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Blog entry for September 30, 2006 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, contending that for most severe character disturbances, psychoanalytic therapy is the treatment of choice.
In contrast to Kernberg, Rothstein appears to welcome nearly all comers, noting that while he himself would not certain kinds of patients such as suicidal folks and drug addicts, others do, with good results. 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.However, this does harken back to Theodore Jacobses paper. Jacobs 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. 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, asserting that every analyst ought to become aware of those patients with whom they can not be effective. I agree with this - but, I also think that any of us (candidates and graduate analysts alike) can expand our range of skill both through personal analysis as well as through ongoing consultation. Here at the Washington Psychoanalytic, analysts formerly at Chestnut Lodge, have had a profound influence. 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.
In his article, Rothstein applies his notions about analyzability to six different cases. He describes two cases in which professional men in their forties sought a consultation after unsuccessful psychotherapies. He recommended analysis and both accepted his recommendation. My conjecture is that they accepted his recommendation for many reasons. First, Rothstein is an analyst of some renown. It is likely that patients seeking his input already have some sophistication in the psychotherapy arena. Second, the fact that they are seeking consultation with a senior analyst may indicate that they are serious about seeking help. Third, Rothstein, an experienced senior analyst, is a "true believer" and witnesses for psychoanalysis. Candidates, many of whom are just beginning their own analyses, may not yet feel his sense of conviction. Fourth, he's a busy, training analyst. Therefore, he may feel more comfortable recommending analysis, and taking the risk of losing the patient - than a neophyte might. Fifth, he's in NYC.
The third case he describes is one that the former analyst describes as "borderline". Rothstein understands the use of that diagnostic label as a reflection of the analyst's countertransference reaction. At the very least, it's fair to say that the patient was, "transference ready". And, Rothstein appears able to tolerate the patient's rage and his more primitive fantasies.
In the fourth case, he is treating a resident-physician who needs special accommodations in order to assume a four times a week schedule. Rothstein yields and arranges a very flexible schedule. Because of the special accommodations, the patient labors under the illusion that he is special. Ultimately, when the reality exigencies in the patient's life change, Rothstein interprets the patient's narcissistic fantasy and moves into a more standard schedule. While many analysts would not have been so flexible, Rothstein accepted him into treatment - and, then worked on the resistance. Had he not done so, the treatment would not have occurred.
In the fifth case, Rothstein made the recommendation for analysis. It then became apparent that the patient was not yet ready. So, he worked with her in a preparatory treatment, allowing her to take a hiatus, while she clarified whether or not she needed treatment. I imagine every analyst encounters many cases like this one.
Finally, in the sixth case, Rothstein manages a patient - resistant to the recommendation for analysis on a "catch as catch can" basis, seeing him when he is willing to attend. This is often necessary as a way to engage more narcissistic patients who are wary of relying on the analyst.
Rothstein couples flexibility with an analysis of resistance. A good model for the new millennium.
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