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· A Letter from Azerbaijan Psychologists

· Greetings from the Department of Psychiatry by Mantosh Dewan, M.D.

· "Forty Years of Consequences."
Remarks by Nelson Borelli, M.D.

· "The State's Insatiable Need to Incarcerate Those Who Frighten It."
Remarks by George J. Alexander, JSD

· "Psychiatry's Moral Anchor"
Remarks by Robert Daly, M.D.

· "Electroshock -- Epitomizing the Myth."
Remarks by John M. Friedberg, M.D.

· "Thomas Szasz's Personalist and Ethical Conception of the Cause and Cure of Character, Conduct, and Conflict."
Remarks by Zvi Lothane, M.D.

· "Therapeutic Paternalism in Australia: A Szaszian Critique of Repetition Strain Injury (RSI)."
Remarks by Professor Robert Spillane

· "Thomas Szasz: Rhetoric and Mental Illness."
Remarks by Richard Vatz, Ph.D.

· "Thomas Szasz's Impact on Political Issues: Two Examples from Germany."
Remarks by René Talbot

· "Some Recollections of a Psychiatry Resident-in-Supervision with Professor Thomas S. Szasz, M.D."
Remarks by Laura W. Neville, M.D.

· Introduction Letter
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Thomas Szasz's Personalist and Ethical Conception of the Cause and Cure of Character, Conduct, and Conflict

Zvi Lothane, M.D.*

[Editor's note: These remarks serve as preface, at Dr. Lothane's request, to his paper below entitled "Freud and the Interpersonal."]

Thomas Szasz's 1961 plea, in The Myth of Mental Illness, for a paradigm shift in American psychiatry is even more relevant in 2000-2001 as we witness the return of American psychiatry to an essentialist brain mythology overturned by Freud now more than a century ago. Such phenomena like person and mind are again being reduced to a mechanistic concept of brain, even though the biological substrate even in the major psychoses is still a matter of hypothesis, not fully established science. Szasz had two important messages: a negative one and a positive one. The negative addressed etiology, the positive the phenomenology of human behavior in order, or health, and disorder, or illness.

The negative message was subsequently misunderstood as Szasz's denial of disorder, viewed by him as problems in living writ large. But Szasz never denied that there are problems: he only insisted that a mechanistic and medical etiological model was neither an explanation nor a remedy for problems in living. On the contrary: he argued that problems in living should be defined by methods appropriate to such problems.

The subtitle of Szasz's book, "Foundations of a Theory of Personal Conduct," less famous than the title, is not less but more important: it is his essential positive message that follows after the deconstruction of psychological problems as illness as a medical etiological myth, with which I concur. That subtitle explains why mental illness, fashioned in the etiological image of medical illness is a myth whereas it remains rooted in the reality of human character, conduct, and conflict. For here Szasz did not mean theory qua hypostasis but theory in the sense of method, he meant the foundations of a method for the understanding of and coping with personal conduct and ethical choices.

The central concept in this method is eminently interpersonal: "No man is an Island (italics), entire of it self," that it takes two to tango, or, in my preferred terms, that it takes one person to have pneumonia, the monadic model of observation and epistemology, but it takes two to develop paranoia, the dyadic model of observation of observation and epistemology.

Szasz's achievement was to flesh out fully the latent aspect of Freud's overarching core concept that symptoms have meaning: Symptoms have meaning not only as meaningful messages fashioned by an author, a sender in a solitary act of creation; symptoms have meaning as communications, nonverbal and verbal, sent from a doer, a dreamer and a dialoguer, to another doer, dreamer and dialoguer who as receiver reacts to the deeds and discourse of the sender. But Freud's focus was manifestly monadic, whereas the implication of his method was latently dyadic, or interpersonal. It is from Szasz's Myth of Mental Illness and his acute analysis of interpersonal human behavior that I gained the unshakable conviction that the meaning of so-called symptoms of emotional disorder, i.e., the actions and conducts in question, was not to be found in the conduct of one person but in the interaction between the person and others in the person's environment.

Therefore, according to this dyadic-interpersonal method, the meanings of the so-called symptoms of character, conduct, and conflict are not disclosed by decoding the symptom as a monadic, impersonal, isolated text. What is needed for a fuller understanding of the suffering person is to examine the interpersonal situation: the interaction between the persons engaged in social action, discourse and dialogue. Just as an unexamined life is not worth living, a psychiatry and psychoanalysis not based on the interpersonal method are not worth having.

---Zvi Lothane, M. D.

International Forum of Psychoanalysis, 6:175-184


Zvi Lothane, M. D.

Abstract: The goal of this communication is to uncover a hitherto unacknowledged interpersonal aspect in Freud: his implicit dyadic conception of symptom formation and interpretation, the competing claims of the object relation and the interpersonal schools notwithstanding. It is argued that Freud delineated a number of models of symptom formation: a drive, dream, and a dyadic, or relational, model. I have renamed the dyadic model the love model. This has implications concerning areas of consensus and conflict among the various psychoanalytic schools of thought.

"Like other neuropathologists, I was trained to apply local diagnoses and electro-prognosis, and it still strikes me myself as strange that the case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science."
---Sigmund Freud


The orientation of this paper is methodological: I propose to underscore the reality of persons and personal relations and the role of interpersonal, i.e., relational, or dyadic (1), determinism in health and disease and in the framework of the analytic conversation, or dialogue. Moreover, my purpose is to show the hitherto unacknowledged interpersonal strand in Freud's writings. To put it succinctly: the dyadic dynamics of persons in interpersonal relations, and most tellingly in love relations (1, 2, 3), are the real and including phenomenon, whereas concepts like ego, object, and self are the included abstractions. It can thus be argued that the various psychoanalytic schools, theories or hypotheses (such as the structural, object relations and self psychology), are, in the last analysis, concerned with dyadic concepts of the person and interpersonal relations while espousing a variety of monadic theoretical formulations. Thus the differences between them are more apparent than real, more metaphysical than methodological, more lexical than logical (4), which adds an ecumenical purpose to my argument: to underscore the common denominator between the various schools, theories, and doctrines. That common denominator is human relatedness: it is an everyday fact of life and it stands above all theory and it belongs in the realm of method, of how things are done. It is not that relating, like story telling, lack the serious stamp of science: relations, and more essentially love relations, are still the greatest challenge to science. As Hegel said, the time has come to put the pyramid on its base.

There is a growing interest in interpersonal dynamics among Freudian (5, 6, 7, 8, 9) and neo-Freudian analysts (10). This has been especially noted in the context of interactions and enactments in the psychoanalytic situation, from nonverbal to spoken communications, specifically listening and intervening, and referred to in a variety of ways. However, it started with Freud himself, in the Studies on Hysteria (11) in his papers on technique (12) and until the last years of his life (13). There has been a growing interest in interactions and enactments between analysand and analyst starting with Isakower, who used the metaphor of analyzing instrument as explicated by Isakower (14, 15, 16) and continued by his students (17, 18, 19, 20).

Defining psychoanalysis methodologically commits one to the scientific method: observation first, theory second. This accords well with Freud's (21) trenchant insight: "For these [speculative] ideas are not the foundation of science, upon which everything rests; that foundation is observation alone. They [i.e., theories] are not the bottom but the top of the whole structure, and they can be replaced and discarded without damaging it. The same thing is happening in our day with the science of physics, the basic notions of which as regards mater, centres of force, attraction, etc., are scarcely less debatable than the corresponding notions of psycho-analysis" (21: 77).

Pursuing the vantage point of method, it is argued that the observable fact is persons in relations, whereas the varieties of theory, or hypothesis, are the speculative, the more or less philosophical, and dispensable fictions. This has been duly recognized by Brenner (22) in his recent revision of the structural hypothesis. Freud repeatedly quoted his teacher Charcot: "La théorie c'est bon, mais ça n'empêche d'éxister" (theory is fine but facts are there to stay). However, as historically psychoanalysis has evolved from medicine, it was inevitable that Freud should define his method in terms of two seemingly competing models, the monadic and the dyadic, the self-contained model of the organism and the interactional model of the person. As I argued (23), the tension between these two models runs like a crimson thread through the writings of Freud (and the psychoanalytic literature):

"Freud's psychoanalytic method ... was from the start applied to dyads -- the analysand and analyst engaged in the psychoanalytic process. By contrast, his theory of disordered behavior was formulated largely in terms that were applicable to monads. Thus, there has persisted in Freud a perennial tension between the theory of disorder and the theory of treatment. Sullivan, on the other hand, even though he was influenced by Freud, developed a transactional and dyadic theory of disordered behavior as a disorder of interpersonal relations [23:170]."

However, as I will show below, the interpersonal model was implicit in Freud from the start. I cannot say whether Sullivan's concept of the interpersonal was borrowed from Freud, of from Ferenczi (24), or developed it under the influence of the George Meade's school of sociology, or came to it independently.

Both the monadic and the dyadic model exist and are observable, they both have their role in the life of the person, and they both give rise to different methodological solutions for the life of the person, thus to different theories of pathogenesis and therapy; but problems arise only when one model is pursued at the expense of the other. There are both monadic and dyadic facts in human physiology and psychology. The physiological functions, such as feeding and breathing qua organismic functions, are necessarily self-contained, or monadic, even as they imply a relation with the environment. Perception of the world we live in through the senses is also a monadic function, for it cannot be said that the objects perceived are in an interaction with the perceiver.

Thinking -- and its subspecies imagining, remembering, and dreaming -- occur as a monadic, self-contained, solitary activity. But here a momentous and radical change takes place: the tools of thinking, that is words, are learnt in the course of dyadic, or interpersonal, development. Therefore thinking always oscillates between being a monologue and a dialogue. Because thinking is done with words, defined by Plato as the soul (i.e., person) talking to itself, it follows that a person is forever conversing either with himself or herself, or with another person. A fortiori, speaking and listening as interhuman situations -- the analytic situation included -- cannot but be inherently dyadic (1).

The locus classicus of the monadic model is the functioning of the brain in both its physiological and pathological manifestations. We do not know much about how brains interact, but we now quite a bit about the interaction of people engaged in sex acts. It feels natural to extend the monadic brain model to the instinctual drive model, when defined in terms of the tension-detension model and compared to the feeding cycles of hunger and satiety. Thus, masturbation seen purely as a tension-discharge function is indeed a monadic and solitary pursuit, even though in the imagination, i.e., the accompanying reverie-fantasy, it always involves an other. But copulation --from copula i.e., couple -- is a trans-action, a transitive action. Therefore, it is not enough to have drives and aims, you need a person to consummate them with. Even though the person can be renamed a love object (the original psychoanalytic term), an object of desire (by creative writers), or simply an object, it still takes two to tango: since the consummation of sexuality requires another person who inter-acts in the sex act, a union of the bodies of two persons, it is ipso facto a mode of interpersonal relatedness (25). The ebb and flow of sexual appetite happens within one person as self-contained and self-reflecting, in whom we can discern the dynamics of drive representation and the economics of tension-discharge, and describe the source and aim of the drive. But as soon as we become aware of the person toward whom the desire is directed, a different reality emerges, such that the sensual-sexual activity becomes the most exquisite of communications and carnal knowledge becomes a profound knowledge of oneself and of the other, as aptly expressed by the Shakespeare:

"So they loved, as love in twain
Had the essence but in one;
Two distincts, division none:
Number there in love was slain [25:]."

Freud set forth the discourse on sexual objects in his Three Essays on the Theory of Sexuality (26). Let there be no mistake: not three essays on sexuality, for that would place the discourse in the realm of sexology, and there were a number of sexologists before Freud and duly acknowledged by him. Freud's theory of sexuality meant something vastly different from sexological research as such, although it included it in his new theory on the etiological role of developmental lines of sexuality. It should also be noted that historically, the term object was a contraction from the original 'love object.' The adjectival noun love was subsequently lost, leaving object and paving the way for the question-begging neologism 'object relations.' But objects, the usual name for things and not persons, have no relations with each other, and in Webster's Dictionary there is no definition of object to mean person. Ironically, the term object relations was supposed to correct Freud's interpersonal omission. Another piece of irony is that, the term subject, which does mean person, gives rise to subjective, i.e., implying the slipperiness of a personalized bias, which seems unscientific. By the same token, speaking of persons as objects is no guarantee of scientific objectivity. Moore and Fine (27) do not even have an entry person or interpersonal. Should anyone argue that there is nothing new in the self-evident concepts person and interpersonal, I would counter: if so, why are these concepts omitted from their glossary of psychoanalytic terms and concepts? Or is the abstraction self, but which commonly means person (as in the expression self and other), more "scientific" than person?

Freud (26), not unaware of the interpersonal nature of sex and love, saw them as two separate developmental lines that coalesced at puberty :

"sexual aims have become mitigated and they now represent what may be described as the 'affectionate [zärtlich, tender loving] current' [emphasis in the original and without single quotation marks, Z. L.] of sexual life. . . . Should these two currents [i.e., the sensual and the tender loving] fail to converge, the result is often that one of the ideals of sexual life, the focusing of all desires upon a single object, will not be attainable" (26:200)."

In spite of the foregoing insight, Freud never overcame the organic, or monadic, bias toward sexuality. But what is to prevent us from claiming that the sexual and the affectionate currents have been a unity from the very beginning?

It is also significant that in spite of an implicit realization that interpersonal aspects are relevant to sexuality, when it came to tracing the connection between psychoneurotic symptoms and sexuality, Freud defined that connection in monadic terms. Thus Freud (28) conceived hysterical symptoms as "mnemic symbols of certain operative (traumatic) impressions and experiences," as "an expression of the fulfillment of a wish," that symptoms "serve the purpose of sexual satisfaction and represent a portion of the subject's sexual life" and that they also "correspond to a return of a mode of sexual satisfaction which was a real one in infantile life and has since been repressed" (28:163-164). The implicit aspect is this: what is now expressed as a monadic memory, or as a wish, or the enactment of a wish, was once an actual dyadic experience that involved an interaction between two persons.


The reason for the above mentioned methodological split in Freud's thought is not a mystery: it was shaped by his anatomical and neurological education and consequently by what he presupposed when confronted with the phenomena of hysteria. Faced with the clinical fact of the so-called hysterical paralysis he asked the medically logical question: what kind of paralysis is it that is presented by this symptom and correctly answered: a functional paralysis, a pseudo-paralysis. This was a monadic answer to a monadic question: the question contained the presupposition that the clinical fact is a paralysis, when in fact it has nothing to do with any paralysis, it is a performance, or enactment of one, a charade of a person impersonating a paralytic. Had Freud posed a different question, what kind of a person is it and what is he or she enacting or communicating to the other person, he would have given a dyadic, or interpersonal answer: the symptomatic act described by the analogical term, or metaphor, "paralysis" means creating verbal and nonverbal messages, determined both unconsciously and consciously, and addressing them to two audiences: to oneself, an internal or intrapersonal audience, and to someone else, an external, or an interpersonal one. In 1895 Freud (11) approached the phenomena of neurosis from the vantage point of symptoms and in 1900 he reformulated the problem from the perspective of the dream: in his Interpretation of Dreams (29) he discovered that dreams have a two tiered structure: a manifest and a latent content. From there it was only one step to the following conception: that the symptom is structured like a dream (30). Even though the dream, like a memory, is a monadic event, it is also potentially addressed to an audience: it is a message to the person to whom the dream is told.

Freud's awareness of the communicational-interpersonal nature of so-called symptoms and symptomatic acts takes shape in the Studies on Hysteria. In their Preliminary Communication Breuer and Freud (11) felt moved

"to investigate a great variety of the forms and symptoms of hysteria, with a view to discovering their precipitating cause ... strictly related to the precipitating trauma. . . . Hysterics suffer mainly from reminiscences [and these] . . . experiences are completely absent from the patient's memory [i.e.,] things which the patient wished to forget, and therefore intentionally repressed from his conscious thoughts [11: 3-4, 7, 9-10; emphasis Breuer's and Freud's]."

On the face of it, the focus here is on monadic memory phenomena, on enacting the memories of traumatic events, i.e., manifesting behaviors called symptoms, without an awareness of their traumatic causes, combined with two additional factors: the "painful emotions" (11: 4) associated with them, and "a connection [that] consists only in what might be called a 'symbolic' [no quotation marks in the original, Z. L.] relation between the precipitating cause and the pathological phenomenon -- a relation such as healthy people form in dreams" (11: 5).

However, the original events always involve an interaction with another person, and that person is always present in the rememorations of the events, as shown in the following vignette of a hysterical man:

[An] employee who had become a hysteric as a result of being ill-treated by his superior, suffered from attacks in which he collapsed and fell into a frenzy of rage, but without uttering a word . . . . [The] patient revealed that he was living through a scene in which his employer had abused him in the street and hit him with a stick. A few days later the patient came back and complained of having had another attack of the same kind. On this occasion it turned out that he had been re-living the scene to which the actual onset of the illness was related: the scene in the law-court when he failed to obtain satisfaction for his maltreatment [11:14; emphasis added].

In this vignette the salient aspects is the fact that it is a dramatic scene, Freud's synonym for event, i.e., something historical and factual, something that occurs on the social stage and involves observed actions and reactions. In this event, the man's attacks of rage are his monadic response to the humiliation of abuse and failure to obtain vindication in court; but the response is also a dyadic event, a communication of a protest addressed at the abuser, at the court guilty of miscarriage of justice, or at any other imaginary audience, a speech without words but with gestures of impotent and inarticulate rage, which is now persisting as a recurrent hysterical symptom, a conscious and unconscious enactment of the event.

Let us now examine the relation between the model of cause and the model of cure of illness, remembering that when this text was written 'cure' meant treatment, not the successful termination of treatment, as in Anna O.'s description of the process as "the talking cure." As far as treatment is concerned, Freud based it on the following unspoken premise: the requirement that there should be a congruence between the cause and nature of disorder and the method of treatment and cure.

On the one hand, the desired end result of treatment is the monadic "fading of a memory or the losing of its affect" (11: 8), in keeping with the observation that "ideas that have become pathological have persisted with such freshness and affective strength because they have been denied the normal wearing-away processes by means of abreaction and reproduction in a state of uninhibited association (11: 11; emphasis of the authors). However, this process requires the dyadic input of a therapist: "Each individual hysterical symptom immediately and permanently disappeared when we had succeeded in bringing clearly to light the memory of the event by which it was provoked and in arousing its accompanying affect (11: 6).

Clearly, the therapeutic procedure is itself an interaction predicated on the skill of the therapist and the collaboration of the patient. Furthermore, it depends to a large extent on the ability of the therapist to influence the patient.

When Freud finally comes to evaluating the newly discovered cathartic method of treatment, he is both humble about his claims and acutely aware of the problems, which still haunt us to this day. While affirming the superiority of the cathartic method over mere suggestion, Freud is aware that in the treatment of the various psychoneuroses, "the cathartic method is not to be regarded as worthless because it is symptomatic, and not a causal one. ... The cathartic method does all that can be asked of it, for the physician cannot set himself the task of altering a constitution such as the hysterical one" (11:262). Moreover, Freud also knows that the cathartic method cannot affect the underlying causes of hysteria: thus it cannot prevent fresh symptoms from taking the place which have been got rid of" (11:261). He thus seems to be aware of the problems inherent in symptom modification and the much wider scope of character disorders, and the more daunting task of character change.

But now a new aspect of therapy comes into focus: investigating "the psychical genealogy of a symptom" meets with a "particular motive for a resistance" in the form of "censoring" (11:281, 282), and this in spite of the well-intentioned "psychotherapeutic activity ... as elucidator, ... as teacher, as the representative of a freer or superior view of the world, as a father confessor who gives absolution, as it were, by a continuance of his sympathy and the respect after the confessions has been made ... giv[ing] the patient human assistance" (11:282). The key word here is sympathy, a synonym for care and a concern for the welfare of the person, Aristotle's defining criterion for friendship, for me, a defining criterion for love.

But love has its problems, it can be derailed by the problematic nature of affective bias, placing difficulties in the path of treatment. Faced with such difficulties of the treatment, Freud is finally drawn to the realization that the "obstacles have lain in the personal circumstances of the patients and have not been due to any question of theory" (11:262). The thrust of all these observations leads him to the discovery of the 'obstacle' of transference, when the spontaneous flow -- later renamed free associations -- of the patient's "pathological ideas" and "reminiscences" grinds to a stop:

"This happens when the patient's relation to the physician is disturbed, and it is the worst obstacle that we can come across. ... Transference on to the physician takes place through a false connection. ... if I had neglected to make the nature of the 'obstacle' clear to them I should simply have given them a new hysterical symptom -- though it is true, a milder one -- in exchange for another one which had been generated spontaneously" [11: 301, 304; first emphasis Freud's, second emphasis added]."

Let us pause to take stock: the mechanism of producing symptoms is the same when it is a spontaneous manifestation of the neurosis and when it occurs in the therapeutic relationship, whether through the true connection of human sympathy, or the false connection of transference, thus, both the normal and the pathological, both the analytic process that stays on course and one that has become derailed. The form and the meaning of the symptom are determined by the interpersonal situation and by interpersonal dynamics, affecting both the creation of symptoms and the process of the analysis. The interpersonal nature of these processes was captured by Ferenczi in 1912 (24), in his formulation of transference as an interpersonal process: transference symptoms are interpersonally determined, and, a fortiori, so are the manifestations of neurosis.

Freud shapes these ideas even more clearly in his Introductory Lectures on Psychoanalysis (31). It is by now established that neurotic "symptoms have a sense and are related to the patient's experience ... that like parapraxes and dreams ... they have a connection with the life of those who produce them" (31:257), that is the life of the actors and the dreamers. Furthermore, the conception of the symptom as produced by a person is defined as an act: To unravel the symptoms means the same thing as to understand the person's disease: "symptoms--and of course we are dealing with psychical (or psychogenic) symptoms and psychical illness--are acts detrimental, or at least useless, to the subject's life as a whole . . . 'being ill' is in its essence a practical concept...you might well say that we are all ill--that is, neurotic -- since the preconditions for the formation of symptoms can also be observed in normal people" (31:358; emphasis added).

These statements are remarkable for their implications. In the realm of the psychical, the word symptom acquires a new meaning: symptoms are acts, and such acts are implicitly inter-acts, or interactions. Such acts are communications that can be both self-directed, i.e., intrapersonal, and other-directed, i.e., interpersonal. The concept of interpersonal is thus latent in Freud but never spelled out as interpersonal. This gap should be closed and such a step beyond Freud is much needed for the completion of Freud's path started at the turn of this century.

The further corollary to saying that psychogenic symptoms qua meaningful acts are the disease, is that there is a continuum and a common denominator to such symptoms in health and disease. This practical conception of sick and healthy conduct entails distinguishing useful from wasteful, adaptive from maladaptive, acts in interpersonal relations.

Without spelling it out, Freud brings us to the next necessary unspoken premise for the understanding of human acts: symptoms are not only motivated, they also have a practical sense. Practical is a Kantian concept, and in Kant practical means ethical. For psychogenic symptoms, as acts, are conducts characterized by moral conflict. Conducts bring people into conflict with themselves and with others, thus, they not only have meaning, or sense, they also possess a moral sense, they are informed by the moral, or ethical, sentiment of the person. As Freud says: "the third factor in the etiology of the neuroses, the tendency to conflict, is as much dependent on the development of the ego as on that of the libido" (31:352). In this passage Freud still views conflict in the terms of forces and structures, of libido rather than love, not yet fully, at this stage, in terms of moral values and conflicts of conscience, seemingly denying his awareness of the portrayals of moral conflict depicted by creative writers and dramatists he quoted, from Sophocles to Shakespeare, from Goethe to Ibsen. That awareness is latent, for his ideas about guilt and the superego were yet to come.

We have filled the gap, Freud's passages during the two decades since the birth of psychoanalysis in 1895: from monadic to dyadic, from symptoms to speeches directed by an actor to his dual audience, himself and others, from dramas of love to dreams and back again. How does this square with Freud's hypothesis of a dynamic unconscious?


In the beginning was the relation, said Buber. All persons begin their life as members in the mother-child dyad and then become solitary selves. Freud assumed the opposite: we begin in a state of primary narcissism, akin to hallucination, and then proceed to relatedness and to sense perception. Who is right? But this is a practical, not a metaphysical issue, and it is a matter of philosophical speculation whether the first act of the neonate is an act of perception or an act of hallucination, and no amount of mother child observation can decide the issue. Once can only justifiably claim that observation of mothers and infants from early on points to a basic relatedness, to what Margaret Mahler called the mother child-unity, and that once established, such relatedness persists for life. This state of affairs is finalized with the acquisition of language: communicating through language, the conjoined activity of speaking and listening, are unquestionably dyadic, even though the perception forever remains monadic in nature. It is therefore not surprising that the bulk of the theories of the life of the mind have been cast from the perspective of the solitary perceiver, dreamer, and thinker with the dyadic dimension of mental functioning left by the wayside.

Starting with the elucidation of the psychological structure of symptoms, Freud was led to his epochal discovery of dream psychology, and the combination of the two became the foundation of depth psychology, unconscious dynamic processes and free association, all aspects of the psychoanalytic method of treatment and research. Freud (32) described the homology of dreams and symptoms as follows: "dreams are constructed just the same way as neurotic symptoms. Like them, they may appear strange and senseless; but, if we examine them by a technique which differs little from the free association used in psycho-analysis, we are led from their manifest content to a secret meaning, to the latent dream thoughts" (32: 199). It works both ways: dreams are constructed like symptoms, symptoms are constructed like dreams (30).

The common trait is that symptoms and dreams are encoded language or text, and therefore decodable. But here is an essential difference between listening to speeches and reading texts of stories in the absence of their author: the dream and the symptom are not like a poem, a drama, or a novel, their meaning is not yielded by interpreting their meanings texts from the outside by means of their lexical or metaphorical significations: the meaning is not in the dream text but in the dreamer, not in the dreams and the symptoms themselves, but, as in the above-quoted passage, in "those that produce them." It is the person's associations, glosses and commentaries that are the key to their meaning, not somebody else's associations, and this is the crucial difference between hermeneutics, exegesis, interpretation and psychoanalytic interpretation, a stance recently expressed by Laplanche (33). But this essential difference is being repressed and rediscovered by analysts time and again.

We can now proceed to a synthesis of the ideas about the structure of dreams and symptoms and dyadic dynamics. Like dreams and symptoms, interactions are enactments between two persons and as such they are also encoded and decodable by the method of free association.

We can now take dyadic dynamics a step further. The proposition that the meaning of the dream is in the dreamer can be extended to encompass the interaction itself: the meaning of the symptom is in the love relation between the two persons in an interhuman situation. A further step is taken in suggesting that the inclusive model of the genesis of symptoms is the love model, the included model of genesis of symptoms is the dream model:

"It is the love, or relational, model of cause and cure that is the prime mover, the vehicle and the medium in which memories and dreams take place. Even as memories and dreams take place within one person (and can be said to be monadic phenomena), they forever retain a dyadic reference to another person, present or absent. Therefore, it is not enough to say that dreams and symptoms have meaning. They are carriers of meaning from one person to another; the speeches and gestures of love between two people [2:5]."

A clinical vignette of Sullivan's illustrates the meaning of the proposition that the meaning of the symptoms is in the interaction, in the love-hate battle of the sexes, in the way the hysterical game is played:

"[T]he hysteric dynamism comes into operation, let us say that a man . . . has married, perhaps, for money, and that his wife . . . cannot long . . . completely blind herself to a certain lack of importance that she has in her husband's eyes. So she begins to get even. She may for example . . . develop a never-failing vaginismus, so that there is no more intercourse with him. And he will ruminate whether this vaginismus that is cutting off his satisfaction is directed against him, for the very simple reason that if you view interpersonal phenomena with the degree of objectivity, you can't use the hysterical process to get rid of your troubles. . . . he will suffer terribly from privation and will go to extravagant lengths to overcome the vaginismus that is depriving him of satisfaction . . . But he fails again and again. Then one night when he is worn out, and perhaps has a precocious ejaculation in his newest adventure in practical psychotherapy, he has the idea, "My God, this thing is driving me crazy" . . . the happy idea that I say the hysteric has. He wakes up at some early hour in the morning, probably at the time when his wife is notoriously most soundly asleep, and has a frightful attack of some kind. It could be literally almost anything, but it will be very impressive to anyone around. His wife will be awakened, very much frightened, and will call the doctor. But before the doctor gets there, the husband, with a fine sense of dramatic values, will let her know, in some indirect way that he is terribly afraid he is losing his mind. She is reduced to a really agitated state by that. So when the doctor comes, the wife is in enough distress--in part because of what led to her vaginismus--to wonder if she might lose her own mind [34:204-205]. "

The same vignette was quoted by Thomas Szasz (35) in the most persuasive interpersonal formulation of hysteria as a problem of interpersonal communication. Of course, the original source was Freud, but Szasz was also influenced by the long-standing interpersonal Zeitgeist in Chicago harking back to the philosophy of Dewey, the psychology of Angel, and the psychoanalysis of Franz Alexander.

We can see here the meshing of personal and interpersonal dynamisms of love's labor lost. As I have argued (1,2, 3) and in my case history of Schreber (36), the main psychopathological syndromes are problems, lacunae, and conflicts of love and self-love and these problems require healing in the context of the analytic situation as a corrective love experience. Ferenczi may have been misguided about the technique of neocatharsis, but he was right about the importance of love conflicts and love needs, as was later illuminated by Michael Balint. The specific defenses employed by each participant are fashioned by the person's temperament, character, and the history of his or her real relations and transferences; but the meaning of each person's symptoms or conduct can only be understood as an interaction. This model, mutatis mutandis, can be applied to any other kind of character and psychopathology. The schizophrenic, the manic-depressive, the borderline, or the narcissist will do likewise, the reaction colored by the specifics of the personal makeup, character, or style.

Both Freud and Sullivan were wise about human nature and its capacity for deception and self-deception in matters of love, with the difference that Sullivan did not become as cluttered with excess metaphysical furniture as did Freud and some of the followers with their metapsychology.

The game model, to be taken seriously and not frivolously, had already been applied by Freud (12) to method , i.e., the procedure and technique, of psychoanalysis (23), using the simile of "[T]he noble game of chess . . . [where] only the openings and end-games admit of an exhaustive systematic presentation and the infinite variety of moves which develop after the opening defy any such description. . . . [in the] treatment . . . rules of the game . . . acquire their importance from their relation to the general plan of the game. . . . The extraordinary diversity of the psychical constellations concerned, the plasticity of all mental processes and the wealth of determining factors oppose any mechanization of the technique . . . [12:123]."

The interactional and reciprocal foundation of the psychoanalytic procedure is here stated unequivocally.

The aforementioned continuum between the normal and the neurotic actor, of whom the prototype is the hysteric, raises the question of the difference between the two, for both the normal and the neurotic act and enact; but the tendency to enact will be greater in the neurotic, with a corresponding fluctuation in the level of consciousness: from awareness to repression; from full wakefulness to partial awakeness and an auto-hypnotic trance state; from the consciousness of an initial intent to its unconscious enactment, according to the laws of dream dynamics, displacement, dramatization, condensation. As was noted, what applies to the dynamics of symptom formation also does to the dynamics of the curative process: the trance like qualities of the path to symptom formation are best investigated in the dream-like quality of the psychoanalytic setting, as expounded by Otto Isakower in his methodological concept of the analyzing instrument (14, 15, 16). My most recent discussion of the analyzing instrument makes a bridge to free association and attempts to constitute the process of the analyzing instrument as an interpersonal process of reciprocal free association (20), a more complete statement, I believe, than Sullivan's well-known notion of participant observation (37). Since the process of free association requires a mutual and complementary regression in the analysand and the analyst's state of mind, conditions are created for the exploration of the unconscious aspects of the interaction. This elevates interpersonal dynamics to a new level and eliminates the often heard objection that interpersonal dynamics only encompass the superficial and conscious aspects of mental functioning. The process of analyzing is by its very nature interpersonal. It is not a situation in which the analyst objectively examines the patient's productions as a slide under the microscope. The analyst and the analyst work as a team, at the same functional level.

Dyadic determinism, no less strict than monadic determinism, postulates that as soon as two people are thrown together in the same space and at the same time, they will have both conscious and unconscious effects on each other. The conscious effects are mediated through perception, the unconscious ones through the phenomena of transference and countertransference. If we liken transference to dreams, then it is possible to view "transference-work as a homologue of dream work ... [such that] in the psychotherapeutic situation both interlocutors react to each other as reality (perception) and as tansference (dreaming)" (30:441-442). In this way a bridge is created between dreaming and relating, between dreaming and perceiving, between Freud's dream psychology and his love psychology.


The interpersonal conception of the cause and cure of symptoms, i.e., of the interpersonal dynamics of symptom formation and the procedure and process of therapeutic symptom resolution, requires the integration of both Freud's models and methods, his dream psychology and his love psychology, both distinct from his more theoretical, rather than methodological, drive psychology. Over the decades, the latent interpersonal model in Freud has been vastly overshadowed by the dream and drive models.

It was the preponderant preoccupation with the metaphysics, or metapsychology, of the drive model that led to the emergence of the various schools in psychoanalysis, from object relation theory to ego psychology and to self psychology, that sought to provide a corrective to the scholastic, not to say talmudic, preoccupation with theoretical abstractions. However, in the rush to correct and revise it was forgotten that the basic message was present in Freud, but largely unnoticed. Freud was keenly aware of the reality of loving and being loved in return, of telling one's dreams and stories to a listener, as the basic everyday experiences of mankind, even if they "lack the serious stamp of science." The time has come to put the pyramid on its base: the various theories of the mind are but attempts to come to come to grips or to escape from the basic human phenomenon, the need to live by love and the ethics of love, in everyday live and in the analytic situation.


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*Zvi Lothane, M. D., is Fellow of the American Psychiatric Association and member of the American Psychoanalytic Association and the International Psychoanalytical Association. He is author of In Defense of Schreber: Soul Murder and Psychiatry, The Analytic Press, 1992. He is Clinical Associate Professor of Psychiatry, Mount Sinai School of Medicine, New York City
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e-mail: schreber@lothane.com
web page: www.lothane.com

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