In the last issue of The Candidate Connection, I wrote on the topic of the widening scope of analytic practice from the perspective of one of its greatest promoters, Arnold “Chuck” Rothstein. Here, I present the thinking at my home base, the New York Psychoanalytic Society and Institute (NYPSI). I was fortunate to interview the head of our Treatment Center (TC), Peter B. Dunn, who is responsible for conducting its monthly case disposition conferences and, ultimately, making the selection of patients likely suitable for analysis that are referred to candidates. Dunn treated me to a tour de force exposition on the history of the “widening scope” and its vicissitudes over time.
Who is suitable for this unique form of psychotherapy, that is, who can benefit from the treatment and whom we as analysts are competent to treat are the questions before us in considering the idea of widening the scope in our selection of patients. In the earliest days, when Freud and his followers eagerly used the new analytic methods, a wider scope of patients was accepted into treatment. Very primitive patients, including those with psychotic processes (e.g. the “Wolf Man” and “Anna O” come to mind), were given analyses; their case histories constitute some of Freud's earliest expositions on analysis and continue to form the primary introduction given for candidates. Today, patients showing an equivalent degree of pathology would not likely be considered suitable control cases for beginning candidates.
After World War II, the influx of European analysts shifted the center of the profession to the United States. The NYPSI enjoyed a particular concentration of this talent and continued the work of developing psychoanalysis, now located in a new society and culture. In the 1950s during the ascendant Hartmann et al. era of ego psychology, the past experiences were codified, more restrictions were placed on the method, and the type of patients thought to be amenable to psychoanalysis was reined in; the scope narrowed. In contrast to Freud's explicit recommendation that only a trial analysis could assess a patient's ability to benefit from the analytic method, an evaluative model focusing on ego strengths and weaknesses was adopted, following the medical model of the psychiatric interview. According to Dunn, this rigid model provoked a counter-reaction among analysts whose clinical experience showed that many ego-healthy patients proved to be poor analysands while patients with sicker egos benefited greatly. Healthier patients often had firmer defenses and greater resistances to dependency and to tolerating regression in the service of the analysis.
More recently, as theory has advanced with the garnering of experience and an accumulating number of treated patients, the scope is cautiously widening once again to include patients that Freud, in his later years, came to regard as outside the capacity of analysis to benefit. The changing popularity of analysis in the culture has further contributed to a widening scope. The drastic decline in demand over the past several decades has correlated with the rise of alternative treatment methods such as medication and short-term, symptom focused therapies. Dunn believes that in light of alternatives to the intensive, highly demanding analytic modality, many analysts themselves have lost faith in their method and abandoned it. However, others have responded by applying the theory and techniques of depth psychotherapy to treating populations with ever greater degrees of disturbance.
In the heyday of psychoanalysis, during the ‘50s and continuing into the ‘70s, there were more patients than places for them in practice. Candidates were assured of a plentiful supply of “good” patients and thus, like an exclusive college with a surplus of applicants, rigid criteria for acceptance by the TC could be maintained. Today, patients are in short supply and institutes struggle to help candidates obtain suitable cases. The current model as practiced at the NYPSI incorporates more of the recent advances in understanding more primitive levels of functioning and, hence, permits a widening scope of patients as capable of benefiting from analytic treatment.
At the NYPSI Treatment Center, a patient applicant is referred to a candidate who is trained to use the evaluative model to take a history and formulate a structural understanding of the patient's functioning. History is considered the best predictor of patient
functioning within the analytic situation. Dunn says that while senior analysts like Freud and Rothstein could evaluate patients very quickly, beginners cannot. The utility of the evaluative model for beginners is to force them to go point by point through the patient's personality.
About 25 percent of TC patient applicants are deemed appropriate for referral to a candidate, a percentage unchanged since 1946 when tracking such data began. However, characteristics of those who seek psychoanalysis have changed since the 1950s when the population was more structured and the intelligentsia flocked to be analyzed. Today's applicants tend to be more disturbed and from a broader cultural spectrum. That the percentage of those accepted has not decreased is due to the widening scope. Furthermore, one quarter of those accepted by the TC following the evaluative process are considered to be only provisionally suitable and the candidate then engages the patient in an initial period of psychotherapy, in effect utilizing Rothstein's process model. The aim, then, is to prepare the patient for a future analysis.
Assessment of analyzability rests on a consideration of two categories: the presence of positive and the absence of negative traits. Positive traits that weigh towards a “rule-in” for a recommendation of analysis include general indicators of ego strength—a capacity to tolerate affect without acting out, an interest in thinking symbolically, the capacity to accept responsibility and tolerate normal criticism, the ability to form normal, dependent relationships and profit from them, and a capacity for “regression in the service of the ego” as Kris delineated (seen in the ability to regress, to play, joke, fantasize, to tolerate being irrational and to misinterpreting the analyst). Negative traits factoring towards a “rule-out” include a history of behaviors present in psychosis, such as severe regressions in the face of painful affect or of acting out, substance abuse and violent or self-destructive episodes, and a history of paranoid or sadomasochistic transferences, including how pervasive they are in defining the person's typical relationships. One underlying premise of the widening scope, and the major value Dunn attributes to Rothstein's advocacy of a process model, is that the positive traits are more difficult to assess via an evaluative approach but will emerge through a period of therapy that develops or exposes the patient's capacity for such things as psychological mindedness and the motivation to endure the rigors of an analysis.
Finally, I asked Dunn about research efforts aimed at predicting who will benefit from an analysis. So far, research has tended to discredit the evaluative approach for making such predictions. Dunn agreed research is needed. He mentioned that at the Columbia Psychoanalytic Institute a research project underway obtains patient agreement to be periodically assessed for progress during the course of treatment by an objective interviewer So far, NYPSI has been reluctant to conduct research that is intrusive into the treatment. At the present, my experience, and from what I have informally deduced from my classmates, is that we candidates use the process model extensively. We are more likely to work in intensive psychotherapy with patients in the widening scope category for many months prior to converting them into analyses than to receive a “good” case that can be started forthwith.
Navah C. Kaplan, Ph.D., is a candidate at NYPSI; editor of the Candidate Connection; chair of the Affiliate Council's Scientific Paper Prize Committee; and is running unopposed for president-elect of the Candidates Council. She is in private practice in NYC.