The International Journal of Int J Psychoanal (2013) 94:1135–1143
doi: 10.1111/1745-8315.12120
Psychoanalytic Controversy What does the presentation of case material tell us about what actually happened in an analysis and how does it do this? Dale Boesky 614 Watkins, Birmingham, MI 48009, USA – [email protected]
Our neglect of context in the inference of unconscious meaning The above title suggested for this discussion (Blass, 2013, p. 1129) alludes to topics of such magnitude and complexity that in the present context I will primarily consider only one of these that has been perhaps most neglected – the process of contextualization that clinical presentations should make apparent, but often fail to. Theoretic pluralism has not eliminated ‘the’ unconscious as a theoretic bedrock source for the suffering of our patients. We have always shared the assumption that this suffering seeps into meaning-altered derivatives, which can only be accessed via an assumption that the links between manifest and latent meaning are disguised. But there is an abiding confusion about our methodology of inferring latent meaning from manifest content. Here, a paradoxical gap between theory and practice is nowhere more apparent or consequential. Our various alternative theoretic models provide diverse explanations for the causes of the transformation of unconscious affective pressures into their manifest derivative. But, without exception, these different theoretical models are, to varying degrees, silent or vague about the best methods of translating latent content to manifest content, and they always have been. Just as we have always known that there can be no meaning without context we have just as often ignored the task of stating why we have claimed that certain data warranted contextual significance. If we pin everything on context, why have we given so little attention to the methodology of contextualization? To contextualize is to privilege and justify certain information. I use the word ‘justify’ here not in the connotation of legitimizing, let alone ‘validating’, but in the sense only of epistemic justification.1 It should be incumbent on our authors to show why they have decided to grant contextualizing importance to certain information. This is not at all the same as proving that this will validate the truth of the meaning justified by this claim. ‘Justification’, as I use the term here, is merely an explanation for making a claim 1 The term ‘justification’ has a variety of applications by professional philosophers. I speak here of a very narrow connotation: “…in epistemology we need to distinguish justification from truth, since either of these might apply to a belief in the absence of the other” (Audi, 1999, p. 457).
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
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for contextual significance (Cavell, 1993). A colleague, noted and respected throughout the international psychoanalytic community for his analytic skill and personal tact, illustrated this link between meaning and context with an anecdote. He said that he had once found it useful to say to a patient of his: “Fuck you.” He explained that if we knew why he said this to his patient we would have quickly understood. Yet our literature is essentially silent about the methodology employed by our authors to support the validity of meanings they claim to have discovered (or constructed). A search of the PEP Web database reveals that there are no citations on contextualization in this specialized sense as a central component of the psychoanalytic process. Instead, there are numerous references to ‘contextualization’ in the general sense of the term ‘context’ and its derivative forms.
The problem of infinite over-determination Freud’s revolutionary epistemological discovery was his revelation that unconscious meaning governs powerful human emotions. Taking meaning at face-value had been a fundamental error before Freud. After Freud’s seminal discoveries about the over-determination of meaning the analyst had to assume that at least theoretically everything that the patient said or did had meaning. This was an epistemological declaration of independence from all prior epistemological views that were based only on conscious meaning. I can think of few analysts who would quarrel with this as essential to their definition of what constitutes the bedrock of psychoanalysis. Its universality spans decades of work from Glover (1952) to Thomas Ogden (2005, p. 18). But only a few have recognized that infinite over-determination is problematic (Glover, 1952, p. 405). I emphasize that it requires of us to make explicit our contextualizing criteria that are too often neglected in our literature and our written case reports. An analogy to contextualization is the staining technique of the pathologist, whose chemical treatment of human tissue vividly exposes contrasting shades of red and blue patterns under the microscope, instead of the confusing shadows of colorless natural tissues. Depending on which stain is used, certain structures are more visible and others less so (Cheshire and Thoma, 1991). We have a large literature and prolonged polemics about the rival truth claims of our numerous theoretic models. But for every pound of polemic there is scarcely an ounce of critical comparison of these rival models’ methodology for contextualizing. To be clearer, I should say that we act as though we need not think about the fact that when we make a claim for a particular interpretation we are simultaneously claiming priority for its particular contextual horizon. That horizon is constituted by a group of associations and we behave too often as if we can simply take for granted why we privilege that particular contextual organization, or why we denigrate others. Instead of being more curious about our famous inability to agree about many clinical vignettes we merely shrug our pragmatic, pluralistic shoulders. The time has come to recognize that our need to prove how open-minded we are obscures the need to clarify why some assumptions Int J Psychoanal (2013) 94
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explain the available data better than others. As long as anything can be said to be a contextualizing marker to justify the inference of latent from manifest content, then anything can plausibly be asserted to mean anything. For example, due to inexperience a candidate might omit from her understanding that a patient’s anger towards her in a particular session would take on a different meaning if she included in her contextualizing criteria the fact that this would be the last appointment before her vacation. The omitted contextual organizer here is the valuable dictum: try to understand why something is happening now. Another example of the omission of this factor (why now?) as a contextualizing criterion (or contextualizing organizer) appeared in the disagreements between some 25 analysts about a clinical report by P. Casement in which a patient ‘suddenly’ demanded that the analyst hold her hand or she would quit the analysis. The controversy divided the analysts mostly into those who approved of his stand in which he declined to hold her hand and those who disapproved. Very few of those who engaged in this debate considered it contextually important to account for the fact that the patient’s demand that the analyst hold her hand appeared almost immediately after the analyst insisted (over the patient’s repeated objections) on the accuracy of his interpretation of a dream she had just reported.2 It is this neglect of our essential (but only implicit) contextualizing methods that was enshrined when Freud (1905/1953, pp. 12–13) omitted defining his methods for interpretation and trivialized this omission in his famous report of the case of Dora: There is another kind of incompleteness which I myself have intentionally introduced. I have as a rule not reproduced the process of interpretation to which the patient’s associations and communications had to be subjected, but only the result of that process. Apart from the dreams, therefore, the technique of the analytic work has been revealed in only a very few places. My object in this case was to demonstrate the intimate structure of a neurotic disorder and the determination of its symptoms; and it would have led to nothing but hopeless confusion if I had tried to complete the other task at the same time. (1905)
In 1905 Freud could say that he was quite prepared to explain his methodology for making interpretations but that it would have been ‘impractical’ because it would have led to nothing but hopeless confusion. Subsequent events suggest that Freud’s belief that he had already resolved the problems of contextualization was premature. In fact the daunting scientific and conceptual problems of codifying how to integrate the mysteries of contextualization, the inference of unconscious meaning, and the methods of fashioning our interpretations, have also continued to defy all subsequent generations of analysts. The irony is that the neglect of this problem has led to the dire confusion Freud was trying to avoid in 1905.
2 For a discussion of this controversy see Boesky, 2008, chapter 2; also published in a different version as ‘Analytic controversies contextualized’ (J Am Psychoanal Assoc 53:835–63, 2005).
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Because of confusion prolonged by the conundrum of infinite overdetermination it seems as though everything the patient says before our intervention needs to be sifted; we cannot discard any of the raw ore of the patient’s associations when we report that something ‘really’ means something else. Everything counts. At the same time, we are left on our own to determine the difference between: (a) everything potentially counting, when we consider rival contextualizing choices before the interpretation, and (b) everything counting equally later down the line when we have arrived at tentative contextualizing conclusions about meaning. But actually and in practice all the associations do not count equally before we decide to venture an interpretation. The very act of making an interpretation indicates the analyst’s prior decision to grant contextual priority to certain associations. And it is too frequently the case that we are not fully or even partly aware of how and why we decided to privilege a particular alternative. My personal experience has been that, when I privilege certain associations, it is very often because I feel that they express the most pressing affective pressure of the moment. Such determining factors often remain private and just as often never reach the printed page in our later reflections and writing about our clinical experience. In 1909 Freud did not have to think that giving the hungry Rat Man some herring mattered or ‘counted’ in his inferred understanding of subsequent events. As our contextual horizons have expanded with our progress, so has the complexity of our contextual choices. Not only do we contextualize, but we also make trial contextualizations that we then find necessary to discard. Clinical presentations should inform us about these, not only the interpretations actually made. We need to know how and why certain material was deemed to be meaningful. When we are left ignorant about this we pay a price. In ensuing disagreements we too often talk past each other because we do not know what ‘counted’ and what ‘didn’t count’ in the formulations of the author.
Linking the flow of material before and after an interpretation Instead of informing us about the contextualizing information by which we determine meaning and interpretations, we tend to rely on a fallacious assumption when we ‘validate’ an interpretation only on the basis of the reactions of the patient immediately after the interpretation (e.g. Wisdom 1943, 1967). However, the emergence of dynamically important new material can follow very bad interpretations and not only good interpretations. Also, too often it is possible to demonstrate – when the information is made available by the author – that something the patient said before an interpretation and which was deemed insignificant actually played a crucial role. It is not news to state that crucial contextualizing opportunities for one analyst are unimportant to another. What I am stressing is that a careful evaluation of an interpretation should, whenever possible, include a comparison of the associations of the patient prior to the associations, with the associations that follow it (both immediately and later). This can reveal dynamic and contextual congruence between prior associations and those that follow Int J Psychoanal (2013) 94
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the intervention. It may show how earlier interventions were a stimulus to those much later ones and in this way they may be especially valuable in documenting the justification for the interpretation.
Presenting the reader with a credible account Authors have imaginary readers in mind. Our best authors follow the golden rule and treat their imaginary reader as they wish to be treated. Our less gifted authors try to manipulate, exhort or sway their readers. This is really a subtext of our discussion: what do we require of an author in order for us to believe in the credibility of a case report? The issue of credibility is related to but not identical with plausibility as well as with methods of validation. Certainly, the mere mechanical reporting of process notes will not convince us of even the plausibility of the claim that the data provided support the claims of the author. Credibility is enhanced when the reader is provided with information about the contextualizing bridges between the raw data and the voiced interpretation. Hartmann used no clinical material at all in most of what he wrote and justified this to his critics by saying that he merely used a different form of shorthand. Loewald also published very little clinical material. But within at least the community of adherents of each author their divergent views have had the cachet of credibility. There is no list of information that we require in order to grant credibility to an author’s claims. I suggest that, as we become better able to map our strategies of contextualization, we shall at least be better able to say why we grant much credibility to some theoretic inferences and less to others. Let us also put aside for the moment ad hominem arguments and assume that competent, honest and fair readers actually exist among our colleagues. What do they want to know and what should we tell them? The problem of selection in case reporting can be compared to the strategy of the kidnapper preparing a ransom note. He wishes a certain minimum level of legibility in order to collect his ransom. But he must avoid detection so he creates a collage from selecting and cutting out the words of his message from a number of newspapers and magazines. A new and deceptively coherent message results but each unit of the message is deracinated from its original source and context. Too many of our clinical case reports are such ransom notes. And too many reports demand our belief. Take it or leave it. In these papers the reader is solely responsible for providing benevolent scepticism. So I would hope that, in preparing clinical reports (my own included), more thought would be given to uncertainties, questions that remain to be answered, self-contradiction in the material still unaccounted for, and a liberal sprinkling of non liquet. Also, it would help if authors who claim that they are not trying to prove anything, but only trying to demonstrate their theoretic views with some clinical material, would specify which parts of their clinical data are illustrative of which theoretic notions. Disclaimers regarding proof have become all too common in our literature. To say, ‘I am merely illustrating what I mean’, too often does not illustrate what the author claims with supposed self-evidential clarity. Copyright © 2013 Institute of Psychoanalysis
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Credibility context and process notes Psychic determinism is a conceptual anchor underlying my views about using process notes for any purpose. Process notes that clearly demonstrate the actual sequences of the patient’s communications are an invaluable tool for preserving and demonstrating the ubiquitous power of psychic determinism. Process notes are therefore an invaluable evidential support for the contextual organizers chosen by the analyst. If used selectively and judiciously they illustrate why the analyst has chosen to infer certain contexts. That is why the preservation of the patient’s communications at the lowest level of observation, the so-called ‘raw’ data, is so important (with due recognition that there is no such thing as an ‘observation’ devoid of subjective bias). These associations are the ore which the analyst sifts when forming trial contextualizations. The presentation of total transcripts or lengthy verbatim examples is not what I have in mind here. Arlow’s suggestions for choosing what to include remain unparalleled: Most important is the context in which the specific material appears. Contiguity usually suggests dynamic relevance. The configuration of the material, the form and sequence in which the associations (appear). Other criteria are to be seen in the repetition and the convergence of certain themes within the organized body of associations. The repetition of similarities or opposites is always striking and suggestive. Material in context appearing in related sequence, multiple representations of the same theme, repetition in similarity, and a convergence of the data into one comprehensible hypothesis constitute the specific methodological approach in psychoanalysis used to validate insights obtained in an immediate, intuitive fashion in the analytic interchange. (Arlow, 1979, p. 202)
It should be added that process notes vary widely in content, in the purpose for which they are used, and in how they are obtained. Since we have no consensually accepted definition of the psychoanalytic process, we also have no consensus about which notes would be useful to preserve. Moreover, every analyst who has attempted to take process notes after the session is over (my own choice) can attest to the fact that inevitably in every session the analyst will forget certain events in the session. And in my experience the strategy of taking notes during the sessions to avoid losing information is a serious distraction for the analyst. At the same time, there is little value to routinized total inclusion of process notes. Reading a transcript of process notes that omit contextualizing information is like watching a movie of a moving car that turns one way and then another. We know the driver has turned right or left but we do not know why. The reason for the turn depends on a context that has not been shared with the viewer. What is needed is the judicious selection of the associations of the patient and the context in which these associations emerged. Because of the daunting diversity of data there is no simple solution to the question of what we should include in our written reports for those analysts who wish to use process material. What I am able to suggest is that Int J Psychoanal (2013) 94
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we should include samples of actual clinical interactions and actual statements that were felt to be contextually organizing for this author and this patient.
An epistemological controversy: The very idea of evidence is fallacious because objectivity is a fiction By this point the reader might wonder if the views I have expressed were written with a lack of awareness that a controversy underlies my views about interpretation and contextualizing. I imply that interpretations are in some sense objective and are offered by an objective analyst. Spence (1976) discussed the problems surrounding this some 35 years ago: As we listen to the stream of associations from an analytic patient, we hear an almost continuous flow of linked ideas. They seem to resolve themselves into a number of strands – sometimes few, sometimes many. But ask a friendly critic to listen to the same material: he hears a mixture of unrelated words and has the impression that the patient simply skips from one topic to the next. Who is right? To put the problem in these terms helps to show how quickly we lose sight of the fact that the links between ideas in clinical material may be imposed from outside and are not always inherent in its structure. Since we find it so easy to see connections between disparate ideas, we assume that the connections are contained in the structure, which is to say that other judges would hear the material in much the same way. But would they? Would 12 friendly critics independently arrive at the same underlying structure, or would each hear his own favorite melody? (p. 367)
While it is not uncommon for many analysts to laugh about the outdated ‘positivist’ view that there can be any such thing as evidence in psychoanalysis, in my view my patients’ associations are the dynamic consequence of powerful unconscious affective linkages. These associations are determinate in retrospect, but never predictable looking forward in the sense of ‘determinism versus free will’. The fact is, however, that the less we know about the contextualizing criteria of the reporting analyst the easier it is to maintain the view that there is no objectivity to interpretations; that consequently we must hold onto the pragmatic fiction that truth is whatever works. Our literature too often suffers from such reductive pragmatism (Jimenez, 2009). If the ‘truth’ is defined to be ‘whatever works’ we do not need to concern ourselves with this very complex problem of over-determination. If certain things ‘work’ for this analyst and this patient, further questions about alternative explanations are merely moot academic points. But who is to say what we mean by ‘works’ when we say it works. We have merely begged the question.
Contextual anchors for clinical reports I will briefly sketch here the conceptual anchors that should appear in the presentation of case material in order to bridge the between theories of pathogenesis, the biographical history of the patient, and the chosen contexCopyright © 2013 Institute of Psychoanalysis
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tual horizons of the author. My view of pathogenesis is both developmental and conflict-centered. I believe that the most important conflicts as well as the most significant deficits of early development are organized in childhood in a manner that is fossilized in the amber of psychopathology. These conflicts become visible in later adult symptoms which become prominent in the behaviour of the patient with the analyst. So when I read a clinical paper I want to know something about all three poles of this dynamic tripod of information (childhood conflicts, adult symptoms and their transference derivatives) that the analyst has used to contextualize his or her understanding of what has gone wrong in the patient’s life. Yet one cannot expect this information to be equally a part of every report. One attempts to guess whether such information is absent by judicious selection or by inadvertent omission. That is also true for missing information about the sexual history. I want to know how the analyst has had to struggle with the transference in order to reach helpful understandings of it and what the analyst did to intervene. But I want also to know what the analyst still does not understand. Some believe that the analysis has to be terminated before one can write about it in order to reduce the chance of undiscovered prior information that could materially alter the perspective of the author. I disagree with that view because there are valuable papers that report preliminary experiences that are instructive. But the reader should know if the case is still in progress. Also if the case is terminated we should be provided information about the termination phase especially how the patient was able to deal with the mourning inherent in this process. There can, of course, be no such thing as a checklist of items to include in a case report. What is essential is the fit between the ‘illustrative’ purposes of the author and the clinical data he or she has chosen. Are these fragments of data sufficiently self-evident to actually illustrate the author’s conjectures? My purpose is not to prescribe rules for presenting clinical material, but to emphasize that how we think about ‘evidence’ is inseparable from how we think about contextualization. At issue is a call for wider recognition of the problems we perpetuate in continually denying the profound epistemological penalties we have incurred by our neglect of this gap in our methodology for how we gather and evaluate our contextualizing criteria. Gradually developing useful measures and guidelines for balancing an author’s theoretic assumptions with the contextualizing criteria adduced to support their views will be an enormous task. And until we refine our methods for contextualizing we will be hampered in our efforts to clarify the manner in which we should accept or disagree with the evidence for our truth claims. We cannot continue to delay the necessity of facing this problem.
References Arlow J (1979). The genesis of interpretation. J Am Psychoanal Assoc 27S:193–206. Audi R (1999). Cambridge dictionary of philosophy. 2nd edition. Cambridge: Cambridge UP. 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 94:1129–34. Boesky D (2008). Psychoanalytic disagreements in context. Lanham, MD: Aronson. Int J Psychoanal (2013) 94
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Cavell M (1993). The psychoanalytic mind from Freud to philosophy. Cambridge, MA: Harvard UP. Cheshire N, Thoma H (1991). Metaphor, neologism and ‘open texture’. Int Rev Psychoanal 18:429– 55. Freud S (1905/1953). Fragment of an analysis of a case of hysteria. SE 7, 12–3. Glover E (1952). Research methods in psycho-analysis. Int J Psychoanal 33:403–09. Jimenez J (2009). Grasping psychoanalysts’ practice in its own merits. Int J Psychoanal 90:231–48. Ogden T (2005). On psychoanalytic writing. Int J Psychoanal 86:15–29. Spence D (1976). Clinical interpretation: Some comments on the nature of the evidence. Psychoanal Contemp Sci 5:367–88. Wisdom J (1943). Determinism and psycho-analysis. Int J Psychoanal 24:140–7. Wisdom J (1967). Testing an interpretation within a session. Int J Psychoanal 48:44–52.
Copyright © 2013 Institute of Psychoanalysis
Int J Psychoanal (2013) 94
doi: 10.1111/1745-8315.12120
Psychoanalytic Controversy What does the presentation of case material tell us about what actually happened in an analysis and how does it do this? Dale Boesky 614 Watkins, Birmingham, MI 48009, USA – [email protected]
Our neglect of context in the inference of unconscious meaning The above title suggested for this discussion (Blass, 2013, p. 1129) alludes to topics of such magnitude and complexity that in the present context I will primarily consider only one of these that has been perhaps most neglected – the process of contextualization that clinical presentations should make apparent, but often fail to. Theoretic pluralism has not eliminated ‘the’ unconscious as a theoretic bedrock source for the suffering of our patients. We have always shared the assumption that this suffering seeps into meaning-altered derivatives, which can only be accessed via an assumption that the links between manifest and latent meaning are disguised. But there is an abiding confusion about our methodology of inferring latent meaning from manifest content. Here, a paradoxical gap between theory and practice is nowhere more apparent or consequential. Our various alternative theoretic models provide diverse explanations for the causes of the transformation of unconscious affective pressures into their manifest derivative. But, without exception, these different theoretical models are, to varying degrees, silent or vague about the best methods of translating latent content to manifest content, and they always have been. Just as we have always known that there can be no meaning without context we have just as often ignored the task of stating why we have claimed that certain data warranted contextual significance. If we pin everything on context, why have we given so little attention to the methodology of contextualization? To contextualize is to privilege and justify certain information. I use the word ‘justify’ here not in the connotation of legitimizing, let alone ‘validating’, but in the sense only of epistemic justification.1 It should be incumbent on our authors to show why they have decided to grant contextualizing importance to certain information. This is not at all the same as proving that this will validate the truth of the meaning justified by this claim. ‘Justification’, as I use the term here, is merely an explanation for making a claim 1 The term ‘justification’ has a variety of applications by professional philosophers. I speak here of a very narrow connotation: “…in epistemology we need to distinguish justification from truth, since either of these might apply to a belief in the absence of the other” (Audi, 1999, p. 457).
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
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for contextual significance (Cavell, 1993). A colleague, noted and respected throughout the international psychoanalytic community for his analytic skill and personal tact, illustrated this link between meaning and context with an anecdote. He said that he had once found it useful to say to a patient of his: “Fuck you.” He explained that if we knew why he said this to his patient we would have quickly understood. Yet our literature is essentially silent about the methodology employed by our authors to support the validity of meanings they claim to have discovered (or constructed). A search of the PEP Web database reveals that there are no citations on contextualization in this specialized sense as a central component of the psychoanalytic process. Instead, there are numerous references to ‘contextualization’ in the general sense of the term ‘context’ and its derivative forms.
The problem of infinite over-determination Freud’s revolutionary epistemological discovery was his revelation that unconscious meaning governs powerful human emotions. Taking meaning at face-value had been a fundamental error before Freud. After Freud’s seminal discoveries about the over-determination of meaning the analyst had to assume that at least theoretically everything that the patient said or did had meaning. This was an epistemological declaration of independence from all prior epistemological views that were based only on conscious meaning. I can think of few analysts who would quarrel with this as essential to their definition of what constitutes the bedrock of psychoanalysis. Its universality spans decades of work from Glover (1952) to Thomas Ogden (2005, p. 18). But only a few have recognized that infinite over-determination is problematic (Glover, 1952, p. 405). I emphasize that it requires of us to make explicit our contextualizing criteria that are too often neglected in our literature and our written case reports. An analogy to contextualization is the staining technique of the pathologist, whose chemical treatment of human tissue vividly exposes contrasting shades of red and blue patterns under the microscope, instead of the confusing shadows of colorless natural tissues. Depending on which stain is used, certain structures are more visible and others less so (Cheshire and Thoma, 1991). We have a large literature and prolonged polemics about the rival truth claims of our numerous theoretic models. But for every pound of polemic there is scarcely an ounce of critical comparison of these rival models’ methodology for contextualizing. To be clearer, I should say that we act as though we need not think about the fact that when we make a claim for a particular interpretation we are simultaneously claiming priority for its particular contextual horizon. That horizon is constituted by a group of associations and we behave too often as if we can simply take for granted why we privilege that particular contextual organization, or why we denigrate others. Instead of being more curious about our famous inability to agree about many clinical vignettes we merely shrug our pragmatic, pluralistic shoulders. The time has come to recognize that our need to prove how open-minded we are obscures the need to clarify why some assumptions Int J Psychoanal (2013) 94
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explain the available data better than others. As long as anything can be said to be a contextualizing marker to justify the inference of latent from manifest content, then anything can plausibly be asserted to mean anything. For example, due to inexperience a candidate might omit from her understanding that a patient’s anger towards her in a particular session would take on a different meaning if she included in her contextualizing criteria the fact that this would be the last appointment before her vacation. The omitted contextual organizer here is the valuable dictum: try to understand why something is happening now. Another example of the omission of this factor (why now?) as a contextualizing criterion (or contextualizing organizer) appeared in the disagreements between some 25 analysts about a clinical report by P. Casement in which a patient ‘suddenly’ demanded that the analyst hold her hand or she would quit the analysis. The controversy divided the analysts mostly into those who approved of his stand in which he declined to hold her hand and those who disapproved. Very few of those who engaged in this debate considered it contextually important to account for the fact that the patient’s demand that the analyst hold her hand appeared almost immediately after the analyst insisted (over the patient’s repeated objections) on the accuracy of his interpretation of a dream she had just reported.2 It is this neglect of our essential (but only implicit) contextualizing methods that was enshrined when Freud (1905/1953, pp. 12–13) omitted defining his methods for interpretation and trivialized this omission in his famous report of the case of Dora: There is another kind of incompleteness which I myself have intentionally introduced. I have as a rule not reproduced the process of interpretation to which the patient’s associations and communications had to be subjected, but only the result of that process. Apart from the dreams, therefore, the technique of the analytic work has been revealed in only a very few places. My object in this case was to demonstrate the intimate structure of a neurotic disorder and the determination of its symptoms; and it would have led to nothing but hopeless confusion if I had tried to complete the other task at the same time. (1905)
In 1905 Freud could say that he was quite prepared to explain his methodology for making interpretations but that it would have been ‘impractical’ because it would have led to nothing but hopeless confusion. Subsequent events suggest that Freud’s belief that he had already resolved the problems of contextualization was premature. In fact the daunting scientific and conceptual problems of codifying how to integrate the mysteries of contextualization, the inference of unconscious meaning, and the methods of fashioning our interpretations, have also continued to defy all subsequent generations of analysts. The irony is that the neglect of this problem has led to the dire confusion Freud was trying to avoid in 1905.
2 For a discussion of this controversy see Boesky, 2008, chapter 2; also published in a different version as ‘Analytic controversies contextualized’ (J Am Psychoanal Assoc 53:835–63, 2005).
Copyright © 2013 Institute of Psychoanalysis
Int J Psychoanal (2013) 94
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D. Boesky
Because of confusion prolonged by the conundrum of infinite overdetermination it seems as though everything the patient says before our intervention needs to be sifted; we cannot discard any of the raw ore of the patient’s associations when we report that something ‘really’ means something else. Everything counts. At the same time, we are left on our own to determine the difference between: (a) everything potentially counting, when we consider rival contextualizing choices before the interpretation, and (b) everything counting equally later down the line when we have arrived at tentative contextualizing conclusions about meaning. But actually and in practice all the associations do not count equally before we decide to venture an interpretation. The very act of making an interpretation indicates the analyst’s prior decision to grant contextual priority to certain associations. And it is too frequently the case that we are not fully or even partly aware of how and why we decided to privilege a particular alternative. My personal experience has been that, when I privilege certain associations, it is very often because I feel that they express the most pressing affective pressure of the moment. Such determining factors often remain private and just as often never reach the printed page in our later reflections and writing about our clinical experience. In 1909 Freud did not have to think that giving the hungry Rat Man some herring mattered or ‘counted’ in his inferred understanding of subsequent events. As our contextual horizons have expanded with our progress, so has the complexity of our contextual choices. Not only do we contextualize, but we also make trial contextualizations that we then find necessary to discard. Clinical presentations should inform us about these, not only the interpretations actually made. We need to know how and why certain material was deemed to be meaningful. When we are left ignorant about this we pay a price. In ensuing disagreements we too often talk past each other because we do not know what ‘counted’ and what ‘didn’t count’ in the formulations of the author.
Linking the flow of material before and after an interpretation Instead of informing us about the contextualizing information by which we determine meaning and interpretations, we tend to rely on a fallacious assumption when we ‘validate’ an interpretation only on the basis of the reactions of the patient immediately after the interpretation (e.g. Wisdom 1943, 1967). However, the emergence of dynamically important new material can follow very bad interpretations and not only good interpretations. Also, too often it is possible to demonstrate – when the information is made available by the author – that something the patient said before an interpretation and which was deemed insignificant actually played a crucial role. It is not news to state that crucial contextualizing opportunities for one analyst are unimportant to another. What I am stressing is that a careful evaluation of an interpretation should, whenever possible, include a comparison of the associations of the patient prior to the associations, with the associations that follow it (both immediately and later). This can reveal dynamic and contextual congruence between prior associations and those that follow Int J Psychoanal (2013) 94
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Psychoanalytic Controversy: Presenting case material
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the intervention. It may show how earlier interventions were a stimulus to those much later ones and in this way they may be especially valuable in documenting the justification for the interpretation.
Presenting the reader with a credible account Authors have imaginary readers in mind. Our best authors follow the golden rule and treat their imaginary reader as they wish to be treated. Our less gifted authors try to manipulate, exhort or sway their readers. This is really a subtext of our discussion: what do we require of an author in order for us to believe in the credibility of a case report? The issue of credibility is related to but not identical with plausibility as well as with methods of validation. Certainly, the mere mechanical reporting of process notes will not convince us of even the plausibility of the claim that the data provided support the claims of the author. Credibility is enhanced when the reader is provided with information about the contextualizing bridges between the raw data and the voiced interpretation. Hartmann used no clinical material at all in most of what he wrote and justified this to his critics by saying that he merely used a different form of shorthand. Loewald also published very little clinical material. But within at least the community of adherents of each author their divergent views have had the cachet of credibility. There is no list of information that we require in order to grant credibility to an author’s claims. I suggest that, as we become better able to map our strategies of contextualization, we shall at least be better able to say why we grant much credibility to some theoretic inferences and less to others. Let us also put aside for the moment ad hominem arguments and assume that competent, honest and fair readers actually exist among our colleagues. What do they want to know and what should we tell them? The problem of selection in case reporting can be compared to the strategy of the kidnapper preparing a ransom note. He wishes a certain minimum level of legibility in order to collect his ransom. But he must avoid detection so he creates a collage from selecting and cutting out the words of his message from a number of newspapers and magazines. A new and deceptively coherent message results but each unit of the message is deracinated from its original source and context. Too many of our clinical case reports are such ransom notes. And too many reports demand our belief. Take it or leave it. In these papers the reader is solely responsible for providing benevolent scepticism. So I would hope that, in preparing clinical reports (my own included), more thought would be given to uncertainties, questions that remain to be answered, self-contradiction in the material still unaccounted for, and a liberal sprinkling of non liquet. Also, it would help if authors who claim that they are not trying to prove anything, but only trying to demonstrate their theoretic views with some clinical material, would specify which parts of their clinical data are illustrative of which theoretic notions. Disclaimers regarding proof have become all too common in our literature. To say, ‘I am merely illustrating what I mean’, too often does not illustrate what the author claims with supposed self-evidential clarity. Copyright © 2013 Institute of Psychoanalysis
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Credibility context and process notes Psychic determinism is a conceptual anchor underlying my views about using process notes for any purpose. Process notes that clearly demonstrate the actual sequences of the patient’s communications are an invaluable tool for preserving and demonstrating the ubiquitous power of psychic determinism. Process notes are therefore an invaluable evidential support for the contextual organizers chosen by the analyst. If used selectively and judiciously they illustrate why the analyst has chosen to infer certain contexts. That is why the preservation of the patient’s communications at the lowest level of observation, the so-called ‘raw’ data, is so important (with due recognition that there is no such thing as an ‘observation’ devoid of subjective bias). These associations are the ore which the analyst sifts when forming trial contextualizations. The presentation of total transcripts or lengthy verbatim examples is not what I have in mind here. Arlow’s suggestions for choosing what to include remain unparalleled: Most important is the context in which the specific material appears. Contiguity usually suggests dynamic relevance. The configuration of the material, the form and sequence in which the associations (appear). Other criteria are to be seen in the repetition and the convergence of certain themes within the organized body of associations. The repetition of similarities or opposites is always striking and suggestive. Material in context appearing in related sequence, multiple representations of the same theme, repetition in similarity, and a convergence of the data into one comprehensible hypothesis constitute the specific methodological approach in psychoanalysis used to validate insights obtained in an immediate, intuitive fashion in the analytic interchange. (Arlow, 1979, p. 202)
It should be added that process notes vary widely in content, in the purpose for which they are used, and in how they are obtained. Since we have no consensually accepted definition of the psychoanalytic process, we also have no consensus about which notes would be useful to preserve. Moreover, every analyst who has attempted to take process notes after the session is over (my own choice) can attest to the fact that inevitably in every session the analyst will forget certain events in the session. And in my experience the strategy of taking notes during the sessions to avoid losing information is a serious distraction for the analyst. At the same time, there is little value to routinized total inclusion of process notes. Reading a transcript of process notes that omit contextualizing information is like watching a movie of a moving car that turns one way and then another. We know the driver has turned right or left but we do not know why. The reason for the turn depends on a context that has not been shared with the viewer. What is needed is the judicious selection of the associations of the patient and the context in which these associations emerged. Because of the daunting diversity of data there is no simple solution to the question of what we should include in our written reports for those analysts who wish to use process material. What I am able to suggest is that Int J Psychoanal (2013) 94
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we should include samples of actual clinical interactions and actual statements that were felt to be contextually organizing for this author and this patient.
An epistemological controversy: The very idea of evidence is fallacious because objectivity is a fiction By this point the reader might wonder if the views I have expressed were written with a lack of awareness that a controversy underlies my views about interpretation and contextualizing. I imply that interpretations are in some sense objective and are offered by an objective analyst. Spence (1976) discussed the problems surrounding this some 35 years ago: As we listen to the stream of associations from an analytic patient, we hear an almost continuous flow of linked ideas. They seem to resolve themselves into a number of strands – sometimes few, sometimes many. But ask a friendly critic to listen to the same material: he hears a mixture of unrelated words and has the impression that the patient simply skips from one topic to the next. Who is right? To put the problem in these terms helps to show how quickly we lose sight of the fact that the links between ideas in clinical material may be imposed from outside and are not always inherent in its structure. Since we find it so easy to see connections between disparate ideas, we assume that the connections are contained in the structure, which is to say that other judges would hear the material in much the same way. But would they? Would 12 friendly critics independently arrive at the same underlying structure, or would each hear his own favorite melody? (p. 367)
While it is not uncommon for many analysts to laugh about the outdated ‘positivist’ view that there can be any such thing as evidence in psychoanalysis, in my view my patients’ associations are the dynamic consequence of powerful unconscious affective linkages. These associations are determinate in retrospect, but never predictable looking forward in the sense of ‘determinism versus free will’. The fact is, however, that the less we know about the contextualizing criteria of the reporting analyst the easier it is to maintain the view that there is no objectivity to interpretations; that consequently we must hold onto the pragmatic fiction that truth is whatever works. Our literature too often suffers from such reductive pragmatism (Jimenez, 2009). If the ‘truth’ is defined to be ‘whatever works’ we do not need to concern ourselves with this very complex problem of over-determination. If certain things ‘work’ for this analyst and this patient, further questions about alternative explanations are merely moot academic points. But who is to say what we mean by ‘works’ when we say it works. We have merely begged the question.
Contextual anchors for clinical reports I will briefly sketch here the conceptual anchors that should appear in the presentation of case material in order to bridge the between theories of pathogenesis, the biographical history of the patient, and the chosen contexCopyright © 2013 Institute of Psychoanalysis
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tual horizons of the author. My view of pathogenesis is both developmental and conflict-centered. I believe that the most important conflicts as well as the most significant deficits of early development are organized in childhood in a manner that is fossilized in the amber of psychopathology. These conflicts become visible in later adult symptoms which become prominent in the behaviour of the patient with the analyst. So when I read a clinical paper I want to know something about all three poles of this dynamic tripod of information (childhood conflicts, adult symptoms and their transference derivatives) that the analyst has used to contextualize his or her understanding of what has gone wrong in the patient’s life. Yet one cannot expect this information to be equally a part of every report. One attempts to guess whether such information is absent by judicious selection or by inadvertent omission. That is also true for missing information about the sexual history. I want to know how the analyst has had to struggle with the transference in order to reach helpful understandings of it and what the analyst did to intervene. But I want also to know what the analyst still does not understand. Some believe that the analysis has to be terminated before one can write about it in order to reduce the chance of undiscovered prior information that could materially alter the perspective of the author. I disagree with that view because there are valuable papers that report preliminary experiences that are instructive. But the reader should know if the case is still in progress. Also if the case is terminated we should be provided information about the termination phase especially how the patient was able to deal with the mourning inherent in this process. There can, of course, be no such thing as a checklist of items to include in a case report. What is essential is the fit between the ‘illustrative’ purposes of the author and the clinical data he or she has chosen. Are these fragments of data sufficiently self-evident to actually illustrate the author’s conjectures? My purpose is not to prescribe rules for presenting clinical material, but to emphasize that how we think about ‘evidence’ is inseparable from how we think about contextualization. At issue is a call for wider recognition of the problems we perpetuate in continually denying the profound epistemological penalties we have incurred by our neglect of this gap in our methodology for how we gather and evaluate our contextualizing criteria. Gradually developing useful measures and guidelines for balancing an author’s theoretic assumptions with the contextualizing criteria adduced to support their views will be an enormous task. And until we refine our methods for contextualizing we will be hampered in our efforts to clarify the manner in which we should accept or disagree with the evidence for our truth claims. We cannot continue to delay the necessity of facing this problem.
References Arlow J (1979). The genesis of interpretation. J Am Psychoanal Assoc 27S:193–206. Audi R (1999). Cambridge dictionary of philosophy. 2nd edition. Cambridge: Cambridge UP. 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 94:1129–34. Boesky D (2008). Psychoanalytic disagreements in context. Lanham, MD: Aronson. Int J Psychoanal (2013) 94
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Cavell M (1993). The psychoanalytic mind from Freud to philosophy. Cambridge, MA: Harvard UP. Cheshire N, Thoma H (1991). Metaphor, neologism and ‘open texture’. Int Rev Psychoanal 18:429– 55. Freud S (1905/1953). Fragment of an analysis of a case of hysteria. SE 7, 12–3. Glover E (1952). Research methods in psycho-analysis. Int J Psychoanal 33:403–09. Jimenez J (2009). Grasping psychoanalysts’ practice in its own merits. Int J Psychoanal 90:231–48. Ogden T (2005). On psychoanalytic writing. Int J Psychoanal 86:15–29. Spence D (1976). Clinical interpretation: Some comments on the nature of the evidence. Psychoanal Contemp Sci 5:367–88. Wisdom J (1943). Determinism and psycho-analysis. Int J Psychoanal 24:140–7. Wisdom J (1967). Testing an interpretation within a session. Int J Psychoanal 48:44–52.
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