Eire y Golberg - Sobre Analizabilidad Tomado Del PEP

(1984).
Journal of the American Psychoanalytic Association, 32:715-737

Observations on Assessment of Analyzability by Experienced Analysts
Joan B. Erle, M.D. and Daniel A. Goldberg, M.D.
THE FIRST ISSUE IN EVERY ANALYSIS IS the decision by the analyst to recommend
analysis to the patient. The process of making that decision and the evaluation of the
subsequent treatment have not been systematically studied in relation to cases selected and
analyzed by experienced analysts in their own practices. This is a report of a pilot study of 160
such cases.
In a review and discussion of the problems in the assessment of analyzability (Erle and
Goldberg, 1979), we noted: (a) a lack of consistency in the definition of terms; (b) difficulty
developing and validating criteria for patient selection; (c) the assumption that prediction of
analyzability is, or might be, reliably made at the outset of treatment; (d) failure to differentiate
between analyzability and therapeutic benefit; (e) the need for a prospective study which would
assess all phases of an analysis: selection, prediction, analytic process, and outcome.
The unsatisfactory definition of terms is a basic problem. To the extent that terms are
employed differently, investigators may be reporting different types of patients, processes, or
treatments. We noted that in studies of psychoanalysis the treatment
Presented at the Fall Meeting of the American Psychoanalytic Association, New York,
December, 1982.
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is often so vaguely defined that it is impossible to ascertain precisely what treatment process
developed.
Criteria for patient selection, often reported in one study or another as explicit or apparently
definable, prove not to be so precise. Either there is little inter-rater agreement on the meaning
of raw data or assessment criteria, or impressionistic judgments prove just as reliable in
experienced hands even though the basis for the judgments is not explicated.
At initial consultation, the assessment of analyzability is limited by the data available. The
fullest assessment of a patient's analyzability can be made only after continuing evaluation of
the patient and the treatment process throughout the entire course to termination (Erle, 1979).
The lack of differentiation between analyzability and therapeutic benefit gives rise to a
common, circular argument that improvement in the patient indicates the successand
presenceof an analytic process, blurring the fact that benefit may well result from a treatment
that is not technically analysis.
Following this research we considered the possibility of a prospective study which would
take these problems into account. We decided a preliminary investigation was required to better
identify significant data and meaningful criteria. It seemed possible to do this in a retrospective
study which could be completed in a briefer period. We also saw an advantage in investigating
what experienced analysts regarded as useful and significant in assessing analyzability . To this
end, we asked a group of colleagues how they had reached the decision to recommend
analysis in their own analytic cases. Rather than limit the discussion to the nature of the
presenting picture in the patientthe approach that has generally been reported in the literature
the object of the study was to see how the analysts thought they actually made the decision.
How much emphasis did they put on various factors? What did they consider significant, and
why? Since the recommendation reflected a prediction that the patient was suitable, we were
also interested in the analyst's view of the further course of that treatment. Had
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the prediction been correct? How did the analyst reach that judgment? What were the criteria for
a successful analysis or for therapeutic benefit?
We wanted to see whether these data would provide more satisfactory understanding than
has been available of what is useful in studying assessment of analyzability . If such methods
could be developed they could then be further tested and refined in a prospective study. The
selection of private cases would minimize or eliminate some problems of treatment center
studiese.g., atypical selection of cases, a different patient population, inexperienced analysts,
incomplete data and supervision.
Thus, while the work would have the familiar limitations of a retrospective study, it would
provide experience with two essential elements of a prospective study: (1) development of a
group of participants who are experienced graduate analysts and (2) the collection and
utilization of data on a group of private analytic patients. Equally important, we would begin to
study systematically how analysts make their initial assessment and how they make further
evaluations throughout the treatment. We might underscore in this connection that all of the
judgments about analyzability and therapeutic benefit are made by the treating analyst. Further
studies would require examination of the data by other judges. Similarly, a refinement of method
might provide for data obtained through other forms of presentation as well as a questionnaire.
Method
The analysts to whom the study proposal was sent had predominantly analytic practices;
many had expressed a prior interest in questions of assessment. All were more than five years
past graduation; a number of senior analysts were included. Of the 33 analysts invited, six
declined to participate for various reasons. These included concern about intrusion on the
analytic work, confidentiality, pressure of other commitments, and
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doubt about the usefulness of such work. Twenty-seven initially indicated their interest; 16
completed the forms and became participants in the study.
A five-year period was to be covered. All cases in ongoing analysis January 1, 1973, and
additional cases started in analysis between that date and December 31, 1977, were to be
reported. Analyses undertaken in an atypical fashion (candidates, supervised cases, lengthy
Treatment Center cases) were to be noted but not included in the detailed responses to the
study. Analysts were also free to exclude any other case if they chose to do so (e.g., for reasons
of confidentiality); they were requested to indicate this and explain the reason.
To ensure confidentiality each analyst was assigned a number; the key was known only to
an administrative secretary who handled distribution and collection of the reports. In addition to
the report on each patient, the analyst was asked for general observations on this manner of
profiling patients and on his overall approach to assessment of analyzability . Two years after
collection of the original reports, a follow-up was obtained on each case continuing at the time of
the first report.
The questionnaire was designed to be specific enough to yield information in the
areas described, but loosely structured enough to permit the analyst to use and
describe his own style of decision-making and expression. That is, we wished to
foster individualized reporting that would, at the same time, produce information
falling roughly into the areas of our interest. The protocol was outlined on a single
sheet (with instructions to use additional sheets as necessary) for each case as
follows:
Demographic: Patient's age, sex, marital status, occupation.
Treatment Date treatment began, frequency and length of sessions, duration of treatment
facts: (date ended, or continuing).
Analyst's
Initial treatment recommendation, basis for decision to attempt analysis.
evaluation:
Description (characteristics, variations, modifications) data emerging relevant

to further assessment of analyzability ; analyzable/analytic process
Treatment:
established? (what criteria used in making these judgments?); therapeutic
benefit: type and extent.
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In an effort to clarify the use of terms we asked each participant to indicate what data were
relevant to a specific criterion. First we wished to understand the basis for the analyst's decision
to attempt an analysis: what criteria were important to him and how they were evaluated. The
other sections of the protocol were also structured to permit the broadest freedom of response
within the outlines. Since analysts may vary in their definition of analysis or the criteria for
evaluating the treatment process, the questions were designed to yield information defining
each analyst's view. Even though it was retrospective, the description of the assessment and
treatment was considered likely to be a reliable indicator of how a given analyst thought about a
particular case.
Findings
Source of Data
The 16 analysts reported 160 cases seen in analysis during the five years specified. Thirty-
seven additional cases had been seen in analysis but not reported (14 candidates, 11 Treatment
Center cases, 6 child or adolescent cases, 5 for reasons of confidentiality, 1 research recorded
analysis). The number of cases seen by individual analysts ranged from 3 to 15; the average
was 10. There was considerable variation between individual practices.
Demographic Data
The age of patients in this study ranged from 20 to 54 years39% male, 61% female. Fifty-
four percent of the women were single, 35% married, 9% divorced, 2% widowed. Forty-three
percent of the men were single, 41% married, 10% divorced,
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6% separated. Twelve percent of the patients had had previous analysis, and 20% had been in
psychotherapy.
In terms of occupation, the largest groups were physicians, 18% (11% psychiatrists, 7% in
other specialties) and students, 16%, including 3 medical students. Eleven percent of patients
were in business; 7.5%, educators; 7%, housewives; 7%, lawyers; 7%, writers and editors; 6%,
social workers; 6%, performing arts; 5%, psychologists; 3%, allied health professionals. The
remainder worked in other areas.
All analysts reported all sessions to be 50 minutes in length. Thirty-eight percent of patients
were seen five times weekly; 62%, four times weekly. An additional 19 cases reported by four
analysts were seen three times a week and were excluded on the following grounds: (a) other
participating analysts excluded patients seen three times weekly; (b) while controversial, a
frequency of three times weekly is generally considered to foster a less intensive process, less
likely to develop into a typical analytic process than a treatment of greater session frequency;
and (c) this group of cases was atypical on other grounds as well. For example, there were no
completed, analyzable cases reported. In many there were long periods of variable or
decreased frequency and limitations imposed by time and financial problems rather than clinical
indications.
Sixty-one percent of the patients completed their treatment by the end of the study. They
had been in treatment up to 12 years. Twelve and a half percent of the entire group left within
two years of beginning; 46% of patients were in treatment more than five years.
Review of Analysts' Evaluations

In the analysts' narrative description of their evaluations prior to the recommendation for
analysis, the patients' presenting complaints were usually noted as well as the analyst's
observation of specific symptoms. These included phobias, obsessions, anxiety attacks, sexual
difficulties, eating disorders, inhibitions,
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affect disturbances. Problems in relationships, work and school difficulties were usually
described as repetitive and persistent. All analysts commented on aspects of personality
structure such as ego function, level and nature of conflict, evidence of unconscious conflict. All
were attentive to motivation, capacity for self-awareness, intelligence. If those attributes were in
doubt, the prediction was pessimistic and the attempt to analyze would be explained in terms of
other pressing considerations, e.g., extent of suffering, long-standing and widespread pathology,
the possibility that motivation would be more adequate as work proceeded, the difficulty in
evaluating that patient.
Most patients were described as having long-standing difficulties in a number of areas.
Certain problems were infrequent: hypochondriasis, excessive drug and alcohol use,
perversions, psychotic episodes, suicide attempts, although there were instances of each of
these. Despite the presence of those factors the analyst made the recommendation either
because the patient had substantial assets which indicated the capacity to do analytic work
and/or only an analytic approach seemed to have the chance to succeed.
Three historical factors were frequently viewed as significant. Substantial pathology in
parents or other close relatives and a life history of sustained or frequent trauma were often
related to a guarded prognosis. The third factor, the nature of the patient's previous experience
in treatment, was viewed as a positive factor if the previous treatment was useful. Several
analysts described their caution if the previous treatment was unsuccessful, although an attempt
at analysis was thought worthwhile. A very long history of previous treatment was also viewed
with concern.
The approaches reported showed several patterns. A number of analysts made a
systematic appraisal of various psychological elements including symptoms, history, diagnosis,
evaluation of specific ego functions, often underscoring some important elements of
motivation.1 Others commented only on
1 It was not possible to tell whether this was done in response to the request on the form to
describe the basis for the recommendation or whether such an inventory was a routine,
conscious part of their deliberation and records at the time of any consultation.
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factors especially favorable or unfavorable for analysis, such as tolerance of frustration or

marked impulsivity. Types of defenses, affect, object relations, capacity to tolerate anxiety were
often mentioned. Some specifically noted an "absence of contraindications" in difficult cases
e.g., "no evidence of psychosis." Clinical data were not always provided to clarify how the
analyst's judgment of a particular factor was made. Even when that seemed clear, the accuracy
of the evaluation was only apparent with the knowledge of the subsequent treatment. Other
factors occasionally mentioned were related to the analyst's own interest. These included an
interest in a specific type of problem, the inclination to accept the evaluation of the referring
analyst (sometimes at variance with the analyst's own impression), a frank admission of
concern to fill time available which may have influenced the decision in a particular case.
Viewed from another perspective, the analysts seemed to regard patients either as those for
whom analysis was the specifically appropriate treatment (as one put it "made for analysis") or
those whose problems were difficult and could not be effectively approached by a less intensive
treatment, but whose capacity to participate in an analysis was less clear. For some of the latter,
analysis was attempted as a "heroic" measure.
Cases Begun in Psychotherapy

In 19 cases subsequently analyzed the initial treatment recommendation was
psychotherapy. These decisions fell in several categories. The largest group (11) consisted of
cases with a question, or observation, of severe pathology which would limit the tolerance of
regression in analysis, e.g., "quasi delusional ideas"; question of a "psychotic core"; "primitive"
or "fragile" defenses; severe depression; grandiose, paranoid rage in a previous treatment;
marked acting out; severe physical problems such as regional ileitis, physical deformity
connected with marked early trauma. Each of these was evaluated in relation to other aspects
of the patient's functioning; none was viewed
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as sufficient indication or contraindication in itself. Two patients had first consulted the analyst in
an acute situation after death or life-threatening illness of a spouse; subsequently, further
problems emerged.
The eventual recommendation for analysis was related to some symptomatic improvement,
a better understanding of the patient which made the pathology less ominous, or the emergence
of sufficient resources to suggest the patient could undertake an analysis which seemed
indicated as the specific treatment of choice. These resources included capacity to tolerate
frustration, to develop trust, self-observation, perseverance, and decreased anxiety or lifting of
depression.
The change to analytic treatment occurred after one month to two years of psychotherapy.
Several analysts specified that the psychotherapy had been conducted in a nonintrusive manner
which would not preclude a subsequent analysis. Except for two references to a more
responsive or "active" stance during the psychotherapy, there was no discussion of the impact
of the earlier psychotherapy or any reference to its emergence as an issue in the analysis.2
Compared to other cases of the same analyst, these patients seemed to be viewed as more
likely to disorganize or flee an analysis, more limited in their capacity for self-observation and
tolerance of frustration, or particularly difficult to evaluate. Serious concern about suicidal
impulses and severe depression was rarely mentioned, perhaps because such patients are not
generally taken into analysis.
Treatment Data
Regarding the course of treatment of each patient, responses were, as expected, quite
varied in style and detail. The authors classified the analysts' descriptions into broad categories
to allow identification of certain trends and problems: (1) analyzability ;
2 This may have been related to the omission of such a question on the form.
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(2) emergence of data altering initial assessment; (3) therapeutic benefit; (4) comparisons of
predictions with outcome.
Analyzability (see Table 1). Descriptions of the treatment and analytic process centered on
the transference. Usually work with resistance, defense, and interpretation were mentioned. It
was not clear in certain cases whether the analyst viewed certain phenomena as a
"transference neurosis" or "transference manifestations." Common, but not invariable, additional
factors listed included free association, therapeutic alliance, a distinction between the
development of and the analysis of transference, and a view of the treatment as a progressive
process yielding deepening material over time (dreams, fantasies, memories, reconstructions,
awareness of unconscious conflict).
Cases were classified as analyzableanalyzed successfully, unmodified technique and
incompletely analyzedsubdivided into either modified or limited. A treatment was considered
modified if the analyst reported a change in technique considered necessary in working with this
patient. For example, one case was "modified in the fourth year when patient began to make
suicidal gestures, one serious. Considered necessary to make confrontation to prohibit use of
nitrous oxide." On occasion quite subtle technical approaches were reported as modifications of
the analyst's usual technique. For example, "Because of severe anxiety these defenses were
handled gingerly. Interpretations made, but sparsely and gently."
Figure 1
Figure 1TABLE 1 RATING OF ANALYZABILITY
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In a limited analytic result, no change in technique was reported. Some of these analyses
reached a stalemate or met stubborn resistance that would not yield. An illustration of cases
given this rating includes:
Analytic process established with significant development and elucidation of
resistances, defenses, and certain aspects of transference. Insurmountable resistance
to further development in transference of conflicts related to wishes for closeness to
mother and consequent anxiety over castration remained at termination. I viewed this
as substantial limitation of the analysis.
Sometimes this distinction between modified and limited was neither feasible nor useful, as
with a writer of whom "it was impossible to avoid reading some of what he wrote." From the way
this was reported, the patient's intolerance of the analytic situation seemed accompanied by
some (whether unwitting or intended) movement of the analyst away from the neutral analytic
stance.
The final category indicated patients deemed unanalyzable. For the terminated patients, a
subcategory was added for those cases leaving treatment prematurely for apparently external
reasons. These patients were of course not analyzed, and no definite determination of
analyzability could be made. For the continuing cases, unanalyzable means the treatment was
reported as having been changed to psychotherapy at some point.
The number of cases falling into each category appears in Table 1. The high proportion of
unanalyzable cases in the terminated group, as compared to those continuing in treatment,
reflects the inclusion of all 40 cases leaving treatment in less than three years. If the entire
group were followed to termination, it seems likely that the overall percentage for the category of
analyzable would be substantially higher and unanalyzable substantially lower than for cases
terminated to date.
Emergence of data altering original assessment. Since every patient is better understood
and assessedas a treatment progresses,
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only those cases where the analyst reported a major revision of assessment are noted. Most
often these revisions were in the direction of negative reassessment (15% of cases), i.e., the
patient was found to be less analyzable than originally thought. For example, in one case, "Very
strong and persistent self-esteem and narcissistic problems emerged which I had not
anticipated," a factor limiting the analytic result. Or, in another case, "Patient had failed to tell
first analyst about sexual symptoms that he half hid from himself as well. Had I known about
them in advance, I would never have begun an analysis."
In three cases, however, developments led to positive reassessment of analyzability . In
one, for example, "It became evident that her disastrous first analysis, which made me worry
about the outcome of this one, could itself be understood as a reliving of traumatic early events,
and once that was understood and assimilated she could make analytic progress."
Therapeutic benefit. Emphasis in the reports was typically on changes in functioning,
symptoms, defenses, object relations, self-esteem, and character traits. A shift might be listed
simply as a change or detailed in various ways, such as "softening of defenses," "greater
flexibility of ego functioning," capacity for "affection" or "object-related pleasure," "increased
mastery," "wider range of sublimation," "increased self-understanding" or "awareness of
conflict." The meaning of a change depended on the specific patient; for example, one patient's
marriage stabilized as a benefit of treatment, while another's divorce was viewed as a positive
therapeutic result. Overall, there seemed to be a conservative appraisal of therapeutic benefit,
commonly with a distinction between areas of benefit and those of no change, occasionally with
a statement of the difference between the patient's and the analyst's views of the results.
From the protocols, we developed four relatively broad categories: Aconsiderable,
substantial, excellent (29%); Bmoderate, good (36%); Cminimal (26%); Dno significant
benefit (9%).
The categories might reflect different types or degrees of change in different patients,
comparable only to the previous
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level of functioning for the given patient rated. For example, in category A, the analyst described
a patient whose "defensive organization became less rigid. Sexual inhibitionpremature
ejaculation and occasional impotencecleared. Deepening of object relationship to latency-age
children."
As expected, analyzability and therapeutic benefit ratings were not identical. Among the
completed cases (therapeutic benefit is still liable to change in continuing cases) the
discrepancy between analyzability and therapeutic benefit was more in one direction than the
other: no case where the analysis was successful rated less than moderate benefit, but 16
cases rated unanalyzable received A or B benefit ratings (see Table 2). All of the 15 cases
receiving D ratings were unanalyzable. Of the terminated cases in treatment more than three
years, 76% were rated good to excellent benefit.
Comparisons of predictions with outcome. Each protocol was rated for any predictions
made at the start of treatment (P) and for the outcome of treatment (O). The purpose of this
comparisonrecognizing that the predictions were made both retrospectively and informally,
and also that the treating analyst made both prediction and outcome reportswas to obtain an
idea of how cases turned out compared to what the analyst expected ("predicted"). Two types of
cases seemed of particular
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interest: those where an accurate prediction seemed possible and those where there was great
disparity between the expectation and the outcome.
TABLE 2
GOOD TO EXCELLENT BENEFIT (A,B) ACCORDING TO DURATION OF TREATMENT
Duration (years) of treatment No. Cases Good to excellent benefit
0-2 20 20%
2-3 20 40%
3-4 22 59%
4-5 25 80%
5-6 29 79%
6-7 19 74%
7-8 7 100%
>8 18 83%
_____ _____ _____
Total 160 65%
These rating categories corresponded approximately to the categories of analyzability ,

with certain exceptions:
Prediction: 1. analyzable (successful unmodified analysis).
2. analyzable with difficulty.
3. substantial question.
4. initial recommendation psychotherapy.
Outcome: 1. analyzable.
2. analyzable with difficulty (includes modified or limited ratings of analyzability ).
3. unanalyzable.
Table 3 shows the prediction/outcome comparison of both terminated and continuing cases.
The outcome seemed substantially at variance with the prediction about 25% of the time in
the cases begun in analysis: 25% of those thought analyzable were unanalyzable; 26% of
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those where difficult analyses were predicted did not prove "difficult" to date, although in 31%
the difficulties were insurmountable and patients were rated unanalyzable; 25% of those where
there was substantial question were analyzable. These findings are of interest but the
significance of such comparisons of prediction and outcome would be better judged in a
prospective study with all cases followed to termination.
TABLE 3
OUTCOME
PREDICTION Analyzable Modified or Limited Unanalyzable
Analyzable (59 cases) 55% 20% 25%
Analyzable with Difficulty (35 cases) 26% 43% 31%
Substantial Question (48 cases) 25% 31% 44%
Initial Recommendation Therapy (19 cases) 37% 26% 37%
Follow-up Data
Brief follow-up of cases incomplete at the end of the original five-year period was obtained
during 1981-1982. Of the 160 cases, 62 were ongoing in the original reports. At follow-up, 61%
were still ongoing, with no change in ratings of analyzability ; 8% were still ongoing, with a
change in rating (toward diminished analyzability ); 27% were terminated, with a rating parallel
to that given originally; 1 was terminated incomplete (the patient left the city); 1 was ongoing at
follow-up, but the frequency of sessions was decreased to three times per week.
Discussion
This project was planned to study how graduate analysts view and report their work: the
decision to recommend analysis, the subsequent course of the patient's treatment, the analyst's
judgment of whether the patient was analyzed and of the therapeutic benefit. Although we
acquired data on the work of a number of analysts and on a large number of analytic patients,
we are mindful of the limited conclusions warranted by such a retrospective and deliberately
informal inquiry.
Keeping that in mind some discussion of this group of patients seems useful. As contrasted
with most other studies (such as those using students), the analyst had responsibility for the
evaluation and recommendation.3 Likewise, previous studies
3 We did not ask how often consultations resulted in other recommendations. The authors
reviewed their own consultations during the same period of time; 174 patients were seen.
Analysis was unequivocally recommended for 25; further evaluation, possibly for analysis, for
11; psychotherapy for 86; no further treatment at that time for 52. Informal discussion with
several colleagues confirmed that general experience.
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have shown a wide variation between patient populations in terms of age, marital status,
occupation, selection, duration of treatment, analyzability and therapeutic benefit. The methods
of study have been so diverse that valid comparisons are difficult (Appelbaum, 1977); (Erle,
1979); (Kernberg et al., 1972); (Klein, 1960); (Knapp et al., 1960); (Sashin, 1975); (Weber et
al., 1974). In this study the private patients differ from the Treatment Center cases reported by
Erle (1979). This group is older, with a larger proportion of male patients and married patients,
and a different occupational distribution; the patients remain in treatment longer, and are more
often judged analyzable. The proportion of cases thought to have derived therapeutic benefit is
the same in the two series. (A smaller group of private cases was briefly surveyed in connection
with the Treatment Center Study, and showed distribution and treatment characteristics similar
to the present study.)
Patients reported by the Survey Committee of the American Psychoanalytic Association (D.
Shapiro et al., 1980, unpublished) were selected and reported in a different manner. In that
group 56% of analytic patients were male (39% in this study); two thirds belonged to the
"highest status" occupational groups (48% here); 17% were seen less than four times per week.
The difficulty in assessing the use of major modifications was noted by the Committee. Duration
of treatment was based on length of treatment to the reporting date plus estimate of time
remaining until termination. Outcome and therapeutic benefit were not discussed. Variations
described by the Committee were regarded as reflections of the original training, institute,
experience, and type of membership in the American Psychoanalytic Association, so that
comparisons with the present report may be of limited value.
The findings in this study concerning analyzability and therapeutic benefit confirmed the
previous observation (Erle, 1979) that the entire course of the treatment must be reviewed
before judging the analyzability of the patient. Cases that seemed accessible for some time
developed limitations, required
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modifications, or were terminated. Some difficult or uncertain cases were reevaluated after
further understanding; work with specific resistances sometimes greatly facilitated the progress
of the analysis leading to a better outcome than had been anticipated. Therapeutic benefit was
not solely related to analyzability : of the terminated patients who were not analyzable, 39%
were thought to have good to excellent therapeutic benefit.
These data should be viewed in the context of the nature of these reports and the frame of
reference of the analyst. The analysts have a common background and training, and articulate
the conviction that psychoanalysis provides the most thorough understanding of the
psychological forces involved in conflict, an understanding they regard as essential to significant
change in suitable patients. The study protocols reflect consistency in the process of
assessment: the analysts note substantial indications of difficulty and evaluate the patient's
capacity to sustain the rigors of analytic treatment.
In the initial assessment, the analysts were aware of the limitations of the data available,
and accustomed to the uncertainty inherent in the evaluation at the time. Prognosis or prediction
might be offered, but was usually expressed in terms of the reasonableness of the immediate
recommendation. There seemed to be what we termed a habit of "automatic inventory"i.e.,
the analyst seemed to assess automatically a number of factors without specific articulation, at
least in these reports. When some aspect seemed to fall outside an unremarkable range
restriction of affect, for exampleit would receive conscious scrutiny and evaluation. Absence
of comment did not necessarily mean that a particular area of function had been ignored; rather
it seemed unremarkable at the time of recommendation.
In some cases the recommendation for analysis seemed to reflect an overall judgment
about the patient that led to the decision despite specific aspects of history or present
functioning which raised substantial questions. The whole, as it were, seemed more than the
sum of its parts. Thus, certain qualities
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in these patientsan urgent wish to understand themselves, the capacity to tolerate suffering
without excessive masochistic gratification, perseverence, gratification through mastery, the
capacity to tolerate uncertaintymight offset such negative factors as marked early trauma,
characterological rigidity, recurrent depression. Many of these qualities might be regarded as
aspects of motivation of particular importance in difficult cases; none of these factors was
limited to such cases. Such judgments, too, seemed connected to the analyst's impression that
he could "understand" the patient or was interested in working with a particular patient. This
factor is difficult to describe and may partly reflect a rapport that is related to the nature of the
patient's object relations. Some of those patients, of course, did not turn out to be analyzable.
These are complex issues, hard to define, and require further study and clarification.
One major dimension of the complexity of the individual judgments involved is the analyst's
frame of reference. For example, some respondents described some analyses as "difficult."
Other cases, which appeared comparable, were not so designated. Might this distinction mean
only that some analyses are characterized by more tenacious resistances than others, and that
some analysts consider this unremarkable and expectable? Or, where an analyst saw a
relatively large number of unanalyzable cases, was this because of interest in certain kinds of
cases, the nature of referrals, less adequate assessment, different criteria? Although there was
some evidence suggestive of each of those factors, the study did not permit adequate judgment.
The frame of reference also pertained to assessment of therapeutic benefit. Changes such
as clearing of symptoms, lifting of repression and amnesia, reconstructions, alterations in affect
and defense, are relatively straightforward. Far more variable are judgments of the extent of
change which is feasible, or the impact of unanalyzed or unresolved conflicts or character traits.
Analysts whose criteria included more extensive change would be less satisfied with the
outcome. Similarly, a judgment
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of "better" or "worse" involves comparison to a standard. Some used both criteria related to the
patient's pre-treatment situation and absolute measures of mental functioning. On the whole,
this group of analysts seemed quite conservative in reporting the outcome of treatment.
The problems associated with using the reports of the treating analyst, particularly
subjectivity and retrospective distortion, should be emphasized. However, it seems that the
analysts were consistent in applying their own criteria for analyzability . Although all of these
cases were thought to be suitable for initiating an analysis, the analysts themselves regarded
46% of the terminated cases as unanalyzable and 28% as modified or limited. The treatment
process had not fulfilled their requirements for classification as a successful analysis. Those
judgments, of course, can be subject to the same questions of objectivity of the analyst-rater,
but they seem to demonstrate the capacity to maintain an observing position.
The most difficult area in which the analyst's frame of reference was central was the nature
and technique of the treatment process. How was the treatment conducted and how was it
rated? Was it a "completed" analysis, a "limited" analysis, a "modified" analysis, an
"unsuccessful" analysis, a psychotherapy? Did these analysts have a particular model of an
analytic treatment? Often when cases are presented the question is asked, "Was the patient
analyzed?" as if there is some ideal model.
In discussions of analytic technique it is almost a truism that no two analysts would conduct
precisely the same analysis with any given patient. Timing, wording, and focus of interventions
all vary according to individual judgment. It is also widely agreed that such precision is not
essentiali.e., that the patient's conflicts can be manifest and worked with through a number of
different connections. In this investigation the participants were asked to describe which
elements were considered in defining the presence or absence of an analytic process. Regularly
recurring elements seemed crucial: in a treatment
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judged to be an analysis, the patient's conflicts appeared in the "transference neurosis" or

"transference"; all seemed to refer to the preeminence of understanding derived from the
analysis of the patient's relationship to the analyst, the development and understanding of his
fantasies, thoughts, fears, and wishes in relation to the analyst. The unfolding and exploration of
the transference neurosis allowed increasing understanding of conflict leading to change. Some
common aspects of technique were noted: use of the couch, frequency and length of visits, free
association, the emergence of material through analysis of resistance, defense, dreams,
fantasies, and reconstruction of forgotten experiences. Familiar as such elements are, we note
them as reflections of these analysts' model of an analysis.
The most pertinent questions concerned what the analysts viewed as variations consistent
with an analytic treatment as compared to modifications that restricted the analytic exploration.
It is relevant in this connection that the analysts consistently seemed to keep in mind the
question of whether the treatment was suitable for the patient. Where the patient seemed
unable to tolerate the abstinence or regression of the analytic method, manifested an
unalterable tendency to impulsivity or acting out, became severely depressed, paranoid, or
disorganized, it seemed that the appropriate alteration in the treatment was made and continued
as necessary.
Are there some technical variations these analysts felt were incompatible by definition with
the analytic situation? For example, there was one patient who was never able to use the
couch, several patients who did not use the couch for short periods of time, and a few cases
where an unusual intervention was required to deal with serious suicidal risk or imminent
psychotic decompensation. On the whole such an external, formal judgment did not seem
satisfactory; when evaluating the effect of an intervention or technical change, the issue was
whether the intervention limited development or exploration of the transference neurosis. The
same criterionfailure to explore or resolve an issue in the transferenceseemed applicable
- 734 -
in describing other limitations, e.g., the patient's unwillingness to deal with a particular situation,
symptom, or conflict. However, it is difficult to ascertain whether those criteria are measured in
the same way by different analysts. The significant questions about modifications consistent
with an analytic process cannot be pursued further with the data available here. Some of the
participants were clearly very conservative about modifications, while others focused more on
the clinical indications and less on the question of possible alteration of the treatment process.
In their observations about reporting their work, the participant analysts emphasized the
problems of criteria and clearly defined terms, retrospective distortion, and the subtlety and
complexity of some judgments. There was a general consensus about the need to have access
to very detailed reports over some period of time for purposes of clarifying such issues as the
presence or absence of an analytic process or the development and analysis of the
transference neurosis. In addition, the authors were aware of some cases where, as might be
expected, our understanding of the data suggested a conclusion at variance with that reached
by the analyst. Except for our exclusion of cases seen less than four times per week, such
differences are not reflected in the report. The extent to which different views reflect differences
in theoretical concepts of analysis could not be evaluated in this study.
While clarity of terminology, usage, and criteria is urgently required, it can be reached only
through slow, careful work on the intricate issues and functions involved in understanding both
the patient and the analyst in the treatment situation. Simpler, formal schemata have been
developed for assessing analyzability (Bellak and Meyers, 1975); (Greenspan and Cullander,
1973); (Schlessinger and Robbins, 1974). They seem unsatisfactory to us, at least in part,
because consistent use by raters is not demonstrated (see also Sashin et al., 1975). Such
concepts may actually be used in an individual and variable frame of reference. Likewise,
attempts to identify the characteristics of
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analyzable patients, including multiple or complex factors derived from certain theoretical
constructssuch as "ego strength" (Appelbaum, 1977)also seem inadequate. Such
schemata are difficult to define in terms of specific criteria, and moreover do not satisfactorily
represent such intricate psychic phenomena as motivation and the capacity to work in an
analysis.
SUMMARY
Some specific approaches to the study of analyzability have been identified in this study as
productive and feasible. First, it was possible to enlist a group of experienced analysts as a
source of clinical materialthe data and their own evaluations. Second, the assessment of
analyzability can only be made at the end of the treatment. Third, the classification of
analysands as either "analyzable" or "unanalyzable" warrants further differentiation. Cases of
patients who develop an analytic process may have variable outcomes: some conclude
successfully with no modification in technique; some conclude with significant limitations in the
analytic resolution; others require an appropriate modification in technique at some point. Cases
of unanalyzable patients also have a variable outcome: some develop no useful treatment
situation; in others the patient's unsuitability for analysis is manifest very early and a change to
the appropriate psychotherapy is made.
The study of how analysts make their evaluations and the subsequent course of those
treatments seems useful in providing information on our work as psychoanalysts pertinent to
practice, teaching, and research. Our experience suggests that a prospective study would be
advantageous: data reported at the time of assessment could be more complete and less
subject to retrospective distortion; definitions and criteria could be established in advance;
important questions could be more clearly defined and explored as the material develops (by
co-investigators as well as the analyst). This might include significant differences between
analysts, the identification and impact of
- 736 -
modifications, and the study of cases started in psychotherapy and subsequently seen in
analysis.
REFERENCES
APPELBAUM, S. A. 1977 The Anatomy of Change. A Menninger Foundation Report on Testing
the Effects of Psychotherapy New York: Plenum.
BELLAK, L. & MEYERS, B. 1975 Ego function assessment and analyzability Int. J. Psychoanal..
2:413-427 []
ERLE, J. B. 1979 An approach to the study of analyzability and analyses: the course of forty
consecutive cases selected for supervised analysis Psychoanal. Q. 48:198-228 []
ERLE, J. B. & GOLDBERG, D. A. 1979 Problems in the assessment of analyzability
Psychoanal. Q. 48:48-84 []
GREENSPAN, S. I. & CULLANDER, C. C. H. 1973 A systematic metapsychological assessment
of personalityits application to the problem of analyzability J. Am. Psychoanal. Assoc.
21:303-327 []
KERNBERG, O. F.; BURSTEIN, E. D.; COYNE, L.; APPELBAUM, A.; HORWITZ, L. & VOTH, H.
1972 Psychotherapy and psychoanalysis: final report of the Menninger Foundation's
psychotherapy research project Bull. Menninger Clin. 36 1 & 2
KLEIN, H. R. 1960 A study of changes occurring in patients during and after psychoanalytic
treatment In Current Approaches to Psychoanalysis ed. P. H. Hoch & J. Zubin. New York:
Grune & Stratton.
KNAPP, P. H.; LEVIN, S.; McCARTER, R. H.; WERMER, H. & ZETZEL, E. 1960 Suitability for
psychoanalysis: a review of one hundred supervised analytic cases Psychoanal. Q. 29:459-
477 []
SASHIN, J. L.; ELDRED, S. H. & VAN AMERONGEN, S. T. 1975 A search for predictive factors
in institute supervised cases: a retrospective study of 183 cases from 1959-1966 at the
Boston Psychoanalytic Society and Institute Int. J. Psychoanal. 56:343-359 []
SCHLESSINGER, N. & ROBBINS, F. 1974 Assessment and follow-up in psychoanalysis J. Am.
Psychoanal. Assoc. 22:542-567 []
WEBER, J. J.; BRADLOW, P. A.; MOSS, L. M. & ELINSON, J. 1974 Predictions of outcome in
psychoanalysis and analytic psychotherapy Psychiat. Q. 48:117-149
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Article Citation [Who Cited This?]

Erle, J.B. and Goldberg, D.A. (1984). Observations on Assessment of Analyzability by
Experienced Analysts. J. Amer. Psychoanal. Assn., 32:715-737
1979). Psychoanalytic Quarterly, 48:48-84
Problems in the Assessment of Analyzability
Joan B. Erle, M.D. and Daniel A. Goldberg, M.D.
ABSTRACT
As additional studies of assessment of analyzability have been reported, research has proven
very difficult and provided little clarification. This paper reviews the literature, particularly of the
last twenty-five years, from the viewpoint of identifying the nature of the problems in developing
useful methods of study. Some approaches to these problems, which might provide increased
understanding as well as a clearer definition of some inherent limitations, are discussed.
Analysts have been concerned with evaluating the appropriate use of psychoanalysis since
Freud first began to publish his findings. Freud (1904) early described some of the conditions
under which this method would be indicated. It would be suitable for a neurotic patient not
accessible to less demanding forms of treatment: a reasonably educated person of reliable
character, possessing a normal mental condition (nonpsychotic), sufficiently young to be
educable and flexible, and free of any dangerous symptoms that would require speedy removal.
What seemed relatively straightforward at first became increasingly complicated. Different
types of patients were to be considered, successes and failures explained, variations in
technique retained or discarded. Increasing theoretical advances led to further clinical
explorations which in turn provided other hypotheses in a sequence that has often been
described in the literature. The "widening scope" (Stone, 1954) has spread still further, and the
discussion of indications, suitability, assessment, and outcome has continued. Definitions and
criteria have become more difficult to articulate clearly enough so that observations could be
compared.
Issues related to the choice of candidates for psychoanalytic training and the selection of
patients as supervised cases for students have also come up in this connection. Most recently,
- 48 -
issues of assessment have emerged as a major methodological question whenever peer review
or insurance coverage of analytic treatment is discussed.
During the past twenty years the emphasis on assessment of analyzability has been
reflected in the publication of an increasing number of studies and discussions. In ordinary
clinical experience the analyst is likely to evaluate a patient as 1) a good analytic prospect; 2)
one for whom analysis is not indicated; or 3) one about whom there is some degree of
uncertainty. Analysts are accustomed to regarding the initial judgment as tentative, although
training and experience provide a degree of confidence that analysis is the appropriate
treatment to recommend. When research or teaching is the focus, however, such judgments
must be made explicit and evaluated in a different manner. This has proven difficult, and efforts
to do systematic research on the selection of patients, the analytic process, and outcome have
been disappointing. Critical review of the literature on assessment reveals increasing complexity
and considerable confusion about all aspects of the process. The formulation of testable
hypotheses required for research has been difficult.
This paper considers the questions pertinent to the decision to undertake an analysis and
the reasons these questions have not been answered. Part I is a critical examination of the
issues related to assessment of analyzability as described in the literature, particularly during
the last twenty-five years. We note that attempts to treat various types of problems through
psychoanalysis are accompanied by discussions of the modifications required in such cases.
When do such modifications so alter the method that it is inaccurate to call the treatment a
psychoanalysis? These controversial issues underscore more fundamental questions which are
also discussed in the literature: How and to what extent can we evaluate our patients reliably at
initial consultation? A number of recent studies of assessment are reviewed, in which the
authors discuss methodological problems that are not yet solved. Part II of this paper discusses
some of the technical and theoretical aspects of the study of patient selection,
- 49 -
treatment process, and outcome which make the study of assessment complex and difficult.
Some approaches to clarifying these problems are suggested. Part III concludes with a
discussion of methods which might supply data for testable hypotheses about suitability for
analysis from initial selection to outcome. A second paper (Erle, 1979) will present the findings
in a study of intake, assessment, and suitability of a group of patients whose treatment has
ended, and a further discussion of the methodological problems.
REVIEW OF THE LITERATURE

Early approaches to the question of analyzability were quite general. In Analysis
Terminable and Interminable Freud (1937) identified three factors important for the success or
failure of analytic treatment: the influence of traumas, the relative strength of the instincts at any
particular time, and the extent of such "alterations of the ego" as defenses and resistances. In
The Ego and The Mechanisms of Defence, Anna Freud (1936) estimated analytic prognosis
according to the type of anxiety serving as the motive for defense. In particular, she noted that
when the defense is derived from the patients' dread of the strength of their own instincts, the
outlook for analysis is unfavorable.
In the next two decades the psychoanalytic method was applied increasingly to a range of
problems characterized as "a widening scope" (Stone, 1954). The heightened interest in just
how far the limits of psychoanalysis might be pushed and what problems might result was
focused on in papers by Eissler (1953), A. Freud (1954), Glover (1954), and Stone (1954).
In discussing the effect of ego structure on analytic technique, Eissler (1953) described the
"basic model of psychoanalysis" as that in which the analyst's activity is limited to interpretation
(and occasional question). He then referred to situations in which the basic model is insufficient.
The example given was
- 50 -
the phobic patient, for whom interpretation often gave way to advice or command that the
patient enter the phobic situation. Such a maneuver Eissler called a "parameter" of a technique,
a technical deviation of minimum degree, whose effect on the transference must never surpass
that which can "be abolished by interpretation." He added that the boundaries marking
irreparable effects on the transference remain to be defined.
Such a command to the phobic patient raises a question: Can the effects on the
transference relationship be "abolished," even though the patient's reactions and associated
fantasies, affects, impulses, and memories may be understood? The analyst in such examples
becomes a "real" as opposed to a "transference" object to the extent that he intervenes in any
way other than by interpretation to effect change in the patient. The analyst, moreover, has told
the patient to act rather than having interpreted the patient's resistance to further analytic work.
Some might argue that this is an inevitable limitation of psychoanalytic technique with certain
patients, but in that case the analytic process has been significantly and substantially altered;
the patient is being treated as if he or she is not analyzable.
Stone (1954), referring to the expansion of psychoanalysis after the Second World War to
include virtually every psychological illness, wondered where analysis left off and psychotherapy
began. He used the term "modified psychoanalysis" to cover the deviations from standard
technique and wrote:
If the essential structure and relationship of analysis have been brought about, if a
full-blown transference neurosis has emerged, if the patient has been able to achieve
distance from it, if it has been brought into effective relation with the infantile situation, if
favorable changes in the ego have occurred as a result of interpretation and working
through, if the transference has been dissolved or reduced to the maximum possible
degree, I would say that the patient has been analyzed (p. 576).
Stone noted, however, that to achieve such goals, an analysis may be modified by the
introduction of "any number and
- 51 -
degree of parameters" necessary to meet special conditions. He took exception to Eissler's

criterion that a parameter must terminate before the analysis terminates:
The practical value of retention of this maneuver as consistent with true analytic work
outweighs the ideal requirement There are very sick personalities who, to the very
end of analytic experience, may require occasional and subtle or minimal emotional or
technical concessions from the analyst, in the same sense that they will carry with them
vestiges of ego defects or modifications, which, while not completely undone, are
vastly improved (p. 576).
Stone's discussion raises further questions about the nature of the transference effects of
certain technical maneuvers and the possibility of "analyzing" them. But his paper does illustrate
a persistently knotty issue: the differentiation between therapeutic benefit and psychoanalytic
process. The discussions by Eissler and Stone mark the start of an inquiry into which
modifications of the basic model are consistent with an acceptable concept of analysis. When is
a modification only different from the "ideal" and when does the process become fundamentally
altered?
Glover (1954) noted that modifications of standard analytic technique would depend on
"how widely the analyst casts his therapeutic net," and continued:
It can, however, be fairly claimed that provided the usual techniques of association,
interpretation and transference analysis are followed whenever possible, such
modifications as are entailed by the clinical necessities of the case or by the need to
safeguard such of the patient's interests as he is for the time incapable of safeguarding,
can justifiably be called psychoanalysis (p. 409).
Suitability or "accessibility" to analysis was determined according to diagnostic groups.
Anna Freud (1954) asked whether standard technical considerations are sufficient for the
analysis of character disorders and
- 52 -
perversions and wondered about legitimate technical means for keeping anxiety at an optimum
level for treatment. She reported her experience in applying to two homosexual patients the
same technical device: that they postpone pathological gratification in order to bring the ensuing
anxiety into the treatment situation. Noting sharply differing results, she remarked, "Similar or
even identical symptomatology may be based on very different psychopathology, and it is the
latter, not the former, which decides how a case should be dealt with from the technical angle"
(p. 51).
These earlier papers, then, deal in a general way with questions of suitability, indications,
and technique. As the "therapeutic net" is cast more widely, issues become increasingly
complex. Symptoms or diagnosis are used to determine technical devices as well as
analyzability . When a term refers to different things in different patients, such a complex end-
product of data collection as the "assessment of analyzability " may be murky indeed.
Since these papers appeared, there has been a burgeoning of literature on the subject of
analyzability which demonstrates the lack of consensus in approach. The papers might be
divided into those which are discussions of issues of assessment from a technical and
theoretical point of view and those which report specific patient groups studied according to
certain criteria. The order of presentation here is essentially chronological; more recent literature
has tended predominantly toward reporting on specific groups of patients in relation to
assessment of suitability, course of treatment, and outcome. This review focuses on those
publications which we deem particularly relevant for documentation of the problems in
developing methods of assessing analyzability .
At a panel on Criteria for Analyzability in 1959 (cf., Guttman, 1960), all of the panel
members referred to the uncertainties, difficulties, and variability in assessing analyzability at
the time of initial consultation. Most proposed approaching this through increasingly adequate
methodology, including clear
- 53 -
definition, increasing experience, and better theoretical understanding. Aaron Karush spoke of
developing methods which would make "consistent early prognosis of analyzability feasible"
(p. 149). During the discussion, Rudolph Loewenstein suggested the possibility of some
insurmountable limitation of judgment at the outset. Some patients may become analyzable
through the process of analysis itself. He described patients whose neurosis is related to
obtaining revenge. This is difficult to overcome; until it has proved possible to analyze that
problem, it is uncertain whether analytic work can proceed. Heinz Lichtenstein asked whether a
definitive initial assessment can be made when there are so many intervening variables and
suggested probabilistic theories as more fruitful than a cause-and-effect model. Since they deal
with the individual, analysts must accept a considerable degree of unpredictability.
In her summary of the panel Elizabeth Zetzel remarked, "While it is extremely likely that
many analysts present would make similar evaluations and predictions with respect to certain
patients, it is equally certain that they would advance different reasons for doing so" (cf.,
Guttman, 1960, p. 150). This observation, made many times before and since, has not received
the careful analysis it warrants. What might explain the different lines of reasoning by which a
similar conclusion is reached? If a patient is seen by several interviewers, somewhat different
material may emerge in each interview. Various interviewers may use somewhat different
criteria and organize the data in varying ways. The reasons given may not reflect all of the
conscious and unconscious considerations entering into the decision. These factors are
recurrent sources of confusion unless explicitly identified and systematically studied.
In 1960, Waldhorn published an expanded version of his contribution to this panel. In a
comprehensive review of the literature, he noted the absence of an "integrated discussion" of
the "technical problems of assessing analyzability and the related theoretical problems of
establishing specific criteria" (p. 478). With few exceptions, he found references to criteria or
suitability
- 54 -
tangential or inferred from other issues under discussion. Approaches to assessing

analyzability range from "clinical hints" (for example, Freud [1911-1915] in the Papers on
Technique) to complex technical and theoretical discussions of the impact of certain character
types, implications of the vicissitudes of development, and significance of functions of the ego
(Anna Freud, 1936). Other approaches, such as those of Stone (1954) and Glover (1954), were
also described by Waldhorn (1960). His survey concluded that "there does not appear to be any
widespread agreement on [the] precise meaning [of such factors] or [on their] proper application
in clinical situations" (p. 487).
Waldhorn proposed an approach through identifying the demands made on the patient by
the analytic treatment: What psychic resources must be available, and how are these psychic
elements to be evaluated? He noted the complexity of such an evaluation. Few of the factors
provide an invariable contraindication. Many are subtle and variable, and much that is crucial
may not be available until treatment is initiated; others may emerge very late or even at the end
of analysis (see also, Waldhorn, 1967).
Some of the issues involved in assessing suitability for analysis were discussed in 1960 by
Knapp, et al., in a report of "a preliminary study of the selective criteria, the way in which they
were being applied, and the degree of resulting success" in a group of treatment center cases.
For supervised analysis, they sought patients with "classical symptomatic neurosis." Other
criteria for acceptance, such as ego strength and motivation, were less explicit. A random group
of these patients was selected for further study after they had completed a year of their
supervised analysis. There was some evidence in this study for the importance of factors which
have previously been recognized through clinical judgment or intuition, or derived from
theoretical propositions. These include motivation, frustration tolerance, capacity for object
relations, and the need for more careful definition of healthy forces in the personality. Also noted
was the relevance of the experience and attributes of the analyst and
- 55 -
of the raters. This was the first of a number of such studies in the literature that have attempted
an evaluation of initial assessment of treatment center patients from the protocols at application
and have compared this to follow-up data obtained from the analyst or supervisor.
A study reported by Feldman (1968) highlights two problems in the evaluation of studies of
assessments of analyzability . The first is dissimilar criteria for measuring results. The second is
the lack of data on the treatment results of graduate analysts with which the results of student
analyses may be compared. Actually such a comparison would be essential not only to a study
of outcome but to the evaluation of any aspect of assessment.
Feldman reported the results of the analysis of all cases selected by the Intake Committee
of the Clinic of the Southern California Psychoanalytic Institute. He noted at some length the
methodological problems raised by lack of criteria and definition, limited information, confusion
about the goal of treatment (e.g., "worthiness," "interestingness," "teaching value," as well as
"potential for improvement through analysis"), and lack of criteria for judging improvement. A list
of eight factors which contributed to an inadequate evaluation by the committee in one or more
cases included four factors related to the patient's withholding information or presenting in a
misleading manner. The remaining categories reflected errors or difficulty in reaching agreement
by the committee. Comparing the 64% of cases reported as having "good" or "very good"
results at the time of review (one hundred sixty to over one thousand hours of treatment,
averaging three to four hundred hours; ninety-nine cases; rated by the researchers) with the
48% in the Boston series (Knapp, et al., 1960) and with 25% of first control cases reported to
the American Psychoanalytic Association (Robbins, 1965), Feldman noted the dissimilar criteria
for good result. It is also clear that there is no standard of comparison for the distribution of
treatment results in other groups of cases where analytic treatment is attempted. There are, for
example, no studies in the literature on results in cases treated by experienced analysts or
- 56 -
in private practice except for some of the patients included in the series of the Topeka
Psychotherapy Project (Kernberg, et al., 1972).
In a more detailed study, "Bases for Judgment of Analyzability ," Lower, et al. (1972)
attempted to determine how practicing analysts decide on analyzability . They also studied the
similarities and differences in the way that twenty-seven analysts (the practicing analysts who
did the interviews) and a fivemember intake committee arrived at their evaluation of suitability
for supervised analyses. They were judging "potential for improvement through psychoanalysis"
with the emphasis on "positive outcome predictors." The screening analysts recommended that
twenty-eight of a group of forty patients be accepted; the committee, after reviewing the data
supplied by the screening analysts, accepted sixteen of the twenty-eight. The more frequent
acceptances by the screening analysts were attributed to their being "more subjective" than the
committee, that is, more influenced by favorable impressions in their contacts with the patients.
The committee responded more often to data the authors regarded as more suitable for
objective demonstration: oedipal pathology, good social adaptation, good work performance,
ego strength, mature motivation.
Three years later a follow-up study of eighteen cases accepted by the committee (Huxster,
et al., 1975) reported that fifteen had been suitable for analysis, although six of these were
suitable only for advanced or able candidates; three were termed unsuitable. The authors
themselves identify a major problem in their assessments:
It is not the existence of "oedipal pathology" in an applicant that makes for his being a
good prospective analytic patient (or, for that matter, "preoedipal pathology" that makes
him not analyzable) (pp. 94-95).
We would now say that many developmental attributes (ego functions) must have
been attained, regardless of the psychopathological condition, the symptom complex,
the level of psychosexual development at which inner conflict occurs, or the
- 57 -
defenses involved in conflict resolution. Most basic among these functions are the
capacities for object constancy, for differentiation of self and object representation, and
for tolerance of frustration, anxiety, and depressionattributes necessary for a stable
therapeutic alliance to exist as a background against which transference phenomena
may be recognized and analyzed (pp. 100-101).
It will be of interest to hear whether a subsequent series is more satisfactorily chosen since
ego functions can be as difficult to evaluate in initial interviews as the structure and dynamics of
what are apparently oedipal conflicts. The authors note that such attributes cannot be
adequately assessed without a trial analysis and state that "there must be pitfalls to each
approach" (Lower, et al., 1972, p. 618).
In each of the contributions we have discussed so far the difficulties in making reliable initial
evaluations are acknowledged. All refer to inadequate methods, particularly criteria not clearly
defined or validated, and the limitations of the data available. The problems in overcoming these
shortcomings are not studied systematically, however, and the obstacles are often viewed as
likely to yield to improved methods. We think it would be more accurate to say that such
attributes as ego functions and oedipal pathology often cannot be adequately assessed at the
onset and that we must study more systematically when and why they cannot be, how this
situation might be improved, and what may remain as a limitation of initial assessments.
Over the next several years even more complicated, multifactorial studies were reported.
They exemplify the increasing difficulty in identifying reliable criteria or bases of judgment when
the study method becomes so complex. An elaborate metapsychological assessment profile
was developed by Greenspan and Cullander (1973) to allow comparison of the same patient
initially and at various points of the analysis as well as comparisons to other patients. Their
method uses a more or less conventional narrative report of the clinical interview and a
twelveitem profile on which each item can be rated along a seven-point
- 58 -
range with a separate three-point specification of the rater's confidence in his ratings. This study
does not adequately deal with problems of clarity of definition of attributes, consensual
understanding, and basis of judgment. The clinical example included allows readers to check
their own impressions against those of the authors in relation to evaluation of the patient and the
usefulness of these scales. The authors comment that "although the final criterion for
analyzability is the analysis itself, we are required in our daily practice to make the
determination of analyzability within the limits of one or several interviews" (p. 303). In our
view, the requirement would be more appropriately defined as the need to determine whether an
analysis should be undertaken and then to evaluate subsequently as treatment continues.
In a study titled "Assessment and Follow-Up in Psychoanalysis," Schlessinger and Robbins
(1974) developed another rating system based on data from various specific points in the
supervised analytic treatment. Material was submitted about the onset, point of decision to
terminate, termination, and follow-up. Ratings were made according to sixteen categories of
psychic functioning, such as object constancy, tolerance of frustration and anxiety, and "defense
transference." Again, definition and evidence of reliability of the criteria are not specified. Similar
problems are posed by a recent paper on psychoanalytic process by Graff and Luborsky (1977).
The active interest in Boston in predictive factors and assessment is reflected in another
group of papers published in 1975. Sashin, et al., attempted to assess the usefulness of specific
factors by rating one hundred five items from the data supplied in the report of initial evaluation
interviews. There were one hundred eighty-three patients accepted for supervised
psychoanalytic treatment through the Boston Psychoanalytic Institute between 1959 and 1966;
each patient had terminated treatment. The outcome groups were classified according to the
nature of the termination: Group 1by mutual consent; Group 2prematurely by the patient;
Group 3prematurely by the analyst;
- 59 -
Group 4analysis became interminable. The groups were examined on over-all change and
certain specific scales. The groups did not show significant differences at onset on those scales.
The discussion of the findings is particularly illustrative of the difficulties in reliably assessing
such factors at onset. Some items were discarded as not discriminatory, but many, including the
factors usually subsumed under "ego strength," found too little inter-rater agreement. There was
a similar problem with "psychological-mindedness" and some items dealing with interpersonal
relationships. No significant differences in motivation could be identified among one hundred
twenty-two patients. Of fifteen predictor items found useful in distinguishing Group 1 from at
least one other group, thirteen were part of the clinical history, such as family history and the
presence of severe obsessional symptoms. The two exceptions, concerning relationships with
other people, are not described in detail, but might require a judgment by the interviewer. In
other words, the items found distinctive were regarded as matters of historical fact; all items
(with the possible exception of two) which required judgment had to be discarded. These
historical factors, such as severe deprivation, a frightened and passive father, a father or mother
with poor work history, are largely negative ones to which clinicians are generally sensitive.
Further information would be needed to demonstrate their usefulness as predictors. For
example, as the analysis progresses, emerging data often requires revision of the initial reports,
as in the recall of the repressed positive aspects of the relationships with parents or an entirely
different version of an important event.
The authors discussed the limitations of incomplete and variable records and of
retrospective information. They suggested that such a study would be stronger with outcome
information from other sources, better records, perhaps including psychological testing, data
about the analyst, and other pertinent items. They hope "to turn the often vague, subjective
assessment procedure into a clearly understood, easily communicated scientific
- 60 -
process" (p. 358). Whether that improved process would be likely to overcome other limitations
of the initial evaluation situation will be discussed below.
Using patients from the Boston Institute Treatment Center, Kantrowitz, Singer and Knapp
(1975) presented another method for a prospective study of suitability: psychological testing. A
review of past contributions noted such advantages as: indirect approach, relative
standardization with easier comparison, survey of total ego function through a battery of tests,
and the observation that in some hands psychological testing is a more accurate prognostic tool
than interviews.
Four global aspects of psychological functioning were selected for study: reality testing,
level and quality of object relations, affect availability and tolerance, and motivation for therapy.
Terms were carefully defined and a detailed rating scale was developed. The authors
emphasize the complexity and difficulty of these assessments. For example, the tests assessed
current functioning and might not illuminate questions of regression. The testers, too, made
"subjective" favorable assessments of certain patients.1 The evaluation of motivation is
apparently a classic difficulty in the current use of psychological testing since the opportunity to
assess certain strengths, historical factors, and choices made by the patient is lacking. Affect
was the most troublesome aspect to evaluate, with difficulty in discriminating between
availability and tolerance of affect. The authors anticipated that the deeper, more refined and
subtle data revealed during the analysis would permit better identification of the crucial
determinants of analyzability . It might also, we may add, further clarify the limitations of
predictions.
The most detailed study of patients treated with psychotherapy or psychoanalysis is the
Topeka Psychotherapy Project. Since the authors (Kernberg, et al., 1972) studied a population
already selected, the criteria for choice of treatment recommended
1 It is interesting how rarely anyone notes or questions subjectively unfavorable distortions,

although there may be an example of this in the case of a woman mathematician reported by
Greenspan and Cullander (1973).
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were not developed as part of the study. The process of the treatment was studied as well as
degree of improvement along a particular scale. For the purposes of this discussion we will note
their correlation of improvement with good initial ego strength, high initial quality of interpersonal
relationships, high initial anxiety tolerance, and high initial motivation. Data was reported on
patients screened by the same clinic staff and not accepted for analysis but instead referred for
various types of psychotherapy.
This study provides information on some of the issues we have raised concerning the limits
of evaluation. It is very common in the other studies we have quoted to discover that motivation
has been overestimated. In this study, a group of psychotherapy patients did not score highly for
initial motivation, but improved nevertheless. The authors comment:
It may be that this issue [evaluation of motivation] can only be settled by studying
motivation factors during an initial, stress-inducing part of the treatment, of a sufficiently
long time to be able to assess this complex factor, and after a sufficiently short time not
to contaminate one's assessment by knowledge of the outcome (Kernberg, et al.,
1972, p. 172).
A. Appelbaum (1972) described another study based on the same data highlighting the
methodological problems in such a complex field.
Although it is not uncommon in clinical discussions to hear reference to the patient who
proves to be more suitable for analysis than had been anticipated, the unduly pessimistic
evaluation is rarely referred to in any of these studies.
A last group of papers directs our attention to some other specific factors which require
further study and clarification. These include the extraneous factors introduced in the selection
for supervised cases, the vagueness in criteria of outcome (which is often proposed as a
measure of correctness of initial assessment), and a number of issues relating to clarity and
definition of terms.
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Problems pertinent to selection for analysis by a candidate under supervision have recently
been explored by Lazar (1976). This issue is highlighted by his example of supervising analysts
initially recommending patients to the clinic and subsequently rejecting these same patients as
unsuitable when they were assigned to candidates under their supervision. He writes:
It is possible that the experienced analyst, functioning as a consultant, may at times be
evaluating the patient on the basis of his own analytic skill rather than in terms of
suitability for a candidate (p. 420).
An attempt is made to provide student analysts with cases that will provide an optimal
learning experience in conducting a psychoanalysis. This brings up another facet of
assessment: analyzable by whom? Whatever the significance of such a distinction, clearly
reports in the literature based on treatment center studies may be expected to reflect some
criteria different from those of more experienced analysts. Lazar reminds us, echoing Knapp, et
al. (1960), that patients analyzable in one analytic situation may not be analyzable in another.
The age, sex, experience, interest, and personality of the analyst are other variables. Some of
these may be systematically explored more easily than others.
Lazar's paper, however, reflects another problem in the literature: the masking of the larger
issue of analyzability behind a seemingly lesser technical or clinical point. He described four
cases, of which three might well be considered unsuitable for analysis by anyone, not just by
candidates. The issue in such cases may not be what Lazar calls "the magnitude of the potential
technical problems" requiring the greater experience of graduate practitioners, but instead the
question of analyzability under any circumstances.
A similar dilemma arises from the paper by Oremland, et al. (1975), one of the few follow-up
studies on patients in analysis (cf., Kernberg, et al., 1972); (Klein, 1960); (Norman, et al.,
1976); (Pfeffer, 1959); (Schlessinger and Robbins, 1974). Oremland's
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study focused on the vagueness surrounding the concept of completed analysis. Using the term
"successful" to indicate analyses in which both patient and analyst agree on the therapeutic
benefits and the decision to terminate, the authors cited two cases to illustrate that such
therapeutic success may be technically and significantly incomplete. Large areas of important
transference material were unanalyzed, with residual effects in the subsequent life of each
patient. In one case a young married woman withheld material on her marriage, unprepared for
the consequences should she decide to leave her husband on whom she was dependent.
Hidden in this reality "resistance" was a significant transference fantasy that was enacted rather
than analyzed by both patient and analyst. The authors noted that the analyst had no
awareness of the withholding of the hidden transference fantasy. The second patient also
withheld material, the authors again citing unresolved areas of the transference only partially
recognized by the treating analyst.
These cases raise questions regarding the definition of a completed analysis and about the
difference between analyzability and therapeutic benefit. Moreover, as in Lazar's cases, we
might question whether they were ever analyzable. Put another way, did the incomplete
analyses reflect the patients' unsuitability? Does such withholding, for example, point to features
of the patient's personality which might render him or her unanalyzable in any case? This does
not mean that therapeutic benefit is impossible. The special technical problems and limitations
presented by such situations have been noted in patients with negative therapeutic reactions
and masochistic personalities and in individuals with an intense wish for revenge.
Further difficulties spring from other inconsistencies in the use of the concept of "analysis" in
various reviews and case reports. Tyson and Sandler (1971) called attention to the variability in
the use of terms. Calling for sharper distinctions between "indications," "suitability," and "
analyzability ," they noted that the concept of "indications," based, as in Glover's work, on
symptoms and diagnosis, is contrasted with the more specific, individual assessment of
"suitability," the "presence or
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absence of those qualities which would make it more likely that psychoanalysis could be of
help" (p. 215). Regarding " analyzability ," they remarked:
It is possible that part of the attraction of the term lies precisely in the fact that it
obscures the vital distinction between whether the analyst understands the patient and
whether the patient can benefit from the analytic procedure (p. 218).
Limentani (1972) emphasized, but did not clarify, the distinction between "suitability" and "
analyzability ."
A variety of techniques have been included under the heading of psychoanalysis, resulting
in vagueness and confusion about its definition. Kernberg (1975), in discussing treatment of
borderline conditions, took care to point out that the techniques advocated reflect sufficient
departure from the standard concept of intervention by interpretation alone to call for the use of
the term "modified psychoanalysis," meaning an intensive psychoanalytic psychotherapy
approaching, but not technically identical to, psychoanalysis.
Fleming (1975), writing on object constancy in the analysis of adults, described such a
variation. She asked:
Is it possible that the structural changes we hope for from the psychoanalytic
experience can be facilitated by responses from the analyst other than interpretation in
the usual sense of the term? My experiences in trying to understand the clinical
phenomena that commonly appear in the course of psychoanalytic therapy have led me
more and more insistently in this direction. The object need in many adults reproduces
in many ways the functional relationship between mother and childthe diatrophic
feeling, without which the analytic process meets with difficulty (p. 749).
Fleming illustrated this in her accompanying case report. A pattern developed in which the
male patient would sit for a minute or two on the edge of the couch at the end of an hour,
"looking me in the eye. Intuitively at first, I returned his gaze and made a comment or two.
Occasionally, this exchange lasted for a couple of minutes." This "was understood as an
intensified
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regressive need for symbiosis. I simply responded to the need without making an interpretation"
(p. 755).
We are not disputing the therapeutic benefits of such an approach in appropriate patients.
However, we emphasize the associated blurring of the line between analysis and
psychotherapy, when observed behavior is not analyzed. This blurring is crucial to the issues of
analyzability , completed analysis, therapeutic benefit, and results. As one example, an analyst
who shared Fleming's approach might call such a patient "analyzable" (and even contribute to a
study of analyzability ) without making such techniques explicit, while a more traditional analyst
might label the patient unsuitable for analysis (and also contribute to the literature on
analyzability ), urging instead psychotherapy or "modified" analysis.
In a recent extensive review of the literature on analyzability since 1954, Bachrach and
Leaff (1979) discussed the failure of investigators to indicate the evidence for their conclusions,
adding, "It is therefore difficult to be fully cognizant of the nature of the populations referred to,
selection, biases, and the extent to which one investigation may be said to truly replicate
another."
Thus it is clear that the study of assessment has been impeded by a lack of consensus on
approach and definition. This may be attributed in part to the failure to make clear statements of
the terms being used, but the issues seem far more complicated. In the next section we shall
explore some pertinent aspects of the evaluation situation, the analytic treatment and the
methods available for study.
II
DISCUSSION
The situation we are examining might be schematically summarized as follows:
Figure 1
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Study of this interaction requires careful definition and understanding of each of these three
elements. Many papers, addressed to a wide range of clinical and theoretical topics, have
touched on various facets of these issues. We will note some of these approaches and present
our suggestions for more effective study of these questions.
Definition
The lack of definition of terms is a basic problem. Certainly, to the extent that terms are
employed differently, investigators may be reporting different types of patients, processes, or
treatments. It seems logical to begin with the definition of "psychoanalysis." Luborsky and
Spence (1971), in a review of quantitative research in psychoanalytic therapy, noted that "it
usually means an intensive treatmentthree to five years of four or five sessions a week, in
which the patient reclines and tries to say whatever comes to mind (free association), while the
analyst responds interpretively with particular emphasis on the concepts of transference and
defense" (p. 410). Other definitions refer more specifically to process, resistance, unconscious
mental functioning, and infantile roots of neurosis (Eidelberg, 1968); (Moore and Fine, 1968);
(Rycroft, 1968) or to transference neurosis and therapeutic alliance (Manual of Psychiatric
Peer Review, 1976); (Rangell, 1968). Brenner (1976) does not define psychoanalysis in terms
of technique or elements of the process. He speaks in terms of the "analytic attitude, i.e., to
attempt to understand the nature and origins of the psychic conflicts that underlie a patient's
thoughts, feelings and behavior" (p. 132).
Whatever the significance of these differences in emphasis, it is surprising how often the
treatment under consideration in studies of analyzability is not defined, or so vaguely defined
that it is impossible to determine what specific treatment process was undertaken. Eissler
(1963) stated:
The classical technique is a subtle instrument; in almost all instances of psychoanalytic
writings not enough details are
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published to make it clear whether it was actually used properly (p. 448).
For example, the technical issues cited in our review of the work of Eissler (1953), Fleming
(1975), Kernberg (1975) and Stone (1954) are either not mentioned in studies of analyzability ,
or sufficient information is not supplied to permit adequate evaluation.
What appear to be minor differences in technique or "style" can often be traced back to an
important difference in definition of the psychoanalytic process. It is conceivable that analysts
might agree on basic concepts yet disagree about specific technical points. In a study group,
two senior training analysts disagreed on whether it was appropriate to read the published book
of an analysand. Should the analyst limit himself to data emerging in the consulting room? Is it
appropriate to seek information about the patient from sources outside the analytic session?
We regard precise definition of the analytic technique or its modifications as central to the
study of the questions of analyzability . For discussion and research it is necessary to identify
the intermediate steps between basic concepts and observable phenomena. Ideally the study
should specify observable phenomena which are regarded as consistent with that definition.
There are differences of opinion about certain pertinent aspects of this question, on both
theoretical and clinical levels. For a given study, however, precise specifications should be
provided to permit evaluation of the nature of the treatment as well as patient selection and
outcome.
The need for definition and specification would also apply to other aspects of the analytic
process, such as transference neurosis, therapeutic alliance, and free association. The
transference neurosis, for instance, is a complicated matter. Questions have recently been
raised not only about its definition, but also about whether the shift in recent years from well-
defined symptom neurosis to more diffuse character pathology in clinical practice meets its
counterpart in a more diffuse, less well-defined
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transference neurosis, more difficult to work with. In relation to outcome, what happens to the
transference neurosis in analysis? Is it "resolved" (Schlessinger and Robbins, 1975)? Freud
(1937), in Analysis Terminable and Interminable, pointed out that conflicts are never actually
"resolved," but rather the balance of instinct and ego is changed so that after analysis increased
drive derivatives are tolerated by a strengthened ego. Pfeffer (1959) has noted the ease with
which transference residues are reactivated in follow-up interviews after completed analyses
and questions "the degree and nature of the resolution of the transference." A clear definition of
transference neurosis and its observable correlates would be imperative in any work describing
the course of one or many analyses.
The term analyzability should be made equally explicit. In our view, the term should be
limited to treatment potential: Is the patient treatable by psychoanalysis? In other words, will the
psychic conflicts of the patient be modifiable through a treatment process which revolves around
recognition, understanding, and eventual interpretation of those conflicts as they emerge in the
analytic situation? The analytic process is distinguished by the analyst's unvarying commitment
to the understanding and interpretation of the material which is revealed progressively through
the patient's associations. Such concepts as "transference neurosis," "free association,"
"therapeutic alliance," "resistance," and "defense" refer to aspects of this process. Thus,
Fleming's (1975) case would differ from this view of the analytic process in that certain behavior
of the patient was not analyzed and interpreted.
Sometimes an analysis is attempted, but the analytic process does not develop. The failure
may reflect the patient's unsuitability or other factors. Such a patient may obtain marked
therapeutic benefit, with the use of some analytic methods and concepts, but such a treatment
can be distinguished from a psychoanalysis. It is essential that the issues of therapeutic benefit
and analyzability be separated, particularly if we are to avoid circularity.
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The Selection of Patients

The major source of information on which the recommendation for analysis is usually based
is the evaluation or consultation interview. What sort of perspective does the interview situation
provide? What are the specific methodological problems related to this manner of obtaining
data?
First, there is the material which is initially accessible to the patient. We are all aware of the
great variation among patients in the nature and extent of the history that they can impart in
initial interviews. Sometimes, detailed, sophisticated, consciously "frank" and "honest"
presentations can be more obscuring than revelatory of historical details. Patients vary
enormously in their capacity as observers of themselves and others. Moreover, their capacity for
self-awareness may be affected in specific ways, such as in hysterics and obsessive patients.
Much of the material presented in the consultation interview is descriptive reporting, and in the
absence of associations and the uniquely specific information obtained in the analytic process,
our conclusions about dynamic formulations may be substantially speculative. Such processes
as repression, amnesia, and conscious withholding may influence material in imperceptible
even if expectableways. Some of the greatest difficulties may surround judgments of strength
and the balance of pathological and nonpathological factors, with such limited information. For
example, it may prove crucial to analyzability whether a specific traumatic experience occurred
in relationship to a particular developmental phase or whether it was only secondarily related to
it. Similarly, it may be difficult to evaluate whether the impairment of an ego function is explained
by its involvement in conflict or in a more severe developmental distortion. The "pseudostupid"
or nonpsychologically-minded patient may be more than adequately competent when a conflict
about curiosity has been uncovered and is being worked through. S. Applebaum (1973) has
given a detailed description of such a case.
It is often said that adequate or noteworthy functioning in
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other life situations has prognostic value. So far, this has not been clearly supported, partly
because the evaluation of a patient's report that he or she has succeeded or failed can be
difficult. Further, the correlation of the attributes required for success in school or work and
suitability for analysis is far from simple. One of the most familiar examples of this is the
evaluation of applicants with very positive recommendations for analytic training. Such
individuals may have done very well in their schooling and work but are found to have
unanalyzable pathology.
Second, given the limitations of the data available to the patient, how does the interview
situation affect its presentation? Again, motivation and honesty are difficult to evaluate when a
patient wishes to impress, please, placate, submit to, or discourage the analyst. The need to
avoid shame, humiliation, anxiety, and guilt can also affect presentation. Character traits of
rigidity or plasticity may be intensified. The reaction to the specific analyst, whether as a
transference manifestation or "reality," also may affect the material presented. Certain
individuals are particularly handicapped in an unfamiliar situation; this may be understood later
and be no substantial obstacle in treatment. The analyst attempts to alter the flow of the
material as little as possible. The spontaneous sequence of the patient's thoughts, including
noticeable omissions, is part of the data. The analyst does not attempt to expand the inquiry
during the consultation, except to clarify some issue. He requires only sufficient material for
making the decision of whether an analysis should be attempted. Because of the importance of
allowing material to unfold in the context of the analytic situation, the analyst usually prefers not
to pursue a systematic history according to some preconceived outline.
There are some further methodological issues in the evaluation which reflect the analyst's
strengths and limitations. Professional competence, experience, and sensitivity provide a
framework. The analyst's own psychoanalysis is expected to enlarge awareness of his or her
own conflicts, in order to diminish their
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effects on work with patients. Nonetheless, the analyst's reactions may include such responses
as marked attraction or aversion to the patient, or other conscious or unconscious phenomena
often subsumed under the heading of countertransference. There can also be complexities in
the analyst's motivation: the wish to do (or avoid) analytic work, therapeutic zeal, time free to be
filled, rescue fantasies.
The question of an implicit value judgment about analysis deserves separate mention.
Patient or analyst may be unduly influenced by such a value judgment in deciding on treatment.
There are many references in the literaturee.g., Knapp, et al. (1960), Stone (1954), Waldhorn
(1960)to the high value placed on analytic treatment especially in the health professions and
in certain social groups. The recommendation for analysis may be thought to reflect an
encouraging view of a potential candidate's future, a mark of status or favor, a reassuring
assessment of the extent of an individual's pathology or, in the more unsophisticated patient, a
frightening reflection of "how sick I am." If the analyst highly values analytic treatment either as
reflecting a more favorable outlook for the patient ("worthwhile") or because the analyst's own
value as a therapist is greater if he or she is doing more analytic work, this may influence the
recommendation or the labeling of a particular treatment as an analysis when it differs from the
analyst's usual criteria in significant respects. Two aspects of the problems this may create are
the difficulties for the unsuitable patient and the conclusion by the analyst or others, when such
treatments fail, that analysis is not an effective treatment or requires substantial modification
from the classical method. This introduces a lack of clarity about the initial recommendation for
analysis.
Finally, we might add here the decisions which are familiar to analysts as "if there is any
hope for this patient it would be through an analysis." Such a recommendation may be made,
for example, when a patient seems capable of self-understanding, motivated by considerable
suffering, and experiences his or her symptoms as alien even though there are substantial
questions
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about ego defects, affective disorder, age, or other limiting factors.

We have noted these aspects of the evaluation situation not because they are unfamiliar or
altogether insurmountable, but because their systematic description might provide some
perspective on the enormous complexity of the decision and the nature of the analyst's task. In
1956, Sargent described such problems when presenting the "Rationale" of the Topeka Study.
She wrote of clinicians using their clinical judgment as the instrument with which they work, as
have many others in different contexts. She noted such characteristics of the instrument as the
clinician's habit of making "more or less" judgments, being "most certain of judgments made
within a context" (p. 230), and clinical judgments coming "in ordinary practice wrapped in
qualifications. Tables of either-or choice, unqualified and unelaborated, are misleading" (p. 230).
Sargent regards this "instrument" as "impos[ing] limitations and offer[ing] certain advantages,
but within it the basic requirements of science are unaltered" (p. 231).
The development of clear criteria for assessing analyzability has been particularly difficult.
In clinical work the analyst arrives at a working decision which may be revised subsequently.
Reported studies, however, deal with treatment center populations which present evaluation and
treatment issues differing from those of private patients (Erle, 1979). Even given comparable
standards for analyzability (see, Lazar, 1976), the clinic programs usually attempt earlier and
more accurate prognostic decisions than are necessary in private practice. Thus, the clinic
determination is generally made on the basis of less information and less time.
Which criteria are important in predicting analyzability ? Numerous papers, many reviewed
above, address this question. Some authors emphasize fewer criteria of broader perspective,
while others cite more numerous, less extensive categories. Bachrach and Leaff (1979), in their
review of this literature, list three hundred ninety individual but widely overlapping items
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which different authors thought important to assess in predicting analyzability . This

compendium makes clear the variation in transposing patient qualities to the rating scale or the
printed page. For example, the tolerance of unpleasant affects is subdivided in the literature into
four "different" categories.
In view of these problems, what would be the requirements for useful criteria and their
validation in a research situation? Once again, a criterion must be capable of clear definition
with specified, observable correlates. Its relevance must be demonstrable. Suitability for
accurate observation would include the item's being clearly discernible and permitting a
significant level of consensus. It should also allow correlation with subsequent observations
during the analysis, particularly to evaluate prediction. Psychological testing has been cited as
having advantages in these respects; it also requires skillful administration and interpretation.
For example, in connection with the Topeka Psychotherapy Project, Kernberg (1977) discussed
the difficulty of using such test batteries in formal research and the crucial importance of the
clinical sophistication of the psychologist.
The consultation interview may seem to be an unstructured situation without systematic
inquiry according to a specific outline or inventory. Actually, like the psychoanalytic situation, it
provides a standard framework, a specific tool which facilitates the emergence of complex
material in a manner that does not distort connections or obscure spontaneous omissions (cf.,
Freud, 1911-1915); (Glover, 1954); (Rosen, 1958); (Stone, 1954). During the consultation
analysts behave in a consistent and deliberate manner: they are quietly receptive, allowing the
patient's spontaneous presentation to unfold, noting difficulties, and intervening only if
necessary to clarify, facilitate, or explore. The patient's response to the situation is noted as part
of the material. More precise methods of evaluating this data need to be developed; it is a tool
which could be further studied and used with greater skill. In these respects it is comparable to
the sophisticated, nonpsychometric psychological testing situation
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(for example, Rorschach) which is standardized in a different fashion with access to certain
data. In both settings we also have to take into account subjective responses of the evaluator.
Particular attention must be paid to developing approaches to complex factors. The concept
of "objective terms" (cf., Lower, et al., 1972) implies that certain data can be clearly defined and
free from subjective distortion. Such "objectivity" is suitable only for relatively simple items, such
as demographic data (age, sex, profession, etc.) or certain items of behavior. Sashin, et al.
(1975) found such factors were not of value in prediction. As more complex constructs (ego
strength, affects, nature of relationships) are involved, it becomes more difficult to reach
consistency or agreement in definition or application. We have to take into account that
subjective responses of the rater may lead to significant distortion.
Translating raw data into judgments, first about the patient's personality, and then further
into decisions about analyzability , is quite complex. Zetzel (cf., Guttman, 1960) noted that
senior clinicians tended to agree on analyzability but not on how they arrived at such a
judgment. Knapp, et al. (1960) found that when impressionistic judgments were replaced with
explicitly stated criteria, patterns of judging in evaluations were not significantly altered. Such
findings reveal the gap between raw data and evaluation result, even when the decision may be
both accurate and reliable. We need to understand and to improve the process of evaluation. It
would be useful to analyze what operations are carried out by the more successful judges and
to formulate testable hypotheses about those methods.
Outcome
Finally, in order to measure which factors are important for evaluating analyzability during
initial consultation, there must be consideration of outcome of treatment. Lofgren (1960)
discussed difficulties in using the concept, "results," in evaluating psychiatric treatment.
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Let us note as our first difficulty that different people when talking about "results" use
different frames of reference, and thus actually are discussing different things. If the
various frames of reference are covert, as they usually are, the discussants are apt to
believe that because they are using the same word they are giving it identical meaning
content (p. 95).
He also noted a further complication: in psychiatric conditions, "results" cannot be
unequivocally explicated or defined as a rule. This opens the way to controversy over which
criteria might define results in psychotherapies (symptomatic improvement, therapist or patient
ratings, conflict resolution, mutual agreement to terminate, as examples).
Studies to date have selected simplistic criteria, giving little explicit definition. Moreover,
there may be wide disparity in outcome ratings when the same treatment is rated by patient,
therapist, and research judges (Harty and Horwitz, 1976). The report by Oremland, et al.
(1975) on the incompleteness of "satisfactory" analyses highlights the dilemma. Pfeffer (1961),
in exploring a method for follow-up of completed analyses, gives considerable detail
documenting the patient's improvement at several clinical levels: both patient's and analyst's
opinions, decreased symptomatology, change in masochistic character structure, with new,
more mature relationships, as well as changed relations with old objects and change in ego and
superego structure. The description of the case and several follow-up interviews include
evidence of transference residues and the brief recurrence of original symptoms. The detail in
this report, or in Dewald's (1972) extended case history, facilitates the reader's own judgment.
However, such data would need to be systematized to be useful for the purposes of further
investigation.
We have been unable to find studies which cover all phases: selection, prediction, analysis,
and outcome. Predictive studies thus far have not extended into the phase of completed
analysis, while outcome studies have been retrospective. Some reports have compared
"predictive" ratings with outcome (e.g., Knapp, et al., 1960); (Sashin, et al., 1975), but in these
cases the predictions were made retrospectively in blind examinations of data
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from patients already chosen and in analysis. More complete and comprehensive data do not
always lead to better understanding. Unless meaningful hypotheses can be developed for
exploration of significant questions, the volume of dataespecially in so prolonged and complex
a process as an analysismay swamp the investigation. It is clear in certain specific areas,
however, that studies which do not include the entire process may be misleading. For example,
a stated interval may be chosen as sufficient to assess suitability, sometimes as short as a year
or eighteen months (Hildebrand and Rayner, 1971); (Knapp, et al., 1960); (Weber, et al.,
1974). It is also reported that patients who remain in treatment many years terminate
unsatisfactorily or are found to be unanalyzable or "interminable" (Sashin, et al., 1975).
Obviously, they cannot be identified in the less complete study. Similarly, a patient whose
analyzability is in doubt due to a marked tendency to negative therapeutic reaction would
require evaluation at termination for adequate assessment. Even then, some follow-up might be
useful.
Problems pertinent to prediction based on evaluation studies have been described above
(cf., Kantrowitz, et al., 1975); (Lower, et al., 1972; and the preceding section of this paper).
Pitfalls of prediction in a longitudinal study have been described by Marianne Kris (1957) in
relation to work with mothers and their young children. Errors in prediction appeared to arise
from several sources, such as the paucity and nonanalytic nature of data on which predictions
were based, the complexity of the mother-child interaction, and the failure to utilize fully and
properly all the available information. Kris noted moreover, that often the significance of earlier
observations could not be appreciated by even the most careful investigators until later in a
clinical course.
III
CONCLUSIONS
When one is involved in the issues of studying assessment, there is a temptation toward
subjectivity and nihilism, partly
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because the issues are so complex and partly because some of the work done seems to
confound rather than clarify the issue. There may be an irreducible level of uncertainty inherent
in such a situation, but we would stress the importance of further attempts to elucidate these
problems.
Collecting data and being precise at the time of initial evaluation is inherently difficult. These
difficulties are increased by lack of specification or agreement on what constitutes an analytic
treatment, variability in usage of terms, insufficient validation of criteria, data which are limited in
extent and skewed by the method of collection or presentation. We have made suggestions for
reducing the confusion: accurate definition, widely-based studies as well as individual cases,
prospective studies, studies which include data of the treatment as it unfolds and its outcome.
Beyond this, however, there remains a crucial question: Can we confidently predict the
establishment of an analytic processcan we say "This patient is analyzable"? The guidelines
we follow in deciding to initiate an analysis in a particular instance are clinically useful. However,
if we attempt to study assessment, a different method of proceeding is required which would
permit investigation of the many aspects of the process that can only be clarified during the
analysis.
Experienced analysts with varying points of view on many theoretical and clinical issues
have repeatedly referred to the problem of understanding clinical material. Bak (1970) noted
that no matter how careful the initial investigation, the true picture of the patient's suitability will
evolve only during analysis. In recognition of the shortcomings of such predictions, Bak
suggested consideration of a flexible period, within which a decision would be made about
"whether the analysis will be productive enough to warrant its continuation" (p. 10). He
recommended early discontinuation or a shift to another form of treatment in unproductive
cases.
Even during ongoing analysis the meaning of clinical material is often uncertain. In his
discussion of the analysis of
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affects, Schafer (1964) warned that a formidable problem is "not to jump to conclusions," and
continued:
Clinical and personal experience teaches us to expect certain types of feelings in
certain situations. The fact that they are expressed does not prove they are genuinely
felt; the fact that they are absent does not mean that they are there but hidden; the fact
that they are conveyed histrionically or in an offhand manner does not mean they are
entirely artificial. The distinctions are not always easy to make. As analysts we wait and
wonder, sometimes aloud, and give ourselves and our patients time and opportunity to
make sure. In practice, we spend much of our time this way (p. 277).
Arlow (1977) emphasized this need for precision; he urged moving beyond apparently
obvious meanings of expressed or described affects and linking them with specific unconscious
fantasies. Brenner (1976) also cautioned the analyst against taking at face value such material
as symptoms, suicidal thoughts, object loss, "realistic" or "normal" behavior, fantasies, hobbies,
or other interests. Before such material can be regarded as understood, it must be approached
with a consistent analytic attitude aimed at defining the nature and extent of the contributing
psychic conflict.
Clearly, then, we often confront a situation where the analyst does not know. In other
connections, the analyst's awareness that he or she does not know or understand is widely
regarded as an essential signpost in identifying the emergence of some significant material in
the patient's associations. Uncertainty must be an even greater limitation of initial assessment.
Are we then suggesting that one "just begin and see what happens?" We are proposing,
rather, that the basis of the decision would be specified and, should an analytic process not be
established, the analyst would then note: 1) the nature of the treatment process that had
occurred; 2) the point at which the treatment was modified and in what ways; 3) what further
therapy seemed appropriate and why. The reasons for such failure to develop an analytic
process might range, for example, from an
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early massive regression or the inability to tolerate the frustration of the analytic situation to
more subtle issues appearing in the form of a stalemate. Similarly, for such a research purpose,
the analyst would specify the evidence that an analytic process had developed. A process of
such complexity demands ongoing evaluation throughout.
At this point, we are again aware of methodological issues. As noted above, a particular
definition of psychoanalysis and the analytic process would be required in a study. Further, it
would be necessary to decide how the patient's involvement in that process could be observed
and evaluated. If the patient is not involved, how could one discriminate between the
unsuitability of the patient and the inadequate use of the technique or the limitations of
psychoanalysis? At the end of treatment, does the process seem to have gone to completion
satisfactorily or might there be limitations? These limitations might be understood in terms of
factors in the patient, the technique, a result of the process (e.g., the development of severe
negative therapeutic reactions or regression with the emergence of paranoid fears), or the skills
of the analyst. In practice, evaluation of each of these is limited by a number of considerations in
addition to complexity. We are concerned about intrusions into the analytic work, whether they
involve evaluations, testing situations, concerns about confidentiality, or the influence of
research interests. There may be obvious drawbacks, as well as potential benefits, in such a
systematic analysis of data. The data can be obtained only from the analyst and, indirectly, from
the patient. Consequently, it cannot be verified directly, and it has been extremely difficult to
develop reliable means of evaluating it indirectly.
Detailed individual case studies are required for clarifying some of these issues, but studies
of groups of casesparticularly those treated by graduate analystsare needed. How often is
an analytic process established? What is the therapeutic benefit in patients who are analyzed?
Are there problems in continuing the treatment of those who do not become involved in an
analysis? As
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far as possible, patients for supervised analysis are chosen for their suitability for that purpose.
How do graduate analysts deal with more complex cases in which there are uncertainties about
the modifiability of pathology or character structure? Can we better understand and identify
patients who do not develop and conclude a classical analytic treatment? Do some of the
failures of which we are aware in clinical practice or published reports reflect the limitations of
prediction? That some analytic treatments are only partially successful or fail does not mean
they should not be attempted or could be predicted.
The work we are proposing should supply more adequate data for testable hypotheses
about assessment of analyzability throughout the processfrom selection to outcome. In such
a complex situation we may be limited to certain kinds of understanding; it may not be possible
to go beyond a certain point. Within that, however, we may be able to construct a framework
which is clear and consistent and which allows replicable results (including similar limitations).
We may also be able to understand and document the bases for persistent and irreducible
uncertainty so that the question of assessment can be approached in some way that allows for
clear communication and the development of further studies.
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Erle, J.B. and Goldberg, D.A. (1979). Problems in the Assessment of Analyzability.
Psychoanal Q., 48:48-84
1992). Contemporary Psychoanalysis, 28:16-31
On the Question of Analyzability 1
Darlene Bregman Ehrenberg, Ph.D.
AS WE HAVE COME TO RECOGNIZE THE profoundly interactive nature of the analytic
field, and the fact that transference and countertransference constitute an interlocking unity,
what has become clear is the degree to which the analyst's participation can influence
transference-countertransference developments and the analytic movement that becomes
possible. My focus here will be on how the nature of the analyst's participation can become the
key to the question of analyzability.
The work of Winnicott (1949), (1969), Little (1951), (1957), Fromm-Reichmann (1939),
(1950), (1952), and Searles (1965), among others, has been ground breaking in demonstrating
that certain kinds of analyst participation can make it possible to work effectively with individuals
who formerly might have been considered unanalyzable. This body of work suggests that
patients are too often blamed for what may actually be the limits of their analysts or of existing
theories of technique, or for what may be the analyst's unwillingness to open himself or herself
to the kinds of turmoil and stress working with more difficult patients often can entail.
Unfortunately if the analyst assumes, for whatever reason, that the patient is unanalyzable
this may preclude an opportunity for the patient to ever realize the limits of his or her own
capabilities.
Winnicott's (1955) view in this regard is that "every failed analysis is a failure not of the
patient but of the analyst" (p. 299).
Stone (1954), (1961), Lipton (1977a), (1977b), (1983), and Klauber (1979), writing from a
classical perspective, and Tauber (1954) from an interpersonal one, have argued that in many
instances
0010-7530/92 $2.00 + .05

Copyright 1992 W. A. W. Institute
20 W. 74th Street, New York, NY 10023
All rights of reproduction in any form reserved.
Contemporary Psychoanalysis, Vol. 28, No. 1 (1992)
1 This is an expanded version of a paper presented at the panel Transference: The Analyst's
Participation, at the Clinical Symposium of the White Institute: Interpersonal Frontiers in
Psychoanalytic Practice, November 11, 1990.
It is also a chapter in a forthcoming book by the author to be published by W. W. Norton &
Company, Inc., 1992
- 16 -
apparent "unanalyzability" may be an iatrogenic consequence of the analyst's "classical"

technique.
What has become increasingly evident is that the establishment of a viable analytic process
often depends as much on the capacities of the analyst as on those of the patient. Certain kinds
of analyst participation can be toxic and stimulate negative interactive developments, or at least
fail to prevent them; other kinds can protect and facilitate an analytic process. This is particularly
true in the context of more serious forms of pathology, where the potential for paranoid
response is great. In such instances an analyst who is experienced as too detached or
ambiguous can evoke the escalation of the patient's anxieties, and the analyst who identifies too
closely with the patient's experience can be terrifying in a different way. Where primitive
transference projections tend to evoke primitive countertransference responses, there is also a
risk that the analyst can find himself or herself overwhelmed or provoked to the point of being
unable to maintain an analytic role (Ehrenberg, 1990).
What seems increasingly clear is that in the context of difficulties in establishing an analytic
process it is important for us to question our technique and address its inadequacies rather than
to assume the patient unanalyzable. In many such instances, modifications of technique do not
constitute a violation of analytic integrity, nor an abandonment of an analytic process, but rather
may be essential to establish or preserve an analytic possibility.
Particularly where patients have been severely traumatized, unless the analyst can
establish that treatment can be of positive value, it is perfectly understandable that a patient
may be resistant to risking yet another catastrophe.
How can we structure the conditions of safety and help generate experiences that will be
sufficiently positive to enable the patient to feel willing to take a risk on analysis, as well as on
life itself?
Lacan's (1958) comment, "With supply we create demand, " seems pertinent in this context.
The question is what kind of "supply" is required? What is it that the analyst must provide?
My experience has been that attending to the subtlest details of the analytic interaction can
be extremely useful where the potential for toxicity is high (Ehrenberg, 1974), (1982), (1984),
(1985), (1989),
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(1990). Particularly with patients who are terrified of intrusion, violation, being co-opted or
coerced, dominated, controlled, and with whom paranoia is easily aroused, I have found that
being able to clarify in the immediate moment how the interaction becomes problematic, and to
make this the focus of scrutiny, becomes a way to establish and maintain a context of adequate
safety for both patient and analyst to be able to engage the work in a positive way. In such
instances interactive stalemates are transcended or prevented, not by avoiding them or treating
them superficially or gingerly but rather, by actually going deeper into them, as the process of
meticulous scrutiny adds a new and transformative dimension to the immediate experience.
Where boundary problems are prominent, acting out is standard, detachment is excessive,
and where primitive forms of behavior and communication prevail, treating the transaction as
primary analytic data allows for each participant's sensitivities to the most subtle nuances of the
other's participation to be clarified and tracked. This can help to keep the relationship grounded
so that it does not become so ambiguous as to become terrifyingly open to all kinds of
unfounded assumptions. Helping the patient to grasp, in the immediate situation, the ways in
which he or she may be structuring his or her own self-mystification, or engaging in varying
forms of masochistic compliance and submission, for example, can serve to detoxify the analytic
field. Particularly in the context of more serious forms of pathology, where primitive transference
projections tend to evoke primitive countertransference responses, this kind of attention to the
interactive subtleties can prevent transference-countertransference from escalating out of hand,
and can help protect against varying kinds of unwitting collusive enactment. It also allows for
clarifying the specific nature of vulnerability to enactment where this is an issue.
This approach is in direct contrast to any idea that one should encourage a transference (or
transference-countertransference) neurosis or psychosis. In fact it becomes a way to protect
against this kind of iatrogenic possibility, and to maintain the safety and the analytic integrity of
the relationship. By protecting the patient from the potential humiliation of "going out on a
transferential limb, " and acting out (or acting in) where this might be a risk, the analyst
establishes that it is possible to work constructively with aspects of experience that otherwise
might be felt to be too threatening. This
- 18 -
allows for sadomasochistic fantasies, paranoid fears, or painful and potentially disturbing
memories and feelings to be rendered accessible and engaged analytically, where they might
remain inaccessible otherwise, and for repudiated and disavowed aspects of experience to be
reclaimed.
The effort is directed towards exploring impulses before they can become problematic. In
this way one facilitates a progressive, as opposed to regressive, process in which the patient is
helped to engage in the analytic exploration of potentially disturbing or disorganizing aspects of
his or her experience without being subject to breakdown, which can become humiliating and
debilitating, and without causing undue risk or provocation to patient or analyst. For many
patients the opportunity to discover that it is possible to contain, and to deal constructively, with
aspects of experience that may have been feared as too threatening, often constitutes an
important form of new experience which has a healing potential in itself, and can become a
basis for increased hopefulness and willingness to risk. It also contributes to the formation of a
solid working alliance as patient and analyst become collaborators in the analytic endeavor.
Here are some clinical data:
Sara, 2 a single woman in her thirties, who felt traumatized by her experience in a prior
treatment, ruminated for a year before finally deciding to call me. When she did she presented
herself in a state of acute anxiety. She seemed terrified, and was barely able to speak. She
asked to meet on a once-a-week basis, and since it was clear that she was not sure whether
she could even manage this, I agreed.
She spent the early months of treatment feeling nauseous and actually vomiting before
every session, and worrying she would vomit at the beginning of each session. She was often
late and left early. When she was present, she usually sat huddled in her coat literally shivering
and freezing even on days when it was quite warm. I would offer a blanket when she did not
have a coat, and I would offer to close the windows as she wished. She was profusely
apologetic about her state, and extremely solicitous of me. She worried about offending me or
being too much a burden. I emphasized
2 I wish to express my deep appreciation to Sara for giving her permission to publish this
material, and for her very thoughtful comments and suggestions.
- 19 -
that her anxiety was not something to apologize for or be ashamed of but what she was here to
deal with. She expressed her surprise about my patience and concern, and about my
tenderness at moments when she seemed to expect scorn and criticism.
She was truly puzzled as to what had happened in the prior treatment, and barely able to
talk about it, and we were unable to reach any understanding despite our efforts to do so. As I
tried to focus on her experience in the moment, however, she produced many associations. I
learned that she felt that her usual role in life had been to protect and take care of others, often
at her own expense, and that this was what she had assumed she would do with me. She
seemed to have no sense of entitlement to anything and no sense of any desires of her own. In
fact, she seemed resigned to getting nothing and to wanting nothing for herself.
In the period following, there were some seemingly inexplicable moments with Sara when I
would find myself becoming distracted despite her apparent great pain. One time when she
began to cry and I found my attention wandering I felt horror at my own insensitivity. Though she
barely even seemed to notice, I told her that I did not understand what had happened but I felt
the least I owed her was an apology. She brushed this off. I persisted and noted that as far as I
was aware, this kind of insensitivity was not typical of me and I tried to engage her as to her
ideas about what had occurred. To my surprise she replied, matter-of-factly, saying that this was
the typical way her mother responded to her whenever she had tried to talk to her mother about
anything. She reiterated her feeling that it was still no big deal to her now. I replied that as far as
I was concerned it was a big deal, and that from my perspective her failure to understand that it
was, and her willingness to accept this kind of treatment from me, or from anyone, without a
protest, seemed to me to be part of the problem. She said nothing.
Sometime later there was an instance in which we were virtually about to reenact a similar
scenario when I was able to observe her withdrawing precisely at a very painful moment and
pushing me away so subtly that we would never even have realized this was so had I not been
vigilant as a result of the earlier interaction. This allowed us to begin to try to clarify who in fact
had done what to whom, and in what order, then with her mother, as well as now with me.
- 20 -
Important associations to painful childhood experiences began to emerge in this context, I

found myself moved to tears as she described the extreme disappointments and hurts she had
endured, and the ways she had learned to cut herself off to protect herself. In these sessions
she described feeling, for the first time now, the pain she had not allowed herself to feel then.
She reported that it was only now, through our interaction, that she could even begin to imagine
that it could have been different then, and how much sadness this realization evoked.
The culmination of this early phase of our work was reflected in her awareness of an
increasing sense of the distress involved in having to wait a whole week between sessions and
a sense of hope and of urgency about now getting to work as intensively as we could. She
asked to increase our sessions to twice a week, and shortly thereafter increased again, to three
times a week.
The whole issue of "wanting" now became a central focus, as she began to want more from
me and from the treatment, and to let herself rely on the developing intimacy in a way she could
not have allowed earlier. She revealed that up until now the idea of "wanting" and being
disappointed had felt unmanageable, and the extent to which she had "protected" herself by
"wanting nothing." She described experiences of endless betrayals in her family, and how
"understanding could be used as a weapon."
Her experience had been that if she asked for something others would specifically go out of
their way to deprive her and to use her revelation of vulnerability against her. She elaborated
that she feared positive experiences because they led her to hope. It was easier to expect the
worst, or to expect nothing. Then she would not be disappointed.
In this context she revealed her desire for a "secret" relationship with me in which she "took"
in aspects of me and my room in a secret kind of way so as to protect herself from the risk of
rejection or betrayal that she felt she would open herself to if she were to ask for what she
wanted in an open way. She now confessed that she had actually been taking tissues from my
office in a deliberate way from the beginning of our work together. She had my tissues in the
pockets of everything she owned and it was comforting to her to know they were there. She also
revealed that before my vacation she had taken a small piece of my doormat to keep with her
while I was away, and that it had felt very comforting to her to know she had it.
- 21 -
Following this we were able to clarify a complex internal "code, " which she thought she
"got" from her mother, that one should want nothing and take nothing from others. She
elaborated the degree to which she had learned to "take" in such a way as not to admit she
takes in order to survive.
She noted that asking for things then had often led to rejection and humiliation. This led her
to wonder how she might learn to "soothe herself." She spoke of "taking in " my compassion in
place of her "self-contempt" and expressed her concern as to whether this was a form of
stealing.
As this was explicated she reported a complex combination of relief and apprehensiveness
as well as new curiosity and hope. She described feeling as though she "had had an infected
wound administered and cleaned out."
There were additional associations to the fact she never knew whether her parents would
be sober or drunk. She also described never knowing if there would be lunch money, and how
home was not only emotionally cold, it was physically cold. There was often no heat because oil
bills were not paid, and no food because there was no money.
As she reported a new realization of her fear that treatment would work, and that if this were
to happen it would constitute such a change it would be frightening, and that she would feel
indebted, there was a dramatic moment in which she finally felt warm enough to take off her
coat.
At a point about a year and seven months into the work, Sara asked to increase the
frequency of her sessions to four times per week. The issue of allowing herself to "want" more,
to ask for more, extended to her life outside of treatment as well as she reported wanting a
"better life, " wanting material things, especially clothes, and wanting a social life. She also
began to experience a very literal sense of physical hunger. She stated she now realized she
had never let herself feel such feelings before because she felt she could not have tolerated the
vulnerability. She also began to be concerned about her weight, her health, getting in "shape, "
and initiated efforts to give up smoking, alcohol, and drugs. In this context she reported the
following dream:
I was invited to a banquet, but I got involved in helping someone else who needed help, so
that I arrived at the banquet late. When I first
- 22 -
entered the room I was upset to realize that everyone else had finished eating and I was
sad as I thought that there was no food left for me. Then I discovered, to my surprise, that
there were many substantial things left and I was able to put together a really more than
satisfying plate for myself.
In the period following she made many important life changes, including moving to a new
apartment which involved assuming a major new financial burden, and taking a new and
challenging job. She was nervous and excited and quite conflicted since it meant at least
temporarily she would have to cut our meetings down to once a week but she felt determined to
improve her life situation.
In this context she began to focus on how devastated she had felt by the many
disappointments and betrayals she had experienced in relationship to her mother whom she
otherwise had perceived as quite caring; and there were associations to how violated she had
felt by a specific beating by her mother, that had been shockingly brutal, after which she had felt
frightened and ashamed to go to school because her bruises would have been seen.
The result of this phase of the work was that she began to allow herself to experience
feelings of anger as opposed to hopeless resignation, and she began to describe new feelings
of deprivation and envy, and of wanting things she had never allowed herself to want before.
She reported how angry she now felt that she could not afford to come four times a week, as
she had in the past. She stated:
I am afraid I will reach a point where I realize there is no hope for me That you will
know what I really wanted and was incapable of achieving. And I won't be able to
continue to pretend that things don't matter to me that really do matter.
Now she toyed with the idea of quitting treatment.
What emerged as we explored this was an acknowledgement that part of the motivation for
holding back, and for the anger, was to keep distance so as to protect me. She worried she
would be putting me at risk to really let me into her inner world. It was a way to protect herself
as well.
I expressed my view that it would seem a shame to have gone
- 23 -
through all of this only to give up now, and reiterated my commitment to continuing.
She told me how dumb I was, how naive, how grandiose, yet she seemed to be greatly
moved and encouraged.
In the session following, she expressed fears that I might betray her.
She reported a dream as follows:
I am in bed with a young man, much younger than me, whom I am "crazy about" in reality. I
am on top. We are not having intercourse but we are going to. At one point he says
something about my being on top so I roll over so he is on top and he penetrates me. And
then I remember we didn't use a condom and I leap up to get one. Then I am in an area
where there are a lot of people and I never go back to bed again.
Her associations were that she was afraid of letting someone get her to the point where she
would be responsive and she indicated that this was true in her relationship with me.
I don't want to let somebody put me in that place and then be betrayed maybe I feel
too opened here, too vulnerable. Maybe it's easier to be frustrated and angry. That is
like getting out of bed. I am afraid of being toyed with, being put in a place of being
responsive and then the other person doesn't really care. The game is to get me to be
responsive and then to hurt me.
There were many associations to her alcoholic father and the constant betrayal and
disappointment she had felt in that relationship. She described his constant false promises to
"get sober" and to be a "real dad, " and specific ways in which he had betrayed and humiliated
her, and her whole family.
The following week she reported a date (in reality) with the same young man she had been
in bed with in the dream reported earlier, and that they had had much fun together. She also
reported a dream that weekend in which she found herself "laughing and laughing, so hard and
so happily. I haven't laughed in a very long time."
In that session she stated that she had decided she wanted to meet three times a week
again despite the financial strain. She elaborated:
I am feeling more involved here and more anxious. Then I get angry and feel very
pushing away and disgruntled. Yet I feel grateful,
- 24 -
though I never tell you that. What I experience lately is feeling very lonely, wishing for a
relationship. The grateful part is that that is what I think I do feel, and what I should be
upset about, so even though it feels painful to me it feels right, I feel like I would
rather feel that than have that whole part of myself be dead or dissociated.
In the fourth year of treatment, following a period of financial stress in which Sara again had
to cut back to two sessions per week again, we had agreed to resume a three times-a-week
schedule. Unfortunately, due to unexpected circumstances, I had to delay this by a couple of
weeks. I apologized, saying I felt sorry, knowing how difficult it would be for her, and offered
makeup sessions, even though it was inconvenient, which I did not say to her. Sara, who had
been so deferential and attentive to my needs in the early period of our work, now was able to
express her anger and resentment unequivocally.
In the session following, however, Sara reported that she hadn't wanted to come to her
session that day, and had even considered quitting analysis altogether. She stated that it was
too painful to deal with disappointment because it reminded her of her family and the constant
despair she had always felt. Her view was that she didn't want to "hope" because she was afraid
she would only get crushed, here, now, as she been there, then. She stated, quite angrily, that
she felt I was "jerking her around" as she had always been "jerked around" in her family.
I was always waiting, waiting, waiting, for my father to be sober, for my mother to care.
It never happened. I was always left bereft. My mother would say "This is not the right
time, " but there was never a right time. Here it's too painful. I can't deal with the
feelings. My life is still the same. Nothing has changed and nothing will change.
I pointed out that assuming there never had been a right time between us before, and that
there never would be again, was not fair based on all we had been through together. I added
that by acting as though I had been totally insensitive by canceling, she seemed to be
insensitive to the fact that I had needs and problems of my own, and that I had not canceled
frivolously. In fact I had gone out of my way to try to make the sessions up precisely because I
knew how important it was to her.
She began to cry and acknowledged this was true. She stated that she was aware how her
reaction related so much to her relationship with her mother and provided more details about
how
- 25 -
this was so. She noted that the fact we could talk about our mutual feelings felt very different
from what had gone on in her family, and that "Whenever I exposed myself there I got crushed
and humiliated and told I was a fool."
She added that actually, even as bad as things could still be, she realized how much she
had changed simply by virtue of the fact she was no longer abusing drugs and alcohol, even
when she was very upset. Then, in a playful moment, Sara acknowledged that although she still
got upset when I disappointed her, she knew our relationship was different and she teased with
affection that she realized "she had to take the bad with the good."
Some sessions later, however, Sara's tone was again one of despair and blaming. She
again seemed to be preoccupied with her anger about the cancellations. She stated quite self-
righteously that I had canceled and I had hurt her.
What I began to realize at this point was that I was feeling put upon, and that I was offering
to make up sessions at times that were inconvenient for me.
As this began to crystallize in my mind, and without my having said a word about it, she
expressed concern that she was getting me angry and that she was being "too much." I replied
that as a matter of fact that seemed to be true. I added that I now realized that part of the
problem for me was that because I already felt guilty about canceling I was feeling especially
vulnerable to her attacks, and that this was my own issue. She seemed surprised at my
openness about this.
What we were able to establish in this session was that we seemed to again be involved in
a replay of the kind of entanglement she had gotten into with her mother. What became clear
was that instead of recognizing how unreasonable her mother's demands had been in the past,
or getting angry when her mother became emotionally or physically punitive when Sara could
not meet her demands, Sara got mad at herself for not being more capable. In some sense
what seemed to be going on between us seemed to be a reversal of roles in which I was
blaming myself for not being able to meet all of Sara's demands, rather than questioning her
expectation, or my own, that I should, much in the way Sara had felt with her mother.
My being able to recognize this had a liberating impact on both of us, and on our interaction.
- 26 -
I then noted that Sara seemed generally to expect that she should be superwoman and that
she was always taking on more than any person could humanly manage and then blaming
herself for not being able to do so. She seemed intrigued as she emphasized how correct this
sounded, and how relieving it felt to hear this, and she began to document the myriad ways this
was true, citing specific examples in the past and in the present, particularly at work.
We then were able to consider that the issue seemed to be how we each could be
respectful of the other and of our wishes to be there for the other, without violating our own real
needs and with due respect for our own human limitations, without feeling guilty. In this context
she reported that she now recognized that her assumption had been that I had canceled
thoughtlessly, and uncaringly. This, rather than the actual cancellation, was really what had
been most upsetting. She then stated how much it meant to her that we had been able to go
through the process we just had, and that this kind of intimacy was totally unlike anything she
had ever been able to engage in with her mother, or anyone else for that matter.
The following session she brought me flowers, and stated that she had felt a sense of
calmness after the last session that she hadn't felt ever before in her life.
Some weeks later when Sara began to distance again, and to express despair she was able
to acknowledge that this was "probably defensive" and a way she was protecting herself from
being disappointed.
As we tried to explore why she was feeling defensive and distancing from me now she
reported her belief that I preferred another patient, whom she had seen in my waiting room after
a recent session. At this point, in keeping with her imagery when she had described her fear of
being "jerked around" by me, I simply said she was being a "jerk, " being quite clear about my
affection for her.
I believe that had I taken a more noncommittal stance it would have been playing with her
emotions at a point when she was clearly risking a new level of vulnerability, and that it would
have been hurtful and counterproductive.
The following session she reported how frightened she was of
- 27 -
the intensity of her feelings for me. Talking about our relationship she stated: "The more it goes
on the more I defend myself. It's a defense like an air bag in a car. When I feel anxious or
vulnerable, or in further, then the air bag opens up. I would probably be psychotic if I didn't have
it."
I replied: "Maybe that is the key."
Sara responded: "That I would be psychotic."
I then replied: "Or a fear of that."
Sara's response to this was to reveal that:
When I am with another person, I often have the experience of intense fear that I am
going to go crazy or act crazy and that I won't be able to take care of myself, and that
the other person will not be able to keep it at a level that will allow me to feel safe and
trusting.
She continued:
In my prior treatment I felt I was insane. I couldn't work through any of this. My fear was
that I would have this dissociated feeling. It's like beginning to go a little psychotic. I
used to have it on dates too. It was a disaster. From early on, as a kid, I felt I was
being driven mad by my parents. I would go for long angry walks alone trying to keep
myself from going mad. I would have to get out.
I asked whether wanting to quit here, as she often stated she wanted to do, was out of fear
of going crazy if she stayed? And more specifically, was the fear that she might go crazy if she
"stayed" in her own feelings?
She replied:
I never stayed through those feelings before. I never stayed to see if I could come out
the other side. It never occurred to me that I could. I always assumed I would just go
crazy. It is a new idea to even think that it might be possible to get to the other side. To
think maybe I can work this through
In the next session she reported that she had been totally exhausted after the last session.
She felt exhausted in "every bone of my body."
Then she had dinner with her sister-in-law and:
Something on a new level happened. At a moment when I would have dissociated, I
didn't! I felt less crazy about going crazy in the moment!
- 28 -
As we went over the details of what had occurred she described her sister-in-law reporting
how her son, Sara's nephew, lies, and how his father had yelled at him about this. Sara
reported:
That is when I would have gone off, I would have dissociated, because I would have
thought to myself "my brother is a liar." Instead I told my sister-in-law "but my brother
lies a lot."
Sara stated that the fact she was able to hold onto her own perception, and even to share it,
and to argue for it, when her sister-in-law tried to make excuses for her brother, seemed
momentous to her. She went on to elaborate how the kind of denial of reality that her nephew
was being subjected to was typical when she was growing up and "could drive you crazy."
She stated:
I went home feeling manic. I knew I was identified with my nephew. I knew exactly what
he was going through then over the weekend I had a very vivid memory of
something I had forgotten for all my life, of being the only person in my family who
called my father an alcoholic. I might have been in Junior High School. And he charged
at me. He physically charged at me. And actually this happened many times. And when
I would tell my mother he was an alcoholic she would not respond. She would not
engage in it with me at all.
I believe that the level of encounter and intimacy integral to my relationship with Sara, and
the painstaking attention to all the interactive details to prevent the escalation of toxic
transference-countertransference developments, enabled Sara to feel secure and safe enough
to begin to engage aspects of her own experience that had been much too threatening and
overwhelming for her to deal with earlier without dissociating.
The fact that she was ultimately able to analytically engage very disturbing material without
becoming "psychotic, " and/or destructive as she had feared, was a healing experience itself
that allowed her to discover a potential in herself she had not anticipated.
It may be of interest that Sara, after reading this, reported:
I think you really touched some deep emotion. I had an image, like an archeological dig,
of a deep chamber inside opened, not with ease. It was
- 29 -
like the antechamber of a tomb. There was all this stuff in there. Two people were
standing at the edge of it. One was you and one was me. I did not want anything to be
touched. I took the position it's not right to open this thing up or disturb any of these
things inside. They will crumble. And you took the position that they should be looked at
and explored.
In a session following, returning to this image, she noted her belief that if I had not been
receptive to working with her, or if our work together had not been productive, "instead of
standing at the edge of the chamber and worrying what to do I would have put something over it
and weighted it down and I don't think I would have come up again."
REFERENCES
Ehrenberg, D. B. 1974 The "intimate edge" in therapeutic relatedness Contemp. Psychoanal.
10:423-437 []
Ehrenberg, D. B. 1982 Psychoanalytic engagement: The transaction as primary data Contemp.
Psychoanal. 18:535-555 []
Ehrenberg, D. B. 1984 Psychoanalytic engagement II: Affective considerations Contemp.
Ehrenberg, D. B. 1985 Countertransference resistance Contemp. Psychoanal. 21:563-576 []
Ehrenberg, D. B. 1989 Beyond words: Affective communication and experience, and enactment,
in the psychoanalytic relationship Also in a forthcoming book to be published by W. W.
Norton & Co., Inc., 1992
Ehrenberg, D. B. 1990 The role of encounter in the process of working through: Some
reflections on the nature of therapeutic action Also in a forthcoming book to be published by
W. W. Norton & Co., Inc., 1992
Fromm-Reichmann, F. 1939 Transference problems in schizophrenics Psychoanal. Q. 8:412-
426 []
Fromm-Reichmann, F. 1950 Principles of Intensive Psychotherapy Chicago: University of
Chicago Press.
Fromm-Reichmann, F. 1952 Some aspects of psychoanalytic psychotherapy with schizophrenia
In:Psychotherapy with Schizophrenics E. B. Brody and C. F. Redlich (ed.). New York:
International Universities Press.
Klauber, J. 1981 Difficulties in the Analytic Encounter New York: Jason Aronson.
Lacan, J. 1958 The direction of the treatment and the principles of its power In:Ecrits New York:
W. W. Norton, 1977 translated by A. Sheridan.
Lipton, S. 1977a The advantages of Freud's technique as shown in his analysis of the Rat Man
Int. J. Psychoanal. 58:255-274 []
Lipton, S. 1977b Clinical observations on resistance to the transference The Int. J. Psychoanal.
58:463-472 []
Lipton, S. 1983 A critique of so-called standard psychoanalytic technique Contemp. Psychoanal.
19:35-46 []
Little, M. 1951 Countertransference and the patient's response to it Int. J. Psychoanal. 32:32-40
[]
- 30 -
Little, M. 1957 "R" The analyst's total response to his patient's needs Int. J. Psychoanal.
38:240-254 []
Searles, H. 1965 Collected Papers on Schizophrenia and Related Subjects New York:
International Universities Press.
Stone, L. 1954 The widening scope of indications for psychoanalysis J. Am. Psychoanal. Assoc.
2:567-594 []
Stone, L. 1961 The Psychoanalytic Situation New York: International Universities Press.
Tauber, E. 1954 Exploring the therapeutic use of countertransference data Psychiatry 17:331-
336
Winnicott, D. W. 1949 Hate in the countertransference In:Collected Papers: Through Paediatrics
to Psycho-Analysis London: Tavistock Publications, 1958 []
Winnicott, D. W. 1956 On transference Int. J. Psychoanal. 37:386-388 []
Winnicott, D. W. 1969 The use of an object and relating through identifications In:Playing and
Reality New York: Basic Books, 1971 []
- 31 -

Ehrenberg, D.B. (1992). On the Question of Analyzability1. Contemp. Psychoanal., 28:16-31
1986). International Review of Psycho-Analysis, 13:453-461
The Occasional Question in Psychoanalytic Assessments
Fred Busch
It is striking that with the increasing literature on analysability, the method of assessing
analysability has received scant attention. This statement is similar to one made over twenty-
five years ago by Rosen (1958). In his article Rosen raised the issue of modification of the
method of free association in the assessment process. Crediting Stone (1954) with initiating the
idea, Rosen suggested that a more active inquiry might be necessary to judge analysability.
This was seen as necessary to diagnose the wider range of patients coming to analysis, and the
more subtle questions thus being raised about analysability. The issue of how actively the
analyst should question the patient, and how this fits with a generally analytic stance in the
interview process, is still a question today and the subject of this paper.
Freud wrote little about the assessment process, but was clear in his disdain for questioning
a prospective patient. Trial analysis was his method for assessing analysability and he stated,
'No other kind of preliminary examination is at our disposal; the most lengthy discussions and
questionings in ordinary consultations would offer no substitute' (Freud, 1913). According to
Rosen (1958) almost nothing was said then about the interview process for over forty years.
Stone (1954) seems to be the first analyst to question the trial analysis as the ideal technique
for assessing analysability, while also advocating the usefulness of questions. He states,
In his response or manner of response, or non response to questions, the patient may
tell us much that might be expected to appear in a diagnostic 'free association'
interview; often more because certain questions cannot be evaded, at least from an
inferential point of view. In his longitudinal history, and in the current patterning of the
patient's activities, one can learn much of the personality structure which underlies the
symptoms (Stone, 1954, p. 590).
Thus Stone suggests there are certain areas that the patient might not spontaneously refer
to which might fruitfully be explored with questions.
In the many articles that appear on analysability since 1954, the issue of asking questions is
often touched on, but only tangentially or implicitly. Waldhorn (1960) suggests that the use of
active interviewing techniques needs to be investigated further, while Knapp (Panel Report,
1960) warns against interfering with the transference by too thorough an evaluation. Studies of
the type of data necessary to judge analysability (Lower et al., 1972) ; (Huxter et al., 1975) ;
(Lazar, 1976) indicate that certain areas might need to be asked about if they are not
spontaneously raised by the patient, but the technical implications of this are not dealt with
directly. Bachrach & Leaff (1978) note the thread of a disagreement running through the
literature on how actively the analyst should question the prospective patient, but turn to the
issue of other methods (e.g. psychological testing) as aids in the assessment process.
Erle & Goldberg (1979) touch on the interview process briefly when discussing problems in
assessing analysability. Active inquiry into certain areas of the patient's life during the
assessment phase is viewed by them as improper technique, with a return to reliance solely on
the method of 'free association'. Thus, the authors state,
The analyst attempts to alter the flow of the material as little as possible. The
spontaneous sequence of the patient's thoughts, including noticeable omissions, is part
of the data. The analyst does not attempt to expand the inquiry during the consultation,
except to clarify some issue (p. 71).
(MS. received October 1985)

Copyright Fred Busch
- 453 -
Thus, Erle & Goldberg return to Freud's initial view of the interview.
There has only been one article devoted exclusively to the psychoanalytic assessment
process and that is very recent (Shapiro, 1984). In this article Shapiro returns to Freud's view of
the assessment process. He states, 'The approach I have evolved encourages the associative
procedure from the outset. The point of view and the instruction to the patient are the same as
articulated by Freud ' (Shapiro, 1984, p. 12). While agreeing with many of the techniques
suggested by Shapiro in his article, I believe that for analysts to use 'free association' as the
only sound technique in their assessment armamentarium would be a mistake. The asking of
questions is frequently useful in making differential diagnoses, is often necessary (e.g. in
assessments for the psychoanalytic clinic), and consistent with sound analytic technique. In this
view of questions I am not advocating a return to a position like Saul's (1957), who suggests
eighteen main areas with fifteen sub-areas to be covered in the interview process. I am
suggesting that the occasional question is a useful adjunct to the 'free association' method.
THEORETICAL PERSPECTIVES
There is almost nothing written on the theory behind using the 'free association' method
exclusively in conducting analytic interviews. Shapiro (1984) speaks to his reasons for not
asking too many questions when he states,
In so doing the ego of the patient is bypassed, as in hypnosis, and resistance as a
dynamic force is obscured. Taking over control of the direction of the patient's thoughts
by asking questions bypasses not only resistances in the unconscious sense, but it also
bypasses those that are quite conscious but suppressed (Shapiro, 1984, p. 12).
I believe this to be erroneous from a number of perspectives. First of all it reflects the
confusion between pre-analytic interviews and analysis in that resistance is a term generally
reserved for a process that occurs once analysis begins (Moore & Fine, 1968). This touches
the crux of one significant issue which is, 'How much the initial interviews are the beginning of
an analysis v. an assessment of the person's capacity to undertake such a process.' I would
suggest that one aspect of the complexity of the assessment process is, in part, due to
balancing these two perspectives. That is, while a process is being started, the analyst needs
certain information to know if the process is applicable to this patient and, if it is, how it might
best be utilized.
I start from the premise that certain information can be useful in making a judgment as to
whether a patient is analysable, and in determining what factors might need to be considered
when starting an analysis.1 But how does one obtain this information? Shapiro's position leads
the interviewer to the assumption that any piece of information which might be useful for
diagnostic purposes cannot be raised until the prospective patient brings it up, because this
would be bypassing a defence.2 However, this is not necessarily the case. Let us look at the
example of asking a question about events from childhood, and let us assume further that the
patient imparts information that seems particularly significant in light of his symptoms or
character. Can we say that the patient must have been defending against imparting the
information or else it would have spontaneously come up in his associations? Not necessarily.
In most cases it is not the historical information itself that is being defended against, but the
affective meaning of the event, along with its accompanying fantasies, and its relationship to the
patient's symptoms that leads to defences being instituted. For example, when asked about
childhood illnesses a man being seen for an evaluation told of being immobilized in a body cast
for six months at around the age of 3. It was only after a number of years of analysis that this
brilliant scholar, with only a mildly successful career and problems in establishing relationships
with women, could see his symptoms were a defence against fantasies that his enforced
passivity was due to phallic pursuits and his mother's sadistic retaliation. His defences were not
erected against knowledge of the event itself. He had always known it. Asking the question
about childhood
1 The reasons for this will be elaborated in the next sections of this paper.
2 Here I am substituting the 'defence' for 'resistance', and still staying within Shapiro's basic
meaning.
3 One important exception to historical information itself not being defended against is when
there has been ongoing sexual abuse in childhood. Even when the patient 'knows' of this
behaviour the pleasurable aspects make it shameful due, in part, to the immature ego's inability
to distinguish its own role in bringing about the sexual pleasure.
- 454 -
illnesses thus circumvented no defences. What was defended against but which was not
challenged in the evaluation was his phallic use of this knowledge for his own purposes.3
Determining when a prospective patient is bypassing an area for defensive v. other reasons
is one of the many challenges in the assessment process. In general, if an individual is talking
about an area and something is glaringly left out, then it is probably safest to assume a defence
is in operation and to deal first with the defence (if one thinks it is important to inquire further).
An example of this would be a discussion of various family members where a parent or sibling is
not mentioned. However, we cannot assume that whatever is left out is being defended against.
As noted above, this ignores the complexity of what is being defended against, but it is also a
denial of patients' navet regarding the importance of past events in current problems.
Furthermore, the assumption that anything the patient doesn't raise spontaneously is due to a
defensive process is a simplification of the potential dynamics in a first meeting between
prospective patients and analyst. In this formulation there is no room for material being left out
based, for example, upon an unconscious fantasy being enacted or expectations derived from a
previous treatment.
Vignette 1
Upon beginning the first evaluation session Mr L, a young man in his early twenties, started
talking about his parents' deprivation of him. His dramatic tale was immediately punctuated by a
torrent of affect, including screaming outbursts and intense sobbing which took up much of the
first session. As I became increasingly concerned about Mr L's regressive state, I asked him if
he was overcome by such intense emotions much of the time. To my surprise, his response was
something like, 'Of course not'. When I questioned him further about his affective display, Mr L's
thoughts led him to his previous therapy with a primal scream therapist. In this therapy
emotional outbursts were highly prized and rewarded by the therapist. When Mr L realized that
this behaviour was not a necessary component of the analytic situation, he could go on to his
reasons for seeking analysis.
There are many tasks required of an analysand in analysis which have remained
unelaborated for assessment purposes. While the prospective patient's reality testing would
certainly be noted in any assessment, what about that same individual's ability to meet the
reality demands of an analysis? The patient who tells us an elaborate dream while neglecting to
mention that his wife moved out of the house may be engaging in a travesty of the analytic
process. Obviously anything in the analysis, including free association, can be used in the
service of defences (Greenson, 1967). Thus, to ask about certain realities in the patient's life
(current and past) in the analytic interviews is also to gauge how the patient might react to one
requirement of an analysis. The patient who resents talking about his work, family, or finances
because they aren't 'his problem' may be the patient who sees analysis as unconnected to the
rest of his life. While potentially an analysable problem, an excessive defensiveness over
discussing 'realities' may be an indication of an insurmountable resistance. How an individual
views the analyst's need to know certain information may tell us much about his or her desire for
self exploration in the face of discomfort.
Vignette 2
Miss A, an attractive 28-year-old woman, sought analysis after a brief psychotherapy
because of longstanding difficulties in relationships with men. Miss A was involved for several
years with a man in a mutually dependent, clinging relationship. With the help of her previous
treatment Miss A became dissatisfied with this situation, but described continuing the
relationship until she could find a replacement. This raised questions for me about the
regressive v. progressive forces in her personality, with specific concerns about her ability to
separate. However, in describing what she meant by 'finding a replacement', I
- 455 -
noted Miss A had become a bit vague. When I asked Miss A if she could tell me more about this
she was briefly silent. Miss A then described having felt panic stricken, as if she was totally
alone. This was then related by her to the feeling she was afraid of when reluctant to leave one
man for another.
Miss A's ability to experience and observe a disquieting feeling, report it, and then relate it to
her problems in leaving a man was an impressive piece of work. This process was, indeed,
repeated many times during the interview. Whenever Miss A came upon a difficult topic she took
the psychological equivalent of a deep breath, and launched into a full exploration of what she
was feeling. Her capacity to work within the assessment interview while experiencing discomfort
seemed an excellent prognostic sign, and mirrored Miss A's ability to function effectively in
school and work situations at times of inner turmoil.
There are times in the pre-analytic interviews when the asking of even the occasional
question is contraindicated. This occurs when the defence is against the sharing of any
information. It can take the form of the patient becoming excessively silent, vague, suspicious,
or belligerent. At these times the asking of questions will intensify anxiety, and increase the
defences against telling the analyst more. When this occurs, the defences need to be worked
with, and the individual's suitablity to cope with the regressive aspects of the analytic situation
are often judged upon the outcome. However, this is different from those situations where the
occasional question is asked within the context of a patient sharing information with a minimum
of defences against this process.
Vignette 3
Miss D came to her first appointment several minutes early in an upset state. She
immediately complained to the candidate that her office was difficult to find because there was
no directory listed in the building. The candidate remembered thinking she had told Miss D this
at the time of their first phone contact, and had given her a way to identify the office. However,
thinking it might be possible she had forgotten and seeing Miss D's upset state, the candidate
decided to recognize the difficulty this must have caused her. Miss D then launched into a series
of questions on how the decision would be made on whether they worked together. The
candidate felt the patient needed to be calmed down, and reassured her that this decision would
be made mutually. Feeling that Miss D was no longer so upset, the candidate asked her why
she was seeking analysis. After describing how she works well with many different types of
people, Miss D enumerated numerous problems with her aggression and defences against this.
After a few sessions, Miss D told the candidate she felt they couldn't work together. What
emerged was that prior to the first session, in their phone contact, Miss D reacted to what she
heard as the softness of the candidate's voice. She remembered thinking, 'This person isn't
strong enough to deal with me'. In spite of the candidate's excellent attempts to work with Miss
D around this issue, she decided to seek treatment elsewhere.
In this case the bypassing of initial defences via reassurance and asking questions may
have been one contributing factor in the patient's decision not to continue with this analyst. Miss
D's initial entry of 'something you didn't say on the phone upset me' could now be seen as a
negation of her reaction to the candidate's voice. The candidate sensed this when she thought,
'Why is Miss D upset over something that didn't occur on the phone, when it did?' With Miss D's
question about how the two of them would decide on whether to work together, we can see the
defence against her thought that she and the candidate could not work together. Finally, Miss
D's opening comment on how she works well with all kinds of people can be seen as a reaction
formation to her thoughts on the phone of, 'I can't work with you'. The candidate's question of
why Miss D was seeking analysis was the opposite of what was on Miss D's mind at the time.
The question that needed to be asked was why Miss D was not interested in analysis, as least
with this particular analyst.
The prospective patient coming into an assessment with strong affective reactions is one of
the most difficult situations for an analyst to deal with. However, to bypass the affect via
questions or support is to miss the salient dynamic, often with unfortunate consequences. It is
worth noting again, though, that this is a different situation from the individual generally
amenable to talking
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about many areas, but where certain information is left out.
THE QUESTION OF DIAGNOSIS

Studies attempting to elucidate factors important in determining analysability have fallen into
disrepute. Bachrach & Leaff (1978) assert that while studies on analysability consistently
suggest the patient's level of ego functioning and object relations are significant factors in
determining analysability, these capacities are usually defined in metapsychological or abstract
terms, making them difficult to assess. Erle (1979), Erle & Goldberg (1979), (1985), and Weber
et al. (1985) view the results of assessing analysability as discouraging, and seem ready to
throw in the 'assessment towel'. They come to the pessimistic conclusion that analysability
cannot readily be assessed until the end of analysis. While in some sense this line of argument
is unassailable, and even though a number of excellent observations on the complexities of the
assessment process are made by these authors, it seems premature to state,
We think it would be more accurate to say that such attributes as ego functions and
oedipal pathology often cannot be adequately assessed at the onset and that we must
study more systematically when and why they can not be, how this situation might be
improved, and what may remain as a limitation of initial assessments (Erle &
Goldberg, 1979, p. 58).
This evaluation seems especially untimely given how little attention has been given to the
assessment process itself.
Why are we as analysts unwilling to talk about the assessment process, and why are we so
willing to give up on it? Twenty years ago Anna Freud (1965) suggested that analysts are
uncomfortable with the assessment process and the data from it. This is especially true when it
comes to the type of objective data obtainable through asking questions. Historically this stems,
in part, from the need of the psychoanalytic pioneers to distinguish between unconscious
meaning and conscious thought.
It is not surprising that under conditions of this kind, all students of psycho-analysis
were warned off such attempts at surface observation, were taught not to by-pass
patient analytic unravelling of the repressions, and to have no dealings with methods
which could only constitute threats to the analysts' principal task of perfecting the
analytic technique itself. It is not surprising either that, at the time, the skill of diagnosing
was neither taught nor regarded as highly significant in psycho-analytic work (p. 33).
Every day our analytic work teaches us to look beyond what is conscious, or what is
presented as 'reality', to find the meaning of a piece of behaviour, a symptom, or an event.
However, it is too simplistic, then, to come to the conclusion that what is conscious or presented
as reality is insignificant. For example, forty years of observational studies have shown us the
importance of the consistent presence of the primary object for ego development, object
relations, and the management of affect. Yet the maternal presence or absence in the home is
often not asked about in assessments, and a patient's statement like, 'My mother always
worked' is often not followed by a question of clarification. This in spite of the fact that we know
the meaning of a mother going back to work when the child is three months, while the child is
left with a series of baby-sitters, will probably be quite different than if a mother starts to work
part-time when a child goes to school, and works only the hours the child is in school.
In her study of analysed cases, Erle (1979) reports a change in diagnosis from the initial
assessment in almost half of the cases. She suggests this is due, in part, to important historical
information being revealed in the analysis. Since the assessment process itself was not under
scrutiny we do not know if crucial historical information was: asked for; asked for but distorted;
or asked for and not given. We also do not know the nature of the historical information, and
whether it might have been obtainable by questioning the patient. Often there are areas of
information not spontaneously revealed by the prospective patient which, by a simple question,
can reveal data significant to a diagnosis and the manner in which we would conduct the
analysis.
Vignette 4
Mr R was 31 years old when he came for an evaluation because of difficulties in getting his
work done. This problem had plagued him since
- 457 -
beginning college, and he told no one that he hadn't completed his last college course and thus
had no degree. At his current job his bosses were continually on him about his getting work in
late. His mother was a dominant force in his life, and still remained a confidante with regard to
his work difficulties. His presentation of himself was as a person with few pleasures in his life.
Mr R was diagnosed as having a neurotic depression with obsessional features. His work
difficulties were seen as a regression from competitive strivings (his father was in the same
field), while holding on to the mother in a less threatening manner.
Upon entering psychotherapy with a female therapist, Mr R immediately started feeling
deprived. He felt he had to wait too long for help, and thought there were other kinds of
treatment 'out there' he could not partake of because of the treatment he was in. The therapist
saw Mr R as withholding involvement due to a regression from sexual feelings towards her.
When I became involved in the case as a supervisor, Mr R was making plans to leave
treatment. I suggested to the therapist she both empathize with and ask Mr R about these
feelings of 'having to wait too long', and there being something better 'out there'. In response to
the therapist raising these issues, Mr R mentioned in passing one session that his mother had
been hospitalized from the time he was six to eleven months old, at which time he was taken
care of by various relatives. The therapist did not know how to integrate this information with Mr
R's increasing anger towards her, and he left treatment shortly thereafter.
There is no guarantee that the information regarding Mr R's mother, had it come out during
the evaluation, would have salvaged the case. However, it is likely that it would have changed
the orientation of the therapist going into the case, and might have pointed to a way of dealing
with possible ego deficits within the transference. One might have thought of Mr R's depressive
affect as a way of managing feelings that might get out of control. The time when his mother
was away is a crucial one in terms of management of affect tolerance, and the beginning
internalization of self soothing. Thus, in such a case the therapist would have to be very
sensitive to affect disturbances. The transference reaction of not being able to wait, and feeling
there was something better he was kept from, could be seen as a repetition of the mother's
leaving and reactions to that. Any attachment to the therapist in conjunction with waiting (i.e.
waiting for an appointment, waiting for the therapist to speak) would become associated with the
probably unbearable frustration of waiting for the return of the mother's face. Alternately, the
therapist being seen as the one who was keeping him from something good would indicate she
had become the relative keeping his mother from him. His secret, in which he kept something
from other people, could now be seen as an identification with the aggressor, while his
symptoms kept him in close proximity to his mother.
There are many psychoanalytic situations where the question of differential diagnosis is
crucial. Nowhere is this seen more clearly than in the psychoanalytic clinic where patients are
screened as potential control cases. In the clinic setting we are asked to make decisions that
have a great impact on patients and candidates alike. In making our differential diagnoses I
think we once again have to turn to the area of ego functioning. This is because symptoms and
character patterns take on different diagnostic meanings with different levels of ego functioning
(e.g. Zetzel, 1968), and this is the area most available to us in the analytic assessment. Various
historical facts and characteristic patterns of action give us a window into the ego that needs to
be explored, not ignored. Separations from primary objects, childhood illness, multiple
caretakers, and divorce are just a brief listing of the historical events in a patient's life that can
have a profound effect upon ego functioning. The earlier the event the more likely will be the
disturbing effect upon such things as affect tolerance, ways of thinking, and defences. While the
specific effects of such events upon ego functioning remain to be spelled out, it is only with
consistent analytic attention in conjunction with child observation that we will better understand
these events. As Anna Freud has stated,
While the analytic diagnostician finds himself at a disadvantage in these areas
compared with the analytic therapist, his status improves decisively with the inclusion of
ego-psychology into psycho-analytic work. So far as ego and superego are conscious,
direct, i.e. surface-observation, becomes an additional legitimate tool of exploration
leading to assessment of development (p. 37).
- 458 -
There was a trend in psychoanalytic research in the 70's where how decisions on
analysability were made in the psychoanalytic clinic was the subject of investigation (Huxter et
al., 1975) ; (Lazar, 1976) ; (Lower et al., 1972). These studies consistently came to the
conclusion that experienced analysts weighed the role of ego functioning most heavily when
considering analysability. While these studies came in for later criticism, I believe they were
leading in a positive direction and spoke to crucial factors in differential diagnosis. For example,
how a prospective patient manages the task of living can be easily determined with a few
questions, and gives important clues to his level of ego functioning. A 28-year-old man coming
to treatment because of difficulties in getting along with women will probably have a different
prognosis if he has only rarely dated than if he had been involved in at least some long term
relationships. In the first situation we see an ego warding off experiences in a manner that goes
beyond what one might expect with neurotic anxiety or guilt. If a prospective patient comes in
describing work difficulties, it is of likely significance whether he has achieved at least a
moderate degree of success in this area, or whether there has never been a time when he's
been able to function effectively in school or work. Many of these adult tasks of living and their
relationship to functioning in analysis were enumerated by Waldhorn (1960) and will not be
gone into at this point. Our child colleagues have known about this type of inquiry for years, and
meticulously gather data from the child's parents and school to see how the ego has mastered
crucial developmental tasks (e.g. developmental conflicts, school performance, friends, etc.).
DISCUSSION
A straw man has been set up in discussing psychoanalytic assessments when these are
portrayed as utilizing the associative v. the anamnestic approach. The latter conjures up visions
of an interviewer poised with pencil and paper, armed with an outline for detailed questioning,
from which the patient's spontaneous verbalizations are an interference with the task at hand.
One component of our current dismal view of the assessment process may be based upon how
we see asking questions as being in stark contrast to the 'analytic' method.
While I believe we have to investigate the role of the occasional question in analytic
assessments, the associative method, with certain additions, still needs to be the cornerstone of
an assessment. The additions I refer to are those suggested by Lipton (1977) when he states,
If a patient has done no more than telephone an analyst, or enter his office, that does
not mean that he has entered an esoteric sanctuary where, without explanation, he is
suddenly confronted with a technical barrier of unresponsiveness and passivity (p. 267).
At a minimum there needs to be an introduction to the assessment process which includes
some structuring (i.e. how many times we expect to meet, what we hope to accomplish, etc.),
and a statement from the analyst as to what is expected from the patient. Given such an
introduction, the associative method serves as a guideline to the interview with the interspersing
of the occasional question where relevant. Rather than being anxiety-provoking, questions can
be anxiety-reducing. The prospective patient entering the analyst's office for the first time is
understandably anxious. With appropriately timed questions we: express our interest in what the
patient is telling us; stimulate his curiosity about aspects of his life he hasn't thought about; give
some structure to the meeting; and show our understanding of what kinds of information might
be helpful in explaining behaviour. From this perspective questions can have a facilitative rather
than disturbing effect upon the beginning of the analytic process.
I haven't elaborated a list of questions, since any questions that might be asked are patient
specific. Thus, with some patients there will be few questions that need be asked, and with
others the questions will focus on particular areas. The nature of the areas to be questioned will
sometimes arise from the information the patient is telling us, at other times from his style of
interacting and manner of imparting information, and at still others from what is left out of what
he tells us. What I am suggesting is that in the analytic assessment we move between the
position of active listener to occasional questioner based upon the spontaneous verbalizations
of the patient. Using our knowledge of development and
- 459 -
character formation as a guide, we will be led to certain questions.

The two broadly defined areas I have suggested might be useful to keep in mind when
undertaking an assessment are potential developmental interferences from childhood, and how
the prospective patient has handled the developmental tasks of adult life.
A 'developmental interference' can be defined as whatever disturbs the typical unfolding
of development. The term may be reserved to describe those situations that involve
gross external (environmental) interference with certain needs and rights of the child or
situations in which unjustified demands are made of the child. In making such demands
the environment frequently does not take into account the child's lack of ego capacity to
comply or cope with them (Nagera, 1966, p. 28).
In looking at those events from childhood which might serve as interferences with
development, we are searching for possible stress on the developing ego which might alter
ways of thinking, the capacity for relationships, and proneness to regression. Examples of such
interferences have been mentioned throughout the paper, and are crucial in determining both
analysability and the special factors which need to be considered if analysis is undertaken.
In asking about an individual's response to various tasks of adult life we are looking for the
ego's response in situations, which will tell us about methods of adaptation, which in turn will
alert us to ways of meeting the demands of the analysis. In this I am reviving Waldhorn's (1960)
formulation, an example of which is,
Analysis requires, for example, a reasonable tolerance of frustration. This is necessary
for several reasons. It is an essential feature of required secondary process thinking,
with characteristic postponement of action, and delay in seeking of gratification. It is
also required to achieve the gradual accumulation of data leading to logical
organization of thought and insight. A further demand for tolerance of frustration is the
consequence of the rule of abstinence on the part of the analyst; also to be patient in
the inevitable delays in attaining the insights that result in therapeutic developments in
the face of suffering and sacrifice. Infantile and narcissistic individuals who during their
lives have been unable to form or sustain object relationships, or lack the ability to
persist in serious work, may therefore give us some concern about potential
analyzability. Patients who exhibit obvious inability to wait on the telephone or in the
consultation room, or those who are quick to seek release from tension in alcohol, food,
drugs, or other compulsive behavior, may well be indicating a significantly low tolerance
for frustration at the very start of their contact with the analyst (Waldhorn, 1960, p.
492).
Our alertness to useful information gathered via questions is no guarantee of infallible
predictions from assessments. There still remains the large task of integrating our data into
workable hypotheses. For example, can developmental interferences be overcome by special
talents, counter-balancing environmental forces, or the use of special techniques in analysis?
These are questions which have been given different answers in the literature at different times.
What is of concern is that by not asking questions in the assessment process, important
diagnostic issues may become submerged. Treating a case with developmental interferences as
a neurotic can so skew the course of treatment that important areas for analytic investigation
become lost.
The assessment interview is one of our most difficult tasks as analysts. We meet a stranger
and, in a short period of time, attempt to engage him in an analytic process. This occurs while
many of our usual methods for understanding are not available to us (i.e. established
transferences, resistances, working alliance, etc.). We then ask ourselves to make a diagnostic
formulation and recommendation that will have significant consequences for this individual, our
work life, or in the clinic for our candidates. In such a situation the rigidification of technique
seems potentially defensive. My suggestion of a role for the occasional question is, in part, an
attempt to allow us to re-think the issue of pre-analytic assessments once again before it is
assigned to its customary position of benign neglect.
SUMMARY
Little attention has been paid in the analytic literature to the assessment process. The
prevailing view that questioning the prospective patient only bypasses defences is challenged.
The necessity of asking questions for diagnostic purposes is elaborated. The suggestion is
made that the two broad areas where questions might fruitfully be asked for diagnostic purposes
are possible developmental
- 460 -
interferences and the patient's response to the developmental tasks of adult life.
REFERENCES
BACHRACH, H. & LEAFF, L. 1978 'Analyzability': A systematic review of the clinical and
quantitative literature J. Am. Psychoanal. Assoc. 26:881-920 []
ERLE, J. 1979 An approach to the study of analyzability and analyses: The course of forty
consecutive cases selected for supervised analysis Psychoanal. Q. 47:198-228 []
ERLE, J. & GOLDBERG, D. 1979 Problems in the assessment of analyzability Psychoanal. Q.
47:48-85 []
ERLE, J. 1985 Observations on assessment of analyzability by experienced analysts J. Am.
FREUD, A. 1965 Diagnostic skills and their growth in psycho-analysis Int. J. Psychoanal. 46:31-
38 []
FREUD, S. 1913 On beginning the treatment S.E. 12 []
GREENSON, R. 1967 The Technique and Practice of Psycho-analysis New York: Int. Univ.
Press.
HUXTER, H., LOWER, R. & ESCOLL, P. 1975 Some pitfalls in the assessment of analyzability
in a psychoanalytic clinic J. Am. Psychoanal. Assoc. 23:90-107 []
LAZAR, N. 1976 Some problems in faculty selection of patients for supervised psychoanalysis
Psychoanal. Q. 16:416-429 []
LIPTON, S. 1977 The advantage of Freud's technique as shown in his analysis of the Rat Man
Int. J. Psychoanal. 58:255-274 []
LOWER, P., ESCOLL, P. & HUXTER, H. 1972 Bases for judgments of analyzability J. Am.
MOORE, B. & FINE, B. 1968 A Glossary of Psychoanalytic Terms and Concepts New York:
Amer. Psychoanal. Assn.
NAGERA, H. 1966 Early Childhood Disturbances, the Infantile Neurosis, and the Adult
Disturbances New York: Int. Univ. Press.
PANEL REPORT 1960 Criteria for analyzability J. Am. Psychoanal. Assoc. 8:141-151 []
ROSEN, V. 1958 The initial psychiatric interview and the principles of psychotherapy: Some
recent contributions J. Am. Psychoanal. Assoc. 6:154-167 []
SAUL, L. 1957 The psychoanalytic diagnostic interview Psychoanal. Q. 26:76-90 []
SHAPIRO, S. 1984 The initial assessment of the patient: A psychoanalytic approach Int. J.
Psychoanal.. 11:11-25 []
STONE, L. 1954 The widening scope of indications for psychoanalysis J. Am. Psychoanal.
Assoc. 2:567-594 []
WALDHORN, H. 1960 Assessment of analyzability: Technical and theoretical observations
Psychoanal. Q. 29:478-506 []
WEBER, J., BACHRACH, H. & SOLOMON, M. 1985 Factors associated with the outcome of
psychoanalysis: Report of the Columbia Psychoanalytic Center Research Project (II) Int. J.
Psychoanal.. 12:127-142 []
ZETZEL, E. 1968 The so-called good hysteric Int. J. Psychoanal. 49:256-260 []
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Busch, F. (1986). The Occasional Question in Psychoanalytic Assessments. Int. R. Psycho-
Anal., 13:453-461
(1978). Journal of the American Psychoanalytic Association, 26:881-920
"Analyzability ": A Systematic Review of the Clinical and Quantitative Literature
Henry M. Bachrach, Ph.D. and Louis A. Leaff, M.D.
FEW ANALYSTS, WE THINK, WOULD DISAGREE that some persons benefit from
classical psychoanalysis while others do not. No sooner had Freud (1893) developed his
psychoanalytic method than he attempted to specify the kinds of persons and conditions to
which it was applicable (1894); (1905); (1913); (1916-1917). More recently, Rangell (1975) has
written of a need to recognize an "optimum scope" for psychoanalytic therapy and, within this
scope, "use psychoanalysis for what it can do" (p. 96).
Differences in response to psychoanalysis can be traced to qualities of analysand, of
analyst, and their interaction. Our aim is to systematically review the psychoanalytic literature in
the first of these areas. We have several purposes in mind: We wish (1) to explore
systematically just what patient qualities are thought to be important to the outcome of
psychoanalysis, and how much agreement there is about these qualities; (2) to compare the
accounts of such qualities given by the clinical and quantitative investigations; and (3) to
We thank Drs. Philip Escoll, Howard Huxster, and Lester Luborsky for their critical readings of
earlier versions of this manuscript, and Mrs. Margaret Smith for assistance in its preparation.
- 881 -
provide methodological evaluation of the contributions as a guide to future investigation.
Methods and Limits of the Literature Review

All papers primarily focused upon " analyzability " or "suitability for psychoanalysis"
published in the mainstream of the American psychoanalytic literature since 1954 were included
in this review. For practical purposes this meant scrutiny of the Journal of the American
Psychoanalytic Association, the International Journal of Psycho-Analysis, the International
Review of Psycho-Analysis, the Psychoanalytic Quarterly, the Psychoanalytic Review,
Psychological Issues, The Annual of Psychoanalysis, and Psychoanalysis and Contemporary
Science; references to contributions in other publications were also explored. The review was
limited to papers published since 1954 because developments in theory and technique over the
years might have led to misleading contradictions not accurately reflecting the current state of
thinking were we to have surveyed the entire literature from its very beginnings. Tyson and
Sandler (1971) have already given a good historical account.
No specific definition of classical psychoanalysis was employed as a guide to our literature
search because most of the papers themselves do not include a definition. Instead, we
assumed there would be some communality as to what was meant by classical psychoanalysis
in papers published in the mainstream of the psychoanalytic literature. Our assumption,
however, is that these references do relate to a process requiring four or five sessions per week,
the use of a couch, and which attempts to foster the development of a transference neurosis to
be resolved by its interpretation.
Governed by these delineations, 24 studies1 were selected
1 The work of the Kris Study Group is reported in two places (Waldhorn, 1960), (1967); we
choose the former for review here because of its more systematic presentation.
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for systematic review, and these form the substrate of our conclusions. Each paper was
reviewed independently by both authors for all specific references to factors relating to (1)
suitability for psychoanalysis, or favorable outcome; (2) unsuitability or unfavorable outcome; (3)
the data conclusions were based upon; (4) the methods employed for the assessment of the
factors; and (5) criteria for the outcome of psychoanalysis. A worksheet following this outline
was prepared for each study, and the findings transferred to the Appendix which appears at the
end of this paper.
The conclusions of the individual studies suggested the following categories: 1. Adequacy
of General Personality Functioning, including all references to adequacy of adaptive functioning,
severity of illness, severity of symptoms, diagnosis, ego strength, reality testing, subliminatory
potentials, adaptive regression, defense, thinking, intellectual abilities, and capacities for
verbalization; 2. Object Relations, including all references to object relatedness, narcissism,
tolerance for separation, object constancy, and capacities for transference and working alliance;
3. Motivation; 4. Affect Organization, including references to availability of and tolerance for
anxiety, frustration, depression, etc.; 5. Character Qualities; 6. Superego Factors; 7.
Demographic Factors; 8. External Factors.
Principal Findings
There are 24 studies in the contemporary psychoanalytic literature primarily focused upon
analyzability . Sixteen are essentially clinical in nature (Aarons, 1962); (Diatkine, 1968); (A.
Freud, 1954); (Glover, 1954); (Karush, 1960); (Kuiper, 1968); (Levin, 1960), (1962);
(Limentani, 1972); (Namnum, 1968); (Panel, 1960); (Stone, 1954); (Tyson and Sandler,
1971); (Waldhorn, 1960); (Zapparoli, 1976); (Zetzel, 1968). Five are quantitativepredictive
(Hamburg et al., 1967); (Kernberg et al., 1972); (Klein, 1960); (Sashin et al., 1975); (Weber
et al., 1974) and
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three employed quantitative methods although their predictions were not related to final
outcomes (Huxster et al., 1975); (Knapp et al., 1960); (Lower et al., 1972). There are a total of
390 separate references to prognostic factors in these studies. Table I summarizes their main
trends.
TABLE I
CONDENSED SUMMARY OF MAIN TRENDS: NUMBER OF REFERENCES INDICATING
FAVORABLE, UNFAVORABLE, OR NEUTRAL PROGNOSIS
Main Trend Number of References
Favorable NeutralUnfavorable?
Adequacy of Personality Functioning
Adaptive functioning 9 0 0 0
Ego strength 10 0 0 0
Reality testing 8 0 0 0
Subliminatory potentials 10 0 0 0
Capacity for adaptive regression 3 0 0 0

Capacity for verbal communication 14 3 0 0
Defense organization (mature) 11 0 0 0
Thinking 4 0 0 0
Intellectual ability 6 2 0 1
Severity of symptoms 0 3 8 1
Severity of illness 1 2 5 0
Diagnosis (re: range of ego weakness) 32 8 0 1
Object Relations
Capacity for transference 7 0 0 1
Capacity for therapeutic alliance 5 0 0 0
Object relatedness
General 20 0 0 0
During interview 2 2 0 0
With parents 13 0 0 0
With friends and marriage 7 0 0 0
Pathological narcissism 0 0 6 0
Tolerance for separations 6 0 0 0
Severe early deprivations 0 0 4 0
Capacity for object constancy 4 0 0 0
Motivation
Self-understanding and change 6 0 0 0
To relieve suffering 4 1 0 0
Other motivations (positive) 9 2 0 0
General 6 0 0 0
Affect Organization
Anxiety tolerance 10 1 0 0
Depression tolerance 3 0 0 0
Tolerance for frustration, suffering 9 0 0 0
Tolerance for other affects & states 4 0 0 0
Availability of tamed affect 14 0 0 0
Character Qualities
Psychological mindedness 13 1 0 0
Other character attitudes (positive) 10 0 0 0
Other character traits (positive) 25 0 0 0
Drive factors (positive) 4 0 0 0
Manifest oedipal conflict 3 1 0 0
Superego Factors (positive) 13 2 0 0
Demographic Factors
Age (young adults) 6 1 0 0
Sex (males more successful) 1 2 0 0
Previous psychotherapy (negative

0 2 5 0
experience)
Other 0 0 1 0
External Factors
Supportive vs. nonsupportive influences 3 1 5 0
- 884 -
Taken together these studies suggest that persons most suitable for classical
psychoanalysis are those whose functioning is generally adequate; they have good ego
strength, effective reality testing and subliminatory channels, and are able to cope flexibly,
communicate verbally, think in secondary-process terms, and regress in the service of the ego
with sufficient intellect to negotiate the tasks of psychoanalysis; their symptoms are not
predominantly severe, and their diagnoses fall within a "neurotic" spectrum. Such persons are
able to form a transference neurosis and therapeutic alliance,
- 885 -
are relatively free of narcissistic pathology, have good object relations with friends, parents, and
spouses, and have been able to tolerate early separations and deprivations without impairment
of object constancy; they are therefore able to experience genuine triangular conflict. They are
motivated for self-understanding, change, and to relieve personal suffering. They are persons
with good tolerance for anxiety, depression, frustration, and suffering and are able to experience
surges of feeling without loss of impulse control or disruption of secondary-process mooring of
thought. Their character attitudes and traits are well-suited to the psychoanalytic work, i.e.,
psychological mindedness. Superego is integrated and tolerant. They are mainly in their late
twenties or early thirties and have not experienced past psychotherapeutic failure or difficulties.
Of all these qualities, those relating to ego strength and object relations are most important. One
third of all references relate to adequacy of personality functioning; one quarter refer to object
relations.
Hence, the contemporary literature has been cast mainly in terms of ego functioning and
object relations, and there is complete agreement that the better the pretreatment level of
functioning, the more favorable the response to psychoanalysis. Motivation, affect organization,
and character are mentioned less often; superego and demographic factors tend to be
mentioned least.
Clinical contributions account for 90 percent of all references. What controlled quantitative
investigation there is, however, accords fully with clinical contributions. There is also strong
agreement about the qualities that make a person suitable for psychoanalysis. Disagreement
occurs only in 9 percent of the references and mainly because isolated factors are not always
regarded prognostic per se. The consensus, occurs, however, mainly on a metapsychological-
conceptual level; most references are cast in metapsychological terms, i.e., ego strength, rather
than as clinical-empirical observations.
- 886 -
These findings are, in part, the product of our method for reviewing the literature, i.e.,
enumerating the number of times something has been said. Such a method, however, does not
account for the reliability and relative importance of the individual references, the factors that
lead people to emphasize in their writings what they do, the interactions among the qualities,
and plainly, how just one or two good qualities in some peoplefor example, the will to be
analyzed and psychological mindednesscan outweigh a plethora of ills.
If one approaches the review differently and attempts to distill the most vital factors stressed
by seasoned clinical contributors and established by replicated controlled investigation the
potentially successful analysand emerges as a young psychologically-minded adult with
capacities for transference and working alliance and who seeks treatment for self-change
through understanding; such a person has good ego strength, mature object relations, and self-
discipline, and their character and interests have depth and richness. Diagnoses fall within a
"neurotic" range and manifest presenting symptomatology and behavior during initial interviews
are not of particular predictive significance. Waldhorn (1960) refers to the capacity for
transference as the sine qua non of analyzability ; Kuiper (1968) refers to psychological-
mindedness as the most essential quality, and Namnum (1968) speaks of the will to be
analyzed as essential. In contrast, persons not likely to benefit come to analysis seeking
magical fulfillments consistent with their infantile attitudes, character traits, and impoverished,
need-satisfying relations with people; their ego functioning is likely within a "borderline"
(Kernberg, 1975) or "psychotic" range.
Despite the consistency of these findings, there are several reasons why it may be difficult
to directly apply them to actual clinical practice at the present time. First, they are case mainly in
abstract terms; it is easier to agree about the importance of ego strength than to confidently
assess its
- 887 -
manifestations. Second, accurate prediction may require analytic data not readily obtainable in
the course of initial interviews. Aarons (1962), for example, argues that data concerning quality
of object constancy in the mother-infant dyad (basic to therapeutic alliance) might become
available only in the course of analysis. Certainly, preanalytic data are different in quality from
analytic data (Kohut, 1959); (Kris, 1957) and the life history we obtain initially (upon which we
base our assessments) is almost always revised in the course of analysis.
Holzman (1976) has commented that psychoanalysis lacks a body of literature in which one
contribution builds upon another so that a steady progress of new knowledge can occur over
time. Inspection of the Appendix shows this is largely true for the studies surveyed; what is
being written about today is by and large the same as what was written twenty years ago,
although there are some new trends:
1. Quantitative methods are beginning to be employed and controlled predictive studies are now
appearing. Before 1960 there were no such reports. Between 1960 and 1970 there were
three (Hamburg et al., 1967); (Klein, 1960); (Knapp et al., 1960). Since 1970 there have
been five (Huxster et al., 1975); (Lower et al., 1972); (Kernberg et al., 1972); (Sashin et
al., 1975); (Weber et al., 1974).
2. In the early literature there were no formal distinctions between indications and suitability for
psychoanalysis. This distinction was introduced by Tyson and Sandler (1971) and is now
being widely employed.
3. The concept of therapeutic alliance was introduced into the analyzability literature by Levin
in 1960; all other references have occurred since 1968 (Diatkine, 1968); (Huxster et al.,
1975); (Tyson and Sandler, 1971); (Zetzel, 1968).
4. With the exception of transference, all but three of the 82 references to object relations have
occurred since 1960. Certainly, it is fair to say that the object-relations point
- 888 -
of view is becoming more important to consideration of analyzability .

5. Discussion of character issues is something relatively new. Only one reference (Stone, 1954)
comes before 1960.
6. Since 1968 the distinction between oedipal symptomatology and the presence of genuine
triangular conflict began to emerge in the literature (Zetzel, 1968). Because the ability to
experience genuine triangular conflict is considered favorable and the mere presence of
overt oedipal symptoms not necessarily predictive, this distinction seems quite important.
Comparison with Quantitative Psychotherapy Research2

Owing to the paucity of quantitative-predictive research relating to the outcome of
psychoanalysis, we thought it would be interesting to compare our findings with those of
quantitative research on factors predictive of the outcome of psychotherapy in general. Strictly
speaking, one might have reservations about making such a comparison. Quantitative
psychotherapy research has tended to be clinically unsophisticated: therapists have tended to
be inexperienced; treatments have been of brief duration, and there have been many problems
with the evaluation of outcome. Despite these reservations, there are many findings in common
with those of the present review.
1. Adequacy of Personality Functioning: The finding from the analyzability literature is that
initial level of adequacy is one of the most potent predictors of favorable outcome. Through
1970 there were 52 quantitative-predictive psychotherapy studies with findings related to
adequacy (i.e., ego strength, severity of symptoms, diagnosis, somatic concerns, social
achievements, defensiveness); in 33 of 34 there was a significant positive relationship
between the initial level of personality functioning and the outcome of
2 Based upon the Luborsky et al. (1971) review of quantitative research.
- 889 -
psychotherapy (statistically significant correlations were not obtained in the remaining eighteen
studies). The quantitative psychotherapy research literature therefore accords with the
analyzability literature in that the healthier a person is to begin with, the better he does in
treatment.
2. Object Relations: According to our review, quality of object relations is directly related to the
extent to which a person will benefit from psychoanalysis. There are only four quantitative
psychotherapy studies directly relating to this area; in all four, interest in people was
positively related to favorable outcome.
3. Motivation: Strong motivation for self-understanding, change, and to relieve suffering
emerges as a favorable prognostic indicator in our survey. Of ten quantitative
psychotherapy studies that deal with motivation, seven find a significant positive relation
with outcome and three are nonsignificant.
4. Affect Organization: Tolerance for dysphoric affects and the availability of tamed affect are
important indications of suitability, according to our review. In fourteen quantitative
psychotherapy studies dealing with affects, the trend is that patients with high though not
overwhelming affect at the beginning of treatment are likely to benefit most.
5. Character Qualities: According to our survey, those character qualities supportive of the
psychoanalytic work are especially valuable assets. In fact, nearly one quarter of all the
references were to psychological mindedness. Eleven psychotherapy studies seem to relate
to psychological mindedness; three out of five found self-awareness prognostically
significant (in the two others the relationship was not statistically significant), and six out of
six found "experiencing" significantly related to favorable outcome. Ethnocentrism is the
only other character quality that has been studied; two out of three studies found it to be a
significantly negative predictor.
Thus, the findings of clinical psychoanalytic investigation
- 890 -
are supported by quantitative research on psychotherapy in general. It does not, however, follow
from this that there is no further need for quantitative-predictive research. Indeed, the clinical
superficiality of quantitative psychotherapy research, and the methodological limitations of
clinical psychoanalytic investigation make such research all the more urgent.
Methodological Evaluation of the Studies

The majority of contributions to the analyzability literature are clinical in nature; it would not
be meaningful to evaluate these according to a methodological yardstick suitable for purely
quantitative research. To do so would be to hold clinical investigations accountable to criteria
that played little role in their shaping and method. However, there are established tenets of
clinical inference and scientific method that are relevant. These relate mainly to questions of
evidence, method, conceptualization, and observability. It is to such standards that we shall turn
in our methodological evaluation. Table II summarizes the studies according to some of these
criteria, i.e., the essential data upon which the conclusions are based, the method employed for
assessing analyzability , and the criteria for outcome of psychoanalysis.
The Meaning and Specification of Outcome and Analyzability

Only five of the studies surveyed clearly specify what is meant by "favorable" or "successful"
response to psychoanalysis. Aarons' (1962) clinical investigation defines successful outcome as
"the resolution of unconscious conflict" as distinguished from conformity, compliance, and
"correct" behavior. Kernberg et al. (1972) employed clinical-quantitative judgments of well-
defined core intrapsychic variables, e.g., ego-strength, unconscious guilt. Sashin et al. (1975)
employed
- 891 -
analyst's and supervisor's ratings of global change and circumstances of termination. Klein
(1960) and Weber et al. (1974) employed rating scales on specific areas of change and follow-
up clinical assessment. In ten clinical studies, no mention is made at all of what is meant by
favorable outcome or what criteria might be used to judge the issue. In three instances,
outcome criteria are stated in the most general terms; Glover (1954) refers to "degree of
accessibility"; Levin (1960) to the analyst's opinion regarding analyzability at termination; and
Stone (1954) to "some improvement." In the other studies, references to analyzability are not
based upon the final outcome of the case but to "in-treatment" developments. Zetzel (1968)
refers to the ability to recognize and tolerate triangular conflict in treatment; Knapp et al. (1960)
refer to judgment of suitability by a candidate analyst and the development of transference and
therapeutic alliance; Lower et al. (1972) to being accepted or rejected for analysis; and Huxster
et al. (1975) to supervisors' response to a questionnaire about the case from three months to
one year after the case was begun.
TABLE II
BASES FOR THE CONCLUSIONS IN THE " ANALYZABILITY " LITERATURE
Data BaseMethod of
Investigation Assessment of
AnalyzabilityOutcome Criteria
Resolution of unconscious
Clinical experience/ Life history/Trial
Aarons conflict rather than behaving in
Literature analysis
the correct way
Clinical experience/
Diatkine Life history/Interview Not specified
Literature
A. Freud Clinical experience Not specified Not specified
Glover Clinical experience Not specified Degree of "accessibility"
Guttman Interviews Not specified
Literature
386 analysts reporting

Hamburg
clinical data about 2,983 Not specified Analyst's judgment
et al. *
cases
18 clinic cases with (Supervisor's response to

Huxster et special emphasis upon 4 Life history/Interview questionnaire about the 18
al. best and 4 worst in by 2 analysts cases after 3 months to one
opinion of supervisor year)
Karush Clinical experience Ego-strength inventory Not specified
Extent of intrapsychic and life

21 cases of
Kernberg Life history/Interview/ change after termination
psychoanalysis 21
et al. * Psychological Tests assessed by independent
cases of psychotherapy
research-analyst judges
Life history/Interview/
30 clinic cases in Clinical judgments and
Discussion with
Klein * analysis for more than independent rating scales; seven
supervisor and
200 sessions specific criteria
committee
1. Judgment of suitability by
100 clinic cases; 25 Life history/Interview,
Knapp et candidate analyst. 2.
control cases in analysis screening by 2
al. Development of transference
for 1 year analysts
and working alliance
Interview; reaction to
Kuiper Clinical experience "group" Not specified
psychoanalysis
16 terminated cases of Analyst's opinion regarding

Levin Life history/interview
six analysts analyzability at termination
Psychodynamic changes and

Limentani Clinical experience Life history/Interview insight into conditions relating to
difficulties
Lower et Life history/Interview (Accepted or rejected for

40 clinic applicants
al. by 2 analysts analysis)
Namnum Clinical experience Not specified Not specified
Circumstances of termination
Life history/Interview
Sashin et (i.e., by mutual agreement,
122 control cases several independent
al. * premature, "interminable
analyst judgments
cases")
Clinical experience/ Life history/Interview/

Stone "Some improvement"
Literature Psychological Tests??
Tyson and Literature review/ Interview/Trial

Not specified
Sandler Clinical experience analysis
Waldhorn Life history/Interview Not specified
Literature
Clinical judgments and

Weber et 271 terminated clinic Life history/Interview
independent rating scales in six
al. * control cases Screening committee
specific areas
Zapparoli Clinical interview Not specified
Literature review
Ability to recognize and tolerate

Zetzel Clinical experience Life history/Interview
triangular conflict in treatment
A controlled predictive-quantitative study.
One might argue it is not necessary to precisely state criteria for response or analyzability
since such matters are common knowledge among Freudian psychoanalysts. There is, of
course, the widely held view that favorable outcome means the analytic resolution of
transference neurosis. In actual practice, however, it is not clear how one recognizes sufficient
resolution, nor is it clear whether Freudian psychoanalysts, even as a group, mean only this
when they refer to favorable response. Ekstein (1956) once pictured the development and
resolution of transference neurosis in successful analysis as a normal curve. Yet, when Graff
and Luborsky (1976) actually plotted quantitative estimates of transference for four analyses,
transference increased over time and remained high at termination irrespective of outcome;
what made the difference between successful and unsuccessful outcome was the analysand's
awareness and ability to deal
- 892 -
with its manifestations, i.e., the therapeutic alliance and insight. Similarly, Pfeiffer (1959),
Schlessinger and Robbins (1974), and Norman et al. (1976) found transference neurosis
strikingly reactivated by brief follow-up visits, even among successfully analyzed persons.
Considerations such as these raise questions about the meaning of resolution of transference
neurosis as the sole criteria for outcome. The relation between symptom relief, patient
satisfaction, emotional growth, autonomy, and transference developments are not as well
understood as we might like. Ticho (1972) distinguished "life goals" from "treatment goals."
Glover's (1955) survey found the majority of British psychoanalysts seemed to rely mainly upon
intuitive impressions of symptom resolution as criteria for termination. Baum and Robbins
(1975) surveyed a group of American psychoanalysts and found intuitive impression of an
analytic growth process having been set in motion the pivotal criterion for termination.
The term " analyzability ," even when refined to "indications" and "suitability" tends to
convey the impression that an analyzable person, barring unforeseen unusual events, is likely to
have a successful analysis and an "unanalyzable" person is not. But in actual practice, the term
" analyzability " has compound meanings; certain patient qualities are more crucial than others
during different subphases of the analytic process. The analytic process can sometimes make a
seemingly unanalyzable person analyzable, as Appelbaum (1973) has shown in cases of deficit
in psychological mindedness based upon repressive defense organization. In actual practice,
the analyzability of a patient may vary with different analysts. Some people do well with certain
analysts and not with others. Some people also do poorly with any analyst. This has a great
deal to do with what goes into forming a therapeutic alliance between two particular people.
Hence, our main finding here is that investigators have not clearly specified what they mean
by analyzability and to what criteria their findings relate. It seems clearly in the
- 893 -
interest of further developments that future investigators do so as specifically as possible,

especially on an empirical-observable level.
Method of Assessing Analyzability

No matter how clear a metapsychological understanding one may have of factors
prognostic of response to psychoanalysis, this understanding can only guide assessment. One
cannot touch, feel, or see ego strength; it is a concept. Rather, our assessments are based
upon what we observe, and our conclusions depend upon our methods of observation as well
as the guiding conceptual templates we employ.
Clinical interview with emphasis upon life history is the method of assessing analyzability
employed in most of the method of assessing analyzability employed in most of the studies
surveyed. Diagnostic psychological testing was employed only by Kernberg et al. (1972), and
referred to by Stone (1954) as potentially useful if better understood. Lower et al. (1972)
augmented interviews with an outline of factors thought important to assessment of
analyzability and also by employing an analyzability committee, as did Sashin et al. (1975),
Klein (1960), Knapp et al. (1960), and Weber et al. (1974). Aarons (1962) spoke of the possible
utility of trial analysis. Tyson and Sandler (1971) indicated that trial analysis provides an
opportunity for evaluating development of the treatment alliance, but has disadvantages in that it
encourages patients to split off part of their lives from the analytic work and it may take a very
long time to accurately assess the important factors.
In the literature (e.g., Knapp, 1960) there seems to be a dialectic between those who
advocate extensive interviews and those who think this interferes with the natural development
of the analytic process. Windholz (1960) suggested that, when the prospective analyst
interviews, defenses are immediately primed and result in an unavailability of important
memories. He also pointed out that the technique
- 894 -
of interviewing demands special training and gifts not always coordinate with what is required of
a psychoanalyst, and that it might be more profitable to employ others for history-taking.
Waldhorn (1960) and Karush (1960) argued that ego structures and functions can be evaluated
in initial interviews, though Levin (1960) did not agree. Zetzel (Panel, 1960) summarized the
consensus of a panel on analyzability with two points: (1) evaluations made after initial
interviews are only tentative approximations of analyzability ; (2) diagnostic interviews can best
provide only a limited amount of anamnestic material, an account of the patient's current
symptomatology and the degree to which it impinges upon functioning as a whole, and an
evaluation of motivation, insight, and the capacity to relate.
Because of such concerns about the limits and consequences of extensive interviews, one
wonders about the effectiveness of other means of assessment. Data regarding the role of
diagnostic psychological testing are available only in one study: the Menninger Psychotherapy
Research Project. Appelbaum (1977) reported that predictions about the outcome of
psychoanalysis and psychotherapy based only upon test data interpreted by psychoanalysts
were significantly (p < .01) superior to those based upon interviews, despite the availability of a
clinical test report to the interviewers. Such a finding raises the question whether diagnostic
testing, when conceptualized according to clinical psychoanalytic theory and interpreted by
psychoanalysts, may provide an untapped resource, particularly for systematic assessment of
ego functioning.3 It also confirms Huxster et al. (1975) in their claim that the subjective
response of the interviewer is a major source of therapeutic overoptimism. At this point, one
might conclude that understanding and prediction of response to psychoanalysis might be
enhanced by developing methods of assessment in addition to the clinical interview. The
3 These issues have been discussed in detail by Appelbaum (1977) and Bachrach (1977).
- 895 -
utilization of several methods not only decreases bias inherent to any single method, but makes
possible a triangulation of understanding from independent perspectives. Thus, research such
as that of Appelbaum (1977) and Kantrowitz et al. (1975) with regard to the role of diagnostic
testing, and that of Huxster et al. (1975) with regard to screening committees is welcome for
clarifying just what each method does best and what contribution it can make to assessment.
Information and Evidence

When one formulates an inference or proposes a conclusion, it is important to know on what
basis the assertion rests. Without evidence, the accuracy of a conclusion can never be
determined. Fewer than half of the studies, however, provide such information or evidence.
Knapp et al. (1960) base their conclusions upon 100 clinic patients under age 35, without
psychosomatic, delinquent, or psychotic trends, with good life situations, coming from
intellectually and psychologically sophisticated segments of the population, referred for control
analysis; also studied were 25 control cases in analysis for at least one year. Kernberg et al.
(1972) studied 42 patients (21 in analysis, 21 in psychotherapy) treated by senior candidates or
recent graduates. Lower et al. (1972) studied the first 40 applicants to a psychoanalytic clinic
interviewed separately by two graduate screening analysts, with the case being reviewed by an
analyzability committee. Huxster et al. (1975) studied eighteen cases from the Lower et al.
(1972) study, focusing primarily on four cases deemed best and four worst by supervisors within
the first year of the analysis. Sashin et al. (1975) based their conclusions upon 122 "carefully
screened" control cases. Klein (1960) studied 30 clinic control cases in analysis for at least 200
sessions (thereby excluding information relating to early failures); Weber et al. (1974) studied
1,348 clinic patients, but based their conclusions mainly upon 271 terminated control cases.
Hamburg et al. (1967) based their findings upon a retrospective survey of 386
- 896 -
analysts who responded to a questionnaire regarding the clinical characteristics of their case
load; included were 2,983 cases about equally distributed between psychoanalysis and
psychotherapy. All of the other investigations are primarily clinical in nature. It is therefore not
surprising that the findings are based upon the author's personal experience. In five of these,
clinical experience is supplemented by references to the psychoanalytic literature. The
evidential bases for the findings are specified only in the minority of cases.
The absence of attempts at specification are, to us, a matter of concern. If a clinical author
does not even attempt to specify the extent of his clinical experience with a particular matter, or
what his range is with clinical problems in general, then how can one contribution be compared
to another? A person whose analytic practice is limited to intellectually gifted analysandssuch
as in a university practicemay regard intelligence as having little prognostic value because
there is little variation among his patients. On the other hand, a person with a more varied
practice may find it has considerable prognostic value simply because of its variability. As the
bulk of the literature now stands, it is difficult to know to what extent one study replicates
another. Are they talking about the same or different things? Rarely does one even find such
concern expressed in the clinical literature.
Overall, our main finding here is that the majority of studies fail to indicate the evidence for
their conclusions and the data upon which they are based. It is therefore difficult to be fully
cognizant of the nature of the populations referred to, selection biases, and the extent to which
one investigation may be said to truly replicate another.
APPENDIX
Legend
0 = nonsignificant relationship
+ = prognostically favorable relationship
- = prognostically unfavorable relationship
? = inconclusive reference
* = quantitative predictive study
Adequacy of General Personality Functioning
Adequacy of Adaptive Functioning
+ Lower et al.
Adaptive ability
(1972)
+ Lower et al.
Good social adaptation
(1972)
+ Waldhorn
Potential for adaptation, i.e., ability to act upon insight
(1960)
+ Lower et al.
Good work and school record
(1972)
Ability to integrate socially and pleasurefully incorporate cultural needs + Karush (1960)
Moral character and educational achievement sufficient to assure a good + Tyson &
position in life with adequate rewards Sandler (1971)
Achievement of autonomy + Zetzel (1968)
Failure of mastery - Zetzel (1968)

- Lower et al.
Regression
(1972)
Ego Strength
Ego strength + Karush (1960)
Ego strength + Levin (1960)
+ Lower et al.
Good ego strength
(1972)
+ Kernberg et al.
High ego strength*
(1972)
- Kernberg et al.
Low ego strength*
(1972)
Availability of creative and synthetic proclivities of the ego + Aarons (1962)
Ego must be able to tolerate impulses and conflict: a quantitative relation

+ Panel (1960)
between defensive and autonomous ego functioning is necessary
Ability to utilize psychological energy consistent with life goals + Levin (1968)
Feeble personality resources - Stone (1954)
Basic ego defects - Zetzel (1968)
Reality Testing
+ Tyson &
Reality testing
Sandler (1971)
+ Waldhorn
Reality testing (absence of projection, denial, hypomania)
(1960)
Reality testing + Zetzel (1968)
Lack of reality testing - Zetzel (1968)
- Lower et al.
Faulty reality testing
(1972)
- Lower et al.
Poor judgment
(1972)
- Lower et al.
Ideas of reference
(1972)
Recognition of fantasies as fantasies + Diatkine (1968)
Subliminatory Potentials
+ Tyson &
Availability of conflict-free capacities
Sandler (1971)
Subliminatory potentials + Stone (1954)
Subliminatory potentials + Lower et al.

(1972
+ Tyson &
Successful sublimations
Sandler (1971)
- Lower et al.
Limited sublimation
(1972)
- Waldhorn
Absence of subliminatory gratifications
(1960)
- Lower et al.
Little gratification
(1972)
Capacity for pleasure in substitutes and in active mastery and learning + Zetzel (1968)
+ Tyson &
Life not centered around analysis
Sandler (1971)
Persistent inhibitions obliterating sublimations - Diatkine (1968)
Adaptive Regression
Regression in the service of the ego + Diatkine (1968)
Adaptive regression + Panel (1960)
+ Namnum
Adaptive regression
(1968)
Capacity for Verbalization
Capacity to verbalize 0 Aarons (1962)
Capacity for continuous verbalization + Levin (1962)
+ Namnum
Capacity for verbal communication
(1968)
+ Huxster et al.
Capacity to communicate meaningfully during interview
(1975)
Ability to communicate + Karush (1960)
Absence of blocking in initial interviews 0 Levin (1962)
+ Waldhorn
Capacity for speech
(1960)
- Knapp et al.
Severe blocking
(1960)
Extreme periods of blocking - Levin (1960)
- Waldhorn
Mutism
(1960)
Silence in borderline or psychotic patients where there is intrinsic impairment

- Aarons (1962)
in communication
Speech defect 0 Panel

- Waldhorn
Gross speech defects
(1960)
Chronic difficulties in communication, i.e., inarticulateness or anxiety - Waldhorn

connected with speech (1960)
- Waldhorn
Erotization of speech
(1960)
- Waldhorn
Long delay of onset of verbalization in childhood
(1960)
- Waldhorn
Presence of deaf or mute parent
(1960)
Defense Organization
Proper mixture of alloplasticity and autoplasticity + Aarons (1962)
+ Waldhorn
Flexibility of defenses
(1960)
- Waldhorn
Rigidity, hypertrophy of automatic defenses
(1960)
Previous history of unchanging defensive patterns, i.e., patient who - Waldhorn

proposed to begin analysis with reservations (1960)
- Huxster et al.
Excessive defensiveness and vagueness during interview
(1975)
- Lower et al.
Defensiveness (rigidity, lack of dreams and memories)
(1972)
+ Lower et al.
Lack of defensiveness
(1972)
Failure to develop stable impulse-defense configurations - Zetzel (1968)
Projective identification - Diatkine (1968)
+ Kernberg et al.
Patterning of defenses (in positive direction)*
(1972)
More serious defense mechanisms (tendency but not statistically significant) ? Weber et al.
are unfavorable* (1974)
Thinking
Imaginative thinking + Diatkine (1968)
Secondary-process thinking + Diatkine (1968)
Undue persistence of magical thinking as might be reflected in grandiosity, - Waldhorn

sexual problems, abortions, divorces, bizarre job and living arrangements (1960)
- Knapp et al.
Thinking and memory difficulty
(1960
Intellectual Abilities
Intelligence + Karush (1960)
+ Namnum
Intelligence
(1968)
+ Waldhorn
Intelligence as related to psychological mindedness
(1960)
Low intelligence (all that is required is sufficient to form working alliance and 0 Tyson &
gain insight) Sandler (1971)
Learning capacity + Karush (1960)
+ Waldhorn
Educability (as relates to psychological mindedness)
(1960)
0 Knapp et al.
Education
(1960)
+ Hamburg et al.
Patients with higher educational level did better*
(1967)
Intelligent patients with higher educational achievement did better (tendency, ? Weber et al.
but not statistically significant)* (1974)
Severity of Symptoms
Severity of symptoms 0 Aarons (1962)
- Kernberg et al.
Severity of symptoms*
(1972)
- Knapp et al.
Severe symptomatology, especially compulsive overeating
(1960)
- Sashin et al.
Severe obsessional thoughts*
(1975)
- Waldhorn
Severe phobias and inhibitions
(1960)
- Waldhorn
Symptoms leading to medical and surgical treatment
(1960)
- Waldhorn
Gratifying symptoms, i.e., perversions
(1960)
0 Limentani
Presenting symptomatology
(1972)
Initial "dysfunction" unrelated to change in dysfunction* 0 Klein (1960)
Fixed, more severe symptoms (tendency but not statistically significant) are ? Weber et al.
unfavorable* (1974)
Severity of Illness
Mild or reactive illness + A. Freud

(1954)
Certain severe ego distortions 0 A. Freud (1954)
Severe psychopathology, sexual perversion, and inhibition - Glover (1954)
Depth of symptom formation, including constitution, developmental, and

- Glover (1954)
precipitating factors
Chronically ill and restricted motility - Karush (1960)
Severity of illness per se 0 Stone (1954)
Mild neurosis and slightness of illness (psychoanalysis should not be

- Stone
invoked for trivial reasons)
Wide range of symptomatology - Zetzel (1968)
Diagnosis
Neuroses
Anxiety hysteria + Glover (1954)
+ Hamburg
Anxiety neurotics did better*
(1967)
Conversion hysteria + Glover (1954)
0 Knapp et al.
Presence of overt hysterical symptomatology
(1960)
Type I hysteric + Zetzel (1968)
Mixed neurosis (obsessional and hysterical) + Glover (1954)
Obsessional neurosis 0 Glover (1954)
+ Knapp et al.
Obsessive compulsive
(1960)
Reactive anxieties + Glover (1954)
Mild depression + Glover (1954)
Neurotic "equivalents" + Glover (1954)
Transference neuroses + Stone (1954)
Phobias
Phobias 0 Glover (1954)
Phobias where patient is able to function without dependency object + Karush (1960)
Phobias concerned with excrement and disease - Karush (1960)
Borderline States
Borderline - Aarons (1962)

Borderline 0 Levin (1962)
- Knapp et al.
Borderlin
(1960)
- Kernberg et al.
Borderline personality organization*
(1972)
Dissociative hysterical states - Karush (1960)
- Lower et al.
Borderline
(1972)
Type II hysteric 0 Zetzel (1960)
Type III hysteric - Zetzel (1960)
- Waldhorn
"As-if" personalities
(1960)
Psychosis
Psychosis - Aarons (1962)
Psychosis and psychotic character - Karush (1960)
- Knapp et al.
Psychosis
(1960)
- Hamburg et al.
Fewer "schizophrenics" improved at end of completed treatment*
(1967)
Schizophrenia - Karush (1960)
Schizophrenia - Stone (1954)
Anxiety hysteria with subpsychotic structure - Glover (1954)
Perversions and
Addictions
Perversions (fetishism, transvestitism, drug addiction, homosexuality in

? Glover (1954)
persons under 40, alcoholism with neurotic basis)
Alcoholism covering endogenous disorders, i.e., depression or paranoia - Glover (1954)
Certain addictions, perversions, and delinquency 0 A. Freud (1954)
Severe sexual perversions and inhibitions - Glover (1954)
- Lower et al.
Perversion
(1972)
- Lower et al.
Heavy drinking
(1972)
Other
0 Sashin et al.
Diagnosis is of no predictive value*
(1975)
Character disorders + Stone (1954)
Patients with marked castration anxiety, i.e., certain homosexual, paranoid,

- Waldhorn
and sadomasochistic persons and others with manifest fear of physicians,
(1960)
barbers, and dentists
0 Limentani
Diagnosis can be an encumbrance
(1972)
Object Relations
Transference
Ability to form workable transference + Aarons (1961)
Ability to develop transference + Diatkine (1968)
Transference potential, especially positive to withstand stress + Glover (1954)
+ Namnum
Transference that can be used therapeutically
(1968)
Capacity for transference + Stone (1954)
+ Waldhorn
Capacity for transference the sine qua non of analyzability
(1960)
+ A. Freud
Capacity for transference
(1954)
Potential for developing unmanageable dependent transference associated ? Weber et al.

with poor outcome (tendency, but not statistically significant)* (1974)
Working Alliance
Capacity to develop analytic process + Diatkine (1968)
Capacity to develop working alliance + Levin (1960)
Capacity for therapeutic alliance + Zetzel (1968)
+ Tyson &
Capacity to form viable treatment alliance
Sandler (1971)
+ Huxster et al.
Capacity for stable working alliance
(1975)
Object Relatedness
General
Failure to establish object relations if due to arrest in object constancy, but

+ Aarons (1968)
not if due to neurotic impediments
Capacity to genuinely invest in objects + Diatkine (1968)
Ability to maintain stable object relations + Panel (1960)
+ Namnum
Capacity to form stable object relations
(1968)
Pattern of object relations + Stone (1954)
Object relations, especially close contacts during infancy, in sex, friendships, + Waldhorn
and enmities of life (1960)
Acceptance of limitations within one-to-one relationships without feeling

+ Zetzel (1968)
seriously rejected or devalued
+ Lower et al.
Good object relation
(1975)
+ Knapp et al.
Relates well, warmth
(1960)
- Huxster et al.
Inability to form stable object relation
(1975)
+ Huxster et al.
Capacity to "engage" in life
(1975)
- Huxster et al.
Withdrawal and lack of involvement in life
(1975)
+ Kernberg et al.
Good interpersonal relations*
(1972)
+ Tyson &
Basic trust
Sandler (1971)
+ Waldhorn
Presence of realistic trust
(1960)
- Lower et al.
Lack of trust
(1972)
- Lower et al.
Infantile relations
(1972)
- Lower et al.
Problems with authority
(1972)
- Lower et al.
Loneliness and isolation
(1972)
+ Tyson &
Capacity to establish rapport
Sandler (1971)
During Interview
Ability to relate during interview 0 Aarons (1968)
+ Lower et al.
Creates favorable, attractive, pleasant response
(1972)
Capacity to relate during interview, including warmth and attractiveness 0 Levin (1960)
Extraordinary negative reaction to analyst (might be rectified by referral to - Waldhorn

another analyst) (1960)
With Parents
- Waldhorn
Identification with dead, psychotic, or psychopathic parents
(1960)
Ability to retain significant relations with both parents + Zetzel (1968)
Mastery of ambivalence in early mother-child relation + Zetzel (1968)
Serious pathology in one or both parents, often associated with unhappy or

- Zetzel (1968)
broken marriages
- Sashin et al.
No close relation with parent of same sex (p < .10)*
(1975)
+ Tyson &
Good early identifications
Sandler (1971)
- Sashin et al.
Parent of opposite sex who was violent (p < .05)*
(1975)
- Sashin et al.
Mothers with poor work histories (p < .10)*
(1975)
- Sashin et al.
Fathers with poor work histories (p < .10)*
(1975)
- Sashin et al.
Poor struggling parents (p < .10)*
(1975)
- Sashin et al.
Frightened, passive fathers (p < .05)*
(1975)
- Waldhorn
Maternal overprotectiveness
(1960)
- Waldhorn
Fear of being dominated by identification with weak parent
(1960)
With Friends and

Marriage
- Sashin et al.
Do not get along with persons of same sex (p < .10)*
(1975)
- Sashin et al.
Select inappropriate heterosexual partners (p < .10)*
(1975)
Absence of meaningful relations with either sex - Zetzel (1968)
Instability in friendships - Zetzel (1968)
+ Lower et al.
Sustained heterosexual relations
(1972)
+ Lower et al.
Good marriage
(1972)
History of adolescent crushes in which "no one else counts" - Levin (1960)
Pathological
Narcissism
History of close relationships where objects are used for infantile and
- Levin (1960)
narcissistic gratification
Primary narcissism - Aarons (1962)
Secondary narcissism 0 Aarons (1962)
- Waldhorn
Need for narcissistic supplies as evidences of affection, power, and prestige
(1960)
- Huxster et al.
Severe narcissistic character pathology
(1975)
- Lower et al.
Narcissism
(1972)
Separations
Incapacity to develop transference in persons losing mother in first year of

- A. Freud (1954)
life and then cared for by repeatedly changing mother substitutes
History shows difficulty in tolerating separations from love object - Levin (1960)
Absence or significant separations from one or both parents during the first
- Zetzel (1960)
four years of life
Tolerance for separation from important objects + Zetzel (1968)
- Lower et al.
Early loss
(1972)
- Waldhorn
Early loss of parent
(1960)
Other Early
Deprivations
- Sashin et al.
Severe deprivations*
(1975)
- Lower et al.
Early deprivations
(1972)
- Lower et al.
Early deprivations
(1972)
- Tyson & Sandler

Early experiences of deprivation
(1971)
Intense physical and maternal deprivation during the first year of life - Karush (1960)
Object
Constancy
Object constancy + Aarons (1962)
+ Huxster et al.
Capacity for object constancy
(1975)
Object constancy + Tyson &

Sandler (1971)
Lack of object constancy - A. Freud
Motivation
Self-Understanding and Self-Change
Need to understand and wish for insight + Aarons
Pleasure in self-discovery and curiosity + Kuiper (1968)
+ Lower et al.
Desire to understand oneself
(1972)
Motivation is for change through insight + Levin (1960)
Change through insight + Levin (1960)
+ Lower et al.
Desire to change
(1972)
To Relieve Suffering
To relieve suffering + Diatkine (1968)
Neurotic suffering and wish for cure with recognition that problems are with
+ Aarons (1962)
self
Wish to be relieved from suffering + Kuiper (1968)
0 Tyson &
Suffering and secondary gains
Sandler (1971)
- Waldhorn
Masochistic exploitation of suffering
(1960)
Other Motivations
Wish to use analysis - Panel (1960)
Need for vengeance, freedom from responsibility, and drive for - Waldhorn
compensatory gratifications (1960)
Motivation is to please, or from envy, competition, magical gratification, or

- Levin (1960)
becoming dependent
- Lower et al.
Magical wish for repair or relief
(1972)
- Huxster et al.
Wish for fantasy fulfillment as motive for undertaking analysis
(1974)
- Waldhorn
Unrealistic aims, wishes for assurance, assistance with or in denying reality
(1960)
Strong manifest motivation for analysis 0 Levin (1962)
+ Tyson &
Motivation to accept help for internal problems
Sandler (1971)
Secondary gain - Glover (1954)
Primitive magical expectations and demands - Stone (1954)
Magical demands or expectations 0 A. Freud (1954)
General
? Weber et al.
Well motivated (favorable tendency but not statistically significant)*
(1974)
+ Waldhorn
Motivation
(1960)
Motivation for more than symptom relief + Panel (1960)
+ Lower et al.
Realistic motivation for psychoanalysis
(1972)
+ Lower et al.
Hope
(1972)
Degree to which patient genuinely experiences symptom as illness + Stone (1954)
Life goals consistent with analysis + Stone (1954)
Affect
Organization
Anxiety Tolerance
Anxiety tolerance + Aarons (1962)
Anxiety tolerance + Diatkine (1960)
Anxiety tolerance + Panel (1960)
- Sashin et al.
Anxiety tolerance*
(1975)
+ Kernberg et al.
Anxiety tolerance*
(1972)
+ Lower et al.
Anxiety tolerance
(1972)
+ Tyson &
Anxiety tolerance
Sandler (1971)
- Huxster et al.
Lack of anxiety tolerance
(1975)
Quality of anxiety (signal more than primitive) + Panel (1960)
Anxiety tolerance (as might be reflected in circumstances precipitating + Waldhorn

request for analysis and life history of tolerance without flight into action) (1960)
- Lower et al.
Limited anxiety tolerance
(1972)
Depression Tolerance
Depression tolerance
+ Tyson &
Depression tolerance
Sandler (1971)
Depression tolerance + Diatkine (1960)
Depression + Zetzel (1968)
Tolerance for Frustration and Suffering
Frustration tolerance + Aarons (1962)
Frustration tolerance + Panel (1960)
+ Waldhorn
Frustration tolerance
(1960)
+ Lower et al.
Frustration tolerance
(1972)
Tolerance for frustration and suffering + Levin (1960)
Tolerance for unavoidable suffering + Stone (1954)
Lack of frustration tolerance, as might be reflected in inability to wait in

- Waldhorn
consulting room; flight into alcohol, food, drugs, and other compulsive
(1960)
behaviors; lifelong intolerance for disappointment
- Huxster et al.
Lack of tolerance for frustration
(1975)
- Lower et al.
Limited frustration tolerance
(1972)
Tolerance for Other Affects and Affective
States
+ Waldhorn
Tolerance for passivity
(1960)
- Waldhorn
Lack of tolerance for passivity
(1960)
Lack of shame tolerance - Levin (1960)
+ Huxster et al.
Capacity to tolerate unpleasant affect without acting out
(1975)
Availability of Tamed Affect
Libido quiescence + Levin (1960)
Experience and recognize appropriate affects + Diatkine (1968)
+ Huxster et al.
Presence of mature affects
(1975)
+ Kernberg et al.
Initial level of anxiety (in patients of high ego strength)*
(1972)
+ Lower et al.
Availability of affect
(1972)
- Lower et al.
Unavailability of affect
(1972)
- Lower et al.
Poor instinctual control
(1972)
Fear of own affective responses, as might be reflected in frigidity; - Waldhorn

intellectualized flight and somatization (1960)
- Waldhorn
Panics, erotization of anxiety, and separation anxiety
(1960)
+ Lower et al.
Workable anxiety
(1972)
Quantity of anxiety is not too restrictive + Karush (1960)
- Knapp et al.
High levels of anxiety or tension
(1960)
+ Waldhorn
Presence of realistic shame
(1960)
+ Hamburg et al.
Anxiety as presenting symptom*
(1960)
Character
Qualities
Psychological Mindedness
Psychological mindedness + Aarons (1962)
Psychological mindedness + Diatkine (1968)
+ Huxster et al.
Capacity to view self objectively
(1975)
0 Kernberg et al.
Initial lack of psychological mindedness (externalization)*
(1972)
Capacity for insight + Levin (1960)
Psychological mindedness as reflected in capacity for insight, introspection,

+ Lower et al.
intuition, remembering of dreams and fantasies, curiosity about drives,
(1972)
awareness of transference and internal conflict
Ability to observe introspectively + Karush (1960)
+ Knapp et al.
Capacity for insight
(1960)
+ Knapp et al.
Capacity for insight
(1960)
Psychological mindedness is the most essential quality + Kuiper (1968)
+ Namnum
Psychological mindedness is essential for analysis
(1968)
Capacity for self-observation as differentiated from symptomatic self-

+ Stone (1954)
deprecation and castigation
+ Tyson &
Self-reflectiveness
Sandler (1971)
+ Waldhorn
Psychological mindedness (outlook, introspectiveness, and reflectiveness)
(1960)
Capacity to split observing ego from experiencing transference neurosis + Diatkine (1968)
Other Character Attitudes
+ Namnum
The will to be analyzed is essential
(1968)
"Do unto others in such a way as to get them to do unto you as you would
- Levin (1960)
like to have them do unto you" attitude
"I have a right to what I want" attitude - Levin (1960)
Demandingness, provocativeness, and distrustful attitudes in initial

- Levin (1960)
interviews, especially attacks on past therapists
- Lower et al.
Paranoid attitudes
(1972)
- Waldhorn
The "exception" and those "wrecked by success"
(1960)
- Lower et al.
Oral characteristics
(1972)
- Lower et al.
Anal characteristics
(1972)
- Tyson & Sandler

Lack of confidence in analysis
(1971)
+ Zapparoli
Therapeutic zeal
(1976)
Other Character Traits
Ability to direct energy with minimal rebellion and maximum of persistence + Aarons (1962)
+ Lower et al.
Persistence
(1972)
+ Huxster et al.
Depth and richness of character
(1975)
Character courage, patience, and deliberate, purposive tolerance + Levin (1962)
Flexibility of character + Huxster et al.

(1975)
- Huxster et al.
Rigidity of character
(1975)
+ Lower et al.
Responsibility
(1972)
- Lower et al.
Constricted and inhibited
(1972)
- Lower et al.
Immature
(1972)
Immaturity - Zetzel (1968)
Lack of self-discipline - Aarons (1962)
Impulsiveness and acting out followed by guilt + Aarons (1962)
Limited acting out and displacement proclivities + Aarons (1962)
- Waldhorn
Temper tantrums, aggressive outbursts, and tensions
(1960)
- Lower et al.
Dependence
(1972)
- Waldhorn
People who constantly need reassurance
(1960)
Passivity and helplessness - Zetzel (1968)
Chronic, extreme, ego-syntonic passivity - Aarons (1962)
+ Knapp et al.
Honesty
(1960)
+ Lower et al.
Honesty, sincerity, and frankness
(1972)
Capacity for and quality of sense of honor + Levin (1962)
+ Lower et al.
Sophistication
(1972)
- Lower et al.
Unsophisticated
(1972)
+ Lower et al.
Cooperativeness
(1972)
- Lower et al.
Concreteness
(1972)
Drive Factors
Excessive oral fixation - Levin (1962)
Intensity of fixations - Waldhorn

(1960)
+ Huxster et al.
Mature drive organization
(1975)
- Huxster et al.
Primitive drive organization
(1975)
Oedipal Conflict
0 Huxster et al.
Presence of oedipal pathology
(1975)
+ Lower et al.
Oedipal pathology
(1972)
Triangular conflict + Zetzel (1968)
- Lower et al.
Preoedipal pathology
(1972)
Superego
Factors
Well-integrated superego + Levin (1960)
+ Huxster et al.
Effective and tolerant superego
(1975)
Balance of aggression and superego + Diatkine (1968)
0 Kernberg et al.
Self-directed aggression*
(1972)
Harsh, punitive superego as in self-pity, jesting, depression, religiosity, and - Waldhorn

masochism (1960)
+ Waldhorn
Absence of need for punishment
(1960)
- Waldhorn
Depression after success
(1960)
- Waldhorn
Improvement of psychological state during illness
(1960)
- Waldhorn
Onset of neurosis after death of love-object
(1960)
Low self-esteem - Zetzel (1968)
Devaluation of femininity in women - Zetzel (1968)
- Waldhorn
Need for approval from superego through compulsive, nonadaptive rituals
(1960)
- Waldhorn
Defensive hypercathexis of superego
(1960)
Defective and corruptible superego, as in delinquency, lying, and accident - Waldhorn

proneness (1960)
0 Tyson &
Ethical and moral considerations
Sandler (1971)
Demographic
Factors
Age
Age over 45, under 15 - Glover (1954)
+ Hamburg et al.
Patients 46 and older did not do as well as younger patients*
(1967)
+ Knapp et al.
Age under 35, the older the better (p < .05)
(1960)
Age + Stone (1954)
0 Tyson &
Age
Sandler (1971)
+ Waldhorn
Age and life prospects as they relate to change
(1960)
+ Weber et al.
Younger adults do better*
(1974)
Sex
0 Hamburg et al.
Sex*
(1967)
0 Knapp et al.
Sex
(1971)
+ Sashin et al.
Males have more successful outcome*
(1975)
Previous Psychotherapy
0 Hamburg et al.
Previous treatment*
(1967)
Presence, amount, and duration of previous treatment* 0 Klein (1960)
- Knapp et al.
Long course of previous treatment
(1960)
- Waldhorn
Unresolved transference expectations from previous psychotherapy
(1960)
- Waldhorn
Unethical behavior of past therapists
(1960)
- Waldhorn
Inappropriate demands and expectations from past therapist
(1960)
History of past failure in therapeutic experience - Zetzel (1968)

Other
- Sashin et al.
Unsuccessful siblings (p < .10)*
(1975)
External Factors
External factors leading to analysis 0 Aarons (1962)
External situation reinforcing unconscious, neurotic needs - Diatkine (1968)
- Waldhorn
Circumstances permitting satisfaction of secondary gains
(1960)
- Waldhorn
Family neurosis that might lead to termination
(1960)
- Waldhorn
Living with neurotic or psychotic objects that contribute to unpredictability
(1960)
+ Waldhorn
Life situation should be supportive and stable
(1960)
Relative stability and freedom from external stress as perceived by patient + Levin (1968)
Life circumstances (stable and supportive) + Stone (1954)
- Waldhorn
Coercion by external party to enter analysis
(1960)
- 897 -
SUMMARY
The contemporary psychoanalytic literature focused primarily upon "analyzability" was
systematically reviewed. We found that most studies are clinical in nature. Within the
- 898 -
past quarter-century new trends have appeared; these include a distinction between
"indications" and "suitability," increasing stress on object relations and character qualities, and
the application of quantitative methods to investigation. We also found considerable agreement
regarding the qualities deemed to make a person a suitable candidate for psychoanalysis, i.e.,
the better the pretreatment level of personality organization, the more favorable the prospect.
The findings of individual studies, however, are cast largely in abstract, metapsychological terms
lacking empirical specification. Most investigations also do not clearly specify what is meant by
psychoanalysis, analyzability, outcome, or upon what evidences conclusions are based. We
hope that future investigators will find ways of addressing these problems.
For a review such as this to fulfill its intent, it should serve as a basis for new perspectives
in future research. One such effort is now beginning, based on a paradigm of studying what
kinds of changes occur in what kinds of persons with what kinds of analysts; a series of single,
tape-recorded cases will be studied, employing extensive pre- and post-treatment information
(including psychological testing) guided by the main findings of this review.
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31:514-531 []
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54:35-46 []
- 899 -
Appelbaum, S. 1977 Psychotherapy: The Anatomy of Change New York: Plenum Press.
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assessment of analyzability J. Phila. Assoc. Psychoanal. 4:147-161
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presented to the Philadelphia Psychoanalytic Society unpublished.
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Ekstein, R. 1956 Psychological techniques In:Progress in Clinical Psychology Vol. II ed. D.
Borne & L. Abt. New York: Grune & Stratton.
Freud, A. 1954 The widening scope of indications for psychoanalysis: discustion The Writings of
Anna Freud 4:356-376 New York: International Universities Press, 1968
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York: International Universities Press, 1956 pp. 406-420
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analytic method applied to four psychoanalyses American Psychoanal. Assn. 25:471-490
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Hamburg, D., Bibring, G., Fisher, C., Stanton, A., Wallerstein, R., Weinstock, H., & Haggard, E.
1967 Report of the Ad Hoc Committee on central fact gathering data of the American
Psychoanalytic Association American Psychoanal. Assn. 15:841-861 []
Holzman, P. 1976 The future of psychoanalysis and its institutes Psychoanal. Q. 45:250-273
[]
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psychoanalysis Psychoanal. Q. 44:71-91 []
Karush, A. 1960 Analyzability and the factors in ego-integrative strength In: Panel 1960
Kernberg, O. 1975 Borderline Conditions and Pathological Narcissism New York: Jason
Aronson.
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Psychotherapy and psychoanalysis: Final report of the Menninger Foundation
Psychotherapy Research Project Bull. Menninger Clin. 36:3-275
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treatment In:Current Approaches to Psychoanalysis ed. P. Hoch & J. Zubin. New York:
Grune & Stratton, pp. 151-175
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Knapp, P. 1960 Discussion of criteria for analyzability In: Panel 1960

Knapp, P. Levin, S., McCarter, R., Wermer, H. & Zetzel, E. 1960 Suitability for psychoanalysis: A
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Psycho-Anal. 10:86-95
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31:528-531 []
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- 902 -

Bachrach, H.M. and Leaff, L.A. (1978). "Analyzability": A Systematic Review of the Clinical and
Quantitative Literature. J. Amer. Psychoanal. Assn., 26:881-920
(1983). Psychoanalytic Quarterly, 52:180-203
On the Concept of Analyzability
Henry M. Bachrach, Ph.D.
ABSTRACT
Much of our understanding of analyzability is based upon a model of inquiry that assumes a
relative comparability among analysts as observing and influencing instruments. This paper
suggests that the individuality in understanding and application of the psychoanalytic procedure
inherent in the psychoanalytic enterprise raises questions about the comparability of clinical
observation and data and must be taken into account in a realistic understanding of the factors
that govern analyzability.
As analysts, we often refer to patients as analyzable or not, or analyzable to varying

degrees. By this, we generally mean that the analyzable patient possesses the potential for
engaging in the psychoanalytic process and, by implication, that pertinent structural change can
be brought about by analytic means. Understood in this way, the idea of analyzability seems
simple enough and has a certain heuristic appeal. A moment's reflection, however, dispels this
illusion of simplicity. We recognize that the development of a psychoanalytic process requires
the disciplined participation of a psychoanalyst who, by attitude and intervention, becomes an
active ingredient in the process. Moreover, our understanding of analyzability can only have
meaning within a common framework of what we understand as analytic means and change,
and the extent to which there is a relative uniformity in this understanding. Indeed, the idea
Earlier versions of this essay were awarded the first Herbert Herskovitz Memorial Prize by the
Philadelphia Psychoanalytic Institute, and were presented to the Philadelphia Psychoanalytic
Society and the New York Freudian Society.
- 180 -
of analyzability rests upon a great deala model of the mind and related theories of
psychopathology and therapy.
As Freudian analysts, we believe we share such a common framework which we bring to
the consulting room with relative uniformity. We recognize that the clinical needs of our
analysands and our own individuality give rise to a certain individuality in application of the
psychoanalytic procedure and in expectations of structural change, but we generally assume
that in the end such differences will be of small consequence. Indeed, the idea of analyzability
demands this much: if the psychoanalytic procedure, or its application, or expectations for the
final result were much varied, clinical data would lose their comparability and the concept of
analyzability would have little specific meaning.
In what follows I shall explore the manner in which differences in the understanding and
application of the psychoanalytic procedure affect the comparability of clinical observation and
our understanding of analyzability . The theme will be thatdespite a common framework
given by the analyst's attitude and the rules of procedure, the structure of the psychoanalytic
situation, the metapsychological principles, and the goal of structural changethere is and
always has been considerable individuality in the understanding and application of the
psychoanalytic procedure; that this individuality raises questions about the often assumed
comparability of clinical observation and data; and that this individuality must be taken into
consideration in a realistic understanding of the factors that govern analyzability . The first
section of this essay will focus upon the individuality inherent in the psychoanalytic method and
its consequence for the comparability of observation; the second section deals with the
individuality and comparability of change; and the third section carries forward the implications
of this individuality for the concept of analyzability .
- 181 -
THE PSYCHOANALYTIC METHOD AND THE COMPARABILITY OF CLINICAL DATA

As the full development of transference is the consequence of analytic situation and
analytic technique, changes of this situation or technique can considerably alter
transference phenomena.
ROBERT WAELDER, 1956
Freud defined psychoanalysis as a method of observation, a therapeutic procedure, and a
general psychological theory, all interrelated. He saw the therapeutic benefit of psychoanalysis
essentially as "reclamation work" taking place within the ego and most particularly upon its
synthetic functions. What first distinguished analysis from psychotherapy was the idea of
reconstructing the infantile amnesia within the psychoanalytic process (Freud, 1904), and to the
very end Freud (1940) held fast to the idea that interpretation of the transference neurosis and
reconstruction of the infantile neurosis were two essential ingredients of therapeutic action.
Throughout his life Freud revised his ideas in concert with his therapeutic efforts and his
evolving understanding of the mind. Theory and technique were always allied. His early model
of hysteria was wedded to a therapeutica of discharge. Recognition of infantile sexuality and of
the role of the oedipal conflict in neurosogenesis brought fresh understandings and changes of
technique. In 1900 a new theory of mind was born (Chapter VII of The Interpretation of Dreams)
and with it free association came to replace forced remembering; interpretation replaced
suggestion; and the infantile neurosis was brought into the "here and now" as the transference
neurosis.
While Freud was eager to lay down the details of his newly evolving theory, he did not feel
he could set forth a systematic account of the psychoanalytic procedure, in part because to him
each case was unique. He likened psychoanalysis to a game of chess in which only a few of the
opening and closing moves could be prescribed, the rest having to be learned by playing
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the game and studying the game with the masters. He wrote only one series of papers on
technique (Freud, 1911-1915)these after about ten years of experience with the
psychoanalytic method properin which he limited himself to describing the outlines of the
procedure, especially in relation to the opening phase, and emphasizing the importance of the
analyst's attitudes, remembering, and interpretation of transference and resistance. A quarter of
a century later Fenichel (1941) reaffirmed that "the infinite multiplicity of situations arising in
analysis does not permit the formulation of general rules about how the analyst should act in
every situation, because each situation is essentially unique" (p. 1). A place for individuality was
therefore woven into the basic fabric of the clinical psychoanalytic model.
Indeed, when Glover sent out his now famous practice questionnaire to twenty-eight
experienced members of the British Psychoanalytic Society during the late 1930's, "substantial
variations" were found "in every imaginable way" regarding method of interpretation, frequency
of visits, length of analysis, criteria for termination, etc., even among those "holding to the
fundamental principles of psychoanalysis" (Symposium, 1937, p. 132). When Glover made
mention of these findings in his introductory remarks at the Marienbad Symposium in 1936 on
the theory of therapeutic results, many of the participants were not surprised, as they
themselves were not of equal mind regarding an optimal technique and its theoretical
underpinnings. It will be recalled that this symposium was held partly to air differences that had
been developing and were brought to a ferment by Strachey's (1934) paper on the nature of
therapeutic action. At Marienbad Strachey re-emphasized his views regarding introjection,
superego modification, and transference interpretation as the solely mutative technical device of
the analyst; Bergler focused upon alleviation of the unconscious sense of guilt; and Bibring,
Fenichel, and Nunberg kept their focus upon the observing and synthetic functions of the ego
(see, Symposium, 1937). The dialogue at Marienbad, however, was
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only one of a series that had been central to the tradition of psychoanalysis as far back as the
Wednesday meetings of the Vienna Psychoanalytic Society (Nunberg and Federn, 1962-1975)
and that had already become an established part of the international scene by the Salzburg
Congress of 1924.
Over the years new findings and perspectives have continually emergede.g., from child
observation and analysis, from object relations theory, from logical and philosophical analysis as
well as from rigorous application of the classical procedure (Panel, 1953), (1964), (1976),
(1977), (1979)and the main chapters in the book of psychoanalysis are about such matters
and their consequences. Theory and technique are continually being questioned and re-
evaluated. Today, for example, one finds spirited discussion about the management of anxiety,
the nature of the analytic alliance, the roles of transference interpretation and reconstruction in
technique, and the place of object relations theory and pregenital influences.
The significance of these differences and developments for our understanding of
analyzability is that they can have important consequences for the conduct of analyses,
including what analysands will come to experience in the analytic situation and recognize as the
landmarks of their story. For example, Gill (1978), (1979) has taken the position that, when all is
said and done, therapeutic change takes place only within a here and now analysis of the
transference that minimizes the role of genetic interpretation and reconstruction. In contrast,
Coltrera (1979) and Rangell (1979) have argued that such single-minded emphasis may impede
the natural development of transference neurosis and effective working through. While the
domain of the idea of analyzability may remain with the analysand, different approaches and
emphases may bring out different things.
The heart of the matter, it seems to me, as with all matters pertaining to the psychoanalytic
procedure, is the consequence of technique for the development of the transference neurosis
and its subsequent modification by interpretation, without
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which there would be no analysis. The analyst's attitudes and rules of procedure, including
anonymity, constancy, nonintrusiveness, and concern, the single-minded emphasis upon
meaning and understanding, the stance consistently equidistant between the analysand's
conflictually interacting psychic structures, along with the recumbent position, the frequency of
visits, and free association, are all catalytic toward this single end. The analytic procedure is
akin to preparing a slide in a certain way and adjusting a microscope in a manner that
maximizes the potential for observing intrapsychic conflict. The conditions of the analytic
situation and procedure correspond to the way the slide is prepared; the analytic inference
process, guided by the metapsychological perspectives, corresponds to the adjustments of the
microscope. When any of the fundamental conditions of the procedure are systematically
varied, as, for example, when the analyst alters his stance, the analysand's productions will be
influenced. The resulting observations may no longer be comparable, and the reason for this is
partly embedded in the nature of the analytic inference process. To obtain analytic data, the
analyst does not direct his notice to anything in particular. He maintains
the same 'evenly-suspended attention' in the face of all that one hears he must
turn his own unconscious like a receptive organ towards the transmitting unconscious
of the patient. He must adjust himself to the patient as a telephone receiver is adjusted
to the transmitting microphone. Just as the receiver converts back into sound waves the
electric oscillations in the telephone line which were set up by sound waves, so the
doctor's unconscious is able, from the derivatives of the unconscious which are
communciated to him, to reconstruct that unconscious, which has determined the
patient's free associations (Freud, 1911-1915, pp. 111-112, 115-116).
It is this mode of inference that the conditions of the analytic situation facilitate. Without
relatively free associations or their equivalents, it would not be possible to obtain analytic data.
Altering fundamental conditions is akin to preparing the slide
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differently or adjusting the microscope to a different perspective. We may no longer be looking

at the same things, or we may have influenced them to a point where they will no longer have
the same meaning. For example, Shevrin (1979) has pointed out that the repeated limit-setting
and confrontation that may be required in the treatment of certain borderline conditions may
alter the relationship between the analyst and the free association process: "In becoming a
more real force to contend with, we can no longer be certain that patients to what they do for the
same reasons [that would have prevailed if we had] remained more neutral" (p. 17). Even in
relation to the transference neuroses, if we alter our perspective, we shall no longer be able to
explain our findings with a theory built upon their assumption (Panel, 1953). What I am
therefore emphasizing is the special relationship between the conditions of the analytic
enterprise and the nature of observation generated by its application. Fundamental alterations,
clinically indicated or not, jeopardize the comparability of observation and inference.
Conclusions about analyzability of observation different perspectives on the psychoanalytic
process of procedure, or from varied technical applications, may or may not be comparable.
Rapaport's lectures on methodology (1944) and on metapsychology (1957), the 1955 Geneva
Symposium on Problems of Transference (see Symposium, 1956), the 1953 New York Panel
on The Traditional Psychoanalytic Technique and Its Variations, and Shevrin's (1979) analysis of
the metapsychological principles are all very illuminating on this point.
In 1957fifty years after the publication of Freud's papers on techniqueGreenson, in his
introduction to the Panel on Variations in Classical Psychoanalytic Technique held at the 20th
International Congress in Paris (see Panel, 1958), addressed himself to the potential
consequences of differences in understanding and application of the psychoanalytic procedure:
It is an accepted fact that every analyst works somewhat differently with each patient
and that no two analysts employ identical
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techniques. Differences in technique run the gamut from mere stylistic variations well
within the basic framework of psycho-analysis to alterations which change one or
another essential procedure or aim of psycho-analysis (p. 200).
He felt it was important to distinguish between
variations of technique which in no way conflict with the basic rules or goals,
modifications which may be necessary but temporary interruptions of our procedures
and aims, or deviations which lead to a permanent change in the psycho-analytic
method with a consequent renunciation of its results (p. 200).
The consensus of the panel was that differences in application are partly a function of the
analyst's style and the unique circumstances of each case. Loewenstein stated, "The
applicability of a rule in a given case or at a given moment will depend upon the patient's
psychological state and on our estimate of the effect its application might have upon him at such
time or in the future" (Panel, 1958, p. 204).
From the 1950's onward, considered efforts have been made to systematically define and
differentiate the fundamental postulates and methods of object relations and ego-psychological
perspectives, and subsequent discussions (e.g., Panel, 1964), (1979) have more sharply
revealed the technical consequences of these differences. However, almost as soon as these
perspectives were becoming more clearly distinguished, fresh insights from child analysis and
observation came to demand consideration for their implications for method, process, and result
(e.g., Panel, 1977), (1979). Within the past decade efforts have been made to question and re-
evaluate more classical hypotheses and perspectives, clinically, conceptually, and
philosophically (Panel, 1977), (1979). What is at issue is the consequences of these differing
perspectives and their diversity for the comparability of clinical observation as it contributes to
our understanding of analyzability .
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THE INDIVIDUALITY AND COMPARABILITY OF CHANGE

one must keep in mind that each of the definitions of the goals of psychoanalysis
refers to one or another kind of psychological difficulty Which is the more important
goal and which is merely an incidental one will depend upon the individual
circumstances of each case The analytic goal will, therefore, vary from case to case
in accordance with the consequences of conflict in each case.
CHARLES BRENNER, 1976
Throughout his life Freud was concerned with the distinction between changes brought
about by application of the psychoanalytic method and those brought about by other means,
especially suggestion. He cast his views about the goals of psychoanalysis in general terms
because he saw the nature of change as too individualistic to warrant greater specificity. In
Analysis Terminable and Interminable (1937) he put into words his final understanding of the
goal of psychoanalysis as the "taming of the instinct." Cautioning against idealized,
perfectionistic expectations, he wrote:
The termination of an analysis is, I think a practical matter Our aim will not be to rub
off every peculiarity of human character for the sake of a schematic 'normality', nor yet
to demand that the person who has been 'thoroughly analysed' shall feel no passions
and develop no internal conflicts. The business of the analysis is to secure the best
possible psychological conditions for the functions of the ego; with that it has
discharged its task (pp. 249-250).
A quarter of a century later, in a retrospective symposium on Analysis Terminable and
Interminable (Panel, 1963) both Loewenstein and Valenstein felt they could add no more.
Over the years efforts have been made to introduce a greater element of generalizability in
defining and studying outcomes. In
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1936 Jones distinguished between "therapeutic" and "analytic" goals; the important therapeutic
goals were the patient's subjective sense of strength and well-being, while the essential analytic
goals were the lifting of trauma and infantile amnesia and an understanding of symptoms and
character. Glover (Symposium, 1937), however, found considerable variability regarding the
application of such criteria among the analysts he polled. In 1941, on the other side of the
Atlantic, Oberndorf (1943) sent a questionnaire to twenty-four experienced psychoanalysts: "no
two replies were very similar." He wrote:
[These results] confirm what [analysts] have long suspectednamely, great
disagreements, dissimilarity and disparity of thought on really critical questions among
mature psychoanalysts who have been more or less subdued by countless experiences
with the struggles and dilemmas peculiar to psycho-analytic treatment Still, the
extraordinary degree of individualism of analysts in procedure and results may exceed
previous supposition. The great divergence exposed may be taken as an indication that
the psycho-analytic method can have no fixed application (p. 113).
Earlier that same year Knight (1941) also made an effort to set forth criteria in a
generalizable from: (1) disappearance of presenting symptoms; (2) improved reality adjustment;
and (3) improvements in the mental economy (e.g., insight, autonomy). Two years previously
Hartmann (1939) had cautioned against equating health with freedom from symptoms, i.e., a
healthy person must have the capacity to suffer. "Individual conceptions of health differ widely
among analysts themselves, varying with the aims which each has set for himself on the basis
of his views concerning human nature, and also, of course, with his philosophy, political
sympathies, etc." (p. 8). Hartmann considered the capacity for adaptation to be a more reliable
criterion.
Oberndorf had a life-long interest in clarifying the results of psychoanalytic treatment and
was instrumental in organizing the first Symposium (1948) on The Evaluation of Therapeutic
Results which was held in Boston in 1948. The focus of this
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symposium was different from that of its predecessors. Past gatherings had asked the question
of what is, or should be, the result of psychoanalysis; in this one the question was how do we
assess what these outcomes actually are. Here Kubie (Symposium, 1948) was the first to
suggest that verbatim tape-recordings were the only reliable basis upon which assessments
could be made; his banner was the most careful clinical description possible. Most participants
were less than enthusiastic about the use of recordings: even recordings do not capture all the
important data, and their analysis is time consuming and no less complex (it was to be yet
another quarter of a century before computer technology could be brought in as an adjunct
[Dahl, 1972]). The consensus was that the greatest difficulties in determining results centered
on inadequate description of the therapeutic procedure, the limitations of the analyst as judge of
the final result, and the exclusion of consideration of the analyst's personality in the treatment
process. Oberndorf (Symposium, 1948) went so far as to say that questions about the
outcomes of psychoanalysis could be meaningfully considered only in the light of "(1) which
type of psychoanalysis , (2) by which type of psycho-analyst, (3) at which particular time is
best applicable to (4) which type of patient suffering from (5) a specific type of illness" (p. 11).
Greenacre, however, summed up what she most felt:
The question of methods of evaluating therapeutic results of psycho-analytic treatment
is an extraordinarily complicated one. I confess that it frightens me somewhat Since
the psychoanalyst is not generally dealing with a specifically circumscribed disease
process in the patient, but with a number of interweaving disturbed functions embedded
in or consisting of the very fabric of the patient's existence, and since psycho-analytic
treatment involves a relatively complicated set of techniques applied over a long period
of time, with the additional variable of the human administration of these techniques
and the peculiarly important rle of the transference which is in itself an interaction
between patient and analyst, because of all these we become
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aware of, and as I said, frightened of the enormous intricacies of the job (p. 11).
The next year the British Psychoanalytical Society held two symposia on criteria for
termination, in which there were almost as many viewpoints expressed as there were
participants (see Symposium, 1950a), (1950b). Four years later Glover (1954a) wrote that
"despite many symposia on the subject, there is no evidence that even an approximate
consensus of opinion on therapeutic criteria has been reached" (p. 95).
Looking back through these many symposia moored in our traditional case study method, it
is surprising, in fact, how much has been learned. The magnitude of the achievement becomes
discernible when viewed within the limitations of the method. For example, when we use
ourselves as judges of our results, we do so with vested interests. The same is true for the
opinions of our analysands. This is why we rely upon complex process criteria in assessing
progressdevelopments in the transference, free association, dreams, and the structure of
fantasy and symptoms. But in so doing, we still depend upon those most unreliable of so-called
autonomous ego functions: perception and memory. It is as if, in trusting ourselves to this
extent, we ignore the very teachings of our enterprise. Another aspect is that the very nature of
our work limits the number of cases with which we can have experience, and there are personal
and external biases involved in our selections. We remain vulnerable to the fallacy of believing
that our own experience is representative of that of our colleagues. We therefore submit our
work to colleagues for discussion, but this too introduces a host of other influences, including
transferences and unconscious group processes. And once our patients are discharged, we
hardly ever see them again. Although much has been learned, the problem is that some of what
has been learned may be imprecise or untrue.
Within the past few decades there have also been countervailing influences. In the 1962
symposium on Analysis Terminable and Interminable (see Panel, 1963), Pfeffer reported
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on his experimental follow-up studies (1959), (1961) of well analyzed persons, in which he
found recrudescences of transference neurosis during a series of unstructured follow-up
interviews. When these findings were subsequently confirmed by Norman, et al. (1976) and
Schlessinger and Robbins (1974), the idea of complete resolution of transference neurosis was
brought into question. It is partly as a result of such work that we are now more cognizant of the
fact that successful analysis results in a loss of poignancy of conflicts, rather than their removal.
In recent years there has also been a tendency to move from interest in fantasy and
symptoms toward overall considerations of character in perspectives on change. This was the
main difference between the Marienbad meeting in 1936 (Symposium, 1937) and the New York
Panel (1976) on the psychoanalytic process. When the blocks in development created by
conflict are resolved, the natural growth processes are freed to develop along less conflictual
lines. This view, firmly anchored in Analysis Terminable and Interminable, is the point of
departure from which Ticho (1972) distinguished treatment from life goals. Baum and Robbins
(1975) found that, for a pivotal criterion for termination, a majority of the analysts they polled
relied upon the impression that such an analytic growth process had been set in motion. Implicit
in this view is the capacity for self-analysis.
That substantial changes occur in psychoanalysis is not at issue. The sheer weight of
clinical experience and survey (e.g., Hamburg, et al., 1967) suggests this much. What is at
issue, however, is the comparability of individual changes for our understanding of analyzability
. That is, do certain kinds of analysands change in characteristic ways, and upon what
perspectives do we rely? Different perspectivesthat of the analyst, the analysand, the outside
observer, or life developments subsequent to terminationcarry different frames of reference
and rest upon their own implicit assumptions. The idea of a single, uniform, and measurable
criterion is an illusion. Individual
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perspectives are inevitable, and what is important is to understand what each perspective
reveals and why. The analytic vision holds that change is to be understood in structural terms,
although the nature of the structures involved depends upon the circumstances of each case
and the personal and theoretical perspectives of the analyst. What may be sufficient and
germane change for one may or may not be for another. Differing perspectives may lead to
different conclusions about analyzability , and it remains that our understanding of analyzability
has not been founded upon consistent criteria of change.
IMPLICATIONS FOR THE CONCEPT OF ANALYZABILITY
We cannot discuss indications without taking the psychoanalyst into consideration
Research about the worth of psychoanalysis has no importance whatever if the
question of who is analysed, by whom, and for what is not taken seriously.
P. C. KUIPER, 1968
Even as Freud was developing his psychoanalytic method, he was concerned with
specifying the kinds of persons and conditions to which it was most applicable. As early as 1905
he developed a view which he never substantially altered:
One should look beyond the patient's illness and form an estimate of his whole
personality; those patients who do not possess a reasonable degree of education and a
fairly reliable character should be refused one should limit one's choice of patients to
those who possess a normal mental condition (pp. 263-264).
The idea of analyzability takes its root in the effort to specify the applicability of the
psychoanalytic procedure, and over the years analyzability has been studied in terms of
patient types (Freud, 1916); (Glover, 1954b), patient qualities (Aarons, 1962); (Karush [Panel,
1960]), indications (A. Freud, 1954); (Waldhorn, 1967),
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suitability (Panel, 1968); (Tyson and Sandler, 1971), diagnostic and categorical groupings
(Fenichel, 1945); (Glover, 1954b), patient selection (Huxster, et al., 1975); (Lower, et al.,
1972), prognosis and prediction (Kernberg, et al., 1972); (Panel, 1960); (Sashin, et al., 1975);
(Zetzel, 1968). Despite differences of emphasis in these many discussions, the domain of the
idea of analyzability has always remained with the person of the analysand: the "ability" to be
"analyzed," the qualities of persons favorable or unfavorable to the analytic undertaking. Any
systematic compendium of the findings of these many studies will reveal a sizable consensus
that the more favorable the analysand's level of ego organization and functioning, the more
favorable the prognosis (Bachrach and Leaff, 1978). For many decades now this has remained
the central thrust of our understanding, as confirmed over and over again by the many individual
studies. One might even say there is a redundancy afoot and wonder to what extent
contributions continue to build upon one another leading to an evolution of knowledge. Similar
findings obtain not only in all forms of psychotherapy (Luborsky, et al., 1971), but also in the
history of nations, economies, and species.
Careful examination of studies of analyzability will reveal that reports of findings rarely
provide a definition of psychoanalysis, the basis for observation and evidence in support of
inferences. Typically, indications and contraindications are given at overly general and
metapsychological levels far removed from the level of clinical observation that is the
touchstone of our everyday work. Erle and Goldberg (1979) have made similar observations.
Since there are today, as there always have been, many versions of the psychoanalytic
procedure and of the nature of change (differing in their visions of human nature, models of the
mind, neurosogenesis, technique, etc.), comparability of observation, inference, and conclusion
is therefore frequently in question.
In the absence of a precisely calibrated observing instrument, it is difficult to know when
observations truly support one
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another. What appears as confirmation or disconfirmation on the surface may really be an

assertion about an entirely different matter. For example, assertions about the analyzability of
borderline or narcissistic conditions, based on cases in which modifications of technique have
altered the relationship between the analyst and the free association process, may involve a
separate set of observations and findings about analyzability as compared with unmodified
approaches to the transference neuroses. Kernberg (1975) is aware of this methodological point
and attempts to keep matters straight by making distinctions between the findings obtained by
modified applications to borderline patients. Kohut (1977), on the other hand, tends to obscure
distinctions in referring to the analyzability of narcissistic conditions with a different meaning
than the analyzability of disorders of intrapsychic conflict. The danger here is that the idea of
analyzability can become reduced to a simple concept of treatability that homogenizes
distinctions between clinical procedures, their effects, and applicabilities.
Even in applications of the psychoanalytic method to the transference neuroses, if we alter
our metapsychological perspective (i.e., that psychoanalytic understanding must include
dynamic, structural, genetic, adaptive, and quantitative aspects), it is possible for entirely
different conclusions to follow from this altered stance on observation. For example, if one
eliminates the dynamic perspective, it becomes possible to understand neurosis as a product of
insufficient nurture alone. Without a structural perspective, it becomes possible to believe that
conflict resolution can transform the patient into a new person. Even if we remain broadly within
the confines of the classical procedure and vision, but emphasize one aspect of technique, such
as transference interpretation, at the expense of another, such as reconstruction, the resulting
observations may no longer be comparable. Even if such a tactic may seem to be more
clinically indicated in a given case, we shall nonetheless have differentially influenced the
analysand's productions. In fact, part of our skill as analysts is to know what tactics apply best
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in what circumstances. The issue here is not clinical but methodological. Clinical (or technical)
questions pertain to the optimal handling of a given case. Methodological questions pertain to
the way technique influences observation and the comparability between observations.
Tyson and Sandler (1971) have taken issue with the concept of analyzability on the
grounds that its multiple referents leave it meaning little more than treatability at best, and at
worst obscure the vital distinction between whether the analyst can understand (analyze) the
patient's productions and whether the patient can benefit from application of the psychoanalytic
procedure. They are correct that a vague and overly general concept of analyzability has little
meaning or utility. However, if the concept of analyzability is conceived more precisely in terms
of factors within analysands that favor the development of a psychoanalytic process, then the
concept can have considerable clinical specificity, consequence, import, and meaning. But a
psychoanalytic process does not develop in isolation.
The psychoanalytic process, as I have emphasized, occurs as a consequence of application
of the psychoanalytic procedure to persons with analytic potentials. It is not simply a
consequence of therapeutic intent, nor does it develop in all therapeutic situations. Its
occurrence depends upon the relative balance of intrapsychic conflict and developmental arrest
in any given case and the ability of the analyst to engage the analysand analytically. This is
where the skill, experience, vision, style, and other personal qualities of the analyst come into
playall of which, I think, are less separable than we often like to assume. However we may
wish to conceive of the analyst's contribution to the evolution of a psychoanalytic process, that
contribution always stands as the silent background of analyzability . Above all, our researches
into analyzability over the years have assumed a relative uniformity in this silent background
namely, that an average expectable analysand is likely to evolve an average expectable analytic
situation with an average expectable analyst and that the observations emerging are
comparable.
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In the early days of psychoanalysis the contribution of the person of the analyst to the
treatment process was minimized because analysts were struggling to establish the validity of
the procedure as distinguished from suggestion. As far back as 1939 however, the Balints
wrote:
A question which frequently arises in psycho-analytical discussions on technical themes
is whether the transference is brought about by the patient alone, or whether the
behaviour of the analyst may have a part in it too. On such occasions one opinion is
always put forward most emphatically by certain analysts. It runs roughly as follows: 'If
and when the analyst has influenced the transference situation by any means other
than his interpretations, he has made a grave mistake' We only wish to assert that
there do exist differences in analytic atmosphere which are brought about by the
analyst himself (pp. 223, 225).
Indeed, the time has long since passed when we were able to view the psychoanalytic
procedure as a "uniform instrumentality" divorced from the person who carries it out, and over
the years numerous analysts have studied the influence of the person of the analyst upon the
treatment process (e.g., Eissler, 1953); (Oberndorf [Symposium, 1948]); (Stone, 1961);
(Ticho, 1973); (Zetzel, 1956). The lesson generally learned from clinical experience is that the
person of the analyst has surprisingly little consequence for the final result with regard to the
transference neuroses (Balint and Balint, 1939); (Stone, 1961); (Ticho, 1973); (Zetzel, 1956).
The rule is that the analytic process and procedure are of sufficient moment to override the
effects of individual differences of style and temperament. However, clinical experience has also
taught that the effect of the person of the analyst takes on clinical significance proportionate to
the ego weakness of the patient (Eissler, 1953); (Glover [Symposium, 1937]); (Ticho, 1973).
Our evidence regarding the effect of the person of the analyst upon the evolution of the
psychoanalytic process is based upon two main sources: (1) the shared, but intimately
individual experiences of practitioners spanning many decades of analytic
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observation; and (2) the repeated findings of surveys conducted by institutes and societies from
the 1920's onward which show improvement rates from sixty per cent to eighty per cent. Said
Glover (Symposium, 1937, p. 132) of the findings of his survey, "So far as I can ascertain the
results obtained by these various methods appear to be much the same." There are, however,
problems with such evidence. First, it emerges from the traditional case study method in which
comparability, as I have suggested, cannot necessarily be assumed. Second, the findings of
these surveys tell us only that a certain proportion of analysands are seen as improved in the
opinions of their analysts whose own criteria for improvement are frequently quite variable (cf.,
Glover [Symposium, 1937]); (Oberndorf, 1943). What such reports do not reveal are the kinds
of changes that occurred; they therefore do not illuminate the nature of change obtained by
varying applications with different kinds of analysands. The sixty per cent to eighty per cent
improvement rate, in fact, is the figure generally quoted for all forms of psychotherapy (Garfield
and Bergin, 1978).
What I am suggesting is that the presumption that basically reliable analysands are able to
adapt to individual differences among average expectable analysts is only a general rule and
that exceptions can be found. Here I am referring to the "match" between basically reliable
analysts and analysands with its better recognized than understood import for the workability of
transferences (A. Freud, 1954); (Gaskill, 1980); (Limentani, 1972); (Pollock, 1960); (Tyson
and Sandler, 1971); (Weber, 1977). There are still elusive distinctions to be made, about which
we know far too little, between what makes this usually trusting and reliable analysand trusting
or distrusting, reliable or unreliable, with this particular analyst and not another. Insofar as the
factors involved in matches pertain to the fate of analyses, any understanding of analyzability
that takes the person of the analysand as its exclusive scope must therefore be incomplete.
It may be objected that by including consideration of the role
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of the analyst as an observing and influencing instrument in our understanding of analyzability ,

I am extending the concept beyond its generally accepted meaning. Yet, since our
understanding of analyzability is a product of the accumulated experience of a wide variety of
individual analysts between whom we cannot assume full comparability, the nature of the
calibration of the observing instrument cannot escape consideration. Oberndorf (Symposium,
1948) and Kuiper (1968), among others, have already suggested that the most meaningful
questions about analyzability are posed in terms of what kinds of changes occur, in what kinds
of analysands, experiencing what kinds of difficulties, when the psychoanalytic procedure is
applied in what kinds of ways by what kinds of analysts.
In considering the matter of analyzability we are dealing with fundamental questions about
the factors that decide a given result. Thus far I have attempted to show that the individuality
inherent in the analytic enterprise provides cause for questioning the assumption of
comparability among analysts as observing instruments upon which our understanding of
analyzability has been founded. What I should now raise for consideration is whether this
assumption itself may be the basis for the redundancy of conclusions about analyzability and
for difficulties in extracting fresh nuggets from our analytic mines. That is, if we assume a
relative comparability among analysts as observing instruments, or uniformity in the silent
background of analyzability , we shall only be able to derive what can be learned from what is
uniform, constant, and generalizable when individual differences are removed from the process
equation. It is in this way that our understanding of analyzability may be partly a product of the
assumptions that have governed our mode of inquiry. A deepening of our understanding of the
factors that govern analyzability may therefore require systematic inquiry into the
consequences of individual differences.
According to the praxis, we now distinguish broadly between the analyzability of three
classes of patients. The first are those reflective persons of basically reliable ego who are able
to adapt
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to the expectable range of differences among analysts and make the most productive use of
their analytic opportunities. The second are those persons whose ego weaknesses or infantile
character attitudes simply leave them unable to participate in the work of analysis. The third is a
"borderline" group for whom the fate of the analytic work often more heavily depends upon the
person and special talents of the analyst. However, the praxis still leaves us with many clinical
and conceptual riddles. For example, what factors are involved and how do we understand
those cases in which the match between the basically reliable analysands and analysts takes on
unanticipated significance? To what extent is analyzability simply a function of ego strength,
and to what extent do particular qualities (e.g., psychological mindedness, determination to
change) stand out as more important than others (e.g., tolerance for separations) in particular
characterological settings? Is a technique that places transference interpretation in the context
of reconstruction optimal for all analysands with basically reliable egos or only for some (e.g.,
hysterical characters), and what are the consequences of a shift in the balance away from
reconstruction? To all these questions and the many others that can easily be adumbrated, we
shall, of course, answer "it depends." But inasmuch as the answer to all such questions bears
upon the analyzability of a given case, our difficulties in providing more systematic answers do
little to further our understanding of analyzability . The fundamental question of analyzability
is: When do workable transferences evolve naturally between average expectable analysands
and analysts, and when is their evolution more dependent upon the individual analytic dyad?
This question cannot be answered as long as analyzability is viewed as a global concept, as
long as our inquiries continue to take the person of the analysand as its nearly exclusive scope,
and until we can be more assured of the levels of comparability among our observations.
Ultimately, the most realistic understanding of the idea of analyzability depends upon the
answer to this question.
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SUMMARY
This paper has attempted to show that, despite a common framework given by the analyst's
attitudes and rules of procedure, the structure of the psychoanalytic situation, the
metapsychological principles, and the goal of structural change, there is, and always has been,
considerable individuality in the understanding and application of the psychoanalytic procedure;
this individuality raises questions about the often assumed comparability of clinical observation
and data; and this individuality must be taken into consideration in a realistic understanding of
the factors that govern analyzability.
It was suggested that much of our understanding of analyzability is partly a function of
assumptions of comparability and uniformity among analysts which have governed our mode of
inquiry and that a deepening of our understanding requires systematic inquiry into individual
differences, including the contribution of the analyst to the development of the psychoanalytic
process. Inasmuch as our understanding of analyzability is a product of the accumulated
experience of a wide variety of analysts between whom comparability cannot always be
assumed, the nature of the calibration of the observing instrument requires consideration. The
conclusion is that the most meaningful questions about analyzability are posed in terms of what
kinds of changes occur, in what kinds of analysands, experiencing what kinds of difficulties
when the psychoanalytic procedure is applied in what kinds of ways by what kinds of analysts.
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Bachrach, H.M. (1983). On the Concept of Analyzability. Psychoanal Q., 52:180-203
Unanalyzability and Narcissistic Transference Disturbances
Klaus Angel, M.D.
In the best working analytic patients their neurotic suffering remains a motive and a
relatively constant preconscious organizing factor for free association (2). This includes the
knowledge that transference fantasies are to be used as a tool in the solution of their neuroses.
In this paper I will discuss some disturbances in free association of certain patients, as
determined by their transference expectations and early object relations, and the relationship of
these disturbances to analyzability in general.
Let me begin by giving some examples.
CASE I
The motive of the associations is exhibitionism and the wish to gain the analyst's love for
the patient's productions. This patient treats dreams as if they were a work of art of some sort,
and makes the most dramatic associations possible to them; he deals with his entire neurosis in
one dream. He thus hopes to gain the analyst's admiration and to deny his own helplessness
and castration fear: he has no problems, no defects, provided the analyst admires him. What
results is a type of acting out in the transference: he acts out his exhibitionistic wishes instead of
discussing them. Another feature is his way of making decisions. For example, he has a conflict
about sending his children to camp because he feels guilty about wanting to get rid of them to
be alone with his wife, just as he wanted as a child to get rid of his younger brother and be
alone with his mother. He waits until the deadline for sending in the application blank and
discusses his conflict on that day. I give him some explanation or interpretation. He then sends
in the application without
I am grateful to Drs. Charles Fisher, Edith Jacobson, Edward Kronold, and George Gero for
their valuable suggestions and criticisms. Dr. Leo Stone deserves my special thanks for his
advice.
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difficulty because, as he tells me, if the camp were dangerous or his fears real and harm would
befall the children there, I would undoubtedly have mentioned it. Furthermore, he is convinced
from what I said that I send my own children to camp. He is therefore safe in sending his.
CASE II
The patient discusses his transference fantasies without much difficulty but he
unconsciously expects them to be indulged or fulfilled by the analyst as a real person. The
associations regarding transference are florid and full of meaning; but the knowledge that they
are fantasies, that is, that they reveal the patient's neurosis, is lacking. The patient has
confidence that he can expect fulfilment of these fantasies if only he stays in analysis long
enough. This also results in a type of acting out in the transference. Nothing can convince the
patient that the analyst is not the omnipotent, loving parent who will cure his neurosis by
indulging his transference demands. The patient has difficulty in seeing these transference
demands as unrealistic because of his belief in his own, and the analyst's, omnipotence.
CASE III
This patient also wants real love from the analyst as a real person but knows, contrary to
the former patient, that the analyst is not going to fulfil these demands. The associations tend to
remain factual, deal with reality problems, and avoid transference fantasies although their
presence is blatantly evident from dreams. It is as if the patient were saying: 'I refuse to be
frustrated and prefer not to mention transference demands if I know they are not going to be
gratified'. In this instance acting out outside the analytic situation results where the patient can
obtain gratification of these transference demands.
CASE IV
The patient cannot lose sight of his problems and the associations concern one problem
after another. The associations
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are motivated by an oral demand 'to get the answer right away'. There is a conscious wish to
find out how the analyst performs certain tasks and makes certain decisions, and the patient
thinks he can be cured by imitating the analyst. However, the transference fantasy that the
analyst is an omnipotent parent who has all the answers is unconscious. Again, this leads to a
type of acting out in the transference; the idea that the analyst has all the answers is acted upon
as if it were a real fact.
CASE V
The patient believes that her childhood suffering has made her into a special person and
has conferred upon her special rights. She continues to humiliate and torture herself with the
expectation of receiving compensation from the analyst who, as an omnipotent parent, will cure
the patient by giving her what she did not receive as a child.
Although these manifestations are all different, they have one transference fantasy in
common: the patient wants real love from an omnipotent analyst. This process of magical cure
is substituted for the real process of cure. The cure is thus not to be accomplished by the
patient's own ego in its mastery of conflicts, but by the analyst's omnipotent love.
It seems to me that the above examples are clinical illustrations of a type of transference
which is distinct from the transference neurosis and which has been called the primary
transference by Greenacre (5), or the primordial transference by Stone (8). These two concepts,
although having certain similarities, also have important differences. Space does not permit
these to be discussed in detail. Greenacre's concept deals with a clinically observable reaction
and is discussed largely as giving the analysis an affirmative push, except where the
idealization of the analyst becomes excessive. Stone's concept is discussed largely as a
resistance, only rarely clinically observable, but it is a primitive underlying force against
separation, accounting not only for oral fixations but also for fixations on a higher level, such as
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incestuous fixations. In the latter case there would be resistance against separating from the
incestuous object. For the purpose of this paper I have drawn from both concepts.
The primordial transference is intrinsically and inevitably ambivalent (8) since its matrix
comes largely from the mother-child relationship of the first months of life (5). Its positive
aspects give, as Stone puts it, 'a driving momentum and power to the analytic process' (8) and
its attenuated aspects form one part of the therapeutic alliancealong with tender aspects of
the erotic transference and friendly feelings of adult type. Greenacre makes a similar point when
she states that the analytic situation has many characteristics of the early mother-infant
relationship, and adds: 'This part of the situation with its progressively developing confidence
forms the primitive basis of the therapeutic alliance' (6).
In my patients we are dealing, however, with the negative aspects of the primal
transference, i.e., those aspects that lead to a transference resistance. In her paper, Problems
of Overidealization of the Analyst and of Analysis, Greenacre has shown how this aspect of the
primal transference (although she does not call it that) can lead to formidable resistances in
certain specific patients. She states: 'It is probably obvious that the transference relationship in
analysis contains by its very nature the seeds for idealization of the analyst in its rootedness in
the early omnipotent stage of the mother-child relationship' (6). Stone has emphasized the
presence of these negative aspects of the primordial transference in every analysis, as well as
the need for their constant interpretation lest they lead to tenacious transference resistances.
He states:
The primordial transference only rarely appears as such in our clinical work. When it
does appear, it leaves an impression not readily forgotten. This is the case when the
underlying transference of the psychotic patient appears, displacing his symptoms, if
only transitorily, or at times, in conjunction with them. However, in the usual neuroses or
character disorders with which we work, even in most so-called 'borderlines',
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this transference is in the sphere of inference, closest to the surface in the separation
experience of termination, or in earlier interruptions, or in periods of extreme
regression. It may be inferred at times in inveterate avoidance of transference emotion,
in extreme and anxious exploitation of the formalized routines of analysis, or in
inveterate acting out Only a type of psychological need (or rather, demand) which
sometimes assumes resemblance to original anaclitic requirements (for example, to
exhibit indirectly the wishrarely, to state it explicitlythat the analyst, in effect, think
for the patient) would seem not infrequent, and often demonstrably allied to the original
struggle against separation (8, pp. 10-11).
It seems worth while to examine these manifestations of primal transference in greater
detail and to raise the question whether they are related to analyzability in general.
A cursory review of the literature on analyzability does not throw much light on this
question. Freud mentions certain women who fall in love with the analyst and insist upon the
satisfaction of their erotic transference strivings. They listen only to '"the logic of soup, with
dumplings for arguments"'; they cannot be convinced that the transference is not real, and they
cannot be analyzed (3, p. 167). Greenson mentions two women who insisted on gratification of
their erotic transference wishes. Their erotic reactions to him represented a defense against
falling into the abyss of homosexual love for the mother. He makes an interesting observation:
'In one of them there was an additional element which eventually came to light. Her extravagant
reactions were also a massive denial of her growing awareness that she was losing contact with
people in general. There was loss of internal object representations' (7, italics added). I shall
return to the important topic of unstable object representations.
In my own experience, this insistence on receiving something real from an omnipotent
analyst is not the exclusive province of women. As my case examples show, the same
transference resistance takes a different form in menor for that matter in women (Cases III
and V)who do not show an erotized transference.
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The question arises whether this form of transference resistance, derived from the
primordial transference, is responsible for unanalyzability, or whether it is merely a defense
against the patient's underlying conflicts which are too frightening for him to discuss. In my first
case, for example, the question would be: Is the patient so frightened of his aggression toward
his children (or his brother in the past) that he uses this magical type of transference as a
defense, or is he 'fixated' on this type of transference by virtue of early predisposition or
traumata? This question is difficult to answer. Greenacre (6) in her discussion of overidealization
as a resistance in certain patients tends to the latter view; she discusses various childhood
constellations and traumata which seem to lead to this type of magical transference reaction.
Stone seems to hint at the same view when he states: 'In any case, the degree to which there is
actual deployment of cathexis from the original object to other environmental objects, including
the inanimate, determines (inversely) the power and tenacity of the primordial transference and
probably has much to do with the basic predispositions to emotional health and illness,
respectively (8, pp. 14-15, italics added).
I have no definite solution to this question but wish to enumerate some factors that seem to
me to be in favor of early fixation on this type of transference. 1, In most patients who are
unanalyzable or barely analyzable such transference manifestations seem to present a great, if
not the greatest, obstacle to successful analysis. 2, I have thoroughly analyzed the castration
anxiety and Oedipal conflicts in these patients as well as their connection to these regressive
transference strivings, but often without significant change. I thus became convinced that, at
least in part, these strivings have a source different from defense. 3, It is striking how these
transference strivings, originally directed toward the early mother, persist even when the analyst
is a male. The patient of course knows intellectually that the analyst is not the mother, but he
wants the same things from the analyst that he wanted from his mother.
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Manifestations of the primal transferencewith clinging to the analyst and analysis, with the
wish to stay in analysis forever, with expectations of magical cure from an omnipotent analyst
are present at some time and to some degree of intensity in the analysis of every patient. But
what makes these reactions either so intense or so refractory to interpretation that analysis
becomes difficult or impossible? Of the five cases mentioned, only Cases IV and V were clearly
unanalyzable. The other three improved during their analyses although the transference
reactions in question presented grave difficulties. The difficulties fall essentially into three
categories:
1. The tendency toward magical transference cure, as exemplified by Case I. The patient dealt
with other conflicts and decisions in a way similar to those described in the example; he felt
fine while in analysis but had regular relapses during summer vacations.
2. The transference neurosis remains obscured due to the onslaught of the primal transference.
An example of this is Case II. This patient came to analysis because, among other things,
he suffered from periodic impotence, premature ejaculations, and had difficulty in making a
meaningful relationship with a woman. He had postponed the writing of his Ph.D. thesis for
several years and felt he could not do it.
Soon after entering analysis he fantasied that he should not have to pay me because he was
giving me each day all of his interesting thoughts and feelings. In return for this he wanted
to be adopted by me; I should take him with me on weekend trips and summer vacations. I
was like a 'king', all powerful, and could teach him these powers if he were always with me
and loved by me, and when he became powerful he would no longer be neurotic. He had
numerous dreams in which he was adopted by a rich heiress, lived on her estate as a
handyman, and in return could have everything he wanted. In one dream I was an
enormous Buddha and he was very small. Attached to me by a rope, he tried to pull a short
distance away but the Buddha could pull the rope close again by a wink of his eye. The
main
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difficulty with girls was that none of them could reach the sublime height and perfection of the
analyst. Therefore he first criticized and later abandoned them. He felt he had been able to
write his thesis only because of the strength he had gained from his relationship with me.
This patient improved considerably in analysis, but his transference neurosis remained obscure.
The history of his impotence or premature ejaculations, with its infantile antecedents, did not
appear in the analysis in a meaningful way. The picture of his father, who had played an
important role in his life, remained vague; and his Oedipal conflicts, although distinctly
present, played a minor role in the transference for a long time. For example, when a girl
stayed overnight at his apartment, he was petrified that her father would find out. He feared
that her father would call her apartment, receive no answer, and then come to his apartment
to beat him up, or demand that he abandon the girl, or threaten to ruin the patient's career.
His associations that I disapproved of his girl made it possible for me to make transference
interpretations of his Oedipal fears, but these were frequently blotted out by his fantasies
that I would protect him and support him by my omnipotence.
3. We now turn to the most serious difficulty: a transference deadlock. The patient cannot
accept that these transference demands are unrealistic. Interpretation either has no effect or
else leads only to more frustration and makes these demands more intense than before.
This occurs if the transference illusion has disappeared and the transference has become
real. There are few patients who do not know intellectually that the analyst cannot
conceivably have the answer to every problem, that there is no reason why the analyst's
real love would cure a certain conflict, or that imitation of the analyst's social or sexual
behavior will not cure their shyness or impotence. However, such knowledge remains
isolated and has no influence on their behavior in the transference. For example, patient IV,
although knowing the reality of these issues, continued for several years to have keen
transference disappointments whenever
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these wishes were interpreted. The disappointments did not affect the persistence of his wishes.
He would convert almost every interpretation into some specific advice or guidance, similar
to Case I, or else feel angry, deeply frustrated, and disappointed. He wished that he could
observe me having intercourse with my wife, or observe my behavior with a girl I had just
met, or at a party. Indeed he had spent several years in his adolescence observing another
couple whenever he could. He admired the boy in question and persisted in his belief that
he would become as proficient in various activities as he thought the boy to be if he could
stay close to him and imitate him.
To recapitulate, the question of the transference having become real involves the inability to
distinguish whether the primordial transference demands can or cannot be gratified by the
analyst. The patient not only hopes he has rediscovered his mother of early years in the analyst,
as every patient does, he insists upon it (for instance, when he translates interpretations into
magical advice), or else he rejects the analyst and analysis out of disappointment and anger.
In a previous paper (1) I tried to show that patients with true symbiotic object relationships
do not suffer from separation anxiety. One can only speak of separation anxiety after the self
and object representations have been separated. As long as they are merged, there cannot be
recognition of the object as separate, and therefore there cannot be a fear of separating from it.
The fear in patients with true symbiotic object relationships is panic of annihilation. The patient
dimly perceives the other person as the 'giver of omnipotence' but not as a separate object. He
is either omnipotent by participating in the object's omnipotence or becomes nothing by being
abandoned. Such patients in their precarious intrapsychic state (merged self and object
representations) must cling to a real object to prove they still exist.
I am not implying that all patients whose transference illusion disappears suffer from
symbiotic object relationships; only that
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they tend in that direction, i.e., their object representation is unstable. On cannot tolerate an
illusion of a person, on the one hand, unless one is relatively certain that this person exists on
the other hand; otherwise the illusion is in danger of becoming real, i.e., the person would cease
to exist and become an illusion. Transference is only possible if a relatively stable mental
representation of the original object is present. It is then possible to distinguish the mental
representation of the object from that of the analyst. It is even possible to 'pretend' that the two
are the same, as occurs in transference. To put it simply, these patients cannot pretend; at least
they cannot maintain the pretending necessary for transference.
It is the thesis of this paper that one form of unanalyzability is closely related to the absence
of the transference illusion in the primordial transference. The analyst and the transference
demands must be made real in order to maintain the cathexis (and presence) of the original
object representation. The presence of pregenital fixations maintaining these primitive
transference strivings may be assumed. However, one must distinguish here between pregenital
fixations of such severity that the Oedipus complex is poorly cathected from the much more
frequent situation in which the primal transference wishes obscure the Oedipal features and the
transference neurosis.
The degree of force and reality of the primordial transference strivings determine the degree
to which they can be resolved, or at least displaced or integrated into some appropriate
expression in everyday life. Stone states: ' it does appear that certain aspects of the search
for the omnipotent and omniscient caretaking parent are, for practical purposes,
inextinguishable' (8, p. 21). According to Stone, these strivings are detached from the analyst,
carried into some reasonably appropriate expression in everyday life, but usually retain a subtle
quality that contravenes reality, one which derives from earliest infancy and remains to this
extent a transference. Here again, it seems to me, the question of illusion versus reality is all-
important. For instance, does a person feel happy at a certain vacation spot because
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it lends itself to the maintenance of the primal transference illusion, or does he feel constantly
disappointed because the expectations are not fulfilled in reality and therefore he keeps looking
for new panaceas?
The five cases described in this paper had the following in common: 1, their neurotic
suffering failed to be a motive and a preconscious organizing factor for their associations (at
least during long periods of time); 2, the transference fantasies were not used as a tool in the
solution of their neuroses; and 3, the associations were 'for the benefit of the analyst', leading to
acting out either within or outside the analytic situation.
I would suggest that one can expect transference difficulties of the type described here
whenever this triad of factors is present. Moreover, such primal transference difficulties may be
found to be the basic stumbling block when at first sight other factors seem to be responsible for
unanalyzability. A brief example is that of a young woman who came to analysis because of
marital problems. She had great difficulty in accepting interpretations. She told me a dream in
which certain events took place in a certain subway station. When I made an interpretation, she
said: 'What you say sounds perfectly reasonable except that it has nothing to do with me
because in the dream it took place on the BMT line which I never take. I always travel on the
IRT.' This attitude, which could be summarized by stating, 'Only what is real counts', proved to
be related to an early profound distrust of her mother and constituted a defense against the fear
of disappointment in her wishes for the omnipotent caretaking parent. This patient is an example
of the transference being real in the sense that she could not imagine how I could have any
meaning to her other than being an analyst.
Such patients are frequently described as lacking psychological grasp or psychological-
mindedness, and as being unanalyzable for that reason. However, they might also fall into the
category of the transference resistance under discussion. We are dealing here with a defense
against the primordial transference wishes.
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A variety of reasons have been given for the greater difficulty in analyzing patients with
pregenital fixations. It may be that an important factor is the greater force which pregenital
fixations lend in the transference to magical cure and concrete thinking, e.g., the loss of the
transference illusion. In Analysis Terminable and Interminable, Freud (4) mentions five
categories of cases in which analysis is extremely difficult, or impossible: 1, patients with
negative therapeutic reactions; 2, irreducible penis envy in women; 3, the struggle in the male
against his passivity or feminine attitude toward another male; 4, when the libido is 'too fluid';
and 5, when the libido is 'too sticky'.
These factors were present in my patients. Yet their difficulties in analysis are all manifested
in the same way in the transference, namely, by the transference resistance under discussion.
The question is therefore raised whether unanalyzability in general frequently manifests itself
this way in the transference, irrespective of symptomatology and character. Freud's categories
and the transference fantasy (and resistance) which I am discussing have something in
common: in all the categories, the need to control the omnipotent parent to overcome a sense of
weakness plays an enormous part. For instance, in Case III the need for a penis was so great
because the patient felt that with a penis she could control the omnipotent parent. The
masochism of Case V was used for control of the parents and acquisition of compensation. The
stickiness or fluidity of libido could be regarded as attempts to control the analysis and the
analyst, if considered from the point of view of the ego.
It is common knowledge that analyzability does not depend only on diagnosis, the severity
of the illness, or the type of character; some neurotic patients are not analyzable whereas some
borderline patients are. If the findings of this paper are correct, they would support this clinical
observation since ultimately it would be the capacity to form a workable transference that would
determine analyzability, and this capacity could be present or absent, independent of the
severity or type of illness.
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SUMMARY
Examples are given of five patients with widely different symptomatology and character.
They have in common certain manifestations of the primal transference, leading to a
transference resistance; they insist on being cured by receiving real love from an omnipotent
analyst. This primal transference resistance is thought to be unanalyzable if there is loss of the
transference illusion. The question is raised whether unanalyzability in general is due to an
unanalyzable primal transference.
REFERENCES
ANGEL, KLAUS On Symbiosis and Pseudosymbiosis J. Am. Psychoanal. Assoc. XV 1967 pp.
294-316 []
BELLAK, LEOPOLD Free Association: Conceptual and Clinical Aspects Int. J. Psychoanal. XLII
1961 pp. 9-20 []
FREUD Observations on Transference-Love 1915 [1914] Standard Edition XII []
FREUD Analysis Terminable and Interminable 1937 Standard Edition XXIII []
GREENACRE, PHYLLIS The Role of Transference. Practical Considerations in Relation to
Psychoanalytic Therapy J. Am. Psychoanal. Assoc. II 1954 pp. 671-684 []
GREENACRE, PHYLLIS Problems of Overidealization of the Analyst and of Analysis: Their
Manifestations in the Transference and Countertransference Relationship In:The
Psychoanal. Study Child Vol. XXI New York: International Universities Press, Inc., 1966 pp.
193-212 []
GREENSON, RALPH R. The Technique and Practice of Psychoanalysis New York: International
Universities Press, Inc., 1967
STONE, LEO The Psychoanalytic Situation and Transference. Postscript to an Earlier
Communication J. Am. Psychoanal. Assoc. XV 1967 pp. 3-58 []
- 276 -

Angel, K. (1971). Unanalyzability and Narcissistic Transference Disturbances. Psychoanal Q.,
40:264-276
Indications for Analysis and Problems of Analyzability
Z. Alexander Aarons, M.D.
I
In 1960, Levin (10) published a provocative contribution to the subject of analyzability and
the indications for psychoanalysis. He began his paper by asking what the analyst must try to
ascertain about a patient during the period of the initial interviews. Genetic formulations cannot
then be made because only as a result of the work of the analysis itself, when resistances are
being overcome, is recall facilitated and are reconstructions possible. How much should the
analyst be influenced by hearing from the patient at the outset of early traumatic events? The
significance of the traumatic event cannot be assessed until the analysis has proceeded for
some time. What constitutes a traumatic event involves a consideration of the developmental
phase in which the event occurred, other factors that have contributed to the patient's neurosis
such as the quantity of affect that accompanied the event, and the opportunity for discharge
at the time of its occurrence. To be sure, that such an event is reported in the initial interview is
not without significance. For one thing, it may be something the patient seizes upon to satisfy
his need for an 'explanation', and may therefore be regarded as a resistance.
An illustration of the complexity of the problem of what constitutes the trauma in a given
situation is given by Anna Freud (1). A child witnessed a fight between her parents resulting in
the murder of her mother. Not until later in the analysis was it discovered that what was
traumatic for the child was not the killing of the mother but rather that during the fight the mother
had frantically shouted at the child to 'get out'. It was
Presented in part at the Annual Meeting of the American Psychoanalytic Association in Chicago,
May 1961.
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the mother's seemingly abrupt rejection that had been traumatic.

What has been said of traumatic events applies, I would think, to any of the patient's initial
communications. Whether it be a segment of past history, or an aspect of the actual situation, it
belongs among the associations in the determined chain of events of the patient's life, and the
analyst must await the unfolding of its 'integrated significance'.
The assessment of the prospective analytic patient's ability to develop a transference
neurosis is directly connected with the quality and nature of his object relationships. Two
possible sources of confusion in Levin's observations should be noted here. One is that the
patient's ability to 'relate' is not identical with his ability to establish a transference in analysis;
second, a distinction should be made as to whether the failure to establish object relationships
is due to an arrest in the development of 'object constancy', or to the existence of neurotic
impediments.
Evaluation of the degree of narcissism may or may not be pertinent to the adequacy of
object relationships, depending upon the nature of the narcissism. A tendency toward the re-
establishment of a state of 'primary narcissism' is attendant upon the withdrawal of object
cathexis with consequent impairment of relationships generally. However, a 'secondary
narcissism' accompanied by a sense of self-esteem and in the service of self-preservation, may
manifest itself in a positive and mature way. Certainly a person who is ridden with guilt and self-
depreciatory feelings, with accompanying masochistic tendencies, will find object relationships
fraught with many difficulties. The analyst's personal standards and values may influence his
assessment of the nature and quality of the patient's object relationships: what the analyst
himself deems to be a good object relationship need not necessarily apply to the patientwhich
is to say that criteria must be kept as objective as possible, and that a limited goal exists for
each patient in the sense that object relationships are determined by the degree of persistence
of infantile fixations weighed against the degree to which genital primacy has been or
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can be achieved. By the time a patient seeks treatment he has often reached a point where he
is so beset that he is preoccupied with his narcissistic needs to the exclusion of all else;
nevertheless, some indication of the capacity to relate should be sought. An example is a
patient who, finding himself in an incompatible marriage from which he could not extricate
himself, could nonetheless discern that he and his wife might be happier in other marital
relationships and that, despite their incompatibility, he respected her. The assessment of ability
to sustain a good object relationship, and the factors that limit this ability, is an integral part of
every analysis. Bearing in mind that the basic determinant of 'object constancy' is the
motherinfant relationship, we realize that this assessment requires postanalytic rather than
preanalytic judgment.
In estimating a patient's capacity to control his impulses, Levin speaks in terms of 'ego
deficiency and impaired superego integration' with reference to patients 'capable of verbalizing
but not executing'. A more basic matter here is the disparity between intellectual insight and the
revelatory insight that causes alternation of habitual neurotic behavior. The reaction to an
interpretation or reconstruction by an exacerbation of symptoms, or by acting out, is far greater.
It would, therefore, be more accurate to attribute impulsive and uncontrollable reactions,
especially in the early stages of an analysis, to resistance and to unconscious material that has
not been educed. This applies also to acting out which is the enactment of an unconscious
fantasy, usually in regard to the transference: as Freud (5) said of a patient's negative
transference, ' the patient is not in fact disputing what has been said to him but is basing his
contradiction upon the part that has not yet been discovered'. Impulsiveness and acting out
followed by guilt should be viewed as an indication for further analysis rather than as a
contraindication for it.
To measure the success of analysis by the tempering of the extremes of the patient's
neurotic behavior is, to be sure, a most therapeutically desirable consequence of making the
unconscious
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conscious; but 'correct' behavior cannot always be the criterion of a successful analysis. The
contending motivations of a neurotic conflict may have become conscious but there may remain
a problem of choice for the patient. It is a common life situation that one may not know until one
has made a choice, and experienced its results, whether it fulfils one's expectations. Assuming
all the determinants that have influenced the choice were made conscious, there is always an
element of risk in making any choice. The factor of choice is one of the variables in a given
course of action. What proves to have been a 'wrong' course of action is not necessarily proof of
an unresolved conflict, nor an episode of acting out.
Because of the adverse social consequences sometimes involved, there is a bias against
impulsiveness and acting out; however, there are patients for whom a certain amount of acting
out seems to be the only means by which a problem can be impressed upon them. They must
get into difficulties as a prerequisite for becoming aware of it. For such patients 'knowing is
doing' in the literal sense; before thinking something out there must be a preliminary action.
Impulsiveness and acting out may therefore be viewed as symptoms, not as contraindications.
Until the work of analysis progresses sufficiently the patient may have no other means of
discharging tensions or expressing his conflict. Acting out is one indication for analytic
investigation.
With regard to the disparity between insight and action, there are those patients who act
correctly without insight. Such patients may present themselves as compliant and easy to work
with. Often there is the ulterior motive of winning approval, of a defense against repressed
hostility, or some profound masochistic need. Another type is the patient who does the right
thing but does not know why he does it. Was all infantile rebellion systematically stifled in the
patient? Perhaps this type of patient who too readily agrees to all circumstances of the analysis
(fee, time, interpretations, etc.) without protest is revealing a defense against the id. Compliance
may be substituted for insight. An extreme example of this is the 'as-if' personality, in whom
secondary
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process elaboration is limited; the more commonplace example is the counterphobic conformist.
Assessing the capacity to verbalize, Levin states that ' those patients who are extremely
blocked almost inevitably have serious difficulties in analysis and, if long silences persist, may
not be analyzable'. The flaw in this statement is the fact that silence is not necessarily indicative
of an inability to verbalize. Silence constitutes a blocking, but it does not belong to that category
of blocking which is resistance in the strict unconscious sense of the term, in which the mind
goes blank or some distracting train of thought intervenes as a flight from the problem under
exploration. The most superficial reason for silence is reluctance to follow the basic rule, which
in the beginning of an analysis is not easy. Initially it requires some practice. An inexperienced
analyst who begins by prodding a silent patient, by urging or questioning him, may be one who
is unable to tolerate silence and his need therefrom to relieve the patient of anxiety. As is
sometimes observed, the uneasiness that mounts in a patient during short periods of silence
may be sufficient to force him to break his silence. Rushing in to break the patient's silence not
only risks becoming 'directive' but may interfere with the patient's spontaneous attempts to
overcome his own resistance. This danger is greatest with passive-submissive patients for
whom the process of working through is a corrective experience. Silence is a contraindication
for analysis in certain borderline or schizophrenic patients who have difficulty in secondary
process elaboration and in whom there exists an intrinsic impairment of communication. Such
patients require some kind of 'relationship' therapy rather than analysis.
More of a problem than the silent patient is the one for whom talking is a resistance. Such a
patient may be initially deceptive to the analyst who equates talkativeness with productivity.
Excluding the patient whose verbosity is a symptom of anxiety, there is a type for whom factual
verbalization is a resistance to fantasies. Nunberg (12) gave an example of such a patient who
' showed from the very beginning an astonishing willingness
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for an understanding of the analysis. His associations flowed easily, and he produced important
recollections.' This was a man whose mother had made him confide all his thoughts to her
during his childhood, to which he apparently complied with great pleasure. His sexual thoughts
and feelings about her, however, he kept secret. His analysis failed to progress until he was
made aware that he was repeating his relationship with his mother in the transference and that
he was insincere and untruthful about revealing his secret sexual thoughts.
Levin suggests that shame may be responsible for silence among certain hysterical patients
and that if this feeling is too painful it may cause disruption of the analysis. Blocking on this
basis he calls a 'phobic manifestation'. We usually speak of a phobic reaction in reference to
severe anxiety displaced to an external object or situation, rather than to thoughts or memories
that are shameful and which we would like to suppress. A patient of mine experienced painful
shame in regard to a seductive episode with her father when she was a child. She later
developed an agoraphobia in which the fantasy of incest played a significant genetic role; her
shame, however, was associated with her guilt, and her phobia was a manifestation of anxiety
lest on the street there occur a compulsive repetition of her traumatic childhood experience
which she felt she had 'engineered'. When shame is a cause of silence it is not from fear of the
emergence of an unconscious impulse. Because the impulse is conscious, it is rather that
certain undesirable consequences may ensue by giving expression to it and that this, in turn,
will give rise to more shame. The patient may fear that talking about the shameful matter will
lead to acting out; that he will not be able to control his feelings once he gives expression to
them. The anxiety is connected with a fear of loss of control rather than with the impulse.
Once the patient is induced to speak, however, some of the painfulness of the affect is
relieved. Like unearthing a memory that has been repressed, it can be confronted and the fear
of it dispelled. In the beginning of an analysis when a patient expresses
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shameful reluctance, I have found sometimes that a simple remark to the effect that the
analyst's function is to analyze rather than to judge may be helpful to the process of free
association. There is a kind of magic in words, and for some obsessive patients they are
equivalent to deeds; wherever words are a cause of anxiety, there is an unconscious action-
fantasy behind the utterance. The analytic situation offers a means of controlling action by way
of the basic rule; to think it out rather than to act it out. Verbalization can then become a
stimulant to thought and insight rather than to action.
Every discussion of the indications for analysis must raise the question of what constitutes a
satisfactory motivation. Levin cites examples of patients who come for extraneous reasons: a
spouse is insistent; it is the thing to do, etc. There are many patients who need such a pretext to
circumvent their resistance to beginning treatment, and an incidental reason may act as a
primer to initiate the analysis. Often an external agency may be necessary (an incapacitating
symptom may be a coercion), but it will not be sufficient to maintain an analysis to a satisfactory
conclusion. Many candidates undertake personal analyses to become psychoanalysts rather
than because of the immediate pressure of a personal problem. An incidental, secondary, or
superficial reason for seeking an analysis might be viewed as analogous to the manifest content
of a dream, and as an initial inability to admit the need for treatment. The fact that the patient
comes, however, may be evidence of an unconscious recognition of this need.
In assessing the presenting symptomatology, Levin implies that the severity of the
symptoms is a relative matter. A 'strong ego' (one in which the integrative and reality testing
capacities are not defective) can withstand severe symptoms better than an ego easily
overwhelmed by id impulses. An example is the obsessional patient who by expenditure of great
energy is able to function despite plaguing compulsions. The severity of symptomatology in
itself is no contraindication for analysis. Often it is the effective motivation, unless an adaptation
to it has been made
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either by way of a secondary gain (narcissistic satisfaction or appeasement of a superego), or if

the symptom is the only outlet for instinctual gratification (masturbation among recluses). Levin
cites a successful analysis of a severe obsessional who was able to look upon his symptoms
with humor, an indication to the analyst of substantial synthetic ego function and ability to
'regress in the service of the ego'; I would add that the symptom had not 'captured' the patient's
ego. I think we would have to say that symptomatology is not a reliable guide for assessment of
analyzability . Like the manifest content of a dream, the full meaning of symptoms can only be
determined upon analysis. As Anna Freud (3) remarked, 'At the beginning of analysis, before we
have insight into the structure of a neurosis, it is impossible to predict how the patient will
respond to treatment. There is no guarantee that two individuals with the same symptomatology
will react similarly.'
Levin's final point has to do with current reality. 'One might start', he says, 'with the
proposition that in order for a patient to be considered analyzable his external reality must be
such that he is not being continuously subjected to a degree of external stress which is capable
of maintaining a severe disruption in his ego equilibrium'. Although the patient's actual situation
is never ignored, a psychoanalytic assumption is that, difficult as the external life situation may
be, a resolution of the patient's neurotic conflicts enables him better to cope with the external
difficulties with which he is faced. Even if nothing can be done to alter the external life situation,
the insight that is gained from an analysis will be a positive influence in the patient's
relationships to that inexorable reality. This is justifiable therapeutic optimism. Though the
possibilities of changing environmental circumstances may be limited, they rarely constitute a
contraindication. Preoccupation with the patient's actual situation is prejudicial to the analytic
process and encourages avoidance of the 'internal reality' wherein the problems lie. Freud's
dismissal of 'educational psychotherapy' was based on his observation that, given normal
intelligence, a patient could be left
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to solve his own external problems, provided he were freed from neurotic impediments; and
Anna Freud (2) reminds us that 'we do not deal with the happenings in the external world as
such, but with their repercussions in the mind'. Distressing reality may be the initial motivation
for seeking analysis, but it may become for the patient the tangible evidence that it is his inner
problems that are largely responsible for the difficulties he encounters. It is not, therefore, a
reliable criterion either for or against analysis as the therapy of choice. We should bear in mind
as a general principle that symptoms and actual conflicts are the effects of unresolved internal
conflicts.
Discussing the question of a patient's chances of arriving at a workable solution of his
problems upon the successful completion of analysis, Waelder (13) recalls the reply that Freud
gave to a colleague who protested that it was no use expending effort in analyzing a spinster,
since her marital and sexual opportunities were so limited. Freud cited a case that had
confounded expectations, and remarked, 'For this the Lord Almighty has his own miraculous
ways and He will never let you into the secret of them'. There may be, to be sure, a serious
question about the 'accessibility to solution' of a neurosis in which for some persons neurosis is
the choice of a lesser evil; but as Waelder states, ' such cases are very rare exceptions
among applicants for psychoanalysis, rarer than they were half a century ago presumably
because psychoanalysis has meanwhile learned to deal with some of them'.1
II
The basic considerations in establishing criteria for analyzability are predictions concerning
the patient's motivation, the probable nature of the transference, and the quality of the patient's
object relationships. Psychoanalysis is indicated when the aim
1 In considering a child for analysis perhaps more initial consideration should be given to
external circumstances because, for a child, sustaining an analysis may depend upon the
stability of the parents and their willingness to coperate in the undertaking. Analysis may not be
possible for a child whose environment constantly threatens him with excessive stimulation,
seduction, or physical injury.
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is to ascertain the causes of the patient's psychopathology, and the nature and origins of his
instinctual and emotional conflicts.
Psychoanalysis is not the treatment of choice for maladaptation from lack of self-discipline
and inability to tolerate minimal frustrations. This applies to patients for whom re-education is a
primary requirement, despite the concomitance of a neurosis. Those applicants for treatment
afflicted by chronic extreme passivity which is ego syntonic may be considered devoid of
substantial motivation.
Another group of patients for whom psychoanalysis seems to be contraindicated are
psychotics and borderline cases. Discussing the treatment of atypical children, Anna Freud (4)
indicated the need for a 'relationship' type of therapy before analysis in the classical sense is
considered with children who from early infancy have suffered severe deprivation, and for whom
a mother substitute is needed as a corrective experience. The therapist becomes an auxiliary
ego, and an object with whom to identify. With borderline adults we may have to reconsider our
scepticism, especially in cases where there is a substantial degree of well-established
secondary ego autonomy expressed in intellectual or creative achievement.
Waelder (13) defines two groups of borderline patients: those who have odd traits of
behavior but maintain tenuous object relations, and those in whom there is a critical awareness
of paranoid ideas and hallucinations, and an attempt to fight them off. Waelder states: ' in
dealing with these cases, psychoanalysis is therapeutically highly promising though the
therapeutic result does not simply rest with the reintegration of the repressed as is the case in
the analysis of psychoneurosis'. If such patients are given to intellectualization, this may be
utilized, at least in the beginning, as a means of keeping inner processes under control and
maintaining contact with reality.2 This is analogous to the defensive intellectualization of
adolescents. 'In the same
2 The Wolf-Man is an example in point, as judged by the subsequent history of that patient. Cf.,
Gardiner (7).
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way in which manipulation of ideas can serve as a defense against the buoyancy of instinctual
drives, psychoanalytic interpretations can be used by the persons under discussion in their
struggle against a threatening psychosis'.
A primary consideration is whether the nature and strength of a patient's motivation will
sustain what an analysis requires in terms of sacrifice, frustration, and the mobilization of
anxieties. A judgment that the patient is sufficiently motivated, together with the expectation of a
'workable' transference, provides the rationale for undertaking an analysis. The opinion in favor
of an extended initial period of assessment is, in large measure, influenced by the desirability of
ascertaining more rather than less about these two criteria.
Neurotic suffering and the conscious wish for cure are important factors in the initiation of
treatment. When there is also a recognition on the part of the patient of impairment in his
capacity for work and inhibition in his ability to love, prima facie evidence for analyzability
seems established. The analyst should nevertheless reserve judgment because suffering is a
negative motivation and, therefore, may not be sufficient to sustain an analysis. There should
also be some positive indication that the patient has a need to understand himself, and that he
has a wish for insightwhether this be a sublimation of libidinal curiosity about oneself or the
synthetic functioning of the ego.
Nunberg (11) has referred to the effort of the ego 'to fuse diverging psychic forces' and to
discover causal connections. Hartmann (8) shows that understanding and assimilation in
analysis are required in addition to making what was unconscious conscious. He speaks of the
ego's ability to make itself an object of thought in the same way that it directs its thinking to the
external world. In this is implied its ability to discover new relationships and connections. This
extends the meaning of synthetic function, in its broadest sense, to include in the ego a
motivation by its own creativity. Hartmann says: 'The mere reproduction of memories in
psychoanalysis can, therefore, only partly correct the lack of connection or the incorrect
connection
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of elements. An additional process comes into play here which may justly be described as a
scientific process. It discovers (and does not rediscover), according to the general rules of
scientific thinking, the correct relationships of the elements to each other.' It is this creative and
synthetic proclivity of the ego that the analyst seeks to find as the ideal desideratum for
analyzability . As a result of liberation of psychic energies by the removal of repressions, the
way is then open for the ego to discover something new about object relationships, and the
interactions between thought, affect, and environment. This activity of discovery is a creative
process within the synthetic function of the ego, an activity for which the analytic situation
affords an impetus.
Ideally, evidence of this proclivity of the ego should be the warranty for analysis. How then is
this capacity to be detected, much less initially assessed? Although we may be unable to
answer this question directly, let us restate that a neurosis is fundamentally the result of an
internal conflict. What we may therefore seek to ascertain is the patient's awareness, however
dim, that his problem is essentially within himself, regardless of external circumstances. Is he
inclined to look within himself for the determinants of his feelings, thoughts, and behavior; and
can he think in terms of how much his reactions influence his relationships? If projective self-
defense prevails, the patient may be assumed to be refractory to the attentive self-inspection
that analysis requires. Among such instances are neurotic character disorders with paranoid
defense mechanisms. Other patients who are rich in experience are poor in judgment: their
traits of ostensible extroversion serve to avoid introspection and the analysis is expected to
provide a proper course of action to correct the 'something that went wrong', the reason for
seeking treatment. What is required for insight is a balance between the discerning and
experiencing functions of the ego. The analyst's judgment of a prospective patient requires a
prediction about the possibility of a cathexis of both functions in the analytic situation.
When in the course of an analysis old, repetitive strivings
- 525 -
are relinquished and replaced by new ones, it may be asked whether they were not always
present in the unconscious and had never completely lost their cathexis. Waelder (14) questions
the possibility of remotivating a patient after cathexis has been transferred to other objects and
strivings. He uses the metaphor of poking around in ashes seeking live coals with which to start
a fire, and he makes the distinction between inhibition and the absence of a goal (motivation). In
the course of analysis, it is reasonable to assume that not only are repressed motivations
revived but that new ones will appear. Events of past and present come to be understood
differently, and new orientations develop. The mature ego in confronting the task of re-
experiencing events in the analytic situation records and reacts in a way that involves new
thinking. The discerning ego in the working-through process also performs a creative task which
may express itself in the discovery of new motivations which were previously nonexistent.
If the nature of the transference were predictable, perhaps one of the main problems in
regard to analyzability would be solved. That the patient will develop a transference which will
promote rather than obstruct the analytic process cannot be taken for granted. Nunberg
contrasts the patient who 'transfers' with the patient who attempts to 'transform'. In the former
by means of displacement and projectionthe patient succeeds 'in getting an identical picture'
of the original love object through the medium of the analyst, and thereby re-experiences the
past relationship; whereas the other type seeks to transform the analyst into a person in the
past. Nunberg cites a patient who attempted to make him be and act like her father which led
only to frustration. She was incapable of re-experiencing and comparing her past with the
present in the analytic situation; she could seek only to re-establish the past: 'The particular
fixation to her father created the wish to find his reincarnation in the person of the analyst, and
since her desire to transform the latter into a person identical with her father could not be
fulfilled, the attempts to establish a working transference were futile' (12).
- 526 -
The attitude that a patient displays toward his presenting problem may afford some
indication of how he will react in analysis. He should be expected, first of all, to formulate what
he thinks his problem is with indications that he has given it troubled thought without arriving at
a satisfactory conclusion. This tells nothing, however, about his resistances, of which some idea
may be obtained by superficial observation of the defenses he employs. Phobic reactions,
temporary regressive measures, or simple denial suggest a more favorable prognosis than do
rationalizations and projections. The nature of his attempts to cope with his difficulties should
reveal in some measure whether he is actively or passively oriented. The 'repudiation of
femininity' was noted by Freud (6) as important in interminable analysis; and it may also be
applied as a prognostic criterion. For males masculine strivings must prevail, and in females the
demand to have a penis cannot be an incontestable claim.
It is important to be able to believe that the patient is capable of sufficiently altering himself
to effect changes in his environment. When a person has to make a choice in which either
alternative necessitates a compromise, adaptation has pertinent meaning. Either unfulfillable
wishes are clung to with all the rancor of frustration, or a realistic revision of needs is made
within the limitations imposed by external circumstances.
Perhaps those who are interested in the research aspects of psychoanalysis are less
concerned about criteria favoring optimum therapeutic results. Anna Freud (3) has said that if
there is doubt concerning analyzability , our bias should be in favor of analysis. If properly
conducted it will do the patient no harm and at least be of research value; at best it will yield
surprisingly favorable therapeutic gains.
Without some substantial degree of sustained object constancy in the infancy of the patient
the transference will founder or fail to materialize. Perhaps the degree of defectiveness in the
duration, quantity, or quality of object constancy establishes the limits of analyzability . A
person's earliest object relationships may provide a reliable basis for an assessment of his
analyzability if, for example, he was reared in an orphanage, suffered
- 527 -
extraordinary deprivations, and other severe traumata; one must then estimate carefully
whether a 'replacement' or a 'corrective' therapy is indicated. We do not know enough about the
traumatic effects of inadequate mother-child relationships to predetermine with any accuracy the
extent to which such deficiencies produce irreversibly defective object relationships.
The problem of analyzability may be that of predictability itself. Although it is desirable to
predetermine, and with some degree of probability, that the patient is analyzable, this may not
be feasible in many instances. Marianne Kris (9), in discussing prediction, notes that preanalytic
data are different in quality from analytic associations. 'Our data', she said, 'were not derived
from an analytic contact; the repressed and unconscious material which would have been
helpful was not available to us'.
Should one undertake a dubious analysis and risk failure; or miss an opportunity to succeed
where there is reasonable doubt? Perhaps therapeutic optimism should prevail and analytic
investigation be accepted as the task in one's hands.
DISCUSSION BY SIDNEY LEVIN, M.D.
As I understand it, Aarons' main thesis centers around the proposition that the initial
evaluation of analyzability is bound to be difficult because it requires evaluation of
hidden potentialities, such as the creative and synthetic proclivity of the ego.
I shall start with a simple premise: when we evaluate a patient for psychoanalysis we
make, among other things, predictions concerning the patient's analyzability . The
issue of developing criteria of analyzability is based upon a desire to limit errors in
these predictions. Let us first ask ourselves whether we have any data concerning our
over-all predictive ability. A pilot study conducted at the Boston Psychoanalytic Society3
undertook a survey of prediction on a series of thirty patients. The procedure consisted
of rating reports of the initial interview on a nine-point scale according to the estimate of
the degree of the patient's analyzability ; then an estimateusing the same scaleof
these patients after one year or more of analysis. The rating of predictability was
unusually high. From
3 Knapp, Peter H.; Levin, Sidney; McCarter, Robert H.; Wermer, Henry; Zetzel, Elizabeth:
Suitability for Psychoanalysis: A Review of One Hundred Supervised Analytic Cases.
Psychoanal Q., XXIX, 1960, pp. 459-477.
- 528 -
a statistical point of view, the odds were one in one thousand that the opinions could
have been the result of chance. Notably, there was also a high degree of agreement
among the independent ratings of the five members of the group. The conclusion was
made that experienced clinicians are able to assess suitability for analysis fairly well in
advance; nevertheless, we made several errors.
The next questions proposed are: How often do experienced clinicians make major
errors in predicting a patient's analyzability ? How often are analyzable patients
rejected for analysis? How often are nonanalyzable patients accepted for analysis? Two
years ago I conducted a small study in which six analystswho had been practicing
psychoanalysis for from six to ten yearswere interviewed to determine what types of
cases they had terminated as nonanalyzable. From these six analysts I could collect
only sixteen cases which had to be terminated as nonanalyzable. The small number of
such cases among these analysts indicates their ability to select cases suitable for
analysis.
The sixteen cases collected fell into two groups: 1, four cases which had to be
terminated within a few months after starting analysis because of excessive anxiety,
depersonalization, or increased depression induced or intensified by the analytic
situation; 2, twelve cases terminated within periods of from one to three years because
of difficulty in verbalizing, excessive orality, or paranoid tendencies. Several patients
were severely blocked in communicating; among the others the content was very
restricted. The cases with excessive oral fixations were chronically querulous or
demanding in the transference, persistent in their efforts to exploit the analysis for
infantile gratification. There was no clear line of differentiation between this type and
those patients who were described as having paranoid tendencies.
These findings indicated that only a few of the errors which the analysts made
pertained to predicting the patient's capacity to tolerate the analytic situation. Most of
the errors had to do with predicting the patient's inability to communicate, inability to
relinquish the familiar gratification of infantile fixations for unknown rewards of maturity,
and inability to relinquish paranoid mechanisms. It is also worth noting of the sixteen
unsatisfactory cases, all but one were considered to be strongly motivated toward
analysis both before and during analysis. In answer to questioning as to what features
of the initial interview might have warned them concerning the difficulties which they
encountered, the analysts mentioned immediate demands upon the analyst,
provocative or distrustful attitudes toward the analyst, and unrealistic attacks directed
toward previous therapists. In none of the cases did the analyst anticipate the
development of severe blocking which many of these patients later manifested.
Many of these points are brought out in Aarons' paper. Freud,4 in describing female
patients who demand direct gratification of infantile cravings in the transference, stated:
'These are women of elemental passionateness who tolerate no surrogates. They are
children of nature who refuse to accept the psychical in place of the material, who, in
the poet's words, are accessible only to "the logic of soup, with dumplings for
arguments".'
4 Freud: Observations on Transference-Love (Further Recommendations on the Technique of

Psychoanalysis III) (1915). Standard Edition, XII, p. 166.
- 529 -
We cannot predict that a certain patient will seek only to gain infantile gratifications from
analysis. The very fact that we raise the question fixes it in mind in our evaluations. It
has been my experience that the patient whose basic orientation toward others has
followed the formula, 'I have a right to have what I want', requires most cautious
consideration.
I have mentioned elsewhere [Cf., Ref. 10] that some of the difficulty in predicting
severe blocking appeared to be due to the tendency of the examiners to counteract
silence by repeated restimulation in the form of questions and other active maneuvers. I
therefore suggested that we might better evaluate the patient's capacity to verbalize if
we tried to avoid prompting and restimulation for a significant trial interval during the
initial interviewing. I have found this procedure useful.
A diagnosis of borderline disorder is not, I agree, of itself a contraindication for analysis,
especially in those patients who show a substantial degree of secondary autonomy with
considerable intellectual and creative achievement. I am reminded of the number of
reports of the successful treatment of such patients presented in seminars at the
Boston Psychoanalytic Society and Institute.
Aarons has raised the question of the value of history of early childhood in predictive
evaluations. I have observed that child analysts in interviewing adult patients are more
apt to investigate the childhood history, and I have become impressed with the
predictive value of their effortsone of the reasons I recommend greater care in
obtaining a past history.
Regarding Aarons' opinion that the assessment of object constancy usually remains for
postanalytic rather than for preanalytic judgment, I believe he would agree that with
increasing experience analysts develop greater accuracy in such assessments. In our
pilot study it was noted that the analysts had higher degrees of predictive ability in
proportion to their senioritythe more experienced analysts were better able to predict
the potentiality for object constancy.
It is generally accepted that when fixations and regressions are resolved through
analysis, certain curative forces are released which lead to recovery. Edward Bibring5
summarized these curative forces: 1, the forces of instinctual tension and instinctual
developments; 2, a 'biological sense' which refers to certain basic tendencies of the ego
and superego; 3, the synthetic function of the ego. As Aarons has clearly stated, it is
difficult to predict accurately the result of releasing these curative forces; however, the
fact that an analyst cannot predict the result does not prevent him from being able to
predict that the patient will respond with benefit to the analytic process.
Although it may be difficult to predict a patient's potentialities for growth, we often make
fairly accurate inferences concerning such potentialities. Even such subtle indices as
the quality of a patient's sense of humor may at times be used for drawing such
inferences [Cf., Ref. 10]. Aarons mentions several such indices: 1, evidence that the
patient has given his problems 'troubled thought'; 2, a patient's inclination to look within
himself for the determinants of his feelings, thoughts, and behavior; 3, a proper mixture
of alloplasticity and autoplasticity;
5 Bibring, Edward: Symposium on the Theory of the Therapeutic Results of

Psychoanalysis (1936). Int. J. Psa., XVIII, 1937, pp. 170-189.
- 530 -
4, a patient's ability to direct his energies with a minimum of rebellion and with an
optimum of persistence.
It is my opinion that in many instances the basic questions about analyzability can be
answered before analysis; however, in those instances in which analyzability is not
contraindicated but cannot be predicted, trial analysis is the only resort.
REFERENCES
FREUD, ANNA Child Observation and Prediction of Development: A Memorial Lecture in Honor
of Ernst Kris In:The Psychoanal. Study Child Vol. XIII New York: International Universities
Press, Inc., 1958 []
FREUD, ANNA Discussion of Grief and Mourning in Infancy, by John Bowlby In:The
Psychoanal. Study Child Vol. XV New York: International Universities Press, Inc., 1960
FREUD, ANNA Problems of Technique in Adult Analysis Bull. Phila. Assn. Psa. IV 1954
FREUD, ANNA The Psychoanalytical Treatment of Children. Technical Lectures and Essays
New York: International Universities Press, Inc., 1959
FREUD Constructions in Analysis 1938 Coll. Papers V
FREUD Analysis Terminable and Interminable 1937 Coll. Papers V
GARDINER, MURIEL M. Introduction to Memoirs of the Wolf-Man 1914-1919 Bull. Phila. Assn.
Psa. XI 1961
HARTMANN, HEINZ Ego Psychology and the Problem of Adaptation New York: International
Universities Press, Inc., 1958
KRIS, MARIANNE The Use of Prediction in a Longitudinal Study In:The Psychoanal. Study
Child Vol. XII New York: International Universities Press, Inc., 1957 []
LEVIN, SIDNEY Problems in the Evaluation of Patients for Psychoanalysis Bull. Phila. Assn.
Psa. X 1960
NUNBERG, HERMAN Practice and Theory of Psychoanalysis New York: Nerv. and Mental
Disease Monographs, 1948
NUNBERG, HERMAN Transference and Reality Int. J. Psychoanal. XXXII 1951 []
WAELDER, ROBERT Basic Theory of Psychoanalysis New York: International Universities
Press, Inc., 1960
WAELDER, ROBERT Discussion of Problems of Technique in Adult Analysis by Anna Freud.
See Ref. 3.
- 531 -

Aarons, Z.A. (1962). Indications for Analysis and Problems of Analyzability. Psychoanal Q.,
31:514-531
1984). Psychoanalytic Quarterly, 53:501-502
Meeting of the New York Psychoanalytic Society
October 26, 1982. OBSERVATIONS ON ASSESSMENT OF ANALYZABILITY BY
EXPERIENCED ANALYSTS: REPORT OF 160 CASES. Joan B. Erle, M.D. and Daniel A.
Goldberg, M.D.
The authors delineated five problem areas in the assessment of analyzability that had
become clear in their previous work on this subject: 1) the need for consistent definition of
terms; 2) the difficulty in developing valid criteria for patient selection; 3) the assumption that
prediction of analyzability can be reliably made at the outset of treatment; 4) the failure to
differentiate between analyzability and therapeutic benefit; and 5) the need for prospective
studies. In preparation for such a study, Drs. Erle and Goldberg undertook a retrospective pilot
study of how experienced analysts assess analyzability and how they judge the course and
conclusion of treatment in terms of their explicit or implicit prediction of analyzability at the
beginning of analysis. The authors hoped to enlist a group of experienced analysts who could
provide a body of data over a period of years. The selection of private cases would minimize
some of the problems of Treatment Center studies (e.g., supervision, inexperienced analysts).
The authors invited 33 analysts (all of whom were more than five years past graduation
from the Institute) to participate in their study. These analysts were thought to have primarily an
analytic practice. Ultimately, 16 became participants in the study. These analysts reported on
160 cases in analysis during a five-year period (1973-1977). 39% of the patients were male and
61% female; 18% were physicians and 16% students. 38% were seen 5 times a week, and 62%
were seen 4 times a week. There were 19 additional patients seen 3 times a week who were not
included in the series because the authors felt the treatment was less intensive; the cases were
also atypical in other respects as well. All sessions were 50 minutes in length. By the end of the
study, 61% of the patients had ended their treatment. 12.5% left after 2 years; 46% were in
treatment more than 5 years.
There were several factors that the analysts reported as important in their assessment of
analyzability . If the patient's motivation, capacity for self-awareness, and intelligence were in
doubt, there was a general pessimism about analyzability . A history of severe pathology in
parents or close relative and/or a history of sustained or frequent trauma led to a guarded
prognosis. The presence of a previous good treatment experience was considered a positive
sign for analyzability ; a protracted
- 501 -
previous treatment was viewed with concern. Other factors reported by the analysts to be
important in assessment of analyzability included tolerance of frustration and "absence of
contraindications." There were 19 cases converted from psychotherapy to analysis. 11 patients
initially thought to have severe pathology were converted after a symptomatic improvement or a
better understanding of the patient.
65% of the patients had a good to excellent therapeutic benefit, 26% minimal benefit, and
9% no significant benefit. Of the terminated cases in treatment more than 3 years, 76% had a
good to excellent therapeutic benefit. In no case where the patient was analyzable was there
less than a moderate therapeutic benefit. 16 cases that were rated unanalyzable received at
least a moderate therapeutic benefit. All 15 cases without significant benefit were unanalyzable.
The authors recognize the problem in these results, given that prediction of analyzability was
made retrospectively and informally. In addition, the treating analyst made both the assessment
of analyzability as well as the outcome reports. The authors stated that significance of such
prediction/outcome comparisons would be better judged in a prospective study with all cases
followed to termination.
In contrast to the Treatment Center study, the patients studied here were older, there were
more males, and more were married. They were in treatment longer and more often judged
analyzable. However, the proportion thought to have a therapeutic benefit from the treatment
was the same. The authors confirmed conclusions from the Treatment Center study that the
entire course of treatment must be reviewed before judging analyzability .
Certain important issues emerged from the authors' study. A uniform element in the frame of
reference of the reporting analysts was the conviction that significant change would not occur in
the patient if she or he remained unaware of unconscious elements in the conflictual areas. All
the analysts agreed that the essential technical variable in an analysis is the patient's conflicts in
the "transference neurosis" or "transference." There were nonessential variables such as timing
and wording. Modifications in technique were sometimes required, as when there was a threat
of suicide or psychotic decompensation.
The authors concluded that it is possible to enlist a group of analysts as a source of clinical
material and that assessment of analyzability can be made only at the end of treatment. Initial
recommendations are not based on single characteristics of patients. Studies that have
attempted to identify only single factors have been unsatisfactory, as have those that attempt to
develop complex factors such as "ego strength," since they do not adequately survey and study
such intricate psychic phenomena as motivation and capacity to work in analysis. Patients who
are judged unanalyzable (no establishment of an analytic process) may conclude successfully
without modification in technique; some conclude with significant limitation in the resolution of
their difficulties; and others require appropriate modification of technique. Some unanalyzable
patients may develop a useful therapeutic situation.
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(1984).

Journal of the American Psychoanalytic Association, 32:715-737

Demographic: Patient's age, sex, marital status, occupation.

Description (characteristics, variations, modifications) data emerging relevant

Review of Analysts' Evaluations

factors especially favorable or unfavorable for analysis, such as tolerance of frustration or

Cases Begun in Psychotherapy

Duration (years) of treatment No. Cases Good to excellent benefit

_____ _____ _____

Total 160 65%

These rating categories corresponded approximately to the categories of analyzability ,

Prediction: 1. analyzable (successful unmodified analysis).

2. analyzable with difficulty.

4. initial recommendation psychotherapy.

2. analyzable with difficulty (includes modified or limited ratings of analyzability ).

PREDICTION Analyzable Modified or Limited Unanalyzable

Analyzable (59 cases) 55% 20% 25%

Analyzable with Difficulty (35 cases) 26% 43% 31%

Substantial Question (48 cases) 25% 31% 44%

Initial Recommendation Therapy (19 cases) 37% 26% 37%

judged to be an analysis, the patient's conflicts appeared in the "transference neurosis" or

Article Citation [Who Cited This?]

REVIEW OF THE LITERATURE

degree of parameters" necessary to meet special conditions. He took exception to Eissler's

tangential or inferred from other issues under discussion. Approaches to assessing

1 It is interesting how rarely anyone notes or questions subjectively unfavorable distortions,

The Selection of Patients

about ego defects, affective disorder, age, or other limiting factors.

which different authors thought important to assess in predicting analyzability . This

Article Citation [Who Cited This?]

0010-7530/92 $2.00 + .05

apparent "unanalyzability" may be an iatrogenic consequence of the analyst's "classical"

Important associations to painful childhood experiences began to emerge in this context, I

Article Citation [Who Cited This?]

(MS. received October 1985)

about many areas, but where certain information is left out.

THE QUESTION OF DIAGNOSIS

character formation as a guide, we will be led to certain questions.

Article Citation [Who Cited This?]

provide methodological evaluation of the contributions as a guide to future investigation.

Methods and Limits of the Literature Review

Main Trend Number of References

Adequacy of Personality Functioning

Capacity for adaptive regression 3 0 0 0

Defense organization (mature) 11 0 0 0

Diagnosis (re: range of ego weakness) 32 8 0 1

Capacity for transference 7 0 0 1

Capacity for therapeutic alliance 5 0 0 0

With friends and marriage 7 0 0 0

Tolerance for separations 6 0 0 0

Severe early deprivations 0 0 4 0

Capacity for object constancy 4 0 0 0

Self-understanding and change 6 0 0 0

Other motivations (positive) 9 2 0 0

Tolerance for frustration, suffering 9 0 0 0

Tolerance for other affects & states 4 0 0 0

Availability of tamed affect 14 0 0 0

Other character attitudes (positive) 10 0 0 0

Other character traits (positive) 25 0 0 0

Drive factors (positive) 4 0 0 0

Manifest oedipal conflict 3 1 0 0

Superego Factors (positive) 13 2 0 0

Age (young adults) 6 1 0 0

Sex (males more successful) 1 2 0 0

___ _ ___