In the interest of furthering our knowledge of the operations of the various committees of the American, George Klumpner, M.D., Chairman of the Committee on Scientific Activities agreed to be interviewed by Estelle Shane.
Dr. Shane: What prompts our talking together today is an interest in a significant new project undertaken by the Committee on Scientific Activities. That project involves a unique effort to improve the quality of clinical reporting in psychoanalytic articles. But before getting to that projeet, perhaps you can say something about the work of your committee in general. First, how did the committee get started? What do you know of its history?
Dr. Klumpner: Well, the Committee was actually begun at the impetus of Heinz Kohut. Heinz, after the experience of serving as President of the American became concerned about the place of scientific activities in the American. The American by that time had become larger and more complicated. In those days institutes were expanding and he feared that because of the pressures of educational and administrative requirements, the scientific questions of the profession were always taking second place to these urgent ad hoc problems that came up one after another. He got the incoming president to appoint him as chairman of a task force. This led him to make a series of suggestions, one of which was to change the structure of the American from a two-body administration to a three-body administration. As you know, the American consisted then, as it does now, of the Board, focusing on the educational unit, and the Council, focusing on professional and administrative activities. Why not, Heinz asked, consider a third body focused on the scientific aspects of the organization, including under this domain the scientific programs, the Journal, as well as all other scientific activities? Of course this plan was not adopted, but instead, to address his concerns, a committee was appointed to consider scientific issues. Heinz was its first Chairman.
Dr. S: When did you come onto the Committee?
Dr. K: Some 15 years ago. I was appointed by Bob Wallerstein, during his Presidency, when Heinz was at the end of his tenure. I've been on ever since.
Dr. S: That's a long time. How do you account for your endurance?
Dr. K: I think it's probably that I've worked hard. As Chairman my longevity has given me a tremendous advantage, because I've got a memory, an historical perspective, on the work of the Committee. When I became Chairman I summarized as an index all of the minutes for the previous 15 years. These were fascinating because there were some marvelous people on the Committee, a lot of creative people, so that all kinds of exciting ideas floated around, without, of course, necessarily having any realistic possibilities. Over the years we have tried to identify any issue that had potential scientific significance for psychoanalysis.
Dr. S: What sort of issues?
Dr. K: Well, for example, a few years ago some analysts first began to be interested in using computers for psychoanalytic studies. We thought we should provide a place for such analysts to get together. So we set up a 7:00 a.m. session at each of the meetings of the American, and we have had 35 to 40 analysts at every one, with some wonderful things coming out of them.
Dr. S: For example?
Dr. K: Well, first Stan Goodman and Vann Spruiell created a bibliography of the analytic literature in four journals—the International, the JAPA, the Psychoanalytic Study of the Child, and the Quarterly—that's kept up to date. Vann Spruiell then did a second project that included all the book reviews for the same time period. Following that, Paul Mosher took that information and turned it into a key-word-in-context index based on these same titles which also has an author index. Mosher's book was published by the Association.
Dr. S: And I think Mosher said half the amount published was sold almost immediately.
Dr. K: They had no idea of how great the demand would be. There will be a second printing, but only after some delay. Here, then, is an index to the titles of 6,500 articles, going clear back to 1920. So now there's no excuse for an author not knowing that there was a previous paper entitled so-and-so, whereas before it was very tough to locate this kind of information. Indexing is now a study group of Scientific Activities, reporting to our committee. That's because they're such a specialized group. It couldn't very well have rotating membership because there just aren't that many analysts interested in indexing. With a study group you can have continuing membership.
Dr. S: What's the Indexing Study Group working on now?
Dr. K: A thesaurus of psychoanalytic terms. The Thesaurus of the American Psychological Association is useless for analysts because it includes a broad range of behavioral and social issues. The way they use words is very different from the way we use them. We've been working on the thesaurus for over five years—the analysts on the Indexing Committee using empirical data to make analytic judgments about the relationships among psychoanalytic terms.
Dr. S: What other activities does CSA, or its subcommittee get involved in?
Dr. K: Well, there is the issue of ethics in research. The Committee on Scientific Activities decided about eight or nine years ago to do a report on ethics. It came up because there were two or three lawsuits in different courts around the country. We were advised that judges would welcome a set of guidelines. What happens when a case comes up is that the two lawyers each present their very one-sided viewpoints and the judge is stuck in the middle without any reference point against which to balance these. If the Association could devise a sensible statement on ethical behavior for psychoanalytic research as a standard, then the judge could turn to that as he listened to and evaluated what each lawyer said.
It makes a lot of sense.
Dr. S: Well, did you find a way around that?
Dr. K: We didn't have a solution, but we became keenly aware of the problem. The place of confidentiality came under this new guidelines project for clinical reporting which you referred to at the beginning of this interview.
Dr. S: Tell us about that project.
Dr. K: Well, the CSA is trying to develop something that would facilitate a new kind of clinical reporting in the Journal. We're not trying to straight-jacket all authors, or to impose rules that everybody has to abide by, but we'd like to make some suggestions that some psychoanalytic authors might find interesting; then maybe we could get something started that would gradually take hold, that people would like and appreciate.
Dr. S: How does confidentiality fit into improved clinical reporting?
Dr. K: Two ways. We spent an awful lot of time talking about the consequences of disguising clinical reporting where erroneous information is inserted for the purpose of the disguise. And I think, particularly now, in view of the possibilities for various kinds of electronic searches, that anytime you introduce erroneous information, it's apt to be pulled out as if it were a reliable sample of a particular thing.
Dr. S: Can you give an example of what you mean?
Dr. K: Well, for example, there is a published psychoanalytic case study where a life-threatening gastrointestinal illness was reported as bronchial asthma to protect the patient's identity. They weren't making a point about the psychodynamics of either of these illnesses; they were simply discussing patients with psychosomatic symptoms, but this disguised study was included in a survey of asthma cases, cross referenced with psychology and psychoanalysis. Thus, at least one of the 100 citations included in this report is untrue. What's useful in one context may therefore be damaging in another.
Dr. S: Yes, but such efforts to disguise are made all the time.
Dr. K: And for the point that is being illustrated, it may not have make a difference. But if then someone else using the material does not limit himself to the particular point the original author was illustrating, then it could indeed make a big difference. It makes it very risky to use any published information because you can't be sure what in the material has been disguised. The Committee spent a long time talking about this issue, concluding that any distortion probably should not be used at all. Then of course we got into the question of the burden on authors and patients; how can you then disguise the material? We considered the difference between omission and distortion. If you say the patient is a young professional, that's different from describing a young physician you treat as a young lawyer. It's an omission of detail, not distortion of fact. It's still accurate, but more ambiguous. Omission is therefore better than distortion.
Dr. S: So, the Committee is attempting to address the question of verification in their suggestions for case reporting?
Dr. K: Yes. That we should at the least try to find additional ways to verify. Nothing is wrong with the clinical test. That, after all, is something we've all grown up with. But it would be nice if there were additional ways of testing some of these ideas, because otherwise we run the risk of having a body of ideas and theory that are essentially authority based. What we are addressing in the report is an attempt to provide ways of presenting clinical material so you know whether it is the analyst speaking, or the analyst thinking, or the patient speaking.
Dr. S: Then you're not talking about testing hypotheses outside the clinical situation, but testing hypotheses within the clinical situation?
Dr. K: Yes. And we're talking about the psychoanalytic literature. Not that we're attempting to have every paper conform to some imposed set of standards, but, rather, to encourage people to think about the fact that there are alternative ways of presenting material, ways that make it clearer as to who said what to whom and in what sequence, and that such specifications need not violate confidentiality. In fact, people involved in tape recorded research often discover that in many situations extraneous information about the patient becomes irrelevant because a different set of questions are being studied: how the psychoanalytic process works; or, how patients respond to particular kinds of interventions. But the point is, first you have to know what the intervention really was. This is what we are trying to focus on: another approach that may be of potential value, not an approach to replace all that has gone before. It's funny how quickly people assume you're going to take everything away from them and impose a new system.
Dr. S: Perhaps at this point you might describe this new approach.
Dr. K: Well, the Committee has written a paper, now in its fifth draft, wherein a number of guidelines are proposed. One we would like to have considered as a universal guideline for editors, authors, and readers, is that every paper which includes a clinical report should be encouraged to have one sample of veridical reporting. It doesn't need to be a whole hour, but just a sample, to provide the flavor of how the analyst was working with this patient, which words were the patient's, which were the analyst's, and which were the analyst's thinking either during the session, or after. Additionally, we recommend that the context be specified from which the clinical sample was taken; whether from psychoanalysis or psychotherapy; how often the patient was seen; from what period of the treatment the sample was taken, how the material was recorded.
How would you specify that?
Dr. S: As did Bowlby, as did Greenson?
Dr. K: Yes, and indeed when they think creatively, they don't want to feel hamstrung. And of course we don't want to hamstring anybody. They also had this question about verification. They think verification in psychoanalysis takes place in the clinical setting. And I don't think anyone argues with that; we all work in a practical way, trying out new ideas. But what the Committee is asking is, is there anything we can add to that in a way that won't be burdensome and that won't lose more than it gains, that will enrich our field and make it possible for us to do more? We said to ourselves, “Okay, we have identified what we think is a problem that people in the profession may not be aware of.” But so often people articulate problems without offering solutions. So we thought further, “Is there some way of addressing this problem with recommendations, not the final word, certainly. Then other people may be stimulated to make still better suggestions. That's what we hope will happen. We're trying to begin a dialogue about the kind of evidence available in our field.
One of the things I've experienced in the discussion groups at the American is how frequently a case report sent out to the group participants in advance provokes questions from these participants based on totally different ways of understanding the same basic document. The analyst, when asked, could then go back to his material and reveal the evidence for his formulation to the satisfaction of the other participants, evidence not originally included. Part of what we struggle with are the complexities of the clinical material we work with. And there is no way of solving this. What we're trying to do is find additional ways to make contributions richer and more stimulating. We want to find ways to provide a clearer picture of the process, in addition to the dynamics; not instead of, but in addition to.
Dr. S: The dynamics can be expressed very clearly in narrative form, but the process is hazy, whereas, if the material is written in the form you're suggesting, that analytic process becomes clearer.
Dr. K: Maybe. We hope.
Dr. S: Some people feel if you take any notes at all in the analytic situation, you're doing it incorrectly. You should just be listening. And it is felt that the tape recording is distorting. What about that? Then all the evidence would be limited to what you recall at the end of an hour. Isn't that a distortion right there?
Dr. K: No matter what you do, you distort. There's no way of getting around that, as far as I'm concerned. Each analyst, I think, develops his own style. You know, most analysts don't write about their clinical experiences. But anyone who is seriously interested in trying to report his clinical experiences will find his own way of doing it. I don't think I could do a tape recorded analysis. I just would not feel comfortable doing it. Other people who've done it have managed, and certainly what they reported has often been stimulating and raised new questions. We're not trying to say which method of gathering evidence is best. All we're saying is we think it would be useful if it were reported.
Dr. S: So at this point they're not available?
Dr. K: At this point there's a necessity just to see that they're protected and not lost. This group had it's first meeting at the December 1987 meetings to begin working out procedures. The committee as a whole has spent two meetings discussing this, concluding that we will be available in a continuing consulting relationship with this group.
Dr. S: So this is another spin-off of CSA?
Dr. K: Yes. Once they develop their own policies, they may not want or need such continuing consultation with Scientific Activities, and that would be marvelous.
Another thing I think is apt to be misunderstood is there are lots of things that have potential value for the profession even if only five percent or three percent of the analysts are interested. That may be true of the pagination converter a few of us created. I would guess fewer than one percent of the analysts have ever used it.
Dr. S: What is that?
Dr. K: It compares the exact page in the Standard edition with the German edition of Freud's Complete Writings. Sam Guttman republished it in his Concordance. The Germans republished it in a series of Freud's collected papers, and the Italians have republished it. It's an example of something that only a small percentage of analysts will use, but possibly the whole profession can benefit from it. And that may be true of the guidelines we just talked about. And if that is so, they are still of potential value.
Dr. S: It appears that the CSA has many interests and projects which all together add up to a most productive committee contributing much to the vitality of the American. In a sense it fulfills the expectation of those who began it as the keeper of the scientific realm.
Thank you for talking with me today.
Dr. K: And so we labored over that for several years. It was accepted by the Council and published in the Bulletin.
Dr. S: What's the status of the report?
Dr. K: It's not clear; that is, is it simply a report that has been received by a committee and filed, or does the fact that it was accepted by the Council and published in the Bulletin imply that analysts have some kind of responsibility
to live up to the standards it includes? But it got us into the whole issue of confidentiality. We felt clearly that in psychoanalysis, and probably elsewhere in medicine, an informed consent is really misinformed consent. There's no possible way people can know in advance what they're giving consent to. And while such consent may satisfy on lots of levels it's not informed consent in the sense that the patient really knows what's going on.
But the concern with confidentiality addresses only certain kinds of clinical reporting. That kind shouldn't be the only clinical reporting available. If the author includes a long, involved case report, then contextual information is necessary to give the reader a picture. But there are other kinds of clinical reports where such contextual information may not be as useful, such as, where there is an interaction described between patient and analyst. We identify as a problem that it is rare, when you read clinical reports of such interactions, that you know who said what to whom. We wonder when the analyst reports what happened, is he reporting what the patient actually said, or what he said approximately? It would be helpful to know. Also, we should know when a patient is discussing something, how did it come out? In addition, it's important to know how the analyst felt about it. This kind of reporting may not require noting whether the patient is a young physician or a young lawyer. You don't have to add such background detail to attend to a clinical problem involving an interaction between analyst and patient. And the Committee feels that this last kind of clinical problem is under-reported in our literature.
Dr. S: I see. You're talking about two different ways of presenting material in the psychoanalytic literature. One would be external material, having to do with the patient's life taking place outside the confines of the office.
Dr. K: Yes.
Dr. S: And the other is internal material generated within the psychoanalytic situation itself. You're saying that for the external, perhaps it's all right to use a certain amount of distortion, or better omission, for the purposes of confidentiality, so long as it doesn't confound the material. But that for internal reporting such distortion is not only potentially damaging, but unnecessary.
Dr. K: Yes. We are saying also that we really have two kinds of literature. One kind is that of hypothesis-generating introducing a new idea. And for that, people could illustrate with a fictionalized case report, because the purpose is to get across the new idea.
Dr. S: Give me an example of what you mean.
Dr. K: Take Kohut's introduction of the idea of the selfobject. He could have illustrated his meaning with a short story. He didn't have to use actual clinical material to illustrate the idea.
Dr. S: So that is hypothesis-generating. You are illustrating a new idea rather than ...
Dr. K: Yes, rather than validating it. When you validate an idea, you need detailed, exact, fully-reported clinical material free from distortion, but which is also concerned to protect the patient's identity. The guidelines address this issue by focusing on means to supply in a clinical report exactly what is said by both patient and analyst, and what the analyst has thought, but has not said. But it's interesting. I presented the Committee's suggestions for alternative methods of case reporting to a group of colleagues I regularly meet with in Chicago who saw the issues very differently. And then it was interesting later to observe the reaction of the Committee to the Chicago group's comments; the Committee reacted similarly to the way I did. I was not surprised at the fact that a group of my colleagues would have questions about our guidelines, but I was surprised at how clearly they were able to articulate them in a very different way than the Committee had come to after all the times we had discussed them together. Essentially the Chicago group's point was that what we need in psychoanalysis is not more data, but more ideas—that if someone can present new ideas, and we clinicians are able to hear them, these ideas are very apt to affect our thinking when we're with our patients. The test of the new idea is what happens in the clinical psychoanalytic situation; and when dozens of analysts who've heard these ideas, talked about them, discussed with their colleagues the results of their application in the clinical situation, gradually, these ideas begin to be part of our clinical approach. This is the test of a new idea, say the Chicago colleagues. Now, I think there are many who have been concerned with a more systematic verification of hypotheses, who feel that the approach described is really a part of
the problem, not part of the solution. And I think that what the Committee wants to do by writing these guidelines is to raise these questions. We see the problem in the question of verification: we believe somehow that because we're psychoanalysts, we don't have to be held to the standards other disciplines are held to.
Dr. K: Just a brief statement saying that the analyst took notes during the hour, or that he recorded it immediately afterwards, or that it was a very vivid case he recalled ten years later.
Dr. S: I agree that that's very important, but we rarely see it in papers.
Dr. K: These suggestions do not violate confidentiality, except perhaps it violates the analyst's confidentiality, how the analyst really works.
Dr. S: I think this may be a worthwhile idea. I would like to try it myself. But what you haven't said is to what end should all papers include veridical reporting? Wouldn't this have the effect of imposing a standard to be lived up to for its own sake? So often the clinical illustration has nothing to do with the point that's being made in the paper anyway.
Dr. K: You mean somebody has to live up to a rule, so they do it in a meaningless way?
Dr. S: Right, exactly.
Dr. K: That's a risk. And we don't want that, obviously. What we really want is an option that authors and editors become aware of, to include in order to enrich the papers published. We would like also to have readers become aware of this option so that, for example, if it's missing from a paper they might notice, and wish it were included. The risk you point out is whenever you make rules people find a way to comply noncompliantly. And that, obviously, is not what we are interested in doing.
Dr. S: You need, it seems to me, a good illustration of how this should be used, so that people will have a model to follow.
Dr. K: We'd like to have a clearer notion of what happens in the clinical situation in the process. You see, most of our literature deals with dynamics, and while we think dynamics are very important, getting a clearer notion of the process is also important. We are concerned with how we can best address this issue.
Dr. S: How did the CSA come to consider this issue?
Dr. K: Scientific Activities is a funny committee. We either assign ourselves tasks or we hope others will ask us to do things. There was a period when we were searching for our identity as a committee. We decided, let's take a look at the papers that have been quoted most frequently in the psychoanalytic literature and see if we can learn anything from them. We had no idea what we'd find. We took a sample of 60 papers cited most frequently by other authors; there's a place in Philadelphia that has a citations index system. We got 20 papers each from the three major psychoanalytic journals cited most frequently by subsequent authors in a particular window of time. We did a general survey of those 60, and we also took ten other papers from each of the journals. Everybody on the Committee read and commented on them in a variety of ways. We found a couple of things. One is that the most frequently cited papers in the mental health literature contained no data whatsoever.
Dr. S: Really?
Dr. K: Yes. Now, in a scientific discipline, this is surprising. Certainly if you looked at the 60 most frequently cited papers in chemistry, for example, I'm sure you would find papers having to do with actual evidence. We became intrigued.
Dr. S: What psychoanalytic papers were included in this most cited group?
Dr. K: Well, Bowlby was one of the most frequently cited authors. Also, Ralph Greenson. A fair number were senior authorities in our field with rather grandiloquent summarizing statements of their clinical experience. We don't question that they are wonderful papers to read and that we need that kind of paper. But what we were struck with was the omission of papers that had anything to do with any kind of evidence. And you know, it reminded me of when I went to the University of Chicago Medical School. We had a revered old professor of physiology, Anton Carlson. The caricature of this man was his going around saying, “What is the evidence?” But in psychoanalysis when you ask the question, “what is the evidence?” it became clear that—it's not an easy answer, and that evidence isn't available in the literature. It was with this type of issue in mind that we began our considerations.
Dr. S: Going back to your experience of presenting this set of ideas to your study group in Chicago, I suppose it is such papers written by authorities that your group had in mind when they suggested to you that what we need in psychoanalysis is not data, but ideas.
Dr. K: Yes, this was the bias of that
group. They are all published, and what they publish is new ideas.
Dr. S: And how it was reported should be stated.
Dr. K: One person I spoke to the other day takes no notes at all, and never does any clinical reports until the analysis is concluded.
Dr. S: That's the model Freud presented, isn't it? He said, don't think about the case for scientific purposes, until it's completed.
Dr. K: That's right. But in any case, this is this particular analyst, and this is a person I respect highly, who has marvelous ideas and wonderful clinical illustrations of his ideas, who never writes up anything until the case is finished and has cooled off. He has no notes. And he actually, I think, would propose that this, in fact, gives him a better grasp of the psychoanalytic process, which is not words and commas and periods, but is an overall integration.
Dr. S: Now that kind of reporting could never include the process notes you're suggesting.
Dr. K: That's right, and this person was objecting on the basis that a real psychoanalytic report talks about the analysis as an unfolding over many years with all kinds of nuances that would get lost with every detail recorded. Now this author does describe dialogue between him and the patient that is a beautifully synthesized summary capturing the essence of their interaction. It's novelized, and he admits it.
Dr. S: But one of your points is that if that's the way the material is being written, he should indicate that. He should say this material is the result of a synthesis arrived at after several years of having had the benefit of looking over in my mind the entire process.
Dr. K: That would certainly help anybody who was thinking of reusing his clinical material. But he says that it's ridiculous to try to reuse somebody else's material, that this is really just a form of sophistry, that it's textual analysis having nothing to do with psychoanalysis. You know analysts are very clever in defending what they have decided to do, and this man does valuable work.
Dr. S: I know you're not saying he doesn't. You're just suggesting that this is not the only way. And that when we attempt to derive data from the psychoanalytic situation, the kind of data derived from this kind of reporting might be, if not falsified or distorted, at least less reusable.
Dr. K: It's certainly not reusable. Now this man is really interested primarily in generating new ideas, new ways of thinking about what he experiences clinically. And he has done that. He's made many wonderful contributions. And he shouldn't be restrained in any way that's going to interfere with this process. It's just that I think it would be helpful for readers to know how he's reporting; they may or may not agree with his assumptions that this is the best way. But if he believes in his assumptions, he should be willing to state them so that other people can come to their own decisions about it instead of his just assuming that they would agree with him. I think the biggest risk in CSA's venture is that people might think we're trying to straitjacket everybody.
Dr. S: Well, I think you make it very clear that that's not what you're attempting to do. Your committee seems to be saying that there is another way of reporting that would get to the process, that some people would be interested in writing in this way and in reading material written in this way, as well. The guidelines do indeed pose interesting considerations. What's the next step?
Dr. K: There's the possibility that our guidelines may get wide distribution by being published in the Journal or discussed in a panel at a scientific meeting of the American.
Dr. S: Can you tell us of any other CSA projects?
Dr. K: One more. Another question we've dealt with is the fact that there are increasing numbers of tape recorded analyses floating around. What happens to them when the people who accumulated that data are no longer available to work with the tapes? They provide rich potential value for subsequent studies. We appointed a subcommittee to think about it. We came to the conclusion that a body independent of the American should be responsible, that there are potential liabilities and administrative problems. So it seemed increasingly clear to us that there should
be a separate entity outside the Association, but obviously closely connected to it. We've now got six people who are willing to serve as trustees for these tapes, at this point just to safeguard them, and catalogue them, eventually to develop procedures for making them available to responsible researchers.