Says’ Who? : Evidence, Fact, Belief in Clinical Psychoanalysis
by Mitchell Wilson, M.D.
SFCP, along with PINC, hosted a conference on October 19 and 20 that engaged the question of the nature of clinical evidence. This conference was sponsored by the IPA’s Committee on Clinical Research. We had over 50 people on Saturday and about 30 on Sunday. Most felt this conference was unusual and exciting because it dealt with an issue that is rarely discussed explicitly The quality of audience participation was especially high. Apropos of the title of the conference, “Says Who? ”, we hoped to minimize the usual issues of authority that often dominate large proceedings of this kind.
The task was daunting: how do you set up a conference about “evidence” that is alive, clinically relevant, and captures key aspects of how a clinician forms ideas and beliefs from feelings and theories? The committee organizers (myself, Bill Glover, Joe Caston, Maureen Murphy, and Don Moss) decided to create an experience for the audience that had the feel of clinical work itself; we made the conference as inductive and on-the-ground as possible. Though we had experts come from far away (Marilia Aisenstein from Paris and Ricardo Bernardi from Uruguay), we emphasized the personal and subjective aspects of how each of us goes about shaping an idea about the patient and an idea about the clinical process being heard. What does each of us look for and why? We were also interested in basic assumptions/theories analysts bring to listening. Our method was to read aloud detailed process from one clinical hour in the morning and have our panelists discuss it. Of note is that little history of the patient was given, nor was any information about the analyst’s counter-transference. Then we had break-out groups for the audience to weigh in with their impressions.
Saturday afternoon we read aloud a second hour, discussed it as a panel and with the audience. Sunday morning we talked, panelists and audience, for nearly three hours about the two clinical hours, and struggled with the question of how we know what we think we know, and how some of us might change our minds about what we think we know.
Key findings include the following:
- Evidence is a problematic concept.
- Evidence is “for” something: to assess the nature of patient’s psychopathology and quality of clinical process.
- The analyst’s theory strongly informs both assessments of psychopathology and clinical process.
- Yet, evidence seems to be for a theory in a circular manner.
- How can we use evidence in a non-circular way? Does evidence arise in the analyst? This was hard to get at, though a few audience members had much to say about this aspect.
- If the clinical process seems problematic (as in hour #2), then thinking about evidence was harder for the audience.
- Many were frustrated that history and countertransference were omitted from the clinical report. But some felt this method made sense in that we wanted each participant to consciously consider what kinds of evidence they typically rely on.
- The notion of evidence seems to bias us in a positivistic direction. There were few mentions of more experiencedistant unconscious fantasy.
- It is difficult for analysts to stay on a self-reflective level regarding evidence; the temptation to discuss the clinical case as if this were a case-conference is strong.
- Analysts like to see the material progress and have different “grids” with which to make this assessment. These grids were discussed in detail.