Freud considered psychoanalysis to be a scientific discipline and psychoanalysis today continues to embrace a scientific identity. Stimulated by a recently published paper by T. Lubbe about an eight-year analysis and its termination, we have accepted Bernardi's advice to encourage discussions of clinical issues across those diverse psychoanalyses newly recognized by the IPA. However, our original paper criticizing the evidence Lubbe provided was rejected by his publisher, Psychoanalytic Review, on the basis of an “editorial policy” of not publishing critiques of previously published papers in that journal. Criticism is essential in assessing the scientific value of theoretical hypotheses. While Lubbe asserts as an empirical, clinical fact that “There is a reworking of the Oedipus complex in every termination” (p. 852), we question whether his clinical material supports this position, because we found a lack of descriptions of expressions of his patient's anger at either the therapist, his wife or other figures throughout the eight-year treatment, including termination itself. Without taking on the task of bridging the Klein/Freud chasm, we direct ourselves to his theoretically anchored but in our eyes clinically evident failure to address and deal with fundamental unresolved aspects of the patientanalyst relationship.
These are issues of science as we co-exist and seek a common ground. Moreover, even if formidable, we believe that evidence from a single analytic treatment is grossly inadequate to support a generalization of scientific value in psychoanalysis.
The theoretical and clinical diversity inside and outside the IPA has been acknowledged. Differences of opinion are no longer solved by exclusion, formerly the stimulus for the formation of many independent
associations outside the IPA. The struggle of the founder and his closest pupils towards “unity” belongs to the past. This recognition of diversity forces our professional community to clarify the areas of agreement as well as the areas of difference. We are, however, still confronted with the old problem of theory influencing therapeutic thought and deed (Fonagy 2006).
It is now officially acceptable to talk about the psychoanalyses, thus bringing the issue of co-existence and the common ground to the fore (Wallerstein 1988). Today's trend is towards a pluralistic approach, both theoretical and technical, which Tuckett (1998, p.446) believes requires formulating criteria for competent treatment to be drawn up; “first, do no harm,” being the very least (Tuckett 2005). This expansion has made it even harder to differentiate between various directions than it was during the spread of psychodynamic psychotherapy in the fifties.
It is our belief that the scale of pluralism, which in its entirety can be said to give psychoanalysis a chaotic image, is largely under-estimated. Earlier, Wallerstein (2005), for example, sought and found binding similarities in clinical observations by stating that both general elucidative theories and those specific to certain schools have a metaphorical character which only questionably matches the phenomena that are to be observed. While these metaphors function to make sense of clinical data, they are an impediment to dialogue as well as empirical research since it is not possible, at present, to check these data in comparative studies. In this context we offer a critical conception implementing Bernardi's (2002) suggestion that “research should centre on particular instances though it should at the same time arrive at conclusions that could be generally valid”(p. 852).
This paper is a response to a recent published case history by T. Lubbe, a Tavistock trained analyst, entitled “The Preoedipal and Oedipal Structure of Termination: an In-depth Case Study” published in Psychoanalytic Review (2016). In it he summarizes an eight-year psychoanalytic treatment conducted at four sessions per week, while focusing on the termination phase. He posits that the Oedipus Complex is the central organizing force in all psychoanalytic terminations during which it is recapitulated. This demonstration is of a “universal”: “There is a
re-working of the Oedipus complex in every termination” (p. 852).
Although PEP lists 223 papers about termination, Lubbe limits his bibliography to nine Kleinian analysts and three papers by J. Novick. He fails to note the large number of criticisms of the concept of termination. His publication preceded our recent proposal (Schachter et al., 2018) to formulate a new concept of termination which we have named, “Progression.”
Psychoanalytic Review, the journal which published this paper, rejected our limited initial responsive paper on the basis of its “editorial policy” not to publish critiques of papers it had published. This struck us as a blow to the future of psychoanalysis as a science and so we reoriented our focus from a clinical critique to a critique in defense of the scientific nature of psychoanalysis. Consider, for a moment, if all psychoanalytic journals adopted the “editorial policy” of the Psychoanalytic Review and refused to publish manuscripts that were critical of papers previously published by their own journal, making it necessary to seek other outlets and further splintering dialogue. That might make it impossible to publish any critique of a previously published psychoanalytic paper. The absence of criticism of theoretical, clinical and empirical psychoanalytic papers would undermine any scientific aspirations or credentials of psychoanalysis, separating our field from other sciences.
Parenthetically, the author, T. Lubbe, failed to respond to our inquiry about the outcome of the post-termination contact which the analyst – to our real surprise—had proposed and to which the patient had agreed. If evaluation of the effects upon the patient of this post-analytic contact could be assessed, it could add to the growing psychoanalytic interest in and controversy about post-analytic patient-analyst contact (; ; ; ; Schachter, J. & Brauer, l., 2001; ; Geller, J.D., & Freedman, N., 2011; Kantrowitz, J.L., 2015).
An alternative conception of termination, named “progression,” has been derived from a “Family Model” of psychoanalytic treatment
. “A patient who has completed treatment may have become independent, self-aware, and engaged in a more satisfying life, while also valuing subsequent periodic contacts with the former analyst” (p. 160).
The complexity of the concept of “progression” (termination) is illustrated by the 223 published clinical papers in the psychoanalytic literature. A book about progression (termination), “Good Enough Endings,” edited by the relational oriented author J. Salberg (2010) presented 16 papers while another book by the ego-psychological author J.L. Kantrowitz (2015), “The Myths of Termination,” provided further important contributions.
In addition to hundreds of clinical papers, there are numerous empirical studies that investigate the phenomenon of progression, without specifically including Oedipal formulations (Kantrowitz, Katz & Paolitto, 1990; Schachter, 1990; Schachter, 1992; Schachter & Brauer, 2001; Craige, 2002; Tessman, 2003; Craig, 2006; and Geller & Friedman, 2011).
Lubbe's proposed original, but otherwise unsubstantiated hypothesis, that “oedipal structures take hold of the termination process so that the final working through and the resolution of the transference/countertransference can be maximized” (p. 819) is, we believe, an example of the analyst finding in his patient's analysis what he expected to find, just what Fonagy had warned of.
The psychoanalytic literature is studded with examples of analysts presenting corroborating clinical evidence for theoretical assumptions, only to discover later that the theoretical assumptions themselves were faulty. Most recently, e.g., homosexuality was regarded as intrinsically psycho-pathological, but both extensive empirical and psychological studies decimated that belief. We strongly propose that clinical findings, therefore, should be viewed cautiously until empirically substantiated. The conclusion that “There is a reworking of the Oedipus complex in every termination” (p. 852) falls within this parameter, particularly since its base is the Oedipus complex, which itself still lacks empirical validation.
We were attracted to this paper in part because we felt the rich
descriptions provided an opportunity for interactional psychoanalytic discussion. Once the patient set a date to terminate treatment, Lubbe writes, “a pall of superficiality fell over the work” (p.835). This, we believe, may reflect the patient's failure to express anger about the analyst's decision to end treatment. We note, however, that five months prior to the end of treatment the patient forgot to pay his bill and also dreamed that his nipples seemed to be in the wrong place; he cut them off with a scissors, but put them in the wrong place, so he cut them off again and placed them where they belonged. We see this ample material as replete with significant enactments and messages; the analyst himself declares shock at the dream. He recognized that it reflected the patient's concern about ending the psychoanalytic treatment: “My patient seemed to fear expressing anger or any sense of outrage about ending” (p. 839, our italics added). But he fails to describe exploring or discussing this significant possible insight with the patient.
Three sessions before the end of the analysis the patient reported a dream in which he killed a man. The patient said “he had never had it out with his father …” (p .846). While Lubbe reflected that it was “his intention to stir up doubt in my mind as to whether I had done the right thing in going along with his ending” (p. 849), he also commented that “he seemed unaware of how similarly he sometimes behaved like her (his mother), especially when he was dealing with his therapist” (p. 849). No further transference interpretations are presented.
Before we return to the issue of the need for an open dialogue about theoretical disagreement, we want to explore further one of the clinical characteristics of this analytic treatment. We accept that the evidence of Lubbe's patient's hostility toward his father and identification with his mother is clearly consistent with theoretical oedipal factors in the patient's development and in treatment, as we know them. However, we find that the more significant clinical data described in this treatment was the patient's inability, during the eight years of analytic therapy, to express anger directly toward his therapist, his wife, or others, which we believe reflects a fundamental undiscussed and unresolved aspect of the patient-analyst relationship not expressed other than in the noted bill default. The occurrence of a psychoanalytic patient's expression of
angry feelings are distinctly different from a patient's acts of aggression, i.e., acts interpreted as hostility, such as a patient's failure to pay a bill. For example, while Lubbe admits to being “shocked” about the patient's dream about cutting off his nipples, he does not mention the possibility that it expresses anger toward the analyst redirected towards the self.
We considered that our reading of the clinical material might be idiosyncratic, so in order to gain a perspective on the patient's apparent failure to express anger during treatment, we started by reviewing the frequency with which various concepts, including anger and aggression, were listed in each of the indexes of twenty-one volumes of Freud's collected works (two volumes contained no index) to evaluate Freud's interest in these concepts. The frequency of listing of these concepts in the indexes is presented in the first column in table 1. The second column provides the number of psychoanalytic papers catalogued by PEP for each of these same concepts. This table enables us, for example, to see that sexuality is listed in the indexes of all twenty-one volumes, whereas anger is listed in the indexes of only two volumes of the collected works. The number of PEP papers in each category is listed in column 2.
| Sexuality | 21 | 526 |
| Anxiety | 20 | 590 |
| Aggression |
Absent a statistical test, clearly the number of papers published in PEP for each concept parallels the distribution of the frequency of these concepts in the indexes of Freud's collected works. Freud's interests have had a pervasive effect upon the formation of psychoanalysis and the
conduct of psychoanalytic treatment. The rare listings of feelings of ‘anger’ suggest it was not considered as significant a psychoanalytic concept as ‘aggression,’ which is an action, not a feeling. PEP lists 364 papers about aggression compared to the noted 46 in the table about anger.
How do we regard this disparity? We agree with Liekierman (1987) that “Anger, being a familiar everyday feeling of an obvious kind, has received minimal attention in analytic thinking, which has preferred instead to concentrate on the concept of aggression” (p.143). Leverenz (1975), among others, highlights the developmental significance of anger: “Yet also anger provides the first sense of self as a separate being who needs and fears” (p.423). In this context, Fonagy, Moran and Target (1993) suggest that aggression is not an instinct in Freud's terms but a defense against threats to the psychological self (p.482) as well as a sign that separation is recognized. Pizer (2014) provides a rare example in the literature of the therapeutic benefits of a patient's expression of anger against her analyst. The patient said: “I came to you in the first place because I could not work…And you kept telling me I'd start soon as a result of our work. That didn't happen. But after I expressed my anger about your paper something changed. I just realized I was on my own, as always, and I better get on with it” and then the patient lets Pizer know that even before receiving the analyst's revision, “I intended to email and tell you that I started working again” (p.27).
In practice, we believe that Lubbe may have failed to address and deal with fundamental unresolved aspects of the patient's anger in transference and counter-transference, because of his focus on those theoretical oedipal factors he deemed critical in ending analysis.
Freud was concerned that a focus on the therapeutic demands of analytic treatment might distract from the creation of psychoanalytic theory: “I only want to feel assured that the therapy will not destroy the science” [theory] (1926, p. 254). As noted, Lubbe appears more concerned about analytic theory than about the clinical aspects of this analytic treatment, leading him to neglect the need to address the patient's failure to express anger at the analyst while defensively allowing his patient to recapitulate a recognized childhood role to satisfy his parents.
As Bernardi (2002) elegantly has noted, major difficulties for psychoanalytic science occur whenever “defensive states aimed at keeping each theory safe from the opposing party's arguments” (p.851) prevent the selection of the most useful conceptions of psychoanalytic treatment. Consideration of such alternate clinical and theoretical conceptions must be debated, discussed, and critically evaluated by empirical research for psychoanalysis to be considered a science. Our hope for our science is to use such explorations to enable the selection of the most useful psychoanalytic conceptions. Criticism is the lifeblood of science. To eschew it, is to condemn psychoanalysis to mediocrity.
| 18 |
| 364 |
| Depression | 12 | 486 |
| Anger | 2 | 46 |