Reflections on Long-Term Relational Psychotherapy and Psychoanalysis

Relational Analysis Interminable

Susan A. Lord

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9780367150150
• eBook ISBN: 9780429620256
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Reflections on Long-Term Relational Psychotherapy and Psychoanalysis explores how relational analysts think about and pursue long-term therapeutic relationships in their practices. Many therapists work intensively with their clients over many years and don't necessarily talk about their work. More exploration is needed into what is taking place inside of these long-term relationships.

The chapters cover a range of topics that focus on aspects of the therapeutic relationship that are unique to long-term psychoanalytic work. They include work with various issues such as trauma, death and dying, cross-cultural issues, suffering, mourning, neuropsychoanalysis, unique endings, attachment, intimacy, and the many ways in which therapists change along with their clients as they go through life stages together.

Reflections on Long-Term Relational Psychotherapy and Psychoanalysis will be of great interest to psychoanalysts, psychodynamic psychotherapists, psychologists, social workers, workers in other mental health fields, graduate students, and anyone who is interested in change processes.

Part I

The terrain

Chapter 1

An interview with Joyce Edward

Joyce Edward and Susan Lord

As I was putting together this book it became clear to me that it would be important to include voices of senior psychotherapists and analysts in order to gain their long-range perspectives on long-term treatment. This chapter offers an interview with Joyce Edward, a 94-year-old psychodynamic social worker and analyst whose career began in 1947 and continued until her retirement in 2007, a total of 60 years. As a clinician who trained with such esteemed analysts as Gertrude and Ruben Blanck, Margaret Mahler, Martin Bergman, Lawrence Friedman, Jacob Arlow and Roy Schafer, Joyce offers a particular view on the evolution of long-term relational psychoanalysis.

Joyce earned her MSSA from Case Western Reserve University in 1946. She began her career at Central Islip State Hospital in 1947, moving to the Nassau County Department of Welfare Children’s Services in 1948. From 1956 to 1969 she worked as a caseworker and supervised clinicians and teachers working with emotionally disturbed children at a therapeutic school. She trained in psychoanalysis and psychotherapy at the Institute for the Study of Psychotherapy in New York, and maintained a private practice from 1972 until her retirement in 2007. Joyce was an instructor at Adelphi University, Hunter College School of Social Work and Smith College School of Social Work for more than 20 years, and also taught at the Society for Psychoanalytic Study and Research and the New York School for Psychoanalytic Psychotherapy.

Joyce is the author of many articles and books on aspects of psychotherapy and psychoanalysis. She wrote The Sibling Relationship: A Force for Growth and Conflict (2010), co-authored Separation-Individuation: Theory and Application (1991), and co-edited Fostering Healing and Growth: A Psychoanalytic Social Work Approach (1996) and The Social Work Psychoanalyst’s Casebook: Clinical Voices in Honor of Jean Sanville (1999). Known for her advocacy work on behalf of clients’ rights, particularly in the area of confidentiality and access to services, Joyce was co-founder and first co-chair of the National Coalition for Mental Health Professionals and Consumers in New York.

Joyce has some very strong ideas about the ways in which managed care interferes with long-term work, and her coalition work was a part of her pursuit of social justice in this regard. Here is an excerpt from Joyce’s writing about managed care and its impact on psychodynamic work:

Managed mental health care is not psychotherapy. Instead it is what it says it is, an arrangement designed to manage people, both patients and therapists. Whereas for the psychotherapist, self-determination is both a means and a goal of treatment, corporate mental health care places serious limits on the freedom of both patients and therapists to determine the means and goals of their work together. The restriction of freedom is perhaps one of the most deleterious characteristics of the managed care system. In depriving individuals of their privacy and of the assurance that their confidentiality can be protected, patients are being deprived of the freedom to speak openly, thereby compromising one of the most basic constituents of the therapeutic process. At the same time, the limited numbers of sessions being offered, and the sudden changes in therapists that are occasioned by companies merging or closing or by the unexplained termination of therapists from panels, are impeding the establishment of a sound therapeutic relationship, the second major constituent of sound psychodynamically-oriented treatment. When these two major constituents of treatment, a free and open communicative process and the establishment of a therapeutic relationship are absent, is psychodynamic therapy possible?

(1998, p. 114)

That final question is an important one that I believe speaks to the central issue. Communication and relationship are core elements of the therapeutic endeavor and must be developed freely without the constraints of time limits or other external regulations. Long-term work certainly offers the opportunity to freely develop both and, with the advent of relational work, it has become even more critical that there is an opportunity for interactions to evolve without constraint.

Joyce is highly regarded for her writing, her teaching, her curiosity and openness and her consummate generosity of spirit. This interview took place in her home in Long Island, New York, where she graciously served me a wonderful lunch and shared her wisdom and her views on long-term treatment. As I sat with her I was able to experience her warmth, her humor, and her passion for social justice in the interview that follows.

Definitions

Susan: Thank you so much for agreeing to talk with me. I am interested in your views on long-term treatment. First, how would you define long-term treatment?

Joyce: While I was in practice I probably thought of long-term treatment as treatment that would go beyond six or seven years. In my own practice three to five years seemed to be the average length of time I saw a patient. It is important to note that in those days psychotherapy patients were frequently seen by therapists like myself twice a week, and psychoanalytic patients three or four times a week. Fees were often reduced in order to provide patients with what we saw as more favorable treatment arrangements. Several of my colleagues were in analysis for more than 20 years. I know two women who have been in treatment on and off for most of their lives, to what they regard as their great benefit.

Susan: What was the longest period of time that you worked with a client?

Joyce: Over the years I have actually only treated one person in what I considered to be long-term treatment. I probably saw him for about 13 years. After about five years of my work with him I became concerned about the limited gains he was making and sought a consultation. What was I missing? Might I be doing something to hold on to the patient? I was surprised when the consultant, reminding me that the patient had been in one treatment or another since adolescence, referred to the patient as a “lifer.” He saw the patient’s need for lifelong treatment as related to the severe traumas the patient had experienced early in life, and the absence of any significant support figure in his life. He pointed to the few but significant gains the patient had made through our work together and emphasized the importance of the therapeutic relationship in fostering the patient’s continued stability.

In retrospect I realize that what we needed to explore in that consultation was my discomfort with the idea of lifelong treatments. What was it stirring up in me? Like some other analysts of my times I was suspicious of long-term treatments. Were they not the result of therapists holding on to their patients for their own gain either psychologically or financially, or both?

Our work together was brought to a close by my retirement. At that point the patient felt he was much stronger, and decided he would like to see how he would fare without treatment. However, I learned from the therapist, whose name I had given him should he wish to continue with someone else, that within the year he had begun a new treatment. While my colleague has been appropriately protective of the patient’s privacy and confidentiality, she has shared the fact that the patient has done well over the intervening years, and was being seen on a once-a-month basis at the time I spoke with her.

When I look back on this case, I see how right the consultant was. The patient was a “lifer” and what I ask now is “what is wrong with that?” In retrospect, why might a man who had suffered the loss of both parents during his first two years and then faced ever-changing caretakers for the rest of his childhood, not seek a supportive therapist for the years to come?

Brief treatment

Susan: When you were trained were you trained to do briefer work?

Joyce: Actually no. I was trained by Gertrude and Rubin Blanck who regarded twice a week or preferably three times a week sessions as optimum arrangements. I don’t recall though any consideration given to the length of time of treatment. However, students at the Blanck Institute tended to work with severely troubled patients and were prepared for their treatments to take time.

I also studied with Jacob Arlow. We were a group of social workers. I don’t recall any discussion of the length of treatment. However, Dr. Arlow apparently noted some urgency in our work to help the patient sooner rather than later. He accused us of a “compulsion to cure.”

There was, during that time, interest on the part of some psychoanalysts in brief treatment. I no longer recall the group that was developing what was referred to by some as “time-limited” treatment. However, I do recall a patient I saw after they had been in such a program. Discharged after the ten agreed-upon sessions, the patient had in the initial session with me noted that he had “failed” his earlier treatment.

When managed care came along, brief treatments became standard. One of the reasons therapists like myself organized the National Coalition for Mental Health Professionals and Consumers that you mentioned, was our deep concern about the limited number of sessions that companies were willing to authorize.

Analysis interminable?

Susan: What do you think about therapists and their clients continuing their work indefinitely? Until one of them dies or is unable to continue?

Joyce: I have unfortunately known therapists who have worked until they died or were unable to continue to work. I have treated two patients whose therapists were seriously ill and died during the treatment. One died during a session! The impact on both these patients was profoundly disturbing.

I also felt that the therapists suffered for continuing to work through their illnesses which, to my knowledge, they did not apprize their patients of until it was impossible to conceal. While the therapists found the work helpful to them, they were aware I think of the potential harm they might be doing to their patients, and troubled by this. Also they found it increasingly difficult to conduct the treatment in the excellent way they had before.

I have always favored retiring when one is fit and able to do so voluntarily. I stopped taking new patients in my early seventies and retired at 83. I am glad that I did so. I loved the work. It was so personally rewarding, I felt like I was being helpful and I gained great satisfaction from feeling like I was continuing to learn and develop, a bonus our profession offers us. However, I have not missed the work. I actually feel relieved not to have the responsibilities that are entailed.

Sometimes when I hear therapist friends talking about a case, I feel I could no longer deal with the challenges they are facing. I could not take the sadness that we therapists often have to “hold.” Like many other elderly persons, I have had to face many losses over the years. They come more frequently as one grows older. I have several ill friends that I try to support to the best of my ability. I feel now that it would be much harder for me to listen fully to the painful material that as therapists we listen to and try to help our patients with.

Future

Susan: How do you think things will develop with long-term treatment over time?

Joyce: The future of long-term treatment is in some ways tied up with the future of psychoanalysis. At the moment, that future seems very uncertain. Woody Allen’s long analysis has long been used to disparage psychoanalysis, and it is not unusual for lay persons to ascribe greed on the part of analysts to a particular person’s lengthy treatment. If it is not the analyst holding on to the patient, it is the patient’s “dependency” that is often said to be offensive.

I can only hope that somehow the public will in time awaken more fully to the deleterious effects of deprivation and trauma on human development and the need for a psychodynamically oriented treatment that can help ameliorate the ill effects of past noxious experiences and foster continuing development.

I do think in the end that it’s all about the relationship. I hate to say that in a way, because we work so hard to learn a lot of things. I always remember a case that I had. One of my first patients had just been released from the hospital, she had made a suicide attempt. I saw her for two years and she got better and left, then she came back and did more work and left again. Years went by and she wrote me a letter. She came back to visit and to show me her two kids. She came to the front door. I sat with her and her two kids, and she said, “Would you like to know what helped me? You listened so. You seemed to think what I said was important.” And I thought, all these years and interpretations … I think bearing witness is very important too. There had been terrible abuse in this family, and it was important to have someone know and indicate that this really was awful and it shouldn’t have happened. You wish you were there to stop it, but you can’t.

I am hopeful that a volume such as this will help clinicians appreciate that there are some individuals for whom long-term, sometimes several intermittent treatments or continued treatment through life are the “treatments of choice.” For some of these “lifers,” their treatment may remain essential in the absence of supportive figures. For some, their goals for self-development will lead them to long-term treatments. For others changes along the life cycle, traumatic experiences, losses or other major events will bring them back to treatment.

While I am far more comfortable with long-term treatments than I was earlier in my career, I do believe that it is important that we carefully evaluate our work with our clients as we proceed. There are treatments that are prolonged due to a therapist’s limitations. Countertransferences, lack of skills on the part of the therapist, poor fit between therapist and patient, and any other number of factors may render a treatment ineffective or even harmful to a client. The importance of self-supervision, consultations with more experienced therapists, group consultations and the highest standard of professional ethics cannot be overemphasized.

References

Edward, J. (1998). Impact of managed care on psychodynamic treatment (book). Clinical Social Work Journal, 26(1), 111–114.

Edward, J. (2010). The sibling relationship: A force for growth and conflict. Lanham, MD: Jason Aronson.

Edward, J. & Rose, E. (eds.). (1999). The social work psychoanalyst’s casebook: Clinical voices in honor of Jean Sanville. Hillsdale, NJ: The Analytic Press.

Edward, J., Ruskin, N. & Tunini, P. (eds.). (1991). Separation-individuation: Theory and application, 2nd ed. New York: Gardner Press.

Edward, J. & Sanville, J. (eds.). (1996). Fostering healing and growth: A psychoanalytic social work approach. Northvale, NJ: Jason Aronson.

Chapter 2

Long-term psychotherapy

Whyever not? (A question of assumptions)

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Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of contributors
• Acknowledgments
• Introduction
• PART I: The terrain
• PART II: Trauma and issues of attachment
• PART III: How could it be otherwise?
• Index