quinta-feira, 28 de julho de 2011

Intersubjectivity in psychoanalysis, Owen Renik

If we simply asked the question 'Is clinical psychoanalysis intersubjective?', I believe we would be hard pressed to find a psychoanalyst who would answer, definitively, 'No'. Most colleagues acknowledge, in principle, that intersubjectivity is a dimension of psychoanalytic events. However, crucial controversies arise when we begin to specify how, in practice, that acknowledgment is applied. What is the impact, if any, upon our psychoanalytic theories? What is the impact, if any, upon how we proceed in our work with patients?
An individual's subjectivity refers to the influence upon that individual's mental activity of his/her various personal, idiosyncratic assumptions, concerns and motivations-including those that arise from membership in particular cultures and subcultures. Psychoanalysts have always taken account of the fact that a patient's subjectivity is constantly being expressed within the clinical situation, mostly in ways of which the patient is unaware. On the other hand, it is only recently that we have begun to take account of the fact that the very same is true of an analyst within the clinical situation.
While psychoanalysts have long recognized the importance of countertransference, the concept itself and the way in which it is ordinarily used reflect a compromised understanding of the participation of an analyst's subjectivity in clinical events. Standard conceptions of clinical psychoanalytic technique direct the analyst to identify his/her own subjectivity and, as far as possible, minimize its influence in his/her analytic functioning. Clinical accounts regularly include descriptions of discrete instances in which countertransference is observed to influence an analyst's experience and activity. The assumption is made that outside these observed instances the analyst's experience and activity is at least relatively uninfluenced by countertransference. One hears references to the analyst's baseline working state, an experience of emotional balance, deviations from which signal to the analyst the presence of countertransference involvement.
From my point of view, this use of the concept of countertransference reflects a naive underestimation of the participation of an analyst's subjectivity in clinical work. Highly personal factors are constantly influencing an analyst's experience and activity, outside the analyst's conscious awareness. As analysts, we should be the first to realize that what we observe concerning our emotions while we do our clinical work is anything but a reliable indicator of the nature and extent of our actual affective involvement. An analyst's subjectivity cannot be effectively minimized, inasmuch as, at any moment of his/her analytic activity, the analyst cannot know to what degree and in what ways he/she is being influenced by unconscious, idiosyncratic elements of personality.
Certain longstanding, central principles within psychoanalytic theory, the principles of analytic abstinence and analytic neutrality, are predicated on the assumption that an analyst-by virtue of being well analyzed and well trained, by continuing with assiduous self-analytic efforts, by seeking consultation with colleagues when necessary, and the like-can minimize his/her countertransference expression and function relatively impersonally within the clinical setting. In other words, these principles rest upon a misunderstanding of the participation of an analyst's subjectivity in clinical analysis. If we fully acknowledge this participation, the principles of analytic abstinence and analytic neutrality are necessarily brought under critical review.
To accept that clinical psychoanalysis is intersubjective means to recognize that the clinical analytic encounter consists of an interaction between two subjectivities- the patient's and the analyst's-and that the understanding gained through clinical analytic investigation is a product of that interaction. Therefore, insights are always specific to the particular analytic couple that produces them. Insight is something co-created by analyst and patient as much as it is something discovered by analyst and patient. To differentiate co-creation from discovery in clinical psychoanalysis is to establish a specious distinction.
Of course, if clinical psychoanalysis has any therapeutic effect, it is because the insights produced through analytic work are applicable outside the clinical situation itself-that is to say, in a successful clinical analysis, what is learned about the patient's psychology and his/her participation in a relationship with a particular analyst has beneficial relevance in other situations, to other interpersonal relationships. There are no criteria internal to the clinical analytic setting which can be used to validly evaluate whether a therapeutic outcome is being achieved. In response to what an analyst hears, the analyst may offer pertinent impressions for the patient to consider, but judgments of therapeutic benefit are assessments that, ultimately, can only be made by the patient on the basis of his/her experience of life outside the treatment relationship.
Acknowledging the intersubjectivity of the clinical analytic encounter obliges us to redefine the nature of the analyst's expertise and authority. Since insights are co-created by analyst and patient, and are specific to the particular analytic couple that co-creates them, the analyst cannot be considered an expert on the patient's mind per se-an expert who can impersonally understand the patient's psychic life. The famous analogy in which the patient is compared to a naive railway passenger who faithfully describes passing scenery, and the analyst to a knowledgeable railway conductor who determines the train's geographic location, based on the passenger's reports, is no longer sustainable. *Conceptions of the analyst as a relatively objective expert observer fail to take full account of the analyst's subjectivity, and of the fact that the observed patient is, in effect, inextricable from the analyst-observer, the two comprising a single observational field. Thus, rather than being an expert on understanding the patient's psychic life, the analyst can be considered an expert on facilitating an intersubjective exchange which permits the patient to understand his/ her own psychic life. Instead of an authority who reveals hidden truths to the patient, the analyst is a partner who collaborates with the patient to create understanding concerning the way the patient constructs his/her reality, and who collaborates with the patient to revise those constructions so as to afford the patient less distress and more satisfaction in life. In a successful clinical analysis, co-created old truths are replaced with co-created new truths.
This view of the clinical analytic enterprise as an intersubjective encounter in which truths, old and new, are co-created is sometimes misunderstood to assert that objective reality does not exist. In fact, no such assertion is being made. What is asserted is the inescapable condition that reality, even if it is assumed to exist objectively, can only be known subjectively by analyst and patient; and, when the two come together within the clinical analytic situation to investigate the reality of the patient's psychic life, the investigation they conduct is an intersubjective one.
The vehicle for the investigation, of course, is the dialogue-spoken and unspoken, conscious and unconscious-that takes place between analyst and patient. The ground rules that are established for the dialogue will structure the intersubjective encounter that ensues and what it produces. Traditionally, clinical analytic ground rules have privileged the analyst's voice in the dialogue. Perhaps most importantly, this has happened because our theories of psychoanalytic process and technique have directed analysts to apply their clinical efforts toward the achievement of special, specifically psychoanalytic goals, formulated separately from therapeutic goals. ***In fact, analysts are warned against therapeutic zeal, which is understood to interfere with the pursuit of psychoanalytic goals. Specifically psychoanalytic goals necessarily derive from psychoanalytic theories. Therefore, when clinical work aims at specifically psychoanalytic goals, the analyst, who is an authority on psychoanalytic theory, is established as an authority on clinical progress and outcome.
A problem with privileging the analyst's voice in the dialogue and making the analyst an authority on progress and outcome is that it disposes to circularity in clinical investigation. The analyst's subjectivity dominates the intersubjective exchange and the co-creations produced by it. What comes to be understood reflects what the analyst assumed in advance. Obvious evidence of this is the fact that successful clinical analytic results around the world tend to differ predictably, according to the psychoanalytic subculture to which the analyst belongs: in one locale, a clinical analysis is understood to conclude successfully when the patient's primal scene fantasies are exposed; in another, when the patient moves beyond the paranoid-schizoid position; in yet another, when the patient successfully completes a separation-individuation process; and so on.
Acknowledging the intersubjectivity of clinical analytic work exposes the problem of circularity in clinical analysis and indicates the need to establish outcome criteria for clinical analysis that are independent of psychoanalytic theory. In my opinion, psychoanalytic purposes are best served by using the patient's experience of therapeutic benefit as the outcome criterion by which the success of clinical analytic work is judged. Obviously, a patient's self-evaluations and self-reports concerning therapeutic benefit will always be highly overdetermined. Nonetheless-whatever the inevitable role of compliance, opposition etc.-a patient's judgments of therapeutic benefit are based on observations made external to the treatment relationship and the clinical setting. This gives the possibility of constructing clinical analysis as an experimental situation, however imperfect. Psychoanalytic propositions can be tested by measuring a dependent variable: valid insights are ones that produce enduring therapeutic benefit; useful analytic techniques are ones that produce valid insights.
This approach to validation in psychoanalysis, which follows from acknowledging the intersubjective nature of the clinical analytic investigation, is often misconstrued to have a hermeneutic orientation because it legitimizes narratives, co-created by analyst and patient, as psychoanalytic propositions. On the contrary, it is a scientific approach. Science always deals in narratives, whether those narratives are competing versions of quantum mechanics in physics, or various psychodynamic formulations in a clinical psychoanalysis. What science requires is that the claims of differing narratives be adjudicated on a pragmatic, empirical basis-i.e. that an experimental situation be established in which narratives can be evaluated according to their ability to predict.
In hermeneutic disciplines, like literary criticism or political history, data do not permit use of prediction as a basis for validation of propositions. Other criteria must be used, aesthetic criteria such as elegance, coherence or rhetorical appeal. When specifically psychoanalytic goals are pursued in clinical analysis, circularity gets built in and aesthetic criteria are used to assess insights-i.e. explanations that analyst and patient find persuasive are held to be valid; validation of insights is not accomplished by testing predictions concerning an independent variable. Therefore, when specifically psychoanalytic goals are pursued, clinical analysis becomes a hermeneutic, rather than a scientific, enterprise.
Acknowledging that insights in clinical analysis are created intersubjectively also obliges us to critically review the principle of analytic anonymity. The technical guideline that an analyst should try, as far as possible, to avoid personal self-disclosure follows from the understanding that clinical psychoanalysis is a project in which the patient is given the opportunity to project psychic representations on to the figure of the analyst, so that the analyst can objectively observe the projections. The analyst's efforts to remain anonymous are intended to safeguard the patient's opportunity for projection and the clarity of the analyst's field of observation. (If certain conceptions of projective identification are applied, the analyst will feel able to observe projected elements of the patient's psychology represented within the analyst's own responses. However, in discussing his/her responses with the patient, the analyst makes interpretations to the patient about the patient's psychology, rather than engaging in personal self-disclosure.) Once we recognize that analytic truths are co-created by analyst and patient, rather than unveiled by means of the analyst's objective observations of the patient's projections, the rationale for the analyst trying to minimize personal self-disclosure becomes obsolete. Quite the contrary, in order to facilitate intersubjective exchange in the clinical situation, the analyst must be willing to make his/her own relevant experience as fully available to the patient as possible.



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