Introduction

It is a long-standing tradition in our field for analysts not to initiate contact with former patients. Unless a patient returns for consultation or additional treatment, the analyst has no follow-up information on a treatment. This results in a feeling that all analysts know well: frustration in not knowing how their patients have fared after analysis. How have their lives turned out? Did they sustain the gains they were able to make in analysis, or was there a falling back? Did they continue the work on their own and find solutions to some of the issues that remained unsettled, or only partially settled, at the end of treatment? What about their relationships? Have these improved and become more satisfactory as a result of the analytic work? How, overall, do they now view their analysis? Do patient and analyst see it the same way or very differently? And what role, if any, does the former analyst play in their lives and psyches? Does he or she continue to be a living presence, someone whose voice they still hear and who, in their imagination, they consult with from time to time, or has the analyst become a figure from the past, someone whose voice and image have faded from consciousness? And, finally and perhaps most important, what can analysts learn about their own work, and the analytic process more generally, from obtaining a follow-up of patients they have treated?

In many cases, such questions about former patients remain unanswered. Not only is this a major frustration that analysts must live with; it is also a major impediment to the effective study of the analytic process and the results of analyses. It is for this reason that a number of our colleagues, notably Pfeffer (1961), Schachter and Johan (1989), Oremland, Blacker, and Norman (1975), Kantrowitz (1986), Wallerstein (1986), and Erle and Goldberg (2003), as well as a number of European authors, have conducted follow-up studies. Usually these are not done by the treatment analyst but by a colleague who interviews the patient. Each of these studies, though limited by the fact that the former patients were not seen by the person who treated them, has yielded valuable information.

Among other findings, these follow-up interviews have confirmed the importance of patient-analyst match and demonstrated that there is no such thing as a “pure” analysis in the classical sense (that is, one whose therapeutic effect is the result of interpretation alone). The studies have shown, rather, that every analysis contains a mix of elements—some interpretive, some supportive, some that operate intrapsychically (if not directly) as suggestions—that cannot be teased apart or divided into separate entities. All of these interventions, in the ensemble, contribute to the therapeutic outcome of analytic work.

We have also learned, contrary to the older idea that the transference is resolved, or dissolved, at the end of analysis, that the original transference, and indeed many of the patient’s original conflicts, are quickly revived in the follow-up interview. This suggests that neither the transference nor the patient’s core conflicts are obliterated after a successful analysis. Typically they live on, but in a quiescent form, having lost much of their strength and what Pfeffer (1961) called their poignancy. What has changed is the role they play in the patient’s psyche. After a successful analysis, they are handled, or responded to, quite differently—that is, more adaptively and effectively. This seems to be one of the chief benefits of analysis.

Patients may use memories of the sound and intonation of their analyst’s voice as a means of remembering his or her interpretations and ways of thinking about their conflicts, thus serving as a guide to carrying out a piece of self-analytic work.

Follow-up studies have shown that longer-lasting treatments, whether analysis or analytic psychotherapy, have better results than shorter-term therapies. These results are measured mostly by the self-reports of former patients.

As these studies are conducted by interviewers other than the treating analyst, they offer the original analyst only the most general picture of the work’s outcome. The analyst is not able to compare her view of the patient’s analytic experience with the patient’s view, or to learn firsthand from the patient what in the analysis was experienced as useful and what not. Nor can the analyst know clearly whether, or to what degree, her expectations of how the patient would fare postanalytically have been borne out.

Equally important, the analyst cannot compare her subjective reaction to, and experiences with, the individual she treated with her reactions to the person she encounters at the time of follow-up.

The analyst’s memory of her countertransference responses to aspects of the patient, if revived, as often happens in follow-up interviews, may help her assess the impact of such countertransference reactions, including any countertransference enactments that may have taken place. Especially interesting is the role, if any, that countertransference played in limiting, or altogether preventing, progress in specific areas of the analytic work.

Finally, the analyst will have a much better feel than any new interviewer could for the extent of the patient’s improvement and where she is psychologically at present as compared with her initial presentation. The analyst will also be better able to judge whether or not more treatment is indicated.

Since, however, analysts do not usually seek follow-up information from former patients, the field has suffered from having very little follow-up data obtained by the former analyst.

The reasons given for this restriction are that the patient may experience such contact as an unwelcome intrusion, that it may interfere with the processing and integration of the analytic work and the termination process, that it may stir up transference feelings without the possibility of their being dealt with, that it may actually alter the results achieved by the analysis by somehow changing the patient’s intrapsychic dynamics, and that the act of initiating contact is likely to represent a need of the analyst rather than of the patient. In the minds of some, gratifying that need by contacting the patient begins to trench on the worrisome problem of boundary violations.

Whether such concerns are valid and show sound judgment or instead are received truths accepted without evidence is not clear. It is entirely possible that some patients would welcome their analyst’s sustained interest in them rather than experience it as an intrusion and that such contact might stimulate and reinforce the self-analytic work that we hope will occur as part of the patient’s identification with the analytic process. It is also possible that such contact might provide an opportunity for further working through of core conflicts, rather than interfering with the patient’s solitary process of working through. The fact is, we lack sufficient information to make an informed judgment about this issue, and our tradition prevents us from obtaining a better understanding of this important question. This, as we know, is not an unusual situation in our field, one that constitutes a barrier to advancing our knowledge.

One thing, however, does seem clear. When it comes to follow-ups, we do not make a distinction between the kinds of patients we have treated. I have had the experience of supervising the analysis of a quite troubled individual who achieved significant gains in treatment, but who, a couple of years after the analysis ended, underwent a severe regression, accompanied by acting out that was terribly destructive to him. It seemed to both the analyst and myself that a few follow-up appointments might have made a significant difference in this case, as the patient could not sustain the kind of inner representation of the analyst that is seen in less troubled patients. Our traditional attitude toward follow-up appointments, in other words, may not serve all our patients equally well. Clearly we need more data about this knotty question and possibly some rethinking of it.

Patients, of course, often wish to return to their analyst for consultation, additional analysis, or, not unusually, a period of once- or twice-a-week treatment. Such psychotherapy following analysis is often enhanced and enriched by the patient’s being able to draw on understandings and insights gained in the analysis. In addition, such treatment often proves extremely useful, as the patient has an opportunity to revisit conflicts and problems that were not sufficiently resolved in the analysis. With any former patient, of course, issues will arise that could not have been dealt with in the analysis, as they had not yet presented themselves. Marriage, divorce, parenthood, illness, aging, painful losses, significant achievements or other positive experiences—the effect of such life experiences cannot be truly known before they actually take place. We hope that analysis has strengthened our patients so they can cope with the vicissitudes of life without pathological reactions, but many still need help at these times. And it is also true that stressful life experiences occurring in the postanalytic period often expose vulnerabilities and fault lines in the patient that were not evident in the analysis. This allows patient and analyst to address important aspects of the patient’s psychology in ways that were not possible the first time around. This situation is quite common and highlights the value, for many individuals, of a second period of analytic work.

Whatever the reason for patients to return to their analyst, the renewed contact offers the analyst a unique learning experience. Now he or she has a chance to assess the earlier treatment, and the approach that was used, in a way that can be done only by the treating analyst. This is an invaluable opportunity, not only for the analyst, but for those of us who have the opportunity to read and to learn from accounts of these follow-up experiences.

The papers that follow will both teach us much and stimulate our own thinking, as these reports will inevitably raise questions about our own experiences, as well as our theories, techniques, and traditional assumptions.