Journal of Psychiatry and Psychology Research (ISSN:2640-6136)
Review Article
Bafflement and Ineffectuality in Apprentices: Indispensible Outcome of Evading Freud and Orthodox Psychoanalysis
Saeed Shoja Shafti*
Corresponding Author: Prof. Saeed Shoja Shafti, Professor of Psychiatry, University of Social Welfare and Rehabilitation Sciences (USWR), Razi Psychiatric Hospital, Postal Code: 18669-58891, P.O. Box: 18735-569,Tehran, Iran
Received: July 02, 2019; Accepted: July 25, 2019 Available Online: January 20, 2020
Citation: Shafti SS. (2020) Bafflement and Ineffectuality in Apprentices: Indispensible Outcome of Evading Freud and Orthodox Psychoanalysis. J Psychiatry Psychol Res, 3(1): 110-117.
Copyrights: ©2020 Shafti SS. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Status quo of psychoanalysis and similar insight-oriented techniques is not alike in different nations, due to a number of cultural, pedagogic or economic reasons.

Bypassing Freud and his methodology or failure to distinguish between his pragmatic hints and meta-psychological remarks has founded a big dilemma in the course of training or practicing clinical psychoanalysis and psychodynamic psychotherapy in developing societies. Methodical study, training and practice of psychoanalysis, as the highest level of psychodynamic approaches, is the only possible and effective way for supporting and promotion of psychodynamic perspectives and therapies. If not, there is no outcome except than bewilderment and fruitlessness in learners and approximately complete ignorance of this genuine exploratory technique and its substitution with more superficial psychotherapeutic approaches like cognitive therapy, behavior therapy and etc., which operate just at the conscious and subconscious levels of mind. Bio-psych-social approach in modern psychiatry cannot be attainable without sensible and clinical considering of ‘unconsciousness’. In this article, which is devoted primarily to developing cultures, a quantity of obstacles against training and development of applied (clinical) psychoanalysis and related procedures has been discussed briefly.

 

Keywords: Psychoanalysis, Psychodynamic psychotherapy, Developing societies, Developed societies, Core curriculum

Psychoanalysis is a theory of psychopathology and a treatment for mental disorders. Fifty years ago, this paradigm had great influence on the teaching and practice of psychiatry. But some believe that today, psychoanalysis has been marginalized and is struggling to survive in a hostile academic and clinical environment [1,2]. This raises the question as to whether the paradigm is still relevant in psychiatric science and practice. In a difficult climate for the theory and practice of psychoanalysis, several responses have emerged, either by attempting to bridge the gap with science or by redefining the field as lying outside of science. Thus, some analysts have supported revised paradigms, such as attachment theory, that are better supported by evidence [3]. Others have taken the view that Freud’s ideas concerning the unconscious mind are compatible with modern neuroscience [4]. Still others have moved in the opposite direction, arguing that it is sufficient to offer a coherent interpretation of psychological phenomena [5]. Since Sigmund Freud (1856-1939) formulated his first psychoanalytic theories about 100 years ago, there has been a rapid development in psychoanalytic theory and therapy, which is evident in central concepts in the four psychoanalytic "psychologies"--drive/ego psychology, object relations theory, self-psychology and interpersonal psychoanalysis. Basic concepts in psychoanalysis have been under a continuous critical review, and psychoanalytic theories remain versatile. The unconscious and the exploration of subjective experience are central common themes. For many analysts, the role of the psychoanalyst has changed from expert to explorer, working together with the patient. At the same time, the analyst has become more active in the therapy room. Also, the analyst's contribution to what is happening between the analyst and the patient has been increasingly emphasized. The development in psycho-analysis has paralleled both developments in the theory of knowledge as well as the change in cultural trends. Creating meaning is central to the psychoanalytic process, but there are divergent views as to how this happens: by articulating meaning, by uncovering meaning, by constructing or deconstructing meaning [6]. Modern medicine and psychiatry expect all forms of therapy to be supported by evidence [7]. While Fonagy [8], a psychoanalyst who is also a respected researcher, has acknowledged that the evidence base for psychoanalytic therapy remains thin. The German psychoanalyst Leichsenring [9] has published meta-analyses of extended forms of psychoanalytic treatment, claiming that there is sufficient evidence to support this treatment in complex mental disorders and other recent reviews of this literature have made a similar argument [10]. Today’s there is an inclination for development of psychoanalytic theory based on data derived from empirical studies other than clinical case study. Particularly noteworthy is the convergence that followed between neuroscience and psychoanalysis and the rise of the so-called neuro-psychoanalysis.

Consequently, this led to eject empirical hypotheses and begin research on defense mechanisms, self, memory, dreams, empathy, dynamic unconscious and emotional-motivational processes (theory of drives). Currently neuro-psychoanalysis constituted itself as a discipline contained in itself three separate areas: the psychodynamic neuroscience, clinical neuro-psychoanalysis and theory building. For example, the theory of Panksepp [4,11] emotional systems is an example of an integrated neurobiology of affect, behavioral biology, evolutionary psychology and psychoanalysis. In this regard, the theory of emotional systems includes the description of the SEEKING system representing basic motivational system of the organism. Apart from a new perspective on the theory of drives described by Sigmund Freud, it offers the possibility to take into account the emotional and motivational systems within the understanding of mental disorders such as depression, addiction and psychosis, which is the core of psychoanalytic thinking [11]. As an extra example, while bio-imaging studies indicate that during REM sleep there is activation of the pons, the amygdala bilaterally, and the anterior cingulate cortex and deactivation of the posterior cingulate cortex and the prefrontal cortex and the images suggest there is a neuroanatomical frame within which dreams can be generated and then forgotten, psychoanalysis studies the dream from a completely different angle. Freud believed it was the expression of hallucinatory satisfaction of repressed desires. Today it is interpreted as the expression of a representation of the transference in the session. At the same time, it also has symbol-generating functions which provide an outlet by which affective experiences and fantasies and defenses stored as parts of an unrepressed unconscious in the implicit memory can be represented in pictorial terms, then thought and rendered verbally. From the psychoanalytical point of view, the dream transcends neurobiological knowledge and looks like a process of internal activation that is only apparently chaotic, but is actually rich in meanings, arising from the person’s affective and emotional history [12]. Another attempt to reconcile psychoanalysis with science has come from the literature on neuroplasticity [13]. It is now known that neurogenesis occurs in some brain regions (particularly the hippocampus) during adulthood and that neural connections undergo modification in all parts of the brain. There is also evidence that CBT can produce brain changes that are visible using imaging [14]. These findings have not been confirmed in psychoanalytic therapies. However, Doidge [15], a Canadian psychoanalyst, has argued that psychoanalysis can change the brain. This may be the case for all psychotherapies. However, more recently, Doidge [15] has claimed that mental exercises can reverse the course of severe neurological and psychiatric problems, including chronic pain, stroke, multiple sclerosis, Parkinson’s disease, and autism. In 2009, the British Journal of Psychiatry published a debate about whether the journal should accept psychoanalytic case reports [16]. The debate pitted a biologist, Wolpert, against a psychoanalyst-researcher, Fonagy [16]. Wolpert argued that psychoanalytic case reports should be excluded because they are in no way scientific. Fonagy, while conceding some of his opponent’s points, defended analysis by pointing out that research is possible and is now beginning to be conducted. But while Fonagy himself is committed to empiricism, he represents a very small minority in a field that lacks that commitment. Unfortunately, the modern revisions of psychoanalysis do not offer a coherent response to critics. It is difficult to see how any of the current responses to criticism can save psychoanalysis from a continued and lingering decline. Analysis has separated itself from psychiatry and psychology by teaching its method in stand-alone institutes. The field may only survive if it is prepared to dismantle its structure as a separate discipline and rejoin academia and clinical science. Whatever its limitations, psychoanalysis left an important legacy to psychiatry. It taught a generation of psychiatrists how to understand life histories and to listen attentively to what patients say. In an era dominated by neuroscience, diagnostic checklists, and psychopharmacology, we need to find a way to retain psychotherapy, whose basic concepts can be traced back to the work of Freud, as part of psychiatry [1,17].

ANALYTIC TRAINING BASED ON CLINICAL EXPERIENCE AND PERSONAL THERAPY

The degree to which clinical experience is a significant factor in predicting positive psychotherapeutic outcomes is an open question. Empirical studies comparing experienced and beginning practitioners on differences in client outcomes have yielded mixed results. While multiple sources have indicated that trainees are generally effective therapists, few of these studies have examined the effectiveness of graduate-level therapists in a psychodynamic training program. In a study, conducted in the United States, the researcher used a practice-based research approach to examine the outcomes of clients working with trainees at a community mental health clinic in the northeast United States. The theoretical orientation identified by the clinic and training program was psychodynamic with an interpersonal and/or relational emphasis. Results indicated that clients working with trainees at that clinic demonstrated improvement across several indicators of symptoms and psychosocial functioning over the time they received treatment [18]. For investigating psychodynamic psychotherapists’ experience of the influence of personal therapy on professional growth during training with a focus on the acquisition of knowledge and the development of psychotherapeutic skills, thematic analysis was conducted on interviews with former students (N=10) at two training institutes for psychoanalytic psychotherapy. The resulting theme “professional subjectivity” indicated that personal therapy was experienced as having a positive effect on learning and growth of professional skill by facilitating the development of a theory- and knowledge-based professional subjectivity, a personally founded, professional attitude. Important elements of this development were “shared experience,” “personal influence” and “knowledge integration.” The emergence of professional subjectivity proved to be an important factor in terms of professional advancement for future psychotherapists. Finding and relating to their own subjectivity was crucial in the process of developing a personally founded, professional attitude in the clinical work [19]. While challenging Freud and his ideas by modern-day therapists may be attractive for some intellectuals, according to a study while inter-subjective analysts often adopts an antagonistic and innovative stance towards Freud with respect to major issues such as the analyst's role in the psychoanalytic process, neutrality, technique and self-disclosure, by taking into account the different aspects of his theories that deal with the influence of the analyst on the analytic process, in terms both of his 'defects' and of his individuality in general, more resemblance than antagonism is palpable. In opposition to the 'myth of the isolated mind' attributed to Freud, he had emphasized in his writings the structuring function of the object and the influence of various groups on the individual. It must be noticed that, cultural and social factors can influence the development of different viewpoints of psychoanalysis in various civilizations [20]. For example, Cohen believes that while psychoanalytic theory has generally avoided religious beliefs and such viewpoint has resulted in a neglect of religion on the part of psychoanalysts, religious beliefs should be included in psychotherapy because they can become involved in transference and countertransference issues in ways that are ignored if religious issues are not discussed in therapy [21].

 

TEACHING APPROACHES IN DEVELOPING CULTURES

Psychoanalysis and its modified versions like psychodynamic psychotherapy constitute important components of modern psychotherapy. Psychodynamic theories stress that early childhood experiences are crucial in shaping the personality. In psychodynamic approaches unconscious conflicts are explored and the insight gained aims to change patients’ maladaptive behavior. The main goals of such kind of psychotherapies are symptom relief and personality modification through exploration of the unconscious. So, the relationship between the therapist and patient is crucially important. Therapies can be offered on an individual, couple, group and therapeutic residential community basis. Psychodynamic psychotherapy has been shown to be a highly efficacious treatment in a range of psychological disorders but patient selection for therapy is important, with consideration of psychological mindedness and a concern with the antecedents as well as the relational contexts of the presenting problem being key [22].

Generally, for trainees in psychiatry, an understanding of psychological therapies is important for many reasons. Early exposure to psychotherapy is important for trainees to decide whether they want to specialize in this field. For psychiatrists who do not go on to specialize in psychotherapy, experience of this area also represents an essential part of their training. For all psychiatrists there is likely to be a psychological component to the presentations of most patients seen in mental health services, and for some there will be significant transference and counter-transference reactions. To care for these patients, doctors will need to be able to understand and deal with these factors appropriately. Psychodynamic factors are also important in many interactions within mental health teams, both community- and ward-based. Doctors who can perceive these, and adapt to them, will make better leaders within these teams. Another relevant factor relates to appropriate referrals for psychological therapies. One model of psychological therapy does not fit every problem, or every patient. Psychiatrists will frequently be responsible for assessing and diagnosing a patient and deciding on a course of treatment, which may be biological, psychological or both. To assess and refer appropriately the treating psychiatrist must understand the indications for a particular therapy and be able to have an idea of its likely success in a particular patient. But training in psychotherapy is likely to be more consuming of resources than other areas of postgraduate study in psychiatry. For example, an area such as psychopharmacology can be learnt in a more self-directed way, relying mainly on written information, whereas the main activity of psychotherapy training is seeing patients, and being supervised in their treatment. With the financial challenges of recent times, mental health services as a whole are likely to be asked to make significant cuts to services. Psychotherapy, particularly longer models, may be a target for reduced services, leading to a further restriction in the availability of training [23]. Psychoanalysis, as second historical revolution in psychiatry, first systematic psychotherapeutic approach, and an essential exploratory tool for study of deeply rooted unconscious mental processes plays a key role. But in spite of its central position among different styles of psychotherapy, its situation as training curriculum is not the same in developed and developing societies, due to a number of clashes between its various theoretical aspects and usual cultural ideals. Some aspects of this topic have been discussed previously in another article regarding process of appearance and progression of psychoanalysis in Iran, as a prototypical developing society in the region [24]. For sure, such a historical process could have more or less similar characteristics and/or problems around the world, particularly with respect to conservative societies. The aforesaid clashes are based on a mixture of valid and non-valid believes, hold by superintendents and/or psychotherapists. The justifiable part of this challenge involves the necessity of special kind of setting, lack of suitable supervision or qualified supervisors, troubles regarding monetary issues and financial assistance or coverage by insurance companies, and above all, lack of qualified institutes for training skillful analysts. The mistaken part of that clash is based mainly on misinterpretation or distorted inference of psychoanalytic theories or overindulgence in them without any experimental or practical proof or perspective. The end result of such a disturbing circle could be nothing except than general ignorance of this deeply investigative method and replacing it with more superficial individual psychotherapeutic methods like Cognitive therapy, behavior therapy and etc., which basically never penetrate so deep into the mental strata and act only at conscious and subconscious levels. While psychoanalysis probe absolutely in the district of unconsciousness, with numerous swinging in the midst of conscious and subconscious levels, all of the other methods starting from conscious layer and reside constantly there or operate maximally at the subconscious level of mind. For a therapist who believes in unconscious processes this means nothing than obvious shortcoming of therapeutic intervention in instances where deep analytical method is mandatory. Although some believe that long-established cultural values or slow psycho-social stage of development may play an important role against progression of psychoanalysis in developing societies, it cannot be ignored that wrong or distorted understanding of the matter is not an unimportant subject (Table 1). Why such a wrong comprehension is common among psychotherapists of developing societies? It seems to be rather due to deviation from fundamental literature and particularly circumnavigating Freud’s basic and pragmatic writings. Psychoanalysis had been introduced to the world by ‘studies on hysteria (1985)’, valuable work of Freud and Breuer [25] and then in around two decades extended overseas up to America. The aforesaid book with a clear medical aspect for treatment of psychoneuroses (hysteria, phobia and obsession), though apparently dated, is still the opening point of teaching and practicing analysis, and this is the same as regards other practical works of Freud as well [26-33]. Touching and probing unconsciousness is not practicable without methodical exploration and interpretation of associations on coach, and such a skill is not attainable without resorting to original works. An enthusiastic psychotherapist must be able to differentiate between what may enhance potentiality for interpretation and construction and what that may just increase reader’s psychological knowledge. So, the first task of every psychotherapist is broadening his or her personal insight. Slow-moving and unmethodical progression of clinical psychoanalysis and its modified versions in conservative societies’ scholastic centers, in spite of availability of necessary resources, shows that simple knowledge or resource is not enough for founding a method. In an unsuccessful forced training program for persuading a small group of psychiatric residents for starting classical method of analysis, lack of enthusiasm and venture were more apparent than lack of setting and knowledge, while some of them had formerly educated additional hours of theoretical lessons in other academic centers and had stated frankly their inclination for performing analysis. Exaggerated interest to theoretical aspects of psychoanalysis, instead of its pragmatic aspects, could demonstrate an inaccurate understanding of the subject by them. This state of affairs proves once more that wishing and knowledge are not equivalent to capability and talent, and motivation is something different from enthusiasm. Showing a sufficient amount of endeavor for performing a job, adequate curiosity for complete study of known and available references [34-39] or prominent interest for clinical evaluation of its effectiveness can reflect interior passion of trainees. Moreover, their expressed inclination to applied psychoanalysis was not easily differentiable from other methods of psychotherapy. Additionally, many of them were not aware of the historical importance of original works of Freud, which have changed forever the direction of behavioral science in the last century. Likewise, disregard to appropriateness of setting and program, it seems that maybe inappropriateness of cultural values of trainers or trainees can impact adversely the entire training sequence, because it can play role unconsciously as tough internal obstacle against proper deduction and judgment. This shows that untimely training, as like as unsystematic approach, may not attain the desired goals. It is understandable that how a psychiatric resident may become easily confused in facing with a large number of psychotherapeutic methods during the educational curriculum. So it takes time for him or her to become familiar with all of them and to choose among them the technique which is best fitting with the participant’s character and objectives, a hope that, however, may never be fulfilled in numerous cases [40-43]. So, acquiring knowledge regarding different styles of psychotherapy during collegiate era possibly will conserve time and energy in post-graduation years. In addition, there are a number of crucial dissimilarities between psychotherapy and psycho-pharmacotherapy, including speed of response, intervening variables regarding therapist’s personality or cultural background and patient’s motivation or conformity, which may altogether stop absolutely psychiatric resident or graduated psychiatrist from perusing psychotherapy throughout his or her profession. While in developed societies such a dilemma has been compensated mainly by other experts in the sphere of mental health, such a solution does not seem to be achievable easily in developing societies, since their position in this regard has not been effectively recognized. Besides, their training is not independent from general educational policies of their society. On the other hand, since practicing psychotherapy in developed societies, as a basic therapeutic instrument, was widespread before emergence of psycho-pharmacotherapy, so existence of some promoting socio-cultural aspects in this regard in that societies is plausible. But such an advantage in developing societies that want to promote psychotherapy, years after practicing psycho-pharmacotherapy, is not as easy as the developed ones, especially with respect to the abovementioned different speed of achievement between these dissimilar methods. It must not be ignored that practicing psychotherapy, firstly must be acknowledged by psychiatrist as something comparable to a full job, not an overtime task or option, and secondly demands additional insight for accounting of unconscious aspect of morbidity plus its phenomenological aspect. So, modification of clinical perspective of learners, as well, is very important, if educational system really wants to promote deep psychotherapeutic methods in training curriculum. Moreover, non-compulsory feature of psychotherapy, in opposite to obligatory aspect of psycho-pharmacotherapy in medical practice is an important reason against its development. Decreasing rate of practice of psychotherapy by psychiatrist in developed societies also can be dissuading for interested therapists in developing countries. According to Chisolm [44] from department of psychiatry and behavioral sciences of Johns Hopkins University School of Medicine, while psychotherapy has long been an integral treatment modality for patients with psychiatric conditions, recent evidence suggests that the practice of psychotherapy by psychiatrists has greatly diminished. Certainly this condition is not in harmony with the academic aspiration of integrating psychotherapy with pharmacotherapy in training curriculums of medical schools, particularly in developing countries. Amid this, psychoanalysis has the most defenselessness. Flawed academic curriculums and lack of appropriate setting or qualified supervisor for teaching psychoanalysis or psychoanalytic psychotherapy to psychiatric residents or zealous graduated psychiatrist or other capable psychotherapists, alongside lack of official psychoanalytic association, institute and psychotherapy departments in the school system are amongst the major impediments in developing countries that prevent promotion of applied or clinical psychoanalysis and psychodynamic psychotherapy among talented psychotherapists, including psychiatrists. The only factor that can overcome such unwanted impediments is the passionate of insightful therapists. If a therapist knows what to do and how to handle the process of analysis, then neither of the abovementioned personal or social barriers can prohibit him or her from probing unconsciousness. If the list of references configures according to the historical process of development of psychoanalysis, then no misrepresentation or distorted assertion may devastate his or her enthusiasm.

CONCLUSION

Bypassing Freud and his methodology, or failure to distinguish between his pragmatic hints and meta-psychological remarks has founded a big dilemma in the course of training or practicing clinical psychoanalysis and psychodynamic psychotherapy in developing and traditional societies. If such a trouble does not resolve wisely, then the progression of psychoanalysis and its modified versions will not succeed smoothly, in spite of its historical and vital position in the realm of psychotherapy and its logical and practical independence from public ethics. Methodical study, training and practice of psychoanalysis, as the highest level of psychodynamic approaches, is the only possible and effective way for supporting and promotion of psychodynamic perspective in conservative societies. Ignorance of genuine and pragmatic literatures, based on any kind of reason or motivation, may not have any outcome except than divergence from true pathway and ending into bewilderment and fruitlessness in learners. Bio-psych-social approach in modern psychiatry cannot be attainable without sensible and clinical considering of ‘unconsciousness’.

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