadership in the form of domination, but leadership in trying to provide what was lacking, and still lacking, namely an analytical rationale for transference phenomena. The question must be asked, of course, whether in fact this would have been a good thing at that particular time in psychoanalytic history. Perhaps not. The exercise of closure, which Freud’s structuring might have amounted to. But although adding to understanding and stability at ceratin theoretical levels, could at another level, so such closures have often done, have placed many obstacles in the way of further analytical developments. Thus, his leaving the matter of transference wide open, even though it led to confusion and uncertainty, may have been just as well.
In many ways the closest Freud ever came to establishing a formal analytical rationale for transference was his first attempt, in the postscript to the case of hysteria (1905). These few pages are and among the most important of all Freud’s writings, outweighing by far the paper to which they are appended. Yet, in the case of Dora has always been taught as an entity rather than the ancillary to the essay on transference. In that essay Freud was clear: His ideas revealed tremendous insights and promised more to come, and that, the powers of the neurosis are occupied in creating a new edition of the same disease. Just think of the analytic implications of his saying that this new edition consists of a special class of mental structures, for the most part unconscious, having the peculiar characteristic of being able to replace earlier persons with that of the person of the analyst, and in the fashion applying all components of the original neurosis to the person of the analytical at the present time. Surely as profound a statement as any he ever made.
He then goes on to say that there is no way to avoid transference, that this ‘latest creation of the desire must be combated like all the earlier ones’, and that, although this is by far the hardest part of analysis, only after the transference has been resolved can a patient arrive at a sense of conviction of the validity of the connection which have been constructed during analysis.
He concludes by saying, ‘In psychoanalysis . . . all the patients’ tendencies, including hostile ones, are aroused, they are then turned to account for reasons to explain or the internalization of justification, and by the same measure was to purposively give a sensible reason for the proposed change in the analysis by which of being made conscious. That, in this way, the transference is constantly being put-down, however, transference, which seems ordained to be the greatest obstacle to psychoanalysis, becomes its most powerfully . . .
These remarkable observations, in conveying a sense of deep conviction that could arise, one feels, only from Freud’s own hard-won inner experience, that nowhere is there a suggestion that transference is a mere technical matter. Far from it, as Freud announces that he has come upon as new and exciting kind of mental function, or, as it is to believe, that a new and exciting kind of ego function.
Very quickly, however, Freud’s conviction sees to have failed him. Nothing he wrote afterwards about transference was at this level, and most of his later references were a retreat from it, for instance, he never did develop the promising idea that the mind constantly creates new editions of the original neurosis and meaningfully incline the minded inclusion in them, an ever-changing series of persons. Instead, he tended to become less specific, even referring to transference at times in a broad terms as if it were no more than rapport between patient and analysts, or as if it was an interpersonal or psychosocial relationship, concepts which, of course, a great many analysts have since adopted, but which were not part of Freud’s original ideas.
Perhaps his most persistent deviation was an on-and-off tendency to regard transference merely as a technical matter, often writing of it as an asset to analysis when positive and a liability when negative.
Significantly, because it indicated that an active struggle was still going on within him, Freud occasionally expressed once again, even though briefly his earlier insights, particularly his ideas that transference is an essential although unexplored part of mental life. An example of this appears in his alternative obtainment such that is gainfully to appear of as quality of being pleasant or agreeable to a feature that makes for pleasantness or ease, among the amenities of the central geniality, otherwise, the prevailing indifference account for the transference in ‘An Autobiographical Study’ (1925). Transference, he says, ‘is a universal phenomenon of the human mind. And in fact dominated the whole of each person’s relations to his human environment. In these few words’ Freud again made the point, and in declarative fashion, that transference is a mental structure of the greatest magnitude, but he never really followed it up.
Rather extensive evidence of his departure from the original concept and his continuing struggle with that concept is seen most clearly, wherein, the ‘Analysis Terminable and Interminable’ is much more than a courageous, brilliant, and pessimistic, appraisal of the difficulties and limitations of analysis, although transference is briefly mentioned in its content, yet a great deal about it comes through, some quite directly, some by easy inference. When looked at in this way, two themes stand out: Freud’s personal frustration with the enigmas of transference and his tacit placing of transference in the centre of success and failure in analysis, both as a therapy and as a developing science. What also comes through, is the perplexing realization of how far Freud had, by now, seemingly moved away from his original concepts. Or had he?
All the same, even if it is insufficient for exclusive reliance in relations to the complicated neurosis, for which it would be fallacious to assign to the recall and reconstruction of the past an exclusively explanatory value (in the intellectual sense), important though that functions be, and difficult as its full-blown emotional correlate may be to come by. There is no doubt that, even in complicated neurosis, equivalently complicated transference neurosis, the genuine complex and complicated transference neurosis, the genuinely experienced linking of the past and present can have, at times, a certain uniquely specific dynamic effect of its own, a type of telescoping or merging of common elements in experience, which must be connected with the meaninglessness of time in unconscious life, compared with its stern authority in the life of consciousness and adaptation to everyday reality. Contributing decisively to such experiences as to whatever degree it occurs, is of course, the vivid currency of the transference neurosis, and central in this, the reincarnations of old objects in an actual person, the analyst.
Thus, an allied problem in the general sphere of transference is the fascination and often enigmatic interplay of past and present. If one wishes to view this interplay in terms of a stereotyped formulation, the matter can remain relatively uncomplicated - as a formulation. Unfortunately. , This is too often the case. The phenomenon, however, retains some important obscurities, which cannot thoroughly dispel, but to which I would like to call attention. To concentrate on the dimension of time, it seems in reference to the complication and immediate aspects of technique, nonetheless, essential. For example, we can assume that the transference neurosis re-enacts the essential conflicts of the infantile neurosis in a current setting. If a reasonable degree of awareness of transference is established, the next problem is the genetic reduction of the neurosis to its elements in the past, through analysis of the transference resistance and allied intrapsychic resistance, ultimately genetic interpretations, recollections and reconstructions and working through. Such that the transference is related to its genetic origins, the analyst thereby emerges in his true, i.e., real, identity to the patient, the transference is putatively ‘resolved’. To the extent that one follows the traditional view that all resistance, including the transference itself, is ultimately directed against the restoration of early memories as, this is a convincing formulation. Is that, only to say, that in his own right as such as having to a certain tightly logical quality? However, we know that it this is not so readily accomplished, apart from the special intrapsychic considerations described afterward by Freud in ‘Analysis Terminable and Interminable’. Although in a favourable case, much of the cognitive interpretative work can be accomplished, there remains the fact that cognition responsibility, in its bare sense, does not necessarily lead to the subsidence of powerful dynamism, to the withdrawal of ‘cathexes’ from importantly real objects. For, as mentioned, a short while ago, the analyst is a real and living object, apart from the representations with which the transference invests him, and which are interpretable as such, for which there is no, at any time a seldom, a confusing interrelations and commonly of the emergent responses, due to the same old seeking, and this is directed toward a new individual in his own right, both are important, furthermore, there are large and important ones of overlapping. Apart from such considerations, even the explicitly incestuous transference is currently experienced (as, at least in good part) by a full-grown adult (like the original oedipus), instead of a totally and actually helpless child. To be sure, the latter state is reflected in the emergent transference elements of instinctual striving, but it is subject to analysis, and the residual is something significant, if not totally different. It is these residual sexual wish, presumably directed toward the person of the analyst, as such, which must be displaced to others, if, as generally agreed, the revival of infantile fantasies and strivings in the biologically mature adolescent presents a new and special problem, one must assume distinctiveness of experience for the adult, although it is true that in the majority of instances, adequate solution is favoured by the adult state. There is, in any case, a residual relationship between persons who have worked together in a prolonged, arduous and intimate relationship, which, strictly speaking, are reversibly disconnected or divorced of services, in that the transference merely ushers out the retirement for which its rendering retreat of that state of mind or feeling by an inner avoidance of something usually felt as unpleasant or pronounced for it’s adverse but mutual colouration. Blending to some confusion between the two spheres of feeling. The general tendency is that both components are fully gratified to some degree. But, there is the ubiquitous power of the residual primordial transference, yet, argue to cling to an omnipotent partisan to resist the displacement of its ‘sublimated’ anaclitic aspects, even if the various representation of the wishes for bodily intimacy has been thoroughly analyzed and successfully displaced. The outcome is largely the transference of the transference, as mentioned earlier, in a different context. For everyday reality can provide no actual answer to such cravings. In this connection, note, Freud’s genial envy of Pfister. If the man of faith finds this gratification in revealing religion, others in a wide range of secular beliefs and ‘leaders’ the modern rational and sceptical intellectual is less fortunate in this respect. Presumably free, he is prone to invest even intellectual disciplines or the proponents with inappropriate expectations and partisan passions, but, least of mention, that within these fields of analytical and theoretical thought, is not to provide exceptions to this tendency.
Though if one is to maintain and beneficially confine its bothering of reservations about the clarity of conceptualization, the explanatory discussion of Kohut and Seitz, is a very useful contribution to the direct complication or which by some understanding the awkwardness of oneself. Both Loewald and Kohut have deliberately associated a special but the different use of one of Freud’s three conceptions of transference, i.e., the transference from the unconscious to the preconscious.
Yet, to furthering comments on primordial transference, at least potentially, are largely psychological (mental) component, the concept of ‘transference of the transference’ would be applicable to this component. For it does appear that certain aspect of the search for the omnipotent and omniscient caretaking parents are implicitly practical as virtually capable for being turned to use or account for its functional practicability for something of a process or the procedure for being all but the essential purpose to come to or tend toward a common point, for which are the knowledgeable information or ideas, is nothing but causative effectuality. As suggested earlier, there are important qualitative and quantitative distinctions in the mode of persistence and such strivings, however, even to the extent that they are detached from the analyst and carried into some reasonably appropriate expression in everyday life, they retain at least a subtle quality which contravenes reality, one which derives from earliest infancy, and remains - to this extent - a transference. ‘Santa Claus’ lives on, where one might least expect to meet him, whether as a donor of miracle drug or of far more complex panaceas.
If one prescribes to this parasymbiotic transference drive, a true primordial origin, it is necessary to take cognizance of certain important concepts dealing with the earliest period of life. If we assume a powerful original organismic drive toward an original ‘object’, a striving to nullify separation from the beginning, how does this make something legally valid or operative usually by formal approval or sanctioned with concepts such as ‘primary narcissism’ or the ‘objectless phase’ or ‘the primary psycho physiological self’ (We note in passing that there are those who do not accept these as usually construed in the technique of Balint), for example, or Fairbairn or - conspicuously - Melanie Klein. These are states, variously defined or conceived, which apply to the earliest neonatal period, in which life, to state more simply, exists only as the potential in physiological processes. Since there is (we postulate) no clear awareness of self-withdrawal from the mother, there can be no ‘mentally’ represented or experienced drive to obliterate the separation (concerning oneself and object, conceiver of as separate, in a continuing sense). There are, of course, discharge phenomena, the precursors of purposive activity, and there are urgent physiological needs, directed toward fulfilment or relief, rather than toward an object as such. However, in relation to these physiological needs as archaistic precursors of object relationships, it must be noted that in all, except respiration and spontaneous sphincter relief (even in these instances, not without exception or reservation), the need fulfilment must be mediated by the primordial object (or her surrogate). There is also, of course, the uniquely important requirement for ‘holding’, in a literal expression, from the outset. The material partner in human symbiosis which supplies what the neonate cannot seek by ‘clinging’, as for Bowlty and Murphy, in the sense that must be experienced to the physiological ebb and flow of tension, even if restricted to the kinaesthetic, connected with a peripheral sensory registration, which is the protophase of the recognition of separation from the object or nonpresence of the object, as a painful instance of, her presence in apposition the converse? That the general context may be only in which the sense of unity is preponderant, or, more accurately, that there is no general awareness of ‘separation’ as such, means that the drive for union does not exist in a general psychological sense. It is, so to speak, satisfied. That object constancy, with its cognate ‘longing’, is quite a different experience from the urgencies of primitive need fulfilment is true, however, regardless of what may be added by maturational and developmental considerations, instinctual and perceptual, there is no reason to assume other than a core of developmental continuity from the earliest needs and their fulfilment to the later state, and some continuing degree of contingency based on them.
There is a very rough parallel in the way certain analytic patients, before a firm relationship with the analyst is established, signal certain primitive experiences and tendencies in special reactions to the end of the hour, to the nonvisibility of the analyst, to interruption of their association, to failure of the analyst to talk, and similar matters. We must note that in the basic formation of the ego is evident amongst the primitive reactions and beyond to separations, in the form of very early identifications as based on care taking functions. Certainly in the very development of autonomous ego of the mother’s investment in the, have a decisive role in the character of the their development. And in the case of object constancy, in its connotation of libidinal cathexis, where is no need whatsoever (emotional or otherwise) is needed for prolonged periods. The importance of the object is, to put it mildly, liable to deteriorate, or to differ complicating aggressive change. Probably the characteristic feature of later developing relations to the object (love and the wish for love), as separate if not always separated from demonstrable primitivity, in the need fulfilment, have a special relationship to those ‘ancillary’ aspects of neonatal nurture, whose lack has been shown to be an actual threat to life in some instances, not to speak of sound emotional development. So that from the first, regardless of the assumed state of libidinal (and aggressive) economy, or the assumed state of psychological nondifferentiation between self and potential object, there are critical percussive phenomena, objectively observed, and probably prototypic subjective experiences of separation, which are the forerunners of all subsequent experiences of the kind. One may generalize to the effect that, with maturation and development, secondary identifications, and the various other processes of ‘internalization’ in its broadest sense, the problem of separation and its mastery becomes correspondingly more complex, and changes with the successive phase of life, but never entirely disappears.
In the view of the psychoanalytic situation described earlier, the latent mobilization of experiences of separation stimulated by the situational structure awakens the driving primordial urge to undo or to master the painful separations which it represents, usually embodied in the various forms of clinical transference that which we are familiar. One legitimate gratification which tends to mitigate superfluous transference regression is the transmission of understanding that at times, are thought that by the ‘mature transference’, in effect, the ‘therapeutic alliance’ or a group of mature ego functions which enter into such an alliance. Now, there is one blurring and overlapping at the conceptual edges in both instances, but the concept as such is largely distinct from either one, as it is from the primitive transference, which we have been discussing. Whether the concept is thought by others to comprehend a demonstrable actuality, which is a further question. This question, of course, can only follow on conceptual clarity. This in saying, of a nonrational urge, not directly dependent on the perception of immediate clinical purposes, a true transference in the sense that it is displaced (in currently relevant form) from the parent of early childhood to the analyst. Its content is not anti-sensational, but largely non-sensual of sometimes transitional, as the child’s pleasure in the assemblages of ‘dirty words’ and encompasses a special and not minuscule sphere of the object relationship: The wish to understand, and to be understood, the wish to be given understanding, i.e., teaching, specifically by the parent (or later surrogate); the wish to be taught to use ingenuity in making or doing o r achieving an end through the actions in a nonpunitive way, corresponding to the growing perception of hazard and conflict and very likely the implicit wish to be provided with and taught channels of substitutional drive discharge. With this, there may well be a wish, corresponding to that element in Loewald’s description of therapeutic process, to be seen in terms of one’s developmental potentialities by the analyst. No doubt, the list could be extended into many subtleties, details, and variations. However, one should not omit to specify that, in its peak development, it would include the wish for increasingly accurate interpretations and the wish to facilitate such interpretations by providing adequate material ultimately, of course, by identification, to participate in, or even be the author of the interpretations. The childhood system of wishes which underlies the transference is a correlate of biological maturation, and the latent (i.e., teachable) autonomous ego function, appearing with it, however, there is a drive-like quality in the participation phenomena, which disqualifies any conception of the urge’s identical with the functions. No one who has ever watched a child importune a parent with questions, or experiment with new words, or solicit her interests in a new game, or demand a storytelling or reading, can doubt this. That this powerful support and integration in the ego identification with a loved parent is undoubtedly true, just as it is true of the identification with an analyst toward whom a positive relationship has been established. That ‘functional pleasure ‘ inscribes the part, where certain specific ego energies, perhaps very likely the ego’s own urge to extend its hegemony in the personality. However, it can be stressed in the derive element, even the special phase configurations and colourations, and with its importance of object relations, libidinal and aggressive, for a specific reason. For just as the primordial transference seeks to undo separation, in a sense to obviate object relationships as we know them, the ‘mature transference’, tends toward separation and individuation, and increasing contact with the environment, optimally with a large affirmative (increasing neutralized) relationship toward the original object toward whom (or her surrogates) a different dynamic of demands is now increasingly directed. The further considerations which has led to the emphasis that the drive-like element in these attitudes are integrated phenomena, as examples of ‘multiple functional’ rather than the discrete exorcise of function or functions, is the conviction that there is a continuing dynamic relation of relative interchangeability between the two series, at least based on the response to gratifications in a significant zone of complicated energetic overlap, possibly including the phenomenon of neutralization. That the empirical ‘interchangeability’ is limited, and that goes without saying, that in no way diminishes its decisive importance. The linguistic communications as in mention, that the excessive transference neurosis regression, which can seriously vitiate the affirmative psychoanalytic process, finds a prototype in the regressive behaviour and demands of certain children, who do not receive their share of teaching, ‘attention’, play, nonseductive, affectionate demonstration, as to use the quality of being appropriate or valuable to some end, even the act or practice of using something or the state of being used to which of responsible interests in development, and similar matters, from their parents. In the psychnalytic situation, both the gratifications offered by the analyst and the freedom of expression by the patient, are diversely limited and concentrated, practically entirely (in the every day demonstrable sense) in the sphere of linguistic expression, on the analyst’s side, further, in the transmission of understanding.
Whereas, the primordial transference exploits the primitive aspects of linguistic communication, by expressing the mature transference as to advocate the seeking mastery of the outer and inner environments, a mastery to which the mature elements in speech contribute importantly, for which these are stressed upon the clear-cut genetic prototype for the free associating its interpretative dialogue is the original learning and teaching of speech, the dialogue between child and mother. It is interesting to note that just as the profundities of interests between people who often include - in the service of the ego - transitory introjection and identifications, of the very word ‘communication’, representing the central ego function of speech, from which is a closely intimate relation to the etymologically certain, in actual usages, to the word chosen for that major of religious sacrament for that which is the physical ingestion of the body and blood of the Deity. Perhaps, this is just another suggestion that the oldest of individual problems does, after all, continue to seek its solution, in its own terms if only in a minimal sense, and in channels so remote as to be unrecognizable.
The mature transference is a dynamic and integral part of the therapeutic alliance, alone with the tender aspect of the erotic transference, even more attenuated (and more dependable) friendly feeling of adult type, and the ego identification with the analyst. Indispensable, of course, are the genuine adult need for help, the crystallizing rational and intuitive appraisal of the analyst, the adult sense of confidence in him, and innumerable other nuances of adult thought and feeling. With these, giving a driving momentum and power to the analytic process, but always, by its very nature, a potential source of resistance, and always requiring analysis, is the primordial transference and its various appearances in the specific therapeutic transference. That it is, if well managed, not only a reflection of the repetition compulsion in its menacing sense, but a living presentation from the id, seeking new solutions, and trying again, so to speak, to find a place in the patient’s conscious and effective life, has important affirmative potentialities. This has been specifically emphasized by Nunberg, Lagache and Loewald among others. Loewald has recently elaborated very effectively the idea of ‘ghosts’ seeking to become ‘ancestors’ based on an early figure of speech of Freud. The mature transference, in its own infantile right, provides some of the unique qualities of propulsive force, which comes from the world of feeling, rather than the world of thought. If one views it in a purely figurative sense, that fraction of the mature transference which derives from ‘conversion’ is somewhat like propulsive fraction as the wind in a boats sailing to windward currents into motion, the strong headwind, the ultimate source of both resistance and propulsion, is the primordial transference. This view, however, should not displace the original and independent, if cognate, a favourable tide or current would also be required. It is not that the mature transference is itself entirely exempt from analytic clarification and interpretation. For one thing, in common with other childhood spheres of experience, there may have been traumas in this sphere, punishments, serious defects or lacks of parental communication, Listening, attention or interest. In general, this is probably far more important than has hitherto appeared in our prevalent paradigmatic approach to adult analysis, even taking into account the considerable changes due to the growing interest in ego psychology. ‘Learning’ in the analysis can, of course, be a troublesome intellectualizing resistance. Furthermore, both the patient’s communications and his receptions and utilization of interpretations may exhibit only too clearly, as sometimes in the case of other ego mechanisms, their origin in and tenacious relation to instinctual or anaclitic dynamism; the longing implement out of silence for which the analyst is to override the uncritical acceptance (or rejection) of interpretations, in that the patient revealingly is to mention the unmindful assimilation, fluently, rich, endlessly detailed associations without spontaneous reflection or integration. In the direct demands for solution of moral and practical probability for an entirely intellectual scope, and a variety of others. It may and always be easy to discriminate between the utilization of speech by an essentially instinctual demand, and an intellectual or linguistic trait or having to be determined by specific factors in their own developmental sphere, however, the underlying and essentially genuine dynamism which have to continue to be placed for a notable time interval or remain to an arbitrary or conventional character most favoured to the purposes of processes of analysis, as it was to the original processes of maturational development, communication, and benign separation. Lagache, on the desirability of separating the current unqualified usage, ‘positive’ and ’negative’ transference, as based on the patient‘s immediate state of feeling, from a classification based on the essential effect on analytic processes. Yet, the later of mature transference is, in general, a ‘positive transference’.
Concerning considerations in the transference neurosis, and the problem of transference interpretation, may be offered at this point. The whole situational structure of analysis (in contrast with other personal relationships), its dialogue of free association and interpretation, and its deprivations as to most ordinary cognitive and emotional interpersonal drives that tend toward the separation of discrete transferences from their synthesis with one another and with defences in character or symptoms, and with deepening regression, toward a continuative enactment of the essential of the infantile neurosis, in the transference neurosis. In other relationships, the ‘give and take’ aspects - gratifying aggressive, punitive or otherwise actively responsive, and the open mobility of searching for alternative or greater satisfaction - exert a profound dynamic and economic influence, so that only extraordinary situations, or transference of pathological character, or both, occasion to comparable regression.
It is a curious fact, whereas the dynamic meaning to the importance of the transference neurosis have been well established since Freud gave this the phenomenon a central position in his clinical thinking, the clinical reference, when the term is used, remains variable and somewhat ambiguous. For example, Greenson, in his excellent recent paper, speaks of it as appearing, ‘when the analyst and the analysis become the central concern in the patient’s life’. However, previous remarks in this connection, for which it is worthwhile to specify certain aspects of Greenson’s definition, for the term ‘central’ is somewhat ambiguous, as to its specific reference. Certainly, the term could apply to the symbolic position of the analyst in relation to the patient’s experiencing ego and the symbolically decisive position which he correspondingly assumes in the relation to the other important figures in the patient’s current life. However, while the analysis is in any case, and for multiple reasons, exceedingly important the seriously involved patient, there is a free observing portion of is ego, also involved, not in the same sense as that involved in the transference regression and revived in infantile conflicts. And here is here being, of course, always the integrated adult personalty, however diluted in may seem at times, of its rarity, although certainly does occur, that the analysis actually exceeds the quality or state of being of notable worth or influence that the other major concerns, attachments, and responsibilities of the patient’s life, nor is it desirable that his should occur, on the other hand, if construed with proper attention to the economic considerations as mentioned, the concept is important, both theoretically and clinically. In the theoretical direction to the assumption that there is a continuing system of object relationships and conflict situations, most important in the unconscious representations, but participating to some degree in all others, deriving in a successive series of transference from the experiences of separation from the original object, the mother. In this sense, the analyst’s applicability to a uniquely important portion of the patient‘s personality, the portion that ‘never grew up’, to maintain a central figure. In the clinical sense, to call or direct attention especially to a supposed cause, source, or to refer to the importance of the transference neurosis as outlining for the essential and central analytic task, providing by its very currency and demonstrability a relatively secure cognitive base for procedural duties. By its inclusion of the patient’s essential psychopathological processes and tendencies, in their original functional connection, it offers, in its resolution or marked reduction, the most formidable lever for analytic cure. Nonetheless, transference neurosis must be seen in its interweaving with the patient’s extra-analytic system of personal contacts. The relationship to the analyst may influence the course of relationships to others, in the same sense that the clinical neurosis did, except that the former is alloplastic, relatively exposed, and subject to constant interpretation. It is also an important fact that, except in those rare instances where the original dyadic relationship appears to turn, the analyst, even in the strict transference sphere, cannot be assigned all the transference role simultaneously. Other actors are required. He may at times oscillate with confusing rapidity between the status of mother and father, but he is usually predominantly in one of the roles for long periods, someone else representing the other. Furthermore, apart from ‘acting out’, complicated and mutually inconsistent attitudes of the anterior apprehensions for realizing often about something not generally realized in the verbalization, may require the seeking of other transference objects, i.e., The husband or wife, friend, another analyst and so forth. Children, even the patient’s own children, may be invested with strivings of the patient, displaced from the analysis, even experience the impulses which they would wish to call forth in the analyst. The range is extensive, varied, and complicated, requiring constant alertness. Transference interpretation therefore often has a necessarily paradoxical inclusiveness, which is an important reality of technique. There is another aspect, and that is the dynamic and economic impact of the intimate and actual dramatist personate of the transference neurosis in the progress of the analysis as such, and on the patient ‘s motivation, as well as his real lifer avenues for recovery. For the persons in his milieu may fulfill their ‘positive’ or ‘negative ‘ roles in transference drama, which may facilitate or impede interpretative effectiveness, they provide the substantial and dependable real life gratification which ultimately facilitate the analysis of the residual analytic transference, or their capacities or attitudes may occasion overload of the anaclitic and instinctual needs in the transference which renders the same process far more difficultly. In the most unhappy instances, there can be a serious undercounting of the motivation for basic change.
There is also the fundamental question of the role of the transference interpretation. At the Marienbad Symposium most of Strachey’s colleagues appeared to accept the essential import of his contribution and thus unique significance of the transference interpretations, despite the various reservations as to detail and emphasis on other important aspects of the therapeutic process. Nevertheless, there are still many who, if not in doubt regarding the great value of transference interpretations are inclined to doubt their uniqueness, and to stress the importance of economic considerations in determining the choice as to whether transference or extratransference interpretations may be indicated. Now, apart from the realistic considerations mentioned in the preceding passage (in a sense the necessarily ‘distributed’ character of a variable fraction of transference interpretation). There is in fact that the extra-analytic life of the patent often provides indispensable data fo the understanding of detailed complexities of his psychic functioning, because of the sheer variety of its references, some of which cannot be reproduced in the relationship to the analyst. For example, there is no repartee (in the ordinary sense ) in the analysis. The way the patient handles the dialogue with an angry employee may be importantly revealing. The same may be true of the quality of his reaction to a real danger of dismissal. There is not only the realities, but the ‘formal’ aspects of this responses. These expressions of personality remain important, even though his ‘acting out‘ of the transference (assuming this was this was the case) may have been more important, and, of course, requiring transference interpretation. Furthermore, they remain useful, if discriminatingly and conservatively treated, even if they are inevitably always subject that epistemological reservations, which haunts so much of analytic data. Of course, the ‘positive’ transference has a role in the utilization of such interpretations that what enables the patent to listen to them and them seriously.
In an operational sense, it would seem that extratransference interpretations cannot set aside, or underestimated in importance, but the unique effectiveness of transference interpretations is not thereby disestablished. No other interpretation is free, within reason, of the doubt introduced by not really knowing the ‘other person’s’ participation in love, or quarrel or criticism or whatever the issue. And no other situation provides the patient the combined sense of cognitive acquisition, with the experience of complete personal tolerance and acceptance, that is implicit in an interpretation by an individual who is an object of the emotion, drive, or even defences, which are active at the time. There is no doubt that such interpretations must not only (in common with all others) include personal tact, but must be offered with special care as to their intellectual reasonability, in relation to the immediate context, lest they defeat their essential purpose. It is not too often likely that a patient who has just been jilted in a long-standing love affair, and suffering exceedingly, will find an immediate interpretation that his suffering is due to the fact that the analyst does not reciprocate his love, even though a dynamism in this general sphere may be ultimately demonstrable, and acceptable to the patient. On the other hand, once the transference neurosis is established, with accompanying subtle (sometime gross) colouration of the patient’s life, th n more far-reaching anticipatory, transference interpretations are indicated, for, if all of the patient’s libidinal and aggression is not, in fact, invested in the analyst, he has at least an unconscious role in all important emotional transactions, and, if the assumption is correct that the regressive drive, mobilized by the analytic situation, is in the direction of restoration of a single all-encompassing relationship, specified pragmatically in the individual case by the actually attained level of development, then there is a dynamic factor at work, importantly meriting interpretation as such, to the extent that available material supports it. This would be the immediate clinical application on the material regarding the ‘cognitive lag’ or ‘cognitive fall-back’.
Post-Traumatic Stress Disorder, resides in a mental illness that some people develop after experiencing traumatic or life-threatening events. Such events include warfare, rape and other sexual assaults, violent physical attacks, torture, child abuse, natural disasters such as earthquakes and floods, and automobile or aeroplane crashes. People who attest of the traumatic events may also develop the disorder.
Post-traumatic stress disorder in war veterans is sometimes called shell shock or combat fatigue. In victims of sexual or physical abuse, the disorder has been called rape trauma or battered woman syndrome. The American Psychiatric Association (APA) adopted the current name of the disorder in 1980.
In the late 1960's and early 1970's, mass demonstrations erupted throughout the United States protesting US involvement in the Vietnam War (1959-1975). Thousands of veterans joined together in a national organization, Vietnam Veterans Against the War, that supported and influenced the antiwar movement. In this transcript from an April 22, 1971, hearing before the Senate Committee on Foreign Relations, committee chairman Senator J. William Fulbright indicated his sympathy for the antiwar movement. Fulbright’s comments were followed by the testimony of Vietnam veteran John Kerry, who called for an end to the war. Kerry also detailed what he believed to be the war’s negative effect in both Vietnam and the United States. Kerry became a Democratic senator from Massachusetts in 1985.
People with this disorder relive the traumatic event again and again through nightmares and disturbing memories during the day. They sometimes have flashbacks, in which they suddenly lose touch with reality and relive images, sounds, and other sensations from the trauma. Because of their extreme anxiety and disruptive opposition to events, they try to avoid anything that reminds them of it. They may seem emotionally numb, detached, irritable, and easily startled. They may feel guilty about surviving a traumatic event that killed other people. Other symptoms include trouble concentrating, depression, and sleep difficulties. Symptoms of the disorder usually begin shortly after the traumatic event, although some people may not show symptoms for several years. If left untreated, the disorder can last for years.
Post-traumatic stress disorder can severely disrupt one’s life. Besides the emotional pain of reliving the trauma, the symptoms of the disorder may cause a person to think that he or she is ‘going crazy.’ In addition, people with this disorder may have unpredictable, angry outbursts at family members. At other times, they may seem to have no affection for their loved ones. Some people try to mask their symptoms by abusing alcohol or drugs. Others work very long hours to prevent any ‘down’ periods when they might relive the trauma. Such actions may delay the onset of the disorder until these individuals retire or become sober.
Studies have set or to bring into a new found control from 1 to 14 percent of people that suffer from post-traumatic stress disorder at some point during their lives. The findings vary widely due to differences in the populations studied and the research methods used. Among people who have survived traumatic events, the prevalence appears to be much higher. The disorder may be particularly prevalent among people who have served in combat. For example, one study of veterans of the Vietnam War (1959-1975) found that veterans exposed to a high level of combat were nine times more likely to have post-traumatic stress disorder than military personnel who did not serve in the war zone of Southeast Asia.
Post-traumatic stress disorder is an extreme reaction to extreme stress. In moments of crisis, people respond in ways that allow them to endure and survive the trauma. Afterward those responses, such as emotional numbing, may persist even though they are no longer necessary.
Not everyone who experiences a traumatic event develops post-traumatic stress disorder. Several factors influence whether people develop the disorder. Those who experience severe and prolonged trauma are more likely to develop the disorder than people who experience less severe trauma. Additionally, those who directly witness or experience death, injury, or attack are more likely to develop symptoms.
People may also have been existing biological and psychological vulnerabilities that make them more likely to develop the disorder. Those with histories of anxiety disorders in their families may have inherited a genetic predisposition to react more severely to stress and trauma than other people. In addition, people’s life experiences, especially in childhood, can affect their psychological vulnerability to the disorder. For example, people whose early childhood experiences made them feel that events are unpredictable and uncontrollable have a greater likelihood than others of developing the disorder. Individuals with a strong, supportive social network of friends and family members seem somewhat protected from developing post-traumatic stress disorder.
Treatment of post-traumatic stress disorder may involve psychotherapy, psychoactive drugs, or both. Psychotherapists help individuals confront the traumatic experience, work through their strong negative emotions, and overcome their symptoms. Many people with post-traumatic stress disorder benefit from group therapy with other individuals suffering from the disorder. Physicians may prescribe antidepressants or anxiety-reducing drugs to treat the mood disturbances that sometimes accompany the disorder.
At the arriving considerations that are marked and noted, through which the essence of functional dynamics as based of the transference in the psychoanalytic process or the basic underlying the most basic of beliefs that in politics there is neither good nor evil, however, in that something that forms part of the minimal body, character or structure of that thing predetermines the properties to the good life. Nonetheless, most psychoanalysts maintain that schizophrenic patients cannot be treated psychoanalytically because they are too narcissistic to develop with the psychotherapist as interpersonal relationship that is sufficiently reliable and consistent for psychoanalytic work. Freud, Fenichel and others have recognized that a new technique of approaching patients psychoanalytically must be found if analysts are to work with psychotics. Among those who have worked successfully in recent years with schizophrenics, Sullivan, Hill, and Karl Menninger and his staff have made various modifications of their analytic approach. The techniques that are in use with psychotics is different from our approach to psychoneurotics. This is not a result of the schizophrenic’s inability to build up a consistent personal relationship with the therapist but due to his extremely intense and sensitive transference reactions.
Let us see first what the essence of the schizophrenic’s transference reactions are and how we try to meet these reactions.
We think of a schizophrenic as a person who has had serious traumatic experiences in early infancy at a time when his ego and its ability to examine reality were not yet developed. These early traumatic experiences seem to furnish the psychological basis for the pathogenic influence of the frustrations of later years. At this early time the infant lives grandiosely in a narcissistic world of his own. His needs and desires seem to be taken care of by something vague and indefinite which he does not yet differentiate. As Ferenczi noted, they are expressed by gestures and movements since speech is as yet undeveloped. Frequently the child’s desires are fulfilled without any expression of them, a result that seems to him a product of his magical thinking.
Are a person’s characteristics primarily shaped by early influences, remaining relatively stable thereafter throughout life? Or does change spontaneously occur continuously throughout life? Many people believe that early experiences are formative, providing a strong or weak foundation for later psychological growth. This view is expressed in the popular saying ‘As the twig is bent, so grows the tree.’ From this perspective, it is crucial to ensure that young children have a good start in life. But many developmental scientists believe that later experiences can modify or even reverse early influences; studies show that even when early experiences are traumatic or abusive, considerable recovery can occur. From this vantage point, early experiences influence, but rarely determine, later characteristics.
Traumatic experiences in this early period of life will damage a personality more seriously than those occurring in later childhood such as are found in the history of psychoneurotics. The infant’s mind is more vulnerable the younger and less used it has been, further, the trauma has quickened the infant ‘s egocentricity. In addition early traumatic experiences shortens the only period in life in which an individual ordinarily enjoys the most security, thus endangering the ability to store up as it were a reasonable supplies of assurance and self-reliance for the individual’s later struggles through life. Thus, as such, a child sensitized considerably more toward the frustrations of later like than by later traumatic experiences. hence many experiences in later life which would mean little to a ‘healthy’ person and not much to a psychoneurotic, mean a great deal of pain and suffering to the schizophrenic. His resistance against frustration is easily exhausted.
Once he reaches his limit of endurance, he escapes the unbearable reality of his present life by attempting to reestablish the autistic, delusional world of the infant, but this is impossible because the content of his delusions and hallucinations are naturally coloured by the experiences of his whole lifetime.
How do these developments influence the patient’s attitude toward the analyst and the analyst’s approach to him?
Due to the very damage and the succeeding chain of frustrations which the schizophrenic undergoes before finally giving in to illness, he feels extremely suspicious and distrustful of everyone, particularly of the psychotherapist ho approaches him with the intent of intruding into his isolated world and personal life. To him the physician’s approach means the threat of being compelled to return to the frustrations of real life and to reveal his inadequacy to meet them or, - still worse – a repetition of the aggressive interference with his initial symptoms and peculiarities which he has encountered in his previous environment.
The difficulty that the patient’s dilemma through his frustrations is the product through which is called ‘delusion’: Delusion itself is a false belief which is firmly held by a person even though other people recognize the belief as obviously untrue. For example, a person who truly believes he is Napoleon Bonaparte is delusional. Religious beliefs or popular conceptions, such as the belief that people have been abducted by aliens, are not delusions because they are widely held beliefs. Delusions are a type of psychotic symptom that indicate a person has lost contact with reality.
There are many different types of delusions. A person with a paranoid delusion believes that others - such as the FBI, or the CIA, even the Mafia as trying to harm or plot against him. A person with a delusion of reference believes that events or people refer specifically to him or her when they do not. For example, a woman with schizophrenia may believe that a television news broadcaster is talking personally to her rather than to the entire viewing audience. A grandiose delusion is a belief that one is extremely famous or that one has special powers, such as the ability to magically heal people.
A delusion of control is a belief that others are able to control one’s thoughts, feelings, or actions. For example, a man with this type of delusion may believe that someone has implanted a microchip in his brain that enables other people to control his thoughts. A somatic delusion is a belief that something is wrong with one’s body - for example, that one’s brain is rotting away - even though no medical evidence supports this belief. A person with an erotic delusion believes that someone is in love with him or her despite a lack of evidence for this belief. In a delusion of jealousy, a person believes that his or her spouse or lover is unfaithful despite evidence to the contrary.
Delusions commonly occur in certain severe mental illnesses, such as schizophrenia, bipolar disorder (also called manic-depressive illness), some cases of major depression, Dissociative disorders, post-traumatic stress disorder, and paranoid personality disorder. In addition, delusions may result from abuse of certain drugs, including alcohol, cocaine, amphetamines, and hallucinogens such as lysergic acid diethylamide (LSD), phencyclidine (PCP), and mescaline. Medical conditions affecting the brain, such as syphilis and brain tumours, may also cause delusions.
Delusional disorder is a relatively uncommon mental illness characterized by delusions. People with this disorder have one or more delusions that persist for at least one month. In addition, they do not suffer from other symptoms of schizophrenia, such as disorganized speech and bizarre behaviour. Usually their delusions are less bizarre than those that occur in schizophrenia and seem merely odd or unsupported by facts. Examples of nonbizarre delusions include beliefs that one is being followed, loved by someone famous, or deceived by one’s spouse. Because delusional disorder is relatively rare, little research has systematically examined its treatment. However, doctors most often use Antipsychotic drugs (also called neuroleptics) to treat this disorder. These drugs help reduce or eliminate delusions, hallucinations, and other psychotic symptoms.
In spite of his narcissistic retreat, every schizophrenic has some underlying notion of the unreality and loneliness of his substitute delusionary world. He longs for human contact and understanding, yet is afraid to admit of himself, or his therapist for fear of further frustration.
That is why the patient may take weeks and months to test the analyst before being willing to accept him, however, once he has accepted him. His dependence on the analyst is greater and he is more sensitive about it than is the psychoneurotic because of the schizophrenic’s deeply rooted insecurity, the narcissistic seemingly self-righteous attitude is but a defence.
Whenever the analyst fails the patient from reasons to be discussed later - one cannot at times avoid failing one’s schizophrenic patients - it will be severe disappointment and a repetition of the chain of frustrations the schizophrenic has previously endured.
The instinctually primitive part of the schizophrenic’s mind that does not discriminate between himself and the environment, it may mean the withdrawal of the impersonal supporting forces of his infancy. Severe anxiety will follow this vital deprivation.
In the light of his personal relationship with the analyst it means that the therapist seduced the patient to use him as a bridge over which he might possibly be led from the utter loneliness of his own world to reality and human warmth, only to have him discover that this bridge is not reliable. if so, he will respond helplessly with an outburst of hostility or with renewed withdrawal as may be seen most impressively in catatonic stupor.
The symptoms of mental illness can be very distressing. People who develop schizophrenia may hear voices inside their head that say nasty things about them or command them to act in strange or unpredictable ways. Or they may be paralyzed by paranoia—the deep conviction that everyone, including their closest family members, wants to injure or destroy them. People with major depression may feel that nothing brings pleasure and that life is so dreary and unhappy that it is better to be dead. People with panic disorder may experience heart palpitations, rapid breathing, and anxiety so extreme that they may not be able to leave home. People whom experience episodes of mania may engage in reckless sexual behaviour or may spend money indiscriminately, acts that later cause them to feel guilt, shame, and desperation.
Other mental illnesses, while not always debilitating, create certain problems in living. People with personality disorders may experience loneliness and isolation because their personality style interferes with social relations. People with an eating disorder may become so preoccupied with their weight and appearance that they force themselves to vomit or refuse to eat. Individuals who develop post-traumatic stress disorder may become angry easily, experience disturbing memories, and have trouble concentrating.
Experiences of mental illness often interact differently but depends on one’s culture or social group, sometimes greatly so. For example, in most of the non-Western world, people with depression complain principally of physical ailments, such as lack of energy, poor sleep, loss of appetite, and various kinds of physical pain. Indeed, even in North America these complaints are commonplace. But in the United States and other Western societies, depressed people and mental health professionals who treat them tend to emphasize psychological problems, such as feelings of sadness, worthlessness, and despair. The experience of schizophrenia also differs by culture. In India, one-third of the new cases of schizophrenia involve catatonia, a behavioural condition in which a person maintains a bizarre statue like pose for hours or days. This condition is rare in Europe and North America.
With appropriate treatment, most people can recover from mental illness and return to normal life. Even those with persistent, long-term mental illnesses can usually learn to manage their symptoms and live productive lives.
By a variety of symptoms, including loss of contact with reality, bizarre behaviour, disorganized thinking and speech, decreased emotional expressiveness, and social withdrawal. Usually only some of these symptoms occur in any one person. The term schizophrenia comes from Greek words meaning ‘split mind.’ However, contrary to common belief, schizophrenia does not refer to a person with a split personality or multiple personality. For a description of a mental illness in which a person has multiple personalities. To observers, schizophrenia may seem or appear for being as some sorted kind of madness or a manufacturing insanity.
Perhaps more than any other mental illness, schizophrenia has a debilitating effect on the lives of the people who suffer from it. A person with schizophrenia may have difficulty telling the difference between real and unreal experiences, logical and illogical thoughts, or appropriate and inappropriate behaviour. Schizophrenia seriously impairs a person’s ability to work, go to school, enjoy relationships with others, or take care of oneself. In addition, people with schizophrenia frequently require hospitalization because they pose a danger to themselves. About 10 percent of people with schizophrenia commit suicide, and many others attempt suicide. Once people develop schizophrenia, they usually suffer from the illness for the rest of their lives. Although there is no cure, treatment can help many people with schizophrenia lead productive lives.
Schizophrenia also carries an enormous cost to society. People with schizophrenia occupy about one-third of all beds in psychiatric hospitals in the United States. In addition, people with schizophrenia account for at least 10 percent of the homeless population in the United States. The National Institute of Mental Health has estimated that schizophrenia costs the United States tens of billions of dollars each year in direct treatment, social services, and lost productivity.
Approximately 1 percent of people develop schizophrenia at some time during their lives. Experts estimate that about 1.8 million people in the United States have schizophrenia. The prevalence of schizophrenia is the same regardless of sex, race, and culture. Although women are just as likely as men to develop schizophrenia, women tend to experience the illness less severely, with fewer hospitalizations and better social functioning in the community.
Schizophrenia usually develops in late adolescence or early adulthood, between the ages of 15 and 30. Much less commonly, schizophrenia develops later in life. The illness may begin abruptly, but it usually develops slowly over months or years. Mental health professionals diagnose schizophrenia based on an interview with the patient in which they determine whether the person has experienced specific symptoms of the illness.
Symptoms and functioning in people with schizophrenia tend to vary over time, sometimes worsening and other times improving. For many patients the symptoms gradually become less severe as they grow older. About 25 percent of people with schizophrenia become symptom-free later in their lives.
A variety of symptoms characterize schizophrenia. The most prominent include symptoms of psychosis—such as delusions and hallucinations - as well as bizarre behaviour, strange movements, and disorganized thinking and speech. Many people with schizophrenia do not recognize that their mental functioning is disturbed.
Delusions are false beliefs that appear obviously untrue to other people. For example, a person with schizophrenia may believe that he is the king of England when he is not. People with schizophrenia may have delusions that others, such as the police or the FBI, are plotting against them or spying on them. They may believe that aliens are controlling their thoughts or that their own thoughts are being broadcast to the world so that other people can hear them.
Research suggests that the genes one inherits strongly influence one’s risk of developing schizophrenia. Studies of families have shown that the more close one is related to someone with schizophrenia, the greater the risk one has of developing the illness. For example, the children of one parent with schizophrenia have about a 13 percent chance of developing the illness, and children of two parents with schizophrenia have about a 46 percent chance of eventually developing schizophrenia. This increased risk occurs even when such children are adopted and raised by mentally healthy parents. In comparison, children in the general population have only about a 1 percent chance of developing schizophrenia.
Some evidence suggests that schizophrenia may result from an imbalance of chemicals in the brain called neurotransmitters. These chemicals enable neurons (brain cells) to communicate with each other. Some scientists suggest that schizophrenia results from excess activity of the neurotransmitter dopamine in certain parts of the brain or from an abnormal sensitivity to dopamine. Support for this hypothesis comes from Antipsychotic drugs, which reduce psychotic symptoms in schizophrenia by blocking brain receptors for dopamine. In addition, amphetamines, which increase dopamine activity, intensify psychotic symptoms in people with schizophrenia. Despite these findings, many experts believe that excess dopamine activity alone cannot account for schizophrenia. Other neurotransmitters, such as serotonin and norepinephrine, may play important roles as well.
Although scientists favour a biological cause of schizophrenia, stress in the environment may affect the onset and course of the illness. Stressful life circumstances - such as maturing in age and character as for living in poverty, the death of a loved one, an important change in jobs or relationships, or chronic tension and hostility at home—can increase the chances of schizophrenia in a person biologically predisposed to the disease. In addition, stressful events can trigger a relapse of symptoms in a person who already has the illness. Individuals who have effective skills for managing stress may be less susceptible to its negative effects. Psychological and social rehabilitation can help patients develop more effective skills for dealing with stress.
Although there is no cure for schizophrenia, effective treatment exists that can improve the long-term course of the illness. With many years of treatment and rehabilitation, significant numbers of people with schizophrenia experience partial or full remission of their symptoms.
Treatment of schizophrenia usually involves a combination of medication, rehabilitation, and treatment of other problems the person may have. Antipsychotic drugs (also called neuroleptics) are the most frequently used medications for treatment of schizophrenia. Psychological and social rehabilitation programs may help people with schizophrenia function in the community and reduce stress related to their symptoms. Treatment of secondary problems, such as substance abuse and infectious diseases, is also an important part of an overall treatment program.
Antipsychotic medications, developed in the mid-1950s, can dramatically improve the quality of life for people with schizophrenia. The drugs reduce or eliminate psychotic symptoms such as hallucinations and delusions. The medications can also help prevent these symptoms from returning. Common Antipsychotic drugs include risperidone (Risperdal), olanzapine (Zyprexa), clozapine (Clozaril), quetiapine (Seroquel), haloperidol (Haldol), thioridazine (Mellaril), chlorpromazine (Thorazine), fluphenazine (Prolixin), and trifluoperazine (Stelazine). People with schizophrenia usually must take medication for the rest of their lives to control psychotic symptoms. Antipsychotic medications appear to be less effective at treating other symptoms of schizophrenia, such as social withdrawal and apathy.
Because many patients with schizophrenia continue to experience difficulties despite taking medication, psychological and social rehabilitation is often necessary. A variety of methods can be effective. Social skills training helps people with schizophrenia learn specific behaviours for functioning in society, such as making friends, purchasing items at a store, or initiating conversations. Behavioural training methods can also help them learn self-care skills such as personal hygiene, money management, and proper nutrition. In addition, cognitive-behavioural therapy, a type of psychotherapy, can help reduce persistent symptoms such as hallucinations, delusions, and social withdrawal.
Because many patients have difficulty obtaining or keeping jobs, supported employment programs that help patients find and maintain jobs are a helpful part of rehabilitation. In these programs, the patient works alongside people without disabilities and earns competitive wages. An employment specialist (or vocational specialist) helps the person maintain their job by, for example, training the person in specific skills, helping the employer accommodate the person, arranging transportation, and monitoring performance. These programs are most effective when the supported employment is closely integrated with other aspects of treatment, such as medication and monitoring of symptoms.
Some people with schizophrenia are vulnerable to frequent crises because they do not regularly go to mental health centres to receive the treatment they need. These individuals often relapse and face rehospitalization. To ensure that such patients take their medication and receive appropriate psychological and social rehabilitation, assertive community treatment (ACT) programs have been developed that deliver treatment to patients in natural settings, such as in their homes, in restaurants, or on the street.
People with schizophrenia often have other medical problems, so an effective treatment program must attend to these as well. One of the most generally shared in or participated in things conforming to a type without noteworthy excellence or faults just as common a rule, by ordinary, frequent and ordinarily as an idea or expression deficient in originality or freshness, yet, only of its exchanging the commonplace of the common associated problems is vehemently and usually coarsely expressed condemnation or disapproved, as the interpretative category of an unequalled vocabulary is itself a genuine abuse. Successful treatment of substance abuse inpatients with schizophrenia requires careful coordination with their mental health care, so that the same clinicians are treating both disorders at the same time.
The high rate of substance abuse in patients with schizophrenia contributes to a high prevalence of infectious diseases, including hepatitis B and C and the human immunodeficiency virus (HIV). Assessment, education, and treatment or management of these illnesses is critical for the long-term health of patients.
Other problems frequently associated with schizophrenia include housing instability and homelessness, legal problems, violence, trauma and post-traumatic stress disorder, anxiety, depression, and suicide attempts. Close monitoring and psychotherapeutic interventions are often helpful in addressing these problems.
Several other psychiatric disorders are closely related to schizophrenia. In schizoaffective disorder, a person shows symptoms of schizophrenia combined with either mania or severe depression. Schizophreniform disorder refers to an illness in which a person experiences schizophrenic symptoms for more than one month but fewer than six months. In schizotypal personality disorder, a person engages in odd thinking, speech, and behaviour, but usually does not lose contact with reality. Sometimes mental health professionals refer to these disorders together as schizophrenia-spectrum disorders.
Severe mental illness almost always alters a person’s life dramatically. People with severe mental illnesses experience disturbing symptoms that can cause of such difficulties and holding to a job, or go to school, relate to others, or cope with ordinary life demands. Some individuals require hospitalization because they become unable to care for themselves or because they are at risk of committing suicide.
The symptoms of mental illness can be very distressing. People who develop schizophrenia may hear voices inside their head that say nasty things about them or command them to act in strange or unpredictable ways. Or they may be paralyzed by paranoia - the deep conviction that everyone, including their closest family members, wants to injure or destroy them. People with major depression may feel that nothing brings pleasure and that life is so dreary and unhappy that it is better to be dead. People with panic disorder may experience heart palpitations, rapid breathing, and anxiety so extreme that they may not be able to leave home. People whom experience episodes of mania may engage in reckless sexual behaviour or may spend money indiscriminately, acts that later cause them to feel guilt, shame, and desperation.
Other mental illnesses, while not always debilitating, create certain problems in living. People with personality disorders may experience loneliness and isolation because their personality style interferes with social relations. People with an eating disorder may become so preoccupied with their weight and appearance that they force themselves to vomit or refuse to eat. Individuals who develop post-traumatic stress disorder may become angry easily, experience disturbing memories, and have trouble concentrating.
Experiences of mental illness often take issue upon its stability for depending on one’s culture or social group, sometimes greatly so. For example, in most of the non-Western world, people with depression complain principally of physical ailments, such as lack of energy, poor sleep, loss of appetite, and various kinds of physical pain. Indeed, even in North America these complaints are commonplace. But in the United States and other Western societies, depressed people and mental health professionals who treat them tend to emphasize psychological problems, such as feelings of sadness, worthlessness, and despair. The experience of schizophrenia also differs by culture. In India, one-third of the new cases of schizophrenia involve catatonia, a behavioural condition in which a person maintains a bizarre statue like pose for hours or days. This condition is rare in Europe and North America.
Of furthering issues regarding depersonalization disorder, meaning, in effect, that it is a categorized illness based within its intendment for being an illness, of mind, in which people experience an unwelcome sense of detachment from their own bodies. They may feel as though they are floating above the ground, outside observers of their own mental or physical processes. Other symptoms may include a feeling that they or other people are mechanical or unreal, a feeling of being in a dream, a feeling that their hands or feet are larger or smaller than usual, and a deadening of emotional responses. These symptoms are chronic and severe enough to impede normal functioning in a social, school, or work environment.
Depersonalization disorder is a relatively rare syndrome thought to result from severe psychological stress. It may occur as part of other mental illnesses, especially anxiety disorders. For example, some people with panic disorder feel nervous, have a sense of doom about their future and health, and have a troubling sense of detachment form the lose in the attemptive use in making or doing or achieving a useful regularity as might be expected of the control over their bodies. Depersonalization disorder may also be a component of more severe mental illness, such as schizophrenia. Treatment may include training in relaxation techniques that enhance body perception and control, hypnosis to modify symptoms, and psychotherapy to explore possible stress-related components of the disorder.
Psychiatrists classify depersonalization disorder as one of the Dissociative disorders. Such disorders involve a disruption of consciousness, memory, identity, or perception.
All the while, the schizophrenic responds to altercations in the analyst’s defections and understanding by corresponding stormy and dramatic changes from love to hatred, from willingness to leave his delusional world to resistance and renewed withdrawal.
As understandable as these changes are, nevertheless may come as a surprise to the analyst who frequently has not observed their source, this is quite in contrast to his experience with psychoneurosis whose emotional reactions during an interview he can usually predict. These unpredictable changes seem to be the reason for the conception of the unreliability of the schizophrenic’s transference reaction, yet they follow the same dynamic rules as the psychoneurotic’s oscillations between positive and negative transference and resistance, however, if the schizophrenic’s reactions are stormy and seemingly more unpredictable than those of the psychoneurotic, that instances suggested to be due to the inevitable errors in the analyst’s approach to the schizophrenic, of which he himself may be unaware, rather than to the unreliability of the patient‘s emotional response?
Why is it inevitable that the psychoanalyst disappoint his schizophrenic patient time and again?
The schizophrenic withdraws from painful reality and retires to what resembles the early speechless phase of development where consciousness is not yet crystalized. As the expression of his feelings is not hindered by the convention that he has eliminated, as his thinking, feelings, behaviour and speech - when present - obey the working rules of the archaic unconscious. His thinking is magical and does not follow logical rules. It does not admit to every last ‘no’, and likewise the no to ‘yes’: There is no recognition of space and time, I, you, and they, are interchangeable expression through which of symbols and often by movement and gestures rather than by words.
As the schizophrenic is suspicious, he will distrust the words of his analyst. He will interpret them and incidental gestures and attitudes of the analyst according to his own delusional experience. The analyst may not even be aware of these involuntary manifestations of his attitudes, yet they mean much to the hypersensitive schizophrenic who uses them as a means of orienting himself to the therapist‘s personality and intentions toward him.
In other words, the schizophrenic patient and the therapist are people living in different worlds and no different levels of personal development with different means of expressing and of orienting themselves. We know little about the language of the unconscious that belongs to the schizophrenic, and our access to it is blocked by the very process of our own adjustment to a world the schizophrenic has relinquished, so, we should not be surprised that errors and misunderstandings occur when we under take to communicate and strive for a rapport with him.
Another source of the schizophrenic’s disappointment arises form which the analyser accepts and does not interfere with the behaviour of the schizophrenic, his attitude may lead the patient to expect that the analyst will assist in carrying out all the patient’s wishes, even though they may not seem to be in his interest to the analyser‘s and the hospital’s in their relationship to society. This attitude of acceptance so different from the patient’s previous experiences readily fosters the anticipation that the analyst will try to carry out the patient’s suggestion and take his part, even against conventional society with which it should occasionally arise. Frequently it will be wise for the analyst to agree with the patient‘s wish to remain unbaited and untidy until he is ready to talk about the reasons for his behaviour or to change spontaneously. At other times, he will unfortunately be unable to take the patient’s part without being able to make the patient understand and accept the reasons for the analyst’s position.
If the analyst is not able to accept the possibility of misunderstanding the reaction of the schizophrenic patient and in turn of being misunderstood by him, it may shake his security with his patient.
That is to say, that, among other things, the schizophrenic, once he accepts the analyst’s insecurity. being helpless and open to himself - in spite of his pretended grandiose isolation - he will feel utterly defeated by the insecurity of his would-be helper. Such disappointment may furnish reasons for outbursts of hatred and are comparable to the negative transference reactions of psychoneurosis, yet more intense than these, since they are not limited by the restrictions of the actual world - that is, it exists in or based on fact, its only problem is a sure-enough externalization for which things are existing in the act of being external in something that has existence, ss if it were an actualization as received in the obtainable enactment for being externalized, such that its problem of in some actual life that proves obtainable achieved, in that of doing something that has an existence for having absolute actuality.
These outbursts are accompanied by anxiety, feelings of guilt, and fear of retaliations which in turn lead to increased hostility. Yet this established a vicious circle: We disappoint the patient, he is afraid that we hate him for his hatred and therefore continues to hate us. If in addition he senses that the analyst is afraid of his aggressiveness, it confirms his fear that he is actually considered as some dangerous and unacceptable, and this augments his hatred.
This establishes that the schizophrenics capable of developing strong relationships of love and hatred toward the analyst. After all, one could not be so hostile if it were not for the background of a very close relationship. In addition, the schizophrenic develops transference reactions on the narrower sense which he can differentiate from the actual interpersonal relationship. For which the schizophrenic’s emotional reactions toward the analyst have to be met with extreme care and caution. The love which the sensitive schizophrenic feels as he first emerges, and his cautions acceptance of the analyst’s warmth of interest are really most delicate and tender things. If the analyst deals with the transference reactions of a psychoneurotic is bad enough, though as a reparable rule, but if he fails with a schizophrenic in meeting positive feelings by pointing it out for instance before the patient indicates that he is ready to discuss it, he may easily freeze to death what has just begun to grow and so destroy any further possibility of therapy.
Some analysts may feel that the atmosphere of complete acceptance and of strict avoidance of any arbitrary denials which we recommend as a basic rule for the treatment of schizophrenics may not avoid our wish to guide of reacceptance of reality, nevertheless, Freud says that every science and therapy which accepts his teachings about unconscious, about transference and resistance and about infantile sexuality, may be called psychoanalysis. According in this definition we believe we are practicing psychoanalysis with our schizophrenic patients.
Whether we call it analysis or not, it is clear that successful treatment does not depend on technical rules of any special psychiatric school but rather on the basic attitude of individual therapist toward psychologic persons. If he meets them as strangle creatures of another world whose productions are not comprehensible to ‘normal’ beings, he cannot treat them, if he realizes, however, that the difference between himself and the psychologic is only of degree, and not of kind, he will know better how to meet him. He will not be able to identify himself sufficiently with the patient to understand and accept his emotional reactions without becoming involved in them.
The process of constant and perpetual change is examined and closely matched within the study of philosophical speculations and pointed of a world view which asserts that basic reality is constantly in a process of flux and change. Indeed, reality is identified with pure process. Concepts such as creativity, freedom, novelty, emergence, and growth are fundamental explanatory categories for process philosophy. This metaphysical perspective is to be contrasted with a philosophy of substance, the view that a fixed and permanent reality underlies the changing or fluctuating world of ordinary experience. Whereas substance philosophy emphasizes static being, process philosophy emphasizes dynamically becoming.
Although process philosophy is as old as the 6th-century Bc Greek philosopher, Heraclitus, renewed interest in it was stimulated in the 19th century by the theory of evolution. Key figures in the development of modern process philosophy were the British philosophers Herbert Spencer, Samuel Alexander, and Alfred North Whitehead, the American philosophers Charles S. Peirce and William James, and the French philosophers Henri Bergson and Pierre Teilhard de Chardin. Whitehead's Process and Reality: An Essay in Cosmology (1929) is generally considered the most important systematic expression of process philosophy.
Contemporary theology has been strongly influenced by process philosophy. The American theologian Charles Hartshorne, for instance, rather than interpreting God as an unchanging absolute, emphasizes God's sensitive and caring relationship with the world. A personal God enters into relationships in such a way that he is affected by the relationships, and to be affected by relationships is to change. So too is in the process of growth and development. Important contributions to process theology have also been made by such theologians as William Temple, Daniel Day Williams, Schubert Ogden, and John Cobb, Jr.
‘Reality’ is a difficult word to use to every one’s satisfaction or even to one’s own satisfaction. In this instance the word reality is used arbitrarily to designate the direct, here-and-now impact of the analyst upon the patient. Reality. In this sense, contrasts with the impact the analyst has through his representation in the patient’s fantasy life, neurosis, and transference, since both kinds of impact seem always to coexist and since the former - the analyst’s real impact - may be the worst enemy of the transference, the matter of their differentiation is possibly the most challenging aspect of analysis.
The analytic situation, which is set up to shut out ordinary reality intrusions, that cannot nor should not exclude all, but to say, that in the beginning months, for instance, reality inevitably has the upper hand. The analyst, the office, the procedure, are all overwhelmingly real. Everything is strange, frightening and exciting, gratifying and frustrating. Unlike the patient can test it and orient himself to it, the impact of this reality is usually so great that even an ordinary useful transference relationship cannot be expected to develop.
Perhaps the most confusing aspect of this beginning period is the frequent appearance in it of what can be regarded as a false transference relationship. With great intensity and clarity, the patient may reveal, through transference-like references about the analyst, some of the deepest secrets only of his neurosis but of its genesis. The pseudotransference, too good to be true, is almost sure to be nothing more than the patient’s attempt to deal with the person of the analyst, the entire spectrum of his various patterns of behaviour. If, it is easy to do, the analyst overlooks the likelihood that the patient’s relationship with at this time is really about that almost everything said about it is related, analysis may get off to a very bad start. And if, as is even earlier to do, the analyst’s interests the genetic meaning of the openly exposed material, a good transference relationship may be seriously delayed and a workable transference neurosis may never appear. even after initial reality has had time to fade, reality may continue to intrude in ways that are very hard to detect and that are very troublesome.
One of the most serious problems of analysis is the very substantial help which the patient receives directly from the analyst and the analytic situation. For many a patient, the analyst in the analytic situation is in fact the most stable, reasonable, wise and understanding person he has ever met, and the setting in which they meet may actually be the most honest, open, direct and regular relationship he has ever experienced. Added to this is the considerable helpfulness to him of being able to clarify his life storey. confess his guilt, express his ambitions, and explore his confusions. Further real help comes from the learning-about-life accruing from the analyst’s skilled questions, observations and interpretations. Taken together, the total real value to the patient of the analytic situation can easily be immense. The trouble with this kind of help is that it goes on and on, it may have such a real, direct and continuing impact upon the patient that he can never get deeply enough involved in transference situation to allow him to resolve or even to become acquainted with his most crippling internal difficulties. The trouble is far too good, the trouble also is that we as analysts apparently cannot resist the seductiveness of being directly helpful, and this, when combined with the compelling assumption that helpfulness is bound to be good, permits us top credit patient improvements to ‘analysis’ when more properly it should often be recognized for being the amounting result for the patient’s using the analytic situation, as the model, for being the preceptors and supporter in the dealing practically within the immediate distractions as holding to some problem.
Perhaps, we can now refer to something in a clear unmistakable manner, and it would be to mention, for being, that one more difficult-to-handle intrusion of reality into the analysis, that by saying, that this is the definitive and final interruption of the transference neurosis by the reality of termination; in the sense, the situation is reversed and the intrusion is analytically desirable, since ideally the impact of reality of impending and certain termination is used to facilitate the resolution of the transference. As with the resolution of earlier episodes of transference neurosis, this final one is brought about principally by the analyst’s interpretations and reconstructions. As these take effect, the transference neurosis and, hopefully, along with it the original neurosis is resolved. This final resolution, however, which is much more comprehensive, is usually very different and may not come about at all without the help of the reality of termination. Accordingly, any attenuation of the ending, such as tapering off or causal or tentative stopping, should be expected to stand in the way of an effective resolution of the transference. Yet, it seems that this is what most commonly happens to an ending, and because of this a great many patients may lose the potentially great benefit of a thorough resolution and are forever after left suspended in the net of unresolved transference.
Yet, utter indistinctly rigorous termination seems understandable, as difficult as transference neurosis may be in the analyst at other times, this ending period, if rigorously carried out, simply has to be the period of his greatest emotional strain. There can surely be no more likely time for an analyst to surrender his analytic position and, responding to his own transference, become personally involved with his patient than during the process of separating from a long and self-restrained relationship. Accordingly, it may be better to slur over the ending lightly than to mishandle it in an attempt to be rigorous.
In considering more broadly the function of the transference in the psychoanalytic process, one is confronted by the apparent naïve, but, nonetheless important questions of the role of the actual (current) object as compared with that of the object representation of the original personage in the past. We recall Freud’s paradoxical, somewhat gloomy, but portentous concluding passage in ‘The Dynamics of Transference.’ This struggle between the doctor and the patient, between intellect and instinctual life, between understanding and seeking to act, is played out almost exclusively in the phenomena of transference. It is on that field that the victory must be won - the victory whose expression is on that field that the victory must be won - the victory whose expression is the permanent cure of the neuroses. It cannot be disputed that controlling the phenomena of transference presents the psychoanalysis with the greatest difficultly, but it should not be forgotten that they do us the inestimable service of making the patient ‘s hidden and forgotten erotic impulses of showing their immediate and manifested impossibilities, for when all is said and done, it is impossible to destroy anyone in absentia or in effigies.
Both object and representation are made necessary by the basic phenomenon of original separation. The existence of an image of the object, which persist in the absence of the object, is one of the important beginnings of psychic life in general, certainly an indispensable prerequisite for object relationship. As generally construed. Whether this is viewed as (or a times demonstrably is) something unstable for allotting introjection, s always subject to alternative projection, or an intrapsychic object representation clearly distinguished from the self-representation, or firm identification in the superego, or in the ego itself, these phenomena are in various ways components of the system of mastery of the fact of separation, or separateness, from the original absolutely necessarily anaclitic (in the earliest period) symbiotic ‘object’. In the light of clinical observation, it would appear to be that the relative stability (parental) object representation. At which time of varying degree, are to a greater extent for the archaic phenomena. Even in nonpsychotic patients, overwhelmed by them, sometimes resembles the restoration from oedipal identification, which provides the preponderant basis for most demonstrable analytic transferences. That within the necrotic patients, the transference is effectively established when this representation invests the analyst to a degree - depending on intensity of drive and most of ego participation - which ranges in all the, wishing and strivings to remake and analyst to biassed judgements and misinterpretation of data, finally are the actual perceptual distortions.
However, the old object representations may be invested, however rigidly established the libidinal or aggressive cathexis of the image may be, this as such can become the actual and exclusive focus of instinctual discharge, or of complicated and intense instinct-defence solutions, only and general energy-sparing quality of strictly intrapsychic processes. For the vast majority of persons, visible to any degree, including those with severe neurosis, character distortions, addictions and certain psychoses, the striving is toward the living and actual object, even at the cost of intense suffering. In a sense, this returns us to the state in which the psychological ‘object-to-be’. Has a critical importance never again to be duplicated, except in certain acute life emergencies, even if the object is not firmly perceived as such, in the sense of later object relations? And it does seem that trance impressions from the earliest contacts in the service of life preservation, and the associated instinctual gratifications, and innumerable secondarily associated sensory impressions. Are activated by the specific inborn urges of sexual maturation? These propel the individual to renew many of the earliest modes of actual bodily contact, in connection with seeking for specific instinctual gratification. Or, to look away from clear-cut instinctual matters to the more remote elaborations of human contact: Few regard loneliness as other than a source of suffering, even self-imposed, as an apparent matter of choice, and the forcible imposition of ‘solitary confinement ‘ is surely one of the most cruel of punishments.
In taking to question, we are entering an area of life in which things are other then themselves, where meaning is multifaceted, and where the line between the old and the new is blurred. It should, by, its immediate measure, help develop our recognition or meaning of the pertinent applicability as to the relevance of interrelated aspects of the psychology of ‘metaphor’. In the psychology of metaphor we will find a useful analogy to the psychology of transference interpretation. Our’;s will be newly encountered as good metaphors, those it response to which we say, ‘That’s it exactly’ or ‘That really captures it‘ or ‘That says it all’.
Some literary and linguistic analysis, (e.g., Lewis, 1936 and Snell, 1953) and also people in everyday life, believe that there are experiences that can only be expressed metaphorically. And it is for this achievement that these metaphors, which may be entire poem or as lines or even words highly valued. But how can this be so? Just what in th e ‘it’ that the metaphor ‘is’ or ‘captures’ or ‘says’? If this ‘is’ or this ‘experience’ can only be rendered metaphorically, when we can know it only as such, that is, as the metaphor itself. Of the position out of which are put forward by, T.S, Eliot (1933) and E.W. Harding (1963) in their discussion of poetry, for in these instances we are granted that there is no known and logically independent version of the experience that can serve to validate the metaphor. Whatever the metaphor makes available to us depends on it and it and so cannot be used to prove its correctness.
It seems justifiable conclude that the metaphor is a new experience rather than a mere paraphrase of an already fully constituted expedience. The metaphor creates an experience that one has never had before. It is an experience one has not realized by oneself. The metaphor does, of course, suggest certain constituent experiences of which one may have been more or less dimly aware. One may say, therefore, that the metaphor speaks for those constituents, on the existence of which much of its appeal depends. But in its organizing and implicit ly rendering these constituents in its new way, it is a creation rather than a mere paraphrase or anew edition. Paraphrasing and new editions never speak as forcefully as good new metaphors, nor could they facilitate further new experience. One analytically familiar feature of these creations is that they make it safe and pleasing to experience something that otherwise would be considered too threatening and so would be kept in fragmented obscurity through defensive measures.
Thus, when one says, ‘That’s it exactly’ one is implicitly recognizing and announcing that one has found and accepted a new mode of experiencing one’s self and one’s world, which is to say, asserting a transformation of one’s own subjectivity. Something is now said to be true, and in a sense it is true, but it is true for the first time. Nothing just like it can ever happen again, for the second time cannot be the same as the first. One can’ t step into the same watering point and then step once again into the same spot of that river. A revelatory metaphor re-encountered or repeated later may lose some of its force, alternatively, it may gain some significance, butt it cannot remain exactly the same metaphor or mobilize an experience identical with the first. The point applies as well as to new metaphors that are similar to familiar ones: They have to be judged or experienced through their conventionalized predecessors, as through methods of knowing or already proved instrumentally of perceiving. The audience and the performer, who may be one person, as such that may not have, as yet.
What is to be said about the psychology of metaphor is analogous to the transformational aspects of developed transference and the steadfast interpretation that both facilitate and organize them as transference. Allowing that these transferences and ‘remembered’ experiences come into existence over a period of time, nothing that is identical with them has ever before been enacted, and nothing will ever be enacted again. They are creations that may be fully achieved only under specific analytic conditions. Such that living was not reliving that moment, words like re-living, re-experiencing and reliving simply do not do justice to the phenomena, that in making this claim. A seeming contradiction over-writes some of our well-establish ideas. - in offering, - I am not contradicting some of our well-established ideas about interpretation and insight, I am , however, disputing the point that insight refers to much than the recovery of lost memories, and takes in as well, a new grasp of the significance and interpretations of events one has always remembered. In point, as, Freud pointed out, ‘As a matter of fact I’ve always known it, only that I’ve never thought of it; (1914), In fact, it is to develop that point in furthering to say that it takes an adult to do that, especially with the help of an analyst. It was, after all, Freud’s analysis of adults that make it possible to define infantile psychosexuality. In this respect, but without disregard, child analysis retains a quality of applied psychoanalysis’ in the same way that the interpreted transference neurosis is: Both are always of describing as true something that was not true in quite that way at the time of its greatest developmental significance. This apparent paradox about ‘remembering’ as a form of creating goes a long way, probably that what it is, is distinctive about psychoanalytic interpretation.
This time, however, to further the discussion on the interpretive technique that surrounds the phase of a mutative interpretation - that in which a portion of the patient’s id-relation to the analyst is made conscious in virtue of the latter’s position as auxiliary super-ego - is in itself complex. In the classical model of an interpretation, the patient will first be made aware of a state of tension of an interpretation, will next be made aware that there is repressive factor at work (that his super-ego is threatening him with punishment), and will only then be made aware of the id-impulse which has stirred up the protects of his super-ego and so given to the anxiety in his ego. This is the classical scheme. In actual practice, the analyst finds himself working from all three sides at once, or in irregular successions. At one moment a small portion of the patient‘s super-ego may be revealed to him in all its savagery, at another the shrinking defencelessness of his ego, at yet another his attention may be directed to the attempts which he is making at restitution - at compensating for his hostility, on some occasions a fraction of id-energy may even be directly encouraged to break its way through the last remains of an already weakened resistance. There is, however, one characteristic which all of these various operations have in common, they are essentially upon a small scale. For the mutative interpretation is inevitably governed by the principle of minimal doses. It is a commonly agreed clinical fact that alternations in a patient under analysis appear almost always to be extremely gradual: We are inclined to suspect sudden and large changes as an indication that suggestive rather than psycho-analyst processes are at work. The gradual nature of the change brought about in psychoanalysis will be explained, as, only to suggest, those changes are the result of the summation of an immense number of minuet steps, each of which correspond to a mutative interpretation. And the smallness of each step is in turn imposed by the very nature of the analytic situation. For each interpretation involves the release of a certain quantity of id-energy, and, if the quantity released is too large, the higher unstable state of equilibrium which enables the analyst to function as the patient’s auxiliary super-ego is bound to be upset. The whole analytic situation will thus be imperilled, since it is only in virtue of the analyst’s acting as auxiliary super-ego that these released id-energy can occur at all.
The effectuality from which follow the analytic attempt to bring unequalled amounts in the confronting collections of some improper use too a resultant quantity of id-energy into the patient’s consciousness all at once. On the one hand, nothing whatever may happen, or on the other hand there may be an unmanageable result, but in neither event will a mutative interpretation have been effected. The analyst’s power as auxiliary super-ego may be for two very different reasons. It may be that the id-impulses was trying to bring out were not in fact sufficiently urgent at the moment: For, after all, the emergence of an id-impulse depends on two factors - not only on the permission of the super-ego, but also on the urgency (the degree of cathaxis) of the id-impulse itself. This, then, may be one cause of an apparently negative response to an interpretation, and evidently a fairly harmless one. but the same apparent result may also be due to something else, in spite of the id-impulse being really urgent, the strength of the patient’s own repressive forces (the degree of repression) may have been too great to allow his ego to listen to the persuasive voice of the auxiliary super-ego. Now we have a situation dynamically identical with the next one we have to consider, though economically different. this next situation is one in which the patient accepts the interpretation, that is, allows the id-impulse into his consciousness, but is immediately overwhelmed with anxiety. This may show itself in a number of ways, for instance, the patient may produce a manifest anxiety-attack. Or the may exhibit signs of ‘real’ anger with the analyst with a complete lack of insight, or he may break off the analysis. In any of these cases the analytic situation will, for the moment, at least, have broken down. The patient will be behaving just as the hypnotic subject behaves when, having been ordered by the hypnotist to perform an action too much at variance with his own consciousness, he breaks off the hypnotic relation and wakes up from his trance. This state of things, which is manifest where the patient responds to an interpretation with an actual outbreak of anxiety or one of its equivalents, may be latent were the patient shows no response, and this latter case may be the more awkward of the two, since it is masked, and it may sometimes be the effect of a greater overdose of interpretation than where manifest anxiety arises (though obviously other factors will be of determining importance, and in particularly the nature of the patient’s neurosis). Yet this threatened collapse of the analytic situation to an overdose of interpretation: But it might be more accurate in some ways to ascribe it to an insufficient dose. For what has happened is that the second phase of the interpretation process has not occurred: The phase in which the patient becomes aware that his impulse is directed towards an archaic phantasy object and not toward a real one.
In the second phase of a complete interpretation, therefore, a crucial part is played by the patient’s sense of reality: For the successful outcome of that phase depends upon his ability, at the critical moment of the emergence into consciousness of the released quantity of id-energy, to distinguish between his phantasy object and the real analyst. The problem is closely related to one that has been discussed elsewhere, namely that of the extreme liability of the analyst’s position as auxiliary super-ego. The analytic situation is all the time threatening to degenerate into a ‘real’ situation. But this actually means the opposite of what it appears to. It means that the patient is all the time on the brink of turning the real external object (the analyst) into the archaic one; that is to say, he is on the brink of projecting his primitive introjected images onto himself. In so far as the patient actually does this, the analyst becomes like anyone else that he meets in real life - a phantasy object. The analyst then ceases to possess the peculiar advantages derived from the analytic situation, he will be introjected like all other phantasy objects into the analytic situation, he will be introjected like all other phantasy objects into the patient’s super-ego, and will no longer be able to function in the peculiar ways which are essential to the effecting of a mutative interpretation. In this difficulty the patient’s sense of reality is an essential but a very feeble-ally: An improvement in it is one of the things that we hope the analysis will bring about. It is important, therefore, not to submit it to any unnecessary strain, and that is the fundamental reason why the analyst must avoid any real behaviour, that is likely to confirm the patient’s view of him as a ‘bad’ or a ‘good’ phantasy object . This is perhaps more obvious as regards the ‘bad’ object. If, for instance, the analyst were to show that he was really shocked or frightened by one of the patient’s id-impulses, as the patient would immediately treat him in that respect as a dangerous object and introject him into his archaic severe super-ego. Therefore, on the one hand, there would be a diminuation in the analyst’s power to function as an auxiliary super-ego and to allow the patient’s to become conscious of his id-impulses - that is to say, in his power to bring about the first phase of a mutative interpretation, and on the other hand, he would, as a real object, become sensibly less distinguishable from the patient’s ‘bad’ phantasy object and to that extent the carrying through of the second phase of a mutative interpretation would also be made more difficult. Or, agin, there is another case. Supposing the analyst behaves in an opposite way and actively urges the patient to give free rein to his id-impulse. There is then a possibility of the patient confusing the analyst with the image of a treacherous parent who first encourages him to seek gratification, and then suddenly turns and punishes him. In such a case the patient’s ego may look for defence by itself suddenly turning upon the analyst as though he were his own id-, and treating him with all the severity of which his super-ego is capable. again, the analyst is running a risk of losing his privileged position. But it may be equally unwise for the analyst to act really in such a way as to encourage the patient to project his ‘good’ introjected object on to him. For the patient will then tend to regard him as a good objective and archaic sense and will incorporate him with his archaic ‘good’ images and will use him as a protection against his ‘bad’ ones. In that way, his infantile positive impulses as well as his negative ones may escape analysis, for there may no longer be a possibility for his ego to make a comparison between the phantasy external object and the real one. it will, perhaps, be argued that, with the best of wills in the world, the analyst, however careful he may be, will be unable to prevent the patient from projecting these various images on to him. This is, of course, indisputable, and, the whole effectiveness of analysis depends upon its being so. The lesson of these difficulties is merely to remind us that the patient’s sense of reality has the narrowest limits. It is a paradoxical fact that the best way of enuring that his ego shall be able to distinguish between phantasy and reality is to withhold reality from him as much as possible. but it is true, his ego is so weak - so much at the mercy of his id and super-ego - that he can only cope with reality if it is administered in minimal doses. And these doses are in fact, what the analyst gives him, in the form of interpretations.
In the psychoanalytic model, neurosis differs from the psychosis, another general term used to describe mental illnesses. Individuals with neuroses can function at work and in social situations, whereas people with psychoses find it quite difficult to function adequately. People with neuroses do not grossly distort or misinterpret reality as those with psychoses do. In addition, neurotic individuals recognize that their mental functioning is disturbed while psychotic individuals usually do not. Most mental health professionals now use the term psychosis to call symptoms such hallucinations, delusions, and bizarre behaviour.
Nevertheless, in 1886 Freud established a private practice in Vienna specializing in nervous disease. He met with violent opposition from the Viennese medical profession because of his strong support of Charcot’s unorthodox views on hysteria and Hypnotherapy. The resentment he incurred was to delay any acceptance of his subsequent findings on the origin of neurosis.
Hypnotherapy, can be considered as an altered state of consciousness and heightened responsiveness to suggestion, it may be induced in normal persons by a variety of methods and has been used occasionally in medical and psychiatric treatment. Most frequently hypnosis is caused through the actions of an operator, the hypnotist, who engages the attention of a subject and assigns certain tasks to him or her while uttering monotonous, repetitive verbal commands; such tasks may include muscle relaxation, eye fixation, and arm levitation. Hypnosis also may be self-induced, by trained relaxation, concentration on one's own breathing, or by a variety of monotonous practices and rituals that are found in many mystical, philosophical, and religious systems.
Hypnosis is ascendent from the results of the gradual inclining assumption by the attenuated subject in some standardization of consciousness. In which attention is withdrawn from the surrounding externalized world and is occasioned to a concentration of mental, sensory, and physiological experiences. When a hypnotist induces a trance, a close relationship or rapport develops between operator and subject. The responses of subjects in the trance state, and the phenomena or behaviour they manifest objectively, are the product of their motivational set; that is, behaviour reflects what is being sought from the experience.
Most people can be easily hypnotized, but the depth of the trance varies widely. A profound trance is characterized by a forgetting of trance events and by an ability to respond automatically to posthypnotic suggestions that are not too anxiety-provoking. The depth of an achievable trance is made calculably fixed by a determinant characteristic that, depends on the emotional condition of the succeeding subject and on the skill of the hypnotist. Only 20 percent of subjects could enter somnambulistic states through the usual methods of induction. Medically, this percentage is not significant, since therapeutic effects occur even in a light trance.
Hypnosis can produce a deeper contact with one's emotional life, resulting in some lifting of repressions and exposure of buried fears and conflicts. This effect potentially lends itself to medical and educational use, but it also lends itself to misinterpretation. Thus, the revival through hypnosis of early, forgotten memories may be fused with fantasies. Research into hypnotically induced memories in recent years has in fact stressed their uncertain reliability. Therefore several state court systems in the US have placed increasing constraints on the use of evidence hypnotically obtained from witnesses, although most states still permit its legible presentation in court.
Hypnosis has been used to treat a variety of physiological and behavioural problems. It can alleviate back pain and pain resulting from burns and cancer. It has been used by some obstetricians as the sole analgesia for normal childbirth. Hypnosis is sometimes also employed to treat physical problems with a possible psychological component, such as Raynaud's syndrome (a circulatory disease) and faecal incontinence in children. Researchers have demonstrated that the benefit of hypnosis is greater than the effect of a placebo and probably results from changing the focus of attention. Few physicians, however, include hypnosis as part of their practice.
Some behavioural difficulties, such as cigarette smoking, overeating, and insomnia, are also amenable to resolution through hypnosis. Nonetheless, most psychiatrists think that fundamental psychiatric illness is better treated with the patient in a normal state of consciousness.
The founder of phenomenology, German philosopher Edmund Husserl, introduced the term in his book Ideen zu einer reinen Phänomenolgie und phänomenologischen Philosophie (1913; Ideas: A General Introduction to Pure Phenomenology, 1931). Early followers of Husserl such as the German philosopher Max Scheler, influenced by his previous book, ‘Logische Untersuchungen’ (two volumes, 1900 and 1901, ‘Logical Investigations’, 1970), claimed that the task of phenomenology is to study essences, such as the essence of emotions. Although Husserl himself never gave up his early interest in essences, he later held that only the essences of certain special conscious structures are the proper objects of phenomenology. As formulated by Husserl after 1910, phenomenology is the study of the structures of consciousness that enable consciousness to refer to objects outside itself. This study requires reflection on the content of the mind to the exclusion of everything else. Husserl called this type of reflection the ‘phenomenological reduction’. On the acceptable consideration that can explain for the expounded account that the mind can be directed toward nonexistence, as well as real objects. In the things to oppose by arguing against the evidences as something took for granted and especially on trivial or inadequate grounds are actualized distinctions as having been known as having existence in space or time. Husserl noted that phenomenological reflection does not presuppose that anything that has recently come into existence, but amounts to a ‘bracketing of existence’ - that is, setting aside the question of the real existence of the contemplated object.
Freud’s first published work, ‘On Aphasia,’ appeared in 1891, it was a study of the neurological disorder in which the ability to pronounce words or to name common objects is lost because of organic brain disease. His final work in neurology, was the article, ‘Infantile Cerebral Paralysis,’ was written in 1897 for an encyclopaedia only at the insistence from the editor. Since by this time Freud was occupied largely with psychological than physiological explanations for mental illnesses. His subsequent writings were devoted entirely to that field, which he had named psychoanalysis in 1896.
Pierre Janet (1859-1947), the French psychologist, born and educated in Paris, he taught philosophy (1881-98) but was also interested in neurology and psychology, which he studied under Jean Martin Charcot. Janet did important pioneer work on the scientific treatment of neuroses and hysteria; his investigations of hypnosis as an aid to understanding the mind and the diagnosis of its disorders greatly influenced the early work of another pupil of Charcot, Sigmund Freud. Among Janet's works are ‘Neuroses’ (1898; trans. 1909), ‘Major Symptoms of Hysteria’ (1907; trans. 1920), and ‘Principles of Psychotherapy’ (1924).
Freud’s new orientation was heralded by his collaborative work on hysteria with the Viennese physician Josef Breuer. The work was presented in 1893 in a preliminary paper and two years later in an expanded form under the title ‘Studies on Hysteria.’ In this work the symptoms of hysteria were ascribed to manifestations of undischarged emotional energy associated with forgotten psychic traumas. The therapeutic procedure involved the use of a hypnotic state in which the patient was led to recall and reenact the traumatic experience, thus discharging by catharsis the emotions causing the symptoms. The publication of this work marked the beginning of psychoanalytic theory formulated based on clinical observations.
During the periods from 1895 to 1900 Freud developed many concepts that were later incorporated into psychoanalytic practice and doctrine. Soon after publishing the Studies on Hysteria, he abandoned the use of hypnosis as a cathartic procedure and substituted the investigations of the patient’s spontaneous flow of thoughts, called ‘free association’. In this was to reveal the unconscious mental processes at the root of the neurotic disturbance.
In his clinical observations Freud found evidence for the mental mechanisms of repression and resistance. He described repression as a device operating unconsciously to make the memory of painful or threatening events inaccessible to the conscious mind. Resistance is the unconscious defence against awareness of repressed experiences to avoid the resulting anxiety. That to probe the unconscious mind, Freud developed the psychotherapy technique of free association. In free association, the patient reclines and talks about thoughts, wishes, memories, and whatever else comes to mind. The analyst tries to interpret these verbalizations to determine their psychological significance. In particular, Freud encouraged his couched patients to associate freely or talk unrestrictively about their dreams, which he believed were the ‘royal road to the unconscious’. According to Freud, dreams are disguised expressions of deep, hidden impulses. Thus, as patients recount the conscious manifest content of dreams, the psychoanalyst tries to unmask the underlying latent content, - what the dreams carries or attemptively communicates (as an idea) that something is held of a measurable understanding and to mean and give to expression of something potentially understood in the mind.
He traced the operation of unconscious processes, using the free associations of the patient to guide him in the interpretation of dreams and slips of speech. Dream analysis led to his discoveries of infantile sexuality and of the so-called Oedipus complex, which constitutes the erotic attachment of the child for the parent of the opposite sex, with hostile feelings toward the other parent. In these years he also developed the ‘theory of transference’, the processes by which emotional attitudes, established originally toward parental figures in childhood, are transferred in later life to others. The end of this period was marked by the appearance of Freud’s most important work, ‘The Interpretation of Dreams’ (1899). Here Freud analysed many of his own dreams recorded in the 3-year period of his self-analysis, begun in 1897. This work expounds all the fundamental concepts underlying psychoanalytic technique and doctrine.
Freud introduced his new theory in The Interpretation of Dreams (1889), the first of 24 books he would write. The theory is summarized in Freud’s last book, ‘An Outline of Psychoanalysis’ published in 1940, after his death. In contrast to Wundt and James, for whom psychology was the study of conscious experience, Freud believed that people are motivated largely by unconscious forces, including strong sexual and aggressive drives. He likened the human mind to an iceberg: The small tip that floats on the water is the conscious part, and the vast region beneath the surface comprises the unconscious. Freud believed that although unconscious motives can be temporarily suppressed, they must find a suitable outlet in order for a person to maintain a healthy personality.
Recognition of these modes of operation in unconscious mental processes made possibly the understanding of such previously incomprehensible psychological phenomena as dreaming. Through analysis of unconscious processes, Freud saw dreams as serving to protect sleep against disturbing impulses arising from within and related to early life experiences. Thus, unacceptable impulses and thoughts, called the latent dream content, are transformed into a conscious, although no longer immediately comprehensible, experience called the manifest dream. Knowledge of these unconscious mechanisms permits the analyst to reverse the so-called dream work, that is, the process by which the latent dream is transformed into the manifest dream, and through dream interpretation, to recognize its underlying meaning.
In 1902 Freud was appointed a full professor at Vienna University. This honour was granted not in recognition of his contributions but from the efforts of a highly influential patient. The medical world still regarded his work with hostility, and his next writings, ‘The Psychopathology of Everyday Life’ (1904) and ‘Three Contributions to the Sexual Theory’ (1905), only increased this antagonism. As a result Freud continued to work virtually alone in what he termed ‘splendid isolation’.
By 1906, however, a few pupils and followers had gathered around Freud, including the Austrian psychiatrists William Stekel and Alfred Adler, the Austrian psychologist Otto Rank, the American psychiatrist Abraham Brill, and the Swiss psychiatrist’s Eugen Bleuler and Carl Jung. Other notable associates, joined the circle in 1908, as well, the Hungarian psychiatrist Sándor Ferenczi and the British psychiatrist Ernest Jones.
Austrian doctor Sigmund Freud spent many hours refining his theories in this study within his home in Vienna, Austria. Freud pioneered the use of clinical observation to treat mental disease. The publication of The Interpretation of Dreams in 1899 detailed his technique of isolating the source of psychological problems by examining a patient’s spontaneous stream of thought.
Increasing recognition of the psychoanalytic movement made possibly the formation in 1910 of a worldwide organization called the International Psychoanalytic Association. As the movement spread, gaining new adherents through Europe and the US, Freud was troubled by the dissension that arose among members of his original circle. Most disturbing was the defection from the group of Adler and Jung, each of whom developed a different theoretical basis for disagreement with Freud’s emphasis on the sexual origin of neurosis. Freud met these setbacks by developing further his basic concepts and by elaborating his own views in many publications and lectures.
After the onset of World War I Freud devoted little time to clinical observation and concentrated on the application of his theories to the interpretation of religion, mythology, art, and literature. In 1923 he was stricken with pallative cancer of the jaw, which necessitated constant, painful treatment besides many surgical operations. Despite his physical suffering he continued his literary activity for the next 16 years, writing mostly on cultural and philosophical problems.
When the Germans occupied Austria in 1938, Freud, a Jew, was persuaded by friends to escape with his family to England. He died in London on September 23, 1939.
Freud created an entirely new approach to the understanding of human personality, by his demonstration of the existence and force of the unconscious in that he founded a new medical discipline and formulated basic therapeutic procedures that in modified form are applied widely in the present-day treatment of neuroses and psychoses. Although never accorded full recognition during his lifetime, Freud is generally acknowledged as one of the great creative minds of modern times.
Among his other works are Totem and Taboo (1913), Ego and the Id (1923), New Introductory Lectures on Psychoanalysis (1933), and Moses and Monotheism (1939).
The ego, the term occurring in psychoanalysis, that designates its term as denoting the central part of the personality structure that deals with reality and is influenced by social forces. According to the psychoanalytic theories developed by Sigmund Freud, the ego constitutes one of the three basic provinces of the mind, the other two, being the id and the superego. Formation of the ego begins at birth in the first encounters with the external world of people and things. The ego learns to modify behaviour by controlling those impulses that are socially unacceptable. Its role is that of a mediator between unconscious impulses and acquired social and personal standards.
In philosophy, ego means the conscious self or ‘I.’ It was viewed by some philosophers, notably the 17th-century Frenchman René Descartes and the 18th-century German Johann Gottlieb Fichte, as the sole basis of reality; they saw the universe as existing only in the individual's knowledge and experience of it. Other philosophers, such as the 18th-century German Immanuel Kant, proposed two forms of the ego, one perceiving and the other thinking.
As well, the term id was oriented into psychoanalytic theory, one of the three basic elements of personality, the others being the ego and the super-ego. The id can be equated with the unconscious of common usage, which is the reservoir of the instinctual drives of the individual, including biological urges, wishes, and affective motives. The id is dominated by the pleasure principle, through which the individual is pressed for immediate gratification of his or her desires. In strict Freudian theory the energy behind the instinctual drives of the id is known as the libido, a generalized force, presented by its sexual nature, through which the sexual and psychosexual nature of the individual finds expression.
Also, the super-ego, in psychoanalytic theory is one of the three basic and most fundamental constituents of the mind, the others being the id and the ego. As postulated by Sigmund Freud, the term designates the element of the mind that, in normal personalities, automatically modifies and inhibits those instinctual impulses or drives of the id that directly addresses, by it’s very absence of an intervening agency, instrumentality or influence, where in having no direct knowledge of such unknowables. By linearity it is shown through the transparency of continuously and unbroken chain by passing into and through a decompressing static cause, is that, to only produce an antisocial actions and thoughts.
According to psychoanalytic theory, the superego develops as the child gradually and unconsciously adopts the values and standards, first of his or her parents, and later of the social environment. According to modern Freudian psychoanalysts, the superego includes the positive ego, or conscious self-image, or ego ideal, that each individual develops.
Psychoanalysis, is the name applied to a specific method of investigating unconscious mental processes and to a form of psychotherapy. The term refers, as well, to the systematic structure of psychoanalytic theory, which is based on the relation of conscious and unconscious psychological processes.
The techniques of psychoanalysis and much of the psychoanalytic theory based on its application were developed by Sigmund Freud. His work concerning the structure and the functioning of the human mind had influential significance, both practically and scientifically, and it continues to influence contemporary thought.
Of Freud’s three basic personality structures - id, ego, and super-ego - only the id is totally unconscious. The first of Freud's innovations was his recognition of unconscious psychiatric processes that follow laws different from those that govern conscious experience. Under the influence of the unconscious, thoughts and feelings that belong together may be shifted or displaced out of context; two disparate ideas or images may be condensed into one; thoughts may be dramatized in images rather than expressed as abstract concepts; and certain objects may be represented symbolically by images of other objects, although the resemblance between the symbol and the original object may be vague or farfetched. The laws of logic, indispensable for conscious thinking, do not apply to these unconscious mental productions.
Recognition of these modes of operation in unconscious mental processes made possibly the understanding of such previously incomprehensible psychological phenomena as dreaming. Through analysis of unconscious processes, Freud saw dreams as serving to protect sleep against disturbing impulses arising from within and related to early life experiences. Thus, unacceptable impulses and thoughts, called the latent dream content, are transformed into a conscious, although no longer immediately comprehensible, experience called the manifest dream. Knowledge of these unconscious mechanisms permits the analyst to reverse the so-called dream work, that is, the process by which the latent dream is transformed into the manifest dream, and through dream interpretation, to recognize its underlying meaning.
A basic assumption of Freudian theory is that the unconscious conflicts involve instinctual impulses, or drives, that originate in childhood. As these unconscious conflicts are recognized by the patient through analysis, his or her adult mind can find solutions that were unattainable to the immature mind of the child. This depiction of the role of instinctual drives in human life is a unique feature of Freudian theory.
According to Freud's doctrine of infantile sexuality, adult sexuality is an end-set-product of a complex process of development, beginning in childhood, involving a variety of body functions or areas (oral, anal, and genital zones), and corresponding to various stages in the relation of the child to adults, especially to parents. This distinguishes the oedipus Complex, in psychoanalysis, a son’s largely unconscious sexual attraction toward his mother accompanied by jealousy toward his father. The terminological distinction of the oedipus complex, derived from the Greek legend of Oedipus, was first used in the late 1800's by Austrian psychiatrist Sigmund Freud, the founder of psychoanalysis. Freud thought that the Oedipus complex was the most important event of a boy’s childhood and affected his subsequent adult life. Freud claimed that in nearly all cases the boy represses the desire for his mother and the jealousy toward his father. Because of this unconscious experience, Freud believed, a boy with an Oedipus complex feels guilt and experiences strong emotional conflicts. Freud thought that young women went through a similar experience, in which they are attracted to their father and surmount the disconfirming antagonistic attitude toward their mother. He called this the Electra complex. According to Freud, if a woman remains under the influence of the Electra complex, she is likely to choose a husband with characteristics similar to those of her father.
Of crucial importance is the so-called Oedipal period, occurring at about four to six years of age, because at this stage of development the child for the first time becomes capable of an emotional attachment to the parent of the opposite sex that is similar to the adult's relationship to a mate; the child simultaneously reacts as a rival to the parent of the same sex. Physical immaturity dooms the child's desires to frustration and his or her first step toward adulthood to failure. Intellectual immaturity further complicates the situation because it makes children afraid of their own fantasies. The extent to which the child overcomes these emotional upheavals and to which these attachments, fears, and fantasies continue to live on in the unconscious greatly influences later life, especially ‘loves’ relationships.
The conflicts occurring in the earlier developmental stages are no less significant as a formative influence, because these problems represent the earliest prototypes of such basic human situations as dependency on others and relationship to authority. Also, basic in moulding the personality of the individual is the behaviour of the parents toward the child during these stages of development. The fact that the child reacts, not only to objective reality, but also to fantasy distortions of reality, however, greatly complicates even the best-intentioned educational efforts.
The effort to clarify the bewildering number of interrelated observations uncovered by psychoanalytic exploration led to the development of a model of the structure of the psychic system. Three functional systems are distinguished that are conveniently designated as the id, ego, and super-ego.
The first system refers to the sexual and aggressive tendencies that arise from the body, as distinguished from the mind. Freud called these tendencies Triebe, which literally means ‘drives,’ but which is often inaccurately translated as ‘instincts’ to indicate their innate character. These inherent drives claim immediate satisfaction, which is experienced as pleasurable; the id thus is dominated by the pleasure principle. In his later writings, Freud tended more toward psychological rather than biological conceptualization of the drives.
How the conditions for satisfaction are to be brought about is the task of the second system, the ego, which is the domain of such functions as perception, thinking, and motor control that can accurately assess environmental conditions. In order to fulfill its function of adaptation, or reality testing, the ego must be capable of enforcing the postponement of satisfaction of the instinctual impulses originating in the id. To defend itself against unacceptable impulses, the ego develops specific psychic means, known as defence mechanisms. These include repression, the exclusion of impulses from conscious awareness; projection, the process of ascribing to others one's own unacknowledged desires; and reaction formation, the establishments of a pattern of behaviour directly opposed to a strong unconscious imperative necessarily in need for or required to employ of its relief. Such defence mechanisms are put into operation whenever anxiety signals a danger that the original unacceptable impulses may reemerge.
The instructive voice regarding ‘neurophysiology’, is given to a commanding of issues, in that the study of how nerve cells, or neurons, receives and transmits information. Two types of phenomena are involved in processing nerve signals: Electrical and chemical. Electrical events propagate a signal within a neuron, and chemical processes transmit the signal from one neuron to another neuron or to a muscle cell.
A neuron is a long cell that has a thick central area containing the nucleus, it also has one long process called an axon and one or more short, bushy processes called dendrites. Dendrites receive impulses from other neurons. (The exceptions are sensory neurons, such as those that transmit information about temperature or touch, in which the signal is generated by specialized receptors in the skin.) These impulses are propagated electrically along the cell membrane to the end of the axon. At the tip of the axon the signal is chemically transmitted to an adjacent neuron or muscle cell.
Like all other cells, neurons contain charged ions: Potassium and sodium (positively charged) and chlorine (negatively charged). Neurons differ from other cells in that they can produce a nerve impulse. A neuron is polarized - that is, it has an overall negative charge inside the cell membrane because of the high concentration of chlorine ions and low concentration of potassium and sodium ions. The concentration of these same ions is exactly reversed outside the cell. This charge differential represents stored electrical energy, sometimes called membrane potential or resting potential. The negative charge inside the cell is maintained by two features. The first is the selective permeability of the cell membrane, which is more permeable to potassium than sodium. The second feature is sodium pumps within the cell membrane that actively pump sodium out of the cell. When depolarization occurs, this charge differential across the membrane is reversed, and a nerve impulse is produced.
Depolarization is a rapid change in the permeability of the cell membrane. When sensory information or any other kind of stimulating current is received by the neuron, the membrane permeability is changed, allowing a sudden influx of sodium ions into the cell. The high concentration of sodium, or action potential, changes the overall charges within the cell from negative too positive. The local changes in ion concentration triggers similar reactions along the membrane, propagating the nerve impulse. After a brief period called the refractory period, during which the ionic concentration returned to resting potential, the neuron can repeat this process. Nerve impulses travel at different speeds, depending on the cellular composition of a neuron. Where speed of impulse is important, as in the nervous system, axons are insulated with a membranous substance called myelin. The insulation provided by myelin maintains the ionic charge over long distances. Nerve impulses are propagated at specific points along the myelin sheath; These points are called the nodes of Ranvier. Examples of myelinated axons are those in sensory nerve fibres and nerves connected to skeletal muscles. In non-myelinated cells, the nerve impulse is propagated more diffusely.
When the electrical signal reaches the tip of an axon, it stimulates small presynaptic vesicles in the cell. These vesicles contain chemicals called neurotransmitters, which are released into the microscopic space between neurons (the synaptic cleft). The neurotransmitter adherently causes to be attached on the surface of the adjacent neuron. This stimulus causes the adjacent cell to depolarize and propagate an action potential of its own. The duration of a stimulus from a neurotransmitter is limited by the breakdown of the chemicals in the synaptic cleft and the reuptake by the neuron that produced them. Formerly, each neuron was thought to make only one transmitter, but recent studies have shown that some cells make two or more.
During the early 1900s, in examining the workings of the nervous system, physiologists were beginning to explore the idea that the transmission of nerve impulses takes place, in part, via chemical means. Loewi decided to explore this idea. During a stay in London in 1903, he met Sir Dale, who was also interested in the chemical transmission of nerve impulses. However, for Loewi, Dale, and all the other researchers pursuing a chemical transmitter of nerve impulses, years of effort produced no solid evidence. In 1921 Loewi suspended two frogs' hearts in solution, one with a major nerve removed. Removing fluid from the heart that still contained the nerve, and injecting the fluid into the nerveless heart, Loewi observed that the second heart behaved as if the missing nerve were present. The nerves, he concluded, do not act directly on the heart - it is the action of chemicals, freed by the stimulation of nerves, that causes increases in heart rate and other functional changes. In 1926 Loewi and his colleagues identified one of the chemicals in his experiment as acetylcholine. This was indisputably a neurotransmitter - a chemical that serves to transmit nerve impulses in the involuntary nervous system.
We acknowledge the neurotransmitters are inherently made by chemically induced neurons, or nerve cells. Neurons send out neurotransmitters as chemical signals to activate or inhibit the function of neighbouring cells.
Within the central nervous system, which consists of the brain and the spinal cord, neurotransmitters pass from neuron to neuron. In the peripheral nervous system, which is made up of the nerves that run from the central nervous system to the rest of the body, the chemical signals pass between a neuron and an adjacent muscle or gland cells.
Chemical compounds - belonging to three chemical families - are widely recognized as neurotransmitters. In addition, certain other body chemicals, including adenosine, histamine, enkephalins, endorphins, and epinephrine, have neurotransmitter-like properties. Experts believe that there are many more neurotransmitters yet undiscovered.
The first of the three families is composed of amines, a group of compounds containing molecules of carbon, hydrogen, and nitrogen. Among the amine neurotransmitters are acetylcholine, norepinephrine, dopamine, and serotonin. Acetylcholine is the most widely used neurotransmitter in the body, and neurons that leave the central nervous system (for example, those running to skeletal muscle) use acetylcholine as their neurotransmitter; neurons that run to the heart, blood vessels, and other organs may use acetylcholine or norepinephrine. Dopamine is involved in the movement of muscles, and it controls the secretion of the pituitary hormone prolactin, which triggers milk production in nursing mothers.
The second neurotransmitter family is composed of amino acids, organic compounds containing both an amino group (NH2) and a carboxylic acid group (COOH). Amino acids that serve as neurotransmitters include glycine, glutamic and aspartic acids, and gamma-amino butyric acid (GABA). Glutamic acid and GABA are the most abundant neurotransmitters within the central nervous system, and especially in the cerebral cortex, which is largely responsible for such higher brain functions as thought and interpreting sensations.
The third neurotransmitter family is composed of peptides, which are compounds that contain at least two, and sometimes as many as 100 amino acids. Peptide neurotransmitters are poorly understood, but scientists know that the peptide neurotransmitter called substance P influences the sensation of pain.
Overall, each neuron uses only a single compound as its neurotransmitter. However, some neurons outside the central nervous system can release both an amine and a peptide neurotransmitter.
Neurotransmitters are manufactured from precursor compounds like amino acids, glucose, and the dietary amine-called choline. Neurons modify the structure of these precursor compounds in a series of reactions with enzymes. Neurotransmitters that comes from amino acids include serotonin, for which it is derived from tryptophan. Dopamine and norepinephrine, under which are derived from tyrosine, and glycine, which is derived from threonine. Among the neurotransmitters made from glucose are glutamate, aspartate, and GABA. The choline serves as the precursor for acetylcholine
Neurotransmitters are released into a microscopic gap, called a synapse, that separates the transmitting neuron from the cell receiving the chemical signal. The cell that generates the signal is called the presynaptic cell, while the receiving cell is termed the postsynaptic cell.
After their release into the synapse, neurotransmitters combine chemically with highly specific protein molecules, termed receptors, embedded in the surface membranes of the postsynaptic cell. When this combination occurs, the voltage, or electrical force, of the postsynaptic cell is either increased (excited) or decreased (inhibited).
When a neuron is in its resting state, its voltage is about -70 millivolts. An excitatory neurotransmitter alters the membrane of the postsynaptic neuron, making it possible for ions (electrically charged molecules) to move back and forth across the neuron’s membranes. This flow of ions makes the neuron’s voltage rise toward zero. If enough excitatory receptors have been activated, the postsynaptic neuron responds by firing, generating a nerve impulse that causes its own neurotransmitter to be released into the next synapse. An inhibitory neurotransmitter causes different ions to pass back and forth across the postsynaptic neuron’s membrane, lowering the nerve cell’s voltage to -80 or -90 millivolts. The drop in voltage makes it less likely that the postsynaptic cell will fire.
If the postsynaptic cell is a muscle cell rather than a neuron, an excitatory neurotransmitter will cause the muscle to contract. If the postsynaptic cell is a gland cell, an excitatory neurotransmitter will cause the cell to secrete its contents.
While most neurotransmitters interact with their receptors to create new electrical nerve impulses that energize or inhibit the adjoining cell, some neurotransmitter interactions do not generate or suppress nerve impulses. Instead, they interact with a second type of receptor that changes the internal chemistry of the postsynaptic cell by either causing or blocking the formation of chemicals called second messenger molecules. These second messengers regulate the postsynaptic cell’s biochemical processes and enable it to conduct the maintenance necessary to continue synthesizing neurotransmitters and conducting nerve impulses. Examples of second messengers, which are formed and entirely contained within the postsynaptic cell, include cyclic adenosine monophosphate, diacylglycerol, and inositol phosphates.
Once neurotransmitters have been secreted into synapses and have passed on their chemical signals, the presynaptic neuron clears the synapse of neurotransmitter molecules. For example, acetylcholine is broken down by the enzyme acetylcholinesterase into choline and acetate. Neurotransmitters like dopamine, serotonin, and GABA is removed by a physical process called reuptake. In reuptake, a protein in the presynaptic membrane acts as a sort of sponge, causing the neurotransmitters to reenter the presynaptic neuron, where they can be broken down by enzymes or repackaged for reuse.
Neurotransmitters are known to be involved in many disorders, including Alzheimer’s disease. Victims of Alzheimer’s disease suffer from loss of intellectual capacity, disintegration of personality, mental confusion, hallucinations, and aggressive - even violent - behaviour. These symptoms are the result of progressive degeneration in many types of neurons in the brain. Forgetfulness, one of the earliest symptoms of Alzheimer’s disease, is partly caused by the destruction of neurons that normally release the neurotransmitter acetylcholine. Medications that increase brain levels of acetylcholine have helped restore short-term memory and reduce mood swings in some Alzheimer’s patients.
Neurotransmitters also play a role in Parkinson disease, which slowly attacks the nervous system, causing symptoms that worsen over time. Fatigue, mental confusion, a mask-like facial expression, stooping posture, shuffling gait, and problems with eating and speaking are among the difficulties suffered by Parkinson victims. These symptoms have been partly linked to the deterioration and eventual death of neurons that run from the base of the brain to the basal ganglia, a collection of nerve cells that manufacture the neurotransmitter dopamine. The reasons why such neurons die are yet to be understood, but the related symptoms can be alleviated. L-dopa, or levodopa, widely used to treat Parkinson disease, acts as a supplementary precursor for dopamine. It causes the surviving neurons in the basal ganglia to increase their production of dopamine, by that compensating to some extent for the disabled neurons.
Many other effective drugs have been shown to act by influencing neurotransmitter behaviour. Some drugs work by interfering with the interactions between neurotransmitters and intestinal receptors. For example, belladonna decreases intestinal cramps in such disorders as irritable bowel syndrome by blocking acetylcholine from combining with receptors. This process reduces nerve signals to the bowel wall, which prevents painful spasms.
Other drugs block the reuptake process. One well-known example is the drug fluoxetine (Prozac), which blocks the reuptake of serotonin. Serotonin then remains in the synapse for a longer time, and its ability to act as a signal is prolonged, which contributes to the relief of depression and the control of obsessive-compulsive behaviours.
Dopamine, chemical known as a neurotransmitter essential to the functioning of the central nervous system. During neurotransmission, dopamine is transferred from one nerve cell, or neuron, to another, playing a key role in brain function and human behaviour.
Dopamine forms from a precursor molecule called dopa, which is manufactured in the liver from the amino acid tyrosine. Dopa is then transported by the circulatory system to neurons in the brain, where the conversion to dopamine takes place.
Dopamine is a versatile neurotransmitter. Among its many functions, it plays a major role in two activities of the central nervous system: one that helps control movement, and a second that are strongly associated with emotion-based behaviours.
The pathway involved in movement control is called the nigrostriatal pathway. Dopamine is released by neurons that originate from an area of the brain called the substantia nigra and connect to the part of the brain known as the corpora striata, an area known to be important in controlling the musculoskeletal system.
The second brain pathway in which dopamine plays a major role is called the mesocorticolimbic pathway. Neurons in an area of the brain called the ventral tegmentalarea transmits dopamine to other neurons connected to various parts of the limbic system, which is responsible for regulating emotion, motivation, behaviour, the sense of smell, and variously autonomic, or involuntary, functions like heartbeat and breathing. A growing body of evidence suggests that dopamine be involved in several major brain disorders. Narcolepsy, a disorder characterized by brief, recurring episodes of sudden, deep sleep, is associated with abnormally high levels of both dopamine and a second neurotransmitter, acetylcholine. Huntington’s chorea, an inherited, fatal illness in which neurons in the base of the brain are progressively destroyed, is also linked to an excess of dopamine.
Commonly known as shaking palsy, Parkinson disease is another brain disorder in which dopamine is involved. Besides tremors of the limbs, Parkinson patients suffer from muscular rigidity, which leads to difficulties in walking, writing, and speaking. This disorder results from the degeneration and death of neurons in the nigrostriatal pathway, resulting in low levels of dopamine. The symptoms of Parkinson disease can be reduced by treatment with a drug called levodopa, or L-dopa, which converts to dopamine in the brain.
Schizophrenia is a psychiatric disorder characterized by loss of contact with reality and major changes in personality. Schizophrenics have normal levels of dopamine in the brain, but because they are highly sensitive to this neurotransmitter, these normal levels of dopamine triggers unusual behaviours. Drugs such as thorazine that blocks the action of dopamine have been found to decrease the symptoms of schizophrenia.
Studies suggest that people who are addicted to alcohol and other drugs like, cocaine and nicotine have less dopamine in the mesocorticolimbic pathway. These drugs appear to increase dopamine levels, resulting in the pleasurable feelings associated with the drugs.
Serotonin, neurotransmitter, or chemical that transmits messages across the synapses, or gaps, between adjacent cells. Among its many functions, serotonin is released from blood cells called platelets to activate blood vessel constriction and blood clotting. In the gastrointestinal tract, serotonin inhibits gastric acid production and stimulates muscle contraction in the intestinal wall. Its functions in the central nervous system and effects on human behaviour - including mood, memory, and appetite control - have been the subject of a great deal of research. This intensive study of serotonin has revealed important knowledge about the serotonin-related cause and treatment of many illnesses.
Serotonin is produced in the brain from the amino acid tryptophan, which is derived from foods high in protein, such as meat and dairy products. Tryptophan is transported to the brain, where it is broken down by enzymes to produce serotonin. During neurotransmission, serotonin is transferred from one nerve cell, or neuron, to another, triggering an electrical impulse that stimulates or inhibits cell activity as needed. Serotonin is then reabsorbed by the first neuron, in a process known as reuptake, where it is recycled and used again or converted into an inactive chemical form and excreted.
While the complete picture of serotonin’s function in the body is still being investigated, many disorders are known to be associated with an imbalance of serotonin in the brain. Drugs that manipulate serotonin levels have been used to alleviate the symptoms of serotonin imbalances. Some of these drugs, known as selective serotonin reuptake inhibitors (SSRIs), block or inhibit the reuptake of serotonin into neurons, enabling serotonin to remain active in the synapses for a longer period. These medications are used to treat such psychiatric disorders as depression; Obsessive-compulsive disorder, in which repetitive and disturbing thoughts trigger bizarre, ritualistic behaviours, and impulsive aggressive behaviours. Fluoxetine (more commonly known by the brand name Prozac), is a widely prescribed SSRI used to treat depression, and more recently, obsessive-compulsive disorder.
Drugs that affect serotonin levels may prove beneficial in the treatment of nonpsychiatric disorders as well, including diabetic neuropathy (degeneration of nerves outside the central nervous system in diabetics) and premenstrual syndrome. Recently the serotonin-releasing agent dexfenfluramine has been approved for patients who are 30 percent or more over their ideal body weight. By preventing serotonin reuptake, dexfenfluramine promotes satiety, or fullness, after eating less food.
Other mental illnesses, while not always debilitating, create certain problems in living. People with personality disorders may experience loneliness and isolation because their personality style interferes with social relations. People with an eating disorder may become so preoccupied with their weight and appearance that they force themselves to vomit or refuse to eat. Individuals who develop post-traumatic stress disorder may become angry easily, experience disturbing memories, and have trouble concentrating.
Experiences of mental illness often differ to be unlike or distinct in nature as it depends on one’s culture or social group, sometimes greatly so. For example, in most of the non-Western world, people with depression complain principally of physical ailments, such as lack of energy, poor sleep, loss of appetite, and various kinds of physical pain. And yet, even in North America these complaints are commonplace. But in the United States and other Western societies, depressed people and mental health professionals who treat them tend to emphasize psychological problems, such as feelings of sadness, worthlessness, and despair. The experience of schizophrenia also differs by culture. In India, one-third of the new cases of schizophrenia involve catatonia, a behavioural condition in which a person maintains a bizarre statue-like posture for hours or days. This condition is rare in Europe and North America.
Schizophrenia, is a very severe mental illness characterized by a variety of symptoms, including loss of contact with reality, bizarre behaviour, disorganized thinking and speech, decreased emotional expressiveness, and social withdrawal. Usually only some of these symptoms occur in any one person. The term schizophrenia comes from Greek words meaning ‘split mind.’ However, contrary to common belief, schizophrenia does not refer to a person with a split personality or multiple personality. For a description of a mental illness in which a person has multiple personalities, to observers, schizophrenia may seem like madness or insanity, but persons with schizophrenia have disturbed, frightening thoughts and may have trouble telling the difference between real and unreal experiences.
The intermittent period from 1895 to 1900 Freud developed many of the concepts that were later incorporated into psychoanalytic practice and doctrine. Soon after publishing the studies on hysteria he abandoned the use of hypnosis as a cathartic procedure and substituted the investigation of the patient’s spontaneous flow of thoughts, called free association, to reveal the unconscious mental processes at the root of the neurotic disturbance.
In his clinical observations Freud found evidence for the mental mechanisms of repression and resistance. He described repression as a device operating unconsciously to make the memory of painful or threatening events inaccessible to the conscious mind. Resistance is defined as the unconscious defence against awareness of repressed experiences in order to avoid the resulting anxiety. He traced the operation of unconscious processes, using the free associations of the patient to guide him in the interpretation of dreams and slips of speech. Dream analysis led to his discoveries of infantile sexuality and of the so-called Oedipus complex, which constitutes the erotic attachment of the child for the parent of the opposite sex, together with hostile feelings toward the other parent. In these years he also developed the theory of transference, the process by which emotional attitudes, established originally toward parental figures in childhood, are transferred in later life to others. The end of this period was marked by the appearance of Freud’s most important work, The Interpretation of Dreams (1899). Here Freud analysed many of his own dreams recorded in the 3-year period of his self-analysis, begun in 1897. This work expounds all the fundamental concepts underlying psychoanalytic technique and doctrine.
In 1902 Freud was appointed a full professor at Vienna University. This honour was granted not in recognition of his contributions but as a result of the efforts of a highly influential patient. The medical world still regarded his work with hostility, and his next writings, The Psychopathology of Everyday Life (1904) and Three Contributions to the Sexual Theory (1905), only increased this antagonism. As a result Freud continued to work virtually alone in what he termed ‘splendid isolation.’
By 1906, however, a small number of pupils and followers had gathered around Freud, including the Austrian psychiatrists William Stekel and Alfred Adler, the Austrian psychologist Otto Rank, the American psychiatrist Abraham Brill, and the Swiss psychiatrists Eugen Bleuler and Carl Jung. Other notable associates, who joined the circle in 1908, were the Hungarian psychiatrist Sándor Ferenczi and the British psychiatrist Ernest Jones.
Austrian doctor Sigmund Freud spent many hours refining his theories in this study of his home in Vienna, Austria. Freud pioneered the use of clinical observation to treat mental disease. The publication of The Interpretation of Dreams in 1899 detailed his technique of isolating the source of psychological problems by examining a patient’s spontaneous stream of thought.
Increasing recognition of the psychoanalytic movement made possible the formation in 1910 of a worldwide organization called the International Psychoanalytic Association. As the movement spread, gaining new adherents through Europe and the US, Freud was troubled by the dissension that arose among members of his original circle. Most disturbing were the defections from the group of Adler and Jung, each of whom developed a different theoretical basis for disagreement with Freud’s emphasis on the sexual origin of neurosis. Freud met these setbacks by developing further his basic concepts and by elaborating his own views in many publications and lectures.
After the onset of World War I Freud devoted little time to clinical observation and concentrated on the application of his theories to the interpretation of religion, mythology, art, and literature. In 1923 he was stricken with cancer of the jaw, which necessitated constant, painful treatment in addition to many surgical operations. Despite his physical suffering he continued his literary activity for the next 16 years, writing mostly on cultural and philosophical problems.
When the Germans occupied Austria in 1938, Freud, a Jew, was persuaded by friends to escape with his family to England. He died in London on September 23, 1939.
Freud created an entirely new approach to the understanding of human personality by his demonstration of the existence and force of the unconscious. In addition, he founded a new medical discipline and formulated basic therapeutic procedures that in modified form are applied widely in the present-day treatment of neuroses and psychoses. Although never accorded full recognition during his lifetime, Freud is generally acknowledged as one of the great creative minds of modern times.
Among his other works are Totem and Taboo (1913), Ego and the Id (1923), New Introductory Lectures on Psychoanalysis (1933), and Moses and Monotheism (1939).
Psychoanalysis, its name is applied to a specific method of investigating unconscious mental processes and to a form of psychotherapy. The term refers, as well, to the systematic structure of psychoanalytic theory, which is based on the relation of conscious and unconscious psychological processes.
In the late 19th century Viennese neurologist Sigmund Freud developed a theory of personality and a system of psychotherapy known as psychoanalysis. According to this theory, people are strongly influenced by unconscious forces, including innate sexual and aggressive drives. In this 1938 British Broadcasting Corporation interview, Freud recounts the early resistance to his ideas and later acceptance of his work. Freud’s speech is slurred because he was suffering from cancer of the jaw. He died the following year.
The technique of psychoanalysis and much of the psychoanalytic theory based on its application were developed by Sigmund Freud. His work concerning the structure and the functioning of the human mind had far-reaching significance, both practically and scientifically, and it continues to influence contemporary thought.
Sigmund Freud, the founder of psychoanalysis, compared the human mind to an iceberg. The tip above the water represents consciousness, and the vast region below the surface symbolizes the unconscious mind. Of Freud’s three basic personality structures—id, ego, and superego—only the id is totally unconscious.
The first of Freud's innovations was his recognition of unconscious psychiatric processes that follow laws different from those that govern conscious experience. Under the influence of the unconscious, thoughts and feelings that belong together may be shifted or displaced out of context; two disparate ideas or images may be condensed into one; thoughts may be dramatized in the form of images rather than expressed as abstract concepts; and certain objects may be represented symbolically by images of other objects, although the resemblance between the symbol and the original object may be vague or farfetched. The laws of logic, indispensable for conscious thinking, do not apply to these unconscious mental productions.
Recognition of these modes of operation in unconscious mental processes made possible the understanding of such previously incomprehensible psychological phenomena as dreaming. Through analysis of unconscious processes, Freud saw dreams as serving to protect sleep against disturbing impulses arising from within and related to early life experiences. Thus, unacceptable impulses and thoughts, called the latent dream content, are transformed into a conscious, although no longer immediately comprehensible, experience called the manifest dream. Knowledge of these unconscious mechanisms permits the analyst to reverse the so-called dream work, that is, the process by which the latent dream is transformed into the manifest dream, and through dream interpretation, to recognize its underlying meaning.
A basic assumption of Freudian theory is that the unconscious conflicts involve instinctual impulses, or drives, that originate in childhood. As these unconscious conflicts are recognized by the patient through analysis, his or her adult mind can find solutions that were unattainable to the immature mind of the child. This depiction of the role of instinctual drives in human life is a unique feature of Freudian theory.
According to Freud's doctrine of infantile sexuality, adult sexuality is an end product of a complex process of development, beginning in childhood, involving a variety of body functions or areas (oral, anal, and genital zones), and corresponding to various stages in the relation of the child to adults, especially to parents. Of crucial importance is the so-called Oedipal period, occurring at about four to six years of age, because at this stage of development the child for the first time becomes capable of an emotional attachment to the parent of the opposite sex that is similar to the adult's relationship to a mate; the child simultaneously reacts as a rival to the parent of the same sex. Physical immaturity dooms the child's desires to frustration and his or her first step toward adulthood to failure. Intellectual immaturity further complicates the situation because it makes children afraid of their own fantasies. The extent to which the child overcomes these emotional upheavals and to which these attachments, fears, and fantasies continue to live on in the unconscious greatly influences later life, especially love relationships.
The conflicts occurring in the earlier developmental stages are no less significant as a formative influence, because these problems represent the earliest prototypes of such basic human situations as dependency on others and relationship to authority. Also basic in moulding the personality of the individual is the behaviour of the parents toward the child during these stages of development. The fact that the child reacts, not only to objective reality, but also to fantasy distortions of reality, however, greatly complicates even the best-intentioned educational efforts.
The effort to clarify the bewildering number of interrelated observations uncovered by psychoanalytic exploration led to the development of a model of the structure of the psychic system. Three functional systems are distinguished that are conveniently designated as the id, ego, and superego.
The first system refers to the sexual and aggressive tendencies that arise from the body, as distinguished from the mind. Freud called these tendencies Triebe, which literally means ‘drives,’ but which is often inaccurately translated as ‘instincts’ to indicate their innate character. These inherent drives claim immediate satisfaction, which is experienced as pleasurable; the id thus is dominated by the pleasure principle. In his later writings, Freud tended more toward psychological rather than biological conceptualization of the drives.
How the conditions for satisfaction are to be brought about is the task of the second system, the ego, which is the domain of such functions as perception, thinking, and motor control that can accurately assess environmental conditions. In order to fulfill its function of adaptation, or reality testing, the ego must be capable of enforcing the postponement of satisfaction of the instinctual impulses originating in the id. To defend itself against unacceptable impulses, the ego develops specific psychic means, known as defence mechanisms. These include repression, the exclusion of impulses from conscious awareness; projection, the process of ascribing to others one's own unacknowledged desires; and reaction formation, the establishment of a pattern of behaviour directly opposed to a strong unconscious need. Such defence mechanisms are put into operation whenever anxiety signals a danger that the original unacceptable impulses may reemerge.
An id impulse becomes unacceptable, not only as a result of a temporary need for postponing its satisfaction until suitable reality conditions can be found, but more often because of a prohibition imposed on the individual by others, originally the parents. The totality of these demands and prohibitions constitutes the major content of the third system, the superego, the function of which is to control the ego in accordance with the internalized standards of parental figures. If the demands of the superego are not fulfilled, the person may feel shame or guilt. Because the superego, in Freudian theory, originates in the struggle to overcome the Oedipal conflict, it has a power akin to an instinctual drive, is in part unconscious, and can give rise to feelings of guilt not justified by any conscious transgression. The ego, having to mediate among the demands of the id, the superego, and the outside world, may not be strong enough to reconcile these conflicting forces. The more the ego is impeded in its development because of being enmeshed in its earlier conflicts, called fixations or complexes, or the more it reverts to earlier satisfactions and archaic modes of functioning, known as regression, the greater is the likelihood of succumbing to these pressures. Unable to function normally, it can maintain its limited control and integrity only at the price of symptom formation, in which the tensions are expressed in neurotic symptoms.
A cornerstone of modern psychoanalytic theory and practice is the concept of anxiety, which institutes appropriate mechanisms of defence against certain danger situations. These danger situations, as described by Freud, are the fear of abandonment by or the loss of the loved one (the object), the risk of losing the object's love, the danger of retaliation and punishment, and, finally, the hazard of reproach by the superego. Thus, symptom formation, character and impulse disorders, and perversions, as well as sublimations, represent compromise formations—different forms of an adaptive integration that the ego tries to achieve through more or less successfully reconciling the different conflicting forces in the mind.
Ego, found its use in psychoanalysis, the term denoting the central part of the personality structure that deals with reality and is influenced by social forces. According to the psychoanalytic theories developed by Sigmund Freud, the ego constitutes one of the three basic provinces of the mind, the other two being the id and the superego. Formation of the ego begins at birth in the first encounters with the external world of people and things. The ego learns to modify behaviour by controlling those impulses that are socially unacceptable. Its role is that of mediator between unconscious impulses and acquired social and personal standards.
In philosophy, ego means the conscious self or ‘I.’ It was viewed by some philosophers, notably the 17th-century Frenchman René Descartes and the 18th-century German Johann Gottlieb Fichte, as the sole basis of reality; they saw the universe as existing only in the individual's knowledge and experience of it. Other philosophers, such as the 18th-century German Immanuel Kant, proposed two forms of ego, one perceiving and the other thinking.
An Id impulse, in psychoanalytic theory, is one of the three basic elements of personality, the others being the ego and the superego. The id can be equated with the unconscious of common usage, which is the reservoir of the instinctual drives of the individual, including biological urges, wishes, and affective motives. The id is dominated by the pleasure principle, through which the individual is pressed for immediate gratification of his or her desires. In strict Freudian theory the energy behind the instinctual drives of the id is known as the libido, a generalized force, basically sexual in nature, through which the sexual and psychosexual nature of the individual finds expression.
Superego, in psychoanalytic theory, one of the three basic constituents of the mind, the others being the id and the ego. As postulated by Sigmund Freud, the term designates the element of the mind that, in normal personalities, automatically modifies and inhibits those instinctual impulses or drives of the id that tend to produce antisocial actions and thoughts.
According to psychoanalytic theory, the superego develops as the child gradually and unconsciously adopts the values and standards, first of his or her parents, and later of the social environment. According to modern Freudian psychoanalysts, the superego includes the positive ego, or conscious self-image, or ego ideal, that each individual develops.
People have tried to understand the causes of mental illness for thousands of years. The modern era of psychiatry, which began in the late 19th and early 20th centuries, has witnessed a sharp debate between biological and psychological perspectives of mental illness. The biological perspective views mental illness in terms of bodily processes, whereas psychological perspectives emphasize the roles of a person’s upbringing and environment.
These two perspectives are exemplified in the work of German psychiatrist Emil Kraepelin and Austrian psychoanalyst Sigmund Freud. Kraepelin, influenced by the work in the mid-1800s of German psychiatrist Wilhelm Griesinger, believed that psychiatric disorders were disease entities that could be classified like physical illnesses. That is, Kraepelin believed that the fundamental causes of mental illness lay in the physiology and biochemistry of the human brain. His classification system of mental disorders, first published in 1883, formed the basis for later diagnostic systems. Freud, on the other hand, argued that the source of mental illness lay in unconscious conflicts originating in early childhood experiences. Freud found evidence for this idea through the analysis of dreams, free association, and slips of speech.
This debate has continued into the late 20th century. Beginning in the 1960s, the biological perspective became dominant, supported by numerous breakthroughs in psychopharmacology, genetics, neurophysiology, and brain research. For example, scientists discovered many medications that helped to relieve symptoms of certain mental illnesses and demonstrated that people can inherit a vulnerability to some mental illnesses. Psychological perspectives also remain influential, including the psychodynamic perspective, the humanistic and existential perspectives, the behavioural perspective, the cognitive perspective, and the sociocultural perspective.
Many mental health professionals today favour a combination of perspectives, acknowledging that both biology and a person’s environment play important roles in mental illness. This approach recognizes that people are not only products of the genes inherited from their parents, but products of the families and social worlds into which they are born. In this view, environments shape how biological factors will be manifested. For example, an infant may inherit genes that could enable her to become a tall adult, but if she is malnourished as a child, she will never achieve that potential. Likewise, an individual who does not possess a biological vulnerability for depression may nevertheless become severely depressed following the death of a loved one or after experiencing an act of torture.
Psychiatry has increasingly emphasized a biological basis for the causes of mental illness. Studies suggest a genetic influence in some mental illnesses, such as schizophrenia and bipolar disorder, although the evidence is not conclusive.
Clinical depression is one of the most common forms of mental illness. Although depression can be treated with psychotherapy, many scientists believe there are biological causes for the disease. In this June 1998 Scientific American article, neurobiologist Charles B. Nemeroff discusses the connection between biochemical changes in the brain and depression.
Scientists have identified a number of neurotransmitters, or chemical substances that enable brain cells to communicate with each other, that appear important in regulating a person’s emotions and behaviour. These include dopamine, serotonin, norepinephrine (see epinephrine), gamma-amino butyric acid (GABA), and acetylcholine. Excesses and deficiencies in levels of these neurotransmitters have been associated with depression, anxiety, and schizophrenia, but scientists have yet to determine the exact mechanisms involved.
Research shows that the more genetically related a person is to someone with schizophrenia, the greater the risk that person has of developing the illness. For example, children of one parent with schizophrenia have a 13 percent chance of developing the illness, whereas children of two parents with schizophrenia have a 46 percent chance of developing the disorder.
Advances in brain imaging techniques, such as magnetic resonance imaging (MRI) and positron emission tomography (PET), have enabled scientists to study the role of brain structure in mental illness. Some studies have revealed structural brain abnormalities in certain mental illnesses. For example, some people with schizophrenia have enlarged brain ventricles (cavities in the brain that contain cerebrospinal fluid). However, this may be a result of schizophrenia rather than a cause, and not all people with schizophrenia show this abnormality.
A variety of medical conditions can cause mental illness. Brain damage and strokes can cause loss of memory, impaired concentration and speech, and unusual changes in behaviour. In addition, brain tumours, if left to grow, can cause psychosis and personality changes. Other possible biological factors in mental illness include an imbalance of hormones, deficiencies in diet, and infections from viruses.
The psychodynamic perspective views mental illness as caused by unconscious and unresolved conflicts in the mind. As stated by Freud, these conflicts arise in early childhood and may cause mental illness by impeding the balanced development of the three systems that constitute the human psyche: the id, which comprises innate sexual and aggressive drives; the ego, the conscious portion of the mind that mediates between the unconscious and reality; and the superego, which controls the primitive impulses of the id and represents moral ideals. In this view, generalized anxiety disorder stems from a signal of unconscious danger whose source can only be identified through a thorough analysis of the person’s personality and life experiences. Modern psychodynamic theorists tend to emphasize sexuality less than Freud did and focus more on problems in the individual’s relationships with others.
Both the humanistic and existential perspectives view abnormal behaviour as resulting from a person’s failure to find meaning in life and fulfill his or her potential. The humanistic school of psychology, as represented in the work of American psychologist Carl Rogers, views mental health and personal growth as the natural conditions of human life. In Rogers’s view, every person possesses a drive toward self-actualization, the fulfilment of one’s greatest potential. Mental illness develops when circumstances in a person’s environment block this drive. The existential perspective sees emotional disturbances as the result of a person’s failure to act authentically—that is, to behave in accordance with one’s own goals and values, rather than the goals and values of others.
The pioneers of behaviourism, American psychologists John B. Watson and B. F. Skinner, maintained that psychology should confine itself to the study of observable behaviour, rather than explore a person’s unconscious feelings. The behavioural perspective explains mental illness, as well as all of human behaviour, as a learned response to stimuli. In this view, rewards and punishments in a person’s environment shape that person’s behaviour. For example, a person involved in a serious car accident may develop a phobia of cars or generalize the fear to all forms of transportation.
The cognitive perspective holds that mental illness results from problems in cognition— - that is, problems in how a person reasons, perceives events, and solves problems. American psychiatrist Aaron Beck proposed that some mental illnesses - such as depression, anxiety disorders, and personality disorders - result from a way of thinking learned in childhood that is not consistent with reality. For example, people with depression tend to see themselves in a negative light, exaggerate the importance of minor flaws or failures, and misinterpret the behaviour of others in negative ways. It remains unclear, however, whether these kinds of cognitive problems actually cause mental illness or merely represent symptoms of the illnesses themselves.
the sociocultural perspective regards mental illness as the result of social, economic, and cultural factors. Evidence for this view comes from research that has demonstrated an increased risk of mental illness among people living in poverty. In addition, the incidence of mental illness rises in times of high unemployment. The shift in the world population from rural areas to cities—with their crowding, noise, pollution, decay, and social isolation—has also been implicated in causing relatively high rates of mental illness. Furthermore, rapid social change, which has particularly affected indigenous peoples throughout the world, brings about high rates of suicide and alcoholism. Refugees and victims of social disasters—warfare, displacement, genocide, violence—have a higher risk of mental illness, especially depression, anxiety, and post-traumatic stress disorder.
Social scientists emphasize that the link between social ills and mental illness is correlational rather than causal. For example, although societies undergoing rapid social change often have high rates of suicide the specific causes have not been identified. Social and cultural factors may create relative risks for a population or class of people, but it is unclear how such factors raise the risk of mental illness for an individual.
psychiatrist Nancy C. Andreasen, chair of psychiatry at the University of Iowa College of Medicine in Iowa City and the author of The Broken Brain: The Biological Revolution in Psychiatry (1984), holds a National Medal of Science for her work on mental disorders. In this question-and-answer format, Andreasen touches on a variety of issues involving mental disorders. Is schizophrenia hereditary? How can you distinguish between a child with attention-deficit hyperactivity disorder (ADHD) and a child who is simply more active than other children? Is mental decline inevitable with aging? Is medication available to treat obsessive-compulsive disorders? Andreasen discusses these and many other questions.
There are no blood tests, imaging techniques, or other laboratory procedures that can reliably diagnose a mental illness. Thus, the diagnosis of mental illness is always a judgment or an interpretation by an observer based on the speech, ideas, behaviours, and experiences of the patient.
For the most part, mental health professionals determine the presence of mental illness in an individual by conducting an interview intended to reveal symptoms of abnormal behaviour. That is, the professional asks the patient questions about his or her mental state: ‘Do you hear voices of people who are not with you?’ ‘Have you felt depressed or lost interest in most activities?’ ‘Have you experienced a marked increase or decrease in your appetite?’ ‘Have you been sleeping less than normal?’ ‘Are you easily distracted?’ The answers to these questions will suggest other questions. Eventually, the clinician will feel that he or she has enough information to determine whether the patient is suffering from a mental illness and, if so, to make a diagnosis.
The process of diagnosis is not as simple as it might seem. Patients often have difficulty remembering symptoms or feel reluctant to talk about their fantasies, sex life, or use of drugs and alcohol. Many patients suffer from more than one disorder at a time—for example, depression and anxiety, or schizophrenia and depression—and determining which symptoms constitute the primary problem is complex. In addition, symptoms may not be specific to mental illnesses. For example, brain tumours, malaria, and infections of the central nervous system can produce symptoms that mimic those of psychotic disorders.
Another problem in diagnosis is that mental health professionals may interpret symptoms differently based on their personal or cultural biases. One study examined this effect by showing 300 American and British psychiatrists videotaped interviews of eight patients with mental illnesses. Although the psychiatrists’ diagnoses substantially agreed for patients with ‘textbook’ cases of schizophrenia, their diagnoses varied widely for patients who had symptoms of both schizophrenia and other disorders, depending on whether the psychiatrist was American or British. The risk of misdiagnosis is even greater when the mental health professional and the patient come from different cultural groups.
Mental health professionals use a number of methods to treat people with mental illnesses. The two most common treatments by far are drug therapy and psychotherapy. In drug therapy, a person takes regular doses of a prescription medication intended to reduce symptoms of mental illness. Psychotherapy is the treatment of mental illness through verbal and nonverbal communication between the patient and a trained professional. A person can receive psychotherapy individually or in a group setting.
The type of treatment administered depends on the type and severity of the disorder. For example, doctors usually treat schizophrenia primarily with drugs, but specialized forms of psychotherapy may more effectively relieve phobias. For some mental illnesses, such as depression, the most effective treatment seems to be a combination of drug therapy and psychotherapy. Although some people with severe mental illnesses may never fully recover, most people with mental illnesses improve with treatment and can resume normal lives. Despite the availability of effective treatments, only about 40 percent of people with mental illnesses ever seek professional help.
A variety of mental health professionals offer treatment for mental illness. These include psychiatrists, psychologists, psychotherapists, psychiatric social workers, and psychiatric nurses.
Drugs introduced in the mid-1950's enabled many people who otherwise would have spent years in mental institutions to return to the community and live productive lives. Since then, advances in psychopharmacology have led to the development of drugs of even greater effectiveness. These drugs often relieve symptoms of schizophrenia, depression, anxiety, and other disorders. However, they may produce undesirable and sometimes serious side effects. In addition, relapse may occur when they are discontinued, so long-term use may be required. Drugs that control symptoms of mental illness are called psychotherapeutic drugs. The major categories of psychotherapeutic drugs include antipsychotic drugs, antianxiety drugs, antidepressant drugs, and antimanic drugs.
Antipsychotic drugs, also called neuroleptics and major tranquillizers, control symptoms of psychosis, such as hallucinations and delusions, which characterize schizophrenia and related disorders. They can also prevent such symptoms from returning. Antipsychotic drugs may produce side effects ranging from dry mouth and blurred vision to tardive dyskinesia, a permanent condition that produces involuntary movements of the lips, mouth, and tongue.
Antianxiety drugs, also called minor tranquillizers, reduce high levels of anxiety. They may help people with generalized anxiety disorder, panic disorder, and other anxiety disorders. Benzodiazepines, a class of drugs that includes diazepam (Valium), are the most widely prescribed antianxiety drugs. Benzodiazepines can be addictive and may cause drowsiness and impaired coordination during the day.
Antidepressant drugs help relieve symptoms of depression. Some antidepressant drugs can relieve symptoms of other disorders as well, such as panic disorder and obsessive-compulsive disorder. Antidepressant drugs comprise three major classes: tricyclics, monoamine oxidase inhibitors (MAO inhibitors), and selective serotonin reuptake inhibitors (SSRIs). Side effects of tricyclics may include dizziness upon standing, blurred vision, dry mouth, difficulty urinating, constipation, and drowsiness. People who take MAO inhibitors may experience some of the same side effects, and must follow a special diet that excludes certain foods. SSRIs generally produce fewer side effects, although these may include anxiety, drowsiness, and sexual dysfunction. One type of SSRI, fluoxetine (Prozac), is the most widely prescribed antidepressant drug.
Antimanic drugs help control the mania that occurs as part of bipolar disorder. One of the most effective antimanic drugs is lithium carbonate, a natural mineral salt (see Lithium). Common side effects include nausea, stomach upset, vertigo, and increased thirst and urination. In addition, long-term use of lithium can damage the kidneys.
Psychotherapy can be an effective treatment for many mental illnesses. Unlike drug therapy, psychotherapy produces no physical side effects, although it can cause psychological damage when improperly administered. On the other hand, psychotherapy may take longer than drugs to produce benefits. In addition, sessions may be expensive and time-consuming. In response to this complaint and demands from insurance companies to reduce the costs of mental health treatment, many therapists have started providing therapy of shorter duration.
Psychotherapy encompasses a wide range of techniques and practices. Some forms of psychotherapy, such as psychodynamic therapy and humanistic therapy, focus on helping people understand the internal motivations for their problematic behaviour. Other forms of therapy, such as behavioural therapy and cognitive therapy, focus on the behaviour itself and teach people skills to correct it. The majority of therapists today incorporate treatment techniques from a number of theoretical perspectives. For example, cognitive-behavioural therapy combines aspects of cognitive therapy and behavioural therapy.
Psychodynamic therapy is one of the most common forms of psychotherapy. The therapist focuses on a person’s past experiences as a source of internal, unconscious conflicts and tries to help the person resolve those conflicts. Some therapists may use hypnosis to uncover repressed memories. Psychoanalysis, a technique developed by Freud, is one kind of psychodynamic therapy. In psychoanalysis, the person lies on a couch and says whatever comes to mind, a process called free association. The therapist interprets these thoughts along with the person’s dreams and memories. Classical psychoanalysis, which requires years of intensive treatment, is not as widely practised today as in previous years.
Psychotherapists who practice behavioural therapy do not focus on a person’s past experiences or inner life. Instead, they help the person to change patterns of abnormal behaviour by applying established principles of conditioning and learning. Behavioural therapy has proven effective in the treatment of phobias, obsessive-compulsive disorder, and other disorders. See Behaviour Modification.
The goal of cognitive therapy is to identify patterns of irrational thinking that cause a person to behave abnormally. The therapist teaches skills that enable the person to recognize the irrationality of the thoughts. The person eventually learns to perceive people, situations, and himself or herself in a more realistic way and develops improved problem-solving and coping skills. Psychotherapists use cognitive therapy to treat depression, panic disorder, and some personality disorders.
Rehabilitation programs assist people with severe mental illnesses in learning independent living skills and in obtaining community services. Counsellors may teach them personal hygiene skills, home cleaning and maintenance, meal preparation, social skills, and employment skills. In addition, case managers or social workers may help people with mental illnesses obtain employment, medical care, housing, education, and social services. Some intensive rehabilitation programs strive to provide active follow-up and social support to prevent hospitalization.
Therapists often use play therapy to treat young children with depression, anxiety disorders, and problems stemming from child abuse and neglect. The therapist spends time with the child in a playroom filled with dolls, puppets, and drawing materials, which the child may use to act out personal and family conflicts. The therapist helps the child recognize and confront his or her feelings.
In group therapy, a number of people gather together to discuss problems under the guidance of a therapist. By sharing their feelings and experiences with others, group members learn their problems are not unique, receive emotional support, and learn ways to cope with their problems. Psychodrama is a type of group therapy in which participants act out emotional conflicts, often on a stage, with the goals of increasing their understanding of their behaviours and resolving conflicts. Group therapy generally costs less per person than individual psychotherapy.
Family intervention programs help families learn to cope with and manage a family member’s chronic mental illness, such as schizophrenia. Family members learn to monitor the illness, help with daily life problems, ensure adherence to medication, and cope with stigma.
Electroconvulsive therapy (ECT) is a treatment for severe depression in which an electrical current is passed through the patient’s brain for one or two seconds to induce a controlled seizure. The treatments are repeated over a period of several weeks. For unknown reasons, ECT often relieves severe depression even when drug therapy and psychotherapy have failed. The treatment has created controversy because its side effects may include confusion and memory loss. Both of these effects, however, are usually temporary.
Seeking a treatment for extreme cases of mental illness, Portuguese neurologist António Egas Moniz invented the lobotomy, a surgical technique that destroys tissue in the frontal lobe of the brain. The procedure, widely performed in the 1940's and 1950's, often left people in a vegetative state or caused drastic changes in personality and behaviour.
Even more controversial than ECT is psychosurgery, the surgical removal or destruction of sections of the brain in order to reduce severe and chronic psychiatric symptoms. The best known example of psychosurgery is the lobotomy, a procedure developed by Portuguese neurologist António Egas Moniz that was widely performed in the 1940s and early 1950s. Psychosurgery is now rarely performed because no research has proven it effective and because it can produce drastic changes in personality and behaviour.
A significant portion of the homeless population in the United States suffers from a chronic mental illness, such as schizophrenia. The shortage of mental health treatment centres in many cities may partly account for the large number of mentally ill people who are homeless or in jail.
Treatment for mental illness takes places in a number of settings. Mental hospitals or psychiatric wards in general hospitals are used to treat patients in acute phases of their illnesses and when the severity of their symptoms requires constant supervision. Most individuals who suffer from severe mental illness, however, do not require such close attention, and they can usually receive treatment in community settings.
Often, patients who have just completed a period of hospitalization go to group homes or halfway houses before returning to independent living. These facilities offer patients the opportunity to take part in group activities and to receive training in social and job skills. In supportive housing, mentally ill individuals can live independently in an environment that offers an array of mental health and social services. Some people with chronic and severe mental illnesses require care in long-term facilities, such as nursing homes, where they can receive close supervision.
Unfortunately, many areas have a shortage of treatment centres, especially community mental health centres and supportive housing environments. This shortage may partly account for the large number of mentally ill people who are homeless or in jail.
Most non-Western countries still lack adequate treatment facilities and services for the mentally ill. In China, with its 1.2 billion people, there are 4.5 million patients with schizophrenia, but only about 100,000 beds for the mentally ill and fewer than 10,000 psychiatrists. On the other hand, there are hundreds of thousands of traditional healers, many of whom treat mentally ill patients. Other people with mental illnesses receive treatment from general physicians. In most countries of sub-Saharan Africa, psychiatric services are so limited that most people with mental illnesses receive little if any professional care. Some developing countries, however, have begun substantial reform and expansion of mental health services.
Evidence for trepanning, the surgical procedure of cutting a hole in the skull, dates back 4,000 to 5,000 years. Some anthropologists speculate that Stone Age societies performed trepanning on people with mental illnesses to release evil spirits or demons from their heads. In the absence of written records, however, it is impossible to know why the operation was performed.
The Greek physician Hippocrates was one of the first scholars to challenge the notion that disease was punishment sent from the gods. He believed that all illnesses, including mental illnesses, had natural origins.
The literature of ancient Greece and Rome contains evidence of the belief that spirits or demons cause mental illness. In the 5th century bc the Greek historian Herodotus wrote an account of a king who was driven mad by evil spirits. The legend of Hercules describes how, driven insane by a curse, he killed his own children. The Roman poets Virgil and Ovid repeated these themes in their works. The early Babylonian, Chinese, and Egyptian civilizations also viewed mental illness as possession, and used exorcism—which sometimes involved beatings, restraint, and starvation—to drive the evil spirits from their victim.
Not all ancient scholars agreed with this theory of mental illness. The Greek physician Hippocrates believed that all illnesses, including mental illnesses, had natural origins. For example, he rejected the prevailing notion that epilepsy had its origins in the divine or sacred, viewing it as a disease of the brain. Hippocrates classified mental illnesses into categories that included mania, melancholia (depression), and phrenitis (brain fever), and he advocated humane treatment that included rest, bathing, exercise, and dieting. The Greek philosopher Plato, although adhering to a somewhat supernatural view of mental illness, believed that childhood experiences shaped adult behaviours, anticipating modern psychodynamic theories by more than 2000 years.
The Middle Ages in Europe, from the fall of the Roman empire in the 5th century ad to about the 15th century, was a period in which religious beliefs, specifically Christianity, dominated concepts of mental illness. Much of society believed that mentally ill people were possessed by the devil or demons, or accused them of being witches and infecting others with madness (see Witchcraft). Thus, instead of receiving care from physicians, the mentally ill became objects of religious inquisition and barbaric treatment. On the other hand, some historians of medicine cite evidence that even in the Middle Ages, many people believed mental illness to have its basis in physical and psychological disturbances, such as imbalances in the four bodily humours (blood, black bile, yellow bile, and phlegm), poor diet, and grief.
The Islamic world of North Africa, Spain, and the Middle East generally held far more humane attitudes toward people with mental illnesses. Following the belief that God loved insane people, communities began establishing asylums beginning in the 8th century ad, first in Baghdad and later in Cairo, Damascus, and Fez. The asylums offered patients special diets, baths, drugs, music, and pleasant surroundings.
The Renaissance, which began in Italy in the 14th century and spread throughout Europe in the 16th and 17th centuries, brought both deterioration and progress in perceptions of mental illness. On the one hand, witch-hunts and executions escalated throughout Europe, and the mentally ill were among those persecuted. The infamous Malleus Maleficarum, which served as a handbook for inquisitors, claimed that witches could be identified by delusions, hallucinations, or other peculiar behaviour. To make matters worse, many of the most eminent physicians of the time fervently advocated these beliefs.
On the other hand, some scholars vigorously protested these supernatural views and called renewed attention to more rational explanations of behaviour. In the early 16th century, for example, the Swiss physician Paracelsus returned to the views of Hippocrates, asserting that mental illnesses were due to natural causes. Later in the century, German physician Johann Weyer argued that witches were actually mentally disturbed people in need of humane medical treatment.
French physician Philippe Pinel supervises the unchaining of mentally ill patients in 1794 at La Salpêtrière, a large hospital in Paris. Pinel believed in treating mentally ill people with compassion and patience, rather than with cruelty and violence. This painting, Pinel Frees the Insane from Their Chains, was completed by French artist Tony Robert-Fleury in 1876.
During the Age of Enlightenment, in the 18th and early 19th centuries, people with mental illnesses continued to suffer from poor treatment. For the most part, they were left to wander the countryside or committed to institutions. In either case, conditions were generally wretched. One mental hospital, the Hospital of Saint Mary of Bethlehem in London, England, became notorious for its noisy, chaotic conditions and cruel treatment of patients.\
The Hospital of Saint Mary of Bethlehem, a London mental hospital commonly known as Bedlam, sold admission tickets to the public in the 18th century, becoming a popular tourist attraction. In this engraving by English artist William Hogarth, part of his series A Rake’s Progress (1735), two women (seen in the background) tour the hospital, watching the mentally ill patients for their amusement. The hospital became notorious for its miserable conditions and cruel treatment of patients.
Yet as the public’s awareness of such conditions grew, improvements in care and treatment began to appear. In 1789 Vincenzo Chiarugi, superintendent of a mental hospital in Florence, Italy, introduced hospital regulations that provided patients with high standards of hygiene, recreation and work opportunities, and minimal restraint. At nearly the same time, Jean-Baptiste Pussin, superintendent of a ward for ‘incurable’ mental patients at La Bicêtre hospital in Paris, France, forbade staff to beat patients and released patients from shackles. Philippe Pinel continued these reforms upon becoming chief physician of La Bicêtre’s ward for the mentally ill in 1793. Pinel began to keep case histories of patients and developed the concept of ‘moral treatment,’ which involved treating patients with kindness and sensitivity, and without cruelty or violence. In 1796 a Quaker named William Tuke established the York Retreat in rural England, which became a model of compassionate care. The retreat enabled people with mental illnesses to rest peacefully, talk about their problems, and work. Eventually these humane techniques became widespread in Europe.
In 1908, after his release from a mental asylum, Clifford Whittingham Beers wrote A Mind That Found Itself, which exposed the poor conditions he had suffered while confined. He went on to establish several organizations dedicated to the promotion of mental health reforms in the United States.
People living in the colonies of North America in the 17th and 18th centuries generally explained bizarre or deviant behaviour as God’s will or the work of the devil. Some people with mental illnesses received care from their families, but most were jailed or confined in almshouses with the poor and infirm. By the mid-18th century, however, American physicians came to view mental illnesses as diseases of the brain, and advocated specialized facilities to treat the mentally ill. The Pennsylvania Hospital in Philadelphia, which opened in 1752, became the first hospital in the American colonies to admit people with mental illnesses, housing them in a separate ward. However, in the hospital’s early years, mentally ill patients were chained to the walls of dark, cold cells.
After suffering a mental breakdown in 1900, Clifford Beers, an aspiring American businessman, spent the next three years in treatment at various mental hospitals. Upon his recovery, Beers wrote A Mind That Found Itself (1908), which chronicled the hardships he endured and revealed the callousness of many hospital attendants to the suffering of patients. The book aroused public concern about the care of people with mental illnesses and launched a worldwide movement for mental health. In the following excerpt, Beers describes his experiences in the violent ward of a state hospital. The passage also reveals the delusions brought about by his state of ‘elation,’ or mania.
In the 1780's American physician Benjamin Rush instituted changes at the Pennsylvania Hospital that greatly improved conditions for mentally ill patients. Although he endorsed the continued use of restraints, punishment, and bleeding, he also arranged for heat and better ventilation in the wards, separation of violent patients from other patients, and programs that offered work, exercise, and recreation to patients. Between 1817 and 1828, following the examples of Tuke and Pinel, a number of institutions opened that devoted themselves exclusively to the care of mentally ill people. The first private mental hospital in the United States was the Asylum for the Relief of Persons Deprived of the Use of Their Reason (now Friends Hospital), opened by Quakers in 1817 in what is now Philadelphia. Other privately established institutions soon followed, and state-sponsored hospitals—in Kentucky, New York, Virginia, and South Carolina - opened beginning in 1824.
American reformer Dorothea Dix championed the causes of prison inmates, the mentally ill, and the destitute. Horrified by the conditions provided for the mentally ill in Massachusetts, Dix successfully petitioned the state government for improvements in 1843. She was directly responsible for building or enlarging 32 mental hospitals in North America, Europe, and Japan.
Nevertheless, circumstances for most mentally ill people in the United States, especially those who were poor, remained dreadful. In 1841 Dorothea Dix, a Boston schoolteacher, began a campaign to make the public aware of the plight of mentally ill people. By 1880, as a direct result of her efforts, 32 psychiatric hospitals for the poor had opened. Increasingly, society viewed psychiatric institutions as the most appropriate form of care for people with mental illnesses. However, by the late 19th century, conditions in these institutions had deteriorated. Overcrowded and understaffed, psychiatric hospitals had shifted their treatment approach from moral therapy to warehousing and punishment. In 1908 Clifford Whittingham Beers aroused new concern for mentally ill individuals with the publication of A Mind That Found Itself, an account of his experiences as a mental patient. In 1909 Beers founded the National Committee for Mental Hygiene, which worked to prevent mental illness and ensure humane treatment of the mentally ill.
Following World War II (1939-1945), a movement emerged in the United States to reform the system of psychiatric hospitals, in which hundreds of thousands of mentally ill persons lived in isolation for years or decades. Many mental health professionals—seeing that large state institutions caused as much, if not more, harm to patients than mental illnesses themselves - came to believe that only patients with severe symptoms should be hospitalized. In addition, the development in the 1950's of antipsychotic drugs, which helped to control bizarre and violent behaviour, allowed more patients to be treated in the community. In combination, these factors led to the deinstitutionalisation movement: the release, over the next four decades, of hundreds of thousands of patients from state mental hospitals. In 1950, 513,000 patients resided in these institutions. By 1965 there were 475,000, and by 1990 state mental hospitals housed only 92,000 patients on any given night. Many patients who were released returned to their families, although many were transferred to questionable conditions in nursing homes or board-and-care homes. Many patients had no place to go and began to live on the streets.
The National Mental Health Act of 1946 created the National Institute of Mental Health as a centre for research and funding of research on mental illness. In 1955 Congress created a commission to investigate the state of mental health care, treatment, and prevention. In 1963, as a result of the commission’s findings, Congress passed the Community Mental Health Centres Act, which authorized the construction of community mental health centres throughout the country. Implementation of these centres was not as extensive as originally planned, and many people with severe mental illnesses failed to receive care of any kind.
One of the most important developments in the field of mental health in the United States has been the establishment of advocacy and support groups. The National Alliance for the Mentally Ill (NAMI), one of the most influential of these groups, was founded in 1972. NAMI’s goal is to improve the lives of people with severe mental illnesses and their families by eliminating discrimination in housing and employment and by improving access to essential treatments and programs.
During the 1980s, all levels of government in the United States cut back on funding for social services. For example, the Social Security Administration discontinued benefits for approximately 300,000 people between 1981 and 1983. Of these, an estimated 100,000 were people with mental illnesses. Although the government eventually restored Social Security benefits to many of these people, the interruption of services caused widespread hardship.
The emergence of managed care in the 1990s as a way to contain health care costs had a tremendous impact on mental health care in the United States. Health insurance companies and health maintenance organizations increasingly scrutinized the effectiveness of various psychotherapies and drug treatments and put stricter limits on mental health care. In response to these restrictions, Congress passed the Mental Health Parity Act of 1996. This law required private medical plans that offer mental health coverage to set equal yearly and lifetime payment limits for coverage of both mental and physical illnesses.
In 1997 the US. Equal Employment Opportunity Commission issued new guidelines intended to prevent discrimination against people with mental illnesses in the workplace. The rules, based on the Americans with Disabilities Act of 1990, prohibit employers from asking job applicants if they have a history of mental illness and require employers to provide reasonable accommodations to workers with mental illnesses.
In recent years international agencies, led by the World Health Organization (WHO) of the United Nations (UN) have developed mental health policies that seek to reduce the huge burden of mental illness worldwide. These agencies are working to improve the quality of mental health services in Africa, Asia, Latin America, the Middle East, and elsewhere by educating governments on prevention and treatment of mental illness and on the rights of the mentally ill.
Psychiatry is a branch of medicine specializing in mental illnesses. Psychiatrists not only diagnose and treat these disorders but also conduct research directed at understanding and preventing them.
Psychiatrist is a doctor of medicine who has had four years of postgraduate training in psychiatry. Many psychiatrists take further training in psychoanalysis, child psychiatry, or other subspecialties. Psychiatrists treat patients in private practice, in general hospitals, or in specialized facilities for the mentally ill (psychiatric hospitals, outpatient clinics, or community mental health centres). Some spend part or all of their time doing research or administering mental health programs. By contrast, psychologists, who often work closely with psychiatrists and treat many of the same kinds of patients, are not trained in medicine; consequently, they neither diagnose physical illness nor administer drugs.
The province of psychiatry is unusually broad for a medical specialty. Mental disorders may affect most aspects of a patient's life, including physical functioning, behaviour, emotions, thought, perception, interpersonal relationships, sexuality, work, and play. These disorders are caused by a poorly understood combination of biological, psychological, and social determinants. Psychiatry's task is to account for the diverse sources and manifestations of mental illness.
Physicians in the Western world began specializing in the treatment of the mentally ill in the 19th century. Known as alienists, psychiatrists of that era worked in large asylums, practising what was then called moral treatment, a humane approach aimed at quieting mental turmoil and restoring reason. During the second half of the century, psychiatrists abandoned this mode of treatment and, with it, the tacit recognition that mental illness is caused by both psychological and social influences. For a while, their attention focussed almost exclusively on biological factors. Drugs and other forms of somatic (physical) treatment were common. The German psychiatrist Emil Kraepelin identified and classified mental disorders into a system that is the foundation for modern diagnostic practices. Another important figure was the Swiss psychiatrist Eugen Bleuler, who coined the word schizophrenia and described its characteristics.
The discovery of unconscious sources of behaviour—an insight dominated by the psychoanalytic writings of Sigmund Freud in the early 20th century—enriched psychiatric thought and changed the direction of its practice (see Psychoanalysis). Attention shifted to processes within the individual psyche, and psychoanalysis came to be regarded as the preferred mode of treatment for most mental disorders. In the 1940s and 1950s emphasis shifted again: this time to the social and physical environment. Many psychiatrists had all but ignored biological influences, but others were studying those involved in mental illness and were using somatic forms of treatment such as electroconvulsive therapy (electric shock) and psychosurgery.
Dramatic changes in the treatment of the mentally ill in the United States began in the mid-1950s with the introduction of the first effective drugs for treating psychotic symptoms. Along with drug treatment, new, more liberal and humane policies and treatment strategies were introduced into mental hospitals. More and more patients were treated in community settings in the 1960s and 1970s. Support for mental health research led to significant new discoveries, especially in the understanding of genetic and biochemical determinants in mental illness and the functioning of the brain. Thus, by the 1980s, psychiatry had once again shifted in emphasis to the biological, to the relative neglect of psychosocial influences in mental health and illness. See Psychotherapy.
Psychiatrists use a variety of methods to detect specific disorders in their patients. The most fundamental is the psychiatric interview, during which the patient's psychiatric history is taken and mental status is evaluated. The psychiatric history is a picture of the patient's personality characteristics, relationships with others, and past and present experience with psychiatric problems - all told in the patient's words (sometimes supplemented by comments from other family members). Psychiatrists use mental-status examinations much as internists use physical examinations. They elicit and classify aspects of the patient's mental functioning.
Some diagnostic methods rely on testing by other specialists. Psychologists administer intelligence and personality tests, as well as tests designed to detect damage to the brain or other parts of the central nervous system. Neurologists also test psychiatric patients for evidence of impairment of the nervous system. Other physicians sometimes examine patients who complain of physical symptoms. Psychiatric social workers explore family and community problems. The psychiatrist integrates all this information in making a diagnosis according to criteria established by the psychiatric profession.
Psychiatric treatments fall into two classes: organic and nonorganic forms. Organic treatments, such as drugs, are those that affect the body directly. Nonorganic types of treatment improve the patient's functioning by psychological means, such as psychotherapy, or by altering the social environment.
Psychotropic drugs (see Psychoactive Drugs) are by far the most commonly used organic treatment. The first to be discovered were the antipsychotics, used primarily to treat schizophrenia. The phenothiazine are the most frequently prescribed class of antipsychotic drugs. Others are the thioxanthenes, butyrophenones, and indoles. All antipsychotic drugs diminish such symptoms as delusions, hallucinations, and thought disorder. Because they can reduce agitation, they are sometimes used to control manic excitement in manic-depressive patients and to calm geriatric patients. Some childhood behaviour disorders respond to these drugs.
Despite their value, the antipsychotic drugs have drawbacks. The most serious is the neurological condition tardive dyskinesia, which occurs in patients who have taken the drugs over extended periods. The condition is characterized by abnormal movements of the tongue, mouth, and body. It is especially serious because its symptoms do not always disappear when the drug is stopped, and no known treatment for it has been developed.
Most psychotropic drugs are chemically synthesized. Lithium carbonate, however, is a naturally occurring element used to prevent, or at least reduce, the severity of shifts of mood in manic-depression (see Depression). It is especially effective in controlling mania. Psychiatrists must monitor lithium dosages carefully, because only a small margin exists between an effective dose and a toxic one.
Three major classes of antidepressant drugs are used. The tricyclic and tetracyclic antidepressants, the most frequently prescribed, are used for the most common form of serious depression. Monoamine oxidase (MAO) inhibitors are used for so-called atypical depressions. Serotonin-selective reuptake inhibitors (SSRIs) are effective against both typical and atypical depressions. Although all three classes are quite effective in relieving depression in correctly matched patients, they also have disadvantages. The tricyclics and tetracyclics can take two to five weeks to become effective and can cause such side effects as oversedation and cardiac problems. MAO inhibitors can cause severe hypertension in patients who ingest certain types of food (such as cheese, beer, and wine) or drugs (such as cold medicines). SSRI drugs, such as fluoxetine (Prozac), take 2 to 12 weeks to become effective and can cause headaches, nausea, insomnia, and nervousness.
Anxiety, tension (see Stress-Related Disorders), and insomnia are often treated with drugs that are commonly called minor tranquillizers. Barbiturates have been used for the longest time, but they produce more severe side effects and are more often abused than the newer classes of antianxiety drugs. Of the new drugs, the benzodiazepines are the most frequently prescribed, very often in nonpsychiatric settings.
The stimulant drugs, such as amphetamine—a drug that is often abused—have legitimate uses in psychiatry. They help to control overactivity and lack of concentration in hyperactive children and to stimulate the victims of narcolepsy, a disorder characterized by sudden, uncontrollable episodes of sleep.
Another organic treatment is electroconvulsive therapy, or ECT, in which seizures similar to those of epilepsy are produced by a current of electricity passed through the forehead. ECT is most commonly used to treat severe depressions that have not responded to drug treatment. It is also sometimes used to treat schizophrenia. Other forms of organic treatment are much less frequently used than drugs and ETC. They include the controversial technique psychosurgery, in which fibres in the brain are severed; this technique is now used very rarely.
The most common nonorganic treatment is psychotherapy. Most psychotherapies conducted by psychiatrists are psychodynamic in orientation—that is, they focus on internal psychic conflict and its resolution as a means of restoring mental health. The prototypical psychodynamic therapy is psychoanalysis, which is aimed at untangling the sources of unconscious conflict in the past and restructuring the patient's personality. Psychoanalysis is the treatment in which the patient lies on a couch, with the psychoanalyst out of sight, and says whatever comes to mind. The patient relates dreams, fantasies, and memories, along with thoughts and feelings associated with them. The analyst helps the patient interpret these associations and the meaning of the patient's relationship to the analyst. Because it is lengthy and expensive, often several years in duration, classical psychoanalysis is now infrequently used.
More common are shorter forms of psychotherapy that supplement psychoanalytic principles with other theoretical ideas and scientifically derived information. In these types of therapy, psychiatrists are more likely to give the patient advice and try to influence behaviour. Some use techniques derived from behaviour therapy, which is based on learning theory (although these methods are more commonly used by psychologists).
Besides psychotherapy, the other major form of nonorganic treatment used in psychiatry is milieu therapy. Usually carried out in psychiatric wards, milieu therapy directs social relations among patients and staff toward therapeutic ends. Ward activities, too, are planned to serve specific therapeutic goals.
In general, psychotherapy is relied on more heavily for the treatment of neuroses and other nonpsychotic conditions than it is for psychoses. In psychotic patients, who usually receive psychoactive drugs, psychotherapy is used to improve social and vocational functioning. Milieu therapy is limited to hospitalized patients. Increasingly, psychiatrists use a combination of organic and nonorganic techniques for all patients, depending on their diagnosis and response to treatment.
Despite radical implications for theory of psychoanalytic techniques and others in a dialectical way, is often without awareness. Where these psychoanalysts disagree in their conceptual frame, create the recognition that analyst and patient cannot simply avoid having an impact on each other. Even so, we cannot be to remove obstructions from whether we have related this to our deliberate technical interventions or intentional aspects drawn upon the conceptual interactions. As for reasons that are useful and necessary to distinguish between theory of techniques, which the interconnectivity established through the conjunctive relationships have in relation of what seemed allowable for us to expand our knowledge of the complex and subtle factors that account for therapeutic action. This, however, can ultimately become the most effective basis for refining and developing our understanding of how best to serve of ourselves to advance the analytic situation and too aculeate more profound and very acute satisfactory depictions in the psychoanalytic engagements, no matter whatever our accountable resultants may be of our theoretical orientation.
An appreciation of the power of interactive forces in the analytic field not only challenges many traditionally held beliefs about the nature of therapeutic action. However, these take upon the requirement for us to recognize the untenability of the traditional view that analysts can be an objective source in the work. They have better to understand it, for example, where patients and analysts may express as a quantity that which the analyst is of a position to be an objective interpreter of the patient's experiential processes. That in this may reflect a form of collusive enactment and a convergence of the needs of both to see the analyst as an authority, and if the patient and analysts' both submit to needs to believe that the analyst is the omniscient other or the benevolent authority to which one can entrust ones' own. As the functional structure of the relationship might serve to obscure recognition of the fact that it is inclined to encourage the belief that, as once put, that wherever a coordinative system is complicating and hardens of its complexities, as recognized of the mind or brain, immediately 'indeterminacy' so then arises, not necessarily because of some preconditional unobtainability but holds accountably to subjective matters' from which grow stronger in obtaining the right prediction, least of mention, that so many things are yet to be known, in that the stray consequences of studying them will disturb the status quo, and of not-knowing to what influential persuasions do really occur between the protective cranial wall of vertebral anatomy. It is therefore that our manifesting awareness cannot accord with the inclining inclinations beheld to what is meant in how. History is not and cannot be determinate. Thus, the supposed causes may only produce the consequences we expect, this has rarely been more true than of those whose thoughts and interaction in psychoanalytic interrelatedness are in a way that no dramatist would ever dare to conceive.
In Winnicott (1969) has noted that there are times when 'analysers' can serve as holding operations and become interminable without any real growth occurring.
An interactive perspective also helps to clarify why in some instances the analysers 'abstinence' carriers as much risk of negative iatrogenic consequences as does active intervention. Although silence at time obviously can be respectful and facilitating, at other times it can be cruel and sadistic, or it can be based on fear of engagement, among a host of possible other meanings and equally attributive to the distributional dynamical functions.
An appreciation of interactive factors also allows us to consider that, to whatever degree the patient's perceptions of the analyst are plausible and even valid (Ferenczi 1933, Little 1951, Levenson 1973, Searles 1975, Gill 1982, Hoffman 1983), this may be due to the patient's expertise of stimulating precisely this kind of responsiveness in the analyst. The reverse is true as well thus, though patient and analyst each will have unique vulnerabilities, sensitivities, strengths, and needs, we must consider why such peculiarities have excited the particular qualities or sensibilities of either patient or analyst at a give moment and not at others. At any moment patient or analyst might be involved in some kind of collusive enactment (Racker 1957, 1959, Grotstein 1981, and McDougall 1979), they have held that their considerations explain of reasons that posit of themselves of why clinicians often seem to practice in ways that contradict their own shared beliefs and theoretical positions, least of mention, principles by way of enacting to some unfiltered dialectical discourse.
Yet, these differences, which occur within and between the diverse analytic traditions, in that an interactive view of the analytic field has some theoretical and technical implications that bridge all psychoanalytically perceptively which each among us cannot ignore. Its premise lies in the fact that we recognize that the analyst and patient cannot simply avoid having an impact on each other, even if both are totally silent, require us to realize that even if a treatment is productive or successful, we cannot be clear whether they have related this to our deliberate technical interventions or to aspects of the interaction that have eluded our awareness.
We have premised its owing intentionality that the recognition that analyst and patient cannot simply avoid having an impact on each other, even if both are totally silent, requires us to realize that even if some treatment is productive or successful, we cannot be clear whether we have related this to our deliberate technical interventions or to aspects of the interaction that have eluded austereness.
Psychoanalysts of diverse orientations increasingly have come to recognize that patient and analysts are continually influencing and being influenced by each other in a dialectical way, often without awareness. This has radical implications for abstractive views drawn upon psychoanalytic technique. Where these psychoanalysts disagree is in their conceptions of what the specific implications of an interactive view of the analytic field might be.
It is therefore that distinguishing between theory of technique is useful and necessary, which relates to what we do with awareness and intention, and theory of therapeutic action, which deals with what is healing in the psychoanalytic interaction whether or not it evolves from our ‘technique’: That recognizing this can allow us to expand our knowledge of the complex and subtler factors that account for therapeutic action. This can ultimately become the most effective basis for refining and developing our understanding of how best to use ourselves to advance the analytic work and to simplify more profound and incisive kinds of psychoanalytic engagement, no matter what our theoretical orientation.
An appreciation of the power of interactive forces in the analytic subject field not only challenges many traditionally held beliefs about the nature of therapeutic action, but also requires us to recognize the untenability of the traditional view that the analyst can be an objective participant in the work? It also helps us to grasp the extent to which presumably therapeutic interpretations, for example, can be ways of harassing, demeaning, patronizing, impinging on, penetrating, or violating the patient, or particular ways of gratifying, supporting, complying, among several of other possibilities. Where patient and analysts assume that the analyst can be an objective interpreter of the patient’s experience, this may factually reflect a form of collusive enactment and a convergence of the needs of both to see the analyst as an authority. If patient and analyst both have needs to believe that the analyst is the omniscient other or the benevolent authority to which one can entrust ones' own, the structure of the relationship might serve to obscure recognition of the fact that they are enacting such a drama. In this regard, Winnicott (1969) has noted that on that point are times when ‘analyses’ can serve as holding operations and become interminable, without any real growth occurring.
An interactive perspective also helps to clarify why sometimes the analyst’s ‘abstinence’ carries as much risk of negative iatrogenic consequences as does actively intervention. Although silence at times obviously can be respectful and facilitating, at other times it can be cruel and sadistic, or it can be based on fear of engagement, among a host of possible other meanings and contributing functions.
The contextual meaning of the patient’s free association also has to be reconsidered from such a perspective. Usually viewed as the medium of analytic work, free association may at times be a profound frame of resistance, and to avoid rather than engage in an analytic process. Alternatively it can reflect a form of compliance or collusion, conscious or unconscious, with the analyst’s needs, fears, resistances.
Amid the welter of competing or complementary theories that have characterized psychoanalyses over the century of its existence, the ideas of transference and the convictions very important in the therapeutic process are an unfiling theme. None of Freud's epochal discoveries - the power to the dynamic unconscious, the meaningfulness of the dream, the uniformity of intrapsychic conflict - having been more heuristically productive or more clinically valuable than his demonstration that human regularly and inevitably repeat with the analyst and with other important figures in their current live patterned of relationship, of fantasy, and of conflict with the crucial figures in their childhood - primarily their parents?
Even for Freud, however, the awareness of this phenomenon and the understanding of its specific significance in the analytic situation itself came gradually. In his clinical observations Freud found evidence for the mental mechanisms of repression and resistance. He described repression as a device operating unconsciously to make the memory of painful or threatening events inaccessible to the conscious mind. Resistance is defined as the unconscious defence against awareness of repressed experiences in order to avoid the resulting anxiety. He traced the operation of unconscious processes, using the free associations of the patient to guide him in the interpretation of dreams and slips of speech. Dream analysis led to his discoveries of infantile sexuality and of the so-called Oedipus complex, which constitutes the erotic attachment of the child for the parent of the opposite sex, together with hostile feelings toward the other parent. In these years he also developed the theory of transference, the process by which emotional attitudes, established originally toward parental figures in childhood, are transferred in later life to others. The end of this period was marked by the appearance of Freud’s most important work, The Interpretation of Dreams (1899). Here Freud analysed many of his own dreams recorded in the 3-year period of his self-analysis, begun in 1897. This work expounds all the fundamental concepts underlying psychoanalytic technique and doctrine. The flamboyant transference events in Breuer's patient Anna O and the unfortunate outcome in the patient of Dora served to consolidate in Freud's mind a view of transference as a resistance phenomenon, as an obstacle to the recollection of traumatic events that, in his view at the time, formed the true essence of the psychoanalytic process. Emphasis in this early period, thus, was on the 'management' of the transference, on finding ways to prevent its interference with the proper business of the analysis - recognizing, always, the inevitability of its occurrence. Freud was most concerned about the interferences generate by the 'negative' (i.e., hostile) and the erotised transference, the 'positive' transference he considered 'unobjectable,' the vehicle of success in the psychoanalysis.
Freud was also concerned to distinguish the analytic transference from the effects of suggestion in the hypnotic treatment he had learned in France, where he interdependently studying from Professor Charcot at the Salpêtrière hospital, and had been the forerunner of his own psychoanalysis technique. He, and his early followers and students, were at great pains to define the transference as a spontaneous product of the analytic situation, emerging from the patient rather than imposed by the analyst. Ultimately, Freud came to view as essentially for analytic cures the development of a new mental structure, the 'transference neurosis' - re-creation of the original neurosis in the analytic situation itself, with the patient experiencing the analyst as the object of his or her infantile wishes and the focus of his or her pathogenic conflicts. The crucial importance of the transference neurosis - it's very reality as a clinical phenomenon - has been and continues to be a matter of debate among psychoanalysts to this day.
Over the resulting decades several themes appear and reappear. One to which Freud alluded is that of the uniqueness versus the ubiquity of transference, is it a special creation of the analytic situation or is it an inevitable and universal aspect of all human relation? More central and perhaps more heated in the continuing debate, as the primary of transference interpretation in which Strachey called the 'mutative' effects of analysis - for example, whether such interpretations are simply more convincing than others or are the only kinds that are truly an effective therapy constitutionally begotten. Echoes of this debate have resounded through the years and to be prospectively descendable in most recent literary works. Finally, are all of the patient's reactions to the analyst in the analytic situations to be of counter-transference or do some partake of the 'real' 'non-neurotic' relationship or of the 'working alliance'?
It is only to mention, at the outset that resistance is, in certain fundamental references, an operational equivalent of defence, its scope is really far larger and more complicated. The thoughts of its nature and motivations on resistances to the psychoanalytic process use an array of mechanisms that sometimes defy classification in the way that fundamental genetically determined defences, derived from importantly and common developmental trends, can be classified. From falling asleep too brilliant argument, there is a limitless and mobile of devices with which the patient may protect the current integrations of his personality, including his system of permanent defences. In fact, Resistances of a surface, conscious type, related to individual character and to educational and cultural background, often present themselves are the patient’s first confrontations with a unique and often puzzling treatment method. While some of these phenomena are continuous with deeper resistances, a closer, and perhaps balancing equilibrium held in bondage to the mutuality within the continuity that we must meet others at their own level. All the same, it now leaves to a greater extent, the much-neglected faculty of informed and reflective common sense, and moves onto the less readily accessible and explicable dynamism, which inevitably supervene in analytic work, even if these initial surface Resistances have been largely or wholly mastered. Its submissive providences lay order to perfect connectivity, premising with which is the specific influence of the immediate cultural climate, stressed of the general attitude of many young people (Anna Freud 1968) toward the psychoanalytic process and its goals.
When Freud gave up the use of hypnosis for several reasons, beginning with the personal difficulty in inducing the hypnotic state and culminating in his ultimate and adequate reason - that it bypassed the essential lever of lasting therapeutic change, the confrontation with the repressing forces themselves - he turned to the method of waking discourse with the patient, in which insistence, with a sense of infallibility, accompanied by head pressure and release, were the essential tools for the overcoming of resistance (Breuer and Freud 1893-1895). Although the affording the unformidable combinations that are awaiting the presence to the future attributions in which the valuing qualities that allow us the privilege to have observed various forms of resistance ( in a general sense) before, as for example, inability to be hypnotized, as far as possible in totality and a willful rejection of hypnosis, selective refusal to discuss certain topics under hypnosis, adverse reactions to testing for stances, it was the effectiveness of insistence in inducing the patient to fill memory gaps or to accept the physician’s constructions that reapproached of extending its lead, in that Freud was to a first and enduring formulation: Since effort
- psychic work - by the physician was required, a physical; evidently force, a resistance opposed to the pathogenic ideas, becomingly conscious (or being remembered), had to be overcome. They thought this to be the same psychic force that had initiated the symptom formation by preventing the original pathogenic ideas from achieving adequate affective discharge and establishing adequate associations - in short, from remaining or becomingly conscious. The motive for invoking such a force would be the abolition (or avoidance) of some form of physical distress or pain, such as shame, self-reproach, fear of harm, or equivalent cause for rejecting or wishing to forget the experience. Such are the appreciative attributions, in that the distributive contributional dynamic functions bestow the factoring understructure of the constellation of ideas, have already comforted us, yet, the later is clearly the ego and especially the character of it. It was thought important to show the patient that his resistance was the same as the original ‘repulsion’ which had initiated pathogenesis. The step later was short to the essential equivalent and permanent concept of defence at first repression. That is, though Freud gave tremendous sight to the effectiveness of the hand pressure manoeuver, he saw it essentially for distancing the patient’s will and conscious attention and thus simplifying the emergence of latent ideas (or images). From a present-day point of view, one cannot but think of the powerful transference excited by an infallible parental figure in a procedure only one step removed from the relative abdication of will. Consciousnessly involved in hypnosis, and that this quasi-archaic qualitative pattern of relationship was more important to effectiveness or failure than was the exchange of a psychic energy postulate by Freud. In this sense, the ‘laying on of hands’ granted its effect on attention, was probably even more significant in inducing transference regression than in the role that the great discoverer assigned to it.
What is important, in whatever way, is the establishment of a viable scientific and working idea of resistance to the therapeutic process as a manifestation of a reactivated intrapsychic conflict in a new interpersonal context. This in its essentials persists to this day in psychoanalytic work, in the concept of ego resistances.
At the same proven capability, as measuring with this development, less explicitly formulated but often described or inferred, was the marginal total rejecting or hostile or unruly attitude of the patient, sometimes evoking spontaneous antagonistic reactions in the physician. In occasional direct references in the early work and in the choice of figurative phraseology for years after that, Freud recognizes this ‘balky child’ type of struggle against the doctor’s efforts. One needs only recall Elizabeth von R., who would tell Freud that she was not better, ‘with a sly look of satisfaction’ at his discomfiture (Breuer and Freud 1893-1895). When deep hypnosis failed with her, Freud ‘was glad enough that once, she refrained from triumphantly protesting ‘I am not asleep, you know, and cannot be hypnotized’; in this context that show with which this categorical type of resistance phenomenon that it represents the evolutionary whisper, though Freud and many others found it to come within the evolving gait of steps in a whisper, after-all, the advance of applied science was bringing to light curious new phenomena that, however hard men might try, would not be fitted into the existing order of things. All this is to encourage along the side of the paradigms of science to agree of it achievable obtainability through with of those has witnessed the impregnable future, least mentions, far and above is the first essentially forced finality to agree that fighting a great adventure in thought at lengths to come safely to shore is necessary, in this glare, the human figure has had to apply formally to be enlarged so that the brave stands which make for civic and academic freedom. Also taken the application in the form to encourage the belief that, as nicely put, 'all men dance to the tune of an invisible piper. Because, we did not attest the big bang, but call its evolution of a particular type of ego-syntonic struggle with the physician that remains potentially important during any analysis by what the negative transference, whatever its particular nuances of motivation. This is, of course, a manifestly different phenomenon from the earnest effortful struggles of the cooperative patient whose associations fail to attend to him, or who forgets his dream, or who comes at the wrong hour, to his extreme humiliation. Still, in that respect is an important dynamic relationship between the two sets of phenomena.
Nonetheless, Freud made the analysis of resistance the central obligation of analytic work and proceeded from primitive beginnings, with rapidly increasing sophistication, both technical and psychopathologic, ideas that remain valid to this day; that conscious knowledge transmitted to the patient may have no, or an adverse, effect in the mobilization of what is similar or identical in the unconscious; that the repressing forces, the resistances, are more like infiltrates than discrete foreign-body capsules in their relation to preconscious associative systems; that the physician must begin with the surface and continue centripetally; that hysterical symptoms are more often serial and multiple than mononuclear, and the resistances participate in all productions and must be dealt with at every step of analytic work, and other matters of equal significance (Breuer and Freud 1893-1895).
Freud always maintained the central concept of resistance, and bequeathed it (reinforced later by the structural theory) to the generations of analysts who have followed him. Still, as the years went on, he elaborated the general scope of resistance far beyond the basic concept of intrapsychic defence, anticathexis that a great variety and range of mechanisms could impede the psychoanalysis as a recognizable process or, beyond this, making it ineffective or reverse expected therapeutic responses, or extend indefinitely the patient’s dependence on the analyst. When extended its direct equation with the anticathexis of defences, the variety of sources - not to speak of manifestations - of resistance multiplied rapidly. To remark upon the merely secondary realizations of illnesses (Freud 1905), under which the ‘external’ resistances are, for example, the hostility of the unmurmuring family line of treatment (Freud 1917), evenhandedly as the persistence of illness, with its detachment, superciliousness, and mechanical compliance as some weapons system for frustrating the analyst, as with the utterly troubled young girl (Freud 1920). The relevant sense of securing the symptomatic primary modes of perturbation conflict solution, and most crucially, the analysable obtainability of such subtly evolving concept of ‘transference-resistance,’ in its oscillating pluralistic sense, for example, (Breuer and Freud 1893-1895: Freud 1912, 1917). In his last writings, conspicuously in Analysis Terminable and Interminable (1937), in considering several possible factors in human personality that obstruct or render ineffectually the successful end of the analytic procedure, Freud offered a variety of psychodynamic considerations that could be fundamental in the extended or broadened concept of resistance: The question of the constitutional strength of instincts and their relation to ego strength; the problem of the accessibility of latent conflicts when undisturbed by the patient’s life situation (briefly but pointedly) the impingement of the analyst’s personality on the analytic situation and process; the existence of certain qualities of the libidinal cathexes - especially undue adhesiveness or excessive mobility; rigid character structure; the existence of certain sex-linked ‘bedrock’ conflicts that Freud regarded as biologically determined (insoluble penis envy in the female, and the male’s persisting conflict with his passivity). Finally and most formidable, there was the cluster of dynamism and phenomena that Freud, beginning in, Beyond the Pleasure Principle (1920) and The Ego and the Id (1923), attributed consistently and with deepening conviction to the operation of a death instinct. That is to say, to the ‘unconscious sense of guilt’ and demands the need for punishment, the repetition compulsion, the negative therapeutic reaction, and the more general operations of the need to suffer or to die or to seek outer or inner worldly concern. Yet, it remains an inexorable truth that the resistances underlying and hidden of representationally inherent cases or certain limitations implicit like psychoanalytic work, are moderately invincibly formidable, and cannot be disestablished by theoretical position any more than they can be thus created.
The varied clinical manifestations of resistance are dealt with extensively throughout Freud’s own writings, in many individual papers of other analysts, and in comprehensive works on analytic technique, for example, those of Fenichel (1941), Glover (1955), and more recently Greenson (1967) of which only makes a selective and occasional reference to their kaleidoscopic variety.
When free association and interpretation displaced hypnosis and derivative primitive techniques, the psychoanalysis as we now construe it came into being. To the extent that free association was the patient’s active participation, it was in this sphere that his ‘resistance’ to the new technique was most clearly recognized as such, cessation, slowing, circumlocution and a lack of informative or relevant content, emotional detachment, and obsessional doubt or circumstantiality became established as obvious impediments to the early (no longer exclusive but still radically important) topographic goals: To convert unconscious ideas largely via the interpretation of preconscious derivatives into conscious ideas. Only with time and increasing sophistication did fluency, even vividness of associative content, tendentious ‘relevancy’ itself evidently can, like over-compliant acceptance of interpretation, conceal and carrying out resistances that were the more formidable because expressed in such ‘good behaviour’.
One may define resistance (and in so doing include a liberal and augmenting paraphrase of Freud’s own most pithy definition [The Interpretation of Dreams 1900]) as anything of essentially intrapsychic significance in the patient that impedes or interrupts the progress of psychoanalytic work or interferes with its basic purposes and goals. In specifying ‘in the patient’ one is to imply as not underestimate the possibly decisive importance of the analyst’s resistances, to separate the ‘counterresistance’ as a different matter, in a practical sense, requiring separate study. One may concur, that as a generalized infraction forwarded of a direction with Glover’s statement (1955) that ‘however we may approach the mental apparatus there is no part of its function that cannot serve the purposes of mental defence and therefore give apparency during the analysis to the phenomena of resistances.’ One may also concur with his formulation that the most successful resistances (in contrast with those employing manifest expressions) are silent, but disagree with the paradoxical sequel ‘. . . they might say that the sign of their existence is our unawareness of them.’ For the absence of important material is a given sign, and becoming aware of such an absence is necessary, if possible.
Freud, in his technical papers and in many other writings, despite his reluctance in this direction did lay down the general and essential technical principles and precepts for analytic practice. We must note, however, that the clear and useful technical precepts are largely in that may be regarded as the ‘tactical sphere’, i.e., they deal with the manifest process phenomena of ego resistances. Other resistances, those largely contained in the ‘silent’ group, for example, detainment or unsuccessful symptomatic alteration, omission of decisive conflict material form free association or [more often] from the transference neurosis, inability to accept cancellation of the analysis, and allied matters. In that saying, the ‘strategic sphere’, relating to the depths of the patient’s psychopathology and personality structure and to his total reactions to the psychoanalytic situation, process, and the person of the analyst. Its use of the tern ‘strategic’ and ‘tactical’ differ from their user by others, for example, Kaiser (1934). While it is not to presume to offer simple precepts for the ready liquidation of the massive silent resistances, heedfully to contribute of something, however slight. To understanding them better and thus, potentially, to their better management but some of these considerations, for example, iatrogenic regression, as to context (1961, 1966). In the ‘strategic’ arena of resistance, so often manifested by total or relative ‘absence’, it is the informed surmise regarding the existence of the silent territory, by way of ongoing reconstructive activity, which is the first and essential ‘activity’ of the analyst. Beyond this mindfulness and subtle potentialities of the shaping and selection of interpretative direction and emphasis and the tactful indication of tendentious distortion or absence.
Because of a possible variety of factors, beginning with the estranging dissimulations that magnetism that the verbal statement of unconscious content puts into action of the analysts and patients alike (of itself is a frequent resistance or counterresistance) the priority of the analysis of resistance over the analysis of content, as discretely separate, did not readily come to its carry out quality. This might have been owing to the difficulties of dealing with more complicated resistances or developing an adequate methodology in this arena, or even the fact that an extensive interval over its timed and tactful reference to content (or its overall nature) sometimes seems the only way of mobilizing (reflexively) and thus exposing the corresponding resistance for interpretation and ‘working through’, an echo of Freud’s early, never fully relinquished diphasic process (1940).
Since this is not a technical paper, the admissive structural functionality, over which an extended discussion of the evolution of views on methods of resistance analysis, although substantiated functions has inevitably related such views to our immediate subject matter. Its mindful approaches that range from the strict systematic analysis of character resistances of Wilhelm Reich (1933) or the absolute exclusion of content interpretation of Kaiser (1934), to the special efforts toward dramatization of the transference of Ferenczi and Rank (1925) or Ferenczi’s own experiments with active techniques of deprivation and (on the other hand) the gratification of regressed transference wishes in adults (for example, 1919, 1920, 1930, 1931, 1932). Developments in ego psychology (for example, Anna Freud’s classical contribution on the mechanisms of defence [1936] brought the variety and importance of defence mechanisms securely into the foreground of analytic work, and the subsequential extent of which is widely accepted priority of defence analysis has rectified a great deal of the original [and not entirely inexplicable] ‘cultural cover with lagging’ in this describing importance, that if not exclusive, spheres of resistance analysis. Concomitant with a more widespread functional acceptance of the essentiality and priority (in principle) of resistance analysis over content interpretation, there is usually a more flexible view of the technical application of the essential precepts, permitting interpretive mobility, according to intuitive certainty or judgement between the psychic structures, according to Anna Freud (1936) principle of ‘equidistance’. Discrete specification may sometimes deal resistance with other than those apart from the intrinsic conceptual difficultly in the latter intellectual process, i.e., the specifying of a resistance without suggesting that against which it is directed (Waelder 1960). There is also a general broadening of the scope of interpretive method. Witness, for example, Loewenstein’s ‘reconstruction upward’ (1951) and Stone, having his own differently derived but often an allied conception, the ‘integrative interpretation’ (1951), both of which recognize that resistance may be directed ‘upward’ or against the integration of experience, than against the affirmative extent and exclusively infantile or against the past. Similar considerations are also reflected in Hartmann’s ‘principle of multiple appeal’ (1951).
It may, nonetheless be of note that while the emphasis on resistance in Freud’s early clinical presentations is overall proportionate to his theoretical statements, his methods of dealing with the concealed and more formidable resistances are not clear, except in certain active interventions, such as the magical intestinal prognosis in the ‘Wolf Man’ (1918), or the ‘time limit’ in the same case, or the principle that at a certain point patients should confront phobic symptoms directly (1910), or the suggestion to transfer to a woman analyst, with the homosexual woman (1920). In these manoeuvres and attitudes it is recognized that (1) interpretation, the prime working instrument of analysis, may often reach an impasse in relation to powerful ‘strategic’ resistances, and (2) an implicit recognition that elements in the personal relationship of the analytic situation, specifically the transference, may subvert the most skilful analytic work by producing massive although ‘silent’ resistances to ultimate goals, and that sometimes where energetic elements are formidable, they may have to be dealt with directly and holistically, in the patient’s living and actual situation.
Freud’s own interest in active techniques stimulated Ferenczi to extreme developments in this sphere (1912, 1920), later combined with his oppositely oriented methods of indulgence (1930). As time presses on, noninterpretative methods, particularly those involving gratifications of transference wishes, whether libidinal or masochistic, were set aside with increasing severity, in recognition of their contravention of the indispensability of the undistorted transference and the unique importance of transference analysis in analytic work. The same has been largely true of tendentious, selective instinctual frustrations (Ferenczi 1919, 1020). However, there is no doubt that the use of interpretive alternatives (sometimes suggests for the deliberate control of obstinate resistance phenomena in this spheric arena) has been sharpened by - partially coloured by - the earlier experiments in prohibition, whose transference implications were fully apparent at the time of their introduction. The type of active intervention introduced by Freud (the time limit, the confrontation of symptoms), confined in actuality to the sphere of the demonstrable clinical relationship, has retained a certain optional place in our work, although the potential transference meaning and impact of such interventions, with corresponding variations or limitations of effectiveness, are increasingly understood and considered. The broad general principle of abstinence in the psychoanalytic situation, stated by Freud in its sharpest epitome in 1919, remains a basic and indispensable context of psychoanalytic technique. The nuances of application remain open to, in fact to require, continuing study (Stone 1961, 1966).
In assent to important developments in ego psychology and characterology (for conspicuous examples, Anna Freud 1936, Kris 1956, Hartmann 1951, Loewenstein 1851, Waelder 1930, the principle factor in deepening, broadening, and complicating the conceptual problem of resistance, and thus modifying the strict latter-like sequential approach (Reich 1933) to the analysis of resistance ad content respectively, even in principle, has been the progressive emergence of transference analysis as the central and decisive task of analytic work. For, to state it over succinctly, and thus to risk some inaccuracy, the transference is far more than the most difficult tool of resistances and (simultaneously) an indispensable element in the therapeutic effort. Given the mature capacity for working alliance, it is the central dynamism of the patient’s participation in the analytic process and, while the proximal or remote source of all significant resistances, but those manifest phenomena originating in the conscious personal or cultural attitudes and experiences of the adult patient or those deriving from the inevitable cohesive-conservative forces in the patient’s personality, for which we must still summon briefly the Goethe-Freud ‘witch’, metapsychology (Freud 1937).
In relation to the ‘tactical’, i.e., process, resistances, an overall view of what is immediate and confronting for example, the threatening emergence of ego-dystonic sexual or aggressive material, may be adequate. All the same, to any casual access to what may be called the ‘strategic’ sphere of resistance. One must have a tentative working formulation of the total psychic situation in mind, including an informed surmise regarding large and essential unconscious trends. Such suggested procedure is, accessibly open to discussion on more than one scope, and it does involve one immediately in some basic epistemological problems of psychoanalysis. Unfortunately, we cannot become involved in this fascinating sphere of dialectic in this brief essay on a large subject nevertheless, in his early work Freud relied enthusiastically on his own capacity to fill primary gaps in the patient’s memory through informed inherences from the available data, and then, with an aura of infallibility, actively persuaded the patient to accept these constructions. However, with the further elaboration of psychoanalysis as process, in the sense of the increasing importance of free association, of the analyst’s relative passivity, and other characteristics of the process as we now know it, there have inevitably been some important modifications of the attitudes reelected in such procedures. While, as far as it had never been revised or revoked, Freud’s view that the resistances are operatives in every step of the analytic work, and knowing that there exists in many minds paradoxical mystiques to the effect that the patient’s free associations as such, unimpeded (and uninterpreted), could ultimately provide the whole and meaningful story of his neurosis, in the sense of direct information. This is, of course, manifestly at variances with Freud’s basic assumptions about the role of resistance, and the germane roles of defence and conflict in the origin of illness.
Nonetheless, in Freud’s, Recommendations (1912) is his advice against attempting to reconstruct the essentials of a case while the case is in progress. Such a reconstruction, here assumes, would be undertaken for scientific reasons. The caution, nevertheless, rests on both scientific and therapeutic grounds, on the assumption that the analyst’s receptiveness to new data and his capacity for evenly suspended attention would be impaired by such an effort. It is true, of course, that rigid preoccupation with an intellectual formulation can impair the capacities. Even so, it is also true that the ‘formulation’ or structuring of a case can and largely does go on preconsciously, in some references even unconsciously, and usually quite spontaneously. One must assume at the very least, that some such process reaches the analyst’s first perception of a ‘resistance’. Some have thought that Freud would have disagreed with using such a process. Still, its use, whatever the form, is a necessity, and, at times, it requires and should have the hypercathexis of conscious and concentrated reflection? One may, of course, assign the more purposive intellectual processes to periods outside hours, and thus better preserve the other equally important responses to the dual intellectual demand of psychoanalytic technique. The ‘voice of the intellect’, all the same, should not be deprived of this essential place in analytic work. It is well known that it must never be allowed to foreclose mobile intuitive perceptiveness or openness to unexpected data. Nor must ongoing formulations in the mind of the analyst be allowed to cram the spontaneity of the patient’s association. They should remain ‘in the analyst’s head’. To epitomize the technical situation: Strategic considerations require varying degrees of reflective thought, possibly outside hours. Except the perspectives and critiques they silently lend to understanding, they should not influence the natural and spontaneous, often intuitive, responses of the disciplined analyst to the never-ending variable nuances of his patient’s ‘tactics’. In relation to any category of clinical psychoanalytic problem. It is the structure of the transference neurosis and its unfolding, with the adumbrative material in characterology, symptom formation, personal and clinical history and the clues from specific data of the psychoanalytic process, taken as an ensemble, which provide the most reliable basis for general tentative reconstruction and thus for the understanding of resistances. While we must marshal our entire body of data, theory, and technology to see the transference neurosis as an epitome of the patient’s emotional life, our comprehension of it is nonetheless based essentially on something that is right before us. Again, the total ensemble is essential, and the objectively observable phenomena of the transference neurosis are of crucial and central valences.
In the background data, the large outlines of life history are uniquely important because they do represent, or at least strikingly suggest, the patient’s gross strategies of survival and growth, of avoidance and affirmation. One may infer that they will be invoked again in the conformation with the analyst, in his pluralistic significance. Some oversimplified and fragmentary illustrations are chosen in the occupational commitments with children and the mood in which they are carried out, with the general character of manifest sexual adaptation, can contribute to rational surmise about whether neurotic childlessness is based predominantly on disturbances of the Oedipus complex, on an original inability to achieve an adequate psychic separation from parent representations, or on the vicissitudes of extreme sibling rivalry. It must surely crystallize illnesses and analytic process if one knows that some patient lives, by choice, the breadth of an ocean removed from parents and siblings with whom there has been no evident quarrel, when this is not a crucial matter of occupational opportunity or equivalently important reality. Necessarily a male patient’s gross psychosexual biography helps us to understand which ‘side’ of the incestuous transference is more likely to be surfacing in his first paroxysm of heterosexual ‘acting out’. While it is true that dreams, parapraxes, and other traditionally dependable psychoanalytic material may dramatically reveal the ego-dystonic directions of impulse and fantasy life, and the specific nature of opposing forces, it is, only, the composite situation that historical and current picture that reveals the prevailing or alternative defences, the large-scale economic patterns, and the preferred or stable, i.e., most strongly over determined, trends of conflict solution.
Tactical problems of resistance were earliest observed largely in disturbances of free association, which, in frequent tacit assumptions, would, or in principle could, lead without assistance to the ultimate genetic truth. This truth was construed to be the awareness of previously repressed memory (or the acceptance of convincing and germane constructions). As time went on, in Freud’s own writing, terms of conative import appeared - such as ‘tendency’ or, more of vividly, ‘impulsiveness’. However, the critical etiological and (reciprocally) therapeutic importance of memory has, of course, never really lost its importance. For, while the recovery of traumatic memories, with an abreaction, is still dramatic in its therapeutic effect, for example, in war neuroses or equivalently civilian experiences and occasionally in isolated sexual experiences of childhood or adolescence, neuroses of isolated traumatic origin are rare in current psychoanalytic experience. Traumata is usually multiple, repetitive, often serving to crystallize, dramatize and fix (something even ‘covers’) more chronic disturbances, such as distortions or pathological pressures in the instinct life, against the background of larger problems of basic object relationships. Freud was already becoming aware of the complex structure of neuroses when he wrote his general discussion for the Studies on Hysteria (Breuer and Freud 1893-1895). Thus, to put it all too briefly, when structurized impulses or general reaction tendencies can truly be accepted for memory, i.e., as matters of the past, other than in a tentative explanatory sense, much of the analytic work with the dynamics of the transference neurosis has necessarily been accomplished. One does not readily give up a love or hatred, personal or national, only because one learns that it is based on a crushing defeat of the remote past.
The manifest communicative phenomena of resistance remain very important, just as the common cold remains important in clinical medicine. Morally justified in those of whom walk continuously among the corpsed of times generations, their circulatory momentum around the cross and forever finding its same death but it's comforting solace and refuge, from which, they dwell of the unknown infinity. It will never cease to be important to tell a patient that he is avoiding the emergence of sexual fantasies, that his blank silence covers latent thoughts about the analyst, or (in a measure more sophisticated) that apparent and enthusiastic erotic fantasies about the analyst conceal and include a wish to humiliate or degrade him. However, we can be better prepared, even for these problems, because of ongoing holistic reconstruction. Surely we are better prepared for the formidable resistances of patients who apparently do ‘tell all’ or even ‘feel all’, in a most convincing way and in all sincerity, yet may finish apparently thorough analysis without having touched certain nuclear conflicts of their lives and characters or, (more often) having failed to meet the transference neurosis, with a sense of affective reality. These instances, for instance refers to the instances described by Freud (1937) in which such conflicts remain dormant because current life does not impinge on them, but to those in which the ‘acting out’, in life or the solution in severe symptoms is desperately elected by the personality in apparently paradoxical preferences to the subjective vicissitudes of the transference neurosis (Stone 1966).
In brief, is a tentative formulation of the respective natures of the two peculiar and yet particular groups of resistance phenomena, ultimately and vestigially related and exists in varying degree in all analyses. It is, however, one or the other is usually important and is, in practical and prognostic sense, quite differently as: (1) Those progress to evidently large discernible impediments of the psychoanalytic process in its immediate operational sense. These are usual in the neuroses, in persons who have achieved satisfactory separation of the 'self' from the primary y object. Nevertheless, whose lives are disturbed by the residues of instinctual and other intrapsychic conflicts in relation to the unconscious representations of early objects and thus to transference objects. (2) Those that may be similarly manifested at times but maybe or even exaggeratedly free of them. Where the essential avoidance is of the genuine and effective e diphasic involvement in the transference neurosis, with regard too fundamental and critical conflicted, and thus of the potential relinquishment of symptomatic solutions and the ultimate satisfactory separation from the analyst. In this context, among other phenomena, there may be large-scale hiatuses in analytic material in the usual experiential sense, or there may be a striking absence of available and appropriate cues of connection with the transference, or failure, this complex of phenomena may repeat an original disturbance in ‘separation and individuation’ (Mahler 1965). Alternatively of other severe disturbances in early object relationships or related pregenital (particular oral) conflicts can have produced tenacious narcissistic avoidance of transference involvement, to facade involvement, or to the alternative of inveterate regressed and ambivalent dependency. Dependable and largely affirmative secondary identifications have usually not been achieved originally, and this phenomenon, related to basic disturbances of separation, contributes importantly to the variously manifested fears of the transference.
Intuitively, the phenomena of the two groups may overlap. There may be deceptively benign ‘aponeuroses’ in the more severe group. In the troublesome phenomenon of ‘acting out’, for example, one may deal with a transitory resistance to an emergent transference fragment, in some instances due to a delay of effective interpretation, or one may be confronted by a deep-seated, variably structuralized, and sometimes even ego-syntonic ‘refusal’ to accept the verbal mode of communication with an unresponsive transference parent in dealing with insistent disturbing and gross affects implored by impulsive unintelligibility.
Freud (1925), pointed out that everything said in the analytic situation must have some coefficient of reflection to the situation in which it is said. This is, of course, consistent not only with reflective common sense but also with the theory of transference and the current view of the central position of the transference neurosis in analytic work. Furthermore, despite his earliest view of the ‘false connection’ as pure resistance (Breuer and Freud 1893-1895) and the continuing high opinion of this aspect of transference, Freud early established the (non-conflictual) positive transference as the analyst’s chief ally against resistances. So, he never stretched out in his appreciation of the primitive driving power of the transference and its indispensable function of conferring a vivid and living sense of reality on the analytic process (Freud 1912). However, in past commination, the transfer is the central dynamism of the entire psychoanalytic situation, and the transference neurosis provides the one framework which give essential and accessible form to the potentially panpsychic scope of free association (Stone 1961, 1966). In this frame of reference the irredentist drive to reunion with the primal mother, as opposed to the benign processes of maturation and separation, underlies neurotic conflict in its broadest sense and is the basis of what is called the ‘primordial transference’, whose striving renewed physical approximation or merger. Speech, which is the veritable stuff of psychoanalysis, serves as the chief ‘bridge’ of mastery for the progressive somatic separations of earliest childhood. The ‘mature transference’, in continuum, alternative and contrast, is that series and complex of attitudes contingent on maturation and benign predisposing elements of early object relationships (conspicuously, the wish to be understood, to learn, and to be taught) that enables increasing somatic separation in a continuing affirmative context of object relationship, as later reelected in the psychoanalytic situation. In this interplay, speech - our essential working tool - plays as these oscillating, curiously intermediates roles, ranging from the threat of regression in the direction of its primitive oral substrate to it is ultimately purely communicative-referential function linked with insight (Stone 1961, 1966).
Nonetheless, the origin of the ‘transference’ as we usually perceive it clinically, and as the term is traditionally employed, is in the primordial transference. Be it essentially the classical triadic incestuous complex or an oral drive toward incorporation or toward permanent nursing dependency or a sadomasochistic and shriving toward a parent, it will be re-experience in the analytic situation, in good part in regressive response to its derivations (Macalpine 1950), and produce the central, and ultimately the most formidable, manifest resistance, the transference-resistance.
No comments:
Post a Comment