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Endings and Beginnings: On terminating psychotherapy and psychoanalysis
Abstract
In this second edition of Endings & Beginnings (Routledge, 2006), Herbert J. Schlesinger explores endings and beginnings within psychoanalysis and psychoanalytic therapy; both the obvious main endings and beginnings of any course in treatment, and the many little endings and beginnings that permeate analysis. The second edition contains new chapters including one on transference and counter-transference as sources of information about the process of therapy and as sources of difficulty in ending. it deals especially with the impact of prospective ending on the therapist, which if not understood and well handled, might interfere with working through and impede termination, if not ending itself. Another new chapter deals with the difficulties in terminating with especially narcissistic patients.
... This was in order to analyse interactions taking place across the course of the therapy. First and final sessions were avoided on the basis that, according to psychoanalytic theory (e.g., Cregeen et al., 2017;Schlesinger, 2014), these are expected to contain specific features in virtue of their position, which was not the main focus of this study. Where the second, median or penultimate session was not available (e.g., had not been recorded), the session immediately following was used. ...
... Am I the Only One Mourning Here? The Impact of Amnesia on the Analyst's Countertransference during Termination It has long been noted -based on the observation of neurologically healthy individuals-that the elaboration of countertransferential feelings during the end of treatment is a particularly difficult challenge for analysts (Schlesinger, 2014). However, an interesting question that remains to be addressed is whether brain damage adds further complexity to such elaboration. ...
Individuals with profound amnesia are markedly impaired in explicitly recalling new episodic events, but appear to preserve the capacity to use information from other sources. Amongst these preserved capacities is the ability to form new memories of an emotional nature – a skill at the heart of developing and sustaining interpersonal relationships. The psychoanalytic study of individuals with profound amnesia might contribute to the understanding the importance of each memory system, including effects on key analytic processes such as transference and countertransference. However, psychoanalytic work in the presence of profound amnesia might also require important technical modifications. In the first report of its kind, we describe observations from a long term psychoanalytic process (72 sessions) with an individual (JL) who has profound amnesia after an anoxic episode. The nature of therapy was shaped by JL’s impairment in connecting elements that belong to distant (and even relatively close) moments in the therapeutic process. However, we were also able to document areas of preservation, in what appears to be a functioning therapeutic alliance. As regards transference, the relationship between JL and his analyst can be viewed as the evolution of a narcissistic transference, and case material is provided that maps this into three phases: (i) rejecting; (ii) starting to take in; and (iii) full use of the analytic space – where each phase exhibits differing degrees of permeability between JL and the analyst. This investigation appears to have important theoretical implications for psychoanalytic practice, and for psychotherapy in general – and not only with regard to brain injured populations. We especially note that it raises questions concerning the mechanism of therapeutic action in psychoanalysis and psychotherapy, and the apparent unimportance of episodic memory for many elements of therapeutic change.
... Others, like Novick and Novick (2006), write of termination as a discrete phase with specific tasks beginning with the setting of an agreed upon ending date. Schlesinger (2014), too, reserves the use of the word "termination" for a planned and agreed upon end date when most of the therapeutic goals have been achieved, yet he uses a helix model to reflect the cyclical nature of therapeutic work. Still others (Gabbard, 2009;Hoffman, 2001), myself included, claim that a linear paradigm-beginning, middle, and end-does not adequately represent the messiness or unique and idiosyncratic nature of the trajectories of individual analyses. ...
This article addresses the complex process of termination in psychoanalysis. Implicit in self-consciousness is the knowledge of death; similarly, one begins treatment knowing that it must end. It is argued that the end is always present in the beginning of treatment and, conversely, termination leads back to the onset of analysis. It is also proposed that termination issues, rather than represent a phase in the treatment, are present throughout the analysis. Terminations are different from endings in that terminations are inevitably incomplete. A case is offered to illustrate these points and to show some of the challenges encountered even when termination is mutually planned and agreed upon. Although the word termination implies finality, artful termination involves transcending the need for the analytic relationship while continuing the work of insight and relational transformation.
... notable exceptions of Bostic, Shadid, and Blotcky (1996); Schlesinger (2005), and Zuckerman and Mitchell (2004), our review of the literature indicates that there is only a minimal amount of published research on the consequences of premature termination or the transfer of long-term psychotherapy cases. This article is an attempt to identify and explore the most commonly encountered patient-and therapist-related phenomena that can confound the successful execution of a transfer. ...
This article reviews patient and student-therapist variables thought to confound the transfer or forced termination phase of long-term psychotherapy conducted in training settings. Previous literature has demonstrated that not adequately attending to this critical juncture in treatment often results in the failure or disruption of therapy. Particular emphasis is placed upon examining the effects of countertransferance phenomena resulting from the student-therapist's necessary affective investment in the patient, and how these reactions may undermine the transfer process and the course of psychotherapy. The authors offer suggestions for supervisors in assisting student-therapists to provide more effective treatment at the transfer juncture.
Establishment of clear outcome measures, along with timely evaluation of interventions, is critical to understanding what works for the client. This chapter will discuss the therapeutic alliance and its influence on the success of therapy, provide an overview of outcome measurement and change indicators, present strategies for analysis, and discuss effective data collection methods. Measurement tools available to evaluate the strength of the therapeutic alliance and the efficacy of common psychotherapeutic treatment modalities will be explored. Key principles and challenges of evaluating psychotherapy will be described, along with recommendations for nurse psychotherapists to evaluate the care they provide. Lastly, the importance of culture-specific evaluation measures will be discussed, followed by the reinforcement of key concepts via a case example.
This article draws on Winnicott's concept of the good enough mother to discuss how to know whether a therapeutic situation is good enough to continue or bad enough to end. This dilemma is explored in terms of clinical syndromes, such as anorexia and pathological gambling, but focuses mainly on analyst-initiated endings, which are termed the 'Casablanca dilemma', based on an amplification of the ending of the film Casablanca. The author goes on to discuss such one-sided endings, drawing on interviews with 40 analysts and therapists about their clinical experience. A typology of bad enough endings is presented. The psychological differences between a good enough analysis as opposed to a bad enough one are explored through the ideas of Winnicott and Neumann.
Ending treatment is inevitably filled with multiple and disparate losses for the analytic dyad. The author sets forth a call for reconsidering termination from a Relational perspective. She argues that many, if not all, terminations, are primed for enactment. The mutual processes of attaching and detaching, of growing close and then saying goodbye elicit powerful feelings and equally powerful dissociative processes. Specifically, she suggests that termination can be understood as co-created enactments of complex unconscious processes between patient and analyst. There is some necessary integrative work that may possible only when ending treatment. Key to this integrative work is the acceptance of both the achievements and the limitations of analytic work for both participants. She argues that we need to suspend our analytic ambition and begin to formulate what a co-created and mutually enacted good-enough ending would look like.
Certain problems in defining the psychoanalytic process emerged during the five years in which a COPE study group was attempting to clarify the concept. There was agreement about the bed-rock criteria to be included in a definition: e.g., transference, resistance, a dynamic unconscious, intrapsychic conflict, defense, infantile sexuality, insight which causes change, and change which brings insight. The disagreements centered on the locus of the psychoanalytic process, the best way to conceptualize change, and the methodological problem of validating whether specific interventions cause specific claimed effects. Confusion about how to account for the interactional aspect of the psychoanalytic situation in a manner consistent with a one-person psychology emerged as an important source of the difficulty in arriving at a satisfactory definition of the psychoanalytic process.
This chapter explores the psychological state of boredom from the psychoanalytic perspective. Boredom appears to be a state of drive-tension in which the drive-aims are repressed; yet the tension as such is experienced, and therefore one turns to the external world for help in the struggle against repression. This formula, which is correct but not specific, makes the "inability to become stimulated" somewhat more comprehensible. The mechanisms of pathological boredom are discussed, as well as the mechanisms of "normal" boredom. Additionally, the relationship between the perception of boredom to the passage of time is examined. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The author discusses the problem of so-called 'interminable' analyses with reference to 2 case outlines. The pathology of the 2 female patients derived from maternal deprivation in early childhood. Dependency on siblings and overwhelming introjections entailed the transference of dependency onto the therapist as well as the fear that the patients would again be flooded by introjections upon the termination of the analysis.
This paper presents a pilot study in which we explore the possibility that the match between analyst and analysand is a factor of central importance in the analytic situation. It is an attempt to look at the issue of match across a large number of patients. The data we used were not collected for studying this topic; thus, the study has serious limitations. Nevertheless, certain patterns emerged which support our thesis that patient-analyst match plays a significant role in the outcome of psychoanalysis. We present this work as a first step in developing concepts and methods which will be pursued in a more systematic and rigorous fashion in a later study.
Termination is a post-Freud contribution to the psychoanalytic process, which is never complete. The concept is illuminated in its analytic history and development. A formal well-defined terminal phase led to a tripartite psychoanalytic process which derived from and contributed to advances in psychoanalytic theory and knowledge. The terminal phase is a valuable addition and conclusion, but may be invested with irrational expectation and analytic myth. Various features and formulations of the terminal phase are explored, and the limitations of termination are noted.
The forced termination of psychoanalysis, such as occurs when the analyst makes a geographic move, uniquely disrupts the analytic setting. This paper recounts the author's experience of terminating a full-time private practice of psychoanalysis and psychoanalytic therapy for such a move. The limited literature on the subject is reviewed with a focus on the use of technical variation in the forced termination situation. The author delineates three areas of interaction with patients where technical variation proved in her experience to be of value: dealing with countertransference and counter-reaction, providing information about the move, and the consideration and process of referral for continued therapy. As opposed to what would be predicted from a classical psychoanalytic perspective, the use of such technical maneuvers seemed to facilitate rather than impede analytic work. These variations in technique served at crucial times to maintain the analytic alliance, to preserve the patient's capacity to recognize and make use of transference, and to provide avenues for resolving past traumas in the transference and the actual loss of the analyst. The concept of the analyst as a new or useable object is proposed as providing a theoretical framework for understanding these observations.
Freud's paper is re-examined and placed in biographical and historical context, Moses and monotheism (1934-1938) is treated as a parallel text. Freud's ironic scepticism is viewed against the background of Thomas Mann's 1936 idealization of psychoanalysis. Freud was a sick and dying man in 1937 with every reason for personal pessimism. The political setting was the triumph of fascism in Austria and the impending seizure of Austria by Hitler. Freud fantasized the protection of psychoanalysis by the Roman Catholic Church. The paper is a polemic against the theories of Ferenczi, Adler, and Rank. Contemporaneous defence of prophylactic analysis by Fenichel is reviewed. Freud's political judgement of the moral equivalence of Social Democracy and fascism is critiqued. Freud's injunction to periodic re-analysis and his vision of analysis as 'unending' is supported. The possibility of intergenerational prophylaxis is presented.
The author suggests that 'Analysis terminable and interminable' should be considered in the context of its particular background of political and scientific history as well as of Freud's personal biographical circumstances. It should not be considered only as a technical discussion. The author looks at Freud's own statements about the paper, together with those of contemporary (Fenichel) and later commentators.
Problems of maintaining psychoanalytic therapeutic effectiveness during a professional lifetime are discussed. Psychoanalysts are subject to paradoxical emotional and characterologic demands, uncompensated by the usual gratifications available in the healing professions. Problems arising from the analyst's character and the paucity of data in the field are discussed. "Burnout" syndromes are liable to occur in those working in a setting of great emotional intensity demanding high degrees of affective awareness and control, empathy and tolerance of uncertainty. Masochistic and narcissistic forms of "burnout" syndrome are described as they occur in psychoanalysts. The profession, as well as the individual, can help to prevent these syndromes.
This paper is a re-examination of the rule of date setting in termination. It reviews the literature and presents an analytic case which was terminated in what the patient called a "natural" manner, i.e., without the setting of a date. Some ideas about the nature of the rules used in organizing analysis are discussed.
This paper is a continuation of an earlier one concerning borderline patients, and I can recapitulate only a few of the many areas touched upon here. The borderline individual is faced continually with the threat of loss, either of his tenuously established individual identity, through fusion with the other person, or of his fragile interpersonal relatedness, through uncontrollable flight into autism of psychotic degree. A basic theme in one's work with these persons is that of unconscious, fantasied omnipotence, variously an aspect of the patient's unconscious self-image or projected into the therapist. The acting-out which the patient does consists in his inflicting loss, deprivation, and other forms of injury upon his introjects of part-aspects of the therapist. The grief involved in the relinquishment of so-called bad introjects is discussed. The patient early in therapy is aware of his inability to grieve, and endeavors to conceal this deficiency by spurious emotionality. I give examples of patients' manifesting regressive dedifferentiation to fusion with elements of the nonhuman environment, as an unconscious defense against feelings of separation and loss. Effective therapy with these patients involves the therapist's deeper working through of his own losses. The significant losses occurred so early in these patients' lives that the therapeutic exploration of these areas may enable the therapist to gain access to comparably early losses on his own part, losses from a developmental era which many a training analysis may not have explored at all adequately.
A method of study is proposed for the assessment and follow up of psychoanalytic treatment. In each case, the samples evaluated include several hours at the beginning of the analysis, at the point of decision about termination, at termination, and in 4 to 6 interviews 2 to 5 yr after the end of the analysis. The data are microscopically reviewed in an analytic manner by a group, including the follow up analyst. The information is then organized according to a schema that includes ego functions entering into the analytic alliance, the defense transference, the special configuration of the Oedipus complex, and dreams. 2 case examples are presented to illustrate the approach and to demonstrate that such a careful effort reveals with some precision the effects of the analytic process and permits an investigation of the nature of the process.
Two major developmental stages exist that have to be achieved in order to establish the normal capacity for falling and remaining in love: a first stage, in which the early capacity for sensuous stimulation of erogenous zones (particularly oral and skin erotism) is integrated with the later capacity for establishing a total object relation; and a second stage, in which full genital enjoyment incorporates earlier body surface erotism in the context of a total object relation, including a complementary sexual identification. A continuum is described in the capacity for falling in love and remaining in love, illustrating this with case material to highlight the particular preconditions that need to be fulfilled at each stage of development of this capacity. Configurations were described on the continuum, ranging from pathology of the most severe types of narcissistic personality structure, through the moderately ill narcissistic personality, the borderline personality organization, the neuroses and the less severe types of character pathology, to normality. (11 references)
This paper calls attention to the importance of understanding the patient and developing an optimal working relationship in which test responses are given both for the diagnostic task, defined narrowly, and for the larger therapeutic purpose for which diagnostic studies are undertaken.
Starting from certain unpublished remarks by Otto Isakower about "the analyzing instrument," we de define it more precisely. The analyzing instrument has two constituents: a voluntary and controlled, situation-specific and goal-specific regressed state of mind in the analysand and a near-identical one of the same nature in the analyst. These parts function together through mutually evocative communication, leading to the elucidation of the analysand's unconscious fantasy-memory constellations.
In this paper, the author has summarised Mahler's views on the initial acquisition of object constancy in early childhood. He then attempts to delineate its vicissitudes during oedipal phase, latency, adolescence, and various phases of adult development. Following this, the author describes, with the help of brief clinical vignettes, six psychopathological syndromes of adult life associated with disturbed object constancy: (i) impaired optimal distance; (ii) persistent splitting of self- and object-representations, with the concomitant intensification of affects; (iii) paranoia; (iv) inordinate optimism and the 'someday' fantasy; (v) malignant erotic transference; and (vi) impaired capacity to mourn, intense nostalgia and the 'if-only' fantasy. Finally, the author outlines the technical implications of these concepts and attempts to show that six tasks seem especially important for analytic work with such patients: (i) safeguarding the analyst's 'holding' function; (ii) interpreting splitting mechanisms, especially as these pertain to negative transference; (iii) maintaining optimal distance; (iv) discerning nonverbal communications, especially through countertransference; (v) encouraging developmental initiatives; and (vi) facilitating mourning, not only of past losses but also of those inherent in the analytic situation. Through all this, the author attempts to highlight, elucidate and extend modestly the work of Margaret Mahler.
Ordinary intellectual capacities can be used for defensive as well as adaptive purposes. The author focuses on how a particular aspect of the intellect--language skills--can serve defensive functions. Using clinical examples, he examines how the defense "mechanism" of isolation operates through the use of common verbal formulas, through the deletion or substitution of conjunctions, through vagueness and indefinite reference. Other expressions of isolation include shifting emphasis away from what is important, excessive generalizing, and the development of an elliptical private language. He concludes with a discussion of how clinicians can learn both to listen to the patient empathically and to recognize and work with these defensive operations.
Numerous psychological factors are involved in converting from psychotherapy to psychoanalysis with the same analyst. The process of making the recommendation and working through reactions to it, both before and after the analysis begins, requires heightened attention to the ensuing transference and countertransference reactions. After reviewing the literature on this area, the author highlights the main factors in this process and presents an illustrative case example.
In the course of followup study of satisfactorily analyzed former patients, there are observed two sets of phenomena: (1) recurrence of the analytic transference neurosis, and (2) rapid recovery from this transference neurosis. These phenomena are telescoped repetitions of the analysis and reflect the ongoing mental representation of the analyst as a displacement from the objects of the past, organized into the transference neurosis. The spontaneous and rapid recovery from the transference neurosis in followup study repeats the "cure" of the analysis and the new ongoing representation of the analyst as a nonconflicted object. This new image of the analyst is based on both the resolution of the transference neurosis and new displacements from positive experiences with significant figures from the past.
The effectiveness of analytic interpretation is conditioned by a number of factors within the patient, within the analyst, and within the analytic situation. I will focus on one of these factors, part of the technical activity of the analyst that I will call follow-up interpretation, one which omitted, or even slighted, sharply diminishes the effectiveness of interpretation.
This article describes the clinical and theoretical significance of intolerance of aloneness for patients with borderline personality disorder. It is intended to make their treatment more effective and less burdensome.
Clinical observations from the author's more than 9,000 hours of psychotherapeutic work and 500 psychotherapy consultations with borderline patients are synthesized with findings of relevant empirical studies and attachment theory.
Intolerance of aloneness is a deficit that is associated with the borderline patient's typical clinging and attention-seeking or detached forms of attachment. Suggestions are given for ways in which clinicians can respond to these dysfunctional attachment behaviors to diminish the patient's feared aloneness without encouraging unnecessary regressions. A framework for understanding the long-term attachment processes required to correct this deficit is offered.
Intolerance of aloneness is a core deficit in borderline patients that can become less handicapping with reliable, but not excessive, responsiveness of the therapist.