Slicing the Psychoanalytic Pie: Or,Shall We Bake a New One? Commentary on Greenberg

We Necessarily Employ “Controlling Fictions”

We do this in order to listen to our patients’ associations, to make meaning out of an otherwise overwhelming amount of information. Greenberg thinks of “our descriptions of the psychoanalytic situation as fictions, in the sense that they are narratives that direct our attention to certain aspects of what is going on while, of necessity, diverting attention from other aspects” (p. 17).

Thus, Greenberg’s fiction concept is a variant of narrative as explanation in a field where the amount of information is great and causal relations are obscure. Riessman (1993) suggests that we make sense of random or complex multicausal experiences by weaving them into story structures. Narrative explanations provide a sense of conviction in the messy situation of analytic treatment. There is also a risk in using narratives, indicated by Greenberg’s use of the word “fiction”: that in developing theories, compelling stories, we may suggest greater certainty than we truly have achieved, or create something that is actually off track. Freud set this all going because in his search for a general psychology he frequently claimed the status of truth—demonstrated, proven—for psychoanalytic observations and for theories built on them. Similarly, Freud’s clinical views were often written in a decisive voice that led to their becoming shibboleths (Almond 2011). Adherence to the narrative became a password for entrance to the group.

Narrative as an explanatory idea was introduced in psychoanalysis by Spence (1982), who argued that what patients convey to us are stories, narratives they have constructed that are not veridical histories but complex creations that explain, justify, and simplify their inner experience. Spence showed how patients’ conflicts or character narrow their personal history into a constricted, monolithic narrative. Psychoanalysis potentially facilitates movement from this limited and limiting narrative to a range of coexisting narratives, thereby enriching patients’ choices and potentialities—narrative flexibility as a valuable outcome. Schafer (1987) extended the sense of narrative to include the analyst’s theory, as does Greenberg here. Schafer anticipated later discussions of relativism, asking what makes one psychoanalytic narrative more persuasive than another. He also asked what degree of certainty the analyst can have regarding the “text” of the patient’s associations. We can’t take what patients say literally, since we understand the workings of defense and resistance; but we also can’t trust that the theory narratives we impose while listening will be any more “true” than the patient’s narrative. Schafer’s solution: “Verification is established by an accumulation of indirect or implicit responses, the kind of responses that become evidence only upon interpretation, further analytic dialogue, and further interpretation” (1987, p. 176).

More broadly, the introduction of narrative as a way of thinking about psychic structures became part of an emerging hermeneutic, postmodern view. In that sense, Greenberg’s “fictions” are part of a shift in language and philosophical outlook that rejects empiricism and the aim of discovering testable models. Schafer, writing almost twenty-five years before Greenberg, introduced a nuanced discussion of arriving at conviction about process—an Hegelian process in the dyad. Greenberg though, seems willing to stop at the level of the analyst’s initial fitting of the patient’s associations to the controlling fiction. I wonder whether he truly holds to this more cross-sectional view of process, or whether he leaves out a view of ongoing discovery in order to dramatize the idea of fiction.

We see the tension between the hermeneutic and the empirical throughout this discussion of pluralism. At the moment, these traditions continue side by side, in unspoken competition, in our journals and in our individual internal modeling of what we believe and what we know (Luyten, Blatt, and Corveleyn 2006; Almond 2006). Another way to put this would be to say that each clinician has his or her own balance with regard to viewing psychoanalysis as interpreted meaning or as science.

Each Psychoanalytic Theory is a Complete, Equivalent Entity

Each is an alternative for comprehending the psychoanalytic situation: “our theories of therapeutic action,” Greenberg writes, “are coherent, persuasive, interesting narratives that are in essence logical deductions from competing and incompatible controlling fictions”; “we are always trafficking in competing, often incommensurable narratives” (pp. 26, 20; emphasis added).

In an era of pluralism we fall roughly into two camps: “I have a good theory; I don’t need more” or “All theories have value.” Greenberg seems to be in the second camp, but he retains the sense that those who hold to a given model claim its exclusive and exhaustive reach. It is surprising that Greenberg, one of the founders of relational theory, characterizes adherents of different schools this way, given that relational analysts tend to be the most theoretically inclusive (Hamilton 1996). Perhaps he is speaking of other schools. In any case, I agree that such adherence creates a vulnerability to the narrative fallacy—the assumption that our stories contain essential truths.

Greenberg illustrates his argument in two ways. He provides a list of psychoanalytic explanations for an imagined patient’s change, in which each theory’s spokesperson makes a claim for explanatory power via its model (pp. 20–21). Second, he deconstructs, from several different theoretical viewpoints, a clinical vignette presented by Civitarese (2005). Again the ghost of Freud hovers over this coexistence of equivalent models; Freud freely introduced new models of mind and of mutative action, without integrating them or choosing one over the others. He presented each of his discoveries as though it was the final word on understanding the psyche as revealed in analysis, but he infrequently made efforts to integrate a new formulation with previous models. Accordingly, subsequent generations of psychoanalytic theorists have felt free to introduce ideas—their way of slicing the pie—while making no effort to integrate them with existing models.

I would suggest the overtaxed metaphor of the blind men and the elephant, but put the blind men on Noah’s ark, attempting to describe what they find. Our actual clinical experience reveals a variety of phenomena, and provokes a variety of explanations. Psychoanalytic theory building is replete with examples of how a particular new observation becomes a theory of everything. An example is Kohut’s evolution from his first observations that there are individuals for whom narcissistic issues are primary in treatment (1971) to a recasting of psychoanalytic theory as a “psychology of the self,” a model in which all experience can be best understood in terms of the intactness or deficiency of the self (1977). In other words, Kohut’s theory evolved from an enrichment of the predominant model of the time, libido/ego psychology, to a “self ”-focused theory.

The blind men on the ark might find that many living beings have legs, some two, some four, some many more; some have trunks, some wings, some fins. Making some taxonomic order could be confusing, the work of many generations, and work that then may be totally recast by the analysis of genetic material. The fact that the task is complex does not justify oversimplification into a conclusion that there are only legs, or only trunks. George Miller’s classic paper, “The Magical Number Seven, Plus or Minus Two” (1956), suggests a reason for the recurring complete replacement of one theoretical model by another. Miller found, in a variety of perceptual/cognitive realms, that people are able to attend to a limited number of items (roughly seven). In psychoanalysis, this may be the case. Ego psychology considers drive, defense, signal anxiety, libido, ego, superego, transference, countertransference; Kleinian psychoanalysis considers paranoid/schizoid, depressive, internal and part objects, anxiety, projective identification. So the clinical situation, with the pressures Greenberg notes, may favor keeping in mind one of these smaller sets of concepts. This perceptual/cognitive limitation would then favor replacement of one language and model by another over the more complex task of integrating old and new ideas.

The reason this distinction is important is that the equivalence idea leads to a continuous impoverishment of our conceptual realm, as one model replaces another. Here is another example: in my psychoanalytic home, San Francisco, ego psychology was the only language spoken for many years. ¹ In fact, there were multiple interpretations of what ego psychology meant clinically, as different, creative applications of the model were developed. Then in the 1990s an influential younger generation of analysts became interested in Klein and in particular the London neo-Kleinians. This seemed in part a reaction to a limitation of the clinical application of ego psychology—that it spoke more clearly to neurotic, conflicted aspects of the psyche than to “earlier,” more dyadic states, or, speaking diagnostically, to personality disorders. Within a few years one controlling fiction had replaced another; there was little discussion of structural concepts, of defenses, of resistance; everything was paranoid/schizoid versus depressive, while, clinically, projective identification and primitive anxiety became regarded as the central processes. These new ideas clearly assisted us in conceptualizing more “primitive” mental states and aspects of personality structure, and in that sense were a valued vocabulary. Meanwhile the chalkboard of ego psychological concepts was erased. I am not simply making an argument for pluralism here. Rather, I am pointing out that different “theories” (Greenberg’s “fictions”) are actually reports on different psychoanalytic observations, and that they serve us poorly when they limit our vision. This is the equivalent of blind men creating a taxonomy on the ark that imagines only elephants, that has not recognized that this is the ark, not the elephant house.

Another assumption that underlies Greenberg’s idea of controlling fiction is that every analyst adheres to a particular fiction. In the real analytic world, however, belief about theory is an extremely complex matter. Victoria Hamilton explored this area in the early 1990s, studying sixty-five senior analysts in various countries and cities through interviews and questionnaires (Hamilton 1996). She found five distinguishable belief systems: classical Freudian; developmental Freudian; Kleinian; independent; and self psychological. Yet there was wide variation among individual analysts in their devotion to these models, with some highly committed to a specific set of precepts and others influenced by a wide variety. Further, each analyst’s relation to theory was affected significantly by personal history, group affiliation, and psychoanalytic politics. ²

Psychoanalysis has been in this state of pluralism for some time (Wallerstein 1987), and quite a number of writers have weighed in on the subject. “Lumpers” like to combine models in various ways into a superordinate structure (Gedo and Goldberg 1973; Pine 1990; Rangell 1988; Boston Change Process Study Group 2010). “Splitters,” too varied to list, work outward from their single theory, exemplified by my training experience during the ego psychology era in San Francisco. Tuckett (2008) has carried out a major international investigation using groups studying clinical process material (“a detailed protocol is employed by a study group to characterize atheoretically how analysts actually work”). One of the most interesting findings in Tuckett’s groups, reinforcing Hamilton’s conclusion, is that the clinical activity of an individual analyst may bear little relation to avowed theoretical preference, a finding that corresponds to my subjective sense of my supervisors’ variability when I was in training, as well as my observations supervising candidates. Clinical behavior is only sketchily related to the practitioner’s theory.

Another observation that challenges the “separate but equal” way of thinking about theory comes from my experience in study groups. In a variety of continuous case discussion settings—ranging from candidate conferences to peer study groups meeting for decades—I have observed that, as Tuckett’s work suggests, analysts working from different theoretical bases can over time arrive at a common understanding of a case. What seems to have happened in these varied group discussions was that as members reacted to clinical material and to one another’s ideas, theoretical language became less salient, and a sense of the individual case and process could be agreed on.

A final critique of discussions of clinical theory—not only Greenberg’s—concerns the patient. Most of our literature on technique speaks of a universal patient. Yes, we acknowledge that everyone is different, but many of the controlling fictions are phrased in a way that implies their applicability to every patient. Let’s take Freud’s remark in “The Dynamics of Transference” (1912) that the enemy cannot be slain in absentia (p. 108). Over the years, this admonition has increasingly influenced psychoanalytic clinical thinking. There is today an unspoken recognition that reconstruction can be a dry proceeding, and that figures outside the office often represent displacements from the analytic dyad. The here and now of the dyad is seen as central. Nonetheless, theories and individual analysts adhere to this idea to widely varying degrees. I suggest that this is because specific patients need or can tolerate varying degrees of the “let’s talk about us” approach. For example, empirical research has shown the efficacy of transference-focused psychotherapy in treating borderline disorders (Levy et al. 2006) and in introjective depression (as opposed to anaclitic) (Shahar, Blatt, and Ford 2003). But other writers (e.g., Schwaber 1981) argue that the transference in the office should not be privileged over attentive psychoanalytic listening. At a more patient-specific level, Arnold Goldberg (1978) has written of forming a “new” psychoanalytic theory for every patient he treats.

Each of these observations of the clinical application of fictions supports the conclusion that in the real world theories are not self-enclosed systems that exist in a homogeneous way for individual analysts, or among groups of analysts belonging to a common school of thought.

Different Fictions Lead to Different Theories of Therapeutic Action

Greenberg sees an “intimate connection between the controlling fiction and our theories of therapeutic action” (p. 20); “the controlling fiction dictates a narrative arc that creates what is seen as a causal chain” (p. 22). Inasmuch as the controlling fiction informs ideas about mutative action, it guides the analyst’s clinical behavior. Fonagy (2003) writes incisively about this connection of theory and practice:

My case, in brief, is that analytic theory is intended to help analytic practitioners to make sense of clinical phenomena and to guide interpretative and other interventions. However, the theories that practitioners actually rely on are specified beyond available data [emphasis added] and are weakened by their extensive reliance on induction: they often amount to no more than the observation that since a particular phenomenon has usually followed another thus far, they are likely to continue to occur together in the future. Clinical observation, irretrievably contaminated by theory-driven expectation, carries an inappropriate burden of validation. There is some truth to the quip that analytic clinicians understand the word data to be a plural of the word anecdote [p. 15].

In other words, thinking about a theory may help the analyst work, but that does not raise clinical observations to the status of theories or laws. Fonagy fears that this confusion of clinical experience with “evidence” creates a “petrification” of practice, a reification of clinical concepts (p. 15). I agree there is a fallacy embedded in the way we usually think about theory and practice; it is a misconception that pervades the healing fields. ³ I don’t think we have to be as self-critical as Fonagy, a researcher-clinician, or as naive as Greenberg. We need our theories, as Greenberg suggests, to make sense of the buzzing disorder of the session; we also need them as part of maintaining our stance as healers while we are with the patient (Almond 2003; Frank 1961). If we think about our work from a social-psychological perspective, this use of theory is not surprising. Judges have “the law,” umpires “the rule book,” and we have our theory to hold us as we play our necessary role in healing. As Greenberg puts it: “a narrative arc . . . seen as a causal chain.”

There is a Tension between the Controlling Fiction and the Clinical Situation

Greenberg believes “we are responsible for acting in ways that will contribute to our patients’ well-being. And at the same time we feel responsible to a particular method for accomplishing this” (p. 27). Here we have the “responsibility” referred to in his title. This is an interesting point that brings much together. As analysts, we need theory to structure listening and to form responses. Yet theory may also lead us astray in the individual case through its rigidity or formulaic nature. Greenberg, working from a clinical vignette presented by Civitarese (2005), imagines critiques by a Kleinian/Bionian and by an “interpersonal” analyst (who sounds at some points also relational). As Greenberg sees it, each school’s fiction leads to criticism of what Civitarese did. Either he didn’t make an interpretation, and thus failed to “contain” the patient (negative Bionian critique) or he missed an opportunity to respond authentically from the feeling of being cornered by the patient’s distress and her request for advice (negative relational critique). Greenberg, by citing these imagined challenges, does show that theory can be used to criticize clinical decisions. The problem here is that we now have to accept Greenberg’s depiction of how other analysts (with their own theories) would evaluate Civitarese’s intervention. It’s equally possible that these analysts would say, “Civitarese effectively contained the patient’s anxiety by metabolizing her demand for advice into a reflection on how one might deal with a painful situation” (positive Bionian critique) or “By being responsive to the patient’s urgency and speaking of his own inner reaction, Civitarese showed his capacity to respond in an authentic but modulated manner” (positive relational critique). I think Greenberg’s somewhat caricatured, imaginary critics distract from a deep clinical truth that he is concerned about—that theory can restrict us from responding in ways that will be valuable for the analytic process. Thus, our controlling fictions are indeed in tension with the clinical moment—but so too are countertransference, counterresistance, and sleepiness after lunch. Any and all of these can lead us to respond in ways that affect the process. The idea that the analyst may be distracted from the “right way” by a fiction/theory, or by the press of the situation, oversimplifies a complexity that Greenberg acknowledges both at the outset of his paper and in its final sentences.

The assumption that one’s controlling fiction leads directly to mutative influence contains an assumption that has always been part of clinical theory, and has been reinforced by the recent emphasis on countertransference. Beginning with Freud, we have assumed that we are the most important element in how a treatment goes. Freud assumed that the interpretation somehow alters the patient’s psyche, although he did recognize, as he reflected on mutative effect, that the patient’s love enables influence by making the patient receptive to the content of interpretation. Freud, as I have noted, assigned the analyst a crucial role in combating transference resistance. In neo-Kleinian theory the analyst’s centrality takes the form of privileging the inner experience of the analyst as a projection of the patient’s unbearable affects and mental contents. In relational theory, it is the affective participation of the analyst that provides mutative effect. Any of these views underrates the importance of the patient’s role in mutative process. Weiss and Sampson (1986) argued—and demonstrated empirically—that the initiative for change comes from the patient’s unconscious wish and plan for change, with the analyst reacting in a way that facilitates these unconscious goals. This finding pushes us toward a perspective in which the issue is how well theory helps us be individually responsive to each patient. Now the meaning of tension between the analyst’s controlling fiction and the press of the moment is altered, since theory (Weiss and Sampson’s control-mastery theory) indicates that responding to the affective pressure in the clinical moment may be theoretically “correct,” rather than necessarily at odds with the analyst’s mental model, his fiction about how change happens.

The Psychoanalytic Situation is Ineffable: Can We Bake a New Pie?

Greenberg thinks that “so much happens in any treatment that any attempt to identify what is essential is unlikely to be satisfying” (p. 15); “we plead for one point of view over another in search of a certainty that I am afraid will elude us forever” (p. 30). Faced with the complexity and variegated quality of psychoanalytic experience, he closes his paper expressing doubt that arguing rival fictions will lead to the truth. I agree. Greenberg has, in effect, diagnosed the problem: the narratives, fictions, theories that we use to organize our experience cannot provide conclusive, predictable results. But why does Greenberg stop there? As Fonagy points out, clinical experience, including our active role in dyadic process, contains data that can lead us to new understandings. Currently the common element in our diverse models is the centrality of the dyad and dyadic phenomena. Some version of this point is contained in enactment theory, in relational, neo-Kleinian, Bionian, and developmental/Winnicottian theory, and in revisions of field theory. All of these take our understanding to a new level. Ironically, Greenberg was a prime mover in this shift in emphasis. Is he perhaps disappointed that relational thinking has not become the new paradigm? Is he caught in a shared inheritance from the Freudian revolution that psychoanalysis must be always be making earthshaking, unifying discoveries? Although a great deal more has been understood and formulated by analysts since Freud, none of these advances has matched the newness and breadth that his ideas had in his time. Our understanding of dyadic phenomena has not reached such a point. But this is not to despair, or even to dwell on our internecine fights over theory. There are new observations out there.

We now appreciate that in addition to the intrapsychic, there is a two-person process, and that systems models reflect recognition of two different kinds of process in psychoanalytic work: (1) intrapsychic processes in the minds of patient and analyst; and (2) interactive/intersubjective processes involving dyadic, external processes, both expressive and communicative. While this might seem to complicate things even further, there are indications that regularities exist within this complicated array.

For example, developmental research has shown us that amid the complexity of parent-infant interaction there are large regularities—attachment, affect attunement, mentalization, reflective function—that can be assessed both in quality and competency (Stern 1985; Fonagy et al. 2002). Such regularities allow us to search for their analogues in the dyadic process of psychoanalysis. An example of baking a new pie can be found in the work of the late Enrico Jones, an analyst–research psychologist who studied process in psychoanalytic psychotherapy (2000). Jones developed a way to characterize reliably all three elements in a treatment relationship: the therapist, the patient, and their interaction. Using statistical methods for analyzing data from every fourth hour in two-year treatments, he was able to show causal relationships. ⁴ For example, Jones describes an interaction between a depressed, complaining patient and her therapist, who initially responds by being “helpful.” When the therapist notices the pattern, points it out to the patient, and alters her countertransference-induced behavior, the pattern changes, and subsequently the patient begins to show symptomatic improvement. In another case the patient’s aggressive style induces counteraggression in the therapist, the process does not change, and the patient does not improve. (These are oversimplified summaries.) What is radical here is not these “mini” single-case narratives, but that the model of the dyadic/intrapsychic system has a reliable, measurable basis, and can be linked causally with symptomatic behavior and internal states. Jones’s measures of process attempt to be theory-free and descriptive. But we can begin to develop models of what happens in different treatment relationships from such studies. His research method follows Fonagy’s proposal (2003) that theory should emerge from clinical experience: “Psychoanalytic theory of mental function could then follow practice, integrating what is newly developed through innovative methods of clinical work” (p. 15).

I am proposing not that the answer lies in psychoanalytic research, but that it is possible to find regularities amid the complexity, that we do not need to fall back on received theory, and that there may be new models of process/mind just over the horizon. Perhaps we have reached a limit of how much we can discover solely through Freud’s methods—introspection and speculation from clinical data. Personally, I think there is always more to be mined by these tried and true sources, but it may also be that such ideas need to interact with outside ideas, such as those revealed by psychoanalytic research, or from contiguous disciplines, such as cognitive psychology and neuropsychology. Seen this way, Greenberg’s conclusion, that “we plead for one point of view over another in search of a certainty that I am afraid will elude us forever,” need not be the end of the story.