The last time I saw Bob Emde in person he was sitting on a couch in a Frankfurt hotel lobby having an animated discussion with a young researcher. This was in the minutes before we all had to leave for the airport after a weeklong Research Training Program and Sandler Conference sponsored by the IPA. Everyone was exhausted, but Bob couldn't resist another chance to teach and learn.
At 82, Bob Emde remains a superb psychoanalytic thinker, a first-rate academic researcher and a generative mentor of the first order. In this interview, I hope to capture for the reader a little of the enthusiasm, brilliance and dedication that has marked his long career. We met by Zoom. This is a condensed version of that conversation.
Bob Emde's first paper was published more than 50 years ago, but I wanted to know where he saw psychoanalytic research being now, and what he saw as its current leading edge. Emde responded that throughout his career he has been involved in interdisciplinary research with a developmental perspective. “I think psychoanalysis is at an exciting critical juncture in opening itself more and more to research, knowledge and work.” He believes psychoanalysis is “assuming a role as an integrated psychology of the mind in the midst of advances in other fields,” and he looks forward to its integration with cellular biology, working toward applications beyond the consulting room, and using our knowledge of a two-person psychoanalytic psychology involving unconscious mental functioning. He sees psychoanalysis in
implementation sciences, working broadly in systems, family and especially community. “Our psychoanalytic psychology is a very powerful meeting place.”
Psychoanalysis is assuming a role as an integrated psychology of the mind in the midst of advances in other fields.
Most of Emde's work involves a convergence of developmental study and clinical interests. For example, his very early work on infant smiling is tremendously suggestive for the analytic encounter. I asked whether this convergence was intentional or came out of the work as it developed. He replied, “It's both and this has impressed me more and more over the years. The fundamental processes we see early in development are processes we use in our analytic work—empathic understanding and emotional communication. The central role … of affect is something that I, with others, used and worked on intensively early in my career. Positive affect as well as negative affect … that's central in our work.”
Emde's interest in this area continued the work of his mentor, René Spitz who pioneered observing infants as a psychoanalyst, filming them, making hypotheses and formulating theory. Spitz was also a committed analytic practitioner. Analytic practice and infant research were integrated in Spitz's work and, from the start, in Emde's career.
Emde recalled a controversy about Spitz's concept of anaclitic depression. A decade after the publication of Spitz's classic papers, he was criticized for inadequate behavioral methodology. His behavioral measures of depression and development weren't good enough, it was claimed. What was missing from the discussion was that Spitz used his clinical skills to feel the sadness of depressed infants. He linked his empathic understandings to the babies' observable characteristics such as posture and facial expression. And he felt depression as an analyst. He thought about infants clinically, using pattern perception as a clinician does, seeing a syndrome over time, and linking separation from caregivers with the depression, and he then introduced reuniting them as a treatment leading to recovery. In addition to being a researcher, he was a “psychoanalytic clinician, finding clinical meaning that included emotional exchanges and reciprocal interactions with babies, himself and others.”
“What about psychoanalysts who think they can learn everything from the clinical encounter?” I asked. I knew Emde had concluded early in his career that to really understand things, you must look at phenomena in other contexts and with other methodologies.
Did he think that analysts could benefit from learning about methodology, especially in a way that integrated with analytic modes of understanding?
“I would even be stronger,” he responded. “If they don't, they're sucking their thumbs.”
“Explain the metaphor,” I asked.
“Babies and young children do more than suck their thumbs. They are actively exploring the world. And likewise, if practitioners are at all successful, they're already doing more, making judgments about evidence, including beyond what is familiar and known. Analysts, if they're of any salt at all, are curious people; they're in their profession because they're curious. And because they're wanting to help. Certainly, those are two strong motivations that are in every analyst I know.”
Besides developmental study, Emde believes a systems approach is central to psychoanalytic theory and practice.
Starting with Freud's classic formulations, analytic work, he said, “is helping people open up closed systems, neurotic systems as these were phrased originally, and that's the enterprise. We deal with closed systems that have happened in our patients for all kinds of reasons, whether one thinks about them as having come about as a result of early traumatic experiences, or some other experiences of early adversity or other unconscious conflicts with a lack of understanding.” People continue to repeat maladaptive patterns trying to master something, “but the system is closed and they can't master it. That's where dynamic work [comes in] revealing, overcoming and practicing new modes of work … giving the patient an opportunity within the therapeutic relationship of opening that system, finding new adaptive ways, not having to do repetitions for whatever reasons.” Often we need to remind ourselves we need the same kind of open system thinking as practicing analysts.
Understanding frustrated colleagues might insist they can learn almost everything in the consulting room, Emde said, “I find it hard to believe they would be in a cocoon of a consulting room and not even want to look out the window.”
“What about psychoanalysts who think they can learn everything from the clinical encounter,” I asked. I knew Emde had concluded early in his career that to really understand things, you must look at phenomena in other contexts and with other methodologies.
He elaborated on systems thinking. It includes the idea that “we're all developing,” and once you say that, there's no other way to think about it than in terms of a dynamic systems approach. “You are building increasingly organized systems at multiple levels across development, differentiation, integration and then hierarchicalization… The process of regulation is occurring at multiple levels all the time to sustain life and to continue development, whether you're looking at energy dynamics, or whether you're looking at the level of the cell, the level of tissue, physiology, the level of immune systems, cardiovascular systems, whether you're looking at stress systems. Whether… from a subjective point of view or from a shared meaning, intersubjective point of view… a systems approach looks at those different levels which have boundaries and regulatory dynamics.”
An example of the systems approach can be thinking about the inverted U curve. It is an elaboration of the ancient Greek idea of “nothing in excess” and the golden mean. In relationship to activation it's a performance curve. One needs enough to activate. With too little activation there is minimal functioning and little adaptive happens. There is a midpoint of optimal activation, a zone of optimal adaptation, and then with more activation, you begin to encounter an excess or overload. “That really is a core dynamic of every regulatory system that you might be focusing on. For example, we need some stress in our lives. Our physiology and our psychobiology is adapted for that…. But then there's excess.”
“Toxic stress” in popular discourse, or “allostatic load” in technical language, occurs when stresses build over time putting you in a maladaptive excess range. This is operative at every level of a physiologic system. Emde, consulting with colleagues, is now excited by current stress research that includes not only behavioral, mental, and psychological manifestations, but also biomarkers of stress.
Another example of systems thinking reflects the distinction between developmental lines as suggested by Freud, and a different kind of trajectory, a stepwise development, a point of view developed by Spitz. Emde's own research started with Spitz's notion of psychic organizers, which were modeled on organizers in embryological study. The stepwise idea of development implies there are times of transitions, times of emergence. These ideas from Spitz's genetic field theory of ego formation launched Emde's 30-year National Institute of Mental Health supported research program on developmental transitions, times when new functions emerge because of reorganization of systems. “There are times in development where you have these transitions … new inputs, new organizations. These are times of creativity,” says Emde.
Asked to elaborate on why study on the molecular level should be of interest to psychoanalysis, Emde associated to cancer research, where we have learned much about how development goes wrong, a process that starts with cellular biology. He was also reminded originally it was thought researchers would find individual genes corresponding to different illnesses including mental illnesses, and this was a major inspiration for the human genome project. But there was a big surprise: The number of genes turned out to be much smaller, 20,000 or so as opposed to 200,000, a number many had been anticipating. Furthermore, it became apparent there were multiple genes involved in mental disorders. Single gene etiologies are really rare. Some believe there may be 400-500 genes involved in the conditions referred to as autism spectrum disorders. Similarly, there are many genes implicated for schizophrenia and bipolar disorder.
“It's a new world. The next big surprise was that the human genome project resulted in more importance being given to the appreciation of environmental transactions across development as being implicated in pathways to psychopathology and human misery. Now, the big field is epigenetics.” It seems every cell in our body contains more than a meter of folded DNA. Genes are being turned on and off in relationship to their specific resident tissues and their functions in relation to their ongoing larger environments. We are just beginning to understand the specifics of how that works.
The opportunity for psychoanalysis is to respond to appeals. already coming from many biologically immersed researchers, for an integrated psychology of mental functioning, that is first person and subjective as well as relational and intersubjective….
Emde went on to describe the amazing, complex world of modern cellular biology where one no longer thinks about simple mutations, but issues like copy number variation and somatic mutations that influence neural functioning. “They're not only looking at individual cells like we did in medical school through a microscope, [but] using big data sets with genetic, genome-wide association studies. So, now you have samples of huge numbers of individuals available for looking at small effects relevant to processes that are interacting. All of these discoveries are mind boggling. But they're going to affect us, and they're already starting to.” The opportunity for psychoanalysis is to respond to appeals, he asserts, already coming from many biologically immersed researchers, for an integrated psychology of mental functioning, that is first person and subjective as well as relational and intersubjective—that can provide understandability and meaning from our increasing new knowledge of complexity.
Admittedly there is a negative side to our focus on molecular mechanisms, and our wanting to understand complexities and multiple emerging ways of helping those with disorder. How will it affect the helping dyadic doctor-patient relationship? Already we see less effort to train medical students in history taking and working with patients over time. Seemingly, psychiatric training has lost its way in this regard as few programs encourage residents to follow patients over two or three training years, “which is a travesty.”
Emde went on to talk about how a systems approach could affect psychoanalytic education, an education that should incorporate some knowledge of cellular biology and how to think about it. Psychoanalytic education should continue throughout one's life and practice, if only because the field of psychoanalysis continues to grow throughout an analyst's life.
An example of such ongoing growth is “implementation sciences,” the study of how to integrate research knowledge into ordinary health care and public health settings. It is a field in which Emde is increasingly engaged as a researcher and a consultant, particularly at the Centers for American Indian and Alaska Native Health located in Colorado. Implementation science involves community work for prevention and intervention in the health and developmental sciences. It used to be called applied or translational work. It explores new forms of treatment within the community. It recognizes we need “not only evidence-based practice but practice-based evidence—what really works in communities.”
Emde asserts that sometimes randomized control trials (RCTs) are like doing a clinical consultation and not being concerned about your patient's life outside the consulting room. “What really makes a difference is not so much whether you have a new intervention [for which you can] get randomized control evidence [but] finding out how it works in the community.” Even if an intervention works in one community up to RCT standards, all you've shown is
that it works in that particular community. “What good is that? Now there's this whole implementation sciences momentum: What works under what circumstances, how, and for whom, in what community. We need to involve the communities in our work. Now there's this whole sub discipline of community-based participatory research. I think analysts need to know about that and become more involved.” Research of this type, for example, is ongoing at the Sigmund Freud Institute in Frankfurt, particularly with the work of Marianne Luezinger-Bohleber. She calls it “psychoanalytic outreach research.”
(To be continued in the next issue of TAP.)