“ANALYZABILITY”: A SYSTEMATIC REVIEW OFTHE CLINICAL AND QUANTITATIVE
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HENRYM. BACHRACH, PH.D. LOUISA. LEAFF, M.D.
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LITERATURE
F
EW ANALYSTS, WE THINK, WOULD DISAGREE that some persons benefit from classical psychoanalysis while others do not. No sooner had Freud (1893) developed his psychoanalytic method than he attempted to specify the kinds of persons and conditions to which it was applicable (1894; 1905; 1913; 1916-1917): More recently, Rangell (1975) has written of a need to recognize an “optimum scope” for psychoanalytic therapy and, within this scope, “use psychoanalysis for what it can do” (p. 96). Differences in response to psychoanalysis can be traced to qualities of analysand, of analyst, and their interaction. Our aim is to systematically review the psychoanalytic literature in the first of these areas. We have several purposes in mind: We wish (1) to explore systematically just what patient qualities are thought to be important to the outcome of psychoanalysis, and how much agreement there is about these qualities; (2) to compare the accounts of such qualities given by the clinical and quantitative investigations; and (3) to
We thank Drs. Philip Escoll, Howard Huxster, and Lester Lubonky for their critical readings of earlier versions of this manuscript, and hlrs. Margaret Smith for assistance in its preparation.
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provide methodological evaluation of the contributions as a guide to future investigation.
Methods and Limits of the Literature Review All papers primarily focused upon “analyzabilityJJor “suitability for psychoanalysis” published in the mainstream of the American psychoanalytic literature since 1954 were included in this review. For practical purposes this meant scrutiny of the Journal of the American Psychoanalytic Association, the International Journal of Psycho-Analysis, the International Review of Psycho-Analysis, the Psychoanalytic Quarterly, the Psychoanalytic Review, Psychological Issues, T h e Annual of Psychoanalysis, and Psychoanalysis and Contemporary Science; references to contributions in other publications were also explored. The review was limited to papers published since 1954 because developments in theory and technique over the years might have led to misleading contradictions not accurately reflecting the current state of thinking were we to have surveyed the entire literature from its very beginnings. Tyson and Sandler (1971) have already given a good historical account. No specific definition of classical psychoanalysis was employed as a guide to our literature search because most of the papers themselves do not include a definition. Instead, we assumed there would be some communality as to what was meant by classical psychoanalysis in papers published in the mainstream of the psychoanalytic literature. Our assumption, however, is that these references do relate to a process requiring four or five sessions per week, the use of a couch, and which attempts to foster the development of a transference neurosis to be resolved by its interpretation. Governed by these delineations, 24 studies’ were selected * The work of the Kris Study Group is reported in two places (Waldhorn, 1960, 1967); we choose the former for review here because of its more systematic
presentation.
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for systematic review, and these form the substrate of our conclusions. Each paper was reviewed independently by both authors for all specific references to factors relating to (1) suitability for psychoanalysis, or favorable outcome; (2) unsuitability or unfavorable outcome; (3) the data conclusions were based upon; (4) the methods employed for the assessment of the factors; and (5) criteria for the outcome of psychoanalysis. A worksheet following this outline was prepared for each study, and the findings transferred to the Appendix which appears at the end of this paper. The conclusions of the individual studies suggested the following categories: 1. Adequacy of General Personality Functioning, including all references to adequacy of adaptive functioning, severity of illness, severity of symptoms, diagnosis, ego strength, reality testing, subliminatory potentials, adaptive regression, defense, thinking, intellectual abilities, and capacities for verbalization; 2. Object Relations, including all references to object relatedness, narcissism, tolerance for separation, object constancy, and capacities for transference and working alliance; 3 . Motivation; 4 . Affect Organization, including references to availability of and tolerance for anxiety, frustration, depression, etc.; 5. Character Qualities; 6. Superego Factors; 7. Demographic Factors; 8. External Factors.
Principal Findings There are 24 studies in the contemporary psychoanalytic literature primarily focused upon analyzability. Sixteen are essentially clinical in nature (Aarons, 1962; Diatkine, 1968; A. Freud, 1954; Glover, 1954; Karush, 1960; Kuiper, 1968; Levin, 1960, 1962; Limentani, 1972; Namnum, 1968; Panel, 1960; Stone, 1954; Tyson and Sandler, 1971; Waldhorn, 1960; Zapparoli, 1976; Zetzel, 1968). Five are quantitativepredictive (Hamburg et al., 1967; Kernberg et al., 1972; Klein, 1960; Sashin et al., 1975; Weber et al., 1974) and Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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three employed quantitative methods although their predictions were not related to final outcomes (Huxster et al., 1975; Knapp et al., 1960; Lower et al., 1972). There are a' total of 390 separate references to prognostic factors in these studies. Table I summarizes their main trends. TABLE I CONDENSED SUMMARY OF MAINTRENDS: NUMBER OF REFERENCES INDICATING FAVORABLE, ,UNFAVORABLE, OR NEUTRAL PROGNOSIS Number of References
Main Trend
Favorable
Neutral
Unfavorable
?
Adequacy of Personality Functioning Adaptive functioning Ego strength Reality testing Subliminatory potentials Capacity for adaptive regression Capacity for verbal communication Defense organization (mature) Thinking Intellectual ability Severity of symptoms Severity of illness Diagnosis (re: range of ego weakness)
9 10 8 10 3 14 11 4 6
0
1
32
0 0 0 0 0
3
0 0 0 0
0 0 0
0 0 0 0 0
2 8
5 0
0 0 0 1 1 0 1
0 0
0 0
1 0
0
0 0
0
0 0 2
3
0 0 8
Object Relations Capacity for transference Capacity for therapeutic alliance Object relatedness General During interview With parents With friends and marriage Pathological narcissism Tolerance for separations Severe early deprivations Capacity for object constancy
7 5 20 2 13
7 0 6 0 4
Motivation Self-understanding and change To relieve suffering
6 4
1
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0
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Number of References
Main Trend
Other motivations (positive) General
885
Favorable
Neutral
9
2 0
0 0
0 0
1 0 0 0
0 0 0 0 0
0 0 0 0 0
13 10 25 4 3 13
1 0 0 0 1 2
0 0 0 0 0 0
0 0 0 0 0 0
6 1
1 2
0 0
0
0
6
Unfavorable
?
Affect Organization Anxiety tolerance Depression tolerance Tolerance for frustration, suffering Tolerance for other affects & states Availability of tamed affect
10 3 9 4 14
0
Character Qualities Psychological mindedness Other character attitudes (positive) Other character traits (positive) Drive factors (positive) Manifest oedipal conflict Superego Factors (positive) Demographic Factors Age (young adults) Sex (males more successful) Previous psychotherapy (negative experience) Other
0
2
5
0
0
0
1
0
3
1
5
0
External Factors Supportive vs. nonsupportive influences
Taken together these studies suggest that persons most suitable for classical psychoanalysis are those whose functioning is generally adequate; they have good ego strength, effective reality testing and subliminatory channels, and are able to cope flexibly, communicate verbally, think in secondary-process terms, and regress in the service of the ego with sufficient intellect to negotiate the tasks of psychoanalysis; their symptoms are not predominantly severe, and their diagnoses fall within a “neurotic” spectrum. Such persons are able to form a transference neurosis and therapeutic alliance, Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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are relatively free of narcissistic pathology, have good object relations with friends, parents, and spouses, and have been able to tolerate early separations and deprivations without impairment of object constancy; they are therefore able to experience genuine triangular conflict. They are motivated for self-understanding, change, and to relieve personal suffering. They are persons with good tolerance for anxiety, depression, frustration, and suffering and are able to experience surges of feeling without loss of impulse control or disruption of secondary-process mooring of thought. Their character attitudes and traits are well-suited to the psychoanalytic work, i.e., psychological mindedness. Superego is integrated and tolerant. They are mainly in their late twenties or early thirties and have not experienced past psychotherapeutic failure or difficulties. Of all these qualities, those relating to ego strength and object relations are most important. One third of all references relate to adequacy of personality functioning; one quarter refer to object relations. Hence, the contemporary literature has been cast mainly in terms of ego functioning and object relations, and there is complete agreement that the better the pretreatment level of functioning, the more favorable the response to psychoanalysis. Motivation, affect organization, and character are mentioned less often; superego and demographic factors tend to be mentioned least. Clinical contributions account for 90 percent of all references. What controlled quantitative investigation there is, however, accords fully with clinical contributions. There is also strong agreement about the qualities that make a person suitable for psychoanalysis. Disagreement occurs only in 9 percent of the references and mainly because isolated factors are not always regarded prognostic per se. The consensus, occurs, however, mainly on a metapsychological-conceptual level; most references are cast in metapsychological terms, i.e., ego strength, rather than as clinical-empirical obseruations. Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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These findings are, in part, the product of our method for reviewing the literature, i.e., enumerating the number of times something has been said. Such a method, however, does not account for the reliability and relative importance of the individual references, the factors that lead people to emphasize in their writings what they do, the interactions among the qualities, and plainly, how just one or two good qualities in some people-for example, the will to be analyzed and psychological mindedness -can outweigh a plethora of ills. If one approaches the review differently and attempts to distill the most vital factors stressed by seasoned clinical contributors and established by replicated controlled investigation the potentially successful analysand emerges as a young psychologically-minded adult with capacities for transference and working alliance and who seeks treatment for self-change through understanding; such a person has good ego strength, mature object relations, and self-discipline, and their character and interests have depth and richness. Diagnoses fall within a “neurotic” range and manifest presenting symptomatology and behavior during initial interviews .are not of particular predictive significance. Waldhorn (1960) refers to the capacity for transference as the sine qua non of analyzability ; Kuiper (1 968) refers to psychological-mindedness as the most essential quality, and Namnum (1968) speaks of the will to be analyzed as essential. In contrast, persons not likely t o benefit come to analysis seeking magical fulfillments consistent with their infantile attitudes, character traits, and impoverished, need-satisfying relations with people; their ego functioning is likely within a “borderline” (Kernberg, 1975) or “psychotic” range. * Despite the consistency of these findings, there are several reasons why it may be difficult to directly apply them to actual clinical practice at the present time. First, they are case mainly in abstract terms; it is easier to agree about the importance of ego strength than to confidently asses its Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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manifestations. Second, accurate prediction may require analytic data not readily obtainable in the course of initial interviews. Aarons (1962), for example, argues that data concerning quality of object constancy in the mother-infant dyad (basic to therapeutic alliance) might become available only in the course of analysis. Certainly, preanalytic data are different in quality from analytic data (Kohut, 1959; Kris, 1957) and the life history we obtain initially (upon which we base our assessments) is almost always revised in the course of analysis. Holzman (1976) has commented that psychoanalysis lacks a body of literature in which one contribution builds upon another so that a steady progress of new knowledge can occur over time. Inspection of the Appendix shows this is largely true for the studies surveyed; what is being written about today is by and large the same as what was written twenty years ago, although there are some new trends: 1. Quantitative methods are beginning to be employed and controlled predictive studies are now appearing. Before 1960 there were no such reports. Between 1960 and 1970 there were three (Hamburg et al., 1967; Klein, 1960; Knapp et al., 1960). Since 1970 there have been five (Huxster et al., 1975; Lower et al., 1972; Kernberg et al., 1972; Sashin et al., 1975; Weber et al., 1974). 2. In the early literature there were no formal distinctions between indications and suitability for psychoanalysis. This distinction was introduced by Tyson and Sandler (1971) and is now being widely employed. 3. The concept of therapeutic alliance was introduced into the analyzabiliky literature by Levin in 1960; all other references have occurred since 1968 (Diatkine, 1968; Huxster et al., 1975; Tyson and Sandler, 1971; Zetzel, 1968). 4. With the exception of transference, all but three of the 82 references to object relations have occurred since 1960. Certainly, it is fair to say that the object-relations point Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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of view is becoming more important to consideration of analyzability. 5. Discussion of character issues is something relatively new. Only one reference (Stone, 1954) comes before 1960. 6. Since 1968 the distinction between oedipal symptomatology and the presence of genuine triangular conflict began to emerge in the literature (Zetzel, 1968). Because the ability to experience genuine triangular conflict is considered favorable and the mere presence of overt oedipal symptoms not necessarily predictive, this distinction seems quite important. Comparison with Quantitative Psy chot h erapy R esearc h2 Owing to the paucity of quantitative-predictive research relating to the outcome of psychoanalysis, we thought it would be interesting to compare our findings with those of quantitative research on factors predictive of the outcome of psychotherapy in general. Strictly speaking, one might have reservations about making such a comparison. Quantitative psychotherapy research has tended to be clinically unsophisticated: therapists have tended to be inexperienced; treatments have been of brief duration, and there have been many problems with the evaluation of outcome. Despite these reservations, there are many findings in common with those of the present review. 1. Adequacy of Personality Functioning: The finding from the analyzability literature is that initial level of adequacy is one of the most potent predictors of favorable outcome. Through 1970 there were 52 quantitative-predictive psychotherapy studies with findings related to adequacy (i.e., ego strength, severity of symptoms, diagnosis, somatic concerns, social achievements, defensiveness); in 33 of 34 there was a significant positive relationship between the initial level of personality functioning and the outcome of * Based upon the Luborsky et al. (1971) review of quantitative research. Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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psychotherapy (statistically significant correlations were not obtained in the remaining eighteen studies). The quantitative psychotherapy research literature therefore accords with the analyzability literature in that the healthier a person is to begin with, the better he does in treatment. 2. Object Relations: According to our review, quality of object relations is directly related to the extent to which a person will benefit from psychoanalysis. There are only four quantitative psychotherapy studies directly relating to this area; in all four, interest in people was positively related to favorable outcome. 3 . Motivation: Strong motivation for self-understanding, change, and to relieve suffering emerges as a favorable prognostic indicator in our survey. Of ten quantitative psychotherapy studies that deal with motivation, seven find a significant positive relation with outcome and three are nonsignificant. 4 . Affect Organization: Tolerance for dysphoric affects and the availability of tamed affect are important indications of suitability, according to our review. In fourteen quantitative psychotherapy studies dealing with affects, the trend is that patients with high though not overwhelming affect at the beginning of treatment are likely to benefit most. 5. Character QuaZities: According to our survey, those character qualities supportive of the psychoanalytic work are especially valuable assets. In fact, nearly one quarter of all the references were to psychological mindedness. Eleven psychotherapy studies seem to relate to psychological mindedness; three out of five found self-awareness prognostically significant (in the two others the relationship was not statistically significant)] and six out of six found “experiencing” significantly related to favorable outcome. Ethnocentrism is the only other character quality that has been studied; two out of three studies found it to be a significantly negative predictor. Thus, the findings of clinical psychoanalytic investigaDownloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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tion are supported by quantitative research on psychotherapy in general. It does not, however, follow from this that there is no further need for quantitative-predictive research. Indeed, the clinical supefiiciality of quantitative psychotherapy research, and the methodological limitations of clinical psychoanalytic investigation make such research all the more urgent.
Methodological Evaluation of the Studies The majority of contributions to the analyzability literature are clinical in nature; it would not be meaningful to evaluate these according to a methodological yardstick suitable for purely quantitative research. To do so would be to hold clinical investigations accountable to criteria that played little role in their shaping and method. However, there are established tenets of clinical inference and scientific method that are relevant. These relate mainly to questions of evidence, method, conceptualization, and observability. It is to such standards that we shall turn in our methodological evaluation. Table I1 summarizes the studies according to some of these criteria, i.e., the essential data upon which the conclusions are based, the method employed for assessing analyzability, and the criteria for outcome of psychoanalysis. The Meaning and Specqication of Outcome and Analyza bility
Only five of the studies surveyed clearly specify what is meant by “favorable” or “successful” response to psychoanalysis. Aarons’ (1962) clinical investigation defines successful outcome as “the resolution of unconscious conflict” as distinguished from conformity, compliance, and “correct” behavior. Kernberg et al. (1972) employed clinical-quantitative judgments of well-defined core intrapsychic variables, elg:, ego-strength, unconscious guilt. Sashin et al. (1975) ernDownloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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m u
Y
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Not specified Analyst’s opinion regarding analyzability at termination Psychodynamic changes and insight into conditions relating to difficulties (Accepted or rejected for analysis) Not specified Circumstances of termination (i.e., by mutua agreement, premature, “interminable cases”) “Some improvement”
Interview; reaction to “group” psychoanalysis Life history/interview Life history/Interview Life historyhterview by 2 analysts Not specifiid Life history/ Interview several independent analyst judgments Life history/Interview/ Psychological Tests??
Clinical experience
16 terminated cases of six analysts
Clinical experience
40 clinic applicants
Clinical experience
122 control cases
Clinical experience/ Literature
Levin
Limentani
Lower et al.
Namnum
Sashin et al.*
Stone
alliance
2. Development of transference and working
analyst.
1. Judgment of suitability by candidate
Kuiper
Life history/Interview, 100 clinic cases; 25 control cases in analysis screening by 2 analysts for 1 year
Knapp et al.
Clinical judgments and independent rating scales: seven specific criteria
Life history/Interview/ Discussion with supervisor and committee
30 clinic cases in analysis for more than 200 sessions
Klein*
Extent of intrapsychic and life change after termination assessed by independent researchanalyst judges
Life history/ Interview/ Psychological Tests
21 czws of psychoanalysis 21 cases of psychotherapy ’
Kernberg et al.*
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Not specified
Clinical judgments and independent rating scales in six specific areas Not specified
Ability to recognize and tolerate triangular conflict in treatment
Life histoxy/Interview
Life history/Interview Screening committee Clinical interview
Life history/Interview
Clinical experience/ Literature
271 terminated clinic control cases
Clinical experience/ Literature review
Clinical experience
Waldhorn
Weber et al.*
Zapparoli
Zetzel
Interview/Trial analysis Not specified
Literature review/ Clinical experience
Outcome Cn'tena
T p n and Sandler
Method of Assessment 0fAnalyrabit'ity
Data Base
Invest igatw n
(Tabfe I I continued)
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ployed analyst’s and supervisor’s ratings of global change and circumstances of termination. Klein (1960) and Weber et al. (1974) employed rating scales on specific areas of change and follow-up clinical assessment. In ten clinical studies, no mention is made at all of what is meant by favorable outcome or what criteria might be used to judge the issue. In three instances, outcome criteria are stated in the most general terms; Glover (1954) refers to “degree of accessibility”; Levin (1960) to the analyst’s opinion regarding analyzability at termination; and Stone (1954) to “some improvement.” In the other studies, references to analyzability are not based upon the final outcome of the case but to “in-treatment” developments. Zetzel (1968) refers to the ability to recognize and tolerate triangular conflict in treatment: Knapp et al. (1960) refer to judgment of suitability by a candidate analyst and the development of transference and therapeutic alliance; Lower et al. (1972) to being accepted or rejected for analysis; and Huxster et al. (1975) to supervisors’ response to a questionnaire about the case from three months to one year after the case was begun’. One might argue it is not necessary to precisely state criteria for response or analyzability since such matters are common knowledge among Freudian psychoanalysts. There is, of course, the widely held view that favorable outcome means the analytic resolution of transference neurosis. In actual practice, however, it is not clear how one recognizes sufficient resolution, nor is it clear whether Freudian psychoanalysts, even as a group, mean only this when they refer to favorable response. Ekstein (1956) once pictured the development and resolution of transference neurosis in successful analysis as a normal curve. Yet, when Graff and Luborsky (1976) actually plotted quantitative estimates of transference for four analyses, transference increased over time and remained high at termination irrespective of outcome; what made the difference between successful and unsuccessful outcome was the analysand’s awareness and ability to deal Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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with its manifestations, i.e., the therapeutic alliance and insight. Similarly, Pfeiffer (1959), Schlessinger and Robbins (1974), and Norman et al. (1976) found transference neurosis strikingly reactivated by brief follow-up visits, even among successfully analyzed persons. Considerations such as these raise questions about the meaning of resolution of transference neurosis as the sole criteria for outcome. The relation between symptom relief, patient satisfaction, emotional growth, autonomy, and transference developments are not as well understood as we might like. Ticho (1972) distinguished “life goals” from “treatment goals.” Glover’s (1955) survey found the majority of British psychoanalysts seemed to rely mainly upon intuitive impressions of symptom resolution as criteria for termination. Baum and Robbins (1975) surveyed a group of American psychoanalysts and found intuitive impression of an analytic growth process having been set in motion the pivotal criterion for termination. The term “analyzability,” even when refined to “indications” and “suitability” tends to convey the impression that ansanalyzable person, barring unforeseen unusual events, is likely to have a successful analysis and an “unanalyzable” person is not. But in actual practice, the term “analyzability” has compound meanings; certain patient qualities are more crucial than others during different subphases of the analytic process. The analytic process can sometimes make a seemingly unanalyzable person analyzable, as Appelbaum (1973) has shown in cases of deficit in psychological mindedness based upon repressive defense organization. In actual practice, the analyzability of a patient may vary with different analysts. Some people do well with certain analysts and not with others. Some people also do poorly with any analyst. This has a great deal to do with what goes into forming a therapeutic alliance between two particular people. Hence, our main finding here is that investigators have not clearly specified what they mean by analyzability and to what criteria their findings relate. It seems clearly in the Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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interest of further developments that future investigators do so as specifically as possible, especially on an empiricalobservable level.
Method of Assessing Analyzability No matter how clear a metapsychological understanding one may have of factors prognostic of response to psychoanalysis, this understanding can only guide assessment. One cannot touch, feel, or see ego strength; it is a concept. Rather, our assessments are based upon what we observe, and our conclusions depend upon our methods of observation as well as the guiding conceptual templates we employ. Clinical interview with emphasis upon life history is the method of assessing analyzability employed in most of the studies surveyed. Diagnostic psychological testing was employed only by Kernberg et al. (1972), and referred to by Stone (1954) as potentially useful if better understood. Lower et al. (1972) augmented interviews with an outline of factors thought important to assessment of analyzability and also by employing an analyzability committee, as did Sashin et al. (1975), Klein (1960), Knapp et al. (1960), and Weber et al. (1974). Aarons (1962) spoke of the possible utility of trial analysis. Tyson and Sandler (1971) indicated that trial analysis provides an opportunity for evaluating development of the treatment alliance, but has disadvantages in that it encourages patients to split off part of their lives from the analytic work and it may take a very long time to accurately assess the important factors. In the literature (e.g., Knapp, 1960) there seems to be a dialectic between those who advocate extensive interviews and those who think this interferes with the natural development of the analytic process, Windholz (1960) suggested that, when the prospective analyst interviews, defenses are immediately primed and result in an unavailability of important memories. He also pointed out that the technique Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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of interviewing demands special training and gifts not always coordinate with what is required of a psychoanalyst, and that it might be more profitable to employ others for history-taking. Waldhorn (1960) and Karush (1960) argued that ego structures and functions can be evaluated in initial interviews, though Levin (1960) did not agree. Zetzel (Panel, 1960) summarized the consensus of a panel on analyzability with two points: (1) evaluations made after initial interviews are only tentative approximations of analyzability; (2) diagnostic interviews can best provide only a limited amount of anamnestic material, an account of the patient’s current symptomatology and the degree to which it impinges upon functioning as a whole, and an evaluation of motivation, insight, and the capacity to relate. Because of such concerns about the limits and consequences of extensive interviews, one wonders abo’ut the effectiveness of other means of assessment. Data regarding the role of diagnostic psychological testing are available only in one study: the Menninger Psychotherapy Research Project. Appelbaum (1977) reported that predictions about the outcome of psychoanalysis and psychotherapy based only upon test data interpreted by Psychoanalysts were significantly (p < .01) superior to those based upon interviews, despite the availability of a clinical test report .to the interviewers. Such a finding raises the question whether diagnostic testing, when conceptualized according to clinical psychoanalytic theory and interpreted by psychoanalysts, may provide an untapped resource, particularly for systematic assessment of ego f ~ n c t i o n i n g .It~ also confirms .Huxster et al. (1975) in their claim that the subjective response of the interviewer is a major source of therapeutic overoptimism. At this point, one might conclude that understanding and prediction of response to psychoanalysis might be enhanced by developing methods of assessment in addition to the clinical interview. These issues have been discussed in detail by Appelbaum (1977) and Bachrach (1977). Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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The utilization of several methods not only decreases bias inherent to any single method, but makes possible a triangulation of understanding from independent perspectives. Thus, research such as that of Appelbaum (1977) and Kantrowitz et al. (1975) with regard to the role of diagnostic testing, and that of Huxster et al. (1975) with regard to screening committees is welcome for clarifying just what each method does best and what contribution it can make to assessment.
Information and Evidence When one formulates an inference or proposes a conclusion, it is important to know on what basis the assertion rests. Without evidence, the accuracy of a conclusion can never be determined. Fewer than half of the studies, however, provide such information or evidence. Knapp et al. (1960) base their conclusions upon 100 clinic patients under age 35, without psychosomatic, delinquent, or psychotic trends, with good life situations, coming from intellectually and psychologically sophisticated segments of the population, referred for control analysis; also studied were 25 control cases in analysis for at least one year. Kernberg et al. (1972) studied 42 patients (21 in analysis, 21 in psychotherapy) treated by senior candidates or recent graduates. Lower et al. (1972) studied the first 40 applicants to a psychoanalytic clinic interviewed separately by two graduate screening analysts, with the case being reviewed by an analyzability committee. Huxster et al. (1975) studied eighteen cases from the Lower et al. (1972) study, focusing primarily on four cases deemed best and four worst by supervisors within the first year of the analysis. Sashin et al. (1975) based their conclusions upon 122 “carefully screened” control cases. Klein (1960) studied 30 clinic control cases in analysis for at least 200 sessions (thereby excluding information relating to early failures); Weber et al. (1974) studied 1,348 clinic patients, but based their conclusions mainly upon 27 1 terminated control cases. Hamburg et al. (1967) based their findings upon a retrospective survey of 386 Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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analysts who responded to a questionnaire regarding the clinical characteristics of their case load; included were 2,983 cases about equally distributed between psychoanalysis and psychotherapy. All of the other investigations are primarily clinical in nature. It is therefore not surprising that the findings are based upon the author’s personal experience. In five of these, clinical experience is supplemented by references to the psychoanalytic literature. The evidential bases for the findings are specified only in the minority of cases. The absence of attempts at specification are, to us, a matter of concern. If a clinical author does not even attempt to specify the extent of his clinical experience with a particular matter, or what his range is with clinical problems in general, then how can one contribution be compared to another? A person whose analytic practice is limited to intellectually gifted analysands-such as in a university practice -may regard intelligence as having little prognostic value because there is little variation among his patients. On the other hand, a person with a more varied practice may find it has considerable prognostic value simply because of its variability. As the bulk of the literature now stands, it is difficult to know to what extent one study replicates another. Are they talking about the same or different things? Rarely does one even find such concern expressed in the clinical literature. Overall, our main finding here is that the majority of studies fail to indicate the evidence for their conclusions and the data upon which they are based. It is therefore difficult to be fully cognizant of the nature of the populations referred to, selection biases, and the extent to which one investigation may be said to truly replicate another.
Summary and Coda The contemporary psychoanalytic literature focused primarily upon “analyzability” was systematically reviewed. We found that most studies are clinical in nature. Within the Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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past quarter-century new trends have appeared; these include a distinction between “indications” and “suitability,” increasing stress on object relations and character qualities, and the application of quantitative methods to investigation. We also found considerable agreement regarding the qualities deemed to make a person a suitable candidate for psychoanalysis, i.e., the better the pretreatment level of personality organization, the more favorable the prospect. The findings of individual studies, however, are cast largely in abstract, metapsychological terms lacking empirical specification. Most investigations also do not clearly specify what is meant by psychoanalysis, analyzability, outcome, or upon what evidences conclusions are based. We hope that future investigators will find ways of addressing these problems. For a review such as this to fulfill its intent, it should serve as a basis for new perspectives in future research. One such effort is now beginning, based on a paradigm of studying what kinds of changes occur in what kinds of persons with what kinds of analysts; a series of single, tape-recorded cases will be studied, employing extensive preand post-treatment information (including psychological testing) guided by the main.findings of this review.
APPENDIX Legend 0 = nonsignificant relationship = prognostically favorable relationship = prognostically unfavorable relationship 7 = inconclusive reference * = quantitative predictive study
+ -
Adequacy of General Personality Funcfioning Adequacy of Adaptive Functioning Adaptive ability Good social adaptation
+ +
Lower et al. (1972) Lower et al. (1972)
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Potential for adaptation, i.e., ability to act upon insight Good work and school record Ability to integrate socially and pleasurefully incorporate cultural needs Moral character and educational achievement sufficient to assure a good position in life with adequate rewards Achievement of autonomy Failure of mastery Regression
Ego Strength Ego strength Ego strength Good ego strength High ego strength* Low ego strength* Availability of creative and synthetic proclivities of the ego Ego must be able to tolerate impulses and conflict: a quantitative relation between defensive and autonomous ego functioning is necessary Ability to utilize psychological energy consistent with life goals Feeble personality resources Basic ego defects
Reality Testing Reality testing Reality testing (absence of projection, denial, hypomania) Reality testing Lack of reality testing Faulty reality testing Poor judgment Ideas of reference Recognition of fantasies as fantasies
A . LEAFF
+ + + +
+
-
-
+
+ + + + +
+
Waldhorn (1960) Lower et al. (1972) Karush (1960) Tyson&Sandler(l971)
Zetzel (1968) Zetzel (1968) Lower et al. (1972) Karush (1960) Levin (1960) Lower et al. (1972) Kernberg et al. (1972) Kernberg et al. (1972) Aarons (1962) Panel (1960)
Levin (1968)
-- Stone (1954) - Zetzel (1968)
+ +
Tyson &Sandler(l971) Waldhorn (1960)
+
Zetzel (1968)
-
Lower et al. (1972) Lower et al. (1972) Lower et al. (1972) Diatkine (1968)
- Zetzel (1968) -
-
+
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Subliminatory Potentials Availability of conflict-free capacities Subliminatory potentials Subliminatory potentials Successful sublimations Limited sublimation Absence of subliminatory gratifications Little gratification Capacity for pleasure in substitutes and in active mastery and learning Life not centered around analysis Persistent inhibitions obliterating sublimations Adaptive Regression Regression in the service of the ego Adaptive regression Adaptive regression Capacity for Verbalization Capacity to verbalize Capacity for continuous verbalization Capacity for verbal communication Capacity to communicate meaningfully during interview Ability to communicate Absence of blocking in initial interviews Capacity for speech Severe blocking Extreme periods of blocking Mutism Silence in borderline or psychotic patients where there is intrinsic impairment in communication Speech defect Gross speech defects Chronic difficulties in communication, i.e., inarticdateness or anxiety connected with speech Erotization of speech
+ +
90s
+
Tyson &Sandler(l971) Stone (1954) Lower et al. (1972 Tyson &Sandler(l971) Lower et al. (1972) Waldhorn (1960) Lower et al. (1972) Zetzel (1968)
+
Tyson &Sandler(l971)
+ + +
Diatkine (1968) Panel (1960) Namnum (1968)
+
0
Aarons (1962) Levin (1962)
+ +
Namnum (1968) Hwster et al. (1975)
+ 0
Karush (1960) Levin (1962)
+
Waldhorn (1960)
-
Waldhorn (1960) Aarons (1962)
0
Panel
-
Waldhorn (1960)
+ + -
-
-
- Diatkine (1968)
- Knapp et al. (1960) - Levin (1960)
- Waldhorn (1960) - Waldhorn (1960)
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A . LEAFF
HENRY M . BACHRACH-LOUIS
Long delay of onset of verbalization in childhood Presence of deaf or mute parent Defense Organization Proper mixture of alloplasticity and autoplasticity Flexibility of defenses Rigidity, hypertrophy of automatic defenses Previous history of unchanging defensive patterns, i.e., patient who proposed to begin analysis with reservations Excessive defensiveness and vagueness during interview Defensiveness (rigidity, lack of dreams and memories) Lack of defensiveness Failure to develop stable impulse-defense configurations Projective identification Patterning of defenses (in positive direction)* More serious defense mechanisms (tendency but not statistically significant) are unfavorable* Thinking Imaginative thinking Secondary-process thinking Undue persistence of magical thinking as might be reflected in grandiosity, sexual problems, abortions, divorces, bizarre job and living arrangements Thinking and memory difficulty Intellectual Abilities Intelligence Intelligence Intelligence as related to psychological mi n dedn ess Low intelligence (all that is required is
- Waldhorn (1960) - Waldhorn (1960)
+
Aarons (1962)
+
Waldhorn (1960)
- Waldhorn (1960)
- Waldhorn (1960)
-
Huxster et al. (1975)
-
Lower et al. (1972)
-
+
Lower et al. (1972) Zetzel (1968)
+
Diatkine (1968) Kernberg et al. (1972)
?
Weber et al. (1974)
+
+
-
Diatkine (1968) Diatkine (1968) Waldhorn (1960)
-
Knapp et al. (1960
+ + +
Karush (1960) Nantnum (1968) Waldhorn (1960)
0
Tyson & Sandler (1971)
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sufficient to form working alliance and gain insight) Learning capacity Educability (as relates to psychological mindedness) Education Patients with higher educational level did better* Intelligent patients with higher educational achievement did better (tendency, but not statistically significant)* Seventy of Symptoms Severity of symptoms Seventy of symptoms* , Severe symptom a tology, especially compulsive overeating Severe obsessional thoughts* Severe phobias and inhibitions Symptoms leading to medical and surgical treatment Gratifying symptoms, i.e., pervenions Presenting symptomatology Initial “dysfunction” unrelated to change in dysfunction* Fixed, more severe symptoms (tendency but not statistically significant) are unfavor able* Severity of Illness
Mild or reactive illness Certain severe ego distortions Severe psychopathology, sexual perversion, and inhibition Depth of symptom formation, including constitution, developmental, and precipitating factors Chronically ill and restricted motility Seventy of illness per se Mild neurosis and slightness of illness (psychoanalysis should not be invoked for trivial reasons)
+
Karush (1960) Waldhorn (1960)
+
0
Knapp et al. (1960) Hamburg et al. (1967)
?
Weber et al. (1974)
0
Aarons (1962)
-
Knapp et al. (1960)
+
- Kernberg et al.
(1972)
- Sashin et al. (1975) - Waldhorn (1960) - Waldhorn (1960) - Waldhorn
(1960)
0 0
Limentani (1972) Klein (1960)
?
Weber et al. (1974)
+ 0
-
A. Freud (1954) A. Freud (1954) Glover (1954)
-
Glover (1954)
-
Karush (1960) Stone (1954) Stone
0
-
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Wide range of symptomatology
Diagnosis Neuroses Anxiety hysteria Anxiety neurotics did better* Coniersion hysteria Presence of overt hysterical syrnptornatology Type I hysteric Mixed neurosis (obsessional and hysterical) Obsessional neurosis Obsessive compulsive Reactive anxieties Mild depression Neurotic “equivalents” Transference neuroses Phobias Phobias Phobias where patient is able to function without dependency object Phobias concerned with excrement and disease Borderline States Borderline Borderline Borderline Borderline personality organization* Dissociative hysterical states Borderline Type I1 hysteric Type 111 hysteric “As-if’ personalities Psychosis Psychosis Psychosis and psychotic character Psychosis Fewer “schizophrenics” improved at end of completed treatment*
A . LEAFF
Zetzel (1968)
Glover (1954) Hamburg (1967) Glover (1 954) Knapp et al. (1960) Zetzel (1968) Glover (1954) Glover (1954) Knapp et al. (1960) Glover (1954) Glover (1 954) Glover (1954) Stone (1954) Glover (1 954) Karush (1960) Karush (1960)
Aarons (1962) Levin (1962) Knapp et al. (1960) Kernberg et al. (1972) Karush (1960) Lower et al. (1972) Zetzel (1960) Zetzel (1960) Waldhorn (1960) Aarons (1 962) Karush (1960) Knapp et al. (1960) Hamburg et al. (1967)
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Schizophrenia Schizophrenia Anxiety hysteria with subpsychotic structure
Perversions and Addictions Perversions (fetishism, transvestitism, drug addiction, homosexuality in persons under 40, alcoholism with neurotic basis) Alcoholism covering endogenous disorders, i.e., depression or paranoia Certain addictions, perversions, and delinquency Severe sexual perversions and inhibitions Perversion . Heavy drinking Other Diagnosis is of no predictive value* Character disorders Patients with marked castration anxiety, i.e., certain homosexual, paranoid, and sadomasochistic persons and others with manifest fear of physicians, barbers, and dentists Diagnosis can be an encumbrance
907
- Karush (1960) - Stone (1954) - Glover (1954)
?
Glover (1954)
- Glover (1954) 0 A. Freud (1954) -
Glover (1954)
+
0
-
Sashin et al. (1975) Stone (1954) Waldhorn (1960)
0
Limentani (1972)
+ + +
Aarons (1961) Diatkine (1968) Glover (1954)
+
Namnum (1968)
+ +
Stone (1954) Waldhorn (1960)
+
A. Freud (1954) Weber et al. (1974)
- Lower et al. (1972) - Lower et al. (1972)
Object Relations Transference Ability to form workable transference Ability to develop transference Transference potential, especially positive to withstand stress Transference that can be used therapeutically Capacity for transference Capacity for transference -the sine q u a non of analyzability Capacity for transference Potential for developing unmanageable dependent transference associated with
?
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908
A. LEAFF
HENRY M . BACHRACH-LOUIS
poor outcome (tendency, but not statistically significant)* Working Alliance Capacity to develop analytic process Capacity to develop working alliance Capacity for therapeutic alliance Capacity to form viable treatment alliance Capacity for stable working alliance
+ + + + +
Diatkine (1968) Levin (1960) Zetzel (1968) Tyson & Sandler (1971) Huxster et al. (1975)
Object Relatedness General Failure to establish object relations if due to arrest in object constancy, but not if due to neurotic impediments Capacity to genuinely invest in objects + Ability to maintain stable object relations Capacity to form stable object relations Pattern of object relations Object relations, especially close contacts during infancy, in sex, friendships, and enmities of life Acceptance of limitations within one-to+ one relationships without feeling seriously rejected or devalued Good object relation + Relates well, warmth Inability to form stable object relation Capacity to “engage” in life + Withdrawal and lack of involvement in life Good interpersonal relations* Basic trust Presence of realistic trust Lack of trust Infantile relations Problems with authority Loneliness and isolation Capacity to establish rapport
+
Kernberg et al. (1972) Tysdn &Sander (1971) Waldhorn (1960) Lower et a]. (1972) Lower et al. (1972) Lower et al. (1972) Lower et al. (1972) Tyson & Sandler (1971)
During Interview Ability to relate during interview
0
Aarons (1968)
+
Aarons (1968)
+ + + +
Diatkine (1968) Panel (1960) Namnum (1968) Stone (1954) Waldhorn (1960)
+
+ + +
Zetzel (1968) Lower et al. (1975) Knapp et al. (1960) Huxster et al. (1975) Huxster et al. (1975) Huxster et al. (1975)
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Creates favorable, attractive, pleasant response Capacity to relate during interview, including warmth and attractiveness Extraordinary negative reaction to analyst (might be rectified by referral to another analyst)
LVith Parents Identification with dead, psychotic, or psychopathic parents Ability to retain significant relations with both parents Mastery of ambivalence in early motherchild relation Serious pathology in one or both parents, often associated with unhappy or broken marriages No close relation with parent of same sex ( p
-
: :
HENRYM. BACHRACH, PH.D. LOUISA. LEAFF, M.D.
:
LITERATURE
F
EW ANALYSTS, WE THINK, WOULD DISAGREE that some persons benefit from classical psychoanalysis while others do not. No sooner had Freud (1893) developed his psychoanalytic method than he attempted to specify the kinds of persons and conditions to which it was applicable (1894; 1905; 1913; 1916-1917): More recently, Rangell (1975) has written of a need to recognize an “optimum scope” for psychoanalytic therapy and, within this scope, “use psychoanalysis for what it can do” (p. 96). Differences in response to psychoanalysis can be traced to qualities of analysand, of analyst, and their interaction. Our aim is to systematically review the psychoanalytic literature in the first of these areas. We have several purposes in mind: We wish (1) to explore systematically just what patient qualities are thought to be important to the outcome of psychoanalysis, and how much agreement there is about these qualities; (2) to compare the accounts of such qualities given by the clinical and quantitative investigations; and (3) to
We thank Drs. Philip Escoll, Howard Huxster, and Lester Lubonky for their critical readings of earlier versions of this manuscript, and hlrs. Margaret Smith for assistance in its preparation.
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HENRY M. BACHRACH-LOUIS
A . LEAFF
provide methodological evaluation of the contributions as a guide to future investigation.
Methods and Limits of the Literature Review All papers primarily focused upon “analyzabilityJJor “suitability for psychoanalysis” published in the mainstream of the American psychoanalytic literature since 1954 were included in this review. For practical purposes this meant scrutiny of the Journal of the American Psychoanalytic Association, the International Journal of Psycho-Analysis, the International Review of Psycho-Analysis, the Psychoanalytic Quarterly, the Psychoanalytic Review, Psychological Issues, T h e Annual of Psychoanalysis, and Psychoanalysis and Contemporary Science; references to contributions in other publications were also explored. The review was limited to papers published since 1954 because developments in theory and technique over the years might have led to misleading contradictions not accurately reflecting the current state of thinking were we to have surveyed the entire literature from its very beginnings. Tyson and Sandler (1971) have already given a good historical account. No specific definition of classical psychoanalysis was employed as a guide to our literature search because most of the papers themselves do not include a definition. Instead, we assumed there would be some communality as to what was meant by classical psychoanalysis in papers published in the mainstream of the psychoanalytic literature. Our assumption, however, is that these references do relate to a process requiring four or five sessions per week, the use of a couch, and which attempts to foster the development of a transference neurosis to be resolved by its interpretation. Governed by these delineations, 24 studies’ were selected * The work of the Kris Study Group is reported in two places (Waldhorn, 1960, 1967); we choose the former for review here because of its more systematic
presentation.
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for systematic review, and these form the substrate of our conclusions. Each paper was reviewed independently by both authors for all specific references to factors relating to (1) suitability for psychoanalysis, or favorable outcome; (2) unsuitability or unfavorable outcome; (3) the data conclusions were based upon; (4) the methods employed for the assessment of the factors; and (5) criteria for the outcome of psychoanalysis. A worksheet following this outline was prepared for each study, and the findings transferred to the Appendix which appears at the end of this paper. The conclusions of the individual studies suggested the following categories: 1. Adequacy of General Personality Functioning, including all references to adequacy of adaptive functioning, severity of illness, severity of symptoms, diagnosis, ego strength, reality testing, subliminatory potentials, adaptive regression, defense, thinking, intellectual abilities, and capacities for verbalization; 2. Object Relations, including all references to object relatedness, narcissism, tolerance for separation, object constancy, and capacities for transference and working alliance; 3 . Motivation; 4 . Affect Organization, including references to availability of and tolerance for anxiety, frustration, depression, etc.; 5. Character Qualities; 6. Superego Factors; 7. Demographic Factors; 8. External Factors.
Principal Findings There are 24 studies in the contemporary psychoanalytic literature primarily focused upon analyzability. Sixteen are essentially clinical in nature (Aarons, 1962; Diatkine, 1968; A. Freud, 1954; Glover, 1954; Karush, 1960; Kuiper, 1968; Levin, 1960, 1962; Limentani, 1972; Namnum, 1968; Panel, 1960; Stone, 1954; Tyson and Sandler, 1971; Waldhorn, 1960; Zapparoli, 1976; Zetzel, 1968). Five are quantitativepredictive (Hamburg et al., 1967; Kernberg et al., 1972; Klein, 1960; Sashin et al., 1975; Weber et al., 1974) and Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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HENRY M . BACHRACH-LOUIS
A . LEAFF
three employed quantitative methods although their predictions were not related to final outcomes (Huxster et al., 1975; Knapp et al., 1960; Lower et al., 1972). There are a' total of 390 separate references to prognostic factors in these studies. Table I summarizes their main trends. TABLE I CONDENSED SUMMARY OF MAINTRENDS: NUMBER OF REFERENCES INDICATING FAVORABLE, ,UNFAVORABLE, OR NEUTRAL PROGNOSIS Number of References
Main Trend
Favorable
Neutral
Unfavorable
?
Adequacy of Personality Functioning Adaptive functioning Ego strength Reality testing Subliminatory potentials Capacity for adaptive regression Capacity for verbal communication Defense organization (mature) Thinking Intellectual ability Severity of symptoms Severity of illness Diagnosis (re: range of ego weakness)
9 10 8 10 3 14 11 4 6
0
1
32
0 0 0 0 0
3
0 0 0 0
0 0 0
0 0 0 0 0
2 8
5 0
0 0 0 1 1 0 1
0 0
0 0
1 0
0
0 0
0
0 0 2
3
0 0 8
Object Relations Capacity for transference Capacity for therapeutic alliance Object relatedness General During interview With parents With friends and marriage Pathological narcissism Tolerance for separations Severe early deprivations Capacity for object constancy
7 5 20 2 13
7 0 6 0 4
Motivation Self-understanding and change To relieve suffering
6 4
1
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0
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Number of References
Main Trend
Other motivations (positive) General
885
Favorable
Neutral
9
2 0
0 0
0 0
1 0 0 0
0 0 0 0 0
0 0 0 0 0
13 10 25 4 3 13
1 0 0 0 1 2
0 0 0 0 0 0
0 0 0 0 0 0
6 1
1 2
0 0
0
0
6
Unfavorable
?
Affect Organization Anxiety tolerance Depression tolerance Tolerance for frustration, suffering Tolerance for other affects & states Availability of tamed affect
10 3 9 4 14
0
Character Qualities Psychological mindedness Other character attitudes (positive) Other character traits (positive) Drive factors (positive) Manifest oedipal conflict Superego Factors (positive) Demographic Factors Age (young adults) Sex (males more successful) Previous psychotherapy (negative experience) Other
0
2
5
0
0
0
1
0
3
1
5
0
External Factors Supportive vs. nonsupportive influences
Taken together these studies suggest that persons most suitable for classical psychoanalysis are those whose functioning is generally adequate; they have good ego strength, effective reality testing and subliminatory channels, and are able to cope flexibly, communicate verbally, think in secondary-process terms, and regress in the service of the ego with sufficient intellect to negotiate the tasks of psychoanalysis; their symptoms are not predominantly severe, and their diagnoses fall within a “neurotic” spectrum. Such persons are able to form a transference neurosis and therapeutic alliance, Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
886
HENRY M . BACHRACH-LOUIS
A . LEAFF
are relatively free of narcissistic pathology, have good object relations with friends, parents, and spouses, and have been able to tolerate early separations and deprivations without impairment of object constancy; they are therefore able to experience genuine triangular conflict. They are motivated for self-understanding, change, and to relieve personal suffering. They are persons with good tolerance for anxiety, depression, frustration, and suffering and are able to experience surges of feeling without loss of impulse control or disruption of secondary-process mooring of thought. Their character attitudes and traits are well-suited to the psychoanalytic work, i.e., psychological mindedness. Superego is integrated and tolerant. They are mainly in their late twenties or early thirties and have not experienced past psychotherapeutic failure or difficulties. Of all these qualities, those relating to ego strength and object relations are most important. One third of all references relate to adequacy of personality functioning; one quarter refer to object relations. Hence, the contemporary literature has been cast mainly in terms of ego functioning and object relations, and there is complete agreement that the better the pretreatment level of functioning, the more favorable the response to psychoanalysis. Motivation, affect organization, and character are mentioned less often; superego and demographic factors tend to be mentioned least. Clinical contributions account for 90 percent of all references. What controlled quantitative investigation there is, however, accords fully with clinical contributions. There is also strong agreement about the qualities that make a person suitable for psychoanalysis. Disagreement occurs only in 9 percent of the references and mainly because isolated factors are not always regarded prognostic per se. The consensus, occurs, however, mainly on a metapsychological-conceptual level; most references are cast in metapsychological terms, i.e., ego strength, rather than as clinical-empirical obseruations. Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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These findings are, in part, the product of our method for reviewing the literature, i.e., enumerating the number of times something has been said. Such a method, however, does not account for the reliability and relative importance of the individual references, the factors that lead people to emphasize in their writings what they do, the interactions among the qualities, and plainly, how just one or two good qualities in some people-for example, the will to be analyzed and psychological mindedness -can outweigh a plethora of ills. If one approaches the review differently and attempts to distill the most vital factors stressed by seasoned clinical contributors and established by replicated controlled investigation the potentially successful analysand emerges as a young psychologically-minded adult with capacities for transference and working alliance and who seeks treatment for self-change through understanding; such a person has good ego strength, mature object relations, and self-discipline, and their character and interests have depth and richness. Diagnoses fall within a “neurotic” range and manifest presenting symptomatology and behavior during initial interviews .are not of particular predictive significance. Waldhorn (1960) refers to the capacity for transference as the sine qua non of analyzability ; Kuiper (1 968) refers to psychological-mindedness as the most essential quality, and Namnum (1968) speaks of the will to be analyzed as essential. In contrast, persons not likely t o benefit come to analysis seeking magical fulfillments consistent with their infantile attitudes, character traits, and impoverished, need-satisfying relations with people; their ego functioning is likely within a “borderline” (Kernberg, 1975) or “psychotic” range. * Despite the consistency of these findings, there are several reasons why it may be difficult to directly apply them to actual clinical practice at the present time. First, they are case mainly in abstract terms; it is easier to agree about the importance of ego strength than to confidently asses its Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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HENRY M . BACHRACH-LOUIS
A. LEAFF
manifestations. Second, accurate prediction may require analytic data not readily obtainable in the course of initial interviews. Aarons (1962), for example, argues that data concerning quality of object constancy in the mother-infant dyad (basic to therapeutic alliance) might become available only in the course of analysis. Certainly, preanalytic data are different in quality from analytic data (Kohut, 1959; Kris, 1957) and the life history we obtain initially (upon which we base our assessments) is almost always revised in the course of analysis. Holzman (1976) has commented that psychoanalysis lacks a body of literature in which one contribution builds upon another so that a steady progress of new knowledge can occur over time. Inspection of the Appendix shows this is largely true for the studies surveyed; what is being written about today is by and large the same as what was written twenty years ago, although there are some new trends: 1. Quantitative methods are beginning to be employed and controlled predictive studies are now appearing. Before 1960 there were no such reports. Between 1960 and 1970 there were three (Hamburg et al., 1967; Klein, 1960; Knapp et al., 1960). Since 1970 there have been five (Huxster et al., 1975; Lower et al., 1972; Kernberg et al., 1972; Sashin et al., 1975; Weber et al., 1974). 2. In the early literature there were no formal distinctions between indications and suitability for psychoanalysis. This distinction was introduced by Tyson and Sandler (1971) and is now being widely employed. 3. The concept of therapeutic alliance was introduced into the analyzabiliky literature by Levin in 1960; all other references have occurred since 1968 (Diatkine, 1968; Huxster et al., 1975; Tyson and Sandler, 1971; Zetzel, 1968). 4. With the exception of transference, all but three of the 82 references to object relations have occurred since 1960. Certainly, it is fair to say that the object-relations point Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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of view is becoming more important to consideration of analyzability. 5. Discussion of character issues is something relatively new. Only one reference (Stone, 1954) comes before 1960. 6. Since 1968 the distinction between oedipal symptomatology and the presence of genuine triangular conflict began to emerge in the literature (Zetzel, 1968). Because the ability to experience genuine triangular conflict is considered favorable and the mere presence of overt oedipal symptoms not necessarily predictive, this distinction seems quite important. Comparison with Quantitative Psy chot h erapy R esearc h2 Owing to the paucity of quantitative-predictive research relating to the outcome of psychoanalysis, we thought it would be interesting to compare our findings with those of quantitative research on factors predictive of the outcome of psychotherapy in general. Strictly speaking, one might have reservations about making such a comparison. Quantitative psychotherapy research has tended to be clinically unsophisticated: therapists have tended to be inexperienced; treatments have been of brief duration, and there have been many problems with the evaluation of outcome. Despite these reservations, there are many findings in common with those of the present review. 1. Adequacy of Personality Functioning: The finding from the analyzability literature is that initial level of adequacy is one of the most potent predictors of favorable outcome. Through 1970 there were 52 quantitative-predictive psychotherapy studies with findings related to adequacy (i.e., ego strength, severity of symptoms, diagnosis, somatic concerns, social achievements, defensiveness); in 33 of 34 there was a significant positive relationship between the initial level of personality functioning and the outcome of * Based upon the Luborsky et al. (1971) review of quantitative research. Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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HENRY M. BACHRACH-LOUIS
A.
LEAFF
psychotherapy (statistically significant correlations were not obtained in the remaining eighteen studies). The quantitative psychotherapy research literature therefore accords with the analyzability literature in that the healthier a person is to begin with, the better he does in treatment. 2. Object Relations: According to our review, quality of object relations is directly related to the extent to which a person will benefit from psychoanalysis. There are only four quantitative psychotherapy studies directly relating to this area; in all four, interest in people was positively related to favorable outcome. 3 . Motivation: Strong motivation for self-understanding, change, and to relieve suffering emerges as a favorable prognostic indicator in our survey. Of ten quantitative psychotherapy studies that deal with motivation, seven find a significant positive relation with outcome and three are nonsignificant. 4 . Affect Organization: Tolerance for dysphoric affects and the availability of tamed affect are important indications of suitability, according to our review. In fourteen quantitative psychotherapy studies dealing with affects, the trend is that patients with high though not overwhelming affect at the beginning of treatment are likely to benefit most. 5. Character QuaZities: According to our survey, those character qualities supportive of the psychoanalytic work are especially valuable assets. In fact, nearly one quarter of all the references were to psychological mindedness. Eleven psychotherapy studies seem to relate to psychological mindedness; three out of five found self-awareness prognostically significant (in the two others the relationship was not statistically significant)] and six out of six found “experiencing” significantly related to favorable outcome. Ethnocentrism is the only other character quality that has been studied; two out of three studies found it to be a significantly negative predictor. Thus, the findings of clinical psychoanalytic investigaDownloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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tion are supported by quantitative research on psychotherapy in general. It does not, however, follow from this that there is no further need for quantitative-predictive research. Indeed, the clinical supefiiciality of quantitative psychotherapy research, and the methodological limitations of clinical psychoanalytic investigation make such research all the more urgent.
Methodological Evaluation of the Studies The majority of contributions to the analyzability literature are clinical in nature; it would not be meaningful to evaluate these according to a methodological yardstick suitable for purely quantitative research. To do so would be to hold clinical investigations accountable to criteria that played little role in their shaping and method. However, there are established tenets of clinical inference and scientific method that are relevant. These relate mainly to questions of evidence, method, conceptualization, and observability. It is to such standards that we shall turn in our methodological evaluation. Table I1 summarizes the studies according to some of these criteria, i.e., the essential data upon which the conclusions are based, the method employed for assessing analyzability, and the criteria for outcome of psychoanalysis. The Meaning and Specqication of Outcome and Analyza bility
Only five of the studies surveyed clearly specify what is meant by “favorable” or “successful” response to psychoanalysis. Aarons’ (1962) clinical investigation defines successful outcome as “the resolution of unconscious conflict” as distinguished from conformity, compliance, and “correct” behavior. Kernberg et al. (1972) employed clinical-quantitative judgments of well-defined core intrapsychic variables, elg:, ego-strength, unconscious guilt. Sashin et al. (1975) ernDownloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
892
HENRY M . BACHRACH-LOUIS
A. LEAFF
e
m u
Y
-
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Not specified Analyst’s opinion regarding analyzability at termination Psychodynamic changes and insight into conditions relating to difficulties (Accepted or rejected for analysis) Not specified Circumstances of termination (i.e., by mutua agreement, premature, “interminable cases”) “Some improvement”
Interview; reaction to “group” psychoanalysis Life history/interview Life history/Interview Life historyhterview by 2 analysts Not specifiid Life history/ Interview several independent analyst judgments Life history/Interview/ Psychological Tests??
Clinical experience
16 terminated cases of six analysts
Clinical experience
40 clinic applicants
Clinical experience
122 control cases
Clinical experience/ Literature
Levin
Limentani
Lower et al.
Namnum
Sashin et al.*
Stone
alliance
2. Development of transference and working
analyst.
1. Judgment of suitability by candidate
Kuiper
Life history/Interview, 100 clinic cases; 25 control cases in analysis screening by 2 analysts for 1 year
Knapp et al.
Clinical judgments and independent rating scales: seven specific criteria
Life history/Interview/ Discussion with supervisor and committee
30 clinic cases in analysis for more than 200 sessions
Klein*
Extent of intrapsychic and life change after termination assessed by independent researchanalyst judges
Life history/ Interview/ Psychological Tests
21 czws of psychoanalysis 21 cases of psychotherapy ’
Kernberg et al.*
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Not specified
Clinical judgments and independent rating scales in six specific areas Not specified
Ability to recognize and tolerate triangular conflict in treatment
Life histoxy/Interview
Life history/Interview Screening committee Clinical interview
Life history/Interview
Clinical experience/ Literature
271 terminated clinic control cases
Clinical experience/ Literature review
Clinical experience
Waldhorn
Weber et al.*
Zapparoli
Zetzel
Interview/Trial analysis Not specified
Literature review/ Clinical experience
Outcome Cn'tena
T p n and Sandler
Method of Assessment 0fAnalyrabit'ity
Data Base
Invest igatw n
(Tabfe I I continued)
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ployed analyst’s and supervisor’s ratings of global change and circumstances of termination. Klein (1960) and Weber et al. (1974) employed rating scales on specific areas of change and follow-up clinical assessment. In ten clinical studies, no mention is made at all of what is meant by favorable outcome or what criteria might be used to judge the issue. In three instances, outcome criteria are stated in the most general terms; Glover (1954) refers to “degree of accessibility”; Levin (1960) to the analyst’s opinion regarding analyzability at termination; and Stone (1954) to “some improvement.” In the other studies, references to analyzability are not based upon the final outcome of the case but to “in-treatment” developments. Zetzel (1968) refers to the ability to recognize and tolerate triangular conflict in treatment: Knapp et al. (1960) refer to judgment of suitability by a candidate analyst and the development of transference and therapeutic alliance; Lower et al. (1972) to being accepted or rejected for analysis; and Huxster et al. (1975) to supervisors’ response to a questionnaire about the case from three months to one year after the case was begun’. One might argue it is not necessary to precisely state criteria for response or analyzability since such matters are common knowledge among Freudian psychoanalysts. There is, of course, the widely held view that favorable outcome means the analytic resolution of transference neurosis. In actual practice, however, it is not clear how one recognizes sufficient resolution, nor is it clear whether Freudian psychoanalysts, even as a group, mean only this when they refer to favorable response. Ekstein (1956) once pictured the development and resolution of transference neurosis in successful analysis as a normal curve. Yet, when Graff and Luborsky (1976) actually plotted quantitative estimates of transference for four analyses, transference increased over time and remained high at termination irrespective of outcome; what made the difference between successful and unsuccessful outcome was the analysand’s awareness and ability to deal Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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HENRY M . BACHRACH-LOUIS
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with its manifestations, i.e., the therapeutic alliance and insight. Similarly, Pfeiffer (1959), Schlessinger and Robbins (1974), and Norman et al. (1976) found transference neurosis strikingly reactivated by brief follow-up visits, even among successfully analyzed persons. Considerations such as these raise questions about the meaning of resolution of transference neurosis as the sole criteria for outcome. The relation between symptom relief, patient satisfaction, emotional growth, autonomy, and transference developments are not as well understood as we might like. Ticho (1972) distinguished “life goals” from “treatment goals.” Glover’s (1955) survey found the majority of British psychoanalysts seemed to rely mainly upon intuitive impressions of symptom resolution as criteria for termination. Baum and Robbins (1975) surveyed a group of American psychoanalysts and found intuitive impression of an analytic growth process having been set in motion the pivotal criterion for termination. The term “analyzability,” even when refined to “indications” and “suitability” tends to convey the impression that ansanalyzable person, barring unforeseen unusual events, is likely to have a successful analysis and an “unanalyzable” person is not. But in actual practice, the term “analyzability” has compound meanings; certain patient qualities are more crucial than others during different subphases of the analytic process. The analytic process can sometimes make a seemingly unanalyzable person analyzable, as Appelbaum (1973) has shown in cases of deficit in psychological mindedness based upon repressive defense organization. In actual practice, the analyzability of a patient may vary with different analysts. Some people do well with certain analysts and not with others. Some people also do poorly with any analyst. This has a great deal to do with what goes into forming a therapeutic alliance between two particular people. Hence, our main finding here is that investigators have not clearly specified what they mean by analyzability and to what criteria their findings relate. It seems clearly in the Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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interest of further developments that future investigators do so as specifically as possible, especially on an empiricalobservable level.
Method of Assessing Analyzability No matter how clear a metapsychological understanding one may have of factors prognostic of response to psychoanalysis, this understanding can only guide assessment. One cannot touch, feel, or see ego strength; it is a concept. Rather, our assessments are based upon what we observe, and our conclusions depend upon our methods of observation as well as the guiding conceptual templates we employ. Clinical interview with emphasis upon life history is the method of assessing analyzability employed in most of the studies surveyed. Diagnostic psychological testing was employed only by Kernberg et al. (1972), and referred to by Stone (1954) as potentially useful if better understood. Lower et al. (1972) augmented interviews with an outline of factors thought important to assessment of analyzability and also by employing an analyzability committee, as did Sashin et al. (1975), Klein (1960), Knapp et al. (1960), and Weber et al. (1974). Aarons (1962) spoke of the possible utility of trial analysis. Tyson and Sandler (1971) indicated that trial analysis provides an opportunity for evaluating development of the treatment alliance, but has disadvantages in that it encourages patients to split off part of their lives from the analytic work and it may take a very long time to accurately assess the important factors. In the literature (e.g., Knapp, 1960) there seems to be a dialectic between those who advocate extensive interviews and those who think this interferes with the natural development of the analytic process, Windholz (1960) suggested that, when the prospective analyst interviews, defenses are immediately primed and result in an unavailability of important memories. He also pointed out that the technique Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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HENRY M . BACHRACH-LOUIS
A . LEAFF
of interviewing demands special training and gifts not always coordinate with what is required of a psychoanalyst, and that it might be more profitable to employ others for history-taking. Waldhorn (1960) and Karush (1960) argued that ego structures and functions can be evaluated in initial interviews, though Levin (1960) did not agree. Zetzel (Panel, 1960) summarized the consensus of a panel on analyzability with two points: (1) evaluations made after initial interviews are only tentative approximations of analyzability; (2) diagnostic interviews can best provide only a limited amount of anamnestic material, an account of the patient’s current symptomatology and the degree to which it impinges upon functioning as a whole, and an evaluation of motivation, insight, and the capacity to relate. Because of such concerns about the limits and consequences of extensive interviews, one wonders abo’ut the effectiveness of other means of assessment. Data regarding the role of diagnostic psychological testing are available only in one study: the Menninger Psychotherapy Research Project. Appelbaum (1977) reported that predictions about the outcome of psychoanalysis and psychotherapy based only upon test data interpreted by Psychoanalysts were significantly (p < .01) superior to those based upon interviews, despite the availability of a clinical test report .to the interviewers. Such a finding raises the question whether diagnostic testing, when conceptualized according to clinical psychoanalytic theory and interpreted by psychoanalysts, may provide an untapped resource, particularly for systematic assessment of ego f ~ n c t i o n i n g .It~ also confirms .Huxster et al. (1975) in their claim that the subjective response of the interviewer is a major source of therapeutic overoptimism. At this point, one might conclude that understanding and prediction of response to psychoanalysis might be enhanced by developing methods of assessment in addition to the clinical interview. These issues have been discussed in detail by Appelbaum (1977) and Bachrach (1977). Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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The utilization of several methods not only decreases bias inherent to any single method, but makes possible a triangulation of understanding from independent perspectives. Thus, research such as that of Appelbaum (1977) and Kantrowitz et al. (1975) with regard to the role of diagnostic testing, and that of Huxster et al. (1975) with regard to screening committees is welcome for clarifying just what each method does best and what contribution it can make to assessment.
Information and Evidence When one formulates an inference or proposes a conclusion, it is important to know on what basis the assertion rests. Without evidence, the accuracy of a conclusion can never be determined. Fewer than half of the studies, however, provide such information or evidence. Knapp et al. (1960) base their conclusions upon 100 clinic patients under age 35, without psychosomatic, delinquent, or psychotic trends, with good life situations, coming from intellectually and psychologically sophisticated segments of the population, referred for control analysis; also studied were 25 control cases in analysis for at least one year. Kernberg et al. (1972) studied 42 patients (21 in analysis, 21 in psychotherapy) treated by senior candidates or recent graduates. Lower et al. (1972) studied the first 40 applicants to a psychoanalytic clinic interviewed separately by two graduate screening analysts, with the case being reviewed by an analyzability committee. Huxster et al. (1975) studied eighteen cases from the Lower et al. (1972) study, focusing primarily on four cases deemed best and four worst by supervisors within the first year of the analysis. Sashin et al. (1975) based their conclusions upon 122 “carefully screened” control cases. Klein (1960) studied 30 clinic control cases in analysis for at least 200 sessions (thereby excluding information relating to early failures); Weber et al. (1974) studied 1,348 clinic patients, but based their conclusions mainly upon 27 1 terminated control cases. Hamburg et al. (1967) based their findings upon a retrospective survey of 386 Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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HENRY M . BACHRACH-LOUIS
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analysts who responded to a questionnaire regarding the clinical characteristics of their case load; included were 2,983 cases about equally distributed between psychoanalysis and psychotherapy. All of the other investigations are primarily clinical in nature. It is therefore not surprising that the findings are based upon the author’s personal experience. In five of these, clinical experience is supplemented by references to the psychoanalytic literature. The evidential bases for the findings are specified only in the minority of cases. The absence of attempts at specification are, to us, a matter of concern. If a clinical author does not even attempt to specify the extent of his clinical experience with a particular matter, or what his range is with clinical problems in general, then how can one contribution be compared to another? A person whose analytic practice is limited to intellectually gifted analysands-such as in a university practice -may regard intelligence as having little prognostic value because there is little variation among his patients. On the other hand, a person with a more varied practice may find it has considerable prognostic value simply because of its variability. As the bulk of the literature now stands, it is difficult to know to what extent one study replicates another. Are they talking about the same or different things? Rarely does one even find such concern expressed in the clinical literature. Overall, our main finding here is that the majority of studies fail to indicate the evidence for their conclusions and the data upon which they are based. It is therefore difficult to be fully cognizant of the nature of the populations referred to, selection biases, and the extent to which one investigation may be said to truly replicate another.
Summary and Coda The contemporary psychoanalytic literature focused primarily upon “analyzability” was systematically reviewed. We found that most studies are clinical in nature. Within the Downloaded from apa.sagepub.com at RYERSON UNIV on October 10, 2016
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past quarter-century new trends have appeared; these include a distinction between “indications” and “suitability,” increasing stress on object relations and character qualities, and the application of quantitative methods to investigation. We also found considerable agreement regarding the qualities deemed to make a person a suitable candidate for psychoanalysis, i.e., the better the pretreatment level of personality organization, the more favorable the prospect. The findings of individual studies, however, are cast largely in abstract, metapsychological terms lacking empirical specification. Most investigations also do not clearly specify what is meant by psychoanalysis, analyzability, outcome, or upon what evidences conclusions are based. We hope that future investigators will find ways of addressing these problems. For a review such as this to fulfill its intent, it should serve as a basis for new perspectives in future research. One such effort is now beginning, based on a paradigm of studying what kinds of changes occur in what kinds of persons with what kinds of analysts; a series of single, tape-recorded cases will be studied, employing extensive preand post-treatment information (including psychological testing) guided by the main.findings of this review.
APPENDIX Legend 0 = nonsignificant relationship = prognostically favorable relationship = prognostically unfavorable relationship 7 = inconclusive reference * = quantitative predictive study
+ -
Adequacy of General Personality Funcfioning Adequacy of Adaptive Functioning Adaptive ability Good social adaptation
+ +
Lower et al. (1972) Lower et al. (1972)
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HENRY M . BACHRACH-LOUIS
Potential for adaptation, i.e., ability to act upon insight Good work and school record Ability to integrate socially and pleasurefully incorporate cultural needs Moral character and educational achievement sufficient to assure a good position in life with adequate rewards Achievement of autonomy Failure of mastery Regression
Ego Strength Ego strength Ego strength Good ego strength High ego strength* Low ego strength* Availability of creative and synthetic proclivities of the ego Ego must be able to tolerate impulses and conflict: a quantitative relation between defensive and autonomous ego functioning is necessary Ability to utilize psychological energy consistent with life goals Feeble personality resources Basic ego defects
Reality Testing Reality testing Reality testing (absence of projection, denial, hypomania) Reality testing Lack of reality testing Faulty reality testing Poor judgment Ideas of reference Recognition of fantasies as fantasies
A . LEAFF
+ + + +
+
-
-
+
+ + + + +
+
Waldhorn (1960) Lower et al. (1972) Karush (1960) Tyson&Sandler(l971)
Zetzel (1968) Zetzel (1968) Lower et al. (1972) Karush (1960) Levin (1960) Lower et al. (1972) Kernberg et al. (1972) Kernberg et al. (1972) Aarons (1962) Panel (1960)
Levin (1968)
-- Stone (1954) - Zetzel (1968)
+ +
Tyson &Sandler(l971) Waldhorn (1960)
+
Zetzel (1968)
-
Lower et al. (1972) Lower et al. (1972) Lower et al. (1972) Diatkine (1968)
- Zetzel (1968) -
-
+
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Subliminatory Potentials Availability of conflict-free capacities Subliminatory potentials Subliminatory potentials Successful sublimations Limited sublimation Absence of subliminatory gratifications Little gratification Capacity for pleasure in substitutes and in active mastery and learning Life not centered around analysis Persistent inhibitions obliterating sublimations Adaptive Regression Regression in the service of the ego Adaptive regression Adaptive regression Capacity for Verbalization Capacity to verbalize Capacity for continuous verbalization Capacity for verbal communication Capacity to communicate meaningfully during interview Ability to communicate Absence of blocking in initial interviews Capacity for speech Severe blocking Extreme periods of blocking Mutism Silence in borderline or psychotic patients where there is intrinsic impairment in communication Speech defect Gross speech defects Chronic difficulties in communication, i.e., inarticdateness or anxiety connected with speech Erotization of speech
+ +
90s
+
Tyson &Sandler(l971) Stone (1954) Lower et al. (1972 Tyson &Sandler(l971) Lower et al. (1972) Waldhorn (1960) Lower et al. (1972) Zetzel (1968)
+
Tyson &Sandler(l971)
+ + +
Diatkine (1968) Panel (1960) Namnum (1968)
+
0
Aarons (1962) Levin (1962)
+ +
Namnum (1968) Hwster et al. (1975)
+ 0
Karush (1960) Levin (1962)
+
Waldhorn (1960)
-
Waldhorn (1960) Aarons (1962)
0
Panel
-
Waldhorn (1960)
+ + -
-
-
- Diatkine (1968)
- Knapp et al. (1960) - Levin (1960)
- Waldhorn (1960) - Waldhorn (1960)
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904
A . LEAFF
HENRY M . BACHRACH-LOUIS
Long delay of onset of verbalization in childhood Presence of deaf or mute parent Defense Organization Proper mixture of alloplasticity and autoplasticity Flexibility of defenses Rigidity, hypertrophy of automatic defenses Previous history of unchanging defensive patterns, i.e., patient who proposed to begin analysis with reservations Excessive defensiveness and vagueness during interview Defensiveness (rigidity, lack of dreams and memories) Lack of defensiveness Failure to develop stable impulse-defense configurations Projective identification Patterning of defenses (in positive direction)* More serious defense mechanisms (tendency but not statistically significant) are unfavorable* Thinking Imaginative thinking Secondary-process thinking Undue persistence of magical thinking as might be reflected in grandiosity, sexual problems, abortions, divorces, bizarre job and living arrangements Thinking and memory difficulty Intellectual Abilities Intelligence Intelligence Intelligence as related to psychological mi n dedn ess Low intelligence (all that is required is
- Waldhorn (1960) - Waldhorn (1960)
+
Aarons (1962)
+
Waldhorn (1960)
- Waldhorn (1960)
- Waldhorn (1960)
-
Huxster et al. (1975)
-
Lower et al. (1972)
-
+
Lower et al. (1972) Zetzel (1968)
+
Diatkine (1968) Kernberg et al. (1972)
?
Weber et al. (1974)
+
+
-
Diatkine (1968) Diatkine (1968) Waldhorn (1960)
-
Knapp et al. (1960
+ + +
Karush (1960) Nantnum (1968) Waldhorn (1960)
0
Tyson & Sandler (1971)
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905
REVIEW OF LITERATURE ON “ANALYZABILITY”
sufficient to form working alliance and gain insight) Learning capacity Educability (as relates to psychological mindedness) Education Patients with higher educational level did better* Intelligent patients with higher educational achievement did better (tendency, but not statistically significant)* Seventy of Symptoms Severity of symptoms Seventy of symptoms* , Severe symptom a tology, especially compulsive overeating Severe obsessional thoughts* Severe phobias and inhibitions Symptoms leading to medical and surgical treatment Gratifying symptoms, i.e., pervenions Presenting symptomatology Initial “dysfunction” unrelated to change in dysfunction* Fixed, more severe symptoms (tendency but not statistically significant) are unfavor able* Severity of Illness
Mild or reactive illness Certain severe ego distortions Severe psychopathology, sexual perversion, and inhibition Depth of symptom formation, including constitution, developmental, and precipitating factors Chronically ill and restricted motility Seventy of illness per se Mild neurosis and slightness of illness (psychoanalysis should not be invoked for trivial reasons)
+
Karush (1960) Waldhorn (1960)
+
0
Knapp et al. (1960) Hamburg et al. (1967)
?
Weber et al. (1974)
0
Aarons (1962)
-
Knapp et al. (1960)
+
- Kernberg et al.
(1972)
- Sashin et al. (1975) - Waldhorn (1960) - Waldhorn (1960) - Waldhorn
(1960)
0 0
Limentani (1972) Klein (1960)
?
Weber et al. (1974)
+ 0
-
A. Freud (1954) A. Freud (1954) Glover (1954)
-
Glover (1954)
-
Karush (1960) Stone (1954) Stone
0
-
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HENRY M . BACHRACH-LOUIS
Wide range of symptomatology
Diagnosis Neuroses Anxiety hysteria Anxiety neurotics did better* Coniersion hysteria Presence of overt hysterical syrnptornatology Type I hysteric Mixed neurosis (obsessional and hysterical) Obsessional neurosis Obsessive compulsive Reactive anxieties Mild depression Neurotic “equivalents” Transference neuroses Phobias Phobias Phobias where patient is able to function without dependency object Phobias concerned with excrement and disease Borderline States Borderline Borderline Borderline Borderline personality organization* Dissociative hysterical states Borderline Type I1 hysteric Type 111 hysteric “As-if’ personalities Psychosis Psychosis Psychosis and psychotic character Psychosis Fewer “schizophrenics” improved at end of completed treatment*
A . LEAFF
Zetzel (1968)
Glover (1954) Hamburg (1967) Glover (1 954) Knapp et al. (1960) Zetzel (1968) Glover (1954) Glover (1954) Knapp et al. (1960) Glover (1954) Glover (1 954) Glover (1954) Stone (1954) Glover (1 954) Karush (1960) Karush (1960)
Aarons (1962) Levin (1962) Knapp et al. (1960) Kernberg et al. (1972) Karush (1960) Lower et al. (1972) Zetzel (1960) Zetzel (1960) Waldhorn (1960) Aarons (1 962) Karush (1960) Knapp et al. (1960) Hamburg et al. (1967)
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Schizophrenia Schizophrenia Anxiety hysteria with subpsychotic structure
Perversions and Addictions Perversions (fetishism, transvestitism, drug addiction, homosexuality in persons under 40, alcoholism with neurotic basis) Alcoholism covering endogenous disorders, i.e., depression or paranoia Certain addictions, perversions, and delinquency Severe sexual perversions and inhibitions Perversion . Heavy drinking Other Diagnosis is of no predictive value* Character disorders Patients with marked castration anxiety, i.e., certain homosexual, paranoid, and sadomasochistic persons and others with manifest fear of physicians, barbers, and dentists Diagnosis can be an encumbrance
907
- Karush (1960) - Stone (1954) - Glover (1954)
?
Glover (1954)
- Glover (1954) 0 A. Freud (1954) -
Glover (1954)
+
0
-
Sashin et al. (1975) Stone (1954) Waldhorn (1960)
0
Limentani (1972)
+ + +
Aarons (1961) Diatkine (1968) Glover (1954)
+
Namnum (1968)
+ +
Stone (1954) Waldhorn (1960)
+
A. Freud (1954) Weber et al. (1974)
- Lower et al. (1972) - Lower et al. (1972)
Object Relations Transference Ability to form workable transference Ability to develop transference Transference potential, especially positive to withstand stress Transference that can be used therapeutically Capacity for transference Capacity for transference -the sine q u a non of analyzability Capacity for transference Potential for developing unmanageable dependent transference associated with
?
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908
A. LEAFF
HENRY M . BACHRACH-LOUIS
poor outcome (tendency, but not statistically significant)* Working Alliance Capacity to develop analytic process Capacity to develop working alliance Capacity for therapeutic alliance Capacity to form viable treatment alliance Capacity for stable working alliance
+ + + + +
Diatkine (1968) Levin (1960) Zetzel (1968) Tyson & Sandler (1971) Huxster et al. (1975)
Object Relatedness General Failure to establish object relations if due to arrest in object constancy, but not if due to neurotic impediments Capacity to genuinely invest in objects + Ability to maintain stable object relations Capacity to form stable object relations Pattern of object relations Object relations, especially close contacts during infancy, in sex, friendships, and enmities of life Acceptance of limitations within one-to+ one relationships without feeling seriously rejected or devalued Good object relation + Relates well, warmth Inability to form stable object relation Capacity to “engage” in life + Withdrawal and lack of involvement in life Good interpersonal relations* Basic trust Presence of realistic trust Lack of trust Infantile relations Problems with authority Loneliness and isolation Capacity to establish rapport
+
Kernberg et al. (1972) Tysdn &Sander (1971) Waldhorn (1960) Lower et a]. (1972) Lower et al. (1972) Lower et al. (1972) Lower et al. (1972) Tyson & Sandler (1971)
During Interview Ability to relate during interview
0
Aarons (1968)
+
Aarons (1968)
+ + + +
Diatkine (1968) Panel (1960) Namnum (1968) Stone (1954) Waldhorn (1960)
+
+ + +
Zetzel (1968) Lower et al. (1975) Knapp et al. (1960) Huxster et al. (1975) Huxster et al. (1975) Huxster et al. (1975)
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Creates favorable, attractive, pleasant response Capacity to relate during interview, including warmth and attractiveness Extraordinary negative reaction to analyst (might be rectified by referral to another analyst)
LVith Parents Identification with dead, psychotic, or psychopathic parents Ability to retain significant relations with both parents Mastery of ambivalence in early motherchild relation Serious pathology in one or both parents, often associated with unhappy or broken marriages No close relation with parent of same sex ( p
