Excerpts from Must Read Books & Articles on Mental Health Topics
Articles- Part XVI



Constructions in Analysis
Sigmund Freud (1937)

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It has always seemed to me to be greatly to the credit of a certain well-known man of science that he treated psychoanalysis fairly at a time when most other people felt themselves under no such obligation. On one occasion, nevertheless, he gave expression to an opinion upon analytic technique which was at once derogatory and unjust. He said that in giving interpretations to a patient we treat him upon the famous principle of "Heads I win, tails you lose." That is to say, if the patient agrees with us, then the interpretation is right; but if he contradicts us, that is only a sign of his resistance, which again shows that we are right. In this way we are always in the right against the poor helpless wretch whom we are analysing, no matter how he may respond to what we put forward. Now, since it is in fact true that a "No" from one of our patients is not as a rule enough to make us abandon an interpretation as incorrect, a revelation such as this of the nature of our technique has been most welcome to the opponents of analysis. It is therefore worthwhile to give a detailed account of how we are accustomed to arrive at an assessment of the "Yes" or "No" of our patients during analytic treatment--of their expression of agreement or of denial. The practising analyst will naturally learn nothing in the course of this apologia that he does not already know.
     It is familiar ground that the work of analysis aims at inducing the patient to give up the repressions (using the word in the widest sense) belonging to his early life and to replace them by reactions of a sort that would correspond better to a psychically mature condition. It is with this purpose in view that he must be got to recollect certain experiences and the emotions called up by them which he has at the moment forgotten. We know that his present symptoms and inhibitions are the consequences of repressions of this kind: that is, that they are a substitute for these things that he has forgotten. What sort of material does he put at our disposal which we can make use of to put him on the way to recovering the lost memories? All kinds of things. He gives us fragments of these memories in his dreams, invaluable in themselves but seriously distorted as a rule by all the factors concerned in the formation of dreams. Again, he produces ideas, if he gives himself up to "free association," in which we can discover allusions to the repressed experiences and derivatives of the suppressed emotions as well as of the reactions against them. And finally, there are hints of repetitions of the affects belonging to the repressed material to be found in actions performed by the patient, some important, some trivial, both inside and outside the analytic situation. Our experience has shown that the relation of transference, which becomes established towards the analyst, is particularly calculated to favour the reproduction of these emotional connections. It is out of such raw material--if we may so describe it--that we have to put together what we are in search of.
     What we are in search of is a picture of the patient's forgotten years that shall be alike trustworthy and in all essential respects complete. But at this point we are reminded that the work of analysis consists of two quite different portions, that it is carried on in two separate localities, that it involves two people, to each of whom a distinct task is assigned. It may for a moment seem strange that such a fundamental fact should not have been pointed out long ago; but it will immediately be perceived that there was nothing being kept back in this, that it is a fact which is universally known and even self-evident and is merely being brought into relief here and separately examined for a particular purpose. We all know that the person who is being analysed has to be induced to remember something that has been experienced by him and repressed; and the dynamic determinants of this process are so interesting that the other portion of the work, the task performed by the analyst, has been pushed into the background. The analyst has neither experienced nor repressed any of the material under consideration: his task cannot be to remember anything. What then is his task? His task is to make out what has been forgotten from the traces which it has left behind or, more correctly, to construct it. The time and manner in which he conveys his constructions to the person who is being analysed, as well as the explanations with which he accompanies them, constitute the link between the two portions of the work of analysis, between his own part and that of the patient.
     His work of construction, or, if it is preferred, of reconstruction, resembles to a great extent an archaeologist's excavation of some dwelling-place that has been destroyed and buried or of some ancient edifice. The two processes are in fact identical, except that the analyst works under better conditions and has more material at his command to assist him, since what he is dealing with is not something destroyed but something that is still alive--and perhaps for another reason as well. But just as the archaeologist builds up the walls of the building from the foundations that have remained standing, determines the number and position of the columns from depressions in the floor and reconstructs the mural decorations and paintings from the remains found in the debris, so does the analyst proceed when he draws his inferences from the fragments of memories, from the associations and from the behaviour of the subject of the analysis. Both of them have an undisputed right to reconstruct by means of supplementing and combining the surviving remains. Both of them, moreover, are subject to many of the same difficulties and sources of error. One of the most ticklish problems that confronts the archaeologist is notoriously the determination of the relative age of his finds; and if an object makes its appearance in some particular level, it often remains to be decided whether it belongs to that level or whether it was carried down to that level owing to some subsequent disturbance. It is easy to imagine the corresponding doubts that arise in the case of analytic constructions.
     The analyst, as we have said, works under more favourable conditions than the archaeologist since he has at his disposal material which can have no counterpart in excavations, such as the repetitions of reactions dating from infancy and all that emerges in connection with these repetitions through the transference. But in addition to this it must be borne in mind that the excavator is dealing with destroyed objects of which large and important portions have quite certainly been lost, by mechanical violence, by fire and by plundering. No amount of effort can result in their discovery and lead to their being united with the surviving fragments. The one and only course left open is that of reconstruction, which for this very reason can often reach only a certain degree of probability. But it is different with the psychical object whose early history the analyst is seeking to recover. Here we are regularly met by a situation which in archaeology occurs only in such rare circumstances as those of Pompeii or of the tomb of Tutankhamen. All of the essentials are preserved, even things that seem completely forgotten are present somehow and somewhere, and have merely been buried and made inaccessible to the subject. Indeed, it may, as we know, be doubted whether any psychical structure can really be the victim of total destruction. It depends only upon analytic technique whether we shall succeed in bringing what is concealed completely to light. There are only two other facts that weigh against the extraordinary advantage which is thus enjoyed by the work
of analysis: namely, that psychical objects are incomparably more complicated than the excavator's material ones and that we have insufficient knowledge of what we may expect to find, since their finer structure contains so much that is still mysterious. But our comparison between the two forms of work can go no further than this; for the main difference between them lies in the fact that for the archaeologist the reconstruction is the aim and end of his endeavours while for analysis the construction is only a preliminary labour.

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It is not, however, a preliminary labour in the sense that the whole of it must be completed before the next piece of work can be begun, as, for instance, is the case with housebuilding, where all the walls must be erected and all the windows inserted before the internal decoration of the rooms can be taken in hand. Every analyst knows that things happen differently in an analytic treatment and that there both kinds of work are carried on side by side, the one kind being always a little ahead and the other following upon it. The analyst finishes a piece of construction and communicates it to the subject of the analysis so that it may work upon him; he then constructs a further piece out of the fresh material pouring in upon him, deals with it in the same way and proceeds in this alternating fashion until the end. If, in accounts of analytic technique, so little is said about "constructions," that is because "interpretations" and their effects are spoken of instead. But I think that "construction" is by far the more appropriate description. "Interpretation" applies to something that one does to some single element of the material, such as an association or a parapraxis. But it is a "construction" when one lays before the subject of the analysis a piece of his early history that he has forgotten, in some such way as this: "Up to your nth year you regarded yourself as the sole and unlimited possessor of your mother; then came another baby and brought you grave disillusionment. Your mother left you for some time, and even after her reappearance she was never again devoted to you exclusively. Your feelings towards your mother became ambivalent, your father gained a new importance for you,". . . and so on.
     In the present paper our attention will be turned exclusively to this preliminary labour performed by constructions. And here, at the very start, the question arises of what guarantee we have while we are working on these constructions that we are not making mistakes and risking the success of the treatment by putting forward some construction that is incorrect. It may seem that no general reply can in any event be given to this question; but even before discussing it we may lend our ear to some comforting information that is afforded by analytic experience. For we learn from it that no damage is done if, for once in a way, we make a mistake and offer the patient a wrong construction as the probable historic truth. A waste of time is, of course, involved, and anyone who does nothing but present the patient with false combinations will neither create a very good impression on him nor carry the treatment very far; but a single mistake of the sort can do no harm. What in fact occurs in such an event is rather that the patient remains as though he were untouched by what has been said and reacts to it with neither a "Yes" nor a "No." This may possibly mean no more than that his reaction is postponed; but if nothing further develops we may conclude that we have made a mistake and we shall admit as much to the patient at some suitable opportunity without sacrificing any of our authority. Such an opportunity will arise when some new material has come to light which allows us to make a better construction and at the same time to correct our error. In this way the false construction drops out, as if it had never been made; and, indeed, we often get an impression as though, to borrow the words of Polonius, our bait of falsehood had taken a carp of truth. The danger of our leading a patient astray by suggestion, by persuading him to accept things which we ourselves believe but which he ought not to, has certainly been enormously exaggerated. An analyst would have had to behave very incorrectly before such a misfortune could overtake him; above all, he would have to blame himself with not allowing his patients to have their say. I can assert without boasting that such an abuse of "suggestion" has never occurred in my practice.
     It already follows from what has been said that we are not at all inclined to neglect the indications that can be inferred from the patient's reaction when we have offered him one of our constructions. The point must be gone into in detail. It is true that we do not accept the "No" of a person under analysis at its face value; but neither do we allow his "Yes" to pass. There is no justification for accusing us of invariably twisting his remarks into an assent. In reality things are not so simple and we do not make it so easy for ourselves to come to a conclusion.
     A plain "Yes" from a patient is by no means unambiguous. It can indeed signify that he recognizes the correctness of the construction that has been presented to him; but it can also be meaningless, or can even deserve to be described as "hypocritical," since it may be convenient for his resistance to make use of an assent in such circumstances in order to prolong the concealment of a truth that has not been discovered. The "Yes" has no value unless it is followed by indirect confirmations, unless the patient, immediately after his "Yes," produces new memories which complete and extend the construction. Only in such an event do we consider that the "Yes" has dealt completely with the subject under discussion.
     A "No" from a person in analysis is no more unambiguous than a "Yes," and is indeed of even less value. In some rare cases it turns out to be the expression of a legitimate dissent. Far more frequently it expresses a resistance which may have been evoked by the subject-matter of the construction that has been put forward but which may just as easily have arisen from some other factor in the complex analytic situation. Thus, a patient's "No" is no evidence of the correctness of a construction, though it is perfectly compatible with it. Since every such construction is an incomplete one, since it covers only a small fragment of the forgotten events, we are free to suppose that the patient is not in fact disputing what has been said to him but is basing his contradiction upon the part
that has not yet been discovered. As a rule he will not give his assent until he has learnt the whole truth--which often covers a very great deal of ground. So that the only safe interpretation of his "No" is that it points to incompleteness; there can be no doubt that the construction has not told him everything.
     It appears, therefore, that the direct utterances of the patient after he has been offered a construction afford very little evidence upon the question whether we have been right or wrong. It is of all the greater interest that there are indirect forms of confirmation which are in every respect trustworthy. One of these is a form of words that is used (almost as though there were a conspiracy) with very little variation by the most different people: "I've never thought (or, I should never have thought) that (or, of that)." This can be translated without any hesitation into: "Yes, you're right this time--about my unconscious." Unfortunately this formula which is so welcome to the analyst, reaches his ears more often after single interpretations than after he has produced an extensive construction. An equally valuable confirmation is implied (expressed this time positively) when the patient answers with an association which contains something similar or analogous to the subject-matter of the construction. Instead of taking an example of this from an analysis (which would be easy to find but lengthy to describe) I prefer to give an account of a small extra-analytical experience which presents a similar situation so strikingly that it produces an almost comic effect. It concerned one of my colleagues who--it was long ago--had chosen me as a consultant in his medical practice. One day, however, he brought his young wife to see me, as she was causing him trouble. She refused on all sorts of pretexts to have sexual relations with him, and what he expected of me was evidently that I should lay before her the consequences of her ill-advised behaviour. I went into the matter and explained to her that her refusal would probably have unfortunate results for her husband's health or would lay him open to temptations that might lead to a breakup of their marriage. At this point he suddenly interrupted me with the remark: "The Englishman you diagnosed as suffering from a cerebral tumour has died too." At first the remark seemed incomprehensible; the "too" in his sentence was a mystery, for we had not been speaking of anyone else who had died. But a short time afterwards I understood. The man was evidently intending to confirm what I had been saying; he was meaning to say: "Yes, you're certainly quite right. Your diagnosis was confirmed in the case of the other patient too." It was an exact parallel to the indirect confirmations that we obtain in analysis from associations. I will not attempt to deny that there were other thoughts as well, put on one side by my colleague, which had a share in determining his remark.
     Indirect confirmation from associations that fit in with the content of a construction--that give us a "too" like the one in my story--provide a valuable basis for judging whether the construction is likely to be confirmed in the course of the analysis. It is particularly striking when a confirmation of this kind slips into a direct denial by means of a parapraxis. I once published elsewhere a nice example of this. The name "Jauner" (a familiar one in Vienna) came up repeatedly in one of my patient's dreams without a sufficient explanation appearing in his associations. I finally put forward the interpretation that when he said "Jauner" he probably meant "Gauner" [swindler], whereupon he promptly replied: "That seems to me too 'jewagt' [instead of 'gewagt' (farfetched)]." Or there was the other instance, in which, when I suggested to a patient that he considered a particular fee too high, he meant to deny the suggestion with the words "Ten dollars mean nothing to me" but instead of dollars put in a coin of lower denomination and said "ten shillings."
     If an analysis is dominated by powerful factors that impose a negative therapeutic reaction, such as a sense of guilt, a masochistic need for suffering or a striving against receiving help from the analyst, the patient's behaviour after he has been offered a construction often makes it very easy for us to arrive at the decision that we are in search of. If the construction is wrong, there is no change in the patient; but if it is right or gives an approximation to the truth, he reacts to it with an unmistakable aggravation of his symptoms and of his general condition.
     We may sum the matter up by asserting that there is no justification for the reproach that we neglect or underestimate the importance of the attitude taken up by those under analysis towards our constructions. We pay attention to them and often derive valuable information from them. But these reactions on the part of the patient are rarely unambiguous and give no opportunity for a final judgement. Only the further course of the analysis enables us to decide upon the correctness or uselessness of our constructions. We do not pretend that an individual construction is anything more than a conjecture which awaits examination, confirmation or reaction. We claim no authority for it, we require no direct agreement from the patient, nor do we argue with him if at first he denies it. In short, we conduct ourselves upon the model of a familiar figure in one of Nestroy's farces--the man-servant who has a single answer on his lips to every question or objection: "All will become clear in the course of future developments."

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It is hardly worth while describing how this occurs in the process of the analysis--the way in which our conjecture is transformed into the patient's conviction. All of this is familiar to every analyst from his daily experience and is intelligible without difficulty. Only one point requires investigation and explanation. The path that starts from the analyst's construction ought to end in the patient's recollection; but it does not always lead so far. Quite often we do not succeed in bringing the patient to recollect what has been repressed. Instead of that, if the analysis is carried out correctly, we produce in him an assured conviction of the truth of the construction which achieves the same therapeutic result as a recaptured memory. The problem of what the circumstances are in which this occurs and of how it is possible that what appears to be an incomplete substitute should nevertheless produce a complete result--all of this is material for a later enquiry.
     I shall conclude this brief paper with a few remarks which open up a wider perspective. I have been struck by the manner in which, in certain analyses, the communication of an obviously apt construction has evoked in the patients a surprising and at first incomprehensible phenomenon. They have had lively recollections called up in them--which they themselves have described as "unnaturally distinct"--but what they have recollected has not been the event that was the subject of the construction but details relating to that subject. For instance, they have recollected with abnormal sharpness the faces of the people involved in the construction or the rooms in which something of the sort might have happened, or, a step further away, the furniture in such rooms--on the subject of which the construction had naturally no possibility of any knowledge. This has occurred both in dreams immediately after the construction had been put forward and in waking states in the nature of a day-dream. These recollections have themselves led to nothing further and it has seemed plausible to regard them as the product of a compromise. The "upward drive" of the repressed, stirred into activity by the putting forward of the construction, has striven to carry the important memory-traces into consciousness; but a resistance has succeeded--not, it is true, in stopping that movement--but in displacing it on to adjacent objects of minor significance.
     These recollections might have been described as hallucinations if a belief in their actual presence had been added to their clearness. The importance of this analogy seemed greater when I noticed that true hallucinations occasionally occurred in the case of other patients who were certainly not psychotic. My line of thought proceeded as follows. Perhaps it may be a general characteristic of hallucinations to which sufficient attention has not hitherto been paid that in them something that has been experienced in infancy and then forgotten reemerges--something that the child has seen or heard at a time when he could still hardly speak and that now forces its way into consciousness, probably distorted and displaced owing to the operation of forces that are opposed to this re-emergence. And, in view of the close relation between hallucinations and particular forms of psychosis, our line of thought may be carried still further. It may be that the delusions into which these hallucinations are so constantly incorporated may themselves be less independent of the upward drive of the unconscious and the return of the repressed than we usually assume. In the mechanism of a delusion we stress as a rule only two factors: the turning away from the real world and its forces on the one hand and the influence exercised by wish fulfilment upon the subject-matter of the delusion on the other. But may it not be that the dynamic process is rather that the turning away from reality is exploited by the upward drive of the repressed in order to force its subject-matter into consciousness, while the resistances stirred up by this process and the impulse to wish-fulfilment share the responsibility for the distortion and displacement of what is recollected? This is after all the familiar mechanism of dreams, which intuition has equated with madness from time immemorial.
     This view of delusions is not, I think, entirely new, but it nevertheless emphasizes a point of view which is not usually brought into the foreground. The essence of it is that there is not only method in madness, as the poet has already perceived, but also a fragment of historic truth; and it is plausible to suppose that the compulsive belief attaching to delusions derives its strength precisely from infantile sources of this kind. All that I can produce today in support of this theory are reminiscences, not fresh impressions. It would probably be worth while to make an attempt to study cases of the disorder in question on the basis of the hypotheses that have been here put forward and also to carry out their treatment upon the same lines. The vain effort would be abandoned of convincing the patient of the error of his delusion and of its contradiction of reality; and, on the contrary, the recognition of its kernel of truth would afford common ground upon which the therapeutic process could develop. That process would consist in liberating the fragment of historic truth from its distortions and its attachments to the actual present day and in leading it back to the point in the past to which it belongs. The transposing of material from a forgotten past on to the present or on to an expectation of the future is indeed a habitual occurrence in neurotics no less than in psychotics. Often enough, when a neurotic is led by an anxiety-state to expect the occurrence of some terrible event, he is in fact merely under the influence of a repressed memory (which is seeking to enter consciousness but cannot become conscious) that something which was at that time terrifying did really happen. I believe that we should gain a great deal of valuable knowledge from work of this kind upon psychotics even if it led to no therapeutic success.
     I am aware that it is of small service to handle so important a subject in the cursory fashion that I have here employed. But none the less I have not been able to resist the seduction of an analogy. The delusions of patients appear to me to be the equivalents of the constructions which we build up in the course of an analytic treatment--attempts at explanations and cure, though it is true that these, under the conditions of a psychosis, can do no more than replace the fragment of reality that is being repudiated in the present by another fragment that had already been repudiated in the remote past. It will be the task of each individual investigation to reveal the intimate connections between the material of the present repudiation and that of the original repression. Just as our construction is only effective because it recovers a fragment of lost experience, so the delusion owes its convincing power to the element of historic truth which it inserts in the place of rejected reality. In this way a proposition which I originally asserted only of hysteria would apply also to delusions--namely, that those who are subject to them are suffering from their own recollections. I never intended by this short formula to dispute the complexity of the causation of the illness or to exclude the operation of many other factors.
     If we consider mankind as a whole and substitute it for the single human individual, we discover that it too has developed delusions which are inaccessible to logical criticism and which contradict reality. If, in spite of this, they are able to exert an extraordinary power over men, investigation leads us to the same explanation as in the case of the single individual. They owe their power to the element of historic truth which they have brought up from the repression of the forgotten and primaeval past.



What is Psychoanalysis? How does it Work?
Murray Meisels (Paper presented to the Michigan Psychoanalytic Council in 2003.)

What is Psychoanalysis?
Psychoanalysis has been defined in numerous ways. Merton Gill, a classical analyst then at the Menninger Clinic, defined psychoanalysis during the post-war period as a theory of personality, a method of research, and a mode of treatment. As a treatment, he stated that it required 4x or 5x sessions a week on the couch during which the analysand would reexperience infantile material, develop a transference, and resolve it by using the analyst's interpretations. Several decades later, while living in Chicago, he changed his mind and said that any treatment that dealt with transference was psychoanalytic, even if it occurred once a week. With that latter definition, many critics thought that he had moved outside of the field of psychoanalysis. However, I find both definitions useful, depending on circumstances.
     I have also favored Karen Horney's (1939) definition. Horney was a German psychoanalyst from Berlin who emigrated to America and evolved her own theories starting in the 1930's. Generally regarded as a culturalist, she considered that psychoanalytic theories entailed a theory of personality, a focus on early childhood and developmental influences, an appreciation of the role of unconscious factors, some theory of conflict, anxiety and defense, and a method of treatment.
In the early 1980's I helped conduct a survey of the members of the Division of Psychoanalysis of the American Psychological Association (see Meisels and O'Dell, 1994). One of the questions was: What three psychoanalytic concepts are most important to you? The three concepts turned out to be transference and countertransference, development, and treatment techniques. Thus, from an empirical point of view, psychoanalysts could be defined as those people who are interested in the vagaries of human relationships (transference and countertransference), in development, and in psychological treatment.
     A definition that recently caught my fancy, however, is vastly different from these because it addresses not the workaday psychoanalytic world but is a characterization of psychoanalysis from an outsider's view. Douglas Kirsner, an Australian historian, studied psychoanalytic institutes in the USA. His definition, "Psychoanalysis is a humanistic discipline that is touted as a science but is organized as a religion (2001, p. 195)." His book, which summarizes his findings about the operation and structure of four psychoanalytic institutes of the American Psychoanalytic Association (APsaA), is called, Unfree Associations: Inside Psychoanalytic Institutes (2000). Kirsner studied four of the premier institutes of ApsaA, those in Boston, Chicago, Los Angeles and the New York Psychoanalytic in New York.. What he found in all four was power politics and dogmatism. Those institutes were controlled by a power elite who maintained a particular ideology, dispersed cases and teaching privileges to their own acolytes and adherents, and did not tolerate academic freedom or dissent. Those younger colleagues and students who followed the accepted ideology, and who diligently supported the leadership and worked for the association, could work their way up the hierarchy and eventually become training analysts. Only training analysts could analyze candidates, and the status of training analyst was awarded only to few institute analysts. In those institutes, the status of training analyst was a virtual guarantee of financial and professional success. According to Kirsner, the young analyst had to be politically savvy and ideologically correct, had to play up to the powers that be in order to advance, and had to maintain the accepted teachings of his elders. Karen Horney, for example, had her teaching privileges revoked at the New York Psychoanalytic Institute in about 1941 because of the popularity and unorthodoxy of her ideas. Kirsner called these institutes "Unfree Associations" because they were organizations or associations of people who were not free to speak their minds or think their thoughts. His profound argument is that the level of scientific knowledge in psychoanalysis is very low, and that "quasireligious thinking and politics" act as substitutes for scientific knowledge. Thus, instead of ideas being supported by evidence, ideas attain a status of truth via a pronouncement by a leading theorist, and those psychoanalysts who disagree may be ostracized or denounced as being antipsychoanalytic. When leaders of these associations came into conflict with one another, the issues were not resolved by scientific study but by political action. This quasireligious, political structure, Kirsner argues, leads to schisms, processes of anointment, arbitrariness, authoritarianism and the stifling of creativity.
     Fortunately, ApsaA institutes are a minority that comprise only 30 of the approximately 150 psychoanalytic training institutes in the country (see Meisels, 2002). Kirstner did not study any of the 120 or so free-standing institutes, most of which, to this writer's knowledge, are not so religious in tone. There are also other venues where psychoanalysis is taught, such as in universities, clinics and hospitals, and those groups are generally not organized in the cult-like, religious structure described by Kirsner. The Michigan Psychoanalytic Council (MPC), our institute, is a good example of a nonreligious organizational structure. In MPC, membership is open to nonpsychoanalysts: They vote, hold office, read papers and participate in the MPC's psychoanalytic life. Also, MPC does not designate a special cadre of training analysts. Our graduates do not have to spend decades ingratiating themselves in order to eventually analyze candidates. In MPC all analysts are training analysts from the moment of graduation. In my view, the policies of APsaA have generated an Oedipal structure in which their sons and daughters are arbitrarily placed in a prolonged state of helplessness and dependency, while MPC has avoided that Oedipal structure and has not experienced the tyranny of gurus or religious or internecine warfare. Yet, there is still a serious worry because of the lack of a substantive scientific knowledge base. If the solution to that lack in APsaA is dogma and religion, the solution in MPC it to acknowledge our differences and to be tolerant of the diversity of theoretical views amongst us.

Definition of Psychoanalysis
Building on Kirsner's definition, I define psychoanalysis as a psychoeducational discipline that utilizes intense psychoeducational experiences, aspires to be a science, is organized as an ideology, and has had a great influence on the modern world. I shall elaborate on these in order.
First, a psychoeducational discipline. Kirsner say psychoanalysis a humanistic discipline, but I prefer the term psychoeducational. Humanistic sounds too free-floating, too abstract, a term more apt to describe the humanities, the study of art, literature, or foreign languages. Psychoeducational sounds like it can put both of its feet on the ground, that it is practical; it is educational and psychological. It involves intense psychoeducational experiences that provide understanding and education of the psychological functioning of individuals. Psychoeducational is rooted both in psychology, which has scientific aspects that are subject to verification by research, and in education, which has as its goal the progressive development of an individual. Unfortunately, this latter is notoriously difficult to evaluate through research. An alternative to psychoeducational might be the term psychotherapeutic, that is, that psychoanalysis is a psychotherapeutic discipline, but that seems too limiting. Psychotherapeutic refers to mental health and illness, while psychoeducational refers to education and growth, a broader dimension.
     There is a common view that people who seek psychotherapy and psychoanalysis suffer from various diagnosable psychiatric syndromes, and that the treatment of such is the practice of medicine. Indeed, when it comes to billing insurance companies, we all adopt that definition. However, people use our treatments who have no obvious diagnosable symptoms or syndromes. Nor do we directly treat symptoms when people do present them: We talk about symptoms, learn about them, and educate ourselves about them. Analogously, learning yoga or tennis is not a medical treatment, and yet both may provide the student with ample health benefits along with newfound physical skills. That is what we do, provide ample psychological health benefits along with newfound skills in teaching people to observe and understand themselves and others.
     While we may define ourselves as mental health professionals for insurance-billing and licensing purposes, we fundamentally function as psychoeducationalists. Insofar as we define ourselves as mental health professionals, and operate under state mental health licensing laws and collect insurance monies, so are we subject to the pressures of government agencies and insurance companies. Increasingly, this will mean justifying our practices by research evidence of the effectiveness of psychoanalysis. The government and insurance companies are trying to control medical costs by increasingly insisting that treatments have evidence for their effectiveness. This is the Achilles heal of psychoanalysis (see, e.g., Gray, 2002), as well as many other treatments.
Second that psychoanalysis aspires to be a science. I shall start with a brief sketch of the history of the attitude of psychoanalysis towards science. For the first 70 or 80 years of its history psychoanalysts viewed themselves as conducting scientific research in their consulting rooms. Freud, Gill and many other considered the consulting room as the place where psychoanalysts carried out research. Freud's writings are filled with scientific references, and it is clear that he viewed psychoanalysis as science. Sheila Hafter Gray (2002), in an article entitled Evidence-Based Therapeutics that was published in 2002 in the Journal of the American Academy of Psychoanalysis wrote:
     "Freud was an avid contributor to the medical literature of his day. In Studies in Hysteria (Breuer & Freud, 1985) he and Breuer followed the case study model that was practiced by every scientific physician and surgeon of their day…(H)is approach and his reporting style were not different from those of his peers in other medical disciplines (p. 10)." Freud's writings illustrate his view of psychoanalysis as science. Scientists collect facts and produce theories about those facts. Freud's case histories were clinical descriptions and his theories were his efforts to explain his clinical findings. In addition to the case study method, Freud described dreams, slips, wit, symptoms and associations to these phenomena. Typically, Freud reviewed the extant scientific literature in any given area, then presented his own data, and then his theorizing. It was all empirical, although not experimental. Other early psychoanalysts were similarly sure of the scientific nature of their work. They would treat some kind of disorder, identify the dynamics, and publish it as a scientific finding.
In 1945, Otto Fenichel published an encyclopedic work called The Psychoanalytic
Theory of Neurosis. His book summarized the extant Freudian literature regarding many types of psychopathology. Fenichel followed Freud in arguing that all forms of neurotic disturbance were libidinal in nature, and emphasized the role of anxiety or fear in initiating and perpetuating disorders. For example, in the chapter on obsessive-compulsive disorders he spelled out a regression from Oedipal to anal sexuality, emphasized the role of guilt as the major type of anxiety, and provided generous descriptions and case histories regarding the observed obsessive-compulsive defenses of isolation of affect, reaction formation, and undoing. In this and many other writings psychoanalysts presented what they considered to be a scientific theory of neurosis, of its etiology, its features, and its dynamics. The point is that earlier generations of psychoanalysts viewed themselves as doing scientific work, and they believed that they had discovered and developed theories about humankind's fundamental nature.
     For many decades, through the 1970s, psychoanalysis had a great impact on the field of psychology. It was one of the two 'big' theories taught in graduate programs, the other being behaviorism. Psychoanalytic ideas formed the basis for much research, and clinical faculty and graduate students were often psychoanalytically oriented. In the 1960s and early 1970s, this writer was one of those academics who did research using psychoanalytic theory. Indeed, psychoanalytic ideas led to many important research findings. An example is the work of Rene Spitz (1946), who showed that a lack of mothering leads to death or severe developmental impairment in infants. Similarly, John Bowlby (1980) used cross species and observational data for this important theories about attachment and loss. In Michigan, both Selma Freiberg and Henry Krystal have provided research material and integrated psychoanalytic thought into mainstream psychological theories.
     End of phase one. Turn now to 1994, by which time this situation had completely changed. I shall shortly tell you why I chose the year 1994. First off, by 1994 it had long been clear that the facts of psychoanalysis led to numerous theories, and that the findings were themselves influenced by the viewpoint of the analyst. As Michael Balint put it is book, The Basic Fault (1968), Freudian patients dreamed about sex and uncovered Oedipal complexes while Kleinian analysands dreamed about feeding and discovered bad breasts. Freud wanted psychoanalysis to operate on the basis of interpretation and not (dreaded) suggestion, but this may have reflected his concern about and awareness of the analyst's actual contribution to the analysis.
     Second, science had changed. The case study method, as compelling as it sometimes seems, came to be regarded as an exploratory, hypothesis-generating method. The ideas derived from case studies needed to be verified by the gold standard of experimental research. For psychotherapy this meant random clinical trials using double-blind controls. Gray, in her 2002 article, wrote about the new demands from government and insurance companies for evidence-based treatment, and she stated that psychoanalysis, along with many other medical and psychological treatments, has never been tested by random clinical trials.
     Third, by 1994 there were increasing criticism that psychoanalysis was unscientific. The logic of some of this criticism is compelling. One criticism is the indefiniteness of some psychoanalytic concepts. For example, Freud said the deepest fear of men was castration, yet many men do not manifest castration anxiety. Undaunted by the lack of supporting evidence, some Freudians redefined castration fear to mean other things, such that any failing could be viewed as a castration equivalent, any threat as a castration threat; vice versa, any success was viewed as proof that one has not been castrated. Thus, where the data did not support the theory it redefined itself on a slippery slope of changing meanings and downright obfuscation, becoming a religious view rather that an scientific hypothesis.
     Psychoanalysts didn't have a problem with facts in the early years, but now many psychoanalysts have a serious problem with them. Freud was quite clear about what the facts were-dreams, slips, symptoms, associations, and case studies-but when developments in science did not support and extend psychoanalytic theory, the whole field seemed to change. Meaning and clarity were lost. When the infant studies literature published results with contradicted every psychoanalytic theory of infancy, some dismissed the findings. Psychoanalysts had developed theories that babies had certain characteristics or needs or experiences, but when the study of babies didn't support their ideas, they dismissed the data! When John Bowlby published his now-popular books on attachment and loss, his ideas were at first dismissed by some psychoanalysts because they undermined psychoanalytic theory. Ditto for Daniel Stern's work on infancy. At this time, some psychoanalysts devalue findings in the new field of neuropsychoanalysis, and yet others dislike the very concept of evolutionary psychology or evolutionary psychoanalysis. Or that medications have been found to be helpful, or that new findings report a genetic contribution to obsessive-compulsive disorders. Some psychoanalysts have decried efforts to build psychoanalysis on a foundation of facts and have redefined the field as the study of hermeneutics, or intersubjectivity, or personal history.
     Now, to 1994. These problems with facts achieved their most remarkable manifestation in the special 75th edition of the International Journal of Psychoanalysis (IJP), published in 1994. The IJP is the official publication of the International Psychoanalytic Association (IPA), which was founded by Freud to advance the field of psychoanalysis. Most would call the IJP the most prestigious journal in the field. The special 75th anniversary edition featured 29 papers by distinguished psychoanalysts on the topic, What is a clinical fact in psychoanalysis? Well, you might expect the usual material about case studies, dreams, and slips, or maybe some findings from experimental research, but there was hardly any of that. The issue contained 29 papers by 29 distinguished psychoanalysts who seemed to be ignorant of and confused about science. These 29 psychoanalysts presented 29 different definitions of what clinical fact was, and no two definitions were alike. In his introductory comments the editor of the journal said "…I assert that by and large our standards of observation, of clarifying the distinction between observations and conceptualization, and our standards for discussing and debating our observations are extraordinarily low (Tuckett, 1984, p. 865)." In their totality, these papers would indicate that there are no agreed upon facts in psychoanalysis, only extreme subjectivism. Each of the 29 writers had a theory, but there is no way to ever test their theories because there is no agreement about those facts that might support or contradict them. That issue of the IJP could be gleefully used by critics as evidence that psychoanalysis is a pseudoscience. Are we entering a religious phase of psychoanalytic history, as Kirsner in fact asserts?
     In summary of this section, over the last century psychoanalysis went from the offense to the defense. At first, it made the discoveries that excited, upset and challenged the Western world. Psychoanalysis was the cutting edge. From Freud's libido theory to Fromm's marketing personality to Kohut's idealizing transferences it was psychoanalysts who were making the innovations and setting the agenda for psychotherapy, mental health and society. Now, in contract, it is the DSMs, the cognitive behaviorists, and the drug companies that define the mental health agenda. At the same time, the efficacy and effectiveness of clinical psychoanalysis has yet to be scientifically demonstrated with nontreatment controls, let alone in comparison with alternative treatments.
Thus, psychoanalysis aspires to be a science, and manifests some scientific aspects, but has a long way to go.
     Third, psychoanalysis functions as an ideology. I think that for MPC members psychoanalysis functions as an organizing attitude, but with few or no religious overtones. For many in MPC, psychoanalysis is a useful way of thinking about people. It provides insightful and exciting ideas, helps people in understanding and living their own lives, and is very useful for treatment. However religious in tone it may be to some IPA and APsaA members, who seem to manifest an ownership interest in psychoanalysis, I have not found this to be the case in the Division of Psychoanalysis or MPC, or in other non-APsaA institutes and groups that I am familiar with.
     I very much admire the psychoanalytic ideology, or at least my version of it. Namely, that things people say and do have meaning, that people react consciously and unconsciously to the events in their lives, that their lives reflect the influences that have affected them, that the study of people and their lives is a worthwhile project, and that understanding and insight lead to greater self-awareness and to the ability to change. The whole of human history has been affected by the very psychological issues and patterns that we observe. For me, there is still a revolutionary aspect to psychoanalysis, a sense of excitement, of surprise, of the unknown.
     Fourth and lastly, that psychoanalysis has had a great influence on the modern world. Early in the 20th century, psychoanalysis was the only major psychological theory that attracted intellectual interest in the general public. Its influence grew. Psychoanalytic thinking permeated people's consciousness, and psychoanalytic ideas were widely used even without mention of Freud. Concepts such as defense mechanisms, unconscious wishes and psychodynamics flourished and influenced many fields. Perhaps all developments in the broad field of psychotherapy were initiated or influenced by Freud and other psychoanalysts. Numerous academic disciplines utilized psychoanalytic ideas, including psychology, psychiatry, social work, sociology, and anthropology. In the humanities psychoanalysis influenced movies, literature, literary and artistic criticism, biography, history, art and art criticism, political commentary, and more, and has permeated social and intellectual thought. These days I often hear people described as anal, or some dynamic or other proffered by TV personalities or magazines to explain someone's behavior. For example, the recent war in Iraq was widely interpreted as an effort by President Bush to undo his father's error in the prior Gulf War, what might be called a manifest content interpretation..
     Here is an oddball effect of psychoanalysis in the social sphere, one that even psychoanalysts might initially find hard to recognize. It happened after WWII, when Revlon, the cosmetics company, was having trouble selling some lipstick. It so happened that they asked a psychoanalytic psychologist from the Frankfort School, whose name I forget, to see if she could figure out why this was so. Why wasn't the lipstick selling? This psychologist utilized established psychoanalytic technique in a novel way in order to answer this question. What she did was to place a group of women in a room and had them free associate, brainstorm, about Revlon lipstick, and what they did and didn't like about it. This differed from psychoanalysis because the purpose of the associations was not to find our about the meaning of the topic to the individual, but about the meaning of the topic in itself (its unconscious pull). This technique is now called the focus group. The focus group is psychoanalysis applied to social goods. Ever since I relearned about the Revlon story, which I knew in college, I have been interested in how pollsters talk about and interpret the results of their focus groups, as evidenced in political talk shows. Prior to the 2002 election Democratic pollsters found that at the deepest level the Democrats were leading or closing the gap quickly, the exact reverse of what the Republican pollsters found. This is analogous to Adlerians uncovering feelings of inferiority and Jungians finding the shadow. The discussions among pollsters about the most important and deepest meaning of their focus groups results after the election had about them the very familiar tone of psychoanalytic argumentation. Some commentators said the recent Republican victory was due to the war on terror, others said it was Bush's campaigning, and some thought it was a fundamental shift towards conservatism, yet others argued that the Democrats didn't get their message out. The pollsters sounded very much like a group of therapists talking about different possible causes of someone's problems. The search for meaning, whether in politics or literature, or in the study of an individual's life, leaves great uncertainty.
     Reuben Fine (1983) and Janet Malcolm (1981), among others, have pointed out the vast discrepancy between the social effect of psychoanalytic thought and the rather restricted range of it pursued in psychoanalytic academies. Psychoanalysis was brilliantly extended to families, but then family therapists developed nonpsychoanalytic models of family functioning and psychoanalytic theorists left the field. When child and adolescent psychoanalysts in APsaA wanted to become part of the APsaA, they were denied admission--because psychoanalysis was for adults, not children. After the Second World War, the mainstream APsaA establishment was appalled when Franz Alexander posited that psychoanalysis works by providing analysands with a 'corrective emotional experience.' Mainstream Freudian psychoanalysis retreated to the position that psychoanalysis was involved with interpretation only, and, strange as it may sound to the modern ear, psychoanalysts of that era strongly rejected the idea that a corrective emotional experience was analytic. Its paradoxical: Psychoanalytic thought spread even as psychoanalysts focused on an increasingly narrow aspect of the total vision.
     So, that is my definition of psychoanalysis: A psychoeducational discipline that provides intensive psychoeducational experiences, aspires to be a science, functions as an ideology, and has had a great influence on modern world. We turn next to the issue of how psychoanalysis works.

How Does Psychoanalysis Work?
In science, the first step is to discover a reliable, replicable phenomena and the second step is to explain it. For example, heredity is a reliable phenomenon and its mechanism is the unzipping of the DNA genome and its copying. For the field of psychoanalysis, the efficacy of the psychoanalytic treatment should be the reliable, replicable phenomenon that requires an explanation (i.e., a mechanism) for how it works. For psychoanalysis, or any other therapy, the questions are, Does it work?, and if so, by what mechanism? I want to take these questions in order.
     Does psychoanalysis work? There is no research in psychoanalysis that has used experimental and control groups, or randomized clinical trials, to determine whether psychoanalysis in effective. The efficacy of psychoanalysis as a treatment, either in comparison with no-treatment controls or with other treatments, is therefore unknown. Fortunately, there is a type of study that bears on the question. This research is based on retrospective reports, which ask former therapands or analysands to rate their earlier treatments. This type of research does not rise to the level of experimental v. control groups, but it does provide suggestive evidence. A number of such studies have been done, including one by Consumer Reports which polled its membership. All of these studies have found that longer therapies are rated more positively, and this strongly supports psychoanalysis as a treatment, since most long treatments are probably psychoanalytic. All of these studies also found that longer treatments were more effective irrespective of the type of treatment undergone. Thus there were no differences between Freudians or Culturalists, or between psychoanalysts and cognitive behaviorists. Longer therapies are more effective, no matter the theoretical orientation of the treaters.
     The comparison of this finding to educational outcomes is quite strong. Those students who take music lessons for longer periods would profit more from it no matter the teacher, and those who stay in college longer become more educated, irrespective of the rating of the school. What is the mechanism? If psychoanalysis is effective, the next issue would be to explicate the mechanism of change. In psychoanalysis, the mechanism is called the 'action' of psychoanalysis, and there are frequent articles and papers featuring the subject of 'therapeutic action.' The literature on therapeutic action follows the usual style in psychoanalysis, in which a thinker may arrive at an interesting insight and illustrate it by examples, an insight that may become popular among clinicians. The thinker's ideas are often illustrated by case examples, but not tested by research. It is the reading of this rich clinical literature that constitutes training in psychoanalysis, much of which is an ability, at least in MPC, to approach clinical material via listening to the patient and using a variety of approaches and theories.
     It is of interest that, even though the effectiveness of psychoanalysis vis-à-vis controls or other treatments has never been empirically shown, there is a scientific research literature on one postulated mechanism for the (hypothesized) successful effectiveness of psychoanalysis. This research tested the Freudian view of the mechanism of change in psychoanalysis. The research was mostly planned in the 1950s and 1960s, executed in the 1960s and 1970, and reported in the 1980s and 1990s. Freudian psychoanalysts from APsaA did the research, and their viewpoint was that psychoanalysis was an intense experience at 4x and 5x frequencies that featured the establishment of a transference relationship which is worked through by interpretation. This was regarded as the analytic process. This analytic process, featuring the development of a transference neurosis (which stemmed from an unresolved Oedipal Complex), and its resolution via interpretation, was hypothesized to be the mechanism of cure. It was the action of psychoanalysis, the hypothesized mechanism that made psychoanalysis work. The presence of an analytic process would lead to cure; its absence to continuing neurosis.
     It is to the credit of these researchers that undertook this research. They dared to test their beliefs, and they represent the only school of psychoanalysis that has done so. They used standardized psychometric assessments of analysands and therapands prior to the onset of treatment, and at subsequent stages during and following treatment. These were prospective studies and not retrospective reporting, and they used objective assessment instruments developed by the psychoanalytic researchers, and these features bring their research into the scientific arena. The major prediction was that successful outcome would be correlated with the therapies that operated by interpretations and resolutions of (oedipal) transferences. There were four major research laboratories that produced six studies, and Wallerstein (2001) who was the chief investigator on the Menninger study, recently reviewed them. The Menninger study involved a comparison of psychoanalysis and supportive psychotherapy with 42 hospitalized patients. The other three laboratories involved urban outpatients at psychoanalytic clinics in Boston and at two institutes in New York City. The study at the Boston Institute clinic involved 130 patients who were seen for an average of 675 treatment hours. The Columbia Psychoanalytic Center study involved two studies of 1,348 and 237 cases, 40% of whom were in psychoanalysis and 60% in psychotherapy. The New Your Psychoanalytic Institute studies involved a first sample of 82 cases, 40 from a clinic and 42 from private practices, and a second sample was comprised of 160 private practice cases.
After the treatments were completed, their effectiveness was measured using objective tests, including such factors as ego-strength, maturity of object relationships, and severity of psychopathology. A "blind" team of psychoanalysts independently assessed whether an analytic process involving transference and its resolution had occurred. The results of these studies were in striking agreement. The major finding of the largest study, at Columbia, with 1,348 and the 237 cases, was that 60% of the successful cases did not develop an analytic process.
Q. What percent successful cases resolved their problems by working through their transferences?
A. 40%.
Q. What percent of successful cases resolved their problems without an analytic process involving transference and its resolution?
A. 60%.
     In the language of the original study, "a substantially greater proportion of analysands derive therapeutic benefit than develop an analytic process" (cited in Wallerstein, 2001, p. 251). The results were virtually identical in the other studies. Wallerstein, a past president of the IPA and APsaA, whose bona fides should be beyond question, is at pains to write that the results of the Menninger study indicate that "The changes reached in the more supportive therapies seemed …to represent just as much structural change…as the changes reached in the most…analytic cases (2001, pp. 257-258.)." And, "It is clear that an overall…finding-and almost an overriding one-has been the repeated demonstration that a substantial range of changes-in symptoms, in personality functioning and in life-style-have been brought about via the more supportive therapeutic modes…(2001, p. 258)." He even goes on to say that psychoanalysis should no longer be considered a heroic-or last-ditch-treatment technique for the desperately ill, but that supportive treatment should be used.
     Another study completed in Boston entailed an intensive investigation of the treatments of 22 supervised analytic cases at the Boston Psychoanalytic Clinic. They replicated the finding that more patients achieved therapeutic benefits than developed transference neuroses, but they hypothesized that the therapist-patient match might effect the treatment. This hypothesis is of interest because 'the match' is a contemporaneous effect. This hypothesis seems to state that the analytic process is not a necessary result of the inescapable repetition of an infantile process, but that it is very much affected by the analyst, by the match. But this is the fate of all hypotheses when they are tested. They always prove to be more complex than initially thought. The Mount Zion group (Weiss & Sampson, 1986), which does research on psychoanalysis and on psychoanalytic short-term psychotherapy, has found that short-term psychotherapies are more successful when the therapist meets the therapands expectations about what he or she wants from the treatment, which supports the 'match' hypothesis.
The second major finding of these studies was that no one factor predicted successful outcome. There simply was no successful prediction of treatment outcome from the variety of standardized measures used in the initial evaluations and compared to follow-up. This is an odd result, but was found in every study. Either the experimenters used invalid tests, or failed to identify real predictors, neither of which seems likely, or else the interactions between the parties is powerful as to negate the effect of predictor variables. That seems hard to believe, since factors like ego strength, severity of psychopathology, or family history should be robust predictors. Still, at the present time we don't know who will effectively use an analysis. The concept of analyzability is a thus a promise awaiting future developments, and these data support the importance of a trial analysis.

Comment and Conclusion
In reference to the issue of the nature of fact in psychoanalysis, the issue that the prestigious IJP fumbled so badly, I would like to state that the research findings cited above are facts in psychoanalysis. Clinical facts, exactly what that IJP issue was supposed to be about, but wasn't. They are facts because they are public, because they used standardized assessment methods and large samples, and because they have been replicated at independent laboratories. In the everyday world of clinical practice, all of the words, behavior, nonverbals, affects, and communications of the analysand and the analyst are facts of psychoanalysis, and that is so because description is part of science.
.     And now, in closing, it is time to give my theory about these facts. As an inveterate object relationist, these findings are heartening. The six researches on psychoanalytic action all found that supportive relationships were as effective, and as long lasting, as transference relationships. For Freud, positive results were either due to interpretations or suggestion, but today's clinician has a much broader range of techniques, including in alphabetical order, attunement, bearing witness, being with, containing, detoxifying projections, holding, listening, permission giving, reverie, serving as an attachment figure, and support. That retrospective ratings show that the length of the treatment (but not the technique) leads to greater results further supports the role of the relationship. These findings are sympathetic to a relational approach, but not definitive. And not rigorous enough. Because, from a scientific view, we want to specify the mechanism of change. We have to know the mechanism.
     What does seem to be definitive is that the concept that psychoanalytic change requires the experience of transference neuroses is inadequate. I have noticed that I rarely get intense or prolonged transference reactions with individuals undergoing divorce, or with those who have a powerful, wealthy, cold and sadistic parent. For those individuals, their emotional investments are already cathected, and the therapist functions as a witness or a floating positive in the transference. This idea, that transference is not all, and that all is not transference, is a striking one. If taken seriously, this will lead to a rethinking of psychoanalytic theory and technique.

References
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