PSYCHOANALYTIC PSYCHOTHERAPY The EFPP Book Series Editor-in-Chief:Anne-Marie Schloesser OTHER TITLES IN THE SERIES Chief Editor: John Tsiantis (cid:2) Countertransference in Psychoanalytic Psychotherapy with Children and Adolescents (cid:2) Supervision and its Vicissitudes (cid:2) Psychoanalytic Psychotherapy in Institutional Settings (cid:2) Psychoanalytic Psychotherapy of the Severely Disturbed Adolescent (cid:2) Work with Parents: Psychoanalytic Psychotherapy with Children and Adolescents (cid:2) Psychoanalysis and Psychotherapy: The Controversies and the Future (cid:2) Research on Psychoanalytic Psychotherapy with Adults Series Editors: Monica Lanyado and Didier Houzel (cid:2) The Therapist at Work: Personal Factors Affecting the Analytic Process (cid:2) Invisible Boundaries. Psychosis and Autism in Children and Adolescents (cid:2) The Development of Consciousness: Psychoanalysis, Neuroscience and Child Development (cid:2) The Analytic Field: AClinical Concept (cid:2) Play and Power (cid:2) Crossing Borders—Integrating Differences: Psychoanalytic Psychotherapy in Transition (cid:2) Assessing Change in Psychoanalytic Psychotherapy of Children and Adolescents (cid:2) Bearing Witness:Psychoanalytic Work with People Traumatized by Torture and State Violence PSYCHOANALYTIC PSYCHOTHERAPY A Handbook Edited by Matthias Elzer and Alf Gerlach First published in 2014 by Karnac Books Ltd 118 Finchley Road, London NW3 5HT Copyright © 2014 to Matthias Elzer and Alf Gerlach for the edited collection and to the individual authors for their contributions. The rights of the contributors to be identified as the authors of this work have been asserted in accordance with §§ 77 and 78 of the Copyright Design and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. British Library Cataloguing in Publication Data A C.I.P. for this book is available from the British Library ISBN: 978 1 78049 119 6 Edited, designed and produced by The Studio Publishing Services Ltd www.publishingservicesuk.co.uk e-mail: [email protected] Printed in Great Britain www.karnacbooks.com CONTENTS ACKNOWLEDGEMENTS xv ABOUT THE EDITORS AND CONTRIBUTORS xvi SERIES EDITOR’SPREFACE xix PREFACE xx CHAPTER ONE PSYCHOANALYTIC THEORY OF THE HUMAN MIND 1 Psychoanalytic models of the mind 1 The unconscious (topographic model, 1900) 4 The psychic apparatus (structural model, 1923) 6 Contemporary models of the human mind 9 A note on symbolisation and mentalization 10 Drives and psychosexuality 11 Bi-phasic psychosexual development 12 Drives and erogenous body zones 13 Object relations 15 Object relations theory 16 So-called undifferentiated narcissistic, or objectless, stage 16 Transitional stage 17 True object relations 17 Part-objects and whole objects 17 Narcissism and self-system 18 Narcissism and the self 20 Historical review 20 Regulation of self-esteem 21 The ideal self 22 v vi CONTENTS The self-system: “three pillar model” by Mentzos 22 Primary process and secondary process, pleasure–unpleasure principle, and 25 reality principle CHAPTER TWO PSYCHOANALYTIC THEORY OF PSYCHIC DEVELOPMENT THROUGH THE LIFE SPAN 27 Methodology of psychological theory of development 27 Reconstruction 27 Observation 27 Baby-watchers 28 Overview of the fundamental theories on psychic development 28 Sigmund Freud (1856–1939) 28 René A. Spitz (1887–1974) 29 John Bowlby (1907–1990) 30 Melanie Klein (1882–1960) 30 Margaret Mahler (1897–1985) 31 Donald W. Winnicott (1896–1971) 32 Erik H. Erikson (1902–1994) 33 Heinz Kohut (1913–1981) 33 Joseph Lichtenberg (1925–) 34 Conclusional remark 35 Perinatal stage and the first year of life: the oral stage 35 The second and third year: the anal stage 37 Fourth to sixth year: the infantile-genital (oedipal) stage 41 Drive maturation 44 Object choice 45 Incest avoidance 46 Structural changes emerging from the resolution of the oedipal conflict 48 Sixth to tenth year: latency 51 Stage of latency 51 Eleventh to twenty-first year: puberty or adolescence 52 Eleventh to twelfth year: preadolescence 54 Twelfth to about twentieth year: adolescence 54 Twelfth to about fourteenth year: early adolescence 55 Fourteenth to about sixteenth year: middle adolescence 55 Sixteenth to about eighteenth year: late adolescence 56 Eighteenth to twentieth year: post-adolescence 57 Twenty-first year to the end of life: adulthood and old age 57 Twenty-first to about thirty-fifth year: early adulthood 57 Living together without children 57 Living together with children: triangulation 58 Living as a single 59 CONTENTS vii Thirty-fifth year to about sixty-fifth year: middle adulthood 59 Over sixty-five years:late adulthood, old age, and death 59 CHAPTER THREE CONFLICT, TRAUMA, DEFENCE MECHANISMS, AND SYMPTOM FORMATION 61 Primary and secondary process 61 Conflict 63 Conflict, excessive demand, and stress 65 Trauma 66 Trauma and conflict 66 The mechanisms of defence 68 The psychoanalytical concept of neurosis 68 Defence mechanisms and their functions 69 Classification of defence mechanisms 69 Narcissistic defence mechanisms 69 Immature defence mechanisms 71 Neurotic defence mechanisms 72 Mature defence 74 Psychosocial mechanisms of defence 74 Symptoms and suffering 75 Symptoms: their origin, and their meaning 75 Symptoms and the way to transmit these to the patient in a psychotherapeutic 76 treatment Symptoms and the change in them during the past century 77 Symptoms as an attempt to solve unconscious conflicts 77 Coping with unconscious conflict and trauma 78 CHAPTER FOUR DREAMS 79 The history of the theory of dreaming and dream research 79 Freud’s dream theory 79 Dream creating motives 80 Sleep and dream work 80 Topical regression 80 Condensation 80 Displacement 82 Secondary revision 82 Special elements of dream presentation 82 Psychoanalytical and empirical dream research 85 The functions of dreaming 87 Other dream-like mentations 88 The dream as therapy material 88 viii CONTENTS CHAPTER FIVE THE THERAPEUTIC RELATIONSHIP 91 Expectations and aims of the treatment 91 Removing developmental restraints 92 Aspects of the self 93 Relatedness to others 93 Acceptance of reality 94 Richness of experience and liveliness 94 Coping mechanisms 94 Integrative capacity 95 Self-analytic capabilities 95 Discussion 95 The essential asymmetry of the therapeutic relationship 96 The patient’s regression 98 Definition 99 History of the concept 99 Further development of the concept after Freud 100 The concept of regression in the view of other psychoanalytic concepts 103 The transference of the patient 104 Clinical example (from Mueller-Pozzi, 1991) 104 The transference and countertransference of the therapist 107 Clinical example (from Mueller-Pozzi, 1991) 109 Resistance 111 Conscious or unconscious acting against the analyst 112 Against the treatment itself 112 Not profiting from the treatment 112 Remaining silent 112 No associations or too many associations 112 Leaving out certain subjects of life 113 Fast relief of symptoms 113 Acting out 113 Function of resistance 113 Resistance and defence 113 Working on resistance 114 Analyst’s resistance 114 The treatment alliance 114 Ethical aspects 116 Common ethical rules 116 Special ethical rules 116 CONTENTS ix CHAPTER SIX THE SETTING IN PSYCHOANALYTIC PSYCHOTHERAPY 119 Frame and setting of the psychotherapy 119 Components of the frame or setting of psychoanalytic therapy 119 Ethical dimension and rules of conduct 120 Functions of the frame 122 The rule of abstinence 124 Neutrality and anonymity 124 The rule of free association 125 Setting components: time and room 127 Aspect of time 127 Aspect of room (office) 127 Additional remarks 128 Other aspects of the setting 129 The fee 129 Changing the setting and the therapeutic method 129 Parallel treatments and medication 130 The patient and his relatives 131 Modification and application of the psychoanalytical method 132 Frequency of the treatment of psychoanalysis and psychotherapy 132 Psychoanalytic psychotherapy 134 Psychoanalytic short-term therapy 134 Psychoanalytic couple therapy 135 Psychoanalytic family therapy 136 Psychoanalytic therapy for children and adolescents 136 Psychoanalytic group therapy 137 CHAPTER SEVEN DIAGNOSIS AND TREATMENT IN PSYCHOANALYTIC PSYCHOTHERAPY 139 The initial interview 139 The first contact 140 Appointment for initial interview 141 Referring of the patient 141 Ethical aspects 142 How to deal with the first interview 142 Second interview 144 Scenic information from the patient 144 Initial interviews and transference and countertransference 145 Diagnosis, indication, and contraindication 146 Assessment for psychoanalytic psychotherapy 147 Check list for assessment 147 Documentation of the diagnostic interviews 147