For the last two decades, in the psychoanalytic world 1, a new research culture has gradually been striving to establish itself, diametrically opposed to the long prevailing attitude: most psychoanalysts, sharing Freud’s scepticism about the importance of empirical research and supporting the so-called Junktim thesis 2 – i.e. the unbreakable bond between therapy and research – have traditionally considered empirical research of very little interest, if not a downright “antipsychoanalytic practice” as they have called it.
This scepticism towards empirical research into psychoanalytic psychotherapy is based on the concern – or rather the conviction – that it is only clinical research conducted by the psychoanalyst him/herself in the psychoanalytic situation that enables one to assess, as Leuzinger-Bohleber, Dreher and Canestri (2003) write, “the quality and the effects of the psychoanalytic experience” in reducing the patient’s symtomatology. The analysts that support this position believe that the specific aspects of psychoanalysis – unconscious processes and fantasies – are not as such directly measurable, and that specific training – in psychoanalysis – is essential for their observation, investigation and correct understanding. This position of closure and rejection towards empirical research3, however, clashes with the more and more pressing demand to demonstrate the efficacy of psychoanalysis as a therapeutic method and leads various authors to wonder to what extent it is sustainable, and whether it would not be preferable to accept the challenge made by such a demand, creating a form of empirical research aimed at increasing the specific psychoanalytic understanding of the quality of treatments, developing a specific research methodology and establishing a fruitful debate with researchers who work in the non-psychoanalytic context.
The publication in 1999 of the first edition of the work edited by Peter Fonagy An Open door review of outcome studies in psychoanalysis, which presents a detailed panorama on outcome studies in psychoanalysis, is very clear evidence of the changed attitude of the psychoanalytic world and the lively debate now underway, not so much about the importance of research as about the type of research – clinical, conceptual, historical, empirical - capable of enriching psychoanalytic knowledge and supporting clinical work.
The book contains contributions by H. Kächele, R. Krause, E. Jones, R. Perron and P. Fonagy himself, and with the aim of gathering new data to sustain clinical work and stimulate fresh research, it presents outcome research on psychoanalytical treatments carried out not only in psychoanalytic institutions but also promoted by research organizations, ranging from universities to mental health departments
The book, which is divided into two parts, opens with a preface by Widlöcher, who underlines that although clinical research is still an extremely rich and productive primary tool, it is necessary to enrich psychoanalytic knowledge using information obtained from epidemiological studies and evidence based medicine.
The first part of the book – leaving ample space to the debate on the importance of empirical research in psychoanalysis – outlines the methodological and epistemological background of research in psychoanalysis with special attention to the “justification” of outcome studies and to psychotherapy research strategies that can be used in efficacy studies. The concluding section of this first part presents, with a detailed analysis, the most widely-used tools and techniques of psychoanalytical assessment4.
The second part of the book surveys the most representative studies of the various research strategies5, starting from Fenichel’s pioneering study of 1930, and sums up the present “state of the art” of empirical research in psychoanalysis.
An appendix presenting the different measurements, in particular process measurement6 used in research in psychoanalysis, concludes the book.
In this brief article, after schematizing the principle guidelines of psychoanalysis outcome studies, I will sum up the positions characterizing the current debate on research into psychoanalysis within the psychoanalytic community, mainly referring to the first part of the Open Door Review.
The development of outcome research
Although they developed along different lines, outcome research and process research are closely intertwined also in psychoanalysis7. Outcome research, which basically aims at identifying the changes that psychoanalysis – as a psychotherapy – produces in the patient, is necessarily linked to process research, which tried to answer the question of how the changes are produced during psychotherapy. Outcome studies do not merely consider the percentage of cases in which a change can be observed, but must establish the criteria of change, derived in turn, as is clearly underlined by the authors of Research in Psychotherapy, recently published (Dazzi, Lingiardi & Colli, 2006), from some form of conceptualization formulated at more or less explicit levels related to the disorder and to the process of change. On the other hand, process studies, which underline the pattern of change within several variables, and collect a series of data and carry out assessment at different times during the treatment, answer the question of how change happens by providing short or long-term outcome indicators. For a more detailed discussion of the methodological and conceptual problems of outcome and process research in psychotherapy - and in particular in psychoanalysis – see the book edited by Dazzi, Lingiardi and Colli (2006), published recently; schematically presented here are the main developments in outcome research8.
In the evolution of outcome research in psychoanalysis, which began almost a century ago, in 1917, and has grown exponentially in the last ten years mainly in the British and North American intellectual tradition, one can identify four phases or generations, which can be distinguished both on the basis of a temporal criterion and on the basis of the level of conceptual and methodological complexity characterizing them (Wallerstein, 2005).
A series of studies, which started in the 1930s, set out to document the results obtained in the early psychoanalytic institutes9 and aroused - not only due to the weakness of their scientific and methodological approach - very little interest in the psychoanalytic world10; from the end of the 1960s on, both in North America and in Europe11, this was followed by a series of more systematic and formalized studies, which document the efficacy of psychoanalytic treatment at a different level and with greater methodological rigour.
These were both statistical studies based on inter-group comparisons and intensive studies of single cases which, despite the use of far more sophisticated methodologies than those used in the first generation studies, still present various significant limitations. While these studies are able to document that the psychoanalytical treatment produces some changes, they are still not able – since they totally ignore the post-psychoanalysis stage – to say anything either about the stability or instability of the result obtained or about the structural change. On this, Wallerstein (2005) writes that the general conclusion reached by all three research groups – the fact that in the analyses considered to have been successful, neurotic conflicts are not annulled or cancelled but mastered, deadened or reduced in intensity – is reflected in the famous ironic comment that all of us can recognise our best friends after they have been through analysis.
It would be the third generation of studies that was to try to solve the problem of the stability of change, by combining the methodological approaches of the studies on groups of patients with those on single cases, defining the terms used more accurately, operationalizing the criteria related to the different aspects to assess and constructing ad hoc assessment. These are, in other words, studies designed perspectively starting from the assessment of the patient before the treatment, and which very carefully distinguish the outcome recorded at the end of the treatment from the functioning found at a later follow-up stage, and also study the developments observed in the post-analysis phase. Here I will confine myself to recalling that the Psychotherapy Research Project of the Menninger Foundation, considered by far the most complete formalized study on psychoanalysis, the only outcome study that covers almost the entire lifetime of its patients, the most ambitious research programme of its type ever carried out (Brachach, 1991, cited by Wallerstein, 2005).
This whole series of studies document that:
- psychoanalysis and the various psychoanalytical psychotherapies obtain similar results;
- treatments in general contain more supportive elements than expected (ie also psychoanalysis contains numerous elements of a supportive kind);
- the supportive aspects therefore deserve to be described accurately and to receive more attention than they are usually given in the psychoanalytic literature;
- both the insight-oriented techniques characterizing psychoanalysis – techniques of uncovering – and the supportive techniques – techniques of covering up - produce the same structural changes in the functioning of the personality.
While on the one hand this third generation of studies tends to support the efficacy of psychoanalytic treatment, it does leave unsolved the problem of the factors that determine change. This question becomes crucial in the fourth generation studies which underline the need to use an integrated study using measurements of process and outcome which are conceptually more sophisticated and technologically more advanced, integrating the outcome study with that on the process of change. As Wallerstein (2005) stresses, the very rapid current growth in process research was made possible by the development of technologies of audio and video recording and of data elaboration. The use of new technologies, which allow for a reasonably non-intrusive recording of sittings, makes it possible to follow in the smallest detail and moment by moment the processes in psychoanalytic interaction. This method also enables the progress of the process to be assessed, by examining single sessions, or small fractions of sessions, or comparing different treatments involving the same or different patients. There is the growing tendency to attribute great importance to the analysis and study of therapeutic “micro-processes” and in particular to the identification of the connections between specific modes of therapist intervention in the individual sessions and the different aspects of patient change (Dazzi & De Coro, 1998), in order to establish links between specific therapeutic factors and a broader assessment of the degree of efficacy of a particular treatment.
The “latest generation” studies also aim to interpret the psychotherapeutic process from different standpoints, thanks to the convergent use of multiple tools. This research strategy aims to increase the validity and reliability of the information obtained, since it simultaneously makes a greater amount of process data available, identifying more accurately the strengths and the respective critical aspects of each tool. It also allows for the refinement of the modes in which the therapeutic relationship and the changes in the patient’s mental organization are carried out, making different aspects of the therapeutic process visible and measurable12. These are particularly sophisticated studies from the methodological and conceptual point of view, which by referring to the Problem – Treatment - Outcome congruence principle13, place great emphasis on the use of outcome measurements conceptually congruent with the theoretical model underlying the description of the patient’s conflicts and the definition of change. These studies also focus more on the post-psychoanalysis phase, encouraging follow-up studies in public and private clinical settings, carry out large scale statistical investigations and also use specially constructed scales which, as well as assessing individual target symptoms, general well-being, and specific behavioural tendencies, also enable personality structure and structural change to be assessed.
Let us now sum up the main outlines of the debate over the importance of research in psychoanalysis and into psychoanalysis, as it is presented in the introductory section of the Open door review, in which the point of view of the French-speaking psychoanalysts, put forward by Roger Perron, is contrasted with the view we can schematically call the “Anglo-saxon perspective”, put forward by Peter Fonagy and shared by many English-speaking analysts.
The debate over empirical research in psychoanalysis
In expressing the positions of the French-speaking psychoanalysts and in posing the preliminary question of what is meant by psychoanalysis research, Roger Perron distinguishes between the clinical approach – the traditional approach used to define psychopathological syndromes, to formulate theoretical constructions and justify the usefulness of specific therapeutic techniques on which to construct clinical models, whose validity is measured in terms of their usefulness – and the approach based on the use of methods of objectivization and systematization, and that is on the use of deepening procedures, whose utility is accepted in other disciplines and which lead to the construction of scientific models. Perron raises the problem of how broadly a model must be accepted for it to be considered valid and of how one can set the boundaries beyond which a model can be considered unacceptable by the community of psychoanalysts, thus leading its author to be clearly excluded from the psychoanalytic community. According to Perron, these models – which fall into the framework either of biology or of the physical sciences, the so-called “hard” sciences – are based on criteria of “scientificness” (observability of the phenomena on the part of experienced observers, use of quantification procedures, repeatability of observations, possibility of predicting the occurrence of specific events, falsifiability, use of a non-ambiguous terminology) which on the whole are not only difficult to fulfil in the psychoanalytic context and do not always seem fully relevant, but are also essentially incompatible with the psychoanalytic approach, since all the procedures that tried to use them would destroy their real object of enquiry14. We can schematically summarize Perron’s argument as follows:
- every scientific approach produces its own facts and organizes them within the territory marked out by its own theories and techniques;
- psychoanalytic facts constructed within the territory delimited by the psychoanalytic theories and techniques do not coincide with historical events and are organized at the level of the individual along the two dimensions of his/her history and his/her structure, a history simultaneously reconstructed during the psychoanalytic process itself;
- in the psychoanalytic approach, and this is what constitutes the peculiarity of psychoanalysis at the epistemological level, the subject and the method of study are identical;
This particular situation of facts and of the psychoanalytic approach gives rise to ambiguities in psychoanalytic terms and concepts: the adoption of a non-ambiguous language and the attempts to operationalize psychoanalytic concepts would deprive psychoanalysis of its multiple meanings, and end up denying and destroying the object of study;
- in the construction of psychoanalytic facts, theory plays a fundamental role;
- this theory, like other theories in the field of biology – and here Perron specifically refers to post-Darwinian evolutionary theories – makes it possible to explain and integrate a wide range of phenomena and, precisely due to its peculiarity, it cannot and must not be subjected to a process of empirical assessment.
According to Perron, therefore, any attempt to subject the data from sessions to the quantitative criteria and methods of the “hard sciences” destroys the real object of the research: in this sense the use of recording techniques to obtain material from which to extract the data is rejected not so much for ethical reasons, as for the fact that it seriously disturbs the transference-countertransference relationship and leads to a fragmentation of the material that no later statistical calculation, however sophisticated, will be able to put back together and return the data to its original unity.
Consequently the usefulness, the relevance and, in the final analysis, the very possibility of using empirical methods is excluded, and it is maintained that a useful increase in knowledge may come not only from traditional historical and conceptual research studies but also from efficacy studies, of which however Perron does not hide the specific problems (definition and measurement of change, operationalization of criteria, choice of judges, etc).
Fonagy’s position is diametrically opposed. We will sum up the essential points.
The undeniable crisis currently underway in psychoanalysis can be attributed basically to its “babelization”, to the lack of a shared language common to the various schools into which psychoanalysis has been fragmented. It is this fragmentation and confusing absence of common assumptions that largely explains the more and more insignificant scientific impact of psychoanalysis, the high level of self-referentiality of the various psychoanalytic schools and the unstoppable slide towards theoretical entropy.
The “clinical” research approach is moreover based on processes of an inductive type15, which give us good reasons to trust certain conclusions which however, unlike those obtained through deductive inferences, do not have the slightest persuasive power. Fonagy writes that we believe that our theories support inductive observations because we assume that these theories imply that the number of observations on which an inductive inference is based is very high and this lends weight to our conclusions. In doing this we are simply generating inductive arguments in favour of the inductive process.
While it cannot be denied that psychoanalytic treatment constitutes a unique window on human behaviour and while psychoanalytic theories allow the construction of extremely rich, specific and lively clinical pictures, it is precisely problems of inductive reasoning ─ which from a clinical point of view represent a valid and adequate strategy ─ that contribute to the dangerous scientific isolation of psychoanalysis, made even more dramatic by the deliberate refusal to reduce the ambiguity of its terminology and concepts. Underlining the heuristic fertility of the psychoanalytic situation and maintaining the need to distinguish between the construction of the theory and its validation, Fonagy writes that clinical data offer a fertile terrain for the construction of a theory but they cannot be used to distinguish between good theories and those that are not so good. The proliferation of clinical theories currently being used is the best proof of the fact that clinical data are more useful for generating theories and hypotheses than for validating them. The convergence of data from different sources (clinical, experimental, behavioural, epidemiological, neurobiological, etc.) constitutes the greatest support for the theories of the mind put forward by psychoanalysis. Clinical research, in Fonagy’s view, is therefore not an adequate basis for the construction of psychoanalytic theory: there is no close logical link between a specific theory and a specific practice. Not only has an adequate deductive reasoning not been developed in relation to the clinical material, but there is also ambiguity in the terms used. It is on this point that Fonagy underlines his distance from the position taken by Perron, who denies the possibility of a non-ambiguous definition of psychoanalytic concepts. Peter Fonagy writes that there is no doubt ––as long as the same term can be used with different scientific meanings the tendency towards fragmentation will be reinforced, since the use of the same term in different contexts undermines the possibility of explaining important differences between theoretical approaches. We need to go beyond clinical research if we are to overcome the problem of multiple meanings.
The way out, according to Fonagy, will have to be found by creating a new epistemic framework so as to break the traditional isolationism of psychoanalysis, achieving an integration with psychology and neurobiology.
Fonagy sustains, in other words, the need for a change in attitude towards scientific research, for a strengthening of the evidence base of psychoanalysis, without turning a blind eye however to the extraordinary difficulties raised by the validation of variables entailed in psychodynamic theories. For instance, psychoanalytic concepts, often formulated with little regard for precision, are difficult to make operational. Fonagy writes that there is a further logical problem of fundamental importance in the reconstructions position adopted by many clinicians, who sustains the importance for psychoanalysis of the contributions made by infant research, and underlines that development theories based on the tale the patients tell of their own childhood experiences not only bring with them the risk of painting a picture of development invalidated by various errors and omissions, but also lead to an enumerative inductivism which will be difficult to overcome. Most of the psychoanalytic theories of development blame the pathology on maternal errors or absences which are difficult to check; moreover, the presence of “healthy” aspects in persons who are otherwise seriously disturbed can lead the clinician to postulate the presence of protection factors such as the presence of a «good object», in an interpersonal context otherwise highly devastated. Fonagy considers that it will also be necessary to adopt constructs endowed with greater specificity, reducing the multeplicity of their referents; interest will therefore have to shift from general global constructs towards greater depth in individual mental processes, in their evolution, their vicissitudes, and their role in pathological functioning.
New attention will have to be paid to the reports of phenomena referring to alternative theoretical frameworks.
Collaboration with other adjoining disciplines, in particular neurobiology and modern cognitive psychology, is, according to Fonagy – here in agreement with Kandel ─ essential in order to preserve the valid clinical insights of psychoanalysis, guaranteeing them a future and leading to the adoption of a “more scientific attitude”, strengthening its basis of “evidence”, and also moving away from vague, broad global constructs towards more specific and better defined constructs. In his conclusions Fonagy argues that although there are no studies –– capable of unequivocably proving the efficacy of psychoanalysis and although analytic experience is probably enough to convince the analyst of the efficacy of psychoanalysis and it is quite easy to be critical of psychoanalytic studies, at any rate the “open” survey presented paints a relatively positive picture of the progress that is slowly but surely being achieved. In particular, while the studies examined in the survey have various limitations which Fonagy acknowledges, they show, in different contexts and on the basis of different measurements, that psychoanalysis has a positive effect on some groups of patients – not only neurotics – and that its outcome is influenced by different variables concerning the therapist, the patient, the process itself16. The scenario presented therefore raises specific research questions which, by overcoming strongly ideological positions, make it possible to shift the discussion of the efficacy of psychoanalysis and the characteristics of the psychoanalytic process onto a plane of “facts”. And this is certainly not a result to be underestimated.
As Kernberg (2006) clearly underlines in an article recently published in the International Journal of Psychoanalysis, in which he again brings up the debate on the importance of empirical research, making a particularly harsh attack on Roger Perron – who continues to maintain a position of total closure towards empirical research – it would be reductive to consider the urgency of increasing the psychoanalysis research effort simply in relation to practical considerations and concerns such as the need to demonstrate the efficacy of psychoanalytic therapy, to respond to economic pressures that are against supporting long-term psychotherapies and to the challenge of pharmacological therapies and of non-psychoanalytic psychotherapies, thus reassuring the public of the efficacy of psychoanalysis and of psychoanalytic psychotherapies. For Kernberg there is above all the scientific need to correct and develop knowledge, moving on the common ground of the construction of clinical theory close to experience (Wallerstein, 1990), making it possible to overcome the worrying phenomenon17 of psychoanalytic pluralism based on metapsychologies, on general psychoanalytic theories of a mainly metaphorical kind, and to increase the scientific relations with science and the related disciplines, consolidating the ties with the clinical and academic world which must push for a greater research effort in psychoanalysis.
In this article, Kernberg puts forwards a broad vision of research – defined as a series of systematic observations carried out in controlled situations that lead to new knowledge – and maintains that it is necessary not to favour either empirical research or conceptual research. It is only the integration of conceptual research with empirical research that will guarantee, however – in Kernberg’s view – real progress in psychoanalytic knowledge: while on the one hand a form of empirical research that neglects the “complex problems” raised by psychoanalytic concepts runs the risk of “misunderstanding what is measured”, and moreover of not giving due acknowledgement to the breadth and depth of psychoanalysis, on the other hand a form of conceptual research excessively focused on “historical development and conceptual definitions” ends up being a futile exercise. “Without an ongoing exploration of the efficacy of psychoanalysis and derivative treatments, – writes Kernberg (2006) – we run the risk of being discarded by mental health delivery systems. The financial pressure that militate against support of long-term psychotherapies at this time, the stress on evidence-based treatments in the medical field, the competing claims of non-psychoanalytic psychotherapies and psychopharmacology require a creative development in comparative research, which demonstrates our contribution to the social and medical environment, and may affect the cultural attitude towards psychoanalysis as well” (p. 919).
References
Bucci, W. (2005). Basic Concepts and methods of psychoanalytic process research. In E. S. Person, A. M. Cooper & G.O. Gabbard (Eds.), The American Psychiatric Publishing Textbook of Psychoanalysis. Washington, DC: American Psychiatric Association Caston, J. (1995). Mannequins in the Labyrinth and the Couch-Lab Intersect. In T. Shapiro & R.N. Emde (Eds.), Research in Psychoanalysis: Process, Development, Outcome (pp. 51-65). Madison: Int. Universities Press.
Dahl, H., Kächele, H., & Thomä, H., (Eds.) (1988). Psychoanalytic process Research Strategies. Berlin-New York: Springer-Verlag.
Dazzi, N. (2006). Il dibattito contemporaneo sulla ricerca in psicoterapia. In N. Dazzi, V. Lingiardi & A. Colli (Eds.), La ricerca in psicoterapia: Modelli e strumenti. Milano: Raffaello Cortina.
Dazzi, N., & De Coro, A. (1998). L'indagine sul processo nella psicoterapia psicoanalitica: per uno studio critico dei metodi di ricerca empirica. In Di Nuovo S. et al. (Eds.), Valutare le psicoterapie, Milano: F. Angeli.
Dazzi, N., Lingiardi, V., & Colli, A. (Eds.) (2006). La ricerca in psicoterapia. Modelli e strumenti. Milano: Raffaello Cortina.
Dreher, A. U. (2005). La ricerca concettuale. In E. S. Person, A. M. Cooper & G.O. Gabbard (Eds.), The American Psychiatric Publishing Textbook of Psychoanalysis. Washington, DC: American Psychiatric Association Fonagy, P. (Ed.) (2002). An Open door review of outcome studies in psychoanalysis. International Psychoanalytical Association.
Freud, S. (1927). Il problema dell’analisi condotta da non medici. Conversazione con un interlocutore imparziale Gill, M.M. (1994). Psychoanalysis in Transition. Hillsdale: The Analytic Press Glover, E. (1952). Research Methods in Psychoanalysis. Int. Journal of Psychoanalysis, 33, 65-141.
Greenspan, S. I, & Shanker, S.G. (2005). La ricerca sull’età evolutiva, In E. S. Person, A. M. Cooper & G.O. Gabbard (Eds.), The American Psychiatric Publishing Textbook of Psychoanalysis. Washington, DC: American Psychiatric Association Holt, R.R. (1989). Freud Reappraised. A Fresh Look at Psychoanalytic Theory. New York: Guilford.
Jones, E.E. (1995). How Will Psychoanalysis Study Itself? In T. Shapiro & R.N. Emde (Eds.), Research in Psychoanalysis: Process, Development, Outcome (pp. 91-108). Madison: Int. Universities Press.
Kächele, H., & Thomä, H. (1995). Psychoanalytic Process Research: Methods and Achievements. In T. Shapiro & R.N. Emde (Eds.), Research in Psychoanalysis: Process, Development, Outcome (pp. 109-129). Madison: Int. Universities Press.
Kernberg, O. F. (1995). Discussion: Empirical Research in Psychoanalysis. In T. Shapiro, & R.N. Emde (Eds.), Research in Psychoanalysis: Process, Development, Outcome (pp. 369-380). Madison: Int. Universities Press.
Kernberg, O. F. (2006). The pressing need to increase research in and on psychoanalysis. International Journal of Psychoanalysis, 87, 4, 919-926.
Klein, G.S. (1976). Psychoanalytic Theory: An Exploration of Essentials. New York: International Universities Press.
Leuzinger-Bohleber, M. Dreher, A. U., & Canestri, J. (Eds.) (2003). Pluralism and unity? Methods of research in psychoanalysis. London: International Psychoanalytical Association.
Migone, P. (2006). Breve storia della ricerca in psicoterapia. In N. Dazzi, V. Lingiardi & A. Colli (Eds.). La ricerca in psicoterapia: Modelli e strumenti . Milano: Raffaello Cortina.
Person, E. S., Cooper, A. M., & Gabbard, G.O. (Eds.) (2005). The American Psychiatric Publishing Textbook of Psychoanalysis. Washington, DC: American Psychiatric Association
Ponsi, M. (2006). Il cammino della psicoanalisi verso il metodo scientifico: Tradimento o traguardo? In N. Dazzi, V. Lingiardi, & A. Colli (Eds.), La ricerca in psicoterapia: Modelli e strumenti. Milano: Raffaello Cortina.
Shapiro, T., & Emde, R.N. (Eds.) (1995). Research in Psychoanalysis: Process, Development, Outcome. Madison: Int. Universities Press.
Strupp, H.H., Schacht, T.E., Henry, W.P., (1988). Problem - Treatment - Outcome congruence: A principle whose time has come. In H. Dahl, H. Kächele & H. Thomä (Eds). Psychoanalytic process Research Strategies (pp.1-14). Berlin-New York: Springer-Verlag.
Thomä, H., & Kächele, H, (1985). Leherbuch der psychoanalytischen Therapie, Berlin-Heidelberg: Springer-Verlag.
Thomä, H., & Kächele, H, (1985). Lehrbuch der psychoanalytischen Therapie. 1: Grundlagen. Berlin-Heidelberg: Springer Verlag..
Wallerstein, R.S. (1990). Preface. In L. Luborsky & P. Crits-Cristoph (Eds.), Understanding Transference: The CCRT Method. New York: Basic Books.
Wallerstein, R.S. (1965). The goals of psychoanalysis: a survey of analytic viewpoints, J. Amer. Psychoanal. Assn., 13, 748-779.
Wallerstein R.S. (2005). La ricerca sull’outcome. In E. S. Person, A. M. Cooper & G.O. Gabbard (Eds.), The American Psychiatric Publishing Textbook of Psychoanalysis. Washington, DC: American Psychiatric Association.
Wallerstein, R.S. (2003). Psychoanalytic Therapy research: Its Coming of Age, Psychoan Inquiry, 23 (2), 375-405.
Notes
* Professor of Dynamic Psychology, “La Sapienza” University of Rome. Top
1. Indicative of this cultural change: the section specifically devoted to research, regularly published in International Journal of Psychoanalysis; the growing number of books devoted to psychotherapy research that contain contributions from authors of the psychoanalytic school; the participation of research groups within psychoanalytic institutions; the creation of a Research Committee of the International Psychoanalytic Association; a whole section devoted to research (outcome, process, evolutive and conceptual research) in the Text Book of Psychoanalysis edited by Ethel S. Person, Arnold M. Cooper and Glen O. Gabbard (2005), recently published also in the Italian translation. Top
2. This thesis was expressed by Freud in 1927 in The Question of Lay Analysis: “[….] in psychoanalysis there has always been – writes Freud – a very strong tie between therapy and research; our knowledge gives rise to successful therapy, and at the same time every treatment teaches us something new. Our procedure is the only one that jealously preserves this convergence. It is only if we carry out our cure for the soul in practice that we can gain a deeper knowledge of human psychic life” (SFO, 10, p. 422). As M. Ponsi (2006) points out, this thesis, based on the “assumption that psychoanalysis is an autonomous discipline that generates its own tools or enquiry and control, has implicitly authorized analysts to produce explanations of the working of the unconscious mind and of the therapeutic process without constructing corresponding tools to check their validity, triggering comparisons with dimensions outside the clinical realm” (p. 718). When discussing the Junktim thesis, i.e. of the insoluble tie between interpretative therapeutic method and causal explanations, also H. Thomä and H. Kächele (1985) – though considering it to be Freud’s greatest insight – sustain the incompatibility of the criteria “set by Freud to satisfy the condition of the insoluble tie with the criteria designed to test the hypotheses, making it the analyst’s responsibility to justify his therapeutic conduct and to constantly check the validity of his conception of the unconscious, experience and the behaviour of human beings” (p.17). The two German authors underline the urgency of a profound re-thinking of the theory of psychoanalytic interpretation and the subordination of psychoanalytical clinical activity to research, concerning process and outcome. According to H. Thomä and H. Kächele, who link the problem of research to that of the scientific position of psychoanalysis: “[…] for decades psychoanalysis was practised respecting Freud’s authority, which produced a stagnation of the therapeutic and scientific potential of his method. As far as the explicative theories are concerned, their union with metapsychology has proved to be extremely unfortunate” (ibidem). Top
3. This attitude of closure and rejection towards empirical research seems somewhat paradoxical when one considers that some of the most famous studies on psychotherapy outcomes such as the Menninger Study, the Columbia Research Project, the Boston Psychoanalytic Institute Prediction Study, actually emerged from the psychoanalytic context. Top
4. In this section, after underlining that all the authors agree on the unacceptability of a sole outcome measurement, the author presents DeWitt’s Scale of Psychological Capacities (SPC), Blatt’s Object Relations Inventory (OBI), the Patient–Therapist Adult Attachment Interview (PT-AAI) by Clarkin, Levine et al., Fonagy’s Reflective Function Scale (RFS) and the Person Representational Coding System by Lemche and Grate. The psychometric properties and clinical usefulness of each tool is discussed. Top
5. The studies are divided into Clinical case studies, Naturalistic studies, Semi-experimental research designs, Follow-up studies, Experimental studies, Process studies, Outcome studies, Studies on psychotherapy with relevance to psychoanalysis. Top
6. This appendix includes W. Bucci’s scales of Referential Activity (RA), with a description of their psychometric properties and clinical utility, Foelsch, Normandin and Clarkin’s assessment system of Transference and Counter-transference Analysis (TCA), Albani, Balser and Jones’s Psychotherapy Process Q-set (PQS) and the Facial Action Coding System (FACS) and the Emotional Facial Action Coding System (EMFACS) by Ekman and Friesen. Top
7. On the relation between empirical research in psychotherapy and empirical research in psychoanalysis see Dazzi, N., Lingiardi, V., & Colli, A. (2006) (Eds.), La ricerca in psicoterapia: modelli e strumenti, in particular chapters 1 (Il dibattito contemporaneo sulla ricerca in psicoterapia by Nino Dazzi) and 30 (Il cammino della psicoanalisi verso il metodo scientifico: tradimento o traguardo? by Maria Ponsi), as well as part IV of Text Book of Psychoanalysis devoted to research (Person, Cooper & Gabbard, 2006). Top
8. See in particular the essay by P. Magone (2006), which outlines a short history of research in psychotherapy, as well as Wallerstein’s article of 2003. Top
9. In 1930 O. Fenichel reported the first results obtained at the Berlin Psychoanalytic Institute and in 1936 E. Jones reported the data on 738 patients who had applied for treatment at the London Psychoanalytic Clinic; in 1937 Alexander reported the data on 157 cases treated at the Chicago Psychoanalytic Clinic with positive outcomes. In his survey, Wallerstein describes three studies conducted on groups of patients treated at the Boston Psychoanalytic Institute, the Columbia Psychoanalytic Centre and the New York Psychoanalytic Institute and three single case studies conducted in New York, San Francisco and Chicago. Top
10. Commenting on the results obtained from the 1st generation studies, Glover, in 1954, highlighted the statistical limitations of these early studies. See S. Person, A.M. Cooper, G. O. Gabbard, 2005, p. 495. Top
11. Among European projects, we wish to recall the study done at the Anna Freud Centre onthe case histories of 765 patients treated over a period of 40 years and the study carried out by the German Psychoanalytic Association on the long-term effects of psychoanalytic psychotherapies and of psychoanalysis, as well as the study of intensive long-term psychoanalytic treatment conducted with the collaboration of Dutch, Finnish, Norwegian and Italian analysts. See Wallerstein’s chapter in Text Book of Psychoanalysis (Person, Cooper & Gabbard, 2005) for a detailed analysis of the various research projects.Top
12. For more details on this point see the book already cited several times by Dazzi, Lingiardi, Colli (2006), La ricerca in Psicoterapia [The research in psychotherapy: Models and tools]. Top
13. According to the PTO principle stated by Strupp and his colleagues in 1988 in the 1st chapter of the book Psychoanalytic Process Research Strategies which contains the Acts of the conference on psychoanalytic therapy held in 1985 at the University of Ulm, the description and illustration, at a theoretical and operative level, of the patient’s conflicts, of the patient’s treatment and of the outcome assessment must be coherent, which means that they must be described in comparable, if not identical, terms. Top
14. This position, which reflects the typical characteristic of the French psychoanalytic world of anchoring the whole discussion by referring to epistemological models which could be euphemistically described as not up-to-date repeats what A. Green has often claimed, that empirical research is not only useless but also misleading, in that it is based on assumptions that are different from those underlying psychoanalysis. In his “uncompromising” critique of infant research, Green for instance maintains that the way Daniel Stern uses the concept of the child’s “inner world” has nothing to do with the Freudian concept of “psychic reality” and that it is highly confusing to compare the concept of desire to that of motivation. For a detailed discussion of this view, see the chapter in Maria Ponsi (2006), cited above. Torna su
15. ie which use arguments based on the accumulation of past observations of a certain individual and on the formalization of past cases by other psychoanalysts in terms of clinical theories (Klein, 1976). Torna su
16. Among the studies surveyed I will just mention those conducted by the authors making up the Research Committee of the German Psychoanalytic Association which, on a sample of patients treated with psychoanalytic psychotherapy, show the efficacy of psychodynamic psychotherapies and the stability of the outcomes obtained; the Munich Psychotherapy of Depression Study, which by comparing the effects of psychotherapy and psychoanalysis shows that in certain conditions psychoanalysis is an effective treatment. Ample space is given to the description of studies using CCRT, the method developed by L. Luborsky for the study of transference. CCRT, which both offers assistance in the clinical formulation of transference and a new research tool, and which is also presented as an easy method to apply, providing explicit, precise guidelines for the formulation of transference and for identifying the patient’s central problem, has been used by many authors as a useful system in guiding the clinician’s judgement on the contents of the central relational models and in formulating inferences characterized by a “moderate level of abstraction” so that they can be easily accepted by clinicians of different orientations.
As a research tool, CCRT, which was the first method to systematically take narratives about relational episodes in psychotherapy sittings as the unit of analysis for psychotherapy research, provides data that can be used both to clarify the origins and function of transference and also as significant aspects of the psychotherapy process and of its efficacy, allowing a psychodynamic assessment of change. By highlighting the features and the advantages of this operationalization of transference – “the focal point of analytic technique and its most complex aspect" (Gill, 1982, p.42) - various authors have maintained that not only does CCRT make it possible to obtain data to support the scientific validity of psychoanalysis using common means of research and testing, but it also helps to clarify the rules of inference, the process of clinical judgement and that of interpretation, to expand understanding of the concept of transference and, as Holt (1970) writes, it also shows that psychoanalysis can be scientifically studied. Torna su
17. On this see M. Ponsi, in Dazzi, Lingiardi, Colli, 2006, pp. 716-722. Torna su
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