Short-term Psychoanalytic Psychotherapy: “a Construction Zone”

Introduction

Occasionally brief therapy is the treatment of choice. More frequently, necessity rules: that is, neither therapist nor patient has the time or the (financial or psychological) resources to undertake a more open-ended psychoanalysis; public/institutional practice will likely mandate brief therapy, too. Necessity argues that the “pure gold” of psychoanalysis must give way to the “copper of direct suggestion” (Freud, 1919, p. 193) in shortterm psychoanalytic psychotherapy.

Hildebrand (1986, p. 8) says: “A brief therapist … needs to be very much on his toes.” In other words, brief dynamic therapy¹ must be active, directive, suggestive, focal, reality-based, interpersonally anchored, mostly present-centered, and antagonistic to regression. In short-term psychoanalytic psychotherapy, therapist and patient cannot collude with passivity or the timelessness of the unconscious (Bonaparte, 1940; Mann, 1973). Because time is tight, the analytic process is condensed. In other words, the clock is ticking; the meter is running. Therapist and patient have been likened to two strangers on a train rushing head-long to an intimate encounter that must end at the next stop (Stierlin, 1968). Brief therapy is sudden intimacy.

This comment argues that the therapist’s grasp of the issues, the empathic forays, the effort to understand the patient, the task of constructing a model of the patient’s life past and present, all are necessarily condensed in short-term psychoanalytic psychotherapy (hereafter, STPP). I will argue that constructions, conjectures on what might have happened, despite the cautionary flags, are necessary and justifiably more frequent in STPP than psychoanalysis. It is a construction zone. I will offer two very brief, garden-variety vignettes (therapist cleverness is not the issue here) to illustrate the use of constructions in short-term psychoanalytic psychotherapy, the discussion culminating in guidelines for their use, before the two parties in psychoanalysis’s most famous reconstruction offer contrasting points of view.

Psychoanalysis Vs. Short-Term Psychoanalytic Psychotherapy

In psychoanalysis, the analyst listens passively, evenly hovering over data that are permissively and slowly sifted over the years in the open spaces among empathy, a working theory of personality, and the transference—countertransference axis. In STPP, the therapist listens actively, in a manner reminiscent of a whirlpool, the data rapidly swirled and funneled into a (focal) vortex collaboratively determined by patient and therapist. Psychoanalysis and short-term psychoanalytic psychotherapy start at the same point: in both the therapist knows nothing about the patient.

However, time is on the side of the analyst; not so the brief therapist. The analyst is in no hurry. Traditional history taking is eschewed. In the formative stages of post-hypnotic technique—the Dora case—Freud (1905, p. 18) said: “It is only towards the end of the treatment that we have before us an intelligible, consistent, and unbroken case history.” Therefore, the earliest phases of treatment are fraught with uncertainty, with many a mystery to be solved. The analyst can wait; not so the brief therapist. In psychoanalysis the analyst may wait till next year; the brief therapist may not be able to wait till the next session. Therapist and patient must proceed without waiting for the sea to give up its dead.

Constructions in Psychoanalysis and Short-Term Psychoanalytic Psychotherapy

Freud (1937, pp. 257-258) sets the table for the discussion that follows: The work of analysis aims at inducing the patient to give up the repressions … belonging to his early development and to replace them by reactions of a sort that would correspond to a psychically mature condition. With this purpose in view he must be brought to recollect certain experiences and the affective impulses called up by them which he has for the time being forgotten.

Even though we assume that “all experience leaves behind a record” (Schachtel, 1947/1959, p. 312; cf, Freud, 1925), many of these “experiences” will not be recalled. There will be gaps in the narrative. “Even the most profound and prolonged psychoanalysis does not lead to a recovery of childhood memory” (Schachtel, 1947/1959, p. 285). Further, there is uncertainty about what is recovered. When the seduction theory was abandoned (although not completely), some recollection was subsequently relabeled or understood as fantasy. Even when memories of childhood experience are gathered, they are often considered “screen memories,” which both reveal and conceal what has been forgotten (Freud, 1899). Subsequent history may be lost to misunderstanding. Semiotic incompetence is to be expected: even Oedipus may have been driven more by mystery than conflict (Levenson, 1983).

Yet, despite the problems in how to recover and how to regard the past, psychoanalysis has never fully relinquished its search for the history that has shaped the present. So, what is the analyst to do? According to Freud (1937, p. 260), the analyst must “construct” a picture of what might have happened, recognizing that these constructions “can often reach only a certain degree of probability.” They are nothing more than “a conjecture which awaits elimination, confirmation or rejection” (Freud, 1937, p. 265).

Familiar rules still apply: no analytic interventions should escape the validation process. What associations follow? What memories follow? Does the construction “result in … an exploration of the experience?” (Paul, 1978, p. 159).

After years of neglect, psychoanalysis has refocused attention to the reconstruction of early experience (Fine & Waldhorn, 1971; Greenacre, 1975; Blum, 1994). A clarification of terms is in order, but a warning: The various writers do not use the terms in a consistent manner. The situation is reminiscent of Humpty-Dumpty, who crowed, “When I use a word, it means whatever I choose it to mean.” Case in point: Freud used the terms reconstruction and constructions in a fairly fungible manner. Interpretations are concerned with the elucidation of meaning, typically aimed at a single psychic element, for example, the unraveling of a parapraxis. Which unconscious wish is obscured by which defense? Constructions refer to “the process of piecing together deductions and inferences drawn from the patient’s productions empathically responded to, developmentally informed and cognitively ordered into tentative hypotheses and formulations” (Curtis, 1983, p. 187, emphasis removed). For example, constructions might refer to the impact of the birth of a sibling on a mother’s availability (Freud, 1937) to the older child. Reconstruction is all that and more. Greenacre (1975, p. 700) describes it as a “part of an ongoing process throughout the entire course of an analysis. It is the joint work of analyst and analysand.” Reconstructions are part of finalizing the big picture, a coherent, meaningful, scientifically and personally plausible story of the impact of the past on the present. Recalling Hildebrand (1986, constructions are “good dialogue” while reconstructions are “good novels” (p. 8). To sum, constructions and reconstructions differ in size, depth, complexity, completeness. and certainty. Spence (1982, p. 35), regarding conjectures as “creative propositions,” remains somewhat indifferent to the issue of historical certainty.

Reconstruction takes us to the heart of the analytic process; Blum (1980, p. 39) offers an ex cathedra endorsement of reconstruction: “the psychoanalytic process may demand it.” Analysis depends on the articulation, understanding and alteration of the past that lives inside us and the past that is often acted out, instead of remembered and mastered (Freud, 1914). Blum (1994, p. 35) agrees: Reconstruction is “the illumination of the past within the present analytic work.” Awareness replaces automatism. Judgment replaces habit. Mature-reality-testing replaces misunderstanding. We can only be whole if fragments and disruptions are pieced together. According to Blum (1980, p. 47), “reconstruction is an integrative act.” We can only be cohesive, if discontinuities are mended. Greenacre (1975, p. 701) concurs: “Reconstruction brings the child and the adult together.” Although it is likely that most reconstructions are aimed at the past, we cannot forget that “the reconstruction of contemporary life is often necessary in adult psychoanalysis” (Blum, 1994, p. 155). Speaking about another here and now relationship, Blum (1994) reminds us that the use of constructions and reconstructions should not be “an escape from current transference conflict to an intellectualized preoccupation with the past” (p. 15).² Nor should we flinch from an analysis of the countertransference: we must determine who is telling the story. Is it the patient’s story or the analyst’s story (Busch, 2003)?

At the same time, constructions, like interpretations, are “explanatory concepts” that carry “the danger of intellectualization” (Bibring, 1954, p. 758). Greenacre (1981) reminds us: “Unless there is this sensitivity to individuality, reconstruction is difficult and may be supplanted by theoretical, intellectualized interpretations (p. 29).” Schafer (1982) admits that theory can saturate reconstructions: “the analyst reconstructs along lines laid down by pre-existing theoretical commitments” (p. 81). Another problem is to be found in the uneven power differential in the analytic setting. The analyst is the authority, often the arbiter of reality. The analyst’s word can be suggestive, the analyst’s “powers of exposition” (Freud, 1918, p. 104) overwhelming the rationality of the patient. When making an interpretation, or construction, Bergmann (1968, p. 275) cautions that therapists should not be too invested in persuading a particular point: “If recall is not forthcoming, I question the wisdom of telling the patient how it must have been” [emphasis added]. Freud reiterates that patients must “have their say” in the validation of any constructions (1937, p. 262)

Two Constructions in Short-Term Psychoanalytic Psychotherapy

Consistent with the need in STPP to select a focus, the following case material is highly condensed, necessarily selective, and artificially extracted from two brief psychoanalytic psychotherapies, the first an inhibited outpatient, the second an irritable inpatient. Both vignettes sample “garden-variety constructions” that were delivered within the initial 5 to 10 sessions. The attentive reader will note that many clinical and conceptual issues must be neglected in this brief comment. If constructions remain somewhat controversial in psychoanalysis, their use in STPP has been utterly neglected. We proceed on the assumption that the brief therapist must intervene before all the data has been collected.

Vignette 1

“Albert” was a 66-year-old, white male, an only child, a college graduate, a married father of three. Childhood was bleak, bereft of affection, with no hugs or kisses, never an “I love you.” He was a latch-key child who lacked the key to his parents’ hearts. He had terrifying experiences with fire in childhood, and later in Vietnam. He survived childhood on what we came to describe as “a thin gruel.”

He came to treatment, “starving.” Although uncomplaining as a child, he now complained that he and his wife—living parallel but distant lives—had not had sex for 26 years and counting. They had had not even disrobed in front of one another since the conception of their third child. He quickly found hope and warmth in our alliance, borrowing some self-esteem and vitality within an idealizing transference. A Civil War buff, Albert likened himself to General McClellan, meaning he was good at drill, but inept and avoidant when it came time to battle. In other words, my patient was good in session (curious, productive, thoughtful, candid, courageous), but fearfully hesitant to leave the session and to ask his wife for “more porridge.”

Construction 1

Albert had expressed disappointment in his parents but could produce very few memories to help us understand the particular affective poverty in which he was raised. In our fifth session, somewhere between his appreciation for my efforts and my (private, unexpressed) wish that there had been someone lovingly available to him as a child, I wondered about family romance fantasies (Freud, 1909). So I asked, “I’ve been wondering, perhaps betting, did you ever—as a child—find anyone who you thought might better parent you?” Validation for this construction—likely premature if this were a classical analysis—followed in a torrent of memories, including:

The construction helped connect his present to his past, filling in some of the gaps. The shared understanding solidified our working relationship and catapulted the treatment forward on a wave of curiosity. The patient took himself as an object of study (Sterba, 1934). In fact his hungry gratitude began to drive the therapy; not too much later in the treatment one could “see” that other ego functions (eg, synthetic function, affect tolerance) began to grow with this nutriment (Rapaport, 1958).

Vignette 2:

Louis was a 55-year-old male, divorced and depressed, angry and agitated. He had been hospitalized following a suicide attempt. He soon spread his misery around the ward, pushing others away, often biting the hand that fed him. Although diagnosed with Bipolar Disorder, it became clear that the ups and downs followed the vicissitudes of his relationships. Initially, he did not regard himself as lonely; instead, other people were self-centered jerks who let him down, frustrating his reasonable wishes. While on the ward, he was seen daily in psychoanalytic psychotherapy. Although he was glad to be with me, sessions were, typically, angry and fairly barren, just before session’s end, he became frantic, clingy and bitter. Although he managed well enough during the week, his mood typically plummeted on the weekends.

Construction 2

During our third Friday session, he complained that there was nothing to do over the weekend in the ward; he was bored (likely a defense against his abandonment rage [Greenson, 1953]), and he felt empty. He spied and then asked to borrow a novel I had in my office. The Monday session was brighter, with nary a complaint of boredom, with no anger at my being away, and capped by Louis spontaneously giving a “book review” of the novel he had borrowed. He commented on the fact that my name was not only ink-stamped on the pages, but also embossed on the title page, which he contentedly palpated as he spoke. It was clear that he seemed to find some comfort in the connection with me, which was otherwise an inadequate umbilicus when we were apart. My book appeared to help him summon my soothing presence. Object constancy deficits were suspected. Was my book a cognitive prosthesis in the absence of evocative memory (Fraiberg, 1969)? In the absence of any relevant memories, I wondered, aloud: “Do you think you have trouble bringing to mind the comforting presence of anybody when you feel alone. Perhaps someone was not available to you when you needed them to equip you with the strength to be alone.” Of course I had no expectation that he could recall the key eras and events along the road to object constancy, which is usually consolidated between 12 and 24 months. He insisted that he had not heard any “family stories” about his lonely beginnings. However, my tentative construction did set several things in motion in- and outside his mind. He associated about how lonely he felt on holidays, which he called “horror-days,” because he was generally all alone. With some embarrassment, he confessed to often using prostitutes on those “horror-days” when he felt, “not horny,” but desperately alone. Although I assigned no such homework, a swelling curiosity sparked Louis to do some spadework into his family history. Hopeful of lifting the veil on his early experience, Louis asked an elderly aunt (his mother’s sister) about his younger days. He was told, for the first time, that when he was between 12 and 24 months old, his mother lost a baby, who was stillborn; she was profoundly depressed for nearly a year. An uncertain cast of characters helped care for him during the time of his mother’s malignant grief. Abandonment, oral rage, and impaired object constancy set the stage for the development of his borderline personality structure.

Constructions in Short-Term Psychoanalytic Psychotherapy

Reconstructions might be considered the bookends to Freud’s psychoanalytic career. That is, psychoanalysis was born in Freud’s self-analysis, which depended upon a reconstruction of his past. Reconstructions figure prominently in the classic case studies, especially the “Wolf-Man” (Blum, 1977). And constructions in analysis are the subject of Freud’s (1937) last technical paper, “Constructions in Analysis.” Coming late in his career/life, the paper may carry some extra weight, some urgency, a summing up of analytic technique, the terminal place in Freud’s technical bibliography, signaling its importance. It’s time to remember that:

A good, well-timed construction links the past and the present, the child and the adult: “Do you see roots of this behavior. Is it possible that your child is the father to your man?” Constructions model our curiosity, and they demonstrate our intent to put things together, to figure out things, attitudes, and actions worthy of identification: “I’d like to figure this out. Are you curious about this?” A good construction is followed by derivative material, more grist for the mill: “While we consider this, let’s see what comes to mind as you think about it.” Constructions make clear that we wish to explain things in a psychological manner, challenging the patient who might retreat to biology: “Instead of simply concluding you were ‘born that way,’ we could consider some alternative hypotheses.” Schachtel, 1985, throws down the gauntlet: “The adult is usually not capable of experiencing what the child experiences; more often than not he is not even capable of imagining what the child experiences” (p. 285). Yet that is what psychoanalysis demands of the analyst, who, is fortunate to have masses of material over a time period. This is unimaginable to the brief therapist. Time, density, and sheer amount of material for (mutual) consideration obviously influence what we say, how soon we say it, how often we say it, and how firmly we might believe it. Reik (1948, p. 219) lays bare the problem:

the way leading to conjecture of the unconscious meaning of a symptom, fantasy, or given behavior, varies with the nature and extent of the available psychological evidence. At an advanced stage of the analysis, when we have already discovered much about the patient’s psychical conditions and motives and are familiar with his individual manner of reacting, we conjecture with greater assurance.

Reik’s unarguable advice leads to the consideration of the following syllogism: Constructions follow gaps in the patient’s narrative. There are more gaps in STPP than in psychoanalysis. Therefore, there will be more constructions in STPP than psychoanalysis. It is a construction zone. Quod erat demonstrandum. No matter their frequency, certain rules should prevent the therapist from “shooting from the hip.” I offer the following “Ten Commandments” for the use of constructions in STPP:

Even when operating carefully within the construction zone, some uncertainty is inevitable. Should that stop the therapist? The parties involved in psychoanalysis’s most famous reconstruction offer conflicting answers to that question: Freud (1918, p. 104) says, “It is better to perform the task badly than to take flight before it,” in effect arguing that constructions are a necessary part of the psychoanalytic process. His partner in reconstruction, the Wolf-Man, years later, struck a more cautionary note (presumably aimed at all of us):

When one tries to reconstruct a childhood neurosis after twenty or thirty years, one must depend on circumstantial evidence. From legal practice one knows how often circumstantial evidence can lead to false conclusions, since one is forced to deduce causes from results (Gardiner, 1971, p. 344).

In the end we conclude that every construction probably repeats the necessary tension between Freud and the Wolf-Man. We weren’t there, but constructions help us get there.