©2004 Institute of Psychoanalysis

Multiple approaches to a single case: Conclusions

Psychic change: What and how?1

ARNOLD WILSON, Reporter144 Union St, Montclair, NJ 07042-2124, USA — Dr.arnoldwilson@verizon.net

ROBERT WALLERSTEIN, Moderator290 Beach Rd, Belvedere, CA 94920, USA — judywall@fi rstworld.net

This panel concluded the ‘Multiple approaches to a clinical case’ series, wherein

clinical material from the audiotaped analysis of Amalia X, presented by Helmut

Thomä and Horst Kächele, was studied from multiple perspectives. The task of this

wrap-up session was to integrate the several panels that preceded it under the ambitious

goal of determining the what and how of psychic change in psychoanalysis.

Robert Wallerstein’s introduction noted that there are three main questions

that run through the recurring considerations of the nature of therapeutic change in

psychoanalysis: (1) the role of supportive vs. expressive-interpretive factors; (2) the

roles of insight vs. the analytic relationship; (3) the relationship of psychoanalysis to

the derivative psychoanalytic psychotherapies. Wallerstein proposed evaluating the

three major presentations from the three major theoretical perspectives in worldwide

psychoanalytic praxis, from the point-of-view of the stands each takes in relation to

these three framing questions.

Juan Pablo Jiménez divided the initial presentation into two sections. In the fi rst,

he emphasized the value of a pluralistic psychoanalysis, one that must serve two

masters, both plausibly integrating different theories as well as maintaining internal

coherence. The second part of his presentation addressed the prior clinical track

panels, and discussed the issues along four dimensions: (1) what made agreement

diffi cult was that everyone defi nes clinical material from a very different point of

view; (2) everyone struggled with how to discuss clinical material in a respectful way

and avoid the temptation to ‘supervise’ the technique of the Ulm-based presenters;

(3) an exuberance of theory and scarcity of empirical observations was noted as a key

aspect of the observed relationship between theory and practice; (4) there was a wide

consensus throughout the panels that, no matter what the differences in theoretical

perspectives, the patient–analyst dyad was proceeding in a way that could be described

as characterized by a ‘psychoanalytic process’, and what was interesting was that

panelists of different persuasions provided different descriptions of how the sessions

were evolving, although all agreed that a psychoanalytic process was present.

Int J Psychoanal 2004;85:1269–71

1Panel held at the 43rd Congress of the International Psychoanalytical Association, New Orleans, USA,

13 March 2004. Panelists: Juan P. Jiménez (Santiago de Chile), Cecilio Paniagua (Madrid), Allan

Compton (Los Angeles).

1270 ARNOLD WILSON

The second presenter, Cecilio Paniagua, addressed the evolving understanding of the relationship between change and the assumptions psychoanalysis makes about change. It is no longer tenable to assume that only insight-driven classically focused psychoanalysis yields structural change. Rather, there is a wide range of quantitative changes obtainable in the different modalities of verbal treatments, but this range is so wide that ‘quantity ends up making quality’. Further, the close knit of the interdependent variables to be conceptualized has made it impossible to defi ne what specifi c factors are responsible for specifi c changes at specifi c times with specifi c patients. However, broadly speaking, Paniagua emphasized that the evidence favored the view that the psychoanalytic approach to sponsoring change can be conceptualized as the promotion of ego maturation conveyed through empathic attitudes that facilitate benefi cial internalizations. It is also the case, then, that therapists differ technically and characterologically in their talents to provide these features to particular patients. Paniagua concluded by saying that, although change can be realized by many verbal treatments, many diffi cult but unanalyzable cases are beyond the scope of any treatment modality except psychoanalysis, and that psychoanalysis remains a unique and unsurpassed treatment for certain patients who present certain confl icts.

The third presenter, Allan Compton, attempted to tease apart the characteristics of a theory of treatment from a theory of the mind. Tactically, to respond to Wallerstein’s charge, the major problem is to get back and forth from Wallerstein’s three questions to the data of the case presented. However, we cannot address Wallerstein’s three questions with respect to the case because all three questions are about comparisons between treatment forms, whereas all we have available in this instance is the intensive study of a single case. Since all we have is this one treatment, we would need more than one patient and more than one analyst treated according to one theory in order to make the inductive generalizations about the hypotheses that follow from that theory.

However, there are things that can be studied in a single-case format with the present material. Compton carefully traced in the clinical material the evolution of both murderous and erotic components, and how this contributed to the patient’s acquisition of insight as well as increasing trust in the analytic relationship. He then suggested that neither the one nor the other, but (as is always the case) a particular combination of the two contributed to the benefi cial outcome of Amalia. In a limited sense, this understanding addresses Wallerstein’s second question. From this particular perspective, insight and relationship can be seen as linked, when both parties almost seem to know what each other is thinking, talk in metaphors they both understand and share, and when both participants have actively brought about crucial therapeutic moments of being together. This can usefully also be understood from the perspective of brain changes, but that is a different albeit valuable perspective.

A good deal of discussion followed these presentations. Helmut Thomä, who conducted and audiotaped the analysis of Amalia X, made clear that this particular analysis was chosen from the Ulm archives to be presented for a number of reasons, in particular that there was a positive correlation of two important aspects of any successful analysis—the relationship and the tool of interpretation. Also appealing

1271MULTIPLE APPROACHES TO A SINGLE CASE: CONCLUSIONS

was that the mechanism of displacement is clearly evident in the clinical data. Thomä also asked an interesting question: how come the strong sense of analytic change in this case is not clear in the clinical discussions? The assessment of change can be found in the empirical measures, but not in the clinical discussions, and this was termed a ‘sad joke’. Other discussants raised some germane and interesting questions. The issue of how demonstrable emergence at the point of change can be documented was discussed. How do we make sense of the manner in which technique applies only in certain situations? Does the separation between analytic schools make sense any more? Whereas 15 years ago, at the IPA congress, it was asked of the members: ‘one psychoanalysis or several?’, the pluralism that followed is not necessarily going to benefi t the future of psychoanalysis. Striving to end the separations between schools may help psychoanalysis to confront the questions introduced by this panel.