Psychoanalytic Treatment in Adults

A longitudinal study of change

Rosemary Cogan, John H. Porcerelli

• Publisher: Routledge
• Year: 2016
• Print ISBN: 9780815359869
• eBook ISBN: 9781317449621
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The outcomes of psychoanalysis, as with other psychotherapies, vary considerably. Psychoanalytic Treatment in Adults examines the results of a longitudinal study of change during psychoanalysis, illuminating the characteristics of patients, analysts and analyses which can help to predict outcomes of treatment.

Written by experienced psychologists and psychoanalysts, chapters in the book draw upon sixty case studies to consider how patients with very different analytic outcomes respond at both the beginning and end of their analysis. Psychoanalysts used a clinician report measure, the Shedler-Westen Assessment Procedure, to describe a patient at the beginning of psychoanalysis and every six months until the analysis ended. This allowed the authors to learn about changes over analysis and, in turn, improved treatment planning and practice for the well-being of other patients.

Chapters explore five outcomes: a negative therapeutic reaction; attrition when the patient drops out; attrition due to external events; mutual agreement between patient and analyst without maximum benefits; and mutual agreement between patient and analyst with maximum benefits.

The findings from these chapters will be of interest to researchers and academics in the fields of psychoanalysis, psychotherapy, psychodynamic therapy, psychoanalytic education, psychiatry and psychology. The results should also help clinicians recognize potential problems early in analytic treatments so that they can work more effectively with patients.

Part I

Beginnings

Chapter 1

Therapeutic aims of psychoanalysis

There are people of spirit and there are people of passion, both less common than one might think. Much rarer are the people of spirit and passion. But the rarest is passion of the spirit. Bertha Pappenheim was a woman of passion of the spirit . . . Hand on this image. Hand on her memory. Be witness that it still exists. We have a pledge.

Martin Buber (cited in Edinger, 1963/1968)

Introduction

The patient was a young woman with a powerful intellect, great common sense, and tenacious will-power, sometimes reaching obstinacy (Breuer & Freud, 1893/1981). When her father became critically ill, she devoted herself to caring for him at night while her mother cared for him during the day. After 5 months of this work, challenging at both an emotional and a physical level, the young woman developed several increasingly serious health problems and became bedridden. The family physician, Joseph Breuer, was called to check on her cough, which was especially worrisome as her father was dying of tuberculosis. Breuer saw the patient on December 11, 1880, and recognized that she had hysteria, with a whole host of widely varying symptoms well beyond a simple cough (Breuer & Freud, 1893/1981; Hirschmüller, 1978). Breuer began to visit her once a day and they talked together each day for about half an hour. After a few months, he began using hypnosis, asking her to talk about the development of one symptom during each visit. He found that when the history of the symptom became clear, the symptom itself eased. The patient spoke of the treatment as the “talking cure” (and sometimes as “chimney sweeping”). However, new and disturbing symptoms continued to develop. At times parts of her body were paralyzed. She had problems with her vision. At one point, she saw her fingers as snakes. At another time, she could not drink from a glass. For some time, she could not speak her native German but could only speak other languages. After about a year, as symptoms continued to develop, Breuer came to talk with her twice a day for about 30 minutes of conversation each time for several months. Her father died on April 5, 1881, and about 10 days later the prominent psychiatrist, Richard von Krafft-Ebing, was also consulted to see about the young woman’s continuing health problems. Breuer continued his treatment, the symptoms eased, and the treatment ended with the mutual agreement of patient and doctor on June 7, 1882 (Loentz, 2007; Orr-Andrawes, 1987). The patient was “free from the innumerable disturbances which she had previously exhibited,” although “it was a considerable time before she regained her mental balance entirely” (Breuer & Freud, 1893/1981, pp. 40–41). Breuer later described the young woman as gifted, energetic, and kind (Breuer & Freud, 1893/1981). However, Breuer never used the cathartic method again (Hirschmüller, 1978).

We know this patient as Anna O., the pseudonym given to her in writings about the case. Her identity was disclosed by Ernest Jones in 1953 and was then confirmed in letters and medical records (Ellenberger, 1972). Her given name was Bertha Pappenheim. She was the oldest living daughter born to a wealthy orthodox Jewish family in Vienna on February 27, 1859 (Hirschmüller, 1978). After her father died and her treatment with Joseph Breuer came to an end in June, 1882, she was in a sanatorium from July 12, 1882 to October 29, 1882, where she was treated for a dependency on morphine and chloral hydrate, medications given to her to treat a cough, sleep, and pain problems (Ellenberger, 1972; Hirschmüller, 1978; Orr-Andrawes, 1987). By 1887 she had been treated four more times in a sanatorium (Orr-Andrawes, 1987). She moved from Vienna to Frankfurt in November, 1888. After several years, about which little is known, she recovered and blossomed. From 1895 to the end of her life she worked with devotion and skill as the director of a girls’ orphanage for refugees from Eastern Europe, as a social worker, as a feminist activist, and as a well-published writer (de Paula Ramos, 2003; Ellenberger, 1970; Freeman, 1972/1990; Kimball, 2000; Loentz, 2007; Orr-Andrawes, 1987; Rosenbaum & Munroff, 1984). She lived from February 27, 1859, to May 28, 1936 and was honored for her social welfare work in 1954 when the West German Republic issued a postage stamp recognizing her in a series on Benefactors of Mankind (Jensen, 1970).

Breuer talked with his young Viennese colleague, Sigmund Freud, about the treatment of Bertha Pappenheim on November 18, 1882 (Freeman, 1972/1990; Strachey, 1981) and again on July 13, 1883 (Hirschmüller, 1978). Breuer and Freud knew each other from the community and from the Institute of Physiology, where both had worked with the physician and physiologist Ernst Brücke at different times. Freud had become engaged to Martha Bernays in June, 1882, and was preparing to move from research with Brücke to private practice in order to be able to afford to marry. As part of Freud’s preparation for practice, from October 20, 1885 to February 23, 1886, he studied with the famous neurologist Jean-Martin Charcot, who was working with hypnosis as a treatment for hysteria at the Salpêtrière Hospital in Paris. Although Charcot’s use of hypnosis was not exactly a “talking therapy,” his use of hypnosis was part of developing ideas about hysteria and how it could be treated.

Freud returned to Vienna and began his medical practice in late April, 1886. Freud and Martha married on September 30, 1886, and he and Breuer continued to collaborate. Freud worked first with hypnosis and then turned to a “talking therapy” without hypnosis. The case of Anna O. is described in the first sections of Studies on Hysteria (Breuer & Freud, 1893/1981), which introduced the core ideas of the “cathartic method,” as it was conceptualized at the time. The complete version of the work, with the histories of Anna O. and four cases treated by Freud, with a fifth case described briefly in a footnote, was published in 1895. Although the case of Anna O. is an important and much studied and debated case in the pre-history of psychoanalysis, perhaps what matters most for us here is that, in an addendum to the case, Freud (1903/1981) ends the last section of Studies on Hysteria with the famous statement about the goals of treatment:

much will be gained if we succeed in transforming your hysterical misery into common unhappiness. With a mental life that has been restored to health you will be better armed against that unhappiness.

(p. 305)

Goals of psychoanalysis and psychotherapy

Goals of psychoanalysis

One of the challenges of considering outcomes of psychoanalysis is differentiating between goals having to do with changes in the structure of the mind, goals having to do with changes in the analytic process, and therapeutic goals. Balint (1936) has described the first of these – focusing on structural changes – as the “classical” group of descriptions and the second – focusing on dynamic and emotional factors – as the “romantic” group.

Analytic goals having to do with changes in the structure of the mind derive from Freud. Freud wrote of helping to make “the unconscious accessible to consciousness” (e.g., 1903/1981, p. 253), with the patient having “rather less that is unconscious and rather more that is conscious in him than he had before” (1917, p. 435). In 1933, Freud considered that the goal of analysis is:

to strengthen the ego, to make it more independent of the superego, to widen its field of perception and enlarge its organization so that it can appropriate new portions of the id.

(p. 80)

Analytic goals having to do with dynamic changes, often called process goals, center around the patient’s ability to free-associate. The development of an analytic process certainly may be related to changes in the structure and dynamics of the mind (cf. Jones, 1936/1961) and to therapeutic outcomes (Bachrach, Weber, & Solomon, 1985). Balint (1936) has described the ability of patients late in analysis to express wishes that had been out of awareness and to then be able to move toward gratification of these wishes as a “new beginning.” In Balint’s view, these newly recognized wishes involve pleasurable activities and are “without exception, directed towards objects” (p. 210). Balint observed that late in analysis an ability to form real relationships develops and the person is able not simply to be loved but to “attempt to begin to love anew” (p. 216). The development of insight has been considered as a necessary part of the process of change by both “classical” and “romantic” psychoanalytic thinkers (cf. Jacobs, 2001, 2004; Kris, 1956; Wallerstein, 1965; Weinshel & Renik, 1992) and may be a necessary precursor to other changes (Weinshel & Renik, 1992).

We do not mean to entirely set aside the extensive and thoughtful literature having to do with structural and dynamic goals of analysis. However, we are concerned here with what are generally called therapeutic goals (cf., Jones, 1936/1961; Sandler & Dreher, 1996; Wallerstein, 1965, 1992). These may include both clinical goals, such as reducing anxiety, and life goals, such as achieving a better quality of life (Bernardi, 2001; Kogan, 1996). If we can assume that symptoms are often more transient and elements of personality structure more stable characteristics of people, we might be concerned with both symptom reduction and changes in personality characteristics with analysis.

The classical psychoanalysts were generally quite cautious about the therapeutic goals of treatment. We have noted Freud’s (1903/1981) comment above about achieving “common unhappiness” as a goal. Hartmann (1939, p. 311) wrote that “a healthy person must have the capacity to suffer and to be depressed.” Knight (1941, p. 437) pointed to the success of analysis in terms of symptomatic recovery, improved productiveness, improved sexual pleasure, more loyal interpersonal relationships, and enough insight to manage the conflicts of daily life. However, Knight then cautioned:

It is an entirely illogical and unfair expectation for the patient, his friends, relatives or referring physician to anticipate that after being treated by the method of psychoanalysis he will become a paragon of all the virtues and accomplished without flaw, defect or anxiety and capable of behaving in every possible situation like a superman. . . . One might as well expect that psychoanalysis would also cure his freckles, his bad golf swing and his aversion to turnips. No, the patient will remain essentially the same person after the best analysis – rid of his disabling symptoms, perhaps, or able to handle what ones are still left, more adaptable, more productive, happier in his relationships, but still the same person as to native endowment, appearance, and basic temperament.

On the more positive side, Freud and Breuer viewed the relief of symptoms as a goal of treatment, along with the restoration of the patient’s ability to work (Breuer & Freud, 1893/1981). In 1904, Freud wrote of the patient’s ability to lead an active life and have a capacity for enjoyment as goals of analysis. Freud wrote as well, in letters to Putnam, that analysis should “find a place among the methods whose aim is to bring about the highest ethical and intellectual development of the individual” (letter of March 30, 1914 in Hale, 1971) and Blass (2003) has considered ethical dimensions of psychoanalytic goals. Jones (1936/1961) said that with analytical success at the highest degree: “One may then expect a confident serenity, a freedom from anxiety, a control over the full resources of the personality that can be obtained in no other way than by the most complete analysis possible” (p. 382).

Statements about the therapeutic goals of psychoanalysis have varied quite a lot. Some examples of statements about therapeutic goals, organized chronologically, are: an active life, experience enjoyment, reduction in symptoms (Freud, 1904); increased sexual pleasure (Balint, 1932; 1952); confident serenity with freedom from anxiety (Jones, 1936/1961); less sadism, more love (Balint, 1936); able to tolerate suffering and depression and freedom from symptoms (Hartmann, 1939); able to handle ordinary problems, symptomatic recovery, increased productiveness, increased sexual pleasure, improved interpersonal relationships, and insight (Knight, 1941); self-acceptance and self-understanding (Glueck, 1960); to love and work (Wallerstein, 1965); personal life goals (Ticho, 1972); professional life goals (Ticho, 1972); and insight (Grinberg, 1980; Weinshel & Renik, 1992).

Goals of psychotherapy

Articulating the goals of psychotherapy is also complicated. After client- centered therapy, Rogers (1951) noted that people “feel more comfortable with themselves. Their behavior changes, often in the direction of better adjustment” (p. 131). With cognitive therapy, Beck (1976) said that people can “create a more self-fulfilling life” (p. 4), and “maintain their equilibrium most of the time” (p. 14). Generally, though, the goal of cognitive therapy is to “alleviate the overt symptoms or behavior problems” (Beck, 1976, p. 321). In behavior therapy, treatment goals are individualized for the patient with the more general goals involving changing habits in order to remove suffering or improve functioning (Wolpe, 1967, 1969). In “rational therapy,” Ellis saw the goals as having the patient minimize anxiety and hostility (Ellis, 1967).

In the tour-de-force meta-analysis of 475 controlled studies of psychotherapy outcome by Smith, Glass, and Miller (1980), the researchers identified 12 outcome categories and listed from three to 43 measures of each. The outcome categories included: addiction, emotional-somatic complaints, fear-anxiety, global adjustment, life adjustment, personality traits, physiological measures of stress, self-esteem, social behavior, sociopathic behavior, vocational-personal development, and work/school achievement.

Conclusion

We confess to being at something of a loss. If each of the therapeutic goals of psychoanalysis and each of the goals of psychotherapy were written on cards and then the cards were shuffled, we doubt that the cards could be successfully sorted into one set for psychoanalysis and one set for psychotherapy. While we might expect the goals of the two types of treatments to be similar, we would sure...

Table of contents

• Cover Page
• Psychoanalytic Treatment in Adults
• Series
• Title
• Copyright
• Contents
• Preface
• Introduction
• PART I: Beginnings
• PART II: Comparing Outcome Groups
• PART III: Insight and Change
• PART IV: Conclusions
• Index