Current Medical Diagnosis & Treatment in Psychiatry



Until the late 1980s, becoming a psychoanalyst in the United States meant doing postdoctoral work, primarily post-MD, in an approved institute of the American Psychoanalytic Association. Of the 3000 or so certified analysts, the majority were psychiatrists or other physicians who had completed 4–5 years of additional course work, undertaken a personal analysis, and passed written and oral assessments of their capacities as clinicians and therapists. In addition to the 29 institutes of the American Psychoanalytic Association, nonmedical institutes exist, some of them run by psychologists and other non-psychiatrists. With the death of Freud and the passing of the generation of psychiatrist-psychoanalysts who knew him personally, and with the rise of biological and laboratory methods in psychiatric research, American psychoanalysis confronts new demands.

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Self Psychology

A similar use of developmental theory and observations occurs in another major contemporary school, that of self psychology. Led by Kohut, self psychologists focus their attention on the qualities and consequences of early child-parent interactions. A core technical term is self-object, which refers to Kohut’s explication of the parent’s ability to maintain a child’s self-esteem. In a broader sense, the term encompasses all the ways a parent provides ego functioning for a child, not just the regulation of self-esteem. A self-object has three crucial characteristics: (1) It is a person, (2) who performs ego functions for another person, and (3) who cannot perform them for the person’s self. Failures in self-object regulation between infant and adult occur because failure occurs in one or all three parts of the infant-adult interaction. For example, an infant who is grossly impaired neurologically may not be able to receive and process what would otherwise be good-enough care. When it seems possible to locate the source of self-object failure in the parent’s response, and not in the child’s neurologic defects, we can speak about parental failures in empathic communication. Better yet, we can speak of partial failures in empathic communication and partial failures, therefore, in ego maturation.

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Psychoanalytic Clinical Findings

Psychoanalytic technique, especially the sustained empathic investigation of the patient’s lived experience, aims to foster ego-syntonic regression, which permits the patient to observe psychological processes that would otherwise go unnoticed. In this sense the psychoanalytic situation, like the telescope in astronomy, permits the observer to record new facts about human behavior. These newly discovered facts constitute the core clinical findings of psychoanalysis. Chief among these findings are (1) the decentering of consciousness, (2) the massive complexity of desire and self-experience, and (3) the ubiquity of transference events. The decentering of consciousness refers to the psychoanalytic aim of enlarging the scope of patients’ conscious awareness of their motivations and thoughts. Freud called this his Copernican revolution, because it revealed that human beings are not always masters of their own psyche, just as the earth is not at the center of the solar system. Second, central to psychoanalytic theory and practice is the attempt to follow the contours of a patient’s multiple desires (sexual, aggressive, narcissistic, and altruistic). In many important ways, contemporary research has refined classical theory about childhood fantasies about love.

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Psychoanalytic Theory Applied

Psychological Testing

All psychological tests that claim to be projective derive ultimately from psychoanalysis through either Freud or his pupils, such as Jung. For example, Rorschach, originator of the famous inkblot test that bears his name, was influenced by Jung. The Rorschach Inkblot Test, Thematic Apperception Test (TAT), Draw-a-Person Test, and hundreds of other instruments all presume validity of the psychoanalytic concepts of internal psychic conflict and ego defense, especially projection and displacement. Thirty years ago projective testing fell into disrepute and seemed on the verge of collapse, but some contemporary research psychoanalysts have sought to place the Rorschach on rigorous, objective footings.

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Concept of Science

Classical theory (including Freud’s work from 1900 on and the concept of ego psychology) retained a 19th-century ideal of scientists as external observers who are to describe the forces and constraints that give rise to structure. All sciences are to be unified, sooner or later, into a single, coherent picture of the knowable universe. That which cannot be known by science in this way cannot be spoken of intelligibly. Unification also presupposes that truths in one science, such as math or physics, cannot be contradicted by claims in other sciences, especially in the less rigorous sciences such as biology and psychology. When Freud speaks of psychic energy, he does so within the constraints of the physics of his time. Hence psychic energy must obey the second law of thermodynamics and have all the tensor qualities that 19th-century scientists said were true of physical energies. Also, because physical energies are interchangeable with all forms of energy (ie, heat may be transformed into mechanical power), psychic energies are also interchangeable. Thus the psyche, too, should show similar transformations. For example, pregenital energies, genital energies, and the theory of sublimation reflect 19th-century physics.

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Foundations of Psychoanalytic Theory

As a form of inquiry, psychoanalysis originated in Sigmund Freud’s modification of 19th-century medical consultations on what were then termed neurasthenias and other disabling psychological conditions, especially hysteria. The majority of all forms of psychiatry that claim a dynamic or cognitive orientation derive from Freud’s original work and from that of his students. Although psychoanalysis began primarily as a theory of neurotic functioning and character pathology, in the past 70 years it has changed dramatically to include severe psychopathology, addictions and eating disorders, sexual abuse, and other maladies.

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