Program summary by etta Saxe, ph.D.

ANALYZING  IN  A  WHITE  COAT:  A  FALSE  SELF  FOR  PSYCHOANALYSIS

The purpose of this panel was to build on Marvin Hyman’s chapter, “Why Psychoanalysis Is Not a Health-Care Profession” in Kaley, Eagle and Wolitzkey, Psychoanalytic Therapy as Health Care and to extend to practice, thinking about psychoanalysis as other than health care.

Based on our belief that the associational flow and context of material is most critical in understanding psychoanalytic process, two consecutive associational process hours and a telephone call were presented. The panelists used this material as a grounding and take-off point for their discussions. 

Instead of the more usual discussion of such material focusing on what the analysand is communicating or trying to communicate from the point of view of different listeners/theories and what proper technique would be, the discussants elaborated on the principles and guidelines each holds for herself about her place in the psychoanalytic encounter, the essential nature of the psychoanalytic enterprise, the aims of the encounter, the context and details of how she listens and processes, the ethical imperatives she experiences, and her self-assigned  tasks or activities, including those activities which she abdicates and prohibits herself in the service of the work.

Since space makes it impossible to include the associational process material within this summary, those portions of the panelists’ discussions specifically related to the presented associational process will not be emphasized/summarized.  Rather, focus will be on the more general aspects of the panelists’ perspectives on the psychoanalytic situation as other than health-care and on the panelists’ definitions of psychoanalysis as other than health-care.

Dr. Etta Gluckstein Saxe, panel chair, began her introductory remarks with a review of Dr. Hyman’s article.  In reviewing many of the contrasts he elaborated between psychoanalysis and health-care activities, she placed her emphasis on those she considers to be current issues and topics within psychoanalysis.  This review set the stage for the discussants to elaborate their own contrasts between psychoanalysis and health-care activities.

Dr. Saxe offered the view that psychoanalysis is not now and never has been a health-care profession, although the creator of the discipline was a physician—a physician who, while earning his living through the profession into which he was credentialed, came to discover those processes he called unconscious and develop a method of inquiry, called free association. 

Dr. Saxe asserted that there is much in Freud’s writings to suggest that he himself was of at least two minds as to where to locate psychoanalysis and whether to locate it as part of medicine/abnormal psychology.  At times Freud describes psychoanalysis as a method of inquiry/research into the psychical or, as Barnaby Barrett describes it, a discipline of inquiry.  At other times Freud suggests psychoanalysis to be a set of discovered facts about pathology, etiology, diagnosis and treatment, in the codifying tradition that Fenichel attempts to follow in The Psychoanalytic Theory of Neurosis.

In his book about the everyday manifestations of unconscious processes and dynamics, Freud framed these processes as psychopathology, raising the interesting dilemma that those very processes which he and most psychoanalytic thinkers tend to agree are ubiquitous and one critical essence of our humanity are simultaneously defined as “sick” processes to be eliminated, i.e., cured.  In holding fast to the view that psychoanalysis is a health-care discipline and profession we present ourselves with the dilemma of attempting to cure and eliminate this essence of our humanity.

Dr. Johanna Krout Tabin began her presentation, “Psychoanalytic Process and Freedom,” with the motto she indicated she often quotes with analysands. “I am a person.  Nothing human is alien to me,” which comes from Terence 100 b.c., from a translated play, “The Self-Tormentor” by Meander, 300 b.c.  She elaborated later that, in her mind, “pathology is a synonym for what is both not understood and disapproved of,” suggesting that a model of pathology and cure reflects a breach of this motto and reflects a way of thinking that makes alien the experience of the other through objectifying categorization.

Dr. Tabin went on to consider the relationship between psychoanalysis and inner freedom.  She prefers this perspective to using a medical model of symptom and cure.  Regarding symptoms as behavior which is not understood nor approved of, she reminded the audience that psychoanalysis is about understanding, not making judgments of others.

The goals of psychoanalysis in Dr. Tabin’s view, are to achieve choice rather than to feel compelled or inhibited, as well as to make sense to oneself.  To achieve these goals, the analytic relationship must provide psychic safety for exploring what seems “wrong” according to the analysand’s perspective. 

Dr. Tabin’s model is a developmental one. Contrasting this developmental model and medical models, Dr.Tabin noted that the medical model is tempting because pain motivates people to enter into analysis.  The trouble with the medical model is its focus on the lacks in the other person, demeaning the position of the analysand.  The purpose in such models then becomes correcting the person’s defects, automatically making the helpful analyst a superior authority.

Dr. Tabin went on to explain that our capacity  to understand each other comes from our “shared treasury of emotions,” as Isaac Bashevis Singer terms it, and in our traversing similar developmental terrain in organizing ourselves into unique individuals.  Analyst and analysand share a common humanity and individual differences.  This serves as the basis for the analyst joining the analysand on his/her voyage of discovery in a manner that is not hierarchical and is always, first and foremost cognizant of the analyst’s obligation to be respectful of the individuality of the analysand and the analysand’s direction.

For Dr. Tabin, the purpose of analysis is to take a voyage of self discovery for the analysand and the analyst’s purpose is to join the analysand on this voyage by offering concentration, with the analysand, on aspects of the analysand’s ways of being that produce incoherence from the analysand’s point of view.  The analyst has no magical power for which the analysand must pay.  The analysand pays for the time and energy of another person who is willing to set aside personal interests as much as possible and to be concerned with the analysand’s  purposes, thoughts and feelings in the analysand’s voyage of self discovery. Psychoanalysis is the most respectful possible of another’s  individuality.  We assume we can learn together.  The analyst offers a sensitivity developed through self-analysis and experience working with others while the analysand brings unique experience and final authority about what fits.

Dr Tabin finds that, offered this developmental model, most people seem to understand that psychic pain results from inner confusion.  Often, they must nonetheless learn to trust that, in the presence of the analyst, they can safely start to understand themselves—and that they are capable of doing so.  They can become “psychologically minded,” i.e., reveal a self-observing part of the ego.  This  preamble to psychoanalysis, as it is often described, need not and should not be an indication for the analyst to take over the direction of the treatment. The analyst in standing for the possibility of  inner coherence helps sustain, rather than directs, the discovery process.

Dr. Tabin’s developmental model includes the unevenness of all personality configurations.  Early mental structure can cause as formidable an imprisonment as windowless concrete walls.  To further the goal of the inner freedom, psychoanalysis engages the ego in the sense of the person’s freest energies at the time.  Dr. Tabin finds that inner harmony, outer competence, self trust and permission for spontaneous joy occur naturally as someone learns that the strictures of early patterning are now a choice, not a destiny.

For Dr. Tabin, as analyst, this is not a value-free situation.  When an analysand achieves significantly greater self-coherence, sense of personal competence, and increased ability to enjoy life, the analyst, as a feeling human being, cannot help being pleased and  has the right to feel so; but that is not to say the analyst should define an analysand’s progress. The analysand is the one to determine when the unconscious elements are disentangled enough for the analysand’s purposes. 

Dr. Susan Gendein-Marshall presented a paper jointly written with Dr. Marvin Hyman, “No White Coat: Joyfully Bearing the Uncertain Truth of Psychoanalysis.”   They put forward the idea that it is the contractual context in which the psychoanalytic work takes place that makes possible a process of inquiry and discovery for analyst and analysand. 

This context is introduced to the analysand in the early part of the work, through the analyst’s communications about the unfolding associations.  The two participants thus come to agree that the analysand is not a victim of forces beyond the analysand’s control, including illness to be cured.  The analysand is made aware that she/he is, rather, pursuing hidden agendas alternative to those in awareness and that these agendas are the motivational factors in the discontinuities in his/her life which are the “problems” for which consultation is sought. Given this conceptualization, analyst and analysand agree that: it would be most useful to know consciously these hidden agendas which compel choice; that, through the associative method, they will work as collaborators in a process of inquiry and discovery; that all thoughts that come to mind, including reports of misery and distress, will be listened to as communicative associations from the unconscious. Contrary to any health-care perspective, the collaborators consider how the analysand’s experiences of discomfort and distress, including the manifest reasons for which consultation is sought, represent a very clever unconscious  “solution” to the “problem” of how to accomplish multiple simultaneous objectives in living one’s psychic life. 

For the analyst, this means assuming a listening stance wherein the analysand’s verbalizations are taken as associative communications from the unconscious  with emphasis on process rather than outcome.  Psychoanalytic discourse is poetic language; it is dynamic and multi-dimensional.  Associative communications from the unconscious are subject to different grammatical rules than ordinary discourse since, as semiotic process, forms and meanings are created out of the living matter of an individual’s narrative or manifest associations.  What is expressed and ultimately understood by the participants is substantially greater than some measurable piece of information, whether about “etiology” or anything else, and new and expanded ways of thinking and experiencing, informing, forming and reforming the self are opened up through the process of “talking” together. In this view meaning, not cure, is the essence of the enterprise. 

This model of the analytic work requires that the analysand be perceived as a fully functioning, capable and responsible individual, a collaborator in the work and not a subject or patient to be acted upon, directed, or in need of our care rather than attention.  Such a person is seen as being free to do and act as people do and to live with the consequences of such action, including the choice of using the process to alter the agendas that motivate life. While the analyst can and should analyze the choices made in this regard, there is no way a choice can be forced on the analysand and the process requires that the analyst not do so.

Within the process itself, belief must be suspended by both participants, especially the analyst, that the matters being dealt with are matters of objective fact or truth. Belief must rather be held that representational language, imagery, ambience and evocations contain the psychic truths of any moment and that only associations to be subjected to the deciphering work are being considered.  For this work to proceed the analyst and analysand must take a stance that no associations are privileged and none are judged. What ensues is a quality of open-mindedness that resists value judgments and foregone conclusions, as in Fenichel’s encyclopedic compendium of symptom-dynamics correspondence and welcomes with open arms all associational material that might emerge.  This is the position of neutrality often mistaken in the literature for chilly aloofness.  The analysand’s task of associating freely is facilitated by this neutrality. The analyst’s abandonment of the judgmental/diagnosing/etiological thinking of the health-care model is necessary for maintaining this neutrality, which privileges no association by judgments of  any kind, including healthy and sick.

This position also requires a restraint on action and words as actions that would violate the agreed upon deciphering process, which is called abstinence.  Abstinence requires that the analyst be honest and humble about herself and the objectives of the analysis and not assume a stance of superior knowledge of the analysand’s mind as occurs within the framework of a health-care model. This position also implies things the analyst is to do which differentiate the analyzing process from treatment and methods within a health-care model.

In order for more full and precise meanings to emerge, the analyst must hold firmly to the positions of neutrality and abstinence. When not acted upon, temptations to depart from the way of thinking and working elaborated in this paper/perspective, can and often do provide useful information about forms and processes of communication and as associations, add to the making of meaning and the collaborative understandings emerging in the work. 

There is an emphasis on process rather than outcome within this perspective.  The outcome is left in the hands/mind of the analysand. While accepting the limits of the analyst’s influence can be humbling for the analyst, it also frees the analyst of responsibilities that are impossible to fulfill and allows the analyst to focus attention on the deciphering work, seeking knowledge of unconscious beliefs/agendas. Acceptance of limitations enhances the work and helps the analyst to find satisfaction in the analyzing process itself, rather than in outcome/cure, the focus of health-care models. 

This summary of the “White Coat” panel discussion, which was first presented at the 2000 Spring Meeting of Division 39, was jointly written by the panel participants, Susan Gendein-Marshall, Ph.D., Marvin Hyman, Ph.D., Etta Gluckstein Saxe, Ph.D., and Johanna Krout Tabin, Ph.D.