Interpretation and Change in Psychoanalysis: What is Left of Classical Interpretation
Psychoanalytic interpretation, traditionally considered the specific intervention of the analyst and the driving force of therapeutic change, is presently in a state of profound crisis. A symptom of this is the prevailing uncertainty in defining this type of intervention. Originally, in The Interpretation of Dreams (1900), Freud linked the meaning of the term “interpretation” to the clarification of a hidden meaning(1). This definition has long characterized the meaning attributed to the term “interpretation” as intervention in analysis, as in Laplanche and Pontalis’s definition in The Encyclopedia of Psychoanalysis; there interpretation is defined:
A) Clarification, by means of analytical investigation, of the hidden meaning in the speech and behavior of a subject.
B) During treatment, communication made to the patient with the intention of providing him access to this hidden meaning, according to rules determined by the direction and the evolution of the treatment”(2). A similar meaning may be found in many current definitions, such as that of Gabbard(3), for whom “Interpretation, in its simplest form, entails making conscious what was formerly unconscious”.
Through the years, however, the meaning of the term interpretation as intervention during analysis has gradually become broader, to include, in Wolf’s definition: “all those intentional activities of the analyst, that in their totality bring about a modification of the analysand’s psyche.”(4) In this definition, the meaning originally given to the term by Freud has practically been lost.
Fossi’s definition, halfway between the previous two, also makes allowance for the new developments in the meaning of the term: “psychoanalytic interpretation consists of the procedure by which the interpreter assigns certain motivations and meanings to a behavior (a dream, a symptom, a communication, a thought, a personal product, etc. ), which go beyond those assigned to the event by the person who has enacted it. Within the clinical setting, this consists of the psychoanalyst’s communications to the patient made for certain purposes”(5). This definition, which would appear to correspond to current practice, is disconnected from any reference to the unconscious or to a hidden meaning, but it is not as broad as Wolf’s definition, which includes all of the transformative interventions of the analyst, be they verbal or non-verbal.
Interpretation and change in psychoanalytic tradition
Freud links change to the insight acquired through interpretation, seen as the clarification of a hidden meaning. Initially, the process of therapeutic change is summarized by Freud (1916)(6) as the transforming of what is unconscious into conscious, and this is done by interpreting resistance and defense. When the structural model gains priority over the topographical one, the aim of analysis becomes the enlargement of the Ego at the expense of the unconscious (“Where id was, there ego shall be”)(7). In order to achieve this aim, Freud understood that it is not enough to bring the unconscious into consciousness by means of interpretation. Indeed, he asserts that the driving force of change is positive transference, seen as a means(8). Also, according to Freud, in the transference the patient substitutes the analyst for his parent; so that, as the parents are at the origin of the formation of the Super-ego, the patient ends up endowing the analyst with the power his Super-ego had over the Ego(9). This makes possible a kind of post-education, correcting past mistakes made by the parents. Such a view implies that the relationship in itself can possess therapeutic potential. But, on the whole, the Freudian view is dominated by the idea that change derives from an increased consciousness acquired through interpretation, seen as the clarification of an unconscious meaning, and from working through; that is, the assimilation into consciousness, overcoming resistance. This view led analysts such as Freud and Melanie Klein to assume that they could analyze their children. The conception, according to which insight, based on interpretation and working through, constitutes the essence of psychoanalytic treatment, dominated psychoanalysis and continues to do so.
In 1934, Strachey(10) wrote an article which was destined to become a classic on interpretation, entitled “The Nature of the Therapeutic Action of Psychoanalysis”. For Strachey, the therapeutic action of psychoanalysis depends on mutative interpretation, which breaks the vicious circle underlying pathology. Strachey, influenced by Melanie Klein, believes that the patient projects all his aggressive impulses on objects which he afterwards introjects as persecutory objects, thereby reinforcing his own aggressiveness and creating a vicious circle. Mutative interpretation is a transference interpretation given at the moment of urgency (moment of emotional emergency). When the patient experiences the contrast between his persecutory fantasies projected on the analyst and his experience of the latter felt as benevolent, the transference interpretation makes the patient aware that his fantasies are directed towards an archaic fantasy object and not a real one, thus permitting him to break the vicious circle and to introject a good object. Interpretation acts upon the Super-ego, in the sense that the analyst proposes himself as an “auxiliary Super-ego” of the patient, and is thus introjected in place of the original one. The idea which is initially linked to the concept of introjection that change results from a sort of corrective experience which occurs in the relationship, reappears in Strachey’s theorization.
From the 1930s on, two theoretical models intertwine in psychoanalysis: the drive-structure model, which gives primary value to drives, and the relational-structure model, which gives primary value to relationships(11). To these two models correspond two different conceptions of change, primarily based on insight or on the experience of a relationship different from the past, which has a corrective function.
On the one hand, Melanie Klein’s school emphasizes interpretation and insight. The interpretations begin right from the start; they focus on transference and the primal scene and are often distant from the patient’s observable experience, while little importance is given to the actual relationship with the analyst(12). On the other hand, a trend which began with Ferenczi emphasizes the therapeutic value of the relationship. Authors like Winnicott and Balint state that change comes not from insight but from certain characteristics of the relationship with the analyst and of the analytic ambiance, such as the analyst’s interest in the patient, his benign neutrality, his capacity to forego retaliations and maintain his integrity (when faced with the patient’s aggressiveness), holding, security, and so on (13). From this point of view, the interpretation-or rather the insight it brings-loses importance. Some authors, like Winnicott(14), Balint(15), and Kahn(16), even stress the importance of not interpreting as a mutative agent for psychic change. The analyst must succeed in withdrawing into the background in order to allow the patient to be “alone in the presence of another”(17), “like a field lying fallow” (Kahn(18)), in a situation which stimulates the patient’s creativity and internal development.
In the 1950s, Alexander(19) coined the phrase “corrective emotional experience”, which, though disparaged by analysts, as it gave the impression of an artificially imposed attitude, made clear the idea that the patient changes because he encounters a different attitude on the analyst’s part (different from the traumatic one experienced previously), which exerts a therapeutic function. Nacht(20) stresses the importance of the analyst’s personality in the analytic process: what the analyst says is less important than his attitude, which is “the main factor in the recovery, as it provides the patient with the acceptance he did not receive during his childhood”. According to Loewald(21), the therapeutic action of psychoanalysis depends on the new experience of the relationship with the analyst, which allows for a resumption of development, since it makes it possible for the patient to experience a more appropriate parental care than the one experienced in the past. From Bowlby’s theory of attachment(22), there emerges the idea that the therapist, functioning as a secure basis for the patient, can operate a change at the level of the internal working models of oneself and of the other, which are at the root of behavior. Thus begins the critique of the classic concept of neutrality, which will become progressively more insistent.
At the end of the 1970s, Cremerius(23) synthesized the state of the art of current psychoanalytic praxis in the article “Do Two Psychoanalytic Techniques Exist?”. Here he compares two methods of working: the “therapy of insight”, based on the classical interpretive attitude and the “therapy of emotional experience”, based on the use of the corrective emotional experience. In the first case, the aim of analytic work is to promote insight, in the second the interpretive work loses meaning and can even be harmful to the patient.
Self psychologists strongly challenge the fact that the essence of the healing process is to be found in the cognitive sphere. According to them the view of therapy which idealizes insight was linked to the system of values typical of Freud’s era and personality, which gave priority to the values of knowledge and truth. For Kohut(24), insight is the consequence, and not the cause of change, a view which is also shared by authors adhering to other currents of thought. For Kohut, the essence of psychoanalytic cure lies in the creation of psychic structures through progressive optimal frustrations and transmuting internalization; that is, the process through which the self compensates for progressive empathic failures on the part of the self-object, activating and developing internal functions. The healing process occurs in three phases: the last and most essential consisting of creating an empathy between patient and analyst. This statement implies the idea, expressed in Kohut’s last public lecture on empathy(25), and later developed by post-Kohutian self psychologists, that the empathic relationship is in itself a therapeutic condition.
To the end, Kohut maintained a certain ambiguity as regards the role of interpretation, asserting that explanation is the basic therapeutic element(26). At the same time, he asserted that its importance lay not so much in producing insight as in making the patient feel understood, anticipating future stances. From the technical point of view, Kohut substitutes fragmentary interpretations, which characterized classical technique, with broad (more acceptable to him) reconstructions of patients’ lives. Moreover, he suggests caution in interpreting. With severely traumatized patients, he recommends foregoing interpretation until the self has become sufficiently strong. In any case, he warns against self-object transference interpretations; for instance, it is useless to interpret the idealizing transference until the self is strong enough to diminish idealization. As a whole, in his work insight loses much of its traditional importance when compared to other therapeutic factors, such as empathic understanding and the working through of empathic disruptions in the self-object bond, which transforms the analyst’s empathic failures into optimal frustrations. In working through the disruptions of the self-object bond, the insight provided by interpretation plays a secondary role, compared to other therapeutic factors, such as the efficacy experience that the patient gains when the analyst, unlike the parent, admits his mistakes and modifies his behavior.
Post-Kohutian self psychologists carry on the theorization of therapeutic interventions other than insight, which was stressed by Kohut: empathy, working through of empathic disruptions, efficacy experiences. They assert more and more that psychic structures are created not only by transmuting internalization, but also during empathic communication. Wolf(27) emphasizes the role of confirming experience which proceeds from the empathic stance of the analyst in restorating empathic disruptions, and recommends that the acknowledgment of the validity of the analysand’s subjective point of view precede the interpretation of the disruption. Basch(28) subsequently stresses the importance of providing efficacy experiences in the analytic relationship, on the basis of the idea that seeking efficacy is a fundamental human motivation. Fosshage(29), combining self psychology and intersubjectivity, points out the therapeutic value of regulating interactions which occur within the analytic couple and facilitate with their constancy the analytic process and the development of the patient’s self. These interactions comprise experiences that self psychologists had already considered as essential to therapeutic change, such as empathic confirmation or efficacy experiences, but also include different interactions, such as validation of one’s own experiences, perception of the calm and secure ambiance of the analytic relationship and of the analyst as one who understands and wants to help the patient. In this view the increase in awareness provided by interpretation would be only one of many regulatory interactions occurring within the analytic relationship.
In recent years, of the two trends, one stressing the importance of insight and one stressing the importance of relationship, the second has prevailed. Weiss and Sampson(30) give a new direction to Alexander’s concept of corrective emotional experience. In the new model they propose, pathology is seen as a result of dysfunctional unconscious beliefs which drive behavior and that have been formed during interactions with parents in childhood. The patient would like to free himself of pathogenic beliefs, which underlie symptoms, but cannot relinquish them because they provide safety. In the transference, the patient repeatedly tests the therapist in order to disconfirm his pathogenic beliefs following an unconscious plan. An important form of testing consists in the patient’s behaving towards the analyst the way his parent behaved towards him in the hope that the analyst will react differently. What is therapeutic is the fact that the therapist does not fail the test, disconfirming the patient’s pathogenic beliefs, which is not a result of insight, as generally understood. When this theory has been empirically tested, through session recording, the only interpretations which appeared to be therapeutic were proplan interpretations, that is, those interpretations which contribute to disconfirm the patient’s pathogenic beliefs, whereas the patient’s insight did not predict therapeutic results(31).
At present the relational model is still in the developing phase, in the sense that we are still in the process of discovering and explaining the healing potential of the therapeutic relationship. In this model the therapeutic action of interpretation is related to the underlying interaction between analysand and analyst.
The present crisis of classical interpretation
In addition to the aforementioned uncertainty in defining this type of intervention, the present crisis of psychoanalytic interpretation would appear to go in several directions: a mounting criticism of the traditional use of interpretation, changes in theorizing its therapeutic action and an increasing appreciation of different types of therapeutic intervention, both verbal and non-verbal.
Changes in the meaning of interpretation as intervention in analysis
Once more, the classical meaning of the term “interpretation”, making explicit a latent content, as communication with the patient in analysis, has implicitly changed, and as a result its reference to unconscious has been lost.
This is in part related to a change in the type of patient treated. For instance, it has been noted that with severely disturbed patients, interpretation aims at clarifying what is confused for the patient rather than at disclosing an unconscious meaning. According to those authors who follow new psychoanalytic models, the term “interpretation” has progressively assumed a broader meaning as compared to the original one, so as to include in Wolf’s definition(32) all the transformative interventions of the analyst. The idea underlying that definition would seem to be that interpretation is whatever redefinition of meaning however obtained, including through non-verbal means.
Criticism of the traditional use of interpretation
Several authors have pointed out that interpretation, as it has been used in the past, can have negative effects on both the patient and the therapeutic relationship.
This in part depends on the type of patients treated currently, often severely disturbed. With psychotic patients, interpretation of unconscious fantasies can weaken their connection with reality and increase their anxiety(33). With borderline patients, the interpretation of aggressiveness, in particular, can cause them to feel persecuted, guilty or criticized, further weakening their self. Patients with narcissistic personality disorders can perceive interpretation as the analyst’s need to draw attention to himself, which disturbs the self-object transference(34).
There is also the risk, glimpsed by Winnicott and later stressed by self psychologists, that a too early interpretation may prevent the patient from comprehending by himself, thus denying him his only possible experience of competence and creativity.
Other authors have observed that insight does not work with severely disturbed patients; with these the only thing which is effective is the message carried by the relationship, transmitted through the tone of voice and the feeling it conveys rather than its content(35). Fonagy(36) has explained the ineffectiveness of interpretation with borderline patients because of their deficit of mentalization, which prevents them even from understanding the content of the interpretations.
At times insight also does not work even with less disturbed patients. Some long analyses full of interpretations do not result in any transformation. On the other hand, were understanding sufficient, psychological therapies would be less lengthy.
A shift of emphasis in explaining the therapeutic action of interpretation
In the past, some authors had noticed the value of interpretation from a relational point of view: for instance, they spoke of interpretation as feeding or as phallic penetration, or as a gift from the analyst, but on the whole, the therapeutic action of interpretation referred to the insight it brought.
At a certain point, there was a change in what was considered therapeutic. While it was previously thought that change was brought about through insight and that change through relationship was unstable, the shift has subsequently been in the direction of the mutative value of relationship(37).
In this view, the therapeutic action of interpretation no longer refers to the insight it conveys, but is sought within the relationship, from which it arises: in fact there is no interpretation without relationship(38). According to Kohut(39) and Wolf(40) interpretation is important as an experience of feeling understood by the analyst. According to Stolorow(41), the therapeutic impact of interpretation lies in tuning with the patient’s affective states communicated by the analyst. Interpretation derives its meaning from the specific self-object transference that the patient experiences: for instance, in the case of an idealizing transference, interpretation corresponds to the intervention of a strong, idealized object, comprehensive and tranquilizing, which was often lacking in the past life of the patient.
Most recent theories regarding interpretation no longer oppose insight to relationship, but relate both to interaction, considered as “a supraordinate rubric that includes all the action, including the verbal exchange that occurs between analysand and analyst”(42). The most interesting models relate change to transformations regarding the invariant principles that unconsciously organize experience, forged within the child-caregiver system of reciprocal mutual influence (Bowlby’s internal working models(43), Stolorow’s organizing principles(44), Weiss and Sampson’s pathogenic beliefs(45). In the therapeutic process such changes are produced by the interaction between patient and analyst which exerts a corrective function, forging new organizing principles, which prevail over the old ones or disconfirm the patient’s pathogenic beliefs.
Increasing appreciation of non interpretive interventions
Although the existence of non-interpretive interventions in psychoanalysis has always been recognized, they were considered to be of little therapeutic relevance and were often associated with psychotherapy rather than with psychoanalysis. As the therapeutic role of insight diminished in importance, these interventions were re-valued, reducing the importance attributed to interpretation. At present, the number of non-interpretive interventions considered to be therapeutic has so expanded as to render listing difficult. The following are the most important.
Empathic confirmation(46). This type of intervention includes statements such as “You had to be very depressed to behave like this” or “It is deeply painful not to obtain what you were expecting”. This type of intervention is a demonstration of the therapist’s attunement with the patient’s internal states. It is based on the idea, which is theorized mostly by self psychologists, that empathy as such is therapeutic. Confirmation is based on the same principles. This type of intervention consists in giving value to patient behavior, by supporting the patient’s self, either verbally or non-verbally. For self psychologists, all self-object functions (mirroring, merging with an idealized self-object, twinship, efficacy and adversarial experiences) exert a positive and structuring influence on the self, although it is not easy to codify them into a list of concrete interventions.
Help in mentalizing and telling. These interventions consist in helping the patient to widen the area of representability (in Bion’s theorization(47), to transform emotional experience into alpha-elements), not so much in the sense of understanding a hidden meaning, as in the sense of verbalizing, describing, thinking, providing meaning, providing a narration. Pure denomination of emotions and feelings has a mutative value because it helps the patient to understand the mental states of both, that is, to acquire (or improve) a theory of mind in the sense intended by Fonagy and Target(48).
Clarification. This type of intervention, distinct from interpretation, consists “in reformulating or resuming the thread of the patient’s speech in order to confer a more consistent image of what has been communicated by the patient”(49). It serves to help the patient to articulate something which is difficult for him to verbalize.
Reality testing. According to Gabbard(50) this type of intervention points out something the patient does not want to accept or it identifies denial or a minimization from the patient. It serves to improve the patient’s reality testing especially when the patient is taking risks. An example of this type of intervention is reported by Kohut(51) with regard to a patient who quarreled with the policeman who had once again stopped him for exceeding the speed-limit. Kohut’s intervention consisted in announcing to the patient that he was going to give him the deepest interpretation he had so far received in his analysis. After which Kohut simply said: “You are a complete idiot”. The patient burst into a warm laughter and relaxed, so that it was possible to analyze certain destructive and self-destructive aspects of his behavior.
Auxiliary memory functions. These are interventions of the type: “As you were saying two weeks ago…”. With certain patients, in particular with borderline patients, it is important that the analyst work as auxiliary memory of the patient, allowing him to experience a continuity with himself, that he cannot feel because of the fragmentation of the self(52).
Questions. Questions in analysis, as in daily communication, have more than just an instrumental value in order to know something we want to know. Direct questions, which in classical technique were considered intrusive and distorting free association, appear instead a useful vehicle for important feelings of the analyst, such as interest, worry, affection etc., fulfilling in some cases a mirroring self-object function. Most important are questions that demonstrate the interest of the analyst for the patient’s self-objects.
Containment. This function, exerted by the analyst, has became progressively more important as the type of patients undertaking psychoanalytic treatment has changed, including more severely disturbed patients. The feeling by severely disturbed patients of being understood and contained by the analyst frequently fails to consider the semantic content of interpretation, since it is based on elements such as the tone of voice, the feeling communicated by words and other non-verbal elements(53).
Enactment. This term is used in psychoanalysis to indicate those situations in which the analyst realizes that he or the patient acts out particular behaviors in connection with particular transferential and counter-transferential circumstances(54). It applies for the most part to non-verbal components of interaction. Enactment has been studied for the most part in order to understand patients, but its therapeutic use is conceivable. An example of this is the satisfaction of wishes not understood by the analyst(55).
Proplan answers(56), as distinct from interpretation. These are interventions which disconfirm the beliefs of pathogenic patients by non-interpretive means, either verbal or non-verbal.
Experiences of play during sessions. Developing some of Winnicott’s ideas(57), Fonagy and Target(58) have recently pointed out the importance of play in the development of the self and thus the therapeutic value of play during the session. They have pointed out the importance of pretend play during infancy in order to acquire a “theory of mind”, that is the capacity to represent ideas qua ideas, fantasies qua fantasies, etc., in oneself and in others. In this view, play in child analysis would not only be useful to reveal unconscious fantasies, but as such would have a therapeutic value.
Meares(59)states that what is therapeutic with borderline patients is not insight, but the repeated experience of playing with the therapist during session. In this view, free association would be therapeutic, since it allows the mind to function according to play modality. The task of the therapist would be, first of all, to establish the field of play, allowing the patient to have a corrective experience.
The crisis of psychoanalytic interpretation, as communication to the patient traditionally intended, is apparent in many trends, from the presently observed difficulty in even defining this type of intervention due to the transformations occurred over the years in the meaning of the term itself, to the progressively more frequent caution demonstrated in its traditional use, the shifting of interest in explaining its therapeutic action, and the new focus on different types of therapeutic intervention.
Many authors have pointed out the uselessness of interpretation with a certain kind of patient, and even the possible damage certain interpretations, although in principle correct, can cause to the patient and to the therapeutic relationship. These authors have recommended more caution in interpreting than previously recommended.
The very conception of the therapeutic action of interpretation has radically changed. It is no longer thought that the main therapeutic factor of interpretation is the insight it provides the patient, but rather the underlying interaction, considered as “a supraordinate rubric that includes all the action, including the verbal exchange between analysand and analyst”(60). There is a tendency to think that the patient changes not so much because he understands something (insight is considered a consequence and not a cause of change), but because he experiences with the analyst a different relationship than he experienced in the past, which performs a corrective function. The place traditionally occupied by interpretation has been progressively more occupied by interaction. This shift of emphasis is partly due to a new way of conceptualizing change, which puts in the foreground the structuring relationships. More recent models point out the role of interactions in strengthening the self or in forming those unconscious organizing principles which underlie one’s behavior (Bowlby’s(61) internal working models, Stolorow’s(62) organizing principles, Weiss and Sampson’s(63) pathogenic beliefs.
Classical interpretation today appears to be less essential to change than was traditionally thought, whereas different types of therapeutic intervention appear more important, including non-verbal ones, such as empathic confirmation, which help in mentalizing and telling, functions of auxiliary memory carried out by the analyst, containment, therapeutic use of enactment, non-interpretive proplan responses, and experiences of play during the session.