The Rupture of Serenity

External Intrusions and Psychoanalytic Technique

Aisha Abbasi

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781780491950
• eBook ISBN: 9780429922060
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

What happens when the outside world enters the psychoanalytic space? In The Rupture of Serenity: External Intrusions and Psychoanalytic Technique, the author draws on clinical material to describe some of the dilemmas she has encountered in her work with patients when external factors have entered the treatment frame. She considers analytic dilemmas that range from how to deal with patients' unusual requests regarding the conduct of an analytic treatment to the question of how to handle events in the analyst's personal life that, by necessity, must be addressed in the analysis. As a Muslim of Pakistani origin, the author is also able to discuss, frankly and with compassion, the role that ethnic and religious differences between patient and analyst can play in treatment-differences that, in the aftermath of 9/11 and the search for and killing of Osama bin Laden, became a palpable presence in her consulting room.

PART I

WHEN EVENTS IN THE ANALYST’S LIFE INTRUDE UPON CLINICAL SPACE

CHAPTER ONE


The analyst’s infertility and subsequent pregnancy

Introduction

Significant events occur in every analyst’s life. Some of these may never directly affect the analyses we are conducting, and thus there will likely be no reason for the analyst to discuss them with patients. Others might enter our analytic work indirectly—as I will discuss in Chapter Three—because a patient has been informed by others about events in the analyst’s private life. Still others might be events that directly affect the frame of an analytic treatment, such as the analyst’s illness (which could include ongoing treatment); the illness, death, or impending death of a family member; and events that necessitate a major change in the schedule or require a flexible schedule. In the latter case, the analyst must decide how to best deal with “telling” or “not telling” her patients about what has caused, is causing, or will cause a disruption in their regular meetings.

Whether one tells or doesn’t tell, the analyst also has to be on the lookout for the meaning of the telling or not telling, as well as patients’ reactions to the disruption itself; their feelings, if they have been told, about the events; and their feelings about what they imagine is happening if they have not been. No part of this is easy. Nor are there easy answers to the questions, “Should I tell my patients about this?”, “When should I tell my patients about this?”, or “How much should I tell my patients about this?” In addition, the answers may be different for each analyst-patient dyad. We are all guided in general by our foundational concepts of theory and technique, but these become interwoven, over time, with our individual personality styles and what comes naturally and feels right for each of us. Each analyst also has to take into account each patient’s needs, strengths, and vulnerabilities, given what she knows about the patient’s history, while being mindful of where the analysis is at that point.

This chapter describes one such series of events in my life, my struggle to sort out how best to handle this in my work with patients, and the route I ultimately took. Over a long period, I suffered from secondary infertility, which led to a sequence of events: treatment, the treatment’s failure, and, ultimately, natural conception. I will present clinical material from one analysis to illustrate a patient’s reactions to this series of events at different stages.

Background to Clinical Material

In early 2000 I was thirty-eight years old, four years past the completion of my formal analytic education, and fully immersed in a vibrant and busy analytic practice. My husband and I had a twelve-year-old child and had been struggling for a number of years to have a second child. I had already gone through two surgeries and the less invasive treatments for the kind of infertility that is caused by severe endometriosis. My doctors and the nursing staff kindly—if not entirely correctly—referred to what I had been going through as “treatments for fertility” rather than treatments for infertility. After much back and forth, my husband and I decided that it was time to move on to in vitro fertilisation (IVF). We discussed the options with our infertility specialist, who said that given the success rate (at that time) of IVF at the centre with which he was connected, I would probably have to go through four IVFs before he would recommend that I not keep trying.

After more research, we consulted with a physician in another state whose success rate for IVF with women in my age group was fifty per cent for each attempt. He recommended that I have only two IVFs, and if that did not work, he would not recommend more attempts—in other words, if it was going to work, it would work with two attempts. The entire sequence, from initial tests through treatments, would mean about six months of periodically being out of town, compared to a little over a year in town. Given the emotional and physical toll that we knew each IVF cycle can take on a couple—and indeed the whole family—my husband and I decided that the option of fewer IVFs would work better for us, even though it would involve air travel back and forth and more extended periods of time away from work and out of town. Neither option was perfect, but that one felt easier for us emotionally and more expedient.

And what about my patients? My husband’s work allowed him significant flexibility in terms of being away, but this was not the case with my analytic practice. My patients knew I had a certain routine with times I took off during the year for vacations, conferences, and holidays, and occasionally I would cancel on short notice for emergencies. With IVF, however, I would not be able to predict when I would need to leave town. Our local treatment centre would work with the out-of-state physician, monitoring me during the first part of each treatment cycle and following the treatment he prescribed. At a certain point in the treatment cycle, however, I would be told that I should go to the out-of-town centre within roughly two days to complete the treatment cycle. I would then have to cancel patients for between ten days to two weeks; to further complicate matters, the exact timeframe could not be predetermined.

Being infertile when one wants a child is a difficult and complex situation. I have written (Abbasi, 2011) about the frustration of infertility and of not being able to do what most people can do naturally and easily, stating that this “often brings about a reactivation of old losses and narcissistic vulnerabilities” (p. 366). Allison and Doria-Medina (1999) have referred to “the invasion that the reproductive act between lovers suffers because of the intervention of a medical team that appears to have omnipotent powers to give or withhold a baby and promotes intense transferential feelings of dependency, infantilisation, and vulnerability” (p. 163). These aspects of infertility are difficult enough on their own—both for the couple and for the individuals. Added to this were my worries about our twelve-year-old’s well being during this extended period of time. Further compounding my distress was the concern for my patients and the impact my sudden departures and erratic absences would have on them—along with my altered and, in all likelihood, decreased ability to be optimally analytic and of use to them.

I struggled with what—if anything—to tell my patients, when I should tell them, and how. Abend (1982) writes about the paucity of literature on this topic, commenting on:

[…] the evident disinclination to study, describe, and report on the problem of the technical management of the analyst’s illness. This is especially unfortunate since such observations are needed in order to provide reliable and convincing answers to the questions I have attempted to highlight. Under what circumstances, if any, and for which patients, if any, is it advantageous to provide factual information about the analyst’s illness? What are the advantages of doing so? What are the difficulties attendant thereon, and what problems ensue if information is not provided? We do not have definitive answers to these questions as yet. A thorough and honest attempt to illuminate this topic is long overdue, and its investigation will be of benefit to many analysts and their patients. (p. 379)

I read all the literature I could find on the topic of disclosure in similar situations and discussed the matter with several colleagues. Finally, I decided to inform my patients that I was struggling with secondary infertility and was about to begin a series of treatments that would, over the next six months, periodically require me to cancel—on short notice—appointments scheduled for the following ten to fourteen days. I added that these were the most basic facts, and that if they had questions they wanted to ask me, that day or later, I hoped that our work would facilitate their being able to do so: their questions, and how we dealt with them, might reveal dilemmas and complex choices for us to negotiate, such as what would be truly helpful for them to know—and why—and whether boundaries were being crossed or too much reality introduced into the analysis. At the same time, I felt that these dilemmas, how we understood them over time, and how we dealt with them would ultimately deepen our work together.

It would be incorrect to say that I arrived at the above decision for some particularly rational or brilliantly thought-through analytic reason; I simply did what I believed would allow me to be most optimally analytic with my patients. It was also the route that felt the simplest and most straightforward, given the strain I was under, my personality style, and my way of working as an analyst in general. There are times in analytic work when each of us has to figure out our own way of dealing with a particular analytic dilemma, and it might not be possible for us to explain fully why we chose the solution we did. I do remember thinking that in the months to come, I would be in a state of great emotional upheaval, pumped up with high doses of hormones, and undergoing a variety of medical and surgical procedures. The thought of having to suddenly announce to my patients, without any explanation, that I needed to cancel a batch of upcoming sessions (for visits to the local treatment centre), followed by another announcement that in a couple of days I would be leaving for two weeks—and repeating this abrupt routine twice over a four to six month period—seemed grotesque to me and unfair to my patients. I realised only much later that had I not decided to explain my reasons, I might not have been able to deal with my patients’ fantasies about the sudden departures—or, in my vulnerable state, their feelings of hurt and rage about being so abruptly and repeatedly abandoned by me.

So even as I thought that my telling my patients the reality of my situation would allow me to be as analytic as possible, I can see, looking back, that telling them was also based on my need to protect myself: by telling them, I was inviting them to bring in all their feelings about what was going on with their analyst. At the same time, part of me was also asking them to temporarily suspend being the analytic patients I had asked them to be in the past and instead be reasonable adults who could understand my situation, and—at least for the next six months—have associations that were tolerable to me in my somewhat fragile emotional state.

Over time, I asked my patients their thoughts and feelings about this new reality in my life. I asked what they felt about my having secondary infertility and undergoing treatment for it. I also asked what they imagined about why I was infertile. I asked, furthermore, what they felt about my telling them the facts and what they might have felt had I not told them. My patients felt that these were useful analytic questions, and they responded, it seemed to me, with rich and vivid associations. I, in turn, responded to their questions with honesty, tact, and careful thought. I was pleased with my decision to disclose why I would be away so frequently. My patients and I continued to speak and listen and analyse—or so it seemed. Only months and years later was I also able to clearly understand how relieved I had been that I didn’t have to deal with fantasies that I was leaving on a wonderful, spur-of-the moment vacation at a time when I was undergoing uncomfortable and sometimes painful procedures. It was only then that I could realise that part of the reason for telling my patients the reality of my situation had to do with my sense that I did not have it in me, at that point, to deal with certain reactions (e.g., rage) and fantasies (e.g., that I was going away to have “fun”).

As planned, I went through two IVFs. The first did not work and my husband and I were immensely disappointed. The second was even more difficult, as it resulted in a “chemical pregnancy”: The pregnancy-hormone levels rose for the first few days, creating great optimism, but then did not double as they should and ultimately fell. My husband and I were heartbroken. A chapter of our lives, we felt, had come to an end. We mourned, quietly, about what had happened and what could not happen. We spoke over the phone with our out-of-state doctor, who empathised with our sense of loss and disappointment but confirmed that this was indeed the end of the road unless we wished to pursue other kinds of treatments or perhaps adoption. Over the next few months, we discussed the other choices and finally decided that enough was enough: it was time to move on with our lives and to gratefully continue enjoying the child we had.

Little did we know that nature was planning something else for us. Five months later, on our return from a few weeks’ vacation in Pakistan, we discovered that I was pregnant. Our doctor said the treatments had “primed” my system to get pregnant. I was more than happy to give everyone involved as much credit as they wanted or needed for this wonderful turn of events. My husband and I were thrilled that we would have another child and that our first child would have a sibling.

I will now share clinical material to demonstrate the fluid and changing nature of transferences that became apparent in an analysis that spanned the period of my infertility treatments, their failure, and my subsequent conception and birth of a second child.

Clinical Material

Ms Lee

Ms Lee, a young African American woman and a physician, came to see me a few years after she got married. She was one of three childless patients in my practice who were struggling with primary infertility and trying to have a first child during the time that I was struggling with secondary infertility and trying to have a second child. The following sessions took place soon after my infertility treatments had failed. At which point, Ms Lee had been in analysis for five and a half years and had recently conceived, as a result of treatment for infertility.

Session 1

The patient, after lying down on the couch, talked about the fact that her coat no longer fit around her belly. She recognised that she was five minutes late again, as she had been for a few days now. She acknowledged that in the previous session, I had been wondering with her about her lateness. She added, “After the last session, I went to the maternity store, looking for maternity bras and clothes. In the dressing room, as I was trying things out, I felt very faint. I remember I felt the same when I was trying on wedding gowns before I got married. It’s something about anxiety about a new life phase.” After a pause, she continued. “I remember at that time, I felt bad that I was getting married, thinking about my mother, who had gotten divorced all those years ago and had never remarried.” Another pause, and then she said, hesitantly, “I think I’m gloating about my pregnancy and the fact that you could not conceive. It feels awful that I have such thoughts.” I asked, “Awful in what way?”

Ms Lee seemed taken aback by this. “That’s a strange question,” she replied, “but a good one, actually. Makes me think, if you can ask me that maybe you don’t really think it’s awful to have such gloating, mean feelings toward other people.” A silence. “It’s hard for me to imagine, I guess, that you might be able to understand these feelings I’m having. I’m feeling glad that I’m pregnant and you’re not. That feels so mean, almost sadistic. I don’t want to feel like that.” I asked if she could tell me more about that. She said, “It’s not nice,” then laughed. “I know, I know, that sounds ridiculous.” I said, “No, I think you’re worried that I would find such struggles in you ridiculous. As though I couldn’t possibly understand how deeply torn you feel about being so fond of me on the one hand, and having thoughts of feeling glad about my loss and suffering, on the other. You’re worried that I couldn’t possibly understand this is a real struggle for you and that I would laugh at you, or look down at you for being worried about not being a ‘nice’ person.”

She replied, “When you say that, I feel perhaps you do understand. I felt so angry at you over all those months when you were going through infertility treatments. I thought it was so unfair that of all the analysts I had chosen to be with, it was you. How could I have known that you would need treatment for infertility? That’s what I came to you for, for help with my infertility, and then lo and behold, you were going through the same problem that I was, except that you already had a child. I didn’t even have one. When you were going through the treatments, I felt that your treatment was going to go really, really well, and I would never conceive. Or you would conceive before I did—that everything would be much easier for you. It’s very hard for me to talk about this, but I really needed you, and I needed your help with my feelings about what if you had your second child and I might not even have one.”

I began to better appreciate what a terrible problem Ms Lee had been—and was still—up against. During the time I was going through treatment, she had needed my help with her wish that my infertility treatments would fail and her envy about the possibility that my treatments would work and hers would not. In other words, she wanted my help with the hurtful and destructive wishes she had toward me about something she knew, in reality, was immensely important to me. It had seemed impossible to her, when I was in the middle of my treatment, that she could receive this much-needed help. It was only now, when I was safely (if unhappily) past that phase and she was safely and happily pregnant, that she could talk abou...

Table of contents

• Cover
• Half Title
• Title Page
• Dedication
• Copyright Page
• Table of Contents
• Acknowledgements
• About the Author
• Introduction
• Part I When Events in the Analyst’s Life Intrude upon Clinical Space
• Part II When Others Intrude upon Clinical Space
• Part III When Machines Intrude Upon Clinical Space
• Part IV When Political Events Intrude Upon Clinical Space
• Notes
• References
• Index