What continues to inspire me about Arnold Goldberg’s contribution is his commitment to questioning easy assumptions and challenging “but be reasonable”
pragmatism. Readers, in this case “behavioral health” professionals, are confronted with the limits of their comfort zones. In short, it is not the purpose of this engaging and thought provoking book to get the reader to feel comfortable; it is the purpose of this book to get the reader to think. The result is a deep, even radical, inquiry into the position of contemporary psychoanalysis in relation both to psychiatry (a medical specialty) and to dynamic psychotherapy (in its incarnations in social work, counseling, and psychology). Remarking that the work is an “autobiographical account,” the first line of the introduction calls out an uncomfortable truth as Goldberg writes: “…I have lived through the heyday of psychoanalysis and am now experiencing what seems to be its ultimate decline …” (p. 01). Thus, the gloves are off in a straight-on, no-holds-bared inquiry.
Providing an account of the relationship between the brain, the mind, and the self is a complex undertaking. In spite of the word “brain” occurring first, this is not a work in neural science or even neuropsychoanalysis (for which a professional journal is now available). Indeed Goldberg is no fan of neuropsychoanalysis, and provides a compelling example of a reduction to absurdity of brain science in the service of empathy by enumerating Simon Baron-Cohen’s “empathy circuit” in the brain. Baron-Cohen enumerates a series of areas of the brain that “light up” in fMRI tests. As one area of the brain after another is listed, topping out at ten major junctures, the reader gets the distinct sense that for all practical purposes, the whole brain is activated in the empathic human interaction. Nor is any specific empathic interaction between analyst and analysand, parent and child, student and teacher, clarified or explained due to the circuitry, interesting though the latter may be from a theoretic perspective in neural science. It seems to be a requirement to get published these days to say something about the brain – an assessment that actually applies critically to Goldberg’s book itself. Good for Goldberg for giving it to us straight – complex psychological issues, states, and processes are not reducible to neural processes, no matter how complex the latter.
Positively expressed, Goldberg engages the relationship between the brain, the mind, and the self by means of an analogy for emergent properties and process. We combine letters in order to get words; we combine words to get sentences; and we combines sentences into narratives. New meanings and referents emerge at every level. This also works the other way around. Ultimately narratives were decomposed into sentences and words and then into phonological components. The fallacy of some neuro-pharmacological accounts that aim at explaining human relatedness (and the breakdowns in relatedness) by means of disorganized brain processes? It is like explaining a Shakespearean sonnet by reducing it to the individual words and letters of which it is composed. Nothing is lost – nothing except the sonnet itself. It is as if a careful analysis of the pixels being displayed on a flat panel television screen were to tell us the score of the baseball game being broadcast over the network. The analogy with reducing psychology and psychoanalysis to neural science is suggestive. We are dealing with separate levels of discourse – semantic dualism – that refer to different entities, different ways of describing the world, and different levels of meaning. An account of neurotransmitters is utterly distinct from an account of how infants develop into related persons in a human community. An account of potassium pumps and neurons firing together wiring together is utterly distinct from an account of a conflict of conscious and unconscious intentions in a guilty person or how Othello, an example of tragic man, distorts the meaning of Desdemona’s loss of his mother’s handkerchief into a murderous, paranoid, narcissistic rage.
The bottom line? The relationship between these different levels of discourse – brain, mind, and self – is arguably not a casual one. The letters in the sonnet do not cause the poem. But if one deleted the letters one would, by definition, also delete the poem. While one can usefully deploy the semantic relationship between parts and the whole, many brain scientists continue to struggle with an alternative to flat out reductionism to their discipline. This is not as self-serving as it sometimes seems, and the what is missing is a robust account of emergent properties and relations. And not just from Goldberg. I am not aware of any really good, detailed account “out there,” though perhaps a reader can provide me with a reference. The brain does not think and feel; people think and feel, using their brain to do so, though they have no awareness of doing so unless something goes wrong with the underlying neurology.
Meanwhile, Goldberg is at his finest – and his strongest – when giving an account of transference, interpretation, and what makes psychoanalysis able to do things no other discipline can accomplish. In example after example, the way the meaning of the patient’s personal relationships, life ambitions, successes, and failures are transferred into the analyst-analysand relationship are a reduction to absurdity of any program of reducing such meaningful struggles to neurochemical processes. At the same time, Goldberg acknowledges that some forms of depression are relieved through the judicious use of medications. Some but by no means all. And, yes, the experience of psychotherapy and the conversation in psychoanalysis change one’s brain. How could it not do so?
Psychoanalysis needs to find its own way forward, according to Goldberg, without the fraught relationship with psychiatry. Psychoanalysis needs to be autonomous in relation both to brain science and to dynamic psychotherapy. The distinctive offering of psychoanalysis? Interpretation. It is an interpretive – hermeneutic – discipline. In other words, psychoanalysis should not spin its wheels trying to connect the dots between the parts of the brain and the neural correlates of consciousness. This may seem like a radical recommendation – do not even try to connect the dots between the two domains of discourse, which are fundamentally diverse in language and meaning – but it is a compelling one. With rare exceptions, neural science has not made a difference to psychoanalysis, psychology, or dynamic psychotherapy (and vice versa). Neural science does many things – and does them well – but it still requires a therapeutic alliance to cooperate and take their medicine or be concerned with why people engage in self-defeating behavior, struggle to sustain intimate relationships, or feel ambivalent about their parents. This list is not complete.
Thus, a bold statement of the obvious: psychoanalysis is distinct form brain science. Likewise with dynamic psychotherapy. Goldberg expresses concerns that dynamic psychotherapy has caused psychoanalysis to stray from its authentic self, which is interpreting the transference, related, and narrative of the analysand’s life (e.g., p. 50). One issue with dynamic psychotherapy is that it takes over the definition of mental illness from the psychiatric Diagnostic and Statistical Manual (DSM (V)). This yet another radical statement by Goldberg that may well arouse push back on the part of dynamic psychotherapists. My take on it? Apply the devaluing labels of the DSM to another human being, then try to relate to her or him empathically. Having trouble getting traction? Many therapists would deny that they do that; but then they fill out a form (presumably using electronic means) using such a diagnostic label on a submission to the insurance company. I can hear them saying “But what do you expect me to do? Do you want my children to starve?” Neither Goldberg nor this reviewer expects anyone to go hungry. But note that the inauthenticity – one might say “blind spot” – gets recruited by the person’s resistance to empathy and to empathic relatedness. How can the therapist be a stand that the client own up to his own blind spots when the therapists is drowning in his? Not exactly “moral stealth,” on which Goldberg has eloquently published elsewhere, but definitely a challenge in a market in which insurance companies have the power of the purse without necessarily knowing what they are doing. No easy answers here – but in order to create a new possibility, one must be straight – be honest – about the challenges that psychoanalysis is facing.
Goldberg proposes a telling metaphor. Psychoanalysis and psychiatry has a “stable marriage” between roughly 1945 and 1985. Then a new and disruptive relationship emerged. Psychiatry found a new lover – psychopharmacology. Like it or not, psychoanalysis is slowing starting to talk about the 2 ton elephant in the living room and what it has known for a long time. Psychoanalysis is not a good fit with psychopharmacology. Goldberg speaks of the “divorce” between psychoanalysis and psychiatry as already having occurred or as at least being all but formally finalized [p. 144]. It is an incontrovertible fact that psychopharmacology has taken the legs out from underneath all forms of talk therapy (and as the jewel in the crown of talk therapies, psychoanalysis has arguably had the farthest to fall); and then the major litigation against an appalling restraint of exchange and subsequent settlement (in the late 1980s) that allowed social workers and psychologists to be trained at the major psychoanalytic institutes. At the risk of stretching the metaphor, some psychoanalysts are trying to maintain what now looks like a “shot gun marriage,” according to Goldberg, a forced relationship that results in a misalliance of the respective goals of psychiatry and analysis (p. 33). Comparative literature (and a diversity of other innovative academic disciplines) is waiting in the wings as a potential new suitor for psychoanalysis; but there are issues. Custody of the children? Who gets to define “mental illness”? Goldberg considers the possibility of dispensing with diagnostic categories altogether in favor of an asymmetrical conversation for possibility between human beings (my terminology, not Goldberg’s) that expands self-understanding and, as a byproduct, many people obtain symptom relief too.
No one escapes Goldberg’s critique, and this is where the pragmatic watering down of psychoanalysis by means of psychodynamic therapy cuts deep. There are lots of tips and techniques to help people to feel better who are otherwise suffering emotional distress. But the only theoretic underpinning seems to be to interrupt negative self-talk. Nothing wrong with that, but many find it incomplete and unsatisfying from a scientific perspective and without an account as to why it sometimes works and sometimes does not work. Nor does the parochial infighting between different approaches to psychoanalysis escape scrutiny. Goldberg calls out the need for toleration and a shift in pragmatism in a shrinking market for psychoanalysis. For example, a Kleinian or Kohutian psychoanalyst is much more likely to refer a patient for medication or CBT than to a colleague of a competing persuasion (say) to a Lacanian. But why should that be so? Just as not every depression is “fixed” by antidepressant medication, suggesting that depression is perhaps not a single unified disorder, why should everyone respond to self psychology? The relationship to aggression and sexuality of some individuals might be such that they would be responsive to a Kleinian approach whereas a Kohutian one leaves them untouched (or vice versa). Why the reluctance to admit the validity of alternative points of view? There are many variables. At the top of the list: “…[W]e are prisoners of our own convictions, and our convictions are prisoners of our narcissism” (p. 122). So Goldberg does remain a self psychologist.
Goldberg makes a nice point polemically that prescribing psychiatrists are allowed to practice their own private versions of psychotherapy without any specific training. Efforts to train non-medical analysts or psychotherapists to prescribe are vigorously opposed by physicians and their organizations in the various state legislatures. Just an idea, but perhaps medical doctors, including psychiatrists, should not be allowed to practice psychotherapy without proper psychotherapy training. Truth be told, many psychiatrists do try to practice psychotherapy but soon realize they need more training and guidance than a didactic online course in CBT (p. 48). They either get it or fall back and restrict themselves to prescribing and medication management.
However, what about the title: “The Last Psychoanalyst”? The “last psychoanalyst” can be read as echoing Zarathustra’s Last Men (in Nietzsche), who confront nihilism – the loss of meaning – from one direction and conformity to the level of the herd from the other. For awhile I was considering asserting that it was possible to have more than one “last psychoanalyst,” but then I decided that would be the easy way out. No half measures. All in. Psychiatrists are voted off the psychoanalytic island (by Goldberg) because they are substituting a biological process instead of the interpretation of the transference (the latter being the essence of psychoanalysis); social workers, licensed practical counselors and psychologists are voted off the island because they are substituting adaptation, conformity, and positive self-talk for interpretation. Nothing wrong with any of these methods as such – nor is there anything wrong with psychoanalysts who are MDs prescribing or using CBT – just that it is not psychoanalysis. True, much is available to be admired in Goldberg’s contribution; but have I not just insulted every other analyst, for example, by implying that Goldberg’s integrity in the matter of psychoanalysis is somehow distinct and beyond the others? He never said or even implied anything like being the last of anything, and he is sensitively attuned to his own limitations, commitments, and method (psychoanalysis). Goldberg’s integrity in the matter of psychoanalysis is second to none; nor is there any lack of integrity among the colleagues who choose to be pragmatic and prescribe or try to combine a bit of CBT with dream work and analysis, especially when the client gets better and flourishes. No lack of integrity – just a lack of psychoanalysis.
True story: in a Wednesday afternoon discussion amongst psychoanalysts, one analyst – a self psychologist – leans over to his colleague and whispers how his prescribing ever so small amount of an antidepressant contributed to a favorable outcome. No further details. My idealization was in free fall, but that was perhaps my problem. Now once again there is nothing wrong with that as such; but it is not self psychology – or psychoanalysis.
The thing that makes Goldberg and any one courageous enough to follow him “the last” – so maybe there is more than one after all – is that he is unapologetic about his uncompromising questioning and interpretation of the transference as the heart of psychoanalysis over against the other alternatives. Now if one asks ten psychoanalysts “What is wrong with psychoanalysis today?” then one will surely get at least ten answers. This points to the next reason that Goldberg is the last psychoanalyst – giving up the paranoid position, he does not think there is anything wrong with psychoanalysis. Psychoanalysis is whole and complete the way it is – as an interpretive (hermeneutic) science – without alternative therapeutic approaches. Still, this position – there is nothing wrong – is consistent with psychoanalysis needing to engage several challenging tasks. Goldberg asserts that psychoanalysis may need its own set of diagnostic categories, which may indeed look nothing like those now being provided by psychiatry and the formal DSM. The transformation may be so radical that they would not be recognized as categories at all but perhaps as alternative life styles, commitments, or forms of relatedness. This is radical – and just because no one has thought of it or is working on it does not mean it is not a priority undertaking. The so called training analyst system seems to have run its course, if I read Goldberg’s position accurately, and new possibilities are needed going forward. Not obvious what those would be; but to perform psychoanalysis one definitely needs to be psychoanalyzed. And to perform psychoanalysis one needs people passionate about or desperate to be psychoanalyzed. If psychoanalysis does have an issue, then it is the tendency not to true to its own authentic possibilities. Just because one is failing in one’s commitment as evidenced by no one calling up to request being psychoanalyzed, does not mean the commitment is invalid. It means one needs a better roadmap. In this respect, Goldberg may be voice crying the wilderness. But it is a wilderness that is getting crowded with individual contributors committed to making a difference wandering back-and-forth or in a circle.
The roadmap called out in the title leads through a path that is different (but perhaps not that different) than that in which Virgil leads Dante – who in this incarnation looks remarkably like Goldberg – through the seven rings of the Inferno of hell. In order to be empathic towards the other one must descend into the hell of one’s own resistance to empathy. Goldberg marshals wonderful clinical vignettes of analysts and patients who cannot seem to stop thinking about one another. The indispensable other strikes again! We are inevitably selfobjects to one another.
Now this is a blog, and I apologize in advance for having some fun with this amidst the high seriousness and significance of psychoanalysis. The analogy of the descent to hell as the roadmap of Dante’s Inferno (not to be found in Goldberg – I emphasize it) has rich comic possibilities: Melanie Klein, dressed as Medea, who killed her own children to get revenge upon her faithless husband Jason, boiling in the vinegar of envy; Sándor Ferenczi trapped in repetitive leg bends on his knees declaring his love before the couch on which his mistress’ daughter, both of whom he was analyzing, is lying as on a bed of nails; Freud himself as a boy on the infamous railway ride in which he saw his mother undress and what he did not see in a scenario like Groundhog Day, repeated ad infinitum; and each analyst getting a suitable punishment, illustrating the maxim implemented by psychoanalytic training programs that “no good deed goes unpunished.” The full exploration must be deferred to another occasion; however, the lowest rung of hell is reserved for the copy editor at Routledge who permitted all the split infinitives in this text. I hasten to add that other than that, really more of a venial than a mortal sin, Routledge did their usual impeccable job of producing the book.
Less amusingly, the psychoanalytic road map leads through the dark woods of the paranoid position – there must be something wrong here – across the stormy seas of emotional disequilibrium and narcissistic rage – acting out to regain narcissistic balance – across the desert of deprivation of the mirroring gleam in the eye of the other – through the suffocating swamp of narcissistic merger – up the steep slopes of idealization and across the treacherous glacier of disappointment – around the whirlpool of the hermeneutic circle of vicarious introspection and optimal responsiveness – until one realizes that when all is said and done, in an empathic interpretation one is quite simply in the presence of another human being.
(c) Lou Agosta, Ph.D. and the Chicago Empathy Project