The Conflict Between the Patient's and Analyst's Reality in Classical and Modern Psychoanalysis

Modern psychoanalysts frequently tell their patients that all the patient has to do is tell the story of his life and the rest is up to the analyst. This division of labor is based upon accepting in treatment a patient who may be an emotional infant and who needs to be completely taken care of while he is on the analytic couch. The assumption of a larger share of the therapeutic burden by the analyst corresponds to an improvement in technique of treatment over that of Sigmund Freud (1904) who designated certain kinds of patients as unsuitable for analysis, and over that of contemporary classical analysts who continue to require that their patients be capable of a working or therapeutic alliance with the analyst. In line with his appraisal of his technical achievement, Freud recommended a trial period to determine whether a given patient was or was not suitable for analysis. Certain patients, however, escaped screening and others were continued in treatment on an experimental basis. If, in the course of treatment during this trial period, the analyst makes interventions which the patient experiences as insulting or damaging to his self esteem, the analyst is free to conclude that the patient was initially unsuitable for analytic treatment.

In discussing the contra-indications for psychoanalytic treatment, Otto Fenichel (1945) considered the possession by the patient of a reasonable and cooperative ego to be of “the greatest practical importance” (p. 577). When lacking, psychoanalysis “seems to be