Some effects of the consultation-referral process on subsequent analytic work

Attention is drawn to some possible consequences of our usual consultation and referral procedures in psychoanalysis. Using four clinical illustrations, it is suggested that the consultant may play a much more significant role in the patient's psychic life than we might expect. He may have an important part in the transference neurosis that subsequently develops; he may be drawn into fantasies in relation to the treating analyst that mobilize very powerful transference resistances. Not only can these retard the development of the analytic process, but they can potentially prevent an analysis from occurring. This type of material seems regularly to be excluded from the analysis by the patient. Although the analyst knows that something is interfering, he cannot determine what it is until the patient is able to tell him. Three explanations are offered for why such material is denied access to the analysis. First, the consultation as a "special event" or "extra-analytic contact" stirs more anxiety than we may realize, may be handled as a minor trauma, and be repressed. Second, the fantasies about the consultant and his relationship to the treating analyst are often difficult, especially for the sicker patient, to distinguish from reality, especially with the relative absence of observing ego. Third, the patient may be too uncomfortable with such realities as the analyst's youth and inexperience. Certain circumstances, such as a wide disparity between the status of the consultant and the treating analyst, may predispose the patient to develop early fantasies that relate to both of them. The presence of special circumstances should alert us to the likelihood of there being such hidden fantasies as described here.