Experiences of loss at the end of analysis: The analyst's response to termination

The therapeutic relationship once established, need never be broken

In the lead article, Hersh (2010) draws attention to the significant phase of ending therapy for clients and in particular, for their therapists. Hersh highlights three main tensions that underpin this process: real versus ideal endings, making and breaking of the therapeutic relationship, and balancing of respect for client autonomy over considerations of caseload and resources. In this paper, I offer a commentary on the first two of these issues by drawing upon my experience as a speech-language pathologist/family therapist specializing in voice, and as an academic fostering the development of student clinicians. This is then linked to parallel discussions in the recent psychoanalytic and psychotherapy literature. I support Hersh's premise that the implicit processes and emotions associated with this final phase of therapy need to be made more explicit and suggest that this is more likely to occur when clinicians acknowledge that they too experience rewards and losses in the therapeutic relationship. I challenge the notion that any therapeutic relationship once established is ever entirely broken.

Poetic closure, psychoanalytic termination, and death

Our pull to grasp narrative structures--including beginnings and especially endings--applies not only to the intentional craft of fictions, but to life as lived, as it is in psychoanalytic termination. Remarkable parallels, for instance, exist between thematic closure in poems and the conscious and unconscious signals of closure that develop in pretermination and accelerate in termination proper. A case illustrates this point: the slow crescendo of cues begins months before the first "pretermination dream." It is the patient's emerging awareness of greater health and freer functioning that likely gives rise to these phenomena, yet this awareness is often warded off because of the grave task of ending that it implies. Literature and psychoanalysis share concerns with how an ending is borne. Fictive closure and apocalyptic narratives allude to or imply finality (i.e., death), and lesser "endings" in daily life may not escape the specter of that linkage. But Kermode asserts that "ending" confers significance on an entire narrative and may thereby console us. Coltart links the realities of mortality and psychoanalytic termination, yet falls short of consolation. Clues to the role of beginnings (in final matters) and how they may help emerge from considering Basho's last days and poems. Nonetheless, the power of narrative has its limits in helping us bear the burden of a real ending, as of an analysis. Joining present to future, as through normal hope, or joining present to past through normal nostalgia, works toward a "bearing of the burden"--but only within the context of health achieved through the analysis.

On men crying: Lear's agony

King Lear vowed that because he was a man he would rather go mad or die than weep. Many adult male patients in psychoanalysis have just such an internal prohibition against crying, learned individually and often culturally encouraged, a prohibition that affects their ability to process loss, maintain intimacy, and accept vulnerability. It is suggested that the appropriate psychoanalytic role with these patients is to recognize and actively address this culturally supported prohibition. In addition, it is proposed that the prohibition against men crying may be a consequence of male envy of maternal traits and other feminine characteristics. Further, it is suggested that the developmental theory that the male child must "disidentify" with the mother memorializes a phallicism that often invokes the prohibition against crying in men and is itself mistaken.

Mourning analysis: the post-termination phase

One hundred twenty-one analytic candidates who had completed training analysis responded to a survey about their post-termination experience. Seventy-six percent of respondents experienced a mourning process that lasted on average between six months and a year, while 24 per cent experienced no discernible sense of painful loss. Twenty candidates were interviewed to obtain a deeper understanding of the mourning process that follows analysis. During the post-termination phase, the analysand's self-analytic capacity is tested in the struggle to contain and understand feelings about the loss of the analyst, as well as transference reactions triggered by that loss. After a "good-enough analysis," the analysand internalizes not only the analyst's functions and attitudes toward him or her, but also a sustaining, positive internal image of the analyst. Four cases illustrate unexpected difficulties that may emerge during the post-termination phase when the loss of the analyst is experienced as a repetition of earlier, traumatic losses or as a rupture of an unanalyzed, selfobject transference.

Love in the therapeutic alliance

Volumes have been written about the patient's love for the therapist, but there has been relatively little discussion of the therapist's love for the patient. In an attempt to create a theoretical and technical space for discussing the appropriateness and role of love in the therapeutic relationship, a revised concept of the therapeutic alliance is applied to provide technical guidelines and understanding of two kinds of love between patient and therapist, corresponding to two systems of self-esteem regulation: an open, reality-oriented system and a closed, sadomasochistic system organized according to omnipotent beliefs. Examples of the role of love through the phases of treatment illustrate the interrelationship of love and the accomplishment of therapeutic alliance tasks.

An application of the concept of the therapeutic alliance to sadomasochistic pathology

This paper traces the history of the therapeutic alliance concept, examining how it has been used and misused, at times elevated to a central position and at others rejected altogether. The loss of this concept created a vacuum in classical psychoanalysis that has been filled by rival theories. The continuing usefulness of looking at the treatment process through the lens of the therapeutic alliance, particularly in relation to the manifold difficulties of working with sadomasochistic pathology, is suggested. To this end, revisions of the theory of the therapeutic alliance are suggested to address some of the difficulties that have arisen in conceptualizing this aspect of the therapeutic relationship, and to provide an integrated dynamic model for working with patients at each phase of treatment. This revised model acknowledges the complexity of the domain and encompasses the multiple tasks, functions, partners, and treatment phases involved. The utility of the revised theory is illustrated in application to understanding the sadomasochistic, omnipotent resistances of a female patient through the phases of her analysis.

Introducing psychiatric residents to psychoanalysis: a visiting analyst's perspective

The serious decline in applicants for psychoanalytic training mandates the attention of psychoanalytic educators. If students are to be drawn to psychoanalysis, creative methods must be employed to convey the vigor and excitement of work in the field. The author describes two experiences as a visiting analyst, in a university hospital psychiatric residency in which there is almost no regular exposure to psychoanalytic thinking. Because he was dissatisfied with an approach that stressed literature review and psychotherapy case presentations and supervision, he developed a teaching technique through which he was able to show the residents how he thought analytically and self-analytically. This teaching method is discussed in terms of Stein's (1988) injunction that analysts reveal more about the process of their thinking when they write, his description of how Bertram D. Lewin taught by encouraging analytic candidates to free-associate as a method of understanding new case material, and Arlow's (1972) view of the centrality of identification in education.

Pains and gains: a study of forced terminations

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.

Recontact with the analyst following termination: a survey of seventy-one cases

A questionnaire was sent to graduate members of the Denver Psychoanalytic Society asking for their experience with patients making contact with them after the analysis. They reported that within three years after termination two thirds of "successfully analyzed" patients had recontacted them. Seventy-one cases were surveyed. Most contacts were brief and did not seem to be the result of incomplete analysis. Rather, they aimed to satisfy ongoing needs for: the continuing deidealization of the analyst, the reactivation of the self-analytic function, and the restructuring of self- and object representations by reporting developmentally significant accomplishments to the former analyst. The analyst's acknowledgement appears to be an integral part of the restructuring. This is work which either cannot be done before termination or the need for which has not been recognized during the analysis.