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8 Comments on “A Neglected Problem About Clinical Evidence By Dale Boesky”
Boesky argues that “Psychoanalytic disagreements are famously heated, polarized, and prolonged.” (p. 835). He believes that these controversies are “often the reflection of a shared agreement by the participants to engage in debate at an abstract level far removed from the clinical context in which the disagreement first arose” (p. 835). He suggests that the “inference of latent meaning from the patient’s associations is the central task of analyst and patient on the path to therapeutic change” (p. 835). He argues that psychoanalysts have never developed consensually accepted guidelines (“contextualizing criteria”) for deriving inferences from these associations (pp. 835-836).
Boesky notes that with one school or across schools, anything the patient says or does can potentially mean almost anything. He argues that the reason for this chaotic diversity is our failure to develop consensual guidelines that make explicit how analysts get from the patient’s associations to a first level clinical inference about those associations. Boesky’s singular contribution is including what the patient said of did (or didn’t say or do) before (not just after) the interpretation as a locus of possible guidelines.
It is at this level that we have the best chance of reconstructing and comparing among ourselves the contextualizing criteria used to infer meaning during individual sessions. Boesky believes that we need to extend our traditional way of assessing the usefulness of an interpretation examining the patient’s associations immediately following the interpretation for a deepening of the material to examining the analyst’s inferences in advance of the interpretation. Boesky adds that despite the “daunting complexity” of the material before the analyst’s inference, “it is nonetheless quite possible to state clearly and exactly what the patient has said that is the basis for the inference” (p. 839). He thinks that we have greater assurance about the validity of an interpretation if there is a dynamic congruence between the associations immediately before and after the interpretation. What would the guidelines for examining the associations before an interpretation look like?
Boesky, citing Arlow’s 1979 paper on interpretation as a rare published example of such guidelines, mentions: the context of the specific material e.g., that contiguity suggests dynamic relevance; the configuration of the material the form and sequence in which associations appear; repetition and convergence of certain themes; repetition of similarities or opposites, and so on (Boesky, p. 840). The analyst emphasizing Arlow’s guidelines would arrive at different inferences than an analyst who privileges information about the relationship with the patient or the moment-to-moment shifts of lived-out internal object relations within a session. Still, discussion of these guidelines would allow “the development of a methodology for a coherent comparative psychoanalysis” (p. 836). In the absence of adequate guidelines, we tend to kick the argument to higher levels of abstraction where we perhaps even champion our own analytic titans.
In this paper, Boeskey uses Casement’s case report of a clinical crisis with a patient who suddenly wanted him to hold her hand together with a series of polemical discussions the report inspired to demonstrate the need to refine a methodology of contextualization to clarify inferential assumptions in our clinical work. He introduces the term ‘contextual horizon’ to facilitate understanding how the psychoanalyst makes inferences from the patient’s associations. After examining Casement’s case report and all of the discussions generated from it, Boesky defines several contextual organizers for interpretation as a bridging tool that links theory, context, and technique.
The paper is a tour de force and would advance our conversation about evaluating psychoanalytic interventions.
I read with interest Sid Phillips admiring evaluation of Dale Boesky’s paper, “Psychoanalytic Controversies Contextualized”, particularly because he identified Boesky’s approach as a possible or probable pathway for a unified understanding of what is basically psychoanalytic. My sense is that Phillips subjectivity is so similar to Boesky’s that he is inclined to find a unifying theme in this paper while others, including myself, find this not to be the case. Boesky’s elevation of following the free associations to discover the latent meaning in the patient’s words is precisely an approach to analysis that has engendered several major developments in how analysis is conducted by those analysts who have found this approach too limited to apply with a broad range of patients who seek treatment in the contemporary world. Relational, self psychological and intersubjective schools have all developed as a response to the clinical limitation imposed by a view of psychoanalysis as a search for latent meanings in the free associations of patients. The importance of the relationship with the analyst, the impact of empathic failures on the analyst’s part, and the use of the analyst’s intuitive sensibility in understanding the affectively significant aspects of the patient’s experience in analysis and in life have all contributed to a different approach to conducting an analysis.
Boesky’s attempt in his paper to establish a methodologically sound approach to interpretative differences can also be seen as a reactive attempt to deny the significance of changes in psychoanalytic theory and technique that have emerged from analysts who have found his basic approach unsatisfactory for their therapeutic aims and goals with actual patients. A search for associative proof of an interpretation by examining the before and after associations appears to those who have developed other approaches to be both mechanistic and reductionistic. Certainly this isn’t the pathway to establishing what is true or basic about either the patient or psychoanalysis. Boesky’s aim appears to rest upon the historical legacy of psychoanalysis as an intellectual study of the mind; an approach that in my view can be seen as having limited the vitality of psychoanalysis and prevented its evolution into a two person approach that includes the subjectivity of both analyst and patient in an interactive field.
It would be easy to simply read Phillips idealizing view of Boesky’s paper and let it rest there. However, the underlying hostility in Boesky’s paper, with its insistence on a rigid and fixed definition of what constitutes the goal of psychoanalysis that can hardly be shared by many psychoanalysts if they managed to notice it, requires that there be some response that challenges the proposal of such a solution to the evolving differences between newer approaches and the one favored by Boesky. The new may not always be better, that is a matter of clinical testing over time. It is, however, important to challenge suppressive attempts to undercut clinical changes in analysis by narrowly defining psychoanalysis as resting upon the approach described in this paper.
While I understand Sid Phillips’ reading of Dale Boesky’s paper as a plea for bringing the debate between competing schools of psychoanalysis to the level of clinical inference rather than keeping it at a level of conceptual abstraction, I continue to believe that Boesky’s paper has a less obvious but nevertheless present attempt to oppose the emergence of new and challenging approaches to analysis by insisting that they meet a standard set by elevating the content of supposedly free associations as the measure of truth or accuracy of any interpretation.
My central point is that Sid has accepted the hypothesis that Boesky’s approach takes us into a realm of clinical proof or at least validation of one interpretation over another. In a two person approach to the content and context of psychoanalysis such an assertion makes little or no sense. The subjectivity of the analyst is of course understood to effect both the content of the patient’s associations and the interpretation that the analyst makes in conjunction with the patient. Any attempt to judge what another analyst considering the same material would make cannot be considered as more objective or more true. So, what then is the purpose of Boesky’s and Phillips’ return to the raw data of the session using the ordering of the patient’s associations both before and after the interpretation as the test of whether the analyst’s subjectivity leads to a correct interpretation? I have no doubt that how one sees this attempt to bring the level of debate to the level of examining clinical inference can be complex. However, it appears to me to mislead the reader into a belief that such an approach can help the field resolve issues of clinical differences between theoretical schools when, in fact, this can hardly be the case. Since subjectivity is irreducible we can never eliminate the influence of the analyst’s official and personal theories and how they perceive the material, the transference and their own countertransference.
In my years of attending APsaA and IPA conferences I have been struck by those meetings in which actual data from clinical hours have been presented to such analysts as Betty Joseph, Hannah Segal, Heinz Kohut, Ed Weinshel, analysts of clearly differing schools, where, in the end the audience would be convinced of the correctness of each of the competing schools when the reasoning of each analyst was presented. As I said in an earlier note, we need to respect the different approaches that have evolved out of dissatisfaction with classical theory and technique. That we failed to do so in the past has lead to the exclusion of whole schools of analysts as the case of the William Alanson White Institute. This in turn has produced a group of psychoanalytic writers whose ideas have begun only recently to filter back into our view but mainly through their journals and our program committee.
I’m afraid that many of our Institutes continue to teach candidates that there is some absolute truth in the “correct” interpretation. They may well continue to intimidate those who we train by increasing their fear of getting it wrong and being told that this is the case by supervisors who knowingly or unknowingly act as if they can evaluate the accuracy of a candidates interpretations to a patient.
I agree that the Boesky plan is a very intelligent one if we are testing for the effectiveness n the moment of the analyst’s comments about the patient’s words. But the question is whether aspects of the relationship other than words make the long term difference in how the patient understands and relates to the people in her or his world. For instance, does it matter if the analyst takes the time and uses the energy to see a movie othat the patient mentions? Does it matter if the office is decorated in a homey way? If there are books around? Pictures? If the analyst knows the patient’s native language? If the analyst looks dressed up? Things we may have no idea about may matter to some patients. Therapeutic action encompasses a lot more than instant reaction and I think we may not be able to encompass it in a theory that just takes account of the words. Arlene Kramer Richards
I haven’t met a psychoanalyst of any stripe who underestimates, as Henry says, “[t]he importance of the relationship with the analyst, the impact of empathic failures on the analyst’s part, and the use of the analyst’s intuitive sensibility in understanding the affectively significant aspects of the patient’s experience in analysis and in life…”
How else, but through such fundamental capacities, can any one person understand anyone else, inside the clinical hour or outside, whether in the year 1915 or 2008? The vocabulary to describe such human givens (Freud, for example, in 1913 called it “a proper rapport” with the patient) varies and shifts over time, in part because of the need to refresh language that becomes tired or confusion-laden. There will never be language adequate to capture with finality the complexity of the psychoanalytic exchange.
Henry tends to make arguments by setting up straw men. At the end of this morning’s post, for example, he speculates about how candidates are taught, making assertions about rigidity and intimidation tied to a theory; he writes, “I’m afraid that many of our Institutes continue to teach candidates that there is some absolute truth in the ‘correct’ interpretation.” I was never taught such an idea nor does it accord with my own analysis. In my experience rigidity and intimidation are more manifestations of individual personalities than of a theory one holds. Any viewpoint, including insistence on subjectivity, can be
presented generously or with bullying
I would like to express my agreement with Henry and Arlene in slightly different terms. I think interpretations need to be considered within the context of the patient-analyst relationship. In the absence of an effective therapeutic relationship, interpretation, “correct” or not, may well have little impact. As examples of the influence of the context of the analytic relationship, I suggest that a patient concerned about expressing compliance may attempt to “validate” an “incorrect” interpretation. Conversely, an angry, rebellious patient may deny the “validity” of a “correct” interpretation. I think that attempting to “validate” an interpretation independent of the context of the analytic relationship is likely to be fruitless.
Since various schools conceptualize the nature of the analytic relationship differently, they will view the context of that relationship and its influence on a particular interpretation from different points of view.
Back from vacation and reading speculation about whether it matters to patients what analysts wear, whether they take the trouble to see a movie, their emotional responses to analysands, etc. I’m just an egg here, I know, but do analysts just not ever discuss their OWN analyses? With all respect to each person’s individual experience, each one does have an experience, and not just an intellectual one, I’d hope. Is it considered pas de rigeur to admit that? If so, I’m going to be drummed out of the corps.
There are different levels in the analytic relationship and I definitely agree in considering language an important – even if not exclusive, of course- vehicle of communication and analytic development, as does Boesky. As I understand him, his emphasis on evidence does not seem to be in contradiction to non-verbal, ‘long-term’ environmental (as Arlene says), and affective levels of the analytic relationship. I hail his focus on clinical evidence because I consider it particularly important in the analytic relationship, especially with severely disturbed patients, to maintain and enhance the patient’s effort to organize new perceptions of the world, relationships and him/herself: these are essential stimuli to their mental growth. I find no other aspect of analysis so powerful in enhancing personal and analytic development as the analyst’s attunement to the patient’s orientation toward evidence. As I understand Boesky, for the analyst the point is not to focus on the latent meaning in the patient’s words, but to follow the patient’s common sense as a powerful – and still undervalued- instrument in approaching reality and mental growth. We must not forget that our difficult patients’ new perceptions are registered only if the analyst is able to stay on the more basic level of communication, as Boesky proposes, mitigating the analytic rush toward symbolism, clinical theories and metapsychology. I feel that an improvement in our ability to find the patient’s wavelength as we follow, in all their detail, his verbal communications, as Boesky proposes, is central to the development of each analysis. As Bion wrote in one of his last papers: “”Now the question is, what was the evidence that the patient was giving me, and what was the evidence that I saw for the interpretation?” In this sense I feel that Friedman’s, Arlene’s and Joe’s comments are very interesting and open up the discussion toward other dimensions, but do not basically contradict the points underlined by Boesky. I wonder whether the authoritarian spirit of psychoanalytic education is driving us to understimate the role of evidence and knowledge in analysis, and discouraging us from seeking a more attuned and empathic way to help our patients follow their own evidence – and the evidence we share during the psychoanalytic session- as one of the main roads to analytic and mental growth. And this way seems absolutely not inconsistent with other possible clinical evolutions, in which the interactive field reveals its role more explicitly.
Riccardo Lombardi, Rome
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