Psychoanalytic Dialogues, 12(6):899-913, 2002 Our Literature as the Problem Child of Psychoanalysis Commentary on Paper by Drew Westen Charles Spezzano, Ph.D. This paper is a response to an essay by Drew Westen. The author agrees with many of Westen’s arguments about problems in the psychoanalytic literature and adds that the psychoanalytic literature has always been a problem for psychoanalysis. If we think of psychoanalysis as an ongoing experiment, then its “trials” are all the analytic sessions that have been conducted. Our “literature” has never systematically drawn on those. Westen critically scrutinizes certain habits that, in his view, haunt our literature, but that we do not explicitly note or disown as conceptual contrivances we mean to get rid of, while they are often misguiding clinical thinking and practice. I suggest that a fascinating question riding below the waves of Westen’s paper is why patients and analysts accept this situation. I suggest that we all treat psychoanalysis as wisdom, art, relationship, skill, and something other than the application of established scientific findings because we recognize and accept it as that kind of human activity. It is unclear if patients care whether or not their analysts are scientists, but it is clear that analysts are not optimistic about sifting the research literature and finding clear clues to more effective clinical thinking, work, or writing. HE PSYCHOANALYTIC LITERATURE HAS ALWAYS BEEN A PROBLEM FOR psychoanalysis. If we think of psychoanalysis as an ongoing experiment, then its “trials” are all the analytic sessions that have been conducted. Our “literature” has never systematically drawn. on those sessions and we routinely say to each other that the fullness Charles Spezzano, Ph.D. is a Training and Supervising Analyst at the Psychoanalytic Institute of Northern California; a contributing editor to Psychoanalytic Dialogues; and on the editorial board of the Journal of the American Psychoanalytic Association. 899 ® 2002 The Analytic Press, Ine.900 Charles Spezzano of our day-to-day operations is not accurately reflected in what we report in our journals. Psychoanalysis is inherently a problematic enterprise for which to create a literature. Patients have always wanted to talk to their physicians more than physicians are inclined or able to make time to listen. Breuer and Freud, our legends have it, made a profession out of deciding to listen, to make listening a key element of the treatment. So patients started talking to Freud, and now they talk to well more than 10,000 formally trained analysts and many more times that number of psychoanalytic psychotherapists around the world. We have been saying things to them that we have hoped would be useful. Our data would be all the details of all those millions of analytic hours. We cannot however, supply, verbatim accounts of every session done everywhere. So, in our books and articles, we include “vignettes” that are intended to capture what has been confirming, revising, important, useful, therapeutic, or counterproductive in our work with one or more patients. We add, in the form of theorizing and speculating, an evolving sense of what we have been doing, are doing, should be doing. This sense is conveyed through our accumulated attempts to stuff what we do into every conceivable existing literary form, from laboratory reports to historical-fiction novellas. When we detail the changes that we and patients experienced and understood to have happened, we try to describe and explain what we did that facilitated those changes. We try not to leave out anything relevant. Yet, as readers, we often are left with an unclear sense of how a particular analysis worked. Mostly, we are a lot of us doing a kind of work whose nature is only partially grasped by any of us, and we have a literature about that work that we know does not fully capture, in its details or its theories, exactly what is involved in the workday of any analyst. We write as if we hope that what we have created in our literature is enough so that, if all of us disappeared, some hypothetical group wanting to start up analysis again could use what we have written to get things going again in such a way that, if we just as suddenly reappeared, we would be able to sit in on analytic sessions and recognize what was taking place. We then would have some proof that our literature had managed to capture what we do— its process and content, its details and sensibility. All sorts of writing may be necessary to add up to such a literature. Drew Westen invites our critical scrutiny of certain habits that, in his view, characterize (or haunt) the describing and explaining we do in this writing. As heCommentary on Paper by Drew Westen 901 ass sses our literature, we seldom explicitly note these habits and are not even aware of them (perhaps we disown them as conceptual devices we mean to get rid of) while they are guiding (more often misguiding) clinical thinking and practice. If that were all he does in the paper—point out five sins of omission and commission in how we write about what we do—commenting on his essay would have been a manageable undertaking. He actually does much more. He embeds a second essay about the dire consequences that result when theory making and theory refining ignore the kind of research he and others do. This embedded second essay turns the task of commenting on Westen’s paper into a task more complex than anticipated. Sometimes Westen himself appears to be trying to settle an argument by using just logic, which, he virtually argues in other places, cannot be done (only empirical research can settle the arguments in our field). At other times, a section that seems as if it will focus on one precise complaint about how we write expands into a long list of complaints about how we write, how we think, and how we talk to patients—all loosely related through being contradicted by available research studies. For example, the long section titled “Developmentally Speaking” makes eight arguments, each of which could be a paper: don't overgeneralize, but always take into account the specific caretaking and cultural circumstances of a child or of the childhood of an adult patient being discussed; don’t “write as if children had an other or an object, as opposed to multiple significant others”; don’t forget that children have multiple adult caretakers and that the mental representations of these characters have to be taken into account in explaining a patient’s internal object relational drama; don’t forget that “children have siblings.” So far, the arguments could be made to hang together because they are all about the obvious complexity of setting and characters in the drama of any child's life. Then, however, the focus shifts abruptly. Westen cites a study of his that apparently suggests that it is difficult to know at what age the primary developmental damage was done to a child. He urges that we “not equate severity of disturbance with age at which the disturbance began.” He points to research to support his claim that our conceptualizations of the child in the adult patient are either farfetched or inconsistent with certain statistical findings (the issue that analysts often see themselves as writing about people’s fantasies about the child inside themselves, not about an inner child whose experiences must902 Charles Spezzano tally with data from observations of children, is not taken up). Westen uses logic to call into question the likelihood that adult patients really harbor the primitive, psychotic child-cores that Kleinian analysts claim they do. Bur then he also calls upon research to dispute the likelihood that such patients suffer as they do simply because of early traumas or early maternal failures in containment of anxiety, rather than “both genetic and environmental sources of vulnerability. The next complaint in this section is that psychoanalysts invent stages and positions. Again, although Westen introduces this assertion as “a problem with the use of developmental language in psychoanalytic discourse” to fit it into the main thread of argument in the paper, it is actually a major paper-within-a-paper questioning what Westen sees as the mindless spread of belief that Klein discovered, and that we have conclusively corroborated, the existence of such quasi- developmental phenomena as the depressive position. Finally, this “Developmentally Speaking” section of Westen’s paper concludes with the complaint that we take our own metaphors literally and talk to patients as if we really believed them to be, for all analytic purposes at the moment, psychological and emotional infants. This is one of those places in the essay where it seems to matter how often we do that, how we do it whenever we do it, and what effect it has on patients. It seems to be the kind of issue about which Westen would not want to write authoritatively in the absence of research showing how often we do that; and showing that it goes badly for patients when we do that, but he simply asserts that we do it a lot and should never do it. He might be right but, by his own criteria, the judgment about whether he is or not will have to wait for more evidence. Despite the problems created for readers by the collage quality of this section, it provocatively reiterates a concern that we (the collective “we” who write about the human condition) have been lamenting at least since Kierkergaard: crushing an individual under a pile of generalizations. When I was learning about projective tests in graduate school and on my internship, | repeatedly heard professors and supervisors warn of the danger of characterizing a person in a static, one-dimensional, and uncontextualized way. The warning was well targeted. In clinical case seminars, especially as we have become aware of the psychotic British infant allegedly alive in all of us, we still argue about patients really operating at much lower (more primitive, maybe prenatal) levels. That “really” is what Westen draws attention to, I believe, and his caveat is well taken.Commentary on Paper by Drew Westen, 903 One concern I have with Westen’s critique of our using such words as “primitive” to explain a patient's unconscious psychology is that he may be underestimating the problem. The focus of his essay is on mistakes we make without realizing what we are doing. So he wonders if “primitive” has come to “be built into the implicit structure of our discourse, guiding clinical theory and practice in unforeseen ways?” It is my impression that we increasingly use this word quite deliberately, guiding theory and practice in quite foreseen ways. When Westen turns his attention to the problem of one-thing-isms in our discourse, he finds an ally here (Spezzano, 1998). In fact, I often find myself agreeing with the content of specific arguments put forward by Westen, and my comments are often in the spirit of pointing out what I think would have made his a better essay. My metasuggestion is that Westen not write in the voice of an annoyed parent or an angry coach, because this leads him to throw a lot of points together in a sort of “and furthermore. . .” or “how many times do I have to tell you guys...” way. The “and furthermore” attitude leads him to leap quickly from one to another category of what he critically views as one-dimensional explanations of multidimensional psychological phenomena. The “how many times do I have to tell you guys?” attitude leads him to write as if it were astonishing that he and a few others could have argued against a term such as primitive and yet people still use it. Both attitudes threaten at some points to turn what is actually a condensed rough draft of arguably five or six potentially important scholarly papers into a rambling, sarcastic editorial. For example, consider “Before you write off my comments here as the musings of a simpleton, a positivist, a poor premodern slob who doesn’t know better, a boor without aesthetic sensibilities, or worse still, a researcher.” If this is a catalog of the types of reception Westen has gotten to the ideas in this paper, that would be both surprising and regrettable. In his paper, he is less likely to have catalyzed any of those reactions in readers than he is to have catalyzed a bewildered wondering about why he would use such lines as “I suspect that a person who relies on poetry for theory is equally unlikely to do good clinical work.” And then he goes on to suggest that not only does such a category of analysts exist but also it is to be contrasted with another group that—unlike the “poets,” who rely on “metaphors, Haiku, or lilting phrases"—telies on “knowing how to formulate a patient’s dynamics, knowing where to turn one's therapeutic attention, and knowing what approaches might be useful904 Charles Spezzano in helping people change.” This type of hyperbolic contrasting, if taken as a model, creates the risk that Westen's essay on how to improve psychoanalytic discourse will end up having the opposite impact. There is so much good stuff in this essay to catalyze self-reflection on the part of all of us that it seems odd for the author to find that kind of us- and-them discourse necessary. For another example, consider “object relations.” | don’t know how often, in case reports, a patient is described as having one set of them. Westen writes as if that happens often. Who does know? His case vignettes, displaying thoughtfulness about the complex object relationships of patients, has nothing to do with his argument that oversimplifying happens a lot. In fact, Westen himself, turning his attention to transference, writes that we “have, at times, postulated a unitary transference neurosis.” The “at times” highlights that Westen is not counting on the accuracy of his estimate that we oversimplify a lot; rather, his message is: “Look, it’s not all right even if we write that way only once in a while. We should know better and never write that way.” (In fact, the essay might well serve as a set of guidelines to authors submitting manuscripts to a new journal Westen would be editing.) I suppose that if I agree with him in principle, then I have to agree with him in each instance. Yet, I still want to say that I have read about “the” oedipal transference neurosis in some journal articles and had the sense that the author did not mean that he or she had never thought about any other transference. In the same spirit, ] don’t know if asking trainees about what is happening in “the transference” pushes them to think in one dimensional ways or to oversimplify mental activity. I am sure that sometimes it does, perhaps especially with younger clinicians, but I have the impression that ordinarily, with analytic candidates, for example, the question would be taken simply as a shorthand way of asking what aspect of the patient’s worrying about, fantasizing about, and relating to the analyst has ended up standing out in the mind of the candidate right now. A similar suggestion I have for this essay is that each section not lead off with the implication that a widespread problem in the field will be examined, when the main text of that section will show only one example of such an allegedly widespread problem. Take the section on “Mechanisms and Activating Conditions.” It opens with the claim that there is a widespread failure to explain what we describe. Yet, it is actually a critique only of the closely related concepts of unconsciousCommentary on Paper by Drew Westen 905 communication and projective identification. We have not spelled out how such processes would work. | suspect that both concepts arose when analysts, especially British analysts working with psychotic and schizophrenic patients, became convinced that the evidence required to construct a useful interpretation was not to be found in a patient’s associations. Yet those analysts still wanted to find evidence with which to build a useful interpretation, Quite suddenly, they began to claim that an analyst’s shifting feeling state was actually that sought-after evidence. In lieu of being able to explain the mechanisms at work, analysts simply reported the results of making interventions based on these allegedly unconscious affective or projective identification communications. Whether or not that is, in fact, a correct historical reconstruction of one source of our current habit of assuming we have established the case for unconscious communication and projective identification, I agree with Westen that we have not explained them sufficiently. Westen’s own speculations about what some of the mechanisms might be are interesting attempts at what an explanation of such phenomena might sound like, but they are neither so compelling nor so well corroborated as to leave me feeling the phenomena have been explained. In fact, when Westen goes beyond pointing out gaps in our explanations of the phenomena that we describe and offers his own explanations, he creates a third paper within this sprawling essay (a paper that offers Westen’s own answers to big questions and problems in psychoanalysis, answers that, while interesting, are not self-evident and deserve thoughtful responses, for which there is no room in this commentary). The next two sections on activating conditions, propositions, and metaphors seem more on target with the goals of the paper. Yet, driven by the kind of annoyance that might characterize an Andy Rooney editorial at the end of the weekly news show Sixty Minutes, Westen’s writing can become muddy and convoluted. In “What Turns Dynamics On?” Westen tells us to be careful about writing as if one of many potential accounts is right or wrong. Yet he also writes that sometimes one position is the correct one; and then he quickly adds that we have few ways of demonstrating this even when it is the case. Similarly, after telling us, “Often what appears to be either/or is really both/ and,” he adds, “Equally often, certain phenomena are more or less accurate under particular circumstances.” I suspect he means that equally often one of several competing explanations for a certain phenomena is more or less accurate. (I don’t know what it would mean906 Charles Spezzano to say whether or not a phenomenon itself is accurate.) But, beyond this editing correction, the line of argument becomes conflicted and confusing here. Nonetheless, even when the writing becomes really muddy, there are gems in the mud. His argument against the ease with which we allow ourselves to assert global theories of motivation, development, and therapeutic action is insightful and sharp. He left me thinking that major theoretical schools operate somewhat like think tanks, taking a few key theories as irrefutably true and then seeing how far they can go in explaining everything from the platform of those few key theories (assuming that the truth of the key theories has already been demonstrated as well as anything can be demonstrated in psychoanalysis) or not seeming to care that competing theories exist in the field. Steiner’s (1996) claim, for example, that the aim of psychoanalysis is the reacquisition and reintegration of projected parts of the self is about the ubiquity of primitive anxiety and defense and is also a virtual claim that contemporary Kleinian theory of therapeutic action is, beyond a reasonable doubt, the universal guide to practice. Westen drifts into an entirely different sea of problems when he insists that we not settle for metaphors without propositions. Westen’s main evidence is, again, one example: Winnicott’s phrase “transitional space.” I agree strongly with Westen’s arguing against our using Winnicott’s concept or any other single psychoanalytic notion to explain the origins of culture. Yet I do not agree that we don’t know what we mean when we use the term transitional space. In fact, in general, a very strenuous effort has been made to create psychoanalytic dictionaries that explain exactly what propositions are contained within, implied by, or derived from each important concept in each major theory (and in general 1 don’t have the impression that we settle for just metaphors without propositions in the widespread way Westen suggests we do). Most pertinent to Westen’s argument by example is Jan Abrams (1996) The Language of Winnicott. Also, Winnicott (1971) clearly defined the concept himself: “The object represents the child’s transition from a state of being merged with the mother to a state of being in relation to the mother as something separate” (p. 17). As with many theorists, Winnicott’s problem and our problem elaborating his concept is not that it is poetic rather than propositional (I believe the sentence of his | just quoted is a proposition and not a metaphor), but that he and we have wanted to be able to assume that we could use the original proposition as a metaphorical account of many things,Commentary on Paper by Drew Westen 907 vague or complicated, such as culture. Winnicott and we have assumed that we could spin off an endless series of metaphoric synonyms for the original proposition—third area, intermediate area, potential space, resting place, play, creativity—each of which we then assume is an explanatory proposition condensed into one word or phrase. So Westen has plenty of fish to shoot at in the transitional object/ space barrel. Why, then, the need for such unnecessary and sarcastic sentences as, “Creativity is not the same thing as play or we would all be Picasso"? Similarly, while Westen has plenty of room to challenge the assumption that Winnicott explained play with his “transitional space” concept, his way of mounting his challenge (it would have made the point, really, just to say that the concept is so captivatingly poetic that we have been seduced on occasion into mistaking it for a solution to the mysteries of play and creativity when it is just a piece in the jigsaw puzzle of such complex phenomena) relies on an odd reading of it, one that most people who have studied the concept will not recognize. In teaching the concept, | cannot recall anyone thinking that a central proposition in the transitional space argument was that all play is soothing. In Abrams’s (1996) The Language of Winnicott (a dictionary and guide to understanding his work), play is linked with creativity, symbolizing, aggression, and self-experience, but not soothing. I never have heard a candidate discussing a case link the notion of transitional space play with soothing. More often, it might be used as a shorthand way of saying that the analyst did not experience one of the patient’s ways of representing the analyst in his or her mind as simply a distortion or an attack but as. a moment of taking a piece of reality (an aspect of the analyst) and imagining it into a character in an internal play, which allows symbolizing of affective experience and also creates a form for communication about that experience. When Westen turns to our tendency to generalize about development, he runs into a problem that plagues the paper throughout: his own ambivalence. He writes, “I do not mean to suggest that we can never generalize.” Yes, he does mean that, and it is his meaning it that give the paper its power. He says as much immediately after that disclaimer: “we would do well to check every sentence in which we use such constructions to make sure we are not overgeneralizing, particularly about children’s internal experiences and fantasies, which are unlikely to be so generic.” How would we know if we were generalizing or overgeneralizing? Westen does not really mean to allow that distinction (and I am glad he does not) nor does he,908 Charles Spezzano obviously, believe that such generalizations as “the oedipal-age child” or “the infant at the mother’s breast” are ever really accurate. For his purposes (he wants us to have a literature we can really stand behind), there could be no value in such generalizations. Sometimes, however, generalizations that Westen claims we make unreflectively seem already to have become objects of intense interest in the field. For example, in the section on development, Westen urges, “The notion that object relations are initially dyadic or “two person” needs to be carefully rethought” (Westen’s italics). Has it not been? This exact rethinking seems central to contemporary Kleinian writing (especially there, with many excellent writings on the intrinsic triangular nature of object relational fantasies, but in the literature of other schools as well). Mostly, when I see the phrase two-person it is not being used to claim that infants live in a two-person psychological space. Rather it is being used as a reminder that the analyst along with the patient is contributing to the content and direction of the current dialogue or to the patient's immediate experience and mental activity. That is a small complaint of mine, however, about one of the really good sections of this essay. In this “Developmentally Speaking” section of his essay, Westen is, in so many places, onto things important that it would be impossible to take the time and space to congratulate him for his courage and insight in mounting the challenges he does to words, phrases, and concepts that have quickly been imported and treated as scientific facts about the human condition from womb through infancy and on into the structuring of each individual's mind. The problem, again, is that some of his arguments are not about implicit rules and habits that guide our discourse, but about ways of thinking to which we explicitly have become committed. Westen’s challenge to Kleinian-inspired explanations of so-called borderline patients, for example, is timely and deserves more room—specifically room in a different essay about the concept “borderline,” and not in an essay on “the implicit rules that guide psychoanalytic thought and discourse,” as his abstract promises. The same is true of Westen’s challenge to the assumption “that the only important traumas children experience . that affect their object relations and subsequent development occur before the age of five.” This subject is dealt with in one paragraph and is supported by only a brief allusion to some research of Westen’s group that suggests that sexual abuse significantly affects development whenever it occurs during childhood. This target shooting (even ifCommentary on Paper by Drew Westen 909 sharp-shooting), while thought provoking in places, cannot do the job that the paper makes clear ought to be done. It is in the final section of the paper (in which Westen argues that we need to rethink the nature and presentation of evidence in psychoanalytic discourse) that its heart is revealed. Here he confronts the familiar notion that psychoanalysis is a unique discipline that can claim to be building knowledge about matters such as how development proceeds, how mind works, and how therapy helps by means other than those used in the domains of theory generation and refinement we generally refer to as scientific. In the “Use and Abuse of Data” segment of the paper (a segment that occupies about one-third of the essay) he flatly rejects that claim: “We should not be writing papers on topics like language, empathy, emotion, unconscious processes, therapeutic action, or any aspect of development without doing a computer search of the available empirical data.” If that suggestion had been followed, the complaints and suggestions made earlier in Westen’s essay would have been moot since there would be a very small psychoanalytic literature. By and large, Westen believes that the literature we do have is probably a thousand times larger than it ought to be: “After the first article or two presenting a theory or hypothesis, however, the next step is to begin testing it... . But this is certainly not the case in psychoanalysis, where theorists have for a century proposed one hypothesis after another—about how children develop, how neuroses form, what leads to therapeutic change, and so forth—with the ratio of hypotheses advanced to hypotheses tested hovering at about a thousand to one... . If we want to know whether, in what ways, and with which patients, it is useful to interpret from surface to depth, focus on psychosexual conflicts, focus on transferential or extra-transferential relational patterns, self-disclosure, offer support, focus on envy, let ourselves be visibly moved by our patients, etc., we will learn very little at this point by reading articles by authors whose work we find congenial and who provide exquisite but carefully selected case examples.” Again, if that is the case, then Westen’s previous suggestions are much less important or at least take on the flavor of “If you are going to continue to churn out this useless stuff, then at least follow the four discursive or grammatical principles I have outlined.” So arguing with the first four suggestions would not really save the psychoanalytic literature from Westen’s fifth and final critique; and I do not really910 Charles Spezzano want to argue about this last, big, main point either. The point has been argued to death anyway, and Westen knows this. He also thinks it is too late to fix the problem, which opinion he makes clear when he writes about “a failure to develop a culture of scientific investigation in psychoanalysis from which we may never recover.” Why have we ended up in the state that Westen laments? One answer is that we wanted to. Analysts are often convinced not simply that research reports are not going to help them do better clinical thinking and work, but also that striving for objectivity is antithetical to psychoanalysis. Describing British Kleinian infant observational practice, Waddell (1988) argued that this approach to observing infants (as opposed to the kind of experimental observing done by such researchers as Daniel Stern) “is a method with no claims to impartiality or objectivity. Rather the reverse, it is one rooted in subjectivity . . . which requires the observer to be as minutely cognisant of his or her internal processes as of those of the subject of observation” (pp. 313-114). And Parker (1995) has complained: “It seems that Stern’s view is that as unconscious conflicts cannot be observed in babies, they cannot be taken into account” (p. 192), which easily translates into the assertion that what matters to psychoanalysts cannot be observed and studied by researchers anyway, Frosh (2001) has captured this core premise of the whole psychoanalytic enterprise (to which Westen objects), as it has evolved into its current form, in the most concise and forceful way I have read: [P]sychoanalysis rigorously and repeatedly demonstrates (italics because I do not want to be misunderstood) that realistic understanding of others comes from a process of unconscious reflection in which the subjectivity of the analyst/observer is intimately engaged. This is obvious really. People do it all the time as they meet on streets, in their homes and beds; but psychoanalysis has claimed it as an epistemological principle: no knowledge of the other without the engagement of the self [p. 630]. In general, psychoanalysis has made little distinction between the rightness of this principle in clinical work and its rightness in theory building and refinement. Comparative outcome studies do not influence our sense of what we do and do not know anywhere near as much, if at all, as they do for practitioners in medical-clinical fields.Commentary on Paper by Drew Westen 911 And Frosh is right that we have not drifted into ignoring outcome studies, nor forgotten we should not do it (as Westen seems to suggest), but appear to be committed to it. In this sense, Westen’s essay is as much a political as a scholarly document, as any paper on the broad issue that he addresses would have to be. It is a campaign platform speech for our equivalent of the Green Party in national politics, the psychoanalytic research party. Many more of us than carefully follow, much less participate in, the kind of research done by Westen and others believe that we should (as we know we should drive electric/ hybrid cars and we should be better informed about the facts and myths of global warming), but we are unlikely to become fully informed about that “other” body of literature. Why don’t patients (virtually all of us have been patients ourselves, so we are them too) demand the type of scientific evidence Westen believes is essential to meaningful clinical work? Cancer patients do expect that their treatments are being determined by comparative outcome studies and other statistical research. They are considering submitting to procedures that are not part of the ordinary course of life, procedures in which, conceivably, they might or might not agree to participate. What we call analysis, however, is a specialized form of a human activity that is unavoidable—one, | believe, that we all engage in with others from early in our lives. This activity is two-fold: attempting to use other minds to find out more about what is happening “inside” of us and attempting to use other minds to regulate or change what is going on “inside” of us. We are constantly aware that there are biological/psychological processes taking place inside of us, which we have come to call unconscious mental or psychological activity. We become aware of the existence of these processes through their products or derivatives, which emerge into consciousness as feelings, images, and thoughts. Just as uncomfortable and painful events in that aspect of ourselves we call body drive us to talk to others, especially physicians, with the hope of finding out more about what is going on “in there” where we cannot see, anxiety and emotional pain drive us to talk to others all our lives in attempts to find out more about what is going on “in there” and in attempts to change what goes on “in there” so that we will feel less anxiety and pain. We do this routinely and, at a certain point in history, we turned into a professional activity the privilege and job of being the one to whom the seekers of insight and change come. This way that we created psychoanalysis makes coming to a psychoanalyst with psychological912 Charles Spezzano distress different from coming to an oncologist with physical distress. Being cut open, taking quasi-poisonous chemicals, and being irradiated are not unavoidable and essential human activities. | am arguing that doing what patients do when they come to psychotherapy is an unavoidable and essential human activity. Now that there is a group of us who do it full time (and exchange observations and ideas about it), many people would rather do it with us rather than with part- timers. I think our “consumers,” unlike the oncologist’s “consumers,” don’t demand scientific proof because they have to do “the thing they do with us” anyway. They know they are going to try to do “it” with someone anyway, so it seems worth it to do it with a professional who is dedicated to doing it. Perhaps they even join us in treating psychoanalysis as wisdom, art, relationship, skill, and things other than the application of established scientific findings, because they recognize and accept it as that kind of human activity. I think patients want their oncologists to be scientists. | don’t know if they care if their therapists are scientists. That, however, need not stop us from incorporating research findings into our thinking. We could divert whatever time we have for continuing education into reading research reports; but, given the demand in everyday clinical work to be good at recognizing and managing our own emotions while translating complex, emotionally charged communications from patients into metaphors that give them the sense of being understood in an alive and thoughtfully managed relationship, we are not likely to do so unless we believe we have quick access to the most important findings— whereas most clinicians, I suspect, feel inept at evaluating findings and arguments in the large literatures on, say, developmental psychology or therapy outcomes. Psychoanalysis, maybe, in part, for the quasi-political reasons Westen suggests, has become a hybrid wisdom tradition, a practical art/skill tradition, and a truth and knowledge accumulating tradition. A fascinating question that rides below the waves of Westen’s paper is why a relatively large group of practitioners and patients around the world seem to want it that way. REFERENCES Abram, J. (1996), The Language of Winnicott, Northvale, NJ: Aronson. Frosh, S, (2001), On reason, discourse, and fantasy. Amer. Imago, 58:627-648.Commentary on Paper by Drew Westen 913 Parker, R. (1995), Torn in To: Mothering and Ambivalence. London: Virago. Spezzano, C. (1998), The triangle of clinical judgment. J. Amer: Psychoanal. Assn., 46:365-388. Steiner, J. (1996), The aim of psychoanalysis in theory and practice. Intemnat. J. Psycho- Anal, 77:1073-1083. Waddell, M. (1998), Infantile development: Kleinian and post-Kleinian theory, infant observational practice. Brit. J. Psychother, 4:313~328. Winnicott, D. W. (1971), Playing and Reality. London: Tavistock. 2252 Fillmore Street San Francisco, CA cjspezzano@aol.comCopyright © 2003 EBSCO Publishing