Publicatii
Revista Romana de Psihanaliza
Publicatie a Societatii Romane de Psihanaliza,
Grup de Studiu IPA
ARCHIVING PSYCHOANALYSIS
Horst Kächele & Helmut Thomä
[Psychoanalysts, German Psychoanalytic Association]
Step 1 : The discovery of a narrative science
Freud´s resignative statement the the „Studies on Hysteria„(1895d)
that his case reports lack the stern character of true scientific reports but
read more like novellas could be made responsible for an unnecessary
continental divide between science and hermeneutics.
Thus psychoanalysis became a field based on narration - hearsay
evidence retreating to narrative truth (Forrester 1980; Spence 1982). To
highlight the importance of this methodological decision, imagine a science
of musicology with musicians sharing their most personal experiences by
writing case histories, or by letting consumers tell their emotional
involvements after a piano concerto. What is wrong about such an
approach? It could well be that one could build a science of musical
experience by collecting a large sample of these reported subjective testimonies.
The German professors Grimm from Göttingen systematically
started out to collect orally transmitted fairy tales. Today we have a well
developed field of fairy tale research with highly sophisticated methods to
analyze the large collections available all over the world (Propp 1928).
One might well take as an example S. Freud´s case report on the
Ratman (1909d) and look up Zetzel´s 'Additional notes' from 1966:
'It was my intention when I first undertook this study to base my
discussion primarily on the 1909 report published in Freud´s Collected
papers. Fortunately, however, I decided to reread the case history in the
Standard Edition. I was surprised and excited by the discovery I made-
namely the unique salvage of Freud´s daily notes covering the first four
months of this analysis'… 'In striking contrast with the 1909 publication,
there are more than forty references to a highly ambivalent mother-son
relationship in the original clinical notes.'
Conclusion: there is nothing wrong with clinical notes as long as they
are available for public scrutiny - this constitutes the essences of any
scientific enterprise.
Step 2 : A Research Institute in Psychoanalytic Psychology
One of the first books we happened to study when entering the field of
psychoanalytic process research was the 'Hixon Lectures on the Scientific
Status of Psychoanalysis' (ed. Pumpian-Mindlin 1952). Kubie expressed
the hope that this series of lectures may point the way to the more
systematic researches in this field which are long overdue, and may even
help to indirectly stimulate the organization of adequately staffed and
financed institutes for research in psychoanalytic psychology' (p. 46).
Later in these lectures he pointed out that 'a fundamental defect of
research in analysis […] has been the fact that only one person could
observe the empirical data of the therapeutic process, and that only once'.
Such data give rise to controversies, but they are hardly the stuff out of
which fundamental scientific advances can be fashioned.
It seems clear, therefore, if we are ever to understand psychoanalysis
deeply, one must begin by solving the problem of how to make adequate
recordings of the therapeutic process without at the same time distorting
the process' (Kubie 1952, p. 118). Kubie called it a dream for the future!
Step 3 : The battle for tape recording
The struggle to introduce technical aids into the analytic space was
begun by E. Zinn in 1933 (Shakow and Rapaport 1964, p.138). Although
it is not over yet, the opportunities offered by the tape recording of
analyses for psychoanalytic training and practice were first mentioned in
positive terms by McLaughlin at the International Psychoanalytic Congress
held in Helsinki in 1982.
Psychoanalysis did not take advantage of these numerous possibilities
for a long time. At the core of many misgivings was the concern that the
presence of a tape recorder could have consequences similar to those of a
third party, namely that the patient 'would become silent as soon as he
observed a single witness to whom he felt indifferent' (Freud 1916/17,
p. 18). Yet, it has long been known that patients, with few exceptions,
readily give their approval to having the interview recorded, discussed in
professional circles, and evaluated scientifically. It is not unusual for
patients to - correctly - expect to profit therapeutically from having
their analyst intensively concern himself especially with their case (Taubner
et al. 2007). Of course, the patient's initial approval and his motivations are
just one aspect; another decisive question concerns the effects of the tape
recording on the psychoanalytic process. One of the early pioneers,
Bergmann (1966) made the following succint observations:
'A research setup puts the therapist in the center of a triangular field
with each point of the triangle representing a potential source of
disturbance, namely, the relationship with the patient […] the relation
with professional colleagues, and the machinery of the setup. Surely, as
long as the therapist can clearly evaluate the threats emanating from each
of these sources his response is amenable to rational control and repair.
Under the impact of anxiety, however, he becomes less able to balance the
stresses, he perceives less clearly, and he tends to use pathological
mechanisms of defense'. (Bergmann 1966, p. 39)
In our opinion, we should respectfully honour the pioniers of tape
recording psychoanalytic treatments such as Earl F. Zinn (1933), Paul
Bergmann (1966), Merton Gill (1964), Hartvig Dahl (1967). It was their
example that encouraged our own involment in this technology.
Step 4 : Archives of Psychoanalyses
In the first edition of the Handbook of Psychotherapy and Behavior
Change (Bergin & Garfield 1971) Luborsky and Spence complained about
the paucity of primary data - data accumulated during actual analytic
sessions. 'Ideally, two conditions should be met: the case should be clearly
defined as analytic […] and the data should be recorded, transcribed. and
indexed so as to maximize accessibility and visibility' (1971, p. 426). Since
then that deplorable situation has changed. Some institutions have embraced
the conception that archiving clinical data provides a secure base to
overcome the deficiencies of the psychoanalytic field in hypothesis testing.
While the junior of us both (HK) was in training analysis recording his
first two analytic cases and at the same time working as a junior research
fellow together with Dr. Mergenthaler we were faced with the sheer
amount of transcribed sessions from our first research case treated by Dr.
Thomä. Out of the necessity of knowing how to handle the data of some
500 recorded and transcribed sessions we developed the daydream of
having as tool a computer based storage device. His training analyst - a
seasoned clinician - never missed an opportunity to interpret the
grandiosity of this idea in various ways as one may surmise. Something like
the Hampstead Index (Sandler 1962) was in our discussions; yet it should
be more basic providing the raw material for any scientist who would come
along. Happily his analysis came to an end and these creative daydreams
survived the analytic work. So, finally, the German Research Society
supported the development of the ULM TEXTBANK, a computer based
archive with built in tools for retrieval and text analysis (Mergenthaler &
Kächele 1988). Meanwhile, a few more data banks have been set up, f. e.
by Waldron (1989) the 'Psychoanalytic Research Consortium, New York'
and by Luborsky et al. (2001) the Penn Archives.
Step 5 : From soft to hard methods
Public availability of data is crucial; however, the kind of material to be
made available to the public less so. For each material, be it case reports,
therapist notes, patients diaries, or transcribed tape-recorded sessions
modern social science offers a vast choice of methods. One of our
favourites demonstrating the power of textual critique as a soft tool is
Steven Marcus (1977) re-analysis of Freud´s Dora-case. That essential
psychoanalysis consists in a conversational activity that had been pointed
out by Freud (1916/17); however, analysts have only recently begun to use
the various methods of discourse analysis. Rosen (1977) initiating the New
York Study Group on linguistics made the point that the study of language
should be at the forefront of our work; Shapiro (2002) has taken up this
lead discussing the conversational features of creative psychoanalytic
work. A few fine examples have been provided by Labov & Fanshel (1977),
by Flader et. al. (1982) and recently by Streeck (2004) and Boothe (2004).
Ever since social science had invented the rating scale technology there
has been no psychoanalytic concept that could not in principle be studied.
And with the introduction of computers in the early seventies,
psychoanalytic process research hooked up with a technology that had
developed in the historical and political sciences where archives are the sine
qua non for researchers.
Step 6 : The need for specimen cases
Research findings have to be replicated in order to prove their value.
The core idea of having specimen cases allows not only testing individual
hypotheses for single cases, but allows testing the comparative fruitfulness
of various methods. Most likely the Schreber case (Freud 1911c) has
stimulated the largest amount of critical discussions just because it was a
publicly available document (Kächele 1981). As single case research has
repeatedly been called the most suitable approach for evaluating
psychoanalytic treatments (Wallerstein & Sampson 1971; Edelson 1988)
what we are in need of are well documented single cases. There are but a
few examples like Mrs. C that has served as material basis for a diversity of
approaches and has demonstrated the fruitfulness of this type of research
activity (f.e. Weiss & Sampson 1986; Bucci 1988; Spence et al. 1993).
Our long standing work on our German specimen case, Amalia X has
served similar purposes among the German psychoanalytic research
community as has been summarized (Kächele et al. 2006) and reported in
great detail in the third volume of the Ulm textbook (Thomä &
Kächele 2006):
4. Amalia X - the German Psychoanalytic Specimen Case
a systematic clinical description
5. Guided Clinical Judgments
5.1 Comparative psychoanalysis on the Basis of a New Form of
Treatment Report
5.2 Emotional Insight
5.3 Changes in Self-esteem
5.4 Suffering from Oneself and from Others
5.5 Dream Series Analysis as a Process Tool
5.6 Studying the Core Conflictual Relationship Theme (CCRT)
5.7 The Unconscious Plan
5.8 The Reaction to Breaks as an Indicator of Change
5.9 The Psychotherapy Process Q-Sort
6. Linguistic Studies
6.1 Introductory remarks
6.2 The Ulm Textbank
6.3 Verbal Activity in the Psychoanalytic Dialogue
6.4 The Emotional Vocabulary
6.5 The Characteristic Vocabulary
6.6 Emotional and Cognitive Regulation in the Psychoanalytical
Process: A Microanalytical Study
6.7 Attachment and Loss
The multitude of studies that can be performed on a single publicly
available case speak to the fertility of providing such research cases for public
use.
The model-case Amalia X represents an example of a research-based
case study which Grawe (1992) marks as an especially successful and
promising way for future process research:
…Such 'research informed case studies'… that is case studies in
which extensive process and measured change on the basis of an
elaborated clinical case conception are interpreted in their entire
context and in which every statement can be traced back to the
base in the recorded measuring, can be viewed as a particularly
promising way for future research of process. Because of the
interpretation in the context of the understanding of a clinical
case, the results make clinical sense; however they differ from
clinical fiction in that they have a close comprehensible relation
on a basis of objective measuring data, which is independent
from the interpretation
(Grawe, 1992, p. 140)
The studies we have performed support not only the finding that this
treatment led to a diversity of changes in the experience and behaviour of
the patient Amalia X, but also demonstrate the benefit of research
techniques in which the findings contribute to the understanding of
change processes. Research techniques provide the essential reliability of
observations that are lacking in clinical inferences. The number of
descriptive dimensions, which can be examined by means of a transcribed
corpus, is huge, dependent only on the availability of suitable process
measures. However, we can conclude that change processes exist and that
these can be recorded reliably and validly. We find these in interactive
dialogical exchange as well as in basic changes in the personality of the
patient.
Therewith, the statement that psychoanalytic therapy occupies itself
with probabilistic states of a person is supported; in other words, the object
of therapeutic efforts are the patient´s response tendencies that in the
beginning show great stability (in the sense of persistent templates, chapter
two in this volume), which in the course of the treatment become more
and more unstable and through which changes of the system become
possible. When the conditions by which a system of response tendencies
is supported are known, then clinically typical statements of probability are
permitted. Due to uniqueness in each individual case these conditions can
also be completely different; consequently, the necessity of single case
studies arises as well as the known problems of generalisation.
The formalized evaluation of treatment reports goes beyond the
heuristic function of clinical description and can secure statistically
significant correlations. Our findings show that such changes of the
probability of the behaviour and the experience of a patient can hardly be
reliably identified in individual sessions; instead, they have to be observed
on the macro-systematic level of multiple sessions over time. Our
empirical studies of our model case Amalia X emphasize that a long-term
view of the course of treatment is essential to identify the structural
changes of the patient. Short range assessments using a few sessions may
be useful for understanding the current interactions, but they do not
provide reliable information about enduring changes in feeling and
behavior. In our view only a long-term perspective over the course of the
treatment can be the arbiter of success.
Step 7 : Comparative Psychoanalysis
Comparing clinical experiences in one case with other cases is part and
parcel in our professional thinking; however the phrase 'comparative
psychoanalysis' is fairly new to our vocabulary (Scarfone 2002). In German
the designation 'vergleichende Kasuistik' (Engl.: comparative case study,
Jüttemann 1990) is often used. It refers to a qualitative comparison of
various forms of psychotherapy, psychoanalysis among them. In a recent
paper we pointed out that in view of the official recognition of psychoanalytic
pluralism brought about by the courage of Wallerstein (1988), we are now
obliged to compare various psychoanalytic techniques and theoretical
assumptions with each other (Thomä & Kächele 2007). To make the
comparison reasonable, reliable and fruitful, shared criteria are needed. In
membership papers and published case reports, criteria are usually only
implied, if not totally missing. Eagle's (1984) complaint is still justified: 'It
seems to me ironic that psychoanalytic writers attempt to employ clinical data
for just about every purpose but the one for which they are most
appropriate - an evaluation and understanding of therapeutic change.'
A corollary of comparative psychoanalysis is the growing interest in
different ways of documenting clinical facts. Within the last decade, an
impressive number of original papers have been published on this topic. In
his foreword to the special 75th anniversary edition of the International
Journal of Psychoanalysis, devoted to 'Conceptualisation and Communication
of Clinical Facts in Psychoanalysis' Tuckett (1994) wrote:
„After 75 years it is time not only to review our
methodology for assessing our truth, but also to
develop approaches that will make it possible to be
open to new ideas while also being able to evaluate
their usefulness by reasoned argument.
The alternative is the tower of Babel„(p. 865).
