Abstract
Psychoanalysis and Psychoanalytic Therapies by Jeremy Safran, a 2013 winner of the Gradiva Award for books from the National Association for the Advancement of Psychoanalysis, is a slim, gracefully written book that offers readers an integrative examination of the history, core concepts, and clinical applications of psychoanalysis. It is geared to the beginning reader but provides a rich synthesis of historical and contemporary ideas for the sophisticated reader as well. The book is part of the twenty-four-volume Theories of Psychotherapy Series from the American Psychological Association. Each volume in the series addresses a particular type of psychotherapy and has an accompanying DVD, sold separately, that demonstrates the therapy in action. On the DVD, Safran conducts a brief psychotherapy of six sessions that he describes and discusses in detail in the book. Given the recent spate of fine books on psychoanalytic therapies and theories currently being used in teaching beginning students and mental health professionals (Cabaniss et al. 2011, 2013; Gabbard 2010; McWilliams 2004; Summers and Barber 2012), one might ask what this book offers that the others do not. Safran’s is unique in being both deeply scholarly and clinically practical, in providing both an historical perspective and a modern sensibility, and in conveying a sense of the richness and complexity of psychoanalytic work through detailed clinical examples. It engages readers with highly relevant and readable expositions on a variety of issues, both basic and advanced.
The book has seven chapters: Introduction, History, Theory, The Therapy Process, Evaluation, Future Developments, and Summary. There is some overlap in these chapters, but in each Safran manages to provide the reader a concise overview of core ideas while focusing on contemporary clinical and theoretical dilemmas. He does not make assumptions about the knowledge base of the reader and has the rare ability to start with the most elementary and basic ideas and definitions (e.g., “Psychoanalysis is a distinctive form of psychological treatment and a model of psychological functioning, human development, and psychopathology” [p. 3]) and develop these into sophisticated and nuanced examinations of complex concepts and historical trends. For example, in the introduction, after defining psychoanalysis and discussing Freud from both theoretical and historical perspectives, he leads the reader into a fascinating discussion of “the tension between conformist and subversive threads in psychoanalysis.” He notes the irony that psychoanalysis “earned a reputation as a conservative cultural force with a tendency toward orthodoxy, insularity, arrogance, and elitism” (p. 8), given that the early analysts were “members of a liberal, progressive intelligentsia—a traditionally oppressed and marginalized group” (p. 9). Safran takes the reader on a concise but wide-ranging journey in describing the shift from the subversive nature of early psychoanalysis to the culturally conservative and elitist nature of American psychoanalysis in the decades from 1940 to 1970. He discusses such diverse influences as Marxism, critical theory and the Frankfurt School, the work of Theodor Adorno, the rise of American consumer culture, and the medicalization of psychoanalysis in the mid–twentieth century. Safran believes that we have come full circle and characterizes psychoanalysis today as a subversive discipline, given its lack of popularity, financial advantage, and prestige. This marginalized status means that psychoanalytic candidates today are more likely to be independent thinkers who go against mainstream views in pursuing psychoanalytic training. Safran sees present-day psychoanalysis as returning to its countercultural roots with “the opportunity to recover and build on some of the revolutionary, subversive, and culturally progressive qualities that were present at the beginning” (p. 191). This includes extending psychoanalysis across lines of race, culture, gender, and social class, preserving aspects of psychoanalysis (e.g., a focus on suffering or pessimism) that may run counter to American cultural values, and engaging in political advocacy individually and collectively (e.g., protesting against interrogation, torture, and oppression by totalitarian regimes).
The ability to contextualize the development of psychoanalysis with political, cultural, and philosophical trends is a major strength of this book and a quality that sets it apart from other introductory texts. In his engaging introduction and throughout the text, Safran holds the reader’s attention by balancing his discussion of the historical and cultural place of psychoanalysis with commentary on current trends in practice, the likely questions students will have about clinical issues (e.g., frequency of sessions, use of the couch, self-disclosure), and what psychoanalysis looks like as it is actually practiced today. He orients the reader to the distinction between psychoanalysis and psychoanalytic psychotherapy with a thoughtful examination, presenting his personal perspective on the clinical benefits of more intensive treatment while simultaneously acknowledging current clinical realities and the contentious historical and political debates around these issues.
The chapter on history traces the evolution of psychoanalysis from Freud to the present. In a few pages and in a relaxed narrative style, Safran covers the development of ego psychology in Britain and the United States, Kleinian and post-Kleinian traditions in Britain, Europe, and Latin America, the movement toward psychoanalytic pluralism in North America, interpersonal analysis, self psychology, relational psychoanalysis, and Lacanian theory. The discussions of Lacan and Klein are especially masterful and clear. Although coming from a relational orientation, Safran presents each theory in a respectful and evenhanded way, finding value in each, and giving the reader a sense of the personalities and relationships of the individuals involved. Reading this chapter is like listening to a family history, becoming familiar with many names, understanding where they fit in the family tree, and discovering how they have impacted one another and the field in general. It is fascinating to follow the sweep of psychoanalytic history, and Safran has an ability to convey the essence of each of these perspectives in a clear and accessible way.
Safran opens the chapter on theory with a discussion of psychoanalytic values and the debate over the classification of psychoanalysis (e.g., as a medical, scientific, hermeneutic, or philosophical discipline or a form of cultural criticism). He classifies psychoanalysis as a liminal or boundary discipline and remarks that this status has created a sense of confusion, as well as a sense of vitality and possibility. In his uniquely integrative way, Safran explores the psychoanalytic notion of mental health and the nature of the good life. He discusses what he considers core psychoanalytic values: (1) complexity, ambiguity, and curiosity, (2) an ethic of honesty, (3) a search for meaning, vitality, and authenticity, and (4) reflection-in-action vs. technical rationality. These values provide a compass for the beginning practitioner and serve as a guide for what is to follow in Safran’s discussion of traditional psychoanalytic concepts like resistance, transference, countertransference, and defense. The chapter ends with engaging remarks on topics including enactment, self-disclosure, attachment theory, emotion, and motivation. While these discussions are brief and leave the reader wanting more, they are well referenced and nuanced in both their historical and clinical dimensions.
The book’s longest chapter, on the therapy process, consists of sections on “principles of intervention” and “change mechanisms,” followed by detailed case presentations of two treatments, one brief and one long-term, that allow the reader to see Safran at work clinically and to witness him dealing with many of the themes he has discussed. It is in this chapter that Safran’s relational orientation comes through most clearly. He discusses various intervention principles and change mechanisms, defining basic concepts and their historical significance, but ends many of these segments with stimulating discussions encompassing a relational, postmodern sensibility, often with an emphasis on dissociation and enactment. The following excerpts illustrate this point.
Formulation. “An important thread in contemporary theory emphasizes that one can never have an objective understanding of how the other is, because any understanding will inevitably be influenced by the enactment in which one is engaged. . . . From this perspective, the only way to truly know our clients is to enter into their relational worlds and play out various scenarios with them in an unconscious way” (pp. 78–79).
Interpretation. “Interpretations are most likely to be helpful when the therapist is able to interpret a disavowed aspect of experience in a way that the client experiences as validating, supportive, and affirming. . . . the therapist’s state of mind (i.e., the extent to which the therapist feels empathically connected to the client or not) is just as important, if not more important, than the specific content of his interpretation” (p. 83).
Working through therapeutic impasses. “The therapist’s task is to facilitate movement to a third position (i.e., an alternative to a binary choice of ‘You’re right and I’m wrong’ or ‘I’m right and you’re wrong’). This process requires an internal shift within the therapist that has a quality of ‘surrendering’ or ‘letting go’ of a position he or she needs to hold on to tenaciously out of fear because of underlying and sometimes unconscious fears and threats of acknowledging dissociated aspects of experience” (p. 97).
Safran’s discussion of the nature of therapeutic change is thought-provoking, especially for classically trained clinicians. He takes up infrequently discussed clinical issues like the importance of nontransference interpretation, the judicious use of support and advice, helping the patient appreciate the limits of agency, and integrating other psychotherapeutic approaches (e.g., cognitive-behavioral) with psychoanalytic treatment. His clarity on the intersubjective, co-created nature of patient-therapist interaction allows readers to grasp traditional ideas in new ways and facilitates a reappraisal of the goals of treatment. Time-honored goals such as increasing insight, exploring unconscious fantasy, and modulating drives give way to those involving the provision of new relational experiences that support internalization of the therapeutic relationship, facilitate affective communication and regulation, and enhance the patient’s capacity for containment. Experiences of rupture and repair and moments of meeting in the relationship expand self-awareness and relational capacity. Exploration of the relational transaction taking place in the here and now between patient and therapist, what Safran calls “metacommunication,” is central to the psychotherapeutic process and to enhancing the patient’s awareness of implicit relational patterns.
Safran illustrates these concepts with two clinical vignettes, one from a long-term, thrice-weekly treatment of a young woman with depression, relationship difficulties, and bulimia, and a six-session treatment (filmed and available on the accompanying DVD) of a young woman with depression and substance abuse. The short-term case is intended as a demonstration of brief relational therapy (BRT), a treatment Safran developed and has studied. He acknowledges the artificial nature of the treatment due to the filming, the fixed number of sessions, and the lack of confidentiality. The patient’s signed treatment consent becomes the focus of a therapeutic impasse and a relational reenactment described as providing valuable insight for patient and therapist alike. But though Safran seems to be trying to convey the benefits and possibilities of short-term treatments, the degree of insight and improvement described in a patient with long-standing difficulties after just six sessions conducted under artificial conditions comes across as suspect. The long-term case is much more believable. This vignette provides a rich demonstration of an intensive, relationally oriented psychoanalytic psychotherapy. It vividly captures the “messiness” of treatment—the confusion, ambivalence, doubt, periods of progress and stasis—that Safran admirably grapples with as therapist. The private reflections Safran shares about what he is perceiving and feeling, both verbally and nonverbally, in the relationship with his patient, and how he brings these insights into the treatment in highly effective and evocative ways, illuminate the ideas he has presented earlier. Importantly, he addresses issues of race and social class. He also illustrates how he works with a variety of typical issues in psychoanalytic treatment (e.g., childhood experiences, trauma, dreams, acting out, and the potential for premature termination).
The book concludes with a brief review of empirical .psychoanalytic research, an examination of issues of race, culture, and social class, and thoughts about future directions for the field. Safran provides a succinct overview of empirical studies of psychoanalytic treatments and discusses some of the challenges involved in this work. He argues for expanding the umbrella of what is considered psychoanalytic treatment and remarks that “psychoanalysis comes in a range of different forms, treatment lengths, and intensities” (p. 172). Broadening the definition of psychoanalysis will extend treatment to a larger number of patients, and he calls for changes in the psychoanalytic curriculum to accommodate this. There is much throughout this book, including these discussions of research and future directions, that could be elaborated. The reader is left wanting more. Topics not covered here include neuropsychoanalysis, the therapist’s preparation, models of diagnostic assessment (e.g., DSM-5) and their implications for psychotherapy practice, and psychoanalytic theories of development. However, trying to include too much might have altered the book’s concision and elegance. Safran has a masterful command of his material and, like a good storyteller, keeps the reader engrossed and wanting more.
This book will be appreciated by both beginning and experienced practitioners for its intelligence, wisdom, and clarity. Safran has exceptional skill in lucidly explaining concepts, whether time-honored or cutting-edge, and integrating them with the political and social dimensions of psychoanalytic history. He corrects misperceptions, examines core values, and puts forward a new vision of psychoanalysis that rediscovers its subversive, egalitarian, and culturally progressive roots. The book is highly accessible, with rich clinical examples that illustrate psychoanalytic therapy at its best. It is written with grace, precision, and deep respect for the field and is an invaluable resource for teachers, students, researchers, and practitioners.