Several authors have written eloquently about the need for further empirical research on psychoanalysis and psychoanalytic concepts (Kernberg, 2006; Wallerstein, 2009; Hauser, 2002; Bucci, 2001; Holzman and Aronson, 1992). The call for empirical studies that directly evaluate psychoanalysis as a clinical treatment has perhaps received the most attention, and indeed an increasing number of studies are available supporting the collective suspicion that psychoanalysis does, in fact, “work” (see, for example, the CORE Research Bibliography, available through the APsaA website). While clinical research remains important, on a more basic level there remains an ongoing need to more clearly define the potential underlying mechanisms of change relevant to psychoanalysis and to refine our understanding of basic psychoanalytic concepts.
The markers of health and recovery most frequently attended to in psychoanalytic treatment do not merely include reductions in symptom severity, but rather encompass broader signs of deep and meaningful psychic change—for example, the development of more mature defensive functioning, greater awareness of previously inaccessible or unconscious emotional experience, or an increase in complexity of thought and interpersonal understanding. Changes in these domains are typically viewed as contributing to improvements in overall psychic functioning, but our ability to evaluate these complex internal processes from an empirical standpoint represents an ongoing challenge. While many psychotherapy researchers have evaluated the beneficial impact of treatment in various ways, including by self-report (e.g., a reduction in self-reported depressive symptoms) or behavior monitoring (e.g., reduced utilization of hospital emergency services), evaluating changes in psychic complexity or other forms of internal maturity and growth is a more subtle and difficult task. Important questions remain about the basic cognitive and affective processes that influence health and psychopathology, and it is essential that psychoanalytic researchers continue to work toward developing a clear understanding of how different psychoanalytic concepts influence symptom manifestation and behavior in daily life, using rigorous empirical designs and multimethod assessment.
Empirical research on psychoanalytic concepts has in recent decades become more open to the use of innovative methodological approaches as a means of studying complex clinical phenomena, typically with positive effect. The empirical study of attachment, for example, benefited enormously from the use of laboratory-based observation paradigms such as the Strange Situation (Ainsworth and Wittig, 1969), as well as more recent studies identifying neural and physiological markers associated with secure versus insecure attachment styles (e.g., Gander and Buchheim, 2015). Susan Andersen’s social cognitive approach to the study of transference, which utilizes innovative experimental techniques adapted in part from the field of social psychology and cognitive science, similarly has aided in the discovery of a wealth of information about the influence of past relational experiences on new interpersonal situations (Andersen and Przybylinski, 2012). Each of these methodological approaches has demonstrated how difficulties in functioning that emerge in daily interpersonal experiences, including interactions occurring in the context of a therapeutic interaction, may
be elicited and examined in research settings to allow for a more precise and controlled examination of features such as sequence (how the construct of interest emerges and recedes), context (the conditions under which the construct is likely to be elicited), and temporal stability. The study of psychoanalytic concepts related to unconscious intrapsychic processes and interpersonal patterns requires psychoanalytic researchers to move away from a reliance on cross-sectional and self-report-based study designs, and instead embrace more complex and creative mixed-methodological approaches (Tillman, Clemence and Stevens, 2011).
For example, social scientists for decades have utilized instruments such as the implicit association test (IAT), (Greenwald, McGhee and Schwartz, 1998) or the affective misattribution procedure (AMP), Payne, Cheng, Govorun and Stewart, 2005) to examine unconscious attitudes about social, cultural and interpersonal phenomena. Recently, IAT methods specifically have been applied to the study of clinical phenomena including suicide and self-harming behaviors, with results showing that the strength of implicit identifications between sense of self and suicide is one of the most robust predictors of future suicide attempts currently known (Nock, Park, Finn, Deliberto, Dour and Banaji, 2010). While this association has been described as a “behavioral biomarker for suicide,” it also resonates with psychoanalytic formulations of suicide that implicate pathological identification as an underlying factor in the development of self-destructive thoughts and behaviors (Freud, 1917; Litman, 1996/1970); despite these connections, methods such as the IAT have rarely been used in psychoanalytic research to date. The field of psychoanalysis would benefit tremendously from increasing utilization of these and similar measures to test hypotheses related to the unconscious and psychoanalytic models of the mind.
The use of mobile technology in intensive repeated measures designs (e.g., daily diary studies) has enabled researchers in the past two decades to collect information about an individual’s momentary experiences over the course of everyday life. These “micro-longitudinal” studies have been used to examine the interpersonal and intrapsychic factors in daily life that contribute to the development of self-injurious behavior (Nock, Prinstein and Sterba, 2009), the effective management of temptation and conflict (Hofmann, Vohs and Baumeister, 2012), rejection sensitivity and daily interpersonal functioning (Meehan, Cain, Roche, Clarkin and De Panfilis, 2018), and subjective experiences of psychopathological symptoms (Tilley and Rees, 2014). Hofmann and colleagues , for example, asked participants to respond to a series of prompts administered via Blackberry over the course of one week about daily experiences of temptation, conflict, and coping or distraction strategies. Participant responses illustrated the cumulative impact of daily conflict on ability to resist temptation across multiple domains, providing detailed insight on the influence of context on daily patterns of experience that would have been difficult if not impossible to reconstruct using a cross-sectional design or other methods that relied solely on participant recall.
There are many areas of exciting potential focus for psychoanalytic researchers that have not thus far been closely studied by other related fields or disciplines. The study of dissociation, for example, has not been examined systematically in real time and represents one opportunity for the creative translation of current psychoanalytic scholarship and theory into new and innovative assessment paradigms. The momentary use of defense mechanisms in daily life similarly remains largely unexplored from an empirical standpoint, and the development of a method for studying defenses in real time (though obviously a challenge) would be a significant contribution to psychoanalytic science. Continuing to develop a better understanding of how psychoanalytic concepts operate and influence mental experiences in daily life remains an essential task for the field.
New initiatives within the field of medicine have focused on integrating the insights and opinions of patients into the design and implementation of treatment research. These efforts have typically taken one of two points of focus: the first, emphasizing patient’s subjective experience of treatment impact and outcome, broadly termed “patient-reported outcomes” research (PROs), and the second, focusing on patient involvement in the actual design and implementation of empirical studies.
Patient-related outcomes research is broadly aimed at evaluating treatment efficacy through an examination of patients’ descriptions of perceived benefit or change in functioning after receiving a specific treatment (Alemayehu and Cappelleri, 2012). Rather than evaluating efficacy based on researcher-defined outcome variables, PROs research adopts a largely hypothesis-generating, not a hypothesis-confirming, approach, thus illuminating those factors related to health and wellness of greatest salience to individual patients. Incorporating PROs into the study of psychoanalytic treatment may help to expand and deepen our knowledge of treatment impact and benefit, allowing a more nuanced understanding of the meaningful changes in functioning patients’ experiences during and after treatment that may otherwise be difficult to formulate or measure.
In addition to PROs studies, research on psychoanalysis as a treatment may benefit from including patients as active voices in the planning and design process. Such programs have been implemented systematically in the United Kingdom for years, with positive effect (e.g., INVOLVE, 2012). For example, a recent study conducted in Scotland evaluated an
at-home telemonitoring program of blood pressure for individuals who had experienced a stroke or transient ischemic attack. Researchers utilized a consultative/advisory approach in which patients with a history of stroke (who were not participants in the study) provided recommendations to researchers regarding the development of recruitment and study materials, and assisted with the crafting of a qualitative research interview (Fairbrother et al, 2013). The researchers in this study noted the tremendous value and benefit of using a consultative approach with patients prior to the full implementation of their study, despite practical challenges such as managing role boundaries and establishing an effective working alliance with the patient consultant group (both issues that psychoanalytically-informed researchers would be particularly adept at managing). Inviting current or former psychoanalytic patients to serve as research consultants and provide their recommendations for areas of focus in psychoanalytic research may similarly prove helpful in identifying ideas for new research directions and areas of empirical focus.
The argument is often made that clinicians must develop and maintain an understanding of empirical research in order to be able to critically evaluate new evidence, make informed treatment choices and remain up-to-date on contemporary scholarship in the field. The reverse argument must also be emphasized: There is an essential need for clinicians to remain not just aware, but actively involved in research to ensure empirical studies remain relevant to the daily lives and experiences of patients and practitioners. The new methodologies and approaches described here demonstrate the many ways psychoanalytic clinicians and researchers may extend knowledge acquired in the consultation room into the empirical study of daily life and interpersonal functioning, either by encouraging patients to participate in the study design process and/or designing multimethod studies that allow participants to describe their thoughts, feelings and experiences in both direct and indirect ways over the course of their everyday lives. The deep knowledge possessed by psychoanalysts of how individuals change and develop over time is an essential asset in research efforts to forge new pathways in the field of empirical clinical research and design.
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