The indications for these three modalities of treatment remain controversial. With the recognition of the limitations of psychoanalysis in many cases with severe, chronic, life-threatening, self-destructive behaviour, such as chronic suicidal behaviour, severe eating disorders, dependence upon drugs or alcohol, and severely antisocial behaviour, psychoanalytic psychotherapy has proven to be a highly effective treatment for many but by no means all patients with these conditions. The differential diagnosis of a spectrum of severity of antisocial behaviour and those cases of severe self-destructive and antisocial behaviour who are amenable to treatment with psychoanalytic psychotherapy has been one of the important side-products of the psychoanalytic exploration of these cases. (35>
Supportive psychotherapy, originally conceived as the treatment of choice for patients with severe personality disorders, now may be considered the alternative treatment for those patients with severe personality disorders who are unable to participate in psychoanalytic psychotherapy. The Menninger Foundation Psychotherapy Research Project showed that patients with the least severe psychopathological disturbances tend to respond very positively to all three modalities derived from psychoanalytic theory, although best to standard psychoanalysis. (38>
Standard psychoanalysis is the treatment of choice for patients with neurotic personality organization, i.e. with good identity integration and a repertoire of defences centring on repression along with sufficient severity of illness to warrant such a major therapeutic intervention. Psychoanalysis has also expanded its scope to some of the severe personality disorders, particularly a broad spectrum of patients with narcissistic personality disorders, patients with mixed hysterical-histrionic features, and selected cases of patients with severe paranoid, schizoid, and sado-masochistic features.
We are still lacking systematic studies of the relationship between particular types of psychopathology and outcome with the various psychotherapeutic treatments derived from psychoanalytic theory. As a tentative generalization it may be stated that there is a definite relationship between outcome and the severity of illness in any diagnostic category. The least severe cases will respond favourably to either brief psychoanalytic psychotherapy, supportive psychotherapy, or psychoanalysis. Psychoanalysis represents the opportunity for most improvement if the severity of the case warrants psychoanalytic treatment. For cases of neurotic personality organization of moderate severity, psychoanalysis is the treatment of choice; definitely less can be expected in these cases from psychoanalytic psychotherapy. For the most severely ill patients (those with severe identity diffusion, predominance of primitive defences centring on splitting, and general 'ego weakness') psychoanalytic psychotherapy is the treatment of choice, with supportive psychotherapy a second choice if psychoanalytic psychotherapy is contraindicated. A few such cases may be able to participate in psychoanalysis and benefit from it.
In all cases, individualized contraindications for the respective treatment are important: in the case of psychoanalysis, individual contraindications depend on the questions of ego strength, motivation, introspection or insight, secondary gain of illness, intelligence, and age. In the case of psychoanalytic psychotherapy, secondary gain, the impossibility of control of life- or treatment-threatening acting out, limited intelligence, significant antisocial features, and a desperate life situation may constitute individual contraindications, particularly when they occur in combination. When psychoanalytic psychotherapy is contraindicated for such reasons, supportive psychotherapy becomes the treatment of choice. Participation in supportive psychotherapy requires a sufficient capacity for commitment to an on-going treatment arrangement, and the absence of severe antisocial features as minimal individual requirements. This is not meant to be a complete list, but an illustration of the kind of criteria that become dominant in the individual decisions regarding the selection of the treatment and its contraindications.
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