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Association Journal of the Psychoanalytic American, 2007; 55; 629. Published by:
Sage Publications, On behalf of: American Psychoanalytic Association

SELF-ANALYSIS AND POSTTERMINATION

IMPROVEMENT
AFTER PSYCHOANALYSIS AND
LONG-TERM PSYCHOTHERAPY
Fredrik Falkenström / Johan Grant /
Jeanette Broberg / Rolf Sandell

ABSTRACT
Long-term follow-up studies of long-term psychoanalytically oriented
5 psychotherapy or psychoanalysis are extremely rare, and few have
focused on the post-treatment process itself. In the Stockholm Outcome
of Psychoanalysis and Psychotherapy project, one of the results was that
patients in psychoanalysis continued to improve after termination to a
higher degree than patients in long-term psychotherapy. In this study
10 20 patients selected from the project were interviewed on two occasions,
one and two years after termination, in order to explore how they
described their post-treatment processes. The interviews were studied
qualitatively using a multiple case study design, and categories of different
types of post-treatment development were created from these case
15 studies. Results indicate that the variation within treatment groups
is large, and that development may continue in several ways after termination.
The most striking difference between psychoanalysis and
psychotherapy was not, as hypothesized, in the self-analytic function, but
in various self-supporting strategies described by former analysands
20 but not by former psychotherapy patients. However, only self-analysis
was significantly correlated with post-termination improvement across
both treatments. Three patients improving after termination and three
deteriorating are described in detail as illustrations. Some methodological
constraints of the design limit the generalizeability of results.
25
INTRODUCTION

S tudies of long-term therapies based on psychoanalytic theories are rare. In a review by Grawe, Donati,
and Bernauer (1994) of international outcome research, not more than 9 percent of the studies reviewed were
concerned with allegedly psychoanalytically oriented therapies (calculations made by Sandell et al. 2000).
30 There was in fact only a single study listed that was concerned with individual, psychoanalytically oriented
therapy of a duration of over two years and a follow-up period at least equally long, and that was the
Menninger Project (Wallerstein 1986). An obvious reason for this state of affairs is that research on
psychoanalysis and long-term psychoanalytically oriented psychotherapy is extremely difficult to carry out
according to the methodological principles of efficacy research, which have been established mainly by
35 students of short-term behavioral treatments; these methods specify the use of control groups,
randomization, and treatments standardized according to treatment manuals. Hence, there is still not a single
study of long-term psychoanalytic therapy satisfying these standards. When it comes to more naturalistic
studies, a few studies of psychoanalysis and long-term psychoanalytically oriented psychotherapy have been
reported in recent years (for reviews, see Fonagy et al. 2002; Crits-Cristoph and Barber 2000). One of these
40 is the Stockholm Outcome of Psychoanalysis and Psychotherapy project (STOPP; Blomberg, Lazar, and
Sandell 2001; Sandell et al. 2000). The quantitative measures used in this study showed that patients in both
psychotherapy and psychoanalysis improved in statistically as well as clinically significant ways on all
measures used, although the measure that showed the most distinct and unambiguous change was the
symptom distress measure. At termination there was no difference in outcome between psychoanalysis and
45 psychotherapy. During the follow-up period patients from both groups continued to improve, but there was a

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tendency that reached statistical significance in the third year after termination for the psychoanalysis
patients to improve more than the psychotherapy patients.
(…)
Intrigued by this finding, we wanted to elucidate what it is that some patients do that makes the therapeutic
50 process continue after they have stopped seeing their therapist or analyst. The most obvious hypothesis
seemed to be that patients in psychoanalysis develop a self-analytic function to a greater degree than
psychotherapy patients, so that they can continue to work therapeutically on their own after termination.
Starting with Freud (1937), many analysts have suggested that the ideal outcome of an analytic process is
that the patient acquires an ability to continue analysis on his or her own after termination. The self-analytic
55 function is usually seen as a product of identification with the analyst’s analyzing function (Hoffer 1950).
This identification is sometimes interpreted as the result of a mourning process during and after termination
(Kramer 1959; Schlessinger and Robbins 1974; Ticho 1967). Another view is that the presence of a self-
analytic function is a criterion for termination (Hoffer 1950; Meltzer 1967).

60 Analytic scholars vary widely in their views on the motivation, feasibility, and even desirability of self-
analysis. Perhaps the most comprehensive discussion of self-analysis, complete with clinical examples and
practical suggestions, was written by Karen Horney in the early 1940s. While not minimizing the difficulties
involved, Horney (1942) was quite optimistic about the feasibility of self-analysis, and she wholeheartedly
endorsed its desirability. For Horney, the motivation for self-analysis was simply to diminish neurotic
65 suffering and to gain an increased sense of mastery through insight. A similar view was endorsed by Ticho
(1967), who described self-analysis from an ego psychological perspective as an adaptive response to almost
any kind of conflict between psychic structures. In Meltzer’s Kleinian view (1967), however, self-analysis is
seen as a form of reparation, in that the patient is taking over the job of the analyst in order to spare him or
her the hard work of analyzing and also leaving room for other patients to benefit from the analyst’s work.
70 Finally, Kohut (1984)—taking a more pessimistic stance—regarded the presence of a self-analytic function
as a sign that treatment is incomplete: a “cured” patient would have no need of self-analysis.

Previous empirical research on continuing development and selfanalysis following psychoanalysis or long-
term psychotherapy is sparse. The German Psychoanalytical Association study claims that former
75 analysands had acquired a capacity for selfanalysis, and that this distinguished them from former
psychotherapy patients (Leuzinger-Bohleber et al. 2003). Unfortunately, the authors do not provide specific
data to support this claim. In the STOPP project the methodology so far has been mainly quantitative. Even
though in the last decade qualitative research has been gradually accepted within the psychotherapy research
community, this movement toward methodological pluralism does not seem to have extended to outcome
80 research. Obviously, questionnaires and selfratings have significant limitations (McLeod 2000), the principal
one being that they provide no data beyond those asked for by the researcher. This means that important but
unforeseen aspects of outcome might not be captured by the findings of current research. In the IPA review
of outcome studies in psychoanalysis (Fonagy et al. 2002), only one study seems to have used qualitative
methodology as its main approach (Leuzinger-Bohleber et al. 2003). Besides, though valuable in their own
85 right, qualitative methods are often extremely useful for throwing light on findings from quantitative studies
(Frommer, Langenbach, and Streeck 2004).

In the present study, qualitative and quantitative methods are combined in order to illuminate previous
findings from the STOPP project. A subsample of patients, besides informing the project through
90 questionnaires, was also interviewed individually following a semistructured format. The interviews were
conducted on two occasions at a year’s interval. As the interviews aimed to explore how former
psychotherapy and psychoanalysis patients describe their treatments and the process after termination, the
subsample was selected among patients having already terminated their treatments. The main objective of
this study is to gain increased understanding of how patients continue to work on their problems after their
95 treatments are formally finished. This puts the study mainly in the exploratory, or hypothesis generating,
research area.

100

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105 DISCUSSION
The results of this study show that most patients in our sample, whether in psychoanalysis or in long-term
psychotherapy, experienced the therapeutic process as continuing after termination. Patients varied widely,
however, in how elaborated their spontaneous descriptions of this continuing process were. Some described
110 the post-treatment process vividly and in detail; others just stated that something continues without
specifying what continues and how. Patients described several processes that promote development after
termination, of which the prospectively hypothesized self-analytic function was one. However, the self-
analytic function was not exclusive to the psychoanalysis cases or even present to any greater degree in
psychoanalysis than in psychoanalytic psychotherapy.
115
Our initial question about the post-treatment differentiation between the psychoanalytic and the
psychotherapy cases found a partly unexpected answer. In line with theoretical expectations, we did find a
quite strong association between the self-analytic function and continuing improvement after termination.
This did not constitute any clear difference between cases in psychoanalysis and psychotherapy, however.
120 Instead, the most obvious difference between the two groups of cases was the use of self-supporting
strategies among the analysands. This was, however, unrelated to post-treatment improvement. So, although
analysands described more active self-supportive strategies than did former psychotherapy patients, it seems
more likely that it is self-analysis rather than self-support that causes post-termination improvement, given
the present results. Although in line with findings from two previous studies (Kantrowitz, Katz, and Paolitto
125 1990; Leuzinger-Bohleber et al. 2003), this should be regarded as a mere hypothesis for further study, as we
cannot draw firm conclusions about causality or generality from this study.

If, nevertheless, we take the findings at face value for a moment, it appears that a specific long-term effect of
psychoanalysis might be the use of active strategies for self-support or self-calming. Most patients after
130 psychoanalysis spontaneously described some such strategies, while none of the former psychotherapy
patients did so. This is surprising, given that the analytic stance traditionally emphasizes resolution of
neurotic conflicts through insight rather than learning strategies to cope with them. Psychotherapy, by
contrast, is considered more problem-focused and might thus be expected to result in finding new ways of
coping with problematic situations. One possible explanation of this finding is that psychoanalysis breeds
135 autonomy, so that the analysand is trained to find ways of working out solutions to problematic experiences
on his or her own. In psychotherapy the therapist may be more prone to support the patient with suggestions,
which might not develop the patient’s own problem-solving capacity as much.
(…)

140 To return for a moment to the issue of self-analysis, psychoanalytic scholars would surely disagree on its
definition. Some might argue that self-analysis is a purely unconscious process, and that our method
therefore is unable to pick up the phenomenon we are interested in studying. We would argue that even
though the identification underlying the self-analytic function is unconscious, it is unlikely that any
significant self-analytic activity would go on without ever reaching consciousness. However, regardless of
145 which definition is the “correct” one, it seems that the phenomenon we identify as “self-analysis” in this
context is related to post-termination improvement. This, we believe, is important in itself. Still, there are
some methodological constraints of the present study that limit the extent to which our results can be
generalized:
-The first limitation concerns the reliability of the qualitative analysis.
150 -The second limitation concerns the representativity of the sample studied.
-Another methodological constraint has to do with the interpretation of causality.
(…)
However, the association between the self-analytic function and continued improvement after termination
is—if it turns out to be a valid finding—an important result in itself, regardless of when and how it came
155 about. Also, the intriguing finding of a specific difference in the descriptions of self-supporting strategies
given by former analysands and those given by former psychotherapy patients is also important, regardless
of whether it was caused by analysis or instead is related to pretreatment differences between those referred
for treatment in the two modalities.
Yet, as a consequence of these methodological constraints, the results of the study are preliminary and can
160 best be seen as hypotheses to be tested in more rigorously designed long-term follow-up studies.

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A) BEFORE READING IN DETAIL

1. Read the title, and skim the abstract

2. Skim the Introduction and the Discussion sections and circle the lexical chains.
3. With the information in questions 1 and 2, what do you think the text is about? Predict.

4. Scan the Introduction for negatives and quasi-negatives (underline/highlight them)

5. What gap in research do the authors indicate? Remember this is a hypothesis, and you
are NOT supposed to give a correct answer yet.

B) DETAILED READING

6. Read the INTRODUCTION of the article, and in your own words, state the
information the authors give when they:

a) revise previous literature/ research

b) indicate a gap in research on this topic

c) indicate the aim of their article

7. Read the DISCUSSION section and, in your own words, state the information
regarding:

d) outcomes

e) reasons for recommendations on more research

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