Saying Goodbye

A Casebook of Termination in Child and Adolescent Analysis and Therapy

Anita G. Schmukler, Anita G. Schmukler

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134881659
• Edition: 1
• Topic: Psychologie
• Subtopic: Relations interpersonnelles en psychologie

Termination of psychoanalysis or psychotherapy is centrally important both to the process of treatment and to the patient's experience of treatment. It is surprising, then, that there has heretofore been no comprehensive study of the subject. This book begins to bridge the gap in this area. It is the first volume devoted entirely to issues surrounding the ending of treatment in analytic and therapeutic work with children and adolescents. Organized into separate clinical and theoretical sections, framed by a preface and sectional introductions, and covering a wide range of psychopathology, this book explores the different ways in which children and adolescents grapple with the experience of separation at the conclusion of treatment. Of special note is the contributors' recognition that the parents of children ending treatment face their own termination experience in relinquishing the support of their child's therapist. The presentations are enriched, as well, by frank discussions of countertransference as it enters into the termination phase of treatment.

I
Clinical Contributions

Early Latency

The chapter by Alan Sugarman describes Sarah, who at six and three-quarters, began a termination phase during the fourth year of her five-times-weekly analysis. A schedule of sessions of decreasing frequency was established, so that each month one weekly session was eliminated. Sarah was told that she could determine the date of the final meeting, provided she gave sufficient notice so that there would be time to talk about her decision.

The rationale for this pattern included Sarah’s early traumata over separation and her relatively undeveloped sense of time. Sarah’s analysis had involved extensive work with sadomasochistic impulses and separation anxieties. Although the termination phase was characterized by symptom revival and various modes of regressive behavior, Sarah responded rapidly to interpretation and demonstrated evidence of increased synthetic function of the ego, development of defenses typical of latency, and reworking of earlier conflicts and developmental delays. The analysis of Sarah’s conflict between her feelings of loyalty to her mother and her loyalty to her analyst enabled Sarah to move from a position of predominantly negative transference. Her symptom of general indecisiveness during the termination process was ameliorated by the analyst’s interpretation of it as representing her worry about choosing the time to end treatment. The analyst’s verbalizing Sarah’s feelings, which she occasionally had difficulty in expressing, permitted her to deal with material that might have otherwise been avoided because of their painful associations.

The reader is also referred to chapter 13, by Novick and Novick, in which the termination of the analysis of a six-year-old boy is presented.

1
Termination of Psychoanalysis with an Early Latency Girl

Alan Sugarman

“I’ll miss you, but I’ll see you tomorrow.”

In describing the termination phase of analysis of a six-year-old girl, I focus on the manifestations and management of clinical phenomena and on such methodological issues as criteria for termination. A more detailed study of the overall case is presented elsewhere (Sugarman, in press).

While taking into account developmental differences and their manifestations in the content and form of the material analyzed, I emphasize the striking structural parallels in the termination process for adults and for children even this young.

The importance of the analyst’s more active role in setting a timetable will emerge as one of the technical modifications that are sometimes needed to effect termination for an early latency child. This case demonstrates too the need for the analyst to address the developmental issue of the child’s limited capacity to verbalize and the need for the analyst, certainly in Sarah’s case, to assist the child in surmounting pronounced separation conflicts.

Sarah

Sarah’s masochistic behavior had been addressed in five sessions weekly of psychoanalysis for slightly over three years, beginning when she was three and a half. Sarah was six and three-quarters when we agreed to set her termination date. She had expressed wishes episodically to terminate throughout her years of treatment and these impulses had been analyzed with regard to their defensive and wish-fulfilling functions. After three years of analysis Sarah’s wish to terminate seemed less defensive. Symptomatic improvement had occurred steadily throughout the analysis, and for almost two years she had been free of the masochistic provocativeness and tantrums that had precipitated her initial referral for analysis. Furthermore, she seemed solidly entrenched in latency with a developmental momentum auguring well for continued growth after termination. Thus, it seemed reasonable to agree with both Sarah and her mother that she was ready to end treatment.

Sarah’s Presenting Complaints and History

A brief description of Sarah’s presenting symptoms and their developmental origins will be the background for understanding the nature of the issues she reworked in termination. More complete information can be obtained by reading about her early stage of treatment (Sugarman, in press). Sarah’s mother brought her for consultation soon after she turned three. Her parents had separated, Sarah and her mother had relocated to San Diego, and her mother had remarried during the previous year. The cumulative effect of these environmental stresses combined with her equally stressful earlier history to make Sarah more negativistic, moody, and tantrum-prone than is typical of a child her age. Her mother felt exasperated by her inability to please Sarah. Sarah’s wishes to be controlled and punished were manifest at the time of the consultation in her requests that her mother “tell me I’m in time-out” or “tell me I did it really, really bad!” The environmental sources of these problems were abundantly clear in Sarah’s developmental history, where parental insensitivity and abandonment were severe enough to warrant being called cumulative trauma (Khan, 1963).

Conceiving Sarah was her parents’ attempt to save a failing relationship. Not only did the attempt fail, but the same personal conflicts that ultimately led her parents to be unable to remain with each other led them to neglect Sarah during her infancy. For example, they left Sarah with a sitter for over two weeks while they vacationed when Sarah was only three months old. Sarah’s lack of manifest reaction to the separation led her mother to feel comfortable about progressively returning to full-time employment over the next several months. This reaction to the infant’s anaclitic and narcissistic needs oscillated with excessive gratification of other infantile needs; Sarah was not weaned from the bottle until she was almost three years old and was still sleeping with a diaper when the analysis began.

Sarah’s father left the family at the mother’s request when Sarah was only 21 months old. A brief reconciliation between the parents failed, and her mother moved out, leaving Sarah with her father between her 26th and 33rd months. The mother then regained custody of Sarah only to move into an apartment where Sarah was not allowed toys because they made a mess. Within a few more months they relocated again and moved in with Sarah’s stepfather-to-be. The mother quickly became angry at Sarah’s refusal to treat this new man in her life as if he were her father.

Sarah’s presenting complaints, coupled with this history, led me to recommend analysis for what appeared to be a nascent masochistic-obsessional character neurosis.

Early and Mid Phases of Sarah’s Analysis

From the beginning of the analysis Sarah amply displayed the multiple determinants of her masochistic tendencies. Separation issues were manifested from the beginning after I unexpectedly canceled our third session because of illness. What probably felt like both a repetition of her mother’s inconsistency and her fears about my reaction to her aggressive play in the first two sessions led to a shift in Sarah’s attitude toward me. She sat on her mother’s lap and complained of feeling ill herself, instead of happily accompanying me from the waiting room to the office as she had done previously. Separation themes became a major focus of our play for the first year of the analysis, and they would emerge again at every separation for the second year also. Drive determinants of her masochism were also prominent throughout much of the analysis. Conflicts over rage were evident early in treatment, alternately being expressed in efforts at sadistic control and, more directly, when she would draw her face close to mine and spit or call me a “fuck face” or “asshole.” Primal scene exposure was evident in surprisingly frank and repetitive expressions of sexual fantasies. Within the first month of the analysis Sarah requested that I remove my clothes, lie on top of her, and make love.

Defensive elements to her masochism also were exhibited. Projection, externalization, intellectualization, and reaction formation were all prominent, but a triad of related defenses played a particularly important role in Sarah’s masochism. Reversal, identification with the aggressor, and turning passive into active were all exhibited by Sarah in her desperate attempts to maintain control of her emotions and her interpersonal world. Being the passive victim was turned into being the sadistic tormentor in an effort to feel actively in control of an otherwise traumatizing maternal neglect and/or sadism. My role in her many enactments was almost inevitably that of the passive, helpless child in these derivatives of the unconscious beating fantasies characteristic of masochistic children (Novick and Novick, 1987). Identification with the aggressor contributed to the harsh, punitive superego evident in Sarah’s repetitive accusation during these enactments that I was “bad,” “dumb,” or despicable. Externalization of her superego was a particularly salient contributor to her masochism. Gradually, we realized Sarah’s need to provoke criticism and punishment in order to avoid her anxiety about losing her mother’s love.

Working through these conflicts and components of her masochism allowed development to resume, and oedipal aggression toward Sarah’s mother became evident after two years of analysis. At home Sarah expressed her anger directly and complained that her mother was the worst possible. Continued primal scene exposure, which included seeing a videotape depicting fellatio, led to Sarah’s stimulated discussions with her peers about ladies sucking on men’s penises and about her older stepbrother’s penis and buttocks. Competition with her mother for her stepfather’s attention began; Sarah repeatedly accused her mother of trying to make her ugly or insisting that she go to brush her teeth so that Mrs. T could have the stepfather for herself. During one session I interpreted her oedipal competition through a displaced enactment. I said that the kitty (Sarah) was angry and wanted the doggy (the stepfather) to love her more than he loved the kitty’s mommy. Sarah agreed with this interpretation, and the intensity of her oedipal behavior at home subsided gradually as we worked through variations on this intervention.

But anxiety over these impulses became manifest as themes of guilt and punishment emerged at home and in sessions. A new symptom appeared in which Sarah worried that her parents would run out of money because they spent so much on her. In one enactment I was to be punished by having my clothes removed. Then I was killed and my “girlfriend”—Sarah—came to grieve: This echoed my bemoaning, based on Sarah’s earlier play that week about being deprived of lovemaking, that we would no longer be able to make love because I had been punished and killed. Sarah, in the role of my girlfriend, agreed that she was sad that we would no longer be able to make love.

Somatic complaints escalated during this phase of the analysis and prompted Sarah’s pediatrician to request an upper GI series, which proved negative. I interpreted her problems in swallowing and her headaches as resulting from her problems thinking about (and swallowing) her sadness, guilt, or anger. One such interpretation led Sarah to attempt to provoke me by knocking over a desk chair. I said that she was trying to get me to punish her so that she did not have to feel guilty. Sarah responded that I should have people make love in my office. Then she began to rip the clothes from two dolls so that they could have intercourse. In this way she graphically linked her guilt to oedipal dynamics.

Oedipal conflicts began to be displaced to competition at school: Sarah experienced difficulty learning to read and handle numbers despite her superior intelligence. She repetitively played at being the sadistic teacher who always criticized Timmy (me) for failing to do things correctly. In one session the police were summoned because I had been so bad. Then my girlfriend spurned me in order to make love to Jonathan. Furthermore, my parents said they were leaving me because I was so mean. Finally, I was killed.

Guilt over aggression became more direct in our sessions as Sarah ordered her mother not to tell me about her accusations that her mother was bad. I said that she must worry that her mother would not love her for having such a feeling. Sarah responded that such a feeling was “mean.” I said that maybe she was afraid I would not love her either. Sarah responded by asking her mother, whom she had not allowed to leave the office that particular day, why she had hit Sarah as a baby. Then Sarah was reluctant to allow her mother to leave the office. Screen memories about being beaten by her mother characterized the midphase of the analysis and helped to assuage Sarah’s guilt over her oedipal aggression toward her mother.

Finally, after three years of analysis Sarah’s conflicts seemed sufficiently worked through to consider termination (van Dam et al., 1975). Her defenses and affects were more balanced and flexible. She was happy much of the time and could comfortably complain to her mother when she was not getting sufficient attention. No masochistic need to provoke her mother’s attacks remained evident, and Sarah’s ego was far more integrated. Her school inhibitions had resolved as she worked through her oedipal conflicts, and she was progressing well. Latency defenses of repression were being deployed. Sarah, whose enactments in play had always been so affectively charged, began to color, read, and play at banal and neutral themes. Modulated use of reaction formation and intellectualization was occurring. Sarah could talk about interactions and events without being overly intellectual but also without intense affect. Neatness in her play was now the rule rather than the exception. Progressive forces were in ascendance over regressive ones. At home and in our sessions she focused primarily on developmentally appropriate themes such as peer relations, school, and athletics. She handled separations well and easily went on overnights with friends. Drive development was clearly on track with oedipal themes in ascendance over preoedipal ones in her play at home and in sessions, and Sarah was moving into latency with a marked reduction of drive derivatives in our sessions. No longer were sessions characterized by rage or manifest sexual themes. Her self-esteem was considerably improved although she remained preoccupied with her physical attractiveness. This preoccupation was also an identification with her mother’s vanity, and therefore seemed, in part, to be a manifestation of her oedipal resolution. Peer relations were vastly improved, and Sarah was one of the most popular children in her class. She was able to traverse the cliques that were prominent at her prestigious private school and to have friends in rival groups without unduly provoking either rejection or competition.

Anxiety about her positive transference still occurred, so Sarah was more hostile toward me than affectionate. We had analyzed her oedipal anxieties, loyalty conflicts, and fears of abandonment as determinants of her negative transference, but I thought that we needed the opportunity to analyze her fears of abandonment once more as they were mobilized in the termination phase to finally resolve her fear of her positive feelings toward me. Thus, in agreement with Sarah’s mother, whose alliance remained positive but reactive to her own conflicts, I felt that Sarah was approaching a terminal phase in treatment.

Sarah’s Termination Phase

The Decision to Terminate

Sarah herself raised the question as we drew close to the third anniversary of the analysis. Our exploration of her question led her to express the wish to terminate and to acknowledge that her worries had disappeared and that our sessions interfered with other activities she wished to pursue. Sarah denied any ambivalence at this time despite my query. Consequently, I agreed with her that she seemed ready, and we negotiated a schedule of gradually reducing the frequency of sessions by deleting one session per week each month during the next six months, with Sarah exercising complete control of the frequency of sessions during the last month of the analysis. I encouraged a prolonged termination phase because Sarah’s separation conflicts had been so prominent that I wanted to ensure ample time for working through, but her counterphobic tendencies also made me concerned that she might decide to terminate “tomorrow” if allowed to make the decision herself. I tried to allow her some feeling of choice by allowing her to decide the frequency of sessions after we had started meeting once a week and to choose our last session, provided that notice was given at least one session in advance.

We planned to terminate in the middle of July. Sarah’s anxiety about the termination was manifested quickly and strikingly. After concluding this negotiation Sarah asked to go to the bathroom in order to clean the pierced earring holes in her earlobes so that they would not get infected. I reminded her of previous insights about her somatizing and said that worrying about her body was often a displacement from worrying about feelings. (Past work on her somatizing led me to make this general interpretation rather than pursue the content about dirty holes. More content-oriented interpretations had been less effective in illuminating her somatic preoccupations.) I went on to say that perhaps she was worried over the prospect of not seeing me. Sarah replied that she did not care about seeing me—in fact, she did not even like me. I interpreted this defense and said that not liking me allowed her not to miss me. Her counterphobic defenses escalated as she exclaimed, “I can stop whenever I want and I can walk out and stop now.” I struggled to avoid being drawn into the sadomasochistic transference-counter-transference interactions that had characterized an early portion of the analysis. Instead, I replied that even though the big-girl part of Sarah now felt ready to stop the analysis, the little-girl part of her remembered how unhappy and unsafe she felt when she was not the boss of saying goodbye—at those times that her mommy had left, her daddy had left, or when she had been left crying in the crib for what seemed like forever. Now she wanted to feel safe and to be the boss of when she stopped with me. Sarah put her hands over her ears in her attempt to deny the anxiety engendered by this interpretation. The session ended with her dragging out part of a box from my office to the waiting room, trying, as she had in the past, to take home things of mine in order to cope with her separation anxiety.

At the next session Sarah and her mother were discussing termination in the waiting room when I came for her. Sarah’s mother was saying that she hoped Sarah could terminate the analysis before starting first grade but that she could not promise it. My own countertransference anxiety about Sarah’s termination led me to ask Sarah if she had forgotten that we had decided the termination date yesterday. To my surprise, she replied that we had not discussed the issue. At that point her mother asked for ...