Clinical Research in Psychoanalysis

Theoretical Basis and Experiences through Working Parties

Marina Altmann de Litvan, Marina Altmann de Litvan

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000407204
• Edition: 1
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

This book offers different theoretical approaches about what clinical research is.

Clinical Research in Psychoanalysis is a unique contribution to the attempts to bridge the gap between clinicians and researchers and to create a culture of a more rigorous and systematic inquiry. It provides an innovative experience because for the first time different methods and perspectives were used to analyse one same clinical material. This was done by analysts from different working parties of the International Psychoanalytical Association (IPA), from a range of different schools of psychoanalytic thought. This allows the reader to have a vision of the different methods that are currently being used by some working parties of the IPA and to learn about the strengths of each one for certain situations and types of research. This book revaluates clinical research, intending to make links between the analysts working through the working parties and the different ways of thinking in clinical research. By covering key topics, such as how working parties can facilitate different types of research; the place of metaphor in psychoanalytic research and practice; and the future for psychoanalytic research, this text is a fruitful dialogue between different theoretical conceptions and between clinicians and researchers, that will expand our perspectives on the evidence we find in clinical material and will broaden our views on the patient.

This book offers a unique and invaluable experience to psychologists and psychoanalysts who are trying to improve their clinical practice and bring research evidence into their psychoanalytic practice. It is an invaluable contribution to psychoanalytic training of candidates, teachers, and students.

Part I

From clinical practice to clinical research

Chapter 1

The mysterious leap from clinical practice to clinical research

Liana Pinto Chaves

DOI: 10.4324/9781003182870-2

Part 1

What do average analysts think of clinical research? What do they think clinical research consists of?

We may intuitively grasp the idea that institutions (for example, the Tavistock Clinic in London, the Institute Alfred Binet in Paris, the Sigmund Freud Institute in Frankfurt, or the Karolinska Institute in Stockholm) promote research in its many expressions, supporting the analyst or psychotherapist with an institutional backup, facilities, and funding, while at the same time offering treatment to the community. But what about the individual psychoanalyst working in their consulting room?

The average analyst thinks almost exclusively like a psychoanalyst. The analyst who intends to do research needs to think simultaneously as a psychoanalyst and as a researcher.

And why is it so difficult to think in terms of research? We become analysts after many years of personal analysis and theoretical–clinical training, and it takes us many more years to become more at ease in our role as analysts, with a free transit between our subjectivity and that of the patient. We are aware of the dialogic character of the exchange that takes place in the transference–countertransference field created between the two protagonists of the analytical scene. To think in terms of research seems to amount to an extra effort, in addition to the fact that many analysts think of the term research with a degree of suspicion or prejudice. It is no longer acceptable to hold the naïve idea that every analyst is a researcher, as we frequently hear, but it is not easy to abandon common sense. Further theoretical knowledge and expertise are necessary to acquire the mind of a researcher.

The complexity of the epistemological and methodological considerations concerning the scientific status of psychoanalytical knowledge baffles the clinician. These considerations (natural science versus hermeneutics, induction, deduction, abduction, causal evidence, causes or meanings, data selection, verifiability, etc.) may seem like Greek to the clinician; they demand familiarity with certain concepts to be able to follow the discussion, not to mention to participate in the discussion of a growing body of work, with an extensive bibliography. One could say that acquaintance with the discussion is a career in itself. It is precisely for that purpose that the Clinical Research Subcommittee of the International Psychoanalytical Association was created: Its aim was to promote discussion about the whole area of clinical research and make it more accessible for clinicians.

Our ancestors, the authors who became our references, wrote their excellent insightful texts that inspired generations of the subsequent analysts. Nowadays, with the growing discussion on the nature of clinical research, it looks as if there was a necessity for a special knowledge, a certain training, in order to build an attitude with regards to research.

André Green (as cited in Sandler, Sandler, & Davies, 2000, p. 24), with his usual rigour and dryness, said,

Up till now, the great contributors to psychoanalytic theory (Freud, Abraham, Ferenczi, Rank, Melanie Klein, Bion, Winnicott, Lacan, Hartmann, etc.) have all enriched our knowledge with their work stemming from their single mind and from the working through of their own experience with their patients.

And then he moved on to say that ‘there is no single major discovery for psychoanalysis which has emerged from research’ (as cited in Sandler et al., 2000, p. 24). We do not have to agree with him and feel despondent, despite his stature.

All of us would agree that what is done in a session has to do with the discovery of the unconscious aspects present in the material, the suffering of the patient that keeps them entrapped in the repetition, and the central aim is the progress of the therapeutic process. But there is a great distance between this view and the understanding of the dynamics of the process becoming research. And then comes the question: How can it be systematic (as we expect research to be) if we are dealing with changeable states of mind?

Freud’s (1923/1955, p. 235), opening paragraph, now almost centenary, in ‘Two Encyclopaedia Articles’ is usually the point of departure for the rich body of knowledge that has accumulated over the years, concerning the nature of the analytical endeavour and quoted by most authors:

Psychoanalysis is the name (1) of a procedure for the investigation of mental processes which are almost inaccessible in any other way, (2) of a method (based upon that investigation) for the treatment of neurotic disorders and (3) of a collection of psychological information obtained along those lines, which is gradually being accumulated into a new scientific discipline.

This statement is valid to this day and it has remained the most succinct expression of what would later develop into an intense and fruitful debate in the last 30 years about the nature of psychoanalytical knowledge and its status among the sciences – to a great extent thanks to the enterprising spirit of Joseph Sandler, with his proposals of discussions around fundamental topics and the relationship of psychoanalysis to other fields of research. There is already a corpus of consolidated debate about clinical and conceptual research.

A brief statement by Anna Ursula Dreher (2016) helps in building the bridge:

In a general understanding, clinical research in psychoanalysis subsumes all research activities directly linked to the core: the analytic situation. The aim of these different research activities and their different methods is to describe and to explain what happens in this analytic situation.

Part 2

I would now like to take as an example the work of Björn Salomonsson, from the Swedish Psychoanalytical Society, better known for his work on psychoanalytical psychotherapy with infants and parents done at the Mama Mia Child Health Centre in Stockholm. He is also a researcher at the Karolinska Institute. I will resort to a paper of his and will try to follow it in some detail to get closer to what I think would help us to ‘see’ what clinical research is and how it evolves, first in the consulting room and then in the work done after the sessions. To my mind his work is a good illustration of the title of Ricardo Bernardi’s chapter: ‘Moving From Clinical Inquiry to Clinical Research’ (Chapter 6, this book). And he also spells out in each one of his papers ‘a clear definition of the questions’ (a point stressed by Bernardi, Chapter 6, this book) he proposes to tackle.

In other words, to my view, his work as clinical researcher can dialogue fruitfully with the work of Bernardi as conceptual researcher. Bernardi focuses on why and how the investigation of mental processes can be considered clinical research, and Salomonsson provides us with the opportunity to follow and grasp these two dimensions.

The paper we are going to use as an illustration, ‘Infantile Defences in Parent–Infant Psychotherapy: The Example of Gaze Avoidance’ (Salomonsson, 2016) is part of an ambitious project that investigates whether the psychoanalytical concepts we use for older individuals are applicable to babies as well. Earlier papers, which were part of this project and many of which published in the International Journal of Psychoanalysis with very engaging titles, dealt with infantile sexuality, ‘Has Infantile Sexuality Anything to Do With Infants?’ (Salomonsson, 2012); transference, ‘Transferences in Parent–Infant Psychoanalytic Treatments’ (Salomonsson, 2013); and primal repression, in the book Psychoanalytic Therapy With Infants and Parents: Practice, Theory and Results (Salomonsson, 2014). They attempt to cover a range of classical concepts in psychoanalysis. In all of these papers he puts the huge question: ‘Can we really speak of the infant as being a subject?’ (Salomonsson, 2016, p. 66). He acknowledges: ‘Undoubtedly, such a project is fraught with heuristic difficulties’ (Salomonsson, 2016, p. 66), considering that he is dealing with a ‘person’ before it becomes a proper person.

Salomonsson is an analyst who lives the therapeutic process with his patient(s), formulates questions, goes after the answers to those questions, does clinical research simultaneously with the therapeutic process (the famous Freudian conjunction), and, through informed analytical discussion of those phenomena and hypotheses and in the light of analytical theory, he builds his clinical reasoning.

The clinical material in this paper on infantile defences is about a mother with a 3-month-old baby girl who has difficulties in their relationship. The baby had an initial satisfactory development in the first 3 weeks of life but started to have colic attacks, and the mother was unable to comfort her. The baby started to avoid mother’s eyes, which led the mother to depression, after a very loving and tender beginning. The baby looks at everything and everybody, except the mother.

I will not attempt to summarise the very detailed and sensitive clinical narrative constructed by Salomonsson, how he gradually collects the history of the mother during the sessions with all of the many important experiences. You will have to take my word. I invite you to read the paper: ‘Infantile Defences in Parent–Child Psychotherapy: The Example of Gaze Avoidance’, (Salomonsson, 2016). For our purpose today it suffices to say that initially he received mother, father, and baby and then concentrated on mother and baby. The therapy was planned to last 5 months, initially in a frequency of four times, then two, and finally one time per week, as the initial complaint resolved.

Salomonsson (2016) reflected on the possible psychodynamics of gaze avoidance. His guess is that the emotional stress during the weeks of colic laid the ground for the baby forming a negative internal image of the mother. This was complicated by the fact that the mother herself had difficulties when looking people in the eyes, presumably linked with her low self-esteem. According to Salomonsson, this created a representation in the baby’s mind of a bad mother figure summarised in the phrase: ‘If I avoid looking at it, I feel better’ (Salomonsson, 2016, p. 97).

This guess (his word), which we could call an informed speculation, can also be considered a hypothesis, an assumption, and the starting point of the therapeutic process and the clinical research. He warns: ‘Evidently this formulation is but a clumsy and speculative verbalization of a representation that was pre-verbal yet impacting the girl’s behavior’ (Salomonsson, 2016, p. 97).

Throughout the sessions the analyst sometimes addresses the mother and sometimes addresses the baby, and after a particular intervention, the girl starts looking into the mother’s eyes. As the atmosphere becomes serene, more and more material come out, dealing with the mother’s relationship with her own mother.

Salomonsson’s theory to account for his analytical observation and clinical experience was inspired mainly by Freudian, Kleinian, and Winnicottian perspectives. I will quote him more extensively here:

The mechanism, I assumed, was as follows: Her perceptions of Mum had been influenced by the pain and distress inherent in the colic and Mum’s ways of handling her. These perceptions were then subjected to splitting mechanisms and projective distortions. This caused a terrifying internal maternal part object to emerge. Any contact with the external Mum, above all looking into her eyes, entailed a risk for Kirsten to get in emotional contact with the feared internal object. Thus, her aim was not primarily to evade contact with her mother’s eyes but to avoid having a scary emotional experience. This process was also fuelled by how the mother perceived the girl; she was desperate about the colic and the gaze avoidance and accused herself of having caused at least the latter. This made Mum tense when she was with Kirsten. (Salomonsson, 2016, pp. 71–72)

The hypotheses about the mother’s internal situation could be investigated in the usual way in therapy, through associations and interpretations. But what about the baby’s internal world? He then proceeds to discuss the question of the baby as a subject, to which he responds affirmatively, after revising the relevant literature and describing the steps in the treatment that led to the dissolution of the symptom and the reestablishment of a more harmonious contact between mother and baby.

He describes the baby’s conflicts like this: ‘I love my mother; she always comforts me. No, she doesn’t. She is helpless when I’m helpless. She can’t take my pain away at once. I close my eyes because I want her out of my life’ (Salomonsson, 2016, p. 76)

His questions as a researcher were the following:

1. Can the baby defend herself against a representation? In his words: Can such a young psyche muster psychological defences?
2. From the perspective of the baby as a subject, ‘Can we ask if psychoanalytic concepts can describe her internal world and its links with her behavior?’

He concluded that gaze avoidance was not a solipsistic symptom but was part of a relationship disorder. Because the baby was seen as a subject and a very active, participative partner, the analyst addressed her directly, following the classic analytic description of a defence. There were three subjects in the room (the baby with her distress and her symptom, the mother with her guilt and depression, and the analyst with his countertransference), and the acknowledgement of this led to the affective breakthrough and to a behavioural change in the baby.

Being a finely attuned analyst and concerned with issues regarding research, he gives us the opportunity of following the progression of his work in a twofold movement: from the clinical experience to the theory and back from the theory to the experience. Given his exceptional clarity, we can follow his naturalistic observational capacity and the discoveries made in the clinical situation in the classical tradition of the single case.

Again, but in other words: I took this particular paper as an example of how phenomena that are found in the consulting room give rise to questions that will be systematically considered under the light of the continuity of the psychoanalytical process submitted to theoretical reflection/consideration.

I think Salomonsson achieved exactly what Bernardi preaches with regards to clinical research: The first task is to identify significant clinical facts and then to gather and attribute meaning to a set of data that, until then, seemed disconnected (Bernardi, Chapter 6, this book).

And Bernardi adds:

Transparency is also essential in the clinical field. In this case, replicability does not imply the repetition of identical clinical situations, which are unique, but rather the possibility of conceptual reproduction. This means traceability of the inferential ...

Table of contents

• Cover
• Endorsements
• Half Title
• Series Page
• Title Page
• Copyright Page
• Table of Contents
• List of illustrations
• Prologue by Mark Solms
• Introduction by Marina Altmann de Litvan
• Note on the IPA’s Committee for Clinical Research in Psychoanalysis by David Taylor
• Part I: From clinical practice to clinical research
• Part II: Different perspectives on clinical research
• Part III: Working with metaphors in psychoanalytic practice
• Part IV: Working parties as research tools?
• Part V: Working parties in action
• Part VI: Final considerations and questions raised
• Index