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Among the many unsolved problems in psychoanalysis I have chosen one that is of practical as well as theoretical importance. It was raised by Freud in 1937 in "Analysis Terminable and Interminable." He suggested that instead of investigating in which way psychoanalytic treatment accomplishes a cure (which is sufficiently known), we should ask ourselves: which are the obstacles standing in the way of achieving a cure? This question is still as interesting as it was thirty years ago. In the meantime, however, our experience and our theoretical knowledge have grown. These can be applied to work out some of Freud's points and to add new ones.
I shall not discuss untimely interruptions of analysis due to external circumstances, or the impatience or inexperience of the analyst, or unforeseen deteriorations in the patient's mental condition, e.g., the outbreak of severe psychosis, which demands discontinuation of analytic treatment and hospitalization. I shall limit myself to those situations in which the patient is sufficiently intelligent and able to cooperate, in which there is a good working alliance that has helped to uncover a considerable part of the unconscious conflicts, and in which the therapeutic effect has nevertheless failed to come about after patient working through in prolonged treatment.
Freud mentioned some of the factors responsible. Among them are the following:
1A strong need for punishment that leads to the negative therapeutic reaction.
2An incapacity to "tame" the instinctual drives and a particularly unfortunate relationship between sexual (libidinal) and aggressive drives.
3An ego alteration or impairment which makes the patient incapable