The International Journal of Int J Psychoanal (2013) 94:1153–1162

doi: 10.1111/1745-8315.12124

Psychoanalytic Controversy Response: What does the presentation of case material tell us about what actually happened in an analysis and how does it do this?1 Catherine Chabert 76, Rue Charlot, 75003 Paris, France – [email protected]

The fact that the clinical practice of analysis, in its connection with theory and method, constitutes an essential and indispensable lynch-pin of psychoanalytic research, must be universally accepted as self-evident. Freud’s epistemology anticipates the development of clinical practice even in 1915: it is certain that the material from Freud’s treatments gives rise to the construction of his metapsychology and its reappraisals and renewals. However, it is equally certain that our understanding of this clinical material is influenced if not shaped by our understanding of Freud’s models. There are therefore constant shifts between theory and clinical practice, and it is these shifts and this dialectic that allow for tension and lively dynamics to be maintained in conducting treatments and developing our ‘young science’. This begins to explain the extent to which clinical material plays a determining role and above all how it can be used for communication and transmission (Blass, 2013, p. 1129–34). The interest of the controversy that concerns us is therefore constantly active in our work: listening, interpreting, constructing, transmitting. These components of the analytic situation are constantly present in debates between analysts but equally in our internal debates, given that the psychoanalyst’s profession is primarily a solitary one.

At the foundations of psychoanalysis, the paradigms of Freud’s work Before going to the heart of this debate, I should like to mention the intellectual development that constitutes the anchoring of our analytic endeavours: the Freudian process that evolves through his works asserts and illustrates, with a tenacity that stands uncontested, the close connections between theory and clinical method and reveals the dynamics and effects of change in a singular way. Let us remember the two major developments that appear in Freud’s work, supported by the two paradigms constituted first by hysteria, and then by narcissism and melancholia. One produces the first topography and 1

Translated by Sophie Leighton.

Copyright © 2013 Institute of Psychoanalysis Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA on behalf of the Institute of Psychoanalysis

1154

C. Chabert

the first theory of the drives in the opposition between the self-preservative drives and the sexual drives; the other leads into the second topography and the opposition between the life drives and the death drives. The first follows the path of pleasure, the satisfaction of desire and healing. The second belongs to masochism, pain, the repetition compulsion and the refusal to heal. No analyst can contest this double path and the need to accept its dual nature; contesting the double path would mean excluding one topology or the other. In fact there is no renunciation or abandonment in Freud but a constantly active and present dialectic that is essential for thinking about clinical practice theoretically and accepting a truly metapsychological approach: we know the pitfalls of theory divorced from analytic experience, the inherent risk of abstraction and disembodiment and the threat of narcissistic blockages; but we also know what problems hang over clinical practice isolated from reflective thought and the possible deviation that can reduce the method to a mere praxis. The communication of clinical material depends on the standpoints of the analyst and his interlocutors: its stated objective is to give an account of the experience constituted by a treatment for each of the two protagonists. In the French language, ‘exp erience’ incorporates the word ‘p eril’ [peril] and even ‘p erir’ [perish] with the intense pressure these words imply. This suggests that all experience carries a risk that is sometimes mortal. In the course of an analysis, the ‘mortal’ risk is one of opposition to change, a psychic paralysis that might afflict the patient and the analyst: this opposition to change must obviously be understood in terms of psychic reality; that is, in terms of the unconscious and fantasy. It is therefore perilous and the peril threatens both protagonists: for the patient, the danger lies in the fear of abandoning his neurotic objects (his Neurotica), a compromise that produces symptoms and suffering but it is a precious compromise because it contributes to a relief paradoxically obtained through the benefits of illness. For the analyst, danger threatens in the risk of losing the capacities for associative listening and the conditions that allow it to develop, that is, the essential reference-points of the setting that guarantee the method. In its efficacy and in its essence, the transference presupposes a displacement (this is really what the word transference means) and the displacement requires abandoning, however incompletely, one place for another. This operation supports the movement intrinsic to the treatment, removing the burdens of cathexis from the original objects towards the person of the analyst. If we accept the idea of a double vector in analysis, we will accept that the transference itself also contains a double valency – oedipal and depressive – one drawing its forces from seduction and its sexual fantasmatic supports, the other tending more towards loss, mourning and death: moreover, the two sides appear in configurations that sometimes unite them and sometimes separate them. However, these two sides and the representations they engender put pressure both on the analyst and on the patient, probably in different ways, but their supporting structures are likely to be the same, they originate in excitation and its satisfaction, and in the forces of attraction and repulsion that foster resistances. Int J Psychoanal (2013) 94

Copyright © 2013 Institute of Psychoanalysis

Psychoanalytic Controversy: Presenting case material

1155

The analytic encounter is strong in these potential representations: an extreme intimacy coexists with a radical otherness, and this double progression is embodied in both partners by unfolding, as a result, sharing and confusion: inside and outside, internal reality and external reality, the requirement of subjectivity and the quest for objectivity. I think the communication of clinical material comes up against the twin pressures of respecting the intimacy of the treatment and therefore of the transference while also finding the minimal conditions for making this material shareable. This unique history constituted by the analytic encounter between a patient and his analyst (the ‘case’ history) can be considered as the kernel of intimacy, that which is so difficult for us to transmit or to communicate without being immediately gripped by the fear of a betrayal. A powerful paradox governs analysis: thinking secretly is a necessity for the psyche; saying everything is an essential requirement of the analytic method. The same paradox underlies the presentation of a clinical case. How can these two injunctions be reconciled? This is probably the paradox with which Dale Boesky and Elias Mallet da Rocha Barros are grappling and I think their standpoints each illustrate one or other path (Boesky, 2013a, p. 1135–43; Rocha Barros, 2013, p. 1145–52).

Contextualization: A privileged path in clinical presentation Boesky seeks to establish ways of presenting shareable clinical material by emphasizing the essential consideration of the context and, more specifically, the context in which an interpretation has been formulated to the patient (Boesky, 2013a, p. 1135–43). He considers in fact that contextualization is too often neglected in the analytic literature when it comes to understanding the developments that allow us to move from the manifest content to the latent content. He emphasizes that contextualization is not about using the context to privilege or validate certain information, but rather it is used for an epistemological justification. If the act of interpreting is to be understood, it cannot be restricted to mere utterance but must involve the whole context to which it belongs: why is one particular sequence favoured over another? The essential issue comes back to the exact moment when the interpretation emerged and this moment is predetermined and co-determined by a set of psychic or real events: associations, circumstances and anything that is potentially meaningful even before this interpretation is brought out and formulated. The author regrets that too often only the effects of the interpretation are taken into account to confirm or disprove the interpretation. However, can an interpretation really be deemed to be good or bad? And for whom is it then good or bad? For the patient as its object or for the analyst’s interlocutors who listen to him presenting the case? Can it be accepted that an intervention is good or bad, following the example of a maternal imago with a quasi-divine power summoned by the analyst’s words? Does judgement have any place in the analytic endeavour, which ideally should not adopt such purposive ideas and should refrain from positive or negative Copyright © 2013 Institute of Psychoanalysis

Int J Psychoanal (2013) 94

1156

C. Chabert

assessments? This is an ideal, of course, for how can we claim that an analyst presenting clinical material is not unwittingly seeking approval. How can we get rid of the narcissistic fears that arise from such a situation? Of course, we try to convince ourselves and to convince our interlocutors that our standpoints and our strategies are valid! In my view, it is more the right words – les mots justes, with the ambiguity of this expression – that are called for in the interpretation: ‘juste’ between ‘justesse’ [correctness] and ‘justice’ [justice, fairness], between correspondence and recognition. When Boesky refers to the ‘credibility’ (Boesky 2013a, p. 1139–40) of the case presentation, he underlines the illusory element inherent in any clinical report. He clearly demonstrates the constant oscillation between two perspectives: the endeavour to objectify, to enable the interlocutor to understand for himself some of the presented material, and the inevitable uncertainty and inherent contradictions that regularly arise. We must in fact (in my view) accept the idea that distortion occurs as much in the analyst as in the analysand and that the ‘raw’ material, when it is (re)presented, is inevitably transformed by the analyst’s listening and by the reconstruction required by the account. Just as the traces and then the dream narrative are distorted by the dream work and then by the work of its formulation in words and narratives, treatment narratives equally conform to this principle of modification-distortion. As we know, there is no objective and perfectly faithful listening; the analyst’s subjectivity modifies and shapes it, on the one hand, and, on the other hand, the communication of clinical material, whether oral or written (although these forms differ widely as I will mention below), inevitably involves modifications, even discrepancies in the transition from the speech heard to the speech recollected: these are not technical, i.e. connected only with the inherent distortion in the migration from one to the other, but methodological and clinical. They are mobilized by the transferential effects of this speech on the analyst and therefore by his countertransferential relation with his patient. According to Boesky, the remedy for these discrepancies is taking notes, which constitutes an ‘invaluable’ tool (Boesky 2013a, p. 1140) for working through this dilemma, even if presenting the complete transcription of the verbatim account is not truly satisfactory. He argues, however, that retroactive notes from the session, if they observe the principle of contextualization, provide a relatively reliable and efficient means of understanding everything that has happened, i.e. not only the patient’s speech (verbatim account) but also everything that accompanies it, to apprehend the place these words occupy in the session as a whole in order to understand its determinants. Three major axes in some sense order the procedure that Boesky advocates: infantile conflicts, symptoms and transference manifestations (Boesky 2013a, p. 1135–43). These strong reference-points enable the analyst to avoid forgetting, in line with the transference, the essentials of the progression of the treatment. It is probably supervision that Boesky has in mind when he writes that he wants to know what the analyst has understood but also what he has not understood: does the contextual note-taking allow this procedure to be sustained? Int J Psychoanal (2013) 94

Copyright © 2013 Institute of Psychoanalysis

Psychoanalytic Controversy: Presenting case material

1157

Many forms of clinical presentation: The variations of the address I will continue the discussion by means of two observations. The first relates to the need to take account of the situation in which the clinical presentation occurs. In this respect, I favour contextualization: speaking and writing require different psychic processes (even when reading a written text out loud) in that spoken thoughts and written words do not follow the same path; they encounter different possibilities and obstacles. My second comment relates to the fundamental dimension represented by the addressees of clinical presentations. To whom are we talking? For whom are we writing? I know that the conscious interlocutors can be joined by unconscious forms and that, perhaps, we are always addressing the same internal objects. Furthermore, I am convinced that the form of communication varies according to whether we are in the supervision situation, a seminar, a lecture, or a conference, or whether we are writing an article or a book. There again, the analyst’s transference or rather transferences are active and shape the translations of the raw material: these are always translations since they do not appear in their first emergence. Is it conceivable that the transference massively mobilized in the supervision has no effect on how the material from the sessions is communicated? In this particular context – although I respect candidates’ procedures – I like to take up the associations from the week’s sessions, even if this may have been supported by retroactive notetaking. For me, the notes that have left their impressions on the analyst have a similar function to the day residues of the dream. Of course, the psychic functioning of each is there, validating or privileging a particular dimension in the account of the sessions, but the supervisor can exercise his analytic listening which, also, will reveal his preferences: the dialogue can then be established and show how the meaning varies according to one or the other, helping to overturn the belief in the existence of a single truth sought in the interpretation. In my view, the clinical presentation in an oral communication addressed to a group uses procedures that are both similar and in some respects radically different. In particular, I think that the question of confidentiality does not arise in supervision, whereas it must be taken into consideration in addressing large groups. Then it may be advisable to transform the clinical material in order to respect this ethical principle. How then can we respect the progression of the treatment? How can we remain faithful to the essential substance and fabric that is conveyed by the clinical material? Although the notes provide us with a valuable resource, they cannot be literally used: the descriptive form seems to me debatable from the perspective of confidentiality but also because the clinical case presentation is not limited to the patient himself – it has to support what happens in the treatment for the analysand but also for the analyst. Without falling into the pitfalls of an exhibition of countertransference, the analyst’s psychic presence (with its unconscious components) is active in his speech, however ‘scientific’ it may be. What concerns us Copyright © 2013 Institute of Psychoanalysis

Int J Psychoanal (2013) 94

1158

C. Chabert

so much about confidentiality in presenting clinical material is really that we are revealing ourselves! Finally, I think that the presentation differs according to whether we wish to explain a sequence of analysis or a clinical case: in the first situation, the detailed consideration and contextualization of the sequence of analysis serve to support the construction and dynamic elaboration of the sessions. In the second situation, it is the entire analytic process that forms the essential object of the communication, and the clinical practice will allow a ‘surplus’ necessary for understanding the emergence of the major shifts that underlie it.

Elias Mallet da Rocha Barros: The analyst–poet’s style and the live transmission of experience Rocha Barros’s viewpoint differs considerably from Dale Boesky’s, although the objectives belong to the same perspective: how to share a clinical material of a treatment with other analysts. More specifically, the question raised can be formulated thus: how to communicate a listening experience to an addressee who has not had direct access, in vivo, to the situation that has given rise to this material? Rocha Barros, however, focuses on a particular mode of transmission, namely writing, and, in this case, the addressee in his comments is always a reader, (Rocha Barros, 2013, p. 1145–52) which, as I have mentioned above, is one of several situations of presenting clinical material. It is true that, as Rocha Barros emphasizes, writing can be considered as one of the means of communication inherent in psychoanalysis, Freud having opened this path from the outset.2 The standpoint adopted by Rocha Barros differs from Boesky’s in that Rocha Barros is more interested in the experience than in the discursive and representative components of analysis (Rocha Barros, 2013, p. 1145–52). Perhaps ‘experience’ should be understood in the sense it is given by Winnicott (1987) in the Selected Letters when he contrasts it with representation, as a validation of the economic dimension or emotions. For Rocha Barros, the living experience has to be preserved via the clinical writing and made accessible to the reader who has not listened to the patient himself. Now, in writing, we recollect and remember the experience of the session: the memory is part of a symbolic reconstruction that preserves the event. To do this, the author–analyst must restore the meaning of this experience and find forms other than that taken in the here-and-now. Rocha Barros argues that style allows a similar experience to be expressively evoked in the reader. The place accorded to the affects is substantial and constitutes the living source of the process. Evocation, convocation and invocation can be achieved by creating for the reader a reverie similar to the analyst’s in the session, a metaphorizing empathy that generates affective pictograms. These conditions allow the expressiveness of the representation, situated precisely between the pure 2

I do not think, however, that all psychoanalysts are writers by disposition, which does not impair their clinical and elaborative capacities.

Int J Psychoanal (2013) 94

Copyright © 2013 Institute of Psychoanalysis

Psychoanalytic Controversy: Presenting case material

1159

experience and the abstraction based on this experience. Rocha Barros describes an adventure in the world of ideas using the vicarious power of fiction: following the example of Gustave Flaubert’s L’ education sentimentale, a kind of sensitivity to the essence of what may have happened in the reported analytic encounter develops in the course of the writing. The writing analyst may resemble an epic poet in that he becomes the interpreter of a story. Listening to a patient in a session and writing about what emerges involve two different attitudes: clarity and precision are required to illustrate theoretical convictions but this standpoint runs counter to the clinical method. Rocha Barros therefore recommends two complementary approaches using a photographic metaphor: one focuses with the zoom and the other with the wide angle! (Rocha Barros, 2013, p. 1150) He also protests at the prevalence of theorizing imperatives when they involve distortions imposed by the concern to illustrate or validate the author’s metapsychological theories. For Rocha Barros, it is the patient’s theories rather than the analyst’s that interest us.

The requirements of the method: Connections between theory and clinical practice It is on the specific problem of the linkage between theory and clinical practice in analytic writing that I should like to concentrate. I subscribe in fact to Rocha Barros’s criticisms when he condemns the ‘theorizing’ tendencies that seek to prove their own pertinence by drawing on the evidence provided by clinical material. However, I will not go as far as to identify the author–analyst with an epic poet: firstly, because analysis is not necessarily a mythical or legendary adventure and often involves a complicated, painful, sometimes laborious and uncertain process. Secondly, because I consider it very difficult, within the analyst’s psychic functioning, to communicate his ‘purely’ clinical experiences and that which forms part of his theoretical training. The two combine, conflict or intermingle from one moment to the next. I certainly believe that conceptualization is suspended during the session and that a sequence cannot be thought about by establishing connections with a specific theoretical concept or notion. However, when it is a matter of writing for readers – that is a published article or a book – metapsychological perspectives are generally expected and can echo (as suggested by Rocha Barros himself) the clinical material. It is by means of these connections – convergent or divergent, harmonious or incongruous, convincing or rejected – that we progress! When Freud calls metapsychology a “witch” (1937, p. 224), he clearly shows us the close connection between fantasy and theory: our contacts with a specific model, our conceptual choices and the way in which we favour one train of thought over another are all lively manifestations of the hold exercised by fantasy on theoretical constructions. Putting them to the test of others’ thought, by following the double path of clinical practice and theory, allows us to construct a scene, a framework that can accommodate a genuine debate. Copyright © 2013 Institute of Psychoanalysis

Int J Psychoanal (2013) 94

1160

C. Chabert

To return to the beginning of this paper, I mentioned how clinical practice and theory but also method are interconnected. But I have concentrated until now essentially on the first two and on their possible interactions. I would like to finish by going further into method, for it is, very often, the object of debate or polemic: it provides a manifest substance for giving a form to the controversial positions that underlie clinical practice or theory. I think that the two developments previously emphasized in Freud’s works involve some changes in how the representations of the treatment itself are constructed. The hysterical model finds its applications in the quest to lift repression and Freud seems convinced that this is an effective operation: the discovery of the pathogenic event is followed by the disappearance of the symptom. But as early as 1914, the obstacles encountered, the failure before the success, then the negative therapeutic reaction, definitely signify different standpoints with regard to method; these arise as a direct result of the new clinical experiences but also of the concomitant metapsychological constructions (repetition compulsion, the second theory of the drives, the second topography, masochism). There are not necessarily any technical modifications, and the method remains fundamentally the same, but the listening is essentially modified and it is this which can hold our attention in clinical narratives. In written presentations, we are highly attentive to the analyst’s perspectives in the clinical experience that he wants to reveal to us, connected in the transference with those of his patient, and in the theoretical reflections that he wants to share with us retroactively.

Avenues and perspectives Without concluding, and to open the discussion, I intend to summarize some points concerning the clinical presentation. I think it is vital to distinguish between the situations to which the case presentation can belong. The essential reason, firstly, is that these mobilize a different transferential address, as I have emphasized on several occasions. The variety of these situations, beyond this constant, forms part of the purpose of this communication, its purposive ideas: the supervision, the account in a seminar, and the scientific lecture, all have different objectives on the conscious level. It can be freely admitted, and even expected, that the presentation will not be absolutely clear and transparent in a supervision session: it is even conceivable that the working through process may begin or develop during the exchanges between the candidate and the supervisor, which may form one of the components of the training. The verbatim account does not necessarily constitute a guarantee of authenticity; the concentrated reading it requires can impede associative thought and make the focus restrictively formal and descriptive: just as it may be productive to take up a dream narrative in detail, the systematic exposition of the verbatim account risks confining both partners in an almost pedagogical system, contrary to the conception of a training that can bring openness and associative flexibility. Boesky emphasizes this as Int J Psychoanal (2013) 94

Copyright © 2013 Institute of Psychoanalysis

Psychoanalytic Controversy: Presenting case material

1161

well: the word-based approach overlooks the context at the risk of losing the essentials. The desire to persuade seems to me very important to take into consideration: I think it is inherent in Freud’s thought and his legacy. Freud’s struggle to impose his ‘young science’ and its scandalous nature, to prove his credibility and to show his correctness and legitimacy continues long after its discovery. Whether it concerns theory or practice, the collective or the individual, we are always confronted with resistances. The account of clinical cases inevitably mobilizes them and it is these imaginary or real resistances that reinforce our need to persuade. I say need rather than only desire to the extent that the issues are narcissistic as much as object-related and in this respect they concern all situations in which cases are presented. The line between the desire to win over and the desire to be reinforced in our status as an analyst is sometimes a narrow one. Boesky and Rocha Barros suggest different ways of achieving this: the former, in terms of a quest for forms of communication that can provide a maximum of elements to allow the most ‘objective’ possible comparison, although it takes subjectivity into account (Boesky, 2013a, p. 1135–43). The latter adopts an almost poetic perspective, in terms of pure emotions and empathy, in the quest for another type of communication that is more characterized by expressiveness and affects, in the choice of a style that can convey the atmosphere of a treatment (Rocha Barros, 2013, p. 1145–52). I do not think that these two very different viewpoints are necessarily opposed: they bear witness to conceptions that demonstrate unique components of the analytic situation that they have chosen to develop. Their suggestions concerning clinical presentations therefore reveal to some extent their own conceptions of psychoanalysis. The comparison of their viewpoints is extremely valuable precisely because they are not in agreement: comparing contrasting standpoints is the most productive condition of a controversy. Finally, I should like to mention a type of clinical encounter that provides an experience of highly valuable work based on the precise account of sessions but also on the examination of the entire process under way: these are the special moments in which a few analysts study a treatment presented by a colleague, approaching the clinical material extremely closely while taking account of the dialectic that has impelled it from the outset. Its interest is particularly acute because these seminars bring together analysts from different societies and countries: although they have different mother tongues, they can find, beyond their differences, a shared analytic listening, sometimes creating a surprising and intense form of intimacy. The most important thing, in my opinion, is to be able to account for, bear witness to and convey the progression of the analysis: this involves in fact the dynamics both of transference and of change. Now is the change of standpoint not one of the major issues in psychoanalysis?

Copyright © 2013 Institute of Psychoanalysis

Int J Psychoanal (2013) 94

1162

C. Chabert

References Blass R (2013). What does the presentation of case material tell us about what actually happened in an analysis and how does it do this? Int J Psychoanal 94:1129–1134. Boesky D (2013a). What does the presentation of case material tell us about what actually happened in an analysis and how does it do this? Int J Psychoanal 94:1135–43. Rocha Barros EM (2013). What does the presentation of case material tell us about what actually happened in an analysis and how does it do this? Int J Psychoanal 94:1145–52. Freud S (1937). Analysis terminable and interminable. SE 23, 209–54. Winnicott DW (1987). Selected letters: The spontaneous gesture. Rodman F, editor. Cambridge, MA: Harvard UP.

Int J Psychoanal (2013) 94

Copyright © 2013 Institute of Psychoanalysis

Response: What does the presentation of case material tell us about what actually happened in an analysis and how does it do this?

Response: What does the presentation of case material tell us about what actually happened in an analysis and how does it do this? - PDF Download Free
193KB Sizes 0 Downloads 0 Views