Alex Crumbley: There’s been a lot of talk about psychoanalysis having flourished recently in humanities departments in this country. How do you view this trend?

Glen Gabbard: I think first of all the comment that psychoanalysis is flourishing in humanities departments is a little misleading. As you know, a lot of my writing has been in an interdisciplinary area involving film and psychoanalysis, so I follow that literature. Interdisciplinary studies in psychoanalysis are a far cry from clinical psychoanalysis. We’re really talking about two different entities when we talk about psychoanalysis in the academy and clinical psychoanalysis. It’s not just the Lacanian influence. It’s a way of thinking about analytic ideas that is completely disembodied from a person sitting in an office. The other thing I would say about interdisciplinary psychoanalysis is that it’s rarely a collaborative, mutual collaboration between two disciplines. It’s more of a sadomasochistic coupling, in which one discipline is subjugated by another discipline. The kind of psychoanalytic writing going on in the academy has a whole set of problems associated with it. Having said that, it’s still better than having no psychoanalytic presence in the academy.

AC: As for debates in the field, I know that you’re a proponent of an inclusive theoretical stance. But there still seems to be a divide, at least in what I’ve experienced of supervisors from different institutes in New York, and I wonder how the broader psychoanalytic community could be convinced to take a more integrative approach.

GG: It’s a real challenge. Right now we’re planning the International Psychoanalytic meeting for July of 2009 in Chicago. We’re trying to base the meeting on dialogue between different psychoanalytic cultures about that, trying to say, “Can we be open to different perspectives with the idea that it might enrich clinical work if you have something outside your own narrow view and have a broader picture?” Now that’s difficult to do because of all the identifications, the loyalties, and the kind of securities that certain theories provide, like a drowning man in a life raft. However, I would say pluralism has gotten to be more and more of the predominant view in many places, and it’s no longer considered idiotic to be pluralistic as it once was. There’s no party line in American psychoanalysis now. Ego psychology is definitely on the wane. In the UK, the contemporary Freudians are really dying out in the three group structure, and the Kleinians are by far the most popular group. I think that various kinds of relational and object relations approaches are holding sway in most areas, and in most of the relational and object relations views, there’s a fairly broad base of what constitutes analytic work and a fair degree of open-mindedness. I think that maybe we’re in an era now when what Joe Sandler said 20 or 30 years ago is true: people are developing their own private mixed models, and now they’re just a little more willing to speak openly about them, like Fred Pine did when he wrote his book. I imagine that was always true, that people said one thing and did another. I think a big problem is that much of the psychoanalytic clinical literature has been fiction, where people wrote about, “This is what I wish I had said, or wish I had done.” And trying to get real clinical material that comes alive with all the messiness in it hasn’t really been around all that long, and probably the relational influence has been very important in that regard, that there has been more of a willingness to expose oneself in the writing. So now I think we see more of that private mixed model approach coming out in clinical accounts.

AC: How important is it to validate empirically psychoanalytic ideas and techniques?

GG: I think it’s important, although very, very difficult. When Kernberg was president of IPA, he said, “Without research, we are dead.” That might be a slight exaggeration, but not too much. We’re in the marketplace with all kinds of research-based treatments, and we are starting to get some randomized, controlled trials of psychoanalytic therapy that’s long-term, like the Cornell study on borderline personality disorder. It is possible to do it. It’s expensive and time-consuming, but we can do it. I think that we’ve got to have those kinds of studies. For formal analysis, it’s so difficult to think about how you would randomly assign someone to analysis versus another treatment. I’m not sure we can quite carry that off. The STOPPP project in Scandinavia tried to do that, and the random assignment just didn’t take, so they had to change their methodology a bit. There’s something very, very important about how an analytic patient finds his or her analyst, so that random assignment is almost anathema to analytic work. I suppose you could get by in the analytic therapy studies, such as the Clarkin and Ken Levy project.

AC: Do you mean analytically informed, manualized treatments, like TFP?

GG: Exactly. You can do that with borderline patients who are going to get that treatment or another one. But analysis itself would be harder to randomize versus something else because the way people seek out an analyst. You know from living in New York that, when someone wants to find an analyst, they talk to everybody and his brother about who the good people are, what kind of approach people have, and it’s very personalized.

AC: What do you think of these manualized therapies that take advantage of certain psychodynamic principles but deploy them in the context of an integrative approach, like DBT? Linehan uses a lot of psychoanalytic thought and doesn’t necessarily say so. Mentalization-based therapy is another one.

GG: It’s everywhere. I’m always interested in watching cognitive therapy tapes, and I sit there thinking, “I do that all the time.” I think that dynamic ideas have influenced all the therapies, although it’s often not given any credit. It’s pervasive, and it’s not going to die out because the influence is everywhere. Even when the manual is for a dynamic therapy like TFP, you make compromises. It’s not exactly what would happen if you were sitting in the room with a patient working naturalistically. But I think it’s essential that, in the current marketplace, we do studies like that, even with the compromises.

AC: What do you think of mentalization-based therapy?

GG: Well, we know for sure from the research that it works, so that’s very important. I’ve worked here with Peter Fonagy, who comes here on a regular basis – he used to come to Topeka and now he still comes to Baylor – I’ve gotten good exposure to it from him and Anthony Bateman. I’ve tried variations on mentalization-based therapy with patients and found it to be helpful. I’m too much of a skeptic to take any pure form of therapy and apply it without using “a little bit of this and a little bit of that” in my own private mixed model. I haven’t tried a pure approach to mentalization-based therapy, but I’d say it seems helpful for many borderline and some narcissistic patients. On the other hand, we also know that TFP works for borderlines, as well as supportive therapy, schema-focused therapy, and DBT. And I think that there’s an inescapable conclusion here that, like much of the psychotherapy research suggests, the therapeutic relationship is probably going to be the most powerful predictor of outcome, regardless of theory or technique. The other thing, I think, is that borderline personality disordered patients want some kind of structure, some kind of conceptual model to make sense of their experience, and a number of different models probably help them get better because it can help them make sense of the chaotic inner world. So mentalization, TFP, DBT, all of those have some value.

AC: I noticed that you and Fonagy had a debate about using transference interpretation with borderline patients. What are your thoughts on that?

GG: Well, see, this is a good example of what I’m talking about. In the writing of Fonagy and Bateman, they don’t do the kind of transference interpretation that TFP adherents do. And yet they do look at the transference relationship, and I think we get into a bit of hair-splitting. It goes back to what you said, Alex. I think that if we did videotapes of a well-trained mentalization-based therapy and a well-trained TFP therapist, you’d hear many of the same kinds of comments, but I think it’s an example of what Freud called “the narcissism of minor differences.” People exaggerate the differences between the two approaches to make the point about how they’re different. But I’m always much more impressed with the similarities, and I think that transference interventions in both therapies are used, maybe more judiciously in mentalization based therapy, but I think that it wouldn’t be accurate to say that one is transference-focused and the other isn’t. I think that Peter and Anthony, in their letter in the American Journal of Psychiatry, were kind of saying, “Well, we do use transference,” but they just have a broader definition.

AC: What I’ve found to be so worthwhile about studying psychoanalysis, is that it’s something that never leaves you. Even if you end up doing CBT later, it’s still going to help you understand your relationship with your patient.

GG: You know, all the good therapists know that. One time, Tim Beck was buying a book of mine on countertransference. I said, “What are you buying a countertransference book for? You’re a cognitive therapist. You’re the father of cognitive therapy!” And he said, “Well, I’m having some countertransference problems with my patient, and I wanted to get a little help.” That’s the kind of guy he is. He is an open-minded guy who is not narrowly confined to one view, but admits he’s having some countertransference issues. I think the good cognitive therapists definitely think about transference and countertransference. I’ve talked to them. And they may have different labels for it, or whatever…

AC: Even if they firmly deny that they would ever talk about it that way.

GG: See, that’s true within psychoanalysis. You might see an ego psychologist who might firmly deny he’s been influenced by Kohut’s ideas in any way whatsoever, but then you would see him working with somebody, he is empathically validating and using Kohut-type interventions, so that his private mixed model has some of that, even if he’s publicly saying something different. Same with cognitive therapy.

AC: How do you account for psychoanalysis being marginalized in certain ways and yet having such a strong presence in popular culture?

GG: I think it’s a reflection of the ambivalence about analysis. We are simultaneously viewed with a certain degree of awe, like we’re mindreaders, and yet we’re devalued as buffoons who don’t know anything about data or research, who are far behind the times and just do wild speculation. You know, I’ve studied analysts in movies, and that’s a great way to get a read on how popular culture views analysts, and most of the time they’re pompous, jargon-speaking buffoons who really don’t add anything to common sense. I think this is a popular view, that the analyst is crazier, or as crazy, as the patient. And that, I think, is a way of devaluing something that is a little bit mysterious and disturbing. “Gee, there’s nothing to worry about here, these people are frauds!”

AC: I would love to know what you think of the end of Tony Soprano’s therapy.

GG: Well, you know I wrote a book on the Sopranos, so I’m a big fan, but I was very disappointed in the way they ended his therapy. To me, the writing took a serious misstep at that point. Up until then, Dr. Melfi’s interventions seemed to grow organically out of who she was and they made sense. This ending seemed like a plot device: “Let’s get him kicked out of therapy so he’ll be all isolated and alone at the end of the series.” Perhaps the most unbelievable aspect about it is that something that she would have learned in her first year of residency, namely that psychopaths can manipulate the therapist for their own ends, seemed to be brand new information. So that, at the age of 45 or 50, Melfi thinks, “Oh, really, an antisocial patient can misuse psychotherapy? I’d better look this up and read about it!” So she reads about it, and then she says, “I’ve been mistreated and used, I’d better kick his ass out of therapy!” Oh please! It’s like the writers had to figure a way to get him out. But what they did doesn’t make sense either from her psychology or from the psychotherapeutic process that we watched for six or seven seasons.

AC: What would have been a better way for them to do that?

GG: Well, probably a more realistic way would be to have them reassess their progress. As the show went on, it looked more and more like it wasn’t really helping him much, and on that basis, they should have come to a mutual agreement that it probably didn’t make sense to continue.

AC: It seemed to be a pretty good representation of therapy for a long time, and then…

GG: Exactly. That spoiled it. But while we’re on the topic, on January 28, HBO starts a new series, “In Treatment,” Which is based on an Israeli series that was the most popular television show ever in Israel. I’ve seen the advance episodes, and it is superb. Most of the series takes place in therapy sessions with different patients, and it’s very impressive. So I’m just putting in a plug for it.

AC: I’ll be looking forward to that. I want to move on and ask you what you’re working on these days in terms of your writing.

GG: Right now I’m co-authoring a paper with Tom Ogden, and we’re writing about the process of becoming an analyst, and how the analyst struggles with finding who he or she is after training. After qualifying as an analyst, one then spends a while developing a sense of authenticity in one’s own voice, one’s own style, and we’re kind of working with that idea and collaborating on that.

AC: I wonder if you could give a global perspective on the state of psychoanalysis, having been the editor of the International Journal. What sort of life does it have currently in other countries?

GG: In other countries, the state of psychoanalysis is highly variable. As Editor of the International Journal of Psychoanalysis, I visited South America and Europe frequently, and in some places, like Argentina, for example, there is a great deal of interest in psychoanalysis, though it is much like once or twice-weekly therapy. Also, there are all kinds of psychoanalytic institutes in Buenos Aires that are basically like a cult, where a charismatic analyst develops his own institute and analyzes and supervises everyone. There are some very good IPA approved institutes in Argentina, but what I am saying is that what we would consider as a reasonable psychoanalytic training setting is very different in other countries.

In Brazil, psychoanalysis is flourishing. In the Francophone culture, analysis is very different than what we think of as analysis in the United States. So it’s flourishing, but that doesn’t necessarily mean we have the same ideas about analysis. I’ll tell you a funny story. One time, at the European Psychoanalytic Federation, Peter Fonagy presented one session of a case, and Paul Denis from Paris was his discussant. Paul edits the French psychoanalytic journal- very nice guy, very clever. After Peter presented the case, Paul said, “Peter, you gave more interpretations in one session than I received in my entire analysis!” Again, it’s a very different kind of approach. In Italy, psychoanalysis seems to be thriving. In the UK, they seem to be having trouble getting cases, and they’re more beleaguered there. One other encouraging thing is that there’s a real enthusiasm for it in Eastern Europe and Russia, and they’re starting to form small study groups there.

AC: What does the future hold for psychoanalysis as a clinical approach?

GG: I frankly feel like psychoanalysis is never going to die off, despite all of the repeated Tiresias-like predictions of doom for the field. There’s a comfort in psychoanalysis being a discipline always on the periphery. It’s subversive. It takes people where they don’t want to go. It has radical ideas about how little control we have over ourselves. The unconscious is terribly threatening to people. It’s always been subversive. It was in Freud’s day. In the 1950s, when everyone in Hollywood was lining up to lie down on the couch, it was still thought of as a subversive activity, and that was kind of the appeal of it. So I think we’ll always be somewhat marginalized, and yet that’s where we ought to be.

I certainly think it will continue to be taught in some a small number of graduate schools in clinical psychology, in residencies in psychiatry and social work programs. I think that there’s such wisdom in it, and it has such clinical utility that it won’t die out. I think that it will be offered to a smaller number of students than it has been in the past, but I also anticipate a bit of a swinging back of the pendulum to the middle. The empirically-based therapies are very limited in their indications. So many people don’t come for a symptom of depression or panic or whatever it might be. They want a more thoroughgoing exploration of who they are. They come with issues of feeling dead inside and wanting to feel alive, issues of authenticity, issues of mourning certain developmental passages that they’re going through. Those kinds of issues aren’t going to be adequately dealt with in some kind of empirically validated therapy. So there’s always going to be a place for psychoanalysis, and in the next twenty years I think we might see a bit of a swing of the pendulum back.

AC: Do you have any advice for young, psychodynamically-inclined clinicians coming out of graduate school?

GG: I think you’re swimming upstream, but it’s definitely worth the effort. Another bit of advice I might have is that you may take a hit in terms of your income by pursuing that kind of work, but that it’s worth it because the quality of your day-to-day work with patients is so much richer, so much more intellectually stimulating. A problem that therapists have, as they get into their middle years, is that a sense of existential despair sets in if they don’t have the kind of richness of the psychoanalytic model, to see the complexity, the uniqueness of everyone. If you’re applying a kind of empirically-based system over and over again to patients, one after another, it gets tedious, and you start to feel a little bit like Sisyphus. You see an infinite variety and uniqueness to all of your patients when you’re using a psychoanalytic model. So even if you get less money, I think you’ll find your practice much more enjoyable and you’ll look forward to getting up each morning and going to the office.