The Impact of Pluralism

Pluralism

Pluralism refers to different theoretical views and clinical practices that often conflict and can be contradictory. Their presence evolves from the history of disagreement that was present from the inception of psychoanalysis. However, their inclusion currently as “really psychoanalysis” seems remarkable. For quite some time such views would not have been accepted in the psychoanalytic field. An orthodoxy prevailed, closely connected to Freud. Some of his views feel out of favor, and certain modifications, as ego psychology, were accepted as logical extensions of his work, but radical alterations to his work did not occur. Psychoanalysis gave the impression of an integrated theory. Pluralism marks a dramatic change.

Apparently, this change was in the making. Shevrin [4] points out that in 1958 there was an attempt to put together a comprehensive theory of psychoanalysis, particularly by Rapaport [5]. However, his effort was incomplete, limited by the already existing diversity of psychoanalytic models. He saw value in this diversity, Opinion namely the potential validity of new ideas to enhance a comprehensive theory of psychoanalysis given that the models appeared so share some basic principles of psychoanalysis, as the concepts of the unconscious and transference, but he also has reservations on their perceived lack of relation to one another.

Pine (pp.823-824) [2] summarizes the growth possibilities in their more recent status.

“I shall suggest that contributions summarized as pluralism can and should be seen as filling in gaps in areas that Freud specifically excluded or failed to develop fully enough…object relations, the self, preoedipal development, action, agency, the impact of the analyst in the office, the ‘stages’ on which the analytic drama takes place, and analytic impacts beyond interpretation.” This views pluralism as an addition, and expansion of knowledge that demonstrates useful evolution. It is in line with the idea that from its origins psychoanalysis was to be considered as an empirical science of developing theories that guide and are tested by practice as to their value. For example, psychoanalysis has traditionally focused on early developmental issues, with pathology explained in terms of regressions to fixations in these early years. However, it is possible that the present difficulties of individuals could be better understood if there was a comprehensive description of phases of human development throughout the lifespan.

Another area where pluralism is a positive influence is the expansion of psychoanalytic theory and practice to the general population of behavior disorders. Many patients are now seen in settings other than analysts’ private offices and with less frequency than traditional for psychoanalysis. Given the cultural shift to the influence of health insurers, psychoanalysts are likely to practice a considerable amount of psychoanalytic psychotherapy as mental healthcare providers. Pluralism opens the door to this broader psychoanalytic influence in treatment. It also means training institutions need to provide the diversity required by the extensive reach reach of pluralism. The relevance of psychoanalysis is potentially enhanced by the effective use of pluralism. Not only are new psychoanalytic ideas available, but contributions from other disciplines, as neuroscience and sociology, merit attention. More consideration needs to be given to increasing research in psychoanalytic theory and practice to provide empirical evidence for the value of hypotheses that too often are treated as facts. The impact of the expansions and revisions mentioned above have recently been reviewed and supported by Jacobs and Kernberg [6]. Pluralism opens all these doors and can breathe new life into psychoanalysis. However, this new democracy has also created problems.

Alternative Facts

At some historical point relational theory made enough of an impression as a form of “real psychoanalysis” to foster a lively dispute calling into question the validity of the prior relatively unquestioned drive theory. A few years after the publication of Object Relations in Psychoanalytic Theory [7], Killingmo [8] noted the increasing number of conflicting theories and “facts” being proposed as psychoanalytic. He supported inclusion as the best strategy until there could be an integrative theory and proposed that such a theory is both desirable and possible. During the waiting-for-it to happen period, which is of significant duration, he viewed psychoanalysis as a “rather loose heading for psychoanalytic subcultures” (1985, p.46). This is not an ideal state in which to remain. The desire to move on is reflected in Cooper’s description of the current state of affairs as “post-pluralism” (p.880) [9].

Using broad strokes, psychoanalytic theories can be divided into drive (classical) and relational (contemporary). Although both have modifications that mitigate some distinctions, they have substantial differences on basic issues, as motivation, that have forced a dichotomy. Ellman [10], reviewing relational critiques of the earlier prevailing classical model, notes a persistent tendency to dichotomize accompanied by proclamations or implications that “my model is better than yours.” A new paradigm is proposed to replace, not modify, the old because that is viewed as incorrect.

Gill [11] summarized differences between drive and relational models. Drive models emphasized the innate, past experience, and the value of insight. Relational models stressed current interpersonal experience. Overlap existed, but thrust was that one model had to be more accurate. In turn that was to be embraced and represented the evolution of psychoanalysis.

The elimination of one model because of its apparent deficiencies with another without these could be appropriate, provided that the new model is demonstrably superior to the old, but stating its value is not sufficient. Pine [2] makes the point that what seems to be missing in the classical model is often a function of the interpretation of that model as deficient when it can be found via a different interpretation. Beyond that, he approaches the issue in a different way, namely that the relational model can supply further knowledge and enrich psychoanalysis by addition. Of course, such a solution requires the relinquishing of the superordinate status of certain assertions that tend to be held sacrosanct. Both major models have significant limitations, Mills [12] having illustrated that for the relational model that has already stressed the limitations of the classical model [13].

Ellman has suggested that there does not have to be an unbridgeable gap between the two schools of thought, that the apparent dichotomy may be a false one. However, he also states, “If one is told there is an unbridgeable gulf, one has to choose sides” (p.22). Indeed, that does appear to be the current state of affairs [10].

For example, in a review of a 2008 book by Hirsch, Interpersonal Tradition: The Origins of Psychoanalytic Subjectivity, Coutu remarks, “Thinking about his clinical work from outside the boundaries of his particular approach would have added a useful dimension, in my opinion. However, given his opposition …, it is unlikely that he would have discovered much to value or utilize…” (p.488) [14].

In essence there is little room for anything other than the interpersonal tradition if one wishes to conduct a successful analysis. Such a position seems to contrast with the reversal of fortune approach currently displayed by a number of classical theorists. For example, Pray states, “I believe that the relational critique of the main body of literature referred to as classical analysis has been correct. A serious relational point of view has been missing from that literature and the theory it has elaborated” (p.257) [15].

Another example of the willingness of this willingness to consider and incorporate differing views of the analytic process appears in a discussion by Kernberg [6] suggesting innovation in psychoanalytic education. In this same discussion Jacobs describes the current situation as representative of a time “in-between” paradigms where there is competition until a consensus is formed. From the classical pint of view that seems to mean modification without elimination so it is primarily an additive process. From the relational point of view, it appears to mean a replacement process, a relational paradigm leaving the heart theory as a faint murmur of the past. Although Jacobs believes the “in-between” time is near its end, the distinctiveness of the two positions in regard to certain fundamental issues seems too strong to disappear any time soon. The relational position wants most of the classical tradition debunked. The latter now appears more open to relational additions, but contains some firm adherents at its base. Given the proclivity of one position to eradicate the other, consensus seems distant. At the same time, the presence of diverse viewpoints does offer the possibility of a better developed psychoanalysis. With that in mind consideration is now given to attempts at convergence.

Integration

The main effects of pluralism are both enrichment of the psychoanalytic field through new perspectives, and the fragmentation of theory and practice. In particular, the diversity has led to separations where analysts value one approach over another for all of their patients with each approach classified by the analysts as psychoanalysis. This implies a unity for psychoanalysis that does not exist as well as having the patients fit the theory rather than the theory fitting the patients. Pluralism actually offers the opportunity to design the psychoanalytic approach to fit the needs of each patient, which means the analyst needs a broad field of knowledge. At the same time that knowledge needs a common core for there to be such an entity as “psychoanalysis.” The term implies the attempt to bring about an “examined mind” in a relatively uniform way. The customary method had rested upon a belief in unconscious motivation and involved transference, countertransference and resistance in the service of enabling each patient to relieve their personal distress. Pluralism increases the analyst’s ways to do this, but does not have to limit a reliance on a relatively standardized pattern of formulations and techniques. If the new and the old can retain an essence that can be considered a psychoanalytic integration, the continuity of psychoanalysis can be maintained with improvements.

In 1990 Pine suggested an integrative approach to the prominent psychologies of psychoanalysis at that time. They were drive, ego, object, and self. He defined each of these. Drives are biologically-based urges with a psychological representation. The dual instinct theory of libido and aggression exemplify drive theory with the aim of drive gratification. Ego psychology emphasizes adaptation, defenses and reality testing in dealing with. These two retain a drive foundation for motivation, but Pine is not offering an inclusive theoretical perspective. Instead, there is considerable theoretical freedom with emphasis on theoretical aspects that fit the individual clinical situation [16].

Object relations theory emphasizes internal object relations and internal roles that exist in some form throughout life. Although Pine does not indicate the ascendance of relational motivation over drives, subsequent relations theory has made that clear. Instead, he points out the presence of object relations within Freud’s theory, particularly in the concepts of identification, the oedipal conflict, and transference. Self- psychology appears as a mixed picture with a drive connection and an emphasis on external causation (parental response) with self-experience having motivational power.

Pine considers these psychologies to be overlapping and does not insist that one be superordinate. Instead, he considers drive, ego, object relations, and self-experience to be present early in life and have their own lines of development as well as being integrated. The results are hierarchies of motivation and conflict that emphasize more of the aspects of the four psychologies and require significant attention in each person’s analysis.

He provides a way to utilize the various points of view without having to declare fealty to any one of them. Instead of reducing motivation he broadens it to allow any one of the four psychologies to be workable in varying degrees based on patient needs as expressed in their personal hierarchies. In practice this may be more of a wish than actuality because patient content can be bent to fit analytic theoretical preferences, but that does not negate the potential value of the attempt to be patient- centered. He is not offering a consensus, however, because there is a leaning towards incorporating these concepts into drive theory which would not be comfortable for relational theorists, his suggestion of broadening motivational possibilities with individual variations in moments of inclusion and causality could be more acceptable. The key to such acceptance is conceding the improbability of any one psychology’s favorite motivation and some of what goes with it, in favor of pluralism with an inherent equivalence of emphasis. Application of this approach is to depend on the needs of each patient, but as they are seen by the analyst. Such a multimodal approach requires analysts to be knowledgeable in all the perspectives as well as the ability to discern the dominance of one (or more) of them as central to each individual’s conflicts. These requirements can be difficult to achieve given that training institutes tend to prefer a singular perspective that is likely to influence an analyst’s perspective.

By suggesting the four perspectives originate at birth and remain developmentally active through the life span in varying degrees, Pine indicates that a pluralistic view of motivation is the most effective clinical approach. Thus, the drive-relational controversy is rendered unnecessary because both are operative and available from birth. If there is to be a controversy it shifts to determining the perspective in each individual’s analysis. Such a shift could be more productive because it is designed to be based on actual analytic session content rather than preformed theoretical preferences.

However, the expansion of motives that includes equality of origin and potential impact has not been a successful path to consensus up to this time. Pray [15] raised the possibility that there is a dominant tendency among analytic theorist to be reductionistic as well as resolving different perspectives. He states, “…today we are engaged in a fierce debate between two radically different theories of pathogenesis and technique, …” (p. 250). He also notes the equal importance of intrapsychic and relational points of view, as well as seeing room for subjectivity and objectivity on the part of analysts, another apparent dividing line for the theories.

Pray concludes that the solution does not depend on the reduction of differences as much as it does on making use of both internal and relational differences. However, his possibilities for doing this rest within the more classical tradition. These include using close observation of associative processes to illustrate both drive and relational motivations, further development of the theory of adaptation, and developing the ideas about splitting the ego in the defensive process While these address relational concerns, they are provisions for a consensus that tends to retain a drive base.

In 2010 Ellman advanced a developmental model which also advocates an expansion of motivations to include both object and pleasure seeking. It is a multifactor schema that emphasizes the interaction of innate and experiential factors. The primacy of one over another varies as a function of the individual and the surround in a given circumstance. This opens the door to a psychoanalytic field theory as well [17].

Ellman states, “In this theoretical perspective it is a mistake to think of development in absolutist terms. It is a mistake to maintain that one factor (either experiential or innate) is, in general, more important than another; it is always the interaction” (p.641).

The thrust of integrated theories is in the direction of expansion rather than replacement. For a consensus to be established the favored view seems to expansion and modification of the original paradigm. This would mean the alteration of a singular view that so far has not been feasible. The ambivalence toward integration appears in the depiction of differences in the models described by Auchincloss [18]. She suggests four basic psychoanalytic models of the mind, namely topographic, structural, object relations, and self- theory. She illustrates the similarities and differences among these, concludes there is not sufficient evidence as to which is best, and suggests the value of being able to use all of them. This also appears as an argument for expansion and inclusion, namely integration. At the same time, she notes that there is a lack of agreement as to the value of integration.

Support for a single theory rests upon the belief that one view is the most accurate and effective. A key issue is the method of determining such a view. At the moment it tends to be based primarily on clinical evidence derived by analysts who put their theories into practice, and due to the differences in the theories along with considerable room for personal bias, the result appears to be a lack of consensus. A viable empirical method for comparative testing is not available, so a current consensus would have to come about within the parameters of pluralism. Pluralism strives to capture the possibilities as well as increase them, one of which being a comprehensive theory that could be richer than any of the existing theories being “the theory.” For pluralism to be maximally effective, analysts need to be open to what is being offered. Existing attempts at consensus are efforts to engage such openness, and their common thrust supports a belief in this possibility, but it remains elusive.

Pine [2] continued his integrative work by expanding coverage of more recent examples of pluralism into what he terms “the workings of mind.” He sees pluralism as covering areas that drive theory either did not develop sufficiently or excluded. His aim is to rectify the fracturing of psychoanalytic theory into competing views that result in a chaotic picture potentially damaging both conceptually and professionally. He states, “I oppose the idea that priority should be given to, or even expected, to any specific developmental issue” (p. 894).

Instead, priority is given to issues based on the clinical picture given by the specific patient. He also states, “I view the issue of centrality as a clinical/empirical question to be answered with each new analysis and, and not a theoretical one, and if the analyst’s theory determines the answer, the patient may not be heard” (p.844).

If theory is indeed comprehensive, then personalized theory is not as likely to get in the way. Pluralism provides theoretical possibilities as conceptual foundations for “hearing’ the patient, but there are practical difficulties. Developmental issues tend to be formulated in theoretical terms, such as oedipal, paranoid-schizoid, etc. Any one theory tends to emphasize certain conceptions while overlooking or denigrating others. This effects clinical practice because the analyst hears each patient in literal and theoretical terms based on the analyst’s theoretical beliefs. Frequently it may not be possible to clearly separate the clinical and the theoretical.

Pluralism does open up possibilities not available in a singular theoretical approach, particularly one that in turn is clinically restrictive. However, to take full advantage of pluralism it is necessary to have a working knowledge of all the schools of psychoanalysis. This is a task that may be beyond the abilities of all but a few analysts. Also, all analysts have preferences which limit both their interest and ability for inclusive understanding. Such preferences include clinical practices and “adjusting” theory and practice to suit countertransference desires.

Formulations based on practical validation and the application of theory are permanent partners requiring continual evaluation and concomitant change. The advent of pluralism exemplifies the continual evaluation that kept taking place despite a lengthy reign of orthodoxy.

Now the question is what to do with this multiplication of possibilities beyond awareness its existence.

The first step is to avoid championing new exclusive doctrines and practices in the same manner as was prevalent in classical psychoanalysis. The next step is to build upon the past. Although Pine appears in favor of loosening the relation between theory and practice, he creates a case for the extension of Freudian theory and practice that accommodates drives, ego functions, object relations, self-experiences, and is open to other extensions, as psychoanalytic field theory. To do this, as other integrationists have also suggested, incompatible assumptions of various psychoanalytic schools are diminished in favor of using what appears to be the best fit in specific cases. Most psychoanalytic schools have something to contribute which can be used without adopting the entire approach. For example, are people inherently motivated by drives or are they object-seeking? They may be both, but differ in the degree of each motivation. Theory is reinterpreted to allow for a broader view of development to inform clinical practice without eliminating the possibility of either motivation. Another way to view this approach is that more than one theory becomes available if needed based on the analyst’s impression of specific patient needs.

Roadblocks

Pine suggest an effective way to make use of pluralism. “This requires clinical listening with all (or many) of our theories in the back of our minds, such that they can surface as it fits the clinical moment” (p. 852) [2]. Implied her is, “if you can achieve such an ego ideal.” Details of the general practical problems previously noted need to be explored. First, analysts are usually trained in depth in one theoretical model, with a rough divide into drive or relational underpinnings. Models other than the anointed one may be noted, but attention often given to their limitations rather than their values. This tends to be true even when training institutes offer more than one possibility because the overall model is competitive preference instead of consensus. This occurs although there is not sufficient empirical data to support one theory over another, and that lack of evidence actually facilitates the privileging of faculty opinion. As a remedy, despite the empirical gap, it is unlikely that training institutes will have the resources to offer all the possibilities of pluralism, but further consideration of the knowledge base could be made available to candidates. This could be reinforced with an attitude of the value of enlightenment beyond singular orientations.

A second issue is that there is security in having a particular point of view to understand clinical issues. The analyst then knows where to place patients’ issues, although such an assumption can result in misplacing them as well. Pluralism expands the possibility of less error, but a variety of conceptualizations may threaten an analyst’s comfort zone. As a result, it becomes preferable to shape clinical data to fit familiar patterns of analytic thought. Pluralism requires open-mindedness and greater breadth of knowledge than is inherent in single models. Given that psychoanalysis already has the “impossible profession” label, asking for more may have limited appeal. It is easier on the analyst to go with what is already an operational method, and endorsed by at least one group of influential analysts, and consider it is proven enough. Pluralism by its very presence and growth demands a more expansive outlook, and one that is difficult to carry out adequately.

Third, pluralism is often used in service of replacement rather than expansion. For example, drive- related conceptions are abandoned in favor of object- related ones. Such an approach sees the thrust of pluralism as an entirely new view, although an emphasis on relations does not require the elimination of drives. Certain past or existing concepts may turn out to be inadequate, but as a number of drive theorists have tended to point in more recent times, there is a workable foundation to keep building a more viable structure, Revisions can and should be made based on the continual accumulation of evidence, but that does not automatically require the wholesale jettison of the past. To do that would mean one orthodoxy replaces another without empirical validation and theory would remain as “good- enough” fact.

Finally, the desire to have an orthodox approach is understandable. It would simplify matters, clarifying such basic issues as having a consensus definition of psychoanalysis. Auchincloss states, “attempts at integration are important because every clinician needs a robust and workable psychoanalytic model of the mind, usable with every patient in every situation” (p.255) [18].

Of course, psychoanalysis did not begin as a theory and therapy for “every patient.” However, over time the “psychoanalytic way” has moved in that direction with the use of psychoanalytic therapy now seen as a competitive treatment in some fashion for most psychiatric disorders. The therapy is based on psychoanalytic models of the mind, but using adaptive clinical practices that fit individual situations rather than being tied to one psychoanalytic theory. Smith describes this as “natural delinkage of theory and practice” (p.140) that remains under the psychoanalytic umbrella [19].

While advocating the value of pluralism and the creation of new knowledge, which includes new theories and practices, Govrin [20] makes the point that theories need to be empirically tested, whereas much of psychoanalytic knowledge is asserted as correct. Also, theories need to be “thick”, meaning they concern themselves with all aspects of human behavior, and their aim is to know the truth, to solve empirical problems. Pluralism is a path that recognizes the role and value of subjectivity without eliminating the know to have an analyst who learns to “know” reality along with uncertainty.

Possible Resolution

Granted that if there was an agreed-upon existing comprehensive psychoanalytic model, it would be interpreted with a certain degree of subjectivity, but the existence of a relative consensus beyond what now exists would be an improvement. Blass [21] (pp. 856-857) states “Not only is it a fact that analysts, insofar as they are practicing analysts, are committed to single conceptions of the person and naturally seek to unify their models of dynamics, pathology, and cure, rather than hold a set of disjointed submodels, but an in-depth perception and understanding of reality is made possible through such unified analytic models.” The lack of an agreed-upon definition of psychoanalysis involves more than internal theoretical dissension. There are notable practical difficulties that occur. Psychoanalysts are mental health providers whose basic existence depends on their ability to limit the suffering of patients. A starting point in attempting to do this is the ability to define their product, which includes defining themselves. At the moment analysts tend to self- define, usually in terms of the “psychoanalysis” at the institute from which they graduated. Although there has never been an exact congruence between practice and what was taught, there is usually a stated allegiance. The result is different types of analysts and of psychoanalysis, with different theories, methods, aims and results. The distinctions are recognized by analysts, but patients are not necessarily aware that significant differences exist in what constitutes an analysis. In the current pluralistic climate it is both difficult and often impractical to explain the distinctions to patients. As a result, it is common to minimize this issue by accepting the belief that there are sufficient basic links that make it all “psychoanalysis”, but the lack of specifics as to these links just raises the question again; what is psychoanalysis?

Turning to the most recent “authoritative” definition [22] there is a length two-page definition (pluralism at work). It begins with Freud and grows in complexity as time has marched on searching for cornerstones and foundations that are subsequently disputed by differing schools of psychoanalysis. “These schools are differentiated from one another on the basis of a model of the mind, a view of psychopathology and development, a theory of therapeutic action, and a technique of clinical practice” (p. 208) [22].

While true, as the growth of pluralism has been demonstrating, the viability and credibility of the “entity psychoanalysis” would be facilitated by unifying concepts that were sufficiently acceptable to all schools of psychoanalysis without impinging upon fundamental beliefs or principles of each school. So far that has appeared not to be possible. However, the work of Pine noted earlier, does move in that direction, with some reservations.

In defining psychoanalysis as “the study of the workings of mind” (p. 825), it is necessary to define “mind” in psychoanalytic terms in order to differentiate it from other therapies and disciplines that also claim to study “mind” from their perspectives. Pine does this, stating he is defining “that mind”, which is an implicit recognition of “other minds.” However, his definition of necessity becomes lengthy and pluralistic as he is describing “the psychoanalytic mind.” He tries to avoid the pluralism of technique by stressing the use of the “observational base”, although with the probability that theory does underlie clinical activity so that there is an ongoing theory of clinical effectiveness bearing degrees of relationship to the analyst’s theoretical orientation. In working with patients, it is unlikely Pine’s ideal will be reached by many analysts, namely to be “equidistance…with regard to the extant theories of psychoanalysis” (p.852) [2].

He seems to recognize the difficulty in operationalizing by indicating, “the aim is to achieve relative autonomy…from particular theories” (p.852). Another issue is that by defining psychoanalysis succinctly as “workings of mind” there is an insufficient clinical explanation that could be used for patients. An operational definition needs to indicate it is a treatment method, but doing that could result in a pluralistic definition that facilitates more confusion than clarity. Being sufficiently explanatory remains an issue.

Nonetheless, Pine illustrates that much of pluralism can be blended to move in the direction of integration.

The utility of a single model does not seem to be questioned, but the ability to create such a model is doubted to the extent hat only a few analysts have attempted it. There are a number of reasons for this, all related to pluralism. The most obvious reason is the belief that there already is an existing model that is accurate. The other models are not. Thus, integration is not sought because there is no reason to question what the analyst knows is true. At present this attitude seems most prevalent among relational models, although all existing models have some extreme loyalists. Achieving change in this situation, even within the model itself, is very difficult.

More flexibility appears in a variation on single-model adherence, namely where some exceptions are permitted. For example, LaFarge [23] describes a session in which she utilized portions of a model other than her own and considers it advantageous. However, the flexibility may have been more acceptable because she found she could understand what she did, in retrospect, from the perspective of her existing model, and her own model retained its relative singularity. At the same time, allowing other possibilities to any extent is a step in the direction of integration.

Some analysts use more than one model, but limit the number and are not trying to be comprehensive. Cooper [9] uses this approach, favoring certain models, but not attempting integration because he believes existing attempts do not accurately represent the concepts being integrated. This suggests that with further evaluation of other possibilities a more comprehensive system could be possible.

There are additional problems. A basic issue for psychoanalysis is the inability to demonstrate the accuracy of any one model. Given a relative disinterest in research by analysts, and the complexity of the work, research attempts have been limited so that empirical evidence may be a long time in arriving. As a result, the justification for personal theory and practice comes from a traditional source, observational consensus for each school of psychoanalysis. This was easier to work with when the choices were more limited. Now analysts appear to be following “personal core models” [23] involving psychoanalytic concepts linked by a common undefined core called “psychoanalysis”. A defined superordinate concept that includes pluralistic models without insisting they all have the same parts or cannot contain contradictions would be an improvement. Pine aims for this without insisting on a singular primary motivation. His umbrella “workings of mind” seems generally accurate and capable of including diverse views, despite the reservations already noted. What stands out is the flexibility and the detailed attempt at integration. Such an approach carries the hope of embracing all psychoanalytic schools that can find a way to demonstrate they are “psychoanalytic.” But, what does that mean? We are back to the matter of definition.

One possibility is the use of basic psychoanalytic concepts, as unconscious, transference, countertransference, and resistance. The problem with doing this is deciding how many and what concepts are necessary to form a core definition, and if agreement could be reached, agreeing on the meaning of the concepts. For example, Govrin [20] describes a causal relationship between the events of childhood and transference as “the most basic tenet of all schools of thought” (p.180). That statement is then qualified by a discussion of analysts who have problems with such a developmental viewpoint.

Probably the unconscious is the best candidate for getting agreement, although to do so it needs to be defined broadly as “out of awareness.” Blass [24] notes the limitation on considering the unconscious as internal reality expressed by Bromberg [25], although that description remains consistent with a distinction between conscious and unconscious. Also, an emphasis on unconscious motivation differentiates psychoanalysis from other psychotherapies. Resistance is another possibility since there does seem to be agreement that all patients “resist” in some fashion during analysis, but resistance is not distinctive to psychoanalysis.

An immediate solution to the incorporation of pluralism does not appear available. Optimism that it is likely to happen in the near future seems unlikely. Agreement as to the value of a comprehensive model has been around for some time without agreement as to its essential parts. How far the field appears to be from reaching such agreement is reflected in the following statement by Govrin [20]: “Only a fundamental change in psychoanalytic organizations and institutions can help psychoanalysis become a science and an academic clinical discipline” (p.180).

Short-term, the presence of pluralism is very apparent and clinical work is ongoing. At issue is how best to do it. That means allegiance to some defined anchors, a “subjective objectivism” that attempts to make use of the offerings of pluralism in service of being “analysts who know enough.” This is in accord with Govrin’s comment, “Patients in distress are more likely to expect their analysts to “know” something than to be uncertain…” (p.191). Of course, “knowing” is relative certainty, but with that awareness, it remains the goal. The possibility of customizing an emphasis and an approach for each patient, apparent in Pine’s synthesis is difficult and open to error, but adaptable. Also, uncertainty about certainty allows room for different approaches amid the recognition of subjectivity in apparent objectivity.

What can be learned from the current state of pluralism? To start with, the creativity and diversity of psychoanalysis continues to fascinate a sufficient number of potential and active practitioners to keep the field very much alive. Psychoanalysis is in continual evolution that requires on going revisions. Hypotheses are vital to this effort, but they are theories, not facts unless validated. In turn, greater emphasis needs to be given to empirical validation. Also, there is a large potential patient population that can be served by psychoanalytic approaches that incorporate flexibility. Analysts operate with their own definitions and theories of psychoanalysis with the belief that there are links that make it all “psychoanalysis”, but these links remain amorphous. A consensus definition of psychoanalysis and a comprehensive theory of psychoanalysis are needed. Finally, despite the elusiveness of such goals, there is enough elasticity in the philosophies of psychoanalysis (positivism and postmodernism) to provide avenues for the desired definition and theory. There is an ego-ideal to be pursued, the ego at the moment being a fascinating mess.