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Herbert J. Schlesinger, Ph.D.: Another Look at Contraindications to Psychoanalysis: Are there Persons We Should Not Take into Psychoanalysis?
Another Look at Contraindications to Psychoanalysis:
Are there Persons We Should Not Take into Psychoanalysis?
Herbert J. Schlesinger, Ph.D.
Introduction
We are not many years beyond the time when psychoanalysis was widely held to be a panacea, the infallible cure for all ills of the spirit. It was not only considered to be the best treatment, it was the only treatment. If we suggested to a patient that a less expensive and less arduous treatment might do, we also would have to reassure him that we intended no implication that he was either too sick, not smart enough, or not worthy enough to be analyzed: We are no longer so single-mindedly ambitious about psychoanalysis, but regard it as a powerful treatment with a limited range of application in its native form. It has given rise, however, to a wide range of dynamically inspired therapeutic approaches that extend its reach enormously. Still, when an analyst comes across a prospective patient who presents the attractive picture of a bright and articulate person who has enjoyed reasonable success at a career and bears the outward signs of a fair social adjustment, but who is dissatisfied with his life, our first thought is likely to be, “why not analysis?” I will propose that some people who look analyzable and who ask for analysis nevertheless should not be taken into analysis without careful consideration of the likely hazards.
The Usual Contraindications
Some analysts now believe that perhaps there are only a few prospective patients who seem analyzable but for whom psychoanalysis might not be the best treatment:[1] In general, these are persons whose life circumstances permit little change, and for whom the “neurosis" might be the best compromise, or best adaptive solution open to them. They are viewed as having little capacity for independent living, or have other severely limiting factors including severe physical defects that would preclude a more gratifying life even if analysis could relieve them of their neurosis.
Some have raised ethical objections even to this minimal degree of exclusionary thinking, “Do we not play God when we decide what another's future must be? Should we arrogate to ourselves the power to dismiss another's capacity for growth, change and development? Is it not wrong to underestimate anyone’s capacity to find new adaptive solutions and to change what may until then have seemed to be unalterable aspects of reality? After all, is it not the spirit of analysis to challenge the assumption of a recalcitrant "reality" and to regard it as a construct until proven otherwise? Of course, we will want to balance this libertarian stance by the humane concern to avoid raising "false hopes."
In recent years, even these minimal contraindications have been seen as less than absolute. Under the banner of the “widening scope,” we have used psychoanalysis either in native form or suitably modified with reasonable success for many groups of patients formerly considered unreachable. Life no longer stops at 40 and we now accept patients from early childhood to the quite elderly and with a wide range of psychopathology. Still, I believe there remains a group of patients for whom we should recommend psychoanalysis with great caution and if we accept them, proceed with respect for the hazards. I do not need to caution you about the persons with fragile defenses who might regress beyond the point of safety. Most analysts are familiar enough with the danger that patients may decompensate in analysis. After all, any treatment that is psycho-effective, under some circumstances, may also be psycho-noxious. Neither do I warn against taking into analysis patients whose defensive structures seem inalterably rigid. Ironically, my concern is not with the patients who are “unanalyzable,” but rather those for whom the result of a “successful” analysis may be socially disastrous.
The Problematic Patient
To highlight the common elements among members of this class of patients, and out of concern for privacy, the clinical material I present is a composite of several patients. For convenience, I will use the male pronoun throughout and I will state specifically if I intend to refer to one rather than the other sex. The class of persons I refer to are those whose “core” character structure is basically “narcissistic," in ways that I will describe and who also have chronic symptoms of neurotic conflict that are organized into what amounts, as it were, to a "superimposed" neurosis, one that typically is mild and usually obsessive-compulsive in form. In the initial interviews, the analyst will find the prospective patient attractive, even charming. He is not necessarily seductive, though that possibility will occur to the analyst. He is a bit aloof, not readily forthcoming, perhaps intriguingly mysterious, but answers questions fully. There is nothing alarming in his background as he tells about it, no obvious psychopathic tendencies, and no cruelty to animals. He has been successful in life to this point, is likely to be in a profession or an entrepreneur and able to afford a private fee. If he is in an appropriate profession and applies to an institute, he may seem acceptable as a candidate; if subjected to no more searching evaluation, he may seem ideally suited for analysis and to join the field.
In his analysis, which may go quite smoothly at first, he may complain of a frank neurotic symptom, perhaps about the obsessive thoughts that occasionally crowd out of his mind things he would rather think about. More likely, he will be uncertain if he even has a focal complaint, his “symptoms” tend to come and go. He is concerned mainly about a vague sense of being inhibited, “held back.” Although to outward appearance he is successful, his life feels unfulfilling. He has a capacity for hard and productive work when he feels like it; he generally gets what he strives for and is appropriately proud of his real accomplishments. Still, it often turns out that what results from his efforts turns out not to be what he wants, but he is not sure what it is that he wants. Whatever it is, it feels always to be just out of reach.
He has never found satisfaction in intimate relationships, tending to turn off when, for the moment, he has had enough. He has to force himself to remember that his partner too has needs and, if he does remember, makes allowance for them with little grace. He has an easy way with women. They find him interesting, even intriguing, but after successful courtship, he soon finds them boring and moves on. He also is bored, if not resentful, at the restrictions placed on his “freedom” by the rules and regulations that most of us abide as a matter of course as the price of living in an orderly society. He has a fussy distaste for irksome restrictions and may even feel they are directed personally at him, just to be annoying. If he is a candidate, he soon is regarded as a nuisance by the administrative staff of the institute as he requires more than the ordinary prodding to get his reports in and to meet other requirements. He claims to have friends, but has none of long duration, and no “best friend.” The people he refers to as friends, that is, the people he tends to spend time with, mostly are younger than he and look up to him as an authority; indeed, he speaks on almost every topic with authority. They tend to call him; he rarely initiates social contacts
As the analysis continues, the analyst comes to see that elements of neurosis the patient complains of, his mild obsessive symptoms, are not so much troublesome in their own right as that they restrict his “will,” they inhibit him from doing what he wants when he wants to. The analyst gets the impression that the neurotic elements are not grounded in his character; that is, as it were, they do not seem to be of his essence, but rather seem to be superimposed on his personality. They seem to be a confining "veneer" rather than an expression of his narcissistic character structure.
As we know, neurotic symptoms yield more quickly to analysis than do malformations of character and patients tend to experience relief from pain long before they have had a chance to tackle, or before they feel any need to face, the tougher issues that are imbedded in character, that is, in who they are. Let us consider the situation of the typical patient we accept into analysis. We expect of any “suitable” patient that the patient’s initial motivation to be rid of pain soon becomes replaced by more intrinsic motives including curiosity about how the mind works, a regressive dependency based in transference, and a valued, trusting relationship with the analyst. As the constraints of the neurosis loosen, the patient naturally feels better, even “well,” and his life expands. When analyzing has freed him, more or less, of the complaints that brought him to analysis in the first place, he does not rise from the couch and walk away pleased with his “cure.” He has found that psychoanalysis has not only helped him to reach some long held goals, but also to discover goals he previously could not have considered. In the course of becoming relieved of his presenting complaints, the patient discovers a new way of relating to himself and new reasons to be less than satisfied with how he deals with himself, with others and with the world. We might put it that, now that the patient has come to see himself and his situation more clearly, he no longer is willing to remain as he was; he can now envision himself in a new stance and wants to be there. Another way of looking at it is that the patient discovers new possibilities of being, new postures in relation to himself and to the world. I have also sketched here, of course, the history of the attitude of our field toward “cure,” or at least toward the goals of treatment, and the shift from rapid relief of hysterical symptoms to analysis of the ego and character, from relief of pain to personality change.
How is it with our more problematic patients? In contrast, after only a period of analysis sufficient to free them substantially from inhibitions, they see little more need to remain in analysis. Even if they can be prevailed upon to stay on, the motivation for change, of which in retrospect there was little enough to begin with, is now so diminished that little more seems to happen. When a patient expects little good to come of more analyzing, attending sessions becomes a burden. He no longer complains about neurotic flaws and now is now impatient to leave. He would reject the implication of smugness in the suggestion that he feels pleased with himself, and he would resent any implication that he is happy with his state of affairs. His mood is something closer to “grimly satisfied,” a mood that does not carry the implication that he now has found whatever it was he was after, only that he is now freer to search for it and believes he is not likely to find it by searching “inside.” He is only sure that he wants more of something “out there” to make him feel complete and he is increasingly restless to get at it.
He grows more impatient as he becomes convinced that the analyst is holding him back. If he is a candidate, he may feel that his cases bore him; he regards himself already an analyst and does not need to rely on the opinions of supervisors any longer. Supervisors have found him puzzling. The first patient assigned to him left after a few weeks complaining that he was “cold.” Somewhat taken aback by this rejection, he turned on more charm and three of the next four patients remained with him. A couple of his patients seem to be doing all right clinically. He is smart, can listen to his patients when he wants to and can say the right things. He shows little compassion for patient’s pain; mostly he seems to feel they just ought to get on with it. He does not seem to want anything from his supervisors but recognizes that he has to put in his time with them, and does so none too gracefully. Mostly just listens to their suggestions with barely concealed condescension. None feel any positive response, let alone gratitude, from him.
As he waits impatiently to be released from his analysis, he even rejects the idea that it has helped him to make any gains, let alone that the analyst might have had anything to do with them. Although he feels he has nothing to be grateful for, he hopes, pro forma, that his saying so hasn’t hurt the analyst’s feelings or offended him. Yet, as he reflects on his last remark, maybe the analysis has helped him to be more honest; he notices that he now can tell people what he thinks of them without pulling punches. The analyst wonders silently but glumly, “So why doesn’t he just quit? The institute is ‘non-reporting,’ there would be no record made of how he ended his analysis, only that he ended it. What keeps him?” The analyst is concerned that if he would raise the issue in just those terms, the patient might take it as a dare and quit. Thus, the issue that he stays on unwillingly remains in the air. He seems to want something from the analyst, though he does not name it. The analyst finally deduces that he is waiting, and none too patiently, for the analyst to acknowledge him and to accept him on his own terms. He would prefer to leave with the blessing of the analyst, but, after allowing some time for the analyst to come around, he concludes regretfully that this affirmation is not essential. It becomes clearer that, while he “believes in analysis” for others, he regards it as a bothersome requirement for himself. He thought he always had functioned at a level above most people and would not settle for being merely “normal.” Though he is happy enough to be rid of the “few inhibitions” he mentioned at the outset of his analysis, and feels good about having mastered them, as he looks back on it, they were not all that troubling. He does not quite say that he did it alone, but seems ready to challenge the analyst if he claimed that he had some part in it. Unlike the ordinary patient who is inclined to give the analyst too much credit for his progress, so much so that the analyst is tempted to say, “But I couldn’t have done it without you,” our problematic patient is averse to owing anything to anyone. I must hedge this last statement; it is not entirely accurate. It is rather that he prefers not to be in the debt of any extant person.
This patient always was an omnivorous and searching reader. Now, the analyst suspects that he was searching for authorities he could respect but who also were sufficiently defunct as to be in no position to challenge him, as his teachers and supervisors do when his pompous declarations cry out for confrontation. He may anoint himself as a disciple or the intellectual heir, it may not be clear which, of a fairly obscure theorist of a generation back. He quotes this authority liberally with the effect of putting an end to discussions since no one else is familiar with what that authority said or why they should genuflect to him.
Another disclaimer: I should note that some of these problematic patients do not press for immediate release from the analysis once their symptoms are relieved. Their main motive for staying on, however, is less to discover more about themselves than to gain the unqualified approval of the analyst. They want endorsement, not analysis. My impression is that this pattern, which also involves sufficient (transference based) wanting something from the analyst, is more amenable to analysis than the dismissiveness reflected in the pattern of demanding release, even though that too involves transference.
To return to the situation of one of the more difficult of the problematic patients, only after the inhibitions imposed by the neurosis had been relieved did it become clear to the analyst that the symptomatic relief the patient experienced also had some undesirable side effects. The analyst could see now that “the neurosis” had served several socially valuable functions. First, it served to "dampen" the expansionist, even omnivorous, proclivities of the patient’s core narcissistic character. The patient had complied resentfully with the inhibitions that kept him from reaching out and grabbing whatever seemed attractive and worth having at any moment. Additionally, his obsessive uncertainty, “Is that really what I want?” held him back. Second, the neurosis, through its connections to objects in fantasy, seemed also to provide indirect connection to objects in reality. To be sure, as these connections were based on fleeting, unstable transferences, they made for distorted, disappointing and short-lived connections. Nonetheless, these temporary connections were "real" and they involved him with the hurt feelings, disappointments and anger of others whom he mistreated; thus they served to remind the patient painfully of his own humanity. They forced on him some awareness that all of us share a common fate and, fitfully, they permitted (or forced) a degree of empathy with others. These painful reminders were not welcome and he resisted learning anything about himself from them. Rather, feeling wounded by the recriminations, he resolved for instance, not to get involved with “one of that type” again. As he generally was able to blame the failure of a relationship on some shortcoming of the other, he could hide from himself his own part in the difficulties.