Suitability Criteria And Contraindications For Psychoanalytic Therapy

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In Freud's time, the selection criteria for psychoanalysis were seductively straightforward: psychoanalysis was only indicated for those patients who suffered from neuroses, whose psychopathology was rooted in the Oedipal phase and who could reveal their infantile neurosis in the transference through the so-called transference neurosis. Although there still exists a minority of therapists aligning themselves with Freud's original views on the matter, since the 1970s cases of patients diagnosed as psychotic or personality disordered have been treated by psychoanalytic therapists of all persuasions.

In the NHS, psychoanalytic therapy is a very scarce resource, weighed down by long waiting lists. It is usually offered primarily to those patients who present moderate to severe difficulties that have taken a chronic course. Generally speaking, such an approach seems most indicated when the patient presents problems of a characterological nature or where there are interpersonal difficulties. Nowadays, the patient's formal diagnosis, for example, whether he is psychotic or suffers from borderline personality disorder, is considered less relevant than whether the patient shows some capacity for engaging with the therapeutic process.

Our understanding of psychotherapy is becoming more sophisticated, but we are a long way from being able to confidently assert which pre-therapy criteria can reliably predict the best outcome for psychoanalytic therapy. Research on suitability criteria reveals correlations with outcome that are small such that multiple factors must be combined to meaningfully predict outcome.3 Although there is little research evidence as to their validity and reliability, this section will briefly review some the most commonly recommended criteria.

• Psychiatric diagnosis is often cited as an important criterion. Svanborg et al. (1999) found that recommendation for psychoanalytic therapy was predicted by absence of a personality disorder and high GAF4 scores, but not by the presence of a psychiatric disorder. Most studies suggest that it is those patients with a predominantly neurotic personality organisation and with inhibitions as the most prominent defence who do best, most probably in any type of psychotherapy. Nevertheless, in practice, the majority of the referrals for psychoanalytic therapy in public health service settings are of patients with personality disorders who present with quite diffuse problems that do not lend themselves to structured and briefer interventions.

• The need for a focus is imperative in brief therapy (Malan, 1980). Brief therapy is most indicated where the conflict is at a neurotic, Oedipal level and is less appropriate where the patient's problems are indicative of borderline or pre-Oedipal problems. Hoglend et al. (1993) suggest that a circumscribed focus addressing problems that are Oedipal, such as assertiveness with the same sex, ambivalence about triangular situations as opposed to more oral problems such as dependency, trust and separation predicts a more positive outcome in brief focal psychoanalytic therapy. Involvement in complex and pervasive dynamic issues usually excludes a patient for brief psychoanalytic therapy but he may still be suitable for a long-term approach.

3Broadly speaking, the criteria for brief psychoanalytic therapy, overlap with those for long-term psychotherapy.

4GAF is a composite measure, which in addition to current symptomatic suffering, assesses more stable characteristics such as aspects of ego strength, quality of interpersonal relationships, level of psychosexual development and anxiety tolerance.

• The analytic frame itself places particular demands on the patient that need to be considered when choosing psychoanalytic therapy. Moore & Fine (1990), in their classic text, suggest that some of the requirements for suitability stem from the very nature of the analytic process and thus include the ability to free associate, to make the sacrifices of time and money, to tolerate frustration and anxiety and other strong affects without recourse to flight or acting out.

• The patient's capacity to sustain the therapeutic relationship in the absence of immediate gratification is essential. For some patients, the more aloof therapeutic stance may prove too persecuting in the face of a relatively weak ego. Indeed, the patient's ego strength (see below for a fuller discussion) is another important factor; patients with weak egos whose capacity to discriminate between the object and the self is impaired, or those with poor impulse control or with limited capacity to accept the limitations of reality, pose special challenges in psychoanalytic therapy. This is especially so when the therapeutic contract is brief and this is often contraindicated.

• A good history of interpersonal relationships, or at least evidence of one positive object relationship, is often thought to be a good prognostic sign. Intuitively this makes sense: if the patient has some demonstrable capacity - however rudimentary - to engage with and trust another person, then it will enable the patient to engage more readily with the analytic process and to tolerate the intimacy of the relationship. The patient's ability to get actively involved with the therapeutic processs is thus a related criterion. Frayn (1992) found that those patients with previous positive relationships with parents, bosses, teachers and other therapists, where applicable, were less likely to terminate psychoanalytic treatment prematurely. Those who recreated disinterested, chaotic, narcissistic or exploitative relationship dynamics were the most likely to drop out. Hoglend et al. (1993) and Hoglend (1993) found that interpersonal relationships, characterised by mutuality, gratification and stability and where the patient related to the other person as autonomous rather than as need-gratifying, were positively correlated with outcome after four years, but not after one year of brief focal psychoanalytic therapy. Similarly, Piper et al. (1991) found that those patients with a high level of object relations (i.e. with a history of good relationships) had the best outcome in brief psychoanalytic therapy.

Absence of any so-called "good" objects in the patient's life is not in itself an absolute contraindication. Some patients who do well in psychoanalytic therapy may start off with a very deprived internal world, yet give the therapist the impression they could hold on to a good object. Our experience of the patient in the room is therefore an important additional source of information that complements the relationship history.

• The patient's degree of psychological mindedness is frequently mentioned as an important criterion. There is little research on psychological mindedness as a pre-treatment variable related to eventual outcome. It is one of those concepts we often invoke as if we all know what it means, yet it is perhaps the most overused and least well defined of all. It purports to refer to the patient's capacity to reflect on himself in psychological terms. So, for example, a patient who has suffered a bereavement and insists concretely that his headaches are the problem and cannot entertain the possibility of a link between the experience of loss and his physical symptoms would not be deemed to be psychologically minded.

Psychological mindedness, like the psychiatric notion of ''insight'', is potentially problematic since at times it can synonymous with the patient's capacity to work, and to agree, with the psychological concepts and formulations of a particular therapist. This criterion is also something of a paradox: the patient's so-called psychological mindedness is used to determine suitability but, it could be argued, it is also a legitimate goal of treatment. One of the aims of psychoanalytic therapy is, after all, to build or strengthen self-reflective capacities when they are weak, thereby helping the patient to become psychologically minded.

Just as any of the above criteria for suitability would be an unreliable guide when used in isolation, so are the contraindications for psychoanalytic therapy. All of the above are contraindications when couched negatively (e.g. the patient is not psychologically minded). The presence of psychosis and substance abuse are also often cited as contraindications. However, although psychoanalytic therapy is rarely recommended, for example, in the treatment of psychosis, it may be very helpful for some patients who have had brief psychotic episodes or those who suffer from manic depression. Nevertheless, working psychoanalytically with psychotic patients is a highly specialised application of psychoanalysis that should never be undertaken without adequate consultation and supervision (see Jackson & Williams, 1994).

Suitability criteria (see Table 4.1) are best thought of as pointers we refer to during the assessment process, but in order for them to be helpful they need to be carefully considered in the context of our own experience with the patient in the room.

Table 4.1 Suitability criteria for psychoanalytic psychotherapy

When assessing a patient with a view to psychoanalytic treatment, consider the following:

• whether the patient is interested in and has a capacity for self-reflection, however rudimentary;

• whether the patient has sufficient ego strength to withstand the inherent frustrations of the therapeutic relationship and to undertake self-exploration;

• whether the patient can tolerate psychic pain without acting out (e.g. threats to the self or others);

• whether the risk of acting out, if present, can be managed within the setting the therapy will take place in;

• whether the patient will be adequately supported personally and/or professionally to sustain him during the difficult times in therapy.

If considering a brief psychoanalytic approach, also think about the following:

• whether the patient's difficulties lend themselves to focusing on one theme or core conflict;

• whether during the assessment the patient responds to interpretations concerned with the identified focus;

• whether the patient is motivated to work with the chosen focus.

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