2-3 Therapy—Let Go and Move On: Interpretations of Love and the Termination of Treatment
Termination has become, in some ways, a sort of expletive in analytic practice. After all, can one say that an analysand has ever completed an analysis? To answer the question at the forefront: no. This does not preclude the possibility of termination, yet analysts continue to wrestle with termination and whether analysands are ready to embark into the “real world.” Some assert that many given terminations are premature and that, in some instances—particularly for those analysands with borderline or psychotic structures—that perhaps certain patients were not “analyzable” in the first place (Ellman, 1997, p. 197). The subject of termination is also introduced passively when clinicians let life events end the analysis—for instance, when a patient moves away, has children, no longer can pay, and so on (Bergmann, 1997, p. 168). While an analysis could theoretically be interminable, I argue that termination is a crucial and critical process of analysis. In this paper, I begin by looking at Freud’s (1959/1937) seminal paper “Analysis Terminable and Interminable” to identify the theoretical and countertransferential issues that plague clinicians about the prospect of ending an analysis. Then I will conceptualize the function of love (presented by Lear, 2003) as a nonspecific factor of analysis that acts as a guiding principle for a successful analysis. Specifically, I will argue that analysis offers a cure by falling in love, working through love, and falling out of love. The falling out of love is critical to the termination phase, as it opens the individual to let go and move on from therapy to find love elsewhere in his/her life.
Are We There Yet? A Freudian Crisis in Termination
While it may seem as if Sigmund Freud’s paper “Analysis Terminable and Interminable” was a first attempt to solidify a technique on ending psychoanalytic treatment, it might be more appropriate to situate it in its historical, intellectual context. The 1937 paper came in response to Hungarian psychoanalyst Sándor Ferenczi’s criticisms that Freud had not written about the proper conclusion of an analysis. Martin Bergmann (1997) believes that the seminal paper does not offer a template for termination but argues for why the majority of analytic cases are unanalyzable or interminable.
Freud (1959/1937) describes termination as a “blackmailing device” (p. 319) used by the analyst in treatment. While Freud describes how setting a termination date can be effective in allowing novel repressed material to surface in treatment, he likens termination to the threat of castration that ultimately fails in its aim, similar to how prisoners (or in this case, patients) will eventually generate new content under the threat of punishment to please their interrogators or to realize an end to their predicaments. Freud believes that the prospect of termination is a bad transaction that trades the project of analysis for an arbitrary conclusion, as material that once propelled analysis becomes buried once again and therapeutically ineffective. And once the date of termination is set, it must be honored or else it will appear as an empty threat to the patient.
Despite this, Freud (1959/1937) does offer a picture for when analysis can be terminated. He writes:
From a practical standpoint [the end of analysis] is easily defined. An analysis is ended when analyst and patient cease to meet for the analytic session. This happens when two conditions have been approximately fulfilled. First, the patient must no longer be suffering from his former symptoms and must overcome his various anxieties and inhibitions and, secondly, the analyst must have formed the opinion that so much repressed material has been brought into consciousness, so much that was inexplicably elucidated, and so much inner resistance overcome that no repetition of the patient’s specific pathological processes is to be feared. (p. 320)
Thus, Freud seems to paint two different pictures about the end of analysis. The first seems to arise from his medical training, as he describes patients reporting or else observes them being less distressed by their symptoms. This picture suggests that symptom reduction is a notable goal for therapy (although clinicians may disagree as to whether this constitutes analysis). It is significant that Freud notes this condition first, a rhetorical tactic that disguises the amorphous, ambiguous quality of the second condition of termination being repressed content having been brought into consciousness. Continuing in the paper, Freud disregards the second condition and offers pragmatic suggestions to help the analyst decide whether or not to terminate a client. Particularly, Freud states that it is beneficial to terminate when the continuation of treatment can act as a defensive obstacle to itself or when treatment can make the patient react maladaptively in his or her everyday life.
Yet in these qualifications that Freud (1959/1937) puts forth, it seems as if he is advocating more for reasons why analyses fail rather than why they succeed. In fact, he questions whether analysis can ever reach a natural end (p. 319). Even the discussion of an end is a loaded concept, as it raises the issue of whether there is a telos of analysis. Analysts presume that there is an unconscious replete with conflicts and ambivalence that is guarded against by defenses and which we attempt to discern through free association to dreams, wishes, and fantasies. However, while our practice is guided along these lines, the picture of a complete analysis is opaque, as there is no form to the finality of analysis that is universal to all analysands. It is as if we are traveling a road that has no destination.
Thus, instead of proposing guidelines for or alternatives to termination, Freud leaves the decision of how and when to terminate in the hands of the individual analyst, but he does not clearly illustrate the finality of an analysis. Perhaps though there should be no destination at the end of the road, as Freud (1959/1937) notes that the second condition, while ambitious, should lead the clinician to address the question of “whether the effect upon the patient has been so profound that no further change would take place in him if his analysis were continued” (p. 320). He seems to remind us that a patient may continue to speak and produce new associations and memories, for the unconscious is inexhaustible in its content. At the same time, though, he introduces the consideration of change, where one must measure whether the generation of new material in an analysis yields any significant benefit for the patient’s life—surely, it may continue to deepen the patient’s understanding of his or her previously unconscious motivations, but by a certain point in an analysis the analysand will already have gained some grounded and reflexive understanding of his or her personality upon which further analysis will plateau. Freud reminds us that the analytic session can also cease to function when the conditions for termination “have been approximately fulfilled [emphasis added]” (p. 320), supporting the assertion that there is no final endpoint of analysis but instead a good-enough point of termination. Similarly, this seems to be Ferenczi’s contention with Freud’s unsatisfactory termination of Ferenczi’s own analysis. Ferenczi writes that there comes a point in any analysis where both the analyst and analysand stagnate in their interpretations and insight, and this moment signifies when the analysis has been exhausted and when termination is not only prudent but ethical (Frank, 1999, p. 120).
Another reason for much of Freud’s (1959/1937) struggle with developing a clear picture for how an analysis could end may be due to the different trajectories of analysis suggested by the topographic and structural models of the mind that he puts forth. In the topographic model, the primary aim of analysis is to move from unconscious processes to conscious awareness; however, in the structural model illustrated in “The Ego and the Id” (1989/1923), Freud develops a model for analysis wherein the analyst is focused on lessening and removing the ego’s resistances. Modalities of psychoanalysis, post-Freud, thus vary in their understanding and implementation of the processes of analysis: While some analysts may focus on their patients’ modes of gaining insight into formerly unconscious processes, other analysts, such as those in schools of ego psychology, pay more attention to analyses of the defenses that the ego uses to guard itself against the impulses of the id and intrusions of the superego.
In the Freudian model, during ego development, children find strategies to cope with the threats from and conflicts between their ids and the “real world,” and these strategies serve to disguise the motivations for certain behaviors to make them more amenable to the superego. Children thus select preferred constellations of defense mechanisms that become prostheses to the ego. While most of the perceived dangers we face in childhood dissipate, those defenses remain the primary means by which we engage with the world as we mature. As adults, they serve a neurotic, maladaptive function, as we seek out situations that serve as substitutes for the original affective states of childhood, thus confirming and validating our irrational beliefs about how to get our needs met in the world. Freud (1959/1937) writes that “the defensive mechanisms produce an ever-growing alienation from the external world and a permanent enfeeblement of the ego” (p. 340-341) when they become habitual modes of interaction.
Here Freud (1959/1937) introduces another view of termination in which the end of analysis is not precipitated by achieving insight—in other words, by making the unconscious conscious—but is instead focused on ego-modification (p. 341). The shift from the topographic to the structural model in Freud can be seen as a catalyst for the debate and confusion still alive today regarding the ends of therapy. Are we, as clinicians, attempting to make clients more aware of unconscious impulses and motivations or are our goals for them to become less guarded and less defensive in their everyday lives? Psychoanalytic practice repeatedly illustrates that insight alone does not seem to be enough in spurring change for the client. Freud himself states this, noting that during the termination process, one way that the analyst may attempt to keep the analysand wedded to the therapeutic enterprise is by exposing the difficulties, due to unresolved psychical conflict, the analysand may anticipate after termination (as if the analyst can predict future struggles!). Yet even if the patient agrees, this insight will only lead him or her to view those difficulties as trivial and continue with termination (p. 335). We see this same phenomenon among those interested in psychoanalytic practice who read about sexual and aggressive impulses and think, “Isn’t this quaint? But now that I know, I can handle it.” In reality they are more susceptible to and defended against those impulses.
In an analysis of the defenses, the analyst is seeking to facilitate the substitution of primitive defenses (for example, denial and repression) to higher-order defenses (such as identification and sublimation) in order to allow for mature expressions of unconscious impulses that can be gratified in the real world. Yet, in spite of this shift in his theory, Freud (1959/1937) seems to continue privileging insight and content throughout “Analysis Terminable and Interminable.” This is where the great divide occurs among clinicians about the work of psychoanalysis: in Freud’s attempt to teeter the line between these two aims, he splits the endgame of analysis between achieving insight versus reducing one’s defenses.
Do You Know Where You’re Going? The Analyst’s Own Termination
One of the contributions that Freud (1959/1937) identified as affecting the termination process is the analyst or therapist him or herself. He invites us to think about how the analyst’s personal characteristics affect the resistance and trajectories of the client’s analysis (perhaps adumbrating the awareness of relational dynamics that are being incorporated into modern psychotherapies), and he warns clinicians not to believe that their own clarity of thought determines whether a client accepts or rejects an interpretation (p. 331). The primary way in which clinicians become aware of how their own subjective presence influences the analytic process is by undergoing their own analysis.
Fortunately, there is research in the psychological literature that addresses how clinicians approach termination. Bergmann (2012) highlights the necessity of productive discussions surrounding termination, and more psychoanalytically-inclined clinicians trained today are instructed to be more sensitive and open to termination. To continuously advocate for prolonged and interminable analyses or therapies can lead to professional and psychological consequences for the analyst, leading him or her to question the efficacy of treatment or approach (p. 303). In other words, psychoanalytic clinicians need some success cases in order to maintain their own level of functioning in providing treatment.
Kramer (1986) notes how the discussion of termination with clients often elicits the therapist’s own transferential reactions toward his or her own analysis and its ending, which can lead to a countertransference response in which the clinician asserts that the client needs more time or awareness to enact changes in his or her life. This leads us to wonder for whose benefit do we advocate the continuation of a therapy—the client or the therapist. If it is for the therapist, then—when the prospect of termination is not earnestly and repeatedly entertained—he or she is stifling the client’s automony in order to fulfill his or her own dependency needs (p. 526). Taken in this context, one would wonder how many case presentations of premature termination are really premature or if they are described in that fashion to intellectually defend against narcissistic wounds of client abandonment. Ellman (1997) identifies that termination is often conflated with the issue of analyzability or suitability for psychoanalytically-oriented treatment, which is inappropriate, as analytic trust—or the degree to which the analyst can establish rapport and understanding with a client—seems to be the greatest prognostic indicator for the efficacy of therapy (p. 197). Similarly, Greenspan and Kulish (1985) concluded that therapists who have undergone their own personal therapy had significantly lower premature termination rates than therapists who had no personal therapy. They hypothesize that one’s therapy can provide the training for termination and validate the efficacy and seriousness of long-term psychotherapy (p. 82).
How we Love to Terminate
Perhaps instead of thinking about termination as the end of analysis, we can conceptualize it as a transition point, or even crucial moment, between analysis and life-after-analysis. From a practical standpoint, the end of analysis is clearly demarcated when the clinician and client cease to do the work of analysis for whatever reason (Freud, 1959/1937, p. 320)—such in when free associations, dream work, and fantasies yield little or no further interpretations that significantly effect change in the analysand’s life. When we think about the plateau that occurs in analysis, it might be useful to conceptualize it through Eros and the death drive. The two forces act in tandem to give rise to the diverse phenomena and motivation of human behavior: “… Eros and Destructiveness, the former of which strives to combine existing phenomena into ever greater unities, while the latter seeks to dissolve these combinations and destroy the structures to which they have given rise” (p. 350).
In analysis, the client presents with a movement toward personality orientations of increasing complexity and flexibility, which—through the influence of the death drive—are continuously called to degradation and dissolution. The unconscious (containing the vast impulses of the id) acts with its own agency that pushes back and resists the organization of the ego. The ego modification that is crucial to the project of termination begins with the analyst allying with the client’s Eros, to act as a scaffold to a building, before delving into the depths of the unknown. Much like a supervisor noted early in my training: if you lay an alcoholic on the couch, and he gives you five reasons for why he is an alcoholic, make sure he does not get off the couch with ten reasons for why he is an alcoholic. My supervisor’s comment conveyed the importance of assessing the client’s ability to cope and, a note, as a clinician to always ally with his or her well-being first, for—even if the picture of a completed analysis is unclear—the task of psychoanalysis is always process of integration.
Eventually, whether through identification, incorporation, modeling, or introjection, the client subsumes the scaffolding role for him or herself. This is the point when the analysand internalizes the role of the psychoanalyst and the capacity for analysis (Lear, 2003, p. 97). Freud (1959/1937) writes, “[W]e hope and believe that the stimuli received in the learner’s own analysis will not cease to act upon him when that analysis ends, that the processes of ego-transformation will go on of their own accord and that he will bring his new insight to bear upon all his subsequent experience” (p. 352). He continues:
Our object will be not to rub off all the corners of the human character so as to produce ‘normality’ according to schedule, nor yet to demand that the person who has been ‘thoroughly analysed’ shall never again feel the stirrings of passions in himself or become involved in any internal conflict. The business of analysis is to secure the best possible psychological conditions for the functioning of the ego: when this has been done, analysis has accomplished its task. (p. 354)
This is why the analyst cannot simply offer insight into client’s defenses and unconscious motivations, for the client must develop the means to cope with conflict on his or her own in order to live the life that he or she desires to live. Didactic and educational approaches with clients often fall short of the intended goals. Instead, guidance through freedom and exploration within the transference allows the client to realize his or her own goals for analysis and set out to achieve them. Yet getting to the point where the client has internalized the analytic function (so that the project of integration can continue without the psychoanalyst) requires discipline on the part of the analyst. It requires a subjective sense of objectivity, which opens and demands ongoing reflexivity about whether one has understood him or herself and others while knowing that what is understood is never complete or fixed (Lear, 2003, p. 50). More importantly, it is a kind of discipline that arises from a particular sensibility, not technique or theory. It requires faith that the client will be able to reach a point of integration with analytic love to guide them to that point.
It should not be a surprise that love should be a component that drives analysis, for even Freud stated that psychoanalysis was a cure through love. The tradition of psychoanalysis, though, has seemed more concerned with how love structures relationships rather than the actual feeling of being in love (Lear, 2003, p. 53). Love in the analytic setting fosters commitments of understanding and respect for autonomy, yet, as Lear (2003) discusses, any love relationship inherently involves a sense of death (p. 56). The logic of love always carries with it the prospect of loss, even if it is not consciously attended to by the person. In the everyday way of falling in love, we do not dive into intimate relationships with partners with the explicit agreement to break up in five days, five months, or five years. However, ironically, this is exactly the understanding that the analyst must bring into treatment; the analyst begins analysis (somewhat absurdly) with the knowledge that love will bring it to an end, even when the client does not.
Lear (2003) writes that “the analyst lives with a lively sense of death” (p. 54) and notes that betrayal and termination are the two ways in which love relationships end. Betrayal, he states, results from love coming undone, but betrayal is a continuous phenomenon that haunts every relationship. In analysis, this betrayal perhaps first appears during intense transferential moments where the client accuses us of misunderstanding him or her and threatens to leave therapy. I am thinking of a session with a client, Aubrey, who struggled with problematic eating (vacillating between binging, purging, and restricting behaviors). About a year into therapy, a critical moment came after exploring the confluence of emotions and associations that gathered around her symptom: Aubrey could no longer purge. She turned to me asking to fix her symptom and revealed her fear that if therapy were successful, then she would gain weight; she was almost asking me for permission to purge. I honestly did not know what to say, so I said nothing. She arrived next session furious with me, stating it would be her last and that I could “no longer have access” to information about her eating behaviors. She was angry because she asked for help, and I—“just like everyone else”—“failed” her. In a moment of desperate honesty, I apologized and admitted my own difficulty in understanding. She spoke very little for thirty minutes, and I blabbered and attempted to use every clinical tool in the box to process what was happening between us in therapy. I eventually interpreted how her language toward me seemed to mirror the ways in which she described significant members in her history: husband, in-laws, ex-boyfriends, brother, father, and mother.
Aubrey, softly speaking, accepted this interpretation, and began to open up again in session. She acknowledged the experience of feeling betrayed was structurally similar in all those relationships and with me; however, she also noted that I did something different from those other relationships: I apologized and admitted I did not understand. She concluded that she was undecided about whether or not she wanted to quit. I proposed that if she was still ambivalent, why not show up for our next session, then make a decision. We continued to work together for two years after that session.
I use this to illustrate Lear’s (2003) point that love involves a commitment to work through feelings of betrayal so that the pair can arrive at an understanding of the event that eventually diminishes the effects of feeling betrayed. It is only when this attempt to understand reaches its limit, when one cannot adopt another point of view, that the efficacy of love is lost in everyday relationships (p. 55). However, the analytic project is already founded on the attempt to understand, although Bergmann (2012) identifies how transference can easily be misused when the analyst leaves the symbolic role and engages in real behavior. For instance, if I would have forbidden that Aubrey restrict/binge/purge and attempted to solve her dilemma by counting calories instead, then there would have been no direct display of anger (although there could have been passive displays of protest and acting out). Consequently, she would unconsciously carry the resentful feelings of being betrayed while not working through them. In this way, analytic neutrality and objectivity can open new paths of understanding.
Had Aubrey left therapy with her feeling of betrayal, then she would have terminated prematurely, which is the threat or “lively sense of death” that pervades any analysis (Lear, 2003, p. 54). But if we are to understand analysis as a cure through love, then we can extend that to involve working through love and its betrayals and falling out of love through terminating. It is no mystery as to why transference love is more attractive than its real-world counterpart, as the analyst makes no demands or conditions to the recipients of his or her love (perhaps except to show up and to be timely with payments), and this is particularly true if the analysand has not had any experience of love in his or her history (Bergmann, 2012, p. 304). Throughout the years, we ask our clients to share their innermost, deep fantasies, and we respond to their associations of love and hate with respect and a generosity of spirit. Thus, it should come as no surprise that when termination is near, clients will resist.
As love has vehicle for Eros to spur change in the client’s life throughout the years in analysis, the absence of the therapist naturally incurs a sense of disintegration. When the scaffolding of therapy is removed, the client wonders whether he or she can stand on his or her own, and this is often when clinicians observe the death drive asserting itself once more. The unconscious attempts to reassert itself and resists change. Psychoanalysts often note that clients begin to act out or that symptoms reemerge when a termination date is set. The way that the psychoanalyst respond to the final demands of the client often reveal the psychoanalyst’s own inhibitions and countertransference about the end of love relationships. Some may prolong termination or even retract the prospect of termination, but this is to betray the faith in the relationship and client’s well-being that was established during the course of analysis. Lear (2003) reminds us that:
[i]f psychoanalysis is aimed at promoting a person’s freedom, part of the freedom is freedom from the need to keep coming to the analyst. It is a manifestation of love that the analyst, in her role as analyst, keeps an eye on that goal. (p. 56)
It is easy to forget that the end is always imminent in any relationship, and we must expect that clients may cling to the analyst. However, just as clients need to work through love’s betrayals, they also need to work through love falling apart—the “lively sense of death” (p. 57) to which I keep returning. This is perhaps why Freud (1959/1937) had difficulty explicating a template for termination, for termination is a movement from a one-person to a two-person psychology, where:
… every psychoanalytic couple must find their own termination point. The limitations of both the therapist and the patient play a role. It may happen during the termination phase as new insights open new doors; in that situation we need not fear to say that what seemed like termination turned out to be a deepening of analysis (Bergmann, 2012, p. 314).
Understood in this manner, termination is a process of therapy. Specifically, termination allows for the individual to effectively separate from a love dyad despite the wish for union; additionally, it allows for the analysand to experience a loss that is neither debilitating nor disintegrating (p. 312). It would help to remember that analysis does not end simply because the analyst and analysand no longer meet, for if the analysand properly internalizes the analytic function, then he or she can continue with the project on his or her own.
Do You Believe in Life after Love? The Termination Phase and Post-Analysis
Termination allows for the opportunity for the analysand to mourn and accept the experience of loss in love, which carries into his or her everyday life (Bergmann, 2012, p. 311). In fact, the loss of love through termination can open the analysand to fall in love again. As Crogan (2009) identified that clients who sought analysis to its completion presented with new approaches for maintaining love relationships alongside increased feelings of contentment, meaning, and satisfaction in life; they also reported less fears surrounding abandonment, guilt, self-reproach, and anxiety (pp. 205-206). Marx and Gelso (1987) also highlight that saying goodbye is a critical part of termination, as it invites a meaningful discussion about feelings of loss. Their clients viewed the experience positively, although they acknowledge a limitation of their study in that their clients engaged in short-term counseling at a university center. However, because of their clients’ positive experience of termination, the authors bring up an important point for consideration: perhaps the negative perceptions surrounding the process of termination may reflect countertransferential reactions on the part of the clinicians rather than the clients (pp. 7-8). It raises the question of whether clients are picking up on our own unconscious anxieties about successful clinical practice and hopes that clients leave therapy in a perfect state, although in practice we know that this can never be the result.
In many ways, clients will communicate their desire to terminate before they become consciously aware that they are doing so. Bergmann (1997) identifies how, as the finality of love approaches, termination will be communicated through dreams, fantasies, and associations that the client is attempting to defend against because of his or her fear of loss. However, a frank discussion about termination can allow the analysand to confront the reality about the end of relationships, and this may spur new, definitive content about past experiences of loss (p. 168)—that is, those memories thought that Freud (1959/1937) thought was a poor exchange for the project of analysis (p. 319) are—in reality—quite fruitful. However, it is a fruitful exchange for the individual who is primed to continue analysis on his or her own. I am reminded of my final month with Aubrey, when termination was imminent and inevitable. We both knew when we began working together three years prior that the therapy would come to an end when I completed my training, but in the final month, she began to describe her own significant experiences of loss, particularly the abrupt deaths of her father and brother-in-law. She talked about me and our work together as if I were dying, and she said that she often takes the approach of the “stable one in the family” so as to never allowed herself to experience loss. The difference in therapy was that she had the chance to say goodbye to me. Although she was loathe to appear vulnerable and would normally be reserved and solemn with her tears, she cried openly in session—not simply for the loss of me but for the loss she experienced in many areas of her life. She commented, “I never got to say it to anyone before, but I just want you to know that this experience was meaningful to me.” In our final moments, she gained the insight from termination that she could be “in control of [her] vulnerability” and express painful emotions without breaking down. Through termination, she allowed herself to separate without feeling abandoned and to carry the analytic project on her own. This kind of love—a love that allows for the loss of one object and, subsequently the beginning or revitaliation—I believe is what termination can offer to our patients, clients or analysands.
Pages: 1 2