Change Through Time in Psychoanalysis

Transformations and Interventions, The Three Level Model

Margaret Ann Fitzpatrick Hanly, Marina Altmann de Litvan, Ricardo Bernardi, Margaret Ann Fitzpatrick Hanly, Marina Altmann de Litvan, Ricardo Bernardi

• Publisher: Routledge
• Year: 2021
• Print ISBN: 9780367560904
• eBook ISBN: 9781000351019
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Change Through Time in Psychoanalysis presents a new stage of the work done through the IPA Committee on Clinical Observation between 2014 and 2020—the advances in our method, the Three Level Model (3-LM), and our clinical thinking.

In this new volume, ideas on observational research, clinical narratives based on 3-LM group discussions, and adaptations of the model for training candidates show more experience, more depth, more answers, and, of course, new questions. Contributors from three regions of the IPA have written extended case studies of 10 psychoanalyses, rich in verbatim session material, focusing on the main dimensions of the patient's psychic functioning, specific changes in the analytic process, and related interventional strategies.

The reader will find, in the method and in the clinical narratives, new and clarifying points of view in the observation of transformations in patients in psychoanalysis and of the analysts' techniques, useful both in professional development and in teaching candidates.

Part I
Clinical thinking in psychoanalysis

Chapter 1
A common ground in clinical discussion groups

Intersubjective resonance and implicit operational theories¹

Ricardo Bernardi

Introduction

In this chapter I discuss the nature of the dialogue among analysts who employ different theoretical frameworks. I focus on the conditions that facilitate fruitful exchanges. The fact that this dialogue can actually take place is relevant to elucidating the epistemological status of our discipline and to laying the foundations for the development of true scientific controversies. Such controversies generate more favourable conditions for the progress of clinical practice and psychoanalytic education and research.

The features and effects of pluralism continue to interest our discipline. First, the word pluralism denotes a fact: there is a plurality of theoretical and technical ideas in psychoanalysis. Second, it suggests the existence of a collective agreement that enables the coexistence of these diverse ideas within the same institutional framework. This was, for instance, the result of the well-known controversies between Freud and Klein (King & Steiner, 1991), which took place in the British Society between 1941 and 1945. These controversies ended with a “gentlemen’s agreement” that made it possible for different schools of thought to coincide in one society.

Yet the idea of pluralism involves a more ambitious aspiration, namely the existence of a space for sharing ideas and experiences among the various schools. The aim is not just to achieve consensus but, more essentially, to develop an interaction that will favour the growth of the discipline. Such interaction includes both agreement and the clarification and explanation of dissent. Nonetheless, the conditions that render this exchange fruitful are rarely found. The Freud-Klein controversies did not lead to the development of such a space. Neither did pluralism help meet this goal in the Río de la Plata (Bernardi, 2001). Widlöcher (2008) has wondered, with good reason, if psychoanalysts know how to debate. Without debate, pluralism may easily cease to be a shared argumentative field where alternative hypotheses can compete and interact and become a “plurality of orthodoxies” (A. Cooper, 2008), resulting in the fragmentation of the field.

A common ground is needed for an enriching interaction to occur. In the philosophy of language, the expression common ground or grounding refers to the “mutual knowledge, mutual beliefs, and mutual assumptions that are essential for communication between two people” (Clark & Brennan, 1991, p. 127). Communication includes productive agreements and disagreements and brings into play not only content-related issues but also questions tied to the exchange itself. In this chapter I pay particular attention to communication that brings to light a clinical common ground and ways in which this common ground may favour a fertile pluralism.

First, I examine the nature of the difficulties posed by theoretical and clinical communication in psychoanalysis. Wallerstein and Green engaged in a key debate on the existence of a clinical common ground in 2005. Both concluded that an exercise or procedure should be developed to determine whether or not this common ground exists. My analysis is based on the experience of IPA clinical discussion groups that applied the Three-Level Model for Observing Patient Transformations (3-LM). Second, starting from these group experiences, I look at the features of the clinical common ground in each of the three levels making up the model: phenomenological observation, clinical conceptualization, and theoretical explanation. Finally, I present conclusions about the relevance of the clinical common ground for psychoanalytic training and scientific dialogue among analysts.

Pluralism: Theoretical integration or incommensurability?

Is it difficult to achieve a conceptual integration of conflicting theoretical approaches? The same word can denote different things, depending on the theoretical framework, and each school may designate the same phenomenon, or aspects of it, with a different name. For this reason, a “top-down” conceptual integration, which starts from universally accepted metapsychological premises or assumptions, is not feasible; axiomatic postulates or assumptions vary. Theoretical diversity, moreover, results in diverse ways of perceiving clinical phenomena. Consequently, it is hard to determine to what extent the various theories speak of the same phenomena and/or conceptualize them in a compatible or commensurable way.

When I started teaching at my institute, I attempted to compare Freud’s interpretation of the Wolfman’s major dream (Freud, 1918) with the reinterpretation of this dream by authors such as Melanie Klein (1932/1964) and Jacques Lacan (1966), discussed by Serge Leclaire (1958). I was powerfully struck by the fact that, while the three approaches considered the dream in similar ways and used similar theoretical terms, the clinical facts they identified as relevant and their metapsychological postulates were clearly different. We should hence ask ourselves if there is a space of shared meaning among these approaches or if, following Kuhn (1962) and Feyerabend (1962), they have adopted incommensurable perspectives. Or, to put it more simply, do different analysts see the same wolves (Bernardi, 1989)?

Freud chose the sexual content of the dream; Klein based her interpretations on the aggressive oral aspects (the wolf’s open mouth); and Lacan and Leclaire focused on the formal determinants (V, W, M. . .), that is, the signifiers. As a result, the aspects deemed relevant are not the same. The three approaches use similar words—unconscious, Oedipus, transference, and so on. Yet the semantic and pragmatic contexts differ. The Lacanian concept of Oedipus must be understood in connection with notions such as the real, the imaginary, and the symbolic. This is not the case with Freud. At the same time, the Kleinian view of the Oedipus complex is part of a network that includes concepts such as positions, early anxieties, unconscious phantasy, and part-objects.

When we base our observation on certain theoretical premises, we choose phenomena that agree with our premises. It is, therefore, very difficult, if not impossible, to achieve conceptual integration on this basis. The attempt by the IPA Project Committee on Conceptual Integration (Bohleber et al., 2013; Bohleber et al., 2015) shows how hard this task becomes when it involves basic concepts such as enactment and unconscious phantasy. Integration is questionable because it is not practically possible to include all the relevant versions of these notions used by different psychoanalytic cultures or to offer a conceptual definition that encompasses them all.

Neither is it feasible to offer clinical examples that are universally accepted. When we start from conflicting theoretical premises, it is hard to find common clinical models. Different theories describe different phenomena. For example, Kohut describes self-objects; Klein, part-objects; and Lacan, objet (petit) a. Rather than unobserved or neglected, the phenomena that are left out are unobservable from certain theoretical frameworks. This situation forces us to wonder if we are in the presence of what Hacking (1999) calls “interactive kinds” or “classes,” where concepts intended to describe reality actually modify it.

Summing up, the situation we find is similar to what philosophers have called semantic holism. This approach claims that a certain part of a language can be understood only in terms of its relationship with this language as a whole. Consequently, a gap is opened between psychoanalytic theories that resembles the deep, gestaltic change in people’s world view described by Kuhn as a paradigm shift, which generates a relation of incommensurability between theories (Kuhn, 1962). Quine’s (1960) holism suggests the inability to prove a specific hypothesis when it is considered in isolation from the rest of the theory. This hypothesis is part of a network of assumptions and auxiliary hypotheses that are being simultaneously tested.

From this perspective, rather than aspiring to speak the same language, psychoanalysts, like many other scientists, must learn to be polyglots. We will thus be able to communicate with colleagues who use a different theoretical language and allow them to speak the language of their favoured theory. The scenario actually becomes more complex if we consider dialects, that is, different versions or interpretations of the same author—a common occurrence within a region or among the followers of this author. Such intra-theoretical differences give rise to debates that are no less passionate or uncompromising than inter-theoretical dissension. For this reason, while areas of intersection or convergence have been found between theories (Kernberg, 1993; G. Gabbard, 1995; Filho, 2003), it does not seem possible to assert that a common language has been achieved.

In general, training in pluralistic institutions responds to the polyglot model. Analysts are taught to use a variety of theoretical languages, and the accent is placed on using them in a way that is consistent with the metapsychological postulates of each. Nevertheless, this should be just the first step. Psychoanalytic training should place a similar emphasis on transmitting ways of creating a fruitful dialogue among theories and of checking them against each other or developing alternative hypotheses that may be compared when tackling clinical problems. Without this second step, we reinforce semantic holism, and each analyst ends up speaking his or her own language and expecting it to encompass the totality of psychoanalysis.

In my opinion, the logical and semantic barriers that stand between theories are not insurmountable. These barriers develop when the clinical material is examined on the basis of theoretical principles that are viewed as the only admissible ones. “Top-down” deductive reasoning prevails, and phenomena that do not fit into the theoretical framework are excluded. As a result, certain metapsychological agreements must be attained for clinical-level agreements to develop. In actuality, however, attaining such agreements is not a necessary or legitimate requirement, nor does it reflect the spontaneous reasoning that unfolds in clinical practice. Furthermore, the detailed study of some current psychoanalytic controversies suggests that rather than as the effect of a real situation of incommensurability, the barriers thus generated may be viewed as defensive strategies to prevent the clinical material from challenging metapsychological premises (Bernardi, 2002).

The clinical common ground

The key question is whether communication can rely on a clinical common ground that is shared by analysts with differing theoretical perspectives. If so, this clinical common ground should serve as a starting point for a “bottom-up” inference process that would make it possible to progress upward from shared clinical experiences toward theoretical explanations of a higher level of abstraction.

The presence or absence of a clinical common ground was the focus of a well-known controversy between Wallerstein (2005) and Green (2005). Reaffirming earlier statements (Wallerstein, 1988, 1990), Wallerstein claimed that, despite their varying theoretical and technical positions, analysts share a common ground at the clinical level. Green strongly questioned this claim. From a perspective close to semantic holism, he argued that theoretical and clinical concepts were inseparable and challenged the analytic community to show the presence of this mythical common ground in scientific papers, congresses, or psychoanalytic debates.

Interestingly, Green suggests an empirical procedure that might be useful to identify a kinship among theories. He states that such kinship should be demonstrated through a long-enough series of discussion sessions among analysts with different theoretical and technical approaches. “Now, to my knowledge, this exercise has never been attempted,” adds Green (2005, pp. 628–629). Wallerstein agrees with this procedure and considers it an example of empirical research. He also indicates the potential existence of “differences in our conception of the necessary steps in the process of this demonstration (or determination)” (Wallerstein, 2005, p. 637), but does not elaborate on this point. Nonetheless, I believe it is critical to identify these steps so as to show where and under what conditions the common ground may be revealed.

We may view the procedure or exercise proposed by Green as an extremely useful and interesting observational study or natural experiment concerning the nature and scope of the clinical common ground. The standard situation would involve communication failures among analysts with different affiliations, which tend to occur, following Green, in scientific exchanges or controversies involving metapsychological differences. Such controversies show, as Green claims, that “most of the time psychoanalysts speak only one language in psychoanalysis, their own” (Green, 2005, p. 631).

The above-mentioned “experiment” suggests, instead, exploring a different path that may provide a basis for communication that will prevent failure. To this end, we must search for the common ground in the immediate effect of the material on analysts’ minds, regardless of the way they will interpret it later, and then identify points of contact, step by step, in the inference process that goes from this first impression to descriptive concepts to theoretical descriptions. A “bottom-up” process of this sort starts at the experiential level, granting this level a consistency of its own, despite the potential influence of analysts’ previous theori...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Contents
• Notes on contributors
• Introduction
• PART I Clinical thinking in psychoanalysis
• PART II Change in metaphors and dreams
• PART III Foci of the analyst's interventions, mechanisms of change
• PART IV Impasse
• PART V New uses of the 3-LM in the transmission of psychoanalysis and in professional development
• PART VI Clinical observation groups and the psychoanalysis of children
• PART VII Improving clinical evidence
• PART VIII Three-Level Model
• Index