From time to time reports are included in the Newsletter on Panels held at the meetings of the Association. As this issue of the Newsletter includes several contributions relating to outcome studies (e.g., Wallerstein interview; Luborsky interview; report on new Task Force) the following summary of the December 1987 scientific panel on Follow-up Studies seems relevant.
Joseph Schachter, Chairman, introduced the Panel by noting that the subject of outcome of psychoanalytic treatment is a sore point for psychoanalysis. Critics of psychoanalysis take this as evidence that the treatment is ineffective. A pilot study of analytic outcome conducted in Pittsburgh suggests that a different, and probably more accurate, impression was gleaned from the follow-up assessment than from the treating analyst's impression at the time of termination as to the results of the analysis, indicating that follow-up contact by the treating analyst would provide the more valid and informative picture of analytic treatment. Furthermore, a tradition of follow-up studies is firmly established in other medical specialities.
But if follow-up contact is thus useful for the analyst, what about for the patient? Based on the fact that the great majority of analysts report considerable post analytic contact with their own training analysts, and that such contact is considered by them to be valuable, certainly not harmful, then it can be presumed that the same might be true for the non-analyst patient.
The proposal this panel considered is that the analyst should initiate post-termination contact with the patient, not for research, and not in conjunction with any modification of basic analytic attitudes of neutrality or abstinence. The audiences' attitudes toward such a proposal were assessed both immediately after the panel and six months later. The pilot questionnaire suggests that women were more open than were men to this idea, both before and after exposure to the panel. There is a suggestion that countertransference fear of discovering less than perfect results might influence this negative attitude.
Gary C. Martin, from Denver, noted, based on his own survey, that while two-thirds of successfully terminated patients re-contacted their analysts after three years, no one has seriously considered the benefits to the patients of such contact. He contends that post-termination contact should be addressed at some time during the termination phase, based upon the fact that analysts report having benefited from post analytic contact with their own training analysts, in terms of consolidation of the sense of self, continued de-idealization in the transference, dealing with residual infantile longings, etc. Furthermore, the concept of adult development leads us to anticipate further maturation in the post-termination phase that might then be assessed with the analyst.
Martin presented three vignettes representing three different approaches to the issue of post-termination contact, stressing the point that termination means different things to different patients and the handling of post-termination contact must respond to these differences.
Nathan Schlessinger described his ongoing follow-up study conducted not for research purposes but as a vital part of the practice of analysis. A terminated clinic case is studied in collaboration with the director of the clinic, the treating analyst, and the fourth-year psychoanalytic class of the Chicago Institute. The case is presented at length and discussed by the class, following which Schlessinger conducts six follow-up interviews with the former patient and presents his results to the class for further discussion. The classic follow-up findings of Pheffer have been repeatedly confirmed, and in the 25 cases studied over the past 25 years, the follow-up interviews themselves have had a facilitating effect on the exercise of self analytic and self soothing functions on the part of the former patient.
A developmental point of view is used to understand the post analytic phenomena. This point of view allows the analyst to see the follow-up interviews as a part of the ongoing experience of the patient rather than a yardstick for success or failure of the analysis. Furthermore, such return visits provide an opportunity and a challenge for the analyst's theoretical outlook and clinical technique, thereby enhancing the growth and development of analysis itself.
A case was presented in detail to illustrate Schlessinger's thesis.
Robert Wallerstein of San Francisco presented conclusions based upon the Psychotherapy Research Project of the Menninger Foundation, drawing the conclusion that the impact of planned follow-up studies upon the termination and outcome of psychoanalytic therapy is not detrimental, but rather can often prove helpful to the patient's and the therapist's therapeutic purposes. He suggests that planned follow-up be part of our regular clinical and research activities to the extent that circumstances permit. This conclusion, based as it is on the 42 psychotherapeutic and psychoanalytic cases carries the weight of a great deal of combined experience. Wallerstein, in commenting upon the method of follow-up used by Pfeffer and by those who replicated his findings, did not feel that such a regression-stimulating procedure need be an obligatory part of follow-up studies. At the Menninger Foundation the follow-up was deliberately designed in a more controlled fashion, with psychological testing, with a limited number of follow-up interviews, often with two interviewers talking at the same time to the same patient, and with additional information about the patient gathered from relatives. Various techniques of follow-up are thus feasible, and this variety can provide generally fruitful results.
Lester Luborsky, from Philadelphia, reviewed extant long-term psychotherapy follow-up studies to answer the question: is it advisable to have planned, routine follow-up procedures for psychoanalysis and psychoanalyic psychotherapy? Findings derived from these research studies include: 1. Gains from therapy remain after many years post-termination. 2. Some patients did show a tendency to eventual loss of gains, e.g., those who are substance dependent, who are depressed, who have habit disorders, or who have poor capacity for internalization. 3. Transference patterns are stable enough to be re-recognizable during follow-up. 4. Wishes toward others are most consistent while the expected response from others shows more change.
There are predictable implications of follow-up studies. First, patients tend to maintain the gains during post-termination before follow-up, seeing the
follow-up as a continuation of treatment and an indication of the therapist's continuing interest, particularly those who have a special deficiency in internalization. Second, follow-up can review the status of the patient post-termination. Third, expectation of follow-up can be negative for patients who have difficulty in separating and who do not, with the expectation of follow-up, complete that work. Fourth, there may be ways of presenting the idea of follow-up that can maximize therapuetic gains.
Luborsky contends that it is best to introduce the plan for follow-up to the patient at the beginning of treatment, as this will more likely obviate involvement with transference meanings. Follow-up is best done one year after termination. Luborsky concludes that follow-up is, at the least, mostly positive, and at the worst, not harmful. For some patients, follow-up may be especially helpful.
The discussant, Kenneth Calder, noting the general positive consensus of the panel regarding planned, routine follow-up, took issue to a limited degree. He concluded, however, that despite his reservations, he was mostly persuaded by the panelists. He left the audience with a cautionary aphorism. In considering the effects on the analyst of seeing his patient in a more friendly, less rigorously controlled and neutral follow-up atmosphere, he said, “remember, familiarity breeds attempt.”
Members who attended this stimulating and challenging panel await the results of the follow-up survey done by Schachter.