The Impossible Formation
Todd Dean, MD
The incompatibility of psychoanalysis and the knowledge economy is elucidated in this personal essay.
So what is left to do? That is how the song
Amiri Baraka (2015, p. 520)
Looking for something else, I came on a notebook I had started almost 20 years ago, early in my second year of formal training at the local American psychoanalytic institute. I immediately wished it had stayed lost.
The first entry: “I am convinced that the biggest job of psychotherapy, at least for the first few years, is making sure everything proceeds reasonably: plans for missed sessions, how payment will be arranged, etc. — all are clearly understood. Not figuring things out, especially at a ‘deep’ level, but observing details, is what has to be done.” Next: “What I most fear — an ‘as-if’ analysis — the reason technique, not theory or development, is the central concern of classes.”
I was horrified when I saw these. To privilege technique over theory is something I would never do today, implying as it does that there is a way to do the work that is beyond theoretical elaboration — “atheoretical” actually, just like the DSM-III — the first version of the DSM to claim to be purely objective – was supposed to be. And to think that following that technique would spare me an “as-if” analysis? Please. Even worse is the first entry, the idea that “proceeding reasonably” — which apparently is a matter of working out rules for payment, mostly — will result in a more genuine analysis? Oh my.
What I do think – and what makes it feel not quite like rank exhibitionism to share these notes, what I hope these notes testify to — is that becoming an analyst is a wildly peculiar thing to do these days. In clinical psychoanalysis, at least as I conceive it, the work goes more and more to the specifics of this analysand working with this analyst. In such a situation, the notion of perfecting a technique or “proceeding reasonably” has to be suspect. The analogy that I cannot get away from, imperfect as it is, is with the writing of a poem. Every poem that is any good is somehow unique: one does not just apply the technique of a successful poem to come up with another successful poem, never mind “proceed reasonably.” Technique will be merely a test of the analyst’s — as it is of the poet’s — sincerity. In both composing a poem and in doing an analysis, all the different influences on the process — historical, political, unconscious, social — come together to make this one, unique act.
For these reasons, it is almost impossible to get one’s bearings in the process of becoming an analyst. Consider, as an example, the impact of the internet on analytic work. I am fairly certain that the ubiquitous presence of the internet has altered the relationship of the people I see to knowledge in profound ways since I jotted down the notes in that notebook. The internet gives knowledge, instantly. Consequently, everybody has answers. Rarely now, as opposed to when I started working, do patients present with a question, e.g., “Why do I react the way I do?” Instead, patients tell me what their problem is. Of course, they have also done research about me on the internet, and are now submitting the problem they know to my expertise. This is psychoanalysis in a knowledge economy.
“Knowledge” is the key point, here. By “knowledge” I mean the belief that all one needs to effect change is to know the correct information, something that can be readily communicated and acted upon by the newly enlightened. To suppose that imparting knowledge will be enough to resolve difficulties is an honest enough mistake: Freud admits to having made it early on, when he told his patient Irma, “if you are still having pain, it is really only your own fault” (Freud 1999, p. 86). “I was then of the opinion” he explains, “that my task did not go beyond informing my patients of the hidden meaning of their symptoms; whether or not they accepted this solution … was no longer my responsibility.” Today, however, the idea that knowledge is the source of change is ubiquitous in the world of mental health care, as almost everywhere else.
Contrast this with the situation when Freud began working. It was newly discovered that neuropathology followed specific patterns, patterns that did not match the findings in conversion hysteria. Thus, when Freud started out, there was a real question: why did Anna O. act that way? But that question, so central at the beginning of the work, is now almost never asked. People who have done enough “research” on the internet know more than the analyst every time — patients just need someone to tell them what to do about the problem they have already figured out. And the irony usually escapes them. Today it may be years before someone asks, “Why do I react the way I do?” This is just one example of what I mean by “the impossible formation”: how does one deal with that? Perhaps, then, I did find one positive note in that first entry of my stupid notebook, my suspicion of figuring things out, especially at a “deep” level. At least, the sophomore who wrote this was suspicious of the quagmire that is knowledge. I decided to keep reading.
I came by my skepticism of knowledge about mental health honestly, having begun my psychiatric training a mere six months before the commercial release of Prozac, at an institution that prided itself on its scientific bona fides, contributing both to the emphasis on biology in psychiatry and to the development of the DSM-III. Far from being atheoretical, this training was predicated on the belief that mental illness comprises a group of biological disturbances of mind — whatever that is (nobody having clarified exactly how mind and biology are connected, either then or now) — that could be meaningfully categorized by an enumeration of symptoms. When I started my training, everybody knew that academic psychiatry did not have all the answers, at least not yet, but we knew they would be coming soon. In fact, however, those answers never showed up. Instead, there arose an ever more sophisticated literature of conjectures in the field, all predicated on the assumption that, eventually, we would know. As an example of what I am describing, consider a recently published account of the developing understanding of mental illness and its treatment by a former president of the American Psychiatric Association, Jeffrey Lieberman, in his very readable story Shrinks: The Untold Story of Psychiatry (Lieberman 2015). This book was widely reviewed when first published, most favorably in the New York Times Book Review (Angier 2015), more skeptically in The Guardian (Appignanesi 2015) and The Wall Street Journal (Tavris 2015). To illustrate my point, I will focus on Lieberman’s discussion of Post-Traumatic Stress Disorder.
Lieberman addresses the phenomenon of PTSD in a narrative arc that he uses throughout his book. He starts by describing how horribly people were treated before the condition discussed was properly defined, DSM-III style, by scientists, then how poorly it was treated by early psychoanalysts, then how a statistically informed approach to diagnosis led to a more uniform picture of the problem, and finally how neuroscience allowed us to see the pathophysiological basis of the condition. At this point, per Lieberman, there is nothing more to say. This kind of knowledge is the final destination because it goes without saying that it will lead us to the only viable goal: symptom eradication and a return to a previous state of health, or symptomlessness — “health” and a lack of symptoms being synonymous. The important points for Lieberman are the factors viewed as “objective”: the symptoms, their relation to a particular traumatic event, and the brain mechanisms involved in the expression of those symptoms, all as understood by the scientists who choose what is important to study. But when it comes to particulars, here as throughout his book, nothing Lieberman says fits with his larger thesis. Thus, he does not address the question of whether a classical analytic treatment was effective: in his description it sounds ridiculous, some Freudian interrogating a soldier about his Oedipal conflicts. In the two clinical examples he gives — his own case and that of a patient — he has nothing to say about the fact that his symptoms appear to have been so mild as to have required no treatment at all, while his patient, after what appears to have been very extensive treatment, ended up as a severe alcoholic, completely isolated and unable to function. He likens his experience of dropping an air conditioner to his patient’s experience of losing his son in an accident, because both engaged “the dynamics of the amygdala-prefrontal cortex-hippocampus circuit” and consequently both he and his patient felt a lack of “cognitive control” (Lieberman, p. 269). There is no question, here, that the untimely death of one’s child and an accident while moving a window unit would be experienced in exactly the same way — after all, it’s the amygdala-prefrontal cortex-hippocampus circuit we are talking about, not personal experience! But an additional anecdote concerning Lieberman being robbed in his apartment at gunpoint raises a question, because he did not develop PTSD as a result of that experience. How did he feel in “cognitive control” when two strangers broke into his apartment and threatened to kill him if he did not give them money, but did not experience such control when he dropped the air conditioner? The explanation he gives — that he did not want the thugs to find his grandfather’s Patek Phillippe watch (p. 241) and so was able to override his fear enough to at least act as though he were in control of the situation — implies a capacity to master his reaction to a traumatic event in a way that allows him to maintain self-control (or, to override the dynamics of the amygdala-prefrontal cortex-hippocampus circuit). It seems to me that, if Lieberman’s description of overcoming a sense of powerlessness were valid, then there would be no reason for PTSD to happen at all: we would all just need to feel some sense of control in difficult situations. Reading his account, what occurred to me was that, in the story of the robbery, he was not personally responsible for the thugs breaking in, but, in the story of dropping the air conditioner, he did feel responsible for potentially harming anyone who might be in its path on the sidewalk. This suggests that his anxiety in the latter situation was the result of guilt rather than overwhelming trauma. But this would be bad for Lieberman’s argument, because PTSD as described in his book is a group of symptoms that is always produced in response to traumatic experience, without the influence of such factors as guilt or one’s feelings about losing a child, but simply a sense of a “loss of cognitive control”.
And that is precisely the problem. In his book, Lieberman completely ignores the fact that each traumatized person brings to her trauma ways of experiencing the world that were first learned in her childhood and that continue to influence the way she deals with every experience, including, unsurprisingly, the experience of massive trauma. In my own work with victims of genocide, I do not think I have ever encouraged anyone to talk about her childhood; however, every patient I have had, of whatever level of sophistication, at some point does just that. Childhood is where we learned a way of communicating with ourselves and others about the world as we experience it. There is no question that, in trying to wrap one’s mind around trauma, one would fall back on those formative experiences.
Bringing up the academic account of “PTSD” is not parenthetical; indeed, it gets to the heart of the problem I am describing. While the would-be analyst is floundering about trying to figure out what to do, the larger world of mental health care is completely dismissive of and oblivious to the problem. The mental health establishment theorizes pathology as it does for a reason: to view the psyche as a function of brain processes that are irrelevant to the world outside the brain, the “amygdala-prefrontal cortex-hippocampus circuit” and such, maximizes the use of medical technology while limiting psychological therapies to an advisory role, imparting knowledge, all based on the premise that restoring a state of symptomlessness is the goal. To even call this a medical model is, I would argue, wildly inaccurate: an emergency room that was devoted exclusively to eliminating symptoms would have an unacceptably high mortality rate in no time. Rather, this is a neoliberal model of psychopathology: it is completely focused on getting people back to the work force, with minimal complaining. A significant part of the impossibility of becoming an analyst is that this dynamic is insufficiently addressed in analytic formation programs; consequently, what we are trying to do in psychoanalysis is conflated with what one is trying to do in pharmacotherapy or behavioral treatment, that is, to get rid of symptoms and return patients to a (hypothetical) state of normality. My point is not to dismiss those modalities — it is not that there is no role for symptom removal in psychological health care, as in emergency rooms — it is simply to note that, when we do analysis, we are doing something very different from these so-called “evidence-based” treatments.
This “something different” starts with a radically different understanding of what a psychological symptom is. To be anxious or depressed or delusional (whatever else it is) is not simply a brain malfunction; rather, it is a way of engaging one’s world, unlike, say, a brain tumor or a coronary occlusion. This became empirically obvious to me when, working in low-fee clinics as a resident, I encountered women in abusive relationships who wanted to take antidepressants precisely in order to tolerate life with their abusive partners. They were fully aware that they were depressed, and why, but they could not afford to leave. Similarly, I was always struck by the ways in which many patients acted to maintain the very symptoms they were seeing a psychiatrist to get rid of, as when a war refugee who has horrible nightmares of bloody violence takes a job at a butcher shop, or a chronically suicidal person volunteers to work on a suicide hotline — both of which I have seen, among many other examples. In these cases, it is hard not to argue that there is something beyond the symptom as symptom that the sufferer is engaged with, a kind of “surplus value” of her pain, such that it cannot be treated as a straightforward problem, even if she never exhibits an awareness of the fact. It took me years to figure out that analysis and what gets called “evidence-based” treatments (an insult, really: am I not basing my argument on evidence?) are really doing completely different things.
To conclude, I would like to look at the impossibility of my title from a different angle. Yes, becoming an analyst is a never-ending, impossible task, a fact recognized by Freud and Ferenczi, Reik, Lacan, Laplanche, Bion, Loewald and Lawrence Friedman, even in JAPA, in a recent series of articles on the “Ethical Implications of the Analyst-as-Person” (JAPA 2016, 1153-1224). But then, so what? Speaking only for myself, the very reason I decided to study psychiatry rather than any other field in medical school was that it was the only field I felt certain I could never figure out — it was the one kind of medicine that, no matter what, I could never be bored by. It is not my fault that the psychiatric establishment chose to suppress that fact, so that the only honorable option available was psychoanalytic training — that is just what happened. This “impossibility” — really, just the impossibility of ever creating a mechanically reproducible analysis — is the ground on which we as analysts walk. In a world where such mastery is always expected, analysts stick out like a sore thumb, because such mastery is irrelevant to what they do. There’s no other way it could be.
At the end of my brief journal are two entries: “[A guest speaker] phrases the problem wrong: not ‘whose reality?’ but ‘what use is an expert when subjectivity is so important?’” Again, I wish I had had a clearer sense of where I would go with this. It would be a few years before I would come across Lacan’s concept of the sujet supposé savoir, the subject presumed to know/presumed subject of knowledge, where he addressed the problem of “whose reality” (Lacan 1973/1978, pp. 230-243), but at least I was dubious about experts. This note ends with a quote from the philosophy professor Louis Mackey: “Truth and reality are never more than the imagined terms of the nostalgia for a truth and reality never possessed. The greater art is the art that embraces this paradox” (Mackey 1997, p. 37). It is the greater psychological formulation of psychoanalysis as opposed to the DSM that embraces this paradox, too.
Psychoanalysis, by definition, is a practice based on not knowing, because it is the practice of the unconscious. What the analyst brings is never the truth, just a way to interrogate truth’s possibility. For precisely this reason, psychoanalysis is also wildly out of step with the knowledge economy and the information age. It’s crazy, being an analyst these days, but I’m OK with that.
Last entry: “Today with[my analyst], after two weeks of wondering what is going on, I said to myself, ‘I’m scared to figure these things out for myself.’ Immediately I thought this was imprecise, then realized that, after all, maybe it was true; in fact, maybe it is the fact, central to everything else going on.”
Again, I winced: did I really think I could “figure things out for myself”? What exactly would that mean, anyway? At the time I was writing this, I was almost 40! When do you finally accept that you just have to go on your gut? Becoming an analyst really is impossible. So what is left to do?
1 Why American psychoanalytic training programs do not, ever, engage in a critique of the nosology, therapeutics, and research methods of academic psychiatry and psychology is a question I very much wish that organized psychoanalysis would address.
Angier, N. (2015, March 26). Your hour is up. [Review of the book Shrinks: The untold story of psychiatry, by J. Lieberman with O. Ogas]. New York Times Book Review, BR17.
Appignanesi, L. (2015, April 5). [Review of the book Shrinks: The untold story of psychiatry, by J. Lieberman with O. Ogas]. The Guardian.
Baraka, A. (2015). All songs are crazy. In SOS: Poems 1961-2013. New York, NY: Grove Press.
Lacan, J. (1973/1978). The four fundamental concepts of psychoanalysis. New York. NY: W.W. Norton.
(Original work published 1973)
Lieberman, J. (2015). Shrinks: The untold story of psychiatry. New York, NY: Little, Brown.
Mackey, L. (1997). Fact, fiction, and representation: Four novels by Gilbert Sorrentino. Columbia, SC: Camden House.
Tavris, C. (2015, March 9). Psychiatry and its discontents. Wall Street Journal.
Various Authors. (2016). Ethical implications of the analyst as person [panel papers]. Journal of the American Psychoanalytic Association, 64(6): 1153-1224.
Address correspondence to:
Todd Dean, MD
130 S. Bemiston Ave., Ste. 707
St. Louis, MO63105
Todd Dean, MD, is a psychiatrist and psychoanalyst in St. Louis, MO. A founding member of the St. Louis Lacan Study Group, he is a senior editor and frequent contributor at Division/Review and an editorial advisor at The Candidate Journal.