Thursday, January 22, 2015

Research and Treatment Outcome: The Reluctant Psychoanalyst Continues to Report from the Convention

Psychoanalysis has a long and uneasy relationship with traditional empirical research.  Freud was quite concerned that researchers would not appreciate that the unconscious cannot be observed directly and he privileged the analytic hour as the one and only position from which we can learn about the unconscious and, indeed, the functioning of the human mind.  Taking this position hamstrung psychoanalysis.  It interfered with it joining the mainstream of scientific development that revolutionized so many fields during the twentieth century.  I suppose it is a testament to the psychoanalytic situation and to Freud’s genius that he developed something from it that still has some relevance now, more than one hundred years later.  But we are woefully behind our peers who work from other disciplines, many of which were founded within an empirical tradition, of using research techniques to both a).  Understand how well our patients “objectively” benefit from our work together and b). Understand what is taking place between ourselves and our patients.

This year, a German researcher, Marianne Leuzinger-bohleber, presented the results of research that she has done with others over the course of the past decade or so.  She is working in a country where insurance is still paying for psychoanalysis – and where the insurance companies are, like those here, asking whether longer term more intensive treatment is worth it.  Some interesting results that mollified the insurance companies – who are concerned not just with their own expenditures on treatment but on the productivity of the workforce – including noting that those with treatment had fewer sick days after the treatment than the population as a whole – and that this discrepancy increased across time – so that they had many fewer sick days six years out of treatment than they did when ending treatment and that they were bucking the trend of the comparison population which had an increasing number of sick days as time passed.  They also noted that, when compared with medications and with shorter term treatments, psychoanalysis led to fewer relapses and, as with the result above, increasing measures of health across time.

I should note that in another session, the folks who study infant's attachment to their parents were discussing their speculations about treatment.  They have shown that poor attachment style in infants is related to difficulties as an adult.  They have also shown that poor attachment styles of parents predict difficulties in the attachment of kids.  Finally they have shown that attachment styles of adults improve as a result of therapy.  The step that is left to demonstrate – the study hasn’t been done, but it will be - is that therapy can interrupt the pattern of poor attachment – so that those who were poorly attached who go through a treatment that improves their attachment style will parent children who are less likely to be poorly attached.  Wouldn’t that both make sense and be neat?

So the question gets asked, what is it that causes these changes?  Why does psychoanalysis foster improved functioning?  Psychoanalysts have long written about this subject.  They have posited many factors.  The early analysts suggested that interpretation – particularly what were called mutative interpretations – were what caused the changes.  In essence, they proposed that increased insight caused the changes that we see in treatment.  More recent analysts have argued that what changes is the quality of the relating that the analysand does, and that this is the result of engaging in a deeply satisfying relationship with the analyst.  (This, by the way, has been a tough sell to the old school psychoanalysts who see a relationship cure as temporary and only lasting as long as the therapeutic relationship – but the relational group has demonstrated that something about the relationship with the therapist sticks).  Yet a third group has proposed that the process of freely associating frees the mind up and the patient can approach difficulties with more creative enthusiasm and solve problems with greater ingenuity and verve.

Leuzinger-bohleber and her group did an interesting thing – they measured all three of these qualities before and after treatment, plotted them in a three dimensional space – and looked at how they changed from before treatment to the conclusion of treatment.  The graph, which had empty spheres for the before data points and solid for those after, looked like two clouds – one dense and compact, centered around poor insight, poor relationships, and little creativity at the beginning of treatment and a much bigger, but also more divergent cloud up, to the right and in back of the beginning of treatment that were the bubbles post treatment.  Some people improved on one dimension, some on two, and some on all three.  A few did not improve, but the majority did (enough for the insurance guys to be impressed), but the intriguing thing is that improvements look different in different people.  Overall there is a shift in the cloud, but on an individual level, some people had much more insight, though their relationships didn’t change much; others were much more creative, but not necessarily significantly more insightful – a myriad of configurations that described the arcs of particular treatments. 

One size does not fit all.  What patients walk away with differs.  When we measure symptoms, there is a reduction – but this may be occurring for different reasons with different people.  One of us may feel less stuck because we finally get how it is that we have ended up at this particular point in our lives.  We may not change things much, but we may derive comfort from knowing – coming to peace as it were – with who we are and how we got here.  Others may figure out a way out of a complicated and convoluted trap – moving away from situations that previously baffled them – and these situations may be external, internal, or some combination.  Yet others may feel more connected with others – perhaps as a result of coming to trust a particular person they may be more willing to risk trusting others in the world.  For most of the people in the study, there was at least some of each of these elements – but there may have been a strong suit among the three – though many seemed to move significantly positively on all three dimensions.

So then the question becomes, what happens that these changes are coming about.  Traditionally the theorizing and the research have focused on what the therapist does, what the patient’s characteristics are, or on the quality of the relationship between the therapist and the patient.  In the discussion within this group, an idea emerged that we may have overly focused on the activity of the therapist.  We, as analysts, are constantly thinking about our technique.  Another group in the discussion presented data that suggested that even when an analysis is going poorly, the analyst may still be doing “good” technique as we measure if formally.  What might matter most – and what might be most mysterious and difficult to assess and to effect is what is going on in the patient.  What is the patient doing in the treatment?  Wouldn’t this be the best predictor of a good outcome?  And what does analysis allow?  It allows space for the patient to work – a place for the patient, in the presence of a reasonable other, to explore.  Perhaps our emphasis on what we are doing is partly a means of helping us stay within bounds – to help prevent us from interfering with a healing process that the patient “knows” how to engage in.

This series of thoughts, which draws on the conversation in the research group but also begins to move away from it, mirrors parts of the conversation with the attachment folks.  The attachment folks were commenting on how much care it took to provide a solid attachment foundation.  They were noting that it was kind of miraculous that the human species is doing as well as it is.  In fact, they noted, if positive attachments in infants to their caregivers were necessary to the survival of the species, we would be extinct.  So how do we pull ourselves up by our bootstraps?  Despite not having gotten all that we need, we are frequently able to provide for other’s needs.  Or, more precisely, others are able to make use of our well-intentioned but not perfect efforts to do what they need to do – to get better.  Yes, the better able to be attuned, to be present, to sense what is just outside of awareness and to offer that at a moment when it can expand awareness we are able to do and be the more we can help this process along, but we might want to focus some of our efforts on the healing desires and abilities of the people with whom we work – to think, as Jonathan Lear alluded to in his plenary address, which I have written about in another blog, not just about what is wrong with our patients and their situation, but to help recognize what might be right, and what might help them make it righter.

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Wednesday, January 21, 2015

A Delicate Balance and Jonathan Lear – The Reluctant Psychoanalyst goes to the Annual Psychoanalytic Convention

The American Psychoanalytic Association holds its annual convention every year in New York City.  This is an opportunity to hear and talk with the finest analysts in America, and many others from Europe, Asia, South America and Africa.  It is also a chance to spend some time with the reluctant wife in the Big Apple.  This year we took a bit of a busman’s holiday and saw Edward Albee’s play “A Delicate Balance” with Glenn Close, John Lithgow, Lindsay Duncan, Bob Balaban, Clare Higgins, and Martha Plimpton, a tight play about three days in the life of a family that is balanced on the edge of madness with the mother, played by Glenn Close, characterizing herself as the fulcrum.  It is a play that was first performed in 1966 – a moment that was itself a fulcrum.  On the one side was a way of doing things the way they had been done – well, not for all that long, but seemingly forever.  It was a kind of Golden Age of the ruling class of the United States.  We had won the war, we were doing things our way and things were going swimmingly – especially economically.  But, as this play and many other works of art, the anti-war movement, and the coming wave of the summer of love and a culture of youth that didn’t trust anyone over 30 was about to expose, there was foment underneath the calm surface.

The Playbill proposed that this play took place “now”, but it so apparently did not.  Set in a neighborhood not unlike the one I live in, the meals were prepared by an unseen “them” – presumably the help who, in those days but certainly not in mine, likely lived on the third floor and did the cooking and cleaning.  Also the brutality of the interactions between the players – brutal as it was – was quite tame by today’s standards.  There was a lot thicker veneer of civilization than in more contemporary plays about dysfunctional families – plays like August: Osage County.  And this, I think, put a greater pressure on the actors to portray the madness boiling just below the surface – the outrageousness of their experience had to be hinted at rather than being paraded across the stage in all its glory – and, not to disparage the great actors that were on the stage, I felt that they failed to create the kind of tragic tension that a play of this sort calls for.

John Lithgow, in particular, played a man who has a hard time saying no.  He likes to have people near him, but he doesn’t really want to be intimately engaged with them.  Perhaps because he fears that they will exploit him, or perhaps because he doesn’t like them, he just likes them to be at arm’s distance.  Well, when you are living in a house with a demanding, prima donna wife and her sister, a mean drunk (who functions as the Greek chorus in this play) and your daughter is about to come home in preparation for leaving husband number four, but before she gets there the neighbors, your best friends in the world, bland people, actually,  decide to come stay with you because they are frightened in their home – for no particular reason – there is a lot of reason to be uncomfortable.  But Mr. Lithgow remains remarkably serene through all of this – as if his ability to ward off the presence of others were so thick that he could take it all in stride – until he can’t, and then he seems to be bemused before becoming distracted and somewhat anxious.  But when the head gaskets blow – there isn’t enough grit – there isn’t enough discomfort under the bland exterior – to make that explosion believable.  We just aren’t as horrified as he is – or should be – at what flies to the surface.

And maybe this is a play, then, about our current state.  We are so assaulted by the stuff of life – whether it is the vaginal crème commercial for post-menopausal women we watched together as a family tonight, or the crude humor – with absolutely no innuendo – that the reluctant step-daughter takes in as her constant fare these days from stand-up comics on comedy central, or the horror of terrorism in its current iteration that we need to confront and deal with and don’t because we are, after all, comfortable.  We have built a huge insulating wall around ourselves that allows us to handle the assaults around us and to focus on what sporting exploit has occurred this week – to marvel at the latest sports score (reluctant son) or newest fashion or nail polish exploit (the other reluctant stepdaughter’s current obsession) and just to stay focused on the details of our lives while the world churns around us.

Jonathan Lear – a philosopher and psychoanalyst – gave the plenary address at the convention.  He proposed that Freud’s theory of mind is strongly and deeply rooted in the philosophy of Plato and Aristotle.  He noted that Plutarch described a Greek who offered a “talking cure”, had some success with it, and then closed up shop to become an orator.  Lear proposed that what Freud came up with – the impossible command to freely associate – was at the center of finally exposing the tensions that the Greeks first sensed.  But then he took a bit of a left turn.  He proposed that we analysts have spent too much time focusing on the bile that lies underneath the surface; that we should instead be using our craft to help our patients live lives of engagement – enjoying their relationships with family members and their engagement in the tasks of living.

Lear went on to propose a distinction between moral functioning and ethical functioning – moral functioning, he proposed, involves invoking rules of law.  Ethical functioning, by contrast, is something that emerges spontaneously out of connected living.  It is based on a sense of empathy with others and having a sense of shared goals and interests and working together to achieve them.  In A Delicate Balance, each of the characters seemed focused on their own needs.  Despite her protest that she was the selfless one who put her husband’s wishes into action, Glenn Close’s character was as self- interested as the others – pretending to be a loving wife and mother, but actually furious at the ways tending to other’s needs interfered with her ability to meet her own needs and, on another level, how everyone else’s self-indulgence sucked up oxygen that would, in a perfect world, fuel her flame so that it would shine all the brighter.

Lithgow’s character, then, contains our hope – the hope that he, who is comfortable, can tolerate  - can connect with others.  Close’s character hints that he can’t.  That he doesn’t welcome his daughter home or talk to the daughter's husbands before she divorces them.  She ridicules him, but she ridicules everyone and we have the hope that he can be more.  And here the analysts have another comment.  A discussion group with the attachment specialists indicates that at the Anna Freud Institute in London, the analysts are required, before they can start classes, to spend a year observing infants.  Why?  Partially to have a better sense of where we come from – but partially because observing infants requires us to confront raw emotions – pain, frustration, and also joy – and, because we are sympathetic humans, to experience those feelings ourselves.  This, the theory goes, better prepares us to be analysts – to be comfortable being present to the powerful feelings of our patients and the powerful feelings that are stirred in ourselves by them.

Well, John Lithgow’s character has never spent time with infants.  He is not connected with others, but pretends to be – and, I think – though I didn’t feel it from the stage – he deeply wants to be connected – to be comfortable not just at a distance, but actually while in contact with others, but he can’t tolerate it.  The best he can do is to be comfortable from a distance and, in the climax moment, he realizes and articulates this – and, realizing his limitations, he perhaps for the first time, feels deeply and powerfully – but what he feels so powerfully is not his capacities, but his limitations - and we should be feeling them with him.  That’s what we go to the theater for.  But this moment was not delivered, at least in my gut – which felt apart from, rather than within – observing rather than experiencing – seeing a shallow character – but just the shallow character, not the depth of the deeply caring man beneath it – a character careening from thought to thought – but not one exploring the taught line between what we believe ourselves to be and who we also are – the experience that the tool of free association allows us, at its best, to explore – and so it felt, not like theater, but like television – something to watch and be entertained by, but not something that deeply moves us.  While his character has never observed infants – or cared for them – we count on Lithgow to have done that.  And for this play, for this part, on this night, he did not access that part of himself – or more precisely, that part of me.

Morally, then, this play delivered.  I was present – in a very privileged way – to the work of six actors – stars – people that I have seen on the big screen and the small.  And they delivered.  They were working.  They brought a play to life.  I got my money’s worth.  But there was an ethical failure.  These people did not deliver on what I really wanted – a sense of connection – not with them as stars – as people to see, to have seen, to be able to brag about seeing – but people who connected with me not as a star but as a person – people who made me feel in my gut what I know to be there – and count on them to help me access – something about my true self – including its limitations, and the terrible pain that I don’t connect with others in the ways that I would like to.  This awful, horrible realization – one that I am all too comfortable not feeling so much of the time – is what I would have had us teeter towards – it is what would have brought us together, not as star and admirer, but as fellow humans sharing what it is like to be human. 

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