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Conundrums: Approaches to Psychoanalysis

Current Controversies in Psychoanalytic Psychology

Jon Mills, PhD, PsyD, ABPP, a prominent philosopher, author, psychologist and psychoanalyst, has written an important new book about controversies within psychoanalysisConundrums: A Critique of Contemporary Psychoanalysis offers a thoughtful discussion of the benefits and limitations of contemporary psychoanalysis, as well as how politics in the field may keep us from thinking about how we can better communicate to the public (and each other) about what psychoanalytic therapies can offer.  

I interviewed Dr. Mills about some of the topics covered in his book, as well as some common sense advice for patients who may be curious about whether a psychoanalytic approach is right for them. If you have an interest in psychoanalytic ideas, this interview is not to be missed! 

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TMG: Your new book, Conundrums: A Critique of Contemporary Psychoanalysis, addresses positive and negative aspects of newer approaches to psychoanalysis. Much of the public, however, is not aware that psychoanalysts have a variety of approaches and ways of thinking about human suffering. Can you tell us the difference between relational theories and more traditional approaches?

JM: The public is probably not aware that psychoanalysis has had a face-lift for some time. People no longer want to be merely analyzed, where an expert authority figure tells you what is wrong with your mind, and through a close examination of your internal thoughts and contents via dream interpretation you can achieve an existence relatively free of suffering. Today the modern analyst is a psychotherapist with a humanistic sensibility, that is, relating to you like you are a human being rather than a scientific object, and being attuned to the unique dynamics that make up the whole person. Although it is misleading to make broad generalizations about different approaches in the field, for our purposes, it is really a matter of emphasis. More traditional approaches focus on understanding internal conflict derived from our frustrated wishes and fantasies, while more contemporary approaches, broadly conceived, emphasize how we relate to other people and how our relationships with others (past and present) form the nucleus of our personalities and current psychological difficulties.

TMG: How does a prospective patient know what kind of psychoanalytic treatment is right for them?

JM: Most consumers today do their research. This may equally apply to psychoanalytic treatment. There are multiple theories and methods that inform any psychoanalytic practitioner, and it is fair to say that each therapist is as unique as each patient. So my recommendation is to seek out a therapist where you feel there is a good fit. This is much more important than one's theoretical orientation. Do you feel you can trust this person? Can you be open and honest without fear or judgment? Do you feel interpersonally safe? Do you feel cared about? These are some of the qualities that go a long way to preparing the soil for doing meaningful therapeutic work.

TMG: One of the many important topics that you cover in the book has to do with therapist self-disclosure. Can you suggest some guidelines for patients regarding how to know if their therapist is talking about themselves too much?

JM: The first question a patient should ask is whether they find it (disclosure) helpful. Or are they uncomfortable, annoyed, burdened, etc. by their therapist's verbalizations about their life or personal opinions? This is usually a good sign that the therapist is disclosing too much and is interfering with the person's own process. Any therapist who gives direct advice on what to do without exploring its implications, who tells personal details about their own private lives, who is quick to discuss their own vulnerable feelings, and especially anyone who volunteers their own psychological conflicts and past struggles (such as, "I had a traumatic childhood too, so I can understand what you're going through," or "I was in an abusive relationship," or "I had problems with anxiety in the past and this is what helped me," etc.)-these are things to watch out for. Excessive self-disclosure is a signal that the therapist has problems with boundaries and in containing their own anxieties in the treatment.

TMG: Psychoanalytic clinicians have a long history fighting amongst themselves regarding theoretical arguments that make little sense to patients just trying to find a good therapist. Why do you think some in the analytic community argue so much?

JM: Analysts are people too. They have their own competitive strivings, professional identities, group identifications, aggressions, narcissistic vulnerabilities, and emotional prejudices just like anyone else. In-fighting is also based on personal passions, self-interest and ambition, intellectual debate, and, above all else, politics.

TMG: What do you think psychoanalysts need to do to reach out to the public?

JM: They need to become more visible in the public eye as a thoughtful alternative to vogue approaches in psychology that offer a pedestrian theory and treatment usually influenced by a quick fix mentality. The public is often not aware that psychoanalysis is the most sophisticated psychological theory in the history of psychology that explains all aspects of human nature and mental functioning. By definition, it is complex; and it is not always easy to make it accessible to a lay audience. That is why analytic clinicians of all kinds-from psychologists, medical doctors, social workers, master level therapists and the like-need to be more vocal about what they have to offer the public. They need to be willing to talk to the public in a down-to-earth manner that connects people to what they are truly looking for but unable to find with other modalities. There needs to be a willingness to engage other professionals, challenge simplistic notions of treatment and cure, dialogue with other academics, scientists, professional organizations, advocacy groups, and political bodies, and take a grass-roots approach to appealing to people's needs. It is important to write for the popular press, give public lectures, do interviews for papers, magazines, radio and television programs, and educate the public about its contributions and values. The bottom line is: Does it bake bread? I would argue it does. Psychoanalytic and psychodynamic perspectives to treatment take a person deeper into themselves in order to expose them to the truth of their inner being and potential for fulfilling their possibilities. Other approaches to treatment often do not because they only get at surface thoughts and behavior. Psychoanalysis gives the person an opportunity to truly understand their multiple inner motivations and contradictory needs that often are responsible for their conflicts and maladjustment. This is much more beneficial than popular methods of treatment, such as cognitive behavioral therapy (CBT), which espouses the simplistic belief that ‘you feel the way you think,' or that all you have to do is change your habits and behavior and you will be happy. It simply does not work that way. That approach is merely placing a band aid on a wound without suturing it up. In other words, it does not get to the root cause of what is creating a person's suffering to begin with. Psychoanalysis allows a person to get at the cause, understanding its motivations and impediments, and then allowing those unconscious (subliminal) processes to have a voice, which transforms unarticulated misery and clinical symptoms into new modes of being that are healthier. And this therapeutic approach is more likely to lead to lasting change than the superficial methods that target symptom relief rather than what is causing the symptoms.

TMG: Do you think psychoanalysis has earned its relatively negative reputation as being unhelpful and outdated?

JM: I suppose this depends upon what we mean by psychoanalysis and whom you consult. If psychoanalysis is characterized by 5 times a week treatment on the couch by a silent, withholding European white male who emits interpretations like a pez-dispenser about why you wanted to kill your father and marry your mother, then I would say it has earned this reputation. Because most people cannot afford this luxury, either financially or practically, many of us who see patients analytically do so in our regular psychotherapy practices, and instead of focusing on esoteric Freudian theory, we attempt to address what is most important to a person so they can lead a more fulfilling life. And this is entirely dependent on the unique nature of the therapist-patient relationship.

TMG: One of the more complicated but important ideas you allude to in Conundrums has to do with the idea of countertransference enactment. Can you break down the basic ideas of this concept and tell us how enactments may hurt or help patients in long-term analytic treatment?

JM: Just like clients who have strong emotional reactions to others in their real life (as well as their therapists) that they transfer onto them based upon what others said or did to them in the past, therapists can act out their own inner conflicts and anxieties without being fully aware that they are doing so in the therapy. This is what we mean by countertransference; and they take enumerable forms. Uninhibited therapist self-disclosure is a good example of this, but saying or doing something unintentional that has unanticipated repercussions is an often more subtle enactment affecting the treatment. For example, one contemporary relational analyst, wrote publically about how she confessed her sexual desire for her patient in the session. This is a palpable example of a countertransference enactment that can be harmful for any patient to hear. But sometimes therapists can act in a way that may be risky or deemed inappropriate, yet it has a positive and helpful outcome in the end. For example, I was recently told by my patient that when she conveyed the news that she was diagnosed with cancer and needed to undergo chemotherapy, I told her I would like to visit her in the hospital during this time so she had my support. The mere fact that I said this spontaneously was deeply meaningful to her despite the fact that many of my colleagues would deem this to be a countertransference enactment.

TMG: Why do you think that psychoanalytic approaches are more helpful than other forms of therapy?

JM: As I said earlier, psychoanalytic approaches often go deeper in exploring the crux of patients' problems, thus unraveling the root cause of conflicts and allowing people to have insight into what motivates and compels them to think and act the way they do. Most contemporary approaches to therapy are brief, solution focused, and examine superficial thoughts and behavior without understanding why a person thinks, feels, and acts a certain way. They are geared toward rapid symptom relief without addressing the cause of the symptoms. In contrast, psychodynamic perspectives are more thorough and holistic, concerned more with getting at repetitive dysfunctional patterns fueled by unconscious conflicts that do not abate with surface treatment methods. That is why analytic therapy is typically longer in duration and geared toward providing not merely symptom relief, but permanent change in one's feelings, attitudes, and life perspectives that transcend the shackles of the past for the freedom of living one's life more satisfactorily in the present.

To read more about Conundrums, including how to buy the book, click here! 

Follow me on Twitter @TMcGreenberg!

Tamara McClintock Greenberg, Psy.D., M.S., is an Associate Clinical Professor of Psychiatry at the University of California, San Francisco.

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