Epilogue: Psychoanalysis Combined with Other Modalities

We would all agree, I think, that there is some variation in stance among the different psychoanalytic perspectives represented in this issue. Some of the authors work relationally, while some work more classically. However, notwithstanding this range of stances, and the diversity of clinical circumstances that are described, all of the authors take up instances in which their customary dyadic stance proves to be insufficient to move their patients forward. It seems that there are two common threads that move therapists toward the use of “non-traditional” modalities to supplement their psychodynamic scaffolding. One factor is the consideration of the body, through which many of the patients feel hyper-stimulated, restricted, dysregulated, or tortured; the other is the source of their psychic injuries, which under the nuanced eye of the dynamic therapist, turns out to be early in their psychological developments. Sometimes, however, it turns out to be so early in development that it precedes the child’s elaborate use of words but is encoded in her body (Van der Kolk, 2014), or has so influenced the child’s primary attachment relationship (usually with mother) that it encroaches on the feeling of safety (with the therapist) necessary for the establishment of the therapeutic alliance.

The implications for technique are serious. For one, the seemingly trusting, verbal, motivated patient may seem appropriate for in-depth treatment, when she actually may have been coerced into compliance by early injurious caretakers, setting up a dangerous alliance. More commonly, for the patient who suffered early developmental trauma (Lyons-Ruth et al., 2006), she will likely have a narrow “window of tolerance” (see Vivian Dent, this issue), and will require specific work to develop the safety necessary for intensive work on un-integrated feeling states. Most patients of this kind will regress if the therapist employs “classical” analytic techniques such as having the patient lie down on the couch four or five times weekly or if she waits over long silences for the patient’s free associations to emerge. Many of these patients require an active, verbal, and non-verbal engagement from the therapist, certainly including some degree of eye contact, or at the minimum, the therapist’s facing the patient and demonstrating careful – if not intrusive – interest in her. Most psychoanalytic institutes teach analysis as a technique separate from psychotherapy, with regressive techniques such as use of the couch, frequent sessions, and free association as vehicles for understanding the patient’s mind. What is the likelihood that these techniques will be therapeutic if the patient is not psychically relatively healthy at the outset of treatment?

I think it is obvious where I am going with this discussion: that we should be learning how to integrate alternative techniques, perhaps after basic analytic and psychotherapeutic techniques are conceptualized and practiced separately and in relatively pure culture. Advanced graduate dynamic training shouldn’t separate psychotherapy training techniques from classical technique entirely, but should teach us how and when to use various techniques to help the patient weave between safety and risk, between past and present, between reality and fantasy. For relatively healthy patients, whose early development was safe and secure enough, free association in combination with a steady, attentive analyst may be sufficient to facilitate these movements. But for most others, more active techniques of the kind outlined by Vivian, Ken, Jill, and Lisa will be necessary. The art of knowing when and how to insert these techniques, and how to understand their impact on the core elements of the treatment milieu – such as the therapeutic alliance, prominent transferences, new relative to past object experiences – will have to be considered carefully.

Sletvold (2014), in “The Embodied Analyst”, outlines an unusual sequence of psychoanalytic training practiced in the Character Analytic Institute: students engage in two years of specialized body training along with traditional classes. When I described this approach to the members of my study group, senior analysts thought it sounded odd and “un-analytic.” I think Freud’s disciples steered away from the body, partly because the educated class over-valued intellect, partly because they didn’t understand the link between mind and body, and partly because they were afraid of the boundary violations that were occurring between therapist and patient. Now, in 2020, we need to include the body more directly in our work, both through recommending engagement with the body outside of sessions – and by asking the patient to report on her visceral responses – and by using it deliberately during sessions. This could include asking the patient to practice a breathing exercise if she is overwhelmed with anxiety. Or it could include initiating some other action or exercise that might on the surface seem alien to our traditional training.

It is worth emphasizing here Ken Frank’s point regarding the reluctance of analytically trained therapists to try these techniques (see Kenneth Frank, this issue). For one, the analytic enterprise may still attract practitioners more inclined toward the mind than the body. Even though contemporary culture has moved us toward the integration of the two, the analytic tradition cautions us against action, especially if outside the verbal sphere, and this caution may serve as an impediment. Moreover, analysts have honed their craft over many hours of supervised casework, and are reasonably apprehensive about importing techniques that are beyond their expertise. Because there is potential benefit for analysts to weave these techniques into the treatment rather than referring the patient to a colleague – both for practical reasons and for eventual dynamic exploration, as Jill Bresler points out – it behooves us to become proficient in at least some of them. The challenge is for us to keep expanding, while also knowing when to refer patients to colleagues for adjunctive treatments.

I would like to conclude by flagging the deleterious consequences of developmental trauma. We know about the obvious sources: parental abandonment/illness, neglect, and physical/sexual abuse. The more subtle ones are sometimes overlooked: maternal depression, temperamental misattunement between child and caretaker, psychological abuse at the hands of a sibling, cultural dislocations, to name a few. The more familiar we are with these ubiquitous circumstances, the more likely we are to appreciate them even if minimized by the patient. And the more prepared we are with a wealth of tools at our disposal, the more likely we are to offer what is needed at just the right time.

Andrew I. Smolar, M.D.

Issue Editor