The four basic components of psychoanalytic technique and derived psychoanalytic psychotherapies
Authors: Otto F. Kernberg
Journal: World Psychiatry (2016)

Four aspects jointly determine the very essence of psychoanalytic technique: interpretation, transference analysis, technical neutrality, and countertransference analysis. Interpretation is the verbal communication by the analyst of the hypothesis of an unconscious conflict that seems to have dominantly emerged now in the patient's communication in the therapeutic encounter. In general, interpretation of a defense or a defensive relationship initiates the interpretative process, followed by the interpretation of the context, or the impulsive relationship against which the defense was erected, and the analysis of the motivation for this defensive process. Interpretative interventions may be classified into: a) clarification, by which the analyst attempts to clarify what is consciously going on in the patient's mind; b) confrontation, that is, tactful bringing into awareness nonverbal aspects of the patient's behavior; and c) interpretation proper, the analyst's proposed hypothesis of the unconscious meaning that relates all these aspects of the patient's communication to each other. This condensing hypothesis is interpretation "in the here and now", to be followed or completed with interpretation "in the there and then", that is, the genetic aspects of interpretation that refer to the patient's past, and link the unconscious aspects of the present with the unconscious aspects of the past. Transference may be defined as the unconscious repetition in the here and now of pathogenic conflicts from the past, and the analysis of transference is the main source of specific change brought about by psychoanalytic treatment. The classical concept of transference analysis has been expanded significantly by the concept of the analysis of the "total transference" proposed by the Kleinian approach1. This involves a systematic analysis of the transference implications of the patient's total verbal and nonverbal manifestations in the hours as well as the patient's direct and implicit communicative efforts to influence the analyst in a certain direction, and the consistent exploration of the transference implications of material from the patient's external life that, at any point, he/she brings into the session. The inclusion of a systematic consideration of the patient's total functioning at the point of the activation of a predominant transference points to an important implicit consequence of transference interpretation, i.e., the analysis of character. Defensive characterological patterns tend to become dominant transference resistances and lend themselves to systematic analysis leading to characterological modification. This is a significant effect of psychoanalytic treatment, surprisingly underemphasized in the literature. Technical neutrality tends to be misinterpreted as a recommendation for an analyst's distant, uninvolved attitude, "a mirror to the patient's presentations". In essence, it simply refers to the analyst's not taking sides in the patient's activated internal conflicts, remaining equidistant, as A. Freud2 put it, from the patient's id, ego, and super ego, and from his/her external reality. Technical neutrality, in addition, implies the analyst's not attempting to influence the patient with his/her own value systems. S. Freud's early metaphor of the analyst as a "mirror" clearly was questioned by himself, and he protested against a view of analytic objectivity as "disgruntled indifference"3. Technical neutrality also implies the concept of "abstinence", in the sense that the analytic relationship should not be utilized for the gratification of libidinal or aggressive impulses of the patient or the analyst. In contrast, technical neutrality does not imply the concept of "anonymity", a questionable development in psychoanalytic thinking in the 1950s, importantly related, in my view, to authoritarian pressures within psychoanalytic education, and the related institutionally fostered idealization of the training analyst, who should not show any usual personal human characteristic to the patient. This idealization of the analyst has been sharply criticized in recent years, particularly by the relational school. Technical neutrality implies a natural and sincere approach to the patient within general socially appropriate behavior, as part of which the analyst avoids all references or focus upon his/her own life interests or problems. The analyst cannot avoid that personal features emerge in the treatment situation, and do become the source of transference reactions. The patient's realistic reaction to realistic aspects of the analyst's behavior should not be considered a transference reaction: not everything is transference! Maintaining the definition of transference as an inappropriate reaction to the reality presented by the analyst, that reflects the activation of the patient's unconscious conflicts, should differentiate transference from other patient's realistic reactions to natural, as well as idiosyncratic, aspects of the treatment situation. Countertransference is the analyst's total, moment-to-moment emotional reaction to the patient and to the particular material that the patient presents. The contemporary view of countertransference is that of a complex formation co-determined by the analyst's reaction to the patient's transference, to the reality of the patient's life, to the reality of the analyst's life, and to specific transference dispositions activated in the analyst as a reaction to the patient and his/her material. Under ordinary circumstances, countertransference mostly is determined by the vicissitudes of the transference, and as such, the analyst's emotional reactions may fluctuate significantly within each session. In contrast to acute fluctuations of the countertransference, chronic distortions of the analyst's internal attitude toward the patient usually indicate significant difficulties in the analyst's understanding of the transference. They often point to a stalemate in the analytic situation that the analyst may need to resolve outside the actual times of analytic sessions with the patient, through self-exploration or consultation. Serious characterological difficulties of the analyst may contribute to such chronic countertransference distortions, but most frequently they relate to more limited difficulties in his/her understanding and interpretations and are related to particular developments in the transference4. Full internal tolerance of countertransference reactions, including regressive fantasies about specific relations with the patient, may be followed by the analyst's internal exploration of the meanings of his/her reaction in terms of the present transference situation, and thus prepare the road for transference analysis. This is an overall outline of the basic aspects that, I suggest, essentially define psychoanalytic technique, and that may be applied to the analysis of various developments in the analytic situation, such as the analysis of dreams, character, acting out, and repetition compulsion, all of which, in the end, will culminate in transference analysis. Otto F. Kernberg Personality Disorders Institute, New York Presbyterian Hospital, Westchester Division, and Weill Medical College of Cornell University, New York, NY, USA