Abstract
Teaching and psychoanalysis are said to be the two impossible professions. That would make teaching psychoanalysis impossible squared. In spite of that, there is no shortage of books on the teaching of psychoanalysis and psychoanalytic psychotherapy. Vamik Vokan has made a significant contribution to this field with Psychoanalytic Technique Expanded: A Textbook on Psychoanalytic Treatment.
Why is teaching psychoanalysis so difficult? (I already have taken the perhaps overly optimistic step of moving from “impossible” to “very difficult”—a step that might be questioned.) Among the more obvious reasons are that there is no agreement in the field about what constitutes an adequate theory, no agreement on elements of technique, and no agreement on how to define, let alone measure, the desired outcome, or even if it is sensible to try to do so. These are all problems for the practice, as well as the teaching, of psychotherapy. In addition, there is the insidious worry that psychotherapy is a practice, a craft, highly individual to both patient and therapist, and that while it can be coached and encouraged, it can no more be taught than one can teach, in general, how to have a good marriage.
There is general agreement that of the three main components of programs for teaching psychoanalysis—the personal experience of analysis, supervision of individual cases, and didactic classwork—the classwork is the least important. However, that is the main area in which a book such as Volkan’s would be useful, and I take it as offered as a primary (or at least adjunct) text for a class on analytic technique. In this light, it must be read in comparison with texts by Gabbard (2010), Kaner and Prelinger (2005), Balsam and Balsam (1984), Storr (1980), Cabaniss et al. (2011), and others. The options for such a text would be to focus primarily, though not exclusively, on theory, on technique, or on case descriptions. Volkan clearly leans heavily toward the last of these; the book consists largely of a series of evocative case reports, each focused on a technical issue, with some theoretical underpinning provided in discussing management of the case.
Anyone who tries to teach analytic technique in a didactic setting will quickly confront, if the students are bright and not excessively obedient, the question “How do you know that?” While this is a question that bedevils the field generally, it becomes especially pressing in the educational context. I will therefore digress briefly to explore some options for dealing with the problem.
There are roughly three ways to respond to the question of how we know what we are teaching, or, to put it in slightly more philosophical terms, what the basis is for our claims to knowledge. These are the correspondence, coherence, and pragmatic theories of truth.
The correspondence theory of truth, broadly put, holds that our propositions are true because they correspond more or less accurately to a reality external to the system of propositions. This view, tracing back in modern times at least to Descartes, and finding its fullest flower in the twentieth-century positivists, was debated most forcefully in our field by Adolph Grünbaum and Marshall Edelson. There are a number of deep general problems with this view, and several problems specific to its adoption in psychoanalysis. In very brief outline, the general problems include how one can have knowledge of anything outside of one’s own mind, what exactly the nature of this correspondence might be, and how to resolve disagreements among individuals with differing views of this external reality. In the analytic context, the major difficulties involve how to define the nature of the data, and how to separate the observer from the observed. Although this view predominated in the second half of the twentieth century, and was surely Freud’s view, it is fair to say that today it is held by a minority of analysts, and by an even smaller minority of our critics.
The coherence theory of truth, again in broadest outline, holds that truth consists in the internal relations, coherence, and power of the system of propositions, without regard to external reality. This approach avoids many of the problems that trouble a correspondence theory, but raises its own set of difficulties (in philosophy, as in life, there is no free lunch). In particular, this approach to a theory of truth raises the problem of an objective test of truth, since it is hard conceptually to establish commensurability between alternative coherent systems. This can leave the coherence theorist without a strong basis for any universal claim to truth, leading to a somewhat solipsistic situation in which everyone is entitled to his own narrative, with no systematic way to challenge the truth claims of others. This can in turn lead to authoritarianism, truth enforced by charisma, with little way to settle disputes between theories, and thus a less persuasive claim to truth that would extend beyond the individual claiming it.
A third approach is to equate truth with the usefulness of a proposition. This line of thinking, often traced back to the pragmatists James and Dewey, also comes from the later Wittgenstein. But basing truth claims on the usefulness of propositions then raises the questions “Useful for whom?” and “How do you know something is useful?” Truth claims based on usefulness tend to be less universal and “objective” than those based on correspondence theories, but also less solipsistic and more verifiable than those resting on coherence theories.
The point of this excursion into epistemology is to place Volkan’s approach squarely in the third category. There are certainly texts that grow out of a positivistic correspondence theory (e.g., Greenson 1967) in a way that seems both dated and tendentious. The approach, though, taken by Volkan is to present a series of convincing clinical stories, and to show how a certain theoretical approach, or technical precept, helps make sense of the vignette, and indeed provides a context for thinking about, and moving forward in, the interpersonal situation. His talent for presenting these clinical stories in a compact but persuasive manner, which will feel familiar to an experienced clinician, lends a convincing tone to his presentation, and will make it easier to answer the student who asks “How do you know that?” or “Why do you do it that way?”
Much of the value of this book is in the series of vignettes, and Volkan’s talent at storytelling is a main virtue. He describes his approach as “anthropological field-work,” which I think is not quite right, as he is not able to step outside his cultural framework to explore another; rather, he works within a framework that emerges organically as he describes the functioning of his own intellectual and technical culture. He has a large repertoire of clinical experiences to draw on, and he makes good use of it. His theoretical approach emerges only piecemeal, and through his explication of various situations and conundrums, as it should. He seems to be largely a classical thinker, though by no means orthodox or rigid in his approach, and he demonstrates a measured but clear degree of human flexibility in his style of interaction and therapeutic intervention. He shows an admirable degree of clinical tact, and respect for the importance of time in a therapeutic process, frequently commenting on the need not to communicate his thoughts or hypotheses to the patient until the time is ripe, often months further along in the process.
He does not explicitly make use of the projective identification paradigm, but he often brings to mind Ogden’s comments (1979) on the usefulness of a theoretical formulation in allowing the therapist to tolerate the interaction with the patient without needing to intervene, at a time when the therapeutic process requires this toleration as part of the therapist’s internalization and metabolism of conflicts and contents that at this point are intolerable to the patient. Ogden says explicitly, and Volkan exemplifies this in many instances, that often a formulation proves its worth by its effect on the therapist as much as on the patient.
A textbook for psychoanalytic teaching must confront the question of the clinical scope to be covered, both in theory and in practice. Volkan’s approach is to start with an extended section on the treatment of neurotic personality organization, and then to transition, through what he calls “transgenerational transmissions,” to the treatment of narcissistic personalities, which then blurs into the treatment of borderline cases. He introduces the concept of “depositing,” which, as he notes, is closely related to projective identification, as a key transition from neurotic personalities to the broad category of narcissistic and borderline cases. He emphasizes the importance of an early, if tentative, formulation of the case: “What am I treating?” is a question he frequently raises. To his credit, he remains tentative in his formulations for much of the case presentations, and he puts a welcome emphasis on using the evolving transference relationship as a key element in diagnostic thinking. So, while avoiding the trap of diagnostic nihilism (often parading in the guise of “Everyone is unique”), he maintains the importance of emerging transference configurations (including countertransference elements) as central to a full diagnostic understanding.
In general, though Volkan demonstrates an admirable flexibility and openness in his formulations and theoretical approaches, one could regard his attitude as largely classical (as I have noted), with a recurring focus on oedipal issues, castration anxiety, and more or less classical transference developments, even with his more disturbed patients. The addition of notions close to projective identification, often with an idiosyncratic spin, add scope and flexibility to his presentations, while keeping them within the broad current of classical analytic thought. His transition to more severe pathology is by way of his concept of “depositing” and transgenerational transmision of trauma. This set of concepts, idiosyncratic to Volkan, are nonetheless in the same family as projective identification, and form an effective bridge to his extended discussion of borderline-like cases. This section, perhaps the most extended theoretical discussion in the book, relies heavily on Volkan’s own writings and experiences. He is clearly aware of the connections between this set of ideas and more conventional ways of viewing borderline and narcissistic pathology, and the transition from classical to borderline pathology is persuasive, especially since he soon returns to his preferred tactic of extended clinical descriptions explicated through the use of his theoretical paradigms.
This book is not a coherent presentation of a theory of analytic practice, nor is it a systematic guide to practice. It is, however, a valuable source of evocatively presented case descriptions, each with a cogent and theoretically informed discussion. I can easily imagine drawing on this text for examples in a course on analytic technique, both for neurotic patients and for more severely disturbed cases. It deserves to be looked at by anyone who is contemplating taking on the difficult, perhaps impossible, task of teaching analytic technique.