CIPS board member, Marilyn Rifkin, LICSW, FIPA submitted the following review of a paper by Allan Frosch, PhD, FIPA recently published in Psychoanalytic Review (February 2011). This paper entitled, The Effect of Frequency and Duration on Psychoanalytic Outcome: A Moment in Time, considers an issue central to all of us endeavoring to practice psychoanalytically in an age endlessly fascinated with ever faster transmission of data and “solution oriented” forms of mental health treatment.

The controversy over the issue of frequency of sessions in analytic treatment is ongoing—and quite heated. It belongs to the larger debate as to what, exactly, psychoanalysis is and how to practice it. In the 1950s the IPA attempted to resolve the debate over frequency by setting up a study group (Alexander, Bibring, Fromm-Reichmann, Gill, and Rangell). Yet, “after five years of deliberating”, the study group “could not arrive at a consensus.” Psychoanalysts “ended up agreeing to disagree and went their separate ways” (1). In 2005 New York State passed a licensing law for psychoanalysts. That law does not specify that psychoanalytic treatment should involve several sessions per week. Many members of the IPA objected and chose not to be licensed under the law. The "FIPA" credential was created in response and has been given to North American members of the IPA in order to assist the public in identifying psychoanalysts trained within the standards of IPA Constituent Organizations. Such standards reflect the view that psychoanalysis is best conducted at a high frequency of sessions.

In recent years, there has been a plethora of psychoanalytic outcome research aiming to delineate, more clearly, how psychoanalysis should define itself. In his rich, thought-provoking, well-argued paper, The Effect of Frequency and Duration on Psychoanalytic Outcome: A Moment in Time, Allan Frosch endeavors “to synthesize input from various components in the overall system of outcome research.” Frosch declares himself an analyst who believes that high-intensity psychoanalysis (3 to 5 times per week with “a duration that is open-ended and measured in years”) is the treatment of choice. His belief, he says, is based on his “institutional affiliations and experience from both sides of the couch,” as well as his own research on frequency/duration and outcome (2). He adds the proviso that his explication of the “facts” in his paper is therefore “embedded in this subjective context.”

Frosch first asks, “What is Psychoanalysis?” In attempting to answer this, he asserts that frequency and duration “may define optimal psychoanalytic treatment but do not define the process itself”. Psychoanalysis, for Frosch, is seen along a continuum. Indeed, he does not distinguish between psychoanalysis and psychoanalytic psychotherapy. He does distinguish between more intense and less intense forms of psychoanalytic treatment.

Freud, in 1914, insisted that the patient’s work on the transference and resistance in sessions was the aspect of the work that effected “the greatest changes in the patient.” He declared that this is what distinguished analytic treatment from other forms of treatment (3). For a good many analysts, the primary aim of psychoanalysis continues to be the resolution of transference and resistance as conceptualized by Freud. So how does the frequency/duration of sessions relate to this aim?

Frosch believes that psychoanalysis has evolved from the model of a “relatively” closed system to an open system. He cites Hans Loewald’s (4) seminal paper on the therapeutic action of psychoanalysis as helping to shift the emphasis.  Frosch notes that this shift affects how we understand the resolution of the transference, for an open system allows the idea that “the affective presence of the analyst makes a difference”. An open system embraces the idea that “the internalization of the positive relationship with the analyst is a crucial aspect.”

For Frosch, the working through of transference fantasies—and countertransference fantasies—“in the heat of the moment” can provide a theoretical basis for more intensive treatment. He also acknowledges that greater frequency helps the analyst gain access to unconscious material (both in the analysand and in the analyst) more consistently and in greater depth.

In the remainder of the paper, Frosch discusses various outcome studies that utilize the concept of internalization—albeit differently from one another. Yet, he feels that Loewald’s approach is the common denominator. The internalization of the therapeutic relationship as a “soothing and helpful inner presence” seems to be central and the interaction of frequency and duration is seen as a “powerful variable affecting outcome” in terms of such internalization.

The “emergent pattern of meaning” from outcome research is that for most people in psychoanalysis, high intensity treatment leads to a better outcome compared to low intensity treatment. But Frosch is careful in acknowledging the “inconclusiveness” of outcome research. After all, he declares, “there are many ways of generating data and many potential interpretations of the data.” Any “emergent pattern of meaning” is necessarily “embedded in the context of subjectivity.” This, of course, is equally true in the clinical practice of psychoanalysis.

NOTES
Frank, G. (2011). Theoretical and practical aspects of frequency of sessions: The Root of the Controversy. Psychoanal. Rev., 98 (1). Freedman, N., Hoffenberg, J.D., Vorus, N. & Frosch, A. (1999). The effec- tiveness of psychoanalytic psychotherapy: The role of treatment duration, frequency of sessions, and the therapeutic relationship. J. Amer. Psychoanal. Assoc., 47:741–772. Freud, S. (1914). Remembering, repeating and working-through. Standard ed., 12:147–156. Loewald, H. (1960). On the therapeutic action of psychoanalysis. Internat. J. Psychoanal., 41:16-33.