Psychoanalytic Theory and Clinical Relevance

What Makes a Theory Consequential for Practice?

Louis S. Berger

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781317737025
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

In this provocative contribution to both psychoanalytic theory and the philosophy of science, Louis Berger grapples with the nature of "consequential" theorizing, i.e., theorizing that is relevant to what transpires in clinical practice. By examining analysis as a genre of "state process formalism" - the standard format of scientific theories - Berger demonstrates why contemporary theorizing inevitably fails to explain crucial aspects of practice. His critique, in this respect, pertains both to the formal structure of psychoanalytic explanation and the technical language through which this structure gains expression.

The pragmatic recommendations that issue from this critique are illustrated with respect to a number of perennial problem areas besetting analysis and cognate disciplines. In a discussion that encompases theories of affect, issues in family therapy, the nature of first-language acquisition, and the philisophical topics of free will and determinism, Berger shows that certain systems of representation (including ordinary language) can describe the psychological realm adequately, and that such systems necessarily follow modern physics in rejecting naive assumptions about the separability of theory and practice. His proposals culminate in a "nonhierarchical" conception of psychoanalytic theory that assigns a separate status to the clinically pragmatic level of theorizing.

In both his critique of contemporary analysis and his reconstructive proposals, Berger fuses into a highly readable argument a fascinating range of insights culled from epistemology, linguistics, physics, logic, computer science, history, and aesthetics. More impressively still, he demonstrates how an investigation of psychoanalytic theory can serve as a vehicle for examining pervasive epistemologicalissues in both philosophy and thesocial sciences.

ONE

Introduction

It is common knowledge that from its inception psychoanalysis has been plagued by difficulties and controversies, internal as well as external. The structure and content of its theory, diverse and sometimes conflicting recommendations concerning its technique, its status as a science, its effectiveness as therapy, its legitimacy as an investigative methodology, and its claim to being a general psychological theory are representative issues that remain largely unresolved today.

In the recent literature, for example, one finds general references to “the chaos pervading the entire area of psychotherapy and psychotherapy research to which several authors … have called attention” (Strupp, 1972, p. 76), or to “disarray in the theory and practice of psychoanalysis” (Levenson, 1972, p. 13). It has been said that “its theory and its method as science seem continuously to require justification” (Wallerstein, 1976, p. 198). Regarding its effectiveness as therapy, Strupp (1972) observes that “in the research literature … one finds a growing disenchantment with psychoanalysis and psychotherapy based on psychoanalytic principles” (p. 71); according to Gedo (1979), there is “a crisis of confidence on our own [psychoanalysts’] part concerning the effectiveness of psychoanalysis as therapy” (p. ix); Stein (1972) reports that “while the majority of patients—probably 60 to 80 percent—respond more or less favorably to psychoanalytic psychotherapy, a considerable number respond poorly or not at all. This is true even when the patients are carefully selected and the treatment is skillfully given” (p. 37).

The issues to which these comments broadly refer will be discussed in detail throughout this work. For the moment, I should like to single out one of them—the effectiveness of psychoanalysis as therapy—for some initial, quite general observations. Let me emphasize that the ensuing discussion is intended to provide no more than an informal introduction to problems I address with greater rigor in subsequent chapters.

As suggested by the remarks of Strupp, Gedo, and Stein, the effectiveness of psychoanalysis as therapy remains as controversial a subject today as it was at the turn of the century, for practitioners as well as observers, and in spite of considerable efforts to settle the matter. The persistence of the controversy supports the view of some (e.g., Greenson, 1967; Glover, 1972) that advances in clinical efficacy have been minimal since the essentials of psychoanalytic therapy were promulgated by Freud. Now, in a way, this is a quite curious situation. Here we have some ninety-odd years of psychoanalytic theorizing, and there are credible commentators within the field who agree that therapeutic effectiveness has failed to make corresponding significant advances, that the clinical yield of intense, concerted, continuing theorizing by a large number of workers has been disappointing.

Clinical relevance. Under these circumstances, it seems reasonable to wonder whether psychoanalytic theorizing is “clinically relevant.” The record suggests that very possibly it is not; one could conclude, almost by definition, that if after so many years of considerable effort theorizing has failed to produce significant clinical progress, then it cannot be relevant theorizing.

I say “almost by definition” because the notion that clinically relevant theorizing simply is theorizing that somehow leads to improvements in clinical efficacy does not take us very far; at best it specifies an outcome measure, a necessary but not sufficient criterion. It does not describe the kind of relationship that ought to obtain between a relevant theory and its clinical products.

Let us try again. Could clinically relevant theorizing simply be theorizing about such clinical phenomena and ingredients as transference, resistance, or interpretation? About psychopathology (e.g., about genesis, nosology)? About the clinical material? About therapeutic action? There certainly has been a good deal of such theorizing in the past; but if we provisionally accept the premise that theorizing has failed to produce advances in clinical efficacy, and the necessary (but not sufficient) criterion that it should, then it becomes reasonable to reject definitions of clinical relevance based on these kinds of specifications and characterizations.

It is unlikely, then, that clinically relevant theorizing simply is equivalent to theorizing about matters that bear directly on the clinical situation. It begins to look as though when one attempts to pin down the meaning of “clinical relevance,” one discovers that the notion itself is elusive and obscure; indeed, as we shall see, such attempts lead into deeper and deeper waters, and into more controversial realms.

It would seem that the meanings, the theoretical and empirical implications, of this notion could stand clarification and explication. It would therefore make sense first to seek an adequate understanding of just what kind of a theory one is searching for, what characteristics a clinically relevant theory should or should not have, before one attempts actually to construct that kind of a theory. To provide such clarification is one prominent goal of this monograph.

Logical entailment. Typically, discussions in the literature that take one or another position on issues concerning the clinical relevance of psychoanalytic theory do so on the basis of theoretical considerations and arguments. Perhaps the most familiar examples are provided by the innumerable discussions for or against the clinical usefulness, the epistemological legitimacy, or the necessity of the economic point of view (see, for example, Yankelovich and Barrett, 1970; Klein, 1973; Gill, 1976; Holt, 1981).

The literature also demonstrates, however, that these issues remain pretty much as they were, controversial and unresolved, in spite of the considerable theoretical attention they have received. The utility and role of notions concerning psychic energy, to cite only one instance, have yet to be settled conclusively. If, then, theoretical approaches have not been productive in resolving issues pertaining to the clinical relevance of psychoanalytic theory, are we not justified in seeking an alternative approach to the problem?

One such approach is suggested by the matter I alluded to earlier: the nature of the relationship between a relevant theory and its clinical products. In this regard, I propose that were psychoanalytic theory in fact clinically consequential, then advances in practices ought to be deductively derivable from that theory. It should lead one, by deductive steps, to more effective clinical practices; one might say that such advances would be “logically entailed” within a relevant theory.

This proposition suggests that the question of relevance could be illuminated by an examination of logical entailment. Furthermore, in the light of all the past failures of theoretical discussions to resolve the issue, it seems reasonable to begin with an empirical rather than a theoretical examination. Accordingly, I begin the study of clinical relevance by examining the literature to see whether therapeutic practice has in fact been logically inferred from mainstream psychoanalytic theory. The study of entailment in Chapter 2 examines representative examples drawn widely from past and current psychoanalytic literature.

Does a study of the literature support the premise that practice is now, or ever has been, logically entailed within theory? Can one substantiate the claim that technique is derivable from theory by logically valid inferential steps? My conclusion, based on several classes of indirect supporting evidence extracted from the literature, is a qualified no. Although theory and practice do exhibit certain kinds of relationships, these are not really inferential.

That conclusion naturally leads one to wonder next about the causes of the situation. It invites one to ask, Why is technique not logically entailed? After all, in the natural sciences it is commonplace to find that theory does harbor logical implications for technique; advances in theory routinely allow inferential deductions that lead to corresponding advances in technology and improved practices in general. Why should it not be the same in psychoanalysis?

I propose two different, yet ultimately intertwined, kinds of answers to these questions: (1) that theory has been circumscribed by the kinds of formalisms that have been employed (Chapters 3 and 4), and (2) that there is a cluster or constellation of what I shall be calling “focal” issues—themes, rationales, motives, perspectives, or goals that guide theorizing—that also contribute to the lack of entailment (Chapter 5). The proposed explanations, then, rest on two pillars—one formal-logical, the other focal.

Issues about formalisms. By “formalisms,” I mean the languages, mathematical or other, that provide the vehicles for one’s theorizing. In my view, the root issue pertaining to formalisms is the issue of representability. The fundamental question is (or should be), Is a given formalism able adequately to represent the phenomena that are central to one’s enterprise? Is it an adequate vehicle, one that enables us to do the job at hand? In psychoanalysis specifically, can the formalisms one is using or proposing to use encompass the ingredients necessary for a clinically relevant theory?

This examination of formal issues grows out of a position I introduced earlier (Berger, 1978; see also 1974). It begins with a particular way of looking at and analyzing formalisms, a way of considerable generality that reveals basic formal-logical commonalities among apparently widely disparate scientific languages. This kind of formal analysis provides a framework within which one can pose and examine questions about representation in productive ways.

The formal issues addressed by the analyses in Chapters 3 and 4 are pertinent not only to recent proposals concerning formalisms and reformulations in psychoanalysis (e.g., Roy Schafer’s [1976] for a “new language,” George Klein’s [1973] for “one theory”), but also to current discussions about how Freud used language in his theorizing. In these matters, a crucial question is, How formalized must the theoretical language of psychoanalysis be? Usually it is accepted as self-evident that a considerable degree of formalization is required (see, for example, Kubie, 1975; Schafer, 1978, Chapter 1). Recent work, however, strongly suggests that Freud’s scientific practices deliberately and consistently eschewed scientistic formalisms (see Bettelheim, 1983; Ornston, in press a,b); apparently, he steadily avoided formalistic practices that, as we shall see, are currently widely recommended and accepted without question, without further inquiry. Those standard presumptions reflect an arbitrary (and, in my view, inappropriate) picking and choosing among Freud’s methodology; certain of his key positions are ignored, distorted, or rejected. To anticipate: The arguments and analyses of Chapters 3 and 4 return us, by way of explicit formal analysis, to less formalized conceptions of theoretical discourse.

The foci of theorizing. When I first mentioned formalisms and representability, the matter of adequacy also made an appearance. Asking about the representational adequacy of a given formalism almost automatically induces one also to introduce issues pertaining to use: One is impelled to ask, Adequate for what tasks? Formal issues almost inadvertently have brought pragmatic issues into the picture.

I shall label certain normative pragmatic issues “focal”—a term that is difficult to define simply, and whose sense will emerge, I trust, in the discussions of Chapters 5 and 6. An example of a focal assumption is the premise that one’s understanding of a given disease necessarily will lead, sooner or later, to finding a cure. I shall propose that the foci of current psychoanalytic theorizing were tacitly accepted from the very start; they were already implicit in Freud’s initial work. They have remained implicit rather than explicit, and so they easily have escaped notice, analysis, and evaluation. Furthermore, these focal assumptions also are consonant with focal assumptions in neighboring disciplines and sciences. At any rate, they tend to be perpetuated without much debate or question.

For reasons that should become apparent in Chapter 5, I call the applicable cluster of focal issues “the pure knowledge medical paradigm.” I shall maintain that in a certain sense these foci have assigned a secondary status to clinical relevance, and that this policy had significant consequences for psychoanalytic theorizing. I will suggest that one’s theorizing inevitably must bear the stamp of one’s adopted foci. Consequently, if those were somehow ill-conceived, if the foci were somehow inappropriate to one’s empirical goals and needs (in our case, to theorizing that could move clinical technique and overall methodology significantly forward), then that would constitute another kind of an impediment. In other words, I shall propose not only that certain formal practices could account for the inability of psychoanalytic theory to entail technique, but also that certain focal issues may have been getting in the way of clinically consequential theorizing as well. Furthermore, although it is convenient to treat formal and focal questions separately to some extent, as the analyses proceed it becomes increasingly clear that each class of questions has an impact on the other class. Issues are related in subtle, even obscure, ways: In the course of developing critiques about formal matters, focal issues insinuate themselves into the discussions, and vice versa. Eventually, the two types of analyses converge on common ground.

Implications and proposals. Chapters 3 through 5, then, primarily consist of analyses and criticisms. They draw on, and attempt to integrate, a great deal of available thought scattered throughout a variety of disciplines. As I explain in Chapter 7 (see the section “About Solutions”), I believe that careful critical analyses carry within them implications for future work; sound criticisms entail solutions. I also believe, however, that the analyses I shall present ought first to be examined, evaluated, and digested, before rushing into proposals and attempted solutions.

Nevertheless, there is the understandable expectation that a critic—especially an unorthodox critic—ought to give some indications of the implications of his criticisms. Chapters 6 and 7 are my guarded attempt to do so. In Chapter 6, I delineate general formal and focal guidelines for clinically relevant theorizing. These describe and specify various characteristics that I believe a relevant theory should exhibit.

Following these quite general considerations, the first part of Chapter 7 presents a more specific outline of how a clinically relevant theory might look. I here wish to state most emphatically some major qualifications (which will be repeated for further emphasis at various junctures in the last chapters). The sample theory that I shall eventually sketch will be just that—an example, intended to illuminate further the points developed in the earlier chapters. There are several reasons for being tentative at this time: The principal goal of this monograph is to clear away old impediments; my own thinking is still very much in flux, and I am not yet ready to offer a firm proposal; the scope of a clinical theory, as developed here, is very great, and may well be beyond the capacity and competence of a single worker; and, as I indicated above, before one would follow their implications, it would be beneficial, even necessary, to review and examine critically the analyses themselves. Thus, I would like to have this work judged principally on the basis of its contributions to critical analysis, that is, on the basis that it clarifies old and obscure issues, formulates productive and generative questions, and discourages the continuation of certain widely accepted, minimally analyzed practices. I would hope that, with this kind of a start, the criticisms and suggestions presented in this work would eventually stimulate others to pursue new directions; that eventually a clinically relevant theory would emerge from a process of orderly growth and “organic” evolution, strengthened by the assimilation of the additions I offer to mainstream thought. I also would hope in future work to join this kind of a sound effort with my own circumscribed clinical contributions.

Finally, there is the matter of generalizations of these ideas and proposals from psychoanalysis to neighboring disciplines. It will become evident just how large a debt this monograph owes to certain workers from a broad range of disciplines—psychology, philosophy, history, mathematics, physics, sociology, linguistics, biology, economics, and medicine. The book attempts to integrate contributions from these diverse sources by means of its main theme, clinical relevance of theorizing; at the same time, however, to the extent that it may have moved previous work forward, it could in turn have a contribution to make to some of the fields to which it is indebted.

The last sections of Chapter 7 consider that possibility. To illustrate the ways in which the material presented earlier might be generalizable to other areas, I present five sample topics for discussion: (1) another clinical framework—specifically, one school of family therapy; (2) certain difficulties that impede unorthodox critics of mainstream behavioral disciplines; (3) first language acquisition; [4] free will/determinism; and (5) affects. In these discussions, questions pertaining to formal issues and representability will predominate.

I am indirectly suggesting here that this monograph can be looked at in two different yet complementary ways. On the one hand, the work can be seen as one that seeks specifically to illuminate and advance clinical relevance of psychoanalytic theorizing. That is the mor...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgments
• Chapter 1. Introduction
• Chapter 2. Logical Entailment
• Chapter 3. Science, State Process, and the Life World
• Chapter 4. Theoretical Discourse
• Chapter 5. The Focus of Theorizing
• Chapter 6. Clinical Pragmatism
• Chapter 7. Speculations and Generalizations
• References
• Author Index
• Subject Index