Recent contributions - clinical research Donald Moss On Cassorla: What, then, is the clinical research problem that Cassorla

poses? The clinical research problem resides within a single conceptual structure consisting of three essential parts, each joined to the others: chronic enactment, acute disruption and trauma. Undreamable trauma constricts analytic work, leading to chronic enactment. Chronic enactment engenders an acute disruption. Acute disruption, contrary to expectations, has a salutary, freeing effect. This structure is both the product of clinical research and potentially the object of further clinical research. I need to clarify what I mean by clinical research. For me, clinical research begins in clinical experience. In particular, it begins in the experience of surprise. Something unexpected takes place, something for which the analysts available conceptual apparatus seems insufficient. There has arisen a conceptual anomaly. The question raised by the anomaly functions as the spine of the clinical research question. Can the existing conceptual apparatus account for what has taken place? If so, if the apparatus can, indeed, account for the moment of surprise, how do we account for the apparent anomaly? And, if the apparatus cannot account for it, what is the minimum conceptual modification of the apparatus necessary to generate an adequate account? Looked at this way, Cassorlas text certainly qualifies as an example of clinical research. For him, the moment of generative surprise comes with the disconfirmed expectation of a destructive effect following the analysts act of acute disruption. Cassorla then asks the clinical research question: how can we account for this surprise? What kinds of changes in our thinking will be necessary to account for this surprisingly salutary sequence? His response seems to me to represent a model for conceptual advance.

Cassorla reacts to a clinical surprise not by generating new terms or new theory but by proposing a rearrangement, a recombining, of preexisting terms within the structure of existing theory. He produces a surprising molecule that then provides an account for a surprising clinical phenomenon. This molecule is the exemplary product of exemplary clinical research. Now then, what happens if we invert perspective here and treat Cassorlas text not as the product of clinical research but rather as an object for our own clinical research? That is, what happens if we scrutinize the molecule and the theoretical assumptions on which it is based? Clinical assertions are invariably susceptible to being debunked as tautological. The reason for this is simple. The clinician aims to give an account for a phenomenon whose appearance might depend entirely upon his/her own conceptual/perceptual repertoire. One might be able to see only what ones theory allows one to see. The pertinent sighting, the productive experience of surprise, the subsequent moments of thinking and hypothesis-generating, the satisfying sense of confirmationall of these might take place within a self-enclosed framework that necessarily lacks the capacity for selfreflective suspicion. One might not be able to get sufficiently outside of ones own theoretical world so as to subject it to the necessary hermeneutics of suspicion. This, I think, is the most vexing problem for all psychoanalytic clinical research. As such, of course, it is also a problem pertinent to Cassorlas text. Cassorlas text is rather long. The questions it takes up, the answers it provides, are fundamentally the product of what Cassorla calls supervisions and clinical seminars. Grounded in these experiences, Cassorla offers us his vision. The vision is deep and elaborate, a thick mix of developmental, structural, and clinical dimensions. The vision is, in my view, quite beautiful, reminiscent, I think, of the kind of beauty available in some Renaissance paintingsiconography and technical mastery combining to produce a picture of extraordinary narrative force and conviction. For evidence, Cassorla offers us two clinical vignettes. I had the feeling that neither of the vignettes derived directly from Cassorlas experience, but rather came from his contact with the experience of colleagues. In both vignettes, we can read of the pertinent sequence chronic enactment/acute disruption/traumatic non-dream. We can also experience the enormous theoretical packaging in which these two sequences are wrapped.

What we cannot do, however, is to find a way to locate ourselves outside the sequences and their packaging so as to be able to consider the sequences as evidence. Sequence and theoretical packaging are so intertwined, so united, that to call any particular element into question entails, I think, calling the entire edifice into question. In other words, the clinical vignettes do not, in themselves, qualify as evidence. If we want to find evidence here, I think we would, in effect, have to take the entire text as evidence. The examples cannot be extricated from their theoretical surround. So then, where does this leave us? I think it leaves us in front of a very useful mirror. A useful mirror is a humbling one, one that checks our theoretical view of our self and, in effect, turns that view into evidencethat is, a useful mirror allows us to adopt a clinical research attitude toward our own image, an attitude of hermeneutic suspicion. Cassorla brilliantly generates a clinical/conceptual molecule by which he can simultaneously ask and answer a set of questions posed by way of a moment of clinical surprise. We can take Cassorlas paperwith its central terms of chronic enactment, acute disruption, and traumahome with us. Like every analyst, we will soon experience a moment in which we acutely disrupt a clinical process. Following Cassorlas lead, we can then be alert to the possibility that our disruption will have a salutary effect on a chronic enactment that has, until then, gone un-noticed. We will then, potentially, have our relevant bit of evidence. Responding to that bit of evidence, we can then try to think about it. We can wonder about our capacities to think, our capacities to step outside our own framework, that is, and to momentarily become non-believers of what we customarily believe. From that position of non-belief, we might be able to submit our experience to the scrutiny of clinical research. And then again, we might not be able to confidently achieve such an attitude. If we cannot, or if we feel we cannot, we might, then, submit a report of our experience to someone else, someone who owes no debt of belief, who, in fact, will greet our report with the requisite attitude of hermeneutic suspicion. And there, in that encounter between believer and non-believer, we will be able to generate the opening exchange in a project of clinical research.