The psychoanalytic instrument
Researching the subjective
It was impossible to treat a patient without learning something new; it was impossible to gain fresh insight without perceiving its beneficent results (Freud 1926a, p. 256).
Thank you for this opportunity to say a little about my book. I will only just make a start on describing its issues. The book came from my concern that we as analysts do not all see the same things in our patients; and that difference comes from analysts, and not just from differences in patients.
Grazie per questa opportunità di dire qualcosa sul mio libro. Inizierò giusto descrivendo come è stato pubblicato. Il libro proviene da una mia preoccupazione che noi come analisti non vediamo tutti le stesse cose nei nostri pazienti; e che la differenza nasce dagli analisti, non solo dalle differenze nei pazienti.
In 1994, David Tuckett, then the Editor of the International Journal of Psychoanalysis, published a symposium of papers that he had collected by asking some 31 analysts to write an answer to the question: What is a psychoanalytic fact? He had something like 31 different answers ! Each answer was based on that analyst’s own theories. In his introduction Tuckett conveyed his sense of shock, saying,
After seventy-five years [of the Journal] it is time not only to review our methodology for assessing our truths, but also to develop approaches that will make it possible to be open to new ideas while also being able to evaluate their usefulness by reasoned argument. The alternative is the Tower of Babel (Tuckett 1994, 865).
I think he is right. We need to consider what sort of reasoned arguments we use when selecting our material for interpretation (or for research), and whether we have good enough reasoning for our work.
Psychoanalysts have the most rigorous professional setting, and yet we are the most unreliable observers of what happens in our setting. In this paper. I can only begin to suggest what a ‘reasoned argument’ could be like, and I shall try to convey a more rigorous approach that might lead us away from the Tower of Babel.
Most other scientists would say that our reasoned arguments are dubious because of our specific material – it is subjective. The fields of ordinary, objective science tend to have different methodologies, based on different methods of observations. You cannot use the same method for Darwin’s biological observations as is used for atomic physics. When Galileo developed the instrument, now called a telescope, he observed the moons of Jupiter, never seen before. These different kinds of equipment produce very different forms of observation. And ultimately different explanatory hypotheses for encompassing the observations.
So, a field of study needs its own reasoned argument which it has to develop for itself. If Galileo’s telescope was specific for making observations of the planets, what is the equivalent instrument for psychoanalytic observation of subjectivity?
Because we study subjective experience, our instrument has to be our own subjectivity (see Skogstad 2004). Our observations yield unmeasurable data. They are, as Robert Caper (1988) said, ‘immaterial facts’. So, our data are personal experiences, and, significantly, they have to be our own experiences. As Rosenfeld remarked,
A prerequisite of psychoanalytic treatment is that it is necessary to make enough contact with the patient’s feelings and thoughts to feel and experience oneself what is going on in the patient’ (Rosenfeld 1987, p. 12).
A patient actually communicates his feelings to the analyst, who must be ‘a delicate receiving apparatus’ – this idea came from Freud’s idea of the unconscious of the analyst receiving that of the patient. It is about our experience as well as the patient’s. Of course, how else could we observe someone’s subjectivity.
It may be that psychoanalysis is not a science in the way physics or chemistry is. Our data is subjective, and not objective, not measurable in time and space. So, should we dismiss psychoanalysis as hopelessly unreliable, and its knowledge cannot compare with the knowledge that the hard sciences produce.
At the same time this is the nature of our particular knowledge. Glen Gabbard encouraged us in this way,
In an era of quick-fix managed care approaches and rampant biological reductionism, we can derive a great deal of gratification from the fact that we still see value in the unique subjectivity of the person who comes to us for help (Gabbard 2000, p. 713-714).
This is a declaration of faith in the uniqueness of psychoanalysis, and the importance of studying subjectivity.
Moreover, almost all the knowledge that we use in our work came originally from the clinical work, so if we accept that our subjective instrument is too unreliable, then we have a serious problem; we would discard all our theories as unreliable. And then we would have nothing to rely on when with patients. There is a lot at stake.
Our unique focus is also our biggest problem.
Is there a way in which we could overcome this problem, so our specific claims may be more reliable? Could we find a parallel method to science for supporting our facts, even though they are unmeasurable, subjective ones? This was the purpose of my book, Research on the Couch: Single Case Studies, Subjectivity, and Psychoanalytic Knowledge. I wanted to explore ways of doing research and reaching conclusions that can lead to greater confidence. I realised there were many epistemological issues we must address.
Being trapped by our unique work being very suspect, has led to a despair about our methods, and we turn to others, those of experimental psychology, neuroscience, and social science fieldwork, and so on.These can be extremely useful, and supportive, but to make these methods central, wipes away our form of knowledge that requires our unique methods of observation.
Here I want to discuss one suspicion of our subjective instrument. This issue is that it leads to a circular argument. We each have our own favourite theories, and those theories are a part of our subjectivity. They are what we use when making our observations. So, we use our theories to select the material we find significant. But then we use that material as the evidence for the theories we have just used for the selection. We form a logical circle – we use our theory to choose the data, which are then used to support the theory we introduced to choose the data.
If we select material in this way to confirm our theories we will tend always to get the result we want. So, we need a method of finding material that will not just confirm a theory in all instances. We need a method which can discriminate when a theory is used correctly and when it is not. And that means thinking hard about the selection of the material we use.
Response to interpretation
Right from the beginning of psychoanalysis, a method emerged for deciding what theory may be right or wrong. In the case of Anna O, Breuer emphasised the immediate reduction of a symptom following a hypnotic abreaction. A significant change occurred right after the intervention. Freud continued this method of assessing the response to the interpretation, and it has become a classic method of checking the work of interpreting.
We do have an extremely rigorous setting, as rigorous as a scientist’s laboratory; and we do something that is like scientists do in their laboratories. They conduct an experiment by setting up a situation, then they make an intervention of some kind, and then observe the result. But this is what Breuer did too. We have a standard situation in our office, we make an intervention – an interpretation – and we observe the response to the interpretation. This process in a session is the same as a scientist’s experiment in the laboratory. So, we could develop a reasoned argument on the basis of a response to an interpretation – but, it has to allow us to say when the interpretation is wrong, as well as when it is right.
A fundamental principle expressed by a British analyst many years ago is,
…an interpretation embodying a clinical hypothesis is corroborated if the response to it can be interpreted by means of the same clinical hypothesis (Wisdom 1967, p. 46).
This is a very specific criterion, it seems to me; we need a similar piece of data after the interpretation which could be matched with the piece of data that gave rise to the interpretation. Both pieces of data, before and after, need to be compared against the same criterion. I can illustrate from a simple example from the literature. It involved a piece of Oedipal theory which gave rise to the interpretation. The analyst says, that the patient typically sustained a very submissive relationship with the analyst during the sessions. But, also the analyst knew that
The patient’s father had died when the patient was in a rebellious phase in childhood leaving him with an uncomfortable sense of responsibility arising from his rebelliousness and the coincident death (Ezriel 1956, **).
So the hypothesis is that the patient remained submissive in order to avoid some outbreak of his childhood phantasies of killing his father. These had been made real in the past; and the patient had to prevent them being realised in the present with the analyst. Then the analyst noticed,
… a patient started a session by unconsciously giving vent to hostile feelings towards me in the form of an attack upon the Government.
The hypothesis is that the murderous Oedipal phantasies were active during the session, in the transference; but unconsciously displaced onto the British Government. The analyst made that interpretation. He found that something changed in the patient,
After my interpretation he criticised the Clinic. The object of his attack had thus moved nearer my consulting room, from Whitehall to the Tavistock Clinic (Ezriel 1951, p. 33).
So the change is that the transference remained the same – an attack on authority. But now it was nearer to an attack on the analyst himself. Therefore we are judging both the original hypothesis – the apparent submissiveness to the analyst – and the material after the interpretation – the attacks becoming closer to the analyst, by the same criterion. That criterion is an unconscious Oedipal rivalry lying hidden in the unconscious transference relationship. It is the same Oedipal rivalry, but a change in the expression of it. It appears that the patient can now risk a more direct attack. The unconscious material – the death of the father – has come closer to a conscious reality of the relationship in the analysis.
The incorrect interpretation
Now, about the importance of finding a response which does not confirm the interpretation. I will try to demonstrate this with some clinical material.
This is a 45 year old professional man who came for a second analysis because of feelings of depression, and an awareness that he did not make adequate decisions in his life, including for instance, resorting alarmingly to cocaine. He was also diabetic, and his lifestyle led to irregularity in taking his insulin, and from time to time he had hypoglycaemic spells when he did not eat regularly. He told me this often happened unexpectedly, and I wondered sometimes what I would do if it happened in a session. In addition, he frequently went to sleep in his sessions, with loud snoring and, more alarmingly, sleep apnoea. This also worried me. I was often beset by the sense that I did not have the resources to help him.
In one mid-week session, he told me of a meeting he had with a friend with whom he was working on a project. The friend did very little towards the project, rarely contributed what he had agreed to do, and was in fact a very unreliable man. However my patient was extraordinarily fond of and loyal to this friend. On this occasion I found myself thinking what an unreliable patient I had, who would literally go to sleep on the project I was conducting with him. I felt a mixture of irritation that I was struggling so much to make headway with his analysis.
Now, there are certain things about the data prior to interpretation. I was impressed by two things
• his description of an unreliable man with whom the patient was trying to develop a project, and
• I often felt my patient unreliable and not contributing sufficiently to the analytic project because of his sleeping.
Someone, it seemed, had an unreliable partner in a project. That story was told twice, in two modes; first in the material, his associations; and second in my countertransference feelings. I think this convergence of the associations with the countertransference is important. They point to something similar, the same unreliable partner.
It seems to me this points to an important principle in both clinical work and in research. The countertransference needs to be checked against the actual associations in the session. So in the example I gave, there was a feeling in my countertransference of some irritation at the way the patient joined me in the work of the analysis, and at the same time if I checked that against the patient’s material, he was also talking of working with an unreliable partner on a project. So here in my notes at the time,
I interpreted the transference along these lines, comparing how we both struggled to keep a project going, him with his friend, and I with him.
Now what was the response?
Checking the response
If we look at the response to tell us if the interpretation was accurate, what will we expect? First I will give the response in this instance, and then discuss it.
Characteristically he was silent, and then he started snoring until he woke with his apnoea and a nasty gasping intake of breathe. He remembered what he had been talking about, and the interpretation; and he courteously acknowledged the link I had made. I felt he was reassuring me, even patronising me a little. He continued to tell me how he had worked with his friend all evening and well into the night, whilst, interestingly, the friend had gone off to bed. He explained how the friend needed a lot of encouragement and reassurance, and his own role was to be very tolerant whilst doing most of the work.
Well, here is a situation in which the response was to continue with exactly the same kind of material, and transference, after the interpretation, as before. He went to sleep in his characteristic way, and then politely responded when he woke up. There was no change, so I had to accept that my interpretation was not correct.
Following the example given earlier of the man who attacked the Clinic instead of the Government, we can think what a confirming change might have been. In the countertransference I would have expected to feel less irritable. And in the material, I would have expected less complaints about his unreliable friend, perhaps with their work more shared between them.
Though my countertransference did change somewhat – from feeling him unreliable, to feeling his patronising reassurance – this was not confirmed by checking with the material, and did not support the expectation (or prediction).
Whilst I was thinking about his reassuring me, he told me how his friend needed so much reassurance and encouragement, and then I could see another double story. First in the countertransference, I felt I was being encouraged, and second I heard the same story of encouraging his friend, in his actual material. So continuing with my notes,
Then I interpreted that he was trying to tell me that he felt he had to be very tolerant of my limited abilities to contribute to the analysis in the way he had expected and needed. Yet I said he felt very loyal to keeping things going.
The question now is what was his response. In fact it was quite different,
This time he did not go to sleep. He changed the subject and said, he had been very interested in two insects flying in the room where he had been working, and he had been trying to estimate the difference in the buzz of each which gave him some thoughts about the project he was working on – it was a musical project. I was heartened by his change of topic as it made me think that something was moving on.
My countertransference had changed this time, I felt heartened that we were getting somewhere. Then, in the actual material, there was a picture of two insects buzzing together. There was again a double story – some kind of buzzing together. I felt heartened, and the two insects represents some harmonious working together. Therefore I would say this response does confirm the prediction.
These are not deep interpretations, but I think that the response to each was strikingly different. After one, there was no change, but after the second there was a change, significantly in line with the one expected.
So with the aid of this illustration, I have tried to show how we can set up a situation that either confirms or disconfirms our interpretations.
In this rather condensed paper, I have asked you to face the fact that there are serious problems in the study of subjective experience, the field of study of psychoanalysis. We need to be aware of these various problems, and here I have described how the use of our own subjectivity may be protected against undue distortions, arising from the subjective wishes of the analyst himself in wanting to support his own theories.
In particular, I claim we must pay attention to two perspectives at once, the actual material and the countertransference experience of the relationship the analyst has with his patient. Two stories that coincide with each other and which show a development from the two stories before the interpretation point to an accurate interpretation. Any other change, is not a confirmation – it would be a kind of false positive.
I have indicated one element of how we need to be more rigorous in the way we select our data for our interpretations, and thus any research we may do. In this way we may begin to restore our confidence in the specific method that has been used to develop all the theories that we need, and we use in psychoanalysis today.