Ethical Aspects of Neutrality

Since Hartmann's era, the concept of neutrality has given rise to considerable controversy about both its meaning and its usefulness. If the term today less often signifies an amoral value-free posture, it continues to be used in writings on technique for a desirable mental state consisting of a combination of benignly attentive and tolerant attitudes and dispositions that are constitutive of analytic listening ¡see Laplanche and Pontalis 1973; Moore and Fine 1990).

The term neutrality, wrhich Strachey introduced as a translation of Freud's indifferenz (see Freud 1915a), comes from the Latin neuter; meaning "neither one nor the other." Unlike "abstinence," which involves not doing something, such as revealing personal information, neutrality is a state of mind. The term attempts to capture Freud's recommendation that the analyst listen with "evenly suspended attention" (Freud 1912, p. Ill), which Anna Freud characterized in structural terms as taking up a mental position equidistant from the demands of the id, ego, and superego {Freud 1936; Smith 1999, 20031. To the Freuds, to be neutral in the sense of free-floating attention was not to be value free, because the rationale for this listening mode was that it would benefit the patient by enabling the analyst to hear the full range of meanings in the patient's communications with minimal distortion and interference from the analyst's subjective opinions. "We will suspend our judgment and give our impartial attention to everything that is there to observe," Freud advised in the Little Hans case (cited in Balsam 1997, p. 5). The analyst was cautioned not to lend a special ear to particular parts of the patient's discourse or "read particular meanings into it, according to...theoretical or moral preconceptions" (Laplanche and Pontalis 1973, p. 271). The idea was to foster "reverie" in the analyst, enabling him or her to be receptive to what Bollas calls "unthought knowms" and to create a mood essential for the analysand's freedom to speak without fear of being encroached upon by the analyst's personal biases, opinions, and judgments (see Bollas 1999).

However, this temporary suspension of the analyst's narcissistic investment in favored theories, moral judgments about the patient's conduct, and particular life goals for the patient does not extend to the moral framework that makes analysis possible or to the analyst's moral character or the long-term moral goals toward wrhich the analysis is directed. For instance, neutral attention does not suspend the principle of respect for the patient as a person or die general obligation to avoid gratuitous harm. Rather than dispensing with moral character, neutrality actually requires it, in that the analyst cultivates the moral attitude of attentive tolerance, even toward the most extraordinarily provocative behavior.

If neutrality is conceived as a technical stance involving evenly suspended attentiveness, it characterizes the way the analyst is present |not absent, as some relational critics contend! in the analytic situation. This way of being present creates an ambiance that fosters both the analysand's freedom to speak and the analyst's ability simultaneously to hear the multiple meanings of the patient's verbal and nonverbal communications, without either party being pressured by the constraints of theories, morals, or goals. This analytic attitude/disposition is in turn warranted by such moral considerations as having respect for the patient and benefiting him or her optimally by facilitating freedom of expression, self-under-standing, and autonomy. The patient is respected both as the conscious not-yet-analyzed self-determining subject who chooses to speak at any given moment and as the more fully self-aware agent he or she might become with the advent of fuller, more authentic, and richer speech (for discussion of these two notions of respect for die analysand, see Blass 2003). Freud described aspects of neutrality based on respect for the patient's autonomy this way; "We refused most emphatically to turn a patient who puts himself in our hands in search of help into our private property, to decide his fate for him, to force our own ideals upon him, and with die pride of a Creator to form him in our own image and to see that it is good" (Freud 1919, p. 164).

Acknowledging that neutrality, as a mental state, is supported by moral standards carries with it the implication that the analyst's evenly suspended attentiveness may be—indeed, should be—modified if the weight of ethical and technical considerations warrants a more engaged style that better facilitates analytic listening (possibly through retrospective interpretation of enactments) as well as a particular patient's freedom of expression, expanded self-understanding, and autonomy. Neutrality in the sense of benign attentiveness is certainly not incompatible with either personal warmth or empathy. In fact, neutrality is intended to facilitate empathy, so that if it does not, some adjustments in its practice are ethically desirable.

Freud's Ethics

The ethics of clinical practice for psychoanalysis do not stand or fall with what Freud or his disciples thought, but it is instructive to look at the deep ethic that informs classical psychoanalytic theory and practice. This ethic, which I explore at length in Psychoanalysis and Ethics (Wallwork 1 991), has not been widely appreciated by psychoanalysts, largely because the prevailing value-neutral, "scientistic" (Habermas 19711 bias against ethics has led to the distortion of Freud's thought on a number of issues central to moral philosophy. However, die deep ethic that informs Freud's work persists to this day as one of the unacknowledged factors that unite psychoanalysts, despite theoretical and technical differences among contemporary schools.


One widely shared misperception is the assumption that Freud embraced the hard determinist thesis that the individual could not have acted otherwise. For exam ple, Arlow and Brenner (1964) echoed Ernest Jones (1953) when they wrote, "[Mental processes] follow the same general laws of cause and effect which we customarily assume to operate in the physical world. Psychoanalysis postulates that psychic determinism is as strict as physical determinism" {p. 7J.

However, contrary to the suppositions of lones, Arlow and Brenner, and Yankelovich and Barrett, among others, none of the few brief references to determinism in Freud's writings actually advocate the metaphysical determinist thesis that all human actions are causally necessitated by antecedent conditions and universal laws (Wallwork 1991). Freud wrote only about "psychic determinism," and he was careful to confine the concept to "motives" as "causes" that affect the occurrence of an outcome without actually requiring it. In the main, Freud employed "psychic determinism" to signal that some particular kinds of behavior (e.g., dreams, symptoms, parapraxes, and free associations) do not occur accidentally or fortuitously, as his predecessors had thought, but are traceable to the influence of repressed unconscious motives that function as "causes" in the realm of mental life. Thus, when Freud stated that "psychoanalysts are marked by a particularly strict belief in the determination of mental life," he went on to explain: "For them there is nothing trivial, nothing arbitrary or haphazard. They expect in every case to find sufficient motives where, as a rule, no such expectation is raised" (Freud 1910, p. 381.

For Freud, "psychic determinism" does not imply an absence of choice so much as the claim that all behavior is motivated and, as such, may fall under conscious voluntary control (Wallwork 1991, 19971. Choice is made possible in the structural theory by the "I" or the "ego," which has 'Voluntary movement at its command" |Freud 1940| 1938), p. 145). Thus, it is not inconsistent with psychic determinism for Freud to claim that the goal of psychoanalysis is to expand the range of "conscious willpower" and "freedom" (Freiheit) |Freud 1905, 1915a). In fact, the ultimate goal of psychoanalysis is "to give the patient's ego freedom to decide one way or the other" among the motives or reasons for action available to consciousness (Freud 1923, p. 50}.

Psychoanalysis is well known for shrinking the domain of moral responsibility by bringing to light new excusing circumstances that explain that an individual acted in a given way in some situation because of unconscious motivations. However, psychoanalysis paradoxically also expands the realm of moral responsibility by encouraging owning one's own disavowed motivations. The analysand is expected to assume responsibility for not only conscious intentions and conduct, as the

Western ethical tradition advises, but also unconscious motivations. In his remarkable 1925 essay "Moral Responsibility for the Content of Dreams/' Freud stated:

I must assume responsibility for both (conscious and unconscious motives)? and if, in defence, I say that what is unknown, unconscious and repressed in me is not my "egp/' then I shall not be basing my position upon psycho-analysis, I shall not have accepted its conclusions—and 1 shall pcrliaps have to be taught better by die criticisms of my fellow-men, by the disturbances in my actions and the confusion of my feelings. I shall perhaps learn that what 1 am disavowing not only "is" in me but sometimes "acts" from out of me as well. |p. 133; see ray discussion of Freud's views on moral responsibility in Wallwork 1991, pp. 75-100)

Egoistic Hedonism

A second commonplace misreading of Freud that undermines both the possibility of morality and the point of ethical reflection attributes psychological egoistic hedonism to the pleasure principle {see Asch 1952; Fromm 1973; Gregory 1975; Hoffmann 1976; Wallwork 1991). Certainly, Freud sometimes wrote as though he subscribed to the psychological hedonist thesis that human desire and volition are "always determined by pleasures or pains, actual or prospective" |Sidgwick 1962, p. 40).

Yet the key ethical issue at stake is whether Freud's hedonism always directs the agent egoistically, so that all seemingly disinterested behavior, such as pursuit of the truth, can be reduced ultimately to a desire for pleasure for oneself alone. That Freud tried to stake out a place for nonegoistic motives is obvious. Writing against egoism, he declared that it is both possible and desirable to pursue knowledge, even though it offers "no compensation for... (those) who suffer grievously from life" |Frcud 1927, p. 54). He made a similar point about the possibility of loving others for their own sake ("ihnen zii Liebe") (Freud 1921 J. In Freud's early work, disinterested motives are attributed to the reality principle's opposition to unrestrained libidinal pleasure seeking. In 1915, Freud added that nonegoistic motivations are a result of die developmental "transformation of egoistic into altruistic inclinations" (Freud 1915b, pp. 283-284). There is an enormous difference, Freud argued, between the egoist (or narcissist} who "acts morally" only for egoistic reasons—that is, because "such cultural behaviour is advantageous for his selfish purposes"—and the person who acts morally "because his instinctual inclinations compel him to" (Freud 1915b, p. 284). The latter individual has undergone "the transformation of instinct |7fr'e-bumbildung] that differentiates the 'truly civilized' from

'cultural hypocrites'" (p. 283-284). The civilized moral agent finds "satisfaction" in acting benevolently for another, but die basis of this is no more egoistic dian it is in the waitings of those many Western moralists since Aristotle who have emphasized the pleasurable aspects of acting morally.

Ethical Relativism

A third common misinterpretation of Freud that affects current attitudes toward ethics derives from the potentially relativistic implications of the concept of the superego |see Wallwork 19911. If the superego is synonymous with morality, as Freud sometimes indicated {Brenner 1982; Freud 1933[1932|, Kafka 1990), and if the superego is nothing more than a set of purely arbitrary standards that the individual has internalized by introjcct-ing the prohibitions and ideals of his or her parents and other authority figures, then nothing can be said in defense of moral standards other than that they are the standards one happens to have. There is no principled basis for choosing one set of ethical norms over another as guides for action—no grounds for reasoning that might persuade in the presence of conflict—other than egoistic strategies for obtaining rewards and avoiding external punishments and internal guilt or shame.

This is not Freud's position, however. Freud resists the pull of ethical relativism by arguing that there are certain reasonable moral guidelines that can be rationally defended (Wallwork 1991). This side of Freud's work has not been appreciated because it occurs as the subtext of Freud's all-out attack on religion in Pulure of an Illusion (Freud 1927). Here, Freud's sub msa point is that weakening the religious grounds for morality poses dangers to society and requires new rational justifications—the main task of ethics. Against ethical relativism, Freud (19271 declared that the time had come to "put forward rational grounds for the precepts of civilization" (p. 44). The challenge to contemporary analysts is to locate these grounds.

The Deep Ethical Theory Informing the Practice of Psychoanalysis

Although Freud never directly addressed the "rational bases" for morality, much can be adduced about the deep ethic in his work from what he said about happiness as the goal of life, the primacy of love of and respect for others as natural dispositions, the good of community, and die value of shared rules (see Wallwork 1991). This deep ethic continues to inform psychoanalysis today.

Freud's alternative ethic to superego moralism is often missed because it is drowned out by the negativity of his critique of religious and duty-oriented—particularly Kantian—ethics. Readers are unprepared for the Aristotelian form of ethics (oriented toward achieving personal happiness) that informs Freud's thinking, including his critique of superego moralism. Instead of viewing ethics as seeking an ahistorical, perspectivcless set of universal principles legitimated by reason alone, without reference to local commitments or particular experiences and affects, Freud saw ethics (at least when he was thinking constructively) primarily as dealing with the question of how it is best to live our lives. Here ethical deliberation is not about finding and applying a meta-decision-making procedure, such as Kant's categorical imperative or Bentham's utilitarian calculus, to resolve moral dilemmas. Rather, ethics is a matter of negotiating or straddling multiple incommensurate conscious and unconscious responsibilities and values that emerge out of "thick" reasoning, supportive of the most fitting moral judgment for the agent(s| in some specific context.

As for the paramount moral standard, Freud was quite explicit that the good that humans universally seek is "happiness" (eudearnonia in Greek, beatitude in Latin): "|W|hat ¡do] men themselves show by their behaviour to be the purpose and intention of their lives...: The answer to this can hardly be in doubt. They strive after happiness; they want to become happy and to remain so" (Freud 1930, p. 76}. In identifying "happiness" as the suinnium bonum, Freud is iti agreement with the mainstream of the Western moral tradition stretching from Aristotle through Augustine, Thomas Aquinas, and J.S. Mill. Like them, Freud does not leave the constituents of the intrinsic good of happiness for an individual to arbitrary personal preference (as it is in current formulations of utilitarianism], nor does he think that subjectively pleasurable mental states alone determine happiness (sec Freud 1930). Happiness for Freud, as for Aristotle, is more a matter of functioning welJ than feeling good. The mentally healthy person's happiness consists in the well-being that conies with certain forms of sublimation: loving and being loved, creative work, the pursuit of knowledge, freedom, and aesthetic appreciation. These goods of life that make happiness possible are not instrumental means to functioning well but constituent aspects of happiness. It is by means of love and work [iieben and arbeiten), for example, that we are as happy as human beings are capable of being {Freud 1912, 1930).

Love was privileged by Freud as a constituent of happiness partly because the qualitatively unique "union of mental and bodily satisfaction in the enjoyment of love is one of its [life's] culminating peaks" {Freud 1915a, p. 169}. Mutual love ¡"loving and being loved"] is universally recognized as one of the chief means for finding "a positive fulfillment of happiness" (Freud 1930, p. 82). Freud also accorded love pride of place because it underlies so many other noncgoistic values: love of family, friendship, love of others in a community (which provides Freud's rationale for acceptance of a community's rules and regulations), and love of humankind. Indeed, Freud 119301 defined "civilization" as a "process in the service of Eros, whose purpose is to combine single... individuals, and after that...peoples and nations, into one great unity" {p. 122}. By means of libidinal ties to the community, the individual feels concern for the welfare of others and can be motivated to "conform to the standards of morality and refrain from brutal and arbitrary conduct" (Freud 1915b, p. 280|, even when it is "disadvantageous" in terms of the agent's short-range self-interest. Of course, Freud never forgot that "man's natural aggressive instinct, the hostility of each against all and of all against each, opposes this programme of civilization" (Freud 1930, p. 122). With characteristic realism, he cautioned that few get beyond common human unhappiness.

Freud is well known, of course, for his sharp criticism of the love commandment ("Thou shalt love thy neighbor as thyself") in Civilization and Its Discontents (Freud 1930|. Less widely appreciated is that this critique is directed only against the excessive demands for self-abne-gation and self-sacrifice of the Christian version of the commandment and that Freud actually reinterprets the love commandment along more modest, broadly humanistic lines. "I myself have always advocated the love of mankind," Freud wrote to Romain Rolland, whose humanism he respected |E.L. Freud 1975, p. 374}. In 1933, 3 years after his harsh criticism in Civilization and Its Discontents, Freud himself explicitly embraced "the love commandment" as the antidote to human aggression:

If willingness to engage in war is an effect of the destructive instinct, the most obvious plan will be to bring Eros, its antagonist, into play against it. Anything that encourages the growth of emotional ties between men must operate against war... . There is no need for psycho-analysis to be ashamed to speak of love in this conncction, for religion itself uses the same words: "thou shalt love thy neighbour as thyself." ¡Freud 1933, p. 212|

Maclntyre, a practice is "any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity arc realized in the course of trying to achieve those standards of excellence which arc appropriate to, and partially definitive of, that form of activity" (Maclntyre 1984, p. 1 87). Tennis and chess are examples of practices, as is psychoanalysis. To enjoy the goods internal to the practice of tennis, one has to play according to the rules and standards of excellence of the game. Enjoyment of a game of tennis or of a good analytic hour comes not from contingent extrinsic rewards, such as fame or riches, but from actualizing the standards of excellence for that kind of activity. A virtue, according to Maclntyre (19841, is "an acquired human quality the possession and exercise of which tends to enable us to achieve those gocxls which are internal to practices and the lack of which effectively prevents us from achieving any such g(X)ds" {p. 191; italics in the original).

The analytic attitudes and dispositions (virtues) that advance the goods of analysis are taught by the example of training analysts, supervisors, and exemplary clinical accounts of how the analyst comports himself or herself, especially when pressured by the patient to act differently. These attitudes and dispositions enable the analyst to see and act correctly with patients—for example, in tolerating being "used" by the patient, as Winni-cott 11982) depicted in his paper "The Use of mi Object" |see pp. 86-94). To be virtuous in the context of analyzing is not only to be disposed to act in a certain way when tempted to do otherwise but to do so with the appropriate affects. For example, a good analyst is able to restrain a momentary countertransference desire to retaliate against a provocative patient by tapping stronger professional attitudes that help to contain his or her own and the patient's destructive affects, without rattling the patient with excessive traces of the analyst's hostility. If an unintentional enactment occurs, additional traits are called forth from the analyst, such as the courage to probe what has transpired and the honesty to admit one's own contribution, even when doing so is humiliating, if this facilitates the analytic relationship and work.

Analysts typically rely more on attitudes and traits (i.e., "virtues"! than on professional principles and rules for guidance in ordinary interactions with patients. Freud said as much when he wrote in 1927 that psychoanalytic "tact," under which he said he subsumed "everything positive that...|the psychoanalyst) should do/' was ultimately more important than rules, which are often too "inelastic" to guide actions well (quoted in Jones 1955, p. 241). Elsewhere, Freud observed that learning analytic technique is like learning to play chess: the rules of the game are less important than the example of master players.

Most of the character traits associated with the analyst's role are variants on familiar virtues in the Western moral tradition. The analyst is expected to be prudent, patient, honest, kind, curious, discreet, tolerant, spontaneous, humorous, courageous, and wise, to mention only a few of the most obvious traits (see Friedman 1996; Crinberg 1980; Jaffe and Pulver 1978; Schafcr 1983). Conversely, narratives of psychoanalytic misconduct depict familiar moral "vices," such as egotism and hostility, under the rubrics of "narcissism," "masochism/sadism," and "sadism" (see Gabbard and Lester 1995|. However, the distinctive ways analysts comport themselves are sufficiently unique to require a specialized terminology, such as the one formulated in the following discussion.

What, then, are the virtues of psychoanalysts? The answers vary somewhat among postclassieal psychoanalytic schools, but some traits are shared across schools because they are so basic to the analyst's role. These virtues facilitate an intrapsychic and interpersonal environment conducive to the analytic process. These "process virtues" arc very different from the idealized "virtues" of the Western moral tradition and the hypocritical ego ideals that many patients bring to treatment. They foster, rather than oppose, the patient's self-reflective capacities by making a virtue out of not being virtuous in the conventional senses of denying deplorable motives. In place of moral grandiosity, analysts cultivate the courage to accept narcissistic deflation in the arduous process of pushing the boundaries of self-knowledge while tolerating not knowing what cannot yet be grasped.

Empathic Respect

Empathic respect for the patient as a unique individual-evident from the outset of the relationship in the tone, affect, and rhetorical quality of the psychoanalyst's verbal and nonverbal responsiveness to the particulars of the patient's life, difficulties, affects, and choices—is an all-important virtue critical to the success or failure of an analysis. Patients come into analysis suffering from self-punitive mental states. The analyst's ability to recognize this and empathize with what the patient is feeling, while continuing to respect the person who is always more than a bundle of symptoms or a diagnosis, is essential in order for the therapeutic alliance to take hold. "Respect" insufficiently captures this analytic attitude, however, because respect can be cold and rower set, and therapeutic aims include not only self-knowledge but also reduced suffering, increased mental freedom, and augmented autonomy. Gabbard (2001} is undoubtedly right that analysts who claim not to be interested in symptomatic changes are disingenuous, because "of course we want to help our patients with distressing symptoms" |p. 294). Yet the debate continues over whether we should focus directly on treatment goals and, if so, how and with what degree of commitment.

Ethical issues arise in connection with treatment goals chiefly in terms of 1) who chooses the goals and 2} on what basis. With regard to the first, the analyst's role in setting treatment goals was privileged until roughly the middle of the 20th century, when the Hippo-cratic tradition's preference for paternalistic decisions informed by the physician's beliefs about the patient's best interests {under the moral principle of beneficence) began to give way, following the civil rights and feminist movements, to the moral principle of respect for the individual patient's autonomy. Owen Rcnik (20011 put the implications of this ethical shift boldly when he proposed that the patient has "die last word" regarding both "the definition of the goals of a particular analysis, and judgments concerning progress towards those goals" (p. 239). The ethical idea behind Renik's position is not only that the patient has the right, under the moral principle of autonomy, to make an informed decision about what outcomes to pursue but that he or she alone possesses the comprehensive information about, and full perspective on, his or her own life to decide what goals arc worth pursuing at what cost in terms of time, money, and effort. In other words, the patient is better suited than die physician to dccide what is or is not compatible with his or her prudential interests.

Although Renik's position captures respect for the patient as a person in deciding on goals, it needs to be balanced by an understanding of the role of collaboration and negotiation between patient and the analyst in arriving at a mutually agreed-on set of realizable aims for their joint undertaking. Ethically, it seems best to view the goals of an analysis as a joint product, unique to each analytic dyad. The result of respectful negotiation and mutual agreement between the parties at the outset of treatment, goals should be repeatedly renegotiated over the course of the analysis as the relationship between the parties changes. The patient can be expected to alter treatment goals as he or she becomes aware of the role of unrealistic unconscious fantasies in initial expectations and arrives, as the analysis unfolds, at more realistic treatment goals and, in turn, life goals.

Ethical considerations enter latently into most efforts to clarify the proper goals of psychoanalysis. Con sider, for example, Ernst Ticho's (1972) familiar distinction between therapeutic goals and life goals. For Ticho, life goals are the personal goals (e.g., a better job, marriage, artistic creativity) that the patient would seek, were he or she overcome inhibiting intrapsychic obstacles. Treatment goals, on the other hand, concern "removal of obstacles to the patient's discovery of what his/ her potentialities are" (Ticho 1972, p. 315). Unlike the attainment of treatment goals, the realization of life goals depends on favorable conditions beyond the influence of the analysis, such as the reaction of others in the outside world, material resources, or just plain luck. Although some interpreters of Ticho have linked ethics with life goals, therapeutic goals are no less ethical. They differ simply in being the moral goals—such as reduction of suffering and increased freedom of thought—sought in treatment, as contrasted with the prudential and moral aims toward which the patient's life is directed.

Ticho's formulation correctly focuses attention on therapeutic goals as the primary moral aims of analysis. Yet it is far too vague about the complex conceptual issue of what it means to be mentally ill and to participate in a "treatment" or "therapy" for it. The conceptual door is dius left wide open by Ticho for analysts of varying schools to smuggle high moral ideals, such as Kohut's transmutation of narcissism, into analytic treatment as "therapeutic" goals rather than clearly identifying them as "moral" aims. Put in terms derived from various theoretical systems (or lexicons), these allegedly therapeutic goals include the following (see Berman 2001:Kohut 1980):

• Making unconscious affects and fantasies conscious

• Encouraging greater flexibility of thought

• Making the superego less persecutory and more subtle

• Facilitating the transition from the paranoid-schizoid position to the depressive position

• Moderating and modifying perfectionist fantasies

• Expanding freedom to know one's own mind, including unwelcome as well as welcome and bad as well as good thoughts

• Improving accuracy in testing the validity of external or internal realities

• Helping one to unflinchingly confront the emotional truth of one's own experience

• Increasing tolerance and curiosity about oneself and others

• Unrolling the life plan or curve of life laid down in each human being's nuclear self

• Remobilizing deep emotional capacities for genuine empathy and love

• Introjecting the analyst's analyzing function as a form of self-examination

Some of these goals are clearly therapeutic, hut others are moral ideals, particularly those having to do with releasing cmpathie capacities and living the kind of examined life urged by Western moralists since antiquity (see Wallwork 19991.

Whatever the moral goals of the analytic enterprise, however, they are best kept in the background as distant aims as the analysis proceeds. Gabbard {20011 is rightly concerned that "the analyst who is too concerned with achieving certain goals may paradoxically promote a transference-countertransfercnce enactment in which the patient defeats the analyst's efforts, thereby winning by losing" {p. 2921.

Moral Decision Making

Moral decision making is a fourth way ethical considerations enter into psychoanalytic practice, around such issues as boundary crossings, self-disclosures, financial relations, breaches of confidentiality, a patient's threat to seriously harm another, damaging rumors about colleagues, and analyst impairment. These topics raise moral dilemmas requiring unique decisions, because an action must be chosen among alternatives, each of which is supported by good principles and values. For example, a pregnant analyst may feel morally conflicted about disclosing her pregnancy, because she wants, on the one hand, to advance the patient's self-understanding by wraiting for the patient to notice her pregnancy so that they can understand together the meaning of the patient's denial and, on the other hand, to make sure the patient has sufficient time to process the meaning of the pregnancy before the due date and to make plans for the time they will not be meeting. Ethical conundrums such as this may be complicated by unconscious motivations that may interfere with finding a timely resolution of the dilemma, such as the analyst's guilt about how she imagines her patient will react to news of the pregnancy. A common feature of unethical conduct by analysts lies with failure to fully understand the potential harm to the patient—in this case, perhaps, the patient's painful humiliation upon belated discovery of his or her denial, reinforced by feelings of being toyed with and betrayed by the analyst during the long period she chose to keep him or her ignorant.

Sometimes the ethical action is transparently obvious, such as whether to sleep with a lovesick patient. Yet very distinguished analysts have rationalized sexual contact, at odds with clear ethical standards against exploiting the asymmetric power of the transference, with profoundly damaging consequences for patients who trusted themselves to their care. Gabbard and Lester's 11995J work in their book Boundaries and Boundary Violations in Psychoanalysis humanized boundary violators by bringing out some typical vulnerabilities. These include a history of abuse, thin defenses, and narcissistic features such as desperate need for validation from patients, a hunger to be loved and idealized, and a tendency to use others to regulate self-esteem, superego, and ego lacunae |see also Celcnza 2007; Wallwork 2009). Boundary violators demonstrate in the extreme the unconscious dynamics often at wrork in analysts who prove unable to think clearly about lesser ethical issues.

Sometimes analysts face seemingly irresolvable conundrums. Consider the case of a therapist, such as Amy Morrison, wrho finds herself confronting the difficult problem of how to handle a diagnosis of cancer with her patients (Morrison 1990). In addition to the usual difficulties of the psychodynamic work, the gravely ill therapist is torn in different directions by her wish to help her patients, concerns about her own well-being, and the impact of her illness on both of them. She may be committed to being open and telling the truth, but not all patients can handle the truth, or at least not all of it at once, and there arc issues not only of whether but how and when to disclose, and then whether and how to go on together. As Judith Chused (1997) pointed out in a thoughtful review of how Amy Morrison handled her life-threatening illness with her patients, these ethical/ technical issues have to be worked through anew with each patient. The sick therapist has die obligation wc all have to hear the patient's reactions verbally and nonvcr-bally, with their multiple conscious and unconscious meanings; to listen to how we receive these messages and how our own subjectivity colors our reactions? and to find a way of using this information in framing fresh interpretations and real choices that will be heard by the particular patient, even as they help the therapist help himself or herself. Ilere again, the therapist must be honest with himself or herself about "therapeutic ambitions, about those goals which are specific for an individual patient and those that the therapist holds dear and would like to achieve with all patients" (Chused 1997).

Historically, analysts have not shown much interest in the problem of thinking ethically about moral dilemmas. Rather, analysts have tended to assume that colleagues who act unethically need more analysis, and thus additional analytic work or supervision has been considered an apt punishment of and rehabilitation for ethical violators. However, additional analysis does not necessar

ily help someone who is at sea about how to think about the moral conflicts that create genuine dilemmas.

To think ethically, the moral analyst needs both a stock of traditional rules and their justifying principles, such as those in the American Psychoanalytic Association's Principles and Standards (Dewrald et al. 2001), and virtuous attitudes and dispositions, without which there is little motivation to be moral. Yet niles and virtues provide inadequate guidance in the absence of "wise judgment" \phronesis, in Aristotle I, which involves the developed capacity to balance conflicting values and responsibilities in relation to the particular facts and dynamics of specific situations. From the perspective of wise judgment, rules and principles set forth a form of boundary ethics that helps identify the moral aspects of a situation. However, because often rules conflict in practice, the "good enough" moral analyst must creatively adapt the meaning of moral standards to the particular circumstances. The boundary metaphor for ethics that has taken root recently in psychoanalysis fails to do justice to wise moral judgment, wrhieh is more aptly captured by "playing the game well within the court" |see Wallwork 20031.

The case method supplies a particularly apt pedagogical approach for the development of wise judgment because it engages the reader in actively thinking about typical situations of moral conflict, as contrasted with complying passively with rules. Good cases have no "solutions." Their value lies in stimulating a type of role-playing that entails stniggling with difficult moral problems by interrogating feelings, biases, selective mis-perceptions, value preferences, and ethical standards before arriving at a creative decision appropriate to unique circumstances. For psychoanalysts, joining with colleagues to grapple writh morally difficult eases is particularly relevant, because ethical problems for us are intertwined with technical considerations, wrhich also entail moral issues to the extent that technique aims at optimally benefiting the patient (Wallwork 2003). Case discussions also prepare analysts to consult colleagues about perplexing moral problems when they arise.


• Psychoanalysis is a moral practice in which normative evaluations are inextricably interwoven with concepts of health, illness, and treatment. Such moral values as truthfulness, respect, empathy, beneficence, nonmaleficence. freedom, and autonomy are part and parcel of the analyst-analysand relationship.

• Freud's determinist statements notwithstanding, the analysand must take moral responsibility for his or her actions. To be sure, psychoanalysis brings to light new excusing conditions for unethical conduct, but it also, paradoxically, expands normal assumptions about moral responsibility to include owning disavowed and "unthought known" motivations.

• Neutrality in the sense of a technical stance involving evenly suspended attentiveness does not entail freedom from morals but rather a moral stance that fosters the patient's freedom and autonomy, among other values.

• The deep ethic that informs much of Freud's work and psychoanalysis after him is a form of neo-Aristotelianism that grounds normative ethics in a conception of happiness as well-being that entails functioning well in a variety of pursuits and enjoyments, such as interpersonal love, creative work, aesthetic appreciation, and the pleasures of communal life.

• For psychoanalysts to make reasonably good moral decisions, a plurality of principles and rules, as well as a variety of role-specific virtues (i.e., dispositional traits cultivated in the practice of psychoanalysis), are required, indeed, without the analytic virtues formed during training and ongoing practice, the goods internal to psychoanalysis cannot be realized.

• Good moral decision making about the dilemmas that arise in practice typically involves balancing conflicting rules, values, ana responsibilities in relationship to the particular facts and dynamics of specific situations. The reasonably good psychoanalyst demonstrates "wise judgment" (phronesis, in Aristotle) in deciding particular moral dilemmas as they arise in treatment.


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mously swollen in numbers and enriched in prestige by the refugees from Nazi-occupied Europe and successfully propelled itself into the dominant voice within the country's medical schools and psychiatric clinical centers {although that development of dynamic psychotherapy has always been intensely contentious in addition to being so substantial and vigorous).

In recounting this development, I focus on the role of the main protagonists in several psychoanalytic panel debates of the early 1950s, brought together in one issue of the Journal of the American Psychoanalytic Association in 1954. However, I first consider the pioneering role of Robert Knight in framing the fundamental conceptions that marked the nature of psychoanalytic psychotherapy as psychoanalytic therapy, which was, as then formulated, nonetheless clearly distinct from psychoanalysis proper.

Knight's principal concerns as a leader in American psychoanalysis were with its relations with psychiatry. He stated that until the advent of psychoanalysis, "psychiatry still lacked a psychology" (Knight 1945, p. 7771, and he devoted himself to what he called "a basic science of dynamic psychology" (Knight 1949, p. 1011, "the chief contributions to which have been made by psychoanalysis" |p. 102). Knight formulated his proposed fundamental distinction, within a psychoanalytically informed framewrork, between what he designated as supportive and expressive psychotherapeutic approaches: "Of the various possible ways of classifying psychotherapeutic at tempts... two large groups amid be identified— those which aim primarily at support of the patient, with suppression of the symptoms and his erupting psychological material, and those which aim primarily at expression" (Knight 1949, p. 107, italics added). The bias in favor of the expressive approach, as more definitive and therefore more desirable, wras at the same time made clear:

Suppressive or supportive psychotherapy...may be indicated...where the clinical evaluation of the patient leads to the conclusion that he is too fragile psychologically to be tampered with, or too inflexible to be capable of real personality alteration, or too defensive to be able to achieve insight The decision to use suppressive measures is made actually because of contraindications to using exploratory devices. (Knight 1949, pp. 107-108)

In a subsequent paper, Knight (19521 further distinguished the goals of supportive and expressive approaches, and within the latter, of psychoanalysis proper: "By the term 'primarily supportive' I mean to imply the intention to support and reconstruct the de fense mechanisms and adaptive methods customarily used by this patient before his decompensation and the implementation of this intention by the use of explicit supportive techniques" |p. 118|—and he went on to indicate an array of "supportive techniques," actually the first such detailed listing in a psychoanalytic article.

Among expressive modes, proper psychoanalysis is clearly the most far-reaching: "Psychoanalysis offers the best method available to achieve the more ambitious goals of fundamental alteration of character structure, with eradication or reduction to a minimum of neurotic mechanisms Psychoanalysis attempts the ultimate in exploration, with a goal of the maximum in self-knowledge and structural alteration of the personality" (Knight 1952, p. 120). In addition, (other) expressive psychotherapy is given a distinctively different place. "The greatest field...(f]or exploratory psychotherapy, which does not involve the more ambitious goals of psychoanalysis, lies in those clinical conditions which are expressed as relatively recent decompensations arising out of upsetting life experiences" (p. 1201. Thus occurred the first clear emergence of the then-declared distinctions among a spectrum of psychoanalytic therapies from supportive psychotherapy to expressive psychotherapy to psychoanalysis proper.

It is these perspectives presented by Knight in this sequence of papers that framed the panels within American psychoanalysis in the early 1950s, all brought together in the dozen articles in one issue of the Journal of the American Psychoanalytic Association in 1954. Collectively they staked out the dominant conceptions about the nature of psychoanalytic psychotherapy— and the controversies about them—that marked what I call the second era in the relationship of psychotherapy to psychoanalysis, that of established diversity of goal and of technique (the spectrum of therapies) within a unity of theory (psychoanalysis), an era that lasted for approximately another 20 years after its full delineation in these manifestos of 1954.

What, then, are these central conceptions about the nature of psychoanalytic psychotherapy—derived from the theory of psychoanalysis but applied to a broad spectrum of patients not deemed amenable to classical analysis—and the relationship to psychoanalysis proper that were delineated at that time, and what were the controversies generated around these positions? The central confrontation was between two major viewpoints on the most appropriate way to conceptualize this relationship between dynamic psychotherapy and psychoanalysis. Basically, the issue lay between the viewpoint advanced by Alexander and French (1946) and Fromm-Reichmann (1950; also Bullard 1959| (but altogether a distinct mi nority) who saw the historical trend as blurring, if not ultimately altogether obliterating, the technical distinctions between dynamic psychotherapy and psychoanalysis, and the viewpoint espoused by analysts (actually the great majority) of whom Bibring (1954), Gill (1951, 1954), Rangell j 1954), and Stone (1951,1954) served as major spokesmen, who conceived the scientific issue to be the more adequate preservation and clarification of the conceptual and operational distinctions between the two. It was these diametrically opposed viewpoints that were contrapuntally propounded so sharply at the panels published in 1954.

Those who "blurred" the distinction between dynamic psychotherapy and psychoanalysis took two somewhat discrepant positions. The more widespread one, seen by its opponents as the more dangerous in its push for the obliteration of the distinction, was that of Alexander. His call was for the total integration of psychoanalysis into psychiatry: "That psychoanalytic concepts...are necessary for every psychiatrist is by now rather generally accepted Psychoanalytic theory [has become) the common property of whole psychiatry and through psychosomatic channels of the whole of medicine" (Alexander 1954, p. 724). With this "unification" of psychoanalysis with psychiatry, "a sharp distinction between psychoanalytic treatment and other methods of psychotherapy which are based on psychoanalytic observations and theory is becoming more and more difficult In their actual practice...all psychiatrists become more and more similar, even though one may-practice pure psychoanalysis and the other psychoana-lytically oriented psychotherapy" (p. 725). Indeed, any distinction between psychoanalysis proper and other uncovering or expressive procedures was declared only "quantitative" (p. 729), and in fact, "the only logical solution is to identify as 'psychoanalytic' all these related procedures which are essentially based on the same scientific concepts, observations and technical principles" |p. 731, italics added).

In the fullest extension of the Alexander position, "the only realistic distinction... is that between primarily Supportive and primarily uncovering methods" (p. 730, italics added), thus collapsing all expressive treatment modes, expressive psychotherapy and psychoanalysis proper, into one category of psychoanalytic psychother apy Alexander, like Knight, also adumbrated a list of supportive therapeutic techniques, comprising gratification of dependent needs, emotional abreaetion with reduction of psychic stresses, intellectual guidance assisting the patient's judgments through objective review of stressful pressures, aiding the ego's neurotic defenses when the patient is unable to deal with the unconscious material, and manipulating the life situation when the patient is unable to cope with life circumstance. On the other side of the dichotomy are all expressive approaches, psychoanalysis included, that were stated by Alexander to vary only in quantitative and not in critical dimensions.

Fromm-Reichniann (1954), somewhat differently than Alexander, took the position that the effort to treat the borderline |and, even more, the overtly psychotic) patient psychoanalytically required not only major modifications of technique (with which, of course, all would agree) but also systematic revision of the theory of "classical psychoanalysis" into the more modern "dynamically oriented psychiatric theory" (p. 713J, based on the interpersonal conceptions of Harry Stack Sullivan. This she defended as being a more up-to-date version of psychoanalysis, and she tried to buttress this assertion by calling on Freud's famous definitional dictum— that every therapy that is based on the concepts of transference and resistance can call itself psychoanalysis/ Set this way, Fromm-Rcichmann's dynamic psychotherapy could simply be redefined as psychoanalysis, with again, as with Alexander, psychoanalysis and psychoanalytically based psychotherapy becoming mdis-tinguishably close on a merely quantitative continuum. In her case, of course, psychoanalysis was assimilated to the new interpersonal theory of dynamic psychiatry, whereas with Alexander, there was the opposite direction of flow, with psychoanalytic psychotherapy blended almost indistinguishably into psychoanalysis. In both directions, the distinctions were blurred, if not yet entirely obliterated.

Both sets of views, those of Alexander and those of Fromm-Reichmann, did at the time have some wide popular appeal, although they were also the distinct minority perspective within the then reigning ego psychology paradigm in American psychoanalysis. Since then the Alexandrian conceptions have essentially dropped

^Freud's definition was stated in his history of the psychoanalytic movement as follows: "Any line of investigation which recognizes these two lacts (transference and resistance] and takes them as the starting point ol its work has a right to call itself psychoanalysis, even though it arrives at results other than my own. But anyone who takes up other sides of ihc problem, while avoiding these two hypotheses, will hardly escape a char^ of misappropriation of property by attempted impersonation, if he-persists m calling himself a psychoanalyst" (Freud 1914, p. 16).

out of psychoanalytic discourse, although his notion of the "corrective emotional experience" has had some checkered survival in varieties of more active psychotherapeutic approaches and can also he discerned, albeit in transmuted form, in varieties of psychoanalytic emphases on the role of the psychoanalytic relationship as a major component factor—alongside working through and insight—in effecting analytic change. Fromni-Reichman

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