Endings and Beginnings

On terminating psychotherapy and psychoanalysis

Herbert J. Schlesinger

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134639403
• Edition: 2
• Topic: Psicología
• Subtopic: Psicoanálisis

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.

One of the main criticisms against psychoanalysis and the psychotherapies derived from it is that it lacks criteria for when the patient has had enough. Herbert J. Schlesinger shows how we may view the process as a series of episodes each with an ending and possibly with a new beginning. He presents the way patients signal, even before they are aware of it, that ending is "in the air, " and how it organizes how they experience the therapy. If alerted, the therapist can make use of these signals to locate self and patient in the process. So informed, the therapist is better able to discern when the therapy should end and help the patient work through the issues of separation and loss to terminate the treatment constructively.

All patients tend to end psychotherapy in the way they end all other relationships. In several chapters on the problems related to severe regression, therapists can learn how to help vulnerable patients, for whom attachment is problematic, deal with separation non-traumatically.

In Endings & Beginnings 2nd Edition, the theory of the continuous experience of ending and beginning and the array of landmarks that parse the clinical process are distinct advances to the technique of psychoanalysis and the psychotherapies derived from it. Schlesinger offers many clinical examples of ending and beginning with their technical problems and solutions. This contribution to the technique of ending and beginning psychotherapy electively will be useful to practicing psychotherapists and psychoanalysts, and to undergraduate and post-graduate students in clinical psychology, psychiatry and social work.

1

A Little History and Some Definitions

This chapter contains what I generally skip when browsing—the boring explanation of why the author feels that the common language has failed him and he must devise a new vocabulary to express his unique views. Still, I judge the risk of confusing you to be greater than the risk of boring you, and so I hope for your indulgence. If you are at all interested in what I have to say and still decide to skip the next few pages, you may have to return to them when you are in a much less receptive mood.

Be warned. If you have read this far, you will have noticed that I refer to beginning and ending rather differently than other writers do; it is time to make those differences explicit. The fog that surrounds so many discussions among analysts results in part from the casual, not to say whimsical, way in which we often abuse the ordinary terms of discourse. It is as if, once we graduate as analysts, we feel we are no longer slaves of the common language but are its masters—free, Humpty Dumpty-like, to use words as we please. In that dismal tradition (but I hope you will agree with better reason), allow me to attempt to clarify the way I use several familiar terms: ending, termination, phase, process, time, and structure.

Ending and Termination

Analysts, as well as psychotherapists in general, tend to refer to all matters having to do with ending treatment as “termination,” as if ending and termination were synonyms; indeed, our tradition encourages it. As I discuss in Chapter 2, there are many ways in which an arrangement between consenting adults, treatment included, may come to an end. English is rich in terms to describe those ways: we might stop, finish, quit, flee, interrupt, discontinue, elope, or drop out. We use all these words discriminately in the clinic to capture the particular way a patient left an episode of treatment. However, if a former supervisor asks you why the patient you once consulted him about is no longer in analysis and you answer with a shrug and say, “Because it ended,” he is certain to follow up with, “But was it successfully terminated?” Analysts do seem to have something special in mind when they use that word, and they do not consider “end” to be a synonym. If you inquire tactfully of the former supervisor (and let us assume he is one of the more patient ones) what he means by his question, you may hear a reasoned reply; he hopes that the ending came about through mutual agreement, that it preferably was not driven by some exigency or by a competing preference in the patient’s life or in yours, and that you took enough time to work through the implications of ending.¹

I believe it is fair to say that in recent years a consensus has formed among analysts that an analysis should end as that supervisor described. It was not always so; early in our history, an analyst would decide that a patient had had enough and announce it to him (I discuss these aspects of ending and termination in Chapter 3). Holding those preferences amounts to our taking the position that the ending or termination of analysis is a serious matter. However, those preferences do not prescribe what a seriously engaged analyst and patient should be doing as they go about bringing the analysis to a close.²

So the puzzle remains. As “ending” and “parting” are adequate to refer to the separating of people, including therapist and patient, and with so many other terms to specify the particulars of how and why two individuals may take diverging paths, why do we need to recruit the new word, termination, which has not previously been used in connection with human relationships?

A review is in order of the relatively brief history of the concept of “termination” in psychoanalysis. It first appeared in the psychoanalytic literature in English in 1937 when Joan Riviere, then an analysand of Freud, at Freud’s request, translated his recently completed article, “Die Endliche und Die Unendliche Analyse” (Freud, 1937a) as “Analysis Terminable and Interminable” (Freud, 1937b). Both the English and the German versions appeared in the same year. Riviere’s translation was later reprinted in The Collected Papers of Sigmund Freud (Freud, 1950), and James Strachey slightly modified that translation in The Standard Edition (Freud, 1937b). Strachey wrote a lengthy and informative introduction to the paper, but did not comment on Riviere’s strange choice of words to translate Freud’s endliche and unendliche. Since then termination has become a term of art, seemingly the generic and proper way to refer to the ending of psychotherapy as well as psychoanalysis.

Oddly, the word termination has no roots in the German language in which Freud wrote. An indication that the term was not in common usage at that time is that it does not appear in the first edition of a standard psychiatric dictionary (Hinsie and Schatsky, 1940). However, “termination” is included, with its current meaning but without comment, in the eighth edition of that dictionary (Campbell, 2004). The Freud Encyclopedia (Erwin, 2002) has no entry for “termination”, but it is discussed, in the now usual fashion, in the article on “Psychoanalytic Technique and Process” (Richards and Richards, 2002). We can no longer ask Riviere or Strachey why they thought it necessary to use “terminable” and “interminable” to translate Freud’s endliche and unendliche, using words that allude to ultimate finality with all its dreary and funereal implications, an implication that Freud did not intend.

Freud’s endliche and unendliche, as Leupold-Löwenthal (1988) pointed out, have connotations different from and richer than terminable and interminable. He proposed that finite and infinite convey Freud’s intention better.³ Note too that interminable has connotations of weariness, boredom and even despair, which are altogether lacking in unendliche. Substituting finite and infinite, as Leupold-Löwenthal suggests, yields an altogether different meaning, which others have also proposed (for example, Hoffer, 1950; Kramer, 1959; G. Ticho, 1967; Loewenberg, 1988; and Blum, 1989), that when a patient leaves analysis, analyzing continues through self-analysis and becomes a process more like education, which has no logical or necessary ending point.

Even if we take this revisionist point of view, we still can recognize that Riviere and Strachey did us a favor. There is something about the experience of ending psychotherapy and psychoanalysis that is different from other kinds of endings in human affairs, a difference that is worth preserving and which needs a distinguishing term. There are several reasons to preserve the word termination to capture what is special about bringing an analysis to a close. There are also reasons to retain “end” to refer to the generic aspects of concluding treatment, and to draw as needed on the many more-or-less synonymous terms to particularize endings. By reserving “termination” to refer to the unique aspect of a beneficial ending of a psychoanalytic treatment, whether psychoanalysis or psychotherapy, we can focus on the special concern of analysts, that when a patient leaves treatment he should own the achievements he has made and take them with him. Analysts recognize the paradox that transference, which is the main focus of a psychoanalytic treatment, can interfere with terminating treatment even though it may speed the ending of treatment. What distinguishes termination from other ways of ending is that the analyst provides the patient with a sufficient opportunity to work through (Freud, 1914a) his fantasies that the gains he made depend on the transference and thus do not “belong” to the patient, that at best they are on temporary loan. I ask you to agree that a patient has terminated his analysis,⁴ and not merely ended it, to the extent that he and the analyst have worked through this issue.

Let me underline some implications of the observation that, in the best case, the analyzing does not stop when the patient leaves the analyst. This permits us to analogize the process to his education, which also continued, one hopes, after he left school. This analogy also has other important implications. It leads us to recognize that even while the formal psychoanalysis is ongoing, something similar is going on: a kind of alternation between active analyzing and another state that we could describe variously, perhaps as testing to see what the consequences might be of the sense of inner freedom that resulted from the previous period of analyzing, or “metabolizing” the changes that have just occurred, or seeming to take a vacation in order to appreciate the value of what analyzing has just yielded. The experience may be too various to capture with a single term, but its thrust is educational.

Let me dwell a bit longer on the implications of this observation. When we use the terms end and ending in connection with psychotherapy, we may not be aware that we are committing ourselves to a particular model of human interaction, one that for convenience we might call the treatment model. The model is of an instrumental relationship into which each party enters to accomplish a purpose external to the relationship. When that purpose is accomplished, or when it becomes clear to one or the other that it is not likely to be accomplished, we expect them to end their meetings. Some human activities do not conform to that model, for example, marriages, parenthood, and friendships. Ideally, at least, these are relationships that should last “until death do us part.” Education follows its own model. Its goals may be either external to the process or internal, and ideally they may be lifelong in duration. Although formal education is parsed by such rites of passage as graduation, it has no natural ending point. We may speak of a person as having been educated, but without any implication that he has reached the end of what he might learn.

In contrast, we tend to speak of persons who have undergone some psychoanalysis as “having been analyzed.” Although Freud (1937a) recommended that analysts undergo reanalysis themselves periodically, the expression “he was analyzed” suggests that having been with an analyst for a sufficient duration should do for all time. Some authorities agree with Freud when he referred to psychoanalysis as “after-education.” They hold that analysis does not conform to the treatment model, as it is not so much a treatment as a form of education.

My position is that psychoanalysis (and psychotherapy) may be viewed from the vantage point of either model, depending on our immediate purpose and provided that we do not place education as necessarily occurring in a school or analysis as occurring only on a couch. Autodidaction and self-analysis capture the idea that the essence of both education and psychoanalysis is that they are lifelong processes of growth and development that need not be directed or conducted by an authority.

As my present interest is in the technical aspects of ending and terminating psychoanalysis and psychotherapy, I remain mostly within the model of an instrumental relationship as a treatment that ought to end when its purpose has been achieved. However, within any particular psychoanalytic treatment the model of education will seem to fit better, and that awareness will add to the koan of thinking about how to end an activity that in practice seems to have no natural ending point.

When one enters analysis or psychotherapy, usually it is because one wants treatment, typically to obtain something that one feels is missing in one’s life or to get rid of some alien element, perhaps something that by courtesy might be called a “disease” or “disorder.” One’s initial expectation is that when one has achieved that purpose, treatment will stop. However, this simplistic formula takes no account of the common experience that psychoanalysis functions as a goal-finding procedure as much as a goal-reaching procedure. While a person may begin psychoanalysis with one wish, typically he finds that in the course of achieving it, much more has happened than he expected. He is no longer quite the same, in ways that may not be easy to define. At the very least, he is no longer satisfied simply to be free from whatever discomfort motivated him to enter treatment. His expectations have risen and his horizons have broadened, much as they do in the course of a good education.

Patients are typically driven to analysis by pain or discomfort, so that their search for health fits well within the medical model. In addition to all the expectable beginning worries, a patient’s initial thoughts will also include the worry, “But how long will this take?” The beginning patient devoutly wishes for speedy deliverance.⁵ However, before long the patient may find that the pain is mostly gone or is bearable, but the motive to seek relief has been replaced by an altogether different motive. Excited curiosity has been aroused and is fed by the discoveries he is making about how his mind works. No longer concerned about speedy deliverance, the patient has become involved in the analysis for its own sake. Clearly, when this point is reached, the treatment model no longer fits what is going on. Probably without full awareness, the patient has become engaged in an educational adventure, one that is “inward bound.”

I am simplifying matters here, of course, for while the newly minted studentof-self explores how his mind works, or looks around the landscape of his mind with newly opened eyes, the analyst will continue to regard himself as a clinician working with a patient. Even though the patient may realize that he no longer presses for relief or discharge, he may be haunted by fears that derive in part from the abandoned treatment model; from time to time he fears that he no longer deserves the analyst’s attention because he is no longer in pain, or conversely because he is not getting well fast enough. Neither deserving because he is “sick” or because he has aced his lessons, the patient is “stuck,” as it were, between conflicting models, but at the same time he is held by an attachment to the analyst that mirrors the separation/individuation conflict of infancy. The analyst will recognize that this force, transference dependency, in addition to intrinsic interest in the process, tends to hold the patient in the analysis while the fear of being dropped as unworthy serves as a new source of resistance. For a considerable time the process will alternate between analysis as treatment and analysis as adventure while the patient works through the implications of his deepened understanding and the conflict between his desire to know and his reluctance to find out.

Moreover, there is a further complication that I alluded to earlier: the patient senses that with his increasing mastery over his life he may no longer be able to justify his analysis as a necessary treatment. A side effect of improvement is the weakening of his claim to patienthood, a status that he has come to value for its own sake and which he is unwilling to give up. Among his fears is the dark thought that maybe he is only fooling himself about being well. Maybe the gains are illusory, or perhaps they are only on loan, as it were, from the analyst, and will have to be surrendered if he leaves.

One of the main tasks of termination, analyzing the patient’s fearful transference fantasy that achievement will inevitably lead to losing the relationship with the analyst, is not solely a preoccupation of the patient at the literal ending of an analysis. That fear emerges throughout the analysis whenever the patient accomplishes, or fears he is about to accomplish, some piece of analytic work. The analyst too is subject to its tugs.

Phase

In its most common usage, phase refers to a period of time. In analysis we speak of the beginning phase or the ending phase to mean a period of indefinite duration around these points of interest in the chronology of a treatment. However, “ending” and “beginning,” like termination, can be delinked from any chronological implication and may be used to refer to the state of mind one is in when one feels, perhaps without being aware of it, that one is facing a new situation or is leaving a familiar one. We often observe, typically after a period of intense investment in some issue, that the patient suddenly, and for the moment unaccountably, is experiencing the analysis as if the situation and the analyst were strangely new and unpredictable. Every therapist can recall a patient who has been in treatment for some time coming into a session and remarking in a puzzled tone of voice, “Have you always had that picture on the wall?” or “Have the walls always been this odd shade of yellow?” The décor has not changed, but the patient has, and he feels for the moment that he has never been here before. We may say that the patient is once again in a beginning phase.

Perhaps less commonly, we may recognize that a patient seems to be at an ending phase; he suddenly slows down, glumly loses interest, and says or acts out the message, “What’s the use? It will all come to nothing.” Both observations, when we notice that the patient is at a new beginning or perhaps at a premature ending, are, of course, occasions for analytic inquiry. In Chapter 3 I discuss the dynamics that give rise to these odd experiences, the typical phenomena that mark their emergence, and how an analyst can use such observations as “landmarks” to locate himself and the patient within the process of the treatment.

Another implication of these observations is that at the inflection point when analyzing yields temporarily to “metabolizing,” or when after a period of useful analyzing the patient wants to pause and perhaps “take stock”, he may be beginning a period of working through, and that process also amounts to what we could call a “mini-termination.” Thus, we can think of termination as a process that may occur in distributed fashion throughout the analysis, not just as a singular “phase” at the end of treatment.

Of course, we may still speak of the patient nearing the end of analysis as being “in the termination phase,” this time using phase in the chronological sense....

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgements
• 1. A little history and some definitions
• 2. Patterns of ending psychotherapy
• 3. How to tell when treatment may end
• 4. Beginning from the vantage point of ending
• 5. Ending for “beginners”
• 6. Ending and termination in the treatment of vulnerable patients
• 7. Some problems of ending and termination, impasse or stalemate
• 8. Countertransference problems at the ending of treatment
• 9. Are there persons we should not take into psychoanalysis?
• 10. To convert or not to convert…
• 11. Ending, termination, and the life course of the analyst
• 12. Mourning in the analytic situation: an aspect of termination, the ubiquity of mourning
• 13. Is there life after termination?
• References
• Index