Monday, January 16, 2012

Psychoanalysis and Research - The Reluctant Psychoanalyst Goes to a Convention

There are a couple of challenges in writing this blog that occur regardless of the object I review, whether book, movie, or experience.  One is trying to boil down a very complex subject into a summary that can be evocative to someone who is familiar to the work or quickly enough sketch the work without restating it – necessarily losing the richness of the work.  The second is that I can only use one nugget or maybe two from the vast array of psychoanalytic insights that are available – and it is not like these nuggets are sitting on a shelf and I pull them down in some kind of organized fashion – there are a variety of analytic perspectives that seem relevant to most of the works, and I choose to write from the one(s) that seems most compelling at the moment.
This parallels the dilemma of describing a particular person – for instance in a diagnostic report – and a psychotherapy.  This morning I was at a professional meeting and was discussing the work of a research group that I belong to.  The research group listens to tape recorded analyses and rates both the patient – how well he or she is doing at the beginning of the treatment and then at the end – and the process of the treatment – what are the therapist and client doing across the course of the treatment?  This process, intended to allow us to quantify what it is that we do in analysis, necessarily boils down the richness of the interaction into values on various scales.  At its worse, “My mother screamed at me as a child,” becomes a value of 3 on a scale from 0 to 4 on “Patient takes a developmental perspective in the hour.”  It also becomes a value of 9 (N/A) on the scale measuring the use of dreams in the hour.

The presentation this morning involved assessing the process of a particular psychotherapy from many, many different perspectives.  The process was evaluated from the perspective of what kinds of psychoanalytic techniques were used by the analyst, from the perspective of the warmth of the analyst, from the perspective of the defensiveness of the patient, from the perspective of the accuracy of the analyst’s interpretation, etc., etc.  What I found to be intriguing is that each of these perspectives was telling a similar tale: that in the analysis the analyst and patient worked well together from the beginning, worked best in the middle of the treatment, and the treatment did not work so well in the last eight sessions of the treatment. 
The process of studying the psychoanalysis involved dividing the psychoanalytic hours up into groups – the first 8 sessions, the 8 sessions after six weeks of treatment, the 8 sessions at one year, at two years and then the last 8 sessions as five separate groups.  Each of these groups of hours was further divided into portions of hours.  Researchers listened to each hour and rated them from a variety of perspectives, rating the hour on a number of different scales each of which was based on a particular theory about what was curative in analysis.  Each of the sets of scales told roughly the same story.   The analyst offered better interventions from the perspective of EACH theory in the fourth and fifth group of sessions, and the patient responded best during that segment of the treatment.

 Now, if the research had been from any one of the various perspectives, the conclusion would have been: THIS PARTICULAR THEORY IS SUPPORTED.  Having multiple perspectives complicates, clouds, or perhaps clarifies just how complex psychotherapy – and I think human interactions in general – are.  In the words of Alice’s Queen of Hearts, who has been quoted before in psychotherapy research, “All are winners and all should receive prizes!”  One way of thinking of this is that intervening effectively on one level or from one perspective – in this case, from the perspective of the analyst’s, that he was helping the patient understand what is taking place between himself and the analysand – helps the patient and therapist work well together on other levels – in this case working through the conflicts that the patient feels, and helping the patient to resolve core conflicts in relationships outside the therapy.  Furthermore, being good at intervening in one way, in this case by again understanding what is taking place between the analyst and the therapist, is also related to changes in other dimensions of the functioning of the analyst – he or she becomes more authentic in his or her interactions, he or she becomes more emotionally immediate, and he or she more closely follows, on a moment to moment basis, what the patient is saying. 
Engagement in psychoanalysis, on the part of both the analyst and patient, is then a complicated process that involves many aspects of the self and many technical and theoretical perspectives that come together in the hour, but that are separated out in both our theoretical perspectives and also in our research.  In fact, in a debate later in the day about why science does not have a bigger impact on psychoanalysis than it does, the process of research was described – one that involves finding very simple variables that can be isolated and compared so that a causal relationship between them can be established.  I think in the same way, theoretical writing about psychoanalysis requires a certain consistency – and therefore a certain simplicity – that clinical work – the engagement of the analyst and the analysand can neither afford nor be confined by.  And yet we need guidance as we work.  And so we move back and forth between the richness of all that is going on in the moment of a therapeutic interaction, and what we can make of it, whether theoretically, empirically, or just in terms of a thought that we can have at this moment, and though other thoughts are trying to crowd in, we only have room to entertain this particular thought and we need, for a moment, to ignore the others.

Also that day, I went to a discussion of a case – a case with an impasse in it.  What was interesting about the conversation about the case is that two seemingly mutually exclusive threads emerged.  One was the breadth of reactions that the members of the group had to the case material that was presented.  Each analyst in the room that spoke, and there were about twenty of them, had a unique perspective on the case.  At the same time, there was a shared view of the case, and each of these disparate observations contributed to an overarching view that partook of each of the different perspectives, and that seemed to pull them together into a narrative that each of these disparate views both contributed to and that reflected some aspect of it.
One of the things that happens in an impasse is that both the analyst’s and the analysand’s ability to think creatively, abstractly and associatively – wondering about the richness of what is taking place – the many things that are in fact occurring – collapses.  And, instead, the analyst and the analysand have a difference – one that can only be resolved by this action or that action and that is what HAS to take place.  The role of theory – and ideally the role of research – in psychoanalysis, is to help us work with our patients who come to us in part because of the points in their lives where they cannot think of another way to solve a problem – another way to conceptualize some particular moment.  What we offer are both additional ways to think (which research and theory help us with) but also that being open to other ways of thinking is not only scary, but enlivening and useful. 

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