Richard M. Gottlieb

A psychoanalytic hypothesis concerning the therapeutic action of SSRI medications.

P yet to fulf ill the promise that its theory and unique form of listening would contribute to our understanding of some effects of psychotropic medications. Analysts are said to listen to their patients as do no other students of mind/brain, yet we have of fered no interpretation of the therapeutic benef its of highly effective SSRI (selective serotonin reuptake inhibitor) medications. One confounding factor has been that the SSRIs challenge traditional diagnostic schemes. They bring about improvement in disorders that were not previously thought to be related to each other, such as depression, obsessive-compulsive disorder, and social anxiety.The successes of medications across diagnostic categories suggest unrecognized commonalities among them. Taken together with certain readily observed clinical phenomena (see below), these facts suggest that the essential benefits of these medications derive from their capacity to modify aggression. Few clinicians can have failed to note the repeated reports of successfully medicated depressives to the effect that “I am no longer angry in the way I used to be.” The details vary, but these reports are consistent around the theme of the patient’s being less inclined toward rages, less irritable. Events that in the past might have provoked fury are now merely irritating: “They roll off me.” Some people do not spontaneously volunteer these reports, but they will speak of the change if asked. From others one might only hear, “My friends say I’m easier to get along with.” And most evident of all is a less hurtful attitude toward the self.

Reconstruction in A Two-Person World May Be More About The Present Than The Past: Freud and The Wolf Man, an Illustration:

The psychoanalytic process of reconstruction has yet to be examined from the perspective of today’s two-person psychologies. Earlier writers on the subject have implicated the analyst and his emotional involvement as influences that may distort the valid recovery of memories, while others have written that the transference and the reconstructed past are interdependent. By contrast with both views, it is suggested here that the reconstructed product itself may reflect the transference-countertransference engagement of the dyad: in some instances, and to some extent in all instances, the scene or story of the presumed past will be a version of the current analytic relationship. In certain cases consideration of the conscious and unconscious emotional entanglements of the dyad will reveal that the reconstruction says more about the analytic present than about the past. Freud’s Wolf Man case provides a good illustration of this point. While a broad consensus exists that its famous primal scene reconstruction cannot be veridical, it has most often been dismissed as distorted by Freud’s theoretical commitments. A closer examination of the relationship between Freud and Pankejeff reveals that the reconstruction is an accurate rendering of warded-off aspects of the dyad’s way of being together. The potential clinical utility of adopting this perspective is that it encourages the analyst to reflect on his clinical reconstructions, interrogating them for clues to otherwise elusive aspects of the current clinical relationship.

Mind, madness, and medications: situating psychoanalysis.

E ach of the five papers in this section presents psychoanalytic case material in which psychotropic medications played a role. Consequently, this section gives the impression that the editors and authors have assumed as true an assertion that once was controversial: that psychoanalytic treatment is in fact compatible with the effects of mind-altering drugs and the medical management procedures that necessarily accompany their prescription. Yet not long ago a wellknown and respected analyst of an earlier generation asked me, rhetorically, “How can you psychoanalyze someone who is asleep?” And, of course, by “asleep” he did not literally mean somnolent, but was referring hyperbolically to the effects of psychotropics. Many matters in psychoanalysis that were once controversial have ceased to be so. Examples are abundant. We no longer automatically assume that prior psychotherapy necessarily rules out subsequent psychoanalysis by the same analyst; we no longer assume that psychoanalytic treatment of the chronically ill or the elderly is out of the question, as many analysts did in the past; and we no longer assume that the homosexualities are “illnesses” to be “cured” by psychoanalysis. Certainly there is not unanimous agreement about the feasibility of combined treatment, but a powerful confluence of factors has developed over the past fifteen to twenty years that has contributed to what many consider a sea change in the attitudes of analysts toward this practice. The first of these was the widespread acceptance of a new generation of psychotropic agents heralded by the introduction of Prozac in 1986. Many of the new agents were safer to use and more specific in ja p a

The Reassembly of the Body from Parts: Psychoanalytic Reflections on Death, Resurrection, and Cannibalism

Terror of the dismemberment, disintegration, and decay of the body after death has been represented in ritual, myth, legend, art, and religious belief throughout the ages. So too has the wished-for triumph over these inevitable processes. Commonly, bodily experience after death is represented mentally in cannibalistic ideas of eating and being eaten, which are then countered by the wishful undoing of cannibalistic destruction through its reversal: swallowing as regurgitation, dismemberment as re-memberment, disintegration as reassembly. Luca Signorellis fresco The Resurrection of the Flesh is part of his celebrated group of decorations (1499-1504) of the Cappella Nuova in the cathedral at Orvieto. The doctrinal, iconographic, social, and political contexts of this admired and influential work are explored in order to illustrate how and why this painting represents our greatest fears, along with our triumph over them, as well as our most destructive urges and their reparative counterparts. The photographer Sally Mann has explored these same themes. In What Remains (2003), a series of pictures with accompanying text, Mann documents her exhumation and reassembly of the body of her beloved pet greyhound. Two clinical examples illustrate some ways these concerns (cannibalism and reassembly) may make their appearance in psychoanalytic work.

Therapies in collision: introduction to Purcell.

I ts footfalls muffled, the psychotropic revolution has been stealing up on psychoanalytic clinical practice over the past quarter century. There is now a convincing accumulation of evidence that psychopharmacological agents are regularly deployed in conjunction with psychoanalytic treatment at all levels of experience: from training analyses of candidates to regular therapeutic analyses to the analyses performed by candidates under supervision. If we add to these all of those gray-area cases of psychoanalytic psychotherapies approaching psychoanalysis in their depth and therapeutic reach, it is obvious that the pharmaco-pervasion of our technique is significant. Although our technique has been profoundly affected, our theories have, in contrast, lagged behind. Even as the addition of medication to psychoanalytic therapy has become a widely accepted practice, our ideas about it have remained curiously undeveloped and one-sided. Mostly we have addressed one dimension of the problem, contributing a profusion of ideas explaining the symbolism of added medication and its choreography (e.g., “split” treatments, the act of prescribing, inquiries about side effects), but we have had little to say about its “direct” effects on mind/ brain functioning. Moreover, when considering medication, analysts have accepted the diagnostic categories of the DSM and been compelled, for want of anything better, to turn to studies based on these as the only ones with sufficient statistical power to rationalize our clinical decisions. (One promise of the Psychodynamic Diagnostic Manual [PDM Task Force 2006] is the ultimate delineation of theoretically and empirically coherent psychodynamic categories against which various therapeutic approaches, including medication, can be tested.) The paper that follows this introduction, by Stephen D. Purcell, defines a direction away from our exclusive reliance on DSM-based thinking. Purcell argues that even when DSM considerations suggest the use of a particular class of medications, psychoanalytic considerations may argue more strongly against such use. At first glance Purcell’s argument may be ja PP a

A patient returns: editors' introduction.

W are publishing these five contributions together, under the rubric “A Patient Returns,” because they reflect the experience of a group of experienced, highly respected senior analysts—major contributors to our field throughout their long careers. While there are important differences among them, we also note important similarities. Perhaps the most important similarity is the one alluded to by Shelley Orgel in his paraphrase of Mark Twain. “When I was a boy of fourteen,” Twain wrote, “my father was so ignorant I could hardly stand to have the old man around. But when I got to be twenty-one, I was astonished at how much the old man had learned in seven years.” While Twain’s comic irony relies on the fact that it is the son who changed, not the father, the emphasis of our authors is on how much they, the analysts, have changed. It is to these changes that we wish to call readers’ attention. We are most interested in changes in the analysts’ technique, the ways they behaved with their returning patients. What we read repeatedly (but not universally) is that they are today more “relaxed,” more flexible, and more demonstrative of their own emotions. They disclose more about themselves and their feelings toward their analysands. There is more of a sense of the importance of “the relationship” than in the first treatments. Self-reflection is more often and more successfully used as a means to access the analytic process. The analysts may be less reliant on making the “correct” interpretation than in the past. They speak more about the analytic dyad, even the analytic “couple,” and only much less about doctor and patient, analyst and analysand. Use of the couch is rare, analysts and patients now preferring onceor twice-weekly sessions facing one another. Much of these analysts’ thinking about their therapeutic work today is redolent of the increasingly accepted analogy between the therapeutic situation and the very early one between mothers and their infants, especially their positive valences: caring, nurturing, mirroring, holding. Our authors rather naturally find themselves comparing their modes of