Psychoanalytic Disagreements in Context (Book Review)

Author:  Boesky, Dale
Publisher: Jason Aronson, New York: , 2008; 229 pp., $85 (cloth), 44.95 (paper).
Reviewed By: Jeffrey H. Golland, XXIX, no. 3, Summer 2009, pp. 51-52 

“Congenial inclusiveness (is) not…enough” (p 75) concludes Dale Boesky in his chapter on comparative psychoanalysis, evoking association to Bettleheim’s (1950) famous title. This book is Boesky’s attempt to develop a method for contextualization of clinical material from which we might develop useful comparisons within and between our differing theoretical models. It can be considered another effort on the theme “pluralism and its discontents,” begun by Wallerstein (1988) and more recently addressed by Pine (2006) and Rangell (2007). Boesky’s aim is to provide a philosophy of science grounding to extend recent successes in achieving professional congeniality, and to help adherents of different models to stop talking past one another.

Boesky considers his aim narrow and modest, focusing solely on the mind of the analyst as interventions are formulated and prioritized, rather than on specifics of technique or the truth claims of different models. Along the way it becomes clear that his task is highly ambitious, even “daunting” (p 117).

Clinical examples are discussed in four chapters. The first addresses the well-known Casement (1982) paper about token physical contact with a patient, and its many published discussions extending over two decades and exhibiting “two dozen analysts divided into two opposing camps, each of which….(omit) important data…”(p 34). Boesky offers eight contextual criteria, defined as bridging tools, “dynamic themes that link theory, context, and technique” (p. 34) – and suggests rules of evidence that he believes could usefully guide a psychoanalyst’s thinking. His next example takes up several works of the Boston Change Process Study Group (BCPSG), and concludes that their promotion of “sloppiness and indeterminacy” (p.71) is a “category error,” an “unrecognized misunderstanding of the nature of the things being discussed” (p. 9).

A third clinical example, from Boesky’s own practice, attempts to show that one- and two-person psychologies are compatible rather than contradictory. A final example offers contextual criteria to clarify a dispute between Brenner (2003) and himself over a presentation by Kogan (2003), a disagreement between adherents of the same theoretical model. In this example, Boesky argues that “equifinality” – the assumption that most analysts get good results (all roads lead to Rome) – is based on faith, not evidence, and is fallacious.

In three concluding chapters, Boesky focuses on what are his basic concepts: associations, contextualization and hermeneutics. Psychic determinism is axiomatic for him, and a patient’s associations are privileged in the search for hidden meanings. Boesky believes our several models agree on seeking hidden meanings, but notes that not all consider determinism and association to be essential. He explicates and subscribes to the “critical realism” of philosopher-psychoanalysts Charles and Margaret Ann Fitzpatrick Hanly (2001) and Marcia Cavell (2002) in contrast to perspectivist claims. He posits hermeneutics as a heuristic strategy consistent with science, rather than a competing epistemology. He emphasizes throughout the need for clinical evidence, clear definitions, and sound research, and laments their inadequacy in every one of our models.

This book is well worth the effort to work through its closely reasoned arguments, laden with extensive footnotes and several heavily philosophical sections. Recognizing that most analysts are not experts in such discourse, Boesky provides a glossary and an extensive list of supplemental readings, but several chapters seem to have been presented as stand-alone papers and are not smoothly integrated, with redundancies that add to the difficulty of comprehension.

A greater difficulty might be Boesky’s evaluation of points of view differing from his own modern structural theory, perhaps straining congeniality. While he lauds pluralism and considers theoretical eclecticism necessary, and he claims (despite acknowledged bias) to “not have a horse in this race” (p 8), a string of judgmental words: “error,” “fallacy,” “flawed,” “misleading,” “contradiction,” “conflate,” would result in many – perhaps all – of the other horses being “scratched.” Those betting on other entries will not likely be persuaded. In his recent review, Arnold Goldberg (2008), a self-psychologist, while praising the scholarship and clear-headedness of the book, is virtually dismissive of Boesky’s central attempt at finding common ground.

This problem is not new. The theme of the recent IPA Congress in Chicago was “Convergences and Divergences.” The search for common ground within pluralism was also begun by Wallerstein (1990). Yet when leaders of various schools are asked to present arguments, mutual dismissal is routine. Recently, Henry Smith (2007), the editor of The Psychoanalytic Quarterly, commenting on papers invited for a special supplement issue on therapeutic action, sharply criticizes several contributions on logical and philosophical grounds similar to Boesky’s. Does this problem represent the long-standing conflict between “thinkers” and “feelers?” Most of us might join Boesky in endorsing Arlow’s observation that an “analyst must have both a soft heart and a tough mind” (p 163), but we fall easily into caricature in judging models different from our own. Attempts at congeniality and inclusiveness may be necessary to promote discourse, but the details of the discourse carry the risk of re-alienation.

I prefer a version of Boesky’s model, but I am troubled by his central assertions about equifinality and clinical error. Lack of evidence and slippery slope are his two objections to equifinality; each argument could be applied to many of our theoretical assertions. Lacking consensus on a definition of treatment success, it seems premature to dismiss claims of models other than our own. I have been surprised recently to discover groups of therapists practicing gestalt therapy and even Orgone therapy, among other nominally psychodynamic approaches. I had thought that these offshoots had been found obsolete decades ago. It will take much more time—if we can achieve it at all—to create a definitive clinical psychoanalysis, since we all properly lionize both individuality and the uniqueness of each patient-therapist pair.

As to the possibility of error in clinical interventions, Boesky admits that the “list of possible meanings (of associations) is inexhaustible” (p. 160). He claims, nonetheless, that if some details are not considered, we are in a situation he analogizes to risking erroneous medical diagnosis. Contextual considerations are proposed as remedy, but different models disagree on contextual priorities. Boesky’s assertion is reminiscent of Glover’s (1955) views on inexact interpretation. Errors in clinical work, and better and worse interventions, surely exist. Unfortunately, we lack agreement on how to judge them. Boesky’s quarrel with Brenner is most telling in this regard, and reminds me of my own study groups in which disagreement on specific clinical interventions is routine, welcome, and experienced as useful—but rarely leads to conclusions. I find Busch’s (1903) “in the neighborhood” notion to be a more useful guide than a Glover-like perfectionism I read into Boesky’s warning about misdiagnosis.

My own resonance with much of the substance of this book leads me to hope it will find a readership and stimulate useful discussion, instead of falling victim to dismissal. Boesky concludes that we must keep trying to come together, so “we will be better able to follow Beckett’s famous advice: ‘Fail again, fail better’” (p 204). Boesky has not failed; but our recent congeniality and inclusiveness has not been nearly enough to render psychoanalysis a consensually understood, coherent therapy among its diverse practitioners.

References

Bettleheim, B. (1950). Love is not enough: The treatment of emotionally disturbed children. Glencoe, IL: Free Press.

Brenner, C. (2003). Commentary on Ilany Kogan’s “On being a dead, beloved child.” Psychoanalytic Quarterly, 72, 767-776.

Busch, F. (1993). In the neighborhood: Aspects of a good interpretation and a 'developmental lag' in ego psychology. Journal of the American Psychoanalytic Association, 41, 151-176.

Cavell, M. (2002). On reality and objectivity. Journal of the American Psychoanalytic Association, 50, 319-324.

Casement, P. (1982). Some pressures on the analyst for physical contact during the reliving of an early trauma. International Review of Psychoanalysis, 9, 279-286.

Glover, E. (1955). The therapeutic effect of inexact interpretation: A contribution to the theory of suggestion. In E. Glover, The technique of psychoanalysis, (pp. 553-566). New York: International Universities Press (Original work published 1931).

Goldberg, A (2008) Book review. Psychoanalytic disagreements in context; International Journal of Psychoanalysis. 89, 1294-1289.

Hanley, C., & Hanly, M., (2001). Critical realism: Distinguishing the psychological subjectivity of the analyst from epistemological subjectivism. Journal of the American Psychoanalytic Association, 49, 515-532.

Kogan, I. (2003). On being a dead, beloved child. Psychoanalytic Quarterly, 72, 727-766.

Pine, F. (2006). The psychoanalytic dictionary: A position paper on diversity and its unifiers. Journal of the American Psychoanalytic Association. 54, 463-491.

Rangell, L. (2007). The road to unity in psychoanalytic theory. New York: Jason Aronson.

Smith, H.F. (2007). In search of a theory of therapeutic action. Psychoanalytic Quarterly, 76, 1735-1761.

Wallerstein, R.S. (1988). One psychoanalysis or many? International Journal of Psychoanalysis, 69, 5-21.

Wallerstein, R.S. ((1990). Psychoanalysis: The common ground. International Journal of Psychoanalysis, 71, 3-20.

Reviewer Note

Jeff Golland is a clinical faculty member in the Department of Psychiatry at Mount Sinai School of Medicine.

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