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Last night my daughter was born by emergency C section. I’m not sure when I’ll be able to drive again, but will let you know when I am coming back to analysis.
Everyone else got a message saying ‘our daughter’, but not him. I had the uneasy idea that he might take it as evidence that I was doing an Anna O.
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Sigmund Freud’s early biographer, Ernest Jones, claimed that in 1882 Josef Breuer left Vienna in alarm after first contact with what would later be called ‘transference’. According to Freud, Breuer took his wife on a second honeymoon to Venice, where they conceived a daughter, following an incident with one of the patients whom he was treating for hysteria using the ‘cathartic method’. Jones claims, following Freud’s suggestion, that this female patient, who famously called her treatment ‘the talking cure’ (Breuer and Freud, 30), had become erotically attached to Breuer. On realising this the doctor ‘fled the house in a cold sweat’ (Jones, 247). He terminated the therapy after witnessing his patient in the throes of a hysterical attack in which she claimed to be pregnant with his child.
Breuer’s account of the treatment of Bertha Pappenheim, dubbed Anna O in Studies on Hysteria (1895), is a foundational document in the history of psychoanalysis. But it contains no evidence of a hysterical pregnancy. Instead, we learn from Breuer that Anna O was restored to ‘complete health’ (Breuer and Freud, 41) from her severe hysterical symptoms – a cough, vision disturbances, speech disturbances, and paralysis of her right side. Her health was apparently remade through the ‘talking cure’ – a treatment that recreated, via words, the chain of unconscious connections forged between repressed traumatic experience and her conscious understanding. The mechanism of the proto-psychoanalytic cure was inferred in these terms: the body no longer needed to translate and ‘speak’ the repressed experience in a hysterical symptom because the ‘talking cure’ had enabled the trauma to be re-voiced.
In 1932, Freud offered an account to the writer Stefan Zweig that cast doubt on Breuer’s claim for Anna O’s cure. In the same letter he told the story of the hysterical pregnancy that Jones went on to repeat. Part of the force of Freud’s comments, if one puts aside the not inconsiderable element of professional jealousy and bad feeling, comes from his assertion that Breuer had in his hands one of the keys to the efficacy of psychoanalysis, though was too straightforward a reader of evidence to realise it. Transference, as Freud came to call it, is the process by which a patient spontaneously and unconsciously redirects emotions and feelings from earlier relationships – say, with parents – into the relationship with a therapist. Although in Studies on Hysteria Freud saw this redirection as a form of resistance and a threat to the treatment, he soon came to understand transference (and indeed counter-transference) as a therapeutic tool that gave vital clues, visible in the external world and both painfully and playfully alive in the present, to the operations of patients’ mental lives and their compulsion to repeat earlier modes of making relationships with others. And it was only if these earlier modes of relating could be brought to consciousness, rematerialised in the present, and contained within the ritualised, formal, and repetitive ‘holding pattern’ of the analytic session, that they had a chance of being ‘worked through’. For Freud, transference came to be one of the ‘royal roads’ of the psychoanalytic process rather than a damaging deviation.
The historical evidence for this pregnancy – the ‘primal scene’ of transference that validates Freud’s account of the sexual aetiology of hysteria and leads to the birth of psychoanalysis – is shaky. A number of writers have cast more than reasonable doubt on the story (see, for example, Breger, Skues). The only retrievable evidence that the incident happened at all is third hand. It also seems likely that Bertha Pappenheim terminated the treatment rather than Breuer. Breuer’s daughter Dora was born in 1882, before the end of Pappenheim’s therapy later that year. It is also unclear whether the claimed effects of the treatment – either complete cure or utter failure – can be trusted.
With its hints of retroactive reconstruction, both in the historical emergence of the concept and within the structure of its supposed workings, transference perhaps sits in an unpromising position for evidence-based understandings of medicine and healthcare. The fact that transference is only ever evidenced by the therapist’s reading hardly helps matters. As Karl Popper has suggested, a theory that is insufficiently precise to produce clearly negative results is immune to a key element in the scientific method: the possibility of falsification (1962).
Isabelle Stengers has suggested, however, that transference interpretation was Freud’s attempt at creating an experimental method. In his assertions about the therapeutic value of transference, Freud imagines himself as something like a nineteenth-century chemist who creates his object in a laboratory in order to study it. Pre-existing neuroses that involve situations outside the purview of the analytic scene are transformed into an ‘artificial illness’ – a transference neurosis – that is decipherable precisely because it occurs within controlled conditions (Stengers, 84). Stengers argues that the experimental method relies on a phenomenon that can act as a ‘reliable witness’ – something capable of not yielding to an experimenter’s expectations and being incapable of deceiving them. But transference cannot act as a ‘reliable witness’ in evidential terms because it can never be free from the analyst’s power of suggestion, nor from the patient’s capacity to resist the articulation of truth. Freud reluctantly came to realise this: ‘the power that transference gives to the analyst is not sufficient, it cannot stand up against the resistances it must face. Patients resist the elucidation of their resistance’ (Stengers, 85). For Stengers, though, psychoanalysis is suggestive precisely because of its failure in this regard: its incapacity fully to separate itself from suggestion or to be accommodated within an account of science in which the world is governed by immutable laws rather than open to more complex and uncertain becomings.
It is notable that one of the strongest attempts to subject psychoanalytic treatment to a randomised control trial in the UK’s National Health Service – the Tavistock Adult Depression Study (TADS) – does not contain any mention of transference. The trial was set up over a decade to test ‘the effectiveness of psychoanalytic psychotherapy using this most rigorous of scientific designs’ and to establish if a long-term intervention offered improved outcomes for patients suffering from chronic depression not helped by the treatments currently provided: antidepressants, short-term counselling, or cognitive behavioural therapy. The results were promising, with this as the headline: 44% of the patients who were given 18 months of weekly psychoanalytic psychotherapy no longer had major depressive disorder when followed up two years after therapy had ended; for those receiving the NHS treatments currently provided the figure was only 10%.
RCTs are set up specifically to minimise suggestion and sources of bias in the collection of data, with double blind placebo-controlled studies representing the ‘gold standard’ in evidence-based medicine. But blinding was, of course, impossible in TADS, and there was no use of placebo treatments. Instead, patients and clinicians were aware of the nature of the therapeutic treatment in which they were taking part. It is worth noting that it is the relationship between clinician and patient, whether transferential or not, that is discarded in the RCT’s method of panning for evidential gold. It is the relationship with the patient, or to the outcome of the trial, that might cause the clinician, whether consciously or not, to select patients who are more likely to do well for the non-placebo treatment. The relationship to the clinician or the treatment might also affect patients’ behaviour in the trial and their responses to subjective outcome measures. Relationships might finally affect ascertainment bias in terms of how data is then judged, recorded, and analysed. For TADS’s attempts to place the increasingly dulled reputation of psychoanalytic psychotherapies within the aura of the gold standard, the evident qualities of the therapeutic relationship are necessarily a problem. Even though phenomenological psychiatry and psychoanalysis have both shown that mental illness tends to manifest itself in terms of a disordering of the elements of the ‘life world’ that include relationships with others, with past experience, or with one’s own sense of selfhood, TADS needs to draw a veil over the therapeutic alliance. Any sense of why a long-term psychoanalytic psychotherapy – an enduring relationship – may lessen the suffering of its participants must happen elsewhere.
For those in the humanities and social sciences, it is hardly a radical proposition that relationships of various sorts inject what might be characterised as ‘dirt’ or ‘noise’ or even ‘resistance’ into the only-ever putative purity of scientific evidence in a way that opens up other possibilities of understanding and meaning (see, Actor Network Theory). Relationships are the basic material of many forms of qualitative evidence. Such evidence, in its myriad forms, is widely recognised in the humanities and social sciences as vital for describing and in turn understanding how human and nonhuman worlds are always already in contact and forming networks of intra-action (Barad, 2007). What the troubling example of transference offers, however, is a suggestion that attention to relationships and particularly the irrational projections and fantasies that structure them – those elements particular individuals and social structures work hard to unvoice – is not simply a preliminary stage of understanding that can lead to a more robust empiricism of action. A commitment to the mad and maddening trouble of transference within psychoanalytic treatment suggests instead that working with the presence of phantasmatic elements that can hardly be brought to consciousness, never mind into rationality, is a mode of understanding that produces an effect in and of itself. Sticking with the transference rather than allowing oneself to be pulled into more comfortable or realistic modes of relating perhaps suggests a particular possibility of what Haraway names ‘staying with the trouble’. Working with the transference names the possibility that re-voicing and rematerialising repressed and painful modes of relating and bringing them into understanding is itself a form of ameliorative action orientated towards the possibility of health.
Although psychoanalysis tends to keep its claims for transference within the analytic dyad, or an intersubjective relationship, or an individual psychology, what may be useful is its idea that understanding relationships (here between internal psychological and external reality), produces change rather than repeats things as they stand. In psychoanalysis, this change is aimed at nothing as falsifiable or pure as cure. In Freud’s simultaneously modest and highly ambitious terms, it is an orientation towards health that would simply turn ‘hysterical misery into common unhappiness’ (Breuer and Freud, 304). It is, nevertheless, a movement towards a form of health derived from learning to accommodate and tolerate rather than repress the ‘dirty’ or ‘noisy’ elements of living, whether they exist in the memories of the past, experiences of the present, or ideas of future. The repressed damage of the past that persists in the present is re-voiced and rendered understandable in such a way that a different future becomes possible, and in turn becomes material.
Psychoanalysis is pretty clear that one doesn’t ever get beyond transference into the light of reason. The idea of simply changing relationships through enduring and coming to understand them, rather than heroically transforming or becoming cured of them, may also seem unhelpfully modest when faced with the most urgent health challenges. One might indeed wonder about the value of attending to the concept of transference when its beginnings and endings are so murky. Bertha Pappenheim’s transference was never analysed, after all, and there is strong historical evidence that she was unwell for some time following the break with Breuer. We can perhaps do nothing more than take note of the fact that she went on to make an outstanding contribution to public life as an author, translator, feminist and social pioneer who founded the Jewish Women’s Association and Neu-Isenburg refuge for girls at risk from prostitution and trafficking. She also seems to have gone on to lead a life that was liveable with a female companion who loved her. We cannot know whether these achievements were the result of making something from her contact with the birth pangs of psychoanalysis or of going her own way without it.
I am left wondering what a commitment to materialising and rendering understandable the repressed elements of past and present networks of relationships with and within human and nonhuman worlds might look like in terms of the ‘holding pattern’ of a research project. I suppose one thing it might just look like is an index for an unfinished, unfinishable book: an index that allows in the cacophonous complexity and contradictory qualities of the scene of evidence and health; an index that flattens out the conceptual hierarchy of its contents but emphasises lateral relationships and agencies, trusting to the possibility of them playing themselves out. A form based around an ongoing playing out of multiple relationships is necessarily risky, suggesting the possibility of troubling offspring. This index might let in voices one might not want to be there – that seem incomprehensible, careless, even toxic. It might just be an evasion: an articulation of the fantasy that one could leap-frog the pain of writing a book and get straight to the summative pleasures of the index, with its satisfactions of achievement and poetry produced by the aleatory qualities of alphabetisation. It might bring to consciousness the fear that I, specifically, could not gestate and birth a book about evidence, maybe even any book at all, that would be worthy of the labour pains. It might end up an unholy mess: a tangled surface with no legible ways through; a site over-spilling with matter out of place, or untranslatable noise, or individual instances with no overarching conceptual containment. But it might, with its multiple voices, multiple sites of labour, and commitment to rendering visible the as yet unknown relationships between them, do more than a single volume could manage, however omnipotent the author.
One of the things the form of this Index seems to be attempting is to materialise a set of relationships between bodies, things, sites, signs, terms, concepts, minds, authors, voices, historical periods, disciplines, and media that returns the complexity of evidence and the highly dispersed spaces of its distribution to themselves. It is working to bring back to consciousness the messiness and the interminable labour of understanding and parsing out how evidence works. It is working to re-voice these elements in the name of understanding the tense, playful, overwhelming, and irrational scene of evidence. Perhaps it is doing so in the hope that such a scene might be remembered, repeated, and worked on, if never quite worked through.
Fonagy, P., Rost, F. Carlyle, J. McPherson, S., Thomas, R., Fearon, P., Goldberg, D, Taylor, D. ‘Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS)’, World Psychiatry, 14 (2015): 312–321 DOI: 10.1002/wps.20267/pdf
Jones, Ernest. Sigmund Freud: Life and Work, Vol. 1. London: The Hogarth Press, 1954.
Popper, Karl R. Conjectures and Refutations. New York: Basic Books, 1962.
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