Abstract
Educators without formal training at an analytic institute may find it challenging to introduce and integrate psychoanalytic ideas and techniques into mental health curricula. A number of factors contribute to this difficulty, including students’ need for a semantic foundation allowing their comprehension of psychoanalytic jargon; the many distinctive theoretical approaches that historically have been shrouded in conflict; a paucity of evidence-based studies demonstrating efficacy; and the lack of a model of therapeutic action that is sufficiently user-friendly for the larger mental health community (Yalof 2015). In the short volume Freedom to Choose, Jack and Kerry Kelly Novick begin to address many of these issues as they present their novel approach to introducing psychoanalytic theory and technique, drawing on their experience as researchers, theoreticians, clinicians, teachers, and supervisors. Published in 2016, Freedom to Choose introduces students interested in clinical psychoanalysis to the Novicks’ synthesis of their evolving ideas over five decades into a systematized approach to contemporary psychoanalytic theory and practice.
Influenced by the field of developmental psychopathology, which studies normal and abnormal development, risk and resilience factors, and the concept of adaptive and maladaptive outcomes, the authors describe two general pathways of self-regulation by which individuals can fulfill the basic “need for homeostasis and mastery, which in turn underlie a sense of self and self-esteem” (p. 3). Their use of the term “self-regulation,” rather than more psychoanalytic phrases such as “affective regulation,” facilitates the integration of psychoanalytic ideas into the wider universe of mental health (Kopp 1982; Cicchetti, Ackerman, and Izard 1995). Self-regulation has become a particular focus in the field of developmental psychology over the last twenty-five years and is now considered an early childhood marker for later successes (Montroy et al. 2016). Even more important, it is commonly used in every mental health discipline as a descriptive term and is frequently listed as a goal of clinical treatment.
“Self-regulation” thus becomes an organizing lens that might be used to structure a general psychoanalytic approach to understanding psychopathology and clinical work. The Novicks posit that through every stage of development, challenges to self-regulation and conflict resolution can be met with a solution that is either competent, creative, and inclusive of reality or defensively omnipotent, sadomasochistic, and denying of reality. They have named these two systems, respectively, “open” and “closed.” The open system solutions of self-regulation are on mutually respectful and pleasurable relationships formed through realistic perceptions (p. 6). The authors define closed system solutions as the sadomasochistic option, where omnipotent fantasies that defend against traumatic helplessness create situations of pain and suffering, along with attempts to control the object, an idea prominent in their earlier work (Novick and Novck 1991, 1996).
The Novicks focus on defensive delusional omnipotence as the major indication of sadomasochistic pathology (p. 7). The specification of that defense as an indication of primitive psychic organization harks back to Kleinian child analytic work of the 1920s and 1930s (Klein 1923, 1934). The oscillations between the open and closed systems echo Melanie Klein’s terminology of the depressive and paranoid-schizoid positions. In fact, the sadomasochistic intertwining of libidinal and aggressive drives with omnipotent fantasies and actions suggests similarities between the closed system and the paranoid-schizoid position. The Novicks’ vocabulary and easy conversational tone, no doubt due to a long history of working with children, parents, and students, make their writing more approachable to the modern American student’s ear than Klein’s work.
In the first section of the book, the Novicks describe the developmental challenge of each phase from pregnancy and infancy through adulthood and old age. Following Erikson’s stages of the life cycle (1980), they describe the developmental expectations that can destabilize the individual, as well as the defenses that are available for expansion and generativity. They then present adaptations that an individual can make as open and closed responses. As part of an introductory course, the book allows the integration of various theoretical approaches, an important consideration at this stage of interest and training.
For clinical psychoanalytic work, the two-system model taken at face value could minimize the complexity of underlying pathological conditions. For example, with an autistic child, what might appear to be “omnipotence” could be a rigid response based on neurological limitations. It is not that a psychoanalytic treatment cannot be immensely helpful, but the individual may not have the capacity to make an “open system” choice as freely as the book describes. Bombarded by sensory stimuli, such a patient might not be able to access help and might need to hide or retreat in order to achieve homeostasis (Alvarez 2014; Sherkow and Harrison 2014). In the authors’ case example of Dr. W., who had previously been diagnosed as having bipolar disorder, the vignette describes a psychoanalytic victory over sloppy psychiatric assessment (pp. 149–154). For a seasoned clinician with acumen and experience as to when and how to take pharmacological risks, this is a meaningful anecdote. Without an explicit caveat, an inexperienced reader, however, might jump to the dangerous conclusion that patients with a bipolar spectrum disorder might not need to be treated with psychopharmacological agents.
Using the perspective of developmental psychology, the authors “emphasize that closed-system functioning is not a deficiency or deficit; rather it is a solution” (p. 7). With this understanding, a practitioner can invite a patient into a therapeutic alliance where the dyad can jointly attempt to understand the painful sadomasochistic dynamics in the past, the present, and the treatment situation from any one of a number of theoretical perspectives. For example, in chapter 17, without referencing clinical theoretical models, the authors present the case of Mr. H., a successful middle-aged man with a recurrence of earlier symptoms who controlled the sessions and effectively paralyzed the analyst by not allowing any interventions or interpretations. Skillfully, the analyst was able to contain any countertransferential hostility without withdrawing from the patient by keeping in mind that the goal was to relate to Mr. H. as “a real separate, whole person” and by remembering that they were “carrying Mr. H.’s open-system capacities” that would allow “gradual expansion of his emotional range and repertoire . . . in the course of the treatment” (pp. 108–109). Pedagogically, this technical intervention could be explained by using any of a number of terms and concepts from object relations, ego psychological, self psychological, intersubjective, or relational perspectives, thereby demonstrating that the open and closed system “metaorganization” is translatable into one’s chosen theoretical model.
Another novel use of language is the authors’ introduction of one-track vs. two-track models. Although only briefly explained in this volume, they define and describe this differentiation in a paper titled “Two Systems of Self-Regulation” (Novick and Novick 2001; see also Novick and Novick 2003). There they refer to it as a “single-track model,” which they present as an interpretation of early Freudian developmental theory, often defaulted to by psychoanalysts of all schools, whereby psychopathology is understood to be rooted in all of early development and emphasis is placed on a “unitary pathological continuum” (p. 97). They explain their perspective that “adult pathology is explained as fixation or regression to, or persistence or arrest of, what was normal in childhood. In this conceptualization, what was normal in childhood is pathological in adulthood” (p. 96). The Novicks cite other psychoanalytic authors, like Tustin and Gillette, who took issue with what could be seen as an archaic developmental theory, as well as contemporary researchers like Cicchetti and Rogosch from developmental psychology, to support their model (Tustin 1994; Gillette 1992; Cicchetti and Rogosch 1996). The Novicks thus transform their one- and two-track models into an approach where one can seemingly “choose” an open trajectory of “behavioral and biological plasticity” and a closed one where the “initial conditions determine the end state” (p. 5). On closer examination, the epigenetic model from developmental psychology differs from the Novicks’ model. Researchers like Cicchetti assess what is “normal” and “abnormal” development and identify what contributes to risk, psychopathology, and resilience (Cicchetti and Toth 2009). Their focus is the promotion of adaptive outcomes and the prevention and amelioration of maladaptive choices. At a certain level, this may appear to have similarities to the open and closed system model, such as determining what poses a challenge at a particular developmental stage and how the organism adjusts to it.
The judgment of whether or not a choice is adaptive or maladaptive, however, cannot always be made in the moment. Time needs to elapse, and research studies of cohorts are either retrospective or prospective in the field of developmental psychopathology (Cichetti and Toth 2009; Sroufe 2005). An open or closed system solution, however, must be assessed within the context of the individual’s internal and external conflicts and ultimately may be found to be a mixture of adaptive and maladaptive elements. For example, in the face of a perception of significant threat, an individual may seek stability that is beneficial even in a compromising, sadomasochistic situation that appears to be closed. For instance, a child may choose not to reveal sexual abuse perpetrated by a stepfather and to accept the abuse and thereby preserve the stability of the home for the sake of the mother and children, including herself, until such time as an alternative solution can be found. In retrospect, that sacrifice, made with the realistic goal of survival, accompanied by the resulting delusion of omnipotence, organized that adolescent and later adult woman to feel strong enough to determine the course of her life, including her clever maneuvering of bedrooms in the home that effectively ended the abuse, her later separation from her family, the satisfaction of her sexual and social needs, her strong and supportive marriage, and her dedicated role as a mother. By any developmental psychological measure, that woman demonstrated remarkable resilience. Now approaching retirement, this patient, with her own children well into adulthood, feels free to explore the impact of her choices on her own development. It therefore could be argued that the patient made an early closed system solution that did not fully determine her end state. The larger question for practitioners and researchers is how to determine when a closed system solution runs the risk of perpetuating negative consequences for growth and development and when it does not.
That comment aside, for students seeking an introduction to clinical work who are looking to understand a patient’s particular solution to a conflict or how to organize themselves within a psychotherapeutic intervention, the open and closed systems can provide a rudder in turbulent waters. For more experienced practitioners, the descriptions of the open and closed system responses in each phase may seem too limited. For example, the abrupt termination of a college student’s treatment could be seen as a closed system response with many of the stigmata like omnipotent unilaterality, projection of oedipal feelings of rejection, regressed communication, and primitive anxieties about being controlled. At the same time, there is another perspective in which the patient with a history of terror linked to separation has developed enough effective self-soothing and self-regulatory capacities to risk leave-taking and determine a more independent course, including bearing the fantasies and affects of risks and uncertainty. That separation for this individual clearly remains a traumatic event is powerfully communicated to the analyst, but so is the patient’s evolving capacity to tolerate painful states in conjunction with a massive developmental surge forward. This kind of event may well be a temporary regression in the service of the ego as well as development (Kris 1936; Neubauer 2003). In this case, the choice between open and closed pathways may be less relevant than a compromise that diminishes the tension between the regressive components of the infantile states in the analysis, on one hand, and those related to the realities and possibilities of dramatically expanding demands and capacities, on the other.
The novelty of the Novicks’ use of the concept of omnipotence, however, lies in their application of their overarching schema to embrace psychoanalytic theory and technique. In their introduction to the second half of the book, which focuses on the phases and tasks of treatment, they extend their open and closed system approach to the therapeutic choices to be made by a psychoanalytically oriented practitioner. It is not that an analyst does not function as a transference object but that, at particular moments of individual development and treatment phase, a repertoire of interventions more expansive than classical interpretations may need to be considered. The Novicks list “mirroring, empathy, reconstruction, validation, support and developmental education” as a few possibilities (p. 83). Practically, what it does is expand a practitioner’s toolbox to allow greater flexibility of technique, mirroring the concept of open system functioning. It is not that the pathological grandiosity or omnipotence is not interpreted but that efforts are made to understand why it was created and still persists as a defense. Less pathologizing approaches to theory and practice may in turn help patients develop more adaptive mechanisms and inclusive thinking (p. 83).
What is remarkable about this small volume is the authors’ effort to integrate multiple approaches to the mind at both theoretical and technical levels. This unified approach presents an alternative in the metadefinition of what is “psychoanalytic,” an enduring problem that has plagued psychoanalytic institutes and teaching, created warring “schools” of theory and practice, and prevented the presentation of psychoanalysis to a wider audience as a unified discipline (Kirsner 2000, pp. 6–7) Further, incorporating developmental theory and observation into these schools has also been challenging, either being relegated to the “adjacent” domain of child analysis, critiqued for premature causal conclusions, or considered to be at odds with both genetic and “here-and-now” approaches (Auchincloss and Vaughan 2001; Grossman and Kaplan 1988; Isserow 2015; Rapaport 1959).
In Freedom to Choose, the Novicks intertwine many factors that contribute ultimately to effective clinical intervention at any age. They boldly present a conceptual structure organized around sadomasochistic dynamics that can be used as a vehicle to teach psychodynamic concepts of anxieties, symptoms, and defenses, as well as clinical formulations and interventions alongside developmental theory. That level of integration has been most difficult to convey to the larger mental health community. This volume throws down the psychoanalytic gauntlet and presents a challenge to competing manualized “evidence-based” treatments in which basic psychoanalytic concepts have been spliced out or diluted. It builds a bridge to the contemporary world in an attempt to make psychoanalysis more comprehensible and user-friendly in a culture filled with touch screens, hashtags, and instantaneous communication. With vignettes of clinical wisdom and boxed take-away messages at the end of each chapter, the Novicks have produced a volume that can introduce psychoanalytic thinking to generations around the world. The book’s broad and relevant view and its accessibility may be more important than smaller details that can be sorted out for students patient and interested enough to pursue in greater depth in psychoanalytic classes and supervision.