ARTICLES

 

Images of psychoanalysis: a phenomenological study of medical students' sense of psychoanalysis before and after a four-week elective course

 

 

Maurice Apprey

Professor of Psychiatry University of Virginia School of Medicine Charlottesville, VA, United States of America E-mail address: MA9H@hscmail.mcc.virginia.edu

 

 

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ABSTRACT

In concept, an image has both verticality and horizontal dimensions. Saturated images within this space have a horizon and can exceed that horizon. Within that horizon where the image dwells something chances itself upon the observer and the observed. Into that public space between self and other, students bring an instrumental approach to how they plan to deploy their new fund of knowledge, only to discover that the setting itself has become an event where surprise and upheaval disrupt their illusion of self-continuity and the façade of familiarity. Phenomenologically, upheaval shows itself when givenness both precedes and participates in the giving of phenomena such as medical students' "before and after" images of psychoanalysis. They discover and reconfigure their erstwhile absolute positions and values into reconfigurations of self and prior commitments. The turning point from their instrumental use of knowledge to reconfigurations of how they situate themselves in the world decisively comes when teaching and learning become an event in se that disturbs their sense of order.
Following Husserl, phenomenological psychological observation has required us to go from the events of history to a sense of history. Would, however, that we could stay at the level of events much longer to see images explode and exceed their horizons from the illusion of order, and patterned repetition disrupted by surprise, upheaval and indeterminacy in the spirit of Alain Badiou!

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Context

In 2014 the International Psychoanalytical Association (IPA) set up an Image Task Force chaired by Angela Mauss-Hanke to study how the field of psychoanalysis is perceived by non-psychoanalysts. This paper reports on one of multiple studies to achieve that end.

The idea of an image is not a formal psychoanalytic concept but a descriptive one within the field of psychoanalysis. Therefore, it is not a topic that has a cadre of published papers in psychoanalysis. For that reason, this account of the subjects' images of psychoanalysis goes outside the field of psychoanalysis to deploy a descriptive phenomenological praxis to capture shared representations of the field of psychoanalysis. I will cite the work of Jean-Luc Nancy and Jean-Luc Marion to provide conceptual borders for this study. This study is therefore not a study to add to the already rich body of either phenomenological philosophy or phenomenological psychology. Rather, this study is a limited use of a phenomenological praxis to capture a profile of the images medical students bring to medical school on their journey to become physicians and what happens after a four-week period of study. What will they do with a nuanced account of psychoanalysis within their medical training? The subjects in this particular study are fourth year medical students who are taking a four-week intensive course on Freud, Klein, Kohut and Fairbairn and are interested in psychoanalysis for any number of reasons. After this fourth year, they would enter post-graduate residency programmes in psychiatry, pathology, paediatrics, anaesthesiology, obstetrics and gynaecology, among others.

After capturing the intersubjective constitution of these medical students' image or view of psychoanalysis, we shall dialogue our phenomenological findings with both psychoanalysis and phenomenologists in the broader field of Continental philosophy where applicable.

 

Introduction

If we are going to study images of psychoanalysis with a phenomenological praxis, we need to proceed from an understanding of what phenomenology is. In essence, it is a methodological attitude proposed by the German philosopher, Edmund Husserl, for looking at problems in the human sciences so that we may reflect on them and ask new questions accordingly. It is an open-ended praxis that requires a problem-centred attitude. This methodology is therefore a fitting one for studying shared images of psychoanalysis within a sample of medical students who have chosen to study psychoanalytic theories in a fourth year elective course. This study will thus give us an opportunity to study external world images of psychoanalysis in the first instance, and then to observe what those findings can contribute to psychoanalysis. In the end, external fields of reference to the internal world will interact with internal fields of reference to the outside.

Long before phenomenology became a disciplined psychological research methodology, the psychoanalyst Heinz Hartmann (1964), well-known for his work on ego psychology, echoed Kronfeld (1920) in defining phenomenology as a preliminary approach for the study of any psychological theory that seeks to explain human phenomena genetically, that is, developmentally, to translate the denotation of "genetically" into modern psychoanalytic discourse. As such, for Kronfeld (1920), phenomenology is "a preliminary approach in the same sense that any psychological ontology is" (p. 394). More poignantly, Kronfeld adds, it is the precondition for the formation of theories; a precondition that nevertheless demands such theories. For, otherwise, phenomenology would remain essentially incomplete.

 

From Basic Assumptions to Method of Inquiry

It must be stated before we venture far afield that the term "image" is what the International Psychoanalytic Association used when they formed a research group to determine how the field of psychoanalysis tends to be viewed by non-psychoanalysts. Here image is very broadly conceived, and intentionally so, in order to allow the findings that emerge to include a wide range of conceptualizations comprising, among others, perception, representation, misrepresentation, prejudice, stereotypes, and so forth. My task here is not to debate the issue but to pose the question to non-psychoanalysts as such.

Nuanced descriptions would therefore come out in the results. For that reason, the probe question posed in the present study is as follows: "What was your image of psychoanalysis before taking this elective course, and what is it now?" Without presupposition, it is our task to collect and faithfully reflect the subjects' images as they present them, and then to interrogate their naïve descriptions in a systematic way.

At the level of theory, broadly conceived, we have located several key thinkers in contemporary French philosophy - Jean-Luc Nancy, Jean-Luc Marion, Alain Badiou and Francois Laruelle - who, along with Robert Sokolowski, are noted for their explication of their arguments for the closure of metaphysics. While this study is not about the closure of metaphysics, these particular scholars provide borders, pivots, direction and evocative metaphors that can enrich the deployment of a phenomenological method without compromising its frame or prejudicing our findings. I will demonstrate how their conceptual borders, pivots, direction and ruling metaphors fit into Giorgi's open-ended praxis in ways that can enrich and deepen our findings. At the end, I will brace all that synthesis and enrichment on Giorgi's praxis and extend its ends by, in the context of the current study and in dialogue with its theoretical framework, asking the following: "What happens when the elective itself becomes an event for our students?"

In my use in this study of phenomenology to provide a broad conceptual frame within which to give an account of medical students' shared sense of psychoanalysis, I will therefore deploy Sokolowski and four contemporary French philosophers who have done substantive work in the area of French reception of German philosophy, notably, Hegel and Husserl.

Certain conceptual depictions of an image present themselves. We therefore start with a strategic and visual use of borders of the image between ground and sky to delimit the scope of our inquiry without risking presupposition. Vertically, Jean-Luc Nancy (2003/2005) tells us the following in a very powerful passage in his book, The Ground of an Image:

Every image has its sky, even if it is represented as outside the image, or is not represented at all: the sky gives the image its light, but the light of an image comes from the image itself. (p. 6; emphasis added)

Having suggested the verticality of an image, Nancy continues as follows:

The image is thus its own sky, or the sky detached from itself, coming with all its force into the horizon but also to take it away, to lift it up or to pierce it, to raise it to an infinite power (p. 6; emphasis added).

This verticality will now make room for a horizon that can both contain the image and overflow it. What must we do with what is contained within the horizon and that which overflows the horizon?

Enter Jean-Luc Marion with his attempt to give us an account of absolute givenness, saturated phenomena and the surfeit of intuitions that overflow the horizon.

Marion's project is to overcome metaphysics without arriving at essences or grounding principles. To that end, Marion asks if the givenness in presence of each phenomenon can be realized without any condition or restriction. The phenomenological reduction conducted by deploying Husserl's epoché would, in the hands of Marion, become the privileged practice. The epoché or bracketing of phenomena would enable the interrogating subject rigorously both to describe and circumscribe the phenomenon that gives itself.

What would Marion do with his account of Husserl's praxis? If, for Husserl, as Marion notes, givenness precedes and participates in the active process of giving, how would Marion then appropriate Husserl? Marion explicates, extends and expands this double meaning of givenness and the act of giving to arrive at the conclusion that "so much reduction, so much givenness" (Marion, 1989/1998, p. 203) must lead to this absolute irreducibility: "Givenness alone is absolute, free and without condition, precisely because it gives" (Marion, 1989/1998, p. 33).

If he wants to exceed the limits and conditions that he considers are imposed by Husserl's phenomenology, what, then, would be Marion's strategy? He introduces the concept of saturated phenomena - phenomena that tend to be classified as exceptional or marginal - in order to enrich our understanding of phenomenality beyond that of everyday phenomena such as objects. He describes four modalities that show themselves as saturated phenomena: (i) event, (ii) idol, (iii) flesh, and (iv) icon.

Under the rubric of event, eventness is the priority that rules all phenomena. It is saturated in that the impact of a historical event is felt by an entire population or multiple populations. The meaning of a historical event cannot be grasped by a single interpretative gesture. Independent of any constituting subject, the phenomenon of eventness and what that means depends on ongoing and infinite processes of deciding what that event means to a population or how that event defines a historical community. James (2012) paraphrases Marion's notion of the saturation of events as follows: "The event imposes itself upon a collectivity of individuals in excess of any singular intentional directedness or horizon of expectation" (p. 34; emphasis added). In Marion's own words: "The plurality of horizons practically forbids constituting the historical event into one object and demands substituting an endless hermeneutic in time; the narration is doubled by a narration of the narrations'" (Marion, 1997/2002b, p. 229; emphasis added).

Under the rubric of idol as a saturated phenomenon, Marion points to a work of art as a privileged example. Here, the saturation occurs when a surfeit of sensible intuitions or sensory perceptions makes it difficult to account for a definitive meaning of a work of art. Due to this surfeit of sensible intuitions, a definitive accounting of meaning must be deferred.

Under the rubric of flesh, Marion writes as follows: "Flesh shows itself only in giving itself - and, in this first 'self', it gives me to myself" (1997/2002b, p. 232).

A first self, flesh is thus the originary sense impression that constitutes auto-affection. Prior to any intentional directedness of consciousness to any objectal phenomenon, flesh is the fundamental, originary medium of givenness that gives all affects attached to pleasure, pain, joy or suffering. As such, flesh therefore exceeds all intentions, significations, categories or classification.

In contrast to the idol, icon offers nothing to the gaze. Not accessible to the gaze, icon operates in reverse. Operating in reverse, the icon imposes its own gaze upon the spectator. The icon is, then, the gaze of the other upon me as a donné. The icon is therefore not constituted by intentional consciousness.

The phenomenological psychological researcher must now ask Marion:

What if that which gives itself, as in the image of psychoanalysis, falls outside the boundaries of his four categories of saturated phenomena: event, flesh, idol and icon?

We thus have a possible methodological limitation to Marion's account of phenomenology. However, we can retain his reading of Husserl, where givenness precedes and participates in the process of giving, as well as his own privileging of absolute givenness. This we can definitely use.

If givenness precedes and participates in the process of giving, what happens in the public space between the subject that perceives and the phenomenal object? For a handle on this, we turn to Robert Sokolowski's (2008) explication of the public space between the interrogating subject and the phenomenal object.

Even though Sokolowski's (2008) critique of Husserl was anticipated by Giorgi's (1975, 1985) creation of a phenomenological praxis for studying the phenomena of human experience - is it nevertheless possible to find a place for Sokolowski's critique of Husserl within Giorgi's praxis?

Before attempting to answer that question, let us follow Sokolowski's argument in his critique of Husserl, which leads to the creation of an intersubjective praxis intended to be used to enrich Husserl's constitution of judgment or predication. In Sokolowski's words,

Husserl's description of the constitution of judgment or predication has the advantage of relating the knower directly to the thing known. When we predicate, we do not merely rearrange our mental representations of things; we allow the things themselves, the things given to perception, to appear in a new, more structured and articulated way. (p. 58)

In order to "improve" Husserl's account, Sokolowski (2008) strives to increase the publicity between two or more people who articulate an object in common. When two people perceive the same object perspectivally, "one person draws the other's attention as well as his own to the object as a whole. The speaker names the object; the speaker establishes a reference for self and other by naming the object. The object becomes the subject that is going to be articulated. By using another term, the predicate, the speaker draws the attention of the interlocutor to some profile or feature of the object/ subject. By conjoining the subject and predicate terms, the speaker articulates "a new, fresh registration for the speaker as well as for the listener" (p. 59). The speaker thereby "'installs' categoriality into the experience and the object" (p. 59) both for himself and/or for the other.

Following the installation of categoriality into the experience for self and other, Sokolowski states that "I would hold on to everything Husserl says, but I would locate it more clearly in an intersubjective context, and I would claim that the categorical forming ... is the achievement not of a single mind but of one mind working with another ... and doing so in public" (p. 61).

In attempting to picture conceptually the idea of an image, where have we come from and where are we going?

We began with Nancy's verticality of an image and imagined with him what happens when the container overflows its horizon. From Marion we gained the idea of an event as a saturated phenomenon. Then, following Sokolowski, we asked what is achieved in the event of two minds intersubjectively creating categoriality in the public space between self and other. Even though he does not call this achievement an event, it is a place of negotiation between two minds about what gives itself and participates in the givenness.

Alain Badiou (1988/2005) now follows, with an elaborate conception of being as multiple, inconsistent, and yet being inside a subset. This will have implications for what it means for humans to be inside, always within, and how our breaking out of the enclosure irrupts as the quintessential event.

But first let us patiently and systematically follow the argument presented by Badiou, never losing sight of the event as the irruption and breaking out from within.

In this praxis, ontology must address what can be said of being as a being as a starting point. The being of an object then is "what remains once all its contingent qualities or predicates such as weight, shape, colour, and material composition ... have been subtracted" (James, 2012, p. 135). What remains is the multiple; the multiple that is inconsistent and non-unifiable.

In line with his philosophical project of determining ontology as mathematics, he reworks the philosophical question of the one and the multiple. Specifically, he names the reciprocal relationship of the one and being as the inaugural axiom of philosophy. But how is Badiou going to align the figure of one with being?

I. If being and the unity of oneness are reciprocal, then multiplicity is not.

II. Nevertheless, since the concrete presentation of being is invariably only a presentation of multiplicity, and

III. Since multiplicity undeniably is, in se, the reciprocity of being, the sense of oneness must be reworked.

IV. "If, then, philosophy does orientate itself according to the axiom that being and the one are reciprocal, then the impasse of the one and the multiple is the exact point where 'philosophy is born and buried'." (Badiou, 1988/2005, cited in James, 2012, p. 137; emphasis added)

If philosophy is henceforth born and buried, Badiou's decision becomes "the one is not" (Badiou, 1988/2005, p. 23). If the one is not anything that is or exists, the one is but an operation of counting as one (ibid., p. 24).

Let us now reiterate Badiou's praxis in the following distribution before addressing its implications. I shall paraphrase and schematize them:

1. Subtract all contingencies from the objectal phenomenon and you get a pure being.

2. This being is multiple, and yet not a totalizable multiplicity but an inconsistent multiplicity.

3. 1 ≠ multiplicity.

4. We have an impasse.

5. Consider, then, mathematics as a procedure of counting as one.

6. We now have a presentation of a presentation.

7. This presentation of a presentation can serve as a template or definition of bodies with a correlate of subjectivizable bodies.

8. Representation is born in the opening of a space of creation that requires destruction.

9. The imperative of being or of becoming a subject requires destruction and creation.

10. The implication of destruction and recreation that follows enunciates the philosophical task: namely, to interpret the world and change it.

To summarize Badiou - the capacity to realize the fecundity of purposeful life is what it means to be a human subject. In his work, there is no recourse to divinity, but rather to open-endedness and fullness of life. This capacity to realize the fecundity of life requires that human beings be able to elevate themselves to the grandeur and dignity of ideas that they can make their own.

Lastly, we ask whether our medical students are bringing with them shared images of psychoanalysis that are pre-representational, representational or transcendent. And how can we move from presentation of being to representation?

If this question is pertinent, we can turn to another philosopher intent on bringing closure to metaphysics by creating what he calls "non-philosophy". In the work of Francois Laruelle (1986/2010), thought leaves the terrain of philosophy by leaving behind philosophy's structuring principles. Laruelle leaves the structuring principles of philosophy behind by suspending them in a new discursive gesture, new thinking, new theory or new knowledge that becomes what he calls "non-philosophy". His is a new gesture that privileges the principle of indwelling. The principle of indwelling, or being intrinsic to something, characterizes the actuality of the real existing of that which is; that is, that which exists independently prior to any conscious apprehension of it.

To give immanence the thought that it merits, it must be understood as that which is One, and as such thus undivided, independent, and resistant to conceptual transcendence and understanding. This One exists before splitting, which accompanies conceptual abstraction, shall have taken place.

Laruelle's philosophical decision, then, goes from presentation of being to representation in a sequence of steps, which proceed from conducting a systematic search for invariants and irreducible structures so that immanence and transcendence are (i) posed, (ii) divided, (iii) mixed, and (iv) synthesized into a greater unity.

 

Integration into Giorgi's Praxis of Nancy, Badiou, Sokolowski, Marion and Laruelle

In order to demonstrate where our new metaphors fit into Giorgi's praxis, let us be purposefully schematic.

Giorgi:

Maintain the original Step 1 (collecting naïve descriptions of a phenomenon like the image of psychoanalysis); Step 2 (breaking up the naïve descriptions into meaningful units); Step 3 (interrogating each meaning unit and determining eidetic psychological essences without essentializing them; and Step 4 (synthesizing the essences into structures of experience).

Badiou:

In Step 2, treat each meaning unit as both a discrete unit, the count of one, as well as a possible subset of the whole phenomenon under interrogation. Without analysis of the naïve descriptions at this point, the researcher notes his or her intuitions of the embedded intuitions of that which gives itself.

Sokolowski:

Transition into a co-creation of meaning in the public space in Step 3, treating the engagement of each unit to be interrogated as an opening for a public space between the interrogating subject and the phenomenological object.

Marion:

In Step 3, bracketing of prior knowledge is now absolute, as is explicating saturated objects as well as other objects that give themselves outside the categories of Marion's saturated phenomena.

Laruelle:

In the discussion of the structures of experience, make a philosophical decision on the invariants identified in Step 4 leading to immanence and transcendence as (i) posed, (ii) divided, (iii) mixed, and (iv) synthesized.

We are back to Giorgi's relatively open-ended Husserlian phenomenological psychological research praxis that allows for what gives itself to be so described, deepened and constituted without the imposition of presupposition.

Here now is the elaborated Giorgi praxis without compromising its frame.

 

Phenomenological Psychological Praxis in the Public Space between Subject and Object of Investigation within Giorgi's Praxis

1. The researcher reads the entire description of the phenomenon, namely the nascent sense of ownership of the phenomenological project, straight through to get a sense of the whole.

[In a second reading, between the naïve descriptions and the creation of the meaning units, inscribe Badiou so that we can anticipate discrete units in se as well as sets of thematic structures that provisionally give themselves. J

2. The researcher reads the naive description a third time more slowly, delineating one transition in meaning from another with the intention of discovering the meaning of the phenomenon. After this procedure of using strokes to delineate where a transition is perceived, we have a series of meaning units or constituents that are then numbered.

[Inscribe Marion's accent on the absolute bracketing, and within that bracketing procedure, preserve Husserl's and Giorgi's free variation within the horizon. This is one area where Marion, Husserl and Giorgi are procedurally in complete agreement.J

3. The researcher reflects on the meaning units, unpacking the constituents, and determines the essences (eidetic abstractions) of that situation for the subject with respect to the phenomenon under study. Each constituent meaning unit is systematically interrogated for what that unit reveals about the phenomenon. Each unit is then transformed into the language of psychological science.

[In Step 3, following Sokolowski, (a) treat the engagement of each unit to be interrogated as an opening for a public space between the interrogating subject and the phenomenological object; (b) transition into a co-creation of meaning.]

4. The researcher synthesizes the essences (eidetic abstractions), integrating the aggregated insights into a coherent description of the structure of experience of the phenomenon under study. The structure of experience that leads to the inter-subjective constitution of the focal phenomenon informs Giorgi's results.

In the discussion of the results, having deployed Giorgi's phenomenological praxis to generate these, the researcher may now dialogue with the literature cited earlier and/or with other literature that further illuminates and/or extends the results. In Giorgi's praxis, the phenomenological investigation conventionally ends with the discussion of the implications of the results for the discipline to which the study belongs.

To this elaboration of Giorgi's praxis, we may now add Laruelle's contribution as follows:

Inscribe Laruelle's philosophical decision on the invariants leading to immanence and transcendence as (i) posed, (ii) divided, (iii) mixed, and (iv) synthesized. Laruelle's philosophical decision can become an alternative to Giorgi's fourth step where the multiple eidetic abstractions have now been gathered into the resulting essences. This framework does not compete with Giorgi's framework. It brings firmer structure to it if the researcher so desires. The results may now be discussed in the light of existing literature in the field of study within which the investigation is conducted.

 

The Resilience of Giorgi's Phenomenological Praxis

Giorgi's research praxis retains its fidelity to Husserl. Nevertheless, aspects of the contribution from the works of Badiou, Laruelle, Marion and Sokolowski can be inscribed into Giorgi's essentially descriptive Husserlian phenomenological psychological research praxis in order to intensify, deepen or extend the investigation. Hence the resilience of Giorgi's praxis: it can retain its boundaries and yet accommodate new contributors without compromising the integrity of the phenomenological psychological research praxis.

 

Phenomenological Presence

Before analyzing the data following Giorgi's praxis to disclose the image of psychoanalysis, the researcher must make his or her own phenomenological presence explicit. My phenomenological presence is two-pronged: a theoretical presence and an affective presence. At the theoretical level, I have always been intrigued that both Freud and Husserl were students of Franz Brentano, who taught them both the concept of intentionality. One took the concept in the direction of pure description as a philosophical praxis and tradition of phenomenology, while the other took it in the direction of interpretation of unconscious phenomena in psychoanalysis. This is where I struggle with the juxtaposition of disciplined description and interpretation. Here, I fluctuate between starting with pure description and ending with interpretation. On occasion I find myself thrown into a place where I do not want to resolve that tension either in my clinical work as a psychoanalyst or in my explorations as a phenomenological psychological researcher.

At the affective level, I am aware of how my difference as a Ghanaian enters into that public space between clinician and patient (Apprey, 2006). Who am I when I become part of the very process I am observing in that public space between researcher and research subject? Who am I when I enter institutions of organized psychoanalysis even when I am invited as a plenary speaker or as a panellist? Who am I when I add an extra bite, as it were, due to issues of identity and difference in the room, to an investigation of the image of psychoanalysis?

These are phenomenological presences that must be bracketed before a disciplined study can occur. We can return to these phenomenological presences if they enter into the data.

 

A Note on the Number of Subjects

The researcher interviews as many subjects as needed; that is, until what gives itself reaches the level of saturation. In practice, then, five to ten subjects tend to be sufficient for a phenomenological study. By the same token, three subjects can theoretically provide sufficient data if the interviews are extensive enough to provide an optimal degree of saturation where one hears the same things said over and over again.

 

Results of the Study

Below are 8 representative results of the study of the image of psychoanalysis that emerged from individual analyses of the naïve descriptions collected.

Subject #001

In this student's world the image of psychoanalysis has changed in four weeks on two fronts. On the one front, psychoanalysis can and has come alive from the dead. On the second front, when psychoanalysis stirs from the dead it can and has come to serve instrumental, present and peremptory purposes for a student doctor. Accordingly, a student doctor who wants to become an anaesthetist can apply the intellectual and human tenets of psychoanalysis to the treatment of patients who are at their most vulnerable stage in treatment; namely, the step just before anaesthesia; that is, before becoming unconscious to be operated on. In the intersubjective constitution of the image of psychoanalysis, there is a reciprocal connection in two directions: psychoanalysis in se is no longer dead; the student doctor is himself no longer dead to the value of psychoanalysis.

Subject #002

In this student's world the image of psychoanalysis was at one time unclear, uncertain and undefined. In her naïve description, "I did not know very much about psychoanalysis. College and medical school gave me no understanding about how human beings come to live fulfilled lives". In her world, Sigmund Freud had been synonymous with sexuality and how that came through dreams, and it behoved the psychoanalyst - who sat behind the patient, writing pad in hand - to decipher unconscious origins that drove human actions.

When a psychoanalyst teaches a medical student about psychoanalysis, the student's image of the field changes. The student begins to understand how difficult it is to understand unconscious human actions, thoughts and feelings. The student begins to appreciate that trust and relationship building serves as an infrastructure to clinical interventions, and that empathy is the primary instrument for entering the world of a patient.

Through guided readings of multiple psychoanalytic frames of reference, the student begins to understand how far we have come since Freud and how "large" and multifaceted the traditions of psychoanalysis are.

Reciprocally, when there is a discovery of psychoanalysis as a large body of practices, the student's own world becomes larger. As the image the student has of psychoanalysis changes, the student is herself changed by it.

Subject #003

This student has come to a place where she can now realize that her initial image of psychoanalysis had been founded on misconceptions that come from Hollywood and popular culture. In this misconception, an analyst is one who sits behind a patient and asks: "How do you feel?" In this misconception, a patient goes to analysis simply to find "someone to talk to". Analysis thus is for someone without an assigned "true" medical diagnosis.

Before arriving at her current image of psychoanalysis, this student discovered that a person with a medical diagnosis could benefit from "a talking cure"; it was, however, not psychoanalysis, but cognitive behavioural therapy, that she encountered. Specifically, Freud was a philosopher, not a scientist; a philosopher obsessed with sex; a philosopher who sat around theorizing about the human psyche.

Now, in the changed world of this subject, the image of psychoanalysis is that it can do many things with different goals. The image of psychoanalysis is that an analyst listens, and, beyond that, the analyst transforms anxiety, actively interprets meaning though dreams and the transference, and makes important links to past history. Most importantly, it is the "patient's truth" that matters. That truth has to be understood through different or multiple lenses such as those of Freud, Klein, or Fairbairn.

The image of psychoanalysis for this student is not passive listening but active listening to make meaning; not just Freud's lens, but also others like Klein's and Fairbairn's; not just for talking to someone because one needed to, but rather for talking to an analyst because he is qualified to change the lives of patients whether or not they had a medical diagnosis.

Subject #004

This student has perceived an evolution of his image of psychoanalysis from three way-stations: preceding medical school; third year psychiatric rotation; fourth year elective exclusively in psychoanalysis.

From the perspective of the first way-station, the student shared the common views of psychoanalysis as depicted in the media of television and film where the analyst behind the couch was out of view while the patient who engages in free association arrives at "an epiphany" that solves the underlying psychological stress.

The student's disappointment in the medical school psychiatric teaching of psychoanalysis revealed itself as follows: Freud is mentioned once; psychotherapy is insufficiently taught; the privileging of evidence-based medicine above all else leaves the patient's subjective experiences untouched. If a physician privileges relationship building in his or her practice, the staff is wary of the longer hours it takes to conduct a psychologically-informed treatment in general medical practice.

Finally, the psychoanalytic elective enabled the student to discover Kohut and psychoanalytic self-psychology, from where an idea such as "sustained empathic inquiry" can travel into a general medical practice. The subject comes away with a perceived imperative that physical and psychological health be seen as intertwined; that a physician must incorporate some understanding of psychological stressors into patient care; that a physician must study psychoanalysis in its multiple forms; in sum, that "being a good doctor means addressing the patient in a holistic manner, and understanding some amount of psychoanalytic theory is a crucial piece of the clinical puzzle".

Subject #005

This student's preconceptions included the following: that Freud "always blamed the mother", that Freud's psychoanalytic theories were "sexual in nature", that the man behind the couch agreed with the patient's self-indulgent one-sided take on what happened in his or her childhood.

Now the student understands how culture, instincts and parenting work together, and that how human beings react to culture, instincts and parenting is decisive in the formation of personality. The student's new understanding of psychoanalysis includes the following: that Freud's theories changed over time; that psychoanalysis helps, through established relationships over time, with patients where unresolved issues from childhood can be refashioned and worked through; that instead of blaming the mother, transference became the medium for reactivating history and transforming human behaviour. As a prospective obstetrician/gynaecologist, the student has learned enough to know when to refer her patients for psychoanalysis.

Subject #006

In this student's world, the image of psychoanalysis before exposure to it and the image of psychoanalysis after exposure to it are essentially the same even though differing in certain respects.

The image of psychoanalysis as a means of helping a patient discover unconscious motivations in order to change unhealthy behaviours remains the same.

The image of psychoanalysis has changed to include the following: that the unconscious mind is bifurcated between the dynamic unconscious and the preconscious mind; that the Oedipus complex can be taken literally in the case of some patients, and as one of many metaphors describing structures of mind in other patients; that psychoanalysis is not a unifocal discipline but has many pioneers, traditions, and practices for treating different patients.

"Overall I was struck by the vast complexities of the theories in psychoanalysis. I have a greater appreciation for the field and for experts [in it] ... . I have a greater appreciation for and understanding of the inner working of the human mind that ultimately affects our behaviour and interaction with one another."

Subject #007

In this student's world, psychoanalysis has a bifurcated image: the prior image that remains the same, and the image after exposure that has now acquired complexity and subtlety.

The image that remains the same is that of the understanding that psychoanalysis brings to the exploration of unconscious human motivations. The image that has expanded includes an understanding that there is a child inside an adult. It is not quite the case that there is one theory of personality development for children, and another personality development theory for adults. Psychoanalysis grasps both continuity and discontinuity when the analyst encounters the child inside the adult.

The changed image of psychoanalysis incorporates the understanding that adolescent development has a great deal to teach us about how parental empathy for adolescents has reciprocal and complementary impact. In one direction a parent may come to appreciate and enjoy with admiration and pride his or her fostering of the adolescent's mastery over disturbing affects. In reverse, through the adolescent's development, a parent completes his or her own maturation as a person while helping the adolescent child mature.

In the student's world, this ideal image of a psychoanalytic view of adolescents' and their parents' mutual growth, and the potential for failure in that mutuality, resonates vehemently with the student's own history given that, during the student's adolescence, both the student's own father and the student's best friend committed suicide; a preconscious motivation, thus, for taking this elective to learn more about psychoanalysis and the development of the human mind.

Subject #008

In this student's world, and prior to his taking this elective, psychoanalysis was for him a field populated by vague, negative and self-serving practitioners with voyeuristic interests; images of psychoanalysts as compassionless villains; images fed by cartoons and the media. For this student there was profound conflict between his personal beliefs and his perception of mental health values. In this tension, his personal belief system says that there is indeed such a thing as the absoluteness of the existence of God and that He is absolutely good, whereas the student expects me and science to say that there are no absolutes.

The student came to test and separate out his tensions, and used the elective as a place filled with events that enabled him to see how an analyst and phenomenolo-gist thinks and works.

The student found those moments when he and I thought similarly and cherished them. Subsequently he allowed his prior perceptions of psychoanalysis to fade away. In his world, when self and other think alike, they are one and conflict can fade away.

Now he sees psychoanalysis as a place where religion and science can co-exist. Accordingly, the event of a psychoanalytic elective enabled him to construct the following view: psychoanalysis and religion are both subserved by the view that gathering and binding brokenness in human beings are processes that are akin to living and dying; dying and re-living; psychical integration in life, physical disintegration in death.

For this student, an integration of Freud and Jesus happens in the field of genuine understanding and caring for patients. This is why the subject can now vow to be open-minded so that he can understand those human investments and intentions that lead to action.

 

In Place of a Conclusion: Aggregate of Individual Results

The aggregate of the intersubjective constitution of images of psychoanalysis across the subjects gives us the following. The sources of information that feed the image of psychoanalysis are varied. They include, among others, film and other media caricatures, an incomplete and incorrect fund of knowledge provided by parents, teachers and psychiatrists, and personal constructions of one's own. The prevailing image of psychoanalysis is, therefore, not a singular one; rather, it is multi-faceted. That image is not a static one; rather, it is dynamic. It is not linear; rather, it is circular. When it is circular, there are internal fields of reference that resonate with external fields of reference. In reverse, there are external fields of reference that inform the internal world. As a consequence, as our images of psychoanalysis change, we ourselves are changed by that expansion of fields. Internal and external fold into each other (Deleuze, 1988/2006). A psychoanalyst ideally mediates the interpretation of images of psychoanalysis by interrogating pretexts and prejudgments, historicizing contexts, and interpreting psychoanalytic texts with the subjects, modelling along the way nondefensive and informed methods of describing and interpreting human phenomena. One explicit implication of this study is that psychoanalysts must teach wherever there are opportunities for them to do so: college students, medical students and residents of psychiatry, the general public, among others. In other words, while psychoanalysts spend years learning how not to be "wild" analysts who interpret without evidence, they do not teach outside their field enough to change wild images of their field. The following verbatim statement from Subject #008 addresses precisely this point:

Dr Apprey

Here's where I must apologize to you for my initial resistance and hostility on that first day of class. I needed to understand that you were caring and open to the idea of discussing different views than [sic] your own (even though I had no idea whether our views even differed at all). I finally did realize how you thought when you discussed your patient who had told you he was cheating on his wife, and that "What she did not know would not hurt her". Rather than assuming a neutral stance, you gave him a piece of your mind according to your own convictions that extend beyond your identity as a psychotherapist, an academic, and a researcher. Like me, you have morals that you hold on to, and from that moment on, I was able to relax.

What the student conveniently leaves out is that I was challenging the blind omnipotence and megalomania of a patient who thought he could do whatever he wanted as long as his spouse did not know it. Importantly, it mattered to the student that I confronted the patient. It meant to him that we both had morals. What shook him up is the consonance.

Some distortions, here and there, notwithstanding, this was a very important event for him. It was an event in the sense that it caused a rupture. By disturbing the continuity of his thinking about absolutes, it enabled him to endeavour to create his own mental conceptions that now include the juxtaposition of Freud and Jesus and how each can create a new setting for a fresh start in life.

 

Discussion: When the Engagement in the Public Space Between Self and Other Becomes an Event

As noted earlier, Marion (1989/1998) has indicated that givenness precedes and actively participates in the act of giving. With that in mind, let us ask what happens when the potentially turbulent space that the observer and the observed occupy becomes an event?

When we teach content, a process evolves. This is not new. However, when we consider the context of the teaching and the upheaval it can potentially cause, we have to pay attention. Badiou's rendition of an event as surprise, upheaval and indeterminacy is pertinent here.

My students sometimes say in private, and later in public, that "I wish Dr. Apprey would stop teaching psychoanalysis and just analyze us instead. We already know this stuff". What happened that caused them to wish for a change in venue and in purpose? Or, "Oh my God, that is what exactly happened to me when ... ". Or, "I wish my mother were here to hear this. She told me not to take this elective. They always blame mothers. If she were to hear this she would feel affirmed". Or, "I am sorry I attacked you. My father just died in Egypt. He committed suicide. And, my best friend committed suicide too when I was in adolescence. Do you know a good clinician I can go to and get help from?" Something happens to chance itself upon these students as they interrogate psychoanalysis as a subject, a field of study and of practice, through different lenses: Freud, Klein, Kohut and Fairbairn.

Now let us go into more detail about the happening of an event.

Earlier, when we introduced Badiou and his metaphors that we could inscribe into phenomenological praxis, we did not in fact go far enough. We noted that Badiou is particularly intrigued by the idea of subsets within a unit, a discreet unit, the count of one.

In Badiou's way of thinking, mathematics and logical structures tell us that we are invariably inside, in the immanence of a situation or world: always held within by that human animal inside us that is subjected to mathematical, biological and psychical laws. However, we cannot restrict ourselves, our being, to that inhuman inflexibility of structures, because chance shows us that something exceeds the structures. That which exceeds all human structures is the event that humans cause, and for them - "it can be said that the event is the occurrence or the flash, the dazzling revelation or an instant, of the void subjacent to the situation, buried in the structures" (Tarby, 2010/2013, p. 142).

In phenomenology, we more or less arrive at our discoveries by going from the events of history to a sense of history and from there to the determination of intentionality. In psychoanalysis, we go from the event as historical reality to the privileged psychical reality that gives us our inner representational world, and from there to the transference wishes embedded in how the patient treats the analyst.

This study makes me question whether we leave the events of history too soon to precipitously arrive at the sense of history or the representational world. Similarly, I realize that every time I have four to six students in an elective class, an event takes place, the class itself constitutes an event, and I must therefore periodically suspend the transfer of conceptual content or information in order to take the time to listen to that which is happening in that public space between me and my students; subjects of this study; co-creators of the events in the room.

 

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About the Author

 

 

Maurice Apprey is a tenured full professor of psychiatry at the University of Virginia School of Medicine, and a member of the Academy of Distinguished Educators. He studied phenomenology under Amedeo Giorgi and psychoanalysis under Anna Freud.

Dr Apprey's life-long passion is his work between description and interpretation without prematurely resolving that tension. He is the English language translator from French of Georges Politzer's (1928) Critique of the Foundations of Psychology: The Psychology of Psychoanalysis (Duquesne University Press, 1994).