I was asked to share my recent journey as an evidence-based researcher and practicing psychoanalyst. I have had a hidden demon in my unconscious for a very long time, inaccessible to me over the last 25 years. Having worked hard at my institute and at the American Psychoanalytic Association as a teacher, administrator, and supervisor of candidates while serving as a training analyst, there remained part of me that envied the empirical researcher. The world of research grants, statistical analysis, and evidence-based treatment was essentially off limits to most analysts due to a culture of relative isolation from typical scientific methods thought not to apply to our field. There was a feeling, I believe, that only someone analytically trained could understand psychoanalysis, thus we could not trust others to explore aspects of our realm. These issues were addressed by thoughtful and creative thinkers in the area of psychotherapy and psychoanalytic research, but I did not have the tools to understand their efforts nor the encouragement to learn them. Then I joined the Psychotherapy Research Program at the Massachusetts General Hospital Department of Psychiatry.
When I began, I never thought I would become more than an analyst consultant, probably expecting to tell the group that what they did was inherently misleading and misguided. Instead I have opened up a new way of thinking about being an analyst and being true to my patients by adding another form of inquiry besides inductive reasoning to explore the dynamic unconscious and psychoanalytic process. I have become aware of a dedicated group of psychotherapists and psychoanalysts who hope to add answers to important questions through innovative evidenced-based research. One of my wishes in this regard is that psychoanalytic institutes, both faculty and candidates, have access to this kind of creative exploration of our work. Several psychoanalytic institutes have included the study of psychoanalysis through process and outcome research courses. I have learned how essential it is for the beginning researcher to have a knowledgeable group of collaborators to guide one through the maze of research administration and development.
Psychoanalysis can be studied empirically and not destroyed in its essence…
The excitement that I have experienced with empirical research at the Psychotherapy Research Program and continue to enjoy is the sense of discovery of a different kind than the therapeutic adventure of clinical psychoanalytic discovery and immersion. Some similarities exist, like the sense of the unknown, the struggle to understand the “data,” and the immersion in a process of discovery. One of the most rewarding aspects of the researcher is the camaraderie and group development, which is “organic” in its growth. People are always interested in exploring new and old ideas and how they can be studied. This delight with the opening up of new ideas to study with ever changing methods is a joy to behold.
Psychoanalysts are missing a wonderful piece of the larger intellectual community, which includes empirical researchers. Psychoanalysis can be studied empirically and not destroyed in its essence, which is what I suspect is the fear. We may even get closer to defining what psychoanalysis is through these studies. I emphasize that I see empirical research as an addition to the larger psychoanalytic debate, not a replacement. I do not feel this is necessary for psychoanalysis to survive, but rather to thrive. There is a fear among some analysts that the truth of the unique and irreplaceable psychoanalytic treatment experience, which is a shared experience of being known by another and that one is knowable, cannot be studied empirically. The shared experience of being open to one's unconscious liberates and educates one's core self, and the chance that the many routes to that experience would be lost is almost unthinkable. Thus, it is guarded sometimes by the fiercest attitudes, including a kind of solipsistic isolation. I do not feel that the inclusion of forms of empirical research, with its enormous creative thrust will injure psychoanalysis but rather enlighten all of us to the unique clinical and theoretical urgency of psychoanalysis. Analysts are the masters of change and the owners of a burgeoning literature of how people change, now from both theoretical and research perspectives. It is another essence of psychoanalysis that there is meaningful change for those stuck in the mire of symptomatic repetition. Yet we are all in the position of being alienated from the kind of change that might emerge from research of all kinds.
The use of the couch and the frequency of sessions are obvious researchable questions though there are also less obvious questions to study. The whole debate about self-disclosure versus neutrality or the “blank screen” could be studied. Instead of listing the myriad possibilities for study, I wonder more how to develop a climate in our institutes and professional
Ira Lable, M.D., is an assistant clinical professor of psychiatry at Harvard Medical School and a training and supervising analyst at the Psychoanalytic Institute of New England, East. He is also in private practice in Boston.
meetings where this kind of endeavor is valued and rewarded. We must get over the idea that to study psychoanalysis will necessitate observation that will change the experience so profoundly that it would no longer approximate psychoanalysis.
As part of my transformation to analyst and clinical researcher, I received a grant from the International Psychoanalytical Association to study the effect of the use of the couch on psychoanalytic process. We used the Psychotherapy Process Q-Set, a research tool developed by Enrico Jones that can assess therapeutic hours for the presence of psychoanalytic process. Our paper is titled “The Effect of the Couch on the Psychoanalytic Process: An Empirical Study.” My co-authors are Ray Levy, Stuart Ablon, John Kelley, Woody Waldron, and Julie Ackerman. We used archived analyses in which the analysands were lying down and sitting up during different phases of the treatment. There are great difficulties in assessing the results of this kind of investigation: choice of sessions, limited access to taped analyses, and overall study design. Controlling the multiple variables—analyst training and style, patient diagnosis and presenting problem, and the idiosyncratic response of both analyst and analysand to the patient lying down and not seeing the analyst—is also a challenge. We are presently examining the types of research design available to stimulate the psychoanalytic community to under take further empirical investigations of the important theoretical and technical ideas underlying the use of the couch in psychoanalysis.
I feel personally the fear of losing the special nature of psychoanalysis and psychodynamic psychotherapy and the access to the nature of the dynamic unconscious that are their unique contribution. I believe that psychoanalysis and psychoanalytic psychotherapy overlap in their ability to access unconscious meanings and develop insight through affective understanding. And yet, I remain in conflict, a part of me continuing to believe that four to five times a week on the couch remains the gold standard for the thorough treatment aimed at the modification of multiple transferences and assessing the unconscious. However, there is a stronger “drive” that is a basic part of the psychoanalytic community, to explore the functions of the mind, and especially to ask questions and devise ways of answering them. Being an evidence-based researcher/psychoanalyst is part of that long psychoanalytic tradition.