The development of a psychoanalytic outcome study: choices, conflicts, and consensus

This article tells the story of the development of an outcome study of psychoanalysis and describes the debate that took place over critical methodological issues. The protocol committee included career psychotherapy researchers who have conducted rigorous outcome studies, clinical psychoanalysts, study methodologists, and a statistician with clinical trial expertise. The committee worked for two years to develop the study design. This project is based on the premise that clinical psychoanalysis is a treatment. Areas specifically addressed are the goals and hypothesis of the study, inclusion and exclusion criteria, choice of psychotherapies as comparison treatments, definition of treatments and selection of therapists, use of medication, development of a treatment adherence measure, randomization of patient assignment vs. patient self-selection, and primary outcome measures. The execution of this outcome study will require significant effort and resources. A positive result would boost the standing of psychoanalysis, but the results may not support the primary hypothesis that there are therapeutic benefits unique to psychoanalysis and that psychoanalysis can effect demonstrable changes in a patient's mental life and adaptation that are not achieved by treatments of different orientation and/or lesser intensity. However, more important than whatever specific results emerge is what executing such a study requires of our field: the process of addressing the clinical issues that a study design requires, the creation of a network of analysts around the country working on a common project, and the joining of the clinical psychoanalytic community with a community of psychodynamic researchers.     

Freud's metapsychological speculations1

In this paper, the author seeks to analyse the nature and function of metapsychological theory in Freudian psychoanalysis. He shows that Freudian psychoanalytic theory is composed of an empirical part‐the psychology of clinical facts‐and a speculative part‐metapsychology. Freud considers this latter part as being a speculative superstructure of value that is only heuristic, capable of being supplanted by other superstructures of the same type. The author sustains the idea that this metapsychology is the fruit of speculative method, whose foundations were elaborated by philosophers and epistemologists before Freud, including Immanuel Kant and Ernst Mach. He concludes with considerations regarding the future of metapsychological theorisation, presenting criticisms of Freudian metapsychology offered by both philosophers and psychoanalysts, and pointing to the perspective opened by Donald W. Winnicott of a psychoanalysis without metapsychology.     

„Es waren ja fast alle weggegangen“

The complex and partly disputed history of German psychoanalysis during the Third Reich has been thoroughly investigated to date. There are various stages of historical analysis which are distinguished by differing discourses that are presented as part of this work. The first stage of historical analysis was characterized by conflicts within the German psychoanalytical societies and marked by two antagonistic narratives about the transformation of German psychoanalysis during the Third Reich. This study investigated which discourses on the history of German psychoanalysis were integrated into the professional biographies of the first generation of post-war psychoanalysts. In this study 23 narrative interviews were conducted with psychoanalysts who where born before 1st January 1937 focusing on the professional biography and the results were analyzed. The interviewees stressed the ‘damage’ to German psychoanalysis in general and on their training in particular. The ‘damage’ was described as an uncontrollable result of National Socialism and the structural and theoretical changes that were connected to it whereby its effects continued to impact on post-war psychoanalysis. Especially the discourses of the first stage of historical analysis appear to have been integrated into professional biographies and are still having an impact on the interpretation of history for the post-war generation to this day. The history of psychoanalysis is presented as a narrative of ‘rescue’ or ‘liquidation’ of psychoanalysis during the Third Reich depending on the professional identity of the psychoanalysts.     

The Adult Attachment Interview and psychoanalytic outcome studies

During the last two decades, the Adult Attachment Interview (AAI) has attracted growing interest from psychoanalysts concerned with empirical research. The paper discusses the application of Crittenden's Dynamic-Maturational AAI method for assessing the outcome of psychoanalysis. The aim is to demonstrate, through a case presentation, how therapeutic change can be expressed in the AAI. The pre- and post-treatment interviews of one patient, having completed a four-times-a-week psychoanalysis, are presented. It is demonstrated that the detailed discourse analysis of the AAI, based on transcribed tape-recorded interviews, focuses subtle formal elements of language and speech reflecting dominant patterns of affect regulation and object relating. The AAI text analysis provides possibility for coding procedural memory as conveyed by the handling of the relationship to the interviewer, incorporating the dynamic relationship between researcher and subject and thus complying with a methodological prerequisite regarded by many psychoanalysts as necessary for capturing data that are relevant to psychoanalysis. On this background, the method emerges as promising for psychoanalytic outcome studies.     

Psychoanalysis,a Bridge Between Attachment Research and Neurobiology

Attachment theory and neurobiology are at the forefront of scientific research, particularly in the area of child psychiatry. Several authors have encountered a surprising isomorphism between findings in these areas and concepts central in psychoanalysis. The author postulates that attachment theory is an outcome of the history of the transformation of the old concept of libido now applied interpersonally. The author also postulates that the neurobiology of attachment mediates but does not substitute psychoanalysis for the final understanding of the human bond. Findings in both fields, attachment theory and psychobiology, often compellingly lead to psychoanalytic concepts; on the other hand, the neurobiology of the psyche does not make full sense without the wealth of research conducted by psychoanalysts during the 20th century. The concept of seduction in particular, in its broad sense, is akin to mirroring and attachment and a useful tool in this regard. Although some cling to the idea of the purity of psychoanalysis and see these kin areas as a threat to its integrity, the author believes that psychoanalysis, serving as a bridge between them, can only be enriched by their empirical and experimental outcomes.The American Journal of Psychoanalysis (2008) 68, 148-155. doi:10.1057/ajp.2008.4.     

Extreme Normality: Preface and Performance

This essay is intended to record and analyze some recent events in psychoanalytic history, in particular the omission of sexual and gender minorities from the planning of the inaugural conference of the International Association of Relational Psychoanalysts and Psychotherapists (2002) and its subsequent protest by several East Coast psychoanalysts. Those events are recounted and analyzed to emphasize the significance for psychoanalysis of the general exclusion of gay, lesbian, bisexual, and transgendered (GLBT) voices from the sites of psychoanalytic authority, to hypothesize the intellectual roots of this historic exclusion, and to make recommendations for remedying this situation. The author suggests that philosophical idealism embedded in psychoanalysis in the form of reified notions of development, gender, and health may be responsible for the failure of contemporary psychoanalysis to fully include GLBT consciousness and perspectives. He further argues that the institutional recruitment and deployment of GLBT psychoanalysts is a likely remedial strategy.     

The relationship between psychoanalysis and schizophrenia-A response to the commentary by Robert Michels

In this section, the author responds to Dr Michels's commentary. In contrast to the situation in the United States, there are far fewer psychoanalysts in the UK and very few indeed working in general psychiatry to influence its practice. It is argued that psychoanalysis differs from all other psychological approaches with its recognition of the inner world and its unconscious influence on the individual's everyday life. Michels invites one to focus on outcome studies to judge the effectiveness of psychoanalysis in schizophrenia. There is a danger of throwing the baby out with the bathwater in that psychoanalysis helps in understanding presenting clinical material and in risk assessment in everyday general psychiatry.     

PSYCHOANALYSIS AND THE ARTS: THE SLIPPERY GROUND OF APPLIED ANALYSIS

The ways in which today's psychoanalysts approach art closely follow the avenues opened by Freud a hundred years ago. Drawing mainly on Freud's studies on Jensen's Gradiva (1907) and on Leonardo da Vinci (1910a), the author examines the main paradigms he used in discussing artistic activity, including his doubts and hesitations. Present‐day approaches to art are then examined via a discussion of the advantages and pitfalls of psychobiography, of the case study, and of textual approaches. The author makes a case for the type of interdisciplinary dialogue in which the goal is to establish a cross‐fertilization between psychoanalysis and other fields of knowledge while striving to avoid hypersaturation of a work of art in order to foster expansion of the mind.     

Psychoanalysis, Nazism and 'Jewish science'

In this paper the author offers a partial examination of the troubled history of psychoanalysis in Germany during the Nazi period. Of particular interest is the impact on psychoanalysis of its 'Jewish origins'-something denigrated by the Nazis but reclaimed by more recent Jewish and other scholars. The author traces the rapid decline of the pre-Nazi psychoanalytic institutions under the sway of a policy of appeasement and collaboration, paying particular attention to the continuation of some forms of psychoanalytic practice within the 'Göring Institute'. He suggests that a feature of this history was the anti-Semitism evidenced by some non-Jewish psychoanalysts, which revealed an antagonism towards their own positioning as followers of the 'Jewish science'.     

Trauma and Contemporary Forms of Subjectivity: Contributions of Argentine Psychoanalysis<Superscript>*</Superscript>

This paper offers arguments to justify the relevance of psychoanalysis—psychoanalyses—in present-day Argentina and reflects on the stance taken by psychoanalysts with different theoretical perspectives in the face of the havoc wreaked by state terror (1976–1983). To this end, the author focuses on the pioneers’ traits, the significance of the Argentine Psychoanalytic Association in the 1950s and 1960s, and the impact of the departure of the Plataforma Group in 1971. The establishment of the latter opened the way for the development of a psychoanalysis tied to popular movements, sensitive to social conflict, and close to human rights organizations. The author explores both on psychoanalysts’ intervention to address the social trauma resulting from the theft of babies during the dictatorship, and on their relationship with Grandmothers of Plaza de Mayo.     

Child psychoanalysis and obsessive-compulsive symptoms: the treatment of a ten-year-old boy

Obsessive-compulsive symptoms have long held interest for psychoanalysts. Currently, pharmacological and behavioral treatments are commonly viewed as the standard of care, and psychoanalytic clinicians are often uncertain of how best to approach these patients. The successful two-year psychoanalytic treatment of a ten-year-old boy with obsessivecompulsive disorder, who remained symptom-free eight years after termination, is reported. While this is but a single case, its outcome implies that for some patients psychoanalysis may be the treatment of choice.     

The analytic setting today: using the couch or the chair?

This paper re‐visits Murray Jackson's 1961 paper in the Journal of Analytical Psychology, ‘Chair, couch and countertransference’, with the aim of exploring the role of the couch for Jungian analysts in clinical practice today. Within the Society of Analytical Psychology (SAP) and some other London‐based societies, there has been an evolution of practice from face‐to‐face sessions with the patient in the chair, as was Jung's preference, to a mode of practice where patients use the couch with the analyst sitting to the side rather than behind, as has been the tradition in psychoanalysis. Fordham was the founding member of the SAP and it was because of his liaison with psychoanalysis and psychoanalysts that this cultural shift came about. Using clinical examples, the author explores the couch/chair question in terms of her own practice and the internal setting as a structure in her mind. With reference to Bleger's (2013) paper ‘Psychoanalysis of the psychoanalytic setting’, the author discusses how the analytic setting, including use of the couch or the chair, can act as a silent container for the most primitive aspects of the patient's psyche which will only emerge in analysis when the setting changes or is breached.     

Grasping psychoanalysts’ practice in its own merits1

The central objective of this presentation is to reflect on the obstacles involved in the task proposed by the Chicago Congress, which is to explore convergences and divergences in psychoanalytic practice. The author discusses two major obstacles. First, the epistemological and methodological problems in relation to the construction of theory in psychoanalysis and especially the inaccessibility, in any reliable way, of what psychoanalysts really do in the intimacy of their practice. He proposes to separate, at least in part, theory from practice in psychoanalysis, in an attempt to grasp psychoanalysts' practice in its own merits. He then outlines a phenomenology of the practice of psychoanalysis, which reveals that, in their work with patients, analysts are guided more by practical reasons than theoretical reasons; that is, their interventions are predictions rather than explanations. Since these practical reasons need to be validated constantly in the analytic relationship based on their effects, he discusses the subject of validation in the clinical context of the core theory of therapeutic change in psychoanalysis, that is, the conditions required for clinical practice to satisfy the thesis of an inseparable union between gaining knowledge and cure. He ends by challenging the core of the psychoanalytic theory of change, arguing that it neither does justice to the practice of psychoanalysts nor to contemporary knowledge of processes and mechanisms of therapeutic change. Finally, he proposes that we detach practice from theory, in order to study the former in its own merits, utilising a plurality of methods ranging from systematic investigation to the recent methodology of the Working Party.     

Toward a Genealogy of Culture

Using psychoanalytic theory, this paper attempts to trace the natural history of the phenomenon designated as Culture. It postulates that psychoanalysis, a product of the Hegelian philosophical revolution, is still one of the best instruments to understand Culture. It traces the origins of culture as postulated by Freud and the pioneer anthropologists and its course from early and evolved religion through humanism, science, and finally postmodernism. It emphasizes the dialectical concepts in psychoanalysis and reviews summarily those psychoanalysts that, according to the author, have had a major impact on the study of culture: Freud, Horney, and Lacan.     

Psychoanalytic training experience and postgraduate professional development: A survey of six decades of graduate analysts

This exploratory study explored the training and post‐training experience of graduates of the Chicago Institute for Psychoanalysis. All living graduates of the past six decades were invited to complete a survey that addressed their training analysis, classroom work, supervision and other training experiences as well as their degree of post‐graduation involvement in teaching, supervising, study groups and other professional endeavors. They were also asked to rate their sense of themselves as psychoanalysts and their satisfaction with their analytic career. Further, they were encouraged to provide spontaneous narrative data. Our findings contribute to the current understanding of the careers of psychoanalysts – including that there is a difference in generational cohorts regarding professional satisfaction, identification as an analyst, and experience of training. We also found that there are no real differences between analysts who do and do not have analytic patients on some important variables: supporting analysis as a treatment method, identifying oneself professionally with psychoanalysis, and disillusionment with psychoanalysis – which is consistent with other studies. Also discovered were differences between male and female analysts' perception of certain aspects of their training.     

Sollen Psychoanalytiker Psychotherapeuten ausbilden?

With respect to the radical changes in psychotherapeutic education as a consequence of the Law for Psychotherapy that has been put into force, the author elaborates on political, medical and strategic aspects. It is of special interest whether psychoanalysts having had the “monopoly” of training in depth psychological therapy should further take responsibility for the training in and the development of this method. Meanwhile, other therapeutic schools are claiming depth psychological psychotherapy for themselves and they deny the essential role of psychoanalysis as a foundation of it. In addition, the psychoanalytic institutes themselves do not agree on this issue. A further aspect of the question is that of marketing strategies: in order to survive, it is for psychoanalytic institutes at a time of lessening interest in standard psychoanalytic training important to offer training in depth psychological therapy with its comparatively less expensive and less extensive curriculum. But the essential question remains: should psychoanalysts train psychotherapists and take responsibility for an independent depth psychological therapy, or not? The author calls for a separate profound education in depth psychology taught by psychoanalysts in order to maintain a positive atmosphere for psychoanalysis e.g. in clinical institutions. He agrees with the IPV that this would help to solve “the crisis of the psycho analysis”. Finally, some of the most important, unsolved questions referring to a separate and profound education in depth psychology are presented and possible solutions are offered. It is of crucial importance to take up again the discussion within the psychoanalytical associations and to adjust their medical as well as political attitude to the new ways depth psychology is taught at psychoanalytical institutes.     

Analytical practice: do the new technologies have an impact?

Through commentary on four clinical vignettes, this article focuses on the anthropological transformations taking place in contemporary society, underlining their differences from the anthropologies of reference of the founding fathers of psychoanalysis. Hybridization between man and machine and the speeding up and alteration of communications which the new technologies promote are now crucial issues facing psychoanalysis. Social media and a 24/7 internet connection have produced deep changes in the way people live and perceive relationships. Analytical practice is not exempt from such issues, which can be particularly insidious, often subtle and difficult to recognize, or even underestimated or ignored by psychoanalysts outright, in order to preserve the illusion of a complete understanding of what unfolds in the analytical space. The authors suggest that such transformations, by (partially) rendering inadequate the theoretical and technical corpus on which the various depth psychologies are founded, require personal engagement on the part of psychoanalysts in the search for new strategies to treat their patients, with the consequent abandonment of the ‘certainties’ offered by sclerotic models of clinical procedure.     

How Does Neurobiological Research Influence Psychoanalytic Treatments?—Clinical Observations and Reflections From a Study on the Interface of Clinical Psychoanalysis and Neuroscience

One of the counterarguments against empirical research in psychoanalysis is that research negatively influences the treatment situation. In this paper, the impact of a neurobiological study on psychoanalytically oriented treatments is presented from three different perspectives: patients' views, a study group of participating psychoanalysts and a clinical case example. Twenty chronically depressed patients, 20 healthy controls and 16 psychoanalysts participated in the project on research. Results show a clear influence of the neurobiological study on the course of treatments. Patients consistently reported that study participation had a positive impact on their treatment experiences. However, study participation was conflictual for the psychoanalysts and forced them to carefully reflect on their unconscious and conscious involvement to establish a psychoanalytic stance independent from empirical research.     

How treating psychoanalysts respond to psychotherapy research constraints.

The psychoanalytic community increasingly recognizes the importance of research on psychoanalytic treatments, yet a significant number of psychoanalysts continue to believe that research is either irrelevant to psychoanalysis or impossible to accomplish. Psychoanalysts who accept the value of research express concern that intrusions required by research protocols create significant distortions in the psychoanalytic process. The authors, all psychoanalysts, are studying the outcome of a brief (twenty-four-session) psychodynamic treatment of panic disorder. They report their experiences and struggles with the intrusions of videotaping, working with a treatment manual, and time-limited treatment. This research process required them to question old beliefs and to confront feelings of disloyalty toward their analytic training and identity, particularly with regard to keeping a "clean field" and routinely performing long-term analysis of character. The therapists' psychoanalytic knowledge, however, emerged as crucial for them in managing specific research constraints. Despite concerns about providing inadequate treatment, therapists were found to engage patients with psychoanalytic tools and focus in vibrant and productive therapies that led to significant improvements in panic symptoms and associated quality of life. The authors suggest that psychoanalysts have been overestimating the potential damage of research constraints on psychoanalytic process and outcome.     

Psychoanalysis as science: the inductivist's resistance revisited

The scientific status of psychoanalysis has been the focus of heated debates among philosophers of science and among psychoanalysts. The most recent challenge to psychoanalysis as a science comes from the quarters of the inductivist philosophy of science. Since inductivism is a self-defeating philosophy, it is not surprising that inductivists demand that psychoanalysts pay an unlimited price for their claim of scientific status for psychoanalysis. Most psychoanalysts, in their response to this impossible challenge, unwittingly claim to have paid the price. What is worse, the claim is made in a confused and emotionally charged manner. Hence, psychoanalysts are usually defensive and, thus, in error when repelling (in this way) the attack of the inductivist philosopher. It is not psychoanalysis inductivists attack, but their own commitment to their own logic which leads inexorably to the dissolution of their argument, of all science, and, indeed, of psychoanalysis as well. It seems much more reasonable to postpone any response to the challenges that confront psychoanalysis today and to invest effort in a reformulation of the problem of the scientific status of psychoanalysis. Different rational solutions to the problem may evolve if we take care to become well informed first about the limits of our theoretical frameworks and show readiness to change them, if and when needed. That is to say, we can start with a somewhat tentative, not to say skeptical, frame of mind concerning the very concept of scientific status. We may try to keep and to contain our skepticism to the degree required by the discourse at hand, carry on exploring in our practice, report our results, and discuss them respectfully. We should start by admitting that, quite possibly, our discourse will end inconclusively.