Pubblichiamo una interessante intervista alla collega psicoanalista Anne Marie Sandler, con pareri molto istruttivi. Tuttavia desideriamo prendere le distanze da alcune affermazioni finali: State of Mind non appoggia l’opinione che alcune psicoterapie approfittino di uno scorretto vantaggio economico e temporale per il paziente che andrebbe a danno della sua vera e completa guarigione mentre altre psicoterapie manterrebbero una supposta purezza. La valutazione di efficacia è frutto di studi empirici e non di giudizi di valore. Detto questo, auguriamo buona lettura.
Intervista a cura di Antonio Cusaniello & Gabriele Cassullo
Anne Marie Sandler is a child and adult training psychoanalyst of the British Psychoanalytical Society. From 1982 to 1984 she has been a Visiting Professor at the Department of Psychology of the Hebrew University, Jerusalem, and from 1993 to 1996 Director of the Anna Freud Centre, London. In 1998 Anne Marie Sandler received the Sigourney Award in ‘Recognition of her Distinguished Contribution to the Field of Psychoanalysis.’
Anne Marie Sandler is the widow of Prof. Joseph Sandler, a psychoanalyst himself, who in 1984 founded the Psychoanalytic Unity the at the University College London, now directed by his pupil Peter Fonagy. Since the 1960s Prof. Sandler started to introduce a research culture into psychoanalysis and, when President of the International Psychoanalytical Association, launched the Open Door Review of Outcome Studies in Psychoanalysis, which now reached its third edition (Leuzinger-Bohleber, Kächele, 2015).
At the end of the interview A.S. Sandler makes an argument, touching on the delicate and largely debated point of the empirical validation of psychotherapy. For an in-depth discussion of the subject the interviewers encourage reading: Westen D., Novotny C.M., Thompson-Brenner H., 2004.
Interview with Anne Marie Sandler
– First of all we would like to introduce your psychoanalytic contribution. And we think that the most striking feature of your husband’s Joseph and yours psychoanalytical work is the idea of background of security (Anne Marie Sandler, 1959), which was developed way before Bowlby‘s most-known secure base. One could say that since then psychoanalysis had only dealt with the human need for freedom, and any search for security was seen as defensive or regressive, eventually alienating the person from oneself. On the contrary, you highlighted how any child or any person needs a background of safety (a physical as well as psychological safety) in order to develop as a healthy, integrated human being.
Anne Marie Sandler: I think that in order to understand our work you have to understand the situation of British Psychoanalytic Society (BPS) where, before the war, Melanie Klein had been invited to the Society and the Society was very psychoanalytic but had gone away in many ways from the classical sexual-centred psychoanalysis of Freud and had developed in two ways. One trying to answer what was going on in the baby much more than in the older child as the adult, to understand the baby’s functions, while on the other side a much more important role was given to the relationship of the child to the parent, as the mother, but also as the father, and so the two theories really clashed on most of those topics. On the one hand, the more classical Freudians saw the idea of phantasies in the baby from birth as pure imagination: there was no proof to it, they said. And then they saw the first (mainly Kleinian) group as no longer giving a central role as to the child emotional development and of thinking to the basic discovery of sexuality, in the sense of Freud’s use of the term.
When my husband Joseph and I became students in the Institute there was a very important split because of the conflict about the different techniques to work with patients, according to the different viewpoints on theory. Those theoretical and technical differences were enormous, and so both my husband and I, through our work with patients, felt that we could not ignore the importance of object-relationship; but that did not mean that you have to accept all the ideas of Melanie Klein about the very early development of fantasies and the idea of very primitive psychotic life, projection, and so on.
Therefore, we thought that the idea for example of the safety principle was one way of showing how, for anybody who develops, you get a feeling of safety if you feel a certain satisfaction with what you have achieved, and this achievement which you spell out was partly due to the relationship. There was a feeling that we have done well or that we can be satisfied with ourselves for what we have achieved, but this basic feeling is much more important than what was untill now seemed that if you cannot create or keep a minimal feeling of safety you will use a message or you will defend in a way which will very soon be quite psychological, because if you don’t have a basic kind of sense of security.
However, the safety principle, as you call it, seem to contradict a certain degree of uncertainty which is inherent to the human condition, and also the push towards the unknown which characterizes the development of the child as well as of any human being.
Anne Marie Sandler: Yes the unknown is always present to a certain degree because this is a part of a push towards learning, towards new experiences. But it’s a question of degree and if you don’t have a feeling of safety to a certain extent you will also refuse what is unexpected. This is important if you have a very depressed mother or a very harsh father; and you come home with the expectation that your mother becomes totally loving and your father goes like: “Oh! You can do what you like my darling”. The child would get very anxious because of all his expectations, and so he may be very pleased to get a present or be cuddled, or whatever. Yet there would always be a part of himself which says: “What’s happening? This is strange, dangerous”.
That’s what we mean by background of safety. A basic need for continuity, even in a not-satisfying environment. However, it’s a very interesting question that you raised because of course if it were always exactly the same and there was nothing new, first of all we would be very bored or it would be very boring but also it would not encourage the development but here we really speak about a degree of basic safety needs, a degree of giving a child a feeling that he can live expecting what’s going to happen. If I can put in that way.
– So, that is why you and your husband revisited the concept of internal objects.
Anne Marie Sandler: Yes. We wanted to show that we have readdressed the concept of Freud and changed it in a sense of bringing constantly the role of the object-relation. You probably remember the clinical case, for example, in our book Internal Object Revisited (J. Sandler, Anne Marie Sandler, 1998, pp. 116-122), where it is clear that we understood the role of sexuality and the problem of fear about sexual understanding; but it was also for us very important to show this woman that she was repeating, even though it had been very unpleasant, something which she was used to, especially because she had been suddenly deprived of the use. She had been traumatized. But that’s one reason why we wanted to revisit it, in order to include psychological trauma by discontinuity in the object-relations, which also shows that you can have a reason why you feel traumatized, even without any massive traumatic event.
At the time Joseph and I worked very much with Anna Freud, to talk about internal-objects was… “no-no”. You couldn’t talk about it because the Freudians did not believe in internal objects: that was Melanie Klein’s domain; but we wanted to show that we can speak of an internal-objects in a way that is not the same as the internal-object of Melanie Klein, it’s not the internal-object of the baby, and the breast, and so on. So we wanted to revisit it to show very clearly where we have different views from the classical Freudians but we believe we are still Freudians, we are not Klenians! But we do believe that there is something lacking in the classical Freudian theory.
– One of the most cogent and controversial issues in psychology and psychiatry today is the issue of narcissistic disregulation of the Self, with the connected compulsion to repeat an idealization-disillusionment interpersonal pattern. You addressed this issue many times by highlighting the pain that results from a discrepancy between an actual state of the Self and an ideal / wished-for state of the Self. How do you make use of this concept in clinical practice?
Anne Marie Sandler: I can take an example. Just this morning I had a patient whose father died when he was four and half years old and he remained with his mother who was quite young when his father died very tragically, and became very depressed. Her depression took a course, but she remained very dissatisfied. She was very angry with life and she kept saying: “Who is looking after me now in my life, I have nobody, my life is destroyed, I have two children and I’ve to be there for them and my life is finished”. Now this little boy who was just four and half (eye on Oedipus) had a touching but absolutely unrealistic belief (because it was more than a fantasy) that in order to help his mother he must look after her, and not only in terms of sexuality, but he must find the way to make her happy; and it’s interesting because this man came to analysis late in his life, but you can see that thread throughout his life. For example, that his main aim in starting to work very early and earning quite a lot of money was in order to give money to his mother, in order to give her a house, in order to make sure and so on. It’s in everything he did… you always have the feeling it was to make the mother satisfied, but it was never any good, because the mother was never satisfied. Now this would be an example where I’ve shown that his wishes left him also very depressed because he could never do this in a successful way. And you can see it was also a way to mourn his father, to try to replace his father on his mother’s side: Yet, since he was a little boy, he couldn’t do so; while on the other hand he was constantly sinful for wishing to replace his father. This is a very good example of what we meant by that concept.
Part of the treatment in analysis is to help the patient realize that the wished-for object is unattainable because it’s a mixture of idealization and a search, or projection, in the object of all the things that one hasn’t managed to get oneself, and that this image can cause pain and disappointment. If you are too dissatisfied with what you have, or if you are too much wanting “always the very best”, then you idealize, and you will surely feel terribly frustrated because you can’t reach what you want: in other words, you haven’t really accepted the limitation of life.
– You are a world-famous psychoanalyst. What do you recommend to the younger generation of psychologists who face the world of psychoanalysis?
Anne Marie Sandler: I would recommend a number of things. First of all, to understand that psychoanalysis is a very specialized part of psychology. Both its theory and clinical practice are dependent on the possibility of the understanding of people about their own psychic needs, and I would say that nowadays the situation is very different than what it was at the time of Freud. For example, the development of pharmacology has brought a lot of medications, too much in my view. When people are just a little bit sad, they take a pill and they feel good again, or when they have a problem to fall asleep they go to get something to fall asleep. When they have anxiety they take a pill for not to feel anxious. Yet I am aware that there is always a number of people who are not satisfied with this, they want more, they want to understand; and these are the people that psychoanalysis can help, not the others.
And this brings me to disclose my thought. I think that in itself psychoanalysis is not for the masses. Psychoanalysts will never be popular. They will never reach hundreds of people. In fact, what is happening in Italy, as I’m sure everywhere, is that there is a lot of psychotherapy. Techniques that use a little bit of psychoanalysis (e.g. the background of safety which became Bowlby’s secure base) mixed with many many many other things. And they do that because it is much cheaper. They see the patients a few weeks, or a few months, and it is finished.
I don’t think this is neither good or bad in itself. If that helps the people why not? But I think it’s very important to face a very unpleasant reality. The reality is that I don’t think that you can want to become a psychoanalyst and then hope that you will become rich. I mean that you will have a lot of patients and you’ll be, you know, really able to work deeper than with any other psychotherapy, as deep as you yourself arrived with your own analysis. But as to the people who will look for that…, I think there are very few, fewer and fewer. There are some… people who often have an important job for whom it is very important to understand themselves and this will help the work that they do, but they are a minority group in society. Lucky enough, it is also usually a group which can afford analysis, because analysts also needs to live! They need to live, to be paid, and government usually don’t pay for analysis because it costs too much. It’s as simple as that. And so I tend to regard psychoanalysis myself as more a scientific enterprise. If you can do research in a lab and you don’t need to get rich, it’s very interesting. But people don’t. They want to get rich. And in England many many people often work half-day as psychiatrists, or psychologists, or do other things, and then they see patients as psychoanalysts. Those analysts are very very happy because they don’t depend for their living on the analysis. It is a sad situation, because one would like to imagine that psychoanalysis would be more accepted as a way to understand people, but it is way too complex, to profound in a way, to be appealing I think. That would be my understanding.
Is there anything that you would like to add?
Anne Marie Sandler: What I would like to add is about the changes in the governments’ desire to make use of psychoanalysis, especially in Europe, and how it has changed since the end of the Second World War. I mean Germany and Scandinavia would be the two best examples. These governments have really understood that after such a terrible war many people were in need of psychological support for a long time and in depth, and they paid the support of psychoanalysis: they paid people to come to analysis four or five times. Real analysis! Not therapy! Psychoanalysis! And I think they did a great deal. Helped a great deal of people in the countries where it was allowed, and it was possible because people did not have to pay. But at the moment when the economy became very very tight the government could not afford it any more. So they started to cut, they said: “Not psychologists, they can’t get money, only the doctors”; or “You cannot do it five times a week, but for times”. And now for example in Germany it’s three times, but then there is a group that says that twice is enough… you know… and so on… . And then they used to pay it for as long as you needed it, while now they say: “It’s only two years”. One understands that the governments don’t have money. But still that’s no good for the poor psychoanalysts that also need to eat and to have a life…, so that’s where you have the problems now. And then of course people rationalise and say “you know, the other methods are just as good”. That’s the situation right now.
Maybe what I also should say is that in many countries, and in England very much, there is a complaint that the result the psychoanalytic method claims to achieve is an improvement that should be demonstrated scientifically. That is a way of demonstrating results most psychoanalysts do not believe in at all, and that’s why psychoanalysts don’t do proper research. Yet, now we do more and more research on psychoanalysis in England. We do a lot of good research with a good outcome about psychoanalytic therapies, but of course the difficulty is that psychoanalysis as such does not aim to achieve a healing but aims to improve the quality of life, or the general understanding of how people function. So people may feel much happier, or better adapted, or able to marry, or able to be comprehended, but you know if you ask them: “Do you sleep better?”, “Do you eat better?”. Yes, maybe, but it’s not all about that. So it’s very very difficult as you know as psychologists to make really the kind of research that would please the government, and there we are, always in competition with brand new therapists which go only for symptoms and promise to offer better results in six months. You know, if you go just for symptoms, it is ok, but it is very difficult to know how to measure contentment or satisfaction, or a better life, particularly in the long run of life, not just after a year. That is our problem as psychoanalysts. How can you find ways to scientifically measure a life worth living?