Tuesday, March 12, 2013

Owen Renik - Intersubjectivity and Psychoanalytic Technique

"The author defines the therapeutic action of psychoanalysis as the patient's increased capacity to make changes in his/ her attitudes or behaviors in order to achieve greater well-being and satisfaction in life. Although most analytic theories generally agree about this, the author notes, they diverge in their specifications of the principles of analytic technique that will best accomplish this aim. The patient's experience of benefit is the most accurate criterion for evaluating the success of the analysis and thus of the resultant therapeutic action, in the author's belief. An extended clinical vignette is presented in which he illustrates how his technical decisions are guided by these principles.

I find that patients usually seek psychoanalytic treatment with what is at heart a simple agenda: they want to feel more satisfaction and less distress in their lives. If I am able to help someone, it is because the way he/she constructs his/her experience is less than optimal for the purposes of pursuing satisfaction and avoiding distress, and the construct can be altered: certain of the patient's expectations, assumptions, and decision-making can be reviewed and revised, as a result of which the patient's attitudes and behaviors change so as to afford the patient a feeling of greater well-being. Such, in my view, is the therapeutic action of clinical psychoanalysis; and it seems to me that any number of psychoanalytic theories describe it, though each uses a particular vocabulary with a particular emphasis. Conflict theorists speak of alterations in the patient's compromise formations, i.e., in the way the patient manages his/her complex motivations; self psychologists speak of re-parative selfobject transferences that allow the patient to regain adaptive narcissism; control mastery analysts speak of the analyst disconfirming the patient's pathogenic beliefs (a version of corrective emotional experience); developmentalists speak of the patient reworking stages of separation-individuation; and so on. These are all descriptions of the same process—a review and revision of the patient's expectations, assumptions, and decision-making, the way the patient constructs his/her reality—seen from different angles of view. To think otherwise is to make the mistake of the blind men with the elephant.

This is not to deny that divergent views regarding therapeutic action exist among various psychoanalytic theories. Far from it. However, if we rise above the narcissism of small differences, I think what we see is that the significant distinctions do not really concern the essential nature of therapeutic action as much as they concern the question of how to bring about therapeutic action. In other words, it is my impression that the important controversies with regard to the therapeutic action of clinical analysis really concern differences in principles of technique — which should follow closely from fundamentally different conceptions of therapeutic action, but which, in fact, often do not.

For example, a great many colleagues are willing to agree that a successful clinical analysis depends, somehow or other, upon a series of corrective emotional experiences. But very few endorse the presumption and contrivance of the clinical method recommended by Alexander and French (1946) for providing corrective emotional experiences. Similarly, while contemporary analysts may differ to some degree as to the role of conscious insight, most allow that nonverbal factors are crucial; and on that basis, there is widespread acceptance of the idea that for clinical analysis to succeed, the patient has to live through a series of transferences whose effect is, ultimately, reparative. At the same time, there is considerable criticism in many quarters of how self psychologists approach their patients.

Recently, a great deal of attention has been paid to the recognition that when a patient's construction of his/her experience can be successfully reviewed and revised in clinical analysis, this review and revision are accomplished via an intersubjective exchange between analyst and patient. This "intersubjectivist" or "relational" orientation—at least as I understand it — does not in itself indicate an altered conception of the therapeutic action of clinical psychoanalysis. What an intersubjective perspective offers is increased appreciation of the epistemology of the clinical analytic encounter. And that has decisive implications with regard to how an analyst optimally goes about arranging for the therapeutic action of clinical analysis to take place — i.e., for our theory of technique.

To begin with, a reconsideration of analytic expertise and authority is called for. Rather than an expert on understanding the patient's psychic life, the analyst is an expert on facilitating a collaboration that permits the patient to understand his/her own psychic life. Instead of an authority who reveals hidden truths to the patient, the analyst is a partner who works with the patient to create understanding concerning the way the patient constructs his/ her reality, and to revise the patient's constructions of reality so as to afford the patient less distress and more satisfaction in life. In a successful clinical analysis, co-created old truths are replaced with co-created new truths. To differentiate between creation and discovery in clinical analysis is to establish a specious dichotomy.

The vehicle for collaboration, of course, is the dialogue — spoken and unspoken, conscious and unconscious — that takes place between analyst and patient. The ground rules that are established for the clinical analytic dialogue will structure the intersubjective encounter that ensues and what it produces. Traditional principles of clinical analytic technique have established ground rules that privilege the analyst's voice in the dialogue. Perhaps most important, this has happened because our theories of psychoanalytic process—and, therefore, our principles of technique — have directed analysts to apply their clinical efforts toward the achievement of special, specifically psychoanalytic goals, formulated separately from therapeutic goals. In fact, analysts are warned against therapeutic zeal, which is understood to interfere with the pursuit of psychoanalytic goals. Specifically psychoanalytic goals necessarily derive from psychoanalytic theories. Therefore, when clinical work aims at accomplishing specifically analytic goals, the analyst, who is an authority on analytic theory, is established as an authority on clinical progress and outcome.

A problem with privileging the analyst's voice in the dialogue and making the analyst an authority on progress and outcome is that it disposes to circularity in clinical investigation. The analyst's subjectivity dominates the intersubjective exchange and the co-creations produced by it. What comes to be understood reflects what the analyst assumed in advance. Obvious evidence of this is the fact that successful clinical analytic results around the world tend to differ predictably, according to the psychoanalytic subculture to which the analyst belongs: in one locale, a clinical analysis is understood to conclude successfully when the patient's primal scene fantasies are exposed; in another, when the patient moves beyond the paranoid-schizoid position; in still another, when the patient successfully achieves rapprochement; and so on.

Acknowledging the intersubjectivity of clinical analytic work exposes the problem of circularity and indicates the need to establish outcome criteria for clinical analysis that are independent of psychoanalytic theory. In my opinion, analytic purposes are best served by using the patient's experience of therapeutic benefit as the outcome criterion by which the success of clinical analytic work is judged. Obviously, a patient's self-evaluations and self-reports concerning therapeutic benefit will always be highly overde-termined. Nonetheless — whatever the inevitable role of compliance, opposition, etc. — a patient's judgments of therapeutic benefit are based on observations made external to the treatment relationship and the clinical setting. This gives the possibility of constructing clinical analysis as an experimental situation, however imperfect. Psychoanalytic propositions can be tested by measuring a dependent variable: valid insights are ones that produce enduring therapeutic benefit; useful analytic techniques are ones that produce valid insights.

This approach to validation in psychoanalysis, which follows from acknowledging the intersubjective nature of clinical analytic investigation, is often misconstrued to have a hermeneutic orientation because it legitimizes narratives, co-created by analyst and patient, as psychoanalytic propositions. On the contrary, this approach is scientific. Science always deals in narratives, whether those narratives are competing versions of quantum mechanics in physics or various psychodynamic formulations in a clinical psychoanalysis. What science requires is that the claims of differing narratives be adjudicated on a pragmatic, empirical basis — i.e., that an experimental situation be established in which narratives can be evaluated according to their ability to predict.

In hermeneutic disciplines, like literary criticism or political history, data do not permit use of prediction as a basis for validation of propositions. Other criteria must be used — aesthetic criteria such as elegance, coherence, or rhetorical appeal. When specifically psychoanalytic goals are pursued in clinical analysis, circularity gets built in and aesthetic criteria are used to assess insights — i.e., explanations that analyst and patient find persuasive are held to be valid; validation of insights is not accomplished by testing predictions concerning an independent variable. Therefore, when specifically analytic goals are pursued, clinical analysis becomes a hermeneutic, rather than a scientific, enterprise.

For me, then, a patient's experience of increased satisfaction and decreased distress in life is the only outcome criterion by which the success of analytic work can be judged. Analyst and patient together may arrive at an understanding of the patient's psychology that offers a comprehensive and elegant explanation of the patient's difficulties, that takes account of the patient's history, the patient's experiences and behaviors both within and without the sessions, an explanation about which both patient and analyst are quite convinced; but if that understanding is not accompanied by a subjective judgment of increased satisfaction and decreased distress on the patient's part, the validity of the understanding — its completeness, at least, if not its accuracy — must be doubted.

These methodological considerations have very practical consequences. An analyst's theoretical assumptions are a crucial part of the analyst's subjectivity, and often have a decisive influence upon clinical work." (pp. 1547 - 1551)

Owen Renik (2007). Intersubjectivity, Therapeutic Action, and Analytic Technique. Psychoanalytic Quarterly, 76S, pp. 1547-1562

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