Lawrence B. Inderbitzin

Substance use: a powerful predictor of relapse in schizophrenia

This study examined substance use among a group of 37 schizophrenia patients participating in a year-long fluphenazine decanoate (FD; Prolixin) dosage reduction study (Inderbitzin et al. (1994) Am. J. Psychiatry 151, 1753-1759). Ten (50%) of the 20 FD dose-reduced patients, and 6 (35%) of the 17 control group patients were identified as substance users. The dose-reduced and control groups did not differ significantly in substance use. We examine here the 37 patients regrouped by substance users (n = 16) versus non-users (n = 21) to determine the effects of substance use. In addition to identifying substance users and types of substances used, we hypothesize that substance users differ demographically from non-users, have worse symptomatology, worse compliance, higher rates of relapse, and therefore, can confound studies. Clinical and demographic data were obtained. At least half of the substance users were using alcohol or cocaine. The substance use group had a significantly higher severity of illness score on the BPRS at study onset. We found no significant differences between the two groups on other rating scales. The non-use group lived more independently, and the substance use group was younger. The substance use group had nearly twice as many hospitalizations in the 2 years prior to the study, a greater rate of missed appointments in the year before and during the study, and 4 times as many relapses during the year of the study than the non-use group. The key finding was that among 9 of the 37 patients who relapsed in the year of the study, 7 of the 9 had a history of substance use. Substance use was found to be a better predictor of relapse and hospitalization than gradual 50% dosage reduction of FD in the related study. Substance use among schizophrenia patients is a major complicating factor.

The Analytic Surface and the Theory of Technique

This paper examines the concept of the analytic surface as a starting point for the interpretive process in relation to the theory of psychoanalytic technique. The history of the concept of the analytic surface within psychoanalysis is reviewed. Four different conceptualizations of analytic surfaces are described (M. M. Gill, P. Gray, A. Kris, E. A. Schwaber). The advantages of a “surface” approach are explored in relation to clinical work, the teaching of psychoanalytic technique, and opportunities for research. Some criticisms of the concept are explored. “Nothing is rich but the inexhaustible wealth of nature. She shows us only surfaces, but she is a million fathoms deep.” Ralph Waldo Emerson

Repetition compulsion revisited: implications for technique.

Freuds repetition compulsion concept is reviewed and examined critically. It has been used as an explanatory concept to cover a wide variety of clinical phenomena similar only in their manifest repetitive quality, and it appears frequently in psychoanalytic and psychiatric literature. Its relationship to trauma and posttraumatic stress disorder is explored. Emphasis is on the detrimental technical legacy of the concept, which has cast a pessimistic aura of unanalyzability over a wide variety of repetitive phenomena, especially analyzable resistances related to aggressive conflicts. We conclude that the repetition compulsion is an anachronistic concept with detrimental technical implications and that it should be retired.

Neutrality, interpretation, and therapeutic intent

Neutrality is a central concept within the theory of psychoanalytic technique. We spell out the major controversies in which the concept has become embroiled, and provide a definition that we believe coincides with actual psychoanalytic practice. We discuss its merits and weaknesses, noting also the negative consequences of relying on older definitions. We relate neutrality to the interpretive process, indicating ways interpretation protects neutrality and is made more effective by it. We discuss the complex and controversial relation between neutrality and the analysts therapeutic intent.

Unconscious Fantasy: A Reconsideration of the Concept:

Despite general agreement about the clinical importance of unconscious fantasy, the concept itself has remained unclear. After reviewing Freuds work on the subject, the conceptual dilemma is specified: where in current psychoanalytic theory do we place this important, dynamically repressed, structuralized mental content? Three conceptual paths have been followed in attempting to deal with this problem. The first emphasizes the structural, tripartite model, discarding topographic concepts. The second replaces the structural model with a schema model borrowed from academic psychology. The third combines the structural and topographic models. None of these approaches is entirely satisfactory and without problems. Because of their central role in mental life, unconscious fantasies deserve careful definition. They should be distinguished from conscious fantasies and daydreams as well as from the process of fantasizing. They are differentiated from other varieties of unconscious content by their enduring quality and their organized, storylike quality reflecting the distortions typical of the primary process. As dynamically unconscious templates from the childhood past, they shape subsequent compromise formations and are relatively impervious to new experience. The development of psychoanalytic theory from a macrostructural to a microstructural emphasis is discussed in relation to the unconscious fantasy concept.

Suggestion and Psychoanalytic Technique

The role of the analysts suggestive influence on the course and outcome of psychoanalytic treatment is explored, and traditional and newer perspectives on analytic technique are contrasted. The intersubjective critique of the neutral, objective analyst in relation to suggestion is examined. The inevitable presence and need for suggestive factors in analysis, and the relationship of suggestion to transference susceptibility, are emphasized. The manner in which the analysis of suggestive factors is subsumed in transference analysis as part of traditional technique is highlighted.

Patient's Sleep on the Analytic Couch

Published reports about sleep on the couch have primarily emphasized its preoedipal (especially oral) determinants and defensive purposes. A detailed case is presented in which sleep became the central symptom of the transference neurosis. The primary determinants of the symptom were from the phallic-oedipal stage of development. Like other symptoms, the sleep symptom was a reliving of earlier experiences and was analyzed primarily through the transference. The analytic data from the case are used to illustrate resistance as an ally in the psychoanalytic process.

Fantasy and psychoanalytic discourse

Psychoanalytic discourse across theoretica l, geographic and cultural boundaries has become increasingly difficult as psychoanalysis has grown internationally from its central European origins. Psychoanalytic terms have been used inconsistently, often with litt le regard for the problems in communication and scientific and intellectu al progress such inconsistency creates. Likewise, what are usually considered alternative or competing psychoanalytic theories, often connected to geographic regions or cultures, create artificial divisions among analysts that further interfere with scientific progress. It is our view that the majority of such theories are partial theories, or shifts in emphasis, wherein all the necessary ingredients of a comprehensive psychoanalytic theory, of which we are strong advocates, are included at the periphery, as secondary themes, so-called ‘givens’ or ‘goings without sayings’, or smuggled in clinically as artfulness, tact or common sense. The term phantasy or fantasy acquires different meanings and more or less importance or centrality, depending on where in the melange of psychoanalytic discourse one encounters it. In what follows, we will try to summarise an American ego-psychological point of view about fantasy, emphasising what we consider the major issues that underlie controversies about fantasy as conceptualised from this and other theoretical perspectives. We emphasise summarise to indicate that even within the perspective of contemporary egopsychology, of which our work is representative, there is considerable variability, contradiction and lack of clarity about what the term fantasy refers to. In an earlier exploration of fantasy (Inderbitzin & Levy, 1990), we attempted to reconcile or at least delineate several trends in thinking about fantasy within contemporary ego-psychology structural theory, and some of our conclusions from that work will be elaborated here. We will argue that fantasy is central to all psychoanalytic work and that inferences about the consequences of different meanings or usages of the term distort and exaggerate differences in clinical work. These distortions regularly centre on whether or to what extent analysts of different theoretical persuasions focus on the unconscious or on unconscious processes, whether on the past or the present, and whether the clinical work is deep or superficial. It is our belief that all the phenomena described by various groups as fantasy are central to a psychoanalytic view of mental life, inform all clinical work in essential ways and find their way into technical precepts more alike than different. We will return to this later.

The Analytic Surface

NDEKBITZIN OPENED T H E PANEL With a brief historical and COIlCeptUal I overview. Freud originally used the term surface as an equivalent of consciousness in his topographic model, and later (19 14) modified the concept to include unconscious resistances observed by the analyst. Fenichel’s (1941) idea of surface closely approximated the later view of Freud. Loeivenstein (1951, 1954) added two descriptions of surface: (1) “the state and the nature of conflicts between drives and defenses at a given moment”; and (2) “all aspects of the patient’s mental life which are at the disposal of his autononious ego functions.” Although “surface” does not appear as a psychoanalytic concept in any of the specialized psychoanalytic glossaries or dictionaries (Paniagua, 1985), analysts continue to use the term in different ways and contexts associated with different frames of reference. The meaning of the surface within the framework of the structural theory remains largely unexplored. An exception to this is the work of Gray (1973, 1982, 1986); he defines an “optimum analytic surface” as being the specific and discriminating focus of attention of both analyst and anal ysand. Equating surface with the data of observation is problematic for a number of reasons, some of which Paniagua (1991) points out. Levy and Inderbitzin (1990) describe the analytic surface as “some aspect of the patient’s verbal and nonverbal behavior to which the analyst and the a i ia l j sad can direct their attention in order to gain access to important material that will be explored in a consistent, systematic manner” (p. 374). Inderbitzin elaborated that the analytic surface is that subset of data of observation from which a conjecture is formed leading to systematic exploration and interpretation. He suggested that a focus on the analytic surface may help us to understand how

On those wrecked by success: a clinical inquiry.

Freuds description of those wrecked by success outlines conflicted oedipal triumph as the central underlying dynamic in this character type. It does not distinguish those patients who avoid success from those driven to achieve and then wreck their success. We present a complex picture that we believe is prototypic of patients who destroy their success. A clinical case illustrates our point of view. We emphasize the developmental problems we believe typical of patients who dramatically wreck the success they achieve. We hope to extend rather than replace Freuds landmark contribution to our understanding of this type of character pathology.