PSYCHE, 1968, Jg. 22, Ausgabe 9-11

To consider psychoanalysis as a medical speciality seems to be a constricting point of view. The concepts of psychoanalysis permit, and indeed require, a wider horizon. The author, as a psychoanalyst, a psychiatrist, educator and student of human behavior feels some concern over the question of whether or not psychoanalysis is having an optimal impact on the crucial problems of today's world. He deplores the isolation of psychoanalysis from the university setting. There was a certain sense of disillusionment with the apparent inability of the psychoanalytical power-structure to put psychoanalytic academic investigation and education ahead of the preparation for psychoanalytic practice and the pursuit of practice. A precious commodity like psychoanalysis ought not to be controlled by organizations of private practitioners, but by the most creative minds of society which are found within the university. The author advocates the integration of psychoanalytic research and education in university departments which should be independent but not isolated.

In addition to the well-known forms in which neurotic conflicts tend to be expressed, the psychiatrist of to-day is increasingly faced with psychopathological pictures in which no inhibitions of instinctual drives and no sense of guilt seem to be present. Apparently other defences are being employed against the tension arising from conflicts between superego, ego-ideal and ego. With the help of some clinical examples it is shown that unconscious guilt, need for punishment, and self-indiction may Iead to disturbances of behaviour which above all will destroy the person's object-relations. The psychic mechanisms underlying this kind of pathology are described.

I have primarily been trying to convey the inherent connection between schizophrenia and the linguistic and cognitive disturbances that are critical attributes of the condition. Ego functioning depends upon language and the ability to abstract common attributes in experiences and categorize them by the appropriate words. The capacity to use language is a uniquely human capacity which all undamaged infants possess; but learning language is a highly involved process that depends largely on the nature of the tutelage and the tutors in the family. It is not a skill learned in isolation but involves and reflects the entire process of personality development. I have tried to indicate some of the ways in which parents of schizophrenic patients are deficient tutors and how the family they create is an inappropriate milieu for teaching the child his cardinal adaptive tool. I have sought to illustrate both how poor grounding in linguistic abilities prepares the way for schizophrenic withdrawal and also how distorted meanings and ways of thinking become an inherent part of the offspring in such families.

Contraceptives and methods preventing the spreading of venereal diseases as well as general social changes are considered to be important reasons for the fact that nowadays sexual genitality has become a »real« private affair »no longer« subjected to any kind of »alienation«. As a sequel to this result we are faced both with chances and dangers. The former consist in the existence of a secure area for gaining sexual experiences at a time when the personality as a whole. has not yet reached its full differentiation. The latter are seen in the possibility that without the restraining influence of sexual tabus differentiation and integration of psychic structures which are bound up with the vicissitudes of partnerships, in particular of two-persons relations, might seriously suffer in a way complementary to the detrimental effects of too strong repressive sexual methods. In this connection it is claimed that H. Marcuse's thesis of sexual repression in the service of the ruling classes and powers is in need of being supplemented by reflections about repression in the service of progress and freedom because, as Freud (1912) recognised, frustrations as well as unrestrained satisfactions may generate defects.

Das technische Vorgehen in der analytischen Behandlung erweist sich in seiner historischen Entwicklung als am Fortschritt der Theorie orientiert. Bewußtmachen unbewußter psychischer Inhalte durch die Deutungsarbeit, Widerstands- und Übertragungsanalyse bildeten die Grundlage für die Behandlung der klassischen Übertragungsneurosen, und diese Technik orientierte sich an dem topischen, dynamischen und ökonomischen Gesichtspunkt der Metapsychologie. Die Strukturtheorie und die wachsende Kenntnis der frühen Entwicklungsstadien der Instanzen des psychischen Apparates und seiner Störungen weisen gangbare Wege für die Behandlung von Patienten, deren Störungen auch vor allem durch frühe Schädigungen der regulierenden Ich-Funktionen bedingt sind.

The technique of psychoanalytic treatment has developed historically in close connection with the advance of psychoanalytic theory. Fundamental for the treatment of the classical transference neuroses were methods envisaging the Iifting of unconscious contents to consciousness with the help of interpretations and the analysis of resistances and transference. This technique took its orientation from the topological, dynamic, and economic viewpoints of metapsychology. With the advent of the structural hypothesis and with the increase of knowledge of the early developmental stages of the systems and regarding the disturbances the mental apparatus may be subject, new alleys of approach were opened up for the treatment of patients whose diseases are co-determined by an early impairment of the regulatory forces of the ego.

The diagnostic apparatus of a psychoanalytical policlinic (the clinical department of the Sigmund Freud Institute at Frankfurt) is based on the whole body of psychoanalytic knowledge, and the tool of psychoanalytic technique is tried to be put to optimal effect in all situations whenever the psychoanalyst meets the patient. Thus it is not the underlying meaning of the patient's verbal communications only that is interpreted but also certain unconscious psychological phenomena that are observed directly – phenomena owing their »gestalt« to processes of integration of perceptions including the verbal and behavioural communications of the patient as well as his transference manifestations. The final evaluation of the analytical findings is made by using structural, diagnostic and prognostic viewpoints and by employing further diagnostic methods. A case report is given for illustration.

The reserved attitude analysts show toward including psychological testing procedures in clinical psychoanalytic settings seems to be based upon discontent with the lack of analytic significance of test results as well as upon concern about keeping analysis free of alienating influences. It is suggested that a thorough and adequate application of psychoanalytic theory and technique to psychological testing – as exemplified particularly in the work of Roy Schafer – may be helpful in making test findings more relevant and more acceptable to the analyst. Three areas of application, the testing situation, interpretation, and communication of test results are discussed.

50 Rorschach tests were subjected to a differentiated analysis of data using a variation of the method developed by S. Fisher and S. Cleveland. Significant correlations were found to exist between the self and body images as expressed in the tests on the one hand, and acceptance for psychoanalytical treatment on the other hand. Two groups were detected: one group showing relatively little anxiety concerning expression of self and ego-regression; they were judged to have positive indications for psychoanalytic treatment. The other group felt the therapeutic egosplit as a threat and therefore shut themselves off from all influences coming from without. Patients from this group were significantly less frequently accepted for treatment. The Rorschach test could thus be used as a reliable indicator for the patients' analysability.

Patients consulting the clinical department of the Sigmund Freud Institute at Frankfurt are subjected to a short »preliminary interview« allowing a rough selection of those patients to whom a detailed diagnostic examination is proposed. According to this first appraisal made with the help of the usual criteria for indication this group should respond to psychoanalytic treatment. The detailed examination however (by interviews, tests and group discussion), revealed that no more than 70 per cent of the selected patients were finally accepted for treatment while the rest had to be referred for non-analytic forms of therapy outside the clinic. A sample of 65 patients was scrutinized for possible criteria determining their acceptance or referral. The first – accepted – group differed from the group of referred patients significantly by the simultaneous presence of two criteria: sufficient motivation and strong pressure from suffering. The presence of only one of these criteria – however strong in itself – proved not sufficient for qualifying the patient for psychoanalytic treatment. It could further be shown that the special kind of relation existing between the two criteria exerts a specific influence determining the therapeutic method offered to the patient (long-term analysis, focal psychotherapy, group psychotherapy). – This study helped to refine the technique used in the preliminary interviews.

There are external and internal criteria determining the indication for group psychoanalysis. The external factors are connected with the patients' reality. The internal criteria are based on the patients' psychic structures. A decisive point is the state of the patients' ego-functions. Some ego-functioning must be expected for qualifying the patient for group-therapy. The patient must be able to oscillate between his own individual experience and the common developmental history of the group. Certain defenses are described as being counter-indications for group treatment.

A short review of the situation and difficulties of follow-up studies in psychoanalysis is followed by a description of the methodological steps in planning such studies. An outline is given of a way leading to a detailed evaluation of changes occurring within the psychic apparatus during therapy.

In a pilot study retests were compared with patients' original tests in order to recognize and evaluate the changes – success or failure – brought about by psychoanalytic treatment. The projective test methods proved to be a relatively differentiated and reliable tool for the understanding of very complicated processes such as psychical change; this is illustrated with several case reports. Evaluations are based upon R. Schafer's scale of five aspects indicating observable changes.

Ausgehend von einer Umfrage Glovers, die zeigte, daß Psychoanalytiker nur widerwillig mit den Angehörigen ihrer Patienten Kontakt aufnehmen, wird im ersten Abschnitt eine Literaturübersicht gegeben. Bei Interviews mit Angehörigen werden auch außerhalb der Psychoanalyse grundsätzliche Fragen der ärztlichen Schweigepflicht berührt. Im zweiten Teil wird dargestellt, warum Psychoanalytiker nur ungern mit Angehörigen sprechen: Auf diese Weise sollen Komplikationen in der Zwei-Personen-Beziehung vermieden werden. Im dritten Teil werden unerwünschte und anti-therapeutische Auswirkungen beschrieben, die auf die psychoanalytische Situation zurückgeführt werden müssen und insbesondere dann auftreten, wenn die exzentrische Position der Angehörigen verstärkt wird, Entsprechende Erfahrungen, die bei rigorosem Vermeiden von Gesprächen mit Angehörigen gemacht wurden, werden beschrieben. Im vierten Abschnitt wird der Widerwille mancher Psychoanalytiker gegen Interviews mit Angehörigen als überindividuelle, professionelle Gegenübertragung bezeichnet. Es wird untersucht, welche ungünstigen Auswirkungen diese unkontrollierte Gegenübertragung auf den Patienten und seine Angehörigen haben könnte. Schließlich werden im fünften Abschnitt erläuternde Fallbeispiele gegeben.

Starting from Glover's inquiry (1939) which indicated that psychoanalysts only unwillingly establish contact with their patients' relatives, the first part deals with the Iiterature on this subject. In interviews with relatives basic principles concerning general professional discretion are touched upon. In the second part the authors show why psychoanalysts prefer to avoid contacts with relatives: they wish to prevent complications in the two-person-relationship. In the third part undesired and non-therapeutic side-effects are described which must be attributed to the psychoanalytic situation and which particularly arise when the eccentric position of the relatives is strengthened. Pertinent empiric results gained by strictly avoiding interviews with relatives are discussed. The reluctance of some psychoanalysts towards interviews with relatives, a kind of »professional counter-transference«, is described and the unfavorable consequences this uncontrolled »counter-transference« may have on the patient and his relatives discussed (part 4). Finally in the fifth part four illustrating case report are given.

Behandlungstechnische Fragen und Probleme der psychoanalytischen Kurztherapie im Sinne der Fokaltherapie Balints wurden anhand eines Fallbeispiels dargestellt. Erstinterview, testpsychologische Untersuchung, Besprechung des Falles in der Ambulanzkonferenz und danach in der Arbeitsgruppe für Fokaltherapie gestatten aus ersten Wahrnehmungen heraus nach mehreren Verwandlungen eine Formulierung des Fokus als Arbeitshypothese in der Form einer Deutung. Im Verlauf jeder Fokalbehandlung ergeben sich Schwierigkeiten im Hinblick auf das Festhalten des Fokus in der Übertragung, so auch bei diesem Patienten. Hier kam es nach 10 Behandlungsstunden zu einer Krise, aus der heraus sich dann eine eindeutige Besserung des Zustandsbildes des Patienten, sowohl symptom- als struktur-orientiert, ergab. Die von vornherein gegebene zeitliche Begrenzung der Therapie ist dabei einer der wichtigen Faktoren dieser Behandlungsform. In unserer Arbeitsgruppe der Fokaltherapie haben wir übereinstimmend die Erfahrung gemacht, daß keiner von uns eine Fokaltherapie auf sich allein gestellt in dem dargestellten Sinne durchführen kann, weil hinter den wenigen Behandlungsstunden sich die zusätzliche Bearbeitung des Materials in der Arbeitsgruppe verbirgt. Insofern wird die Hoffnung enttäuscht, die Fokaltherapie an sich werde die Behandlungskapazität eines Therapeuten wesentlich steigern. Wir nehmen auch jeweils nur einen Patienten in Fokaltherapie. Andererseits hat sich aber gezeigt, daß die Teilnahme an der Arbeitsgruppe für Fokaltherapie Konsequenzen hatte für alle anderen Therapieformen, z.B. für die sogenannte psychoanalytisch orientierte Psychotherapie, die jeder von uns jetzt klarer strukturieren und gezielter handhaben kann.

Items and problems of psychoanalytic short-term therapy in the sense of M. Balint's focal therapy are discussed, and an illustrating case-report given. Initial interview, test results, discussion of the case in a staff conference of the out-patients department and afterwards in the special workshop for focal therapy yield a first inception and after several re-formulations a working hypothesis – the so-called focus in the form of an interpretation. In the course of each focal therapy difficulties tend to arise in maintaining the focus within the transference. The same was true in the case of the patient presented here. After 10 sessions a critical point was reached which, however, resulted in a distinct improvement of the patient's state both symptomatically and structurally. The Iimitation of the therapy to a fixed number of sessions has proved an essential factor of this form of treatment. But all members of the workshop agreed that none of them would be able to do this kind of focal therapy without the help of the group. Thus behind the few sessions of the therapy the work of the whole group is concealed. This must ruin the therapist's hope of significantly increasing his potential with the help of focal treatments. The workshop never accepted more than one patient for treatment by one of its members. On the other hand participation in the workshop yielded experiences which proved useful for all types of therapy, f. i. for the so-called psychoanalytically oriented psychotherapy which became better structured and could be handled with greater security.

Bericht über psychoanalytische Beobachtungen an 57 Frauen mit primärer oder sekundärer Amenorrhoe und Oligomenorrhoe, von denen 53 von der endokrinologischen Abteilung der Universitäts-Frauenklinik Frankfurt/M. überwiesen worden waren. Patientinnen, bei denen die Amenorrhoe die Folge einer anderen organischen Erkrankung oder Begleiterscheinung einer schweren psychischen Erkrankung wie z.B. psychotische Depression oder Anorexia nervosa war, wurden in diese Untersuchung nicht einbezogen. Das Material stützt sich auf 57 psychoanalytische Interviews, 23 projektive Tests (Rorschach und ORT), 3 Psychotherapien und eine Psychoanalyse. Eine beträchtliche Zahl von Patientinnen (34) war in den Interviews affektiv kaum erreichbar; wir fanden eine Übereinstimmung zwischen der Kontaktfähigkeit der Patientinnen im Interview und ihrer Fähigkeit, emotionale und zwischenmenschliche Konflikte wahrzunehmen. 35 der 57 Patientinnen gaben an, sexuelle Beziehungen zu haben oder gehabt zu haben. Von diesen waren 27 verheiratet. Diese Zahlen weisen, bezogen auf die Gesamtbevölkerung in dieser Altersgruppe, keine großen Abweichungen vom Erwartungswert auf. Hieraus wie aus aus dem Fehlen ausgesprochen viriler und phallischer Frauen in dieser Beobachtungsgruppe kann geschlossen werden, daß die Amenorrhoe nicht als somatischer Ausdruck einer Ablehnung der weiblichen Rolle gedeutet werden darf. Obwohl wir nur in wenigen Fällen Angaben über die Orgasmusfähigkeit der Frauen erhielten, haben wir Hinweise darauf, daß amenorrhoische Frauen im allgemeinen frigide sind. Unter der Gesamtzahl von 57 Frauen befanden sich nur 9 Mütter mit insgesamt 11 Kindern. Diese Zahl ist in Anbetracht der Tatsache, daß nur 4 Patientinnen jünger als 18 Jahre waren, sich das Lebensalter der anderen Patientinnen jedoch auf 18 bis 36 Jahre erstreckte, außerordentlich gering. Nur eine Mutter ließ im Interview eine gute affektive Beziehung zu ihrem Kind erkennen; alle Patientinnen erlebten die Mutterschaft als negativ und konflikthaft. Die Ehen der 27 verheirateten Frauen waren im allgemeinen bemerkenswert stabil (zwei Scheidungen, zwei unglückliche Ehen). Die anderen boten häufig ein übereinstimmendes Bild eines geschützten Daseins in ordentlichen Wohnungen mit mütterlich-fürsorglichen Ehemännern, ein Zustand, den wir als »prägenitales Paradies« bezeichnet haben. Bis auf 3 Psychose-Grenzfälle waren bei den untersuchten Frauen die adaptiven Ich-Funktionen nicht beeinträchtigt. Sie bewahrten vielmehr ihr psychisches Gleichgewicht durch eine starre Charakterabwehr mit weitgehender Verdrängung von Trieben und Affekten unter der Herrschaft eines strengen Über-Ichs und eines überhöhten, »reinen« Ich-Ideals, welche Konformismus, Vermeidung von Konflikten und Verbleiben in kindlicher Abhängigkeit von einer Elternfigur forderten; die letztere wurde häufig vom Ehemann repräsentiert. Mit gebotener Vorsicht in bezug auf die Spezifität psychosomatischer Symptome schließen wir, daß die unbewußte Bedeutung der Amenorrhoe mehr Vermeidung der Mutterschaft als Ablehnung der weiblichen Rolle im allgemeinen ist.

This is a report of psychoanalytic observations with 57 women suffering from primary or secondary amenorrhea, carried out in collaboration with the endocrinological department of the Gynecological Hospital at the university of Frankfurt. Patients in whom the amenorrhea was the result or a concomitant of other organic pathology or a severe mental disorder sum as e.g. psychotic depression or anorexia nervosa, were not included in this study. The data were obtained from 57 psychoanalytic interviews, 23 projective tests (Rorschach and ORT), 3 psychotherapies and 1 psychoanalysis. A considerable number of the patients (34) were emotionally hardly accessible in the interviews; this was seen as being in direct correlation with the patients' general lack of contact and inability to perceive emotional and interpersonal conflicts. 35 of the 57 patients were married or had sexual relations. These numbers are not very much at variance with the average rates in that age group in the total population. This fact as well as the absence of virile or phallic types of women in the sample seemed to indicate that amenorrhea as such cannot be interpreted as being the somatic expression of a rejection of the female role. Few data only were obtained as to the orgastic capacities of the women; but there were indications that amenorrhoic women tend to be frigid. Of the 57 women only 9 had children, totalling 11. Since only 4 patients were under 18 years of age, while the rest of 53 were in the age group of 18-36, this number of births is remarkably small. Of the mothers only one showed a good emotional relationship to her child, while to the rest of the mothers as well as to the other patients of the sample all aspects of motherhood seemed difficult and negatively tinged. The marriages of the 27 wives in the sample were generally good and stable (with only 2 divorces, 2 unhappy marriages). Most of the wives presented a rather uniform picture of a sheltered existence in tidy homes with maternally protecting husbands, a state the authors have come to call the »pre-genital paradise«. Apart from 3 borderline cases, the patients' adaptive ego-functions were unimpaired. They kept their emotional balance with die help of rigid character defenses including repression of instinctual drives and affects under the control of strict super-egos and highstrung, »clean« ego-ideals which demanded conformity, avoidance of conflict and fixation to an infantile dependence on some parental figure, the latter frequently represented by the husbands. With due caution as to the specificity of psychosomatic symptoms the authors conclude that the unconscious meaning of amenorrhea is avoidance of motherhood rather than rejection of the female role in general.

As in the case of a traumatic neurosis the patient's pathology is rooted in his mode of experiencing, an evaluation of his state must establish the causal connection between his subjective feelings arid the traumatic event. By introducing the metapsychological concept of a psychical apparatus we are enabled to see and judge the traumatic experience as a mange in the patient's structure. The usefulness of this concept is.illustrated by a consultant's opinion on a case of persecution sequelae.

Apart from the rare mother-child symbiosis described by M. Mahler, there are many other simpler and more frequent forms of symbiotic relations between mother and child. They develop in cases where the solution of the normal dependency of the first year of life has failed; manifestations are over-long breast feeding, many forms of sleeping disturbances – mother and child sharing the bed or at least the bedroom – and later on various forms of school phobias. Absence of the father (because of illegitimate birth of the child, divorce, death) tend to reinforce the original symbiosis of mother and child, particularly so in the oedipal phase. Psychosomatic diseases will lead to regressive behaviour and help to fixate or reestablish the symbiotic relationship. Secondary symbiosis is the frequent outcome in cases of severe anomalies like cerebral disturbances, heart diseases and malformations of the child. During puberty and adolescence the tendencies for individuation are often associated with very ambivalent feelings of love and hatred in both mother and child. Indications for symbiotic relationships may be got with the help of projective testing procedures like the »Scenotest« and the tests »Draw a man« and »Draw a family«, taken both from the child and the mother. Simultaneous psychotherapy is the best method of dealing with this syndrom. In case of some psychosomatic illness of the child the mother should not be trusted with the nursing; these are also the cases when rooming-in of mother and child is counterindicated.

On the basis of a common emancipatory interest in enlightenment a co-operation is viewed of psychoanalysis with the other social sciences. When looking for starting-points leading to a critical social psychology in Freud's own writings, the author concludes that the Statements Freud made on explicitly sociological issues are obviously ensnared in the social and scientific prejudices of his time. Freud's clinical argumentation, however, especially after the development of ego-psychology, introduces a true potential of enlightenment into psychoanalysis. The danger of psychologism arising in a co-operation with other social sciences is equally menacing as that of sociologism – social phenomena cannot be reduced to psychology, psychical phenomena cannot be completely reduced to society. A paragraph taken from »Totem and Taboo« is subjected to a social-psychologically conceived semantic interpretation of the therapeutical processes of psychoanalysis, in an attempt to show why Freud called the private neuroses of patients a-social, in contrast to social pathology. The private neurosis excludes – entirely or in part – the diseased person from being a factor in the sociological process of enlightenment insofar as he has withdrawn into a phantasy world of his own. The defense mechanisms of reaction-formation and isolation are taken for instances proving the value of psychoanalytical concepts as concepts of social-psychology in which the individual is seen as one molded by his society.