Myths of Termination

What patients can teach psychoanalysts about endings

Judy Leopold Kantrowitz

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317645467
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Psychoanalysis can make a huge difference in the lives of patients, their families and others they encounter. Myths have developed, however, about how psychoanalysis should end – what patients experience and what analysts do. These expectations come primarily from accounts by analysts in the analytic literature which are often perpetuated in an oversimplified form in teaching. Patients' perspectives are rarely presented. I her book, Judy Leopold Kantrowitz seeks to address this omission. Exploring the accounts of 82 former analysands, she illustrates the rich diversity of psychoanalytic endings and ways of maintaining analytic benefits after ending; in presenting patients' experiences Kantrowitz provides correctives for some myths about termination.

Myths of termination: What patients can teach psychoanalysts about endings is not a book that seeks to refute or support any specific idea about a best way of ending analysis, but rather to show that there are countless ways of having a satisfactory conclusion to the process. Nor is the author espousing any particular analytic theory. Kantrowitz sets out to show that an oversimplified view of psychoanalytic endings not only diminishes an appreciation of the diversity of psychoanalytic outcomes but may also interfere with the creativity of individual psychoanalysts. In this book, former analysands describe and illustrate how their analyses ended. They reflect on the effect of non-mutual endings due to external factors (moving, retirement, illness or death) or psychological factors (wishing to avoid facing some issue); the impact of post-analytic contact; and the ways in which they have held on to their analytic benefits after ending their analyses.

Myths of termination confronts and refutes the myths about the termination phase of psychoanalysis that are passed from generation to generation. It is a refreshing and insightful study that will be welcomed by psychoanalysts, psychodynamic therapists, such as clinical psychologists, social workers, and others trained or in training to do clinical work.

Chapter 1

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A short history of termination

The ideal versus the real – it ain’t necessarily so

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Today when we think of analysis, we assume a beginning, a middle and an end. But it was actually not until the 1950s (Reich 1950; Glover 1955) that termination as a phase of treatment was conceptualized. The most likely explanation for this is that early analyses had short durations. For the most part, patients sought treatment for symptoms they did not understand. Transforming ‘what is unconscious into conscious’ (Freud 1917: 455) would – and often did – alleviate the manifest problem. However, it was only when patients regained sufficient capacity to love and work (p. 457) that Freud considered that they had been returned to health.

Issues related to the transference both complicated and facilitated the process of analysis (Breuer and Freud 1895). Freud’s recognition that unconscious factors affected both the analysand and analyst led to an appreciation that individuals who would be analysing others needed to know about their own unconscious conflicts and motivations. Because of this new understanding, training analyses began. At first these, too, were often very brief.

Ferenczi (1927) had originally believed that the process of ending analytic work would take care of itself. Neither analyst nor patient had to bring an analysis to conclusion; it would simply peter out on its own, dying of exhaustion. Later, however, Freud (1937) proposed more elaborated criteria. He stated that analysis could be concluded when the patient was no longer ‘suffering from his former symptoms’ and had ‘overcome his anxieties and inhibitions’, and when the analyst believed that the patient’s specific difficulties would not recur because ‘so much repressed material had been brought to consciousness’ (p. 320). By the end of his life, Freud explicitly acknowledged the limitations of analysis, noting that ‘bedrock’ issues were unlikely to yield to analytic scrutiny. In addition, only those conflicts that were active during the time of analysis would be analysed. He was clear that conflicts that had seemed sufficiently quieted could be reawakened. He also reflected that analysts themselves were especially vulnerable to such a resurgence, due to their work with patients’ unconscious. Enthusiasm for what analysis could reveal and change often led many of Freud’s followers not to think too much about what Freud himself had viewed as the interminability of analysis.

In the post-Freud generations, there was agreement that, although the disappearance of symptoms was an important indicator of intrapsychic change, it was not a reliable criterion for whether such change had occurred (Firestein 1974). Glover (1955) expanded on the importance of having a termination phase, maintaining that without it, no analysis would be complete. The idea that a ‘complete’ analysis included a discrete termination period then followed.

Novick (1988) stated his agreement with Glover’s view that the termination phase should be distinct from the rest of the analysis and assumed that most analysts would agree. Rangell (1982), for example, wrote that

insight and working through occur simultaneously or in sequence from the beginning … with small increments alternating with large reconstruction of traumatic events and constructions of developmental phases of the history – all coming to a peak some time during the heart of the analysis. What follows is a reworking and absorption of the entire process during the final segments, in which the phases of development and the web-like history become meshed. (p. 369)

He added that rather than new material emerging in the termination phase, the material deepens understanding and working through occurs (p. 347). Gilman (1982) concurred: ‘The benefits of a designated, time-limited period … are now well-established’ (p. 471).

But other of their contemporary theorists of the period challenged this idea. Dewald (1982) noted that, while the termination phase had typical issues, apart from agreeing on a date to end, the treatment during this period should follow the kind of analytic work that had been characteristic of the patient. No special techniques were required. And almost ten years later, Novick (1997) changed his earlier view, observing that by the late 1980s there was disagreement about whether the termination phase was unique or necessary for all analysands (De Simone Gaburri 1985; Goldberg and Marcus 1985; Pedder 1988; Blum 1989; De Simone 1997).

Criteria for termination

In the 1950s and 1960s, especially in North America, the analysis of ego activities, especially ego defences, replaced the concern with modifying drives as an indication that treatment had been successful. By the 1970s, some notable North American analysts proposed that the last part of analysis should indicate a change in unconscious fantasy organization (Arlow 1969; Abend 1979, 1990; Boesky 1982), and this view flourished in other parts of the world (De Simone Gaburri 1990).

Over the years, analytic writers set forth a range of additional indicators¹ that an analysis had achieved its purpose and could end. These included: recognizing and managing resistances; resolving the transference neurosis through reaching and maintaining the oedipal level of relationship (Novick 1982) and the development of self-analysis (Hoffer 1950; Gaskill 1980; Novick 1982; Schlessinger and Robbins 1983; Kantrowitz, Katz and Paolitto 1990b; Bergmann 2005); experiencing de-idealization and disillusionment with the analyst and analysis (Rickman 1957; Novick 1976; Dewald 1982); belief in the analyst as a ‘good object’ who could confront the patient’s acted aggression in the world and toward the analyst (Nacht 1962); more ‘good hours’ and a strong therapeutic alliance (Gitelson 1962); a deepened understanding and working through of the material rather than the emergence of new material, (Rangell 1966; Firestein 1974); and the capacity to tolerate uncertainty (Grinberg 1980).

Subsequently, a greater appreciation of developmental theory led to termination criteria focused on intrapsychic and interpersonal separation/individuation, autonomy from the drives, and increased differentiation of self. The goal of analysis was the internalization of a new structure to achieve a modification of self- and other-representation (Loewald 1988; Blanck and Blanck 1988) and self-cohesion (Kohut 1977).

Ticho’s important distinction between life goals and analytic goals (1972) further refined termination. Analytic goals were to free patients from internal obstacles that impeded the attainment of their life goals, which might take longer to achieve. Once a developmental process that had been interrupted or distorted was resumed, it was assumed that growth and discovery of personal potential would occur. Kogan (1996) expanded on Ticho’s idea by defining analytic goals as those shared by the patient and the analyst for the treatment, and life goals as those the patient wished to attain in life.

Decades after Ticho, the Novicks (2006) echoed his perspective, emphasizing the resumption of progressive development as an analytic goal. De Berenstein and De Fondevila (1989) refined ideas about progressive development. They made a distinction between aims that were general therapeutic goals – such as ego synthesis, sublimation and reparation capacity and an enrichment that affected the whole personality – and aims that were unique to each patient.

Despite such acknowledgements of the importance of specificity of the particular patient’s goals, generic and idealized criteria still characterized what analytic candidates were taught. Gilman (1982) presented a survey of 48 successfully completed cases, based on reports prepared for graduation and certification from 15 institutes. Although his report supported the diversity in the nature and quality of the patient material, he continued to use language that overstated what had occurred. For example, ‘For many of the patients who were working through Oedipal problems in the termination phase, termination signified the final relinquishing of the Oedipal object’ (p. 468).

Even analysts who focused theoretical interest in this topic held inconsistent beliefs about the importance of the termination phase. For example, Novick (1982) pointed out that all criteria for a successful analysis were about cure, not about entering the termination phase. Less than a decade later, however (1988), he cited Glover as saying that ‘unless there was an end phase passed through, it is very doubtful whether any case had been analyzed’ (p. 378). As indicated above, Novick (1997) later changed this view.

Many ideas existed about what transpired during the last period of analysis. For example, some analysts believed that during the end phase the central themes returned (Ekstein 1965; Greenson 1965; Bird 1972). Others referred to the reoccurrence of symptoms (Firestein 1974) as well as a condensed revisiting of the transference neurosis (Buxbaum 1950), with a rapid oscillation between integration and fragmentation (Muslin 1995). Still others maintained that previous understanding was synthesized (Ekstein 1965) and unfinished business emerged (Calef and Weinshel 1983). Sometimes the last stage of analysis was characterized by the recovery of memory (Mahon and Battin 1981).

According to Bird (1972), during the last phase there was a sense of collaboration between analysand and analyst in the analysis of the transference, with an experience of the analyst as the ‘Other’ in the conflict. Cooper (2009) stated that not only could old conflicts and difficulties reappear, but previously unexplored and insufficiently worked through aspects of conflict could become manifest in the patient-analyst interactions. Orgel (2000) observed that an oscillation occurred between impulses to remain and to leave, as well as shifts in mood. Also evident were an intensification of transference reactions to separation and experiences of anxiety, as well as depressive affects stemming from losses at different developmental stages (Schubert 2000). Adolescent approaches to separation foretold and paralleled terminations patterns (Novick and Novick 2006).

Although so many ideas about the nature of the termination process were offered, Blum (1989) and Bergmann (1997) noted that a paradigm for ending analysis had never been developed. Many of the phenomena cited are likely in endings, but do not invariably happen.

Both Dewald (1982) and Siegel (1982) viewed ideas of complete resolution as idealized and unrealistic. Dewald stated that limitations always remained. Siegel emphasized that powerful forces can be released by real-life events that may not have been occurring at the time of analysis. There were many future challenges that the patient may not yet have encountered, such as marriage, raising children and growing old. Like Freud (1937), he believed that only those conflicts that were active when a patient was in treatment could be analysed during termination.

When I was an analytic candidate in the late 1960s and early 1970s, we were taught that we needed to assess patients’ analysability before taking them on as supervised patients. It was assumed we would be able to make these assessments by evaluating the patients’ reality testing, the nature and quality of their object relationships, their affect availability and tolerance and their motivation for psychoanalysis. It was also assumed that, provided the analysand showed enough ego strength to be analysed, problems in these areas would be resolved at the termination of analysis.

My CORST project, which was a prospective, longitudinal study of the outcome of psychoanalysis (Kantrowitz et al. 1975, 1986, 1987a, 1987b, 1989, 1990a, 1990b, 1990c; Kantrowitz 1987, 1993), revealed that these factors were not, in fact, predictive of analysability. The factor that had the highest correlation with a positive outcome was the patient-analyst ‘match’. The vicissitudes of the ‘match’ could not be predicted at the outset. It could only be revealed in the course of the work. What is more, some matches that initially seemed facilitating could, as the nature of the issues of the analysand evolved, become impeding. The overlaps and clashes in conflicts and character and the blind spots that touched on the patient’s difficulties – which the treating analyst could or could not overcome – these were the most important factors influencing the outcome of the treatment, provided the patient was able to tolerate the depriving aspects of analytic work.

Although the nature of the analytic relationship itself – for example, the candour between patient and analyst – had been a focus for some analysts in the 1950s (Weigert 1952), in the 1960s and 1970s many North American psychoanalysts taught that clinicians were interchangeable, blank screens (Glover 1964). The only personal factor that was presumed to have an effect on the treatment outcome was the individual’s level of experience. My project demonstrated that when analysis was successful, the level and quality of object relations and affect availability and tolerance did improve (Kantrowitz et al. 1986, 1987a), and, as stated above, the variable most closely related to this improvement was a facilitating patient-analyst ‘match’ (Kantrowitz et al. 1989, 1990c). However, this did not mean that all difficulties had been resolved.

By the 1990s the nature and quality of the analytic relationship itself had become a main criterion for ending. For example, analytic trust – the patient’s and analyst’s capacity to hear, listen to, and respond to each other as separate people (Ellman 1997) – had developed. The change in focus in North America was due predominantly to Relational analysts, who conceptualized analytic work and its goals in different terms from those employed by classical analysts.

Whereas Freud sought to uncover buried, unconscious conflicts in order to attain greater mastery of impulse and freedom from inhibition (1937), Relational analysts focused on expansion, curiosity about affect states and deeper engagement in life (Salberg 2010b). Interpersonal analysts (Levenson 1978) had always regarded the patient-analyst relationship as central in analytic work. But it was not until the last two decades of the twentieth century that their views gained influence and were incorporated into the mainstream psychoanalytic movement in North America. I am inclined to think that the goals of Relational analysts with regard to termination are actually shared by most psychoanalysts today. It is the particular method by which one attains expansion, modulation of affect states, and deeper engagement in life and relationships that might still differ among various theoretical schools.

Increasingly, not only the nature of the relationship but the specifics of characteristics and experiences of the analyst have been taken into consideration in terms of how they approached ending analyses. Holmes (2010) linked types of endings to an analyst’s particular attachment style. The analyst’s personal history of separation and loss (Silverman 2010) and experience in termination (Salberg 2010b) are also now thought to influence the nature of the process in ending with their patients.

Mourning

While, as we have seen, there has been much disagreement among classical analysts about what criteria were required for termination, most maintained that mourning was a central and a necessary part of the termination process (Reich 1950; Balint 1950; Loewald 1962: Grinberg 1980; Dewald 1982; Cancrini 1988; Pedder 1988). Mourning was also thought of in terms of facing limitations of one’s own omnipotence and omniscience and what analysis itself could offer (Milner 1965; Grinberg 1980; Novick 1982; Dewald 1982; Orgel 2000; Moraitis 2009). I will address this topic in Chapter 2.

In 1937 Deutsch described an absence of grief as the consequence of a child’s having an insufficiently developed ego to be able to mourn and, therefore, becoming narcissistic as a self-protective defence to avoid the strain of a mourning process; she called this ‘unmotivated depression’. Weigert (1952) stated that ending analysis is a painful process ‘which calls forth the labor of mourning’ (p. 467) that was avoided in all neurotic difficulties. Johnson, as described by Weigert, thought the importance of mourning, manifested in the analysand’s grief in ending, reflected the loss of Oedipal fantasies. If the patient did not mourn, it was taken to mean that he or she was refusing to give up Oedipal wishes.

More recently, Craige (2002) observed that the final phase might serve as a trigger for evoking previous experiences of loss. Schlesinger (2005) believed that loss and mourning occurred throughout analytic work as patients relinquished symptoms and changed. In his view, ‘Loss, especially unacknowledged loss’, is the major reason patients come to psychoanalysis. ‘When relationships dissolve, the tension of impending separation is painful; significant relationships do not dissolve painlessly’ (p. 217). Patients may try to lessen the pain by putting off mourning, or they may ‘analyse’ the experience to diminish its emotional impact. Schlesinger’s assumption was that resistance to termination is based on the dependency on the analyst – an assumption that maintaining analytic gains is also dependent on the analyst’s presence. The process of mourning was therefore seen as necessary for making analytic gains one’s own.

Tessman (2003) observed that although mou...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword by Glen O. Gabbard
• Acknowledgements
• Introduction
• 1 A short history of termination: The ideal versus the real – it ain’t necessarily so
• 2 Developments in the ending of psychoanalysis: Insight, loss and mourning
• 3 Non-mutual endings
• 4 The effect of post-analytic contact
• 5 As time goes by: Ways of keeping analysis alive
• 6 Afterwards: What we learn
• 7 Reflections and reconsiderations
• Appendix
• References
• Index