Schlesinger - The texture of treatment : on the matter of psychoanalytic technique

Perhaps most analysts were introduced to the mysteries of psychoanalytic technique as I was: that it was not so much a cohesive body of structured knowledge and practice as a loose collection of dos and donts. A chill in the heart warned me that to violate any one of them would ruin the analysis. Cowering before gray eminences, I and my fellow candidates had a bad case of transference to the Institute, for none of our teachers had literally laid down any such doctrine. It was more that no one troubled to disabuse us of the idea that, if somehow we were lucky enough to avoid all the pitfalls set by our natural enemy, the patients, the residue of our avoidance would be pure essence of psychoanalysis. We feared analysis was a fragile flower, one easily crushed in the hands of clumsy beginners. And the patients, we feared, were secretly out to do us in, to abort our nascent careers. Simply through recalcitrance, they could keep us from graduating. It took a while to discover that our patients were even more frightened than we were. It took more time to discover that analysis is not a fragile flower, but a sturdy affair. What we once regarded as fatal mistakes turned out mostly not to matter that much; sins of omissionwhat we failed to doproved much more harmful.

It also seems to me, after later reflection, that we were working with more than a collection of rules of thumb, that there was a structure to the knowledge we use when analyzing patients and that it would be useful to spell out this structure. Karl Menninger and Philip Holzman (1973) have offered us a systematic theory of technique, one that makes great sense to me. The reader will find resonance of this approach in what follows. But their overall approach seems to me too heavily committed to the model of a rational compact between analyst and patient, an idea that does not fit with my experiences in the analytic situation.

I am not offering here an altogether new view of psychoanalytic technique. Rather I am attempting to make explicit that there is a logic to the way we go about analyzing as we listen to our patients and follow their associations. We generally do not pay attention to that logic while analyzing any more than we think about the physics of keeping the bicycle upright while riding (Schlesinger, 1994). But one needs to pay attention to the science when designing a bicycle or when designing a treatment for a particular patient, which after all is what one does when one analyzes. In this book I will present the technique of psychoanalysis and psychotherapy in a way that is both more systematic and simpler than I recall it being taught to me.

The very term technique strikes some clinicians as repellant when applied to psychotherapy or psychoanalysis; it seems to signify a manipulative intent rather than a collaboration and tends to substitute a mechanistic approach for intuitive and empathic understanding. But the term has other implications that are inescapable for a clinician. Psychoanalysis certainly ought to be collaborative: to rest on the analysts intuitive and empathic understanding of the experience of the patient and to encourage the patient in intuitive self-understanding. But the analyst or therapist is more responsible for the conduct of the treatment than the patient is, and the analyst is expected to know what she is doing and why and what to expect when she intervenes. Technique refers to this responsibility of the clinician to conduct a rational treatment.

Technique has a politicized history. Almost from the beginning of the psychoanalytic era, the field has been marked by fervent arguments about preserving the integrity of the method. Self-appointed custodians of the field have worried that any deviation from received wisdom would spoil what was truly psychoanalytic, would dilute the purity of its technique and lead inevitably to seduction of the innocents. The debate has taken different forms and has used different terms across the generations but always within the general concern that, on one hand, ill-considered modifications would impair the integrity of Freuds legacy and, on the other, hide-bound adherence to outmoded doctrine would make the field irrelevant.

The struggle has often had the character of a religious war with clinching arguments based on quotation from authoritative texts rather than experiment and data. The crowning denunciation from the right has been But thats not analysis, and, on the left, But it works. Neither charge is apposite. Both are flawed, logically and psychologicallyand also analytically.

To pursue this discussion of technique with less heat it is necessary to clarify the operative terms and to set down some ground rules: I do not use the word analysis to describe the process under consideration. Rather than permitting the wholesale derogation of a clinicians work with the denunciation, Thats not analysis, or, in its ultimate form, We all know he doesnt do analysis, and between us, neither did his analyst, we require that objectors specify at what point(s) they believe the clinician under observation failed to analyze, either by not attending to something at all or by attending to it in some way the objector considers unanalytic.