Two parallel strands developed since the start of the century in psychoanalysis. One was the relational turn initiated by Steven Mitchell (Mitchell, 1988, 1998) and his many inspiring and inspired co-workers (Aron, 2006; Hoffman, 1999, 2006; Knoblauch, 2007), just to mention a few of those authors whose enormous influence in demystifying some psychoanalytic myths held for irrefutable for so many years can be felt from their writings.
Just to mention one point. In “Influence and Autonomy” Mitchell (1997) described his study of psychoanalytic therapists’ intervention in the process. He provided a detailed description of what went on in the patients’ mind (as the analysts thought it were) and what the analysts then said was a summary of the kind “These connections were interpreted to the patient”. No clear representation of what the analysts said nor the answer the patients gave to the interpretation. The patient was viewed as deliverer of “material” and the analyst delivered “interpretations”. As long as such a model of division of labor seemed to work we had something called “classical psychoanalysis”. Doubts increased if what we think we do really is what is done. Meanwhile these doubts are certified:
“We believe that there has not been as much diligence in confronting the reality of our clinical practice, that is, what it really is, and not what we say it is or what we would like it to be” (Canestri, 2011, p. XX).
Parallel voices were heard from one of the most experienced scholars in infant research:
“Although the coconstruction of the inter subjective field is currently of great interest to psychoanalysts, detailed clinical material illustrating the nonverbal and implicit dimensions of this process remains rare” (Beebe, 2012, p. 97).
While many confessed to interpersonalist or intersubjective or relational terminology the empirical study of what was really done in details was still hardly studied by psychoanalysts (be them classical or relational !!) themselves. But by a group of conversation analytic researchers who turned away from studying court interaction or medical discourse in the consulting room of psychotherapists of various schools. The
Correspondence concerning this article should be addressed to Prof. Michael Buchholz, International Psychoanalytic University (IPU), Stromstr. 2-3. 10555 Berlin, Germany. E-mail: .
study of psychotherapeutic and psychoanalytic discourse was conducted by many researchers with a linguistic or sociological training and interest (see Kächele's concluding remarks), however this was seldom recognized by psychoanalysts. Their publications were published in journals out of reach for many practitioners who practiced eight hours or more per day, although the findings would have interested them. Another obstacle might have been the terminology of linguistic and social scientific jargon, although many clinicians readily joined neuro-psychoanalytic research and learned how to read these publications and study it's terminology.
This situation changed when conversation analysis appeared (CA) on the stage. Although blackened as “behavioristic” this turned out as an error. Gail Jefferson who edited the “Lectures on Conversation” of Harvey Sacks (Sacks & Jefferson, 1992, 1995) after Sacks’ untimely death in 1975 wrote a lot of papers that took up psychoanalytic topics as e.g., Freudian slips (Jefferson, 1996). What she found was close to the original Freudian approach, however, Freud's observations could be confirmed and extended. One of Sacks’ co-authors, Emanuel Schegloff, became one of the most prominent CA-researchers and he wrote a paper “The surfacing of the suppressed” the title of which took up the Freudian “sound”. What he discovered was the following: When a slip happened in a conversation and its topic, although relevant for the conversationalists goes unnoticed there is a strong tendency for another slip to happen in the next one or two minutes of the conversation. And he gathered a lot of material where just this happened. Schegloff (2000) published his study in German and two psychoanalysts (Kazanskaya & Kächele, 2000) wrote a comment which substantiated the convergence of CA and the original Freudian position.
In 2008 it was time for a compilation of CA-results in psychotherapy process research (Peräkylä, Antaki, Vehviläinen, & Leudar, 2008). A lot of studies turned to the dimension of therapeutic empathy (Weiste, Peräkylä, & Perakyla, 2014) and it seemed that empathy is a subject that could be studied by CA, although earlier attempts had warned how complex the study of empathy is (Elliott et al., 1982), achieving high agreements among raters cannot be expected.
With such developments CA in psychotherapy loosened a little bit the singular fixation to linguistics only and turned more to the social dimension of human interaction. Linguistics and social science were at the offspring of CA, both were “parents” of CA. A more social orientation originated from the work of Goffman (Goffman, 1981) who invested much energy to embedd interaction and conversation in relevant institutional contexts (Goffman, 1974, 1986). What happened in psychotherapeutic treatment rooms, thus, could be understood as a special type of institutional interaction - dealing with emotions. This was another challenge for CA. But the papers gathered (Peräkylä & Sorjonen, 2012) give a sustained impression of CA-power to deal with emotions as very influential “things” - in interaction, not in indivuals alone. CA kept to the interactive primacy. Interactive - as opposed to an individualistic - primacy could be debated in a clinically important text (Peräkylä, 2015); Goffman's “face-work” and what Freud had termed “narcissism” were brought into a fruitful dialogue.
However, interactive primacy poses a lot of new methodological problems. Schegloff had turned to the macro-micro-problem in early years (Schegloff, 1987) where he refused to explain what happens in conversational interaction by abstract concepts which pre-exist in the interpreter's mind so readily. This was supported by a German social psychologist (Graumann, 1979) who wondered about psychologists’ shyness towards interaction. Schegloff showed the relevance of details regularly overlooked when using abstract and prefabricated concepts too fast.
Let me give just one example of the relevance of details. In our CEMPP-project (CEMPP = Conversation Analysis of Empathy in Psychotherapy Process) we compare psychoanalytic, cognitive behavioral and psychodynamic psychotherapy. Of each therapeutic school we have 5 patient-therapist dyads using one session form the start, the middle-phase of therapy and of the terminal phase. Per Dyad are 3 sessions available (beginning, middle, end), per school of therapy we have 15 sessions available.
While transcribing this material we observed that so-called “change-of-state-tokens” (Heritage, 1984) were uttered in some sessions more often than in others. In change-of-state tokens, “hm”s are uttered in a special prosodic fashion: they have two summits and a special shape of intonation. Together with a relatively strong increase of pitch and a slow decrease they have the potential the inform the speaker that the listener's “state” has changed; he understands a story better when e.g., a missing detail is told or when the change of perspective in the narration is understood as an important detail. This is undoubtedly important when you think of a therapeutic intake interview while listening to a patient's narrative, complaints or biography and when you utter such a token the patient experiences a) that you are an active listener and b) that the patient has the influence to change your state-of-mind.
Patients value when they can influence their therapist. It increases their feeling of agency and self-worth. Undoubtedly, this is an important interactional feature. However, we do not know of any study in psychotherapy process research having mentioned this feature before. Narrative Process Coding Systems (Angus et al., 2012; Boritz, Bryntwick, Angus, Greenberg, & Constantino, 2014; Singer & Bonalume, 2010) do not code therapist's utterances while the patients narrative activities, they are oriented to the patient in order to measure improvement(Mendes et al., 2010). However, from a CA-point of view this methodology ignores the therapist's contribution in narrative coconstructing.
Florian Dreyer (this volume) presents an interesting example of how influential the therapist's “change-of-state”-tokens are - above all, if they are missed. Adding to his findings we worked on coding all change-of-state-tokens in our transcripts and found the following distribution (see Figure 1):
Over all sessions, from beginning to the end, CBT therapist utter a very small number of change-of-state-tokens (CST), less than one per session. The psychodynamic therapists use it most often. Is this a result attributable to therapists’ orientation alone? The answer is no, as there is obviously a time factor. If you sum up across all therapies and list according to the state of “relational development” you can find another result: In the beginning CSTs are as often as in the middle; at the end of therapies this sign of acquiring a new understanding in interaction decreases.
This is a very simple result. However, it confronts us with some methodological questions. First, does this difference represent a difference of approach between psychoanalysis, psychodynamic psychotherapy and cognitive-behavioral therapy? Or is it more of the therapist's personality? In what relation stands such a result of micro-analysis to meso- or macro-levels of outcome? How can the relationship of micro-details and macro-outcome be thought? One way is to think of micro-events like the brickstones while building a house. Putting one above the other you can observe how the walls of your house grow.
What about the role of the architect with a plan? All brickstones look like the same. However, there is a difference. Some of them are cornerstones, others not. Removing the cornerstones or those below the others willl produce different results. One important methodological lecture to learn from this way of thinking is that same things are not always the same. This must have consequences for a “coding and counting” - approach (Kondratyuk & Peräkylä, 2011) which treats every element with the same code as if it were the same.
The other way is to think of the micro-macro-relationship in a more systemic fashion including temporality. The effect of omitting a CST in the first meetings might be greater than at the end irrespective of how positive or negative this effect might be. There is something else to be mentioned. If it is right what CA-researchers attribute to CSTs then each CST could be considered according to a part-whole principle. Uttering a CST is, then, not only an element to be counted. For the individual dyad such an element might direct the interactive course slowly in different directions. If a CST is recognized favourably by a patient it might become part of a hopeful investment that the therapist might be a person who is not stubbornly following own rules but is person accessible to
influence by the patient. Thinking that way, a CA procedure could be not simply to count CSTs, but to include the responses of patients to CSTs.
Viewing these two alternatives of the micro-macro-problem both end with an unresolvable clash of the wish to keep to the individualized meanings in the dyad and the wish to understand larger groups of treatment. To find good answers to this, and other types of unresolved methodological problems will be a task for the future. What we have tried here is to present cases of very unusual dream tellings (Marie-Luise Alder), where telling a dream of the last night is used as allusion to the ongoing interaction. Michael Dittmann studies not the final phase of a therapy, but how single sessions are closed with interesting results, e.g. something he calls JETH (Joint evaluation of therapeutic help). More often than not such evaluation is done not by external researchers but by participants themselves. The other attempt here is to compare good and less good solutions for typical problematic situations in therapies which is my contribution. Laura Cariola explores patients’ semantic changes in patient person-centred therapy and how it relates to the mind-body paradigm by focusing on body boundaries.
We hope that readers might become interested in this kind of study combining CA and clinical competence in order to better understand what we mean when we speak of the therapeutic process.