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1 | INTRODUCTION How and why do people enter psychoanalysis? |
Imagine more than 500 psychoanalysts from all over the world participating over a period of eight years in a total of 45 workshops where case material from first interviews was presented and discussed. This gives an idea of what an immense amount of clinical material has been metabolized, and of what an extraordinary wealth of information, details, nuances, different perspectives and first-hand experiences of what actually happens in initial interviews this study draws upon. Then imagine an international team of 12 psychoanalysts working together to pursue an in-depth study of 28 of these cases, looking for common patterns or contrasts, through several rounds of elaboration.
In the following chapters, based on the study of this rich material, the Working Party on Initiating Psychoanalysis (WPIP) of the European Psychoanalytical Federation (EPF) will try to clarify how analysts actually perform the task resulting in recommendation of analysis, and what goes on that makes it possible to initiate an analysis.
We want to thank all the analysts who have participated in these Clinical Workshops. Without their active and engaged involvement and their permission to keep recordings and notes from the workshops, the material would have been much poorer. We are especially indebted to those analysts who offered their own experiences and session material from initial interviews where they explored the possibility of initiating a psychoanalysis, and who were prepared to participate in the workshop process, being not only willing to discuss the material but also, at times, to be open and frank about their own emotional feelings and responses. These presenting analysts also gave permission for the WPIP to continue work on the interview protocols and workshop minutes. It has been a fascinating opportunity to follow these presentations through the initial workshop meetings and subsequent WPIP Investigative Team meetings, where the various dynamic elements were not just objects for static study but generators of further processes within the subsequent research Stages, which sometimes became a secondary line of containment and transformation.
These analysts have also approved the case-material vignettes used in the following chapters. For reasons of confidentiality, we unfortunately cannot recognize the individual analysts nominally for their gracious participation and permission.
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The original questions behind the creation of the WPIP were: why don’t more people enter psychoanalysis, and how can we help more people to do so? The psychoanalytic community has often worked on the basis of the implicit assumption that it is something about the patient that decides whether psychoanalysis will be suggested or not. But all research that has tried to isolate patient characteristics which could inform the decision of whether psychoanalysis should be initiated or not, or could predict whether a psychoanalysis with a given patient will succeed, has consistently failed to find any (Bachrach and Leaff 1978, Bachrach et al. 1991, Wallerstein 1994, Caligor et al. 2009).
As a result of this another question has arisen, namely why analysts seem to be reluctant to take on analytic patients. The focus of investigation has shifted towards the analyst, in order to examine the possible resistances that analysts themselves may experience about taking on new patients. Several authors (Ogden 1992; Rothstein 1994, 1998a; Caper 1997; Quinodoz 2001; Ehrlich 2004, 2013; Wille 2012; Møller 2014) have described different aspects of these resistances: the anxiety aroused by a new meeting, linked to a bias against psychoanalysis because of unpredictable and disturbing countertransference reactions; the confrontation with the patient’s and the analyst’s own ‘madness’; lack of trust in psychoanalysis and the need for psychoanalysis as a good internal object in order to be able to contain the strains for the analyst. These thoughts have brought much light on the burdens of practising psychoanalysis.
Several authors have already advocated the view that the indication for analysis lies as much in the analyst as in the patient. According to some, psychoanalytic patients are not ‘found’, they are ‘created’ by analysts who are able to help patients to begin what could be the best treatment for them (Rothstein 1998a, Levine 2010, Crick 2014). On the basis of our own experience with the WPIP study, we believe that what actually happens is that the patient and analyst work together to co-create an analytic couple, and that the analyst’s role as a participating agent in this process is essential. It then becomes interesting to understand the developing dynamics of the analytic couple, and how the analyst functions in this context.
Judy Kantrowitz’s work (1986, 1993, 2002) can be considered to be a part of an important shift away from the focus on analyzability, first towards the compatibility of patient and analyst as individuals, and later to their functioning as a unique, working analytic couple. She has described how the analyst is also changed by the interaction, and has done a careful study of the patient’s impact on the analyst (Kantrowitz 1996).
Arnold Rothstein (1998b) gave an articulate account of how the impact on the analyst can lead the latter to diagnose instead of entering the psychoanalytic relationship. More recently, Antonio Pérez-Sánchez (2012) described indicators of suitability for psychoanalytic treatment, but which are rooted in the developing relationship, including the examination of the analyst’s countertransference. Many other relevant viewpoints that represent the shift in the field are to be found in the collected readings published by the WPIP, Initiating Psychoanalysis: Perspectives (Reith et al. 2012). We see the present study as another contribution to this debate.
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Our study originated as part of the European Psychoanalytical Federation’s Ten-Year European Scientific Initiative, launched in 2001 under the presidency of David Tuckett (Tuckett 2002, 2003, 2004; Tuckett et al. 2008; Basile et al. 2010).
The aim of this programme was to do clinical research. By getting psychoanalysts from many different orientations to work together in peer groups, the hope was to turn the diversity of psychoanalytic cultures within the EPF into a resource that might help us to discover more about the clinical realities of psychoanalysis than what can be extracted from the existing psychoanalytic models.
In particular, we wanted to look at how psychoanalysts really work – not how we would ideally like to think that they work – and attempt to see how we can understand real-life psychoanalytic practice. One of the basic plans was to ask the groups to study process notes of psychoanalytic sessions (or, in our case, process notes of first interviews) to see what goes on there – or not.
In practice, several investigative teams, called Working Parties, were set up, each ideally composed of members from different EPF societies and psychoanalytic cultures. These Working Parties were responsible for setting up investigative programmes addressing specific issues of interest to the analytic community and in which EPF analysts, also from different EPF societies and psychoanalytic cultures, were invited to take part. Many of these programmes involved bringing together the participating analysts in Clinical Workshops, held annually at the EPF conferences (as well as IPA and other conferences), where they could study the case material.
A palette of workshop methods was tried out, ranging from very structured to purely free-associative group work (for a detailed description of the different methods, see Chapter 3). Our own Working Party, WPIP (Reith et al. 2010), chose an intermediate format, with some structure, for example asking the groups to respond to a few basic discussion questions as part of their task but also leaving considerable space for free-associative group work; the reasons for this choice will be described in Chapter 3. The aim of such procedures is to use something psychoanalysts already know how to do well, namely clinical case discussion groups, as a starting point for more disciplined and systematic forms of study, i.e. to turn clinical case discussions into a research tool. We see these procedures as attempts to develop forms of qualitative research in psychoanalysis (see Chapter 3).
This Working Party (WPIP) was formally established in 2004. Its Team members were delegates designated by their EPF societies. The WPIP conducted its Workshops at the EPF Conferences from Vilamoura in 2005 up to and including the Paris conference in 2012; workshops were also held at the IPA congresses in Berlin and Chicago. During this period, a North American Initiating Psychoanalysis Working Party was also set up, and we have collaborated with them to hold similar workshops at the IPA conferences in Mexico, Prague and Boston.
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What the WPIP set out to study was based on the original broad mandate of the European Scientific Initiative, which called for:
1) the development of skills for assessing patients for psychoanalysis and determining the conditions for advising psychoanalytic treatment both in private and institutional settings; and
2) finding ways to improve referrals for full analysis and to share them among practitioners.
Implicit in this was also an aim to secure the future training in and practice of psychoanalysis.
The evolution of the WPIP’s work is described in its interim report to the EPF in 2010 (Reith et al. 2010). After exploring several options it was decided to concentrate its efforts on a core issue that seemed relevant to all aspects of the mandate, and so the following central research theme was chosen:
From the outset, our focus was on the dynamics of the analytic couple in first interviews. Although these dynamics can of course be expected to be influenced in part by the patients’ unconscious structures and dynamics, to focus on the impact of the latter would require another study. We see this couple-oriented perspective as complementary to, rather than opposed to or exclusive of, more patient-oriented perspectives.
Our research on first interviews can be defined as a psychoanalytic study, using psychoanalytic exploration by peer groups of psychoanalysts as its core procedure. It is a hypothesis-generating study, aiming to develop grounded theory based on careful and disciplined observation (see Chapter 3), and not a hypothesis-testing study, designed to test the logical consequences of a pre-existing theory. It is based on clinical work discussed by practising analysts, using their divergent theoretical backgrounds as leverage for more precise, experience-near observation. It is therefore intended to be as independent of specific psychoanalytic theories as possible. Whether or not our findings fit in with existing theories remains an open question warranting further exploration.
It is not, therefore, a controlled experimental or epidemiological study, nor is it a standardized observational study designed to reliably apply and test pre-defined psychoanalytic concepts. What is empiric about the method is that it is a study of many real cases, and that the same specific pre-defined procedures have been followed for all the cases: from the presentation of the clinical material, through the semi-structured discussion in the Clinical Workshops, to WPIP´s subsequent work with the clinical material and the workshop findings. Comparing the cases, deriving explanatory hypotheses from them and checking these against further cases were also done following systematic procedures, as described in Chapter 3.
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We are not offering a manual or textbook on how to initiate psychoanalysis, but a psychoanalytic study of the initiation processes as we think they can be seen to take place in the work of practising analysts. The aim is to use the findings of this study to promote reflection on what happens when patient and analyst meet. Our study on how analysts and patients work together in their first meeting has enabled us to develop ideas about the initiating processes along different but interlinked lines, which are all related to the unconscious dynamics of the patient-analyst couple, and which will be described in the successive chapters of the book. Our aims will have been reached if our work promotes further debate, exploration and research in the psychoanalytic community, if it stimulates clinical reflection on our psychoanalytic practice, and most especially if it helps psychoanalysts in training to overcome their fears about beginning analyses.
To describe consultations from these dynamic perspectives provides a kind of evaluation of the possibility for analysis that is more in accordance with psychoanalytic principles and the interactive psychoanalytic process that will eventually be initiated, than with a more assessment-like search for analysable patients, which as mentioned above has proven ineffective. This does not mean that it becomes irrelevant to consider the patient’s psychological structure and other characteristics, but it transforms the decision to recommend analysis into a different undertaking. It becomes more complex, but is based on a grasp of the situation that is more in accordance with its nature.
We have seen work involving very different patients, with very different pathologies, and very different analysts, coming from different analytic subcultures, who met and interacted in consultations that led to the initiation of psychoanalysis, or in some cases to other choices of treatment.
While we recognize that differences in the consultation process are related to differences in psychoanalytic subcultures and the specific institutional/social context in which analysis can be offered, as well as to the individual patients’ pathologies, we have come to the conclusion that it makes sense to understand these differences from a specifically psychoanalytic, inter-psychic perspective. By this we mean that the outcome of each consultation can be understood as a result of how analyst and patient adapted, often unconsciously, to the situation created by their encounter, including the broader sociocultural and institutional context. In one way or another, this inter-psychic dynamic will be the specific focus of all the following chapters. The chapters follow a developmental line, beginning with a description of the research method, and moving on to the different perspectives that the WPIP came to adopt in order to understand the interview dynamics.
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The whole WPIP Team is regarded as author of the book. We have functioned as one research group, and want this to be reflected in the presentation of our findings. Because the work within the WPIP has been so intense that it has become di...
