Indications and Contraindications for Psychoanalysis for an Adult
INDICATIONS AND CONTRAINDICATIONS FOR PSYCHOANALYSIS FOR AN ADULT
Borrowed from traditional medicine, the notions of indications and contraindications have been very much present in the writings of Freud and his medical following from the very beginnings of psychoanalysis. Moreover, the indications and contraindications for psychoanalysis have changed in the course of theoretical and practical developments that have profoundly altered attitudes toward psychoanalytic treatment.
In Studies on Hysteria (1895d), Sigmund Freud and Josef Breuer listed certain conditions for applying the cathartic method: "The procedure is not applicable at all below a certain level of intelligence. . . . The complete consent and complete attention of the patients are needed, but above all their confidence (1895d, p. 264). In "Freud's Psycho-Analytic Procedure" (1904a ), Freud specified further indications and contraindications: "Chronic cases of psycho-neuroses without any very violent or dangerous symptoms are the most favourable ones for psycho-analysis: thus in the first place every species of obsessional neurosis, obsessive thinking and acting, and cases of hysteria in which phobias and abulias play the most important part; further, all somatic expressions of hysteria whenever they do not, as in anorexia, require the physician to attend promptly to the speedy removal of the symptoms. . . . The patient must be capable of a psychically normal condition; during periods of confusion or melancholic depression nothing can be accomplished even in cases of hysteria. . . . Deep-rooted malformations of character, traits of an actually degenerate constitution, show themselves during treatment as sources of a resistance that can scarcely be overcome. . . . If the patient's age is in the neighbourhood of the fifties the conditions for psycho-analysis become unfavourable" (pp. 253-254).
Gradually, with the work of Karl Abraham, Ernst Simmel, and Wilhelm Reich, the range of cases regarded as appropriate for treatment expanded to include psychoses and borderline conditions, even perversions and drug addiction—with uneven results. As time went on, efforts were made to separate the issue of indications from medical categories and traditional diagnostic procedures, in order to create a suitable framework for understanding the metapsychological factors underlying the demand for treatment and a suitable framework allowing prediction of its results. Otto Fenichel (1945) included in his contraindications, in addition to advanced age and unfavorable life conditions, the "absence of a reasonable and cooperative ego" and the existence of significant secondary gains derived from symptoms.
In 1955 Edward Glover, discussing the "transference potential of the patient," distinguished "accessible" cases (psychoneuroses, reactive depressions, psycho-sexual inhibitions, optional bisexuality) and "moderately accessible" cases (obsessional neurosis, fetishism, alcoholism and drug addiction, chronic maladaptation, psychopathic delinquency) from "rebel cases" (psychoses, grave character disorders, and sexual disorders). The list presented by Sacha Nacht and Serge Lebovici in 1958 was fairly close to this one.
The issue of indications and contraindications has acquired another dimension with the notion of "analyzability," especially after the Twenty-Fifth International Congress of Psychoanalysis (Copenhagen, July 1967) and René Diatkine's 1968 article. Diatkine proposed evaluating the patient on first encounters to prognosticate the evolution of future treatment: evaluation of imaginative capacities, flexibility in object relations, screening for an "operational idea," and so on. Subsequently, McDougall (1972) used the notion of the "anti-analysand" to characterize a patient who dissembles normalcy, sometimes as a cover for serious relational problems—a trait that poses a risk of making analysis impossible.
As a result of a growing interest in the role of the psychoanalyst's counter-transference, whether psychoanalysis is indicated has come to mean considering the analyst's particular capacities for empathy and tolerance for various kinds of pathologies in a candidate patient. In 1945 Otto Fenichel noted that analysis could be counterindicated with a given analyst for reasons other than the analyst's sex or prior relationship with the candidate analysand. Robert Barande has also discussed "analyst indication."
The expansion of the range of indications and the multiplication of approaches in psychoanalytic and related forms of psychotherapy has modified, sometimes in the direction of excessive laxity, decisions about whether analysis is appropriate. This proliferation has even been seen as a reason for the disappointment of those who expect miracles from a psychoanalytic approach to difficult cases.
Finally, it is appropriate to recall what Freud wrote to Ludwig Binswanger on May 28, 1911: "Truthfully, there is nothing that man's organization makes him less apt for than psychoanalysis" (2003).
Alain de Mijolla
See also: Analyzability; Congrès des psychanalystes de langue française des pays romans.
Diatkine, René. (1969). L'enfant prépsychotique. Psychiatrie de l 'enfant, 12, 2, 413-446.
Fenichel, Otto. (1945). The psychoanalytic theory of neurosis. New York: W. W. Norton.
Freud, Sigmund. (1904a ). Freud's psycho-analytic procedure. SE, 7: 247-254.
Freud, Sigmund, and Breuer, Josef. (1895d). Studies on hysteria. SE, 2: 48-106.
Glover, Edward. (1955). The technique of psychoanalysis. London: Tindall and Cox.
McDougall, Joyce. (1972). L'anti-analysant en analyse. Revue Française de Psychanalyse, 36, 167-206.
——. (1992). Plea for a measure of abnormality. New York: Brunner/Mazel. (Original work published 1978)
Nacht, Sacha, and Lebovici, Serge. (1958). Indications et contre-indications de la psychanalyse chez l'adulte. In Sacha Nacht (Ed.), Psychanalyse d'aujourd'hui. Paris: Presses Universitaires de France.
Grand, Stanley. (1995). Classic revisited: Stone's "The widening scope of indications for psychoanalysis". Journal of the American Psychoanalytic Association, 43, 741-764.
McNutt, Edith R. rep. (1992). Panel: Psychoanalysis and psychotherapy: indications, contraindications. Journal of the American Psychoanalytic Association, 40, 223-232.
Stone, Leo. (1954). The widening scope of indications for psychoanalysis. Journal of the American Psychoanalytic Association, 2, 567-594.