Sándor Ferenczi, clinical empiricist

Karen Starr: In a 1929 letter to Freud, Ferenczi wrote, “My true affinity is for research, and, freed from all personal ambition, I have become deeply immersed, with renewed curiosity, in the study of cases” (Dupont, 1988, p. xii; also see Freud & Ferenczi, 1920–1933, letter of Ferenczi to Freud, dated December 15, 1929, p. 375). We believe Ferenczi would have felt right at home sharing a panel with psychotherapy researchers investigating the therapeutic alliance and the processes of rupture and repair in the psychotherapy relationship. Ferenczi himself dedicated his professional life to researching, identifying, and refining his understanding of the psychotherapeutic factors that were the most effective agents of psychic change, but perhaps his most creative and radical contributions to the field that continue to reverberate in contemporary psychoanalytic practice to this day involve his research into the mutative aspects of the psychotherapy relationship.

It is, by now, well known that Ferenczi was considered by his contemporaries to be the analyst of “last resort” (Dupont, 1988, p. xix). He was widely recognized by his peers, including Freud, as a “brilliant therapist” (Sterba, 1982, p. 88). Ferenczi was deeply concerned about helping his patients, many of whom were hopeless cases referred to him by other analysts from all over the world (see Balint, 1949, p. 216; Dupont, 1988).

Ferenczi (1931) described himself as “above all, an empiricist” (p. 419) whose ideas were either rejected or confirmed by his clinical work. Rather than adhere rigidly to an overly intellectualized and dogmatic conception of psychoanalytic practice, Ferenczi passionately believed it was the analyst’s responsibility to devise a treatment that would most effectively treat the patient’s problems. In the service of this goal, he conducted numerous experiments with technique. Many of his cases were what today we would call “difficult patients”—people with obsessional, narcissistic, borderline, and psychotic disorders. They struggled with free association and did not respond well to interpretation, demonstrating a drying up of associations in response. Rather than blaming the patient, as was customary among analysts of his time, Ferenczi searched for solutions. In fact, we can locate the historical origins of experimentation with psychotherapy integration (Bresler & Starr, 2015) and brief psychodynamic therapy in Ferenczi’s innovations as well as his collaborations with Otto Rank (Ferenczi & Rank, 1924). Also traceable to Ferenczi and Rank is the contemporary understanding of the importance of the “here-and-now” in the psychotherapy relationship, including the therapeutic value of enactment and the curative potential for the patient of having a new, reparative experience in the analytic relationship (Miller-Bottome & Safran, 2018, p. 228).

Over the course of his career, Ferenczi’s technical experiments included incorporating hypnosis, meditation, and behavioral interventions into his psychoanalytic treatments. Brennan (2018) provides us with an interesting account from a patient, Eleanor Morris Burnet, who sought out Ferenczi for treatment during the period when he was lecturing at the New School in 1926. Burnet was afraid of sunlight and was living confined to a darkened room. Ferenczi employed his “active technique”—what today we would refer to as exposure—by taking her out “into the hustle and bustle of Broadway” and walking with her down the streets of Manhattan (Brennan, 2018, p. 93). Burnet described Ferenczi as incredibly patient and kind, with a “Puckish” sense of humor. She noted, “One felt safe with him, safer with him than any other man or woman” (cited in Brennan, 2018, p. 93). Describing her treatment as life-changing, Burnet noted that from the beginning, Ferenczi invited her not just to say whatever came into her mind, but also insisted that she “speak out anything about himself” (p. 93). She would later describe her treatment as a “redemption by love” (p. 93).

Throughout his career, Ferenczi believed that a healing relationship with an empathic analyst lay at the heart of analytic cure. The criticism he leveled against classical psychoanalytic technique—considering it cold, removed, disinterested, depriving, and overly intellectualized—was the same criticism he would come to level against his own analyst, Freud. In Ferenczi’s view, revolutionary for its time, the relationship between patient and analyst was a more powerful agent of psychic change than was insight achieved through the analyst’s interpretations.

Ferenczi’s democratic professional attitude and non-authoritarian stance led him to the understanding that who the analyst is as a person will invariably impact the way he or she engages with patients, and even more revolutionary, that the patient is able to perceive who the analyst is as a separate subjectivity. He reformulated the analyst-analysand relationship as being interactive, reciprocal, and subject to examination. In Ferenczi’s paradigm, what we would now refer to as a “two-person” psychology, both analyst and analysand are considered sources of data about the analytic encounter as well as mutual participants in the analytic process (Aron, 1991).

Ferenczi long had an interest in the dialogue of unconsciouses between patient and analyst, which, differing from Freud, he viewed as a two-way communication. But it was through his difficult work with his patient Elizabeth Severn, which (at her insistence) led to his experimentation with mutual analysis, that he came to understand the significant impact of the analyst’s countertransference on the patient (Ferenczi, 1932). Ferenczi encouraged his patient, R.N., as he refers to her in in the Clinical Diary, to share her perceptions with him directly, and he was open to what she had to say. (See Haynal [2018] and Rudnytsky [2023] for important perspectives on mutual analysis in the Severn-Ferenczi treatment.)

Ferenczi’s belief in the centrality of the analyst-patient relationship to psychotherapeutic healing ultimately led him to a radically new understanding of resistance, transference, and countertransference. He proposed that resistance can be understood as a legitimate attempt by the patient to communicate his or her needs in the therapy interaction and, at times, even as a self-protective response provoked by a lack of empathy from the analyst. By the same token, transference is not inevitably a distorted projection emerging from the internal workings of the patient’s psyche but may also include accurate perceptions of the analyst, including aspects of the analyst of which the analyst himself is unaware. Ferenczi was an early advocate of working with countertransference not as an interference to be analyzed away, but as an experience that should be examined as potentially communicating something important about the patient and the interaction with the analyst (Bass, 2018).

Throughout his life, Ferenczi believed in the healing power of the analyst’s emotional availability, empathy, and sincerity. His suggestion that therapeutic impasses and resistance from the patient may be a response to the analyst’s own deficiencies and conflicts expanded the field of analytic data to include the contributions of the analyst. It sharpened the focus on patients’ communications as reactions to the analyst in addition to being revelations of their own intrapsychic material. In sum, Ferenczi’s research into the mutative agents of psychic change was a precursor to, and paved the way for, our contemporary understanding of the two-way street of interpersonal processes, including the processes of rupture and repair, in the psychotherapy relationship.

Thinking beyond borders: psychotherapy integration in the work of Jeremy Safran

Jill Bresler: Born in different times, Sándor Ferenczi and Jeremy Safran were fellow travelers. As I read Karen’s paper, I had a fantasy of the two of them, time travelers, I guess, walking rapidly through Greenwich Village near the New School where they both taught,3 excited by each other’s ideas. Both men were scientist practitioners, imaginative empiricists and devoted and creative clinicians whose life’s work centered on a penetrating examination of the therapeutic relationship in the service of making psychotherapy more effective.

I first met Jeremy at the annual Society for the Exploration of Psychotherapy Integration (SEPI) meeting in 1990. It was a transitional year for him, as Interpersonal Process in Cognitive Therapy (Safran & Segal, 1990) had just been published. Jeremy was about to move to New York to begin teaching at Adelphi University. At the time, I was living largely inside the Cognitive Behavioral Therapy (CBT) world, but I was becoming aware it would not be a permanent home. I felt immediately I had met a fellow traveler—albeit one who was travelling at warp speed, while I was walking.

Many readers may be unaware that in the mid-eighties, while Jeremy was just in his mid-thirties, he was director of the Cognitive Therapy Unit of the Clarke Institute of Psychiatry in Toronto. Although Jeremy quickly established himself as a leader in CBT, he identified as an integrative therapist. In fact, Jeremy believed an integrative approach was necessary since any therapeutic approach would ultimately have limits. In a beautiful paper written with Stan Messer (Safran & Messer, 1997), he wrote that an integrative approach could transform contempt and aversion to the other into surprise and eagerness to learn. From the beginning of his career, Jeremy demonstrated this kind of intellectual approach, engaging rigorously with multiple models.

Psychotherapy integration not only directs you to approach other schools of therapy with an open mind, it is also a pathway to acknowledging the lacunae in your own model. Assimilative integration is when you are working from a home model, but looking to other models for how they can inform and enhance your work. As a model of assimilative integrative thinking, Interpersonal Process in Cognitive Therapy (1990) is a tour de force. In it, Jeremy invited CBT therapists to think about what others, including experiential therapists such as Les Greenberg, with whom he co-authored Emotion in Psychotherapy (Greenberg & Safran, 1987), but also Freud and Sullivan, saw as central to their work: attending to and talking about the therapeutic alliance.

At that time, the majority of CBT therapists thought of the alliance in very simplistic terms. The alliance would be assumed to be in good health if the patient was working as expected, challenging assumptions, engaging in new behaviors, and mastering difficult emotions, especially outside of the treatment room. If therapy was not progressing, the therapist would likely come up with new interventions such as new ways of reshaping cognition or new homework exercises. During my postdoctoral training at his institute, Albert Ellis (personal communication) famously urged my cohort of trainees to “dispute more vigorously!” when patients were stuck. As a second tactic, they might look for how the patient’s core maladaptive assumptions were playing out in the therapy relationship. However, training in this promising line of inquiry was extremely limited, and attention to the influence of the therapist as a unique individual with their own set of assumptions and ways of being was almost non-existent.

I was Jeremy’s rapt reader. I was frustrated with the way many CBT treatments were dead-ended by the lack of a framework for thinking about the interpersonal field inside the therapy room. In a way that felt revolutionary and intensely exciting, in Interpersonal Process in Cognitive Therapy (Safran & Segal, 1990) Jeremy compellingly demonstrated that attending to and working with the therapeutic alliance could be a path forward.

There is pedagogical genius in how Jeremy, a natural teacher, structured this project. There was no serious precedent in CBT for putting the relationship front and center, and so the reader had to be brought along as ideas from outside CBT were brought in. While the term psychoanalysis does not appear in the index, Jeremy’s interest in psychoanalysis was evident in the book. He exposed CBT therapists to Sullivan’s participant-observer approach, and to the progression from the one-person Freudian model to the newly conceptualized relational two-person model. In fact, he cited Greenberg and Mitchell (1983) long before many psychoanalysts had even heard of their seminal book. However, with the reader in mind, the arguments for working in the relationship were laid out primarily by citing developmental theory, including attachment theory; research on cognition, emotion, and memory; and core concepts from experiential therapies and constructivist CBT.

The bulk of the book is a thoughtful, well-illustrated discussion of what it means to use yourself and your own reactions to what is going on between you and your patient to guide your interventions. The central clinical chapters begin on familiar ground, with many examples of how to work with out-of-session material. The reader is made comfortable reading about interventions that feel like the ones they already do. In the second clinical chapter, the focus shifts to in-session material, so that the clinician can see that many of the rules that govern talking about out-of-session material can be applied to in-session material. At a time when CBT therapists would be turned off by direct references to transference-countertransference, Jeremy illustrated these very processes using common language that was not distracting because it did not pull for factional hostility. His talent for helping others approach new ideas with surprise and eagerness is on full display in these pages. I’ve been struck as I’ve been writing that his project was so similar to Ferenczi’s: introducing new ideas about the centrality of the therapeutic relationship into a model that did not previously privilege the relationship as focal.

In closing the book, Jeremy described the research project that started in the mid-eighties during his time at Clarke as the Short-Term Cognitive Therapy project, and that continues to this day, as the model, now known as Brief Relational Therapy (BRT), has been picked up by researchers worldwide. Given the CBT world’s investment in research as a means to knowledge, the final chapters lend extra legitimacy to the ideas presented in the book.

Shortly after he moved to New York, Jeremy became a candidate at the NYU Postdoctoral Program in Psychotherapy and Psychoanalysis—in fact, one year before I did. While there are many questions I wish I could ask him now about his path, I did once ask him why he was doing analytic training, and his answer was simply, “I’ve always been an analyst.” By that, I think he meant that he always saw the relationship, the authentic encounter, as the most compelling part of work as a therapist.

Ten years after Interpersonal Process in Cognitive Therapy (1990), Negotiating the Therapeutic Alliance (Safran & Muran, 2000) was published. By that time, Jeremy had made a home for himself in the psychoanalytic world. He traced the origins of BRT to the work of Ferenczi and Rank—both their interest in brief therapy as well as their emphasis on the experiential and relational aspects of treatment (Ferenczi & Rank, 1924). Importantly, Jeremy thought of the work as transtheoretical and relevant to clinicians of all modalities, and his arguments for the approach drew from many sources.

Jeremy’s empiricism took the form of a contemporary research project that has extended for almost forty years now, an uncommon achievement in our field. The type of research he wanted to do was not central to the CBT research program, which was focused on amassing Randomized Control Trial (RCT) study after RCT study, trying to parse out which technical aspects of therapies were effective. In fact, Jeremy was critical of whether that research was actually useful to clinicians. Instead, he became a pioneer in process research. Those of you who do not keep up with trends in CBT might find it interesting that in recent years, some leading behavioral researchers, themselves disillusioned by the limits of RCTs, have become enthusiastic proponents of the process-oriented research Jeremy was doing from the beginning. In this way, Jeremy also calls to mind Ferenczi, whose ideas were ahead of his time. If you haven’t yet, I urge you to read both of the books I’ve referenced here. They can be understood to be Jeremy’s Clinical Diaries, and I’m sure Ferenczi would have been transfixed by them.

Notes

  1. 1

    Dr. Karen Starr is faculty at the NYU Postdoctoral Program in Psychotherapy and Psychoanalysis. In addition to journal articles and book chapters, Dr. Starr is the author of Repair of the Soul: Metaphors of Transformation in Jewish Mysticism and Psychoanalysis; coauthor with Lewis Aron of A Psychotherapy for the People: Toward a Progressive Psychoanalysis; and coeditor with Jill Bresler of Relational Psychoanalysis and Psychotherapy Integration: An Evolving Synergy. Dr. Starr maintains a private practice in New York City and Great Neck, New York.

  2. 2

    Dr. Jill Bresler is faculty at the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis and is Co-Director and faculty at the Psychotherapy Integration Program at the National Institute for the Psychotherapies. She is co-editor, with Karen Starr, of Relational Psychoanalysis and Psychotherapy Integration: An Evolving Synergy. Dr. Bresler maintains a private practice in New York City.

  3. 3

    At the invitation of the president of the New School, Ferenczi gave a series of weekly lectures at the New School for Social Research in New York from September 22, 1926 to June 3, 1927. During that time in NYC, Ferenczi continued analysis with some of his American patients, took on new patients and gave clinical supervision to others (Stanton, 1991, p. 38). As Professor of Psychology and Director of Clinical Training, Jeremy Safran taught at the New School from 1993 until his death in 2018. In 2008 he became one of the founders, along with Lewis Aron and Adrienne Harris, of the Sándor Ferenczi Center at the New School.