Philosophy, Psychiatry, & Psychology

The concept of integration is important in analytic thought and practice, and it is used in various ways. These uses inevitably involve theories about the mind which may differ substantially. Following Wittgenstein, such uses and theories form a family with important resemblances but no necessarily unifying essence.

Now, analysts take it as a maxim that we act unbeknownst to ourselves, that the synthetic moments of consciousness are shaped by multiple cryptic forces. It is the business of clinical analysis to bring these into the provenance of language. This mostly involves the clarification and specification of affects, fantasies, self-protective measures, and complex modes of relating to self and others. It is another analytic maxim that this plurality forms a potentially knowable constellation of desires, evasions, and attachments called transference, which is typically conceived as repetitious self-enslavement.

Integration is said to occur when evasions lessen, desires become more patent, and the nature of attachments more clearly articulated and experienced. Hence integration means relatively greater freedom, richer affective tones and the possibility of new experiences. How this occurs is not clear and is a matter of considerable theoretical abstraction and controversy. Accounts may invoke the liberation of inherent maturational forces, the reliving of developmental moments with a new object, changes in drive-state fusion, ego growth, increased self-cohesion, etc.

Integration is not just involved with mental models. As used in psychoanalytic discourse, the work “integration” carries a powerful valence. It tends to connote what is desirable, valuable, and good. Abstract models of mind are given to add theoretical substance to the term, so that what is being integrated and how this comes about can be ostensibly described. This may or may not stay close to actual clinical experience. Integration, then, can refer to theories, a collection of changes in behavior and experience, or a collection of such changes which the speaker takes to be good.

Hinshelwood’s model stresses the interpersonal field. He sees persons as giving up aspects of themselves in relationships and, in some way, placing this aspect onto the other. The analyst, by ultimately refusing this role and by interpreting the patient’s creation of such a field, allows the disavowed aspects to take their place within the totality of the self. Thus integration here means a fundamental coming together that is manifest insofar as the person’s position in the relationship changes.

Helping patients achieve integration involves specific psychoanalytic techniques. These are related [End Page 155] to the unique relationship of the analyst and analysand. This relationship, despite important analogs, is like no other. Put briefly, the relationship is radically skewed. There is a paradoxical deep involvement and deep uninvolvement; powerful forces are mobilized but are not directly acted upon. The analysand eventually speaks what has not been spoken, and reveals much to an analyst who reveals relatively little. This is an unusual interpersonal field. Psychoanalytic technical procedures are aimed at creating such a field and allowing the transference to develop and become a matter of reflection.

These forms of behavior find their place in other sorts of relationships, but in their totality they do not. Abstinence, anonymity, neutrality, and an interpretative stance would not necessarily enhance freedom in other settings. They might, in fact, lead to quite discernible forms of madness. Such behavior with one’s children would not likely lead to good things. Thus in different forms of relationships, different behaviors might lead to what an analyst would describe as increased integration.

Two related questions come to mind. First, is technical behavior within an unusual relationship something on which to ground an ethics? Second, is psychoanalytic technique inherently and essentially moral? Let me give some clinical examples to help explore these themes.

A woman with a long history of schizophrenia angrily discontinues her medication. She is grandiose and paranoid, saying that she is a great queen with new internal organs and is followed by a hidden camera at all times. Voices seem to come from all the air vents. She becomes agitated easily, cursing loudly and requiring seclusion because of aggressiveness. In the past, while on medication, she remained delusional but was less distressed and...