The International Journal of

Int J Psychoanal (2010) 91:1385–1404 doi: 10.1111/j.1745-8315.2010.00336.x

Creating analysts, creating analytic patients1

Howard B. Levine
124 Dean Road, Brookline, MA 02445, USA – hblevine@aol.com

(Final version accepted 16 March 2010)

This paper applies a contemporary, ‘two-track’ – transformational as well as

archaeological – perspective on psychoanalytic process to clinical issues in the cre-
ation of analytic patients: case finding, recommending analysis, and recommending
and negotiating the intensification of frequency of sessions in analytic psychother-
apy. Central importance is assigned to the role of the mind and analytic identity
of the analyst, including the analyst’s capacity to maintain an internal analytic
frame and analyzing attitude from the very first contact with the patient and
throughout the treatment, the analyst’s confidence in and conviction about the use-
fulness of analysis for a given analytic dyad and the role of the analyst’s theory,
which must be broad and consistent enough to allow the analyst to feel that he or
she is operating analytically when addressing non-neurotic (unrepresented and
weakly represented mental states) as well as neurotic structures.

Keywords: initiating analysis, intensifying frequency, intersubjectivity, unrepresented

mental states, treatment process, analyzability, case finding, transformation,
countertransference, psychoanalytic psychotherapy

I. A two-track model of psychoanalysis

Case finding has become a significant problem at all levels of analytic pro-
fessional development. As fewer analysts see fewer analytic patients, morale
suffers, colleagues are losing confidence in the possibility, perhaps even the
effectiveness, of psychoanalysis and the specificity and unique, transforma-
tive potential inherent in psychoanalysis are in danger of being replaced by
a more limited vision, in which analysis is viewed as a ‘super psychother-
apy,’ directed towards problem-solving and adaptation. These circumstances
call for a re-examination of the very meaning of psychoanalysis, the scope
of its application and how the analyst’s assumptions and beliefs about its
meaning and relevance, along with the analyst’s attitudes towards and con-
victions about analysis, influence prospective patients and affect our ability
to find and develop analytic cases. They also invite us to re-think some of
the technical issues involved in recommending and initiating analysis and
intensifying the frequency of analytic therapy. In this paper, the goal of this
re-examination will include the elucidation of a theory that allows analysts
to think and operate in ways that they feel are consistently ‘psychoanalytic’
in the face of patients and situations that lie outside the bounds of the more
usual (neurotic) psychic functioning based on represented mental states.
1
Earlier versions of this paper were presented at the European Psychoanalytic Federation’s (EPF)
Plenary Session of the Working Party on Initiating Psychoanalysis, held in March 2006 in Barcelona and
at the 2004 winter meetings of the American Psychoanalytic Association.

Copyright ª 2010 Institute of Psychoanalysis

Published by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and
350 Main Street, Malden, MA 02148, USA on behalf of the Institute of Psychoanalysis
1386 H. B. Levine

When I began analytic training in the early 1970s, psychoanalysis was

defined in the narrowest of terms and case finding was synonymous with
the assessment of ‘analyzability.’ The latter was seen as an objective function
of the patient’s ego capacities, relatively independent of the potential of a
particular analyst or dyad. At that time, initial interviews were conceptual-
ized as exercises in medical triage, with the evaluating analyst functioning as
‘gatekeeper.’ The prevailing wisdom was that careful assessment of a
patient’s motivations, ego strengths and psychopathology would allow ana-
lysts to select appropriate patients (i.e. neurotics with more or less well-
structured psyches), who, in the hands of a ‘good enough analyst,’ would
then go on to have successful analyses. Even allowing for recommendations
of ‘therapy preparatory to analysis’ (e.g. Rappaport (1960) and even after
the ‘conversion’ of patients from psychotherapy to psychoanalysis with the
same analyst became an accepted practice (Bernstein, 1983; Levine, 1985),
analysts, at least in the US, still tended to evaluate potential analytic cases
from a perspective in which hurdles had to be cleared before analysis would
be recommended.
The rationale for this set of assumptions derived in part from disappoint-
ing clinical results with patients whose psychic functioning did not readily
conform to the requirements imposed by the classical model of technique.
Our field, conceived in terms of the model of neurosis, repression and repre-
sented mental states, had gone from an unjustified optimism about the appli-
cation of psychoanalysis to almost all forms of psychopathology, to a
sobering recognition of the limits of our therapeutic ambitions relative to the
level of development of our clinical understanding and theory of technique.
Economic and historical circumstances also played a part. As a treatment,
psychoanalysis was held in the highest esteem, other forms of therapy were
not readily available and psycho-pharmacological treatment had not yet cap-
tured the imagination of the general public or the market-place. An abun-
dance of presumably analyzable cases coupled with a relative shortage of
analysts permitted analysts to be highly selective about whom they took into
treatment. Subsequently, however, either the pathology of the patients
appearing in our consulting rooms began to change or we have deepened
our appreciation of the depths and complexity of all our patients’ difficul-
ties. Whatever the case, the increasing number of non-neurotic patients now
present in contemporary analysts’ caseloads – and the recognition of non-
neurotic portions of the minds of even neurotic patients2 – has challenged
us to rethink and expand our views of analytic technique, the indications
for analysis and the very nature of psychoanalysis, itself.
As these changes were taking place, there were already indications that
something was amiss in our traditional assumptions about assessment and
analyzability. Attempts by psychoanalytic researchers to substantiate the
classical assumptions about analyzability and outcome were proving
2
That the minds of even neurotic patients contain unrepresented mental states and therefore have non-
neurotic sectors is implicit in Freud’s (1923) description of the id as force rather than specific content
and was noted explicitly in Analysis terminable and interminable: ‘‘Every normal person, in fact, is only
normal on the average. His ego approximates to that of the psychotic in some part or other and to a
greater or lesser extent’’ (Freud, 1937a, p. 235).

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 Creating analysts, creating analytic patients 1387

problematic. For example, in an extensive review of the outcome literature,

Bachrach et al. (1991) concluded that even for patients considered most suit-
able for analysis (i.e. patients selected for ego strength and presumed analyz-
ability) ‘‘the extent and quality of therapeutic benefit and analyzability
…[was] relatively unpredictable’’ (p. 907, original italics).
In retrospect, it seems that this conclusion was the inevitable result of try-
ing to apply a vision of psychoanalysis allied to a narrow reading of tech-
nique derived from Freud’s first topography – i.e. a psychoanalysis of
neurosis – to (non-neurotic) patients and situations for whom and in which
it was not suitable or sufficient. Recalling Freud’s (1937b) famous metaphor,
we might call this vision the archaeological model of the mind and note its
connection to his initial formulations about dreams, dream analysis and the
Unconscious (Freud, 1900).
Restating these formulations in contemporary terms, we would say that
the archaeological model was best suited for situations in which psychic ele-
ments have achieved representation and have been more or less symbolically
invested and associatively linked to one another. It is this symbolic tie to
dangerous and ⁄ or unacceptable wishes, feelings, fantasies and needs that
leads to the familiar situation of psychic elements becoming enmeshed in
conflict, undergoing the vicissitudes of repression or other defensive disguise
and remaining hidden from conscious awareness, while continuing to exert a
pressure on the psyche until the conflicts they are involved in are discovered
and worked through to some resolution.
In instances where non-neurotic cases were successfully treated within this
archaeological formulation of psychoanalysis – we might say despite this
formulation of psychoanalysis – success was less often due to the rigorous
application of a theory of technique and more often due to the influence of
non-technical factors, such as the analyst’s intuitive response to the patient’s
needs, the inspired application of what used to be referred to as the ‘art of
psychoanalysis,’ engaging the patient in a search for meaning almost inde-
pendent of the nature of the discovered meaning itself or the salutary effect
of non-specific therapeutic factors in the analytic relationship – e.g. consis-
tency, empathy, non-judgemental concern, maintenance of an analytic frame
and attitude, etc.3
Clearly, the archaeological model has had enormous value for the treat-
ment of neurotic patients and has been central to the development of psy-
choanalysis. However, while it remains relevant for many patients some of
the time, as the basis of a theory of technique, it is not sufficient for all our

3
For example, it may be questioned how much the therapeutic gains, which Relational analysts claim to
derive from ‘throwing away the book’ (Greenberg, 2001; Hoffman, 1994), follow from the need to escape
the strictures of an archaeological theory of technique in clinical situations where some other theory of
technique is needed instead. Whether this ‘other theory’ is best formulated in terms of a transformational
model of analysis allied to aspects of Freud’s metapsychology requires a more comprehensive and
extended discussion than the scope of this paper permits. The two-track model that I am proposing may
be only one of several possible solutions to the problems that I believe arise from a predominant or
exclusive reliance upon the archaeological model. For those who already operate from within such a
model, albeit a different one, I hope that what follows will offer confirmation. For those who lack such a
model and are struggling to maintain a consistent sense of operating within an analytic framework when
faced with non-neurotic patients and situations, I hope that what follows will prove useful.

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1388 H. B. Levine

patients all of the time. Patients who suffer from the consequences of unrep-
resented or weakly represented mental states (Botella and Botella, 2005;
Green, 2005a) require the addition of a constructive or transformational
model of analytic interaction, one that centers upon the functioning of the
mind of the analyst as a part of the analytic dyad in the creation and ⁄ or
strengthening of psychic elements rather than, or in addition to, their uncov-
ering or discovery. The outlines of this second model derive from the later
Freud (e.g. 1920, 1923, 1937b), the seminal work of authors such as Bion
(1962, 1970, 1992), Winnicott (1958), and Baranger et al. (1983) and find
further adumbration in contemporary thinkers, such as Green (1975, 2005a,
2005b), Ferro (2002, 2005) and Botella and Botella (2005).
This transformational model emphasizes that psychoanalysis is a pair-
specific, two-person activity that is liable to be as much if not more about
the creation of symbols, thoughts, feelings and the unconscious than it is
about their uncovering or discovery. In some situations, the task of the ana-
lyst may be less about analyzing defenses or uncovering hidden or disguised
meanings and more about lending one’s psyche to the work of facilitating
the patient’s development of thoughts, feelings and mental states; of elabo-
rating these newly formed psychic elements and linking them to other com-
ponents, in the mind of either participant or in the intersubjective mental
space that lies between them. In short, of ‘‘binding the inchoate, and in con-
taining it within a form’’ (Green, 1975, p. 10) and working ‘‘with the patient
in a double operation: to give a container to his content and a content to
his container’’ (Green, 1975, p. 8).
From the perspective of this second model, the findings of Bachrach et al.
(1991) seem almost inevitable. To the extent that important data of psycho-
analysis, even in patients deemed to be neurotic, are highly subjective, fluid,
co-determined within a specific analytic dyad and waiting to be created,
rather than objective, fixed, a function only of the patient’s psyche and wait-
ing to be discovered, then intangible, intersubjective qualities of relationship
between patient and analyst can be expected to assume equal if not greater
importance than ‘objective’ patient-centered factors in determining depth of
analytic engagement, qualities of analytic process and eventual psychoana-
lytic outcome.
The work of Kantrowitz (1993, 1995) and her colleagues (Kantrowitz
et al., 1989) inadvertently offers further support for this line of reasoning.
They sought to study analytic outcome in relation to four patient-centered
criteria of ego strength and presumed analyzability – reality testing; object
relations; affect tolerance; and motivation. To their surprise, they discovered
that the strength and presence of these four qualities were less predictive of
analytic outcome than were certain interpersonal qualities of the dyad,
which they called ‘the analytic match.’ Their formulation of ‘the match,’
however, was restricted by a theory that remained embedded in a traditional
(i.e. archaeological) analytic framework and which did not allow for a full
consideration of the richness and complexity of the intersubjective relation-
ship that can take place between patient and analyst (Levine and Friedman,
2000). They focused on the important, but more limited consideration of
complementary or congruent conflicts and blind spots that exist within a

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 Creating analysts, creating analytic patients 1389

given analytic dyad. What is noticeably missing from their work is a consid-
eration or discussion of the conditions under which those patients who did
not possess the requisite qualities of trust, self-observation, affect tolerance,
etc. before beginning an analysis could be helped to develop them or the
possibility that analysis was a powerful means, often the treatment of choice,
in helping them to do so.
Recognition of the latter is facilitated by the transformational model
because it emphasizes the emergence of spontaneous, unconscious, interac-
tive and intersubjective processes of transformation that allow for the crea-
tion and strengthening of psychic representations, symbols and meaningful
chains of associations. This model supports the view that assessment of
prognosis and analyzability is pair specific for any given dyad, that it
requires the consideration of analyst-centered variables along with patient-
centered variables, and is a function of the inter-affectivity and potential
interactions and emotional connections that may develop between any given
analyst–patient pair. The focus of this model also helps shift attention away
from extrinsic factors in the definition of psychoanalysis, such as the fre-
quency of sessions, towards intrinsic factors, such as the degree to which a
psychic space in which the analysis can take place is opened within the pair
and for either participant.4
What I am contending is that we now have the outlines of – and ought to
be using for case finding – a ‘two-track’ model of psychoanalysis that is trans-
formational as well as archaeological. The analyst’s comfort and familiarity
with the technical implications of this ‘two-track’ model and conviction
about its usefulness will allow analysts to think and act analytically in the
face of unrepresented as well as represented mental states, disorganized as
well as organized sectors of their patients’ psyches, and autistic, psychotic
and borderline phenomena as well as neurotic–normal phenomena. The
addition of the transformational track completes a more comprehensive the-
ory that can be applied to a wider scope of patients and will therefore help
in the matter of case finding, as it emboldens analysts to encourage even
‘sicker’ patients to enter into analysis and more intensive treatments.
With the expectation that each analysis or analytic therapy will require an
unconscious, joint improvisation, the process will begin from the initial con-
tact, with the analyst – and hopefully, but not necessarily, the patient – won-
dering and discovering what and how this pair will begin to improvise
together, unconsciously, spontaneously. In initiating treatment, the ‘diagnos-
tic questions’ then shift from the traditional focus on the individual patient
and his or her ego capacities to the functioning of the mind of the analyst in
response to the patient and to the analytic pair. Thus, from the first contact
with a new and prospective patient, analysts may profitably wonder: ‘Do I
feel able to function as an analyst with this patient and in which ways? Does
the patient’s internal world and history have a meaning for me? In what ways
does it resonate with my own feelings and internal experience? Can I

4
This definitional shift from extrinsic to intrinsic factors is consistent with the aims of Gill (1994), who
urged analysts to link their definition of psychoanalysis to therapeutic process rather than frequency of
sessions and use of the couch.

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1390 H. B. Levine

represent this patient’s internal world for myself ? How vividly can I do so?’
And, if any given analyst feels unable to do so, to what extent does that feel-
ing represent a reaction to emotional withdrawal, stasis (Green, 2005a) or
loss of internal coherence within the patient, which can then, upon further
reflection, become quite vivid as an object of reflection in the analyst’s mind?

II. The analyst’s mind and the analytic dyad

When psychoanalysis is viewed along these lines, our understanding of the
locus of the important determinants for the recommendation of analysis – and
the factors that will determine the degree to which the analysis will be
accepted and prove successful – move from ‘inside’ the patient to ‘inside’ the
dyad. And in regard to the latter, one of the most fundamental and impor-
tant determinants of analyzability and outcome will be the degree to which
an analyzing perspective and attitude can be successfully maintained within
the mind of the analyst with any given patient.
In emphasizing the analyst’s role, I do not wish to detract from the fact
that, if the analytic couple is to function successfully, then both participants
must ultimately acquire some degree of flexibility and permeability of the
boundaries of their identity. However, for some patients this flexibility may
have to be the result of their analysis, rather than its starting point. Thus, in
many instances, the creation of a given analytic patient will be a function of
the degree to which the analyst will be able internally to create and maintain
him or herself as an analyst with and for that particular patient. This last
assertion also directs our attention to the centrality of the countertransfer-
ence in all of its manifestations – normal (Money-Kyrle, 1956) and patholog-
ical, characterological and specific, totalistic and narrow – and implies that
what is required of the analyst is tantamount to an act of analytic formation,
which must be repeated anew with every patient, perhaps in every session.
Since the traditional literature on ‘analyzability’ tends to be skewed
towards the archaeological model, I will not attempt to review it here.
Instead, I would like to call attention to Rothstein’s (1995) book, Psychoan-
alytic Technique and the Creation of Analytic Patients. Although it does not
go as explicitly far as it might in redefining psychoanalysis along the lines I
have indicated, it does mark a watershed in that it replaces the traditional,
exclusionary assumptions about indications for analysis with an almost cate-
gorical inclusivity, by implying that one crucial element in the development
of an analytic practice is the analyst’s conviction5 that a trial of analysis is
the ‘optimal choice’ for almost all patients who consult an analyst for help.6

5
For a discussion of the analyst’s affirmative conviction about the success of a prospective analysis, its
roots and its effects on the recommendation process, see Grusky (1999).
6
Rothstein’s reversal of the once traditional position about analyzability has proven especially valuable in
empowering candidates, who, because of their inexperience and uncertainty, are often in need of support
and encouragement to help them recommend that their patients enter analysis. It is also useful in
implicitly supporting the hopes and courage of prospective patients, who are initially faced with the
difficult decision of whether or not to begin an analysis. On the other hand, the categorical way in which
Rothstein has asserted that a trial of analysis should be offered to almost all patients seeking treatment
has led to questions and concerns about patient compliance, the transference of authority and the
potential for authoritarian, even unethical, misuse of his recommendations (see Bornstein et al., 2000).

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 Creating analysts, creating analytic patients 1391

Once the analyst’s conviction is implicated as a motivational element in

the process of recommending and helping patients accept the recommenda-
tion to enter analysis, we are forced to recognize the extent to which these
processes are dependent upon factors which are unconscious, intersubjective
and co-determined. Whether or not Rothstein intended to take the matter
this far is really beside the point. His work, at least in my reading of it,
encourages us to arrive at the implicit outlines of a more interactive,
intersubjective conceptualization of the process of initiating analysis than
the traditional archaeological theory had allowed.
One implication of this new conceptualization, especially useful in the
understanding and treatment of sicker patients, is that the analytic process
is something that occurs, at least initially, if not for long periods of time –
and perhaps in some instances for nearly the whole treatment – in the mind
of the analyst. With such patients, the challenge for analysts often becomes
how to maintain this internal process in the face, not only of the patients’
resistances, but of their evident psychic disorganization and our own
expectable oscillations of confidence and conviction, uncertainty and doubt,
that occur as we find themselves caught up in conflicts, countertransfer-
ence, enactments and our patients’ projective identifications, each of which
are inevitable components of our participation in the analytic process
(Levine, 1994).
What will help to sustain analysts in their attempts to meet this challenge
is the achievement of a solid analytic identity, one that includes the expecta-
tion that they will find themselves being used in different ways by different
patients according to the dictates and needs of their transference strivings,
confidence in analysis based on their own experiences on both sides of the
couch, a belief about the potential usefulness of analysis for each particular
dyad and, perhaps most important of all, a clinical theory and theory of
psychic functioning that will allow analysts to feel that they are operating
consistently within the context of a comprehensive theory that they feel is
truly psychoanalytic across the full spectrum of patients and situations that
they encounter. The awareness that these oscillations are expectable vicissi-
tudes of analytic work will further support analysts in the vital task of
maintaining an analytic attitude (Schafer, 1983) and an internal sense of the
analytic process and frame (Bleger, 1967).
The core corollary for technique that follows from the above reasoning is
that the analyst must hold firm, internally, throughout the treatment to an
analytic perspective and consistently meet both the patient’s words and
actions and what is stirred up in the analyst, with an analytic response. This
is true from the first inception of the possibility of analysis in the mind of
the analyst, through the evaluation and recommendation phase and
throughout the entire treatment. Thus, for example, if patients initially
respond to recommendations of analysis or intensive treatment with objec-
tions and resistant behavior, the analyst must ‘translate’ these responses, at
least in the privacy of the analyst’s own mind if not in more overt interpre-
tive explorations and interventions, into the stuff of analysis: conflict,
resistance, transference, interpretations, etc.

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1392 H. B. Levine

Similarly, when analysts find themselves thinking about the patient in

objectifying terms, such as ‘suitable’ or ‘unsuitable’ or ‘needs to be referred
for medication or to a non-analytic treatment,’ such thoughts should raise
the possibility that these thoughts are countertransference fantasies elicited
by something in the patient and ⁄ or the analyst–patient interaction that is
unpleasant, distancing or activating of the analyst’s wish to reject the
patient or to flee (Rothstein, 1995). While thoughts of diagnosis, prognosis
or medications may be appropriate in the psychiatric or psychological con-
text, from a psychoanalytic perspective, even in an initial interview, such
thoughts should be viewed as analytic data in need of understanding rather
than as causes for specific actions.
In one dramatic example,7 a young woman with a chaotic life, anxiety, depression
and suicidal feelings, a history of violent, traumatic losses and an estranged father
recently diagnosed with cancer sought treatment with the hope of stabilizing her
personal and professional life. As her initial interview approached, she became anx-
iously preoccupied with being able to leave the meeting when it was over and so
decided to park her motorbike at the entrance of the analytic clinic the night before.
When she arrived for her session the next day, however, she found that her bike was
missing. The patient did not realize that it had been parked in a tow zone and had,
as the signs clearly indicated it would be, been towed. She only knew that her plan
for a smooth exit had been ‘unexpectedly’ thwarted. She entered the analyst’s office
in a state of agitation, unable to reflect upon or explore either the reasoning behind
her need to have the bike at the ready or her distress at its disappearance.

Whatever the origins or meaning of this initial action – the blind, unseeing expres-
sion of something, presumably of an unrepresented or weakly represented state of
mind, perhaps the confluence of split or conflicting impulses towards fleeing and
staying forever – the turbulence it conveyed and produced for both analyst and
patient in the very first session was palpable. It was the kind of initial presentation
that might have led some analysts to conclude that the patient was too anxious,
impulsive or disorganized to undertake an analysis. For this analyst, however, it was
an introduction to the dialect of action in which the patient was able to express and
display her difficulties and the psychic terrain on which this patient’s analysis would
have to be engaged; an indication of the kind of transformational work in the realm
of affect regulation that would await them.

In those initial moments, the analyst was not yet aware of the patient’s history, but
recognized the panic that the absence of the motorbike had induced and felt pres-
sured to respond. Although uneasy about responding to her patient in too concrete
and reality oriented a fashion, the analyst sensed that her patient was not yet ready
to explore or understand the meanings of her actions, her loss or their underlying
anxieties and fantasies. With some hesitation, the analyst pointed out that if the
patient ‘looked carefully,’ she would discover the tow warning sign, which in turn
would direct her to the tow lot where the motorbike would be found.

This intervention helped relieve and calm the patient and, at the very least, initi-
ated a setting and relationship in which panic in the patient would be recognized

7
This case was taken from Reith and Crick (2007) Looking again at the dynamics of preliminary
interviews, the report on work in progress of the Working Party on Initiating Psychoanalysis (WPIP) of
the European Psychoanalytic Federation.

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 Creating analysts, creating analytic patients 1393
by the analyst and met with by attempts to dispel it. It also helped begin to cre-
ate a space within the relationship in which discussion and exploration of this
incident and the patient’s life circumstances and feelings could begin. At a deeper
level, the analyst’s seemingly ‘realistic’ response was also an unsaturated interven-
tion (Ferro, 2002) that represented an intuitive understanding of the experiences
of catastrophic, possibly irreparable, loss with which the patient was struggling. In
retrospect, it attempted to convey to the patient ‘if we read the signs carefully, we
can talk about your traumatic experiences and give meaning to them’ or, more
symbolically, ‘There is still hope: you have a sense of having irretrievably lost your
objects, but they are still there to be found within you, if you know where to look
for them.’

Of course, it is doubtful that these meanings could have been consciously known or
understood beforehand by either patient or analyst. They are the kind of under-
standing that would only be able to be reconstructed after the fact [aprs-coup] in
the context of the subsequent analytic work and relationship.
That this initial intervention occurred via action rather than exploration
and verbal interpretation – it could perhaps be seen as an ‘interpretative
action’ (Ogden, 1994) – raises the possibility that it could also be seen –
alternatively or at the same time but from a different perspective – as an
enactment or countertransference-driven response, which might present
problems at later stages of the analysis.8 It could, for example, have actual-
ized crucial internal object relations in which panic in one object drives the
other into action or it could have set a generalized tone or expectation of
action rather than exploration and reflection. However, since at this stage in
the patient’s development action was a major ‘dialect’ for her expression of
her inner world, some sort of action response, and a transformational clini-
cal theory that could encompass and allow for it, may well have been essen-
tial, if, under these circumstances and with this patient and analyst at this
moment in time, a viable treatment could have been begun. Having success-
fully weathered the storm of this initial presentation, this analyst felt confi-
dent enough about her beginning internal picture of the patient and their
potential for an analytic process to recommend an analysis and the patient
felt sufficiently soothed and responded to, to accept the offer of what even-
tually turned out to be a helpful, although by no means classical, analysis at
four times per week.
As this case also implies, maintaining an internal analytic stance about
one’s initial reactions to the patient not only preserves the range of ana-
lytic functioning within the analyst’s mind, but also can help foster a more
balanced and affirmative view of the patient within the dyad and can con-
tribute to the creation of a more positive, hopeful and alive analytic set-
ting from the very first contact. This analyst’s initial response, coupled
with the recommendation of analysis, expressed her quiet confidence in
their joint ability to work together despite this patient’s initial limitations

8
It is worth pointing out that the complexity of psychic interaction is such that conceptualizing the
analyst’s response as part of an enactment, with the possible negative implications that this might hold,
would not negate its simultaneously functioning in a potentially positive sense, when seen from a
different perspective.

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1394 H. B. Levine

and in the possibility that together they could create a potentially benefi-
cial treatment situation. The encouragement and possibility that this
patient was able to feel as a result of this initial interaction – her panic
was recognized and addressed and she was not disqualified as analyzable
because of her action-oriented style of discourse or the initial limitations
in her impulse control, capacity to think reflectively about herself or ability
to use interpretations – supported her sense of hope and optimism about
the treatment and contributed to the development of her unobjectionable
positive transference.
More commonly, in less dramatic circumstances and for less disturbed
patients, the action that initially needs to be accepted, dealt with and, when
possible, subsequently understood is that of the patient’s initial resistance to
a recommended frequency and setting of treatment. In addition to being
plausible objective ‘facts’ of the patient’s external life, these objections may
be seen as metaphors, enactments and transference phenomena reflective of
underlying conflicts, fantasies and anxieties in the patient’s internal world,
all of which have or can be made into something that has potential commu-
nicative value within the analysis and are suitable subjects for eventual
analytic investigation.9
The stance towards initial objections and resistances to analysis or inten-
sive therapy that I am suggesting, that of presumptively treating them as
‘communications in action,’ is analogous to the child analyst’s stance
towards play. Although these objections and resistances are expressed in the
dialect of action, if the analyst can come to see them as a form of communi-
cation – the patient’s way of actualizing (Sandler, 1976) and expressing cer-
tain fantasies, fears and conflicts – then they can be accepted and allowed
into the treatment so that they can eventually be addressed. Keeping this
principle in mind will help analysts maintain an initially flexible attitude
towards the extrinsic features of the analytic situation – frequency, fees and
use of the couch – and, if necessary, allow treatments to begin at what the
analyst may feel is less than the optimal frequency or setting.

III. Maintaining an analytic perspective

It is a truism that analysts must continually be alert to forces that attempt
to drive them away from an optimal analytic listening stance in the treat-
ment of their analytic patients. When the analyst is able to maintain such
a stance, then the understandings and interventions that can follow will
offer the patient the opportunity to have a meaningful first-hand experience
of the value of analytic understanding. This is true whether that understand-
ing is reflected manifestly in the analyst’s interpretations or indirectly in
the quality of the analyst’s receptivity, listening stance and intuitive
response. In either case, patients who have had a first-hand experience of
what analytic understanding and an analytic relationship can offer will not
have to rely solely or predominantly on the analyst’s authority as ‘expert’

9
The same may be true for the patient’s initial acceptance of the recommendation for analysis, which
may have to be explored and analyzed, as well.

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 Creating analysts, creating analytic patients 1395

in accepting recommendations for analysis or an intensive analytic psycho-

therapy.
When an analyst suggests to a prospective patient that analysis is the opti-
mal choice of treatment, the analyst is speaking from a position of author-
ity. From one perspective, this makes eminent good sense. After all, the
patient is seeking help from the analyst as a trained, professional caregiver.
As such, the analyst possesses expertise by virtue of training and experience
in diagnosis and treatment. It is, therefore, not surprising that the patient
would come expecting instructions, recommendations or an opinion as to
how to proceed. This, however, frames the matter in a predominantly
rational context, or may serve as the screen for submission, compliance and
other power-based transference responses.
As we know all too well, patients often come to us with specific ideas in
mind, irrational as well as rational, about how treatment will or should be
structured. These ideas are not only determined by social, cultural and other
external factors, such as past experiences, standards of practice in the com-
munity, what third parties will pay for, and so on, but are invariably influ-
enced by unconscious factors, such as conflicts, fears, fantasies, resistances
and, in the case of unrepresented mental states, inchoate pressures towards
blind discharge and action. As a result, and in the face of such overpower-
ing forces, reason and the analyst’s role as authority can be a rather fragile
foundation on which to build a treatment contract.
In contrast, the patient with first-hand experience of a salutary analytic
relationship, of either the archaeological or transformational kind, will have
a much more secure foundation on which to begin an analytic treatment.
The principle of trying to provide patients with a first-hand experience on
which to base their judgement and decision not only follows the basic
analytic goal of helping patients to better and more fully know their own
experience, but it may help mitigate potential control struggles, as it fosters
self-reliance and autonomy rather than dependence on the advice of experts.
At times, circumstantial factors may contribute to an analyst’s failure to
maintain an analytic perspective about the patients they are treating. I have
observed, for example, that it is often difficult for some analysts to main-
tain such a stance while working with patients in what are conceived of as
non-analytic settings. Many analysts and candidates now perform multiple
roles in multiple work settings. While it may or may not be useful to the
conduct of a behavioural or pharmacological treatment, for example, to
‘think analytically’ about one’s patients, it is certainly useful to think ana-
lytically about the patients seen in those modalities of treatment when con-
sidering whether or not they may be appropriate for more analytic forms
of therapy. For analytic case finding, it is important always to maintain in at
least some part of one’s mind an active analytic perspective about the
patients one is seeing, no matter what the form of treatment or treatment
setting.
Another circumstance that may tend to erode an analyst’s overall analytic
vision of a case may, paradoxically, be the fact of having a patient in an
on-going psychotherapy, even an analytic psychotherapy. It is as if the status
quo of the therapy takes on a momentum of its own and any broader sense

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1396 H. B. Levine

of the treatment begins to be lost in the drift of day-to-day struggles and

details. While I subscribe to the view that, within the session, the moment-
to-moment emergence of the experience at hand is the most appropriate and
useful perspective to focus upon, I also believe that outside of the hour it is
sometimes worth checking in with oneself or one’s colleagues to consider
the sweep of the treatment from a more distant vertex.
To facilitate this process, I have suggested to analysts and candidates who
are considering the creation of analytic patients that they review the patients
in their current caseload and briefly articulate for themselves why the patient
is in treatment, what patient and therapist hope therapy will achieve, what
the dominant transference and countertransference configurations in the
case have been, what the current problems, tasks, resistances and other
struggles are that they face, and so on. This exercise, which is analogous to
the Barangers’ ‘second look’ (Baranger et al., 1983), often leads to col-
leagues’ wondering why they have not already thought about or recom-
mended intensifying the treatment and to a closer study of the mutual
resistances and struggles that have been exposed and joined in the current
treatment. Whether or not the given patient goes on to accept the recom-
mendation for more intensive work or analysis, this exercise often helps ana-
lytic therapists become more effective in their current settings, as they
refocus on the fears and resistances evoked by the treatment and articulate
what has to be addressed and worked through.
A female colleague was struggling in a twice-weekly psychotherapy with a middle-
aged man, who had felt incompetent and unlovable as a child, because of a pro-
nounced stutter. He described himself as rejected because of his defectiveness by his
own father, whom he longed to be close to and yet kept at an emotional distance.
As she described the case, my colleague realized her previously unrecognized uncon-
scious identification with the patient’s father. She, too, had been ‘turned off’ and
pushed away by her patient’s approach–avoidance form of relationship, which she
now realized reflected his fears of exposure and rejection and was akin to ‘psychic
stuttering.’

The patient further described how as a child he felt dismissive of his speech thera-
pists, because the exercises they gave him were too simple and did not accurately
reflect his potential for growth. While the latter communication presumably served
to deny his all too apparent and emotionally painful speech defect and insisted on a
compensatory, grandiose assessment of his potential, it also raised the possible
opening for a consideration and more direct discussion of whether or not the
patient felt that the therapist, too, was failing to see his native intelligence and
capacity beyond the superficial exterior of his manifest (psychic) stutter.

From this perspective, was not recommending analysis or an even more intensive
form of therapy a repetition or enactment of the patient’s traumatic past? Seeing
the case in these terms, my colleague was better able to be aware of and think about
her previously unrecognized countertransference, more specifically address some of
the dominant transferences and resistances in the therapy and resolve an uncon-
scious, jointly created countertransference resistance, which paved the way for her
eventually raising the possibility of analysis with this patient.

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 Creating analysts, creating analytic patients 1397

IV. Additional considerations of technique

De-centering oneself from the day-to-day status quo of the treatment in
order to ‘think analytically’ about one’s patients can have the effect of rein-
forcing or re-starting an internal dialogue within the mind of the analyst
about the optimal and most appropriate frequency of meetings for the treat-
ment. Introducing the question of session frequency directly into the initial
session may have a similar impact upon the patient.
For example, towards the end of an initial session, once it becomes clear
that the patient and I are comfortable with meeting again to explore further
what the terms of our working together might be, I find it useful to ask the
patient when he or she would like to come back to see me. This often evokes
a surprised response in the order of ‘I assumed that in therapy you meet
once a week’ or sometimes a more considered question, such as ‘What are
the options?’ Asking the patient what he or she thinks or would like can
help initiate or reinforce a tone of exploration and collaboration in the treat-
ment and indicate to the patient that the structure of the treatment is pair
specific, is a subject for mutual consideration and can be tailored to the
needs of the individual.
At times, the patient’s initial request regarding frequency of meetings may
have specific, symbolic psychological determinants that must be analyzed, if
the patient is to achieve freedom of choice in the matter.
A colleague from an Asian country contacted me and requested treatment. She was
a mental health professional who was very interested in analysis, but practiced in a
location where analytic training or analysis was not readily available. Her husband
had come to the US for a prolonged period of time on a professional assignment
and she wished to take advantage of being here to have an analysis.

Since her English was at first very limited and I could not speak her native tongue,
I was concerned that language would be a problem. Initially, I struggled to under-
stand her heavily accented English and found myself wanting to pull away from her.
She felt ‘strange,’ ‘incomprehensible’ and ‘too foreign’ to take into treatment.
Despite this initial response, I continued to meet with her and soon found myself
forming a picture of her internal world.

During an extended consultation period, I was able to make a clarifying interpreta-

tion that she seemed to find useful and to which she associated in a way that felt
hopeful to me. This more familiar sequence led to my feeling confident that I could
internally form the image of an analytic process occurring between us despite our
language problems. I told her that if she felt comfortable I thought that we could
work together and, when she agreed, I asked what her thoughts were about how
often we should meet. She described her financial situation and suggested twice-
weekly meetings. I asked why she chose this frequency and she then told me that
she had had some analytic therapy back home with the one trained analyst in her
area. Despite her initial request for a more standard analytic schedule, however, she
had been limited to once and occasionally twice a week sessions. I asked how this
came about and she told me that, since he was the only analyst in the area, he was
very busy, worked with other, sicker patients who needed him more than she did,
and that he only had one or two sessions per week to give to her. In her culture,
she told me, it was considered very bad form to ask for more than what was

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1398 H. B. Levine
offered, especially from one’s respected elders. She also feared that, since he was
old, the strain of working too long and too hard might be dangerous and overly
taxing for him. This latter comment struck a resonant chord as she had told me
that her mother, who had been a hard-working professional, had died of cancer
when my patient was 13 years old. In my mind, the picture began to form of an
unresolved grief reaction in regard to mother’s death and guilt produced by their
many conflicts.

As we explored these issues further, we learned that my patient really wanted to

meet with me more often than twice a week, but feared that, like her previous thera-
pist, I, too, would be too busy to give her all the time she desired. She did not want
to ask for more than I was prepared to give and feared burdening or overtaxing me
or being responsible for my falling ill. Once this fear was clarified, she requested
and we began to meet three times per week. But there was more to the story as I
wondered with her: ‘Why three sessions and not four or five?’

Still further exploration revealed that, in her native language, the ideogram for the
number ‘four’ had embedded within it the symbol for the word that meant ‘death.’
In her culture, four was considered an unlucky number and subjectively, the fourth
session was, for her, the ‘death session.’ Thus, at a less conscious level, she could
not initially ask to meet four times per week for fear that I might be damaged or
destroyed by the strain of having to meet her demands or put up with her conflicts
and anger should her demands be refused, as she unconsciously feared had been the
case with mother and mother’s cancer!

Once these meanings and their associated fantasies, conflicts and anxieties were
clarified and worked through, the analysis proceeded at a frequency of four times
per week. Her feelings of culpability in mother’s cancer and death and her need to
mourn her mother’s loss continued to be important features of her analysis and
were engaged and worked through to good effect on a number of levels. In addition,
my initial response to her as ‘foreign’ and ‘other’ proved to have interesting corre-
lates in her history and complex and conflicting attitudes towards the ‘foreign’
American troops who had bombed and conquered her homeland and yet had also
defeated the military industrial complex that she felt had perverted her traditional
culture and its structures of authority.
The lesson that this instance so graphically portrays is that the very
choice of session frequency may be intimately and inextricably related to
the patient’s underlying unconscious conflicts and fantasies and more sym-
bolically specific than simply a matter of external factors (time, money,
expectations, etc.) or a general response of resistance arising from fear of
what may emerge or be discovered in the course of a psychoanalytic
treatment.
Once a therapy is under way, there may be value in specifically drawing
the patient’s conscious attention to the impact of the spaces and the time
that elapses between sessions within the ongoing treatment schedule. Some-
times it is the patient who will open up the opportunity to do so by indi-
rectly calling attention to the gap through a long opening silence or by a
seemingly ‘innocent’ remark, such as ‘What were we talking about last
time?’ or ‘Where did we leave off last session?’ Comments such as these have
the potential to alert both patient and analyst to an erosion of focus or

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 Creating analysts, creating analytic patients 1399

affective intensity that has occurred in the gap between sessions and that
the gap may be working to dilute intensity and ⁄ or affect.
At times, and from the perspective of the patient’s defenses, this dilution
may not at all be unwanted. It may even be a part of a patient’s more
unconscious, global defensive strategy to diminish affective intensity and
slow down the process of self-exposure or confrontation with the limits of
reality or change or a reflection of a return to indeterminacy and stasis
reflective of non-neurotic states of mind. Whatever the underlying issues,
whether the gaps are welcome or inadvertent impediments to the progressive
goals of the treatment, whether they reflect represented or unrepresented
states of mind, directing the patient’s attention to what happens to thoughts
and feelings in the time between sessions and their impact on the treatment
process may have a salutary effect in helping to mobilize the exploration
and analysis of the patient’s resistances to treatment and ⁄ or the way in
which the very structure of the treatment is working against jointly shared
therapeutic goals.
Anna Freud (1936) observed that, from the perspective of the patient’s
ego, the analyst’s presence and interventions threaten to destabilize the
patient. The prospect of relaxing or relinquishing defenses aimed at avoiding
the recognition of contents and feelings that produce anxiety is not always a
comfortable or pleasant one, even if the patient also recognizes that such
work is required in order to relieve them of the painful and distressing
symptoms that have brought them to treatment. Frequently, we discover that
the very methods by which patients have been trying to protect themselves
are the source of the symptoms and dissatisfactions that have caused them
to seek treatment. Although Anna Freud (1936) described this process in
relation to the ego’s repression of unacceptable, drive-derived wishes and
painful past memories, the same reasoning holds true for the integration
and unification of disparate (split off and ⁄ or dissociated) parts of the psyche
and for the very process of change, which for some patients can only be
imagined as catastrophic (Bion, 1970). What this means in effect is that, as
soon as the patient begins to contemplate or imagine the idea of treatment,
analysis or otherwise, the patient is likely to be in an ambivalent state of
mind about what its impact or consequences will be.
Once treatment is begun, the fears and terrors attendant upon self-
discovery, acknowledgement and acceptance of reality and the prospects of
change will be mobilized. These then underlie and are inherent in the vari-
ous forms of transference and resistance that are encountered and need to
be resolved. Indeed, it is the exploration, analysis and working through of
these transferences and resistances that may constitute an important core of
the analytic treatment process no matter what the frequency of meeting.
From the perspective of the analyst’s recommending an increase in fre-
quency or a change from analytic therapy to analysis, a key consideration
will be the assessment of the balance within the patient at any given moment
between the fears of exposure, self-knowledge and change on the one hand
and the hopes for symptom relief and emotional growth on the other. In
this context, an invitation to more intense therapeutic involvement is an
invitation to the patient to risk exposing themselves to more threat or to an

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1400 H. B. Levine

even greater expenditure of energy to keep that threat at a distance. Thus,

timing of the invitation to analysis must be borne in mind, with the princi-
ple being that the more the patient is feeling the need for contact and sup-
port, the more the patient is feeling that the treatment is helpful in reducing
terror and anxiety, the more the patient has experienced at first hand the
progressive, helpful aspects of the work of analyzing in containing, trans-
forming and reducing terror and anxiety, the more the patient is in a state
of transference towards the analyst and the treatment itself that tilts towards
the realistically positive, the more likely the recommendation for increased
frequency will be to succeed.
Recognizing that the balance in the patient’s mind between hopes and
fears may be a precarious one implies that, while most patients may deserve
and benefit from an intensification of therapy or a trial of analysis, helping
them to reach a place of comfort and safety where they can risk accepting
that recommendation may be a lengthy process that will require considerable
analytic work aimed at reducing anxiety, demonstrating that treatment is
safe and showing them that change can be tolerated.
In some instances, analysts’ recommendations for increased frequency or
analysis are a response to the frustration and helplessness that they feel upon
coming up against the powerful resistances of a very disturbed and frightened
part of the patient. In such instances, the invitation to intensify treatment
both mobilizes and is in part initiated by the very conflicts and forces within
the patient that militate against any possibility that the invitation will be
accepted. In effect, analysts may wind up asking patients who are already ter-
rified and threatened by the treatment that is under way to consider exposing
themselves to even greater levels of terror and threat, before they have
offered patients a sufficient opportunity to analytically reduce or master
those intense feelings. No wonder such offers are so often refused.
A 30 year-old married woman sought therapy for distress at work – she felt that
her boss did not understand her, appreciate how hard she worked or care about her
development as a unique individual – and difficulties in her marriage to a husband,
who was unemployed and was beginning to drink to excess. Her past history
included intellectual precocity as a child and a mother who was physically abusive,
at times psychotic, and may have even tried to murder her.

Using her work schedule as a rationale, this patient would initially agree to only
once-weekly therapy. When her husband’s drinking intensified to the point of crisis,
she accepted the invitation to meet twice-weekly on the grounds that it would offer
her more support in her time of need. Despite this intensification, however, in her
sessions, she remained ‘reality bound’ and problem oriented, with a tendency to
externalize and a reluctance to look at her own self. She refused to consider her
therapist’s recommendation for an even more intense schedule of meetings.

A telling metaphor, which the patient used to describe her mind, was that of a clo-
set filled with row upon row of sealed boxes, many of which were unlabeled. She felt
that she could not afford to risk opening them up to see what was inside for fear of
what she would discover, what would emerge or what her therapist would come to
realize about her.

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 Creating analysts, creating analytic patients 1401
Unconsciously, she tried to manage her relationship to her female therapist by keep-
ing the latter in the position of a good, helpful mother figure and could do so only
at the cost of ‘never opening up the boxes.’ Consequently, while the treatment was
helpful at a supportive level, it showed little sign of deepening or moving towards a
freer, more reflective ‘analytic’ exploratory engagement. Her stability was supported,
but at the cost of psychic development and progressive change.

The therapist found herself frustrated and continued to want to recommend a more
intensive treatment but, for reasons that she initially did not understand, could not
do so. She found herself thinking that they ought to meet three, rather than four or
five times per week. In this therapist’s mind, the latter was the ‘usual’ analytic sche-
dule and she recognized that, in considering offering this patient something less
than usual, some countertransference determined reluctance might be at work.

Upon consultation with colleagues, it became clear to the therapist that her wish to
intensify the treatment reflected in part her frustration with the stasis that had
developed in the process – no ‘boxes’ were being opened – and with the narrow
range of affective personal contact allowed by the patient’s severely restrictive
defensive style. Her colleagues suggested that, at the same time, her reluctance to
imagine a fourth or fifth session per week for this patient may also have reflected
her ‘absorption’ of the patient’s projected self-image of having a mind and self that
were filled with things (‘boxes’) that were too dangerous to open and her anger at
the patient for being so frustrating in regard to her own therapeutic ambitions and
wishes for greater human contact. This suggestion helped the therapist begin to
consider that she had indeed been blocked in her view of the treatment possibilities.

It is also likely that, in addition to the represented metaphor of the boxes, the very
stasis of the situation itself reflected the presence in the patient of not yet or only
weakly represented mental states. The disruptive force that these exerted within both
members of the dyad worked against any possible forward progress of the treat-
ment. This, too, was weighing upon the therapist who was both the target of and
identified with these forces within the patient. As a result, the therapist was feeling
discouraged, devitalized and lacked appropriate hopefulness and resiliency within
the hours and within her own mind in relation to this treatment.

Further clarification within the group of the complex transference–countertransfer-

ence situation that seemed to obtain between this therapist and her patient – each
was at some unconscious level felt to be the murderous mother destroying the mind
and hope of the other – and of the ambivalence and complexity of the patient’s
unconscious relationship and attitude towards the treatment, helped focus the thera-
pist on the issues and anxieties that had to be addressed and worked through in
both parties.

In this case, the act – in addition to the content – of the consultative clarification,
itself, may have been necessary, in that it helped reinstate an alive and progressive
working couple – the therapist and the group – in addition to or in place of the frozen
stalemated patient–therapist couple in the mind of the therapist and subsequently in
the dyad. For the therapist, this new development helped remobilize her capacity to
feel and think creatively and analytically with and about this patient. For the
patient, the presentation of a more enlivened object in the transference helped alter
the deadly stasis that had begun to grip the analytic encounter. Together these
changes held out the potential of mobilizing and deepening the treatment, even at

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1402 H. B. Levine
its current frequency of meetings. And eventually, as the treatment deepened, these
changes helped the therapist to better assess and reduce the patient’s feelings of ter-
ror and threat, so that a recommendation of analysis would be able to be accepted.

V. Summary and conclusions

I have broadened the definition of analysis to include ‘transformational’ as
well as ‘archaeological’ dimensions of treatment and argued for a view of
analyzability as an emergent, dyadic, intersubjective process heavily influ-
enced by the attitudes and actions of the analyst, rather than something that
is inherent in the character of the patient alone. From this perspective, the
possibility of establishing an analytic setting does not depend solely upon
pre-existing qualities of the patient’s ego strength, but on the capacities of
the dyad, including newly formed or strengthened capacities that may
emerge as a part of the work of the analysis. This view diminishes the ‘pre-
conditions’ for beginning analysis and allows analysts to cast a much wider
net in the search for potential analysands by alerting them to the possibility
– indeed, the necessity – of creating, rather than simply discovering, analytic
capacities in our patients. The latter capacities are pair specific and inti-
mately connected to the quality of the analyst’s psychic functioning and par-
ticipation. These attributes, in turn, rest upon the twin foundations of a
strong analytic identity and a positive attitude towards the possibilities of
analytic treatment,10 which are of fundamental importance, because they are
what will:
• Support the analyst’s ability to maintain an analytic perspective and
attitude towards all that transpires within the therapeutic relationship
from its very inception.
• Support the analyst’s capacity to maintain in his or her mind the vision
of an analytic process with a given patient even in the absence of a clas-
sical analytic discourse.
• Support the analyst’s determination to analyze and use analytically
whatever emerges in the patient or within the analyst’s self, rather than
to respond only at the level of objective reality.
Concurrently, for the patient, these attributes and capacities of the analyst
will provide the greatest opportunity for a first-hand, positive analytic expe-
rience, for the development of hope in the possibilities of the treatment and
the strength to risk engaging in an intensive analytic therapy.

Translations of summary
Über das Erschaffen von Analytikern und Patienten. Diese Abhandlung verfolgt eine zeitgençssi-
sche, ,,zweigleisige’’ – transformative wie auch archologische – Sichtweise des psychoanalytischen Proz-
esses hinsichtlich klinischer Fragen bei der Schaffung analytischer Patienten: Fallfindung, Empfehlung
zur Psychoanalyse sowie Empfehlung und Aushandlung einer Erhçhung der Stundenfrequenz in der ana-

10
The latter is not simply a matter of adopting a voluntarily positive stance, but includes a commitment
to exploring, within ourselves and with friendly colleagues, the inevitable doubts, hesitancies and
resistances – even at times the sheer hatred! – toward the analytic endeavor that may arise (Scarfone,
personal communication).

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 Creating analysts, creating analytic patients 1403
lytischen Psychotherapie. Zentrale Bedeutung wird der Rolle der Psyche und der analytischen Identitt
des Analytikers beigemessen. Dazu gehçren die Fhigkeit des Analytikers, einen inneren analytischen
Rahmen aufrechtzuerhalten und die Haltung vom allerersten Kontakt mit dem Patienten an ber die ges-
amte Behandlung hinweg zu analysieren, das Vertrauen des Analytikers und seine berzeugung ber die
Ntzlichkeit einer gegebenen analytischen Dyade und die Rolle der Theorie des Analytikers, die umfas-
send und folgerichtig genug sein muss, um dem Analytiker das Gefhl zu ermçglichen, dass er oder sie
analytisch handelt, wenn nicht-neurotische (nicht und schwach reprsentierte mentale Zustnde) wie auch
neurotische Strukturen angegangen werden.
La creación de psicoanalistas y de pacientes psicoanalı́ticos. El presente artculo aplica una per-
spectiva contempornea de ‘dos pistas’ – una transformacional y otra arqueolgica – del proceso psico-
analtico a temas clnicos relacionados con la creacin de pacientes psicoanalticos: el hallazgo de casos,
la recomendacin de anlisis, y la recomendacin y negociacin de la intensificacin de la frecuencia de
sesiones en psicoterapia psicoanaltica. Se asigna una importancia central al papel que desempeÇa la
mente y la identidad analtica del analista. Esto incluye la capacidad del analista de mantener un marco
analtico interno y una actitud analizadora desde el primer contacto con el paciente y a lo largo de todo
el tratamiento, la confianza y conviccin del analista respecto a la utilidad del anlisis para una diada
analtica determinada, y el papel de la teora del analista, que debe tener la amplitud y coherencia que le
permita sentir que est trabajando analticamente cuando aborda estructuras tanto no neurticas (esta-
dos mentales no representados y dbilmente representados) como neurticas.
Créer des analystes, créer des analysants. Appliquant aux probl mes cliniques une conception actu-
elle du processus analytique – base sur un double point de vue, le point de vue transformationnel et le
point de vue archologique, l’auteur de cet article examine la question de la cration de patients analy-
tiques: cas d’indications d’analyse, recommandation d’analyse, recommandation et ngociation relatives

l’intensification de la frquence des sances de psychothrapie analytique. L’accent est mis essentiellement
sur le rle du psychisme et l’identit analytique de l’analyste, y compris la capacit de l’analyste de main-
tenir un cadre analytique interne et une attitude analytique d s la premi re rencontre avec le patient et
tout au long du traitement, la confiance de l’analyste en et sa conviction de l’utilit de l’analyse pour un
couple analytique donn, ainsi que le rle de la thorie de l’analyste, celle-ci devant Þtre suffisamment
tendue et toffe pour lui permettre de sentir qu’il fonctionne sur un mode analytique qu’il ait affaire

des structures non-nvrotiques (tats psychiques o les reprsentations font dfaut) ou nvrotiques.
Creare degli analisti, creare dei pazienti analitici. Questo saggio applica una prospettiva contempo-
ranea, a ‘doppio binario’ – trasformazionale e archeologico – al processo psicanalitico riferito a prob-
lematiche cliniche nella creazione di pazienti analitici: individuazione dei casi, proposta di analisi, e
proposta e discussione sull’intensificazione della frequenza delle sessioni di psicoterapia analitica. Viene
assegnata importanza fondamentale al ruolo della mente e all’identit
analitica dell’analista, inclusa la
sua capacit
di mantenere una struttura analitica interna e un atteggiamento analitico sin dal primissimo
contatto con il paziente e per tutta la durata del trattamento; la fiducia dell’analista e la sua convinzione
dell’utilit
dell’analisi per una data coppia analitica; e il ruolo della teoria dell’analista, che deve essere
sufficientemente ampia e coerente da permettere all’analista di avere la percezione di operare in modo
analitico sia quando affronta strutture nevrotiche (stati mentali non rappresentati o debolmente rappre-
sentati) sia strutture nevrotiche.

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