I recently observed a dramatic example of this process in a case I was supervising. The patient, Ms. A, a highly intelligent, attractive 40 year-old woman, sought psychoanalysis for treatment of chronic depressive symptoms. She was the second of three children, and the only daughter.  Her father, a constitutional attorney often away at work, was critical and self-centered. Her mother, a thoracic surgeon, seemed to compete with her from infancy. She overtly rejected her, calling her “stupid,” “ugly,” and “foolish.” 

Ms. A’s mother practiced with another prominent surgeon, a male who molested Ms. A first at ages four and five, and then again at age 14 when he attempted to rape her. The mother, who was having an affair with this same medical colleague, defended him. She insisted that Ms. A had fabricated the sexual assault. The evolution of the chronic mental pain in Ms. A, the extreme feelings of emptiness, emotional insecurity, and terror of intimacy, was unusually obvious.  Equally so was her terribly negative image of herself, a self-valuation that contributed to her tendency to choose abusive romantic partners. 

What follows is the transcript of a critical juncture in the psychoanalysis conducted by my supervisee. This particular interchange occurred about two years into the psychoanalysis, after many layers of defense had been penetrated, and the transference was being intensely scrutinized.

Ms. A: If you continue to move that close to me, to follow me so well, to know me, I will hurt you.

Dr. B: How?

Ms. A: I’m thinking of that dream I had, of the glass window with the wooden frame around it. And I am on a grass field, lying down, covered by it. Remember?

Dr. B: Yes.

Ms. A: Now I imagine nothing but the glass. The frame is gone. As I try to stand, the glass shatters. You are there, trying to help me up, but the shards of glass are pointing towards you. [Ms. A began sobbing uncontrollably at this point].

Dr. B: And you fear I will be hurt.

Ms. A: Not hurt, bloodied and killed.

Dr. B: But I’m right here, with you, hearing you, looking at you. And I’m not hurt.

Ms. A: [Entering a semi-psychotic state and becoming agitated now]. You’re not getting this. It’s not a metaphor. It is real. I’m stabbing you right now. [She sobs again]. The glass is cutting you up.

Dr. B: [Silence, and then:] You feel like your being itself is dangerous, like you will kill me.

Ms. A: Because I will.

Dr. B: You are so open and vulnerable right now, so defenseless. And I’m right here with   you.

Ms. A: [Seeming as if she did not hear what Dr. B just said]. No, I will poison you for sure, and you won’t see me anymore. You will vanish. You will not have me as a patient.

Dr. B: [More silence, and then]: Ms. A, we are here, together, at the core of your open wound. You had no mothering and little fathering. You think you caused it. [More silence]. And you are convinced your trauma will recur, that I will abuse and abandon you, and all because of you. And yet here I am, uninjured, right next to you.

Here is a true moment in time, a feral, transformative encounter between two people that clearly exemplifies Fairbairn’s key ideas.  Dr. B guided the relationship to an extremely regressed point, one in which Ms. A experienced herself, in the anguished present, as the bad infant deserving of criticism and neglect.  She successfully competed with Ms. A’s attachment to her “internal objects,” entering the space they previously occupied.

By staying so closely attuned to Ms. A, Dr. B was able to offer a different, healing emotional experience.  Ms. A’s depression lifted for several weeks.  If Dr. B and Ms. A are able to re-enact these encounters at such depth and intensity – “shattering” describes them appropriately – it can be expected that the chronic depression will resolve and, to use Fairbairn’s own words, the “bad” self will be “exorcised.”

Viewing patients in this way allows us to see them as real human persons.  Patients are no longer either anxious or depressed.  They are no longer neurotic, borderline, or psychotic.  They are human beings struggling with losses, not just walking poster-boards for the DSM-IV-TR.

Of course this line of reasoning does not simplify our work, but it does allow a unifying way to think about patients in psychotherapy.  The brain/mind functions as a sort of processing system, allowing us to cope with any number of changes, exigencies and endings.  Individuals typically seek help because their capacity for motion has become paralyzed as a result of loss.

Jacques Lacan once said that we are in love with our symptoms, implying just such a paralytic process.  Loss seems to create symptoms we love the most.  Consider the infinite lyric permutations of Oh, baby baby, I miss you so.  Loss follows the contour of life itself, from the lost paradise of the womb to the final loss of our existence.  Perhaps this is what makes our relationship to loss so primal, falling somewhere between a romance and a phobia.

Some patients avoid facing loss altogether by holding on to their pain. The pain becomes a substitute for the lost object, be it a person, an experience, or a bodily function. They obsess over whatever they have lost, and this becomes the focus of their experience.

A number of other patients simply cannot mourn.  It’s too painful for them. They unconsciously prefer to believe, omnipotently, that the mourning process can be avoided. They seek refuge in what Klein called the manic triad: triumph, contempt and control.  Losing is beneath them, mourning is a weakness of some sort, the forces of life and loss can be resisted.

Others prefer to remain in a state of denial, thinking they can keep moving forward without integrating their losses.  They progress through life with holes in their history, all in an effort to avoid facing whatever is now absent.  One patient of mine was stricken with anxiety when the woman he’d been with romantically for two years left him to marry another man, even though my patient had refused to marry her.  He still knows in his heart that marrying her was and is out of the question.

But now he can only focus on their times of closeness, her abandonment having become a screen for the death of his mother when he was two.  Remarkably, he does not deny his denial, readily affirming the immaturity, financial chaos, extreme family dysfunction and substance abuse the woman dragged into the relationship, making a marital commitment to her impossible. This vaguely psychotic dissociation allows him to indulge fantasy sentiments and avoid the finality of loss.

Interestingly, we psychotherapists must ourselves confront loss, mourning the absence of a neat system for characterizing the complexity of the human psyche. We don’t have the certitude of our scientific colleagues, who always have one or more constant variable on which to build a system that offers specificity and predictability. We will never have such constancy, except perhaps that life constantly brings changes, separations, and losses.

Virtually all of the psychodynamic models offer vehicles for such a process.  In the early Freudian days, abreaction released the emotions associated with loss. In the more modern, relational models, loss is dealt with by careful explication and exploration in the context of an intimate psychotherapeutic encounter between two subjectivities.

We must continually hone our skills in assisting persons to mourn.  Mature character is built through such a process of letting go of losses, integrating absences into the personality, and then moving forward more prepared for the next loss or change – a fundamental dynamic of the human condition.

I currently have two patients who are actively suicidal, having lost all meaning in their love and work lives.  Lately I have noticed myself feeling more hopelessness in reaction to them. But there’s another patient who has recently elicited this feeling in me even more deeply. He has descended into a hopelessness of a different nature. The loss that catalyzed it is more subtle – not a loss of job, of health, or of love, but the loss of control over another person in whom he had invested a great deal of his identity.

This patient, Thomas, has been almost solely in charge of rearing his granddaughter, Rachel. Her parents have such a laissez-faire attitude that he has stepped in increasingly, to teach her about life. His involvement began at her birth, and she recently turned sixteen. Thomas is a devout Catholic, and so his influence on Rachel has included exposing her to the various aspects of that religious tradition, including arranging for her baptism, her first communion, and her confirmation. He also attended Sunday mass with her whenever his circumstances allowed. Thomas also introduced her to every cultural experience imaginable, from the Getty Villa to the Nisei Japanese Festival, from concerts at the Hollywood Bowl to the Brewery Art Walk.

Just this last summer, Thomas was a chaperone for World Youth Day in Madrid, and Rachel was one of twenty local students under his care. The journey proved a grave disappointment for him. Rachel was openly oppositional and defiant. She completely renounced her faith, describing the priests as believing in an outdated myth. She flouted the dress code required at sacred sites. Beginning last fall, her parents allowed her to drop out of regular school and instead instituted a bare-bones type of home schooling. Rachel has, in fact, rejected formal education, has no plans to go to college, and her final career goal is to work as a Bartender. She is already adorned with the tattoos and piercings her parents vowed they would never permit till she turned eighteen.

For sixteen years, Thomas has striven to shape Rachel into a responsible, well-cultured, and spiritual young woman. According to him, he has “utterly failed” in that quest. He returned from the summer trip severely depressed. Because this “project” – Rachel’s upbringing – had become central to his life, he reacted with extreme hopelessness. He viewed it not only as losing her to the worst elements of contemporary culture but as evidence of his own failure as a person. We had already been working on Thomas’s identification as a “failure” in his life. He was a technical writer rather than the novelist he had striven to be; he’d struggled with a loveless marriage; he felt he’d neglected his own children when they were young because of his career.

Perhaps it was the suicidality of my other two patients, perhaps it was the intensity of Thomas’s reaction, but I found myself mired in a pit of hopelessness with Thomas for weeks. Approaching 70, his other “projects” in self-styled ruins, Thomas viewed his ultimate lack of influence over Rachel as a near-lethal failure, leaving him little to live for.

            As if a lens were slowly twisting back to a wider angle, the hopelessness began to fade into a broader landscape – quickly for me, more slowly for him – as we were gradually able to dismantle the organizational system of his personality that he’d come to label as “failure.” Thomas actually had many successes – deep friendships, published works, the esteem of colleagues and students, an intact and close extended family, and more. Ironically, our acute despair served as a catalyst for the ultimate breakdown of this “failure complex.”

Thomas is now involved in mourning his loss of influence over Rachel – and the loss of the woman he thought she could be. He is learning to keep on loving her as much as he always has, even though many of her choices and values are at odds with his own. He is beginning to explore his own narcissistic need to control her. He is rebuilding other, more meaningful and positive ways to view his life. And I, in close attunement with him, feel my own counter-transference turning towards hope.

But the most dismaying aspect of the entire fiasco was the leave-of-absence Weiner took to obtain “treatment.” This relatively recent cultural phenomenon – the rich and famous seeking “treatment” following the public disclosure of embarrassing or disturbing behavior – cheapens our work as psychologists. Worse, it is reminiscent of Soviet-style psychiatry. Let me explain.

During the Soviet era, certain psychiatric institutions, such as the Serbsky Institute in Moscow, were specifically set up for the “treatment” of individuals who stood against the political system. Psychiatrists could incarcerate people for their political beliefs alone. One such disturbance was known as “sluggish vilotekushchaia schizophrenia.” It was characterized by otherwise normal-appearing people who could break into “cases” of “nervous exhaustion brought on by a search for justice” or “reformist delusions.” The assumption was that you had to be insane to find fault with communism.
Our own society, too, has been rife with such abuse of treatment – treatment offered up for ideological rather than psychological reasons. Any number of celebrities, politicians, and other public figures are corralled into “treatment programs” when none of their problems qualify as mental disorders. A perfect example of this is Mel Gibson.

Like some Soviet dissident sent to the nut-house for wearing American jeans, Gibson was shipped off to a rehab facility in Malibu. Why? Among other things, to “cure” what the Jewish Anti-Defamation League condemned as his proclivity to utter “vicious words,” a reference to Gibson’s anti-Semitic outburst during his DUI arrest. Yes, Mr. Gibson needed to have his mouth – and his soul – washed out with soap. But his vicious words do not emanate from any form of madness requiring treatment. They are, pure and simple, the expression of an ideology, in this case anti-Semitism. Neither man – neither the hip Soviet dissident nor the un-hip Gibson – would find in “treatment” a “cure” for the ideological “mental disorder” their respective societies tagged them with.

To be fair, Weiner might clinically present with a touch of Narcissistic Personality Disorder, or maybe he has symptoms of what the DSMV will be referring to as a Hypersexual Disorder. But doesn’t this frantic search for formal labels reveal a kind of self-imposed poverty? Has our vocabulary become so strapped by labels and categories that we can no longer articulate, or even appreciate, the concept of accountable personhood? Have we totally abandoned the humanist vision of woman and man, creatures of consciousness and conscience?

When the Roman empire was descending into much the same kind of debauchery we now see in America (think Reality TV), Stoic philosophers such as Seneca preached for “the good, the true and the beautiful” and “the right life” against such moral decline. Seneca wrote, “Most powerful is he who has himself in his own power.” Some thirty years earlier, Aristotle wrote that ethical virtue “is a habit disposed toward action by deliberate choice… and defined by reason as a prudent man would define it.” Congressman Weiner is not ill. He acted “by deliberate choice,” at odds with “the right life” as even a less-than-prudent man would define it.

I believe that Weiner, simply put, has quite the problem with his weiner. Why does he have to be declared insane? Why can’t he just be a moron? Does every human error of judgment have to be reduced to a disease? Weiner is a man of flawed character. He does not need treatment. He needs a long walk in the woods, a long talk with a best friend, a long look in the mirror – but not the one in the congressional gym, on our dime. He needs to reflect on his poor judgment, his arrogance, his stupidity – the stuff of human frailty, not human insanity. For him and us, it’s time for simple common sense about the simple common flaws in human character.

Osama’s power as symbol was most strikingly manifested by the crowds that gathered within hours at the White House and Ground Zero, waving American flags and chanting, “Obama got Osama.” But what exactly was bin Laden a symbol of for these surging, ecstatic throngs? His death symbolized the end of a notorious terrorist, yes, the mastermind of 911 and other horrific attacks. But our jubilation was disproportionate, and that’s because it was also a sort of American psychological symptom: Our collective psyche condensed terrorism in all its global, historic complexity to a single event, masking truths that bin Laden’s death calls us to confront.

All our neurotic national baggage – our insecurity, our anxiety, our terror of terrorism, our economic uncertainty, our guilt, our moral qualms about our own capacity for evil, our unhappiness – these symptoms fed the symbol and the symbol allowed us to exult and forget. No wonder we were obsessed. And though we celebrated Osama’s death like the end of an era, dancing around it like a hanging at high noon, it’s hard to imagine it will ultimately make much of a difference in our “war on terror.”

Ironically, the same week that the bin Laden story broke, I began treating a woman who had a different obsession. She had fallen in love with her husband’s best friend, and thoughts of him were haunting her day and night. She felt extremely anxious; she couldn’t sleep or eat. She loved her husband, but something had “snapped,” causing her to be almost totally psychologically consumed.

When I first met her I was struck by the intensity of her distress, and the single focused nature of her thinking. Unfortunately for her, I was briefly distracted thinking about the parallels between her acutely frightened state, and the country’s obsession with bin Laden. The man she loved was a symbol that was similarly fed by her symptoms – her underlying lacks, fantasies and yearnings. Some of the reasons for her obsession could include deprivation of attention during childhood, insufficient emotional attention from her husband, depletion of her own emotional needs by the birth of her first child five months earlier, projection of unmet parental needs onto her dinner guest, or of course the possibility of authentic love-feelings that could threaten her marriage. Moved by her pain, and wanting to offer some immediate relief, I could only suggest these possibilities in that first session, warmly offering to spend time with her to explore what was fueling the obsession, and thereby helping her to break it up.

Bin Laden was a symbol personifying evil, while the man who came to dinner was a symbol personifying good. But together they offer identical examples of the typical meaning of the psychological symptom: A panoramic matrix of processes and dynamics condensed into a single arresting symbol. As Adam Phillips, a contemporary Object Relations theorist once wrote, “A psychological symptom represents a truth that can’t be told in any other way.”

The public glommed onto bin Laden’s death as if it represented the defeat of terrorism; the woman glommed onto her husband’s friend as if he represented salvation. The relationship of symbol and symptom is endlessly complex, but it always involves a distortion of the truth, a trick of the psyche, a distraction from where conflicts or deficits really lie. And the job of the psychoanalyst is to recognize symbols and symptoms for what they are: An interim focus of attention whose multiple causes and layers of subtle meaning beg for gradual unraveling. Hopefully the American public will soon acknowledge the essential insignificance of bin Laden’s death and instead explore the historical and political realities that provoke and sustain terrorism; hopefully the woman will soon let go of her painful focus on her dinner guest and similarly begin to explore the multifaceted meanings behind it that subvert her self-understanding and peace.

Yet, behold, now we encounter another verbal pigeonhole for complex and individualized psychological difficulties—namely, dual diagnoses, aka, DD (an abbreviation that might have actually fared better as a TLA, since DD sounds for all the world like a new brand of jeans, but I’ll save the marvels of pop culture for another time). As I’ve noted elsewhere, reductionist approaches to mental health problems have reached epidemic proportions. The increasing popularity of so-called dual diagnoses over the past two decades is a prime example of this disturbing trend.

Now, before I am assassinated by one of the multi-million dollar corporations that cater to the dual diagnosis population – one for a fee of $56,000 for a one month residential ranch program in Malibu – please note that my critique does not intend to imply that such disorders do not exist. They do. But their complexity, in which a mental condition and a substance abuse problem coincide, risks obliteration through the simplistic DD label. To be fair, the concept behind DD has added a more dimensional understanding of alcohol and substance abuse disorders, linking them with mental disorders that may be fueling or complicating them. But the benefits of the popular use of the dual diagnosis—aside from a catchy alliterative quality—appear to end there. Remember too that DD is hardly new news: before there were DSMs, nay, before there was even organized civilization, humans relied on any number of substances to cope with mental pain.

One could argue that use of DD allows for shorthanded communication between professionals. But a Cocaine abuser with an underlying Major Depressive Disorder is completely different from a Benzodiazepine abuser with an underlying Schizotypal Personality Disorder. So in referring a “dual diagnosis” patient, one provides almost no useful information. And the sheer number of substances abused, from recreational to prescription, in relation to the sheer number of potential mental disorders, from psychotic to neurotic to character disorders, creates dizzying permutations. Here, a short-hand designation of “dual diagnosis” may actually prove harmful by implying a uniformity that does not exist.

Perhaps there should be triple, quadruple, and even quintuple diagnoses. This must be true if we are to work on eliminating the mind/body/cultural splits that unfairly carve up the human experience. So a patient who abuses Cocaine to deal with depressive feelings may also have a cardiomyopathy that contributes to the depression. He or she may be depressed at the loss of their physical stamina. The Cocaine, frighteningly, could be adversely affecting their cardiac condition. If their Cocaine abuse has bankrupted them, then they are also facing financial impoverishment which will prevent their stay in one of those $56,000 treatment programs. So now we potentially have a quadruple diagnosis: Cocaine, Depression, Cardiomyopathy, and Financial Impoverishment.  But of course this is ridiculous, an endless reductionism that relegates the human person to a series of categories.

In the harshest light, the term Dual Diagnosis can be seen as a marketing tool, a branding, in Madison Avenue lingo, to enhance shelf appeal and profit margin. Take a fig and a raisin, package and price them as a Dual Prune, and maybe you’ve got yourself the latest sensation at Trader Joe’s. But what you’ve also got is just a fig and a raisin at twice the price. I mean no disrespect to the folks in Malibu, and perhaps I’m being a little too cynical, but my hope is that they never lose sight of the unimaginable complexity masked by the trendy alliteration of their logo – the human person who may be designated by this highly popular diagnostic designation, but can never be reduced to it.

After these five TLAs have been listed and described, a section of prose is rationed out to those therapies that sadly lack reduction into TLA categories. These include, also in order, psychodynamic psychotherapy, art or expressive psychotherapy, therapy involving animals, and light therapy. There was a footnote after psychodynamic psychotherapy that I turned to with trepidation. To my surprise, the authors note that the psychodynamic psychotherapies – those that most overtly emphasize the centrality of human relationship to the treatment process – have been shown to be as effective as any of the TLA therapies. I thought I detected a regretful tone in the footnote, however, almost as if the writer were ashamed that a TLA-less treatment modality could be effective at all.

If you read the way psychotherapy is described, particularly in any medical or health-related setting, you will envision armies of diseased faceless humans being subjected to rote interventions in an impersonal fashion. This parallels changes in the medical profession that emphasize diseases over patients, the so-called industrialization of medicine. In a similar fashion, clinical psychology is increasingly being reduced to a set of “procedures” intended to be applied to “patients” to cure or alleviate the effects of certain definable “diseases.” Such depersonalization is disastrous, even tragic, given the crucial importance of the establishment of a basic interpersonal relationship to the success of any healing process.

The establishment of a working interpersonal relationship is critical in any psychotherapy, even the most TLAish of them. The reductionist trend to cram the complexity of any of the psychotherapies into TLAs marginalizes the importance of the intricate interpersonal relationship that forms the core of any psychological treatment process. The same is true in medicine, of course, but whereas in medicine interventions are procedural and standardized, the interpersonal relationship is actually the fundamental component of any psychotherapeutic process.

Establishing the core competencies required of practicing psychotherapy proves rather difficult. Because of the ambiguous nature of human personality, they could never be completely operationalized, as could, for example, the competencies required to be an automobile mechanic. In psychotherapy, practitioners should be able to have insight, to be interested in human subjectivity, to be intelligent, to have tolerance and flexibility in their thinking, to be empathic, and to have a caring desire to be helpful. Notice how every one of these competencies relates to an interpersonal process.

And what is most sadly ironic about this trend is this: Individuals experiencing depression almost inevitably feel lonely, despair, a lack of interest in activities, and a loss of motivation or direction. They feel unworthy and unloved. The last thing such persons need is to view themselves as just another cog in a machine, soon to be exposed to CBT, DBT, IPT, FFT, or EFT to help them. (And yet – isn’t it interesting that some patients DO seem to find comfort in TLAs, and in the general idea that they are, to use an analogy, a machine in need of a tune-up rather than a human being with complex and ambiguous pains.) These TLAs all sound so similar; one wonders if the suffering patient might fear exposure to DDT, or evaluation by the FBI, CIA, or NSA.

In the final analysis, regardless of the “mode” of intervention, we psychotherapists must never lose sight that our interventions are offered in a context of interpersonal connection, and that this relationship in fact forms the absolute foundation of our work.

Working with certain compulsions, particularly those in which the behavior is illegal, requires us to encounter the fascinating interplay between psychological “illness,” personal freedom, and the need for societal protection.  As psychoanalytic psychotherapists, we must believe in free will; our work rests on a foundational belief that people can make free choices and change.

Patients’ free will is easy to see in milder forms of psychopathology. A man whose romantic partner just left him, and who becomes anxious and depressed as a result, can be expected to respond well to standard psychoanalytic interventions.  Although he may feel helplessly gripped by his emotional distress, we can be confident that by facilitating a mourning process, by eliciting anger he may be experiencing, and by otherwise “working through” the trauma, his condition will improve. Psychotherapy provides ways to free him from his painful experience; perhaps the relationship was destructive anyway, and in any event, he will grow from the experience. Once his relatively mild inner constrictions have been lifted, he is further freed to seek social support, exercise, and other outside interventions that will help him to recover.

In stark contrast, I recently provided a course of sessions to a true Kleptomaniac, a Mr. Jones. He clearly met the criteria for the “illness” of Kleptomania. He could not resist impulses to steal objects – most of which he did not need. He would experience an increasing sense of tension immediately before stealing, and then pleasurable relief after the theft was completed. Mr. Jones experienced little if any freedom in managing his feelings. He had already been arrested and convicted twice, and was facing time in prison should he steal again. As a child, he had been severely abused, at one point being literally tied to a tetherball pole for an entire day while his mother ran errands. He never met his father.

We explored his compulsion to steal from a variety of different angles, focusing particularly on how his childhood had left him feeling worthy of punishment. The same pattern emerged in the transference when he would enact ways he could be seen as unworthy. The Kleptomania was, in effect, an unconscious strategy for ensuring that he would be punished.  It was like a game. A successful theft offered faux competency and autonomy; to be caught was to be tethered again. It was a drama about freedom and punishment.  We worked through these and other themes repeatedly.

Despite our best efforts, Mr. Jones was arrested again for stealing a $10 item. I wrote a letter to the District Attorney advising her of Mr. Jones’ progress in treatment. She extended his probation period. Then, after another six months of intensive psychotherapy, Mr. Jones was arrested again. Since it was by then his fourth offense, the Court sentenced him to one year in prison. The Court – which also believes in free will following a long legal tradition with roots in both Judeo-Christian and Graeco-Roman ethics – concluded that Mr. Jones could have freely chosen not to steal and stole anyway.

Exploring the question of free will and psychopathology could elicit endless obsessive ruminations, but one simple solution is to view freedom as existing on a continuum. I can willfully lift my right arm, for example, but cannot change my height. I may be able to change my weight, but this metric has its own continuum of freedom in that some lose weight easily and others feel their free will proves insufficient for dieting. In the final analysis, we should cling dearly to our belief in free will, and intensively work to enhance the personal freedom of our patients, despite the fact that some of them experience, or actually have, little freedom to change.

In one of our sessions, out of desperation to bring his narcissistic features to his attention, I took out the DSM-IV-TR and reviewed the criteria with him. He announced with pride that he met all nine criteria.  Attempting to provoke some emotion, I then described the Kleinian triad of narcissistic features: Triumph, contempt, and control.  Smiling wildly, he laid claim to these characteristics as well. 

When Carlos first entered psychotherapy with me, which was in September 2007, he idealized me in such a fashion that he seemed to create a mirror of himself in me. Of course, he needed to see me as fantastic so that he could be so elevated. He called me the best psychotherapist in Pasadena. Because of what I admitted in the first paragraph, I fleetingly wondered if maybe he was on to something. He later referred to me as an “intellectual giant,” a description that propelled my ego into the heavens. The next day, with a touch of admirable timidity, I asked my lunch date, Diane Laughrun, PhD, if my patient’s assessment of me could be true. She replied, with admirable kindness: “Certainly not.” The swift shattering of my ego, although painful, ultimately helped me to see the power of Carlos’ personality style.

As yet another example of my humbling, Carlos quit drinking alcohol and abusing drugs after abruptly terminating treatment when I was hospitalized for endocarditis. Smarting from an acute sense of abandonment, he had written: “I will never pass through your doors again.” I smarted a little myself. Recently Carlos returned after a two-year absence and boasted of his healthier, happier lifestyle with which I’d had absolutely nothing to do. But within a few weeks it became apparent that he had simply switched addictions and was intensely pursuing body-building. He had read books on the subject by Arnold Schwarzenegger and Lou Ferrigno. He attended Gold’s gym on a seven day per week basis, two hours or more per day, and indeed looked much more muscular than he had in the past. He advised me, with the absolute certitude that Jacques Lacan claims is indicative of psychosis, that he would become the next Mr. Universe.

One day several weeks ago, while dressed in a T-shirt and sweatpants, Carlos was again bragging about his body. Then, without warning, he quickly removed his shirt and pants, rendering himself completely naked except for his black underwear. Needless to say, this was the first time this had happened in my 31 years of practice, and I was somewhat at a loss as to how to respond. He stood across the room in front of me and began to display poses characteristic of body builders. Just as the psychoanalysts would predict, I felt not only surprised by his behavior, but suddenly like a 99-pound weakling.

Fortunately—or unfortunately—my ego is resilient. I immediately noticed that, despite his otherwise muscular physique, Carlos sports more of a pot belly than I do, though in admirable humility I should warn would-be admirers that my abs fall well short of a classic six-pack.

Talking of Michelangelo…”

Perhaps the ebb and flow of relationships, including the therapist-patient relationship, is what TS Eliot meant by these lines in The Love Song of J. Alfred Prufrock. Not only women, of course, but all those who consult us naturally come and go. They may leave psychotherapy weeks after beginning the process, or years after, with warning or without, improved or not. Since we cannot help but become intimately involved with our patients, we must exercise caution in managing our feelings as termination approaches.  

The termination process in fact elicits any number of intense emotions in us, many of which might be viewed as shameful or unprofessional. Who among us has not felt deeply hurt, even abandoned, by the unexpected decision by a patient to suddenly leave the psychotherapy process? And what of the even darker emotions rarely discussed: Anger at patients’ leaving during some crucial phase of the therapy relationship; relief to be away from those we find too frustrating; fear that they may seriously mishandle some aspect of their lives without our help; sadness that we will deeply miss patients that we have come to love; worry that we will suffer financially because of lost income. Because psychotherapy is an intensely personal process—more a structured transformation than a “treatment”—many complex feelings are to be expected during its end.

What then are we to do with such emotions, particularly the ones that strike us most powerfully? We process them as we would any strong counter-transference feeling encountered as part of psychoanalytic psychotherapy. We endeavor to derive the meaning that is beneficial for the patient and then to deliver it via confrontation, interpretation, or empathy.  

But perhaps even more importantly, we must be on guard for the likelihood that our feelings as the relationship winds to an end often have more to do with our own psychology. Generally, counter-transference is elicited by a combination of ours and our patients’ feelings, a manifestation of the so-called two-person model of psychoanalytic psychotherapy. But some counter-transference is more localized in the therapist alone, and terminations are particularly prone to this. This is because therapists find themselves in the more vulnerable role of the party being left; for most of the relationship, patients are in the more vulnerable position.

The best way to proceed when faced with feelings about a termination is to look inside and determine what nerves are being struck within us. Once we have delved into our own psychology, then our attention should turn back to that two-person model. The therapeutic dyad should then mutually explore the meaning of the desire for the termination. Here it is crucial to place most weight on the autonomous functioning of the patient. In my view, we should err on the side of honoring the patient’s desire to terminate. But, in consonance with every phase of the work, we also explore the meanings of the decision, which range from an accurate assessment that a piece of therapeutic work is completed to any number of destructive reasons for early termination. Sometimes patients quit in order to avoid encountering a particularly painful aspect of themselves, their relationships, or some other aspect of their lives. Sometimes they leave masochistically, having achieved all the positive gains that they can tolerate. Sometimes they grow tired of exposing and exploring their vulnerability. 

Managing the termination phase requires great skill by the therapist: We must identify our own vulnerability; we must actively engage the patient in exploring the possible meanings of their decision; we must allow patients’ their autonomy at a time when we may disagree with, and be highly emotionally impacted by, their desire to leave. We are left alone with some of our most intense emotions, ranging from triumph to defeat, from loss to joy, from anger to relief. Having invested heavily in time, love and care for these individuals, we end up alone. Here we should be seeking solace from our connections with our colleagues, our friends, and our family members. Perhaps we should apply the Buddhist ideals of neither clinging nor craving, thereby more freely allowing our patients, in TS Eliot’s words, “come and go, talking of Michelangelo.”