ABSTRACT
Psychoanalysis has developed from the early days when Freud (1904a, 1905a, 1912e, 1937c) felt that narcissism, psychosis, and certain character weaknesses and defects were contraindications for analysis, as he believed these patients would be unable to form a transference relationship. Now, we recognize how difficult it is to make such a clear-cut distinction, as some patients have aspects of both neurosis and psychosis: Hopper’s (1991) “encapsulated pathology”. Moreover, Freud excluded deeply rooted depression and states of confusion, as well as patients aged over fifty. He believed this last group of patients would be too rigid and their capacity for intrapsychic change would be severely curtailed. Again, today, we think very differently; for instance, we not only have people over fifty, but over seventy. This is hardly surprising, as it is part of the socio-political climate of the day. For Freud, assessment for psychoanalytic suitability was based on the classical medical model; hence the use of the term indication and contraindication. The former is used to suggest the most appropriate treatment of the illness based on symptoms and the patient’s history. Contraindication refers to the unsuitability of the form of treatment. Our assessments are based 34on the distinction between what the patient complains of (symptoms) and our observations (the signs that we pick up). It may be useful to note that symptoms are not so confined to a diagnostic category as we used to believe: for example, depression, phobias, and obsessions can be a feature of many assessment profiles. However, during an assessment session, we need to be very aware of possible contraindications for psychoanalytic work. We believe the only category which would completely rule out the possibility of this type of therapy is organic brain disease, although now even this is open for discussion; for instance, the neuropsychoanalyst Mark Solms has suggested that a modified version of psychoanalytic psychotherapy could be useful with some patients in this category. Ogden (1989) believes that we would do a patient a disservice if we embark on treatment aware that we do not like him. Although one might feel that it should be possible to analyse an initial negative countertransference response, in practice Ogden feels that it imposes an added burden on the beginning of treatment if there is an intense negative transference or countertransference.
