The PANY Bulletin

Psychoanalytic Association of New York
Volume 42, #2 Summer 2004

Conversion from Psychotherapy to Psychoanalysis:
A Comparison of Two Cases
April 19th, 2004
Chair: Malini Singh, MD
Moderator: Samuel Herschkowitz, MD
Presenters: Stephanie Newman, PhD.,
Pauline McHugh, MD
Supervisors: Shelley Orgel, MD,
Melvin Stanger, MD
Reporter: Hilary Rubenstein, Ph.D.

Dr. Singh introduced the annual PANY meeting devoted to a topic chosen by candidates. The goal of the panel presentation was to examine the factors that might determine whether converting a patient's treatment from psychotherapy to psychoanalysis will lead to the development of an analytic process. Two senior candidates were asked to present clinical data from psychotherapy cases, both converted to analytic cases, one leading to a successful analytic process, the other leading to an abruptly terminated analysis. The topic was chosen because of the large number of psychoanalytic training cases drawn from candidates' psychotherapy practices. A future panel was recommended to address the topic of working with psychotherapy patients' resistance when the clinician believes analysis to be the treatment of choice. Both patients discussed in this panel converted readily from psychotherapy to psychoanalysis.

Dr. Samuel Herschkowitz made some introductory remarks about the history of conversion to psychoanalysis and current controversies surrounding the topic. Prior to the 1970's, it was common practice to refer psychotherapy patients to another analyst when analysis was determined as the treatment of choice. Many senior faculty members concurred later during the open discussion that they were trained under this model. The consensus of many analysts at the time was that the prior psychotherapy relationship would contaminate the patient's transference and have a detrimental impact on the analysis. After the 1970's, conversion of psychotherapy patients to psychoanalytic patients with the same analyst became common practice; however, many analysts continued to have reservations about the negative impact on the analytic process. Dr. Herschkowitz suggested that the paucity of patients presenting to clinicians for analysis and the economic incentive to analysts to convert psychotherapy patients may have driven the change. Dr. Herschkowitz outlined two areas of controversy in the field that related to the current panel.

1. Do psychotherapy and psychoanalysis exist on a continuum or are they significantly distinct enough that they should be considered separate processes?

2. Are there observable criteria that can be predictive of a reasonable psychoanalytic process emerging from a psychotherapy process or is a trial of analysis the only way to determine whether an analytic process will develop?

Dr. Herschkowitz articulated his position that the quantitave focus on transference distinguished psychotherapy from psychoanalysis and that there are "certain ego, superego and id observable criteria that can be predictive" of the development of a reasonable psychoanalytic process (Herschkowitz, in press). He suggested that the transition to psychoanalysis and the analyst's suggestion of analysis would lead to fantasies on the part of patient and analyst which would need to be understood in the course of the analysis.

As the candidates, Dr. Stephanie Newman and Dr. Pauline McHugh, addressed Dr. Herschkowitz's questions in their presentations, both stressed the pressure candidates experience in finding psychoanalytic cases. Both had reservations about their psychotherapy patient's ability to work analytically and both experienced hesitation from supervisors and faculty as their cases were reviewed prior to beginning analysis with the patient. Both patients had symptomatic behaviors that were of concern such as violence, eating disorders and substance abuse. Both candidates felt optimistic about analytic work with the patient, but also felt the decision to suggest analysis was influenced by the candidate's need to meet the requirements of candidacy.

To protect the patients' confidentiality, limited clinical data will be included in this report. Dr. Newman, whose patient terminated abruptly, spoke of the following "catch-22" dilemma. When a patient has profound difficulty trusting others and entering deep relationships, analysis may be the best kind of treatment for the very narcissistic issues that make being in analysis intolerable for the patient. Dr. McHugh suggested that several factors may have predicted the positive outcome in her case. In spite of the patient's severe history of trauma and behavioral symptoms, the patient had managed to maintain significant deep relationships in her life prior to analysis and had a healthy sense of humor. While both candidates felt the psychotherapy process with their patient had been successful, Dr. Newman suggested that her patient had an unarticulated reaction to Dr. Newman's pregnancy during the psychotherapy. Dr. Newman felt that her repeated attempts to bring the response to the pregnancy to the patient's attention did not lead to meaningful analytic exploration.
The candidates' supervisors added some additional comments to the discussion.

Dr. Shelley Orgel, who supervised Dr. Newman's work with this patient, commented on the important role shame played in this patient's relationships. The patient felt shame about her past and about her internal experience. Dr. Orgel suggested that the analyst may have experienced shame that paralleled that of the patient. She may have internalized the patient's projection of her social shame and become embarrassed that she felt stuck having to treat an unpromising, unrewarding patient partly because she needed to meet clinical requirements in her candidacy. And further, she might be exposed as a "failed" analyst to her colleagues. Dr. Orgel suggested that this patient needed to engender such a countertransference response. He also suggested that certain issues may have been stirred up for both patient and analyst by the latter's pregnancy and childbirth. The analyst and the patient may have experienced the patient as an older rivalrous sibling to the newborn. The analyst would then struggle between feeling guilty about depriving the patient of her full attention and "maternal" care while also feeling guilt about expending so much of her limited energy on a difficult patient who was taking away from the pleasure of being with her baby.

Dr. Orgel commended Dr. Newman for her courage and dedication to learning in agreeing to discuss this case before an audience.
Dr. Melvin Stanger, who supervised Dr. McHugh began his comments by saying "we need to admit that we analysts are not very good at predicting the future" even when we already know the patient well through a psychotherapy. He spoke of the complexity of the patient, the multiple variables involved in the creation of a successful analytic process and the likelihood that predictions about analyzability are countertransferentially motivated. In Dr. McHugh's case, he believed that the patient's availability to experience and explore the transference made her able to use the psychoanalytic method. Although the patient seemed to have little in the way of good early objects, Dr. Stanger noted that some patients seem able to put together fragments of many experiences into good objects, often persons outside of their home and sometimes even imagined others. The issue of patient-analyst match was also seen as contributing to the success of the treatment.

With the end of the formal presentation, the floor was opened for audience remarks.

Dr. Anne Erreich commented that the conversion had a particular meaning in the context of candidacy where candidates are often treating low fee patients and are desperate for cases. Dr. Erreich suggested that patients' issues of entitlement may be much easier to analyze when the analyst is receiving a regular fee.

Dr. Robert Fischel spoke about the term "conversion" as a problematic term both in its implied religious connotation and its suggestion of a radical change. He expressed his concern that analysts may feel pressured to relate to the patient differently once the conversion to analysis takes place and this could negatively impact the process.
Dr. Rajiv Gulati wondered about the impact of the analyst liking the patient and whether that predicted the success of the treatment.
Dr. Ann Appelbaum cited research by Kernberg et. al. This research, meant to study patient analyst attachment, looked at two analytic cases over the course of a year and determined that the case where the analyst genuinely liked the patient was significantly more successful. This study suggested that it was not the severity of enactment or level of pathology in the cases, but the degree of positive attachment between patient and analyst which made the treatment work.

Dr. William Jeffrey talked more about the history of conversion and analysts' fears that the transference would not develop because of the history of prior psychotherapy with the same analyst.
Dr. Orgel noted that in Dr. Newman's case, the patient experienced the analyst's attempts to make meaning out of the patient's behavior as a criticism, while in Dr. McHugh's case, the patient welcomed and reciprocated in the analyst's attempts to explore conflicts outside her awareness. The candidates agreed.

Dr. Michael Singer suggested that terms like conversion and parameters should be avoided because they lead to a detrimental focus on purity of the analytic process. Dr. Singer suggested that this purity should not be upheld as an ideal. He suggested that psychotherapy and psychoanalysis may not be so different and proposed that analysts consider that therapeutic interventions may in fact enhance the analytic process at times.

Dr. Herschkowitz responded that since a the 1954 panel on conversion, analysts have argued that some three time weekly sitting up patients are engaged in an analytic process and some five times weekly patients who were lying down were not engaged in an analytic process.

Dr. Harvey Bezahler suggested that the pressure to convert patients to analysis and the difficulty of doing so was not simply a candidate issue but an issue of anyone in practice today who wanted to practice analysis.

Dr. Milagros Picon felt the issue of when and how to make a recommendation should be discussed further and that issues of the fee, particularly the issue of patients wanting more for less must be addressed.

Hilary Rubenstein, Ph.D. is a clinical psychologist in private practice in New York City and a candidate in the psychoanalytic training program at NYU Psychoanalytic Institute. Papers from her study, "Therapist's Experiences of Patient Suicide" have been presented at the American Psychoanalytic Association Meeting in 2002 and at the American Academy of Psychoanalysis and Division 39 of the American Psychological Association in 2003. Dr. Rubenstein was a 2001-2002 Fellow of the American Psychoanalytic Association. She is a graduate of the Clinical Psychology Program at City College in New York City.