Kernberg, O. F.

(1999) Psychoanalysis, Psychoanalytic Psychotherapy and Supportive

Psychotherapy. Int. . Psycho!"nal., #$%1$&'!1$91
(onte)porary (ontroversies
The author explores the controversies involving psychoanalytic psychotherapy from conceptual,
clinical and educational perspectives. He proposes an integrated concept of psychoanalytic
modalities of treatment, and their subdivision into standard psychoanalysis, psychoanalytic
psychotherapy and psychoanalytically based supportive psychotherapy. Indications and contra-
indications for these therapeutic approaches are outlined in the light of clinical experience and
psychoanalytic research on these issues. It is proposed that psychoanalytic institutes teach
psychoanalytic psychotherapy to candidates in psychoanalytic training. The author stresses that we
now possess a broad spectrum of psychoanalytically based approaches to patients that significantly
expand the therapeutic effectiveness of our profession, and thus can strengthen the social impact of
psychoanalysis.
(ontroversies *egarding Psychoanalytic Psychotherapy
The relationship between psychoanalysis and psychoanalytic psychotherapy is becoming a central
concern of the psychoanalytic community for a combination of the following reasons: (1) the
development of a broad spectrum of psychoanalytic psychotherapies derived from psychoanalysis
as a basic underlying theory and a method of treatment; (2) the widely recognised usefulness of
these derived psychotherapeutic methods for many cases too severely ill to participate in a standard
psychoanalysis, and the possibility of reaching a large number of patients by derivative couple and
group psychotherapeutic methods carried out with less frequent sessions (and less financial cost)
than standard psychoanalysis; () the conceptual challenges presented by the developments in
psychoanalytic theory and practice that have broadened or changed psychoanalytic technique within
some schools, implicitly blurring the differentiation between psychoanalysis and psychoanalytic
psychotherapies; (!) the development of independent schools of psychoanalytic psychotherapies,
training practitioners in theories and techniques that appear to be in competition with those taught in
psychoanalytic institutes; (") the question as to whether psychoanalytic psychotherapies should be
taught as part of the training of psychoanalytic candidates, whether they should be left to
institutions other than psychoanalytic institutes, or
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This paper was presented to the $ruguayan %sychoanalytic &ssociation in 'ontevideo on &ugust 1", 1((), and to the *uenos &ires
%sychoanalytic &ssociation in *uenos &ires on &ugust 1(, 1(()+ ,t has also been selected to appear for discussion on the -ournal.s /orld
/ide /eb pages and *ulletin *oard+ 0or details see http:11www+i2pa+org+
3 145" 3
conducted as postgraduate programmes to be developed by psychoanalytic societies; (6)
significantly more controversy within psychoanalytic circles, growing out of the question whether
psychoanalytic institutes should train psychoanalytic psychotherapists who do not receive full
training as psychoanalysts, with the related question of what requirements for personal analysis,
supervision and seminar e7periences would be adequate to this tas8; (5) the challenging question of
what attitude psychoanalytic institutes and societies should ta8e towards the certification, national
or federal recognition of and third3party reimbursement for psychoanalysis, and how they should
define the boundaries with non3psychoanalytic practices and organisations+ The questions raised by
the relationship of psychoanalysis to psychoanalytic psychotherapy are, therefore, conceptual,
clinical, educational and political+
97ploring the conceptual question of the relationship between psychoanalysis per se and the
psychoanalytic psychotherapies would seem to require a clear definition of the essence of the
psychoanalytic method of treatment (or :psychoanalytic technique;), a clear definition of the
boundary between psychoanalysis and psychoanalytic psychotherapy, and of the boundary between
the latter and the supportive psychotherapies that derive their rationale from psychoanalysis+ <iven
the development of alternative psychoanalytic theories and their corresponding technical
approaches at this time, however, is a comprehensive definition of psychoanalysis as distinct from
the psychoanalytic psychotherapies really possible=
>egarding the clinical issues, the corresponding questions involve the indications and contra3
indications for psychoanalysis and its derived methods of treatment, and the prognostic and
technical implications of these different treatment modalities+
0rom an educational perspective, the role of psychoanalytic institutes and societies in providing
training in psychoanalytic psychotherapies raises questions of educational methodology, the
possibility of several :trac8s; or specialisation of training, the advantages and liabilities involved in
providing training in psychoanalytic psychotherapy for academic institutions outside psychoanalytic
institutes proper (such as psychiatric residency training programmes and training in other public or
private institutions), and finally, the question of the relationship of psychoanalytic institutions to
other institutions that train practitioners in psychoanalytic psychotherapy+
>egarding the political issues, the alliance or competition with and the differentiation from other
psychotherapy institutions, common approaches with them to national health delivery systems and
third3party payer systems, in short, the professionalisation and legalisation of psychoanalytic and
psychotherapeutic practice (how to protect the public from :wild therapies;) all have important
political implications+
,n this paper, , shall limit myself to conceptual, clinical and educational issues+ The political
strategies and tactics to be followed by psychoanalytic institutions appear to be so dependent upon
local situations that vary from country to country that any generalisation at this point would seem
premature+ ?evertheless, the clarification of the conceptual, clinical and educational principles and
issues that follows may help some societies and institutes to develop political strategies appropriate
to their particular geographical regions+
,n a previous publication (1(() , e7amined the development of convergences and divergences in
contemporary psychoanalytic technique, concluding that e7tensive mutual rapprochement between
the ego3psychological, @leinian, *ritish ,ndependent and 0rench mainstream psychoanalytic
approaches now permit the definition of a common basic technique that allows for setting an overall
boundary for psychoanalysis+ These common techniques include maintaining a central focus upon
transference analysis, remaining alert to character analysis (:pathological organiAations; BCteiner,
1()5, 1((4D in @leinian terminology), and focusing sharply on unconscious meanings in the :here
and now;+ There is an increasing trend towards translating unconscious conflicts
3 1456 3
into ob2ect3relations terminology, an increasing emphasis on countertransference analysis, and on
the importance of the patient.s affective e7perience as an entrance3point into the e7ploration of
unconscious meanings+ &dditional areas of convergence of the different psychoanalytic approaches
include the increasing concern with :indoctrination; of patients, (@ernberg, 1((6), the consideration
of a multiplicity of :royal roads; to the unconscious (*lum, 1()") and a questioning of linear
models of development+
'eanwhile, a new psychoanalytic current is gradually diverging from the mainstream 2ust
summarised (@ernberg, 1((5)+ This new current, particularly mar8ed in the $nited Ctates, is the
development of ,ntersub2ective and ,nterpersonal psychoanalytic approaches that include Celf3
psychology, on the one hand, and the cultural psychoanalytic tradition e7pressed in contemporary
,nterpersonal psychoanalysis, on the other+ ,n so far as Celf3psychology focuses on selfEself3ob2ect
transferences as the ma2or matri7 of psychoanalytic treatment, it implies a movement away from
technical neutrality, an emphasis on emotional attunement and the analyst.s sub2ective immersion in
the patient.s sub2ective e7perience+ This approach also accentuates an :anti3authoritarian; attitude on
the part of the analyst, questioning the privileged nature of the analyst.s sub2ectivity+ The present3
day intersub2ective and interpersonal approaches, moving in the same direction, focus on the :real;
aspects of the transference1countertransference bind, on the analyst.s role in compensating for past
overstimulation or understimulation of the patient.s archaic self, and consider that the personality
develops continuously within a relationship matri7 (rather than in the conte7t of e7pressing
conflicts between drives and defences against them)+ This concept of development requires a
consistent focus on the intersub2ective field in the relationship between patient and analyst, and
assumes that the patient.s emotional growth depends on the integration of new affective
interpersonal e7periences+ & ma2or consequence of this overall shift in psychoanalytic perspectives
is the questioning of the traditional, positivist view of the analyst.s ob2ectivity in interpreting the
patient.s transference distortions and their origins+ The intersub2ective and interpersonal approach
favours a constructivist model, in which the e7ploration of developments in the new affective
relation in the psychoanalytic encounter is the basic source of interpretation, and the patient.s
incorporation of this affective e7perience is considered a ma2or therapeutic factor+
The ma2ority of ?orth &merican analysts apparently still operate within an ego3psychological
approach, influenced, to varying degrees, by ob2ect3relations theory+ This version of psychoanalysis,
as it is increasingly enriched by @leinian viewpoints, can be clearly differentiated from
psychoanalytic psychotherapies+ ,t is more difficult to establish conceptual boundaries between
psychoanalytic psychotherapy and the *ritish ,ndependent, 0rench mainstream and &merican
constructivist approaches, a reflection of their greater fle7ibility and e7pansion of technique, and at
the same time a threatening challenge to the identity of their practitioners+ ,n this regard, the
widespread practice of psychoanalytic psychotherapy by analysts over many years in the $nited
Ctates has made this less of a problem for &merican psychoanalysts than it has become for the
0rench mainstream, where a broader spectrum of psychoanalytic method and a reluctance to accept
the constraints of a specific :analytic technique; accentuate the problem (Fahn, 1((6; /idlGcher H
*raconnier, 1((6; /idlGcher H %rot, 1((6; <ibeault, 1((); ,srael, 1(())+
9ven considering these complications, , propose that a basic common boundary between
psychoanalytic method and that of psychoanalytic psychotherapy can be established and spelled out
within limits+ This conceptual boundary may apply to all the psychoanalytic schools referred to+
Iowever, a further issue needs first to be spelled out+ ,n the traditional &merican approach to
psychoanalytic psychotherapies, strictly psychoanalytic techniques have tended to be combined
with supportive
3 1455 3
interventions, and in practice, the discussion of psychoanalytic psychotherapy by contrast with
psychoanalysis often refers to the inclusion of supportive elements in such psychotherapies+ This
issue has been e7plored in great detail by /allerstein (1((") and by >oc8land (1()(), the former in
presenting the arguments for a continuum of psychoanalytic techniques from a
psychoanalytic1e7pressive polarity to a suggestive1supportive polarity, the latter in differentiating
distinctively supportive from e7pressive psychotherapy+ ,n what follows, , propose a rather strict
differentiation of standard psychoanalysis, psychoanalytic psychotherapy and psychoanalytically
based supportive psychotherapy+ To clarify a minor semantic issue, psychoanalytic psychotherapy
has also been referred to as e7ploratory or e7pressive psychotherapy+ :%sychoanalytic;
psychotherapy and supportive therapy imply that both modalities of treatment are based on
psychoanalytic theory (@ernberg, 1()!)+ There are, of course, respectable non3psychoanalytic
supportive psychotherapies that are effective and validated by research, and in what follows, , shall
limit myself to the psychoanalytically based supportive psychotherapy+
+i,,erentiation o, these -odalities o, Psychoanalytically based .reat)ents
,n order to differentiate psychoanalysis, psychoanalytic psychotherapy, and supportive
psychotherapy from each other, it is important, first of all, to distinguish the overall theory of the
treatment from its ob2ectives, and to separate the techniques employed from the resulting process+
Jbviously, one also has to differentiate process from outcome, but , believe we can dismiss efforts
to define treatment modalities on the basis of the outcome+
>egarding the underlying theory of unconscious motivation (unconscious conflicts between
aggression and libido, on the one hand, and the defences against them, on the other, including the
structural implications of impulse1defence configurations, and the internalised ob2ect relations
within which such unconscious conflicts are embedded), this general theory is common to all three
modalities of treatment, although the emphasis on and relations between drive theory, ob2ect3
relations theory and structural organisation (:first and second topic; in 0rench psychoanalysisEthat
is, the topographical, and respectively, structural theory) varies in different psychoanalytic
approaches+
>egarding the ob2ectives of the treatment, these treatment modalities vary: the ob2ective of
psychoanalysis is fundamental structural change, the integration of repressed or dissociated
unconscious conflict into the conscious ego+ ,n e7pressive or psychoanalytic psychotherapy, the
ob2ective is a partial reorganisation of psychic structure in the conte7t of significant symptomatic
change+ The ob2ective of supportive psychotherapy is symptomatic improvement by means of a
better adaptive equilibrium of impulse1defence configurations, with a reinforcement of adaptive
defences as well as adaptive impulse derivatives+ The ob2ectives of treatment, however, in my view,
do not lend themselves to sufficiently differentiating these modalities of treatment+ ,t is the
translation of these ob2ectives into a technical approach that characterises each treatment+ &lso, we
still have serious methodological difficulties in assessing structural change+ Curprisingly
fundamental structural changes have been observed in patients treated with psychoanalytic
psychotherapy, while patients with severe personality disorders have been found to respond with
profound structural change to a particular variant of psychoanalytic psychotherapy (@ernberg, 1()!,
1((2)+
, propose that it is in the techniques utilised that differentiation between these treatment modalities
becomes possible+ Jne might argue that it is not technique per se that permits the differentiation of
these treatments, but the interaction between technique and the patient.s response, or even the
interaction between the therapist.s personality and technique, on the one hand, and the patient.s
personality and interaction with the therapist, on the other+
3 145) 3
This broad approach to the differentiation of techniques, however, would confuse, for e7ample, a
psychoanalytic stalemate in which the patient is unable to proceed any further along a
psychoanalytic modality of treatment with a therapeutic stalemate in a psychoanalytic
psychotherapy+ ,t is true that the patient.s capacity or incapacity to participate in a definite modality
of treatment may induce the therapist to shift his technique: and this technique will then determine
the nature of the treatment+ & therapist may, of course, combine or shift his technical approach in
any single case over time: a clear definition of techniques may permit diagnosis of that shift+ 0rom a
conceptual view3point, , believe that a differential definition of these modalities in e7clusive terms
of the technique employed, separating the technique from the therapeutic interaction and its
effectiveness in the individual case, permits the clearest and clinically most meaningful
differentiations+ Jbviously, in clinical practice, the attitude and personality of the therapist will
colour the e7pression of any technical approach, and the patient.s reaction, in turn, will affect it+
Flinical and research e7perience, however, convincingly indicates the possibility of defining a
consistent, basic technique applied in each case in the light of the following guidelines+ The
following are the basic technical differences between the three modalities of treatment based on
psychoanalytic theory+
Ctarting from <ill.s (1("!) definition of psychoanalysisEnamely, the facilitation of the
development of a regressive transference neurosis, and its resolution by interpretation alone, carried
out by a psychoanalyst from a position of technical neutralityE, would define interpretation,
transference analysis and technical neutrality as three essential features of the psychoanalytic
method (@ernberg, 1()!; @ernberg et al+, 1()()+ &lthough <ill himself questioned that definition in
later years, , strongly believeEon the basis of nearly forty years of involvement with naturalistic
and empirical research on psychoanalytic modalities of treatmentEthat this is the simplest and,
both clinically and theoretically, most useful definition of the psychoanalytic method+ /ith the
underlying assumption that a regressive transference neurosis reproduces, in the psychoanalytic
situation, the pathogenic unconscious impulse1defence configurations dominant in a patient.s
psychopathology, most &nglophone psychoanalysts will probably still feel comfortable today with
such a definition+ ,f, at the same time, it is specified that impulse1defence configurations are
embedded in partially and totally internalised ob2ect relationsEso that both the impulsive and the
defensive sides of pathogenic unconscious conflicts are represented by such internalised ob2ect
relationsEa broad spectrum of ob2ect relations theoreticians in all three regions of the
psychoanalytic community should feel comfortable+ ,f, finally, it is spelled out that the content of
these unconscious conflicts involves aggressive and libidinal impulses centring on infantile
se7uality, the archaic and advanced oedipal constellation, primary seduction, castration an7iety and
the primal scene, 0rench psychoanalytic authors also should feel reassured, leaving it open to what
e7tent archaic oedipal issues and pre3oedipal conflicts are intimately lin8ed+ This definition of
psychoanalysis in terms of its technique should thus satisfy the conceptual requirements of the
psychoanalytic :mainstream;+ This definition (particularly regarding technical neutrality), may not
satisfy the conceptual requirements of the &merican ,ntersub2ectivist, ,nterpersonal and Celf3
psychology approaches, but may contribute to clarifying the e7tent to which these approaches
incorporate psychotherapeuticEin contrast to strictly psychoanalyticEtechniques, and where they
would draw the boundaries between the three modalities of treatment , have outlined+ Thus, for
e7ample, these schools. emphasis on countertransference analysis and on the intricate nature of
transference3countertransference binds may be compatible with the proposed definition of
psychoanalysis, e7cept when countertransference communication or enactment decreases or
eliminates technical neutrality, which, if not interpretively reduced, would
3 145( 3
shift the treatment modality into psychoanalytic psychotherapyEor even a supportive one+
The technique of interpretation includes clarification of the patient.s conscious and preconscious
e7perience, confrontation as the tactful focus on verbal and non3verbal behaviour that complements
the communication of the patient.s sub2ective e7perience by free association, and interpretation per
se of the unconscious meaning of what has been clarified and confronted, unconscious meaning in
the :here and now; being usually an important bridge to the interpretation of the unconscious
meaning in the :there and then; (Candler H Candler, 1()5)+
Transference analysis is the main interpretive focus in standard psychoanalysis, carried out
systematically, in the sense that an actually emerging sequence of transference developments is
systematically e7plored without a biased presumption of the genetic order of these transference
dispositions+ The consideration of synchronic and diachronic e7pressions of the transferenceEthat
is, condensations of conflicts from different stages of development, contrasting with a sequential
narrative of a particular period of developmentEhas conceptually replaced older models of linear
development (@ernberg, 1(()+ /hile transference analysis, particularly within the @leinian notion
of analysis of the :total transference situation; (-oseph, 1()() always incorporates developments
outside the sessions, it essentially focuses on the unconscious developments in the patient1analyst
relationship, with countertransference analysis as an essential component of the analysis of the
therapeutic relationship+ 9ven granting significant differences regarding the approach to the
transferenceEfor e7ample, the sharp focus on linguistic communication and structure in 0rench
analysis, the focus on the activation of primitive ob2ect relations in @leinian and *ritish
,ndependent approaches, the focus on character defences in ego3psychologyEthe dominance of
systematic transference analysis may be considered an essential characteristic of the psychoanalytic
method+
Technical neutrality refers to interpretive equidistance from the patient.s superego, id, acting ego
and e7ternal reality, that is, approaching the material from the position of the observing segment of
the patient.s ego (@ernberg, 1((5)+ Technical neutrality implies a concerned ob2ectivity that permits
the highlighting of the transference, and its analysis as an implicit distortion of the :normal;
therapeutic relationship established at the outset by setting up the framewor8 and defining the tas8s
of both participants (free association for the patient, interpretation for the analyst)+
0ree association is a method common to psychoanalysis and psychoanalytic psychotherapy+ The
only additional characteristics of psychoanalysis that contribute to its differences from
psychoanalytic psychotherapy are the frequency of sessions and the use of the couch+ ,t may be
argued that psychoanalysis cannot be carried out below a certain frequency of sessions without
becoming :anaemic;, and most psychoanalysts would agree that three or four sessions constitute the
minimum for psychoanalytic wor8 to be effective+ *ut in my view neither the frequency of sessions
nor the use of the couch is a conceptually significant defining feature of psychoanalysis+
%sychoanalytic psychotherapy may be characterised by the same basic techniques as
psychoanalysis, but with quantitative modifications that, in combination, result in a qualitative shift
in the nature of the treatment+ &ny given session of psychoanalytic psychotherapy may be
indistinguishable from a psychoanalytic session, but over time the differences emerge quite clearly+
%sychoanalytic psychotherapy utilises interpretation, but with patients with severe psychopathology,
for many of whom this is the treatment of choice, clarification and confrontation occupy a
significantly larger space than interpretation per se, and interpretations of unconscious meanings in
the :here and now; a larger space than interpretation in the :there and then;+ 0or practical purposes,
clarification, confrontation and interpretation in the here and now are the main aspects of
interpretive technique utilised in
3 14)4 3
psychoanalytic psychotherapy, with a clear predominance of clarifications and confrontations
(@ernberg, 1()!; @ernberg et al+, 1()()+
>egarding transference analysis, in the treatment of patients with severe character pathology it is
the essential focus of psychoanalytic psychotherapy from the very beginning, but it is modified by
the active interpretive connection of transference analysis with e7ploration in depth of the patient.s
daily life situation, an approach made necessary by the predominance of primitive defence
operations in these patients+ Cplitting operations in particular tend to dissociate the therapeutic
situation from the patient.s e7ternal life, and may lead to severe, dissociated acting out either in the
sessions or outside the sessions+ Therefore, interpretive lin8age between the patient.s e7ternal reality
and transference developments in the hours becomes central+
Technical neutrality is an essential tool, but in the treatment of patients with severe character
pathology, the need to set limits necessitates abandoning neutrality again and again, in order to
control life3threatening or treatment3threatening acting out+ ,n psychoanalysis, in contrast, technical
neutrality ideally is maintained throughout the entire treatment+ The self3perpetuating nature of
acting out in these cases may prove impossible to resolve interpretively without such structuring or
setting limits+ ,n practice, this means that, for e7ample, characterologically determined suicidal
behaviour (by contrast with suicide in the conte7t of severe depression) requires limit3setting+ &n
initial therapeutic contract, in which the patient commits himself either to get himself hospitalised,
or else control his suicidal behaviour rather than acting on it, may become a precondition for
treatment that clearly represents an abandonment of technical neutrality+ &ny such abandonment of
technical neutrality should be e7plored immediately after its establishment in terms of the
transference implications of the therapist.s structuring behaviour, followed by the analysis of the
transference implications of that very behaviour itself, followed in turn by the gradual resolution of
the structure or limit3setting by interpretive means, thus restoring technical neutrality+ ,n short,
technical neutrality in psychoanalytic psychotherapy is an ideal wor8ing state, again and again
preventively abandoned and interpretively reinstated (@ernberg, 1()!, 1((2; @ernberg et al+, 1()()+
%sychoanalytic psychotherapy usually requires two to four, but no fewer than two sessions per
wee8, in order both to e7plore transference developments and to follow the changing reality of the
patient.s daily life+ ,t is not possible to carry out these tas8s with patients with severe
psychopathology on a schedule of wee8ly sessions: on a once3wee8ly session, the time would either
be utilised completely by updating the therapist of developments in the patient.s life, thus
precluding transference analysis, or else, systematic transference analysis under these circumstances
may foster the splitting off of important developments (and acting out) in the patient.s e7ternal life
situation+ %sychoanalytic psychotherapy should be carried out in :face3to3face; sessions that permit
highlighting the communication of the patient.s non3verbal behaviourEa predominant mode of
communication in severe personality disordersEand facilitate the therapist.s simultaneous attention
to (a) the patient.s communication of sub2ective e7perience by means of free association, (b) the
communication by means of non3verbal behaviour, (c) the therapist.s countertransference analysis+
&s in psychoanalysis, the combined analysis by the analyst of the information coming from these
three sources permits the establishment of a :selected fact; (*ion, 1(6), 1(54), signalling the main
thrust of interpretation+
%sychoanalytic psychotherapy thus does not dilute the :gold; of psychoanalysis with the :copper; of
support, but maintains an essentially psychoanalytic technique geared to analyse unconscious
conflicts activated in the transference within a modified framewor8, spelled out and e7plicitly
agreed to by the patient in advance+ The attention to developments in the patient.s e7ternal life
represents a
3 14)1 3
modified focus from the standard psychoanalytic approach, in contrast to the :goallessness; of each
psychoanalytic hour within an ego3psychological framewor8, or the :absence of memory and desire;
(*ion, 1(65) within a @leinian framewor8+ Foncern regarding the patient.s e7ternal life in
psychoanalytic psychotherapy also e7tends to the maintenance of alertness to the relationship
between transference developments and the long3range treatment goals, that is, attention to the
e7tent to which the treatment itself, as a sheltered haven, may acquire secondary gain functions as a
protection against e7ternal reality in the case of patients with severe psychopathology (@ernberg et
al+, 1()()+
Cupportive psychotherapy based on psychoanalytic theory may also be defined along the lines of
the three ma2or techniques mentioned+ >egarding interpretation, supportive psychotherapy utilises
the preliminary steps of interpretive technique, that is, clarification and confrontation, but does not
use interpretation per se+ ,n contrast, it utilises cognitive and emotional support, that is, statements
of the therapist that tend to reinforce adaptive compromises between impulse and defence by means
of the provision of cognitive information (such as persuasion and advice) and by means of
emotional support (including suggestion, reassurance, encouragement and praise)+ ,n addition,
supportive psychotherapy utilises direct environmental intervention, by the therapist, relatives, or
other mental health personnel engaged in au7iliary therapeutic functions (>oc8land, 1()()+
The transference, therefore, is not interpreted in supportive psychotherapy, but it is not ignored
either+ Fareful attention to transference developments helps the therapist to analyse, in a tactful way,
the :inappropriate; nature of the transference developments, their reproduction, in the hours, of
pathological interactions the patient generally engages in with significant others; and the
encouragement of the patient to reduce such pathological behaviour in the hour+ %ointing out the
distorted, unproductive, destructive or confusing nature of the patient.s behaviour is matched by
clarifying the patient.s conscious reasons for his behaviour in the hours together with confrontation
of its inappropriate nature, followed by the transfer or :e7port; of the 8nowledge thus achieved to
the patient.s relationships outside the treatment+ ,n short, supportive psychotherapy includes the
clarification, reduction and :e7port; of transference, thus contributing to the re3educative functions
of supportive psychotherapy together with the direct cognitive and affective support of adaptive
combinations of impulse and defence, and direct supportive environmental interventions+
Technical neutrality is systematically abandoned in supportive psychotherapy, the therapist ta8ing a
stance alternatively on the side of the ego, superego, id or e7ternal reality, according to which
agency represents, at a certain point, the more adaptive potential for the patient+ The main dangers,
of course, in supportive psychotherapy, are, on the one hand, infantilising the patient by an
e7cessively supportive stance, and, on the other, countertransference acting out as a consequence of
the abandonment of the position of technical neutrality+ The therapist carrying out supportive
psychotherapy, therefore, needs a heightened awareness of the ris8 of these complications+ Ki8e
psychoanalytic psychotherapy, supportive psychotherapy is carried out in :face3to3face; sessions,
and has the advantage of considerable fle7ibility regarding its frequency, from several sessions per
wee8, to one session a wee8, or one or two sessions per month, according to the urgency of the
patient.s present difficulties and the long3range ob2ectives of the treatment+
The proposed differentiation of psychoanalytic psychotherapy from supportive psychotherapy may
be criticised from the viewpoint of actual psychotherapeutic practice, in which supportive and
interpretive techniques are often combined, in treatments ranging from eclectic to :wild;
psychotherapy+ 0rom a theoretical viewpoint, this practice has received support from the
consideration of the supportive effects of psychoanalytic interventions, so
3 14)2 3
that all treatments based on psychoanalytic theory are supposed to contain supportive elements+ ,n
any event, the combination of e7pressive or psychoanalytic psychotherapy with supportive
psychotherapeutic interventions is prevalent in clinical practice+ Iowever, , believe that the
supportive effects of any intervention must be differentiated from supportive techniques proper, and
that the prevalent combination of interpretive and supportive techniques in clinical practice is a
highly questionable one+ , believe that this combination interferes with the possibility of
transference analysis in depth by the abandonment of technical neutrality, and with the full
deployment of supportive techniques in order to reduce the deviation from technical neutrality and
protect some possibility for transference analysis+ ,n this regard, , believe, a thorough
psychoanalytic training facilitates both the learning of a strictly psychoanalytic psychotherapy and
its differentiation from supportive psychotherapy+ ,n addition, such training can facilitate learning
in3depth the methodology of supportive psychotherapy based on psychoanalytic theory+
(o)parisons, Indications and (ontra!Indications
Cummarising the differing characteristics of the three treatments described, in terms of strategies,
tactics and techniques, we may say that the techniques of psychoanalysis and psychoanalytic
psychotherapy are essentially identical, with quantitative modifications that create a different
ambience in psychoanalytic psychotherapy throughout time+ ,n so far as the proportion of
clarification and confrontation to interpretation per se may shift in the course of any psychoanalytic
treatment, the differentiation of psychoanalysis from psychoanalytic psychotherapy cannot be
ascertained in any particular session, but only be established by the evaluation of the treatment
throughout time; a :grey area; of uncertainty is unavoidable in clinical practice+ The clearly different
prevalence of interpretation per se, of unwavering adherence to technical neutrality, and of
systematic transference interpretation throughout time ma8e the differential diagnosis of
psychoanalysis in contrast to psychoanalytic psychotherapy easy in the large ma2ority of cases+
%rimitive defensive operations are systematically interpreted in both psychoanalysis and
psychoanalytic psychotherapy as they enter the transference, in the conte7t of the analysis of the
activation of primitive ob2ect relations that represent the unconscious intrapsychic conflicts between
drives and defences against them+ ,n addition, because of the systematic elaboration of the
transference neurosisEthat is, the naturally evolving sequence of transference paradigmsEin the
course of psychoanalytic treatment, the atmosphere of the analytic situation gradually shifts from a
predominance of the analysis of the intersub2ective nature of transference1countertransference
formations into the gradual predominance of the e7ploration of the deeper levels of the patient.s
intrapsychic e7perience (&ndrL <reen, personal communication)+ ,n contrast, the consistent
dominance of the e7ploration of the intersub2ective developments in psychoanalytic psychotherapy
without that gradual shift signals the relatively limited nature of the transference analysis in these
cases+ *y the same to8en, the clear difference in techniques of supportive psychotherapyEthe
absence of interpretation of unconscious conflicts, particularly of the transference; the utilisation of
cognitive and affective supportive techniques, and direct environmental intervention; the utilisation
of the transference for re3educative purposes, and the consistent abandonment of technical
neutrality at the service of the supportive fostering of adaptive impulse1defence configurationsE
signal the definite difference between this approach and psychoanalysis and psychoanalytic
psychotherapy, while it is still based on psychoanalytic theory+
Iow does psychoanalytic theory influence supportive psychotherapy= ,t does so first by the use of
techniques derived from psychoanalysis (clarification and confrontation)+ ,t
3 14) 3
renders the therapist alert to transference developments, it facilitates the diagnosis of primitive
defensive operations in the therapeutic interactions, enabling the therapist to clarify and comfort
their present functions in protecting the patient.s security and self3esteem, without pointing to their
unconscious roots+ &lertness to the countertransference also helps to sharpen the therapist.s
approach in supportive psychotherapy+
0rom the viewpoint of strategies of treatment, the strategy of psychoanalysis is the resolution of the
transference neurosis; the strategy of psychoanalytic psychotherapy, with patients with severe
personality disorders or borderline personality organisation, involves resolving the syndrome of
identity diffusion and permitting the integration of normal ego identity+ %athological character
constellations operating within a normal identity structure may not be elaborated sufficiently in the
treatment of these patients in spite of radical personality changes and resolution of their neurotic
symptoms (@ernberg, 1()!, 1((2; @ernberg et al+, 1()()+ The strategy in supportive psychotherapy
is the careful, gradual mapping out of the patient.s dominant interpersonal difficulties and neurotic
symptoms, reflecting unconscious conflicts, and their psychotherapeutic modification in the
direction of reinforcing adaptive solutions to unconscious conflicts in all areas available to
psychotherapeutic e7ploration, with particular utilisation of the clarification, confrontation,
reduction and e7port of transference as a ma2or treatment technique+ ,n supportive psychotherapy,
the strategy involves fostering a better adaptation to intrapsychic and e7ternal needs rather than
efforts at structural intrapsychic change+
>egarding the tactics of these treatments, that is, the approach to the patient.s material in each
session, psychoanalysis and psychoanalytic psychotherapy utilise the same approach+ The therapist
attempts to diagnose the predominant transference issue on the basis of the simultaneous
e7ploration of the patient.s verbal communication, non3verbal communication and the
countertransference, to establish a
:selected fact; and then wor8s interpretively with the affectively dominant unconscious conflict that
this selected fact represents+ The analyst.s free3floating attention permits him1her to capture that
affectively dominant material+ ,n supportive psychotherapy, the patient.s dominant symptomatology
and behavioural disturbances dictate the point of entry of the therapist.s interventions+ The therapist
focuses on the transference (as previously described) only when transference complications
interfere with the effort to change impulse1defence configurations by means of supportive
interventions+ Thus, strategy, tactics and techniques 2ointly clarify the differences between these
three modalities of treatment based on psychoanalytic theory+
The indications for these three modalities of treatment are still sub2ect to debate, and the clinical
e7perience we currently have needs to be strengthened (or confronted) with empirical data+ /ith the
recognition of the limitations of psychoanalysis in many cases with severe, chronic, life3threatening
self3destructive behaviour, such as chronic suicidal behaviour, severe eating disorders, drug
dependence and alcoholism and severely anti3social behaviour, psychoanalytic psychotherapy has
proven a highly effective treatment for many but by no means all patients with these conditions+ The
differential diagnosis of those cases of severe self3destructive and anti3social behaviour who are
amenable to treatment with psychoanalytic psychotherapy has been one of the important side3
products of the psychoanalytic e7ploration of these cases (@ernberg, 1((2)+ The indications of
psychoanalytic psychotherapy for patients with neurotic personality organisation, where, actually,
psychoanalysis per se would be the treatment of choice, is still controversial+ ,t may be indicated as
an alternative treatment when individualised contra3indications play a significant role+ ,t often is
chosen over psychoanalysis for financial reasons, or geographical or time3limits considerations: this
is precisely the controversial area+ , believe it is fair to say that, given the present cultural and
financial climate, and the very recent nature of
3 14)! 3
empirical research regarding the effectiveness of these treatments, financial and cultural pressures
often tend to override at this time the clinical evidence for the indication of psychoanalysis as the
treatment of choice+
Cupportive psychotherapy, originally conceived of as the treatment of choice for patients with
severe personality disorders, may now be considered the alternative treatment for those patients
with severe personality disorders who are unable to participate in psychoanalytic psychotherapy+
The 'enninger 0oundation %sychotherapy >esearch %ro2ect showed that patients with the least
severe psychoneurotic disturbances tend to respond very positively to all three modalities derived
from psychoanalytic theory, although best to standard psychoanalysis (@ernberg et al+, 1(52)+
Ctandard psychoanalysis is the treatment of choice for patients with neurotic personality
organisation+ %sychoanalysis has also e7panded its scope to some of the severe personality
disorders, in particular a large spectrum of patients with narcissistic personality disorders, patients
with mi7ed hysterical1histrionic features, and selected cases of patients with severe paranoid,
schiAoid and sado3masochistic features+
&lthough we are still lac8ing systematic studies of the relationship between particular types of
psychopathology and outcome with psychotherapeutic treatments derived from psychoanalytic
theory, as a tentative generalisation it may be stated that, for the least severe cases, brief
psychoanalytic psychotherapy, supportive psychotherapy, or psychoanalysis are the treatments of
choice, psychoanalysis representing the opportunity for most improvement if the severity of the
case is sufficient to warrant psychoanalytic treatment+ 0or cases of moderate severity, but still
within neurotic personality organisation, psychoanalysis is the treatment of choice, and definitely
less can be e7pected from psychoanalytic psychotherapy+ &s mentioned before, because of financial
restrictions, in many countries, perhaps particularly the $nited Ctates, psychoanalytic
psychotherapy has become a prevalent treatment for cases where optimal improvement might be
e7pected with psychoanalysis per se+ Technical indications for optimal treatment and cost3benefit
considerations unfortunately do not always coincide+ 0or the severest cases, psychoanalysis is the
treatment of choice only in selected individual cases, and psychoanalytic psychotherapy the
treatment of choice for the large ma2ority, with supportive psychotherapy a second choice if contra3
indications for psychoanalytic psychotherapy dominate+
,n all cases, individualised contra3indications for the respective treatment are important+ ,n the case
of psychoanalysis, individual contra3indications depend on the questions of ego strength,
motivation, introspection or insight, secondary gain, intelligence and age+ ,n the case of
psychoanalytic psychotherapy, secondary gain, the impossibility of control of life3or treatment3
threatening acting out, limited intelligence, significant anti3social features and a desperate life
situation, may constitute individual contra3indications, particularly when they occur in combination+
&s mentioned before, when psychoanalytic psychotherapy is contra3indicated for individual
reasons, supportive psychotherapy becomes the treatment of choice+ ,n the case of supportive
psychotherapy, finally, a sufficient capacity for commitment to an ongoing treatment arrangement,
and absence of severe anti3social features are minimal individual requirements+ This is not meant to
be a complete list, but an illustration of the 8ind of criteria that become dominant in the individual
decisions regarding the selection of the treatment and its contra3indications+
'a2or Fritiques and %otential Jb2ections to this %roposed Jutline of Mifferential Fharacteristics
and ,ndications for %sychoanalysis, %sychoanalytic %sychotherapy and Cupportive %sychotherapy
1) To utilise highly specialised psychiatric diagnostic criteria to decide indications for
treatment does in2ustice to the psychoanalytic
3 14)" 3
2) concept of the universality of unconscious intrapsychic conflicts, and to the determination
of psychic equilibrium by the nature of these conflicts rather than by psychiatric diagnoses+
%sychiatric diagnostic considerations may restrict and bias the mind of the psychoanalyst, and
preclude his open engagement in e7ploring the unconscious+
) The prognosis for treatment depends on highly individualised features of the analyst and
patient couple+ The nature of the particular relationship established by the therapeutic couple
overrides in its prognostic implications all aspects of psychiatric diagnosis or psychotherapeutic
modality+
!) The transformation of psychoanalytic methodology into a circumscribed theory of
technique does in2ustice to the comple7ity of the analyst.s intuitive understanding, his
psychoanalytic instrument, the analyst.s creativity, and the many ways in which unconscious
communications from both participants stimulate the activation of understanding in self and other+
&ll :techniques; restrict the richness of intuitive grasping and communication of the manifestation
of the unconscious+
") The need, with the proposed model of indications for treatment, to e7amine patients
initially in great detail and depthEto establish not only a descriptive but a structural diagnosis in
order to clarify their predominant personality organisationEruns counter to the principles of open
e7ploration of unconscious meanings in the patient.s presentation, and threatens to distort the
transference by the active and intrusive intervention of the psychoanalyst+ The spontaneous
development of transference1countertransference binds will give more information to the
psychoanalyst than a diagnostic psychiatric evaluation+
6) The differences between the three modalities of treatment described do not ta8e into
consideration the differences between various psychoanalytic approaches that cannot be fit into the
procrustean bed of the proposed definitions of interpretation, transference analysis and technical
neutrality+ Thus, for e7ample, in so far as Celf3psychology recommends an interpretive approach
from the psychoanalyst.s position of a self3ob2ect of the patient, it runs counter to the concept of
technical neutrality as an essential characteristic of psychoanalytic technique; or else, in so far as
,ntersub2ective psychoanalytic approaches are tolerant of partial e7pression (:enactment;= or acting
out=) of the countertransference as a stimulus to transference activation and interpretation, again,
transference analysis as proposed is too restrictive in ruling out the introduction of supportive
techniques into the psychoanalytic setting+ ,nterpretive interventions, within a 0rench
psychoanalytic model, may attempt to directly contact the patient.s unconscious by focusing on the
linguistic aspects of a segment of the patient.s communication, on metaphor or metonymy in the
patient.s free associations+ &ddressing that segment with an interpretive comment that has an
elusive quality to avoid a premature saturation of meaning, preserving an :enigmatic; aspect of the
interpretation to stimulate the une7pected in the patient.s unconscious, may not be consonant with
the restrictive definition of clarification, confrontation, interpretation in the :here and now; and
:there and then; referred to before+
,n response to these critiques and ob2ections, , propose that an initial, sophisticated psychiatric
diagnosis can only help to provide the analyst with a richer and more in3depth picture of the patient+
,n addition to facilitating the e7ploration of potential limitations or ris8s to the treatment approach,
such a diagnostic evaluation also may provide a framewor8 that becomes helpful at later stages in
analysis, to relate the unconscious present to the unconscious past+ ,t is not a matter of requiring the
analyst to 8eep the historical data in mind throughout the sessions and thus restricting the analyst.s
freedom to react to the patient.s material, but rather of letting diagnostic and historical 8nowledge
emerge spontaneously when it contacts, in the analyst.s mind, the currently :selected fact;+
The evaluation of the patient.s psychopathology obviously needs to be carried out from a position of
technical neutrality, and, if
3 14)6 3
it should affect transference developments, these should be readily detected and analysed once the
treatment starts+ ,n more general terms, clarity of thin8ing and precision of categories in the
analyst.s mind should not interfere with free3floating attention once the treatment has started and the
analyst is engaged with the patient+ Flinical e7perience, even with a manualised te7t of
psychoanalytic psychotherapy for borderline patients (@ernberg et al+, 1()(), has demonstrated that
a well3defined technical approach leaves ample room for variations in individual approaches to
patients, and for very different styles and modes of therapeutic interaction that are still within the
same general category of a defined intervention+ Flarity of conceptualisation and planned mode of
intervention, in short, do not need to be in conflict with intuitive openness and creative
formulations+
%erhaps the most important critique of the proposed model is that, given the developments within
the Celf3psychology1,ntersub2ectivity1,nterpersonal schools, with the shifts in transference analysis,
countertransference utilisation, and the fle7ibility with regard to technical neutrality advocated by
these approaches, the differences between psychoanalysis and psychoanalytic psychotherapy, and
even their common differences with supportive psychotherapy become so blurred that the model ,
proposed no longer applies+ ,n this regard, indeed, the proposed model fits the psychoanalytic
mainstream (ego3psychology, @leinian analysis, 0rench psychoanalysis, *ritish ,ndependents)
better+ ,t needs to be pointed out, however, that the differences between psychoanalysis and
psychoanalytic psychotherapy, on the one hand, and supportive psychotherapy on the other, are
definite and clear enough to override all presently e7isting differences within psychoanalytic
approaches proper+ The differences between psychoanalysis and psychoanalytic psychotherapy, as ,
have suggested earlier, may be diagnosed only over a period of time; and that very fact may present
fewer difficulties in the long run with differentiating psychoanalytic psychotherapy from various
alternative psychoanalytic approaches, in contrast to attempting to classify any particular treatment
hours in terms of whether it is psychoanalysis or psychoanalytic psychotherapy+
,f the theoretical and technical assumptions e7pressed throughout this paper are valid, then
psychoanalytic psychotherapy and supportive psychotherapy are important derivatives of
psychoanalytic treatment that can be differentiated from it, which vastly e7pand the realm of
psychoanalytically based interventions, and which may provide a spectrum of psychoanalytically
derived therapies helpful to a large segment of the population who cannot or should not be treated
by psychoanalysis proper+
,n this paper, , have not e7amined the psychoanalytic psychotherapy of couples (Mic8s, 1(65),
psychoanalytic group psychotherapy (9Ariel, 1("4; 0oul8es H &nthony, 1("5; *ion, 1(61;
Ccheidlinger, 1()4) and psychoanalytic psychodrama (-eammet, 1((6; <ibeault, 1(())+ &ll of these
are also derivatives of psychoanalytic theory+ ,n any case, the spectrum of individual psychoanalytic
modalities of treatment e7plored in this paper should facilitate the definition and description of
other modalities of psychoanalytic psychotherapy and supportive psychotherapies related to them+
Cuch a spectrum of psychoanalytic psychotherapies may further broaden the field of
psychopathology treatable by psychoanalytic approaches+
.raining in Psychoanalytic Psychotherapy
, now turn to the last question raised at the beginning of this paper, namely, to what e7tent should
psychoanalytic education include teaching such modalities of treatment= , started out referring to
the fact that, in some circles, because of the difficulty in clearly differentiating psychoanalytic
psychotherapy from psychoanalysis proper, and the tendency to view psychotherapy as a mi7ture of
psychoanalytic and supportive techniques (:mi7ture of
3 14)5 3
gold and copper;), concern has been e7pressed over the threat to the psychoanalytic identity of the
candidate in training if he1she were e7posed to training in psychoanalytic psychotherapy+ , believe,
on the basis of what , have said so far, that a solid grounding in the theory of psychoanalytic
technique, and a precise delimitation of psychoanalytic technique proper, should help the advanced
candidate in psychoanalytic training when confronted with the opportunity to learn psychoanalytic
psychotherapy for patients for whom psychoanalysis proper is contra3indicated or not feasible+
, propose that the systematic teaching of psychoanalytic psychotherapy in advanced courses offered
in psychoanalytic institutes should provide the psychoanalyst in training with a greater fle7ibility of
technique, prevent the frequent tendencies to :wild psychotherapy; carried out by some
psychoanalysts when they are not applying standard psychoanalytic technique, and put an end to the
problematic contradiction, in many places, between teaching and learning the technique of standard
psychoanalysis, while psychotherapeutic wor8 predominates over psychoanalysis proper in the
clinical practice of our candidates and graduates+ ,n the long run, such psychotherapy training
should contribute significantly to the clinical e7pertise and sophistication of graduates of
psychoanalytic training, while providing a degree of quality control to the practice of psychotherapy
by candidates, many of whom have had little or no systematic training in psychotherapeutic
modalities before entering psychoanalytic institutes+
Jne highly controversial issue is the question, whether psychoanalytic institutes should also offer
training in psychoanalytic psychotherapy to non3analysts, such as psychoanalytically oriented
psychiatrists and psychologists+ This question has conceptual, clinical, educational and political
implications+ Fan and should non3analytically trained psychotherapists carry out psychoanalytic
psychotherapy as defined in this paper= ,f the answer were, even conditionally, positive, what
would the corresponding requirements for such a training be= Iow would such a training
programme affect the psychoanalytic institute=
, believe that we cannot avoid raising this question+ The widely divergent responses to it within the
psychoanalytic community illustrate the importance of this issue+ &t the same time, it is
unquestionably the most politically influenced issue relating to psychoanalytic psychotherapy+ ,n
the $nited Ctates, several psychoanalytic institutes offer training programmes on psychoanalytic
psychotherapy for psychiatrists and psychologists, and e7perience these programmes as positive
outreach activities in the conte7t of a generally indifferent or hostile ambience within departments
of clinical psychology and psychiatry in universities and medical schools+ They also see such
programmes as potential recruitment activities for future psychoanalytic candidates+ ,n some
9uropean institutes, in contrastEfor e7ample+ in 0rance and ,talyEsuch programmes would be
strongly opposed and re2ected out of a deep3seated concern for the identity of psychoanalytic
education in the conte7t of a social environment filled with psychoanalytic psychotherapy
programmes of varying degrees of professional quality offered by questionable training institutions+
,n these countries the ma2or concern is to protect the specific nature of psychoanalytic training from
contamination with diluted and :wild; forms of psychotherapy+
Iowever, this is not the central issue affecting psychoanalytic education in its concern with
psychoanalytic psychotherapy+ & more pressing question is the recruitment of e7perienced faculty+
'any e7perienced psychoanalysts who systematically practice psychoanalytic psychotherapy as
well, carry out research and teaching on psychoanalytic psychotherapy in university settings rather
than psychoanalytic institutes+ ,nstitutes thus may be deprived of the educational contributions of
these colleagues+ , propose an active effort on the part of psychoanalytic institutes to engage these
e7perts in the teaching of psychoanalytic psychotherapy within the institute proper+ The tendency to
shift the responsibility for such an educational endeavour to the psychoanalytic
3 14)) 3
society in the form of :postgraduate; courses, tends to deny, in subtle messages, the essential nature
of this educational e7perience by placing it outside the institute+ Cuch a displacement fits with a
traditional approach to psychoanalytic psychotherapy in psychoanalytic institutions that tended to
loo8 at it as a second3rate treatment, a form of degraded or diluted psychoanalysis+ %sychoanalysis
and psychoanalytic psychotherapy, derived from a common theory, are not competing modalities of
treatment, as , see it+ The latter is a highly sophisticated, specialised technique with indications and
contra3indications, that e7pands the realm of the therapeutic effects of psychoanalysis+ &s such,
from a theoretical and clinical viewpoint, as well as from that of the social responsibilities of the
psychoanalytic profession, the teaching of the psychoanalytic psychotherapies deserves to be in the
hands of the highest levels of teachers, practitioners and researchers+
Kast but not least, the fle7ibility built into the technique of psychoanalytic psychotherapy derived
from the combination of limit3setting, the interpretive resolution of movements away from technical
neutrality, the concern with protecting the patient.s survival as well as the survival of the treatment
by specialised types of contract3setting, and above all, the e7perience with the severest types of
transference regressions (that is, severely psychopathic, paranoid and depressive transferences
B@ernberg, 1((2D), have facilitated the development of new technical approaches that may be
transferred to psychoanalysis proper+ ,n this regard, psychoanalytic psychotherapy may be
considered an e7perimental setting in which new psychoanalytic techniques for the standard
treatment situation may be e7plored, in parallel, of course, to the application of technical
approaches derived from standard psychoanalysis to psychoanalytic psychotherapy+ Iere , have in
mind techniques described by our research group on psychoanalytic psychotherapy with borderline
patients at the /estchester Mivision of the ?ew Nor8 Iospital (Flar8in et al+, 1(()), which include
technical approaches to patients with chronic dishonesty in the transference, patients who develop
micropsychotic episodes and paranoid transference psychosis, severe types of acting out within the
treatment sessions, perversity in the transference, chronic sado3masochistic transference stalemates
and defensive social parasitism+ 0or all these conditions, new technical approaches derived from
psychoanalytic psychotherapy may broaden the range of action and protect the framewor8 of
standard psychoanalysis as well+ ,n conclusion, the teaching and learning of psychoanalytic
psychotherapy in the conte7t of psychoanalytic training may significantly enrich the educational
e7perience and the clinical e7pertise of the analyst in training, and strengthen our research efforts
and our therapeutic contributions to a changing social, cultural and economic environment+
3 14)( 3
*e,erences
*ion, /+ >+ (1(61)+ 97periences in <roups+ ?ew Nor8: *asic *oo8s+
*ion, /+ >+ (1(65)+ ?otes on memory and desire + %sychoanal+ 0orum, 2:2523 and 25(3)4+
*ion, /+ >+ (1(6))+ Cecond Thoughts: Celected %apers on %sychoanalysis+ ?ew Nor8: *asic *oo8s+
*ion, /+ >+ (1(54)+ &ttention and ,nterpretation+ Kondon: Ieinemann+BOD
*lum, I+ %+ (ed+) (1()")+ Mefense and >esistance: Iistorical %erspective and Furrent Foncepts+
?ew Nor8: ,nt+ $niv+ %ress+
Fahn, >+ (1((6)+ %sychothLrapies des nLvroses et des psychoses + ,n %sychanalyse by &+ de 'i2olla
and C+ de 'i2olla 'ellor+ %aris: %resses $niv+ 0rance+
Flar8in, -+ 0+ et al+ (1(())+ Treatment of *orderline %ersonality+ ?ew Nor8: /iley+
Mic8s, I+ P+ (1(65)+ 'arital Tensions+ ?ew Nor8: *asic *oo8s+
9Ariel, I+ (1("4)+ & psychoanalytic approach to the treatment of patients in groups + -+ 'ental
Ccience, (6:55!3(+
0oul8es, C+ I+ H &nthony, 9+ -+ (1("5)+ <roup %sychotherapy: The %sychoanalytic &pproach+
*altimore, 'M: %enguin *oo8s+
<ibeault, &+ (1(())+ Q la dLcouverte de l.arriRre3%ays + Mu processus analytique en psychanalyse et
en psychothLrapie ($npublished)+
<ill, '+ '+ (1("!)+ %sychoanalysis and 97ploratory %sychotherapy+ -+ &mer+ %sychoanal+ &ssn+
2:55135(5 BOD
,srael, %+ (1(())+ >eport of the Fommittee on %sychoanalysis and &llied %sychotherapies of the
97ecutive Founcil of the ,%& + ($npublished 'C)+
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ed+ M+ /idlGcher and &+ *raconnier+ %aris: 0lammarion, pp+ 3!+
-oseph, *+ (1()()+ %sychic 9quilibrium and %sychic Fhange+ Kondon and ?ew Nor8:
Tavistoc81>outledge+
@ernberg, J+ 0+ (1()!)+ Cevere %ersonality Misorders: %sychotherapeutic Ctrategies+ ?ew Iaven
and Kondon: Nale $niv+ %ress+
@ernberg, J+ 0+ (1((2)+ &ggression in %ersonality Misorders and %erversion+ ?ew Iaven, FT: Nale
$niv+ %ress+
@ernberg, J+ 0+ (1(()+ Fonvergences and Mivergences in Fontemporary %sychoanalytic
Technique+ ,nt+ -+ %sycho3&nal+ 5!:6"(365 BOD
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-+ %sychoanal+, "5:2(5312+
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at the panel: :&nalyAing transference: contemporary responses to 'erton <ill;, at the &nnual
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($npublished)+
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0oundation.s psychotherapy research pro2ect + *ull+ 'ennin+ Flinic++ 6:1325"+
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Picissitudes of <uilt+ ,nt+ -+ %sycho3&nal+ 6):13!1 BOD
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and Mepressive %ositions+ ,nt+ -+ %sycho3&nal+ 6):6(3)4 BOD
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%sychanalyse et %sychothLrapies+ %aris: 'Ldecine3Cciences, 0lammarion+
(,nitial version received 241"1(()
(0inal revised version received 1)1141(()
3 14(1 3