Fred Busch - Rethinking Clinical Technique

Myth #1 is that American psychoanalysis has been dominated by ego psychology. Wallersteins (1988) view of ego psychology, universally accepted since the 50s, as holding a monolithic hegemony over the psychoanalytic domain in America, must be examined closely. I believe it has been one of our most enduring and complex myths, dominating the thinking of critics and defenders of so-called classical analysis.

It is my impression that is primarily in three areas that ego psychology has dominated thinking in American psychoanalysis over the last half century. The first of these is the area of the developing ego in its environmental surrounds, and the investigation of conditions leading to either a flourishing of or interference with ego functioning. Foreshadowed in the work of Anna Freud (1936) and Hartmann (1939), its first convincing demonstration was in Spitzs (1945, 1946) work on hospitalism, which showed the devastating effects of maternal deprivation, followed by Eriksons (1950) interpretation of the threatening or affirmative feelings associated with the nature of the resolution of the psychosexual stages. Mahlers (Mahler et al. 1975) work on the separation-individuation subphases is an example of how ego psychology was developed and utilized in the United States in a manner unlike that used anywhere else in the world. By pointing to the developmental sequence of certain anxieties, and the disruptive consequences for the child of the unavailability (emotional or physical) of needed objects, Mahler pointed clinicians to a greater understanding of one of the factors in the egos capacity to tolerate anxiety in the face of a threatened loss (either real or imagined). It has become another possible explanatory cause in the analysts understanding of threats to the ego, and finds immediate currency in the work of Pine (1985), who helps us understand how such problems might manifest themselves in the analytic situation, for example, in distinguishing between separation problems where there is differentiated other (p. 233) and those where there has been a failure of differentiation (p. 233). In short, the mapping of the effect of environmental and developmental factors on ego functioning has had extraordinary impact on our thinking about human development, and can be seen in the marked changes in our views about childhood and adolescence, and such diverse clinical concepts as action, narcissism, and trauma, just to name a few.

The second important contribution of American ego psychology appears in the 19381959 work of Rapaport (Rapaport 1967) and involved the increasingly sophisticated diagnosis of psychological states based on the intactness of the ego. It led to significant changes in how we understood pathology, and shifted diagnostic understanding from its primary emphasis on dynamics to diagnosis, which investigated the intactness of the patients ego in all its manifestations. It is demonstrated at its most succinct in Zetzels (1968) classic paper, The So-Called Good Hysteric, and at its most exhaustive in Kernbergs (1976) delineation of the syndrome of the borderline personality organization. It has led to sweeping changes in what type of patients we believe can be treated in psychoanalysis, and the development of special methods of interpretation in dealing with more disturbed patients.

The third major contribution of American ego psychology was Brenners (1982) conceptualization of mental content as a compromise formation, which crystallized the significance of contributions from the agencies of the mind on any mental act. This led us to understand, for example, that in the psychoanalytic setting any content can be used as a resistance, and that dreams are more than just the experience of a drive derivative. Thus the concept of compromise formation has allowed for the possibility of a more richly textured view of the ego. A patients increasingly hostile behavior toward the analyst can be seen not only as an expression of a sadistic impulse, but also as response of the unconscious ego to any one of myriad of threatening thoughts and feelings. Unconscious fantasies, seen primarily as an expression of a drive derivative, could also be looked at from the side of the resistances, while their effects on ego functions could also be explored (Arlow 1969). Paradoxically, Brenners views on compromise formation have led him to de-emphasize the significance of highlighting the ego in clinical technique with, as we shall see, important consequences.