Therapeutic action, epistemology, and the ethic of psychoanalysis

International Journal of Applied Psychoanalytic Studies2(3): 220–235 (2005)DOI: 10. 1002/aps.11

Copyright © 2005 John Wiley & Sons, Ltd 2: 220–235 (2005)

Therapeutic Action, Epistemology,and the Ethic of Psychoanalysis

FRANK SUMMERS

ABSTRACT

It is contended that changes in the theory of psychoanalytic technique resulting in therecognition that interpretation is insufficient and the analytic relationship plays a signif-icant mutative role have far-reaching implications that have yet to be sufficientlyappreciated. The theoretical changes undergone by two prominent analysts, HeinzKohut and Herbert Rosenfeld, are used to illustrate the importance of shifting therelationship between theory and practice so that the patient’s experience is given primacy.Although theoretically psychoanalytic technique has given importance to listening closelyto the patient’s material, in fact this technical principle has always conflicted with theassumption of presumed analytic knowledge of the patient’s psychopathology. Theemerging technical stance undercuts the objectivist epistemological position that has longdominated psychoanalysis in favor of a hermeneutic model of psychoanalytic under-standing. While it is recognized that theory is essential to the analytic process, the thesis isthat psychoanalytic praxis must be informed by the patient’s experience and thereforerequires a psychoanalytic ethic of not knowing, thus reversing the objectivist epistemo-logical stance. Copyright © 2005 John Wiley & Sons, Ltd.

Key words: epistemology, ethic, therapeutic action

INTRODUCTION

This is an era of not only a plurality of psychoanalytic theories, but also aquestioning of virtually every assumption of the theory and practice. In themidst of this depth of questioning, it seems a daunting task to argue for aparticular psychoanalytic ethic. Nonetheless, it is necessary because without anethic there is a very real question of what makes any particular therapy psycho-analytic. Without an answer to this question, psychoanalytic treatment is indanger of losing its identity as a unique form of human healing. This paper is aneffort to take a step back from the heat of the debate among competing psycho-analytic ideas to reflect on what now constitutes an ethic for the practice ofcontemporary psychoanalysis. While “ethic” may seem a strange term to use for

IJAP 2.3 crc 10/3/05 2:22 PM Page 220

a model of how to conduct a psychoanalytic therapy, perhaps the term will bemore understandable if we consider the way I mean “ethic.”

Philosophers distinguish three types of ethics (Brand, 1961). An ethicalproposition can address the issue of: (1) what is morally right or wrong; (2) whois blameworthy; or (3) what is desirable. The first two encompass the issuesmost commonly thought of as ethical dilemmas in psychoanalytic practice,such as boundary violations. But, the third question, what is the desirablebehavior of the analyst, is a broader notion that defines the analyst’s code ofconduct. As the principles for what the analyst ought to do to, the desirable isthe guide for therapeutic praxis. What the analyst uses to steer herself throughthe patient’s world will be intimately linked to her model of therapeutic action.

A HISTORY OF THE DESIRABLE IN PSYCHOANALYSIS

Freud’s ethic was outlined as early as his first psychoanalytic publication,‘Psychotherapy of Hysteria’ (Freud, 1895), in the last chapter of which, heoutlined a clinical strategy for removing hysterical symptoms by making uncon-scious memories conscious. Given his view that symptoms are the disguisedexpression of repressed memories, Freud believed that the key to their removal layin making conscious this psychical material. He advocated use of any techniquethat would render the repressed conscious, such as becoming the “fatherconfessor” or “tricking the patient’s ego” by catching it unawares. Whateverbrought forth the repressed was valid technique because topographic shifts wereregarded as the essence of therapeutic change. The original psychoanalytic ethic,then, was a code of conduct built on the cardinal virtue of making the uncon-scious conscious. How the memories became conscious was immaterial. While ashift occurred in the theory of psychopathology when Freud abandoned theseduction theory in favor of the view that repressed wishes and fantasies cancause neurotic symptoms, this change did not have a fundamental impact on thetechnique of doing whatever helps to uncover the pathogenic material. Thedifference lay only in the nature of the “pathogenic nucleus.”

Freud was able to adopt this strategy because he had a definite view of theorigins of neurosis. Nevertheless, despite his certainty of the causes ofpathology, he did not believe a patient could simply be told that an uncon-scious wish lay at the core of his symptoms. He insisted that the patient’sassociations must be elaborated and heard by the analyst before the pathogenicnucleus could be uncovered in a useful way. The affect of the repressed contenthad to be made conscious, and this topographic shift could occur only if therepressed material could come to light in the free associational process. Itappears, then, that Freud’s technique was based on two competing ideas: on theone hand, the cause of the neurosis was predetermined, but, on the other, thefree associational process must take place to reveal the repressed material.These opposing positions have often been defended on the ground that freeassociation is required to bring out the affective element of the neurotic

Therapeutic Action, Epistemology, and the Ethic of Psychoanalysis 221


IJAP 2.3 crc 10/3/05 2:22 PM Page 221

conflict. Nonetheless, these two principles of therapeutic action conflictbecause the theory contains a definitive belief in the causes before theevolution of the process, but psychoanalytic technique maintains that thepatient’s associations determine the analyst’s understanding. This conflictmarks the beginning of a tension that has permeated not only the history ofpsychoanalytic technique, but also the theory of therapeutic action and theethic of the field. Although individual analysts have tended to emphasize oneside or the other of the dilemma, I believe it is fair to say that when the Oedipaltheory of the neurosis was the dominant theory of psychopathology, the weightof psychoanalytic technique was on the side of the knowledge of causes morethan openness to the flow of the material.

A significant technical modification occurred when Freud clarified that hehad learned from working with patients that the analyst could not make theattempt to bring a pathogenic event into the picture, but rather “contentshimself with studying whatever is present for the time being on the surface ofthe patient’s mind, and he employs the art of interpretation mainly for thepurpose of recognizing the resistances” (Freud, 1914, p.147). Although thisshift to defense interpretation is commonly attributed to the inclusion of thestructural model in psychoanalytic theory, the fact is that Freud’s (1923) super-imposition of the id-ego-superego on the topographic model gave theoreticalcodification to a technical change that had been going on for at least nine years(Freud, 1914).

This fact demonstrates that the technical emphasis on interpreting defenseswas not just theoretically driven, but a necessity that evolved from encountersin the consulting room. The analyst could not afford to overlook surfacematerial not because it might be a symbolic representation of the repressed, butbecause it might contain defenses that must be analyzed. Shifting focus to theanalytic surface meant that the analyst could not ignore any aspect of thepresenting material or to attempt to circumnavigate it with an extra-inter-pretive intervention without violating the new psychoanalytic code of conduct.After the introduction of the structural theory, Anna Freud (1936) took thenext major step by making ego analysis one-half of analytic technique. N o t ethat the alteration in technical strategy lay in the content of the interpretation,not the role of interpretation as the mechanism of therapeutic action, aprinciple that remained unquestioned.

However, many analysts found that interpreting defenses and the analyticsurface, however useful it seemed to be in bringing the patients’ characterpatterns to light, all too frequently did not change them. Many theorists whobecame disenchanted with the results of the classical model began to emphasizethe importance of the analytic relationship. Object relations theorists in theUnited Kingdom, such as Fairbairn, Winnicott, Guntrip, and Balint, allexpressed doubts that interpretation was sufficient for many cases they regardedas analytically accessible once the model was modified to include extra-inter-pretive interventions. Beyond these severely disturbed cases, these theorists

222 Summers


IJAP 2.3 crc 10/3/05 2:22 PM Page 222

found from their clinical work that conflict, being ubiquitous, only becomessymptomatic if there is a deficiency in the self ’s ability to manage tensionstates. Concluding that all patients’ problems are rooted to some degree in anarrest of emotional development, they proposed that a new object relationshipis at least a component of the therapeutic action in any good analytic outcome.

On this side of the Atlantic Ocean, Kohut (1984) and subsequent self-psychologists reached a remarkably similar conclusion: that a defect in the self,owing to faulty early self–self-object relationships, is at the root of all diffi-culties in functioning. Additionally, theorists from the relational school haveproposed, on a different theoretical basis, that the nature of the analytic inter-action plays a decisive role in therapeutic change (Mitchell, 1988; Aron,1996). From the viewpoint of relational analysis, the more radical self-psychol-ogists, and many object relations analysts, including some Kleinians, aninterpretation is one aspect of the analytic relationship and holds no privilegedplace. For other object relations analysts and more conservatively inclined self-psychologists and Kleinians, interpretation is still given pride of place, butother factors in the relationship are accorded a prominent role in the changeprocess. The decisive shift here is to the analyst’s sensitivity to the relationshipas not simply an alliance building maneuver, but a significant mutative factor.

What I wish to highlight here is that there is no reason to bring therelationship into the therapeutic action if the cause of the neurosis is repressionof wishes. Once the emotional exchange between patient and analyst isregarded as a component of the change process, the theory of the repressedpathogenic nucleus has been relieved of its central role, however implicitly.Conversely, if the relationship matters, the analyst is operating on the principlethat parts of the patient must be articulated and brought to fruition through theanalytic relationship.

I believe we have not yet fully appreciated the implications of this changeand the analytic sensitivity to which it leads. I will now consider in some detailthe journeys of two eminent analysts to demonstrate the depth and breath ofchange in technical strategy implied in giving a significant role to the analyticrelationship. I choose the paths traversed by two analysts from widely differingtheoretical traditions and geographic locations probably without awareness ofeach other’s work who underwent remarkably similar and instructive analytictransformations.

TALES OF ANALYTIC TRANSFORMATION

Kohut’s case of Miss F was pivotal to the evolution of his thought; indeed, thiscase is often credited with providing the impetus for his shift to self-psychology(Ornstein, 1978). Because she associated and reflected on her associations,Kohut thought his patient capable of a great deal of self-analysis. When hesummarized her material, she was gratified and enjoyed the analysis. However,Kohut noticed that when he was either silent or went beyond her associations,



IJAP 2.3 crc 10/3/05 2:22 PM Page 223

she felt disrupted, became angry at Kohut, and accused him of ruining theanalysis. Based on these reactions, Kohut concluded that what appeared to beself-analysis hid the patient’s need for approval and confirmation of hergrandiosity and that she regarded him not as a separate person, but a function.For a period, he struggled with the patient’s disruptions, regarding them as aresistance, but he eventually realized that her demands constituted a mirrortransference. Most significant for our purpose, he ultimately came to what heregarded as his most important discovery in the case: that her effort to use theanalyst to meet her narcissistic needs was not a resistance, but the mobilizationof her childhood grandiosity in an effort to integrate it with the rest of herpersonality. Rather than insisting on interpreting this need against the patient’sresistance, Kohut decided that Miss F’s demands were a positive effort to moveforward. It was at this point that the treatment finally began to make the properprogress. Kohut’s recognition and appreciation of what Miss F was trying toaccomplish was not an alliance building preparatory to therapeutic action, butan important component of the therapeutic action itself.

Initially Kohut conceptualized the transformation of his analytic stance as“indulging a childhood wish” which he thought, albeit ambivalently, had to bedone in some cases. Eventually, he changed his language to the recognition andappreciation of the patient’s perspective even if it disagreed with his interpreta-tions. Beginning with his change during the treatment of Miss F, the purpose ofpsychoanalysis for Kohut was not uncovering meaning as much as promotingself-development, a process that can be facilitated by seeing the patient’ssubjective experiences and registering them within the psyche of the analyst.Seeing and hearing the patient had become key components of his theory ofthe change process. This transformation of analytic strategy became a corecomponent of his later self psychology in which Kohut (1984) reconceptualizeddefenses and “resistances” as the “forward edge of development.”

We are bearing witness here to Kohut’s rearranging of his psychoanalytic valuesystem. The greatest importance is given to the unblocking and facilitation ofstrangulated development; whatever promotes that goal becomes a part of thetherapeutic strategy. Once the aim of the process became self-development, inter-pretation no longer held its unquestioned place of supremacy in the model oftherapeutic action. Recognition of the patient’s viewpoint is often more likely tostimulate the growth of the self than uncovering deeper levels of meaning. Whichintervention was chosen at any given point became a decision based on thejudgment of what was needed to facilitate the realization of arrested aspects of theself. In opposition to what he called the “truth morality” of classical technique,Kohut believed that the patient often needs an appreciation of her strivings tomove forward more than awareness of the unconscious meaning of the effort.

This shift to listening to the voice of the patient was also instrumental in thetransformation of another major analytic figure, Herbert Rosenfeld, who workedwithin the Kleinian tradition. A devoted follower of Melanie Klein, Rosenfeld(1987) underwent a remarkably similar clinical transformation to that of Kohut,

224 Summers


IJAP 2.3 crc 10/3/05 2:22 PM Page 224

based on his work with psychotic and borderline patients. A pivotal event in theevolution of his technical approach occurred two and one-half years into thetreatment of a multiply traumatized borderline patient, when the man becamehostile to Rosenfeld and attacked his analyst for being critical of him. Theincreasingly vicious attacks made Rosenfeld feel like a helpless child filled withfutile rage. These vituperative verbal assaults led to a therapeutic stalemate andthe patient finally decided to terminate his analysis within two weeks. At thispoint, Rosenfeld made a decision to ask the patient to sit up and go over all hiscriticisms of Rosenfeld’s work. Rather than offering interpretations as usual,Rosenfeld chose not to interpret, but instead, “adopted an entirely receptive,empathic, listening attitude to him” (Rosenfeld, 1987, p. 219). The patientdecided to stay. This moment represents the type of clinical encounter that ledRosenfeld (1987) to conclude, “It is clear that the borderline patient requiresfrom the analyst complete openness and receptiveness; for in this area of theprimitive object relationship the borderline patient suffered his main trauma”(Rosenfeld, 1987, p. 221). For this reason, Rosenfeld changed his clinicaltechnique from the singular emphasis on interpretation of the traditionalKleinian school to holding the patient’s projective identifications for a sustainedperiod. Indeed, he suggested that the analytic relationship must replicate a goodmother–infant relationship so that the patient feels held. Rosenfeld eventuallywent so far as to suggest that the beneficial effect of interpretations can often beattributed to their ability to gratify and soothe, an effect similar to physicalholding. With psychotic patients, Rosenfeld proposed that the patient’s needsmust be satisfied by the analyst’s behavior rather than verbal interpretations.While some may find these technical recommendations unexceptional forseverely disturbed patients, in the Kleinian tradition of Rosenfeld’s time, thesesuggestions were apostasy. Moreover, Rosenfeld departed even further fromclassical Kleinians by proposing tact, sensitivity, and empathy as significantfactors in the treatment of all patients.

In the case under discussion, Rosenfeld conceptualized his receptiveness tothe patient’s complaints as holding the bad parts of the self the patient hadprojected into him. He advocated taking in the projections and pursuing theinterpretation only when the timing was appropriate. Warning that interpreta-tions can be harmful if done with improper timing and tact, Rosenfeld believedthe treatment ultimately hinged on the analyst’s openness and sensitivity. OtherKleinians, such as Bion (1957), also emphasized the importance of holding thepatient’s projections as a necessary component of the therapeutic action withcharacterologically disordered patients. For Rosenfeld, the emphasis on themutative value of the relationship and the therapist’s nonverbal behavior repre-sents a decisive transformation of Kleinian technique from the strictinterpretation only strategy advocated by its founder to the inclusion of asensitive, open relationship as a crucial element of therapeutic action.

Both Kohut and Rosenfeld not only saw the patient’s viewpoint, but alsoadapted to it by shifting their therapeutic approaches so that the patient



IJAP 2.3 crc 10/3/05 2:22 PM Page 225

experienced an analyst who was willing to relinquish his clinical strategy infavor of the patient’s perspective. It is remarkable that this willingness of theanalyst to abandon a formulation in favor of adapting to the patient’s viewpointis rarely accorded a role in therapeutic change. Nonetheless, what these twootherwise diverse clinical moments have in common is the analyst’s transfor-mation in response to the patient’s dissatisfaction. It seems likely that themutative effect in both cases can be attributed at least in part to the patient’shaving had an impact on the analyst’s technique. Miss F began to show signif-icant therapeutic movement and Rosenfeld’s patient decided to stay after theiranalysts no longer persisted in an interpretive stance against which they had tofight, but made an attitudinal transformation in response to the patient’snegative reactions. The patient had a significant influence on the analyst’sbehavior, and thus, a major effect on the shape of the analytic relationship.

Whenever I have shifted my formulations or ideas in response to thepatient’s overt objections or changes in the analytic material, the patient’sexperience of having influenced my technique has given her both a sense ofeffectiveness and new confidence in her ability to create a needed relationship.Absorbing interventions, no matter what their veracity, puts the patient in apassive position from which he does not create alternatives to pathologicalpatterns. That is why compliance with the analyst’s ideas is rarely effective.From decades of interpreting patient’s behavior, we have learned thatmeaningful and lasting change comes about when the patient creates her ownmeaning from the analyst’s offerings (Summers, 2001). The uniquely psychoan-alytic stance is to abet the patient’s ability to create her own meaning andultimately her life; the analyst’s ideas matter only if they help the patientaccomplish this task.

We now appear to have a theory of therapeutic action in direct oppositionto the early model of technique with which we began this discussion. Fromcircumventing defenses in order to find the pathogenic nucleus, the analyst isnow willing to yield his perspective in order to adjust to the patient’s subjec-tivity and promote its expansion. However implicitly, any analyst willing tochange his therapeutic strategy to accommodate the patient’s experience of thetreatment is operating not just with a different theory, or a more flexibletheoretical approach, but with a different ethic. Indeed, the evidence suggeststhat neither Rosenfeld nor Kohut at the time of the treatment saw the implica-tions of the changes they were making. Both theorists understood the conflictswith their patients according to an amended theory of psychopathology. Kohutinsisted that Miss F’s demands were her grandiosity, and Rosenfeld conceptu-alized his patient’s attacks as the projective identification of his aggression.However, one wonders: If Miss F’s demands were grandiose and the borderlinepatient’s hostility was a defense, rather than being accommodated, why wereboth pathological constructions not interpreted and worked through?Rosenfeld and Kohut were trying to have it both ways by advocating anadjustment to recognizing the positive value of the patient’s expression of needs

226 Summers


IJAP 2.3 crc 10/3/05 2:22 PM Page 226

while they called these needs pathological and defensive. In both these pivotalclinical moments, the analysis became effective when the analysts treated thepatients’ complaints not as grandiose or defensive, but as valid communicationsfrom people whose needs were not being met. Unlike Rosenfeld, Kohut (1984),in his last work, did seem to conclude that the implications of his sensitivity toand appreciation of the patient’s forward movement implied that demands,such as those expressed by Miss F, were not pathological, but normal needs forthe responsiveness required for growth.

To recognize the patient’s objections to the analyst’s behavior as a striving forprogress is to adopt a psychoanalytic ethic in which the patient’s experience isattended to as the highest value. This code of conduct is a reversal of the ethicFreud adopted when he believed therapeutic action lay in making conscious thepathogenic nucleus. In both the Kohut and Rosenfeld situations, in order toovercome a therapeutic impasse the analyst not only questioned his ownapproach, but also learned from the patient. As can be seen from these examples,the concept of learning from the patient advanced by Casement (1962) is gainingcurrency in the consulting room even by those who might not use the phrase.

The analytic transformations of Kohut and Rosenfeld are two prototypicalexamples of the evolution undergone by many individual analysts and the fieldas a whole. Not only is the analytic relationship accorded a major role in thera-peutic action, but also the purpose of the process is to facilitateself-development, a goal that requires guidance from the patient’s experience.Object relations theorists, including many Kleinians, later self-psychologists,and relational analysts, and even contemporary structural theorists, all operateon the basis of forming an analytic relationship designed to realize buriedaspects of the self.

THE RELATIONSHIP BETWEEN THEORY AND PRACTICE

This type of change in analytic attitude has profound implications for the roleof theory in psychoanalytic praxis. Both Kohut and Rosenfeld had foundthemselves imposing a theoretical understanding that did not fit theanalysand’s experience, a stance that put the patient in the position of choosingbetween agreeing with an interpretation that did not correspond to hisexperience or coming into conflict with his analyst. As Winnicott (1960) hasnoted, agreement with an interpretation that the patient does not feel iscompliance. From the viewpoint of a theory of pathogenesis, compliance is nota major problem because the transforming event is the topographic shift.Analysts who view pathology in this way are not reluctant to utilize theauthority of the analyst, as Freud did, to induce acceptance of an interpretation.However, if psychopathology has to do with blocked emotional development,compliance colludes with the patient’s pathology by opposing the realization ofauthentic experience. As Winnicott and many other analysts have found out,getting the patient to concur with our understanding without experiencing the



IJAP 2.3 crc 10/3/05 2:22 PM Page 227

proffered interpretive remarks is of no value. While this principle may seem tobe widely accepted, the reality is that some analytic concepts and behavior arenot guided by our avowed belief that the patient must experience an interpre-tation if it is to be effective. Labeling a patient’s behavior “resistance” that mustbe overcome or invoking analytic authority both depart from this principle. Ifwe are to remain true to our conviction that the ultimate test of the value ofour input is the patient’s experience and ability to create new meaning from it,then fealty to the patient’s experience is the overriding principle of therapeuticaction. And commitment to being guided by the patient’s viewpoint meansavoiding the temptation to invoke resistance or authority in favor of choosingthe patient’s experience when it conflicts with the analyst’s understanding.

As both Kohut and Rosenfeld discovered, if theory is applied in a preconcep-tualized way, it interferes with the patient’s access to her experience. The analystlooks for signs in the analytic material to confirm the presumed explanation. Wemight call this the reification of psychoanalytic theory. Although no analystwould acknowledge operating in this fashion, we have witnessed thisphenomenon with virtually every analytic theory of pathology, including theOedipal theory of neurosis, the concepts of splitting and projective identifi-cation in Kleinian thought, and the narcissistic formulations of self-psychology.Although these concepts are valuable contributions to the field, they are misap-plied when accorded the status of an explanatory principle across patients andsituations. Although we may believe theoretically in the importance of thepatient’s experience, the fact is that when theories are reified, the patient’spathology is explained before he walks into the office. The patient’s subjectivitythen can only be ignored or used as confirmation of the preexisting explanation.

The effort to avoid the reification of theory undoubtedly motivated Bion’s(1962) admonition to approach every session without memory or desire. WhileI applaud the spirit of removing theoretical barriers between the patient’sexpressions and the analyst’s understanding, we must also recognize that Bion’sdictum is ultimately an impossibility. As Gadamer (1988) has shown, prejudg-ments lie at the very core of our being. No experience can exist without ahorizon, a context within which it occurs. It would be a bizarre and torturedstate of both dissociation and repression to attempt to erase memory and desirefrom our being, even for one hour. Nonetheless, I believe Bion captured animportant element of the psychoanalytic spirit with his overstated dictum. Hewas telling us that we should make every effort to resist theoretical impositionin order to encounter the patient’s experience as directly as possible. WhenKohut and Rosenfeld were able to bracket their theoretical certainty in order tohear the patient’s speech in a fresh way, they made contact with deeper levels oftheir patients’ experience. And reaching the patient’s buried experience is whatthe analytic process is about.

Analysts, of course, will commonly say that even though they have a theory,such as the Oedipal origins of neurosis or self-object failures as the cause ofnarcissistic disturbances, they wait until the patient’s material emerges because

228 Summers


IJAP 2.3 crc 10/3/05 2:22 PM Page 228

without affect the understanding has no impact. Such constraint is motivatedby the timing of conveying presumed knowledge, whereas it is this verypresumption that is at issue here, not its timing. If an explanation is precon-ceived, then the analyst can only be listening for confirmation of what isalready believed.

Both Kohut and Rosenfeld found a new theory that could explain theirconflicts with their patients, but neither seemed to recognize that such a theorycould become an imposition to which the next patient might object. Thepregnant revolutionary implications of the changes made by Rosenfeld andKohut, and similar shifts in analytic theorists such as Fairbairn, Winnicott, andBalint, all of whom had clinical experiences that forced transformations intheir technical stance, is that the analyst may not have a theory that wouldapply to the patient, at least in a way that fits the details of the patient’s life.The analyst may have to adapt to the emergence of the patient’s properties andself-expressions. The importance of the analyst’s responding to the patient’sexperience is recognized, in theory, in every psychoanalytic school of thought.Even in present day ego psychology, often referred to as “contemporary struc-tural analysis,” a cardinal principle is to avoid telling the patient what hisunconscious is saying in favor of questioning the indications of anxiety anddefense as they manifest themselves in the analytic encounter (Gray, 1990;Busch, 1995). Such an open-ended attitude, it seems to me, is an emergingclinical stance not only because there are a multitude of analytic theoriescurrently competing for the center of the analytic stage, but also because of thegrowing recognition that theory cannot be held as an expectation into whichthe patient must fit. The new psychoanalytic ethic gives priority to the patient’sexperience over theory in an effort to limit the interference of theory onexperience. The ethic implied in the technical recommendations of Kohut andRosenfeld, along with many others, means that theoretical understanding tendsto evolve along with the analyst’s experience of the patient, that is to say, as helearns from the patient. This therapeutic attitude virtually turns the originalpsychoanalytic posture on its head. This marked shift in perspective does notmean that theory has no role in current practice. It is a truism among practi-tioners that one cannot practice without theory because the analyst needs someway to organize the clinical material. The resolution of the problem oftheoretical preconception is not to eliminate theory, which is an impossibility,but to redeploy it. The analyst’s conceptual representation of the patient’smaterial will inevitably have an impact on what is heard, but if the analyst isgoing to remain consistently responsive to the patient’s experience, the latter’sperspective must have an influence on the analyst’s theoretical understandingas well. If the analyst cannot hear the material without theory, it is equally truethat the theory must be created from the patient’s material. There is then adialectical relationship between clinical evidence and the theoretical principleswith which the patient’s experience is understood.

To make the classical posture work the analyst had to be certain that the



IJAP 2.3 crc 10/3/05 2:22 PM Page 229

patient’s unconscious contained a pathogenic nucleus at the core, thus therelevance of Freud’s archeological metaphor. If the analyst is now willing toforego his views to adjust to the patient, does this openness not suggest alessened confidence in what he knows and the inapplicability of the archeo-logical metaphor? The evolution of technique to a posture of adaptation to thepatient’s experience suggests that the analyst’s self-questioning has becomecentral to the therapeutic endeavor. The issue of what the analyst can claim toknow brings us into the treacherous territory of psychoanalytic epistemology.

THE EPISTEMOLOGICAL DILEMMA OF PSYCHOANALYSIS

When Freud discovered that he could remove hysterical symptoms by makingconscious unconscious wishes, he believed that he was uncovering theobjective reality of the patient’s psyche. This certitude represented the side ofFreud that saw psychoanalysis as a natural science based on observation ofnature. The patient’s free associations, dreams, and transference perceptions allreflected the reality of the patient’s psyche that had to be read by the analyst.The next generation of analysts tended to adopt this objectivist epistemology,and while its hold on the self-understanding of psychoanalysts has waned inrecent years, a group of analysts have maintained this view to the present(Bachrach, 1989; Rubenstein, 1976, 1980). However, a growing number ofanalytic theorists have questioned the applicability of objectivism to theanalytic process. Briefly, there are two major thrusts to this criticism. BothSchafer (1983, 1992) and Spence (1982, 1993) have argued that there is nosingle compelling interpretation of analytic material. The patient’s associationscan always be looked at from a variety of perspectives, each of which can bejustified by the evidence. Spence has gone further than Schafer in contendingthat all analytic interpretations are inevitably flawed because the analyst usesthe “haze of his own experience” to fill in missing gaps in the patient’s commu-nications. In his early work, Spence attested that although analyticunderstanding had no historical truth, it can claim “narrative truth,” acoherent story that brings an aesthetic appeal to otherwise disparatephenomena. In his later work Spence (1994) decried narrative truth as poorscience that must be corrected. Both Schafer and Spence concluded that thetruth claims of psychoanalysis are relative to the viewpoint of the analyst.Nonetheless, Schafer does not believe his position is solipsistic because hecontends that analytic interpretations are subject to the criteria of verification,coherence, consistency, and completeness.

The other source of the relativist position is relational psychoanalysis.Theorists of this persuasion argue that the analyst’s immersion in the inter-action with the patient makes it impossible for her to step outside this matrix toview the patient or the analytic dyad. Hoffman (1998), for example, contendsthat the analyst’s understanding is necessarily skewed due to his embeddednessin the process. Consequently, from a relational perspective, the analysts’s

230 Summers


IJAP 2.3 crc 10/3/05 2:22 PM Page 230

proposed understanding is relative to her viewpoint within the interaction(Mitchell, 1988; Hoffman, 1998). Nonetheless, Hoffman insists that hisposition is not unqualified relativism because ambiguity does not connote theabdication of objective reality. He believes there is an objective frameworkwithin which constructivism takes place.

The problem with the relativist alternative to objectivism is that it cannotavoid unqualified relativism, which is tantamount to solipsism and underminesany claim to psychoanalytic knowledge. To avoid this pitfall, relativists resortto non-relativist categories, as Schafer does with his criteria for the truth valueof analytic interpretations, and Hoffman does with his belief in objectivereality. These contentions contradict relativism. To say this plainly: Hoffmancontends that the analyst is immersed and therefore has a skewed perspective,but then claims to know there is an objective framework within whichconstructivism takes place. Moore (1999) shows that Hoffman undercuts hisconstructivist view of reality by laying claim to objective reality and proposesinstead a pure constructivism untainted by any objectivist assumptions.Clinical technique then becomes a joint construction between patient andanalyst. The purpose of this process is to overcome a “deficiency in the processof construction” in order to achieve an “optimal construction.”

Moore’s attempt to provide an alternative to Hoffman is significant becauseit represents the ultimate effort to propose a model of the analytic process freefrom judgments about reality. But, once Moore acknowledges his effort toovercome a perceived deficiency he has gone beyond pure construction to evalu-ations about the patient’s reality. The fact that Moore fails to avoid suchassessments shows the impossibility of any attempt to found psychoanalysis on arelativist epistemology. To make any claim for psychoanalytic knowledge is totranscend relativism which is why every relativist theorist ultimately contradictshimself. The only consistent relativism is an abdication of any claim to thevalidity of psychoanalytic knowledge by reducing analytic truth to solipsism.

But, the failure of relativism does not imply that we can return to objectivism.Objectivist philosophers of science, such as Hook (1959), Scriven (1959), andPopper (1962), have launched devastating and decisive attacks on any psychoan-alytic claim for objective knowledge by showing that the psychoanalytic settingdoes not meet the objectivist criteria of falsifiability and logic of discovery. Therelativists are correct in their critique of the objectivist foundation for psychoana-lytic truth, but have failed to propose a viable alternative.

So, reality judgments are inevitable for the very conduct of psychoanalysis,but these judgments cannot be regarded as objective. If the analyst’s assessmentof the patient’s issues is not objective, what is the basis for psychoanalyticknowledge? Psychoanalysis finds itself today struggling to find a foundation forthe claims it must make to operate. This is the epistemological crisis in whichcontemporary psychoanalysis finds itself.

I have argued elsewhere that the root of this dilemma is the contention sharedby both sides that the only valid knowledge is objective (Summers, 2004). The



IJAP 2.3 crc 10/3/05 2:22 PM Page 231

difference between the two epistemological schools is that one believes suchknowledge is available to the analyst, and the other does not. Neither appreciatesthe uniqueness of psychoanalytic knowledge. The solution I proposed was therecognition of psychoanalysis as a hermeneutic science in which the criterion fortruth is coherence, the goodness of fit. That is, an interpretation has truth valueto the extent that it fits the available evidence of the patient’s behavior. Thiscoherence is not a relative criterion, but a transcendent category. Nonetheless,any fit is subject to modification depending on newly emerging data. There areno “final truths” in human understanding because the infinite possibility of theexpansion of human experience makes new evidence and knowledge inevitable.Nonetheless, the fact that understanding is always subject to modification doesnot mean that there is no way to adjudicate among differing ways of under-standing the patient’s symptoms, the inevitable conclusion of relativism.Analytic judgments are assessed according to their ability to account for the dataof the patient’s behavior. To the degree that they do not, they must be altered orthe evidence is called into question. To evaluate interpretations on this basis is totranscend relativism. However, the criterion is not the objectivist standard ofexperimental falsifiability for that would not apply to understanding the other.Goodness of fit is the standard of truth applicable to hermeneutic investigation,one example of which is the elucidation of the other’s behavior.

Of course, the standard for an analytic interpretation goes beyond accuracyto clinical effectiveness, the test of which is the affective impact on the patient.Affective extension of the interpreted material coheres with the offered under-standing. Other material, of course, is also relevant, but the patient’s affectivereaction and experiential elaboration of the interpretation offer the best test offitting the patient’s subjectivity. Absent such affective resonance, the burdenfalls on the analyst to question the veracity or timing of her intervention. Onecan see that the clinical posture of searching for the patient’s experience toguide the analysis correlates with the hermeneutical epistemological position.

CONCLUSION

From both the epistemological and therapeutic action viewpoints, the patient’sexperience is the focus and ultimate arbiter of the analytic process. The analystmust justify any proffered understanding in accordance with the patient’ssubjectivity. While it can be argued the patient’s experience has always beenappreciated as crucial in theory of technique, the fact is that the field has ahistory of using theory to understand pathology according to preconceivedorganizing principles, a method employed since Studies on Hysteria (Freud,1895) and continued by many to this day from a variety of theoreticalviewpoints.

The new psychoanalytic ethic struggles to free itself from the vestiges ofanalytic authority as a criterion for analytic truth or a means for the patient’sacceptance of it. The analytic encounter, while never as raw as envisioned by

232 Summers


IJAP 2.3 crc 10/3/05 2:22 PM Page 232

Bion’s code of conduct, is a way of meeting the patient’s experience, thestructure of which may make little sense to the analyst. But, such a grasp of thepatient’s life world is not possible if knowledge of its principles is presumed.This attitude of openness to the patient’s experience, no matter how alien itmay seem, is the posture most conducive to seeing the world as the patient seesit. The more the analyst claims to know, the less receptive he is to the patient’sidiosyncratic meaning constructions. Understanding is not application ofpreconceived principles, but the elucidation of how the patient structures herway of living. The maintenance of openness and receptivity to the patient’ssubjectivity requires the analyst to adopt a stance of not knowing because anyunderstanding must be built from encountering the patient’s experience. Theepistemological position maximally conducive to understanding the uniquenessof the patient’s life world implies not knowledge, but ignorance. Not knowingis the essence and uniqueness of the analytic ethic.

Several significant implications follow from this definition of the analyst’sstance. First, we have come to a complete reversal of the original analytic ethicof certainty and the invocation of authority. The analyst who comes to thepatient with a full appreciation for his own lack of knowledge presumes anabsence of what gave the early analysts their authority. The leverage of thecontemporary analyst who invokes no authority and claims no knowledge liesprecisely in the opposite: the willingness to suspend assumptions and judgment.The fact is the patient can and often does find many who will be only too gladto provide opinions about his behavior. Patients often ask friends and acquain-tances for advice and frequently get it. Indeed, many who do not even knowthem would be free with advice. It seems only in the analyst’s consulting roomdoes he find someone who seems not to have suggestions for what he should do.The uniqueness of the analyst’s posture lies precisely in minimizing thepresumptions that characterize the attitudes of most people.

Because openness is necessary to understand the structure of the patient’sexperience, it is precisely the analyst’s lack of knowledge that puts him in aposition to offer a unique understanding. The most decisive and clear breakfrom the past is not the adoption of any particular theory of development,pathology, or therapy, but the willingness to hold knowledge in abeyance. Theanalyst offers not a particular content, but a way of understanding the self andfacilitating the creation of previously arrested forms of self-expression. Thepsychoanalytic ethic is not a special form of knowledge, but a unique process ofovercoming self-imprisonment and freeing the buried self. Ironically, this thera-peutic posture defines precisely the approach Breuer (1895) took with Anna O.He suspended his preconception that she was uttering nonsense in favor oflistening seriously to her “mutterings.” His willingness to engage and attempt tounderstand her subjectivity marked the origins of psychoanalysis. However, onthe basis of discoveries made first by Freud and Breuer, and later by otheranalysts, there has been a vexing tendency in the field to use knowledge gainedfrom some patients to restrict openness to subsequent experience. My advocacy



IJAP 2.3 crc 10/3/05 2:22 PM Page 233

of ending the reification of theory is, in a sense, a plea to return to thebeginning. We would all do well to be reminded of Hegel’s warning that “theowl of Minerva spreads her wings only as dusk is falling.”

The psychoanalytic ethic, then, is the willingness to suspend presumptiveknowledge in order to meet the uniqueness of the patient’s experience, under-stand its structure and workings, and then make it possible for the patient tocreate new ways of being. Note that we “make possible” and the patient creates.The analyst cannot envision what the patient will create, so the analyst doesnot have a prejudged image of who the patient will become. The analyst’sexpertise lies in making possible the patient’s self creation, not in knowing whothe patient should become. It is the analytic process, the way of aiding thepatient’s becoming himself, that defines the uniqueness of psychoanalytictherapy. Psychoanalysis is not a special form of knowledge, but a method forexploring the patient’s experience to find its underlying motivation andstructure. The process of coming to know and be defines the psychoanalyticcontribution to human experience. The ethic is the willingness to makecontact with all aspects of the patient, both known and unknown, and let thisencounter work on the analyst, to be influenced, as much as to influence.

REFERENCES

Aron L. Meeting of Minds. Hillsdale, NJ: The Analytic Press, 1996.Bachrach H. On specifying the scientific methodology of psychoanalysis.Psychoanalytic Inquiry

1989; 9: 282–303.Bion W. Differentiation of psychotic and non-psychotic personalities. In: Spillius E (ed.),

Melanie Klein Today: Vol. 1. Mainly Theory. London: Routledge, 1988; 61–80.Bion W. Learning From Experience. New York, NY: Basic Books, 1962.Brand R. Introduction. In: Value and Obligation. New York, NY: Harcourt, Brace & World, 1961.Breuer J. (1895) Fraulein Anna O. In Breuer J, Freud S. Studies on Hysteria, Standard Edition 1895;

2: 21–48.Busch F. The Ego at the Center of Clinical Technique. Northvale, NJ: Aranson, 1995. Casement P.

Learning From the Patient. New York, NY: Guilford Press, 1962.Freud A. The Ego and the Mechanisms of Defense. New York, NY: International

Universities Press, 1936.Freud A. How Does Analysis Cure? Chicago, IL: The University of Chicago Press, 1984. Freud S. Psychotherapy of hysteria. In: Breuer, Freud S. Studies on Hysteria Standard Edition 1895;

2: 255–305.Freud S. Remembering, repeating, and working through (further recommendations on the

technique of psychoanalysis II). Standard Edition 1914; 12: 145–156.Freud S. The ego and the id. Standard Edition 1923; 19: 3–68.Gadamer H. (1988) Truth and Method. New York, NY: Continuum, 1988Gray P. The nature of therapeutic action in psychoanalysis. Journal of the American Psychoanalytic

Association 1990; 38: 1083–97.Hoffman I. Ritual and Spontaneity in the Psychoanalytic Process. Hillsdale, NJ: The

Analytic Press, 1998.Hook S. Psychoanalysis, Scientific Method, and Philosophy. New York, NY: New York

University Press, 1959.

234 Summers


IJAP 2.3 crc 10/3/05 2:22 PM Page 234

Kohut H. How Does Analysis Cure? Chicago, IL: University of Chicago Press, 1984.Mitchell S. Relational Concepts in Psychoanalysis. Cambridge, MA: Harvard University Press,

1988.Moore R. The Creation of Reality in Psychoanalysis: A View of the Contributions of Donald Spence,

Roy Schafer, Robert Stolorow, Irwin Z. Hoffman, and Beyond. Hillsdale, NJ: The AnalyticPress, 1999.

Ornstein P. The evolution of Heinz Kohut’s psychoanalytic psychology of the self. In: Ornstein P(ed.), Search for the Self. New York, NY: International Universities Press, 1978; 1–106.

Popper K. Conjectures and Refutations: The Growth of Scientific Knowledge. New York, NY: BasicBooks, 1962.

Rosenfeld H. Impasse and Interpretation. London: Tavistock, 1987.Rubenstein B. On the possibility of a strictly clinical psychoanalytic theory: an essay on the

philosophy of psychoanalysis. In: Holzman PS, Gill MM (eds), Psychology VersusMetapsychology: Psychoanalytic Essays in Honor of George Klein. New York, NY: InternationalUniversities Press, 1976; 229–264.

Rubenstein B. The problem of confirmation in clinical psychoanalysis. Journal of the AmericanPsychoanalytic Association 1980; 28: 397–417.

Schafer R. The Analytic Attitude. New York, NY: Basic Books, 1983.Schafer R. Retelling a Life. New York, NY: Basic Books, 1992.Scriven M. The experimental investigation of psychoanalysis. In: Hook S (ed.), Psychoanalysis,

Scientifice Method, and Philosophy. New York, NY: New York University Press, 1959; 226–251.Spence D. Narrative Truth Versus Historical Truth. New York, NY: WW Norton & Co, 1982.Spence D. The hermeneutic turn: soft science or loyal opposition? Psychoanalytic Dialogues 1993;

3: 1–10.Spence D. The Rhetorical Voice of Psychoanalysis. Cambridge, MA: Harvard University Press,

1994.Summers F. “What I do with what you give me,” The creation of meaning as therapeutic action.

Psychoanalytic Psychology 2001; 18; 635–655.Summers F. The epistemological foundations of psychoanalytic knowledge: a third way. In:

Reppen J, Tucker J, Schulman M (eds), Way Beyond Freud: Postmodern PsychoanalysisObserved. London: Open Gate Press, 2004; 113–131.

Winnicott DW. The theory of the parent–infant relationship. In: Maturational Processes and theFacilitating Environment. New York, NY: International Universities Press, 1965; 37–55.

Frank Summers PhD, ABPPSupervising and Training Analyst

Chicago Institute for PsychoanalysisAssociate Professor of Clinical Psychiatry

and the Behavioral SciencesNorthwestern University Medical School

333 East OntarioSuite 4509B

ChicagoIL 60611

USA(E-mail: [email protected])



IJAP 2.3 crc 10/3/05 2:22 PM Page 235

Documents

Therapeutic action, epistemology, and the ethic of psychoanalysis