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This introduction to the symposium explores the key features of the American Psychological Association empirically supported treatment (EST) guidelines, the forces leading to their development, and some of the potential implications of these guidelines for the future of psychoanalysis. The EST guidelines consist of (a) a set of criteria for identifying psychotherapeutic treatments that can be considered effective on the basis of research evidence and (b) a list of treatments that meet these criteria. These guidelines are an outgrowth of a more general trend in the health care system – the shift toward an evidence-based practice model. Although the EST movement clearly has important professional implications for psychoanalysis, categorizing and possibly dismissing the relevant concerns as exclusively political or territorial would be a mistake. At issue are fundamentally important epistemological and ethical concerns.
Two ways of evaluating the implications of empirically supported treatment research for psychoanalysis and other long-term therapies are considered. The first involves the comparison of the relative benefits of various psychotherapies the second involves the comparison of short-term and long-term psychotherapies. The major findings are that (a) each of the different types of psychological treatments shows benefits, (b) the amount of benefits from each type of therapy shows mainly nonsignificant differences, (c) these nonsignificant differences are especially evident when the researcher's therapeutic allegiance is taken into account, (d) both short-term and long-term treatments show some positive benefits for some patients, and (e) there is a tendency for longer treatments to show more lasting benefits. The main gap in research studies consists of a lack of comparative studies of psychoanalysis versus other treatments. This review highlights the virtue of >methodological pluralism,< which means here applying to the same data a variety of methods for comparing psychotherapies with one another and for comparing long-term and short-term psychotherapies.
In this article, I critique the empirically supported treatment (EST) movement and discuss the limitations of traditional psychotherapy research from a psychoanalytic perspective. The EST movement is based on a medical model that assumes that a psychotherapeutic treatment can be conceptualized independent of the human relationship in which it takes place. Psychotherapy and psychoanalysis are, however, treatments only in a metaphorical sense and are more akin to educational processes than medical treatments. Every therapeutic dyad is unique, and research that treats therapy as a standardized, disembodied entity will not contribute to our understanding. Nevertheless, there is a real need for psychoanalysts to become more actively involved in psychotherapy research both for political and scientific reasons. Although I do not believe that >empirical validation< in the form envisaged by the American Psychological Association task force is a realistic goal, I do believe in the value of microscopic studies of therapeutic process, particularly in the context of research-informed case histories.
I discuss the views of Lester Luborsky (quite optimistic) and of Hans H. Strupp (less so) concerning the accumulating evidence for the favorable impact of psychoanalytic therapy research, as it has grown over recent decades, in shaping clinical psychoanalytic activity. I offer my perspectives on their views of the issues of (a) the effectiveness of psychoanalytic (psychodynamic) therapies vis-à-vis the varieties of nonanalytically based therapies (b) long-term (time-unlimited) vis-à-vis short-term (time-limited) therapy, (c) the call for empirically supported treatments (ESTs), (d) the call for randomized clinical trials (RCTs), (e) the trend toward >manualization< of therapy approaches, and (f) the light that all these considerations can cast on the extent to which, and how, psychoanalytic therapy helps.
The current emphasis on identifying empirically supported treatments (ESTs) can distort psychotherapy research by emphasizing the investigation of treatment in an atypical context, with atypical patients, in a contrived treatment contract. An alternative to comparing the efficacy of different types of therapeutic techniques for treating focal symptoms is to seek to identify the factors that facilitate therapeutic change in various types of therapeutic intervention. The emphasis on identifying ESTs also has the potential for distorting clinical training and limiting clinicians' ability to develop the skills necessary for becoming effective therapists.
I outline the arguments advanced by Lester Luborsky and Hans H. Strupp on the current controversy regarding empirically supported treatment (EST). I support Luborsky's criticisms of some current attempts to provide empirical support for psychoanalytic treatment, but, unable to endorse the conclusion that therapies are equally effective, I argue that substantial evidence does exist to guide clinicians, even if this evidence is not yet accessible through a mechanical process of review. I also suggest that Luborsky's >open verdict< on the length-of-treatment issue is too conservative: Longer psychoanalytic treatments have been repeatedly associated with superior outcomes across a range of measures. I agree with Strupp that the current emphasis on EST is probably motivated primarily by economic rather than ethical conditions. However, I criticize Strupp's largely negative treatment of the issue of treatment >manualization< and argue that, though manualization is a mixed blessing, only a clear, structured, and coherent framework that guides the therapeutic process can enable the therapist to withstand the interpersonal pressures inevitably generated in the consulting room. I conclude by arguing that there is a need for refinement of the concepts and methods by which outcomes are evaluated in order to help psychoanalysis and psychotherapy become a more specific family of treatments for particular conditions.
In this conclusion, I synthesize and elaborate on some of the central threads running through the contributions to the symposium on the implications of the empirically supported treatment (EST) controversy for psychoanalysis. I argue that the EST controversy brings increased urgency to discussions about the role that empirical research should play in the development of psychoanalysis and about the potential contributions of different research paradigms to the field. Different research paradigms are associated with different epistemologies and worldviews, and the dialogue between these worldviews is critical to the vitality and health of the field. On one hand, the EST movement embodies limited, mechanistic, and one-sided values, and psychoanalysis has an important role to play in challenging these values. On the other hand, the EST movement can offer an important corrective to the more insular and rarefied strands within psychoanalysis and to its tradition of argument on the basis of authority.
This essay explores the sometimes uncanny quality of unconscious experience and unconscious communication that often characterizes life in psychoanalytic relationships. As Ferenczi noted some 70 years ago, the psychoanalytic relationship may >significantly promote the development of subtler manifestations of receptivity.< Special qualities of unconscious receptivity and deep points of contact in the psychoanalytic relationship are explored, with reference to the history of psychoanalytic ideas (e.g., Freud, Ferenczi, Singer, Loewald, Symington) and to findings from other fields such as contemporary quantum science. Clinical vignettes are provided to illustrate such phenomena.
In this commentary, I discuss Anthony Bass's humane, courageous article about the unconscious connection between analyst and analysand. His focus on the meeting of unconscious minds lends a refreshingly democratic tilt to the treatment relationship. His primary emphasis on the unconscious, however, seems to de-emphasize the vital role of consciousness and its capacity to engage the revelations of the unconscious. Similarly, Bass's theoretical focus on a fundamental underlying unity, though of great significance, seems to minimize the importance of separateness and the fact that the analyst and analysand have discrepant experiences. Bass's treatment of Ralph, a patient with terminal cancer, highlights the differences in the experiences of both participants as well as the underlying human frailties they have in common. In this light, I suggest that Ralph's relationship with Bass enabled him to >live before dying,< to separate and gain a sense of integrity before returning to the whole.
Anthony Bass's paper is viewed from the perspective of the object relations orientation of a member of the British Group of Independent Psychoanalysts. The perceived transference – countertransference >equality< in the interpersonal model is described in the light of the asymmetry of the analytic relationship implied in the object relations relation model used by many Independents. The structuring role of object relationships in analysis is touched on, and the relationship between exploration of the unconscious and internal construction processes is raised. In addition, Bion's model of >O,< which seems to me to reflect many of the inherent qualities of Singer's and Bass's model, is not referred to in Bass's paper. To what extent has Bion's thinking influenced the interpersonal model?
This essay elaborates on some of the ideas set forth in >It Takes One to Know One< in response to Peter Shabad's and Paul Williams's commentaries on that paper. In particular, the distinctions between process and mental structure and between unconscious process and relationship are explored and developed. An attempt is made to clarify some of the similarities and differences between British object relations perspectives and some U.S. relational ideas as they apply to these distinctions and their relevance to clinical technique.
This article juxtaposes two orientations to psychoanalytic theory and clinical action – the prescriptive, embodied in the metaphor of classical theater, and the improvisational, embodied in the metaphor of improvisational theater. The metaphor of classical theater is analogous to how the theoretical predilections of each school of psychoanalysis has its own set of prescriptions (>sets,< >roles,< and >scripts<) for how an analyst influences mutative moments of change with a patient. In contrast, the metaphor of improvisational theater refers to actions that arise on the spur of the moment, without preparation. These improvisational moments ineluctably communicate to the patient a special instance of authenticity, which may well be antidotal to the crushing reality of the patient's life of pervasive inauthenticity. They also enable analysts to more readily engage disparate, often dissociatively disconnected parts of the patient through imaginative intersubjective engagement with each. This may take the form of reverie within the analyst – from which his own mental state of play informs his interpretation. Still, at other times, it may involve a form of spontaneous engagement that conveys not only a moment of deep recognition but also the purest state of authentic engagement – that is, one that cannot arise with comparable impact when reflection precedes the analyst's action. In sum, the capacity for engaging in improvisation may well be one of the most defining capacities for the development of a genuine psychoanalysis.
Philip Ringstrom tackles a neglected but important topic – therapeutic improvisation. In my view, this is better termed spontaneity. A central issue is the therapist's freedom of mind, which, in the typical case, is restricted by the transferential – countertransferential field. I argue that the value of spontaneity, on the part of both partners, lies in its contribution to a growing >aliveness< in an individual previously >dead.< In this commentary, three forms of spontaneity are distinguished: The therapist, immersed in the patient's experience, is able to resonate with and amplify a moment of vitality in the patient's expression in pseudospontaneity, the therapist believes he or she is responding spontaneously but is acting under the influence of the transferential – countertranferential field and there is a spontaneity in the therapist's >leap to freedom< from the constriction of this field. In that this expression is genuine, and new to the patient, it may have benefit in the manner of a >corrective emotional experience.< The example of therapeutic spontaneity that is given suggests that, ideally, all therapeutic language is, in a nonsalient way, spontaneous – fresh and unscripted. In this example, the therapist's form of responsiveness leads to the emergence of a larger, reflective form of consciousness in the patient – a state toward which the therapeutic endeavor is directed.
Philip Ringstrom presents improvisation as an important dimension of the analytical process. I propose that we take this idea even further and look at the ability to improvise as the desired goal of analysis or therapy – to live one's life as a free, responsive, and spontaneously expressive person. Improvisation is the normal mode of human communication. In a natural, healthy life, we do not write down what we are about to say before we say it. We simply say and do, prompted by the incalculable mixture of conscious and unconscious influences that shape the self at that time and place in our development. The two things one hopes to avoid in psychoanalysis and therapy are rigidity on one hand and chaos on the other. Improvisation, the natural and spontaneous flow of activity that is also self-discovery, presents the happy medium between these extremes. To improvise means on one hand not to be constrained by the forces of habit, fear, and conformity and on the other hand not to be constrained to act randomly or impulsively without reference to context, but to be able to perceive the true outlines of the situation in which one finds oneself and to act accordingly as the need arises.