Kantrowitz Match

(1989).
Journal of the American Psychoanalytic Association, 37:893-

919
The Patient-Analyst Match and the Outcome of Psychoanalysis:
A Pilot Study
Judy L. Kantrowitz, Ph.D., Ann L. Katz, Deborah A. Greenman, M.D.,
Humphrey Morris, M.D., Frank Paolitto, M.D., Jerome Sashin, M.D. and
Leonard Solomon, Ph.D.
ABSTRACT
This paper presents a pilot study in which we explore the
possibility that the match between analyst and analysand is a
factor of central importance in the analytic situation. It is an
attempt to look at the issue of match across a large number of
patients. The data we used were not collected for studying this
topic; thus, the study has serious limitations. Nevertheless, certain
patterns emerged which support our thesis that patient-analyst
match plays a significant role in the outcome of psychoanalysis.
We present this work as a first step in developing concepts and
methods which will be pursued in a more systematic and rigorous
fashion in a later study.
TRADITIONALLY, THE SUCCESS OF A psychoanalytic treatment has
been assumed to be dependent on the psychological characteristics of the
patient, and the skill of the psychoanalyst in facilitating and then resolving the
transference neurosis. Although analysts have long recognized that patients'
reactions
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Dr. Kantrowitz is on the faculty of the Boston Psychoanalytic Institute, and
Adjunct Associate Professor of Psychology, Boston University; Drs. Katz,
Greenman, and Morris are Instructors in Psychiatry, Harvard Medical
School; Dr. Paolitto is a member of the Boston Psychoanalytic Society and
Institute; Dr. Sashin is on the faculty of the Psychoanalytic Institute of New
England; Dr. Solomon is Professor of Psychology, Boston University.
This study has been partially funded by a research grant from the Boston
Psychoanalytic Society and Institute. Accepted for publication March 9,
1988.
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may be triggered by something in the therapeutic interaction, the focus has
remained largely on the patient's psychodynamics and rarely on the two-
person engagement and the effect of its particular quality on the outcome of
psychoanalysis. Reflecting this emphasis, research studies of psychoanalytic
outcome have focused primarily on the psychological characteristics of
patients and how they have changed during the course of analysis.
Recently, in the context of a developing view of the analytic treatment as a
two-person situation (Cooper, 1986); (Greenson, 1967); (Kantrowitz,
1986); (Sandler, 1976); (Shapiro, 1976); (Tartakoff in Panel, 1981), the
influence of the patient-analyst match on the process and outcome of
psychoanalysis has become a subject for study. Match is an interactional
concept; it refers to a spectrum of compatibility and incompatibility of the
patient and analyst which is relevant to the analytic work. Because of the
interplay of the participants, each analytic treatment takes on its own unique
character. The interaction may facilitate or impede the engagement in, and the
resolution of, the analytic process.
Some clinicians believe that apart from neutral analyzing responses, most
reactions of the analyst are based on countertransference. Such a view seems
an oversimplification, unless countertransference is defined so broadly that its
original meaning is lost. It is generally agreed that countertransference
phenomena include the analyst's reactions to a patient or to a patient's
transference, evoked because of their similarities to a significant person from
the analyst's won past or present. Reactions to patients that reflect the
analyst's characteristic responses to particular qualities, styles, values, and
attitudes are also undoubtedly rooted in the analyst's own dynamic history, but
might or might not be viewed as countertransference phenomena. Although
many analysts consider any manifestation of these reactions to be
countertransference (Blum, 1986), others view the inadvertent expression of
these reactions primarily as a reflection of the analyst's personal
characteristics (Berman, 1949). Similarly, the patient's reactions to the
analyst are shaped
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by whatever the patient gleans of the real characteristics of the analyst, in
addition to dynamic factors that lead to the development of a particular
transference neurosis. Patients also respond to what they perceive of their
analysts' reactions to them. These reverberating perceptions vary in intensity,
in the extent to which they are shaped by transference and reality, and in the
impact they have on the analysis. They may become the focus of analytic
inquiry or may go underground. Cooper (1986) believes that patients
consciously or unconsciously express their resistance to analysis by "fitting or
thwarting the analyst's characterologic needs" (p. 581). He states that it is the
analyst's job to recognize this occurrence and to be aware when his emotional
reaction to the patient is excessively negative or positive; such intense
responses to patients makes treating them impossible. While Cooper is
humble about analysts' limits in terms of whom they can treat, he seems to
imply that analysts are capable of being aware when their reactions pose an
impediment to the treatment. We are suggesting that there are other factors, in
addition to strong positive and negative emotional responses, of which the
analyst might remain unaware, that might be deleterious to analysis.
For the purpose of our investigation, we restrict the definition of
countertransference to Freud's (1910), (1915) original description of those
responses aroused in the analyst by the patient or the patient's transference
which resemble responses that the analyst has experienced in relation to
significant people in his or her past. Match, in contrast, covers a broader field
of phenomena in which countertransference is included as one of many types
of match. The individual history, characteristics, attitudes, and values of each
analyst and patient predispose them respectively to certain
countertransference and transference reactions. Match, however, also can
refer to observable styles, attitudes, and personal characteristics which are
rooted in residual and unanalyzed conflicts, shared or triggered in any patient-
analyst pair.
While the interactive dynamic between analyst and patient
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has rarely been the focus of psychoanalytic research, some psychoanalysts
have specifically attended to its impact on the analytic process. Berman
(1949) noted that the analyst's generalized attitudes and reactions, as
distinguished from countertransference, may be reflected in temporary or
minor changes in the analyst's tone of voice or timing of interpretations. He
stated that patients may accurately sense when their analysts are unable to feel
genuinely warm or dedicated to them, or when their analysts have emotional
or defensive reactions. Some patients may react by distancing their own
emotional reactions and creating a "pseudotranquil atmosphere" in which
important issues are excluded from analytic work; other patients may have
intense emotional responses or may act out, leading to periods of frustration
ending in mutual agreement to terminate or to abrupt, unexplored termination
by the patient. Bibring (1936), aware of the potential difficulty in her
particular character and style being too much like a patient's mother,
described transferring this patient to another analyst because she believed
there could be too little "as-if" brought about by the transference. Greenson
(1967) cited an instance in which the impact of his personal political values
led him to selectively inquire only when his patient's views differed with his
own. The patient was aware of this selectivity and, without talking about it in
the analysis, tried to modify his views to accord with Greenson's. It was only
when the analysis became stalemated, and the reasons for the disruption of the
analytic work were explored, that this dynamic was revealed.
Anna Freud (1954) stated that analysts never react and respond to any of
their patients in exactly the same way. The manner of making interpretations,
the extent to which one is humorous or serious, the extent to which a real
relationship is allowed to exist alongside the transference relationship, the
degree of the patient's and analyst's ease are somewhat different for each
analytic pair. According to Anna Freud, these variations are neither planned
nor intended; they are the reaction to subtle nuances and pressures from the
patients' personality. Sandler
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(1976) further developed this idea in his concept of "role-responsiveness."
He believes that the patient subtly and unconsciously prods the analyst into
reactions and behaviors that repeat experiences and relationships that have
been crucial to the patient in the past. How the analyst responds to these
pressures will vary and often is not based on a conscious awareness of what
is happening. When analysts respond to patients in ways that are
uncharacteristic of them, this may sometimes be considered a compromise
formation between the analyst's own personal tendencies and his unconscious
and unintentional acceptance of the role the patient is trying to get him to
assume in the transference. According to Sandler, the extent of the analyst's
response, the roles to which he will respond, and the relative proportion of
contribution from the analyst's own issues and the pressure from the patient
will vary for each patientanalyst pair. Sandler's conceptualization is to be
distinguished from the interpersonal theories of Harry Stack Sullivan.
Sullivan focused more on the interpersonal therapeutic relationship. Our
interest is in the meaning each patient makes of the "real" characteristics of
the analyst and the interdigitating influences of these with the patient's various
issues and conflicts.
The acknowledgment of the importance of the interaction between the
analyst and analysand has been followed by elaborations upon the idea that
"fit" is an important factor in the analytic process. Tartakoff (Panel, 1981)
stated that considerations of transference and countertransference, while
central to the analytic situation, were not enough to account for all of the
analyst's cognitive and emotional responses to the patient. While the analyst's
self-understanding gained through analysis is critical to the analyst's work, the
personal attributes of the analyst are also critical in determining what the
analyst responds to and communicates in treating the patient. She viewed the
"fit" or "misfit" of patient and analyst as a crucial factor in determining the
outcome of the analytic endeavor.
Shapiro (1976) surveyed candidates in psychoanalytic training about their
psychoanalytic treatment. Thirty-two candidates
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responded to his questionnaire. Of these, one fourth attributed major
difficulties to their analysts. One sixth of this group believed the difficulty
was due to countertransference problems. Others cited personal attributes or
problems, such as the analyst's "rigidity and remoteness," "his desire to adopt
me," "his depressive character," or "the similarity of the analyst and myself."
Shapiro concluded that unless the candidate's initial pathology is too severe
for steady progress to occur in the analytic work, the fit between the
analysand and the analyst may be the most important element in the training
analysis. To our knowledge, no systematic study has been undertaken to
assess the impact of patient-analyst match on psychoanalytic outcome.
Outcome studies of psychoanalytic treatment have focused primarily, if not
solely, on the analysand's psychological characteristics and the change in
those characteristics during the course of analysis (Appelbaum, 1977);
(Bachrach and Leaff, 1978); (Weber et al., 1985a), (1985b); (Wallerstein,
1986); (Kantrowitz et al., 1986), (1987a), (1987b).
We assume that all analysts do better work with some patients than with
others. We also assume that all analysts retain some areas of only partially
resolved conflict and some attitudes, values, styles, and reactions of which
they are not completely aware. The analysand's reaction to the analyst, beyond
elements of the transference neurosis per se, is also influenced by the
analysand's experience of the analyst's style, attitudes, values, and conflicts
(to the extent to which these are apparent). The analysand will react to the
analyst's characteristic reactions. Although it may become the focus of
inquiry, the resulting interaction often escapes the notice of both parties.
Our interest in investigating the impact of the two-person interaction on the
analysis evolved from a prospective, longitudinal study of psychoanalytic
outcome that focused on both suitability for and response to psychoanalytic
treatment. The study sample consisted of all patients who applied for institute
analysis and were assessed by senior analysts as suitable for supervised
psychoanalysis in a given calendar year. These patients
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were then rated prospectively for capacities thought to be critical to the
psychoanalytic process: reality testing, level and quality of object relations,
affect availability and tolerance, and motivation for treatment (Kantrowitz et
al., 1975). We were surprised to find that the degree to which an analysand
gave evidence of these capacities, both as determined by clinical interview
and psychological test findings, was not predictive of successful outcome
(Kantrowitz, 1986). Our inability to predict outcome using such measures
has been confirmed by other studies (Weber et al., 1985a). We concluded
that such dimensions of psychological strength may be necessary, but are not
sufficient prerequisites for successful outcome. While we recognized that
various factors, including limitations of our assessment process, could
account for our failure to predict outcome, we speculated that a particularly
important omission might have been consideration of the effect of the match in
shaping the two-person psychoanalytic interaction.
It is our hypothesis that when the analyst's characteristics that remain
outside his awareness are confluent with difficulties the patient has either kept
out of awareness or deliberately avoided in treatment, such difficulties or
characteristics will go undetected and, therefore, will remain unanalyzed. If
this difficulty is central to the patient's pathology, the analysis will not have a
successful outcome. If the overlapping "blind spot" exists in an area that is
peripheral to the central issues, the analysis may be seen as successful
overall, but no change will occur in this particular area. We also hypothesize
that if an analyst's character or style, as manifested in the analysis, provides a
quality or dimension that has been absent or limited in the history of the
patient and is centrally related to the patient's difficulties, then the personal
characteristic will have a facilitating effect on the outcome of the treatment
(Kantrowitz, 1986a).
In undertaking an exploration of the patient-analyst fit from our existing
data, we were confronted with several very significant limitations. The data
we were examining had not been collected with this question in mind and
were not what
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we would choose to systematically evaluate this question. Nevertheless, we
thought it worth our while to examine the material we had collected as a pilot
for future systematic studies. The limitations of our existing data include: (1)
small sample size, (2) lack of comparable data for the patients and analysts,
(3) lack of experience of the treating analysts, (4) inability to take into
account the effect of supervision on the analyst, and (5) lack of comparability
of the analysts' interviews in terms of openness and completeness.
Our original research project was begun at the Boston Psychoanalytic
Society and Institute in 1972. Twenty-two patients, accepted for supervised
psychoanalysis, became the subjects of this longitudinal study. The
methodology and results of this study have been reported previously
(Kantrowitz, et al., 1975); (Kantrowitz, 1986); (Kantrowitz et al., 1986),
(1987a), (1987b).
For the purpose of this pilot study, the analysts' recorded, transcribed
postanalytic interviews were reexamined. These interviews reviewed the
course of the analytic treatment and the obstacles encountered within it. The
same research psychoanalysts independently assessed the treating analysts'
more personal responses to their patients, and the ways in which these
reactions were manifest in their interactions with the patients. The data we
used were found in the spontaneous comments that analysts made about their
patients and about their own attitudes, reactions, and responses to them during
the course of analysis.
A rating system was designed to codify our findings along dimensions
related to the effect on the match. We labeled the first area Basic Attitudes.
Here we noted any statements the analyst made which reflected (1) negative
and/or positive value judgments about the patient, (2) reactions of liking or
disliking the patient, and (3) sympathy or lack of sympathy toward the patient.
The analysts' responses to the patients were evaluated in terms of the extent
and the direction of deviations from a neutral analyzing position toward either
gratification or distancing. Withholding or antagonism are examples of
extreme
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distancing. The extent to which the analyst entered into and accepted the
patient's psychic reality was assessed. Here the continuum ranged from the
analyst who totally entered the patient's psychic world and only reflected its
content and affect without interpretation or question, to the opposite end
where the analyst contradicted and argued against the patient's expressed
views and experiences. More subtle expressions of this latter position are
seen in attempts to alter the patient's point of view and silent disagreement or
disrespect for the patient's point of view without any open disagreement. The
raters gave specific quotes from the treating analyst's interview to document
the assessments.
The concordance of patient and analyst views was assessed independently
by the same judges. They compared the patient and analyst views expressed in
their postanalysis interviews. The judges compared patient and analyst (1)
assessments of the patient's major issues, conflicts, strengths, and limitations,
(2) accepting or unaccepting attitudes toward the patient's character structure,
conflicts, behavior, and mood states, (3) views of the analyst's goals,
intentions, and methods used in relation to the patient (e.g. increasing the
patient's self-understanding, making conscious what has been unconscious,
analyzing defenses and transference or modifying the patient's behavior), (4)
agreement or disagreement about the goals of treatment, and (5) views of the
methods that should have been used to attain those goals. Finally, whatever
aspect(s) emerged as highly concordant or discordant for each patient-analyst
pair were evaluated for both centrality in the analysis and for the extent of the
analyst's awareness, acceptance, neutral exploration, or lack of acceptance in
this area.
The assessments made by the researchers showed a very high degree of
agreement. A profile for each analyst was constructed in which the views of
all judges were incorporated. In the summary, the authors speculated about the
important aspects of the analyst that emerged in relation to this patient and the
possible effects these might have had on the analysis.
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Another psychoanalytically trained psychologist, a psychoanalytic
candidate, uninformed about any of the analysts' data or the patients'
interviews, evaluated the pre- and postanalysis tests. A description of the
central conflicts and concerns at the outset of treatment was made.
Comparisons of pre- and postanalysis tests were used to assess the extent to
which the patients had changed with regard to these presenting issues. In
addition, any other areas which had improved or deteriorated were noted.
Reliability of these pre- and postanalysis test evaluations was established by
comparing these reports with the psychological assessments made at the time
the test material was initially collected and evaluated.
All 21 cases were evaluated for the impact that match might have on the
outcome of analysis. Two advanced psychoanalytic candidates independently
compared the analyst profile and the evaluation from the psychological tests
for each patient-analyst pair. Their task was to assess whether or not the
match of patient and analyst influenced the success of the patient's analysis.
To do this, they listed the central characteristics and issues for the analyst as
revealed in the profile, and the central problematic issues or areas for the
patient as revealed in the test report. They were then asked which, if any, of
these issues interdigitated for patient and analyst in a manner which they
thought might influence the success of the analysis. They were asked to
evaluate the amount of influence, the centrality, the direction (i.e., negative or
positive), whether it impeded or facilitated the engagement in the analytic
process, the course of the analytic work, or the completion of the process, and
the degree of certainty they had in their evaluations. The judges also grouped
the cases into two broad categories of outcome, based on psychological test
results: improved, and little or no improvement. Next they reviewed the
actual interview with the analyst to corroborate or modify their impressions.
They did not make major shifts in their assessments based on these reviews of
the transcripts. Each judge wrote a summary paragraph describing, with
documentation, his or her perception of the
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influence of the patient-analyst match on the outcome of treatment. While this
method did not allow for formal tests of reliability, the agreement between the
two raters was high. Differences were only in terms of emphasis.
Match seemed to play some role in all 21 cases; however, in eight of the
21 cases1 we were unable to evaluate the extent of its importance because a
preponderance of other factors seemed more central. These factors included:
lack of skill on the part of the analyst, possibly due to lack of experience;
severity of the patient's pathology, even to the extent of unanalyzability; lack
of agreement between supervisor and analyst; and a traumatic experience
which occurred between termination and retesting. This left us with 13 cases
in which we could try to study the role of the match. This sample size is
suitable only for exploratory investigation. Given these data, our findings do
not allow us to validate our hypothesis, but the patterns that emerge suggest
we may have a concept that can be validated by future research using a
similar strategy.
In devising this protocol, we were aware of the lack of comparable data
for the analysts and analysands. While objective test data were available for
the analysands, inferences had to be made about the analysts. From interview
data alone, raters derived information about the analysts' personal
characteristics and the nature of their work in the analysis of one particular
patient. This information may include inaccuracies because the analyst's
views of the analysis may be variously influenced by (a) retrospective errors,
(b) the need to see the analysis as successful (for graduation and for self-
esteem), and (c) supervisory transference revived in the interviews. In
addition, while a two-to-four-hour interview may reveal styles, attitudes, and
characteristics representative of the analyst, we can be less certain that the
profile reflects the analyst's actual behavior with the
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1 One case included in previous followup study reports was excluded from
consideration in this investigation because the treating analyst had died.
Followup information used in the earlier papers had been obtained from the
psychoanalyst who treated the patient subsequently.
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patient. The analyst's report may also be influenced by the outcome of the
analysis, especially if it was problematic or unsuccessful. For example, in the
interview, the analyst might express more criticism of the patient or of his or
her own analytic work than was actually reflected in his or her behavior in
relation to the patient during the course of the analysis. Relying on such
interview data alone poses a serious problem for research of this kind. We
consider these data useful for our exploratory purposes and our effort to
generate hypotheses about patient-analyst match, but the data clearly lack the
rigor desirable and necessary for a systematic study.
Participants in this study were analytic candidates and the patients they
treated while they were in training. For eight of the 13 analysts, this was the
first analytic patient they ever treated. When we consider the extent of their
difficulties, the significance of the analysts' inexperience must be taken into
account. Their anxiety about being candidates and discussing their work,
though they were informed that the material would remain confidential, may
be another influential factor. It is also important to note that in many cases the
length of analysis was relatively short. Five of the 13 patients were in
analysis for less than four years. It may be that pressures of analytic training
increased the likelihood of an abbreviated analysis, contributing to the
incompleteness of the work.
The role of supervision must also be considered. In this study, there is not
only the effect of the analyst on the patient to be taken into account, but also
the effect of the supervisor on the analyst. Some candidates said they would
have responded differently to their patients were it not for their supervisors;
others said their supervisors were extremely helpful. Some even said that they
could not have continued to treat their patient were it not for their supervisor's
support and perspective on the case.
The process of interviewing the analysts raised some important research
questions. Some of the candidates were very
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open about their experiences as analysts, ready to talk about their difficulties
and vulnerabilities. Others were more guarded and controlled, so that we had
a fuller view of some analysts than others.
In reviewing the data, we found an interdigitation of patient and analyst
issues in all 13 cases evaluated, but found the match had a varying degree of
impact on the treatment process. We examined the nature of correspondence
between the issues and traits in the patient and the observable issues and traits
in the analyst. Because of the nature of the data, we could study the patient's
characteristics more completely and in more depth than the analyst's. We
found that these cases could be grouped into three categories of match,
categories which seemed to provide one way, perhaps not the best, and
certainly not the only way to group the data we reviewed. We offer these
categories as a possible way to conceptualize the material available to us. In
a formal study designed to investigate the patient-analyst match in particular,
we would expect to have somewhat fewer confounding variables and data
which would relate more closely to our questions. Given a larger sample and
more rigorous methods of assessment, we might find that the data fell
naturally into somewhat different categories.
In this pilot investigation, it appeared that two types of match impeded the
analysis, and one type of match facilitated the analytic process. We
conceptualized the impeding categories as follows:
Matches of similarity involve similar issues or traits, or similar expression
of conflict and conflict derivatives in analyst and analysand. The analyst
might or might not be aware of these traits in himself or herself, but was
unlikely to notice that they overlapped with similar traits in the patient. When
the analyst did notice the overlap, he or she did not see the similarity as an
impediment to the treatment. The shared area might or might not constitute a
major difficulty for the analyst, but it did represent an area of central
difficulty for the patient.
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Matches of complementarity involve areas of different expression of
similar conflict, where the analyst is unconsciously defending against the
issue with which the patient is manifestly struggling. The analyst in these
cases was unaware of the shared problem area. This problem area, while
always shared, was central to the patient's difficulties, but might or might not
be a central problem for the analyst.
We conceptualized the facilitating category as follows:
Matches based on compensation involve areas in which the analyst's
character or style provides a beneficial effect for the patient. The patient
identifies with or uses a quality or dimension of the analyst to balance or
modify a previously negative identification or to resolve a conflict. The
concept of a compensatory feature in the analyst facilitating the
psychoanalytic treatment is to be distinguished from the concept of "a
corrective emotional experience" as described by Alexander (1950). What
we have in mind are characteristics of which the analyst is not necessarily
consciously aware in the analysis and which are not intentionally used for
therapeutic effect.
While the 13 cases could be classified as primarily representing one or
another of these three categories of match, many of the cases also had
characteristics of the other categories.
For each case where the patient and analyst shared an issue, we rated the
issue as (a) central to the patient's difficulties, preventing any significant
analytic work from occurring; (b) not central to the patient's initial
difficulties, so that much analytic work was accomplished before the issue
which was similar for patient and analyst became central for the patient in
treatment, preventing the completion of analytic work in this area.
Because of the small number of cases, the confidential nature of the
material gathered from both patients and analysts, and because the original
material was collected for purposes of investigations other than the effect of
the patient-analyst match, the material that follows will give clarifying
examples but must necessarily present summarized data rather than full case
reports.
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Matches of Similarity
Issues Central for the Patients
Five cases were assessed as having similar issues to their analysts where
the issues were central to the patient's difficulties from the outset.
The similar issues for these five analysts and analysands were narcissistic
ones. These matches were characterized either by mutual idealization and
overvaluation, particularly of intellectual skills, or by a shared experience of
vulnerability and neediness. In both instances, the analysis of these
narcissistic issues and of the patient's aggression was severely impeded. For
example, in one case the analysand described primitive sadistic fantasies with
great verbal fluency, creativity, and wit. There were also strong depressive
longings underlying the rich verbal presentation. The analyst focused on the
patient's creativity and access to the unconscious, bypassing and seemingly
unaware of the intensity of the analysand's affect, especially to the presence of
sadism. The analyst viewed the lurid fantasies as evidence of internal
freedom and verbal facility. In another case, the analysand was extremely
fragile. Rage and homosexual longings were thinly concealed behind
intellectual skill and verbal elegance. The analyst's admiration for the
analysand's mind bordered on an idealization of intellect. While the analyst
was aware of and referred to the severity of the patient's disturbance, neither
the primitive rage nor the sexualization of the intense early longings was
analyzed or explicitly recognized. The analyst did help the patient bind and
organize affective experiences, and the patient was both better related
interpersonally and more interested in life following analysis, but neither
narcissistic nor aggressive and sexual fantasies had been modified according
to the postanalysis testing. In cases where mutual idealization was
characteristic of the match, we found that the analytic process itself was
idealized; in cases characterized by mutual need and vulnerability, the
analysts seemed to
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wish to be kind and supportive, and had a tendency to keep things "smooth,"
leading to avoidance of both the sense of inner damage and rage these patients
experienced. In one case, the analyst and analysand seemed to believe that if
they were harmoniously in aggreement, the analyst was helping the patient. If
the patient totally accepted the analyst's way of seeing things, then both of
them could feel good about themselves, and the patient would no longer feel
defective. According to testing following analysis, this patient became less
depressed and felt less defective, but reality testing showed an impairment not
previously noted. We wondered if this impairment was the result of the
patient's conforming to the analyst's reality, relinquishing his own sense of
what was real in order to unite with the analyst.
Neither patients nor analysts expressed awareness of the central problems
in themselves or in the other. Four of these five analysts viewed their patients
as having successfully entered into and benefited from psychoanalytic
treatment. They believed a transference neurosis had been established and at
least partially resolved. The fifth analyst was less positive about the patient's
ability to enter into psychoanalytic work without the use of some parameters,
and was more actively gratifying to this patient than would be usual with
standard psychoanalytic technique. The therapeutic benefit for the patient was
regarded by the analyst as considerable. According to psychological test
findings, these five cases showed little or no improvement following
psychoanalysis.
In all five of these cases, the analyst's failure to see a central troubling
feature for the patient seemed based on a mutual "blindness" for the issue.
Three of the five analysts were particularly reflective about their patients and
the analytic work; they seemed careful and skilled in analyzing many issues.
These analysts did not seem to be "unanalytic" or unable to do analytic work
overall. However, with respect to a shared idealization of intellectual and
creative processes, they were deflected from pursuing the psychoanalytic
work. The other two analysts were also able to be reflective about their
patients and their analytic
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work; however, their seeming identification with their patients' neediness,
while particularly stimulated by two intensely needy patients, became an
impediment to the work. Such identifications could be an issue with any
patient, since the regressive process of treatment tends to bring more intensely
felt needs to the fore. It seems possible, however, that if the needs of these
patients were less intensely experienced, these two analysts might have been
more "neutral" and effective in the analytic work.
Issues Not Central for the Patient
One case was assessed as having a match of similarity in which the analyst
and analysand shared a set of values that led to their avoiding analysis of
certain defenses and thereby preserving, for both, a narcissistically invested
self-image. Neither patient nor analyst was aware of this avoidance. The
difference in this case, compared with those previously described, is that this
was not a central problem for the patient. According to preanalysis
psychological testing, the analysand's character appeared more borderline
than narcissistic. The analyst evaluated the patient as having successfully
entered into and as having benefited from psychoanalysis. The analyst's work,
as it was later described, demonstrated care and skill and a great deal of
insight into the patient's difficulties, with the exception described.
Psychological testing showed that this patient was greatly improved in many
areas. Narcissistic issues, however, had not improved and even seemed
slightly more prominent as central conflicts were less acute.
Complementary Match
Two cases were assessed as having a complementary patient-analyst
match in which an issue was central for the patient's difficulties, and no
analytic work seemed to be accomplished
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to resolve it, according to psychological tests. In both cases, the analysands
were openly provocative and aggressive, and the analysts avoided their own
aggression. For example, in one case, the analysand was overtly hostile,
devaluing, and conscious of intense anger. At times this was expressed in
primitive and sadistic ways, both outside the analysis and within the hour,
according to both the patient's and analyst's reports. Sexualization was a
primary way of relating. The analyst consistently tried to minimize the extent
and impact of the patient's highly erotized transference, blatant oral-
aggressive fantasies, and rageful expressions by taking a sympathetic,
nonjudgmental stance, describing the analysand as well-meaning but out of
control. The analyst referred to the analysand's aggressive behavior in the
interview, but was not able to recognize it in the context of the analytic work.
Postanalysis testing for this patient showed evidence of increased aggressive
fantasies, more pessimism and depression, and some slight deterioration in
reality testing in comparison with preanalysis psychological test results.
Although the analyst was not aware of having minimized the patient's
aggression, there was evidence of reflective, careful analytic work in other
areas. Nevertheless, the analyst's perception that this patient had been
successful overall in the analytic endeavor underscores the lack of awareness
of significant aspects of their work. While we assume all analysts need to be
able to face and analyze aggression, and suspect that this analyst may have
more unresolved conflicts in this area than many analysts, we think the
intensity of this patient's rage may have increased this analyst's need for
denial, avoidance, and reaction formation. Had the patient's affect been less
intense, the analyst might have been more flexibly defended. While probably
analyzable, this patient was among the more primitive in the study. In the other
case which fits this category, the patient's aggression was again the important
unanalyzed area. The analyst reacted to the aggressive behavior of the
analysand with a rigid control that interfered with analysis of the behavior.
Analyst and patient seemed locked in a struggle. On followup psychological
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testing, although the analysand's reality testing had improved, the patient's
depression continued, and there was now evidence of enormous rage,
previously warded off by denial. The analyst did not believe that a successful
resolution of a transference neurosis had taken place. It may be that this
analyst's tendency to rigidity is characterological, but we suspect that it was
accentuated by the aggressive, provocative behavior of this analysand.
Compensatory Match
In five cases the role of the patient-analyst match seems to have prevented
the completion of a portion of the analytic work, but considerable analytic
work was accomplished. We think these cases had a positive outcome. What
we are highlighting is how the patient-analyst match may have influenced
what issues were left at the point of termination, or the time of termination
itself, because of the interdigitation of issues that had become central in this
latter phase of analysis. The extent of resolution of issues varies from case to
case.
Three cases were assessed as a compensatory patient-analyst match which
seemed to facilitate the analytic work. In all three cases, qualities of the
analyst that were initially facilitating to the analytic process, later served as
an impediment as different issues came to the fore in the analytic work. All
three treatments were considered successful by the analysts.
One analysand, who prior to analysis experienced the world as threatening
and herself as fragmented, had a non-judgmental, gentle analyst. Followup
psychological testing showed the analysand to be much improved. She was
far less frightened and had a better differentiated sense of self. The analyst's
gentle patience seemed to have helped her to separate from a mother she
perceived as critical and terrifying. However,
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sexual anxiety and intense feelings of depression not present initially emerged
in the course of treatment. This change was evident when we compared the
earlier testing with the followup test results. The analyst recognized the
development of increased sexual concerns, but felt that the analysand was not
able or ready to deal with them. Termination took place at this point.
According to the postanalysis interview, the analyst was very concerned
about being gentle and patient and not frightening this "easily intimidated"
analysand, and so had difficulty helping her to analyze the sexual and
depressive material that emerged in the later stages of analysis. There seemed
to be a similar discomfort in the analyst and the analysand with sexual
material, and the analyst's gentleness began to operate in this context in the
service of defense. Thus, the very gentle approach which had facilitated the
extensive work they had accomplished now served as an impediment since
the analyst failed to actively pursue a particular area, which the patient was
reluctant to pursue as well. Their mutual retreat from the material may be
based on a now newly relevant match of similarity.
The second patient in this group had poor reality testing, related to others
on a level of part-object relations, and experienced unmodulated rage,
according to preanalysis testing. The analyst was careful and thoughtful with
this patient, while also being distant and somewhat rigid in style. The analysis
was characterized by many affective storms, loss of accurate reality testing,
and an intense negative transference throughout most of the treatment. Despite
the analysand's fragile psychological state, no parameters were used. The
analyst remained calm and neutral, while rather remote. Postanalysis testing
revealed improved reality testing and better modulation of aggression, but
difficulties with sexuality now emerged as a central concern. The analysis
ended when the analysand said that his analytic relationship conflicted with
his real-life love relationship; he could not be involved with two people at
the same time. The analyst seems to have accepted his wish to stop rather than
analyzing it. Thus, the calm acceptance of whatever the patient
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presented, while previously helping the patient to contain, reexamine, and
eventually modify both his perceptions of the world and his experience and
management of affect, later presented a barrier to exploring what appeared to
be oedipal material and conflicts, when they emerged. The analyst viewed
that analysand as successful in psychoanalysis and perhaps did not believe the
patient could do more. This seems less likely, however, since the conflict was
not addressed or explored. The analyst, perhaps, had residual conflicts
around sexual issues; we have no data to deny or confirm such a speculation.
There was no awareness on his part of a "blind spot." If the analyst was
defending against an unresolved conflict, then a complementary match was
now emerging, or similarity in terms of a rigid, distant way of managing
sexual material. Our hypothesis is that whatever its origin, the detachment of
the analyst that was so enormously beneficial during most of the analysis was
an impediment to doing this next piece of analytic work.
In the third case in this group, a patient began analysis feeling isolated and
depressed, and strongly defended against rage. Difficulties with separation-
individuation were paramount. The analyst's style was forceful, energetic, and
often confrontational. The analyst's interview suggested that the analyst was
less comfortable with sad, depressive affects. According to the postanalysis
psychological test results, this patient emerged from analysis as more
differentiated, responsive to others, and less worried about aggression.
Depression persisted, however. We hypothesize that the analyst's comfort
with aggression along with the analysis of unconscious issues enabled this
patient to explore her rage and made it seem less frightening. Since her
difficulties in separation and differentiation were tied to her rage and related
conflicts, her development in this area was facilitated. In the followup
interview, the analyst's tone was impatient in describing the patient's sadness.
While the patient brought up the depressive affect, it did not become the focus
of analytic inquiry. The analyst's active, assertive style may have been a
disadvantage when it came to analyzing dysphoric experiences. While
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predominantly a compensatory match, the match may be categorized as
complementary around depressive concerns and feelings, with the analyst
defending against dysphoria which the patient presented.
Categories such as we have proposed are not found in pure culture; their
characteristics exist in various combinations, and in clinical reality, they often
overlap. Not only will one kind of match give precedence to another during
the course of analysis, but sometimes two or more kinds of match may exist
simultaneously. In one case, where a compensatory match facilitated the
progress of analysis, a match of similarity simultaneously impaired the work
in an area of central conflict. In another case, with a compensatory,
facilitating match, a complementary match coexisted, impeding work in a
central conflict area from the beginning. To illustrate the first instance, an
accepting, easygoing, causal analyst helped a constricted, anxious, and
isolated analysand to become more emotionally open and capable of intimacy,
according to the postanalysis psychological tests. However, the analysand's
central anxieties and conflict around loss were avoided by the analyst whose
own history had parallels with that of the patient. While the analyst mentioned
these similarities in the interview, he seemed quite unaware that he had
bypassed dealing with issues of loss with his patient. He viewed the
analysand as having a partially resolved transference neurosis. The
postanalysis testing suggested "a magical flight into health"; the concerns
around loss did not appear greatly changed. The analysand was consciously
aware that an area was being avoided, was also aware of some of her
analyst's history, and seems to have complied with her analyst's wish to be
protected by agreeing that all was well on terminating her analysis.
Discussion
In focusing on the role of patient-analyst match in the outcome of
psychoanalysis, we found that in almost every case we were able to identify
match as playing some role in the analysis, but
- 914 -
only in 13 of the 21 cases did match stand out among other factors as centrally
relevant to outcome. It might be argued that in putting a microscopic focus on
the issue of match, we found what we were looking for. We do believe,
however, that match issues are always present in some way; it is the extent of
their influence on the process that varies. We do not believe that match is
necessarily the primary reason, and it is certainly not the exclusive reason, for
analytic successes or failures, but we believe that match is a factor which may
significantly influence the outcome of analysis.
There is no perfect analysis; every analysis remains incomplete in some
ways. Some limits may be due to the nature of the patient's difficulties, the
accessibility and valence of particular issues at particular times in the
patient's life, the patient's willingness and motivation to work on particular
issues, and various forces from outside which may impinge on the work.
Some of these limits also may be due to the analyst's skill, level of
experience, unresolved issues, particular character and style, opinions and
beliefs, motivation, and the particular time in the analyst's life.
The question of how analysts maintain their analytic stance deserves
consideration. While analysts' self-awareness and self-analytic function are
crucial to the maintenance of this stance, there remains a dynamic interplay
between tolerance and avoidance of tension. At times analysts' skills may
enable their patients to explore and deepen areas in which the analyst has
conflicts, in or outside of consciousness. Under such circumstances, it is
possible that the analyst as well as the patient may grow in the work. While
some errors may be due to limited skill, we believe that what may be
perceived as "poor technique" leading to a disruption of the analytic work
may frequently be the consequence of a dynamic interplay between the
patient's difficulties and some quality, characteristic, or conflict of the
analyst.
Seven cases showed little or no improvement on psychological tests. In
five of these seven cases, the analysts believed at least partially successful
resolution of the transference neurosis
- 915 -
had taken place. In most of these cases, the issues shared by the analysts and
their patients were narcissistic ones. It is not surprising that pairing analysts
and analysands with prominent narcissistic issues would lead to a covering
up or ignoring what seems defective or unpleasant, and to idealizing the
analytic process. While in these particular cases the shared issues were
narcissistic, we do not mean to suggest that this is the only kind of issue that
can lead to a problematic match. It may be that shared narcissistic issues
show up most in our study because they are more likely to go unnoticed in the
service of idealizing the analysis, and they may be more common among
younger, less experienced analysts. Future outcome studies will need to take
into account that any given analyst may be "blind" to personal issues that
"match" the issues of a given patient and, as such, his or her evaluation may
not concur with what has actually taken place. The more abstract and
generalized the description of what occurs in the analysis, the less verifiable
it becomes. At the very least for research purposes, we need analysts to
document what they mean by change and why they believe changes have
occurred.
It is difficult to find descriptive language that captures the feeling of the
analyst's attitudes, stance, and general way of relating and responding to the
patient, since these are often subtle and elusive dimensions. To protect the
confidentiality of both patients and analysts in our study, we have refrained
from using direct quotations, thus losing a sense of nearness to the process,
sacrificing vividness and complexity. It is not our intent to be judgmental or
reductionistic, though these are pitfalls of which we must be aware in this
work. For the purposes of our study, we have cast in relief aspects of the
analysts' style and manner which may not usually stand out so boldly against
the whole picture of the analysis.
Examination of the pilot data resulted in our recognizing two types of
impeding match. In both types, the analyst was unaware of his or her dynamic
or characterological issue in relation to the patient. In the match of similarity,
the analysts
- 916 -
were unaware that their styles and/or issues mirrored those of their patients.
In matches of complementarity, the patient seemed to be expressing something
the analyst found unacceptable in himself or herself, defended against, and
disowned. The underlying issue in a complementary match might actually
have been an area of similarity. Put another way, an analyst may
unconsciously ward off awareness of an issue with defenses such as reaction
formation and undoing, leading to a complementary match, or with seeking
union, merger, or a mirroring relationship with the patient around certain
areas, resulting in a match of similarity. In this light, while match seems close
to usual notions about countertransference influences on treatment, we are
also including in our categories relatively conflict-free characteristics, such
as style and attitudes.
It may be helpful to think of a continuum for the analyst around conflict-
free and conflict-based responses that are relevant to match. Aspects of
responses at either extreme may be conscious or unconscious for a given
analyst. Characteristics or style may or may not reflect underlying conflictual
issues in the analyst and may be experienced as disquieting to some patients
and not to others. At one extreme there are issues of style which, although they
develop out of the analyst's history and may be based on positive and/or
negative identifications as well as constitutional factors, are primarily
neutral, or conflict-free for the given analyst. Conflict-free traits might
include, for example, tempo, level of activity and passivity, and verbal
fluency. These traits in the analyst may have a particular dynamic meaning,
positive or negative, to any given patient based on his or her personal history.
At the other extreme are conflict-based responses to a patient. An example
would be issues an analyst fails to see or responds to unconsciously,
precisely because they are threatening and would revive painful affective
experiences. The result of such a match is illustrated by the two cases we
have described as complementary matches in which the analysands were
openly provocative and aggressive, and the analysts avoided their own
aggression. The reactions that fall
- 917 -
in this part of the spectrum would include those customarily defined as
countertransference. In between these two positions, there are undoubtedly
blends of conscious and unconscious conflictual and nonconflictual
characteristics, sometimes one and sometimes the other being predominant.
Such combinations may be evident, for example, in certain of the analyst's
opinions.
Matches of patients and analysts that appear to have facilitated the analytic
process for the patients in our study are those in which the analyst's
characteristic style provided some quality that was inhibited, deficient, or in
some other way lacking for the patient. We suspect that the patient's
acquisition of a formerly missing attribute may be based on the patient having
internalized an identification with the analyst. This hypothesis would be in
agreement with Pfeffer's (1961) conclusion that part of a successful analytic
outcome is the patient's new identification with the analyst. While Pfeffer was
referring primarily to the patient's identification with the analyst's analyzing
function, we extend the concept to include identification with particular
characteristics of the analyst manifest in the analytic work, not previously
internalized by the patient.
It is our hope that this exploratory project will lead to the development of
systematic and replicable research which will examine the effect of patient-
analyst match on the outcome of psychoanalysis. Studies of senior,
experienced analysts with several, rather than one, of their patients would be
very elucidating. Under such circumstances, we would be able to increase our
sample size and exclude the variable of inexperience.
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Article Citation [Who Cited This?]
Kantrowitz, J.L., Katz, A.L., Greenman, D.A., Morris, H., Paolitto, F.,
Sashin, J. and Solomon, L. (1989). The Patient-Analyst Match and the
Outcome of Psychoanalysis: A Pilot Study. J. Amer. Psychoanal. Assn.,
37:893-919

Kantrowitz Match

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