Abstract
Lee Jaffe’s presidential plenary paper demonstrates his career-long emphasis on unifying psychoanalysis and its theories. His use of Freud’s various technical concepts to make psychoanalytic theory applicable to talking psychotherapies of all kinds, analytic and nonanalytic, is a notable achievement and a useful pedagogical tool. By valuing common ground and unification, he aligns himself with luminaries such as Wallerstein and Rangell, who had similar goals. In keeping with these values, I offer a schematic outline of what the sort of integrated model valued by Jaffe might include.
Contemporary psychoanalysis continues to struggle with defining itself as it attempts to evolve beyond its hundred years and more of theoretical and organizational factionalism. Beginning with Freud and continuing until the present, our field has spent an inordinate amount of time arguing over differences, and significantly less time trying to find common ground. Freud’s excommunication of disciples such as Adler, Rank, and Jung for having somewhat different ideas was repeated in a milder form in the struggles between the followers of his daughter and those of Melanie Klein in England. In this country, analysts who wanted to modify the ego psychological model preferred by the American Psychoanalytic Association had to develop new schools of thought, and sometimes new institutes and journals, to make room for interpersonal, object-relational, self psychological, intersubjective, and relational ideas. These theory wars were waged through the last decades of the twentieth century until the combatants arrived at our current state of détente called pluralism.
One can see similar acrimony and skirmishes in our local, national, and international psychoanalytic organizations, most typically around so-called educational standards, including but not limited to the contentious issue of who can analyze candidates. Only in the last five years has the American Psychoanalytic Association found an organizational solution to the decades-long struggle between its educational arm, the Board on Professional Standards, and its administrative arm, the Executive Council. That solution involved a serious and comprehensive overhaul of its organizational structure to put the years of strife behind them. Similar struggles have occurred within the International Psychoanalytical Association as different regions of the world developed different ideas about how best to train aspiring psychoanalysts. Its current attempt to avoid strife and splintering involves three separate and distinct training models: the Eitingon model, the French model, and the Uruguayan model. It remains unclear at this time whether these national and international solutions will be able to contain what can seem like an inherent tendency in psychoanalysts to acrimoniously divide rather than integrate.
Lee Jaffe’s Contributions To Psychoanalysis
This brief and perhaps overgeneral history has been offered to put the contributions of Lee Jaffe in his presidential plenary paper, and in his psychoanalytic career, in context. Most psychoanalysts spend their careers seeing patients. Some also write papers and/or teach in their local institute. And some even take on organizational leadership positions locally, nationally, or internationally. Lee Jaffe was one of those rare analysts who did all these things. Always maintaining a full practice, he published several peer-reviewed articles and two books, and served as president of both his local institute and the American Psychoanalytic Association. Before that, he was president of the International Psychoanalytic Studies Organization, the international organization for candidates, as well as APsaA’s Candidate Council. In each of these pursuits, he showed a predilection for integrating and unifying rather than dividing and splitting. That is, his emphasis was always on practical ways to cohesively apply psychoanalytic thinking to a range of clinical modalities: psychoanalysis, psychotherapy, couples therapy, and psychological testing. Similar tendencies can be seen in his writings, most of which are more practical and cohesive than theoretical or divisive. Finally, his various presidencies were characterized by attempts to persuade those on various sides of an issue to find compromise and common ground rather than to divide and polarize based on some abstract principle.
His plenary paper is an excellent example of this emphasis on unifying that runs through his psychoanalytic career. In essence, this paper argues for the value of seeing Freud’s body of work as an integrated body of knowledge composed of several strands, what he calls modes of therapeutic action, that can be used to support a variety of psychoanalytic models and applications, along with various so-called nonpsychoanalytic therapies. Jaffe takes a position opposite those who consider Freud’s succession of theoretical and clinical models (affect-trauma, topographic, structural) to be distinct stages in which new models of therapeutic action replace earlier ones. Given the modes of action Jaffe highlights, it is reasonable to assume that he would argue that more recent models in contemporary psychoanalysis should be included in this integrated body of knowledge and not be regarded as distinct schools.
Is psychoanalysis one technique or many?
It is fitting that Jaffe emphasizes the use of psychoanalytic modes of therapeutic action in nonpsychoanalytic therapies, given that a significant issue in the tendency for U.S. psychoanalysis to split rather than unite is the question of psychotherapy versus psychoanalysis (Wallerstein 1995). The debate over whether or how to differentiate the two continues to this day on APsaA listservs. Parallel to and interacting with this debate has been the pedagogical question of whether to teach psychotherapy to psychoanalytic candidates or to restrict institutes to teaching the technique of clinical psychoanalysis exclusively. That subject was discussed at an Educational Forum of APsaA’s Department of Psychoanalytic Education. Its continuing importance can be seen in the inclusion of a Psychotherapy Section within that department. But the debate has a long history, as Wallerstein (1995) made clear: The emerging consensus within the American psychoanalytic world on what constituted psychoanalysis proper, what constituted the array of varying supportive and varying expressive psychoanalytic psychotherapies, and how they were related was crystallized, as noted, in the publication in 1954 of an issue of the Journal of the American Psychoanalytic Association. . . . An important impetus for the outpouring of contributions on this theme was the intense ferment stirred up by the bold technical proposals of Alexander and his co-workers. These proposals were received with reactions ranging from great enthusiasm to dismay; some believed that they pointed the way to a more effective and also speedier psychoanalytic treatment, others feared . . . the dilution of proper psychoanalysis into an amorphous psychotherapy, all the more dangerous because it masqueraded as psychoanalysis and so could hoodwink the uninformed. . . . An even stronger impetus to publications of 1954 was the growing controversy over the similarities and differences between psychoanalysis and psychotherapy” [p. 71].
Jaffe stepped squarely into this controversy with his plenary. Implicit in his thinking is the idea that psychoanalysis is different from psychoanalytic psychotherapy, which itself is different from other psychotherapies. Yet at the same time he sees psychoanalysis as a body of knowledge (one might say an academic discipline) that has applications to psychotherapies of every kind. Thus, he says explicitly that classifying different psychotherapeutic techniques (including psychoanalysis) according to their basic modes of therapeutic action provides a common ground on which Freud’s various models of the mind are applicable to the full range of mental health treatments. In this he stands with Gill (1954) and a host of others influenced by the Menninger Foundation and its famous psychotherapy research project (Kernberg et al.1972). The basic distinctions that guided that research were between psychoanalysis, exploratory or expressive psychotherapy, and supportive psychotherapy. What unified these different treatment modalities was the acceptance that psychoanalysis involves a broad range of knowledge about mental functioning, mental development, and pathogenesis. This knowledge should guide different treatment approaches based on the organization of the patient’s mind. Each of these approaches involved a different type of therapeutic action while maintaining the same unified model of mental functioning, development, and pathogenesis.
Where Jaffe goes beyond Gill and other Menninger-affiliated analysts like Wallerstein and Kernberg is his expansion of the types of therapeutic action to include six. This greater inclusiveness allows him to consider types of psychotherapy beyond the exploratory and supportive. “Freud wrote about six such basic modes of psychotherapeutic action,” Jaffe writes, “and even though at different times he emphasized one mode of therapeutic action over others, each mode he formulated still identifies a means to real therapeutic gain. In fact, cognitive-behavioral therapy, behavioral psychotherapies, and supportive psychotherapies, as well as psychoanalytic treatments and exploratory psychotherapies, rely on the same modes of therapeutic action that Freud identitfied a century ago” (p. 574). With this, Jaffe makes psychoanalysis not only relevant but crucial to mental health professionals of all persuasions.
This expansion of psychoanalytic thinking, so that it becomes central to and unifying of most mental health treatments, offers a crucial pedagogical tool. This plenary and the book from which it derives (Jaffe 2014) should be staples in mental health graduate programs, psychiatric residencies, advanced psychotherapy training programs, and perhaps psychoanalytic training programs. This last recommendation may be controversial, as there are some who believe that psychoanalytic education should focus exclusively on what they regard as the “gold standard” of clinical psychoanalysis. Many others, however, would point to surveys indicating that most trained psychoanalysts do more psychotherapy than psychoanalysis in their careers. Given that reality, it seems reasonable to suggest that analytic candidates be helped to think critically about whom and how they treat with different modalities. Jaffe’s ideas offer a valuable way to promote such critical thinking. Generally, the disagreement about how to differentiate psychoanalysis from psychoanalytic psychotherapy revolves around whether to view the modalities as qualitatively different or to regard them as on a continuum. Those who see them as qualitatively different suggest that analytic process occurs in a psychoanalysis that is a distinct modality, and that it is difficult or even impossible, because of a reduced frequency of sessions, to develop such a process in psychotherapy. By contrast, the continuum perspective argues that both modalities involve the same phenomena (transference, resistance, etc.) and that they simply occur in different proportions.
Still others differentiate psychoanalysis from psychotherapy based on external criteria such as frequency of sessions or use of the couch. This sort of distinction can be seen most recently in those espousing transference-focused psychotherapy (Caligor et al. 2018; Yeomans, Clarkin, and Kernberg 2015). Another contemporary approach is to differentiate psychotherapy emphasizing the promotion of mentalization from psychoanalysis (Allen, Fonagy, and Bateman 2008; Bateman and Fonagy 2006, 2016). These authors take care to qualitatively distinguish the therapeutic action in psychoanalysis from that in mentalization-based psychotherapy. “In this respect, the overall approach pursued in the program is a reversal of the classic psychoanalytic interventions. Psychoanalysis opens paths to the experiences of repudiated affect. In contrast, helping patients who are prone to inhibiting mentalizing in the face of threatening internal cues requires that they learn to use their ideational capacity to modulate their emotional experience” (Bleiberg 2003, p. 219).
Jaffe’s ideas offer a more articulated way to differentiate the treatment modalities of psychoanalysis and psychotherapy while remaining clear that both are fundamentally psychoanalytic, based as they are on the body of psychoanalytic knowledge that began with Freud. Rather than have us rely on the complex but ephemeral concept of analytic process, a concept that has been difficult to operationalize, his ideas allow us to more concretely and simply differentiate treatments based on the primary modes of therapeutic action they employ. Teaching candidates to think about how they are working in terms of their implicit modes of therapeutic action would be a valuable contribution. It also has the potential to sidestep arguments, all too familiar, over whether a control case has achieved a psychoanalytic process and can therefore count toward graduation; instead, we can teach candidates to think more critically about their work. Here again we see Jaffe’s emphasis on the practical over the theoretical. Like Wallerstein (1990), he sees common ground occurring more in concrete clinical work than in abstract, conceptual debates.
Is there one psychoanalytic theory? What must it include?
Given his emphasis on the tangible, one might indeed wonder how much he also agrees with Rangell’s emphasis on an integrative theory (2008). After all, Rangell (2004) is unequivocal about there being but one theory: In the ongoing debate over “one theory or many,” I favor one total, composite psychoanalytic theory, unified and cumulative: total because it contains all nonexpendable elements, composite because it is a blend of the old and all valid new concepts and discoveries, and psychoanalytic as fulfilling the criteria for what is psychoanalytic. . . . Under its embracing umbrella coexist drives and defense; id, ego, and superego; self and object; the intrapsychic and the interpersonal; the internal and external worlds. . . . I have said in many papers that I am an id-ego-superego-internal-external-psychoanalyst-psychosynthesist—“synthesis” because the purpose of psychoanalysis is not only to tease apart but also to put together [pp. 237–238].
In fact, Jaffe does make clear his agreement with Rangell in the last sentence of his paper: “Either way, it is important that psychoanalysts avoid ‘straw man’ distinctions that needlessly fragment and weaken the voice of the profession” (p. 591). Despite his interest in the common ground of technique, Jaffe clearly views a unified theory as equally important.
What would jaffe’s ideal of an integrated theoretical model look like?
At this point, I would like to take up the challenge of articulating what such a unified theory might contain. Jaffe offers a jumping-off point when he says that Freud’s approach was to create different theories of the mind that provided different bases for understanding psychopathology. He also mentions that sometimes these new models of the mind offered a different view of treatment and therapeutic action. It seems to me, then, that Jaffe’s ideas lead to the conclusion that a unified psychoanalytic theory must encompass a model of the mind that includes all the facets of mental functioning discovered by Freud, as well as those discovered by subsequent generations of analysts. In general, these various facets have been discovered through the psychoanalytic process—aspects like unconscious mental contents and processes, primary and secondary processes, defenses, the superego, the representational world, part objects, intersubjectivity, and so on. But it is important to realize that some important psychoanalytic mental phenomena have been discovered via the enrichment of psychoanalytic thinking by related disciplines. For example, ego psychological concepts like primary autonomy, adaptation, and an undifferentiated id-ego matrix were brought to psychoanalysis from cognitive psychology (Hartmann 1964). Realization of the importance of narrative (Spence 1982) and hermeneutics (Schafer 1976) have come from philosophy (Ricoeur 1977). Even clinically derived concepts like the representational world and intersubjectivity have been elaborated and enriched by infant research (Sander 2008; Fonagy 2001; Tronick 2007). Regardless of sources (within or without psychoanalysis), a unified psychoanalytic theory must involve an overall model of the mind and its workings that integrates all these facets and the sources of data from which they come. Saying that it should include all these things is not sufficient, however. It is crucial to describe their interaction and organization. I suggest that it seems most reasonable to assume that this organization is a hierarchical one so that certain mental phenomena are subordinate to others in a dynamic fashion (Wilson and Gedo 1993). These days we tend to assume that this hierarchical structure is not a strictly linear one (Galatzer-Levy 2017).
A Model of Pathogenesis
In addition, there are certain components that are necessary for an ultimately unifying psychoanalytic theory. As Jaffe notes, Freud always included a model of pathogenesis in his various theories. To be sure, the model shifted as he first emphasized the etiological importance of childhood seduction and trauma only to supplement it with the role of infantile sexual fantasies and their repression. Later he added the importance of internalized object relations, most notably via the formation of the superego and its moral injunctions and aspirational ideals. Analysts since Freud have always included a model of pathogenesis in their attempts at amending or overthrowing the hegemonic analytic theory of the mind. Thus, it is crucial that our eventual integrated theory be able to explain how mental functioning goes awry.
A Model of Therapeutic (Mutative) Action
Jaffe notes that some of Freud’s new theories of the mind modified his understanding of treatment and how it “cures.” I would suggest that every one of them did so. Abreaction was his model of therapeutic action during his affect/trauma stage of thinking (Sandler et al. 1997). As he pivoted to the importance of repressed infantile sexual fantasies during his topographic period, he understood therapeutic action to involve making the unconscious drive derivatives (mental contents) conscious. This model of therapeutic action informed generations of analysts into the 1980s. In fact, it remained implicit in so much thinking about therapeutic action that it became decried as a “developmental lag,” an interference in articulating and applying the technical implications of the structural model that superseded topography (Busch 1995; Gray 1994). Nonetheless, a structural model of therapeutic action evolved, and technique changed in important ways. This different model of therapeutic action involved the ego expanding its control and mastery over the id. Doing so required the patient to become more aware of both his most central unconscious conflicts and their components (id contents, ego defenses, and superego injunctions and ideals at the very least). This process was described as either analyzing the maladaptive compromise formations to replace them with adaptive ones (Brenner 1976) or expanding the realm of the conscious ego (Busch 1995, 1999; Gray 1994) by helping the patient observe his intrapsychic activity. Subsequent additions to our current pluralistic state have all emphasized different models of therapeutic action. Hence it is clear that an ultimate unifying theory must include a model of therapeutic action.
A Model of Development
One more aspect should be included in this unifying psychoanalytic theory. It must have a model of development. Development is different from pathogenesis, though understanding it is essential for understanding pathogenesis. That is because psychoanalysis has generally assumed a continuum between normality and pathology. Unlike descriptive nosological systems, psychoanalysis does not see pathology as qualitatively different from normality. Instead, our assumption (not always made explicit) has been that psychopathology involves development gone awry. That is, we assume that something in the developmental process has occurred to interfere in the mind’s normative functioning. Thus, psychoanalysis can be thought of as correcting developmental mishaps to restore normative mental functioning. Hence, Anna Freud described the goal of child analysis as helping the child regain positive developmental momentum. Something similar has always been implicit in our understanding of what adult analysis accomplishes. Thus, Brenner has emphasized that analysis does not eliminate compromise formations. They are an inviolate fact of mental life. Instead, analysis strives to replace maladaptive compromise formations with adaptive ones. Or, to paraphrase Freud, we aim to replace neurotic misery with the misery of everyday life.
To think about how to do this, and how to decide when our patients have regained functioning that is developmentally normative, it is necessary that a psychoanalytic model of development be part of an overall unified psychoanalytic theory. Freud, of course, began with a simplified and minimal developmental theory with his emphasis on psychosexual development. His famous sequential stages of sexual development (oral, anal, phallic, oedipal) were elaborated by Abraham (1916, 1924a,b). Klein (1928, 1933, 1952a,b) added the importance of aggression to Freud’s emphasis on the libidinal. The advent of the structural model led psychoanalysts to study the development of its tripartite structures. Anna Freud (1963) eventually brought the concept of developmental lines to address the complexity of the factors that develop and interact. With the greater appreciation of the importance of object relations, separation-individuation was added to the developmental mix (Mahler, Pine, and Bergman 1975). Generally, psychoanalytic models of development have either debated or tried to integrate the relative roles of the environment, the internal world, and constitutional endowment.
Currently, most child and developmental psychoanalysts have adopted a nonlinear dynamic systems model of development because it best captures the psychoanalytic emphasis on the importance of development described by Gilmore and Meersand (2014), whose “approach is based on the premise that every individual at any given moment is a complex product of his or her endowment, developmental history, current circumstances, and relationships with key figures . . .” (p. 1). Thus, such a model is a key component of any overarching and unifying psychoanalytic theory of the mind.
Conclusion
Lee Jaffe’s plenary paper demonstrates and continues the emphasis on unifying psychoanalysis that was the guiding principle of his psychoanalytic career. The paper stands on its own as a theoretical contribution and as a teaching tool for all aspiring therapists, including psychoanalytic candidates. In and of themselves, these contributions are important. But a careful reading between the lines of his contribution reveals an even more important message. In essence, it can be viewed as an inspirational call to arms to help our field evolve beyond its current pluralistic position. He can be seen as standing with luminaries like Rangell and Wallerstein in urging our field to find a theoretical and technical common ground that unites instead of divides. My hope is that the schematic outline I have offered of what I think his goal of an integrated psychoanalytic theory would include might induce some among us to take on that goal and begin to develop the integrated theory so necessary for our field.
Footnotes
Training and Supervising Analyst and Supervising Child and Adolescent Analyst, San Diego Psychoanalytic Center; Clinical Professor of Psychiatry, University of California, San Diego.