Failures in Psychoanalytic Treatment (Book Review)
Author: Reppen, Joseph and Schulman, Martin (Editors)
Publisher: International Universities Press, 2003
Reviewed By: Wendy Katz, Fall, 2003, pp. 38-39
Freud himself, as is well known, was ultimately not much of an optimist regarding the therapeutic efficacy of psychoanalysis. In “Analysis Terminable and Interminable” he catalogued the many obstacles to full, lasting psychoanalytic change, and lamented the difficulties of overcoming them. As analytic theorizing has developed, there has been a gradual emergence of theoretical rationales for greater optimism. The fuller development of ego psychology and the advent of object relations theory have resulted in views of the way the mind works that allow for the possibility of achieving more—and more lasting—change.
Alongside these theories have grown clinical theories of technique that aim to explain, and find ways to overcome, the obstacles enumerated by Freud (as well as obstacles that Freud did not foresee). Nevertheless, inevitably there continue to be analyses that fall far short of their goals, disappointing both analyst and patient. While outside of psychoanalysis we may find many willing to talk about the inadequacies of the treatment, in our literature there is an avoidance of this topic that is understandable but counterproductive. Not only is failure a painful topic, but in the context of psychoanalysis, it is a very complicated topic. What constitutes the failure of an analytic treatment? For that matter, what constitutes success? Certainly, we do not take the relief of symptoms in itself as a sign of analytic success. But is the absence of such relief a sign of failure? If only one member of the dyad is satisfied with the outcome, has the treatment failed? What if both are satisfied but third parties continue to find the patient unbearable? What does it mean to be unanalyzable? Any practicing clinician can no doubt think of numerous other questions. Failures in Psychoanalytic Treatment represents an admirable attempt to take an honest look at the problem of analytic failure, and to explore its causes and uses, but ultimately this book falls short of giving the topic proper consideration.
The thirteen contributors to this volume are a richly international sampling, representing a variety of schools of psychoanalytic thought, including Kohutian, Kleinian-Bionian, American ego-psychology and relational thinking. Nevertheless, with a few interesting exceptions, their thoughts on the topic of failures in psychoanalysis converge on a few main ideas. The role of severe character pathology in the patient, and the role of countertransference enactments by the analyst (the former often eliciting, and therefore co-occurring with the latter) are mentioned by most as the factors that lead to an unsatisfactory result. In addition to this tendency to sound a single note, the volume suffers from unevenness in the quality of the contributions and from inadequate editing. In fact, several of the papers read like early drafts, stimulating the question of whether the writing on this topic may suffer from the same causes that give rise to the treatment failures reported in it—that is, the difficulty of thinking clearly around the clinical problem may manifest in a difficulty in writing clearly about it. The editors’ introduction does little to guide the reader to an understanding of overall organization (say, into subtopics), nor is there any attempt at comprehensiveness in addressing the complex issues involved in defining, explaining and addressing failure in psychoanalysis. That said, there are several very good essays here, and even some of the weaker ones raise interesting points.
While almost all of the authors acknowledge the central difficulty of defining failure in the immensely complicated context of psychoanalysis, only a few take up this problem seriously. Among these, Marvin Hyman’s opening essay—presumably intended to be provocative—takes a turn toward the absurd, calling failure in analysis an “oxymoron.” If analyzing takes place, Hyman asserts, the analysis has not failed. No particular therapeutic outcome is required. This perverse literalism leaves unaddressed the question of why anyone would make the required substantial investment in such a process. Hyman defines analysis as a process of insight-collection, and argues that to make a recommendation of analysis is simply to communicate a “value judgment that it is advantageous to know one’s hidden motives so that one is not taken unawares when these motives make their appearance…” (p. 14).
Beyond this goal of avoiding surprises, he seems not to recognize any other possible advantages to such insight, nor does he consider other possible products or by-products of the analytic process. Hyman proceeds to set up an oddly idealized straw man in medicine, which he paints as a field in which a “linear” schema “characterizes the relationships between diagnosis and treatment, treatment and cure…and cause and effect,” and argues that it is only a misguided identification with the medical model that leads analysts to attempt to cure at all. Recognition that analysis is “non-medical,” he argues, entails liberation from the expectation of cure, and therefore from the possibility of failure to cure. Unfortunately, as most practicing clinicians do not share Hyman’s definition of analysis, they may be less than reassured by this exemption from responsibility to help the patient.
In contrast, Alan Skolnikoff’s thoughtful piece, centering on two of his own cases, acknowledges that the definition of failure in analysis is tricky, but does not attempt to sidestep the difficulty. Indeed, he focuses on the fact that “different clinical theoretical frameworks offer different perceptions of outcome.” He presents a variety of hypotheses about his two cases, demonstrating how by using different theories one could see the cases as either successes or failures, and even within these categories one could explain the results in a variety of ways. He points out that the evaluation of outcome depends on when and by whom the evaluation takes place, and observes that subjective assessments by analyst or patient can be distorted in either direction.
Robert Wallerstein’s reflective essay, also focusing on several of his own early cases, also recognizes the complexity of the issue, by pointing out the historically shifting nature of the scope of analysis and the criteria for recommending analysis rather than psychotherapy. Many outcomes that were seen as failures in analysis might have been considered successes in more supportive forms of psychoanalytic psychotherapy, he suggests, partly because expectations are lower and partly because the patients’ severe pathology makes the analytic process impossible or intolerable.
Indeed, the attempted analysis of patients with severe psychopathology is the most frequently represented category of failure in this book. Many of the contributors present extensive descriptions of failed cases in which the patient’s inability to work within the analytic frame is offered as the primary cause of failure. Stuart Twemlow, Judith Vida, and Cecilio Paniagua describe cases of severe character pathology, and the difficult countertransference experiences that accompany them. Impasses, interminable treatments, and premature terminations result. The authors console themselves and the reader with the thought that failures are also opportunities for learning. Certainly this is true, but what was learned is not always clear, and one cannot help wondering whether another opportunity—perhaps supervision and consultation with colleagues—was overlooked. The initial presentations of many of these patients make even the attempt at formal analysis seem a surprising choice, one that these authors do not explicitly justify by reference to clinical theory.
Johanna Kraut Tabin’s essay sheds a new light on the issue of failure, by arguing that a single failed analysis may be a step in a successful series of analyses, particularly with certain borderline patients. She observes that while any one of these treatments might be considered a failure, eventually such patients, by “taking attachment and separation into their own hands,” are able to build on the earlier treatments, each analysis constituting a separate developmental step.
Augusto Escribens writes about a specific aspect of transference and countertransference in his essay on “fantasies of cure.” He argues that there is an optimal balance of convergence and divergence in the unconscious fantasies of the two analytic partners about the way that cure will occur. Too much similarity leads to blind spots that can impede the treatment, while too much difference can destroy the potential for necessary identifications.
The volume contains a few essays that do not seem to fit in, although they are interesting in themselves. Ann-Louise Silver’s poignant account of the decline of Chestnut Lodge, once a unique holding environment for severely disturbed patients and their therapists, cannot really be said to be about failure in psychoanalysis. It is more about a failure of psychoanalytic ideals to withstand the ascendance of other treatment ideals, in a particular historical/political moment.
In sum, this volume would have benefited from a stronger editorial presence. An introductory essay providing a firm historical and theoretical framework, and a concluding essay tying the contributions together, would have made this a more valuable volume for psychoanalytic teaching. It is unfortunate that such an important topic was given such a cursory treatment, but perhaps the book will stimulate other thinkers to contribute to the much-needed exploration of the very complex problem of psychoanalytic failures.
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