Twenty-Ninth Melitta Sperling Memorial Lecture

Monday, October 27, 2003, 8:30 pm

Einhorn Auditorium, Lenox Hill Hospital, 131 E. 76th Street, NYC

On Analyzability
Samuel Herschkowitz, MD Clinical Associate Professor of Psychiatry, New York University Medical Center Training and Supervising Analyst, NYU Psychoanalytic Institute Chairman, Education Committee, NYU Psychoanalytic Institute

Summary
The delineation of analytic suitability has always remained a vexing problem within analytic literature. Freud himself never dedicated a paper whose aim was to specifically outline the selection criteria of patients for psychoanalysis. Moreover, within the last 20 years few analytic writers have focused their attention on the choice of psychoanalysis compared with the choice of psychotherapy. The selection of patients for analysis has been further complicated by the divergence of theoretical platforms within our field, the concomitant technical divergences and the ensuing controversies as to what constitutes therapeutic action. This paper will focus its attention on the presentation of clinical data and theory concerning the selection of patients for psychoanalysis.

Three "Borderline" patients will be presented. These three patients will represent three categories of patients: those who should be in therapy; those who are suitable for analysis; and those who require psychotherapy before beginning psychoanalysis.
The paper is divided into 4 sections: an introductory overview, a review of the literature, 3 brief illustrative case presentations, a discussion of the cases with an eye towards selection and analyzability and a conclusion which integrates the past literature with the authors own views on analyzability.

It is the author's contention that it is impossible to assess analyzability without understanding the underpinnings of therapeutic action. The selection of patients for analysis requires that both the patient and the analyst participate in a process that requires certain talents and interests within the analyst; certain talents and motivational drives within the patient; and a proper "analytic fit" between patient and analyst. Stone's classic article on the "Widening Scope" heralded these requirements but did little to delineate the selection process. The author contends that central to this issue is the question of the definitions of transference within an analytic process. Recently, these definitions have been debated within the literature.

Therapeutic action within an analytic treatment requires a true understanding of the "as if" relationship. Both the analyst and the patient must have the ability to "play" within the analysis. “Play” in the analytic sense refers to the utilization of transference reactions within the analyst/analysand dyad for curative purposes but at the same time provides a safe interplay for conflicts apart from the outside world. This parallels Emde’s assertion that “need” dyadic relationships are pre-wired into the self, thus making individuals “transference ready.” In a similar vein, the author contends that therapeutic action within a transference relationship requires an ability to “play” which seems to be pre-wired in all mammalians. Several areas touch upon this specific analytic "play" ability. The action of playing within the transference requires the utilization of memory recall, screen memories, reconstruction, and the jockeying between past and present in conjunction with its meaning within the dyadic relationship.

A review of the importance of "play" in its various dimensions both within analysis and outside the field are discussed. Neurobiological, sociological, and evolutionary biological literature are discussed with respect to how "play" is essential for learning, reassessing and practicing in preparation for coping with frightening prospects. In addition, it allows for the containment of ambivalence and ambiguity--an essential ego function necessary for drive modulation. The assessment of this function requires close scrutiny during the consultative period.

The author suggests that the selection of patients who are able to "play" can be more readily seen in patients who have verbal or nonverbal sublimated areas such as a love of music, art or theatre (where the concept of "play" is literally applied). While this particular aspect of a patient hardly constitutes the central criteria for analytic selection, it is illustrative of certain aspects of selection that have been overlooked in the literature. Specifically, it focuses on "mental processing" versus more classical selection criteria such as object relations, tolerance of frustration, and genetic underpinnings. A mental processing assessment, employed in conjunction with classical criteria, enhances our ability to select patients who are more suitable to undergo psychoanalysis.