Clinical and Observational Psychoanalytic Research: Roots of a Controversy (Book Review)

Author:  Sandler, Joseph, Anna-Marie Sandler, Rosemary Davies and André Green (Editors)
Publisher:  Madison, CT: International Universities Press, 2001
Reviewed By:  Andrew Gerber, Summer 2002, 67-70

To many, if not most, followers of the psychoanalytic literature, the discussion of research and psychoanalysis is getting stale. The debate usually goes something like this: a practitioner of psychoanalytic research exhorts his colleagues in a moralistic tone to bring research findings into their consciousness or face not only intellectual failure, but the scorn and withdrawal of support from non-psychoanalytic researchers, clinicians, and funding agencies (e.g., see my column in the Summer 2001 issue of this newsletter). Typically, the psychoanalytic community responds to this with grudging acceptance but caution as to the applicability of such research for their clinical work and a general discomfort that the world of psychoanalysis be occupied by a culture quite different from the one that first attracted them. The conversation is hardly a new one—efforts at psychoanalytic research, not fundamentally different from those of today, date to the 1920’s, and the challenges to these projects sound eerily familiar (Fisher & Greenberg, 1977; 1996; Fonagy et al., 2001; Galatzer-Levy, Bachrach, Skolnikoff, & Waldron, 2000).

It is refreshing, then, to find a volume on psychoanalytic research edited by psychoanalysts who find themselves in the middle of this debate, yet not adherents to one or the other camp. Joseph and Anne-Marie Sandler and Rosemary Davies are London analysts (Joseph Sandler died in 1998 and the book is dedicated to him by the publisher), all three predominantly clinicians and authors of numerous clinical and theoretical papers, who have also participated in psychoanalytic research and understand from the inside the benefits and limitations of such work. In their book, they bring together the words of two notable American psychoanalytic researchers—Robert Wallerstein and Daniel Stern—with the voice of an unapologizing anti-research, anti-objectivist French psychoanalyst, André Green. The mixture is alternately electrifying and stultifying—the former when Green challenges the claims and very value of the work done by Wallerstein and Stern, the latter when the speakers argue about definitions of terms (“science,” “psychoanalysis,” and “research” to start with) and avoid the substance of their differences. Nevertheless, through the interplay of these figures, as well as through the introduction, commentary, and questions of analysts who attended these talks, the debate over psychoanalytic research is elucidated and a reader is offered the opportunity to assess the substance behind the wrangling.

Given the deference with which science and research are treated in our society, as well as Green’s animated writing style, the editors are astute in giving the underdog Green first say in both sections of the book. Part I (a set of articles from the International Psychoanalytic Association [IPA] newsletter) begins with a generic challenge to the value of objective research for psychoanalysis, based on his polemical belief that the methods and models of researchers will never be complex enough to add anything significant to the observations of clinicians. Wallerstein, who for 30 years was the director of the most ambitious psychoanalytic outcome study ever conducted, the Menninger Psychotherapy Research Project, as well as a past president of the International and American Psychoanalytic Associations, answers agreeably that “the proof of the pudding is in the eating” (i.e., Green may be right about some specifics, but it is still too early to write off the contributions of all research). Green is not only given a chance to respond to Wallerstein (which he does in a characteristically fervent but obscure way, alluding to the “indigestibility” of pudding) but then begins Part II (edited proceedings of a 1997 conference on research and psychoanalysis chaired by Joseph Sandler) with another attack on psychoanalytic research, this one aimed more specifically at the value of infant observations for psychoanalysis. The calm and thoughtful voice in defense of observations is Stern, an American psychiatrist, psychoanalyst, and leader in the field of studying videotaped interactions of mothers and babies. To round out the debate and suggest ways in which the remarks might be useful to clinicians, the reader is presented with the remarks of three London analysts, each with her own ties to research and observation: Rosine Perelberg (trained as a social anthropologist and a member of the Anna Freud Centre Young Adult Group), Anne Alvarez (involved in observational research with autistic children at the Tavistock Center), and Irma Pick (child analyst and teacher of infant observation as a component of child analystic training). Finally, in a plenary session all the participants from Part II engage in a short but lively exchange of ideas.

Green makes several convincing points in his pair of essays. First, he argues (with Wallerstein’s reluctant agreement) that despite the wealth of psychoanalytic research conducted over the last 80 years, few if any findings have emerged that have significantly changed the way clinicians think. Second, he charges (again with Stern and Wallerstein’s forlorn nods) that a concerning fraction of psychoanalytic researchers show a poor understanding of analytic concepts and use oversimplified models, with a particular failure to appreciate the intrapsychic and the dynamic unconscious. Finally, Green notes that much of opinion in psychoanalysis, including the current emphasis on research, is cultural and faddish in nature. In today’s world, for instance, science has such a strong position that anyone who opposes it is labeled a hermeneuticist “which is a polite term for one of a religious mind.” Perelberg, with the eye of a trained anthropologist, calls these trends “tribal” in nature, reminding us that until recently relatively little of Green had been translated into English, while in Paris, many analysts are completely unaware of Stern’s work. Who are the researchers to argue for the universality of their work, if their opinions end up dividing neatly along American versus French lines, with the British somewhere in the middle? The contributions of the discussants and conference audience make clear that Green’s fears are far from the isolated charges of a contrarian Frenchman. Perelberg, Pick, Ricardo Steiner (in his excellent introduction), Sally Weintrobe and Nicola Diamond (in the plenary discussion) state that Green’s worries resonate with their experience and encourage them to question their dutifully respectful attitude toward research. I suspect that, like the audience members, most psychoanalytic clinicians who pick up this book would have a guilty enjoyment of Green’s venom towards research.

A careful look at Green’s most substantive arguments, though, reveals an absolutism unaccompanied by sufficient evidence, that undermines his principle challenges to research. It is naïve of him to claim that simply because a handful of research techniques - he particularly targets that of infant observation—do not, in his opinion, properly address the complexity of the intrapsychic and the unconscious, that no such methodology could ever be devised. How can it be, as Green states, “observation cannot tell us anything about intrapsychic processes that truly characterize the subject’s experience”? Are not the analyst and analytic supervisor themselves part-observers, who while incapable of truly knowing the subjective experience of an analysand, nonetheless can piece together enough through their observations and experiences of countertransference to engage with and understand a patient? Methodologies and models in science never spring forth from the minds of scientists fully formed. Rather, they are developed through an iterative process whereby an experimentalist tries one method and model, and if this proves too crude to record the phenomenon he hopes to demonstrate, he refines one or both and tries again. In psychoanalysis, after years of self-report questionnaires, symptom inventories, and arbitrary diagnostic schemes, we have only begun to develop the measures that record truly interesting parameters of the intrapsychic world and therapeutic process (e.g., Main’s Adult Attachment Interview, Fonagy’s Reflective Function, Westen and Shedler’s SWAP-200, and Jones’s Psychotherapy Q-sort). One can scarcely imagine the richness that would result if theorists of Green’s stature engaged with researchers and operationalized their clinical acumen into psychoanalytic measures of tomorrow.

Even the most well intentioned of commentators, such as Perelberg, are wrong in excusing the failures of psychoanalytic research by saying that studying the unconscious is difficult because it “can only be reached through its derivative” or the nonlinearity of patient’s and analyst’s thoughts. Virtually nothing in modern science is ever measured directly or without multifactorial influences, whether it be subatomic particles (traced by their electromagnetic properties), DNA (manipulated through enzymes that invisibly cut and splice it), or general relativity (quantified by miniscule effects on light from stars billions of miles away). The forces of psychoanalysis are no more complex, no more distant, and no less manipulable than these. Psychoanalytic research’s only disadvantage is its relative youth, and the unwillingness of its adherents to perform the painstaking experiments necessary to move the field forward incrementally.

Green expends a great deal of energy insisting that the “infantile” in adult psychoanalysis has little to do with what we might learn from observing infants. He even rejects Stern’s modest proposal that infant observations not tell analysts what happened in infancy, but only suggest the capacities available to infants at different stages, thus providing a reality check on the processes retrospectively assigned by analysts to this time of life. Here, Green and the French analysts may truly be on their own, as infant observation is a valued part of child analytic training in most of the world.

The worst flaw in Green’s argument, however, is his paranoid insistence that he would rather define the borders of psychoanalysis so narrowly that the field can barely breathe, rather than allow for useful input from outside disciplines. It is a tenet of intellectual life, as Stern and Alvarez suggest, not just of science, that true knowledge benefits from cross-fertilization, and is not destroyed by it. Green accuses psychoanalytic researchers of trying to destroy the very “spirit of psychoanalysis” with their experiments and their overzealous citation of non-psychoanalysts, thereby “diluting” the purity of psychoanalytic thinking. He recognizes that there are other valid models of the mind, but cannot imagine how they can bear on what goes on between him and an analysand in the consulting room. He goes so far as to claim, without evidence, that conscious and unconscious can never be integrated into the same model. “I will not commit suicide,” he declares.

The beauty of this edited volume is that in 142 pages it allows Green to lay out his principle arguments and gives researchers and clinicians just enough time to counter and discuss them, so as to whet the appetite of an interested reader and encourage an independent appraisal of the different perspectives. While I hesitate to suggest anything that would disturb this careful balance, I agree with Riccardo Steiner that a few things are missing. First, it would be instructive to have an historical overview of the relationship between psychoanalysis and empirical research, with particular reference to the views of Sigmund Freud as well as Anna Freud and Melanie Klein (both of whom made significant use of infant observations in the Freud-Klein Controversies of the 1940’s). In a field so dominated by its legacy and tributes to its founders, it is likely that a good part of Green’s, Wallerstein’s, and Stern’s arguments (along with some of their intransigence) hide a considerable developmental past.

More serious, I believe, is the absence of any voice for contemporary psychoanalytic outcome and process research, such as Fonagy, Kächele, or Jones. Baby observations are only one small part of analytically informed research, and Wallerstein’s contributions, while significant, are now dated. Any reader with the slightest interest in the current state of psychoanalytic research would be remiss in ignoring the latest edition of the IPA Open Door Review of Outcome Studies in Psychoanalysis (Fonagy et al., 2001, found on the web at http://www.ipa.org.uk/research/R-outcome.htm). The only mention of a contemporary psychoanalytic outcome study is made by Perelberg, in reference to the Young Adult Research Scheme at the Anna Freud Centre in London. Since 1994 I have worked with the Young Adult Research Group, its chairperson Anne-Marie Sandler, research director Peter Fonagy, and sixteen analytic members including Rosemary Davies, Rosine Perelberg, and Sally Weintrobe. Although the project is not described at great length in this volume, its spirit imbues much of what is said by virtue of the number of its members involved. When the group was first convened in 1990, under the leadership of George Moran (then director of the Anna Freud Centre), Anne-Marie Sandler, and Fonagy, it raised the question of how best to study the process of day to day psychoanalysis and psychodynamic psychotherapy in a climate where videotaping of sessions was neither acceptable to the analysts or the basis of a satisfying methodology for the researchers. The group jointly designed a 900 item questionnaire (the Young Adult Weekly Rating Scale) to be completed by an analyst at the end of each week (in the case of analyses) or each month (in the case of psychodynamic psychotherapies) which summarized the analyst’s perspective on the conscious, preconscious, and unconscious themes that had appeared and been interpreted (using separate rating systems) during the preceding sessions. Over the next decade more than 1500 of these questionnaires were collected from treatments of 28 patients, accompanied by extensive data on the patient’s diagnoses, symptomatology, and attachment classification before, during, and after treatment. Data analysis of all aspects of this study is ongoing and publication of results is anticipated in the next few years. Meanwhile a modified version of the Weekly Rating Scale has been adopted by Jan Stoker at the Amsterdam Psychoanalytic Institute, and similar quantities of data are being collected there.

My intention in describing this project is to show that given a set of theoretical constraints imposed by analytic thinkers, it is invariably possible to develop a methodology that will provide interesting and useful information. The members of the Young Adult group felt that only a trained psychoanalyst would be qualified to provide meaningful data about the elements of psychoanalytic process, so the questionnaire was designed to collect that information. What they wanted to learn was what elements in their concurrent recording of psychoanalytic process would predict positive and negative outcomes (assessed through symptomatology) in their patients. Preliminary data suggests that, even from the earliest interactions between analyst and patient, the therapy that was dealing with issues of body and sexuality were predictive of a positive outcome. We are, of course, a long way from understanding the meaning of such a finding and all the possible confounding factors, but the fact exists that data were generated according to analytic principles that clinicians are finding worthwhile.

Does a controversy so deep leave hope for reconciliation? Perhaps an answer could come from the physical sciences, where men and women studying the same phenomena from different perspectives have coexisted for hundreds of years, using the careful parsing of roles. André Green, a psychoanalytic theoretician, might be likened to the fundamental theorist (mathematician or theoretical physicist) who weaves a complex theory with his greatest concern to its internal consistency and not to its verifiability. It would be folly to attempt to hold such a thinker back, as his contributions lie in this mode of work. On the opposite end of the spectrum, we are also in need of the most practical of psychoanalytic methodologists, akin to engineers, who build reliable and precise instruments to measure the phenomena that we study. What this role gives up in glamour and ability to answer the big questions, it gains in empirically verifiable certainty and repetition. Finally, the large middle ground is occupied by psychoanalytic experimentalists whose difficult and frequently political job is of the translator, drawing from the theories of the one and the methods of the other to produce practical experiments that may slowly lead the field forward. Perhaps with this spectrum of roles, different minds may coexist peacefully in psychoanalysis and contribute together to the success of the field.

References

Fisher, S., & Greenberg, R. P. (1977). The scientific credibility of Freud’s theories and therapy. New York: Basic Books, Inc.
Fisher, S., & Greenberg, R. P. (1996). Freud scientifically reappraised: Testing the theories and therapy. New York: John Wiley & Sons, Inc.
Fonagy, P., Jones, E. E., Kächele, H., Krause, R., Clarkin, J., Perron, R., Gerber, A., & Allison, E. (2001). An open door review of outcome studies in psychoanalysis. Second edition, London: International Psychoanalytic Association.
Galatzer-Levy, R. M., Bachrach, H., Skolnikoff, A., & Waldron, S., Jr. (2000). Does psychoanalysis work? New Haven: Yale University Press.
Gerber, A. J. (2001). A proposal for the integration of psychoanalysis and research. Psychologist-Psychoanalyst, 21(3) , 14-17.

Reviewer Note

Andrew J. Gerber graduated from Yale College in 1993 with a degree in physics and completed a Master of Science degree in Psychoanalytic Developmental Psychology at the Anna Freud Centre and University College London. He enrolled in a psychology PhD program with Peter Fonagy and Joseph Sandler as his advisors, investigating the process and outcome of psychoanalysis and psychoanalytic psychotherapy in personality disordered young adults. He graduated from Harvard Medical School and is currently a psychiatry resident at New York Presbyterian Hospital.

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