An epistemology consultant has joined the psychoanalytic process course at Columbia University Center for Psychoanalytic Training and Research. This is one of a number of innovations in the psychoanalytic curriculum, initiated by the Curriculum Committee under the chairmanship of Ellen Rees.
The process class continues to be taught by a senior training and supervising analyst who leads a clinical discussion of an ongoing control case — a format familiar to many psychoanalytic institutes. Now a second instructor has joined the class who might be designated the epistemology consultant.
The role of the consultant is to promote examination of underlying assumptions raised during the class, while preserving the flow of the clinical teaching. How do we select or create a clinical fact in the material being presented? What gives us a feeling of knowing at a particular point? What hypotheses and theories are embedded in our interventions with this patient? What do we use as evidence to confirm or disconfirm our sense that we know something analytically? What lines of authority are part of pur sense of knowing?
The experiment began last year with Robert Michels teaching an eight-week segment to the second-year candidates. Ellen Rees provided the epistemological commentary. The same class, now third-year candidates, met again during the 2000–01 school year. John Munder Ross and I have started the same format with the new second-year class. Our plan, still in evolution, is to follow the same patient with the same class and same instructors through graduation and then to reconvene the class as a post-graduation seminar in the termination phase. A new pair of instructors will begin with each new second-year class.
In a recent class, a candidate presented a session of her work with an analysand who after a succession of missed appointments spoke of money problems. The candidate interjected, “And you have not paid me.”
The process instructor, hearing this, remarked that he would rather have said, “You have not mentioned that you have not paid me.” The instructor inferred from the exchange that the analysand had this on his mind and that his not broaching it was a disruption of the basic rule.
“I think it likely that the model provided by the interaction of the two instructors, in their defined roles, facilitates this freedom to think and speak critically. This model of non-defensive questioning and challenging between the two faculty members is a key innovation in the course, something a single instructor providing his own epistemological commentary could not provide.”
Such a statement invites the patient, in alliance with the analyst, to self-reflect, wondering why he is not comfortable saying what he is thinking. When we make such interventions, we encourage the analysand to differentiate between his observing self and his participating self, perhaps through identification with the analyst.
The second instructor, the epistemology consultant, commented that we make certain assumptions when we use this kind of intervention. One assumption is that appealing to the analysand's self-observing capacities engenders insight, and insight is mutative and therapeutic. This patient, however, talks in emotionally charged situations as if he were observing himself. Inviting him to look at what he is doing, or not doing, could be counterproductive here. We might predict this and look for confirmation.
The process instructor agreed and added that we could offer a follow-up interpretation: “I notice that when things get emotionally charged here you start making observations. What's that about?”
The epistemology consultant asked about other ways to address the patient's silence. We drew the patient's attention to something he is doing: in this case, he is not mentioning his outstanding bill. At first blush, this has a certain epistemological neutrality because we seem to be minimizing suggestion and persuasion (which, in turn, seems more analytic).
The consultant elaborated. We are not telling the patient what he is defending against or why. We are not telling him what he might hope to achieve by not talking about his debt. In saying “You have not mentioned that you have not paid me,” are we inviting, suggesting perhaps that the patient observe and explore his defensive stance?
The class thought we needed to know how the patient would hear the analyst. Would he hear it as condemning and judgmental? Was the analyst more concerned about her needs than his? Perhaps the interpretation would resonate with the analysand's descriptions of his disparaging father and remote mother, and therefore would be experienced as something closer to retraumatization.
The presenter talked more about her feelings about the fee and the patient's non-payment. She was averse to entering into a confrontation with the patient that could provoke him to flee analysis.
At times the second instructor has moved the discussions further from the clinical material. Returning to our notions that self-observation and insight are mutative and beneficial, findings from psychoanalytic outcome studies were brought up. A number of these studies have found that significant and lasting change can occur without insight and that insight or the capacity for self-analysis does not correlate with therapeutic benefit.
Although we can find methodological flaws in these studies, the results were a surprise to the researchers. These findings disconfirmed their hypotheses. The findings were also surprising to the class. A more detailed look at these
Jeffrey K. Halpern, M.D., is a psychoanalyst at the Columbia University Center for Psychoanalytic Training and Research.
studies occurs in a separate methodology course. Although such discussions can be lively, it supports the purpose of the class to stay closer to the process material.
Responses from the candidates to this new format have been encouraging. Several candidates said that what was most useful was the second instructors elaboration of the underlying and dimly articulated theory or part-theory implicit in the candidate's comments to the patient or thoughts about the case. This attempt to recognize and explicate the candidate's own nascent understanding is analogous to the psychoanalytic process itself.
There are other venues at Columbia for further and more systematic teaching of psychoanalytic epistemology: methodology courses in each year, a course on psychoanalytic research, and a course on epistemology in the candidate's fourth year. In addition, each process class represents an eight-week segment in the thirty-two weeks of process classes each year.
One process class has multiple instructors from different psychoanalytic perspectives who comment on the clinical material. In another class, a faculty member presented her own process material, something that the faculty usually has been fearful about. For many years there has been an elective in which the same sessions are presented each week to a different visiting psychoanalyst, prominent in the field. Other process segments remain more traditional.
The second instructor's role includes trying to question and understand the hidden authority embedded in our relationship to theories, techniques, teachers, supervisors, and the larger psychoanalytic community. An inability to think within alternative theories, to think of alternative hypotheses, or to raise questions may indicate not insufficient learning but unexamined authority.
When we presented this process class “live” at the meetings of the American last December, the viewers were impressed with the ease with which candidates questioned, debated, and argued with the instructors. This may say more about our candidates than our pedagogy. I think it likely, however, that the model provided by the interaction of the two instructors, in their defined roles, facilitates this freedom to think and speak critically. This model of non-defensive questioning and challenging between the two faculty members is a key innovation in the course, something a single instructor providing his own epistemological commentary could not provide.
Some have been concerned about the danger of bewildering candidates by introducing critical thinking about theories and techniques as they are trying to learn them. Might this subvert the candidate's understanding of a theory, systematically and from within, or blur contradictions and incompatibilities in a pluralistic viewpoint? We are still experimenting. Without a theory (from the Greek theoria, a viewing) it is impossible to see what is going on or to make an interpretation. Nonetheless, to paraphrase Keats, it is often necessary for analysts to remain in uncertainty and doubt, without any irritable reaching after techniques and theory.