Review of Joseph Schacter, “Transforming Lives”

In Transforming Lives [1] the psychoanalyst Joseph Schachter collects case reports of seven analyses of clients by psychoanalysts and, for four of them, client replies. Notably, the case reports are not identified by author. Schachter avers this is to protect confidentiality, however, it lends a pleasant frisson to the text. This is not so much because one engages in speculation as to which case report is connected with which author. While the authors probably are well-known within the psychoanalytic community, they have no presence I was able to discern outside of it. Rather, it emphasizes the randomness and contingency of how individual clients end up with individual therapists, a mirror of the facticity and thrownness of life itself.

The client replies to the write-ups of their cases are strange. One cannot help but wonder how their creation influenced the therapeutic process–a dialectic of the therapist writing the case study, the client reading and considering it, having the insight (possibly the courage) to respond and then the therapist’s consideration of what the client has to say. Talk about transference and counter-transference!

Schachter has had a distinguished career as a therapist. He is editor for psychoanalytic research of the publication International Psychoanalysis. His background is neurophysiological and developmental studies of the children of mothers with schizophrenia. He was a training and supervising analyst at the Pittsburgh Psychoanalytic Center and presently is on the faculty of the Columbia Psychoanalytic Center for Training and Research. He has written or co-authored two other books: Transference: Shibboleth or Albatross [2] and From Psychoanalytic Narrative to Empirical Single Case Research: Implications for Psychoanalytic Practice. [3] The former is a critical look at the theory of transference and transference interpretation, which is central to the psychoanalytic project. The latter deals with the vexing issue of empirical support for psychoanalysis as a discipline in today’s competitive marketplace for delivery of mental health care, with its emphasis on medicalized, evidence-based treatment for psychiatric disorders.

Schachter observes (correctly) that in many circles, psychoanalysis has fallen into disrepute. Psychoanalytic papers are read and cited far less frequently than those of other disciplines. Psychoanalysts have developed a kind of inferiority complex or defensive reaction about their work, possibly out of concern that clinical practice is disconsonant with research findings. Translational research in psychoanalysis works in reverse to most psychological disciplines, which start with clinical cases and then try to establish theory to support them. Psychoanalysis, however, starts with metapsychology, then goes out hunting for clinical confirmation. This makes it a lot easier to argue about just what theories the clinical findings support, possibly accounting for the historical discord among different schools of psychoanalytic thought. Clinical styles and techniques between analysts vary tremendously, making it difficult to generalize. This also makes it harder to disconfirm a hypothesis, or set forth conditions under which it might be falsified – typically regarded as one of the “gold standards” of a scientific theory. [4]

Schachter’s move in response to these concerns is to argue for an idiographic, nomothetic case-study approach, not dissimilar to that deployed under the rubric qualitative research. [5] Qualitative research in psychology adopts what best might be characterized as a hermeneutic method: to understand a phenomenon, or a person, as fully as possible. It eschews statistics and focuses instead on context, semiotics and content analysis. In this way it captures the nuances and idiosyncrasies of particular individuals, rather than forcing them into a preconceived template. He then applies this thesis to an analysis of a patient Amalia X.

This approach seems about as far as one ever will be able to get with psychoanalysis. Freud pioneered case study methodology with his analysis of the “rat man,” published as Notes upon a Case of Obsessional Neurosis. [6] He authored several other case studies. Later psychoanalysts continued in the same tradition, which reached its fullest expression in the phenomenological psychology movement of the 1930s: Ludwig Binswanger’s analyses of Ilse [7], Ellen West [8] and Lola Voss [9] and Medard Boss’ analyses of Dr. Cobling [10], Wilhelmina [11] and Maria [12]. These are far more than mere vignettes. Rather, they are rich with clinical observations. The authors develop their patients in a way that is as complex as one might find in the character studies of Dickens, Dostoyevsky or Tolstoy. The analyst is not some cult-like priest interpreting preexisting but hidden meanings. Rather, the process of analysis (as I observed at the start of this review) is dialectical. Because they merge theory with praxis, these detailed treatment reports are the best argument for comparative psychoanalysis as a discipline. They are hypothesis-generating, not hypothesis-truncating.

I was unable to get a clear perspective from the case histories as to what contributed the most to salient improvement in psychodynamic work, which is unfortunate seeing as how that’s the objective of any type of therapy. While I may be missing some of the nuances of this, only Watt’s case (pp. 53-74) seemed explicitly self-psychology oriented; only Sarah’s case (pp. 95-111) seemed explicitly object relations oriented. In a way the whole purpose of the book was to try and avoid theory, jargon and “schools” of psychoanalysis, in favor of concentrating on the work of analysis itself. One of Schachter’s main points is that a transdiagnostic, interdisciplinary approach is necessary if psychoanalysis is to have any contemporary validity. Consistent with this orientation, he advocated a heterogenous, diverse assortment of analytic techniques, ranging from free association to dream interpretation and (of course) transference. The result, though, is more of an undifferentiated humanistic approach, with the therapists trusting intuition to guide them and their clients through a morass of tangled and conflicting evidence to a result that made sense to both of them. 

One of the vignettes was particularly concernful, the case of Sarah. She seemed emotionally disregulated in a way that psychoanalysis never will be able to address. Says her therapist:

“She talks heatedly, without stopping, and usually without finishing her sentences. A new subject takes the place of the previous one, which has been barely outlined, so that after I have been listening to her for a while, I feel submerged by disparate fragments of subjects started and dropped. I don’t have the elements I need to understand what she is talking about” (p. 95)

The therapist continues:

“While her communication has a strong affective quality that conveys a reasonably understandable meaning, the meaning of her words is much less clear and intelligible; her speech tends to be incoherent, chaotic, with overlapping subjects.” (p. 97)

In other words, even though her speech had a “strong affective quality,” she wasn’t able to make the connection between her words and the underlying emotions she was experiencing, which she intended the words she used to convey. I recognize the idea of talking about emotions is problematic because emotions are enactive, not discursive. There is an imperfect fit between what one feels and what one can express; often one “can’t put it into words.”  Sarah, however, couldn’t even recognize that she was feeling an emotion to begin with. She lacked viscerality or sensitivity to interoceptive cues (she complained throughout of being “sick to her stomach,” a typical somatic marker of psychological disaffection such as anxiety). Even when she was behaviorally activated, she couldn’t identify the emotion she was experiencing, either because it was too complex, obscure, or difficult to isolate from the background of her affective life. This suggests to me DBT would have been far more effective for her than psychoanalysis. 

In clinical practice, I never cease to be amazed at the incredible diversity of human experience and ideation. I also frequently am flabbergasted by the extent to which many clients are as disconnected from their inner cognitive and emotional life as an extension cord is from an outlet when the light doesn’t work. I’m convinced that in order to be a successful psychologist one must develop a deep sense of empathy for and understanding with one’s clients. However, that alone isn’t insufficient; it’ll lead to disillusionment and burnout. One also must have an abiding interest in and curiosity about the workings of the human mind, particularly when it goes awry. To a large extent this consists in the capacity of being able to be awe-struck and amazed by the simplest of phenomena. For example, why is there something rather than nothing?  How does it happen that words refer to objects?  How does consciousness result from a gooey combination of wet-ware housed inside the cranium?  And how is it possible ever to understand what’s going on in somebody else’s head? 

Endnotes

[1] Schachter J. Transforming lives: Analyst and patient view the power of psychoanalytic treatment. Lanham, MD: Jason Aronson; 2005. 

[2] Schachter J. Transference: Shibboleth or albatross? Florence, KY: Routledge: 2001.

[3] Kächele H, Schachter J, Thomä H. From psychoanalytic narrative to empirical single case research: Implications for psychoanalytic practice. Florence, KY: Routledge; 2008.

[4] Ever since Popper, K. The logic of scientific discovery. London, UK: Routledge; 1959/2002.

[5] Merriam SB. Qualitative research: A guide to design and implementation(3rd ed.). Hoboken, NJ: Jossey-Bass; 2009.

[6] Freud S. Notes upon a case of obsessional neurosis. In: 9 case histories II. New York, NY: Pelican; 1909/1979.

[7] Binswanger L. Insanity as life-historical phenomenon and as mental disease: The case of Ilse. In: May R. Existence. New York, NY: Simon and Schuster; 1958:214-236.

[8] Binswanger L. The case of Ellen West. In: May R., ed. Existence. New York, NY: Simon and Schuster; 1958:237-364.

[9] Binswanger L. The case of Lola Voss. In: Needleman J, ed. Being-in-the-world: Selected Papers of Ludwig Binswanger. New York, NY: Harper & Row; 1963:266-341.

[10] Boss M. A patient who taught the author to see and think differently. In: Lefebre LB, ed. Psychoanalysis and Daseinsanalysis. New York, NY: DaCapo Press; 1982:5-27.

[11] Boss M. A patient who suffered alternately from colitis and migraine. In: Lefebre LB, ed. Psychoanalysis and Daseinsanalysis. New York, NY: DaCapo Press; 1982:147-154.

[12] Boss M. A patient with functional and structural “psychosomatic” disturbances. In: Lefebre LB, ed. Psychoanalysis and Daseinsanalysis. New York, NY: DaCapo Press; 1982:147-154.