Abstract
Bruce Fink began as an academic psychologist and is today a Lacanian analyst and noted translator of Lacan. His graduate and undergraduate courses on Freud provide some background for this book, indicating as they do that although he is a Lacanian he has wide knowledge and a serious interest when it comes to Freud. Fink’s interest in clinical technique that directly impacts the unconscious is demonstrated in his 2010 paper, “Against Understanding: Why Understanding Should Not Be Viewed as an Essential Aim of Psychoanalytic Treatment”: “psychoanalysis clearly aims at the establishment of a new relationship between the ego and the unconscious whereby the ego no longer rejects and represses so many things” (p. 263). In addition, displaying his cultural sophistication and playfulness, Fink writes mystery novels in which the detective is based loosely on Lacan. He brings all these talents together in this introduction to the clinical Freud.
Fink’s goals for the book are broader than understanding Freud clinically. The title and the picture on the dust jacket give clues. The book’s subtitle is Techniques for Everyday Practice, but the picture is not of Freud’s couch and office. The picture, rather, shows the pleasing décor of a contemporary analyst’s office, yet with familiar Freudian images: the couch, a chair, a table with an open book. The title and the picture seem to underscore Fink’s wish to place us in Freud’s shoes in his journey to discover free association and dream analysis to help patients explore their unconscious. He extends Freud’s techniques to explore the unconscious by showing how he and Lacan grasp and impact the unconscious so that patients will live more satisfying and meaningful lives. He wants clinicians to have more tools in their toolboxes. As Warren Poland, in “Reading Fiction and the Psychoanalytic Experience: Proust on Reading and on Reading Proust” (2003), points out, a book can change the reader. Fink challenges the reader to change like Freud did: by discovering knowledge, skills, and attitudes that will help patients.
This book would be very helpful as a teaching text. For example, Fink recommends background readings from Freud’s work: “the recommended reading comes to about 700 pages . . . an amount easily included in a semester-long course on psychoanalysis” (pp. xxii–xxiii). The book reminds me of an anatomy text I prized in my first year of medical school. I learned basic anatomy by reading about sophisticated surgical procedures. Fink’s book, to my mind, is a more interesting way to learn Freud and to develop as an analyst than explicating Freud’s basic twenty-four volumes, as I did when a candidate! For the experienced analyst, reading Fink will be like Proust’s Remembrance of Things Past.
Fink’s style is scholarly but readable. The book is well organized, with extensive and informative footnotes. Substantial appendices present responses to Freud’s critics and further insights into Freud’s Rat Man and Dora cases. Fink uses epigraphs, often from Freud, to contextualize the chapters and sections, as well as, in a Lacanian manner, to stimulate our minds. Fink is a clear writer, moving easily among Freud’s theories and cases, his own vignettes, examples from popular culture, and contemporary analogies (e.g., the mind as computer). All of this is offered in a personal and friendly tone, with a persuasive yet open-minded approach.
In the first two chapters, Fink shows how tracing symptoms and speech to their origin reveals the unconscious and how it works. In the third chapter, he uses dreams to show Freud’s exploration of the unconscious. This chapter alone, in its heuristic approach to dream analysis, makes the book worthwhile. In chapters 4 and 5, Fink focuses on the structure of the unconscious and the techniques Freud used in exploring the Rat Man’s obsessive structure and Dora’s hysterical structure. In chapter 6, Fink investigates symptoms in greater depth to show how causality works in the unconscious. Throughout, Fink offers numerous clinical pearls, apothegms like “try as we might to forget the truth, the truth does not forget us” (p. 4). In the last chapter, he wrestles with contemporary issues (e.g., diagnosis, new psychoanalytic theories, frame issues, the use of medication, and other treatment modalities) related to Freud’s theories.
Afraid that the unconscious is minimized today, Fink strives to show its power in our clinical work. He succeeds. Another good introductory textbook, Psychodynamic Psychotherapy: A Clinical Manual (Cabaniss et al. 2011), approaches technique in a systematic way, with clinical vignettes and a few cases, while stressing the importance of listening, reflecting, and intervening. But Fink’s focus is different. He stays close to clinical Freud in listening to the unconscious. For example, he explores how the unconscious works in Anna O’s symptomatic cough. The cough is shown to keep her from hearing the music playing, so she would not be tempted to leave her father’s side and go dance, which would have caused self-blame for such a wish not to fulfill “her filial duty” (p. 22). To this he responds personally: “the more I have suppressed my own wish to retaliate, . . . the worse I feel, the guiltier I feel, . . . and the more extreme my eventual explosion is likely to be” (p. 5). He has intriguing sections on “negation” (p. 52) and “jouissance,” a Lacanian concept of drive satisfaction (p. 136). Fink demonstrates that the “royal road to the unconscious” is to collaboratively explore the patient’s symptoms, psychic structures, and dreams. He gives a hypothetical example of how to encourage a patient to associate to an element of a dream, in this case the word blue. He reveals the creativity of his working self by showing his own associations to the word.
“Blue” . . . is part of expressions like “black and blue,” “out of the blue,” “the wild blue yonder,” and “the deep blue sea”; it may make one think of “the blues,” whether in reference to the musical tradition, a mood, or an army during a particular war (or even bands like The Moody Blues or The Blues Brothers), . . . “Little Boy Blue” (a nursery rhyme), blue balls (a painful male condition), or the homonym blew, as in “I blew it”—the list goes on and on” [pp. 87–88].
I am impressed with Fink’s imagination and playfulness, as well as his access to his own unconscious, as he thinks of helping patients explore theirs. Fink states that any of these associations to “blue” “could prove to be extremely useful associations, reminding the analysand, for example, of events of the previous day, weeks, or years, previously unmentioned times in his life, or long-forgotten sexual experiences” (p. 89). For example, an analysand may in associating to “blue” recall a “stressful time in which he wore blue in the Navy” (p. 89). Fink is dedicated to finding the analysand’s meaning of “blue.” In showing how to listen like Freud, he reminds me of the way Evelyne Schwaber writes about listening in “The Psychoanalyst’s Mind: From Listening to Interpretation—a Clinical Report” (1995): finding the logic in the patient’s psychic reality.
Fink emphasizes the importance of affect generally, but in the chapter on dreams he does not stress it as an heuristic approach to dreams. I wonder if his Lacanian focus on speech, idiomatic expressions, and hesitations as ways to get to the unconscious takes priority over feelings in approaching dreams. I was taught, following Freud, that affect is the least disguised part of the dream. Fink is helpful in directing us to listen for nonverbal routes to the unconscious.
Fink demonstrates how countertransference can undermine technique. He makes technique come alive by in effect supervising Freud. He shows how Freud made mistakes in conducting his cases. Freud did not live up to his own expectations: the stance he took with Dora and other patients did not match with his ideals of anonymity, abstinence, and neutrality. Fink reveals how Freud’s interventions with Dora were more authoritative and suggestive (e.g., “he badgers her at times” [p. 160]), as opposed to collaborative and investigative. Fink also reviews comments made after treatment by Freud’s patients from the 1930s. He wonders about the effect of Freud’s countertransference issues, including his overinvestment in proving his ideas correct. But after all, Freud did not have a personal analysis!
To assess the effectiveness of a technique, Fink devises a “four-part harmony” goal: “important stories from the past and current (or even former) dreams and fantasies . . . for the fullest detail possible and including all of their voices” (p. 37). He purposely does not focus on resistances, defense analysis, and transference per se; if these are overemphasized, he believes, they will minimize the uncovering of the unconscious. Obviously, this is an area of debate. Other areas open for debate are Fink’s view of the limitations of medication, psychodynamic psychotherapy, and cognitive behavioral therapy. I wonder if he might underestimate them, and whether some techniques that Gabbard (2004) describes, such as exposure and confrontation of dysfunctional beliefs, can be useful to clinicians directly or indirectly addressing the unconscious.
Ultimately, Fink stresses change. Thus, he proceeds from “listen, reflect, and intervene” to therapeutic action and change. Gabbard (2004), in another useful clinical primer, describes technique in relation to therapeutic action. Fink presents therapeutic action by investigating cases and vignettes. He summarizes his approach and theory of change: Part of our goal as clinicians is thus to find ways in which to bring thought and affect back together, which is what has to happen for symptoms to get resolved. One might, without exaggeration, say that virtually all of psychoanalytic technique is designed to do just that. Getting analysands to talk in great detail about hurtful events in their lives is our best bet for bringing painful and/or distressing affects into contact with the events that first gave rise to them and with all their subsequent thoughts about them. And helping analysands free-associate about both past and present happenings, intrusive thoughts, perplexing reactions, dreams, slips, and fantasies is our ticket to bringing the “inexplicable” experiences in their lives into contact with the affects that went into their constructions [p. 63].
Fink shows that Freud saw the point of therapeutic action to be helping the patient “understand” and get to the next deeper level. Lacan emphasized the importance of “stirring” the unconscious. Fink maintains that Freud got stuck in an authoritarian transference enactment with the Rat Man in relation to “understanding.” As mentioned, Fink stresses that therapeutic action comes from the patient’s connecting early experiences affectively with present issues. I wonder, though, if he underestimates the importance of working through transference enactments, and the importance of the therapeutic alliance to effect change.
Mark Levey (2012) points out that by looking at clinical material to detect the concepts, strategies, and techniques used by the analyst, we can best debate what helps the patient. He systematically describes seven analytic process goals, which then lead to therapeutic action and change. I haven’t space here to compare these goals with Fink’s ideas, but I recommend that readers do so. Fink points out that there is not enough data to put Freud’s cases under this type of exploration. It would be interesting to look at the micro and macro processes in a case to assess the efficacy of a Freudian, Lacanian, or other type of intervention. Although a Lacanian, Fink is open to using interventions based on other theories, and accentuates the importance of assessing the impact of interventions on changing the patient. For example, the dream interpretation “becomes internally coherent”; “becomes convincing given the context in which the dream was dreamt in the analysand’s life and everything that has been said up until that point in the analysis”; “fits in with at least some of the analysand’s other thoughts and wishes”; and “fits in with some of our theoretical notions” (p. 109). Fink looks to the patient as our best supervisor.
In “Beyond Freud?” the book’s final chapter, the content leads to lively debate that Fink clearly enjoys. The topics include diagnosis, psychopharmacology, and other forms of treatment. I can imagine a class co-taught by Fink and another teacher. Fink admits the limitation of his knowledge of Kleinians, relationalists, and intersubjectivists, but worries that they focus too much on the “here and now” transference relationship and that the past is regarded as “passé.” If Fink co-taught a class with the late Stephen Mitchell, an expert on contemporary psychoanalytic thinking, there would be interesting debates on different theories, techniques, and ideas of therapeutic action/change. It would be informative to hear a discussion between Fink and Gabbard on the value of medication for obsessive-compulsive disorder (the Rat Man) and the effectiveness of psychodynamic psychotherapy. What other factors (such as, biology, relationships, and social-ethnic-religious-economic factors) are there that influence and interact with the unconscious? I would like to hear Fink discuss a case with Salman Akhtar, considering cultural and biological (ADHD) factors versus the unconscious on an individual level. Fink’s major and quite appropriate concern about these debatable issues is that they may divert clinicians from seeing the power of the internal world.
The book ends on this same note by showing how to avoid frame struggles (e.g., use of the couch, scheduling and cancellation policy), while not overlooking the unconscious. Fink wants us to be in that chair on the book jacket with Freud inside us. He inspires the new generation of students about the relevance of Freud today. At the same time, he encourages the older generation to continue to grow as clinicians and teach the younger generation how to impact the unconscious. Finally, he urges us to examine our inner worlds so they do not prevent us from helping our patients. In short, Fink “stirs” and helps us in our journey to be more effective clinicians.