COMMENTARY

On empiricism: A response to McKinley and Shedler

Psychoanalysis is often omitted from research designs because of the difficulties faced in validating the treatment process

By Sibel Halfon

The role of empirical research has become a central debate in contemporary psychoanalysis. At the heart of this debate lies the question of what kind of research, if any, is suitable for the study of psychoanalysis. The current methodological and statistical approaches used in mainstream psychotherapy research confront major challenges in studying psychoanalysis. The culture of randomized, controlled clinical trials makes it very difficult to validate treatment approaches that are not brief and/or circumscribed to a standard manual. As such, psychoanalysis is by default excluded from any such research designs. Moreover, conforming to such empirical demands brings major dangers. As McKinley (2011) points out in the previous issue of this Review, embracing empiricism may lead to an artificial quantification of the psychoanalytic process that reduces the most significant elements of psychoanalysis into measurements rather than meaning.

Because of such concerns, many psychoanalysts believe that the psychoanalytic process resides in the subjective experience of the patient and the therapist and cannot be studied by objective empirical measures (Tuckett, 2000; Perron, 2002; Green, 2003). Only the case study has the means to represent these dimensions. There is no question that the case study method, as first used by Freud, has been instrumental in building the core of psychoanalytic theory on the structure and functioning of the mind, the dynamics of the analytic setting, and psychoanalytic technique. However, it too has significant limitations. The case study by its very nature covers only part of the psychoanalytic process, because it is filtered through the analyst’s subjectivity. Unless the analyst has full access to aspects of his experience that are dissociated or repressed, these aspects will inevitably influence what is being reported while escaping representation. Moreover, the only access to the patient’s conscious or unconscious experience is conveyed through the analyst’s subjectivity, and the patient’s direct voice is absent.

Bucci (2007) states that if the psychoanalytic encounter resides in the subjective experience of the participants, the data used to study it cannot be limited to the subjective experience of one participant. Moreover, if the central core of psychoanalytic therapy is about the unconscious, the data that the conscious and explicit formulation in a case study provides is quite limited. This brings up a major challenge as to how to study the subjective experience of the patient as well as the analyst, and to include what remains outside their awareness.

Given this state of affairs, neither a reliance on mainstream empirical studies, which run the danger of developing artificial methods that are unsuitable to capture the complexity of the psychoanalytic process, nor the use of case study, which skews the analytic field toward the analyst’s voice, is satisfactory. Therefore, even though a lot can be said about the tension between the more clinical culture, which relies on case studies, and the more research-oriented culture, it is clear that they both pose limitations. Luyten, Blatt, and Corveleyn (2006) suggests that perhaps the field needs to take a stance that focuses on bridging the gap between these two polarized tendencies while still preserving the integrity of the psychoanalytic process. However, the original question still remains: is it possible to create a research methodology that can preserve the meaning, interpretation, and narrative that the case study method provides, yet at the same time bring in other perspectives so that the clinical data is not restricted to the analyst’s subjectivity?

I believe one problem that we constantly encounter in this debate, as Jonathan Shedler has articulated (2011), is that the otherwise extraordinarily creative psychoanalyst becomes quite uncreative and rigid when it comes to developing methods suitable to address rich and complex psychoanalytic concepts that only analytically minded empiricists can fully grasp. The psychoanalytic tradition that is built on the premise of “multiple function” collapses into single polarized camps when the issue of research is put to the fore. I trust that an empirical stance that emphasizes “methodological pluralism” (Luyten et al., 2006) and is still creative at its core should be capable of enriching psychoanalytic knowledge and support clinical work.

One of the methods that come closest to this stance is psychoanalytic process research, which redefines the way most people think about research (Wallerstein, 2001). Such a method, which is possible to execute with only one participant, provides the arena for an intensive focus on individual factors of history and context and also include multiple perspectives that incorporate the subjectivity of the patient and the analyst as well as additional assessment of the sessions, which may include both qualitative and quantitative measures. This is possible through the collection of the actual analytic material (through audio recordings), the analyst’s impressions after each session, qualitative analyses of clinical consultants, and quantitative analyses using analytic process scales and computerized linguistic measures (see Bucci and Maskit, 2007, for detail on this research framework).

Moreover, the research questions that can be addressed with such a methodology are not limited to simplified efficacy studies that bypass the finer grained study of therapeutic interaction. I agree with Andre Green (1996): “When we come to research and psychoanalysis, the first question is what we are trying to find” (p. 11). Paradoxically, the so-called psychoanalytic research studies do not address the specificity or essence of what we try to do in psychoanalysis. One main body of psychoanalytic research, such as the ones reviewed by Shedler (2010), appropriates a language from a psychological and statistical perspective and borrows concepts such as “posttreatment effect size” or “symptom reduction” that have never been the true concern of psychoanalysts. Another trend, led by Peter Fonagy and Daniel Stern, applies the discoveries of infant research and cognitive science to child and adult psychoanalysis without sufficient psychoanalytic validity. Both research approaches pose the threat of a false overintegration across different fields and a mutation of psychoanalysis into something that it never was:

There is a neglect in most investigations of the specificity of what is intrapsychic and unconscious, and an underestimation of the parameters of the analytic situation related to the setting, with the implicit idea that an observational procedure of interpersonal relationships can better account for the object of psychoanalysis than the speculation of psychoanalysts drawn from their therapeutic experience (Green, 1996, p. 12).

I advocate that it is precisely the true concerns of these psychoanalysts who struggle with the complexities of therapeutic experience that should be the main focus of our research, and not appropriations from other realms of study. Our field is being torn into different schools of thought as we try to understand the nature of the therapeutic experience that is effective. The study of “therapeutic microprocesses” with particular codification of the analyst’s interventions in individual sessions and a close study of psychic shifts in the patient’s functioning may make it possible to address and refine central questions.

To reiterate, the aim of this paper is not to make a blind call for application of any kind of research strategy to psychoanalysis, for this creates a dangerous amalgamation of disparate concepts and a dilution of psychoanalysis. However, I am hopeful that a careful and creative research design that takes into account the intricacies of the psychoanalytic process, the subjectivity of the patient and the therapist, and relevant questions that matter to psychoanalysts can preserve the integrity of psychoanalytic constructs and further the field.

References

Bucci, W. (2007). Building the interface of research and practice: Achievements and unresolved questions. In W. Bucci & N. Freedman ( Eds.), The integration of clinical and research perspectives in psychoanalysis: A tribute to the work of Robert Wallerstein, 175–204. London: International Psychoanalytical Association Press.

Green, A. (1996). What kind of research for psychoanalysis? International Psychoanalysis: Newsletter of the International Psychoanalytical Association, 5, 10–14.

Green, A. (2003). The pluralism of sciences and psychoanalytic thinking. In M. Leuzinger-Bohleber, A. U. Dreher, & J. Canestri (Eds.), Pluralism and unity? Methods of research in psychoanalysis, 26–44. London: International Psychoanalytical Association.

Luyten, P., Blatt, S. J., & Corveleyn, J. (2006). Minding the gap between positivism and hermeneutics in psychoanalytic research. Journal of American Psychoanalytic Association, 54(2), 571–610.

Perron, R. (2002). Response to Peter Fonagy. In P. Fonagy (Ed.), An Open Door Review of Outcome Studies in Psychoanalysis, 2nd ed.,30–33. London: International Psychoanalytical Association.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy.American Psychologist, 65(2), 98–109.

Shedler, J. (2011). Shedler Replies.DIVISION/Review, 1(1), 30.

Tuckett, D. (2000). Commentary on Michels’s “The case history.” Journal of the American Psychoanalytic Association, 48, 403–411.

Wallerstein, R. S. (2001). The generations of psychotherapy research: An overview. Psychoanalytic Psychology, 18, 243–267.