Psychoanalytic Treatment in Adults The outcomes of psychoanalysis, as with other psychotherapies, vary consid- erably. Psychoanalytic Treatment in Adults examines the results of a longitudi- nal study of change during psychoanalysis, illuminating the characteristics of patients, analysts, and analyses which can help to predict outcomes of treatment. Written by two experienced psychologist psychoanalysts, chapters in the book describe longitudinal changes in sixty completed analyses to consider what patients with very different analytic outcomes were like at the beginning and end of psychoanalyses. Psychoanalysts used a clinician report measure, the Shedler-Westen Assessment Procedure, to describe a patient at the beginning of psychoanalysis and every six months until the analysis ended. This allowed the authors to learn about the prediction of analytic outcomes. An applied mathematician then considered the relationship between changes in insight and changes in other characteristics of patients ending analysis with maximum benefits. Chapters explore five outcomes: a negative therapeutic reaction; attrition when the patient drops out; attrition due to external events; mutual agreement between patient and analyst without maximum benefits; and mutual agreement between patient and analyst with maximum benefits. The findings from these chapters will be of interest to researchers and aca- demics in the fields of psychoanalysis, psychotherapy, psychodynamic therapy, psychoanalytic education, psychiatry, and psychology. The results should also help clinicians recognize potential problems early in analytic treatments so that they can work more effectively with patients. Rosemary Cogan is Professor of Psychology in the Department of Psycho- logical Sciences, Texas Tech University, USA. John H. Porcerelli is Director of Behavioral Medicine and Professor in the Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, USA. Psychoanalytic Explorations series Books in this series: The Heart of Man’s Destiny Lacanian psychoanalysis and early Reformation thought Herman Westerink Wish-fulfilment in Philosophy and Psychoanalysis The tyranny of desire Tamas Pataki Environmental Melancholia Psychoanalytic dimensions of engagement Renee Lertzman Psychoanalytic Treatment in Adults A longitudinal study of change Rosemary Cogan and John H. Porcerelli Psychoanalytic Treatment in Adults A longitudinal study of change Rosemary Cogan and John H. Porcerelli First published 2016 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2016 Rosemary Cogan and John H. Porcerelli The right of Rosemary Cogan and John H. Porcerelli to be identified as authors of this work has been asserted by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Cogan, Rosemary, author. Psychoanalytic treatment in adults : a longitudinal study of change / Rosemary Cogan and John H. Porcerelli. p. ; cm. — (Psychoanalytic explorations) Includes bibliographical references and index. I. Porcerelli, John H., 1957- , author. II. Title. III. Series: Psychoanalytic explorations series. [DNLM: 1. Mental Disorders—therapy—Case Reports. 2. Psychoanalytic Therapy—Case Reports. 3. Longitudinal Studies— Case Reports. 4. Treatment Outcome—Case Reports. WM 460.6] RC480.5 616.89′1—dc23 2015033271 ISBN: 978-1-138-90258-9 (hbk) ISBN: 978-1-315-69736-9 (ebk) Typeset in Bembo by Swales & Willis Ltd, Exeter, Devon, UK Contents Preface vii Introduction viii PART I Beginnings 1 1 Therapeutic aims of psychoanalysis 3 2 Research on psychoanalytic outcomes 12 3 This project 29 PART II Comparing outcome groups 45 4 Negative therapeutic reaction vs. others 47 5 Attrition: Dropping out vs. others 61 6 Attrition: External events vs. others 75 7 Attrition: Dropping out vs. external events 84 8 Analyses ending with mutual agreement between patient and analyst: Without maximum benefits vs. others 93 9 Analyses ending with mutual agreement between patient and analyst: With maximum benefits vs. others 104 10 Analyses ending with mutual agreement between patient and analyst: With vs. without maximum benefits 116 vi Contents PART III Insight and change 125 11 The role of insight in change with N. G. Cogan 127 PART IV Conclusions 141 12 What we have learned with N. G. Cogan 143 Index 153 Preface We met some years ago when we were each in a training year at Detroit Psy- chiatric Institute Hospital. We both cherished clinical work, psychoanalytic theory, and research. Rosemary returned to the faculty in the Department of Psychological Sciences at Texas Tech University and was in clinical practice for many years. John went to the Department of Family Medicine at Wayne State University School of Medicine and is also in clinical practice. Our collabora- tion and friendship continued at a distance as we both completed psychoana- lytic training at the Dallas and Michigan Psychoanalytic Institutes respectively. We are deeply grateful for the patient, careful work of the participating analysts that made this longitudinal study possible. We are grateful as well to the International Psychoanalytical Association, which provided important funding for this project as it began. We thank Drew Westen and Jonathan Shedler for sharing their measure, the Shedler–Westen Assessment Procedure, and for discussions with us about the measure and this project. We thank Brian Quinn and others on the faculty and staff of the Texas Tech University Library for their outstanding help throughout this work. We thank Kathy Gillis, our superb writing consultant at Texas Tech University; we have watched our writing improve because of her help. We thank our families and friends who encouraged this work. Finally, we thank analysts past, present, and future. Introduction Three longstanding questions have led to this work. First, what characteristics of patients at the beginning of analysis predict different outcomes of analysis? To answer this question required a longitudinal study. Second, what character- izes patients at the end of analyses that have ended with different outcomes in the view of analysts? What, for instance, differentiates between patients who end analysis with maximum benefits in contrast to patients who end analysis with good outcomes but without maximum benefits? These questions have really not been answered in the wealth of psychoanalytic clinical and research literature. Finally, we wanted to know more about how change occurs in analysis. The development of the Shedler–Westen Assessment Procedure (SWAP: Shedler, 2015; Westen & Shedler, 1999a, 1999b) made this longitudinal study possible. The SWAP, a clinician report measure, includes 200 items that might describe a person. The items were developed over some years and are worded in theory-neutral language that can be agreed on by all sorts of clinicians with widely varying perspectives. The clinician sorts the items into eight categories ranging from those that describe the patient very well to those that are irrelevant, do not apply to the patient, or about which nothing is known by the clinician, with a fixed number of items required in each category. From this, individual items or groups of items can be used to describe an individual patient or group of patients; scales of personality disorders, traits, and adaptive functioning can also be used to describe patients. The SWAP was grounded in extensive research and further empirical support for the measure developed rapidly after the measure became available. We tested the measure ourselves in several preliminary studies (Cogan, 2007; Cogan & Porcerelli, 2005; Porcerelli, Cogan, & Hibbard, 2004). Satisfied with the results, we set to work on the longitudinal study of change during psychoanalysis that is the subject of this book. A SWAP Insight scale was later developed by Lehmann and Hilsenroth (2011) and we have included this with the original SWAP scales. As we begin, in Chapter 1 we consider the beginnings of psychoanalysis itself. The first of the “talking therapies” began when Joseph Breuer, a prominent Viennese physician, met once and then twice a day with his patient Anna O. Psychoanalysis developed as Breuer and Freud met and contemplated this Introduction ix interesting and complicated case. Questions about understanding the outcome of a case began even in this first case. We then consider the literature on the goals of psychoanalysis and the goals of psychotherapy. In Chapter 2, we organize a review of the empirical literature on the outcomes of psychoanalysis, which began with Coriat’s work in 1917. For our review, we use the template developed by Wallerstein (1995).This template includes first-generation studies which are retrospective and have the analyst as the assessor, second-generation studies which are studies with independent judges of outcome, and third-generation studies which are prospective and include contemporary international studies. In Chapter 3, we describe the background of our longitudinal project. We describe the development of the SWAP-200 (Westen & Shedler, 1999a, 1999b), which provides a clinically grounded, reliable and valid clinician report measure of pathological and healthy dimensions of personality. The SWAP-200 provides a measure that has been used in idiographic and nomothetic studies, as well as in longitudinal case studies of psychoanalytic outcome. We describe how we recruited analysts for this longitudinal study. We describe the analyses at the beginning, including descriptions of the analysts, the analysands, and the analyses. There are some unique features to our descriptions, interesting in their own right. Just as at the beginning of any talking therapy, the picture at the beginning is only a background for what will develop. A primary purpose of this longitudinal study was to identify characteristics at the beginning of analysis that predict the eventual outcome of analysis. This long-term prediction will help analysts maximize patients’ gains from analysis. After describing characteristics of the patient, analyst, and analysis every 6 months from the beginning to the end of analysis, as each analysis ended, the analyst identified the analysis as having ended in one of five different ways. A few analyses ended with a negative therapeutic reaction, with a serious worsening of the patient’s problems. More than a few analyses ended with attrition, either when the patient dropped out of analysis or when the analysis was interrupted because of external events. Analyses also ended with the mutual agreement between analyst and patient either with or without maximum benefits. We describe what patients were like at the end of analyses with the different outcomes. In Chapter 5, we consider analyses ending with a negative therapeutic reaction. We compare these analyses with all of the other analyses in the project at the beginning and end of analysis. We then consider analyses ending with attrition. We compare analyses ending when the patient dropped out with all of the other analyses. In Chapter 6, we compare analyses ending because of external events with all of the other analyses. We continue in Chapter 7 by directly comparing analyses in the two attrition groups to understand more about similarities and differences between analyses in which the patient drops out and analyses which end because of external events. Our goals in the three chapters on attrition have to do with being able to predict dropping out and