BPAS: The Practice of Psychoanalysis, by Michael Brearley

The Practice of Psychoanalysis
Michael Brearley

This article was first published in the News & Events publication. Michael Brearley was Chair of the External Relations Co-ordinating Committee. In this, the second of two articles, he responds to criticisms of its practice: Psychoanalysis is said to be:
(i) elitist, (a) in seeing itself as superior to other psychotherapies, and (b) it is anti-medication; it is ineffectual, dabbling in the discontent of the middle-classes and having nothing to offer the really ill.
(ii) Psychoanalysis is dangerous and radical, it brainwashes. Take the issue of child abuse where it is accused both of denying the facts of abuse and of implanting false memories.
(iii) Psychoanalysis is impractical and ineffectual, going back to the past and ignoring present problems.
(iv) Psychoanalysis is conservative; anti-creativity, anti-homosexuality.

Psychoanalysis is the most radical way that human beings have devised for making available unknown and archaic aspects of the self which persist and enter into one's life, often in destructive and out-of-date ways. It is a potent instrument, and can therefore be used to ill effect as well as to good effect, and the quality of its impact is limited by the quality of its practitioners

There is, however, some reassurance for the public. Firstly, it is of the essence of psychoanalysis that the analyst should be familiar in himself with the kinds of things that he meets in his patients; and that he constantly scrutinise his own responses, conscious and unconscious, not only to minimise bias or prejudice, but also because the analyst's self-scrutiny is necessary to understand the patient's emotions. It thus contains within itself the means of its own self-correction in a way that no other treatment does.

Secondly, the Institute of Psychoanalysis has rigorous selection and training processes, as well as a culture of continuing education and peer consultation; it takes ethical issues seriously. Nevertheless people are fallible.

Is this fallibility in an analyst dangerous or simply a waste of time and money? Can analysts damage the mind, like bad surgeons damage the body? I think damage can occur; but not directly, by the analyst's 'scalpel'; he can't simply excise healthy tissue or implant toxic matter. And the analyst aims not to take sides, as between patients and their families, over matters such as abuse; we are not afraid of admitting what we don't know.

For the analytic process to 'take' there is an intrinsic need for involvement by the patient. Indeed, one defence that a patient adopts is to sit back and wait for the analyst to apply the knife or the pills. Much of what is unavailable to the patient in himself has been disowned for strong reasons; even his own mental capacities may have been damaged in the desperate hope of annihilating what is unbearable.
So when in analysis some of these emotions, ideas and mental actions become to become more available, the patient may become depressed or suicidal. Handling such states is part of the skill, but the analyst may not always get it right, and the patient may be determined, at any cost, not only to abolish emotional knowledge, but also to defeat the analyst.
So analysis, in approaching the most primitive parts of the personality, sometimes evokes violent and frightening emotions and responses. Change is often turbulent.

But psychoanalysis may also fail for the opposite reason, that the analyst and patient between them lack the courage and skill to make available and then to face difficult unconscious aspects of the patient's mind. The treatment may then become either a stalemate, or a more or less agreeable supportive therapy in which the possibility of radical change is lost.

Contemporary psychoanalysis is not a matter of going back to the past, or living in the past. Far from it. In fact patients often complain that it is all too much in the present, in the transference. I see it like this: what the patient tells us about his past and about his current life outside the consulting room is hearsay, and thus to some degree unreliable.
Our job is to try to be open to elements in, and movements of, the patient's mind that are contrary to his stated views of himself, and we have first-hand experience of these in the sessions and in the relationship with us.

Is psychoanalysis elitist? It is of essence labour-intensive, and therefore expensive, though many analysts earn less than they would have done had they stayed in their previous professions.
The insights that analysts have struggled through in their intensive, four - or five-times weekly work, are made use of in less intensive ways - in group therapy, for example, and in psychoanalytical psychotherapy, and among other health workers who utilise personal experience with analysts, whether in treatment, training or supervision. Many of these insights are also part of our society's general knowledge.

Unfortunately, psychoanalysis is not as widely available, either in its full form or less directly, as we would wish. There are now, however, more psychoanalysts working outside London, and more people who live outside London who are in training than ever before.
Psychoanalysts vary in their opinions about the feasibility of offering analysis to people who are psychotic. Some believe it to be the treatment of choice here, while others are more doubtful. What analysts increasingly agree on is that analysis can and should uncover the psychotic elements in less flagrantly ill people - which means all of us.

Psychoanalysts do not condemn medication wholesale. Often its use goes counter to the aim of uncovering, but it may be that at some stages, for some patients, medication can calm them enough to make talking therapy possible.

Are psychoanalysts hostile to homosexual patients? No. Such people are treated in just the same way as heterosexuals; that is, as people whose unconscious tendencies are elusive. We are interested in what all kinds of behaviour might mean in terms of denied and split-off emotional experiences.

Finally, is psychoanalysis anti-creativity? Again no. Early psychoanalytic theory may have encouraged the view that creativity was, like symbol-formation, a symptom resulting from repression - though even then theorists attempted to differentiate sublimation from symptoms.
Nowadays, psychoanalytic theory emphasises that we are prevented from being emotionally available for creative activity of all kinds by our unconscious blockages.