Dear colleagues,

I would like to thank Dr. Prall for his comments which contribute with new perspectives to the discussion.

I also find this exchange very stimulating. It invites us to look at problems from perspectives that are different from our own, and that brings us new challenges. I believe that this is a valuable function of controversies and in this sense our dialogue constitutes in a certain way a parallel process that makes us reflect about how we are debating about debates.

My impression is that we are talking about the same things, which is not frequent in controversies, although, naturally, each of us in our own way. We have achieved a perceivable degree of agreement regarding which were the aspects that were interesting to discuss. The agreement was smaller regarding how much and how these differences could eventually be settled and about the means (reasons, arguments) that would enable us to achieve it. I will refer to these aspects.

I can completely coincide with Dr. Prall when he says “we have no better option than to put our faith in the possibility that it is the better (truer) stories/theories which, over time, gain more traction on 'reality' and therefore equip us better to deal with this world, this life.” I don't know if I'm attempting to take the agreement too far if I add that in order to achieve that traction about reality it is necessary that we put in the first place the benefit of the patient above the factors that inevitably put pressure and even condition our ideas and that have origin in authority, prestige and cultural and institutional trends.

Running the risk of being considered outdated in this post-modern time, I must admit that I keep respect for certain ideals of the Enlightment. Without adoring the Goddess of Reason, I keep faith in the possibility of some form of reasonability, so as to use Toulmin's term. I accept that our personal and cultural constructions give shape to reality, but I believe that there is still something out of our mind capable of refuting it and force us to seek new ones. I believe that in some good times, with a calm see and favourable winds the reality principle may talk a little louder than the pleasure principle and that narcissism of small differences may leave place to superior forms of narcissism. These general principles certainly are not enough to solve all our differences, but if we apply them to the seeking of the benefit of the patient, maybe it is possible to advance in some directions.

I have not been able to understand well the expression “au contraire” used by Dr Prall to refer to different forms of the ideas change process. This may be due to my limitations with English language, but I see more complementarity than counterposition. For greater clarity I will take as an example the controversies that happen in the "internal forum”, I mean, not in the public "science forum" but in the deliberation and “dialogue interieur” that takes place in each analyst when (s)he reflects about her/his work with patients. Certain changes happen in an unperceivable way, but at other times the analyst also faces clinical and theoretical dilemmas that take him to confront ideas “in order to challenge each other and to hold each other to account” using Dr. Prall's terms. This aspect of struggle and competition is inevitable, often being painful and sometimes dramatic. When I asked analysts about how their ideas change they talked about processes that imply only the competence among ideas, but also internal processes of the loss of identifications and acquisition of new identifications, that put into play loyalties and rivalries with masters and colleagues. If from the intellectual point of view, paradigm change implies, as Kuhn says, a gestalt change, from the emotional point of view it puts into play idealizations, narcissistic balances, affiliation or exclusion, feelings of love and hate of different nature. Precisely because these emotional processes are very intense, I believe that it is necessary to foreground the arguments based on the benefit to the patient. At the risking to being too optimistic, I believe that in this way, "selected facts" can prevail over "overvalued ideas" (Bion, Britton &Steiner), and in the long run, diminish the absolute character of unquestionable paradigms, leading to a more critical and personal thought. (It may also lead to the conversion of another unquestionable paradigm). But usually the degree of change is not great and it is probable that, as Kuhn states, changes of paradigm are changes that happen more at a generational level rather than at the individual level.

As a matter of fact certain ideas were widely disseminated and were adopted by analysts of different psychoanalytic cultures (e.g.: reverie, holding, empathy, the Lacanian idea of father’s law, etc.), because they are valuable, clinically useful, and they have inner resonance in the analyst. Interestingly, these ideas (or metaphors, or mini-models) carry with them the seed that transforms the previous implicit theories of the analyst. They question the idea of a unique and unquestionable system of thought. The core ideas of psychoanalytic approaches are certainly immune to controversies, but their clinical consequences can be challenged by facts which  allow the competition of arguments from multiple sources. The open and indefinite debate of the strengths and limitations of these arguments help in the long run to settle the differences… or at least to open the door to a new generation with new ideas. 

Once I had written this answer to Dr. Prall, I received the comments by Dr. Luepnitz and Dr. Hogenson, which seemed very stimulating to me because they propose the type of arguments that may make controversies advance.

Dr. Hogenson underlines the complexity of the relation of psychoanalysis to the Geisteswissenshaften and the Naturwissenshaften. As a consequence we can ask ourselves: Should our controversies depend mainly on arguments based in the empirical or hermeneutic sciences?

Some authors, like J. Laplanche, place psychoanalysis “between” natural sciences and hermeneutics.  I would prefer that psychoanalysis encompasses questions that belong because of their nature to one or another of these fields, but also include core questions that can only be undertaken by its own method.

I agree with Dr Hogenson about the convenience of confronting our ideas, e.g., of transference and countertransference with the findings of neuroscience. Here we have a vast field of issues that can be settled by research. For example, to what extent is empathy related to the activity of mirror neurons? Or should we include the whole right brain whose role is fundamental in pre-verbal development? Or do we have to consider the more complex neural structures related to attachment and sexuality? Etc. In a similar way we can discuss and reach agreements (always provisional) regarding brain changes related to different kinds of psychotherapy, and compare this changes with those related with drugs or placebo. Or the activation of brain structures during dreams, etc. Research procedures can, to a certain extent, help to settle differences. The consilience of a psychoanalytic hypothesis with other disciplines is a strong argument in favor of this hypothesis.

However, we must recognize the limits of that kind of arguments. To what extent can we read the mind reading the brain? I am not an expert in this field, but philosophers like Davidson and many others have expressed caveats regarding this topic. Qualia are not detected by scans.

In my opinion, the same warnings are valid in relation with hermeneutics. The permanent risk in this field is the attraction of mystery, revelations and religious thinking. Perhaps the relation with art is more fruitful if we focus on the power of metaphors to communicate (or perhaps it is better to say to create) inner experiences shared by analyst and patient. These metaphors also provide arguments that can put us on the road to settle differences if we do not ask them to act as geometrical principles nor like seductive rhetoric, but as an appeal to resonance with inner experience.

However, I would not say that the core of psychoanalysis is natural science or hermeneutics but, as Green says, psychoanalysis is basically a “pensée clinique”. That means, in my opinion, both natural science and humanities (as we are both body and mind).

This issue leads me to Dr, Luepnitz' invitation to say something more about the possibility of using clinical observation as a way of establishing agreements and disagreements among analysts with different approaches. I have proposed to the IPA´s Committee on Clinical Observation (of which I am a member) to develop a guide or heuristic (called Three-Level Model or 3-LM) aiming at a systematic observation of patient transformations during analysis. The material to be discussed are the first interviews and later sessions (months or years later) selected by the analyst because of their usefulness to access if there are changes (positive, negative or no changes at all). It´s an observation of the observations, since groups of analysts discuss trying to go beyond the analyst’s description of the material. Transformations are described from three consecutive levels or steps: first, from a phenomenological perspective, seeking for the immediacy of the analytic listening of the material. The second level intends to identify the main dimensions of change, selected from diagnostic systems, especially the Operationalized Psychodynamic Diagnostic (OPD-2), the Psychodynamic Diagnostic Manual (PDM) and scaled of mental functioning (DSM-5, 2010 draft). The third level discusses the explanatory hypotheses of transformations, firstly the explicit and implicit theories of the analyst and then other alternative hypotheses emerging from different theoretical approaches.

This model was applied in different regions for group discussions, and the participants are invited to use plain language, as if it were an informal conversation with a colleague. The level of agreement in level 1 and also, but less, in level 2 is astonishing. Level 3 is more conditioned by school preferences, but in one of the last experiences, level 3 discussion was more focused on partial theories, e.g., about trauma and adolescence and at the end of the discussion one of the participants commented that, after many hours of discussion, she would not be able to identify the theoretical preferences of the other colleagues. (More information about this can be found in https://sites.google.com/site/clinicalobservation/; in http://youtu.be/2R4a1vFAG78; and in a paper currently in press).

Best regards to all,

Ricardo Bernardi 

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