Stefano Bolognini “2015 BOSTON: PSYCHOANALYSIS IN A CHANGING WORLD”
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The complexity of the changes underway in our lives as human beings, due to political and social evolutions, cultural trends and new forms of communication made possible by technology, not only reaffirms the well-known unpredictability of the future, but makes it difficult even to describe the present with sufficient realism: the objective of an "overall vision", albeit limited to our field, is undoubtedly a very ambitious one.
Nevertheless, my position as President of the IPA gives me the special opportunity (and perhaps duty) to present you with a comprehensive picture from an "inter-regional" point of view, thanks to my travels and my constant exchanges with colleagues and with societies all over the world; and to add an "inter-generational" perspective, given my scientific interest in this area.
Due to time constraints, the considerations I propose today will be schematic and concise, and I invite you all to explore them in more depth, reflecting on their veracity and their possible implications through your subsequent dialogue with colleagues; some of these considerations may not concur with everyone's wishes, but may nonetheless be worth thinking about and discussing further.
WHERE WE ARE
The general scientific level (theoretical knowledge, clinical skills and mental mobility) of the average psychoanalyst has, in my opinion, benefited from the growing intensity of our exchanges as a result of new technologies.
Even though the ease with which psychoanalytic papers are now disseminated through the Internet, and through the myriad of conferences organized here there and everywhere, may have created some hyper-saturation and discouragement (it is frustrating for our narcissistic ideals to know that no one can possibly read even a tenth of what is produced at levels of excellence), nevertheless it is undeniable that the spread of ideas and experiences has, year after year, transformed and enriched the mentality and the theoretical baggage of the majority of analysts.
I am convinced that the model of "cross fertilization" represented by CAPSA symbolizes well the change taking place in the new generations of analysts, who are open to innovation and to furthering their knowledge of colleagues’ work in other countries and regions; and – while respecting the legitimate concerns of those who fear the effects of confused theoretical bastardization and superficial eclecticism – I think I can say that the pluralistic reality described by Wallerstein, as well as being an evident historical reality, is also producing a substantial enrichment of the analyst’s toolset.
We notice this especially in international clinical discussion groups, where the "theological" component of transferential loyalty to our original theories (that is placed under greatest tension during exclusively theoretical debates and sometimes conditions them in a restrictive way) loosens, dissolves and gives way to associations, fantasies, emotional developments and inter-subjective exchanges between colleagues that engender something new: I sum this up simply with the observation that after this kind of experience "you don’t go home exactly the same as you were before".
Easier access to scientific papers, through the Internet and through the multiplication of translations and publications, goes hand in hand with increased geographical mobility (despite the ups and downs of recurrent economic crises) and the growing linguistic knowledge among many colleagues who speak at least one other language in addition to their own: all this means greater opportunities for wider participation and dialogue.
The IPA plays a unique role in this regard, and it is precisely by virtue of this inter-regional connecting role at all levels that the IPA’s work goes far beyond mere administrative and regulatory functions: through its many Committees and Working Groups, the IPA creates and maintains the links in our worldwide psychoanalytic community, and actively contributes to enabling analysts to gain real knowledge of other cultural, scientific and, I dare say, "psychic" realities.
The result is not a homogenization of psychoanalysis, but rather an informed articulation where each one of us maintains our own original family DNA, yet each of us "has traveled" more (either concretely or symbolically), thus enriching both our own inner world and – following those exchanges and by osmosis – our national and local "psychoanalytical homes".
I would go further and say that in terms of authentic, theoretical and experiential knowledge of the specific subject, psychoanalysis has never been better than it is today; and if I had to do the famous "final test" summed up in the question: "who would you send your family to for analysis?" updated to "would you send your family to an analyst from the past or to one of your contemporaries (all things – level and experience – being equal)?", I would send them to a colleague today, precisely because that analyst can benefit from the work of past analytical generations, because he/she “has traveled" more (always in a figurative sense) and because he/she knows that there can be different ways to treat different problems and different people.
NOT-IN-THE-ROOM SESSIONS
The issue is complex and I will limit myself here to some brief notes about not-in-the-room sessions (for example, via telephone or online) as an institutional problem.
We are well aware of how these technological tools have become a new and undeniable reality in the clinical activity of many psychoanalysts, and as I write these notes many authoritative colleagues spring to mind who are staunch supporters of arguments either for or against the use of telephone or online sessions in psychoanalysis; just as they are informed about the growing spread of this practice.
This new development is fueled by potentially positive factors (such as treatment in remote geographical areas where "in person" analysis is physically impossible due to a lack of analysts), but also by other, frankly resistential, factors (a patient who occasionally doesn’t feel like making the journey from home, and calls their analyst) and very basic economic factors (analysts with few patients who have to survive, or patients who cannot be absent from work to attend four sessions a week for risk of dismissal); what is certain, is that this phenomenon is spreading rapidly.
As you may know, the IPA, officially called upon to take a stand on this issue, has so far established few key points, which have not been translated into legislative resolutions.
In general, there seems to be a consensus on the evaluation of the difference between an "in person" treatment and treatment via telephone or online. It is certainly not the same thing: there are significant differences that cannot elude the common sense and fine eye for detail of anyone who carries out our work.
There have also been hypotheses about the likelihood that these technological tools will develop (in a compensatory or Lamarckian sense) some audio-visual functions, for example, to make up for the lack of olfactory sensations and proxemics experienced in an in-person session.
For now, the IPA, in the representation of its Board, believes that the matter still needs to be studied in depth: we have to know more, in terms of documented experience and subsequent epicritical discussion.
It is widely held that in post-graduation private practice every analyst disciplines themselves as they see fit, "according to science and conscience", but as far as analytical training is concerned this is maintained outside of the distance-sessions area; the only document that touches on this subject (and that is not formalized, however, as an effective rule) concerned very special cases of alternating distance sessions /in person sessions in countries lacking analysts at practicable distances.
The discussion is, therefore, open.
SOCIO-CULTURAL CHANGES
This is the chapter to which I have devoted more wide-ranging reflections during my term, by virtue of the sincere and intense exchanges I have enjoyed with colleagues from many countries; for the sake of brevity, I will condense the result of these exchanges into just a few remarks.
The undeniable fact to be taken into account, beforehand, is that there are rich countries and there are poor countries; but, above all, there are countries in which the National Health Service and/or insurance companies provide for payment of treatment (particularly in the Germanic and Scandinavian regions), and other countries in which this does not happen; if, on the one hand, this opportunity is not without contractual complications, it cannot be denied that, on the other hand, it considerably changes how the patient is able to face the financial commitment involved.
But besides the (admittedly) important concrete economic factors that affect the performance of psychoanalytic treatments (and that in any case should not be ignored if we think that attention to internal reality must be sensibly integrated with recognition of external reality, so as not to fall from the neurotic into the frankly psychotic pole), new recurring types of mental organization are taking shape that seem to pose new problems for the practice of psychoanalysis as we are traditionally accustomed to conceiving of it.
A common observation, and one that is painful for us all, is that the full frequency of the four sessions is becoming increasingly impracticable, at least at the beginning of treatment, and that the initial indication of this frequency alone results, more often than not, in a firm refusal and withdrawal on the part of the patient.
The truly analytical aspect of this phenomenon can be found in the fact that it affects not only those who do not have enough money or who cannot be absent from work for 4 sessions a week (an increasingly common circumstance, like it or not, since our patients today no longer hail exclusively from the wealthy or very wealthy classes and since every employee knows that outside their employer’s door there is a long line of people ready to take their place ...) but it also affects people who do have the economic resources to afford treatment.
Of course, in those cases it is textbook resistance; and, for that matter, a substantial part of our work now seems to be precisely that of "creating the analytic patient", as verified by some working groups dedicated to the study of this phenomenon. But what are the roots of such an imposing change on such a large scale?
I believe that the changing world in which we live is undeniably affecting our work, and that – as far as the sphere of human relationships is concerned – it is impossible to insist categorically that "human beings are always the same"; this may be true for the most part, yes, but in some specific aspects this is no longer the case.
Many patients today, in fact, reject the idea of depending openly and intensively on someone.
For complex, but not necessarily mysterious, reasons they seem to bear the signs of a substantial distrust and/or disaccustoming with regard to the presence and the constancy of the object, its substantial reliability and the consequent dependence on it.
In an ideal line connecting the subject to the object, the investment center of gravity seems in many cases today to remain pre-emptively and implicitly shifted toward the subject itself, which is careful not to put its own libidinal and narcissistic capital in the hands of the other, at least until the other has (with time) overcome the barriers of mistrust and Self-protection that we presume were built up early on.
If we think of the necessary primary fusionality between mother and child and of the subsequent need for a strong continuity in the family organization, we might ask ourselves – fully aware of the risks of such a potentially "politically incorrect" question... – whether analysts are not inheriting in their consulting rooms at least some of the consequences of a series of circumstances typical of our contemporaneity: the early interruption of maternàge for professional reasons, where mothers are called straight back to work by legislation and excessively demanding corporate environments; the confusing fallback on a rotation of private and institutional caregivers in bringing up very young children, in "nuclear" families without grandparents, who often live very far away; ubiquitous family ruptures owing to separations and divorces, especially where a new family member enters the scene who "must" be accepted, sometimes in an atmosphere of rejection or at least denial of the difficulties involved; narcissistic self-centered parenting organizations, favored by contemporary, and largely individualistic, cultural models; the loss of the large container of "extended families", and in general all those circumstances that influence the psychic environment in a child’s growth today, better now than in the past from the point of view of food, but probably less so from the point of view of real, genuine relationships.
We no longer have – at least for now – massive and devastating world wars, what we have instead are countless micro-fractures in the initial mother-infant dyad and in the family that may instinctively deter the subject from "surrendering to the relationship"; and here I cannot but mention the extreme and emblematic clinical case of that child, treated by one of my Italian colleagues, who moved away from the other children he was playing with to hug and kiss the TV.
Let me be clear: I am not saying here that mothers should not return to work, or that families should live with grandparents, or that unhappy couples should not be able to separate, and so on. I am saying that psychoanalysts should not deny the momentous consequences of these huge changes, and neither should they be surprised by their impact on the relational styles and possibilities of this new humanity, when a patient who hears the phrase “four sessions a week” vanishes right away without any negotiation.
CLINICAL, THEORETICAL AND TRAINING EVOLUTIONS
Analysts should also develop appropriate clinical and theoretical reflections, with sufficient freedom of thought, through understanding what is really possible and what is useful in our work today, given these new evolving realities, and maintaining an inner attitude that is mobile and responsibly creative, aware of our theoretical heritage but open to freely exploring what is new.
In this sense, there are signs of discomfort in our communities that are spoken confidentially "in the hallways" or in personal interviews, but that struggle to emerge in official meetings, where the Ideal is the master with respect to the real Self of the psychoanalyst.
But I believe that the IPA should not ignore or minimize these problems, just as a doctor should not cut short her clinical reflections too early in the face of symptoms, dismissing them too easily: a persistent fever may be due to a common flu, but sometimes it is not.
Not only that: any potential remedies should also be the result of reflection and not of enthusiastic but a priori adherence to stereotypical guidelines that satisfy a feeling of compliance with the standards of the category.
The famous adage: "The surgery was a complete success, but the patient died" should be kept in the forefront of our minds in our daily practice, beyond rigid doctrinal faiths, that reveal more of an unresolved transference towards devotional idealized internal objects than a real love for this "art/science with special status" that has transformed (this I can affirm) above all our own personal lives.
And I can add that in the ideal triangulation between the analyst, the theory and the patient (an equivalent reproposition of the inner family triangle) the contemporary analyst should provide the interpsychic field for a shared Oedipal organization that is as livable, balanced and harmonious as possible. These three components should be conjoined in an appropriate and creative way.
Obviously the opposing risk should also be noted: that of an iconoclastic desire towards our scientific and training tradition, which instead stems from negative transferential residues, irrespective of the evaluation of these complex evolving realities.
What are the consequences of this perspective?
Undoubtedly the awareness that in many cases today, much more than in the past, there is a need to "build the analytic patient", which cannot fail to affect the manner and timetable of analytical training: if we want future analysts who know how to build the analytic patient, we should allow young people to include this aspect in the already difficult training plan, probably by reviewing some criteria that have up to now been considered indisputable.
The increasingly worrying phenomenon of "ageing" of our membership and the lack of growth in many of our Societies is undeniably linked to these widespread psycho-socio-cultural changes, and we must be capable of thinking about all this.
Secondly, we must continue the already initiated process of study, knowledge and recognition of further specific forms of treatment, also including them as official specializations in our field; the Child/Adolescent Integrated Training is a move in this direction, as is the establishment by the IPA of the Mental Health Field Committee for the integrated treatment of serious disorders, the scientific activity dedicated to "Families and Couples" and the broad field of Group Analysis.
These extensions will not replace the basic psychoanalytic training and activities by any means, but nor will they any longer be condescendingly regarded as "drifts" or lower ranking by-products: the evaluation will assess other criteria such as the training and experiential process and the quality of what is produced.
It is up to us, and our scientific and professional community, not to lose sight of the "nuclear" value of the experience of analysis as an inescapable starting point for further extensions of the method and the fundamental criteria of our expertise.
CONCLUSIONS
Will we succeed in being inclusive towards these articulations of analytic practice without losing our specific values?
Will we know how to reflect with true freedom of thought on the consequences of the general changes for our professional practice and training?
And in terms of theoretical and clinical evolutions, will we know how to preserve the inestimable richness of our Freudian heritage, the real trunk of our genealogical and scientific tree, without having to be afraid of the spreading branches and without prematurely "pruning them" for fear of deviation? Will we be able to think that after Freud also other thinkers have produced fertile ideas that are seemingly different but actually enriching?
In my view, an unresolved idealizing transferential component seems, in some cases, to prevent the phantasmatic figure of Sigmund Freud from "becoming a grandfather", and seems, for some, to lay claim to an exclusive right to a past, present and future theoretical uniqueness that risks being more phallic than genital, in thinking that no one else after him can contribute substantially to the evolution of psychoanalysis with new ideas and original creativity; just as, on the contrary, the failure even now to recognize the validity of most of his contributions seems to reveal, in some cases at least, a sort of underlying ingratitude.
Ultimately, I hope that the IPA is and will remain the "home" in which psychoanalysts can work through their difficulties, differences and new inspirations both about the changing world, and about psychoanalysis that can change and in fact does change: a home that is livable, open to reflection and exchange, and also to complex debate and (necessary and authentic) transformations, both in individuals and in our societies.
A home made up of adults who are respectful of our heritage but open to what is new, and capable of dealing with the changes in the world and the consequent difficulties without denying them, either through fear and/or self-reassuring idealizations.
What should distinguish us at least a little, compared to the rest of humanity who do not have our training and are not engaged in our work every day, should be a combination of awarenesses that are sometimes painful: after all, one of our strengths is precisely the healthy, slightly depressive awareness of our human frailty, so often denied by others, who idealize us in analysis.
We should have at our disposal a sufficiently good work of reflection between colleagues, in the spirit of our international community, and this is also one of the goals of the IPA: our ability to "think together" can be exercised from the time of our analytic training, integrating into the classic "tripod" (analysis-supervision-seminars) the fourth element of group development of clinical and theoretical experience, as some Latin American societies are already planning to do in their training programs.
Finally, we will have to support one another in dealing with our inevitable group and institutional tensions (and this is also why, for example, we have established the "Task Force on Institutional Issues", which will study this conflictual dimension so as to improve our knowledge of it).
In conclusion, as you can see, my message is intended to suggest we keep ourselves open to thinking together, to not wanting to change just for the aesthetic and narcissistic pleasure of "change for the sake of changing", but neither to be closed "a priori", for fundamentally "theological" reasons, to the evolutions in the world and in psychoanalysis itself.
The reason for my conveying these thoughts to you lies in the painful awareness of the power and rigidity of our inner defensive mechanisms, from which none of us, neither we as individuals nor our institutions (including IPA), are exempt.
I wish you all a fruitful, satisfying and “non-conventional” Congress.