Abstract
Beginning Analysis presents a robust and original attempt at using qualitative research methods to investigate the processes and core dynamics underlying initial interviews in psychoanalysis. This book begins by providing a detailed foundation of a research project conducted as part of the European Psychoanalytical Federation’s Ten-Year European Scientific Initiative, in which the Working Party on Initiating Psychoanalysis (WPIP) was created to investigate “the specific dynamics of preliminary interviews, how psychoanalysts work with them, and what it is in these dynamics that leads a potential patient to enter full analysis (or not)” (p. 4). Written by an international team of eight senior psychoanalysts and members of the WPIP, the book compiles the work of hundreds of psychoanalysts who contributed their time and attention to investigating case material from initial psychoanalytic interviews. Analysis of the results presented here not only challenged the authors’ initial hypotheses, but also led to the creation of novel theoretical concepts that encourage further exploration, research, and reflection. As stated by the authors, it is crucial to understand how psychoanalysts really work, not simply how we would like to think they work (p. 3). I believe the authors have achieved this goal through their detailed, methodologically sound, and thoroughly elaborated work. Reading this book has encouraged me, as a clinician-in-training, to consider the unconscious dynamics underlying initial interviews and overcome my apprehension regarding initial sessions. Through their description of clinical case materials, the authors have normalized the experience of uncertainty that accompanies the initiation of a therapeutic relationship and highlighted the importance of openness and receptivity in the analyst to experience the patient as an individual while co-creating a space where change can be facilitated.
Reith and colleagues present the results of over eight years of discussions based on clinical case materials. The sheer scale of this research program is noteworthy and speaks to the significance of the findings. This book addresses two important limitations in the current state of knowledge and research practice within the field of psychoanalysis. First, as previous attempts to identify patient characteristics predicting the clinical decision to offer psychoanalysis have been unsuccessful, the authors have decided to turn to analysts themselves, with the goal of identifying analyst characteristics—or analyst-initiated processes—that predict whether or not analysis will be initiated. Second, concern has been raised regarding the appropriateness of employing quantitative methods to understand psychoanalytic processes and outcomes. In psychoanalysis, as with other fields in the human sciences, there is a burgeoning interest in qualitative methods that rely primarily on narrative data and qualitative interpretation of that data. For instance, Cartwright (2004) presents suggestions for the use of the initial interview as a tool for research in psychoanalysis, as it incorporates important empirical assumptions related to the construction of meaning, the associative nature of verbal material, contextual factors, and transference-countertransference impressions. For their research, Reith and colleagues sought to generate new theory based on careful, standardized, multi-staged qualitative observations of clinical material. The significance of this study lies not only in the types of questions that were asked, but also in the approach used to answer those questions. I am convinced by the authors’ argument for a novel systematic method of qualitative research in psychoanalysis.
The WPIP’s research strategy is best described as an attempt to develop grounded theory based on clinical case discussion groups (pp. 25–26). As psychoanalytic work is a “complex, contextualized and highly individualized process, largely dependent, moreover, on the patient’s and analysts’ subjective involvement” (p. 25), constructivist grounded theory provides the ideal framework from which to generate hypotheses grounded in clinical observations. The authors summarize the constructivist method of grounded theory (Charmaz 2006; Charmaz and Bryant 2011; Tweed and Charmaz 2012) as follows: “The method of grounded theory research is to generate hypotheses on the basis of an intensive and methodological study of detailed cases, and to test these hypotheses using the similarly disciplined study of new and varied cases, including atypical ones or counter-examples. Hypotheses emerge and are refined in an iterative process involving inductive analysis of the data leading to theory construction” (p. 26).
The authors developed their a priori working hypotheses based on the literature (e.g., Quinodoz 2001, 2003), expecting analysts to initiate psychoanalysis by “switching the level,” or helping patients view problems or life stories in a novel manner, which would then result in a “meaningful common formulation” that allows the analytic couple to move toward a productive and emotionally meaningful exchange (p. 28). The authors expected that these processes would be common to both “institutional settings” (where the interviewing analyst does not continue with the patient) and “private settings” (where the analyst can take the patient into treatment him- or herself) (p. 29). Importantly, the authors remained open to modifying or renouncing their hypotheses throughout the research process.
As the research program was carried out over twelve years and involved over five hundred psychoanalysts from around the world, it is understandable that the WPIP team would have multiple objectives and research questions. Attempting to isolate the specific research questions was no easy task, as the authors highlighted the intent, aims, and objectives of both the European Federation and the WPIP. Through a compilation of these objectives and questions, I have come to an overview of the questions the authors aimed to answer through this study: (1) What are the specific conscious or unconscious dynamics taking place between analyst and patient during initial psychoanalytic interviews. (2) What is the relationship between such dynamics and treatment choice? Through their analysis, the authors identified two specific dynamics underlying initial interviews—the “unconscious storm” (p. 76) and “opening the psychoanalytic space” (p. 78). However, the authors found no relationship between the presence of these dynamic processes and the decision to initiate psychoanalysis.
To address these research questions, the core unit of analysis was the individual case study, each of which included the following three elements: (1) initial interviews conducted by an analyst; (2) clinical workshop discussions of the case; and (3) WPIP team meetings discussing the case. This set of observations was collected for twenty-eight cases. Initial interviews included all interviews up to the recommendation to begin (or not begin) psychoanalysis; typically, this might be just one or two sessions, but it could be as many as five. Presenting analysts were asked to provide detailed process notes while protecting the identity of the patient, and their notes were shared with the WPIP team. Each case was discussed in a four-hour clinical workshop, both in a free-associative manner and in response to four questions developed by WPIP. Detailed process notes were taken by a WPIP observer attending each workshop, and proceedings were audio-recorded. Finally, the WPIP team met for periods ranging from four to twelve hours to discuss workshop findings on each case; to derive explanatory hypotheses for the dynamics observed; and to compare cases in a systematic fashion. Overall, this approach—eventually termed the “three ‘stage’ model” of psychoanalytic research (p. 58)—allowed the team to observe unconscious dynamics at all three serial investigative stages, as those dynamics were reenacted and re-presented by the analysts involved in various stages of the research process. As this enactment and representational process emerged repeatedly across cases, the researchers noted that the group exploratory approach worked partly by using a “parallel process” (p. 58) of unconscious anxieties and defenses as a tool to gain insight into the unconscious dynamics underlying initial interviews.
Although the WPIP team developed working hypotheses as part of their research program, these hypotheses were not supported by the analysis of case materials. Indeed, what the authors found was that aspects of transference and countertransference dynamics often overwhelmed even first encounters, influencing the developing analytic relationship, while being active even before the analyst and patient met (p. 75). Contrary to a hypothesized need for analysts to “switch the level,” the team observed that there was no need to prompt an upwelling of emotions or unconscious conflicts, as this happened immediately and spontaneously (p. 70). Given this result, the team adopted an appropriate concept from Bion (1979) to describe the common psychic change that occurs when two individuals first meet in an analytic setting. This phenomenon, which Reith and colleagues call the “unconscious storm,” 1 was “often experienced internally by one or both protagonists, and it always seemed to be active unconsciously, whether or not it was noticed in subjective experiences” (p. 76). Following the experience of this metaphorical storm, the team argued that psychoanalytic work involves a process of “‘opening psychoanalytic space’ so as to create a relationship in which the ‘storm’ can be dealt with and may have a chance of finding meaning” (p. 76). The concept of the psychoanalytic space, originally introduced by Freud (1914), considers the transference-countertransference dynamics between patient and analyst and the role of the patient-analyst pair in co-creating a space where change is facilitated. Overall, these two common elements of all initial psychoanalytic sessions are critical to understanding how two individuals can meet and initiate an analytic relationship. The experience of opening psychoanalytic space and “‘weathering’ the ‘storm’” (p. 82) is entirely subjective, yet it appeared to be a common aspect of all first psychoanalytic sessions.
The methods implemented by the WPIP team included a rigorous attempt to use clinical workshops for research purposes in psychoanalysis. Strengths relevant to the validity and reliability of the study are twofold: (1) the fact that patterns were observed and a consensus was reached to describe the phenomenon by a variety of psychoanalysts from varied cultural backgrounds, in varied theoretical frameworks, and (2) that the unconscious dynamics remained observable through parallel processes after each stage of the investigative process. Further, the fact that all twenty-eight cases were studied in a systematic fashion—with specific aims—speaks to the time and energy involved in developing and ameliorating the study protocol. However, this study also has noteworthy limitations, including potential bias in the cases the presenting analysts chose to present, and the manner in which these cases were discussed in the clinical workshops. Since discussion questions were developed with the aim of testing predetermined hypotheses, the results of the study might have been different had the clinical workshops been dedicated purely to open-ended discussion among the analysts. Nevertheless, these findings are convincing, and speak to the therapeutic process more broadly. It seems that certain common factors (Asay and Lambert 1999) are present in all initial meetings between a patient and a therapist/analyst. Whether a therapist’s practice is informed by a psychoanalytic framework or not, the unconscious storm will still be present, and the therapist will have to find a way to remain open and create a space where the patient can engage in a meaningful and transformative interaction.
The book ends on a reflective note, revisiting the aims of the research program and how the identified dynamics make a significant contribution to understanding the process and dynamics of initial psychoanalytic interviews. As a whole, the authors have accomplished their aim of generating theory grounded in clinical observation. Reflecting on their experiences, the authors speak to the importance of training and supervision in psychoanalysis and how an analyst’s “internal frame” (p. 176) plays an essential role in the ability to make room for the client, which in turn would allow for meaning to emerge. Additionally, the authors make it clear that to best understand and help the patient, analysts must be open to experiencing the unconscious storm within the first few sessions, as “psychoanalytic work is an embodied experience” (p. 173) that requires balance. This balance must be established in the analyst’s use of theory, in taking on an observing role, and in intervening. Overall, the authors hope that through their presentation and analysis of clinical cases, readers are able to confirm what they already knew from their clinical experience and recognize how the experience of “weathering the storm” withstands the methodical scrutiny of case materials by hundreds of analysts from around the world.
