From Psychoanalytic Narrative to Empirical Single Case Research

Implications for Psychoanalytic Practice

Horst Kächele, Joseph Schachter, Helmut Thomä

• Publisher: Routledge
• Year: 2011
• Print ISBN: 9780881634884
• eBook ISBN: 9781135468804
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Recognition of the need for empirical research and interest in its findings are growing in psychoanalysis. Many psychoanalysts now acknowledge that research is imperative to try to deal with the factors propelling the diminution in status and prestige of the discipline, as well as the number of patients in intensive psychoanalytic treatment. In addition, there is increased pressure to expose and acquaint candidates with analytic research in the course of their education.

From Psychoanalytic Narrative to Empirical Single Case Research revivifies the experimental potential of psychoanalysis by focusing a number of structured research methods on a single case study. Drs. Kächele, Schachter, and Thomä, in tandem with the Ulm Psychoanalytic Process Research Study Group, bring their formidable tools and knowledge to bear on Amalia X, a former patient of Dr. Thomä's, whose case history is well-documented, preserved and available for formal empirical study. After providing an intensive review of the problematic aspects of clinical psychoanalytic research and an exegesis on the use of the case study itself, the specific case history of Amalia X, which dominates and centers the remainder of the book, is thoroughly examined. The following two chapters – utilizing clinical and linguistic models, respectively – deconstruct Amalia's psychopathology along a variety of methodological axes in an effort not only to uncover the roots of her presenting symptoms, but also to reify and validate the strange bedfellows of psychoanalysis and empiricism in general. The book would be incomplete, however, without its final chapter, which provides suggestions and insights into the clinical applications and implications of their combined research.

Chapter 1

Psychoanalytic Therapy
Process Research^*

INTRODUCTION

The case for psychoanalytic research is not academic; it is imperative. Psychoanalysis worldwide is under stress, and especially traditional American psychoanalysis is confronted by a simmering crisis reflected in decreased status and prestige. Although the roots of these crises are manifold, unresolved disagreements about fundamental theoretical and clinical tenets have resulted in a fragmentation of psychoanalysis that contributes to this decline (Hauser, 2002). For example, starting around 1960, questions were raised about the reliability and validity of the concept of “psychoanalytic process.” Numerous attempts to achieve a consensually agreed definition all failed. Vaughan, Spitzer, Davies, and Roose (1997) conclude from empirical studies that analysts cannot judge analytic process reliably and question whether it is a viable construct on its own. Process definitions have to be related to the outcome. Sigmund Freud (1912e, p. 114) implied this when he coined his famous inseparable bond thesis.

Dialogues repeatedly have failed to resolve the lack of consensual agreement regarding theoretical or clinical issues. Wallerstein (2002) concludes the following:

We are without warrant … to claim the greater heuristic usefulness or validity of anyone of our general theories over the others, other than by the indoctrination and allegiances built into us by the happenstance of our individual trainings, our differing personal dispositions and the explanatory predilections then carried over into our consulting rooms. (p. 1251)

It is time, Gabbard and Westen (2003, p. 338, italics in original) urge, that “we attempt to move from arguing about the therapeutic action of psychoanalysis to demonstrating and refining it.” The best possibility for resolving these differences and for developing some consensus about the fundamental tenets of psychoanalysis rests with empirical research generating relevant data that can provide a basis for consensual agreement about fundamental psychoanalytic principles (Schachter, 2005b).

For many years the Ulm Psychoanalytic Process Research Study Group has implemented a program to examine the material bases of psychoanalytic therapy. We were and are convinced that only the careful exploration of the patient’s interaction with the analyst can illustrate the central aspects of psychoanalytic treatment and enable an empirically driven theory of the process. In a panel discussion about psychoanalytic process research at an annual meeting of the German Psychoanalytic Association on October 11, 1968, in Ulm, Germany, the senior of this group, H. Thomä articulated the necessity of systematic examination as follows:

1. The psychoanalytic and the relevant psychosomatic research seems, as one can learn from literature, to move mainly in two directions that can simply be described as “process” and as “outcome” research. Process research mainly concerns the scientific evaluation of psychoanalytic treatments of single cases. However, in examinations that mainly deal with results of therapies, greater numbers of treated and nontreated cases are compared with one another. The two research directions overlap in many points because Freud’s (1937a, p. 256) “beneficient results” of the therapy are dependent on the course of the psychoanalysis. The differentiation of process and outcome dates back to the Marienbad Congress 1936 and in particular to a lecture by E. Bibring (1937).
2. However, “one of the famous claims of analytical work is that research and treatment coincide” (Freud, 1912e, p. 114); in another place Freud (1927a, p. 256) speaks about a “precious encounter,” an “inseparable bond between healing and research.” But it should not be concluded eo ipso that treatment and research are identical. There is no assurance that the observation of the analyst and his theoretical conclusions drawn from observation are really reliable.
3. Process research is the most original field in psychoanalysis. The psychoanalytic process is determined by the events in the psychoanalytic situation. The specific technical psychoanalytic means is the interpretation. In the interpretation, technique and theory are combined. Process research serves for the completion of the technique and the validation of the theory (Thomä, 1968).

It has been argued that clinical case reports, especially Freud’s, have had a greater influence on psychoanalytic theory and practice than findings generated by formal research. That influence, however, has had negative as well as positive consequences. A number of case-report-based theories and practices have proven to be erroneous, such as the conception of infantile omnipotence, the conception of female sexuality, and the belief that homosexuality was intrinsically psychopathological. Clearly, plausibility of the clinical implications of case reports is not a solid basis upon which conclusions can be drawn (Schachter & Kächele, 2007).

Wallerstein and Sampson (1971, p. 47) conclude that it was necessary to conduct formalized and systematized examinations of therapeutic process in psychoanalysis: “Our central conviction is that the informal case study, in spite of its forceful power of conviction, has certain realistic and obvious scientific limitations.” Several observers attested the lack of reliability of clinical inferences (Schachter & Kächele, 2007). Pulver (1987a) demonstrates that analysts with different theoretical convictions vary widely in the analytic inferences they derive from case material, and Fosshage (1990) and Streeck (1994) replicate this finding. Spence (1992, p. 562) observes, “The clinician … tends to listen to the clinical material with a favorite set of theoretical predispositions.” And he concludes, “Interpretations in a clinical setting have an unfortunate tendency to reflect the therapist’s expectation rather than the underlying facts of the matter” (ibid., p. 559). Masling and Cohen (1987, p. 65), citing several clinical examples, even draw the conclusion that all psychotherapies generate clinical evidence that support their theoretical positions and so can be understood as “instances of therapists systematically rewarding and extinguishing various client behaviors.”

In addition to these limitations in the usefulness of clinical case reports, there are analysts who cite the extraordinary difficulties in empirical study of psychoanalytic case material and believe that the result of such study is likely to be of little value to psychoanalysis (Green, 2000) or may well be damaging (Perron, 2006). Many analysts criticize nonclinical analytic research, arguing that formal research destroys the uniqueness of individual patients.

Since in scientific terms there are serious limitations to the value of clinical case reports, progress in psychoanalysis should not rest solely on such reports. Clinical findings need to be tested by empirical research. Those critics fail to recognize that some sacrifice of the uniqueness of phenomena and individuals is necessary in order to conduct empirical studies. Krugman (2007) articulates this in the field of economics, explaining why the abstract conception of “economic man” is useful. It is easy, he notes, to make fun of such abstractions:

You might ask, why not represent people the way they really are? The answer is that abstraction, strategic simplification, is the only way we can impose some intellectual order on the complexity of economic life. And the assumption of rational behavior has been a particularly fruitful simplification. (p. 27)

Comparable abstractions are necessary to impose some intellectual order in the complexity of psychoanalytic treatment. Ever since Glover undertook a questionnaire study with British analysts (Glover & Brierley, 1940) interpretation was the first subject of manifold efforts to examine aspects of the treatment process in a formalized and clinical manner. Thomä and Houben (1967), picking up the long debate on interpretations as a central aspect in the analyst’s technique, registered the patient’s reactions in order to estimate the effects and the ensuing reactions on the former. In the course of these examinations the problems concerning the effectiveness of interpretations and the related problem of truth resurfaced again and again.

To systematically evaluate the impact of interpretations, Thomä and Houben (1967) followed Isaacs’s (1939) suggestion and designed a report-schema. This demanded that the analyst write an hourly protocol and localize his interpretations theoretically, and, in addition, to state exactly the patient’s reactions (for a precise description see Thomä & Kächele, 1994b, pp. 22–23). In the course of the examinations it became obvious that the appropriate validation can be obtained only by empirical process and outcome research. In agreement with many authors the Ulm study group decided to perform a series of process studies within the intensive model design that is adequate to meet—as Bucci (2007) spells it out—the characterization of psychoanalysis as the science of inner experience, conscious and unconscious, or one might say the science of psychological representations and processes. Psychoanalysis is not a science of behavior, and not neuroscience. In cognitive psychology as in psychoanalysis, one makes inferences from what is observed to inner experience, including conscious and unconscious experience. Scientifically, one doesn’t access inner experience introspectively, that is, through one’s own subjectivity (Bucci, personal communication).

The positive assessment of the formal single case study in which Wallerstein and Sampson (1971) aim at the reconciliation between clinical impressions and research was the critical methodological suggestion in developing their research strategy. If one follows their recommendation, the systematic single case study provides the intersection of clinical and scientific work.

Davison and Lazarus (1994) also comment positively about the possible advantage of an intensive case study:

• A case study can raise doubts about a generally accepted theory.
• A case study can be a valuable heuristic for following better controlled examinations.
• A case study allows the examination, even if not really controlled, of a seldom but important phenomenon.
• A case study provides the possibility for new principles and ideas to be tested in a new way.
• A case study can in certain circumstances allow enough experimental control of phenomena to provide scientifically acceptable information.
• A case study can supply meat for a theoretical skeleton.

In exploring these arguments, the case-study methodology was rediscovered also in academic psychology (Bromley, 1986). Furthermore, new methodological approaches and the growing appreciation of qualitative research (Frommer & Rennie, 2001) have produced in the meantime a lasting impact on social science in general and on the field of treatment research in particular (Hill & Lambert, 2004, p. 102). Today there is more emphasis on what kind of questions must be examined by which methodological approach in order to find interesting answers that enrich the field (Kächele, 1986). The purpose of these approaches is both “to do justice to the subjective factor in social sciences and to focus research efforts on the individual fate” (Leuzinger-Bohleber, 1995, p. 446).

RESEARCH IN CONTEMPORARY PSYCHOANALYSIS

The psychoanalytic culture differentiates between research in psychoanalysis and research on psychoanalysis. Scientific investigations in psychoanalysis originate in the therapeutic situation. In a rather optimistic stance it is assumed that the clinicians apply the psychoanalytic method in a critical vein and thus fulfill the requirement of scientific thinking.

The English language allows a play of words: Wallerstein (2001) distinguishes between search and research. Analysts are constantly “searching,” but to come from search to research a certain degree of formalization and systematic categorization has to be applied. In the prevailing vignette-culture most psychoanalytic authors limit themselves to the description of transference and countertransference processes, thus leading to the rather extreme stance of subjectivism.

The prevailing representation of treatment reports is characterized by reference to essential psychoanalytic concepts. Research-minded analysts differ from clinicians who prefer to remain “on-line” (an expression introduced by Moser, 1991) that characterizes an analyst’s stance in the evenly hovering attention in the clinical situation; it is in contrast to the objectifying “off-line” position of a clinician outside the consulting room or of a researcher. Both figures of speech grasp the pendulum from subjective experience to objectifying reflection within and outside the session. Already when writing session notes the analyst leaves the on-line position, and when case reports are published another basis of collegial and interdisciplinary discussions is reached.

Research in psychoanalysis thus refers to the “mother ground” (Schlesinger, 1974) of the therapeutic situation and always includes the analyst, his thinking, and his actions, which is not only reflected from the outside by himself but also by others. Therefore, the contrasting of research in psychoanalysis and research on psychoanalysis separates what belongs together (Perron, 2003). Both perspectives refer to intraclinical research (in contrast to extra- or nonclinical research). To raise clinical reports to the rank of single case studies detailed and reliable criteria have to be made explicit.

Nonclinical empirical psychoanalytic research has two large realms, independent from each other. The application to all topics of culture knows no boundaries; therefore, the interdisciplinary exchange with all humanities covers a wide field, and we are unable to cover it here (see Section 6 of the recent Textbook of Psychoanalysis [Person, Cooper, & Gabbard, 2005]). However, we will mention some points with regard to extraclinical, experimental research about psychoanalytic topics.

Although the experimental approach is the most appropriate method for examining hypotheses (Campbell, 1967), manipulation of the examined object is not possible in the clinical situation. Nonclinical studies examining the diverse aspects of basic psychoanalytic theory, though often largely unknown to clinicians, have attracted many experimental psychologists (Shulman, 1990). Quite extensive compilations and secondary analyses by well-meaning critics have been compiled (Fisher & Greenberg, 1977, 1996; Hilgard, 1952; Kächele, Ehlers, & Hölzer, 1991; Kline, 1981).

There is no reason to view the clinical situation as a deficient version of the experiment; a formerly popular way of expressing this was to say that the psychoanalytical treatment situation is a quasi-experimental event. Shakow (1960, p. 88) criticizes this view and prefers to speak about the psychoanalytical interview as a seminaturalistic approach. The proper methods of examination are therefore not experimental methods but are methods of the systematic, social-science-based analyses of material as Allport (1942) documents. The single case study can be handled with exactness and procedures that are suitable to the examined materials. Edelson (1988, p. 231ff) especially emphasizes in his book Psychoanalysis—A Theory in Crisis the possibilities of the single case research to surpass the heuristic discovery oriented perspective. Generally speaking, it is remarkable how many papers are published about problems of doing research and how few substantial reports about systematic studies performed are available.

CONCEPTUAL RESEARCH

Recently a new genre has been created for which Dreher (2000, 2005) has coined the expression conceptual research. It is fair to say that conceptual clarifications have constituted not a small bulk of analysts’ efforts to come to grips with the ongoing change of terms and their referents (e.g., Compton, 1972; Pine, 2006). A recent overview concluded that “if IJP accurately reflects the international viewpoint, conceptual research is a central issue in current psychoanalytic research” (Leuzinger-Bohleber & Fischmann, 2006, p. 1361).

Concepts characterize the cosmos of psychoanalytic theory and its change. Therefore, the range of concepts and their relationship to clinical experience, their operationalization in the widest sense of the word, has been in the center of the psychoanalytic profession for a century. Written definitions attempted to determine what pychoanalysis was and is. One easily can consult using a conceptual dictionary—for example, the highly appreciated Vocabulary of Psychoanalysis by the French analysts Laplanche and Pontalis (1967), the American Psychiatric Association sponsored A Glossary of Psychoanalytic Terms and Concepts (Burnes, Moore, & Fine, 1968), Klumpner’s (1992) A Guide to the Language of Psychoanalysis, or The Dictionary of Kleinian Thought (Hinshelwood, 1989). However, what psychoanalysts make out of these definitions in their practical works remains opaque. In our view pure conceptual research without empirical underpinnings remains sterile and may even hinder progress.

THE CONTEMPORARY VERSION OF FREUD’S INSEPARABLE BOND THESIS

The scientific study of single cases, not the clinical reports, constitutes in our view the Contemporary Version of Freud’s Inseparable Bond Thesis. In this sense Freud’s beneficial effect—the therapeutic success—represents a pragmatic criterion of truth. It requires the clinician to spell out his hypotheses on structure and dynamics and to look for independent criteria to refute or confirm these.

Clinical inferences from the material of a case history may be valuable sources of hypothesis development—which Blatt (2004, p. 4) beautifully argues recently by pointing out the importance of his two initial psychoanalytic cases for his later thinking about anaclitic and introjective types of depression—but are not of scientific value for hypothesis testing, largely because clinical inferences are diverse and notoriously unreliable. Clinical material from a case history is almost invariably viewed very differently by different analysts. A prominent scientist notes that it is ironic “that psychoanalytic authors attempt to employ clinical data for just about every purpose but the one for which they are most suitable—an evaluation and understanding of therapeutic change” (Eagle, 1984, p. 163). However, for the assessment to be scientific it must be based on reliable measurements.

A first striking example was provided by Lester Luborsky (1955), who, working together with Raymond Cattell, i...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Foreword
• Editors
• Contributors
• Preface
• Chapter 1: Psychoanalytic Therapy Process Research
• Chapter 2: Problems of Metascience and Methodology in Clinical Psychoanalytic Research
• Chapter 3: The Significance of the Case History in Clinical Psychoanalytic Research
• Chapter 4: Amalia X The German Psychoanalytic Specimen Case
• Chapter 5: Guided Clinical Judgments
• Chapter 6: Linguistic Studies
• Chapter 7: A Summary and Implications of Research for Psychoanalytic Practice
• References
• Footnotes
• Index