How Much Is Enough?

Endings In Psychotherapy and Counselling

Lesley Murdin

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134659081
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

How Much is Enough? addresses this important question, looking at the reasons why therapy can go on for too long or can come to a destructively premature ending, and offering advice on how to avoid either, with a timely conclusion. Using vivid examples and practical guidelines, Lesley Murdin examines the theoretical, technical and ethical aspects of endings. She emphasises that it is not only the patient who needs to change if one is to achieve a satisfactory outcome. The therapist must discover the changes in him/herself which are needed to enable an ending in psychotherapy. How Much is Enough? is a unique contribution to therapeutic literature, and will prove invaluable to students and professionals alike.

1

WHAT ARE WE WAITING FOR?

Aims and outcomes

Each theoretical model of psychotherapy implies a goal or set of goals and a body of techniques that form a process. In order to be defined as psychotherapy, any procedure must imply that change is possible, even if the change is to return to the original position with renewed conviction or confidence. Whatever the therapist takes to be the purpose of therapy will be a major determinant of his or her willingness to help a patient to end. Even those who decry any kind of normative goals may well be waiting for developments in the patient's ability to philosophise or to be free of conventional thought patterns. Such aims can never be wholly achieved and the therapist will have to settle for less than perfection.

Originally, psychoanalysis was a treatment performed by a doctor on a patient and the cure of symptoms was its aim. It has developed on many fronts but most practitioners today would accept that in spite of the power imbalance between the one who seeks help and the one who is supposed to be an expert, both people must submit to the process although in different ways and to different degrees. Two subjects are involved and both must change if the process is to be valuable.

Freud (1937) says that we are looking for:

• all repression to be lifted

• all the gaps in memory to be filled

• the ego to be strengthened

• the transference to be resolved.

Freud was concerned with memory and the damage that memories can do whether they are consciously held or, worse still, repressed by conscious or unconscious attempts to save oneself from pain. Clearly, not all memories can be recovered, but Freud's model offers the possibility that at least the most traumatic ones might be. His other criteria are even less absolute. The ego or conscious thinking self is unable reliably to assess its own strength or usefulness. The resolution of transference is often quoted as a goal and will be discussed further in Chapter 2.

To be fair, Freud recognised perfectly well himself that these aims were ideals and could not be achieved in any absolute sense, and that what is achieved is often not permanent. Freud's project was to develop the rational, thinking subject in contact with another. Giving more strength to the conscious, rational processes is reclaiming territory for conscious, civilised use. His image of analytic work was the cultural achievement of draining the Zuyder Zee in Holland. The North Sea is still there and although one can keep it at bay, more water is ready to pour in from the vast ocean of unconsciousness beyond to ruin our civilised achievements. Bettelheim (1983) emphasised the cultural aspect of the work in Freud and Man's Soul.

Jung also gave a list of possible criteria, some of which are similar to Freud's:

• a more or less complete confession is made

• a new philosophy of life is worked out

• a hard won separation from the childhood psyche is achieved.

(Fordham 1978)

Separating from the childhood psyche implies the same sort of cultural achievement as Freudian theory. More land is made available for cultivation by separation from the powerful, overwhelming terrors of childhood that continue to lurk just beyond the dikes that we build. Jung adds the idea of discovering religion or perhaps rediscovering the religion of one's childhood. Individuation is perhaps the central concept for Jungian therapy, defined by Samuels (1986: 76) as a person ‘becoming himself, whole, and indivisible, distinct from other people or collective psychology’. Like Freud's therapeutic aims, these are statements about progress along a continuum, not an achievement that can be reached.

Lacan challenged the search for wholeness that is implicit in ego strength or individuation, and showed that in his view, Freud's theory of the ego implies that we place too much faith in a function that is supposed to represent rationality and the relationship that we have with reality, but is nevertheless bound to distort and deceive because its task is defensive. It defends against recognition of lack and loss and hence is always against wholeness, since wholeness must include what comes from the unconscious. The best we can do in analytic work will be to track the mysterious passage through chains of signifiers of the elusive and eluding meaning of each individual. We are constituted in and by language, and language is always one step away from the thing itself. We express ourselves in the language that is passed on to us and we are formed by the desires of others.

In this model, therapy works if it can help the individual to find his own desire where it shows through the cracks and the gaps. This desire, like a fish glimpsed and briefly touched, slips through the fingers. While it is held, it may be spoken in what Lacan called ‘full speech’ instead of our usual ‘empty speech’. In his Ecrits (Lacan 1977) he said that analysis could end when the patient can speak of himself to the analyst. Before he is able to do this, he will speak of other people's images of him or will not speak directly to the other in the room. He may speak to what he imagines to be the therapists desire, avoiding what is in his own mind.

Lacan's thinking implies the following goals:

• the unconscious is glimpsed from time to time

• the defensive nature of conscious thought is recognised

• the patient can speak to the therapist about himself.

Relief of symptoms

Many people come to a therapist in order to obtain relief from suffering. Suffering takes many forms, only one of which is apparent in what might be called symptoms. Both patient and therapist might wait hopefully for a change in symptoms as described in the presenting problem. The earliest attempts to relieve symptoms psychologically fall under the heading of catharsis and involved the patient in a process of change while the therapist stayed outside it as the doctor or facilitator. The theoretical rationale for the benefits of catharsis is basic Freudian theory. Breuer's work with hysteria discovered the value of ‘chimney-sweeping’:

it [the technique] consisted in bringing directly into focus the moment at which the symptoms were formed and in persistently attempting to reproduce the mental processes involved in that situation in order to direct their discharge along the path of conscious activity. Remembering and abreaction … were what was at that time aimed at.

(Freud 1914)

This kind of work was done with the aid of hypnosis and had some startling and useful results. Nevertheless, its usefulness appeared to be limited and the cures that were effected were often very short-lived. It leads to no obvious ending, as the contents of the unconscious are as broad and deep as the Atlantic.

A small amount of drainage might make a difference, however. In the early days, the hypnotist gave suggestions that the symptom should be forbidden to recur. In some cases and up to a point this worked and still does. If it were sufficient there would be no need for any of us to look further. Suggestion under hypnosis would be all that anyone would need. Freud pointed out that the problem was that this method of treatment might deal well with one symptom but would leave the cause untreated. Unless there are structural changes, the patient will not achieve a better resolution of future conflicts. Hypnotic suggestion does not involve the patient actively: ‘Hypnotic treatment leaves the patient inert and unchanged and for that reason too, equally unable to resist any fresh occasion for falling ill’ (Freud 1917, lecture 28).

There are models of therapy where a great deal is achieved by working cognitively or behaviourally with one symptom, or we might say, with the presenting problem (see Chapter 9), where there is nearly always active involvement of the patient. If the treatment of one symptom is to be considered sufficient, there must be good grounds to expect that one piece of changed behaviour will generalise. If the patient is given the opportunity to understand the change, he may be able to use the understanding in other contexts. Many therapists would no doubt add that the patient also benefits from learning that he or she can achieve greater understanding and choice through the experience of therapy. In this model, the therapy will usually have an obvious ending when the symptom disappears or decreases and the therapist will have worked hard but may not have needed to make such an adjustment in himself, as in long-term work where the outcome is not predictable to either person when the work begins.

Freud continued the argument about the nature of the therapeutic action of therapy by discussing his view that the cause of symptoms is the repression of forbidden memories and impulses in order to avoid psychic pain. Because of the extent of the unconscious, the patient often cannot say enough to complete the cure. Even for minimal improvement, the pain of awareness must be risked and often experienced, or defences will not shift. Given this assumption it is clear that merely expressing the thoughts and feelings available to consciousness will never be enough to effect a considerable or lasting improvement. Other forms of therapy may not accept the hypothesis that the sources of symptoms are unconscious, but most will accept that something is needed from the therapist even if that is not what Freud called the educational function of analytic interpretation:

This work of overcoming resistance is the essential function of analytic treatment: the patient has to accomplish it and the doctor makes it possible for him with the help of suggestion operating in an educative sense.

(Freud 1917, lecture 28)

However much or little they intend to educate the patient, therapists inevitably add something to the work that is done. Pure catharsis with nothing else added is impossible. Saying ‘mmm’ at a particular point is reinforcing, adding emphasis, showing interest, encouraging, etc. A very minimal kind of listening might be of great value to some people at some times, but it is unlikely to be seen as sufficient by either patient or therapist for most of the problems that people bring. Suggestion is bound to play a part whether covert or overt. Unfortunately, although it may be powerful it is unlikely to be enough if it is overt and specific. For example, a therapist might say after two sessions: ‘Now you have brought me your problem and told me your story. You are better, go home.’ Suggestion of this sort is often used by the charismatic and in very powerful hands can work for better or worse, but it hardly develops the patient's choice and strength for future new difficulties.

My own conclusion is that relief of symptoms is an honourable goal and cannot be ignored by any therapist. Nevertheless, directly attacking the problem is not enough in the long term. A more complex view of the therapeutic process is needed if there is to be a profound change in an individual. The purpose of therapy must encompass the complexity of the human mind and body. Some writers (e.g. Spence 1982) have argued that the therapist's task is to help the patient to write the autobiography that satisfies him or her by its coherence and the meaning that can be discovered for the person whom the patient is at present. This view of autobiography is clearly distinct from a view that emphasises historical truth. In this context, what is important and therapeutic is that the story makes sense of a person's memories. A therapist might be comfortable with this role because it does not require much change in him. He is there merely to supply help with the most problematic and apparently senseless memories that a person presents.

Even by adding meaning therefore to the essential purpose, we may still not be addressing the full scope of the therapeutic process which always involves two people who are willing to affect each other and be changed by the impact.

The therapist's management of loss and damage

With some justification, Bowlby (e.g. 1973) and the attachment-based therapists have taken separation and loss as the basis of their theoretical approach. No doubt object relations theorists following Fairbairn (1952) would agree that the premature loss of good or satisfying object relationship is what leads to disturbance and psychic defence. Freud had reached the view that absence is what leads to development: the first thought is the absent breast. So loss has clearly a central position in theoretical structures, and coping with the losses inherent in therapy must require that both patient and therapist learn to accept that loss is both inevitable and can be survived. During the process, there is bound to be resistance from both patient and therapist to facing the painful realities of loss.

Klein and the object relations school provide a view of the aim of analytic work which focuses on damage and repair. The therapist is damaged over and over in fact or in phantasy until both patient and therapist are able to believe in survival. Both partners are guarantors to the other that survival is possible. The therapist hopes that the reliability that he or she provides will be internalised as a sense of goodness in the self so that love and gratitude can prevail at least some of the time and the testing can decrease along with fear and hate and envy. If the therapist's own defences against loss are shaky, he will need the patient to prove to him that loss is temporary and tolerable. The concept of the two positions – paranoid/schizoid and depressive – is a theory of moral development because it implies moving from the unreal world of projection to a greater awareness of the existence of another person. This always implies the possibility of loss as well as concern about its accompanying potential for guilt and repair. On the other hand, facing guilt and the reality of loss is too painful a position to be held indefinitely by either patient or therapist.

Modern Kleinians tend to see value in the cyclical movement between the depressive and paranoid/schizoid positions, with much creative potential resting in the paranoid and schizoid defences. Steiner (1987) has restated this aim in terms of helping the individual to be able to move between these positions with the awareness that nothing lasts for ever. Much will depend on whether the therapist is able to move between the two positions sufficiently to see the patient as a separate whole, rather than as a projection of her own insecurity and damage. If the therapist is still having problems in dealing with loss, the patient becomes the means of denying and objectifying the problem. Another way of stating this view is in terms of what goes on inside the psyche. Kleinians talk in terms of internal objects in order to be able to communicate more easily about the two or more sides of an internal conflict. The dominating force in the psyche may cease to be a persecutory and death-dealing avenger, but may become capable of concern and of giving and receiving reparation for the damage that it causes either in reality or in the imagination.

Meltzer points out (1967: 41) that the father enters the child's consciousness as a whole object just as much as the mother at the time of the ...

Table of contents

• Front Cover
• Title Page
• Copyright
• Dedication
• CONTENTS
• Acknowledgements
• Introduction: the problem
• 1 What are we waiting for? aims and outcomes
• 2 Happy endings: the goal of resolving transference
• 3 Dealing with illusions: narcissism and endings
• 4 Staying alive: the patient’s unilateral ending
• 5 Time to go: the therapist ends
• 6 What is truth? values and valuing endings
• 7 Ends and means: the ethics of ending
• 8 Endgame: last sessions
• 9 In my beginning is my end: the time-limited solution
• 10 Endings in training and supervision
• The good ending
• Index