Golnar A. Simpson, Ph.D.
(American Association for Psychoanalysis in Clinical Social Work, formerly NMCOP)

Freud’s Legacy and New Challenges in Clinical Treatment: A Clinical Social Work Perspective

Greetings.

In these early years of the twenty first century, we are at a point in our understanding of human functioning that instead of either/or dichotomies, we can begin having a more coherent conversation about the “seamlessness” of mind/body/context dynamics in health and in illness. From a clinical social work perspective, with our “person-in-environment” core orientation, and our historical and ongoing intimate relationship with psychoanalytic thought, Freud’s contributions to this exciting process of discovery, analysis and synthesis is so enormous that it is hard to imagine getting to this point without him. It is in this holistic context and taking the “inclusiveness” (Shapiro, 2004, P. 332) of Freud’s theory regarding psychology, biology and social factors into account that I situate my brief comments on Freud’s legacy and new challenges in treatment.

Relationship of Theory and Practice:

First, a few words about the relationship between theory and practice. It is usually assumed that in clinical practice, theory and technique are informed by one another in a continuous circular fashion. Accordingly, treatment can be conceptualized as a process in which appropriate knowledge and skills, provide the practitioner with a reasonable chance to gain access to the patients’ meaning systems (conscious and unconscious) or internal world. Then, in the context of an empathic and trusting professional relationship, and with the help of appropriate techniques, we can move forward with the co-construction of new meanings and thus change and growth.

Freud, as a pioneer and scientist, utilized a variety of approaches to the discovery and unfolding of his theoretical formulations and his recommended techniques. Fonagy (2003) states that, as a neurologist, Freud was aware of the nonconscious workings of the brain and the importance of this fact in the development of psychopathology. This lead Freud to put “two radical propositions” forward:

First, mental health problems … may be understood in terms of certain nonconsciously experienced mental states – that is beliefs and desires (Freud and Breuer, 1895). Second, the effective treatment of mental health problems could be undertaken if (and only if) the individual suffering from mental disorder was made aware of these nonconscious, and by definition maladaptive, beliefs and desires in an interpersonal context of considerable emotional intensity (Freud, 1909, 1916). P. 30.

This of course is the elegant formulation about the therapeutic process that by now is accepted as a matter beyond argument. Regarding techniques, Freud freely acknowledged the fact that his recommended techniques were based on his years of personal experience and based on the fact that unwanted results had made him abandon other methods. (Fonagy, 2003).

In psychoanalytic treatment, for a variety of reasons, the correspondence between theory and technique has not always been smooth. Today, with the diversity of theoretical schools, changing patient populations and socioeconomic realities of practice, the situation has become even more complex and challenging. In this context, the metaphor of “developmental lag” proposed by Gray (2005, p. 30) to denote the relationship between ego theory and technique, can also be used for other areas of the psychoanalytic theory and technique as well. However, it is also essential to remain aware of positive aspects of this metaphor and the potential for enhancement of the creative tension necessary for narrowing the developmental lag and the integration of theory and technique. In my brief time with you, let me share some thoughts and propose a few questions regarding three important areas of Freud’s legacy which we can build upon through our continuing examination and conversation:

1- The Unconscious:

The first example has to do with the concept of the unconscious, where everything begins. Today, in addition to Freud’s dynamic unconscious, there is also the neuroscience nonconscious with its processes not having the potential for becoming conscious; and/or a variety of other definitions such the three realm of the unconscious comprised of the pre-reflective unconscious, the dynamic unconscious and the unvalidated unconscious based on experience near intersubjective dynamics proposed by Stolorow and Atwood (1992). What are the implications of these different definitions for treatment process? Are they compatible in any shape or form? In what ways, these different conceptualizations impact our way of listening for the unconscious material?

2- Transference:

A second core related issue is the concept of transference. Today, cognitive neuroscience information (Westen and Gabbard, 2002), and elaborations of our clinical theories suggest that in addition to a global understanding of transference, it is more accurate and useful to consider a multiplicity of transferences related to the changing self-state dynamics of the participants in the moment to moment transactions involved in the treatment process. This requires appreciation for the complexity of the simultaneous mind/body/context dynamic transactions and the subjectivity and intersubjectivity of the participants. In this context, issues such as race, ethnicity, gender, life style and other sociocultural factors present further challenges to the conceptualization of the dynamics of transference. Also, how about the role of language and the elaboration of Freud’s ideas by Loewald (as cited in Mitchel, 2000) emphasizing the importance of the affective link that binds “language in primary process and language in secondary process”? (Mitchell, 2000, p. 8). How do we listen to the manifestations of the “conflictuality” which denote “the way in which the discourse alternately moves towards and away from a meaningful nucleus or a set of meaningful nuclei which are trying to enter consciousness”? (Green, 2005, p. 43). How do we discern the meaning of the messages that patients send to themselves? (Green, 2005). What are the implications of all of these processes for the different elements of technique? With all that is going on in the clinical encounter, how do we get to the “moment of meeting” defined as the therapist’s “response beautifully adjusted to the situation immediately at hand”? (Stern, 2004, p. 169).

3- Social Justice Issues:

As a third and final comment, I would like to invite your attention to an aspect of Freud’s legacy that is not often talked about: Freud’s social activism and concerns with social justice issues. In a recent book, titled: Freud’s Free clinics: Psychoanalysis and Social Justice, 1918-1938, Elizabeth Danto, a social worker tells the story of Freud and other first generation analysts’ establishment of free clinics such as the ambulatorium in Vienna and other European cities and developing a voucher system in lieu of money for the pro bono patients in order to protect their sense of pride and dignity. Danto, recounting Freud’s September 1918 speech before the fifth International Psychoanalytic Congress, states that:

“He invoked a set of modernist beliefs in achievable progress, secular society and the social responsibility of psychoanalysis. And he argued for the central role of government, the need to reduce inequality through universal access to services, the influence of the environment on individual behavior, and dissatisfaction with the status quo. (P. 17).

She follows with a direct quotation by Freud, which states:

It is possible to foresee that the conscience of the society will awake and remind it that the poor man should have just as much right to assistance for his mind as he now has to the life-saving help offered by surgery; and that neuroses threatens public health no less than tuberculosis and can be left as little as the latter to the impotent care of individual members of the community (Jones, 1955, as cited in Danto, 2005, p. 17).

Today, universal, accessible, acceptable and accountable mental health services are among the most urgent societal needs in the United States and the rest of the world. What are the impacts of social justice issues on the treatment processes? How do we respond to these challenges as mental health professionals and citizens of the world?

Thank you for listening.

REFERENCES

Danto, E.A. (2005). Freud’s free clinics: Psychoanalysis and social justice, 1918-1938. New York: Columbia University Press.

Fonagy, P. (2003). Some complexities in the relationship of psychodynamic theory and practice. Psychoanalytic Inquiry, 72(1), pp. 13-47.

Gray, P. (2005). The ego and analysis of defense, (2^nd Edi.). New York, Jason Aronson.

Green, A. (2005). Key ideas for a contemporary psychoanalysis: Misrecognition and recognition of the unconscious. New York: Routledge.

Mitchell, S. (2000). Relationality: From attachment to intersubjectivity. Hillsdale, NJ: The Analytic Press.

Shapiro, T. (2004). Use your words! Journal of the American Psychoanalytic Association, Vol. 52(2), 331-353.

Stolorow, R. D. and Atwood, G. E. (1992). Context of being: The intersubjective foundations of psychological life. Hillsdale, NJ.: The Analytic Press.

Westen, D., and Gabbard, G. (2002). Cognitive Neuroscience and Transference. Journal of the American Psychoanalytic Association, Vol. 50(1), 99-134.

Stern, D., N. (2004). The present moment in psychotherapy and everyday life. New York: W.W. Norton and Company.