13. Afterthought: Changing Theories and Changing Techniques in Psychoanalysis

The ideas presented in the preceding chapters were developed over many years. I want to use the opportunity provided by this final chapter to emphasize some of the crucial aspects of my approach and some of the ways I have changed my opinions.

From the beginning of my interest in psychological medicine I was curious about patients who were difficult to treat and were thought to be incurable. From this grew my interest in schizophrenia and other psychotic conditions, which I discussed in Chapter 1. As my analytical work progressed I became more formally interested in the therapeutic action of psychoanalysis and simultaneously in the factors which may be responsible for treatment failures or impasse. I have had much opportunity to think about this problem because during the last thirty years I frequently accepted patients for analysis who had a number of analyses before consulting me but who had not improved or had even become worse after their analysis. I have also described two such failures of my own in Chapter 7. It has long been widely accepted, of course, that some failures will arise in a psychoanalytic treatment when it activates latent psychotic processes, and that great care will be needed to work through such situations, which can be a frightening development. In the case of an impasse developing in an analysis, however, I have come to accept the existence of several varied causes (not just the eruption of psychotic processes) and believe that in each case what has been going on in the treatment has to be examined in very great detail in order to understand as specifically as possible how the problem has arisen. It is with the prevention of impasses and their working through that