Excerpts from Must Read Books & Articles on Mental Health
Articles- Part X
MORTAL GIFTS: A Two-Part Essay on the Therapist's Mortality
Journal of The American Academy of Psychoanalysis, 30(2), 173-204, 2002
Part 1: Untimely Loss
How should this grief be properly put into words?
Melpomene, to whom the Father gave
The voice that to the music of the lyre
Flows out in mournful measure, teach me the art.
-Horace, from "To Virgil," translated by David Ferry
Abstract: The absence of theoretical and practical provisions for the patient
whose therapist dies or becomes seriously ill reflects underlying problems regarding
termination. Therapy is unique among human intimacies in that its goal is separation, a
paradox that informs both the near-silence of early termination theory and the confusion
in more recent writing. The therapist's emotional involvement must be understood through
the therapeutic relationship as part of "mortal" life, that is, as a specialized
category within ordinary human interactions. The profession has neglected the therapist's
mortality, in figurative as well as literal senses. This neglect, a covert grandiosity, is
the "Olympian Delusion." On one level, inadequate termination theory underlies
failure to confront the therapist's mortality; more profoundly, failure to confront the
therapist's mortality underlies deficiencies in termination theory. The mystique of the
superhuman therapist can lead to a professional reticence that is less than fully human,
abrogating the patient's right to a decent, human leavetaking.
Key Words: illness; termination; mortality; death; therapeutic relationship;
When my therapist suddenly died at the end of May in 1994, I felt lonelier than
ever in my life. 1 turned for comfort to the same sources I have always turned: to people
and to books. The first were wholly satisfactory, the second only partly so. In turning to
people, there were two directions to go, the personal and the professional. Lucky in the
safety net provided by the comfort and understanding of my friends and family, I was
additionally fortunate in the strong support tendered by my therapist's professional
community. His colleagues offered themselves immediately and generously, at every point
proceeding carefully and wisely, all in the face of their own confusion and grief. They
remained available throughout the immediate crisis, making clear their availability if
needed into the future as well. In my view, this full assumption of responsibility for the
patient's well-being provides a model. I was truly fortunate in people, in both the
personal and professional realms.
However, I can't say the same for the comfort I got from reading. In
turning to books, I also had two accustomed directions to take: first, I could go to
literature, which has cushioned and buoyed me since I was small, and, second, I could go
to psychoanalytic theory. In literature I found what I needed; but in psychoanalytic
theory, not only did I not find what 1 needed, but what I did find outraged and
discomfited me. Looking for a way to lessen my pain and confusion, I turned to the body of
papers on the illness and death of the therapist. I found instead of comfort a great deal
of avoidance, confusion, condescension, self-delusion, and dissimulation. Rarely did I
find the voice of the patient.
My purpose here is not to review these papers, something others have
done well elsewhere; rather, I aim to illuminate some factors that underlie the manifest
difficulty the profession has had creating a literature adequate to a subject touching our
deepest anxieties: we all die, we are all at every moment vulnerable, and we are all
inclined to deny the fundamental terror. I raise far more questions than I answer. In
taking a strongly critical stance about the profession's failure to adequately address the
therapist's mortality, I do not mean to undervalue the courage required of every author
who risks approaching this difficult subject. Most especially, I hope my admiration is
apparent for those whose search for understanding in the frightening, painful but vitally
important matter of human vulnerability is particularly respectful and truthful.
People really die, not only some but all, each of us in our turn.
--Freud, from "Thoughts for the Times on War and Death"
When people part, whether for the moment, for a while, or forever, they will say
good-bye. This ritual of parting holds whoever the people are, whether greengrocer and
customer, teacher and pupil, lover and beloved, two brothers, or two friends. The more
important they are to each other, and the longer the anticipated separation, the more
important it is to take leave well. These are just commonplaces.
In matters so thoroughly ordinary, we may assume that the needs of
therapist and patient are no different from the needs of other ordinary people; and it
follows that the greater the depth of the therapeutic relationship, the greater the need
at parting for an adequate good-bye. These simple truths hold, whatever the otherwise
peculiar qualities of the psychotherapy situation. In the odd technical language of
psychoanalysis, this work of parting is named "termination," and it is the
endpoint toward which every therapeutic engagement naturally moves; that is because,
unlike other relationships of depth and intimacy, the therapy relationship intends right
from the outset to end. Here we are faced with a paradox: the goal of this special form of
closeness is separation.
In his cogent examination of the word, Pedder (1988) suggests that
termination "is a curiously inappropriate term with its negative and finite
connotations which fail to convey the positive hopes for a new beginning that normally
surround the end of a satisfactory analysis" (p. 504). However, his suggestion that
the term is exactly appropriate when the ending is forced or premature is strikingly
germane to the topic under consideration, the threatened and sometimes literal
"termination" of the analyst's life. But we might then wonder what lies behind
the adoption of such a "curiously inappropriate" word to describe the natural
ending of the analytic relationship. Perhaps the relationship's paradoxical intent--an
intimacy that intends separation--builds into every analysis an inherently traumatic
ending, and in that sense the word "termination" is quite apt, capturing an
emotional truth in the experience of parting.
Ekstein's (1965) distinction between positive trauma and negative
trauma may be useful here; referring to the Freudian model of thought in which delay and
frustration explain both "the development of psychopathology and the development of
creative and healthy function" (p. 63), Ekstein points out the need in such a model
"to differentiate between the positive trauma, which leads to creative solutions, and
the negative trauma, which leads to the experience of being overwhelmed and to
pathology" (p. 63). Ekstein likens termination to the epilogue of a play; emphasizing
successful mastery as central to the process of ending a therapy, that epilogue "now
becomes the prologue for another play:
The epilogue, the termination phase of the analysis, sums up once more
what has taken place. It is a kind of Thanksgiving, a good-bye and a mourning, and a
cautious trying out of new wings. (p. 680
Termination becomes the final adaptive act of mastery without which all that
precedes it is not complete; in these terms, it is a "positive trauma" and a
But while the work of a sound ending necessarily includes the painful
task of acknowledging the human limitations of each partner, and likely the limits of
therapy itself, the therapist's literal mortality, the fundamental shared human
limitation, is not supposed to precipitate that ending. (Although it is not my subject
here, it should be said that neither is the patient supposed to die.) As Winnicott's 12th
rule states, "The analyst survives," and anything else is a breach of
expectation. And the more importance theory gives to this ritual of ending--that is, to
the proper "termination" of a therapy--the greater, in theory, the difficulty
for the patient who loses the partner. In Ekstein's terms, there is potential in such an
ending for "negative trauma."
Every patient, in embarking on a therapy, risks attachment, dependence,
and intimacy, quite possibly without knowing what he or she risks; after all, the patient
can't know at the start the power of the transferential relationship whose sweep "has
the dynamic potential to reawaken every past desire for communication and love, protection
and admiration, that the patient has experienced in the course of his life. Together with
the desire and the hope come the fears of past rejections and failures, traumas and life
injuries" (Rizzuto, 1998, p. 5). Nor is the embarking patient likely to consider,
much less be able to measure, his isolation in this most private of professional affairs.
The patient expects the joint labor to bear fruit, with the therapist remaining to an
agreed-on ending. The implicit promise of constancy makes risk tolerable: the helper will
be there for safety and guidance through to that ending. One's connection to other
professional figures--a lawyer, accountant, or cardiologist, for example--bears little
comparison, as is true even of the connection to a beloved teacher or mentor, a priest or
pastor, though these may provide a better analogy.
It should go without saying that this summary does not mean to blame
the therapist who becomes sick or dies for his human condition; the analyst, like the
parent (and all others who assume roles of guardianship), knows that he "has
implicitly promised what he cannot possibly guarantee" (Ogden, 1997, p. 11). Rather,
because any therapeutic contract by its nature creates a situation which fosters emotional
dependence on the professional caretaker, in every instance a mortal man or woman, it
would seem an obvious responsibility of the profession, in an institutional and
theoretical sense, to look hard at this contingency. It is, after all, a loss which moves
onto center stage a new problem for the patient, one that has been imposed by the vehicle
through which he has sought help. Without blame, there has been a catastrophic breach of
the therapeutic contract itself.
In this respect, however, the profession has been remarkably slow, even
unconscionably slow, to take responsibility for the tremendous power of its very method. Gardner
refers to the "failure of psychoanalysts to practice the self inquiry they
preach" (1989, p. 6). If the therapist's job (as Winnicott says) is in some sense to
survive, and if the therapeutic endeavor is a self inquiry requiring of the patient an
honest, unwavering examination of the most frightening truths about himself, how shall we
reconcile the fact that therapists get sick and die with the fact that, historically,
remarkably little has been written either about such loss or the underlying realities it
raises? "Death terrifies us all into silence," Margulies writes (1998, p. 3),
the simplicity underscoring the profound truth; but responsibility is not thereby
In the scholarly writing that does exist, themes of omission and denial
emerge repeatedly, an "affect filled silence" (Schwartz and Silver, 1990, p. 2)
continuing to shroud the profoundly difficult subject even as the literature slowly grows.
And when the subject is addressed, the chief focus is almost always on the therapist: on
his dilemma, his perception of the patient's resultant dilemma, his decisions about what
will work best for the patient, and his judgment about the effect of a chosen
intervention. Silence about the matter of his own mortal vulnerability being a frequent
choice; the patient's voice throughout is very faint. Ultimately, as in any human
relationship, the dilemmas of patient and therapist are inextricable.
Freud is reported to have liked quoting Charcot, "`Theory is good; but
it doesn't prevent things from existing"' (1893, p. 13, n. 2). It also does not
prevent things from happening. If' the discipline of psychotherapy locates at its heart an
intense, intimate and private relationship with the reliable professional caretaker,
should not its theory incorporate the fact of that caretaker's mortality--an ultimate
unreliability? The therapist's death suspends the therapy in a movie freeze-frame,
isolating and magnifying the nature of the very peculiar relationship: professional and
private, fiduciary and intimate, limited and intense. This suspension reveals the absence
of provision for the patient, both theoretical and practical, when the therapeutic frame
collapses. How may we account for this absence?
The theory of termination ought to inform the "affect-filled
silence" surrounding the therapist's mortal vulnerability. The link between the
theory of termination and the event of the therapist's untimely loss should be a vital
one. Termination theory should tell us about the theoretical ideal: leave-taking at the
natural conclusion of the therapeutic engagement. That leave-taking, or farewell, is a
necessary ritual performed within the therapy frame. But a paradox or anomaly arises from
the conflict between the theoretical ideal of termination, in the technical sense, and the
brute reality when the therapist's life is threatened or literally terminated.
I want to emphasize that "untimely loss" has broader meaning
than loss through the therapist's death; while the neglect of that most extreme
eventuality is my narrow focus, "untimely loss" has at every moment wider
implications, just as "mortal nature" implies far more about the therapist's
human limitation than that he can die. For example, the sick therapist may be untimely
lost, though temporarily, if his illness makes him absent; or, he may be physically
present and simultaneously lost if his illness makes him distracted and inattentive; to
take the reasoning further, the therapist who commits an ethical violation may in some
sense be "untimely lost," profoundly so, even to those patients he has treated
ethically. Clearly the idea means to incorporate the caretaker's entire "human
being," and my subject in its broadest sense is the implications for treatment of the
It could perhaps further be argued that every ending, even the most
unproblematic, involves an "untimely loss" because, as Bergmann puts it,
"On a certain date, every analysis comes to an abrupt end" (1997, p. 137,
my italics). I am in this way returned to the idea of trauma inherent in every
termination, the parting inevitably involving, in some sense, an "untimely
loss." In the best of endings, this would approximate Ekstein's positive trauma, that
"final adaptive act of mastery which is the dress rehearsal for future adaptive
behavior" (1965, p. 62); at the other end of the continuum would be catastrophic
breach, whatever form that takes: the worst of endings.
If we can understand what theory postulates about the course of the
natural ending to a therapy, we may be able to understand better the dilemma for the
patient and therapist when ending is untimely and neither the therapy nor the termination
process can approach an ideal conclusion. The more emphasis theory places on the
importance of a termination phase, the greater the calamity when it cannot take place; and
therefore the greater the weak spot in our theory itself, insofar as it makes insufficient
allowance for the reality. 1 am considering, then, the potential (and always implicit)
conflict between the theoretical ideal of termination--a process of mourning--and the fact
SILENCE AROUND ENDINGS
For almost 75 years, psychoanalysts had been unable to conceive of the
idea of a terminal phase ...Novick, 1997, p. 146)
As soon as we examine the history of how psychoanalysis has thought about endings, the
silence about the therapist's mortal vulnerability makes more sense: what we find is that,
as far back as the inception of psychoanalysis and up to this day, there is a remarkable
lack of clarity about how the psychoanalytic engagement concludes. Not only does
termination theory enter the psychoanalytic discourse relatively late in the century, but
there remains into the present a great deal of confusion about what comprises the course
of a natural (unproblematic or ideal) ending. It is by now generally agreed that
termination is an identifiable and important part of the therapeutic process (although
just how important is still questioned by some), and few would any longer question that it
involves the work of mourning; but beyond these two ideas there is little consensus. How
may we understand this delay and confusion?
Novick (1997) proposes that analysts have a deep-seated resistance even
to thinking productively about termination, tracing the difficulty back to the very
beginnings of psychoanalysis. As the first analyst, everything Freud did was an
experiment. He had a great capacity to notice mistakes and acknowledge failures, using
them to further refine his theory. "It is therefore significant that neither he nor
his followers seemed able to look at termination practices with the same scientific
objectivity and courage" (1997, p. 153).
Freud's significant omission must have meaning as well as consequences.
Confusion in the part of theory whose purpose is to elucidate the completion of the
therapeutic process, and to guide in its navigation, is in itself a curious gap, but it
must also have implications for understanding the confusion around endings that are
problematic. If the theoretical frame is itself wanting, obviously there is less to guide
difficult contingencies. The psychoanalytic situation is structured to set in motion a
process of remarkable power; the spectacle of the sorcerer's apprentice comes to mind,
that small magician frantically trying to control the powerful forces he has unleashed.
Bergmann (1997) aptly uses this image in a paper dealing with the concepts of the
transference neurosis and the resolution of the transference as they relate to the process
of termination. He writes: "If psychoanalysts can foster a transference neurosis but
are helpless at resolving the transference they themselves have created, they may well be
in the position of the sorcerer's apprentice who can begin a process that he cannot bring
to a conclusion" (p. 146).
In 1913 Freud presents the metaphor of the chess game, saying that the
opening and endgames of chess, unlike the middle, could be systematically elaborated;
making the comparison to analysis, he lays out rules for the beginning but does not go on
to deal with the ending (Novick, 1997, p. 145). In Freud's conception, analysis, like
chess, "could be brought to a successful end (not a stalemate), but the criteria,
characteristics and management of the ending were never discussed" (Blum, 1989, p.
275, my italics). Of significance as well for the fate of termination theory, and for the
more specific topic of the mortal therapist, is that, even after dealing explicitly with
object loss in Mourning and Melancholia (1917), Freud "did not refer [in his writing]
to the loss of the analyst and the meaning of the loss of the analyst's direct
participation in the analytic process" (Blum, 1989, p. 279). This additional omission
helps explain the late entry of mourning into the theory of termination.
Nor do Freud's immediate followers attend to a termination phase (Hurn,
1971; Novick, 1997); except for small steps in that direction by Ferenczi and Rank (1924)
and by Ferenczi (1924), the literature is silent until 1950 and remains sparse for another
twenty years. For example, in 1950 Annie Reich writes, "Astonishingly, the topic of
termination of analysis has rarely been the subject of psychoanalytic investigation"
(p. 179), and in 1966 Rangell remarks on "the relatively scant literature" (p.
141). In 1971, Hum says of termination that "precise and detailed definitions of the
term do not exist in the literature" and there is "no paradigm of the terminal
phase" (p. 332). Freud's 1937 essay "Analysis Terminable and Interminable"
does not deal either with termination as a phase or with techniques to guide it;
abandoning the myth of human perfectibility, Freud concerns himself in the essay with
"the inherent limitations of psychoanalytic technique, the patient, and the
analyst" (Novick, 1997, p. 145).
In light of Freud's advancing age and his painful battle, by then
fourteen years long, with cancer, this concern with limitation has a special poignancy. It
is clear in Freud's correspondence that he preferred his friends not inquire about his
health, a choice his biographer Schur attributes to a combination of strength of character
and avoidance: "Freud not only wanted to spare others the necessity of asking about
his condition; he himself did not want to be asked about it" (1972, p. 378). Whatever
Freud's motivations, it must be wondered how his handling of his own lengthy illness may
have subtly permeated expectations within the culture of psychoanalysis, both written and
unwritten, for the failing analyst's conduct. Theory, whether articulated or implicit, may
in such profoundly difficult matters ease anxiety, serving self justification and denial.
At any rate, in 1939 Freud died, never having referred to the effects
of his disabling cancer or impending death on his work with patients, this fact in itself
a noisy commentary on the silence around the therapist's mortal vulnerability. Schwartz
(1993) points out that even Jones and Schur, Freud's analytic biographers, make "only
passing mention of the clinical impact of his obvious and incapacitating disability"
(p. 143). Schur's "passing mention" refers to a letter to Marie Bonaparte
"in which Freud apologized to her in a deeply moving way for having allowed his
preoccupation with his cancer to keep him from recognizing a certain transference
phenomenon in her analysis" (Schur, 1972, p. 382). As Schwartz suggests,
"Perhaps clinical analysis as a science was still too young to document the seeming
technical confusion introduced by real disease in the doctor" (1990, p. 143). My
suggestion, carrying this idea further, is that the "seeming technical
confusion" has a basis more profound than the youth of the science, and that it
resides at the heart of the paradoxical endeavor of clinical analysis: to foster an
intimacy that intends separation. The idea is consistent with Stone's conceptual iztion of
the analyst as representing the mother-of-separation in the primordial transference (1961,
In the last quarter of the century there has been an explosion of
attention to termination, the literature so fast-growing that "the range of views
concerning the conceptualization and management of this phase of treatment is now vast . .
." (Novick, 1982, p. 329). In light of a literature suddenly enormous in both size
and range of views, it is all the more intriguing that, as Stephen Mitchell puts it as
recently as 1997, "There is less useful literature on the termination of analysis
than on any other major feature of the work" (p. 26). Also in 1997, in an essay
titled "Termination: The Achilles Heel of Psychoanalytic Technique," Bergmann
bluntly states that, in spite of a vast literature, "psychoanalysis, and particularly
the literature on technique, has so far failed to offer a paradigm for termination"
(p. 163). A half century of silence is followed by a half century of confounding
Perhaps more fundamentally at issue than either paucity or confusion,
then, is the manifest difficulty in understanding the ending. This difficulty harks back
to my introductory statement of purpose regarding the neglect of the therapist's
mortality: I began by trying to illuminate some factors that underlie the profession's
manifest difficulty in creating a literature adequate to a subject touching deep human
anxieties: "We all die, we are all at every moment vulnerable, and we are all
inclined to deny the fundamental terror." That formulation implies that weakness in
termination theory underlies the failure to confront the therapist's mortality. However,
the more I investigate this subject, the more I feel that the reverse may be closer to the
truth: fear of mortality underlies and clouds the dilemma of termination.
THEORY: IT'S JUST SO MUCH CULTURAL DISCOURSE
Can it be that psychoanalysis, as Novick suggests, cannot conceive its endings and if
so, how have therapists managed to guide treatments to their conclusion for a hundred
years--as indeed, practically and experientially, we certainly have done? This gap between
what we say we do and actual practice could thus be called benign, pragmatically. But to
close the gap even a little can only benefit both theory and practice. In a tour de force
presentation, Novick isolates five obstacles "that make termination
inconceivable"; he examines factors "in the history of psychoanalysis, the
training of the analyst, the counterreactions of analysts, the theoretical models held by
analysts, and the kind of termination experience analysts themselves have had that create
continuing obstacles to conceiving of termination" (1997, p. 147). I am in agreement
with him and am also proposing a perhaps deeper difficulty.
If there is consensus about the theory of termination, it is about
inadequacy, a problem of neglect and evasion that applies equally, and I think not
coincidentally, to the literature on the death of the therapist. Remarking that clinicians
have obviously been "bringing analyses to some conclusion or other all along,"
Kaplan asks: "So how can we have a large literature on a practical subject that omits
most of the actual practice the subject entails?" (1997, p. 175, my italics).
Presumably, the majority of therapies play out reasonably successfully,
unburdened by dire intrusions; and presumably there are also many instances of sick or
dying therapists managing extraordinarily difficult endings with dignity, courage, and
skill. That is, Kaplan's question about a literature that fails to reflect the actualities
of clinical practice is equally applicable to the mortality of the therapist. In my
instance, as noted in the introductory comments to this essay, that extraordinarily
difficult ending was successfully facilitated at a remove, by the dead person's community.
To me this seems a striking example of responsible clinical practice expertly carried out
under potentially disastrous circumstances; my contention is that such expertise must have
theoretical implications and underpinnings, though unarticulated. Although there is a
growing literature on the illness and death of the therapist, it has so far brought us no
closer to an adequate theory or to the provision of technical guidelines (or clear
institutional supports, for that matter) to help therapist and patient in managing the
painful reality; yet therapists' illnesses and deaths have been bringing therapies to some
sort of conclusion for a century and of course will continue to do so.
Kaplan proposes one explanation for the disjunction between theoretical
formulation and actual clinical practice: "Too much of the technical literature of
psychoanalysis," he writes, "has been simply so much cultural discourse"
(p. 176), and one must be cautious in drawing conclusions about the actual world from any
cultural discourse alone; it is a fallacy "that cultural data--literary works,
religious tracts, and so forth--directly embody actual social experience and
practice" (p. 176). Tongue-in-cheek, he wonders: "How much about the actual
sexual practices of priests would you expect to learn by consulting church edicts and
other such writings?" (p. 176).
He is referring to the tendency for psychoanalytic theory--the formal
documents or "cultural data" of psychoanalysis--to reflect idealizations rather
than empirical observations, theory often being the production of "highly cultivated
minds" trying, especially in the early years of psychoanalysis, to make legitimate an
emerging discipline; as that discipline has developed (and ironically, at century's end,
it once again struggles to legitimate itself), the tendency to idealization lingers in the
body of literature. Kaplan pokes at psychoanalytic writing:
It has required a cunning capacity to read between the lines of our
professional journals to avoid getting drawn into demoralizing comparisons of one's own
actual practices with the hypothetical practices of the idealized Standard Psychoanalyst.
Ours is the literature that has given us the exemplary analyst, who, upon being told
excitedly by the patient that the latter's wife has given birth to twins, inquires,
calmly, "What comes to mind about two?" (p. 176)
This analyst from an earlier time, whose exemplariness results from
his being thoroughly analyzed, evokes the dilemma for the analyst who, if he experiences
strong and merely human feelings for the patient, must strive to meet an impossible ideal;
the danger is that in such striving for the impossible, the analyst tends to hide or deny
his very ordinary and real human responses, these feelings being a sign of dangerous and
theoretically damned countertransference. Furthermore, this kind of idealized
self-expectation, creaking under the strain of denial, more easily accommodates the
self-delusion that he has succeeded; and the less humbly he tends to view his capacity to
control what he feels, or always to know what he feels, the closer he is to believing he
inhabits a superior realm. Of course the only such realm is the realm of the gods; and we
all know that only the gods need not consider their mortal nature.
I do not mean to imply that the dilemma of this hypothetical analyst
from an earlier time is simply and easily eradicated by the trend toward acknowledgement
and acceptance of feelings in the analyst; whatever may be the particular benefits (or for
that matter, the real dangers) of shifts in theory, my more important point is the merely
human tendency -- universal and ineradicable -- to self-deception. It may take many forms.
As the "keeper of the analytic process" (Calef and Weinshel,
1980, p. 279) -- a role of guardianship -- the analyst strives to be truthful; that is, he
monitors his own tendency to self-deception, engaging in a selfinquiry (Gardner, 1989)
parallel to the one he guides and guards for the patient. One fundamental goal of that
self-inquiry (for both analyst and patient) is to chip away as truthfully as possible at
this self-deception. Truthfulness, one might say, is thus a central concern for the matter
of termination: possibly it is the definition of the end, the defining point of the
end--it is the termination point reached.
It is important to emphasize that I am not talking about the
acquisition of a definitive "truth" but about an increased self-awareness
leading both to a greater freedom and to a greater sense of responsibility; at the end of
a successful therapy the patient has learned to speak "truthfully enough," and
also to understand that speaking absolutely truthfully is a never achievable ideal -- a
vital understanding. This success involves commitment to the possibility while accepting
the impossibility. One remains, however, committed to the approach, just as psychoanalysis
remains committed to articulating its best understanding of what it does. Margulies puts
this elegantly: "And so we attempt to observe what we do -- and who we are when we
are doing what we do -- knowing that our words are never adequate to the task. We have no
other choice but to try" (1998, p. 2).
"A culture," writes Henry Louis Gates, "defines itself
not by what it permits, among the near infinitude of human possibilities; it defines
itself by what it doesn't permit" (1997, p. 122). Even after all this time, the vast
literature on termination does not reflect what practitioners - ordinary mortals, one
might say -- have actually learned to do, hour by clinical hour, working over the years.
Nor have the many useful threads of a coherent theory that are already imbedded in the
large literature been successfully pulled; rather, they seem to be lost in a proliferating
tangle. Why is termination theory in particular so problematic to psychoanalysis? Why have
psychoanalysts been unable to examine what clinicians over generations have learned to do
when they end a therapy? And why have psychoanalysts been unable to extract from the body
of written theory what makes sense about endings, blending practice and literature to come
up with a more satisfying, unified theory and more useful clinical guidelines? Each of
these questions applies not only to "good enough" terminations but equally to
endings breached by the therapist's illness or death.
I can think of no better way to summarize the aim of the first part of
this essay than by returning to the question at its beginning, the question posed not in
my words but those of the ancient poet in the epigraph: "How should this grief he
properly put into words?" Embedded in this question is an explanation for
Schwartz's "affect-filled silence" about the therapist's mortality as well as
the suggestion of an answer that begins to fill it. The "termination" that
designates the end of the therapy relationship is an extended process of mourning, a
"long drawn-out leave taking" (Loewald, 1988, p. 258) that requires the
patient's experience of and expression of sorrow or grief. It is through this experience
and articulation that the patient takes leave well (perhaps in both senses); with an
adequate ending, the therapeutic relationship -- an intimacy that intends separation --
terminates, and the therapy is complete.
But there is a second person in the room, and that person also loses a
partner. Though the therapist's role is different, the task is the same and it involves
leave-taking -- unless, that is, the commonplaces about partings with which I began this
essay do not apply to the therapist alone, uniquely exempt. How any individual analyst
manages his heightened experience during this farewell, and how he (or she) determines
what he will articulate or will hold private in the course of the ending, is a matter of
his temperament and clinical judgement, and is not my point here. Rather, my
suggestion is that the difficulty psychoanalysis has in articulating its theory of
endings, both good enough endings and disastrous ones, reflects a difficulty with the
experience of loss and grief. That very human difficulty, I further propose, is located
just as much, and sometimes more, in the psychoanalysts (and in the cultural
documents of psychoanalysis) as it is in patients.
And here there is a quandary: to perform the ritual of saying goodbye
is not only the patient's task but also a right; it is part of the provision implicit in
the therapeutic contract. Therefore, it stands to reason that if any individual analyst
suffers to a high degree with this difficulty, and if the "documents" of
psychoanalysis as a whole tend to reflect such considerable difficulty, then the grieving
patient's task may be immeasurably harder. The helpers in this case become the obstacle.
Part II: The Olympian Delusion
Mr. L. remarked that you can't expect even psychoanalysts to be superhuman, especially
when they are dying. (Freedman, 1990, p. 308)
The ancient saying, De mortius nil nisi bene [sic] (of the dead speak nothing but
good), is still an absolute command obeyed by everybody, surprisingly even by analysts.
(Tauber, 1989, p. 179)
When the god Zeus feels desire, he likes to come down from Mt.
Olympus where the gods dwell and pleasure himself with mortal women. Often he transforms
himself for the purpose of taking his satisfaction; the woman Europa, for example,
perceives him in the shape of a bull "beautiful beyond all bulls that ever were,
bright chestnut in color, with a silver circle on his brow and horns like the crescent of
the young moon. He seemed so gentle as well as so lovely . . . " (Hamilton, 1969, p.
79). But the gods don't get involved. Once Zeus has ravished the woman, he goes back to
Olympus where the inhabitants don't feel our merely human mortal misery and pain; the gods
are apart: not only do they not feel or suffer consequences as we do, but they also live
forever. Blinded into submission by the god's magnificence, gentle demeanor, and force,
the woman must bear alone both the mortal burden and the child.
Each of the two quotations above contains the same disturbing
assumption: analysts, although still human, are closer to gods than other people; and when
circumstances force us to face their ordinariness, we are surprised and disappointed. Mr.
L. is a businessman whose analyst died during the therapy. What is disturbing in his
remark resides in the words "even" and "especially." The imbedded
proposition is that, if it were possible for anyone to be superhuman, then psychoanalysts
would be among those most likely to inhabit that godly realm. But Mr. L. has learned that
psychoanalysts cannot attain the level "superhuman," something he found out
painfully through his analyst's behavior when that man was dying.
The second epigraph reflects a similar delusion perhaps more bizarrely,
again involving the word "even"; the writer is herself an analyst. What can it
mean to state that "an absolute command," one that is obeyed by all of humanity,
is obeyed as well by psychoanalysts--but in their case it is a surprise? I am calling this
view of the therapist "The Olympian Delusion."
These epigraphs together capture a dilemma. There is a tendency for the
profession, as well as the patient (and, more problematically, the patient's partner), to
idealize and elevate the therapist, seeing him or her as someone not subject, in the same
way as other people, to vulnerabilities of body and mind--a definition of the therapist as
apart, "god-like." The roots of the dilemma are at least double, both
theoretical and experiential, fostered not only in the theory that conceptualizes the
therapeutic situation, but in the experience of each participant in the actual clinical
exchange as well.
In the instance of theory first, definitions of the psychoanalytic
situation and of the therapist's function tend to emphasize the uniqueness of that
encounter and role--it is no ordinary exchange. Throughout the literature the analytic
relationship is conceived as like no other, a notion articulated by Freud in 1915 in
specific reference to the analyst's handling of the patient's transference love: the
doctor's role "is one for which there is no model in real life" (p. 166,
my italics). To give shape to the peerless therapist, then, one must compare that paragon
to something that can be known, and that is exactly what Freud and his followers did, and
continue to do, as analyst and analytic interaction are conceived and reconceived, for a
hundred years now--from a simile of analyst as blank screen upon which fantasies are
projected, to a parental figure holding a vision in safe-keeping (Loewald, 1988), to a
participant in a mutual self-inquiry (Gardner, 1989). While it may be that the therapeutic
situation both resembles other human connection and at the same time is not exactly like
any other, the same can be said of many other relationships. But we don't find education
experts (for example) regularly reminding us of the uniqueness of the student-teacher
bond, nor is there much controversy about defining the essential role of the teacher; yet
that pedagogical bond is also unique, the teacher, like the therapist, in a position of
In the discomfort revealed by such reminding, repeating, and redefining
we hear an echo of the dilemma elevating the analyst's role, so difficult to define, to a
special realm, apart--a position dangerously close to "god-like." While shifts
in theory may of course represent the effort to grapple with this very dilemma (as we see,
for example, the analyst removed from a position of "god-like" authority with
the gradual democratization of the relationship in the shift toward an intersubjective
understanding of the situation), the dilemma is not thereby erased. In her commentary on
Amy Morrison's (1997) moving paper describing her work with patients over the ten years of
her illness, Chused (1997) addresses the potential for self-deception in adhering blindly
to psychoanalytic concepts, no one of which is absolute; that caution holds for the
time-honored ideas and equally for the newly fashioned: for example, she writes,
"though analytic anonymity can be deceptive (to the therapist and to the patient),
self-disclosure, in its motivation and its effect, can also be deceptive. One truthful
self-revelation can be used to hide another, perhaps more important one--as all lawyers
know" (p. 246). Paradoxically, in the effort to define and redefine the analyst's
function, we may find both the dilemma and its best safeguard; that is, the role is hard
to conceive and like no other, which sets the analyst apart, and at the same time it is
through this on-going self-examination and redefinition that self-deception may be best
The second root of the dilemma that elevates the therapist is
experiential and, naturally, entwined with the first. The analyst in the specialized
analytic situation may take on what Fliess calls a "rare and exalted perfection"
(1942, p. 225) as well as being a human being. For the patient the tendency to elevate the
therapist to the realm of invulnerability is understandable, even invited, given the
structure and specialized purpose of the situation, the task for each participant, and the
place of illusion if their shared work is to get done; that same tendency, if it lulls the
therapist, is of course less benign.
Hoffman poses the question, "Could it not be argued that the whole
ritual of psychoanalysis is designed, in part, to cultivate and protect a certain aura or
mystique that accompanies the role of the analyst?" (1991, p. 83). It is an unusual
role, even in mundane terms, evoked simply by Modell:
Where in everyday life can you find persons who, for an agreed-upon period of time,
will place their own needs and desires to one side and be there only to listen to you and
who are more than usually punctual and reliable and can, for the most part, be counted on
not to retaliate and to he free of temper tantrums? (1991, p. 25)
Both partners assume that this unusual arrangement will continue for the benefit of the
patient until a planned ending, an assumption which encourages in both people the fantasy
of a therapist invulnerable to the ordinary contingencies of life. While that fantasy may
be beneficial for the patient, it may prove hazardous if it blinds the therapist.
Modell also writes about the essential place of illusion in a therapy:
For both therapist and patient, the other person is experienced both as an individual
in ordinary life and as someone transformed by the therapeutic process, a ...
[transformation ] that we label as transference and countertransference. Therapist and
patient are also everyday people, but within the frame of the therapeutic process an
illusion is created that can he described as another level of reality. (1991, p. 15)
But what kinds of beings are these who, within the therapeutic frame, inhabit
"another level of reality"? They are at every moment in that habitation no less real,
no less less ordinary "everyday people." While a break in the treatment
frame or a rupture of the illusion is a breach of expectation for both people, the
potential for such a breach is an ever present reality; after all, both people are in fact
always mortal in body and fallible in character. But if the therapist, who guards
the process, loses sight of the distinction between an idealization, an "as-if"
that is a necessary, benign illusion and an idealization that is a dangerous delusion,
then the therapist has adopted an Olympian stance.
Another seed of the kind of thinking that elevates the therapist to
superhuman can be traced to Freud's early optimism about the psychoanalytic method and its
potential for cure, that is, for producing perfect health: "the myth of
perfectibility" (Weinshel, 1990); in the counterpart of that myth, we may posit an
analyst who is superman (or Mary Marvel) or magician: that is, one who has the capacity as
healer to create mortal perfection. Far from disappearing, however, the myth of the fully
analyzed analyst--the same myth implied in Mr. L.'s and Dr. Tauber's "even a
psychoanalyst"--lives on in conceptions of the analyst with superhuman capacity to do
this very hard work.
Analysts continue, for example, to have extraordinary expectations for
their own performance and that of their peers (Abend, 1986), that expectation also
implicit in the tendency to deny imperfection, even the most gross imperfection, as in the
example of sexual violation and a century spent denying it and hiding it. Sexual violation
is arguably the most egregious and disturbing manifestation of the Olympian delusion. If
expectations are so high for the practitioners of the profession, it follows that those
expectations will extend to qualities required of trainees:
The Panel (1961) on selection of candidates for analytic training collectively provided
such an array of aptitudes to be sought in the budding analyst that to one participant
suggested a composite portrait of Pasteur and Thomas Mann. (McLaughlin, 1981, p.
651, my italics)
And that portrait is of the candidate before the training analysis!
Having abandoned his hopes for the attainment of perfect health through
psychoanalysis, Freud wrote in 1937, straightforward and modest in the claim,
"Analysts are people who have learned to practice a particular art; alongside of
this, they may be allowed to be human beings like anyone else" (p. 247). But what
happens if the analyst is not permitted (or himself denies) his own mortal nature--that
is, if he (or she) denies or suppresses realities like anxiety, anger, desire, temptation,
irritability, fatigue, sadness, ill health and so on? Perhaps the greatest danger is that,
in self-effacement--a form of self-idealization--there is easily a reversal wherein the
therapy, an arrangement ostensibly set up to meet the needs of the patient, becomes a
vehicle to serve the needs of the therapist. Once that reversal takes place, there is the
potential, its harmfulness depending on the particular needs of the therapist and the
vulnerabilities of the patient, that the therapy will be used, as Calef and Weinshel put
it, "as a tool to be directed against others" (1980, p. 289). The result of
self-denial is thus a paradoxical one: Obliteration of the self brings with it the even
greater danger of obliterating the other.
The analyst's role of course requires a certain denial of self, an act
of generosity intended to remove the therapist's needs from obtruding, thus reserving the
focus for the patient; self-effacement, it might seem, safeguards rather than endangers
the patient. But that is not always the result. The more fully the therapist believes in
his capacity for literally selfless service to the patient, and the more the therapist is
conceptualized as above being a subject himself (or herself)--that is, as one who
during the engagement is not subject to strong emotion, to sexual desire, to
discouragement, to self-delusion in the very same ways that the patient is--the greater
the danger of crossing the boundary that keeps the patient safe: a selflessness that
blinds the therapist to his own need and vulnerability leaves him (or her) prey to the
arrogance of perfection.
Such a conception, in removing the therapist from the room as a
subject, loses sight of the fundamental: There are always two people present. If there is
only one subjectivity, there can be no boundary. The Olympian delusion is thus encouraged
by a monolithic subjectivity. Since subjectivity can never be unilateral in reality,
selflessness paradoxically inverts itself and becomes a tyranny. Both patient and
therapist are then in danger.
It is important to reiterate that the dilemma elevating the therapist,
while it is addressed by increased acknowledgement of the therapist's participation,
influence, human feeling (and so on), is not consequently eliminated: psychoanalytic
concepts, whether old or new, serve in part to ease the therapist's discomfort and do not
necessarily reflect what he actually does or its effect. In addition, the elevation of the
therapist, as I have argued, is to some extent built-in, doubly so: first, the role
of analyst is unlike any other and therefore "apart," and second, the
psychoanalytic situation works by encouraging a powerful illusion.
A peculiar imbalance is built into the therapeutic relationship. By its nature the
situation encourages the patient's dependence on and attachment to the (hired) partner, an
arrangement that emphasizes the patient's need and vulnerability; the therapist, like
priest or doctor or teacher, is in a position of power. Therapy works by offering a sale,
delimited illusion, like a play, a paradoxical intersection of the real and the illusory
that inheres in the psychoanalytic notion of transference (Freud, 1915; Modell, 1990;
Szasz, 1963). The therapist, a living, actual man or woman, is also a presence without
explicit dimension, a kind of shadow figured--mysterious, known yet not known, and thus
available for the patient's invention. This vehicle of illusion can only be a human being
who guides a process of tremendous power that intends its tilt--an imbalance of
need and dependence. It is thus a position of both trust and illusion.
But what does the guardian offer in this peculiar transaction?
"It must be said at the outset," Modell writes, "that we do not yet possess
a theory that explains how psychoanalysis works" (1990, p. 1)--a startling statement
given the endeavor's century-long history, but perhaps not surprising at all given the
complexity and ultimate mystery of all human connection. Not only do we not know how
psychoanalysis works but what the analyst gives the patient in honoring their contract is
also not definitively established and will likely never be; absolute definition is not
possible, although we may articulate some components and try to understand the nature of
this profound exchange--a transaction, we might say, in human "being." In an
essay about the devotional poetry of George Herbert, William Nestrick writes: "The
only appropriate gift is discovered to be a thing inseparable from the giver, for the very
reason that, in his role as giver, man can only give himself" (1975, p. 200).
The therapy offering has, like the analyst's role, been variously
conceived and named over time. For example, the analyst may offer interpretations,
insight, love, respect, reassurance, acceptance, understanding, compassion, or
companionship; he may offer passionate companionship, dispassionate companionship,
compassionate companionship, all of these, or only some. Indeed, it can be said that both
people give and that both receive (although only one pays), and that all of these matters
are inextricably bound up with and dependent on each other, just as in any other intimate
human relationship. For the immediate discussion, however, it is not relevant whether the
one on the serving side of the contract thinks of himself more as participant than
reflecting screen, or more as detached than embroiled, nor does it matter what he calls
the offering. In every case, the offering is in some sense oneself: with all its
imperfection and temporal limitation, it is a mortal gift.
It is essentially a mystery why any one human being chooses to give the
way the therapist gives to another, or why any one cares about (or for) another; even what
we mean by "caring" is perhaps in the end elusive. However, the capacities to
care and to give derive ultimately from the common condition that separates human beings
from animals and gods. The burden -- consciousness and imperfection -- is also the
wellspring of the gift. But while this capacity inheres in the humanness that all share,
it may only be inherited: that is, one person must pass it to another. To put it another
way, the capacity develops only through human connection; it is a gift that must be given
and received. The baby's development can only take place "provided one includes with
it the care it receives from its mother" (Freud, 1911, p. 220); if the infant is not
nurtured, the infant will not live (Spitz, 1965).
Novick (1982) objects, tartly and rightly, to a colleague's remark that
the analyst is the "first person who really understood the patient" (Panel,
1975, p. 175); calling this "the therapist's fantasy of being the perfect and better
mother," Novick retorts, "If ... the analyst were the first person to really
understand the patient, then the patient would be dead.... No one has ever been or will
ever be as important as the primary mother" (pp. 350-351).
This is perhaps another way to understand Winnicott's aphorism,
"There is no such thing as an infant." There is only a baby and (mother)
caregiver; without the caregiver, "baby" has no meaning and the baby also dies.
With more modern conceptions of reciprocity, we might sensibly reverse the aphorism:
"There is no such thing as a mother." The reversal, of course, is not so tidy;
although "mother" without "baby" loses its meaning, the mortal woman,
unlike the baby, does not necessarily die. And unlike the infant, the patient who loses
the caregiver does not necessarily die--although it does happen.
Psychotherapy is an endeavor conceived and carried out by ordinary
beings, its basis the intimacy of human connection. With this observation I return to the
commonplace: the therapeutic relationship, specialized though it is, rests on the same
foundation as any other close relationship. This sameness of course does not preclude
difference; the uniqueness of the psychoanalytic relationship is at the center of the
discipline's effort, now over a hundred years long, to say what it is and what it does.
However, a problem of great magnitude arises if, in the articulation of what is unique to
the relationship, the sameness is denied, obscured, or forgotten. In my view, this
fundamental ordinariness is easily forgotten, set to the side as an assumption or
psychoanalytic given, in much the same way that Freud buried in a footnote the requirement
of the mother's care, an assumption of the provision without which no human development
takes place (1911, p. 220, quoted above). The provision is a second human being.
What of literal mortality? When the therapist dies, what is lost is
another soul and one soul will mourn for the lost other. But in order to do this work of
mourning, there must be provision for the grieving one and, again, psychotherapy can in
this matter be no different from ordinary life. The bereaved patient, however, is in a
position of very peculiar isolation, alone, without the person known only in the dual
isolation of the consulting room. To quote the poet once again: "How should this
grief be properly put into words?" (Horace, from "To Virgil").
Behind my consideration at every moment of the patient's peculiar
difficulty lie two assumptions, the first about a right, the second about a
responsibility: When the therapist dies, the patient has the common customary right to
take leave of that person; and it is the responsibility of the profession providing the
service rendered through the relationship to help with the leave-taking: it is a rite of
passage, requisite no less in psychotherapy than in the rest of the world. That
expectation is equally part of the contract when a therapist does not die (a therapy
ending at its natural conclusion), as if he does die. Although these are matters of common
sense, psychoanalysis, whether we look to its theory or to its practical, clinical
guidelines, does not reflect acceptance of either the right or the responsibility.
"'How reluctant is the professional community to accept responsibility in this
essentially clear-cut matter? In 1990, during a Panel held at the annual meeting of the
American Psychoanalytic Association, Paul Dewald describes "The longstanding and
resounding silence in the field about an issue as commonplace as the analyst's becomng
ill" (Schwartz, 1993, p. 191). Dewald reports an insignificant return rate when he
tried to survey the policies, both formal and informal, of all institutes associated with
the Association regarding the illness, death, or retirement of the analyst. Every
institute among those who replied declared that the issue was important but that the
institute had no preplanned policy, and that the problems could be handled "on an
individual basis, given the close-knit functioning of the group" (Schwartz, 1993, p.
192). Both avoidant and self-satisfied, it is a remarkably loose approach.
These dilemmas of confusion and denial do not arise from an absence of
feeling for the patient but rather from a struggle with the power of what the clinician,
as well as the patient, feels--a dilemma arising less from an emotional insufficiency than
from its opposite, a well of feeling that swamps articulation. Difficulty with the uneasy
subject of the therapist's mortality is in part a difficulty of articulation. The
technical language of psychoanalysis may be especially unsuited to uncomfortable subjects
more readily addressed by poets or philosophers. On the other hand, it may be that
psychoanalysis sometimes employs its language in a motivated, if not always conscious,
effort to deflect and avoid what might be more fully felt, if it were only more plainly
THE PROBLEM OF FEELING
And psychoanalysts try mechanically not to be mechanical. They try to show they are
human. How can we show we are human? Either we are human or we are not. (Gardner, 1989, p.
Here I address the problem of feeling--not the patient's but the therapist's. In
the first section I have described the silence and confusion that have characterized
theoretical discourse about termination. If the heart of the termination process involves
the work of mourning, and if therapists are uneasy with their feelings, then we may
understand better the silence around termination, both when it is routine and when the
mourning is intensified because the therapist is sick and may die. It is my assumption
that this mourning and intensification of feeling refer to the experience at parting of both
partners in the therapeutic dyad.
I want to emphasize that always implicit in my consideration of the
dramatic example of the therapist's illness or death is the therapist's merely human
limitation of every kind; that limitation, however it is manifested, is bound to collide
with the patient's fantasied illusion and idealization of the wished-for protector. In
such collision, perhaps especially strong in the ending phase, is the heart of the work
all along: that is, it effects the gradual dismantling of transference illusion. <>Disillusionment
(and de-idealization) will thus be a necessary part of every ending as the patient
gives up (though never relinquishing completely) the "transferred, early omniscient,
omnipotent, all-protective and allgiving parent" (Novick, 1982, p. 35 I ).
Reviewing the termination literature, Novick summarizes in one
paragraph "all there is in the vast literature on termination in regard to the
feelings of the analyst when the patient leaves" ( 1982, p. 356). He notes that, at
the end of a panel on termination in 1975, one participant remarked on the silence
throughout the discussion itself about the subject of the analyst's feelings at the end of
a therapy; he summarizes the participant's comments: "the discussion omitted any
reference to the sense of loss that analysts experience at the prospect of separation from
patients with whom they have had a prolonged, intimate, and frequently very gratifying
experience" (p. 355). The single reference Novick presents of an analyst clearly
moved by strong emotion at the parting is Balint's admission (1950):
Usually the patient leaves after the last session happy but with tears in his
eyes--and, I think I may admit--the analyst is in a very similar mood. (p. 197)
If this virtual silence means merely that analysts' feelings at the parting are
inconsequential or nonexistent, then we must conclude that the psychoanalytic relationship
involves a prolonged, intimate connection between two human beings, only one of whom is
subject to ordinary feeling. As a measure of what actually faces the analyst at the end of
the relationship, however, Novick closes with the suggestion that "it may often be
... that termination will be a greater real loss for the analyst than it is for the
patient" (p. 356, my italics). That is because, while the patient (in Novick's view)
has relinquished mainly the transference object of illusion, a shadow puppet, the analyst
knows the patient more fully and clearly, as well as intimately, and therefore loses a
more real object.
It isn't necessary to agree about what kind of loss, real or fantasized
(or what proportion of each), is involved for each partner to appreciate the point: that
is, the analyst experiences a significant loss at the end of the extended, close
relationship with the patient, but analysts have an unusual difficulty acknowledging this
sense of loss. That these reactions at ending are rarely acknowledged, much less freely
articulated by the doctors of feeling, is a legitimate cause for wonder given that the
therapist serves as guide to a patient whose essential task in ending is to acknowledge
the loss of the partner. Mourning is at the center of the termination process.
I will try to illustrate this idea and the difficulty very simply, not
by citing the results of scientific studies, but by presenting two examples of therapists
who seem uneasy with a range of emotions. Stephen Firestein's book, Termination in
Psychoanalysis, frequently quoted in the literature, appeared in 1978. Firestein
presents eight case examples which he studies in relation to their termination. Among the
questions he considers in a chapter titled, without irony, "Substantive
Conclusions" is the following: What is the impact on the analyst of approaching
termination? The study informs us that analysts do indeed experience something when a
therapy ends, but nowhere in the brief analysis of responses does Firestein use the words
"emotion" or "feeling"; rather, he refers to "the impact" of
the ending and to "a range of affective responses." He then carefully separates
those affective responses into two categories.
The first category of analysts' responses involve anxiety, and within
it Firestein specifically notes reactions of "concern about the stability of the
therapeutic result," "doubt about the timing of the termination," and
"misgivings about the thoroughness of the work" (pp. 214-215, my italics). While
the words naming the categories of anxiety have an affective flavor--"concem,"
"doubt," and "misgiving"--there is no reference to the relationship;
instead, the object of each anxiety concerns the analysts's professional performance and
expertise, thoroughly omitting the second person. The second and more problematic category
of experience Firestein struggles mightily even to name. The analysts, he writes,
"experienced not only varying degrees of anxiety over termination, but gradations of
what, for want of a better description, could be called grief" (p. 214, my
italics). These words reflect the heart of a difficulty.
In this sentence Firestein is proposing that, in the year 1978, there
does not yet exist in the English language a term adequate to describe the eight analysts'
affective responses to the loss of their patients at parting. We must conclude that,
truly, they are an extraordinary set, these psychoanalysts whose human feelings defy our
common language to describe! A thoroughly reasonable man, Firestein proposes a compromise
to avoid a distracting fuss over the limitations of English: He writes that the word
"grief," wanting though it may be, will do. The implicit alternative would be to
coin a word whose definition might read: "that affective response peculiar to a
psychoanalyst at the termination of a treatment."
Within this category which, until the better word is found, we will
also call "grief," Firestein includes "regrets about ending," regret
being as close as the analysts venture toward acknowledging a direct sense of loss for a
person deeply known. Such regrets surface, Firestein reports, either because the patient
may have been an especially "interesting, witty, or gifted individual" (p. 215)
or because he or she was "responsible for an especially instructive learning
experience for the analyst" (p. 214)--the patient serving chiefly, it seems, as a
source either of entertainment or edification. Firestein allows as well the experience of gratification
at the conclusion of an analysis, noting that "the analyst's gratifications ...
consist of more than the functional satisfaction of doing one's job well." Of what
does that "more" consist? Inching closer to personal sadness at losing the
person with whom one has worked long and hard, Firestein concludes his discussion: "Separation
reactions are experienced by both members of the dyad" (p. 215, my italics).
However, here the analysis of responses ends; there is no further consideration of the
nature of these "separation reactions," already in the wording somewhat diluted
and shifted away from their focus on the analyst by mention of the second "member of
The author's effort here seems Herculean as he works to avoid words
like "feeling," "sadness," or "affection" (the avoided range
includes, of course, words such as "relief," "joy,"
"hatred," or anything else common to human experience), and as he in effect
apologizes for his (perhaps indecorous) use of the word "grief"; nowhere is
presented a therapist comfortable with missing someone grown familiar, just as he or she
misses, and easily would say so, other people once present in one's life, from the retired
mailman to the former teacher to absent loved ones, whether dead or gone around the block.
The analysts appear to need protection from the power of feeling, perhaps less from the
patient's feelings directed toward them than from the power of their own. In such
extremes, the therapist remains sheltered behind a mask, untouched, the
"countertransference" well under control, if not altogether denied, as he safely
brings the relationship to its conclusion. "The enthusiastic and engaging assertion
of an older colleague many years ago," writes Leo Stone, "that his patient would
have developed the same vivid transference love toward him `if he had been a brass
monkey,' is alas (or perhaps, fortunately!) just not true" (1961, p. 41). In
Firestein's study of termination, the brass monkey is alive and well. "Harold
Searles, for interesting contrast, in 1959 refers to the feelings potentially evoked in
the analyst at termination: "The real and unavoidable circumstance of the closing
analytic work tends powerfully to arouse within the analyst feelings of painfully
frustrated love which deserve to be compared with the feelings of ungratifiable love which
both child and parent experience in the oedipal phase of the child's development"
(1965, p. 300). Accompanying this love, Searles writes, may be "feelings of jealousy,
anxiety, frustration-rage, separation-anxiety, and grief" (p. 300).
In a ground-breaking study, the first to explore systematically the
patient's reactions to the therapist's death (Lord, Ritvo and Solnit, 1978), the authors
report a broad range of mourning reactions in 27 participants whose analysts had died.
Only two of the respondents appear to have experienced no mourning reaction at all
following their loss, and one of these, a young candidate in training, is quoted as saying
that "the analyst only mattered as a transference figure ... a peg on which to hang
attitudes" (p. 193). Although not categorized by the authors as a normal response,
this trainee's reported absence of grief is still quite remarkable; presumably, one peg
may be replaced with another, and it would indeed be much easier to feel no grief for the
loss of a piece of wood than for the loss of a beating heart. The candidate's
"peg" has even fewer distinguishing characteristics than Stone's brass monkey:
one brass monkey may not so easily be substituted for another, after all, as one peg for
another. The candidate's comment makes as much sense as to say that one's parents are
handy pegs for one's affection and dependence, the implication being that attachment to
the person is neither reasonable nor relevant.
But my second example offers to the "wooden peg" analyst a
worthy companion. Four years after the publication of Firestein's book, Viorst (1982)
looks in greater depth at analysts' responses to termination, directly conceiving the
separation as a loss in the title of her paper: "Experiences of Loss at the End of
Analysis: The Analyst's Response to Termination." Viorst's study is conducted by
unstructured personal interview rather than the questionnaire format used by Firestein,
and this difference itself accounts partially for the range and depth of her findings in
contrast to Firestein's. In her note on procedure, Viorst writes that "the interview
setting ... evoked in a number of analysts not only thoughtful comments but a
confessional, emotionally charged response" (pp. 400-401). What did they need to confess?
In marked contrast to the superficial, mild and ultimately vague responses
reported by Firestein, Viorst found that "anger and guilt and frustration and
disappointment, along with sorrow, were openly manifested as we spoke of loss at the end
of an analysis" (p. 401). Viorst believes that the sixteen analysts spoke, for the
most part, "with a high degree of frankness and that they spoke individually in ways they
would never speak publicly, or collectively" (p. 401, my italics). The italicized
words speak to the gap between cultural discoursed--the public and collective face of the
discipline manifested in theoretical formulations-and the actual individual responses of
working analysts, responses which they keep hidden.
Lord, Ritvo and Solnit's study (1978) reports a psychoanalytic
candidate who did not need to mourn the loss of an analyst who, said the candidate,
functioned merely as a "peg" for transferences; similarly, Viorst reports in her
study a spiritual twin of this unbereaved candidate, the only analyst interviewed who
"claims no problems with loss at termination. `Professionalism,' he remarks,
`defends against loss"' (p. 402, my italics). While the student is protected from
feeling by the analyst's role as transferential hook, the analyst in this example is
protected by his professionalism. It seems reasonable to view these two, student and
analyst, as captive to theoretical formulation turned dogma, and thus imprisoned, cut off
from acknowledgement of, and consequently perhaps even access to, the most fundamental of
human emotions. But how is it possible for such a therapist to do what the patient
In his paper "On the `Unexpected' Termination of Psychoanalytic
Therapy" (1982), Limentani addresses the effects of sudden endings of various kinds,
emphasizing the seriousness of such breaches of expectation. "As psychoanalysis must
rank among the most demanding, stressful, and intimate of human relations, where trust
plays an essentially central role, we should take it for granted that severe and deep
reactions will occur when it is brought to an abrupt end" (p. 420); a little later he
writes of concern about "inevitable scarring" and "broken trust and
promise" (p. 420). Although Limentani's focus is ostensibly on the patient, these
words reasonably may be applied to both members of the dyad, an implication residing in
the vagueness of reference. It is noteworthy that, of the seven case examples of forced
termination presented, only two actually refer to therapist-induced endings while the
remaining five turn the tables, the patient precipitating the ending. Here the unspoken
focus is clearly on the therapist as recipient of the unexpected, a fact that reemphasizes
the vagueness as to which member of the pair the author means when he speaks of
"severe and deep reactions," "inevitable scarring," and "broken
trust and promise."
At the end of the paper Limentani reminds readers of a consideration
that he says should always be held in mind by any therapist working with a patient whose
therapy must come to an unexpected ending. He is referring to the reactions of people
whose therapists leave them, for example, by moving to another city, or by dying. In what
is perhaps another instance of implicit emphasis, an omission worth noting, Limentani
writes of the special difficulty for the therapist in working with a patient who has been
abandoned this way:
Human beings are not reasonable, even though it would be convenient for the therapist
if they were. They do not easily accept "rejections" by fellow members of the
human species, no matter how unavoidable and totally unexpected the circumstances. (p.
This wry acknowledgement of human irrationality does assign that quality to the
patient--that is, to one half of the dyad, while remaining silent about the other.
Perfectly reasonable patients and, to include the omitted, missing half
of the dyad, perfectly reasonable clinicians, would be exactly like the Houyhnhnms
Gulliver meets on his travels, creatures who, when friends or relations die, express
"neither joy nor relief at their departure" (Swift, 1963, p. 287). Houyhnhnms
feel no affection for their young, but care for them according to theoretical principles
derived "entirely from the dictates of reason" (p. 286). In that idyllic and
chilling Swiftean world, common human feeling does not exist. Only a Houyhnhnm-therapist
(and therapists, Limentani reminds us, are "fellow members of the human
species") who thus "rejects" the patient by dying perhaps does not discover
"the least regret that he is leaving the world" (p. 287). That is, the
hypothetical Houyhnhnm-therapist, a perfectly rational creature, not only resembles
Firestein's therapist who barely feels the loss of the patient, Viorst's therapist who is
shielded from loss by "professionalism," and the candidate whose analyst's death
evokes no sense of loss. On top of that, the Houyhnhnm-therapist who does not miss the man
or woman who once came to talk to him also does not miss himself, discovering as he is
dying not the least regret at his own departure. That is how thoroughly reasonable this
creature is. But in a world lacking common mortal feeling, there is no need for the
therapeutic exchange--a transaction in human "being."
MASTERING THE LANGUAGE
In his prose book Vigil (1997), the poet Alan Shapiro tells the story of his sister's
final four weeks of life, the family gathering during this time to tend her in a hospice
room. ]n a section titled "The Doctor," Shapiro tries to make sense of her
oncologist's emotional withdrawal from her as she lay dying, of his "fumbling with
emotions that squared so awkwardly with his professionalism" (p. 55). Of his sister's
deep dependency on the doctor, Shapiro writes:
More than anyone else, early and late in her disease, he determined how she felt about
herself. When she was doing well, meaning when she responded well to the treatment he
prescribed, he bolstered her self-esteem by saying he was proud of her, she was his best
patient, she was his favorite patient. But if he were the benevolent deity when she was
doing well, responding to his treatment, he became the deus ahsconditus when the cancer
had metastasized, and it was clear she was going to die. (p. 53)
Later, after his sister's death, Shapiro is faced with the failure
of his brother-in-law, also a doctor, to acknowledge the death. At first uncomprehending,
Shapiro chooses, in the end, to understand both of these failures not as the doctors'
incapacity to feel but as the incapacity to know what to do with how they feel. He
writes of his sister's doctor:
Though it seemed he struggled to maintain his superior role as doctor at my sister's
bedside-checking the morphine pump, examining her chart--her status as a treatment failure
forced him to face her not as doctor but as a needy, fearful, fellow human being, as just
another mortal citizen among the dying. She was asking him, as I had asked my
brother-in-law, to speak a language that he couldn't master. (pp. 58-59, my
How are we to help the patient with the task of every
termination--to mourn the losses at ending? And if the therapist is dying, how are we to
help now with the double task? This patient must mourn not only the end of the
treatment and loss of a rightful expectation, that is, the loss of the
never-to-be-completed therapy, but he or she must also mourn the impending ultimate loss,
inside the therapy frame and in the real world, of a human being. The patient has to say
good-bye and will need help.
The psychoanalytic situation is carefully structured to induce an
extraordinary intimacy that is its reason to exist; it is through this singular human
connection--an intimacy that intends separation--that the work is accomplished and the
endpoint reached. The patient is in a quandary, however, if the helper is shy of endings
and also lacks a vocabulary, as Shapiro puts it, to know what to do with how he feels. The
capacity to consider one's mortality, by which I mean human frailty and limitation in
every sense, perhaps defines the capacity to be a good guardian of the therapeutic
situation: a medium through which patient and therapist alike may discover, and discover
again, how closely related are the workings of grief and love.
But the helper who is sick faces an additional quandary, the pain and
complexity of which touches the deepest terror. I believe that the therapist, no less than
the patient, has the rightful expectation of help from his or her profession. Such
matters, while they reflect on the individual therapist, reflect first and most deeply on
the theoretical and professional supports that are every therapist's own mortal right to
have. Silence for the therapist compounds silence for the patient. In how many ways is the
sick therapist abandoned? The patient, we may then say, is doubly abandoned.
Abend, S. (1986), Countertransference, empathy, and the analytic ideal: The impact of life
stresses on analytic capability, Psychoanalytic Quarterly, 55, 563-575.
Balint, M. (1950), On the termination of analysis, International Journal of
Psychoanalysis, 30, 196-199.
Bergmann, M. (1997), Termination: The Achilles Heel of psychoanalytic technique,
Psychoanalytic Psychology, 14, 163-174.
Blum, H. (1987), Analysis terminable and interminable: A half century retrospective,
International Journal Psychoanalysis, 68, 37-47.
Blum, H. (1989), The concept of termination and the evolution of psychoanalytic thought,
Journal of the American Psychoanalysis Association, 37, 275-295.
Calef, V., and Weinshel, E. (1980), The analyst as the conscience of the analysis,
International Review of Psychoanalysis, 8, 279-290.
Chused, J. (1997), The patient's perception of the analyst's self-disclosure: Commentary
on Amy Lichtblau Morrison's paper, Psychoanalytic Dialogues, 7, 243-256.
Clark, R. (1995), The pope's confessor: A metaphor relating to illness in the analyst,
Journal of the American Psychoanalytic Association, 43, 137-149.
Ekstein, R. (1965), Working through and termination of analysis, Journal of the American
Psychoanalytic Association, 13, 57-78.
Feinsilver, D. (1998). The therapist as a person facing death: The hardest of external
realities and therapeutic action, International Journal of Psychoanalysis, 79,
Ferenczi, S., and Rank, O. (1924), The Development of Psychoanalysis, Nervous &
Mental Disorders Publishing Co., 1925, New York.
Firestein, S. (1978), Termination in Psychoanalysis, International Universities Press, New
Fliess, R. (1942), The metapsychology of the analyst, Psychoanalytic Quarterly, 11,
Freedman, A. (1990), Death of the psychoanalyst as a form of termination of
psychoanalysis, In H. Schwartz and A. Silver (Eds.), Illness in the Analyst: Implications
for the Treatment Relationship, International Universities Press, Madison, CT, pp.
Freud, S. (1893), Charcot, Standard Edition, vol. 3, pp. 11-23.
Freud, S. (1911), Formulations on the two principles of mental functioning. Standard
Edition, vol. 12, pp. 213-226.
Freud, S. (1915), Observations on transference-love, Standard Edition, vol. 12, pp.
Freud, S. (1915), Thoughts for the times on war and death, Standard Edition, vol. 14, pp.
Freud. S. (1937), Analysis terminable and interminable, Standard Edition, vol. 23, pp.
Gardner, M. R. (1989), Sell Inquiry, Analytic Press, Hillsdale, NJ.
Gates H. L. (1997), The naked republic, The New Yorker, August 25 and September 1, pp.
Hamilton, E. (1969), Mythology, New American Library, New York.
Hoffman, I. (1991), Discussion: Toward a social-constructivist view of the psychoanalytic
situation, psychoanalytic Dialogues, 1, 74-105.
Hoffman, I. (1998), Ritual and .Spontaneity the Psychoanalytic Process, Analytic Press,
Hoffman I. (2000), At death's door: Therapists and patients as agents, psychoanalytic
Dialogues, 10(6), 823-846.
Horace (1994), To Virgil, In D. Ferry (Trans.), The Odes ofHorace, Farrar, Straus, & Giroux,
Hurn, H. (1971), Toward a paradigm of the terminal phase: The current status of the
terminal phase, Journal of the American Psychoanalytic Association, 19, 332-348.
Kaplan, D. (1997), Discussion of Martin Bergmann's and Jack Novick's articles,
Psychoanalytic Psychology, 14, 175-180.
Loewald, H. (1980), On the therapeutic action of psychoanalysis, papers on
Psychoanalysis, Yale University Press, New Haven, CT.
Loewald, H. (1988), Termination analyzable and unanalyzable, The Psychoanalytic Study of
the Child, 43, 155-166.
Limentani, A. (1982), On the "unexpected" termination of psychoanalytic therapy,
Psychoanalytic Inquiry, 2, 419-440.
Lord, R., Ritvo, S., and Solnit, A. (1978), Patients' reactions to the death of the
psychoanalyst, International Journal of Psycho-Analysis, 59, 189-197.
Margulies, A. (1998), Discussion of Ellen Pinsky's dissertation, Mortal Gifts: A View of
the Therapeutic Relationship through the Lens of Mortality, Paper presented at The
Massachusetts School of Professional Psychology, March 5, 1998.
McLaughlin, 1. (1981), Transference, psychic reality, and countertransference,
Psychoanalytic Quarterly, 50, 639-664.
Mitchell, S. (1997), Influence & Autonomy in Psychoanalysis, Analytic Press, Hillsdale,
NJ. Modell, A. (1990), Other Times, Other Realities, Harvard University Press, Cambridge.
Modell, A. (1991), The therapeutic relationship as a paradoxical experience,
Psychoanalytic Dialogues, 1, 13-28.
Morrison, A. (1990), Doing psychotherapy while living with a life threatening illness, In
H. Schwartz and A. Silver (Eds.), Illness in the Analyst: Implications for the Treatment
Relations, International Universities Press, Madison, CT, pp. 227-250.
Morrison, A.(1997), Ten years of doing psychotherapy while living with a life-threatening
illness: Self-disclosure and other ramifications. Psychoanalytic Dialogues, 7, 225241.
Nestrick, W. (1975), George Herhert--the giver and the gift. Ploughshares, 2, 187-205.
Novick, l. (1980), Negative therapeutic motivation and negative therapeutic alliance,
Psychoanalytic Studv of the Child, 35, 299-310.
Novick, J. (1982), Termination: Themes and issues, Psychoanalytic Inquiry, 2, 329-365.
Novick, J. (1988), The timing of termination, International Review of Psychoanalysis, 14,
Novick, J. (1997), Termination conceivable and inconceivable, Psychoanalytic Psychology,
Ogden, T. (1997), Reverie and Interpretation, Jason Aronson, Northvale, NJ.
Panel (1975), Termination: Problems and techniques, W. S. Robbins, reporter, Journal of
the American Psychoanalytic Association, 23, 166-176.
Pedder, J. (1988), Termination reconsidered, International Journal of Psychoanalysis, 69,
Pizer, B. (1997), When the analyst is ill: Dimensions of self-disclosure, Psychoanalytic
Quarterly, 56, 450-469.
Rangell, L. (1966), An overview of the ending of an analysis, In R. Litman (Ed.),
Psychoanalysis in the Americas, International Universities Press, New York, pp. 141-165.
Reich, A. (1950), On the termination of analysis, International Journal of
Psychoanalysis, 31, 179-205.
Rizzuto, A. M. (1998), Sound and sense: Words in psychoanalysis and the paradox of the
suffering person, Canadian Journal of Psychoanalysis, 3, 1-15.
Samuels, L. (1992), When the analyst cannot continue, The San Francisco Jung Institute
Library Journal, 10, 27-38.
Schur, M. (1972), Freud: Living and Dying, International Universities Press, New York.
Schwartz, H. (Reporter) (1993), The life cycle of the analyst: Pregnancy, illness, and
disability, Journal of the American Psychoanalytic Association, 41, 191-206.
Schwartz, H., and Silver, A. (Eds.), (1990), Illness in the Analyst: Implications for the
Treatment Relationship, International Universities Press, Madison, CT.
Searles, H. (1965), Oedipal love in the countertransference, Collected Papers on
Schizophrenia and Related Subjects, International Universities Press, Madison, CT.
Shapiro, A. (1997), Vigil, University of Chicago Press, Chicago.
Silver, A. L. (1990), Resuming work with a life-threatening illness--and further
reflections, In H. Schwartz and A. Silver (Eds.), Illness in the Analyst: Implications for
the Treatment Relationship, International Universities Press, Madison, CT, pp. 151-176.
Silver, A. L. (2001), Facing mortality while treating patients: A plea for a measure of
authenticity, Journal of the American Academy of Psychoanalysis, 29(1), 43-56.
Spitz. R. (1965), Symposium: Transference: The analytic setting and its prototype,
International Journal of Psychoanalysis, 37, 386-388.
Stone, L. (1961), The Psychoanalytic Situation, International Universities Press, Madison,
Swift, J. (1963), Gulliver's Travels, Bobbs Merrill Company, New York.
Szasz, T. (1963), The concept of transference, International Journal of Psychoanalysis,
Tauber, G. (1989), Re-analysis after the death of the analyst, Modern Psychoanalysis, 14,
Viorst, J. (1982), Experience of loss at the end of analysis: The analyst's response to
termination, 2, 399-418.
Weinshel, E. (1990), How wide is the widening scope of psychoanalysis and how solid is its
structural model?, Journal of the American Psychoanalytic Association, 38, 275296.