Psychoanalytic Treatment

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PSYCHOANALYTIC TREATMENT

The psychoanalytic treatment is a method for treating psychic suffering that advances self-knowledge. It is characterized by the interpretation of the free associations of a patient, who in becoming aware of feelings and forgotten memories, can thus resolve or express differently the unconscious conflicts behind his/her neurotic symptoms. The way sessions are structured—couch and armchair—and their frequency and regularity facilitate this process through the transference onto the psychoanalyst of affects and childhood fantasies.

From 1886, when he set himself up in private practice to 1909, the year of the "Rat Man" analysis, Freud gradually developed the system of psychoanalytic treatment. In fact the method emerged from the hypnotic treatments that he used after his recognition of the failure of medicinal and physical therapies in vogue at the time. Sessions in which the patient relaxed on a couch in an atmosphere of calm and comparative sensory deprivation resulted from the conditions imposed by somnolescent suggestion and later by the "cathartic method" developed by Joseph Breuer to treat his patient, Anna O. Patients themselves contributed towards the maturation of the structure of the treatment, beginning with Emmy von N's command at their first encounter on May 1, 1889, to "Keep still! Don't say anything! Don't touch me!" and her angry demand that he stop interrupting and let her speak freely.

The abandonment of hypnosis in favor of an interrogatory technique, and the application of pressure to the forehead to release ideas, repressed through resistance, introduced a decisive turn in method, even though Freud appears to have taken a particularly active role, insisting patients surrender the pathogenic secrets buried in their unconscious, as the chapter entitled "The Psychotherapy of Hysteria" in Studies on Hysteria demonstrates (1895d).

The Interpretation of Dreams (1900a) introduced the innovation "free association," which would become the "fundamental rule" of all psychoanalytic treatment. At the same time the therapist was required submit to the principle of "evenly suspended attention" which entails the scrutiny of even the most apparently insignificant detail (Freud, 1904a).

Freud could thus describe his "psychotherapeutic method" in 1904 as follows: "Without exerting any other kind of influence, he invites them to lie down in a comfortable attitude on a sofa, while he himself sits on a chair behind them outside their field of vision. He does not even ask them to close their eyes, and avoids touching them in any way, as well as any other procedure which might be reminiscent of hypnosis. The session thus proceeds like a conversation between two people equally awake, but one of whom is spared every muscular exertion and every distracting sensory impression which might divert his attention from his own mental activity" (1904a, p. 250). Through the transference, whose importance Freud had discovered with his patient Dora, resistance became common, both as an obstacle to treatment and as its major driving force.

There remained one last significant innovation in technique, which Freud reported to his disciples at a meeting of the Vienna Society on November 6, 1907, via an account of the early stages of his treatment of the "Rat Man." Otto Rank noted in The Minutes of the Vienna Psychoanalytic Society that "analytic technique has been modified to the extent that the psychoanalyst no longer actively seeks to obtain material that interests him, but rather allows the patient to follow the unprompted and natural course of their thoughts."

Hereafter the framework was determined and has remained to the present day. The features that Freud was to recall in "On Beginning the Treatment" (1913c) include the analyst's position outside the reclining patient's line of vision, regular sessions of a prescribed duration, and terms for the payment of fees. These conditions create the setting for a "psychoanalytic situation" in which, for Jacques Lacan (1953) and his followers, the principal, indeed the exclusive role, would be one given to speech; but a speech and an aural attention going beyond words to include silences, expressions of affect, and even minuscule movements. Freud had observed this when treating Dora: "If his lips are silent, he chatters with his fingertips; betrayal oozes out of him at every pore. And thus the task of making conscious the most hidden recesses of the mind is one which it is quite possible to accomplish" (1905e, p. 78).

Even when supplemented by professional motives (as in training analysis), it is psychical suffering that compels individuals to consult a psychoanalyst. After one or more preliminary interviews, which Freud advised should not be repeated and in relation to which he preferred "a trial treatment of one to two weeks" (1913c), the direction of the treatment is set out; the two protagonists then decide whether to embark on this venture whose initial temporal duration is indeterminate but whose eventual length is assured. "To speak more plainly," added Freud, "a psycho-analysis is always a matter of long periods of time [. . .] of longer periods than the patient expects. It is therefore our duty to tell the patient this before he finally decides upon the treatment" (p. 129).

Since Freud some features of this initial framework have changed; thus the six hour-long sessions per week were reduced to five, then to four, and eventually to three and the length of sessions has been cut from one hour to forty-five minutes. Following his lead, disciples of Lacan have instituted short sessions, and even sessions whose variable length is based on the analyst's attention to the scansion effect in his patient's discourse, a practice that has been keenly disputed. Some analysts believe that two sessions per week is possible, others, that the couch advocated by Freud is in no way an absolute requirement.

The notion of a "standard treatment" (Bouvet, 1954), which was similar to descriptions of the medical standard that characterized the manuals of the 1950s, was counterbalanced by what were described as its "variants" (Lacan, 1955); it has now been replaced by the "classic" or indeed the "orthodox" treatment for those who see themselves as liberated from its formal constraints.

It is essential that a "psychoanalytic process" be established and that it is encouraged to advance through the development of the transference neurosis, whose infantile origins are revealed in analysis, but that it is also always jeopardized by the initiation of a "negative therapeutic reaction" which would counter the original love-based "therapeutic alliance." The analyst's "abstinence" in the face of the patient's demands for affective gratification is a requirement for thisz development, as is his capacity to manage conflicts that may engender "secondary gains" from the illness and, once the initial honeymoon period is over, a transferential and countertransferential relationship that is as intense as it is unusual. According to Freud: "the therapeutic effect depends on making conscious what is repressed, in the widest sense of the word, in the id" (1937c). Analytic interventions address this aim, but more importantly so too do interpretation, construction, and reconstruction (1937d) as well as the analysis of resistances and the dispelling of amnesia that masks infantile sexuality. Active periods alternating with inactive phases, which for Freud were occasionally indicative of a patient's "working through" (Durcharbeitung ) of the material analyzed, mark the stages of what has been described as "autohistorization" (P. Aulagnier) and highlights the journey towards autonomy which will determine the treatment's cessation.

The termination of analysis has occasioned a number of studies since Freud's own (1937c) and is dependent on the aims that the psychoanalyst and the analysand have given themselves. Curing the symptom has never been the most important function of the treatment and so Jacques Lacan could speak of the "cure as surplus." However, patients do have every right to expect relief from the psychic suffering that led them to analysis in the first place, alongside the capacity to better manage the pathological responses that the vagaries of life engender through the repetition compulsion.

The extension of psychoanalytic treatment to more severe pathologies, to borderline conditions and psychotic disorders, has altered both the notion of its outcome and the means by which it is reached. Freud's formulation "Where id was, there shall ego [or 'I'] be (Wo Es war soll Ich werden )" and its possible translations has produced a range of possible interpretations according to whether the Freudian Ich is translated as "ego," as in ego psychology for example, or as "I," as in the "subject."

However, the termination of treatment does not mark the end of the analytic process; its ongoing working-through continues in self-analysis and in the return to the couch, of either the same psychoanalyst or of another, or to an analyst of the other sex or to one from a different school.

Alain de Mijolla

See also: Abstinence/rule of abstinence; Active technique; Analyzability; "Analysis, Terminable and Interminable"; Biological bedrock; Cure; Face-to-face situation; Framework of the psychoanalytic treatment; Free association; Fundamental rule; Indications and counterindications for psychoanalysis; Initial interviews; Lay analysis; "Lines of Advance in Psycho-Analytic Therapy"; Money and psychoanalytic treatment; Neutrality, benevolent neutrality; Techniques with adults, psychoanalytic; Techniques with children, psychoanalytic; Termination of treatment; Training of psychoanalysts; Training analysis; Transference.