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| Faculty: | Howard Benensohn, M.D. and Lynn Friedman, Ph.D. |
Blog entry for September 17, 2005 on Rothstein's article
About who should be in analysis and what constitutes analysis, Kernberg is firm and resolute. He makes explicit the distinctions between psychoanalysis, psychoanalytic psychotherapy and supportive therapy. He contends that for most with more severe character disturbances, psychoanalytic therapy is the treatment of choice.
In contrast to Kernberg, Rothstein seems to welcome nearly all comers. While he notes that he himself would not certain kinds of patients such as suicidal folks and drug addicts, he notes that others do. Moreover, they have treated them successfully. He begins his paper noting that candidates are traditionally trained to evaluate a patient's "suitability" on the basis of a brief evaluation, despite the fact that there is noempirical evidence that analyzability can be predicted on that basis. He cites Bachrach's assertion that one can not judge analyzability until the analysis is complete. Just as I found myself recoiling in reaction to the notion that patients should spend thousands of dollars and thousands of hours, on a hope, he added that many analyses that are "unsuccessful" help patients to achieve their life goals but fail to lead to bedrock change. So, I relaxed, a little. That's not so bad. The patient gets a much improved life.This takes us back to last week's paper by Theodore Jacobs. He subscribes to the notion that we ought to help our patients not only make structural change - but, also to alter the trajectory of their lives. I think that we ought to reconsider the idea that an analysis is NOT successful when the patient fails to make structural changes. Yes. It is wonderful when patients can come to analysis, make significant structural changes and achieve satisfaction in work and lives. Of course we want that. But, it seems to me that expecting that of every analysis is asking a lot, maybe too much, not only the analyst but of the patient. Do we really have to devalue the analysis that leads to a happier life but not to structural change. From the standpoint of the patient, it seems to me that this is still a success. Just a success of a different stripe.
Rothstein has some interesting things to say. He approaches consultation with optimism. Unlike Kernberg, for example, he does not require that patients meet certain stringent criteria for analyzability. Rather, he operates with three assumptions (he calls them hypotheses). First, he believes that psychoanalysis is the best psychotherapy for most adults. Second, his attitude towards new patients seen in consultation is that they are all potential analysands. He assumes that their analysis will be successful. Third, he alters that assumption only after an analysis proves unsuccessful.
Because he believes that most patients are analyzable, he pays attention to the patient's reaction to him, the consultation and the recommendation for analysis. I agree with Rothstein about this - if one focuses on these things one can get a pretty clear preliminary picture of the anxieties/wishes/hopes that the patient brings to treatment. Exploring these reactions and clarifying their origins increases the patient's experience of being understood. This, in turn, may make him more accepting of the recommendation.
Rothstein echews the diagnostic approach a la DSM-III. Instead he has his own nomenclature. This is: (1) inhibited; (2) enactment prone; (3) too disturbed or disturbing for me. He adds that the inhabitants of the latter category vary from analyst to analyst. But, that every analyst ought to become aware of those patients with whom they can not be effective. One of the terrific things about the Washington Psychoanalytic Institute is the profound influence of analysts, formerly at Chestnut Lodge. The impact of their presence is that there is enormous support for developing the requisite skills to work with more troubled patients. In fact, candidates are even allowed to opt to treat a more troubled individual as their third case.
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