Modern Psychoanalysis

Modern Psychoanalysis is a treatment for relieving mental and emotional distress. Its simple technique heals through the talking interaction between patient and therapist. Join us to learn more or post your own thoughts.

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Monday, February 27, 2006

Long-Term Treatment in Modern Psychoanalysis

Long-Term Treatment in Modern Psychoanalysis
Psychoanalysis is often criticized for taking too long, and for being far too costly when the money paid over all those years in treatment is added up. This brief writing contains just a few thoughts on the uses and resistances involved in thinking about long-term treatment.
The average time of those staying in psychoanalytic treatment in the United States is estimated to be somewhere over 5 years. Yet, when our patients first come to see us, it is unlikely that many plan on staying in treatment for over 5 years; let alone for the 10 or 20 years that some do.
As Dr. Hyman Spotnitz notes: (1985, pp. 112-13)
When contemplating treatment… pathologically narcissistic individuals are rarely interested in change. What they want primarily – and immediately – is relief from emotional suffering. They are more likely to feel that they would be investing time, money, and effort just to prove they are incurable.
So, how long is too long to be in analysis – how much time and money should one spend addressing life-long difficulties? Perhaps our views about therapy before we enter it would help with the answer.
Arnold Bernstein (1995, p. 52) contends that:
The expectations of both the therapist and the patient are derived from their preconceptions of what psychotherapy is, and of what it means to be cured. Foremost among these preconceptions is that the patient is ’sick’ and that the treatment is to be regarded as medical in nature.
Prior to entering treatment, patients can entertain a variety of other ideas about what treatment means and what might happen during the treatment. (See e.g., Strean, 1985, pp. 110-112).
Modern psychoanalysts generally try to create an analytic space or “holding environment” where it is safe for the patient to “say everything.” In this context, resistance most often refers to whatever interferes with saying everything (talking) and the modern analyst works at whatever level the patient is at.

Thus, a patient with difficulties which may have developed in the pre-verbal (or pre-oedipal) stage of maturation might be helped to develop a narcissistic transference before moving further.
According to Spotnitz, (1985, p. 121), in most cases 2 years would be “… the minimum duration for significant change to occur” and “(a)lthough the effective reversal of the schizophrenic reaction requires a minimum period of 5 years, the treatment may continue for a longer period.”
Freud (1913, p. 130) similarly stated “(t)o shorten analytic treatment is a justifiable wish… unfortunately, it is opposed by a very important factor… the slowness with which deep-going changes in the mind are accomplished.” We can certainly see the point where serious difficulties, such as schizophrenia, are concerned.

However, our minds often reject the idea of creating such intense long-term emotional attachments to strangers.
As Bernstein (1995, p. 51) says:
A prolonged therapeutic relationship is more likely to be a source of embarrassment… than a cause for rejoicing. Quite the contrary is the case when other personal human relationships come to an end. When marriages, families, friendships and loveships break up, it is generally conceded that something went wrong.
So it may horrify one, looking at it from the outside - to hear of an individual spending many thousands of dollars over 5, 10 or 20 years in analysis - but, if it helps that individual achieve a real and meaningful life, was it all worth it? Only that person can say.
In the end, perhaps its all a question of value and connection. How do we view our attachments, ourselves, and our value as human beings? What are those things worth?
References
Bernstein, A. (1995). Some Clinical Observations Upon the Emergence of the ‘Wonder Child” (CMPS/Modern Psychoanalysis, Vol. XX, No. 1, 1995).
Freud, S. (1913). On Beginning the Treatment. Standard Edition. London, Hogarth Press, 12:121-144.
Spotnitz, H. (1985). Modern Psychoanalysis of the Schizophrenic Patient: Theory of the Technique, Second Edition, NY, Human Sciences Press.
Strean, H. (1985). Resolving Resistances in Psychotherapy, NY, Wiley.


© 2006, James G. Fennessy, M.A., J.D.
Matawan, New Jersey 07747
E-mail:
njanalyst@hotmail.com

12 comments:

Escapee said...

Hey, thanks for this site; both for the discussions of the concepts and your compassionate and thought provoking (feel provoking?) responses to the bloggers.

My question: I have no problem with working for 5 years or so but... 20!?! On the other hand, I would hate to EVER lose the benefits that I am currently receiving from therapy (or for that matter, the relationship that has developed).

I am currently a client in a 1x a week psychodynamic psycho-therapy relationship that has gone on for 2+ years. Years ago, during my time in University, I worked with a humanist (who had some regrettable predilections toward attempting cog-beh techniques on me) for 3+ years. When it was time for me to leave the university, I had an amazing "escape into health". Currently, I am finding my therapy relationship amazingly revealing, challenging and (surprisingly) quite safe. And yet I feel ambivalent (okay, outright uncomfortable) about feeling dependent upon another. At the same time, I feel equally ambivalent about (potentially) losing someone who has made it safe for me to explore myself.

So, in short; when does one truly KNOW. Especially when one has a history of an "escape into health"?

"Escapee"

Jim said...

A wonderfully thoughtful question!

Perhaps 20 years should shock any reasonable person.

On the other hand, in modern analysis its always the patient's decision... and the analysis should end when the goals of the patient have been achieved. Some may want to keep the relationship for the reasons you outlined.

A potential danger with all types of therapy might be the therapist creating the situation... i.e., fostering a certain type of unhealthy dependency in the patient in order to keep the patient around (consciously or unconsciously).

Its slightly more difficult to answer how one truly KNOWS, especially due to the constant operation of resistance in us all; but I am still comfortable saying that each of us should let our feelings be our guide.

Has your therapist had anything to say regarding your outright uncomfortability about feeling dependent upon another?

Anonymous said...

Hi Jim,
Don't know when this post from Escapee came, but in looking for an old article, I just came across it. It struck me that Escapee used the term, "dependent upon another" for the analytic relationship. A friend of mine said the exact same thinhg when I suggested counseling (never even mind "analysis"!).

It's interesting, the notions people have about counseling in general, and I guess those notions are even stronger about analysis. I have only been familiar with analysis for about 9 months now and I certainly have a "good mother" transference going for my analyst, but I don't think I feel "dependent" on her. Heck--I barely even know what she looks like!!--- since I only see her for about 30 seconds at the start of a session and maybe more like 45 seconds at the end. In 9 months I've only called her one time when in distress. Do I think about her all week? Sort of... I admit to having imaginary conversations in my head with her, and I kind of imagine what her responses would be. I'm presuming that will wear off a little as my "overwhelming issues" are resolved and replaced by just "ordinary issues." :-)
I plan to stay in therapy with her as long as my insurance is reimbursing me 80%, or until one of us dies. Otherwise, I would be very hard-pressed to continue at all.

However, I know there are "bad" and "unethical" therapists and analysts who have boundary problems and allow themselves to be too involved in their clients' lives. THAT'S when trouble arises. But my analyst seems to be straight as an arrow- no crossing any lines with her.
She has been reliable and forthright all along, like a good-enough mother, right?

But Jim, What's your take on the "dependency" view that so many people seem to have? I would say they, like my friend, were just clueless about therapy, but Escapee is not clueless, and s/he used that phrase too.

Thanks so much, always enjoy your writing.
CLC

Jim said...

Hi CLC,
I think we'd probably need to ask, and then listen carefully, to know the meaning of "dependency" to an individual in a particular case.

However, generally speaking, I feel we usually relate to our analysts as we relate to others - our "dependency" viewpoint often has more to do with our feelings about attachment, than our feelings about "therapy."

What's your take on it?
Jim

CLC said...

Hello Jim,
Are you saying that those with the need for attachment have the propensity to develop dependency feelings no matter what the relationship? That these people would tend to be "dependent" on any semi-significant other, whether it was a therapist, or lover, friend, or whoever, because of their craving for attachment? (or conversely, their determination NOT to be attached or dependent)

"Escapee" is concerned about "feeling dependent" on his or her analyst. Isn't that dependency feeling inevitable with an analyst, what with the transference and all? I've heard it said that a certain amount of transference has to take place in order for the therapy to be effective. And finally, if one does stay with an analyst for 15-20-25 years, does that transference-dependency feeling become something else, some other kind of relationship not based on dependency but some other feeling?

CLC

Jim said...
This comment has been removed by the author.
Jim said...

Hello CLC,

In one way of looking at it, attachment issues are the lifelong task of each person. At one extreme, we are alone/isolated/separated from others; and at the other extreme we are symbiotic/engulfed/enmeshed. Many of us have a normal “comfortable” level of closeness/attachment/dependency with others, but are still pushed and tugged between these extremes for much of our lives.

Attachment research indicates that the basic emotional attachment pattern of the infant is usually set by infant interactions with the mother and tends to persist throughout life. [See e.g., Ainsworth, M. D. S., & Bowlby, J. (1991), “An ethological approach to personality development.” American Psychologist, 46, 331-341, and Main, M. (1995). “Attachment: Overview with implications for clinical work.” in S. Goldberg, R. Muir, & J. Kerr (eds.), Attachment theory: Social, developmental, and clinical perspectives, Hillsdale, NJ: Erlbaum].

We can also look at any of the issues involving emotional connections, or fear of same, through the lens of the degree of narcissistic difficulty involved for any one individual. (See e.g., “Narcissistic Transference.”)

So, I guess I am saying that in many cases there's a kind of general predisposition in each person’s character to view attachment or dependency in one way or another. It certainly might make a difference to the patient whether the person is a “lover, friend, or whoever” - though with the deepening of the analytic relationship, transference will develop, i.e., patients often end up resorting to the old patterns they had/have with their “significant others.”

It may even be that all of our feelings are based in one way or another on those earliest feelings of our lives. What do you think?

Jim

CLC said...

Shouldn't we expect patients to resort to old behaviors when a narcissisic transference has developed? (unconsciously, I mean). Aren't those behaviors usually the ones we are looking to modify because they no longer serve us well?

As you noted, I also have heard it said that when under pressure, we resort to our earliest learned behaviors. That would tie-in to what you said about infant-mother behaviors being the first-learned behaviors which stay with us and tend to dictate how we'll be throughout our lives. But, analysis can change those first-learned behaviors, right?
CLC

Jim said...

I expect people will normally act “in character,” regardless of whether or not a narcissistic transference has developed.

A thornier question is whether we are “looking to modify (those behaviors) because they no longer serve us well.” Modern analysts would first be inclined to ask the patient “what are your goals?” We would then want to work with the patient towards understanding what is blocking the patient from achieving the goals. During this process it might even be necessary for the analyst to strengthen the patient’s defenses, narcissistic or otherwise. The goal would be to help the patient develop sufficient emotional maturity so that the narcissistic defenses become less necessary and can be abandoned if the patient desires to do so.

Can “analysis can change those first-learned behaviors?” I believe so. Scientific evidence also seems to suggest that it can. See Fennessy, J. (2006). The Mind in Modern Psychoanalysis. (Online at: http://modernpsychoanalysis.org/Documents/MindMod_PsyA.pdf, p.7).

Jim

Anonymous said...

This is an unrelated question, but I'm not quite sure where to post it. I know that play, work, and love are some of the spheres of life that psychoanalysis focuses on most intently, at least in theory. But it seems to me that the concerns with love and other emotions and possibly with play get a lot more air-time. Or at the least I can say that I feel like I could bullshit a 2-minute answer to a question about those topics. But what does a psychoanalytic attitude to work look like? What kind of conceptual languages have psychoanalysts adopted/developed to describe the place of work in human life?

Jim said...

I'm not certain I know what a psychoanalytic attitude to work ought to look like.

Looking at it from a clinical perspective - if a person becomes aware of a substantial difficulty in one of those three areas (love, work or play) they're more likely to seek treatment - from that point, modern analysts are most likely to let patients define their problems and explore their own goals.

What's your idea of what a psychoanalytic attitude to work ought to look like?

Anonymous said...

I appreciate your blog. I've been in analysis since April 1991 after quitting graduate school. At that time my life seemed to be winding down to a certain end. Fortunately for me, I met a very highly trained and empathetic analyst. He helped me understand myself and helped me build a life. It is a very expensive process and often misunderstood. I very rarely tell anyone that I'm in analysis. Sometimes, people need a safe place to grow. Unfortunately, growth takes time - that's just part of the human condition.