HOW MUCH IS ENOUGH?

Bringing therapy to an end either too early or prolonging it can be equally

counter-productive. How Much is Enough? explores the reasons for such
unsatisfactory endings and offers advice on avoiding them and achieving
a timely conclusion to the therapy.
Using vivid examples and practical guidelines, Lesley Murdin examines
the theoretical, technical and ethical aspects of endings. She emphasises
that it is not only the patient who needs to change if one is to achieve a
satisfactory outcome. The therapist must discover the changes in him/
herself which are needed to enable an ending in psychotherapy.
How Much is Enough? is a unique contribution to therapeutic
literature, and will prove invaluable to students and professionals alike.

Lesley Murdin is Chair of the Training Committee and Deputy Head of

Training at the Westminster Pastoral Foundation, and Chair of the
Psychoanalytic Section of UKCP. She is also a psychotherapist in private
practice.
HOW MUCH IS
ENOUGH?

Endings in Psychotherapy
and Counselling

Lesley Murdin

London and New York

 First published 2000
by Routledge
11 New Fetter Lane, London EC4P 4EE

Simultaneously published in the USA and Canada

by Routledge
29 West 35th Street, New York, NY 10001

Routledge is an imprint of the Taylor & Francis Group

This edition published in the Taylor & Francis e-Library, 2001.

© 2000 Lesley Murdin

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or
by any electronic, mechanical, or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or retrieval system, without permission
in writing from the publishers.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication Data

Murdin, Lesley.
How much is enough? : endings in psychotherapy and counselling/Lesley Murdin.
p. cm.
Includes bibliographical references and index.
1. Psychotherapy–Termination. I. Title.
RC489. T45M87 2000
616.89´14–DC21 99–30170
CIP

ISBN 0415-18892-X (hbk)

ISBN 0415-18893-8 (pbk)
ISBN 0-203-13073-1 Master e-book ISBN
ISBN 0-203-17660-X (Glassbook Format)
To Meg: with thanks
 CONTENTS

Acknowledgements viii

Introduction: the problem 1

1 What are we waiting for? aims and outcomes 12

2 Happy endings: the goal of resolving transference 23

3 Dealing with illusions: narcissism and endings 44

4 Staying alive: the patient’s unilateral ending 61

5 Time to go: the therapist ends 80

6 What is truth? values and valuing endings 97

7 Ends and means: the ethics of ending 117

8 Endgame: last sessions 133

9 In my beginning is my end: the time-limited

solution 149

10 Endings in training and supervision 160

The good ending 172

Index 173
vii
 ACKNOWLEDGEMENTS

I should like to thank my husband, Paul Murdin, for advice, support and
technical help throughout the seemingly unending process of writing
this book.
I should like to thank the following for generous help in reading the
manuscript and making invaluable suggestions: Jenny Corrigall, Mary
Anne Coate, Meg Errington, Sheila Russell, Fiona Sinclair.
I should also like to thank all my trainees, supervisees and, above all,
my patients and clients for all that they have taught me.

The following have kindly granted permission to use extracts from

their work: The Estate of Robert Frost for ‘Some Say the World Will End
in Fire’ from The Complete Poems of Robert Frost edited by Edward
Connery Lathem, published by Jonathan Cape. From ‘Fire and Ice’ from
The Poetry of Robert Frost, edited by Edward Connery Lathem, Copy-
right 1951 by Robert Frost. Copyright 1923, © 1969 by Henry Holt Com-
pany, LLC. Reprinted by Permission of Henry Holt and Company, LLC. ©
Kate Atkinson 1997. Extracted from Human Croquet by Kate Atkinson,
published by Doubleday, a division of Transworld Publishers Ltd. All
rights reserved. Faber and Faber Ltd for an extract of ‘As Sweet’ from
Serious Concerns by Wendy Cope.
Every effort has been made to trace copyright holders and obtain
permissions. Any omissions brought to our attention will be remedied in
future editions.

viii
 INTRODUCTION
The problem

Some say the world will end in fire

Some say in ice.
From what I’ve tasted of desire
I hold with those who favour fire.
(Robert Frost)

The psychoanalytic paradigm has become part of popular culture. It has

already lasted for over a hundred years; inevitably there are questions
about its survival. Can the body of psychoanalytic theory and technique
survive into the twenty-first century or will it be seen as merely a feature
of the twentieth century’s unsuccessful project for a science of the human
mind?
New models of psychotherapy arise and acquire followers and
exponents. Integrative models seek to arrive at a positive synthesis that
uses the best of the available thinking and practice. There are plenty of
new beginnings. Psychoanalysis itself as a discipline gives rise to many
varieties of psychoanalytic and psychoanalytically inspired
psychotherapy or counselling. All versions of this paradigm share a
structure in which some kinds of change are valued and at some point a
choice is made to end the work. Psychotherapy is a therapeutic process,
not a lifestyle.
Ending by choice rather than necessity implies faith in the future.
Psychoanalytic therapy must have the capacity to be flexible and to
change, just as it must encompass change and ending for the people who
come to therapists. If it is to survive, it will need to be able to tolerate a
future that is different from the present or the past. Visions of the future in
fiction tend towards the negative. Orwell’s 1984 or Huxley’s Brave New

1
 HOW MUCH IS ENOUGH?

World, for example, have been followed by the films of bleak future worlds:
Star Wars, Blade Runner, Water World. Perhaps there is some difficulty in
allowing our descendants a better life than we have had. This points
immediately to a potential difficulty for therapy. We are all required to
work with the finite nature of each individual’s therapy. The therapist is
continually faced with the need to allow his or her patients to go and,
perhaps, to have a better life than he1 does. In order to do this, the therapist
must go through a change and a development with each person he sees.
Quite apart from the potential envy of each other’s future, both therapist
and patient will be faced with loss when ending is to be considered.
Most people come to a therapist, do a reasonable amount of work, get
a bit better and leave. There is no great difficulty for either therapist or
patient2 and both are able to come to an agreement on when to end.
Unfortunately, this does not always happen. The purpose of this book is
to look at the factors that are involved in making an ending and the
factors that get in the way of a satisfactory ending. A theory of ending
implies a view of what therapy sets out to do. Anyone who offers to work
with distress, pain, dysfunctional patterns of thought, feeling and
behaviour must have a view about how much can be achieved. The people
who come for therapy cannot know beforehand what is possible and, in
addition to the basic uncertainty of the therapeutic enterprise, the
symptoms themselves may prevent the patient from having a realistic
idea of what can be achieved. In any case the therapist might have an
entirely different view from that of the patient. This difference in aim is
discussed further in Chapter 6.
In this book I shall look at the importance of change in the therapist for
the achievement of a satisfactory ending in therapy. Change implies
awareness of the way in which aims and values affect the nature of
endings as both act and process. The theoretical and technical implications
of the kinds of ending that we encounter in psychotherapy and also in
training and supervision are also important in arriving at some views of
what is necessary or desirable in endings. Endings in therapy can be
satisfactory, sometimes scarcely noticed or they can be counter-
productive and apparently destructive. Endings across the spectrum will
be examined in the light of problems that we encounter in theory and
practice and also for what they reveal about individual cases.
We are capable of both seeking and rejecting endings, sometimes both
at once. Thinking about the specific character of the ending phase
1 I have used masculine and feminine pronouns indiscriminantly throughout the
text.
2 The term ‘patient’ is used throughout because I am mainly although not exclusively
speaking of psychoanalytic work

2
 INTRODUCTION

delineates the areas of theory that help to make ending part of a

constructive process, rather than merely something that happens to us.
Therapists are likely to have a theoretical model which will lead them to be
waiting for specific indicators of readiness to end. They may be waiting
for something modest and attainable or for an ideal which will never
arrive. Therapists are not always good at recognising the right time for a
patient to end. Macdonald’s study found that the therapist’s judgement
of whether or not a patient was ready to end bore no significant relation to
whether or not the patient reported a satisfactory outcome for the therapy
(Macdonald 1992).
The dimensions of the problems of ending are as broad as therapy
itself. On the one hand, there are difficulties of different degrees of severity
in agreeing to arrive at the act of ending. On the other hand, there are
problems inherent in the process itself, created by its nature and by the
nature of the men and women who are involved:

Ms A3 comes to a therapist because of difficulties in

relationships with men. She has been in love with a married
man for some time and is consciously aware that he will not
leave his wife and three children for her but is unable to let
him go. Ms A also has a male friend who has been around for
several years but who does not really count. The therapy
works by dealing with the way in which she treats the therapist
as the person who is available. After three years of working,
particularly with the way Ms A deals with the therapist’s
absences, they reach a point where she begins to speak
about ending therapy. The first time she mentions it, the
therapist interprets it as a way of making him unimportant,
like the man friend. This leads to a period of reassessment of
the friend (who is present), in contrast to the absent married
man (who is desired for his absence). The next time that
ending the therapy is mentioned, it is in the context of a
much greater ability to accept what is offered in the present.
The therapist also has changed enough to be able to agree
that this is a good time to stop. The only task then is to
decide how long the ending phase should be and to discover
what needs to be done before the final session.

3 The case material in this book is fictional unless I have indicated otherwise,
although it is bound to contain elements related to my experience and memory.

3
 HOW MUCH IS ENOUGH?

Ms A seems to have had an ordinary, good enough therapy. There was

a task which could be agreed by both therapist and patient at the conscious
level. She had tried to give up her relationship with a married man. She had
not, however, been able to do more than move away physically and give
up some of the telephone calls that they were still inclined to make to each
other at the beginning of the therapy. She had become very depressed
and tearful. She was unable to concentrate on work and had no enjoyment
of leisure. In common with everyone else, she wanted to feel better. She
described this as being able to be less dependent. Here she and the
therapist probably had different views. Ms A was torn by the conflicting
desire to have the relationship with the man and also to be free of it and
not feel the pain of loss. The therapist might well have understood this
conflict but might privately have been thinking that becoming completely
independent of other people is not the aim of therapy.
This immediately sets up the tension between goals that is inherent in
most therapies and will be discussed further in Chapter 6. An unstated
agenda is the need for the aims of both to converge. This means that both
will have to change. As the full pain of the confrontation in therapy
emerges, Ms A decides that it is time to leave. She has recognised that she
chose the married man precisely because he was only ever partly available,
leaving her with the option of withdrawing. She has begun to see the
possibilities in the man who is available but is taking fright from the
possibility of greater commitment to him. The therapist is sure that this
ending would not be constructive but would be a flight in the middle of
the most difficult and anxious part of therapy. He deduces this from his
experience of the course of other therapies and from his own feeling of
anxiety and from his knowledge of the processes of therapy.
The conclusion that the therapist reached when ending was first
mentioned was that it was not yet time, even though at that point the
initial goals had been achieved in that the patient was much less depressed
and no longer wept her way through sessions. She had also ended the
relationship with the married man so that even though she thought about
him at times, she was no longer obsessed by these thoughts. If therapy
were merely a matter of achieving goals, this might well have been the
agreed ending point. Because therapy is also a matter of process, there
were other considerations. The process that had been going on in parallel
with the conscious achievement of goals was of course embedded in the
relationship with the therapist, where both could acknowledge that more
needed to be done.

4
 INTRODUCTION

In some cases more is done in the processes of therapy than is safe.

Occasionally, the therapist is tempted to allow a sexual relationship. This
causes damage of all sorts because it is always akin to sexual abuse, in
that the therapist has power and authority over the patient. Sometimes
the result is a long drawn out therapy that saps energy from other aspects
of life and leads the patient nowhere. This will be discussed further in
subsequent chapters. In the case of Ms A, more useful work was done, in
that the therapist did not let her stay where she was, but continued to
emphasise the ways in which she minimised his role and she set out to
prove to herself that no man was able to supply anything that she lacked.
In fact her aim was to prove that she did not lack anything. The therapist
refused to accept this version of events, and persisted in seeing a more
complex story.
By the time Ms A returned to the idea of leaving she had achieved the
ability to see her own attempts to deceive herself and ruefully, but not too
triumphantly, point them out to herself and the therapist. At this point, the
therapist found her much more likeable and after initially resisting the idea
of ending, rather sadly had to acknowledge that there was no reason why
they should not. To try to keep her, even if he had that power, would have
been to fall into the very trap that she was leaving: to preserve a tantalising,
never fulfilled relationship instead of struggling with a living partner.

Mr B is a highly successful accountant. He comes to a

therapist because his fiancée is in therapy and has demanded
that he too should have therapy. He has never made clear the
purpose of the therapy from his point of view, but talks about
his difficult relationship with his father who was a famous
academic and whose achievement can never be equalled by
Mr B however hard he tries. After three months he is saying
that he really does not see what use therapy can be to him
because he knows he should feel something for the therapist
– maybe he should miss her when she goes away on holiday
– but in fact he feels nothing. The therapist thinks of this as
resistance and hopes that the therapy will enable him to
acknowledge his feelings. She does not see the extent to
which her own attitude makes him desperate. She does not
change.
At the next holiday break he writes to say that he has
decided to end the therapy and will not return. The therapist
is extremely frustrated by this, feeling that if only he would
continue to attend therapy, there could be great changes.

5
 HOW MUCH IS ENOUGH?

She writes and suggests another session to discuss his

reasons for leaving but he does not reply.

Mr B’s therapy is the kind that most would think of as a failure. He attended
for a while, did not seem to be much changed and left suddenly. Because
he would not return to discuss his reasons for ending, the therapist was
left to process her own emotions and deal with her own loss. She was
deprived of the opportunity to change gradually with him and was suddenly
wounded both narcissistically in the sense that her view of herself as a
competent therapist was dented and also in the sense that she felt bereft.
We could all see reasons why there were difficulties. She had approached
the work with an agenda of her own. She had desired something even if
she had managed to keep it to the level of desiring that the therapy should
continue long enough to find a chink in the armour of indifference that Mr
B had found it necessary to wear. She could try to console herself by
thinking that perhaps he had left because he had discovered that she had
made a chink. On the other hand, it was equally possible that he had left
out of despair that nothing had taken him sufficiently by surprise to make
much of an impression.
These considerations imply that the outcome of a therapy is a matter of
technique. To some extent, that is of course the case. It might have been
possible for someone more skilled to surprise Mr B out of his fortifications.
Such a view is of course based on the theoretical assumption that what is
needed is a change at an unconscious level.
Mr B never found his own way to therapy and never acknowledged
that he was there for any reason other than the desire of a woman that he
should be there. In the first case, he was sent by his fiancée; thereafter he
could see his attendance as required by his therapist. It came as no surprise
to his therapist that his mother had been very self-centred and had ruled
his powerful father by illness and neurosis. He suffered from the memories
of his own weakness in the face of his mother’s demands and his father’s
scorn. A satisfactory therapeutic alliance would have been difficult to
make in the face of these images. He had learned to hide his own thoughts
and wishes from everyone and probably from himself too. His therapist
was in the paradoxical position that if she understood him at all he would
want to escape from her power, and if she did not she would be useless.
Given this situation, the probability of a sudden ending imposed by the
patient was high from the outset and might have been avoided only if the
therapist had tackled the problem overtly throughout.

6
 INTRODUCTION

Not all therapists would accept such a view. Some forms of

psychotherapy would make the assumption that what is needed is a
constant feedback of the way in which Mr B is thinking and feeling until
he himself sees a need to change and a way to do it. Maybe what he
needed was to be convinced that the therapist believed in his ability to
work things out for himself. He had a serious difficulty with the way in
which he could construct an image of himself as a man. Perhaps he needed
more empathy with this aspect of his problem. Yet again, other
psychotherapists might have tried to work first with his lack of motivation.
He needed to acknowledge that he had a problem before anyone could
help him to solve it. Cognitive approaches might have tried to get him to
see how he could improve or change his life. Specifically, he could be
asked why his fiancée thought he needed therapy and the problem
inherent in this area could have been probed and worked through.
Mr B’s therapy shows what happens when a therapist approaches a
patient with hope and optimism but is not able to find the way in which he
needs her to change so that something different can emerge.

Mr C comes to a therapist because he is a writer who is not

able to write. He has a job as a journalist for a paper which he
despises. He has managed to write a few short stories but is
very dissatisfied with them and believes that therapy could
help him to unblock. He speaks in a monotone and leaves
little space for any interventions. He seems quite content to
attend once a week and complain about the way he is treated
at work and at home where no one values him according to
what he feels that he deserves.
The therapist finds it very easy to sit and say little, although
she occasionally galvanises herself into commenting on the
way in which he keeps her from being able to join in the
events of the session. He successfully prevents this from
having any effect by becoming hurt and criticised, leaving the
therapist feeling that she has castrated him. The therapy
continues with little change. The therapist knows that she
needs to change but does not know how. When she mentions
ending, he says that therapy is his only hope and without it
he will despair.

7
 HOW MUCH IS ENOUGH?

Mr C’s therapy has reached what many therapists would recognise as

an impasse. The therapist wishes to end because she cannot believe that
she is being any help to Mr C. She has tried every way that she and her
supervisor can think of to engage him in discovering his own responsibility
for what happens to him. He has not found it tempting to make any move
from the paranoid position that he has discovered for himself. Everything
is someone else’s fault.
When the therapist points this out to him, he accepts what she says as
a criticism: ‘Yes I know I am hopeless. You have told me before that I
ought to get on my feet and pull myself together, and I know that I should,
I just don’t know how.’ The implication is that the therapist should have
shown him how and that she is being unreasonably demanding in
expecting him to do it for himself. He is firmly stuck in what Kleinians
would call the paranoid schizoid position. He pushes all the bad out on to
other people or on to parts of himself which he sees as ‘other’ to what is
really him. He cuts himself off from the bad by projecting it out in this way
or by saying, ‘Yes, yes, you’re right’ which prevents further thought. His
reward is that everything remains the same. There are no risky changes to
encounter. The therapy trundles on, week after week, and he feels
marginally better each time for having been able to experience the warmth
and interest of the therapist’s genuine concern for him. The last thing he
wants is for it to end.
When the therapist finally ceases agonising over what it might do to
him and mentions ending, the effect is devastating. He realises that he will
have to move in one direction or another because he cannot stay exactly
where he is. His immediate thought is of suicide. That is a mixture of
escape for him and punishment of the therapist. An analytic therapist
might think of this as a developmental problem. He has all along wanted a
mother who would provide all for him and hold him blissfully in her arms.
Within the developmental metaphor, one could say that he has not
discovered a reason to move forward and in fact is now wishing to return
to an even more passive state: death, or, as he might imagine it, a return to
the pre-birth state of union and inaction.
The therapist has a serious problem posed to her in this case. If she
continues, the therapy could well go on for the rest of Mr C’s life. Some of
the accounts of therapies recounted in Rosemary Dinnage’s book, One to
One (1988), show a temptation in just this direction. Therapy can become
a way of life and the therapist can become a regular adjunct like the
hairdresser, although with a greater degree of emotional importance. In
fact it is the emotional importance, usually called dependency and greatly

8
 INTRODUCTION

feared, that is the cause of the difficulty. The therapist is afraid to end the
therapy because she thinks Mr C might fall apart, might be worse off than
when she is there, and might kill himself. In other words, she acquires
some of his belief that she is keeping him alive. This is the belief that he
requires of her so that she will allow him to continue in his dysfunctional
passivity. In order to be as sure as possible that there is nothing further
that she can do, the therapist seeks supervision and consultation from
experienced colleagues. She tries various interpretations which make a
great deal of sense about his passivity, resistance to change, and his
attachment to his current state of mind. Nothing makes any difference,
and so for her, the only possibility left is to take the risk of mentioning
ending. In order to do so, she has to have achieved a state in which she is
confident that it is the best thing for him and that he can manage without
her. This may be the only change that is possible for either of them. It may
be the one action that will free him. It could go either way. Freud told his
patient the Rat man that he could have one more year and this produced
satisfactory changes (Freud 1909). Other patients have created uproar
and made official complaints against therapists who have, in their view,
abandoned them. Very few, to my knowledge, have actually killed
themselves.

Ms D is a woman aged 45 who comes to a therapist because

she is taking a counselling course. She is a member of an
evangelical sect and believes that counselling is the path
that God has chosen for her. She is required to have forty
sessions of counselling herself as part of the course
requirement. The therapist disagrees with this limitation and
encourages more involvement with the therapy. Ms D responds
with enthusiasm; she comes once, twice, then three times a
week. She falls in love with the female therapist and believes
that they are meant for each other. She leaves flowers on the
therapist’s doorstep and telephones her at night and at
weekends, asking for more time and extra sessions. After
six months, the therapist is unable to stand the onslaught
any longer and says that the therapy is not right for Ms D and
she will not see her any more. She also suggests that Ms D
might like to see a psychiatrist and says that she will write to
the GP to explain that the therapy has ceased. Ms D refuses
to leave at the end of the session and the therapist has to
mention calling the police before she will agree to leave. After
a few weeks, Ms D institutes a complaint against the therapist

9
 HOW MUCH IS ENOUGH?

for abandoning the therapy irresponsibly. The therapist receives

mysterious telephone calls at odd hours with the number of
the caller withheld.

Ms D represents the kind of person for whom the intensity of therapy

is difficult and even dangerous. She might manage well enough with
cognitive or short-term work that had a very specific goal but even then
would be inclined to develop a strong attachment to a therapist who
becomes the loved and hated parent figure with power to give or to
withhold. When the therapist is as important as this, she may be able to
achieve a great deal through suggestion if the patient is compliant. From
Freud onwards, therapists have recognised that they are in a unique
position to suggest in all sorts of subtle ways that their own belief about
what constitutes health or normality is what is right for the patient.
Very often, a therapist feels satisfied if the patient becomes somewhat
like him, accepting the same values and acquiring the same thought
processes. If this stage is reached, there can often be a peaceful end to
the therapy. On the other hand, sooner or later, the therapist will fail to
provide what the patient wants. Many patients can accept this and it will
be one of their reasons for moving forward. At this moment of
disappointment and separateness, however, the disillusionment may be
catastrophic and may lead to the kind of rage that makes therapy untenable.
Confronted with this fury, many therapists are inclined to be worn down
over time or to panic and suddenly withdraw. Instead, of course, the
therapist needs to change to a position where she can honestly see that
she is contributing to the difficulties. At that point there may be some
hope. I shall discuss the kind of difficulty experienced by Ms D further in
Chapters 3, 4 and 5.
Each of the above cases represents one point on the spectrum of
mutuality and satisfaction that might be achieved in ending therapy. Cases
like the first one show the ending of the therapy happening at the time
when it stops. In the other cases, the therapy comes to a stop with the act
of one of the participants, but there is no process of ending to give it
meaning and a place in a lifetime of events so that it can be eventually
more or less forgotten. What we do know in such cases is that the therapist
is not satisfied. We often do not know what happens for the patient. Each
vignette shows that there are crucial points where the therapist’s belief,
anxiety or wish comes to the forefront, and may precipitate or prevent an
ending.

10
 INTRODUCTION

Many complaints received by the professional organisations from

patients relate to endings that were too precipitous and were brought
about because of the therapist’s anxiety and inability or unwillingness to
sustain a difficult relationship. On the other hand, persisting with a
relationship that has become very negative requires considerable faith in
the two people concerned and in the process itself. De Simone is insistent
that the therapist does have the responsibility to continue the work no
matter what the counter-transference experience may be. She argues that
an impasse must be understood in theoretical and technical terms and
that dropping the therapy and hence the patient is not acceptable (de
Simone 1997: 45). Therapy must continue until the work is done. This is
the rule, but, like all rules, it must have exceptions. Sometimes the therapist
cannot make the necessary moves in him- or herself and the work becomes
destructive. Sometimes external reality intervenes. I shall consider what
the occasions for making exceptions might be in the following chapters.
Therapy needs to be lived at full volume and then, when it is ended, it
needs to be allowed to fade until only a few moments can be consciously
recalled. Obviously therapy needs to come to an end. It costs money.
People enter a therapeutic relationship because they want something and
sooner or later it may be achieved. Therapy is not intended to be a
substitute for life or for relationships outside. Therapists undertake a task
in taking someone on for therapy and they need to make the necessary
intellectual and emotional adjustments in themselves to enable the patient
to reach the end.

References

de Simone, G. (1997) Ending Analysis, London: Karnac.

Dinnage, R. (1988) One to One, Harmondsworth: Penguin.
Freud, S. (1909) ‘Notes upon a case of obsessional neurosis’, SE 10.
Macdonald, A. (1992) ‘Training and outcome in supervised individual
psychotherapy’, British Journal of Psychotherapy 8 (3): 237.

11
 1
WHAT ARE WE WAITING
FOR?
Aims and outcomes

Each theoretical model of psychotherapy implies a goal or set of goals

and a body of techniques that form a process. In order to be defined as
psychotherapy, any procedure must imply that change is possible, even
if the change is to return to the original position with renewed conviction
or confidence. Whatever the therapist takes to be the purpose of therapy
will be a major determinant of his or her willingness to help a patient to
end. Even those who decry any kind of normative goals may well be
waiting for developments in the patient’s ability to philosophise or to be
free of conventional thought patterns. Such aims can never be wholly
achieved and the therapist will have to settle for less than perfection.
Originally, psychoanalysis was a treatment performed by a doctor on a
patient and the cure of symptoms was its aim. It has developed on many
fronts but most practitioners today would accept that in spite of the
power imbalance between the one who seeks help and the one who is
supposed to be an expert, both people must submit to the process although
in different ways and to different degrees. Two subjects are involved and
both must change if the process is to be valuable.
Freud (1937) says that we are looking for:

• all repression to be lifted

• all the gaps in memory to be filled
• the ego to be strengthened
• the transference to be resolved.
Freud was concerned with memory and the damage that memories can do
whether they are consciously held or, worse still, repressed by conscious
or unconscious attempts to save oneself from pain. Clearly, not all memories
can be recovered, but Freud’s model offers the possibility that at least the

12
 AIMS AND OUTCOMES

most traumatic ones might be. His other criteria are even less absolute.
The ego or conscious thinking self is unable reliably to assess its own
strength or usefulness. The resolution of transference is often quoted as
a goal and will be discussed further in Chapter 2.
To be fair, Freud recognised perfectly well himself that these aims were
ideals and could not be achieved in any absolute sense, and that what is
achieved is often not permanent. Freud’s project was to develop the
rational, thinking subject in contact with another. Giving more strength to
the conscious, rational processes is reclaiming territory for conscious,
civilised use. His image of analytic work was the cultural achievement of
draining the Zuyder Zee in Holland. The North Sea is still there and
although one can keep it at bay, more water is ready to pour in from the
vast ocean of unconsciousness beyond to ruin our civilised achievements.
Bettelheim (1983) emphasised the cultural aspect of the work in Freud
and Man’s Soul.
Jung also gave a list of possible criteria, some of which are similar to
Freud’s:

• a more or less complete confession is made

• a new philosophy of life is worked out
• a hard won separation from the childhood psyche is achieved.
(Fordham 1978)
Separating from the childhood psyche implies the same sort of cultural
achievement as Freudian theory. More land is made available for
cultivation by separation from the powerful, overwhelming terrors of
childhood that continue to lurk just beyond the dikes that we build. Jung
adds the idea of discovering religion or perhaps rediscovering the religion
of one’s childhood. Individuation is perhaps the central concept for
Jungian therapy, defined by Samuels (1986: 76) as a person ‘becoming
himself, whole, and indivisible, distinct from other people or collective
psychology’. Like Freud’s therapeutic aims, these are statements about
progress along a continuum, not an achievement that can be reached.
Lacan challenged the search for wholeness that is implicit in ego
strength or individuation, and showed that in his view, Freud’s theory of
the ego implies that we place too much faith in a function that is supposed
to represent rationality and the relationship that we have with reality, but
is nevertheless bound to distort and deceive because its task is defensive.
It defends against recognition of lack and loss and hence is always against
wholeness, since wholeness must include what comes from the
unconscious. The best we can do in analytic work will be to track the

13
 HOW MUCH IS ENOUGH?

mysterious passage through chains of signifiers of the elusive and

eluding meaning of each individual. We are constituted in and by
language, and language is always one step away from the thing itself.
We express ourselves in the language that is passed on to us and we
are formed by the desires of others.
In this model, therapy works if it can help the individual to find his
own desire where it shows through the cracks and the gaps. This
desire, like a fish glimpsed and briefly touched, slips through the
fingers. While it is held, it may be spoken in what Lacan called ‘full
speech’ instead of our usual ‘empty speech’. In his Ecrits (Lacan
1977) he said that analysis could end when the patient can speak of
himself to the analyst. Before he is able to do this, he will speak of
other people’s images of him or will not speak directly to the other in
the room. He may speak to what he imagines to be the therapists
desire, avoiding what is in his own mind.
Lacan’s thinking implies the following goals:

• the unconscious is glimpsed from time to time

• the defensive nature of conscious thought is recognised
• the patient can speak to the therapist about himself.

Relief of symptoms

Many people come to a therapist in order to obtain relief from suffering.

Suffering takes many forms, only one of which is apparent in what
might be called symptoms. Both patient and therapist might wait
hopefully for a change in symptoms as described in the presenting
problem. The earliest attempts to relieve symptoms psychologically
fall under the heading of catharsis and involved the patient in a process
of change while the therapist stayed outside it as the doctor or
facilitator. The theoretical rationale for the benefits of catharsis is
basic Freudian theory. Breuer’s work with hysteria discovered the
value of ‘chimney-sweeping’:

it [the technique] consisted in bringing directly into focus the

moment at which the symptoms were formed and in persistently
attempting to reproduce the mental processes involved in that

14
 AIMS AND OUTCOMES

situation in order to direct their discharge along the path of

conscious activity. Remembering and abreaction . . . were what
was at that time aimed at.
(Freud 1914)

This kind of work was done with the aid of hypnosis and had some
startling and useful results. Nevertheless, its usefulness appeared to be
limited and the cures that were effected were often very short-lived. It
leads to no obvious ending, as the contents of the unconscious are as
broad and deep as the Atlantic.
A small amount of drainage might make a difference, however. In the
early days, the hypnotist gave suggestions that the symptom should be
forbidden to recur. In some cases and up to a point this worked and still
does. If it were sufficient there would be no need for any of us to look
further. Suggestion under hypnosis would be all that anyone would need.
Freud pointed out that the problem was that this method of treatment
might deal well with one symptom but would leave the cause untreated.
Unless there are structural changes, the patient will not achieve a better
resolution of future conflicts. Hypnotic suggestion does not involve the
patient actively: ‘Hypnotic treatment leaves the patient inert and
unchanged and for that reason too, equally unable to resist any fresh
occasion for falling ill’ (Freud 1917, lecture 28).
There are models of therapy where a great deal is achieved by working
cognitively or behaviourally with one symptom, or we might say, with the
presenting problem (see Chapter 9), where there is nearly always active
involvement of the patient. If the treatment of one symptom is to be
considered sufficient, there must be good grounds to expect that one
piece of changed behaviour will generalise. If the patient is given the
opportunity to understand the change, he may be able to use the
understanding in other contexts. Many therapists would no doubt add
that the patient also benefits from learning that he or she can achieve
greater understanding and choice through the experience of therapy. In
this model, the therapy will usually have an obvious ending when the
symptom disappears or decreases and the therapist will have worked
hard but may not have needed to make such an adjustment in himself, as
in long-term work where the outcome is not predictable to either person
when the work begins.
Freud continued the argument about the nature of the therapeutic action
of therapy by discussing his view that the cause of symptoms is the
repression of forbidden memories and impulses in order to avoid psychic
pain. Because of the extent of the unconscious, the patient often cannot

15
 HOW MUCH IS ENOUGH?

say enough to complete the cure. Even for minimal improvement, the pain
of awareness must be risked and often experienced, or defences will not
shift. Given this assumption it is clear that merely expressing the thoughts
and feelings available to consciousness will never be enough to effect a
considerable or lasting improvement. Other forms of therapy may not
accept the hypothesis that the sources of symptoms are unconscious,
but most will accept that something is needed from the therapist even if
that is not what Freud called the educational function of analytic
interpretation:

This work of overcoming resistance is the essential function of

analytic treatment: the patient has to accomplish it and the doctor
makes it possible for him with the help of suggestion operating in
an educative sense.
(Freud 1917, lecture 28)

However much or little they intend to educate the patient, therapists

inevitably add something to the work that is done. Pure catharsis with
nothing else added is impossible. Saying ‘mmm’ at a particular point is
reinforcing, adding emphasis, showing interest, encouraging, etc. A very
minimal kind of listening might be of great value to some people at some
times, but it is unlikely to be seen as sufficient by either patient or therapist
for most of the problems that people bring. Suggestion is bound to play a
part whether covert or overt. Unfortunately, although it may be powerful
it is unlikely to be enough if it is overt and specific. For example, a therapist
might say after two sessions: ‘Now you have brought me your problem
and told me your story. You are better, go home.’ Suggestion of this sort
is often used by the charismatic and in very powerful hands can work for
better or worse, but it hardly develops the patient’s choice and strength
for future new difficulties.
My own conclusion is that relief of symptoms is an honourable goal
and cannot be ignored by any therapist. Nevertheless, directly attacking
the problem is not enough in the long term. A more complex view of the
therapeutic process is needed if there is to be a profound change in an
individual. The purpose of therapy must encompass the complexity of the
human mind and body. Some writers (e.g. Spence 1982) have argued that
the therapist’s task is to help the patient to write the autobiography that
satisfies him or her by its coherence and the meaning that can be
discovered for the person whom the patient is at present. This view of
autobiography is clearly distinct from a view that emphasises historical
truth. In this context, what is important and therapeutic is that the story

16
 AIMS AND OUTCOMES

makes sense of a person’s memories. A therapist might be comfortable

with this role because it does not require much change in him. He is there
merely to supply help with the most problematic and apparently senseless
memories that a person presents.
Even by adding meaning therefore to the essential purpose, we may
still not be addressing the full scope of the therapeutic process which
always involves two people who are willing to affect each other and be
changed by the impact.

The therapist’s management of loss and damage

With some justification, Bowlby (e.g. 1973) and the attachment-based

therapists have taken separation and loss as the basis of their theoretical
approach. No doubt object relations theorists following Fairbairn (1952)
would agree that the premature loss of good or satisfying object
relationship is what leads to disturbance and psychic defence. Freud had
reached the view that absence is what leads to development: the first
thought is the absent breast. So loss has clearly a central position in
theoretical structures, and coping with the losses inherent in therapy
must require that both patient and therapist learn to accept that loss is
both inevitable and can be survived. During the process, there is bound
to be resistance from both patient and therapist to facing the painful
realities of loss.
Klein and the object relations school provide a view of the aim of
analytic work which focuses on damage and repair. The therapist is
damaged over and over in fact or in phantasy until both patient and
therapist are able to believe in survival. Both partners are guarantors to
the other that survival is possible. The therapist hopes that the reliability
that he or she provides will be internalised as a sense of goodness in the
self so that love and gratitude can prevail at least some of the time and the
testing can decrease along with fear and hate and envy. If the therapist’s
own defences against loss are shaky, he will need the patient to prove to
him that loss is temporary and tolerable. The concept of the two positions
– paranoid/schizoid and depressive – is a theory of moral development
because it implies moving from the unreal world of projection to a greater
awareness of the existence of another person. This always implies the
possibility of loss as well as concern about its accompanying potential
for guilt and repair. On the other hand, facing guilt and the reality of loss
is too painful a position to be held indefinitely by either patient or therapist.

17
 HOW MUCH IS ENOUGH?

Modern Kleinians tend to see value in the cyclical movement between

the depressive and paranoid/schizoid positions, with much creative
potential resting in the paranoid and schizoid defences. Steiner (1987) has
restated this aim in terms of helping the individual to be able to move
between these positions with the awareness that nothing lasts for ever.
Much will depend on whether the therapist is able to move between the
two positions sufficiently to see the patient as a separate whole, rather
than as a projection of her own insecurity and damage. If the therapist is
still having problems in dealing with loss, the patient becomes the means
of denying and objectifying the problem. Another way of stating this
view is in terms of what goes on inside the psyche. Kleinians talk in terms
of internal objects in order to be able to communicate more easily about
the two or more sides of an internal conflict. The dominating force in the
psyche may cease to be a persecutory and death-dealing avenger, but
may become capable of concern and of giving and receiving reparation
for the damage that it causes either in reality or in the imagination.
Meltzer points out (1967: 41) that the father enters the child’s
consciousness as a whole object just as much as the mother at the time of
the achievement of the depressive position. When there are two parents
who are allowed in the child’s mind to love each other, this provides a
model for creative and reparative potential to be recognised. Negotiating
the Oedipus complex becomes possible. In other words, the patient who
has been able to recognise the value of both his father and his mother will
be able to allow for his own creative sexual union. When this creativity
appears in what the therapist is told, it might well be a marker for the
readiness to end therapy. It is not so far from Freud, for whom the
achievement of full genital sexuality might be a criterion for ending.
Self psychologists following Kohut (1977) or Kernberg (e.g. 1974) would
look at the development of a sense of self through the use of the therapist
as self object. The therapeutic relationship could be used to echo or
amend the early use of the mother or significant other as part of the self
for development of a safer structure. Kohut saw the self as a superordinate
structure over and above the ego and the id, capable of a sense of
wholeness. This sense of self is developed through the use of another
person as a self object. Clearly the therapist may see himself as a self
object for the patient. He may try to help the patient to develop a firmer
sense of self, and may enjoy the need that is expressed in this relationship.
He may well use the patient as a self object, affirming his own sense of

18
 AIMS AND OUTCOMES

worth and making him feel safer. In this model, the therapy will be able to
end when both therapist and patient have achieved a greater degree of
self-sufficiency.
The models described so far are based on the structure of the psyche.
Change in these structures is brought about by the dialogue with the
therapist. What sort of change has taken place will be known primarily
through the therapist’s experience of the patient, derived from accounts
of love and work outside therapy and of course from the experience of
being with him or her. Some models, while still implying structural changes,
emphasise the parallel to the developmental processes of infancy and
childhood. Attachment-based therapies are looking at the blocks in the
way of attachment and will see the possibility of ending when,
paradoxically, there is a possibility of connection. Differences in theoretical
models mean that each therapist is bound to construct a different task for
the therapeutic relationship while remaining within the general boundaries
of a model.
Whatever the therapist’s purpose, he or she is likely to have to be
content with less than might be possible. Gradual failure is built into
psychoanalytic theory. The therapist, like the parents, inevitably fails to
give the patient all that he or she wants, but this failure should not be
catastrophic if it is tempered with the reliability of the setting, the therapist’s
presence and the steadiness of the technique that is used. Therapists
may be well aware of this process and allow movement towards the point
at which the patient can manage deprivation and disappointment alone.
Therapists are not always equally good at managing their own sense of
failure when the patient does not meet the demands of the theoretical
model espoused. In addition, the therapist may not be conscious of his or
her avoidance of deprivation or disappointment. As long as there is a next
session, there is hope of fulfilment. Searles’ paper (1965) on the patient as
Oedipal love object for the therapist is invaluable, because he is one of
the few writers to face the therapist’s need and desire for the patient (see
Chapter 3).

How much is enough?

The ideal in most models of therapy is that the patient decides how much
is enough. We all know that such a position begs many questions.
Therapists may not be omnipotent but they have great power for good or
ill over many of their patients. They may be waiting for some sort of
assurance that the work is well done – that the point of no return has been
reached, as Rickman described it (1950). In 1937 Freud raised the question

19
 HOW MUCH IS ENOUGH?

of what the therapist might think is sufficient in ‘Analysis terminable

and interminable’. Although this was, to some extent, Freud’s spiritual
testament, nevertheless it does not constitute the last word, and many
today would disagree with its central contention. Freud argued that
some elements of the psyche are appropriately susceptible to analysis
and given a good enough analysis and a good enough patient, the
outcome should be an improvement. For Freud, improvement was equated
with a reduction of neurotic symptoms. Freud’s project is essentially
rational and assumes that reason can and should be in control of instinct
and impulse. Achieving a reduction of symptoms would also imply greater
ego strength in the sense of the ability to perceive and use a shared
external reality. An improvement in the ability to share a cultural and
social reality might come about through the contact over time with a
therapist and would be an aim of many therapists.
Nevertheless, in Freud’s view, there is an irreducible something that
cannot be analysed. There will be areas that cannot be changed. Once
the therapy reaches this hard layer, it may as well stop. He thought that
the bedrock of the psyche, the point at which no more could be done for
a man or a woman, would be the impossibility of accepting femininity; in
other words, penis envy. More recent writers are less likely to accept
that there is any universal complex that cannot be resolved or changed,
and the outcome of therapy will depend on the existential problems and
situations encountered by the individual. The title of Freud’s paper
suggests that analyses will have in them both terminable and interminable
elements and that we can celebrate the necessary acceptance of both,
while being prepared to allow an ending that is never perfect or complete.
Perhaps ‘how much?’ is easier to answer if the work is the kind of
counselling that has specific goals related to solving problems in
everyday life. If the presenting problem is ‘Should I leave my partner?’
the work is finished if the decision is made and the step taken. If, however,
this presenting problem is seen as posing questions about the need for
others or the other as a sign of deficiencies in the sense of self or as a
question about gender identity or about paranoia versus reparation, the
ending may be much more difficult to recognise. Time-limited work sets
the ending from the beginning and enables the process of ending to be
extremely valuable, but it obviates the necessity and also the therapeutic
value of having to decide about when to end. Instead it demands that

20
 AIMS AND OUTCOMES

the patient and the therapist both have the courage to stick to the
contract and end when they have agreed to end (see Chapter 9).
In spite of all the pitfalls, the ending phase of therapy may bring great
rewards. In making the decision to end, especially when the theoretical
model gives no specific reason to end this month or this year, many of the
most difficult and delicate aspects of relating to another human being
may need to be negotiated. There will be experiments with leaving at the
end of each session, but the choice to leave voluntarily can still feel like a
very risky business. The patient will know what partings are like from past
experiences and also from the inevitable breaks in therapy for holidays or
illness. The final parting will be different if it is allowed to be final or at
least final as far as the two participants can tell.
Ending is inherently painful if it is fully experienced, but it can bring
strength and contentment when it is actually achieved. Much that has
belonged to previous partings and deaths can be remembered in order to
be set aside. This time a fair amount of sadness may be mixed with the
disappointment, and the feelings may be met with a less paranoid response.
All of this may involve the therapist, not only as a professional but also in
strong personal feelings for what is evoked from his or her own past and
also because of what this patient has come to mean. Both people will
emerge from the experience changed.

References

Bettelheim, B. (1983) Freud and Man’s Soul, London: Chatto & Windus.
Bowlby, J. (1973) Attachment and Loss, Harmondsworth: Penguin.
de Simone, G. (1997) Ending Analysis, London: Karnac.
Fairbairn, M. (1952) Psychoanalytic Studies of the Personality, London:
Routledge. (Reprinted 1992.)
Fordham, M. (1978) Technique in Jungian Analysis, London: Academic Press.
Freud, S. (1914) ‘Essay on narcissism’, SE 14: 67.
Freud, S. (1917) ‘General theory of the neuroses’, SE 17.
Freud, S. (1937) ‘Analysis terminable and interminable’, SE 23.
Kernberg, O. (1974) ‘Further contributions to the treatment of narcissistic
personalities’, International Journal of Psycho-analysis 55: 215–240.
Kohut, H. (1977) The Restoration of the Self, New York: International
Universities Press.
Lacan, J. (1977) Ecrits, London: Routledge.
Meltzer, D. (1967) The Psycho-Analytical Process, Perthshire, Scotland:
Clunie.
Rickmann, J. (1950) ‘On the criteria for the termination of analysis’,
International Journal of Psycho-analysis 31.

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 HOW MUCH IS ENOUGH?

Samuels, A. (1986) A Critical Dictionary of Jungian Analysis, London:

Routledge.
Searles, H. (1965) Collected Papers on Schizophrenia, London: Maresfield.
Spence, D. (1982) Narrative Truth and Historical Truth, New York: Norton.
Steiner, J. (1987) ‘The interplay between pathological organisations and the
paranoid schizoid and depressive positions’, International Journal of
Psycho-analysis 68: 69.

22
 2
HAPPY ENDINGS
The goal of resolving transference

Only the imagination can embrace the impossible: the

golden mountain, the fire breathing dragon, the happy
ending.
(Kate Atkinson, Human Croquet)

Imagine blindfolding someone and teaching him to make his way across a
room filled with tables and chairs. After several attempts, he might be able
to pick his way across the room without bumping into anything. If you
play a joke on him and remove the furniture, you can watch him pick his
way around obstacles that are no longer there. The theory of transference
is describing exactly this phenomenon. The patient picks his way around
obstacles that no longer exist in the present, but were there at one time in
the past or perhaps have been always imaginary.
The analytic theories of psychotherapy postulate, following Freud,
that counter-productive manoeuvres to avoid bumping into pain caused
by conflict are at the root of neurotic suffering. The way to change these
defensive manoeuvres is through reexperiencing with a therapist some of
the pain. This will allow a rearrangement of defences and a better way of
living with oneself and with others. When therapy is successful, it will be
possible to have a satisfactory ending. There are many different ways of
stating this basic assumption and humanistic therapies would not place
emphasis on defences but would emphasise even more the importance of
what happens in the present relationship with the therapist.
We therefore have a situation in which a relationship develops, more or
less intentionally, between patient and therapist. Depending on the
orientation of the therapist, there will be a greater or lesser degree of
mutuality, of interpreting and of restraint. Nevertheless, common to all

23
 HOW MUCH IS ENOUGH?

therapies is the highly significant and emotionally charged relationship

that is likely to develop and in some models is encouraged. The problem
is then, how and why should such a relationship end and how satisfactory
can the ending be? There are two possibilities for models that work with
feelings and images transferred from the past on to present experience.
Either the old images can be completely dissolved, or a better relationship
with the present can be achieved while still preserving some of the
emotions and images from the past.
Ernest Gellner, writing a critique of psychoanalytic theory and technique,
concludes:

Modern humans, unlike their peasant ancestors are drilled to expect

an astonishingly high standard of logical order. Human work
requires it; human education prepares them for it. But when in
distress they seek their shepherd, they are instructed to abandon
all semantic restraint, and display not only their intimate and
shameful secrets, but also the total and deplorable chaos of their
mental content, which otherwise they must strive to hide. They
must ‘free associate’; then it would seem they develop feelings
for the person in front of whom they have so abased themselves.
The intensity of the feeling so generated appears to confirm the
validity both of the theoretical and the specific insights attained
in the course of the therapeutic sessions, thus producing that
characteristic blend of strong feeling and sense of cognitive and
liberating illumination which defines mystical experience.
(In Dryden and Feltham 1992: 52)

If Gellner were right, the therapeutic situation itself might be generating

all the effects that we observe in therapy. Frosh, in his response to Gellner
(Dryden and Feltham 1992: 53), points out that we can never prove either
case. Most therapists would not be unhappy to agree that the therapeutic
situation generates powerful emotions particularly towards the therapist.
In recent years the emphasis has shifted from the past and the recovery of
memories to a much greater reliance on change happening in and through
the present relationship with the therapist. The past is seen as
corroboration of the truths being discovered in the present.
Therapy undoubtedly generates the specific form of the emotions
produced and is responsible for the way in which memories appear and
the time at which they appear. Yet this provides an opportunity to engineer

24
 THE GOAL OF RESOLVING TRANSFERENCE

a different outcome to situations that have been experienced in essence

before. It is both a magnificent opportunity and the source of the greatest
dangers in psychotherapy. The question that this chapter will address is
how the intense relationship created in therapy can be brought to an end,
as to do so deliberately, while inevitable in a professional contract, is
contrary to the natural order in any other sort of relationship.
The therapeutic relationship is professional and therefore it is limited.
In most psychotherapy there is the payment of a fee. This emphasises the
framework of professionalism which keeps limits visible, although some
patients welcome the chance to use it as a defence against strong feelings.
Psychoanalysts and psychoanalytic psychotherapists tend to address
their patients by the title of Mr, Mrs, etc. and to call them patients rather
than clients. This formality does not prevent powerful and passionate
emotions from arising, but it does perhaps serve to remind both parties to
the work that this is a finite relationship with a limit to it somewhere in time
and always a limit to the availability of the therapist. Other formal reminders
of limitation are the ends of sessions and the preparations for holidays
and breaks when the therapist takes care to make clear that he or she is
going away and that although there might be concern for the patient, it
will not stop the therapist from leading his or her own life.
There are therefore some inhibitors to prevent the therapeutic
relationship from ever developing as an ordinary human relationship.
This is just as well, because ordinary human relationships do not have in-
built obsolescence or time limits. Friendships may come to a natural end
when the common task or connection comes to an end. School or college
friends may or may not be kept into later life, and friends made at work
may prove not to be as desirable in other contexts. These sorts of limits
may arise in therapy too. The task, if it is specific enough, will come to an
end. Patients may simply find that they have completed the task sufficiently
well, or that they have become bored with a predictable therapist.
Therapists might prefer to make efforts, as Lacan suggested, always to be
surprising, never to say what is already known, but nevertheless,
eventually it may be no bad thing if the therapy is in some sense outgrown,
or outworn.
If there is a passionate attachment, a falling in love during the therapy,
that may also give a natural shape. Falling in love is much more likely to be
followed by disillusionment than is a more moderate valuation of the
therapist. Freud wrote his paper ‘On transference love’ in 1914 to describe
the kind of falling in love that happens in therapy. The patient shows us
what he or she is like when loving or trying to love and the therapist must

25
 HOW MUCH IS ENOUGH?

accept these feelings without reciprocating them overtly. Since the

therapist will not reciprocate, we might expect that ending will come out of
despair. The therapist will never respond as the patient wishes and
therefore he or she will give up and go elsewhere. This is the Oedipal
theory of ending therapy. Just as the child must relinquish the parent
whom he can never marry, the patient must relinquish the therapist and
move on to other relationships outside. In long-term therapy this may be
precisely what happens. On the other hand, there are cases where the
patient accepts a kind of stasis with relief, taking just as much as the
therapist will give and using it as an excuse not to go any further with
anyone else. Some patients never get anywhere near falling in love or
loving and leave before there is any risk of that. Some manage to stay
without allowing any change and the problem becomes one of finding a
way to enable them to end. In short-term or time-limited work, the
responsible therapist makes no effort to draw feeling towards himself and
the task will not include analysing at first hand the way the patient behaves
in intimate relationships. In any case, most patients defend themselves
from passionate feelings:

Ms E is a woman aged 40 who has been seeing a

psychoanalytic psychotherapist for some years. She came
because her partner seemed very unstable and she was
finding it difficult to endure the uncertainty of his next mood
or his actions, particularly when he was high. As she talked,
she surrounded herself in a flat depression that was difficult
to penetrate. She was also very unhappy in her work as a
computer operator where her degree was not being used.
She had a painfully close connection to her mother but was
never able to look her in the eye or to talk to her directly
about anything of importance. Everything about her spoke of
limitations, either self-imposed or imposed by external
circumstances.
Not surprisingly, the therapy became similarly limited. There
was much talk about her relationship with her mother who
lived alone and exerted a great pull from her cottage in a
northern village. Every few weeks Ms E had to visit her mother
but was never willing or able to do more than sit in miserable
silence, longing to escape. Her father had left when Ms E
was 3 years old and her mother had never remarried. Ms E
was aware that she was all her mother had and that she

26
 THE GOAL OF RESOLVING TRANSFERENCE

should fill her father’s place. This left her with a gender
confusion and a refusal as the only alternative to inevitable
failure in the role that she had been assigned.
In the therapy she would begin by talking about what had
happened during the week but would soon wind down and sit
in the miserable and awkward silence that showed the
therapist how painful she found it to be with her mother without
being able to provide what her mother wanted. The therapist
was able to clarify some of this for both of them and Ms E
was able to make herself comfortable enough to continue to
attend. She was able to gain some comfort over the difficulties
with her partner and with the head of the department where
she worked. These men, along with the therapist, took on
the character of depriving fathers and were punished by her
accordingly by being resented and resisted through a passive
form of aggression which they did not understand. At the
same time, huge demands were made of them that they should
understand what she wanted and make clear that they loved
her without her having to ask. She always said that she would
not ask her father for anything. She had met him once and he
had seemed uninterested in her and she said that now he
would have to come and find her before there could be any
further contact.
The therapist found himself in an impasse. There had been
some improvement in the initial flat depression, but no real
change in the relationships described. After four years Ms E
said in the last session before the therapist’s summer holiday
that she thought she had better stop and would probably not
return after the break. She would write and say what she had
decided. The therapist was completely surprised by this and
found himself feeling angry. ‘You mean that you intend to just
stop, just like that, by writing a letter!’ The patient looked
surprised: ‘Well, I don’t like goodbyes.’ The therapist thought
about this and said he could imagine that sudden endings
were the only kind which Ms E knew about but that perhaps
a different sort of ending could be considered this time. Ms E
went away saying that she would think about it.
The therapist was left with uncomfortable feelings of having
resisted the patient’s wish to end rather than working with it,
and of having failed in the work because the patient wished to

27
 HOW MUCH IS ENOUGH?

re-enact the ending with her father rather than working towards
an ending in a more considered way. If the therapy ended
there, the therapist felt that he would have to regard it as a
failure.

This case illustrates the way in which an ending can be determined by the
pattern of previous endings. It also shows the difficulty for the therapist
in dealing with an ending when he is still playing a role required by the
patient within the relationship. His response to the possibility of ending
is to delay it, and this might well be what is needed from a therapist: the
sudden ending of a therapy that has reached an impasse may not be the
best possible outcome. The therapist needs to recognise the extent to
which he is playing the required role of the mother who is holding on to
her daughter, or the complementary role of the child whose father will not
be close to her, hoping that the relationship will improve and give her
more of her heart’s desire. At the same time, he has to do what is needed
as a therapist in the present.
There are two major schools of thought about such a situation within
the analytic therapies. On the one hand, the therapist is not to play the
role required by this transference but might comment on it. The therapist
in this model would not show any wish or desire to keep the patient but
would merely point out the contamination of the present by the past. This
can be done either by saying to the patient: ‘You are treating me as if I
were a figure from your past’ or by encouraging exploration of why that
particular attitude might be uppermost. The latter approach is more likely
to enable further elaboration and understanding because the patient is
less likely to feel criticised for being a child or childish. The purpose for
therapists of these schools would be to relate past memories to the present
situation in the hope that the present could be freed from the compulsion
to repeat. This is the approach of what might be called the conflict school.
Deficit models would be more likely to regard making up for previous
deprivation as the priority. Such a therapist might emphasise the need for
more therapy as the best thing for the patient in this situation. Either of
these approaches could be combined with an honest assessment of the
therapist’s own narcissistic involvement in achieving what would feel like
a ‘good ending’.
Most models of therapy assume that the past influences the present,
and that pain and suffering arise from memories. Because of this
fundamental problem for humanity we develop defences, and therefore

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 THE GOAL OF RESOLVING TRANSFERENCE

contentment or equanimity depend on the balance of pain against defence

for any individual. Most therapists are delving into the stories of the past
that are brought to them and are interweaving their own thread with all the
others. Memories will be produced or suggested. They will be lived through
with the therapist and assigned to places where they can either be
forgotten or allowed to rest for the time being. The conflict school might
encourage the patient to elaborate on the desire to end, whereas the
deficit school might be considering either what is missing in the therapy
that makes the patient wish to end, or might take the view that deficits
have been repaired sufficiently to allow the person to function
independently and leave.
The Lacanian critique of both these models might point out that the
therapist is working within a required transference relationship which the
Lacanian sees as imaginary in the sense that the patient is imagining the
therapist through a blindfold of constructed meaning. He is not free to
speak for himself but is speaking a language especially developed for
speaking to the other that he imagines the therapist to be. We hear about
the patient who sees a Jungian therapist and begins to dream in a way
that particularly appeals to Jungian methods of working with dreams, and
the same might apply to Freudian free association or Rogerian
genuineness. This argument leads to a model of technique in which the
transference that evolves must continually be dissolved by the therapist
who tries to see where it fails or where it becomes false and sterile.
Although there are criteria for readiness to end such as those discussed
in Chapter 1, they provide a check-list only, and each therapist will be
relying on his own experience of the patient as well as a theoretical model.
An ending seems appropriate to many therapists when the patient has
become sufficiently like the therapist for the remaining differences to be
comfortable. In other words, patient and therapist both perceive the same
obstacles in the room. Thus, Ms E had remained different enough to
cause the therapist to feel concern that her functioning was not healthy.
Therapists who use both conflict and deficit models are looking for
something that they can recognise as healthy functioning. Although this
may often lie behind whatever are said to be the criteria, therapists
obviously need to have a rationale that demonstrates both that they do
have criteria and that they are not merely seeking to turn out clones of
themselves. If the Lacanian critique is borne in mind, the therapist will
always remember the dangers of his own subjectivity and will not court a
dependent transference, but will, on the contrary, seek to cut through it to
what is still hidden in the unconscious.

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 HOW MUCH IS ENOUGH?

The therapist’s claim to authority

An important question often asked by the general public and the media is:
Why does anyone need a therapist? What can a therapist do that is not
done better by a good friend or partner? Two answers present themselves.
One is that not everyone has a good enough friend. Many of those who
do may not present themselves for therapy because by definition they are
not too bad at relationships. On the other hand, therapists have special
skills for tracking down what is repressed or forgotten. They do this by
listening to what is not said and to what might lie in the gaps, distortions
and vicissitudes of what is said and remembered. They are always looking
at the residues of the past in order to understand the present.
The therapist is not a perfectly tuned instrument and is affected by his
own past and present. If there is a process by which old patterns of
thinking and feeling are revitalised to a point where they can interfere
with the present, then clearly we would be asking a great deal if we expected
therapists to be free of what we hypothesise to be a universal process.
The case of Ms E shows that the therapist is not free. The patient, as
Searles has pointed out (1965), is an Oedipal love object for the therapist.
The patient is a narcissistic object and an object of desire for the therapist,
providing scope for the wish to make a difference to someone else and a
difficulty to overcome. If the patient is forced to experience his past,
repeated in different forms in the present, so is the therapist. Therapists
are likely to be seeking their own satisfaction through relationships of
this particular one-sided sort. Why else are they therapists?
In spite of the therapist’s personal involvement, she does have expertise.
Her expertise is in finding and recognising dysfunctional patterns that
have been obscured by forgetting. Freud made use of the term
nachtraglichkeit to convey the idea of deferred action. The child’s failures
come back to haunt the adult with ghostly imperatives and prohibitions
which may no longer have a useful purpose. It is through action deferred
to the present, but now dysfunctional, that the therapist can recognise
what has once been an obstacle even though there is no obstacle there
now. One way of describing what has happened when a pattern survives
as a template but without its original reason is to use the concept of
repression. We know about this also through dreams or through symptoms
where the dammed-up memories resurface. This is the way of the neurotic.
When memories do not have this form of release, there may be a total
cutting off from availability to consciousness as we find in psychosis.

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 THE GOAL OF RESOLVING TRANSFERENCE

Repression provides a way of preventing oneself from having to be

aware of the full effect of trauma such as loss or forbidden desire at the
time that it might be felt. Actions may occur which are in effect the deferred
results of the original trauma. Because of this, the repression may cause
more problems than it is worth, although, like all defences, it is undoubtedly
worth something. There are various possible ways of looking at the project
of analytic work in this context. We make connections and perhaps some
of the hidden patterns or origins of trauma come to light and are
remembered. The trouble is of course that any remembering is bound to
be a process of revising and altering the original event or events. Each
time a memory is activated it will be different. The concept of working
through implies that memories which have been forbidden for whatever
reason will resurface many times in different forms and will be seeking
each time a tolerable context in which to embed themselves so that they
can be forgotten rather than repressed. Inevitably, the process of
remembering will involve some pain and the patient will wish to avoid
pain by cutting off the therapy that is felt to cause it.
A newly qualified therapist when working with a patient who talked
about having been sexually abused as an adolescent asked in supervision
whether it is necessary that the patient should recount the details of
‘what happened’. There was no sign of any wish or intention to do so,
and the therapist raised doubts about whether the work could safely be
ended because there had been no reference to any detail. This is a difficult
question to answer without knowing whether the patient was repressing
the memories or had access to them but was choosing not to tell the
therapist. If the latter were the case, there might be some point in working
to understand the motivation for hiding this from the therapist. Perhaps
there is an argument for putting the dilemma to the patient: Is it a problem
for you that you have not told me anything more about it, or are you
satisfied to leave things as they are?
Adam Phillips sees Freud’s unconscious as requiring a continuing
process rather than a dramatic purging with an obvious ending. Memories
may be allowed to surface from the unconscious:

Freud is close here to a picture of psychic life that lives in a continual

present tense, nothing is forgotten, nothing is deferred, there is
just intermittent redescription.
(Phillips 1994: 35)

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 HOW MUCH IS ENOUGH?

Such a view of the process of therapy would not be much help in deciding
when it might be right to end, as there could always be further scope to
modify and improve the redescription. Yet patients and therapists obviously
do come to a decision, often jointly and amicably, that it is now a good
enough time to end. One of the main forces that enable this to happen
may be the ability to give up the infantile imperatives for perfection and
the therapist must be able to do this when the patient is ready to do so.
The therapy may not be completed, but may be enough for now. In other
words, the repetition of the redescriptive process can reach a point where
it is tolerable and where it allows for desire and abstention.
Since Freud’s model of neurosis implies that what goes wrong and
causes psychic pain is a disease of the memory, any device that speeds
up the recovery of memories is desirable. Specifying an ending date does
seem to speed up the process of therapy in some cases. In this model, a
rapid processing of relevant memories would be sufficient if it led to
putting together a coherent story of the past as it is now being relived in
the present. Once this has been done, we could expect the ego to be
strengthened and the patient to be able to think more clearly and make
choices. The therapist knows the extent to which this has happened from
the reports of what goes on in the real world and, of course, much more
reliably, from a difference in the kind of treatment received via the
transference. Old dysfunctional patterns of relating will no longer be
predominant. Ms E had not managed to remember more than she already
knew. Her therapist had not managed to become a large enough force to
break through the resistance, and she was able to persist in her current
patterns which were held in place by her own version of the past. What
changed for her was something external which worked in conjunction
with the therapy.

Ms E wrote to the therapist during the break saying that she

had decided to return to therapy because she had found a
lump in her breast and had to go and have a biopsy. The fear
that this induced was insupportable and she realised that
she could not do without the therapy. She never said that she
could not do without the therapist. The therapist felt very
uncomfortable with this reason but was glad that there was
to be another chance. The biopsy found no malignancy and
the therapy became the place where there was a chance to
discover what was beneath the surface. The therapist was
able to acknowledge that he had felt disappointed at the

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 THE GOAL OF RESOLVING TRANSFERENCE

ending because he wanted something better for Ms E and

also for himself. This enabled both of them to consider how
they had needed an external third element to enable thinking
to take place.

Ms E was not only suffering from patterns from the past, she was also
suffering from alienation of her own desire. She had to find an external
event to lead her back to the therapist. She could not find the need and
the wish in herself, but the work that she had done enabled her to make
use of an external event. Once back in therapy she moved towards greater
recognition of what she had been denying: the importance of the person
who was there for short periods but who would take himself off for holidays
and was not under her control.
In this view of problems and cure, the problem is said to be caused by
a conflict between the patient’s desires and the dictates of the part of the
psyche which seeks to control emotions, particularly the emotions
connected with the desire to be loved and to love, whatever that means to
the individual at the time. Because desire is perceived as a source of pain
it is repressed, and a symptom or neurotic problem will arise. The relation
to the therapist will be distorted by this attempt to avoid pain but the
distortion shows the place where the wound is. The avoidance causes
many small endings. Some patients stop talking before the end of a session.
Some try always to end a session before the therapist does. Some patients
will exercise control, not only at the end of the session but also by ending
their therapy abruptly.

The therapist’s subjectivity

For some time, Freud continued his enquiries into the nature of therapy
without looking too closely at the therapist as a subject, not just a doctor.
Other forms of therapy may not accept the hypothesis that the sources of
symptoms are unconscious, but most will accept that something is needed
from the therapist that is more than just the administration of a technique.
Freud saw that the doctor makes therapy possible. The difficulty is that
the doctor, however well analysed he might be, still has his own resistance,
his own repression. In the transference relationship, the therapist is working
with a blindfold over his own eyes so that although he can hear the words
of the patient, he cannot see clearly the person from whom they are
coming; they are filtered through his own net. It therefore follows that in
any therapy, the therapist must be working on the repressions that defend

33
 HOW MUCH IS ENOUGH?

him from the patient. He must suffer the illness but be able to make some
headway towards recovery.

Not letting go: the therapist’s use of power

Within the therapeutic relationship, transferred feelings and desires give

the therapist power which can be used or misused. Oedipal theory suggests
that the patient will need to work out some of his difficulties with the
problems of the way the parents used their power. The power of the
mother and father may be handed to the therapist in the hope that he can
use it well. Even when the therapist’s power is great, the patient’s own
defences may be greater, but a resolution as negotiation or redistribution
may be essential.

When Sandor Ferenczi persuaded Freud to take him into

analysis, he had only three periods lasting a matter of weeks
in each case, between 1914 and 1916. Ferenczi had been
called up to serve in the army and was able to come for
sessions only when he was on leave. For this reason, he had
several periods of intensive therapy; at one time he attended
for three hours per day. There was already a powerful emotional
link between them and on Ferenczi’s side, a strong positive
feeling which was clearly recognised as feeling for a father.
When Ferenczi had to return to the army on 9 October
1916, that analysis was declared to be finished, but the
struggle that Ferenczi had in accepting the ending illustrates
well the difficulty of stopping when there is a powerful
transference in full swing. He continued to write letters to
Freud so we have an account of his reactions and feelings on
stopping and Freud’s responses in his letters, usefully
summarised in a paper by Judith Dupont (1994). Freud was
clearly aware that the analysis had not reached resolution:

You know that I consider as ‘finished’ your attempted

analysis; finished and not terminated; interrupted by
unfavourable circumstances.
(Dupont 1994: 309)

Freud then goes on to comment on a love affair of Ferenczi

with a woman called Gizella which Freud thought could not
possibly work out well. Clearly, Ferenczi was faced with a

34
 THE GOAL OF RESOLVING TRANSFERENCE

need to work out for himself an ending to the love affair with
Freud as his analyst/father/mother. Ferenczi felt the whole
gamut of anger and longing and was aware of the transferential
element:

I must admit that I have got nowhere with my self

analysis. It might be that I actually muddled up the
situation . . . but I must also let work in me untroubled
the hostile tendencies towards the father that certainly
are existing in me. I am . . . fully aware of the
transferential character of my reaction to your letter
and consciously I am even grateful to you.
(Dupont 1994: 310)

He had asked Freud for just one more session and accused
him of trickery in being against the relationship with Gizella.
Freud’s lack of response to both love affairs was a source of
great pain and struggle, but Ferenczi had the advantage of
analytic understanding and continued a sort of self-analysis.
By Christmas 1916 he was able to write more hopefully:

Let this sheet of paper be the proof that I have again

attained a degree of normality . . . I hope that from now
on I will be content with less than formerly. I don’t want
to promise too much . . . this will not succeed without
relapse . . . I am happy to feel grateful once more.
(Dupont 1994: 310)

This last paragraph expresses well the degree of resolution of transference

feelings that we might hope for at the end of a brief but powerful piece of
work. Ferenczi achieved it by means of his self-analysis and the passage
of time. The ability to feel that there is a possibility of being content with
something ‘less than formerly’ might well be another aspect of readiness
for termination as well as a realistic assessment of the possibility of feeling
worse again. Therapists might regard these as criteria for readiness to
end, although there will always be some patients who have to achieve
this position on their own once the therapy is over. Gratitude too, as
Ferenczi expresses it, if it is genuine and heartfelt is, as Klein pointed out,
a most valuable experience, as it mitigates against excessive envy and

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 HOW MUCH IS ENOUGH?

destructiveness and allows that the therapist may continue to exist

independently, and may be at least partly good.
Ferenczi was right in expecting further difficulties. Neither Freud nor he
was ready to end. Dupont emphasises that he continued to look for a
strong father figure for the rest of his life. He was one of eight children
and his own father had died when he was 15. His mother was a strong
woman but had difficulty in giving enough time to each of her children.
Freud took on the role of father and presumably mother, in some respects,
and continued to try to influence Ferenczi, particularly in his work and
research. There was much pain in the relationship for both of them.
Ferenczi recognised his dependence and his desire for a father, but
recognition did not remove the need. The struggle for independence or
freedom from this aspect of transference, particularly for Freud, continued
until his death in 1933. He had at least acquired the ability to analyse
himself and to put his feelings into words, an important benefit, but the
story shows us how persistent some aspects of transference can be, and
should also remind us that external circumstances that shorten or lengthen
therapeutic work must be taken into account.
In the story of Ferenczi, we can see in his urgent and continuing need
to have Freud’s approval for all that he did, his problem with power and
his need for a father figure to be behind him, making him feel stronger than
he otherwise could. Most of the models of psychotherapy involve a
powerful father or mother with disciples who follow or rebel. This seems
to be a universal phenomenon and it is hardly surprising that therapists
make their patients go through a process of compliance or resistance.
One of the requirements of the Oedipal father is compliance. You must be
like me or you must do as I say in order not to be a rival or a threat. This
pattern of transference compliance will vary according to the sex of the
therapist and whether the patient is a man or a woman, and it may impose
a requirement for health or illness, staying or leaving.
In classical Oedipal theory, the child is released only because he submits
to the father’s rule and goes away first into the busyness of childhood in
the latency period and then to find a partner. The girl must give up her
love and desire for her mother and accept a man as a substitute for her.
The motives for this movement are partly resignation as a response to
being deprived of the parents who, in ideal circumstances, have each
other, and partly out of fear of punishment: castration or abandonment.

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 THE GOAL OF RESOLVING TRANSFERENCE

This whole process can be seen in the therapeutic situation and of course,
for analytic therapies, it is the validity of this analogy that allows
transference work to be done. A requirement of the therapist is that he
should be totally aware of his role and able to step aside from it so that he
does not act it out but merely comments on it. As Lacan pointed out,
however, both partners in the analytic couple have an unconscious and
both transfer feelings from the past. Can we expect always to be aware? If
the complex is, as Freud claimed, connected with the most powerful fears
of mutilation and abandonment, how can we expect the therapist to be
immune?
If the fear of losing one’s own power is a motive for leaving therapy
precipitously, the fear of losing the therapist and his loving approval will
work in the opposite direction. At some time during any prolonged therapy,
the fear of loss and its equivalents in death and dying will be highly likely
to emerge. If the work is being done within the transference, the loss that
is feared will be the loss of the therapist or the patient in the place of the
needed parent. There is no short cut and no way in which loss can be
made painless if loving attachment is allowed at all. For some schools of
thought, these feelings may not be seen to be connected with infancy,
but whether they are seen to be so or not, they will be part of the
constellation that surrounds ending. These are the sorts of emotions that
are most likely to be hidden or denied:

Only when the resistance is at its height can the therapist, working
in common with his patient, discover the repressed instinctual
impulses which are feeding the resistance . . . the doctor has nothing
else to do than to wait and let things take their course, a course
which cannot be avoided or always hastened.
(Freud 1923: 155)

The difficulty of letting go

The greatest difficulty in therapeutic work arises from hidden anxieties

about loss. These anxieties may be equally strong for both patient and
therapist. Within the therapeutic relationship the therapist concentrates
on finding out what causes the most resistance and this shows where the
patient’s wounds are. If he looks at his own resistance he may discover
more of his own. Ira Miller (1965) discusses the anxiety over separation
brought about by any thoughts of ending therapy even when there is an

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 HOW MUCH IS ENOUGH?

agreement to end. He points out that this phase will activate the deeply
buried memory of infantile omnipotence when the child tried to hold his
parents and prevent them from leaving him by the magic of will-power. At
the same time, Miller’s patient tried desperately to hold on to the therapist
by refusing to give him all the material that he needed. The attempt to
tantalise with the possibility that there is more to uncover is another way
in which the patient in the grip of the transference resists an ending. The
patient demonstrated his need to withhold good things from others
through the symptom of ejaculatio retardata. Holding back from the
climax will be a problem in external relationships and may be susceptible
to change in the ending phase, because ending the therapy implies
allowing the climax and discovering whether it is equivalent to a loss of
one’s own good things to the other or whether there is a renewable source
that the individual keeps and develops after the end. The whole ending
process involves questions about who has the power and whether or not
it can be given up or shared.
Much of what has been said already implies the difficulty of letting go
for both patient and therapist. Transferred feelings of desire for the one
who can repair you or can allow you to repair him hold both patient and
therapist in thrall. The therapeutic couple often find that their neurotic
needs fit together like a happy marriage. But like most marriages, one
partner, hopefully the therapist, is able eventually to move on. The neurotic
pattern ceases to be a perfect fit, but there is a possibility for change. In
some cases however, an impasse is reached. It may be a contented sort of
impasse in which both parties enjoy the therapy and not much harm is
done, except that the patient is missing out on other places to put his
libidinal attachment.
Patients have many ways of prolonging therapy and other therapists
and analysts have written about the technical difficulties of resistance;
for example, the silent patient (Coltart 1993), or the patient who acts out
and splits himself so that only acceptable parts of himself are brought to
the therapy. The therapist’s task is always to try to catch out the
unconscious self-revelation that will enable the status quo to be shaken
a little. The dangers of shaking the tree are of course obvious, in that a
patient may be precipitated into a psychotic breakdown or suicide if the
tree is shaken too hard. This is why the therapeutic relationship is still
important and the old-fashioned values of containment and empathy are
not to be despised.

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 THE GOAL OF RESOLVING TRANSFERENCE

Object constancy

What makes it safe enough for a patient to end? Casement (1985) writes of
an object relations view that the therapist constructs a container. The
theory of object constancy is another way of looking at the therapist’s
ability to make ending possible. All therapists emphasise the extent of
their availability in the vertical sense of the depth of the contact that is
possible in the moment and in the horizontal over the passage of time.
They are continually modelling tolerance of separation even though we
know that, at times, waiting for the next session is difficult for the therapist
if there is anxiety that the patient might not come or, to take one of the
worst examples, might have killed himself. Interpretations or interventions
may make it apparent that the therapist thinks that separation is not such
a terrible thing.

Dr F is a doctor who has had a very successful academic

career and is working her way up the career ladder. She has
had a series of passionate sexual relationships with men but
the man always turns angry and abusive and leaves her, or
drives her to leave him. Recently she has bought her own flat
and has not had a man living with her. In one session she
says:
‘I have been in on my own for three nights running. In one
way it’s a relief to have some peace and quiet, but then I get
into a panic that no one will ever telephone me again and I
have to ring someone up.’
The therapist has many choices of response and can of
course stay silent here, but thinks this is an important point
and so makes an intervention:
‘Yes, I know that silence or absence means abandonment
to you, and it’s difficult to wait and trust that a person might
be still there when you look again.’

Dr F can begin to hold on to a sense of sufficiency which could be

described as object constancy or as the introjection of a good object
which is not lost in silence or absence. Hartmann invented the term ‘object
constancy’ in 1952 using Piaget’s concept of the need to be able to develop
a mental representation of an object in its absence. Hartmann added to
the cognitive aspect the need to be able to keep the object as loving.
Some of the most difficult therapies centre around the inability of a patient

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 HOW MUCH IS ENOUGH?

to keep the therapist and his or her words good enough to be useful again
the next time. Everyone is familiar with the person who comes back to a
session and literally or metaphorically turns to face the wall. The therapist
has become hated and bad as the absent object.
The therapist may work with the difficulty of returning to the next
session in two ways. She may merely observe the non-verbal effects of
habituation and the wordless experience that the therapist remains and is
not greatly changed either by the absence itself or by the attacks that
have been launched against her by the patient either consciously or
unconsciously. In addition it is possible to make interventions that focus
on what happens to the image of the absent object and how it is attacked.
The therapist who is there to speak has survived the attack and is available
to be tested in reality against the damaged therapist that the patient
brought with him and from whom he turned away.
Both during the session, through the interweaving of silence and words,
rapport and distance, the therapist and patient play the fort-da game, or
peekaboo, or whatever we call the learning game that all babies need to
play, to prove to themselves that the object can disappear from sight
without disappearing from the mind. Akhtar et al. (1994) point out that
object constancy is closely related to self constancy. After summarising
the relevance of the developmental concepts of Mahler (1968) and
Winnicott (1965) to understanding how children come to be able to be
independent and to survive absence, they conclude that adult
psychopathology in such areas as paranoia and malignant erotic
transference are connected to a failure in self and object constancy:

In sum, lack of object constancy impairs the capacities to mourn,

tolerate ambivalence and maintain optimal distance. Lacking inner
cohesion, such individuals tend to develop compensatory
structures leading to paranoia, erotomania, and inconsolable
nostalgia. These dynamic and structural configurations have
considerable bearing upon the treatment of such individuals.
(Akhtar et al. 1994: 449)

Because the therapeutic relationship can embody both therapeutic and

developmental processes, there is a possibility that therapy will enable an
individual to form more stable self and object representations which will
enable the ending process of therapy itself to take place.

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 THE GOAL OF RESOLVING TRANSFERENCE

Ending by achieving the symbolic

For some therapists, the therapy has been successful if the patient is able
to speak his feelings and thoughts to another, whether the other is a part
of himself or whether it is the therapist standing in for other possible
social relationships. This is a considerable achievement but is only ever
partial. The patient can voice his or her reasons for wanting to leave and
this ability and willingness to articulate one’s thoughts is, of course, one
of the criteria for readiness to leave. Words are always addressed to the
other whether internal or external and therefore this view of analytic work
always implies recognising who is being addressed at any time. When
words can be used to communicate, rather than to damage or to confuse,
the patient has some hope of being able to process his or her own needs,
feelings and desires. If this is achieved, transference, or the imaginary
relationship, has decreased. Instead, the needs and demands can be part
of a dialogue both internal and with the other in which there are choices.
There is, however, a difficulty. Language is all we have, but in the post-
Lacanian world we cannot avoid recognising the inbuilt inadequacy of
language. Roger Kennedy writes: ‘the unconscious, thanks to language,
can speak about the lacking object which shines forth with its very
absence’ (Kennedy 1986: 180).
Words stand for something which is not the word itself. This implies
that language inevitably introduces us into the state of lack or
incompleteness that is our lot. Caliban did not thank Prospero for teaching
him to speak:

You taught me language; and my profit on’t

Is, I know how to curse.
(The Tempest I, ii)

There is no guarantee of gratitude from patients either. Lacan’s view of

language is that it inevitably brings us into the realm of castration, where
language hints at what is not known through its gaps and inadequacies.
For Lacan, the unconscious ‘strives to express what is forbidden to the
speaking subject – jouissance and death’ (Kennedy 1986: 186). Language
in fact is the province of the ego which seeks to ward off the desires of the
unconscious and is doomed to remain in an imaginary world. For Lacan,
analysis is about the tension between the possibility of some awareness
of this hopeless situation and our ability to become a speaking subject
who is part of a social order.

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Since Lacan terminated his own school of psychoanalysis before his

followers were willing to end and without their consent, it is interesting to
relate his view of the human subject to the possibility of ending therapeutic
work. Achieving the symbolic level by acquiring a language is like
achieving a pass in the Ecole Freudienne. It is an initiation but it does not
solve the difficulties of being human in any way. The individual has to
give up expecting that the analyst or the therapist knows everything and
be willing to engage in a dialogue with the other even while knowing that
talking can never enable us to reach the truth. Nevertheless, it does achieve
something. The French verb causer is both to cause and to talk, and the
Cause Freudienne which is the organisation that continues to teach and
debate Lacanian ideas is therefore carrying on its work in the irony of
knowing that the task is impossible.
Language will therefore enable us to try to reach each other but will
inevitably frustrate. One possible effect of speech is to allow the subject
to define him- or herself: I am this or that sort of person. At the same time
it forces us to accept an awareness of human limitations. The other can
never know all, whether the other is part of me or you. Desire is infinite
and language is all too finite. Ending therapy states the limits of human
relationship but it also leaves the possibility of being a little closer to the
truth in the future. The habit of talking need not be lost.

References

Akhtar, S., Kramer, S. and Parens, H. (1994) ‘The internal mother: conceptual
and technical aspects of object constancy’, International Journal of Psycho-
analysis 78: 1046.
Casement, P. (1985) On Learning from the Patient, London: Tavistock.
Coltart, N. (1993) Slouching towards Bethlehem, London: Free Association Books.
Dryden, W. and Feltham, C. (eds) (1992) Psychotherapy and its Discontents,
Buckingham: Open University Press.
Dupont, J. (1994) ‘Freud’s analysis of Ferenczi’, International Journal of Psycho-
analysis 75 (2).
Freud, S. (1914) ‘Remembering, repeating and working through’, SE 12.
Freud, S. (1915) ‘Repression’, SE 14.
Freud, S. (1917) ‘General theory of the neuroses’, SE 17.
Freud, S. (1923) ‘The ego and the id’, SE 19.
Freud, S. (1937) ‘Analysis terminable and interminable’, SE 23.
Hartmann, H. (1952) Ego Psychology and the Problems of Adaptation, London:
Hogarth Press.

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 THE GOAL OF RESOLVING TRANSFERENCE

Kennedy, R. (1986) The Works of Jacques Lacan, London: Free Association

Books.
Mahler, M. (1968) On Human Symbiosis and the Vicissitudes of Individuation,
Vol. 1, New York: International Universities Press.
Miller, I. (1965) ‘On the return of symptoms in the terminal phase of
psychoanalysis’, International Journal of Psycho-analysis 61 (4).
Phillips, A. (1994) On Flirtation, London: Faber and Faber.
Sandler, J., Dare, C. and Holder, A. (1992) The Patient and the Analyst, London:
Karnac.
Searles, H. (1965) Collected Papers on Schizophrenia, London: Maresfield.
Winnicott, D.W. (1965) The Maturational Processes and the Facilitating
Environment, London: Hogarth.

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 3
DEALING WITH ILLUSIONS
Narcissism and endings

I long to see you, hear your voice,

My narcissistic object choice.
(Wendy Cope 1992)

Narcissism can be used to account for a particular kind of imprisonment

within the self, manifesting itself in rage or indifference. In this sense it
was noted by Freud as a pathology that makes analytic treatment very
difficult. The narcissistic character structure describes a state in which it
is very difficult to establish a therapeutic relationship. Sudden endings
from either patient or therapist are often the outcome. The term has more
recently acquired a broader swathe of meaning, extending its range to
normal self-interest and self-development. In this sense it has become
part of popular culture. By this definition, both patient and therapist are
inevitably narcissistic and the therapist will need to recognise and use as
constructively as possible his own narcissism.
The narcissistic structure is based on an illusion. Narcissus gazed on
the surface of the pool and saw his own reflection, but took it to be that of
another. Because of this conviction which the nymph Echo, who fell in
love with him, could not shake, Narcissus would not look up and see the
real other person who presented herself to him. The narcissistic illusion
therefore becomes a delusion if it cannot be changed by the presence of
another. The ending of the therapy will remain within the delusional
structure unless the therapist can be seen as another and not merely as a
projection of some part of the patient’s self. The image that Narcissus saw
in the pool was incredibly beautiful and he wished to see nothing and no
one else. The illusion was maintained with great persistence. He also saw
the image in the water as cruel and unresponsive. The patient is most

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likely to leave when he is projecting the cruel unresponsive aspect of

himself on to the therapist, but he may also leave out of a wish to preserve
the ideal image unchanged.
This chapter will examine the vicissitudes of the therapeutic relationship
when narcissism prevails in either or both partners at the pathological
level. Either or both partners will be seeking to preserve their own
narcissistic illusion in a way that either prolongs or curtails the therapeutic
relationship. At the more normal end of the spectrum, the therapist must
make use of his own narcissism to enjoy and value the rewards of the
work. This can have a negative side in that the value may be derived too
much from the opinions or confirmations of the other. The therapist usually
prefers endings to be planned and processed over a long period. This
may be for the patient’s good. It may also be for the therapist’s own
satisfaction. The therapist must also experience his own pathological
narcissism to work with a patient whose narcissism prohibits constructive
relationships.
Freud, in his ‘Essay on narcissism’ (1914), describes two types of
relationships. He defines both by the developmental metaphor. In the
first, the desire for food and comfort is satisfied by the mother, and the
infant learns to turn first to her and then to others for satisfaction. This he
calls the attachment type of object choice. In the second, there is a
disturbance of the attachment which might have arisen from satisfactory
early relationships and, instead, the individual cannot find others satisfying
and turns him- or herself into the only love object. This means that the
only kind of relating possible in these circumstances is a search for
someone else who will echo love of the self well enough to remove the
pain of the early failures. Freud goes on to say that the attachment type of
choice is typically the way of relating seen in men and the narcissistic
need to be loved is typical of women. He does, however, emphasise that
these are two types of object choice and that one individual may vary
over time in the choices made. Human beings are not divided into two
sharply differentiated groups.
The essential question for a therapist is how and whether a particular
kind of self-referenced relating can change to something more mutual.
Freud used his own observation and also drew on the work of Havelock
Ellis in psychology and neurology to arrive at a description of narcissistic
relating. He had still not found a satisfactory explanation for the way in
which the interest of the individual either stays predominantly focused
on the self and images of the self, or moves through a further process
towards greater recognition of another. Freud later moved on to distinguish
between primary narcissism and secondary narcissism. Lacan criticised
this distinction as untenable, since primary narcissism postulates a state

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in which there is no input from the outside because there is no outside.

The infant inhabits a world in which self and other are totally
indistinguishable. Lacan asked how the baby could then move to a
relationship, even a narcissistic relationship, if there were no way to enter
the original closed system.

The illusion of wholeness

For Lacan, the primary human goal is the maintenance of consistency of

the pleasurable experiences of bodily satisfaction. These experiences never
last and, from its earliest moments, the infant learns the loss that is at the
heart of all its pleasure. The infant calls out to the mother only because of
the need to maintain pleasure and the awareness of its own lack. Therefore
the satisfactions of the body achieved in the earliest moments give rise to
a calling out to the other to fill the void that is always opening. Lack is the
initiator of the construction of the ego whose purpose is to defend against
awareness of privation and loss. For Lacan, the ego holds the organism
together in a fiction of wholeness which leads to a turning to others to
find the satisfactions or objects of desire which distract from the
fundamental lack.
This view of the ego implies an inevitable narcissistic element in relating
to others. Such a view leads on from Freud’s view of narcissism as a
pathology that needs to be cured. For Lacan, it is not so much a curable
disease as an inevitable part of the human condition. If this is so, therapy
can modify but never cure a narcissistic state. An ending will have to be
found from within a more comfortable level of narcissistic need. Therapists
are deluded if they believe that they can cure narcissistic tendencies in
their patients or themselves. They may well need patients in order to
diminish their own narcissism which may be at the normal level, seeking
confirmation of the self-image, or they may be at the pathological end of
the spectrum in that therapeutic relationships are sought in order to avoid
or replace ordinary human relationships.
Being embedded in what is essentially an illusion produces some
difficulty. For Freud, both boys and girls begin the history of their love
relations by loving themselves. At the mirror stage, the infant catches
sight of a delightful image of him- or herself as whole and powerful. There
is a joy and a triumph in this perception which is always balanced by the
rage and aggression that accompany the hints that it is an illusion. The
dependence on the mother which is almost total at this stage is at odds
with the perfect body of the imagination. Dependence implies love and
need for the mother. Both sexes develop an illusory view of themselves at

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this stage as being a partner for the mother, based on an unreal wholeness,
integration and desirability.
Freud and Lacan were not far apart up to this point, but Freud runs into
difficulties because of a more literal view of the importance of the penis as
a physical reality rather than for the phallic power which it symbolises.
According to Freud, a boy can more easily love someone for being different
from his own image, because he is driven, through fear of the father’s
presence and possible jealous punishment, to give up the desire for the
mother and seek her in another woman. The narcissistic option might be
to seek his own image in another man. This is a much disputed view of
homosexuality. Girls are more problematic even in normal development in
Freud’s theory because they do not have the fear of punishment (or
castration in Freud’s terms) as they already lack a penis. Therefore gifts
will always retain a degree of narcissism, needing to be loved and admired
in order to retain the illusory image of wholeness for themselves. This is
a much disputed view of femininity.

Preserving the illusion

Mollon (1993) points out that for Freud, both femininity and a certain type
of religious belief tend towards the maintenance of a narcissistic structure.
If religious belief involves the conviction that one is specially loved and
chosen by God and that God is all powerful, this can mean that there is an
omnipotent belief in one’s own power, safety or rightness. An individual
might find that this is a helpful protection and may never bring it to a
therapist. On the other hand, if it is brought to therapy, we can assume
that it is available for reflection and possible change. There is always an
ethical question about whether a particular belief is available for analysis
in psychoanalytic or other terms and whether therapy should continue to
the point where such matters become an inevitable part of what is
considered. Some clients make it very clear that there are areas which are
not available for any kind of analysis.

Mrs G came for ten counselling sessions. She was taking a

counselling course and the course requirement was for a
minimum of ten sessions. She was just about to finish the
training but needed to complete the self-awareness
component. She arrived for an assessment saying that she

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could see that there was some value in experiencing

counselling herself, but she really did not think that she had
any problems. She had a strong religious faith and believed
that God wanted her to help others, perhaps eventually through
ordination but currently through counselling. She said that
she had a loving and supportive husband and four beautiful
children. She pointed out that she did not wish to discuss
her faith or family, but she would be prepared to look at the
difficulty she was having in the training course.
The therapist was very torn in that this looked like a
hopeless situation as far as any meaningful work was
concerned. On the other hand, if Mrs G was going to be
working as a counsellor, perhaps it was better to embark on
some counselling and see whether what felt to the therapist
like a very omnipotent defence could be modified at all. The
therapist was immediately engaged by the narcissistic need
for Mrs G to see herself as successful. The contract was for
eight sessions followed by a review after which she would
either leave after a last session or consider further work.
Mrs G came for the eight sessions during which she talked
about the difficulty she had in restraining herself from criticising
other members of her course who were behaving in a way
that she saw as selfish: ‘They just say what they feel without
considering whether they might be hurting someone’s
feelings.’ She restricted her remarks to supporting other
members of the seminar when they were attacked and could
not understand why her support did not seem to be welcomed.
The therapist suggested that perhaps Mrs G was wanting to
be the person who ran the seminar rather than being willing
to be a member of it which might have involved acknowledging
her own vulnerability. Mrs G thought about this and said that
perhaps she was quite well suited to lead or to teach but at
the moment she was humble enough to recognise that she
had more to learn.
The therapist was gradually becoming more angry and
frustrated. She experienced a great desire to break the
apparently impregnable sense of rightness that Mrs G was
able to convey. This might not have presented such a problem
if Mrs G had not chosen to train as a counsellor, although it

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seems most unlikely that she would have come for any
therapy. As it was, the therapist had an ethical dilemma related
to the fitness of this client to be a counsellor herself and
whether or not confidentiality should be broken. [This aspect
of the work will be discussed in subsequent chapters.]
The therapist also had a technical dilemma in deciding how
much to challenge the narcissistic problem. Too much
challenge would simply lead to a walk out and too little would
leave the problem unchanged. The deciding factor was her
own anger and frustration which she recognised as arising
from her own need to be successful, but decided must be
broached, but only in terms of Mrs G’s own anger that was
not being expressed to the students but was being left to
others to express. This anger seemed to relate to the basic
narcissistic problem of not being appreciated, which might
well be traceable to a repressed experience in childhood with
a narcissistic mother. The difficulty was that Mrs G might be
left with some of her certainty dented but no time to work it
through. Of course, a more likely scenario was that she would
be well able to fend off any attempt that the therapist might
make to enter her feelings.
In fact, what happened was that the therapist did speak
about the possibility of hidden anger in Mrs G that might be
conveying itself to other members of the group. Mrs G
appeared to be able to accept that possibility and spoke
openly about her anger with certain members of the group for
not being empathetic enough with those who were being
attacked. They were not carrying out God’s will that the weak
should be supported. This was not, of course, quite what the
therapist had been expecting. The time ran out before much
more could be done and the result was that Mrs G, perhaps
just a little shaken, decided that she would not continue with
the counselling for the time being, although she might return
at some point ‘to hear some more of your very interesting
ideas’. The religious attitude conveyed was something that
the therapist found difficult to accept, because it seemed to
imply such an invincible barrier to any kind of intimacy. It
also implied that more powerful help than the therapist could
ever provide might be available. This would not in itself be a

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difficulty if it had not also implied that the therapist was to be

allowed very little scope to be effective. Sadly, the short-term
nature of the work allowed little opportunity to work with the
underlying fear and insecurity.

The religious viewpoint of this patient was embedded in narcissistic

grandiosity and illusion. Mrs G might not be able to believe in her own
omnipotence but would accept an illusory view of the world, and
particularly of death, if both could be dominated by her image of God. An
ending that would be satisfactory to the therapist would include some
acknowledgement of vulnerability and some lowering of the barriers
designed to keep the other person at a prescribed distance. Such a change
might have brought with it a different way of seeing God. This, of course,
brings us into the realm of the therapist’s own narcissism and need to feel
that a good job has been done.
If narcissism implies an illusory view of the value of the self, the ending
of the therapy with a narcissistic patient would have to achieve some
more realistic sense of self-value as well as of the value of others. It might
also imply a modification of the nature of religious belief away from a
conviction that God specially protects the individual from all adversity. In
other words, God could no longer be made the recipient of projections of
omnipotence. Religious faith can, of course, vary in the extent to which it
places emphasis on certainty and the extent to which it emphasises hope.
Hope might well be an element in the ending of a therapy. Total dependence
on God and none on man is problematic. Freud’s view of narcissistic
illusion implies that readiness for ending would require a greater
acceptance of external reality and perhaps also an understanding of what
is truth. This of course begs the question of how we can expect the
therapist or therapist and client between them to come to a greater or
better understanding of what is truth. There is a possibility here of an
endlessly repeating series of mirrors showing more and more narcissistic
illusions, including those of the therapist.

The omnipotent illusion

Religious belief is not, of course, the only way in which an individual can
achieve a defensive sense of omnipotence. Kernberg (1974) argued that
the narcissistic solution to the dangers and threats of the outside world
and to relationships in particular is to create an amalgam of the self with

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an image of power and strength derived from others. This certainly has an
illusional quality to it because it involves a person saying in effect: ‘By
myself I am weak and vulnerable. I will therefore take my ideal brave,
strong, and beautiful and join myself to that. Then I will need no one else
and can be totally self-sufficient.’
This creation of a grandiose self, as Kernberg calls it, defends against
feelings of vulnerability. This inevitably also implies a defence against
acknowledging the existence of the other because that might imply a risk
of coming back to some sort of dependence. The task for therapy is to
struggle with fear and anxiety which the therapist inevitably shares. The
therapist must recover first and can often do so only by giving up his own
narcissistic investment in being successful. The first time the therapist
can allow himself to fail with this patient is likely to be the first time that
the patient is able to risk letting some of his own omnipotence go.
The relevance for a theory of ending in therapy is not difficult to see.
Given that many of the people whom therapists see come along with some
version of a narcissistic problem, we need to look at the way in which the
desire to turn oneself into the loved object rather than to allow oneself to
love and be loved will have immense implications for the ability to leave
the therapist. If a person remains stuck in the narcissistic position, the
therapist is needed to fill the role of the one who loves and offers comfort
and a feeling of self-worth. Even if the narcissism has allowed development
to the point where others are given marginal recognition to the extent that
they contribute to the narcissistic needs, there will be great difficulties in
relating. No ordinary human partner is likely to offer quite the non-
retaliatory, undemanding empathy that a therapist offers. Fortunately, the
therapist will fail in other ways and there will be a need to seek other
relationships, even if the narcissistic position is particularly resistant to
change. The therapist has the constant challenge of showing how he is
eliminated from consideration without becoming demanding and critical.
If relating remains dominated by demand, and if that is totally split off
from being able to love, parting is likely to be sudden and to arise from
catastrophic disillusionment, rather than being manageable and bearable.

A problem with seeing and hearing

Threatened by the rage of a narcissistic patient who is too suddenly

disillusioned, the therapist may wish to remain throughout the relationship
as just the voice of Echo among the mountain caves, gradually dwindling

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away to silence. Freud believed that it might not be possible to form a

useful therapeutic alliance with someone whose relating was of this sort.
In the most extreme cases, ‘they become inaccessible to the influence of
psycho-analysis and cannot be cured by our efforts’ (1914). Freud is here
speaking of the group of people whom he called paraphrenics, who had
withdrawn their libido or desire from all people and things in the outside
world. Because of this, there was an inevitable inability in these people to
respond to influence from the therapist. In order to maintain this position
and to sit like Narcissus on the edge of the pool refusing to look at
anyone else, the narcissistic individual needs a considerable degree of
omnipotence or megalomania. He needs to be able to feel that wishes and
desires are extremely, even magically, powerful and can transform reality
into the desired shape.
Most therapists sooner or later encounter a client who is not only able
to attend, but becomes passionately attached to therapy, yet seems to
have no positive feelings about the therapist and is impervious to any
kind of change. There are many possible situations in which this kind of
stalemate may arise, but clearly we cannot simply wring our hands and
say, too bad. Some sort of ending of the therapy must be reached in time
and the question is whether it can possibly be constructive in any way.
There is a strong and powerful motive to try to understand the difficulty
better in order to try to arrive at a resolution. Fortunately in most cases,
the impasse is not total. A patient described by Donald Meltzer illustrates
the existence of another strand in the psyche of the kind of person who is
likely to come to do long-term work. Meltzer describes a man:

[He dreamt that] he was walking uphill on a lonely woodland track

and saw another man about his age, a former business client of
very paranoid disposition ahead of him. When the track divided,
instead of going to the right as he had intended he followed the
other man, going down on to a beach which he recognised as
belonging to the village where he had been born and from which
he had departed at the age of 6 months when his parents emigrated.
On the beach he listened with admiration as the other man
declaimed at length about his income and importance, how even
on holiday he had to keep in constant touch with his office as they
could do nothing without his advice.
(Meltzer 1988: 231)

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The business associate was understood as a part of himself that he

described at other times as foxy or even as an actual fox who appeared in
some of his dreams about a story he had heard as a child. The foxy,
narcissistic part was extremely powerful. Simply making conscious what
it was like and what it was doing made no difference to it at all. For the first
three years of the work, it seemed to grow stronger and increase its hold.
This part of the personality also seemed to be involved in a sexual
perversion which involved masturbation. Developmentally, Meltzer could
make some sense of the perversion as a secret pleasure which could be
kept from the patient’s mother who was a long-term invalid, and whom the
patient cared for in what Meltzer calls a ‘custodial manner’.
Nevertheless, even at his worst, we can see that this man had a secret,
profound attachment to the therapist. He expressed this partly in an
uncanny and disconcerting ability to know things about the therapist.
For example, Meltzer describes having borrowed the car of a friend and
colleague who lived in a road that the patient traversed in order to reach
his session. Although the car was parked out of sight, the patient described
a dream in which he saw the house of the colleague with a hole in the road
outside, that was just about the size and shape of a car. This kind of
connection is disturbing but familiar to all therapists who have worked in
depth with such patients. There is no obvious working alliance but there
is a deep, often destructive attachment which belies the image of a total
narcissism. Even the first dream about the colleague is significant because
there is the ‘I’ of the dreamer as well as the narcissistic colleague who is
supposed to be a separate person from the dreamer. What is the ‘I’ of the
dreamer up to, and how will he ever be able to work with the therapist?
In the case described by Meltzer, work was possible and the therapy
was not prematurely ended. For a long time the foxy part of the patient
prevented him from acknowledging any dependence or love. It kept him
impoverished because it denigrated any and everyone else. It allowed
love neither of the therapist nor of a woman. Why should anyone submit
to such a destructive inner force? The hypothesis that Meltzer puts
forward is that if there is no sense of ever having had anyone good, there
is bound to be an all-pervading fear. The tyrannical, foxy, businessman
aspect of the personality offers some sort of safety because it purports to
know the answers. This is what leads it to have an addictive quality. An
essential and highly problematic aspect of the therapeutic relationship in
this sort of situation is that it has the power and impermeability of an

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addiction which attempts to force the therapist to stay in the role of

supporting the tyrant.
There is an inherent difficulty in working with such a structure. If there
is a great deal of fear at the root of the tyrant’s power, what is the fear and
where does it come from? Winnicott and the object relations school would
look at the problem in terms of the mother’s failure to meet the infant’s
gesture sufficiently at the right time. The baby who has to wait longer
than it can bear has to develop defences against its rage and distress. If
there is too much frustration too soon, the omnipotent defence is
developed to deny that there has to be any dependence on an unreliable
other. Kohut and the self psychologists have looked at the need for the
mother or significant carer to be available as a self object which can
gradually move from mirroring to being a separate entity in its own right.
From the writers who have put more emphasis on the development of
early infancy as a system in which physical and phantasied interaction
both play a part, such as Klein, Mahler and later Stern, the most significant
contribution to the illumination of the problem has been in the area of
understanding what happens when there is not sufficient gratification in
the phase that Mahler (1968) calls normal symbiosis. At this stage the
mother and infant form an omnipotent system which provides the safety
for the ego to develop and to allow the gradual awareness of the
separateness of the other. If this safety is not available for reasons which
Klein might see as more constitutional and internal and Stern (1986) might
see as more interactional, the result is likely to be a tendency to separate
the phantasied powerful part of the self, like the foxy part of Meltzer’s
patient, and the weak, helpless part of the self which cannot make the
mother do what is wanted. In the same way, the mother is seen or responded
to as if she were either the gratifying mother who does sometimes provide
what is needed or the frightening, depriving mother who cannot be
controlled. The effort to control becomes paramount and there is no
freedom to allow the other person to be him- or herself. The therapist who
is playing a part in this struggle will be forced into a position where he has
to take some control, at least to prevent damage from being done, and the
only way out of a repetitive pattern may be an acknowledgement of the
impasse to the client. This has the effect of showing that the client is not
speaking to a controlling parent, and also shares responsibility for what
happens.
Symington (1993) emphasises the part played by the infant and child in
what goes wrong for the adult. His point of view is valuable in clinical
practice in that he points to the choice of the narcissistic person to turn

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away from the life force. This can be seen in physical terms as a refusal to
take the breast or the nipple when it is offered; a useful metaphor to
describe the sense in which the person refuses all offers of the symbolic
feeding provided in therapy. The fear is that choosing to take what is
offered will lead to much greater disappointment and abandonment. This
leads us back to the difficulty in working with such clients. Any acceptance
of hope and the value of what the therapist is offering inevitably
strengthens the resistance because the potential loss is greater. We then
have the impossible situation of working with someone who hates and
envies the therapist for having good things and does not recognise that
anything is given, and yet is quite unable to tolerate absences, ends of
sessions or holidays.
The thought of the ending of therapy cannot be tolerated with ordinary
mixed feelings. An impending disastrous end may always be present as a
threat. For some people the threat is seen to be coming from the therapist:
‘I know you want to get rid of me.’ It may be felt to belong to the foxy,
controlling, businessman part of the patient denying any love or care for
the therapist. Such a person may often speak of his intention to leave the
therapy because it is not useful or is said to be doing positive harm. The
harm may be imagined as being in the mind of the therapist who is seen as
omnipotent and using his power for evil purposes. This can be clearly
seen as a projection of the omnipotent part of the patient which is then
perceived as if it were in the therapist. Unfortunately, of course, with
these patients, we are all much more inclined to act in the way that we are
being seen and to become unduly powerful, make mistakes and become
harmful. This situation enables the patient to feel justified in maintaining
the tyrannical part of himself in order to protect him from the threatening
therapist. Quite often such a situation is resolved only by a sudden,
apparently catastrophic ending in which the patient leaves and the
therapist never knows what he takes with him. The patient perhaps seeks
to convince himor herself that anger is justified and that of course it is felt
at the time to be preferable to the vulnerability of dependence.
Because the unduly narcissistic person tries so hard to maintain the
status quo, endings are likely to be problematic, not only because they
may be made too soon, but also because there is often very little sign of
any change.

Mr H, a man of 35, had been seeing a therapist for several

years. He had made some progress in his work situation
where he had been successful in a promotion and his

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relationships with his colleagues had improved. His

relationship with the therapist remained static however. It was
not difficult in any way. He seemed to be prepared to continue
to attend sessions once a week, describe his week at work
and go away again.
This began to worry the therapist, who was aware that
relationships outside work were not good. Mr H was describing
homosexual and heterosexual encounters but they were
ephemeral. His main satisfaction came from masturbating in
front of a mirror. He was willing to engage in various attempts
to understand this, first in terms of his fear of women and his
powerful and rather frightening mother. Second, it was seen
to relate to his desire to internalise his father who had been
absent for much of his childhood and had died when he was
10 years old.
The trouble was that the interpretations seemed to be well
received, and he left each session better than he arrived in
that he always began slow and depressed. For a long time
this kept the therapist going, but gradually she began to be
aware that what was happening was circular and was showing
no sign of any change. The conclusion was that the sense of
impasse should be presented to the client. Mr H accepted
this with interest, but again it seemed to sink without trace.
As a result, the therapist decided that she had to make herself
a real person rather than a part of the patient’s fantasy as the
watcher. In order to do this and to make a difference, she
decided to set a date for ending the therapy. This was met
with shock and distress that went on for several weeks in the
form of silent misery or indirect anger. The ending was difficult
for both because it was not possible to pretend that a great
deal had changed. Nevertheless, there was a degree of
strength in the way in which the patient eventually accepted
that the therapist was determined that the ending should take
place. Coming up against this reality caused both mourning
over the loss of the ideal therapist and eventually enough
anger to set some hope going.

When the therapist overcomes her narcissism enough, an ending may

be possible. Nina Coltart (1997) in her last book The Baby and the
Bathwater wrote that she feared that training analysis or therapy makes

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therapists more rather than less narcissistic. Why should this apply more
to trainees than to anyone in therapy? The obvious, if superficial,
interpretation would be that many years of compulsory self-observation
required in most training induces a habit of gazing inward and looking at
one’s own responses to all interactions. This might well be the case,
although one would hope that the inward looking would result in a self-
examination in relation to another rather than an inability to look at the
other.
Nevertheless, the therapist’s own narcissism is bound to be an element
in any therapeutic relationship. It leads to two main groups of responses
to clients. In the first group, the therapist needs to compel gratitude and
appreciation from the client. This is in order to obtain the sense of life
from an image which reflects back to the needy therapist: ‘Yes, you are a
good therapist, you are worthwhile, you are loved, you are desired.’ this
is an emotional bond that is felt to be needed and therefore the therapist
does not let go of clients and is blind to indications of a reasonable need
to end. The second group is more sophisticated and has recognised the
difficulties inherent in the obvious narcissistic satisfactions being sought
by the first group. These therapists are inclined to exaggerate their
independence of the client and to become oblivious of the client’s efforts
to be connected.
The following cases show the sorts of situations that can arise:

Ms J had been seen by a psychodynamic counsellor for over

two years. She had worked through considerable difficulties
in her relationship with her partner, had become much more
accepting of his emotional limitations and was prepared to
enjoy what he had to offer. At the same time, she became
much more relaxed with the counsellor and was able to accept
the counselling sessions and say that they were useful to
her. She felt that she had benefited greatly but as she was
not in paid work and had two small children, the fee was
difficult to find. She talked about one of her children reaching
the end of primary school. She had enjoyed the experience
greatly but was now ready to move on and was excited, if a
bit anxious, about the new possibilities at secondary school.
The counsellor said that she understood that J was ready
to move on from what she had been working on to a new area
and that there were perhaps things in her childhood that she
had not yet discussed. Perhaps they were exciting but also
frightening to contemplate. J was surprised by this and said,

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no, she really did not think there was anything else that she
needed to work on and that actually she was contemplating
making an ending in about six weeks’ time. She added that
the fee was rather difficult to find and she could not go on
indefinitely, although she did enjoy the sessions. The
counsellor was shocked by this and said that they would
have to talk about it the following week.
When J arrived for her next session, the counsellor was
looking much happier and J thought with relief that the ending
might be easier than she had feared. The counsellor began
the session by saying that she had been thinking about what
J had said last week and was very concerned indeed that J
might leave prematurely because she could not afford the
fees. She had therefore arrived at the idea that J might like to
do some work instead of paying the fee. The counsellor had
a large garden and thought that J might be able to work for
two hours in the garden in order to earn an hour of therapy.
With this issue out of the way, they could both concentrate
on what was preventing J from being able to talk about what
was still bothering her. J was very surprised at this but said
that if the counsellor thought so, perhaps she did have some
more work to do and agreed to the proposal. The ending was
not mentioned again for some weeks. When it was mentioned
again, J said that she was very unhappy with the counselling,
did not know what the counsellor expected from her and did
not wish to work in the garden any longer. At this point the
counsellor became angry, saying that J needed to learn to
experience gratitude. After this session, J did not return and
the therapy ended in anger on both sides.

The problem in this situation is caused partly by the therapist’s no doubt

genuine wish to encourage the client to continue to explore her own
experiences at school and perhaps to illuminate her relationship to her
daughter’s experiences further. Unfortunately, this is not justified by the
client’s account of external circumstances, nor is it clear within the
relationship to the therapist that there was any urgent need for the patient
to do further work. The counsellor was the one who could not let go.
The therapist’s readiness for the work to end cannot be taken as a
criterion for ending if the therapist is not sufficiently aware of his own

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narcissistic need to have the client continue to attend sessions. In this

case, the therapist wanted the client to be in the role of gardener. This
might seem to be perfectly sensible because the client was good at
gardening. Following Voltaire’s conclusion to Candide where the ultimate
good was seen to be the acceptance of the need for all of us to be content
to work in the garden, there is philosophical justification for seeing some
health in the reality and symbolism of gardening. Nevertheless, in
psychodynamic or psychoanalytic work, this situation is not healthy
because the client was going to be working for the therapist and this
means that the therapist was in a position of control and power which is
totally unacceptable in conjunction with the continuing therapeutic
relationship. Inevitably there would be potential for the therapist to approve
or disapprove of the work done and for the client to cheat or work extra
hard. This could lead to all sorts of muddles because these real problems
would be ongoing, created by the therapist’s action, and would need to
be resolved through negotiation. In every therapeutic relationship valuable
work can be done when real mistakes are made or difficulties arise.
Nevertheless, the therapist seeks not to introduce his or her own material
because that may need more work than the client’s problems. Some
therapists might disagree with this conclusion and would feel that such a
problem based in reality could provide valuable therapeutic experience.
The opposite attitude towards clients is demonstrated by the therapist
who has no need of clients at all in his or her own mind. When a client
mentions ending, this type of therapist is inclined to greet the move with
enthusiasm as a sign of growth and autonomy. The enthusiasm may well
hide a deeper need which is disguised even from the therapist. This attitude
may make it easier for the client to leave, if prematurely, but it may also
lead to aborted endings where the client has to keep returning in the hope
of getting the therapist to show some warmth and desire. Very often a
client tests out the therapist’s willingness to let him or her go, in the hope
that an early experience of indifferent parents can be changed into a
knowledge of being wanted. The experience of not being wanted in the
first stages of development may have been illusory of course, and the
task of the therapist in the case of the client who is testing out his or her
welcome is to make clear that not knowing the therapist’s mind but deciding
to go or stay without that reassurance is still possible.
Since Lacan, we have had a much more sceptical view of the possibility
of achieving a relationship with the other that is free of narcissistic illusion.
At the point at which the client or the therapist decides that the work

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should end, each has to recognise some of the illusory nature of the
relationship to the other. In the more extremely narcissistic patient or
therapist, the illusion of a pleasing self will have been maintained by the
presence of the other and it will be much harder to maintain without the
reflection that has been provided. The ending process itself will perhaps
allow for some of this need and distortion to be addressed.

References

Coltart, N. (1997) The Baby and the Bathwater, London: Karnac.

Cope, W. (1992) Serious Concerns, London: Faber and Faber.
Freud, S. (1914) ‘Essay on narcissism’, SE 14: 67.
Kernberg, O. (1974) ‘Further contributions to the treatment of narcissistic
personalities’, International Journal of Psycho-analysis 55: 215–240.
Mahler, M. (1968) On Human Symbiosis and the Vicissitudes of Individuation,
New York: International Universities Press.
Meltzer, D. (1988) ‘Terror, persecution, dread, a dissection of paranoid anxieties’,
International Journal of Psycho-analysis 49: 396–400.
Mollon, P. (1993) The Fragile Self, London: Aronson.
Stern, D. (1986) Interpersonal World of the Infant, New York: Basic Books.
Symington, N. (1993) Narcissism, A New Theory, London: Karnac.

60
 4
STAYING ALIVE
The patient’s unilateral ending
Be absolute for death. Either death or life
Shall thereby be the sweeter.
(Shakespeare, Measure for Measure III. i)

If therapy is valuable, why do people not stay until a mutually agreed

ending can be achieved? Unfortunately, the desirable length for a therapy
is a subject on which therapists and patients often disagree. This chapter
will look at the ways in which patients take charge of the ending process,
in opposition to the view of the therapist. Occasionally therapists do
harm and in such a case it is only the patient who knows this and must
make an ending (Murdin 1995). Usually, patients and therapists are able
to arrive at a joint agreement over ending but when there is a sudden or
apparently premature end, therapists do not find it easy to work with a
patient’s unilateral decision. If the patient allows any time to the therapist
at all, she must ask questions: is it right for this patient at this time or is it
the result of inadequate work on the part of the therapist? Therapists
often do not know the answer and have to accept the discomfort of not
knowing. This chapter will examine some of the theoretical and practical
background for patient-determined endings and some of the ways in
which therapists handle them in practice.
Patients may be driven to leave by the working of the death instinct or
by their desperate clinging to life as it is. There are three emotional states
which predominate when patients leave therapists without agreement:
they leave in anxiety, they leave aggressively, and they leave in silence.
Each of these endings presents the therapist with a different problem to
solve, because each is a different version of the refusal of the awareness
that therapy offers.
Ending is closely connected with dying at conscious and unconscious
levels. One of life’s most difficult tasks for all of us is to face personal

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death. Ending long-term therapy creates a microcosm of an individual’s

way of dealing with his own dying and his defences against it. Most
people find the helplessness of dying to be one of its most frightening
components, and face it with anxiety, with anger or with silence. Ending
therapy, like dying, involves giving up the possibility of total control of
the other person. The patient may begin in a state in which he or she is so
afraid of what other people do that the only hope seems to be to control.
A successful therapy may be one in which this need for omnipotent
control has lessened enough to allow a mutual decision and the possibility
of the other person going his or her own way. A unilateral ending is still an
attempt at total control. Either the therapist has to be eliminated, or those
parts of the self that the patient cannot tolerate must be silenced by
ending the therapy that threatens to give them a voice.
This exercise of power relates very closely to the view that human
beings have a tendency that pushes and pulls them towards death. Both
Freud and Lacan have written of the concept from different angles and
most other theorists, notably Melanie Klein, have taken a stance on whether
or not there is an impetus towards death and self-destruction. Klein added
the vitally important idea that envy is the deflection outwards of the
feelings of hate and destructiveness. It is a universal and powerful force
which is potentially responsible for destructive endings. The patient may
envy the therapist his knowledge, or his calm or all the good things which
he possesses in the patient’s fantasy. In Klein’s view this envy is
omnipresent and leads to continuous attempts to subvert the therapy
(see e.g. ‘Envy and gratitude’, 1957: 184). Alternatively it may lead to the
destructive catastrophic ending. When envy is operative, the patient
may prefer to deprive himself of the therapy that he needs rather than
allow the therapist the satisfaction of doing good work and reaching a
planned ending.
Envy is generally recognised to be a powerful force but even many
followers of Freud have rejected his concept of the death instinct, for
example, ‘Freud’s tortuous formulations of the death instinct can now
securely be relegated to the dust bin of history’ (Sulloway 1992: 394).
Lacan’s critique of the concept has shown that it is still of explanatory
power when we try to understand the patient’s devotion to his suffering.
For Freud, death was equated first with the biological tendency of all
living cells to age and to return to an inanimate state. He hypothesised
that such an instinct must exist in the psychological makeup of man as an
animal and as a collection of cells. Later he developed the view that there

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is a drive towards death and destruction which is potentially equal and

opposite to the drive towards life. The aim of the death drive is to achieve
stability, calm, peace. It is the force that leads to repetition, conservatism
and maintaining all sorts of counter-productive but familiar situations. It
may lead to an attempt to force the therapist into compliance and
maintaining the status quo or it may lead to abandoning a therapy that is
working only too well. The life force can be seen as leading towards
change and development. The strength of each force varies in each
individual.
Very often, a sudden unpredicted ending is a repetition of a pattern of
sudden endings or abandonment in which the therapist is unwittingly or
unwillingly playing a familiar (to the patient) role. Ending in this view is an
attempt to maintain the stability of the familiar even if that is painful and
counter-productive. From Lacan’s point of view, devotion to pain, or the
symptom, is caused by the death instinct working through jouissance:
the irreducible need to suffer that lies at the depths of the unconscious:
Ragland relates this closely with Freud’s position:

Freud found chaos in what one could not control and called it
negative transference or unconscious masochism. Lacan viewed
masochism as a symptom of fundamental displeasure, discontent,
even perverse enjoyment, in the breach of the pleasure principle
that places a stubborn obstacle in each person’s life and a malaise
in civilisation. Yet the malaise or lack in being or want to be lingers
because it is structural.
(Ragland 1995: 92)

In other words, for each of us there is a terror of the void or lack in us and
we trap ourselves in familiar suffering so that we do not have to see it.
For Freud, repetition of patterns of behaviour or relating fulfilled the
need to maintain stability and consistency and therefore he linked them
more positively to the seeking of pleasure. Stability and consistency are
preferable to the pain of awareness, but even here there is a problem
because what is seen as self-indulgence leads to guilt. Anything that can
be felt as pleasurable must be hidden. The therapist is often not allowed
to know what has been satisfying in the therapy for this reason.
For Lacan, repetition of counter-productive patterns of behaviour is a
sign of the working of the unconscious attachment to one’s own suffering.
Because it is so deadly to continue to repeat what is painful, the therapist

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should try to show how the patient is caught in networks of repetition.

These repetitions contain in them the fossilised remains of old family
myths and desires, but not the desire of the patient. If we can gain some
inkling of this, there is a possibility of freeing the patient who otherwise
continues to struggle within the historical need to maintain the status
quo both for himself and for the other, however negative that might be.
Therapists of course have the problem that both ending and not ending
can be ways of maintaining the status quo. Patients are trying to show
what they are, and at the same time attempt to hide their tracks. The
therapist also has an investment in the status quo; this will be considered
further in Chapter 5.

May I go now?

Although some patients leave therapy in anger or dissatisfaction, the

great majority make a plan to leave and often ask the therapist’s view
before making a decision. The former may tax the therapist’s judgement
and tolerance but the latter case is even more difficult. The therapist
might experience the question as continuing dependence that requires
more work or as part of a healthy autonomy. Consulting the therapist
about her view may be seen either as lack of confidence in the patient’s
own judgement or as a rational desire to have the whole picture available
before making a decision. If we accept that the therapist’s own feeling
about the potential ending is one of the most reliable indicators of
readiness to end, we can see that two different patients asking the
therapist’s view about readiness to end might use exactly the same words
in each case, but for one they might indicate that the patient is ready to
leave, while for another it is too soon. The only detectable difference will
be in the therapist’s internal response to the level of anxiety from which
the request arises.
Consciously, the neurotic patient may try to work with the therapist
and to achieve a constructive ending at the right time. The anxiety at
facing one’s own pain may be concealed beneath a veil of rationality. At
the beginning, the patient who has no knowledge of therapy or analysis
has no idea what sort of time scale will be useful. Stories in the media
emphasise the possibility of exploitation: therapists just want to hold on
to patients for the sake of the income they provide. Of course there is an
element of truth in this. The world of therapy is no different from any
other in that it is dominated by economics, and the economics dictate that

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there is a limited number of people seeking therapy at any given time.

Therapists are not allowed to advertise according to current Codes of
Ethics and therefore they must wait for patients to present themselves via
self-referral or the referrals of colleagues, family doctors, etc. This
inevitably produces a climate of some uncertainty. In the early stages of a
career there is a need to seek work and the temptation to try to hold on to
people can be strong.
Patients have equal and opposite conscious motives for wanting therapy
to end. Developmentally, leaving home implies adult status and
independence. Therapy may be costing a great deal of money. It may be
interfering with work, time with family or just involve tiring journeys.
Logic and rational thought imply that therapy should end as soon as
possible. Judging the degree of anxiety that tells of suffering beneath the
surface is a skill that therapists must acquire in order to form a view about
when a patient needs help to end, and when the right thing is to continue
to try to interpret the ending as an attempt to escape from anxiety.

External reality

Therapists whose model emphasises the internal world of the patient

often have problems with recognising external reality. Many therapists
would say that the job of the psychotherapist is to interpret what the
patient brings and therefore there is no need to pay any attention to
external reality. The therapist makes clear what is the fee, what are the
hours and when and how long holidays will be. Beyond this, he or she
has no concern with the realities of the patient’s life. In his biography of
Winnicott (1986), Adam Philips describes a meeting of the British Psycho-
analytical Society during the war. While the meeting continued, bombs
began falling outside. Winnicott, who could recognise external reality
even if it had not been crashing about his ears, drew the attention of the
meeting to the air raid. He was ignored, and the meeting continued as if
nothing were happening. Therapists can be very good at ignoring the
limitations imposed by such realities as lack of money or a long journey.
At the other end of the spectrum are the therapists who will try their
best to accommodate the reality needs of their patients. For example, what
happens if a patient tells the therapist that he or she can no longer afford
therapy? This sort of potential ending may arise as a result of the patient
or a partner losing a job. It may also be caused by separation of partners

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or by a patient voluntarily giving up a lucrative but hated job because the

therapy has enabled greater courage and freedom in choosing. Does the
therapist then allow the patient to attend for a lower fee, or simply say
nothing and allow the patient to end? (See also Chapters 7 and 9). I have
often heard it said that if a patient really wants therapy he or she will find
the money somehow.

Ms K told me that in her twenties she had gone to London,

taken a job as a cleaner and stayed there for three years in a
squalid bed-sitter in order to have analysis there. Reduced
fees were not available. Although she had a university
education, she had no place on a career ladder and had not
yet acquired dependants.

In fact, Ms K needed the help of analysis in order to be able to achieve

those things. The situation would have been different if she had had
dependent children or a place in a career already. Her analyst would not
reduce his fee and she would have done without the help that it
undoubtedly gave her.
There are many people who are in the middle of therapy but have
changes of circumstances. Each therapist must decide whether or not to
continue at a lower fee or to try to work with the ending that these
circumstances impose. This may well involve anger and disappointment
that the therapist is not willing or able to be the rescuer. This situation is
particularly difficult if it occurs in the middle of long-term therapy. The
arguments for continuing may be strong both for the well-being of the
patient and for the therapist’s own satisfaction, but therapists, like other
professionals, are not obliged to continue with a patient who cannot
afford to pay.

Therapist exploitation

Of course there are other situations in which it is necessary or desirable

for the patient to leave. Unethical behaviour, most obviously the therapist’s
inability to control sexual attraction to the patient or emotional exploitation
may cause the patient to flee. That therapists abuse patients sexually and
also in other ways is incontrovertibly true. Samuels writes:

What we know from the psychological study of incest is that

when one meets a universal moral taboo, with which everyone in

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a culture seems to agree, one is probably in the presence of

universal impulse.
(Samuels 1999: 150)

Samuels makes the point that public concern over the sexual behaviour of
therapists, usually but not always male, is justified and should also be the
concern of the profession. Patients who are being abused often may not
be able to leave because they are enmeshed in the web woven by their
own desires as well as by the therapist’s desire. Samuels adds:

Relationship not orgasm is the secret goal of the sexually aroused

patient. Power not orgasm is the secret goal of the sexually active
male analyst as he replicates the power relations between men and
women in our culture.
(Samuels 1999: 153)

How can there be safe analytic work in which a patient will never be
caught in a net of abuse nor forced to flee prematurely in order to be free?
Samuels makes the useful point that there can be no wholly safe way of
working with sexuality. Perhaps the recent emphasis on mother and baby
of the object relations school has encouraged a denial and therefore an
acting out of sexuality in the therapeutic relationships. Samuels advocates
a somewhat enigmatic stance which is neither literal nor metaphorical
(Samuels 1999: 154). The difficulty of achieving safe therapy, like safe sex,
is that there is no such thing, and in each therapeutic partnership the
therapist will have to work out a new resolution of desire versus self-
denial. Female therapists may not be as prone to abuse their patients
sexually as males but they are more prone to the emotional exploitation of
the mother who cannot let her child go and who exercises all sorts of
emotional manipulation to keep the patient who fulfils her narcissistic
needs. In this sense, she too seeks power. If the therapist cannot recognise
this impulse and find a way of working with it, the patient must be helped
to leave and find another therapeutic relationship in which to seek a
resolution.
Sometimes, however, patients leave because of the fear of their own
unethical behaviour. A male patient may find his erotic feelings about a
woman therapist very difficult to accept because he is afraid that he could
carry them out through his superior strength. Therapists owe it to patients
to make sure that the setting in which they work is safe and that the
patient knows that it is. Thoughts and feelings can then be expressed

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without there being danger in reality. There will always be danger in

(ph)fantasy. Almost any unacceptable feelings of murderousness or
sexuality may arouse such shame and guilt that the patient chooses to
leave rather than risk revealing them. Therapists can do no more than try
to guess when there are such feelings and make them available to thought
and words.
Patients may leave out of fear of breakdown. Winnicott’s well-known
paper (1986) points out that this is essentially fear of a breakdown that
has already happened. Nevertheless, the grip that the ego has on reality
is always tenuous, and patients may be right in fearing being overwhelmed
by the unconscious if they give it a chance to surface. Winnicott calls it
the search for ‘personal non-existence’ (1986: 181) and he points out that
it is connected with the need to experience emptiness. Emptiness is
necessary as a prerequisite to filling. There cannot be hunger for food or
new experiences until emptiness is accepted and lived through. Premature
ending may relate to the fear of emptiness and to the inability to survive
the experience of it when it occurs again in therapy.
Therapists may be much more insouciant than patients about the risks,
but must recognise that the cost of therapy to an individual may be more
than financial. Some patients leave in order to avoid breakdown or the
collapse of a carefully constructed defensive framework that keeps them
functioning at least adequately. Therapists may wish to see their patients
through such a breakdown because they are confident that the patient
will emerge in a better state at the other side, but the patient does not
share this belief. Moreover, the patient does not know that there is a way
through. The effect of an intransigent therapist will certainly be to produce
an angry patient even if the patient had not been overtly angry in the first
place. There might be much to be said for making the anger overt, but the
therapist who lets a patient leave in a rage of misunderstanding is allowing
himself to be such a bad object that the earlier work of the therapy may be
spoilt or wasted.
The patient is seeking an experience that is worthwhile in itself while it
lasts and that seems to hold some hope of a better life in the future.
Rosemary Dinnage, in her anecdotal account of a number of therapies
(she interviewed forty patients and printed the accounts of twenty of the
forty in her book One to One (1988)), found that out of twenty interviewees,
a few were angry and disappointed, a few were deeply impressed and
grateful and the majority had mixed feelings about the therapy they had
received. Dinnage’s conclusion is that therapy is a process and that the

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process must be worthwhile. The patients were not necessarily seeking

an experience that would be easy or pleasant, but they needed to feel that
it was a movement or a progression. The image of a journey is often used.
In many cases the process is enjoyed in its own right, so much so that
sometimes the end of the journey is avoided for that very reason. It is
sometimes better to travel than to arrive.
The patient is also seeking satisfaction, which may well be derived from
something that is challenging and allows for deep feeling. Veronique, one
of Dinnage’s interviewees, points out that she was dissatisfied with her
first therapist, whom she left because he did not probe or penetrate deeply
enough. With him she was able to get away with her persona and her false
self. This had led to a therapy that was comfortable and supportive but
not deeply satisfying. Here again we are faced with the problem of deciding
at the beginning whether the process will be sufficiently satisfying to
justify the difficult parts and the lack of enjoyment that will inevitably be
part of a long and deeply experienced therapy.

Substitute satisfactions

Anna Freud wrote on ‘Acting out’ in 1968. She cites Freud’s view of ‘the
compelling urge to repeat the forgotten past and to do so within the
analytic setting by actually reliving repressed emotional experience
transferred onto the analyst and also to all other aspects of the current
situation’ (Freud 1968: 166). Wishes and desires are being held in check
by neurotic behaviour which disguises them, but the wishes are always
striving to make themselves felt. There is a constant threat to the balance
that has been achieved. In therapy, the balance is threatened by the
actions and words of the therapist. She points out the essential difference
between the aims of the therapist and those of the patient within this
paradigm:

struggles between analyst and patient ensue due to the fact that
in the analyst’s intention, this re-living of the past is meant to
increase remembering while from the aspect of the patient’s id it
has one purpose only: to attain belated satisfaction for formerly
frustrated strivings and to do so via the appropriate actions.
(Freud 1968: 166)

This view of mental functioning implies that the patient comes to therapy
to attain satisfaction that will substitute for the satisfactions lost or denied

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to the child that the patient once was. Substitute satisfactions do not
allow a full life but preserve a minimal living. The analytic therapist, on the
other hand, is not setting out deliberately to give those satisfactions but
to encourage the patient to be conscious of the desire so that the
underlying wishes and needs can be verbalised and the anxiety faced and
lessened. This is as far as therapy goes because the patient is then left
with the need to accept those unmet needs in consciousness and to get
on with living in the light of that truth but without too many neurotic
substitute satisfactions. If this is accepted as the therapeutic situation, it
will obviously lead to strife and disharmony at times as the patient seeks
satisfaction which the therapist does not, or probably cannot give. Acting
out in this view is the way in which the patient tries to achieve such
substitute satisfactions as attacking the therapist in the form of a friend or
relative, or achieving substitute erotic satisfaction from promiscuous sexual
encounters.
Satisfaction can be achieved from almost any emotion along the gamut
from masochism to sadism, from idealisation to hatred. Anxiety can be
assuaged by any form of defence but in the ending process it is noticeable
that patients may be so successful at concealing their fears even from
themselves that they appear totally calm and rational, congratulating the
therapist on having been helpful. The only recognition of the underlying
state comes through the therapist’s own feelings. Can the therapist be
trusted to distinguish anxiety that is a response to the patient from that
which arises from more selfish motives?
Other patients provide a more overt agenda in that they react with fury
to their internal pain and often to mistakes made by therapists reacting
badly under their attack. Commonly such patients threaten ending before
they leave. Therapists deal with such attacks from their patients in various
ways, one of which of course would be to retaliate in order to satisfy their
own hatred and sadism. Some prefer masochistic satisfactions and will
put up with anything. Training, along with the therapist’s personal analysis,
is intended to minimise this. A potentially more constructive response is
to make a theory about destructiveness, calling it, for example, ‘negative
transference’. If patterns of behaviour can be seen to be repeated or
attempted, the patient may be helped by seeing the patterns. The therapist
too is helped by having a name for what is happening and an explanation
for the attacks that may well continue for long periods. Threats of imminent

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leaving seem to the therapist like a manifestation of the death instinct.

Repetition seems like a dead weight. Cycles of threat followed by a
grudging continuation may need what Symington (1986) called the
‘analyst’s act of freedom’. After a long impasse he managed to see that he
was disregarding his patient’s potential for change and development. His
disregard had been expressed by allowing her to continue to pay a low
fee. This emotional deadness had held both of them in a repetitive groove.
When Symington was able to move, the whole course of the work changed.
If the therapist cannot find some life in this way, the patient may commit
an act of freedom which will turn out to be destructive.
Some therapists may well seek to excuse bad work blaming it on the
patient’s envious destructive instinct. On the other hand, all therapists
are likely to encounter sooner or later the patient whose thinking and
reflecting function is so unreliable that he is not able to respond to what
is being offered or to ask for something different with anything other than
hate and acting out. The acting out may take the form of missing sessions
or of being late for sessions. Either of these may be interpreted or
occasionally ignored by the therapist, because, if anything, they make
the therapist’s life easier, and therefore the therapist is tempted to let them
continue. More problematic is the patient who creates a noisy disturbance
or refuses to leave at the end of the session time. The refusal may be
confined to the small delays of putting on clothes, finding car keys, going
to the lavatory, etc. It may take the form of sadistic behaviour to relatives,
friends or work colleagues. It may be easy to ignore because it may be
carefully separated from the relationship with the therapist. If these
communications are ignored, they may escalate until there is a furious
outburst in which the therapist can stand no more or the patient leaves.

Predicting problematic endings

A careful look at some examples of patients’ behaviour in ending therapy

shows that it relates closely to the kind of problem the patient brings in
the first place. If we could assess accurately, we might be able to estimate
the kind of ending that a patient would seek and to work with that in mind.
Insofar as the projected ending might be a repeating pattern of impulsive
behaviour that cannot be thought about or negotiated, it might well display
the pathology that the patient is coming to discover and change. Of
course, one of the aims of assessment is to discover what the patient
does wish to do in therapy, so that the patient’s wish can be considered

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as part of the whole picture. Unfortunately, assessment in psychotherapy

is still a very inexact science. Many therapists would deny that it is a
science at all, preferring to see it as an art in that every patient is unique
and no laws can be deduced that will not eventually become strait-jackets
preventing or limiting creativity and humanity in treatment. Nevertheless,
trends in patterns of feeling and behaviour can already be discerned even
with the limited longitudinal studies that are currently available.
One way to anticipate the kind of ending that a particular patient might
shape for himself would be to think in terms of psychopathology. I have
already discussed the acting out of the patient who has difficulty in
containing his own anxiety sufficiently to continue in therapy. Does a
hysterical patient seek a different kind of ending from that of an obsessional
person? Does a depressive tend towards a different process from that of
the phobic? Certainly they need different responses from the therapist.

The hysterical patient

If hysteria implies a bodily expression or enactment of a sexual problem, a

hysterical patient will approach intimacy with a need to achieve a sexual
relationship, but will break it off before there is a risk of his or her true
involvement. In this way, anxiety is allowed to rise to a point that is felt to
be bearable and then suddenly cut off before it can damage the patient.
This is the pattern that will be repeated in the therapy in various ways and
will tend towards a sudden and unexpected ending just when the therapist
least expects it. Dora is one of Freud’s best known cases. She has been
made into a heroine by feminists because she loved another woman and
kept her love secret while Freud exercised his male mind on the various
combinations of males desired and desiring that entered her story. Dora
walked out on Freud, simply leaving after one session and refusing to
return. Appignanesi and Forester (1992) in their book on Freud’s women
say, however,

the way in which Dora walked out on Freud is not unambiguously

the victory of her desire for self determining solitude . . . but her
departure may not have been so much the incarnation of the revolt
of women forced to silence but rather a declaration of defeat. For
Dora to have truly succeeded we would have to have seen her
finding the promised land that can be glimpsed through her story,

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the adorable white body of her loved one and her own feminine
silent body, the body that lies beyond the phallic world of Oedipal
triangles, the (m)other woman whom Dora adores.
(Appignanesi and Forrester 1992: 147)

In other words, Dora asserted her desire through her symptoms – her
cough – and kept it hidden from the therapist’s consciousness, but her
walking out was a way of achieving independence of the abusing male
standing in for an abusing father. If, as Lacan suggested, the hysteric is
asking the question: ‘Am I a man or a woman?’ the therapist can expect to
be confused. The way to independence would have possibly been
through therapy and through finding an answer to the question rather
than by circumventing it. As it was, the possibility of arriving at the truth
of her feelings and desires remained only a possibility. In such a case, of
course, we now have the benefit of hindsight and of all the work that has
been done since. At least now, we can expect that someone who seems to
be concealing his or her sexuality by flaunting it will set up a relationship
with the therapist where someone is tending to be abusive and someone
is abused. A sudden ending can be anticipated and the possibility can be
addressed consciously.

The obsessional patient

The opposite difficulty arises with the patient who is obsessional. Such
patients are likely to make therapy into a ritual which cannot end. The
question being asked by the obsessional patient is: Am I alive or dead?
He or she is trapped within deadly repetition that is felt to be safe since it
prevents change. The obsessional patient, however, may make a sudden
ending if the therapist is unable to anticipate the anger that is being
hidden by the obsessional symptom. A moderate degree of obsessionality
can help the therapy because it will enable the patient to come regularly to
sessions and to tolerate the rhythm of the hour and the week. If the
obsessional symptom is itself the presenting problem, it may be
inaccessible to psychological treatment and may respond best to
cognitive/behavioural approaches. The obsession has been developed
in order to protect the patient from an awareness that would be extremely
painful.
Nemiah (1961) describes a patient who had obsessional thoughts of
anxiety about bumping into someone in the street. Nemiah tracked the
anxiety down to fear of knocking the person into the road, and was then

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able to reveal the wish to do so and the hate and anger that lay behind the
wish. In that case, the patient was totally dependent on his mother, still
living with her at the age of 40 and fearing to go out without her. His
obsessions protected him from the knowledge of his aggression and fury
with her and his wish to achieve his freedom and to begin to live his own
life. The patient was very afraid of this knowledge and had endured an
unpleasant state of mind for some time in order to avoid just this
recognition. A therapist who gets near to such a revelation is bound to
risk the sudden ending which protects the patient and also protects the
therapist from the full brunt of the anger that would come his way.

Slamming the door

Patients with narcissistic difficulties in relating are raging internally, often

to the point of walking out of therapy. They may be held back by a number
of internal factors. The most positive might be the hope that somehow the
therapist’s containing presence can help to ease the painful compulsion
to hate and destroy. The definition that Kernberg gives for the narcissistic
personality implies grandiosity and an inordinate need for praise and
reassurance. There is a ‘curious apparent contradiction between a very
inflated concept of themselves and an inordinate need of tribute from
others’ (1985: 17). He and Kohut (1971) add the idea of sexual perversity
as a characteristic quality of these patients, at least in fantasy. All these
writers emphasise the idealising of the therapist that may happen because
one way of feeling sufficiently loved and admired is to separate out the
people who are not responsive from those who are. The therapist must be
kept in the admiring role and the others are then despised. Therapists may
be tempted to collude with this because it is a welcome change from
addressing the negative feelings of other patients. Kohut gave a rationale
for staying with the idealising for a while, but sooner or later the
disillusionment must begin. This situation is highly unstable and can
change into hatred and scorn of the therapist. If this happens there is
clearly a risk of a sudden ending.
Kernberg (1985) has set out a very detailed diagnostic framework in
which he makes distinctions between narcissistic, hysterical and borderline
pathologies. He arrives at a prognosis for each in general terms and
discusses what is likely to happen when the syndromes are mixed. He
makes clear that in his view not everyone can or should receive therapy.

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Borderline psychotic and paranoid symptoms particularly benefit from

the support of a team working within an agency and are not likely to do
well with a therapist working alone in private practice where there is too
much scope for paranoid fear and aggression to become unbearable for
either the patient or the therapist.
Therapists need to know how to work in such a way that these people
might be able to stay and work through to a more balanced and realistic
view of the therapist and therefore of other people. Kohut’s view that the
therapist should use empathy to work with the patient’s feelings of need
and entitlement rather than to challenge them is well known. Kernberg
believed that because rage and frustration is so prominent in these patients,
they need to be faced with their destructiveness. For Kernberg,
interpretation of defensive behaviour and its purpose was essential
technique if the patient was to stay and work.
Mollon (1993) puts forward a model in which he emphasises the role of
the father as the essential element that must be brought in for there to be
successful work. That of course does not mean that there must be a
mention of the actual father or that there must be a male therapist. What is
implied is a need for the therapist to use a thinking function so that the
patient is not allowed to stay in an unreal world with only the mother. The
therapist must bring in other ideas from his separate thinking processes
to challenge the patient to move out of his own fantasies and into a
dynamic relationship.
Each of these writers is emphasising a different way in which the therapist
can contain the rage and the wish to act out sufficiently for the patient to
stay long enough for work to be done. The choice of technique will
depend on the therapist’s own background, training and supervision,
and of course on temperament and the way in which personal therapy has
made parts of the self available for use. Somehow the patient needs to feel
that the therapist has his measure and can cope with him. Any sign of
weakness or fear will lead to panic expressed as rage and a walk out, or a
refusal to stay within boundaries of time or place. Thus it is probably
most important that the therapist is confident with her own model and
feels able to do what is possible within it. Comparison of models is fruitless.
In any model the therapist should be willing to be changed by the meeting
with the patient. If the therapist tries to stick rigidly to a way of working
the result is likely to be disaster because the patient may unconsciously
infer that there is some sort of internal partner with whom the therapist is
communing. The patient is shut out and an explosive situation is created.

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The patient will derive much more benefit from an ending that arrives
when both the therapist and the patient are able to find a way of agreeing
that it is good enough.
A therapist needs to consult feelings about a patient’s ending with
great care. Responses may come from sadistic and retaliatory feelings
that are not recognised, at least at first.

Dr M had been in therapy for five years and had done useful
work on her counter-productive patterns of relationship. Her
mother was a difficult and demanding woman who
nevertheless loved her daughter and was fiercely protective
of her. Dr M found it difficult to express feelings face to face
and often resorted in the early days to writing letters which
the therapist read and brought to the sessions. After five years
she had achieved a better relationship with her partner and
was able to manage the emotional demands of her work as a
doctor. She came twice a week and had reached a point
where she was beginning to think about ending. Dr M found
herself quite unable to raise the idea of ending with her
therapist. Eventually she wrote a letter in which she said that
she would need some help with it because it would be very
difficult, but she thought that she was beginning to be ready
to look at the possibility of ending. The therapist’s response
was to be disappointed that the patient could not say these
things face to face and had reverted to letter writing which
she had not done for some time.
In the next session, the therapist said she had read the
letter and understood that the patient wanted some help to
fix a date for ending, and perhaps the best time would be the
therapist’s summer holiday. The patient seemed to accept
this and went away. She came back to the next session,
burst into tears and said that she had not been able to say
how upset she was that the therapist had jumped to the
conclusion that she wanted to settle the ending date so soon.
She had been afraid to mention ending at all face to face and
could see that this related to the kind of response she might
have found in her mother. The therapist’s response had played
right into the fear that her mother’s love was conditional and
would be taken away if she showed any sign of independence.
The therapist searched her own feelings and realised that

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she had been angry about the move towards independence.

She enjoyed working with this patient and did not want her to
go. The response was in effect saying, ‘all right, if you want
to go, go; see if I care.’ After this work had been done, there
was a possibility of both working towards an ending and setting
an ending date with, perhaps, more regret on the side of the
therapist. This was the therapist’s problem and while sadness
at ending can always be acknowledged, the therapist must
be responsible for managing his or her own feelings enough
to work without burdening the patient.

Whatever the therapist thinks about the patient’s unilateral decision to

end, at the last minute he must give his blessing to the one who is
departing. This is movingly described by Dorothy Hamilton. She told her
supervisor that she was losing a patient. ‘He said “Give her your blessing”
and just in time I did’ (1997: 173).

Silence

Many of the patients who leave therapy prematurely, in the therapist’s

view, do so because they have not formed a strong attachment to the
therapist or, in other words, they have not been able to bring the re-
enactment of past conflicts powerfully into the present with the therapist,
or the conflicts themselves were buried before they ever surfaced. This is
the problem of the schizoid personality, the person who guards against
relating most carefully because loving is felt to be more dangerous than
indifference. Guntripp (1968) described vividly the arid desert landscape
of the schizoid personality. These are people who come to therapy because
their lives are empty or dull. They are only half alive and yet they know
that there must be more to life. They provide a great challenge to the
therapist and are most likely to leave disappointed though quite calm
after two or three years of therapy, saying that it was quite interesting but
not enough happened. They may not have been literally silent but their
speech has been empty.
Of course such patients are doing their best to make sure that nothing
does happen, but they may also be with a therapist whose personality is
not useful to them. Two schizoid people together may never make sparks
or be able to stir up some life. In such cases, more interpretation may only
increase the intellectualisation and the desert is not allowed to bloom.
Jeremy Holmes (1997) has pointed out the problems that may arise for the

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patient who is avoidant in relationships if he is with a therapist who

emphasises the structure and boundaries of the therapy rather than
emotional attunement. Such a patient may end too soon. If the patient is
ambivalent in relationships he may cling to attachment figures, and if the
therapist is too empathic and not sufficiently aware of the need for limits,
the patient may stay too long. There are many variations on this theme of
patient–therapist fit, but each therapist needs to discover what is her own
tendency so that it may adapt to the needs of a particular patient.
Finally, some patients simply leave therapy in silence, giving the
therapist no explanation for their disappearance. This may arise from fear,
happening just when there is a possibility of greater vulnerability for
some reason, but the effect on the therapist is such as to lead to the
suspicion that there is unexpressed anger. Most therapists when left in
this way feel injured, abandoned, mystified, undervalued. Leaving behind
such feelings as these makes the aborted therapy feel like a bereavement
or, worse still, a suicide. The silence of the grave is absolute and so very
often is an aborted therapy. Therapists have to be able to deal with the
feelings aroused in themselves and to try to learn what they can from the
experience. Very often, something can be discovered about what was not
said or done in time, but sometimes there is no answer, and the therapist
has to live with the silence and the sense of failure and whatever that
means to him or her personally. One of the reasons for undertaking this
profession is, I suspect, that therapists desire to learn to cope with loss,
since it is our constant professional experience. However patients leave
us, we have to put up with the loss of what had at least the potential to
become an intimate relationship.

References

Appignanesi, L. and Forrester, J. (1992) Freud’s Women, London: Weidenfeld &

Nicolson.
Dinnage, R. (1988) One to One, Harmondsworth: Penguin.
Freud, A. (1968) ‘Acting out’, International Journal of Psycho-analysis 49: 165.
Guntripp, H. (1968) Schizoid Phenomena, Object Relations and the Self, London:
Hogarth.
Hamilton, D. (1997) ‘Response to Jeremy Holmes’, British Journal of
Psychotherapy 14: 172.
Holmes, J. (1997) ‘Too early, too late: endings in psychotherapy – an attachment
perspective’, British Journal of Psychotherapy 14: 159.
Kernberg, O. (1974) ‘Further contributions to the study of narcissistic
personalities’, International Journal of Psycho-analysis 15: 215.

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Kernberg, O. (1985) Borderline Conditions and Pathological Narcissism, London:

Aronson.
Klein, M. (1957) ‘Envy and gratitude’, in (1984) Envy and Gratitude, London:
Hogarth Press.
Kohut, H. (1971) The Analysis of the Self, New York: International Universities
Press.
Kohut, H. (1977) The Restoration of the Self, New York: International Universities
Press.
Mollon, P. (1993) The Fragile Self, London: Whurr.
Murdin, L. (1995) ‘What harm can it do?’, Psychodynamic Counselling 1: 3.
Nemiah, J. (1961) Foundations of Psychopathology, New York: Oxford University
Press.
Philips, A. (1986) Winnicott, London: Fontana.
Ragland, E. (1995) Essays on the Pleasures of Death, London: Rebus Press.
Samuels, A. (1999) ‘From sexual misconduct to social justice’, in Mann, D. (ed.)
Erotic Transference and Counter Transference, London: Routledge.
Symington, N. (1986) The Analytic Experience, London: Free Association Books.
Symington, N. (1993) Narcissism, a New Theory, London: Karnac.
Sulloway, F. (1992) Freud Biologist of the Mind, London: Harvard University
Press.
Winnicott, D. W. (1986) ‘Fear of breakdown’, in Kohon, G. (ed.) The Independent
Tradition, London: Free Association Books.

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 5
TIME TO GO
The therapist ends

Since there’s no help, come let us kiss and part.

Nay I am done, you get no more of me,
And I am glad, yea glad with all my heart
That thus so cleanly I myself can free.
(Drayton 1975)

Therapists do not generally initiate endings in therapy unless they have

very good reason to do so. There are times when people leave because
the therapist unconsciously wishes them to do so, but by and large,
therapists would prefer patients to stay until there can be a mutual
agreement that the patient is ready to go. There are three main identifiable
areas in which the therapist may be the one who initiates the ending. The
first is obvious. Therapists are susceptible to external reality just as their
patients are. They will have partners who need to change jobs, and parents
who need looking after. They will get sick and they will die. They may just
want to stop practising therapy and retire to the country to open a
restaurant or a shop or do the garden. Another group of endings will be
those that take place because the therapist cannot or does not wish to
continue working with a given patient. Finally there will be the endings
that are more or less mutually agreed but have been initiated by the
therapist for therapeutic reasons.

The therapist’s need

The first group of endings will be likely to be difficult for all sorts of
reasons. If the contract had not stated that there would be an ending at a
particular time (see Chapter 9), the patient will at best have mixed feelings

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on being told that the therapist will not continue the work beyond a
certain date. Schachter (1992) states that a study of endings shows that
as few as 50 per cent of analysands continue to a mutually agreed ending,
but the therapist who decrees an ending is rare. When the therapist does
have to announce that the work will end at a certain time, the patient is
likely to be faced with conflicting desires. On the one hand, there is the
anger and disappointment over being abandoned. For some people that
might translate directly into action, such as leaving before being left or
demonstrating independence by being late for sessions and so on.
Depression as a result of powerlessness leading to suppressed anger for
sessions and displaced grief might well be expected.
On the other hand, some people work as hard as possible in the time
that remains in order to achieve all that can be done in the time available.
On the positive side is the wish to end well with the therapist so that he or
she can be taken away in the patient’s head as a good, conscious image to
be called upon when it is needed. This conscious recall of the therapist
which is expected and thought about by some people is part of a much
deeper need. Unconsciously, there may be the possibility of a sense of
self which at this stage is still being formed by multiple experiences in
therapy of learning to think and to use what the therapist does and what
the therapist is.
The development of a reliable sense of self depends on many factors.
First of all, of course, it depends on the definition given to the concept of
self. The group of people who have a very undeveloped sense of self and
cannot reflect usefully on themselves are often described as borderline
because they cannot easily process their thoughts and feelings, if at all,
and are on the edge of losing control completely. Freud gave the ego the
highest position in the psyche as the agency of thinking, rationality and
the relationship to the outside world. The self psychologists, most notably
Kohut (1977), postulated a self that exists in addition to the psychic
structure of id, ego and superego, and is in fact a superordinate structure
in its own right. Therapeutically, Kohut’s views have been influential
because he has emphasised the role of the therapist as a self object; that
is, someone who is used by the patient to enable the self-concept to form
adequately. The self object is someone who is not wholly you and not
wholly me. In Kohut’s view, it functions through the therapist’s empathy
and depends on the therapist being reliable and more loved than hated.
The patient may be aware of this need at some level and this need conflicts
with and limits the desire to act out resentment and anger.
The essence of Kohut’s view of the therapist is that he is valuable to
the patient, particularly the narcissistic aspects of the patient, by becoming

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a self object. This is important because the narcissistic problem has, at its
heart, fear of injury from others. As long as the patient fears that closeness
to others is going to result in damage to the illusion of omnipotent control
by which the other can be kept as nothing more than a mirror image of the
self, there is no hope of adequate relationships with others. The therapist
is therefore of value because he or she is empathic and does not offer
unbearable injuries. This usually means keeping interpretation or response
of any kind to a level that conveys understanding and warmth but does
not emphasise separateness by over-clever interpretation.
Therapists have disagreed about the extent to which interpretation, in
the sense of making links with the past or outside world or commenting
on the workings of the psyche, will be useful to these patients. Few would
disagree that reliability and a steady technique are of great importance
because when the therapist is under great pressure, there is most
temptation to retaliate by abandoning the patient. Clearly, therefore, the
therapist’s decision to end therapy because of illness or other
circumstances is likely to feel like an injury. The illusion of unity and
control is shattered. One would expect this to cause serious disturbance
or at least further regression. In some cases it does, but for many, provided
that there is a long enough period of warning, useful work is done under
the pressure of time.
Therapists are becoming aware of the need to provide for patients in
the event of their own death or serious illness. Therapeutic wills are now
generally recognised as a necessity. Another therapist is named as the
executor who will be told by the next of kin to speak to the affected
patients and will try to see them or decide whether they need a referral to
another therapist. The death of a therapist is a blow which may cause a
grief reaction, frozen in the regressed infantile state in which thinking
capacity had been temporarily delegated to the therapist who is no longer
there to help.
Not dying but leaving is a more common trauma imposed by therapists
on their patients. I have had the experience of deciding to close a practice
in one part of the country in order to move to another area for personal
reasons. This meant that I gave those patients who were in psychoanalytic
therapy with me one year’s notice of my departure. For most people the
one year’s notice gave time to move through variations of love and hate
and to arrive at some sort of readiness to end. A few went to other
therapists. Most managed to find resources in themselves both to make
extra use of the time that was available and to forgive me enough to let me
be at least an ambivalently loved and hated object, rather than all bad.

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One patient who found the ending particularly difficult was Mr

N. He was an artist but had ceased to paint and did some
part-time teaching. He suffered a great deal from bisexual
desires and sometimes went to act out his homosexual
feelings in men’s toilets and clubs. He was married and had
one child and once, when his wife was away, he had gone
out and left a tap running which had caused a flood. Agonies
of guilt and terror had haunted him ever since, along with a
sort of awe at the power of his own desire, as he saw it, to
cause such a disaster. He had been to various therapists
who had tried to cure him of his guilt but he had successfully
resisted all attempts to change him.
Twice Mr N left to take up teaching jobs which took him
away from therapy, but each time he came back after a few
months and returned to therapy. The third time, he resolved
to stop running away and to stay until he was cured, which
would mean that he would be able to paint again and stay
settled in one place with his family. I then told him that I was
going to be leaving in a year. He was in the middle of working
out the ways in which his outbursts of anger at this wife were
expressions of the anger and resentment left over from his
infantile and Oedipal experience. His father had left home
when he was 4 years old and his mother had withdrawn into
a cold, grudging depression. He found me cold, heartless
and indifferent, but as long as he was able to continue to see
me three times a week, this was bearable for both of us. As
soon as he knew that the time was limited, the sense of sin
hit him powerfully. My leaving was because he was so evil
that I could not bear to stay. He veered wildly between begging
forgiveness to the extent of being willing even to say that the
therapy had been useful, and a cold rage that expressed
itself in arriving late and missing sessions without warning or
explanation.
The need for a self object that would enable Mr N to develop
a sense of independent self was intense. He longed for a
father who would be strong and reliable, but who would also
judge him with justice. He had no such reliable and authoritative
internal father and I was worried too that he would not be able
to make enough use of me in the time remaining to allow him
to develop what he needed inside himself. I was especially
worried that my leaving would deprive him of the ability to see

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me as good enough. Mr N’s visions of what life might be after

I left were split. On the one hand, he might allow himself to
be better, having enough inner calm and strength to stay with
his wife and not go out looking for men. The trouble with this
was partly that such a vision for him at that time meant
something static but pure like being in heaven. The other
possibility was that he might be taken over by his evil desires,
as he saw them, which would take him away from the
benevolent father for ever but, as in hell, the picture would be
full of his vigorous sexual energy. He was afraid of my
judgement of him and his judgement of me. Paintings of the
Last Judgement show God the Father enthroned, presiding
over the work of the angels and devils who are literally weighing
the souls of the dead to determine whether they go to heaven
or hell. Heaven has beautiful colours and light but tends to be
static. Everyone sits still with beatific expressions. Hell is
full of overwhelming action and energy all directed towards
torture.
One of his dreams soon after I told him of my impending
departure illustrates his anxiety about having or not having
what he longed for. He was in a sweet-shop with a very high
counter but he was afraid to go up close and look at the
sweets. He wanted something that he had once had before
but could not remember its name. Perhaps it was some sort
of medicinal mixture. He thought to himself, ‘Oh it won’t be
there anyway.’ Telling me about it afterwards he said, ‘I forgot
that I could have mixed it for myself from the other sweets
that were there. I was ashamed to go near and ask for
something. I was ashamed of the excitement of maybe getting
what I wanted. It would have to be offered to me. But then I
think I would not have wanted that either. I would have to get
it for myself but there is not time. The shop is going to close.’
The thought of ending was bringing him both hope and fear
of change. The unconscious conflict between the two was
well represented in the sweet-shop dream. On the one hand,
he hoped for heaven: milk, honey, medicinal sweets. He
wanted to return to his mother’s body and have his father’s

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love and approval all at the same time. On the other hand,
moving forward brings the risk that he might steal the sweets,
or at least be exposed as wanting too much. He might just
steal the sweets and run. Mother and father will never give
him everything he wants. The fear of ending, like the fear of
death, becomes the fear of change itself and what that might
mean, and also fear of the loss of the ability to change. If the
shop closed or the therapy ended there would no longer be
any possibility that some sweets might be offered legitimately,
or that he might allow himself to mix them.
Many times Mr N had said that he would be able to paint
only after he left me. At the time, I thought that he needed to
leave me as the clinging depressed mother who did not want
him to grow up and leave her. He could not leave his mother
and he could not satisfy what she wanted. If he tried to satisfy
her, the powerful image of his father threatened him with
punishment and impotence. The only way he could get
something for himself was by stealing it. He had been able to
feel that he could steal from me in some ways, by taking
what I said or did and not letting me know that it was any use
to him, but once I said that I would be leaving, I had stolen his
time away from him and left him nowhere to go.
Abandonment can feel like deprivation. Mr N had been
abandoned by his father and left emotionally alone by his
mother. My abandoning him always felt bad at the ends of
sessions. The abandonment of ending seemed unforgivable.
Yet the therapy itself had perpetuated something of what
paralysed him. He was always hoping that I would be the
father who would empower him, but he found me frightening
and dangerous. He wanted me to be the loving mother who
would want him there and yet would free him to be himself.
He had become stuck between his conflicting needs, making
very little progress because taking in my words made me
seem too powerful. In the ending period though, he knew that
he would have to move on. Things could not stay the same.
The one way in which Mr N believed that he could feel less
impotent was in choosing the time of ending. He wished to

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leave before I left. He developed the idea that doing so would

be a creative and freeing act. I was uncertain whether he
needed to do so in reality or whether it would be sufficient for
him to know that he could. I continued to say to him that I
believed he could derive strength only from destroying me as
the mother who deprived him and as the father who would not
help him to be a man in his own right, but that perhaps he
could still find some use for the time in discovering whether
there was any other way of going. The actual ending was a
compromise because he chose to leave two weeks before
the date that I had proposed, but in this way he gave himself
most of the time available.
Once this ending was agreed, a great deal emerged in the
last few sessions of his need and love for his mother and his
gratitude for my having not let him go too easily, while not
holding on to him too powerfully. He was able to tell me that
he loved both his father and his mother as well as being
furiously angry with them and wanting to wipe them out by
flood or fire. This represented the best that he could manage
in his feelings about me. His feelings for his wife had become
more calm and seemed less to be a matter of projection.
Nevertheless, he left me with the feeling that there was much
more to do. I experienced a great deal of regret and concern
for him. I could not say that there was a resolution of the
process by which I had represented the parents, but that
there was perhaps a better solution within it. The ending
became the ending of therapy, but not the end of the process.

The therapist loses faith

Mr N’s ending demonstrated both the difficulty and pain of an imposed

ending and also its possible value. A second group of endings is even
more difficult for both patient and therapist to tolerate. These are the
endings caused by the therapist ceasing to have the heart or the courage
to continue. These sorts of endings occur for a variety of reasons. We
hear about them often because they lead to complaints. Ethical questions
are raised by the patient who is hurt, feels damaged and wishes to force
the therapist to continue against his or her will. In fantasy, the patient

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believes that he can compel the therapist to want him after all. The
therapist’s wish to end is all a terrible mistake. One or two examples have
come to light where the patient has developed a severe version of what
Balint (1968) calls a malignant regression.
Balint describes the situation in which a patient cannot bear the usual
frustrations of the therapeutic situation in which, essentially, the therapist
gives only words:

traditional behaviour of sympathetic but passive objectivity is felt

by certain patients as unwarranted and unbearable frustration.

As a result, he

decides – either for himself or in agreement with his patient – that

a new regime must be established by doing something more, over
and above the traditional passivity. This something more amounts
always to gratifying some of his patient’s regressive urges, to
responding positively to the patient’s acting out. As a rule this
change brings some immediate improvement.
(Balint 1968: 113)

Unfortunately, as Balint goes on to point out, this gradual approach to

gratifying the patient leads to greater and greater demands. As he puts it,
the patient responds gratefully with the more developed part of himself,
but the seriously regressed part just demands further gratification to
prove the therapist’s love. The problem is intensified because the patient’s
need is such that the gratification must be irrespective of the patient’s co-
operation or gratitude, and must be offered without any taint of
compulsion. Any frustration provokes a vehement response and further
acting out.
Most therapists come across the kind of difficult regression that Balint
is talking about at some point either directly or through the difficulties of
a colleague. The patient will be persistent far beyond the norm in
demanding extra time or physical contact. There will be telephone calls,
extra sessions, difficulties in ending sessions on time. The therapist will
often try to find reasons to accede to the demands in the beginning. As
Balint points out, this may bring a period of calm and is such a relief that
there is a strong temptation to continue in that direction. Theoretical
justification could be found in the concept of management or Winnicott’s

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nursing care (1985: 131). Intuition is often invoked: ‘I just know that he
needs this or that in reality and symbolic care will not be enough.’ Nothing
is ever enough, and sooner or later there will be a point beyond which the
therapist is not prepared to go. The telephone calls will come in the night
or will break too often into personal time and will lead to objections from
other family members. In desperation, the therapist makes a sudden move
to end, either by trying to make a referral to a more senior colleague or
simply by trying to hand over to the medical or psychiatric services.
Sometimes a specific referral provides continuity that helps with the
ending. Sometimes a referral to a specific person emphasises too much
the continuing emotional presence of the original therapist and therefore
the difficulty. Anne Leigh has written about termination and referral issues
for counsellors. She discusses referral letters and offers a prescription for
making a good referral (1998).
Ferenczi’s experiments in treating regression by gratification were not
encouraging. In some cases there was a small improvement, in some the
result was disastrous (Balint 1968: 113). Nevertheless, Ferenczi died leaving
many questions unanswered and we certainly cannot say that his methods
would never have been successful. Balint pursues the idea that a regression
may lead the patient to make demands for satisfactions that belong to
very early infantile states. He points out that to gratify these needs may
be a different category of behaviour from gratifying demands which have
become genital. The difference is expressed in terms of the type of
regression: is the patient seeking to make use of the therapist with the
regression in the service of a new beginning, or is he aiming only at
gratification from the other person? This question is obviously difficult
to answer. Difficulties arise because so often it can be answered only
once the patient is already in the midst of the work.
Balint recommends that the therapist should consider some forms of
regression to be helpful and potentially in the service of development.
This is currently a common view of regression, but there is still no infallible
answer to the question of how to deal with the patient whose demands
are for gratification only. Perhaps in many cases there is no alternative to
an ending which is just made as tolerable as it can be for both parties.
Balint, however, does have some hope. He illustrates his position with a
description of a patient who asked for an extra session over a weekend. In
this case the therapy was just entering the stage where it might become a
malignant regression:

What I tried to do in this case was first to recognise and respond

to his distress so that he should feel that I was with him and then
to admit that I did not feel that an extra session granted by me

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would be powerful enough to give him what he expected and

perhaps even needed at this moment; in addition this would make
him small and weak while his analyst would become great and
powerful, which was not desirable. For all these reasons the
request was not granted. The patient then departed dissatisfied.
(Balint 1968: 171)

Balint’s patient was dissatisfied, but he returned and was able to work
with what had been said to him. Searles (1965) demonstrates the need to
work with his own sexual tension. He tells of the attraction he felt to a
woman patient and his attempt to deny it by speaking to her of the maternal
transference in terms of feeding and her need for him to feed her adequately.
But, he points out, the patient was well aware of his feelings of sexual
desire for her. She seems to have pointed it out tolerantly and gently.
Some patients are not so kind and are capable of abusing the therapist in
revenge for their own unfulfilled and unspoken longings. When there is a
powerful erotic desire on either side, the therapist is likely to be tempted
into a precipitous ending out of fear, rather than for the benefit of the
patient.
One parent alone with a child runs the risk of potentially abusive power.
Internally, at least, the therapeutic relationship needs the reflective third,
whether an actual supervisor or an internalised therapist or a supervisor
from the past. Sadly, this is not always enough. For some therapeutic
pairs, the only answer seems to be an ending. The therapist may find the
demands of the very regressed patient too much to handle. The work with
Mrs Q shows how difficult it can be to continue to work in these
circumstances:

Mrs Q is a recently divorced woman in her late twenties. She

is a teacher working with adolescents and presents herself
as bright and sharp. She comes to a therapist after having
interviewed three other therapists in the area, all of whom
she had rejected because they were not prepared to see her
after school hours for a reduced fee. She settled on her actual
therapist, Mrs R, with a bad grace, complaining that she
needed more empathy with the difficulties she had experienced
with the previously visited therapists. At some level she
probably knew that she needed some toughness in the
therapist. As a result, the therapy began with a clearly negative

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feeling. The therapist was just tolerated. Mrs R tried

interpreting the scorn that she experienced as Mrs Q’s way
of protecting herself from having to feel any gratitude for finding
someone who actually would take her on for a low fee at the
desired time of day. Mrs R had taken her on because, in
spite of some misgivings, she saw a possibility of working
with the narcissistic problems presented – the failed marriage
and a powerfully negative relationship with the headteacher
who was an older woman – and also because she had a
space at the time requested.
The first sessions were very bumpy. The patient became
extremely angry because Mrs R was not being sufficiently
empathic and because her use of words was irritating. On
one occasion, she was being told about the patient’s desire
to move out of her shared flat. Mrs R said, ‘You are cramped
in your present home.’ The patient became enraged. ‘I can’t
stand people who say “home”. Why can’t you say “house”?’
Very little was known about the patient’s history except that
Mrs Q’s mother was ill and in hospital a great deal during her
childhood and her father had left and remarried when the
patient was 10 years old. Any mention of the past was felt to
be an avoidance on the therapist’s part of her responsibility
in the present and for not being sufficiently understanding,
wise and helpful.
At the same time, the patient was doing all in her power to
prevent the therapist from being able to understand what she
was saying. The patient’s communications were always rapid
and confusing, with stories beginning in the middle and
referring to people who had not been previously mentioned,
but giving a clear indication that they should be known to the
therapist already. ‘You remember I told you about Joy . . .’
A great deal of the scorn was related to the therapist’s
having a different style from the two male therapists who had
been interviewed by the patient. Mrs R interpreted this as the
scorn for the therapist who would take her on, like the mother
who remained, in contrast with the ones who had not been
willing to make the necessary concessions. Interpretations
were greeted with rage and comments about the stupidity of
the therapist. ‘You just want to make it all my fault so that
you don’t have to see how you’re not helping me.’ The therapist
acknowledged that she was not helping much but said quietly

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that perhaps there would have to be some attention to why

the patient found it so difficult to see anything at all as helpful.
At the end of the third session, the patient said, ‘I’m not
leaving until you say something useful.’ The therapist was
quietly firm and Mrs Q left after five minutes. The next time
she found reasons to stay even longer, and the therapist
became anxious that she would intrude into the next patient’s
time.
Supervision was helpful in containing the therapist’s anxiety.
Various techniques were employed to make the end of the
session less difficult. There was a temporary improvement,
but in the sixth session the therapist told the patient about
her impending holiday which was a month away. The patient
stayed, refusing to move until the therapist said that she was
going to collect the next patient. Mrs Q then rushed out of
the building and stood screaming outside the therapist’s
window until the receptionist persuaded her to leave. The
therapist decided that she could not cope with such upset to
her other patients and wrote to say that she would not see
Mrs Q any more but would help her to find another therapist
if she wished. Mrs Q wrote to the therapist’s professional
body to complain about Mrs R as incompetent for having
abandoned her in the middle of ongoing work. The complaint
was not upheld because Mrs Q had constantly told the agency
that the therapy was harmful to her, and the conclusion reached
was that she could not claim that a referral elsewhere was
potentially more damaging, and in fact, such a referral might
actually help.

From the outside, it is very difficult to see how this therapist could have
worked more helpfully within this situation. There is probably a sense in
which the problem is one of personality. There are some therapists with
an internal warmth and authority which comes across to patients in a way
that leaves no need for dangerous acting out. As in teaching, this seems
to be difficult to acquire. Either you have it or you do not. Sometimes, a
crisis of this sort will produce it, but, as with classroom teaching, the
therapist who is tentative or anxious at the first time of challenge is unlikely
to be able to regain the necessary authority. The patient at some level
knows that the therapist is powerless to prevent the kind of scene that
happened in this case, and is of course, at one level, setting out to destroy
the therapy. Whether any therapist could have worked usefully with this

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patient is debatable. Certainly, the implication is that the therapy as it

developed was too dangerous and had to be stopped. The therapist did
not address the difficulty and fear for the patient in being alone with a
woman who represented her mother and symbolically was felt to have
abandoned her and also somehow deprived her of her father. Perhaps it
was just too dangerous with this particular therapist if she could not hold
the damaging part of the patient sufficiently firmly and safely.
Anna Freud (1968) makes a useful distinction between the habitual
acting out of the impulsive patient, and the neurotic patient who acts out
in order to communicate with the therapist. She characterised the impulsive
patients as those who are psychotic, pre-psychotic, paranoid or addictive.
These groups will act impulsively whether or not they are in therapy and
will not restrict their actions to the therapeutic context, however carefully
the therapist works. To work with these sorts of difficulties implies
accepting the inevitability of destructive behaviour of various sorts and
the willingness to tolerate a certain amount of it while knowing very
clearly where one’s limits must be set. Nevertheless, she points out that
even in these cases, memories, or as we might prefer to say today, meaning,
can be extracted from observing and experiencing the behaviours. It is
therefore possible that some sorts and degrees of these behaviours can
be brought sufficiently into the therapy and contained there for the work
of symbolising and reflecting to be done. This will depend on the tolerance
and firmness of the therapist, although Anna Freud herself places the
responsibility for the safety of the therapy on the ego strength of the
patient:

There is no doubt of course that also in this extended form of

acting out the patient repeats his past and that memory can be
extracted from the re-enactment. Whether the ensuing
reconstructions serve the recovery of the patient will depend in
the last resort not on the quantity or quality of the acting out itself
but on the intactness or otherwise of the ego’s synthetic function
to which the regained material is submitted.
(1968: 169)

If the therapist could survive and contain the anxiety, he could say to the
patient that it would be a great pity if the disastrous experiences of the
past had to be repeated to the extent of ending the therapy. This may well

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be heard as a threat which, of course, to some extent it is. On the other

hand, it may provide a patient with a way out of the impasse if the therapist
is able to show that he or she is nearly at the point of giving up but is still
prepared to go on working if the patient will allow. The only hope in this
sort of difficulty is to address the patient’s thinking potential and to
combine it with very firm management.

Referral in a hopeless situation

Masud Khan (1989) gives an account of a therapy in which he worked

with a patient who had driven her first therapist, whom she called Calamity,
to the point of abandonment. She had, however, managed to make a
referral to Masud Khan before she gave up completely. Masud Khan
began work with the patient with the advantage of already knowing the
sort of uproar that she created. He describes the first meeting in which he
made clear that his houseboy was available in the background to deal
with any trouble. He also shook the patient’s hand with a powerful grip,
shocking her by his strength and his willingness to demonstrate it to her.
He tells us that he then had no problem with her in the sense that, although
the therapeutic work was difficult, the acting out in the sessions was
minimal. One conclusion we can draw from this is that although physical
strength and reinforcements are desirable in this sort of case, there is also
some help to be had in knowing what has gone before and facing the
patient very clearly with the destructive nature of their behaviour. If this
can be done, it may be possible to avoid the disastrous ending even
without Masud Khan’s physique or domestic retinue. What Khan’s
demonstration of strength does reveal is the importance sometimes for
the patient of knowing that the therapist will not change in terms of the
firmness of the management and the framework of the therapy. At the
same time, he shows that he is willing to listen and be changed internally.

Ending an impasse

In cases where the therapist decides that the therapy cannot be improved,
it may be ended gradually and by design rather than catastrophically.
Freud ended the analysis with the Wolf Man, not because he could not
continue but because he was aware that no progress was being made. He
had set out the course which he considered an analysis must take if it

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were to be considered complete. First of all the infantile phantasies must

be laid bare. By this he meant that beneath symptoms, whether phobic,
hysterical, or obsessional, there will be phantasies which are derived from
infantile misunderstandings of adult sexuality and the bodily functions of
the child. These phantasies must be discovered from the symptom itself
and from clues such as dreams and details of the person’s history as it is
remembered in snatches and fragments. Once these have been put together,
there is the possibility of moving on to something else:

After the infantile phantasies had been disposed of in this way, it

would be possible to begin a second portion of the treatment
which would be concerned with the patient’s real life.
(Freud 1918: 283)

In other words, the turning away from reality which the symptom allows
in the present will be understood in the context of an infantile phantasy. If
this understanding is not used by the patient, however, the normal process
of analysis will come to a standstill. Freud found the Wolf Man to be
resistant in a way that will be familiar to most therapists. He had an attitude
of ‘obliging apathy’. He listened, he understood and he remained
unapproachable. He had an unimpeachable intelligence and understood
everything that was said to him perfectly, but he remained largely
unaffected. In fact, Freud says that when there was some small change,
this caused him to take fright to such an extent that he ceased to work
altogether. Freud understood that there was an attachment to him, but
saw it only as a counterbalance to the fear of independence. In fact, it
seems as though the love for the analyst might well prevent the patient
from wishing to get better. In any case, a firm determination to end seems
to have galvanised the Wolf Man into further work because the alternative
would have been to leave without either his loved analyst or the change
that might help him to survive alone.
Freud found by decreeing that the analysis would end on a certain
date, that the patient was able to set to work and produce more useful
associations in the remaining time. Even though the analysis was ended
firmly by Freud, the patient still had further work to do, and although the
neurotic symptoms improved, there was a need for the patient to return to
analysis later with Ruth Mack Brunswick (Murdin 1994: 357). Nevertheless,
there is sometimes a clear rationale for the therapist to end the work, either

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because he cannot find a way to make progress and therefore the patient
is wasting time and money, or because the therapist judges that an ending
date will lead to better progress.
However good the rationale, therapists are taking a risk if they decide
to impose or even suggest an ending date. Klauber (1986) was against
imposing an ending. He writes of two patients who found ending
difficult. Both had suffered loss and were unable to deal with it and
return to healthy functioning. Both formed a strong attachment to Klauber
and were unable to recognise any negative feelings towards him. One of
them, Mrs P, was the more psychotic of the two and she, ironically, had
been referred to him with a flying phobia. She proved quite unable to fly
or leave. After five years of five-times-weekly sessions, Klauber felt
that the analysis was stuck and suggested that she consult a colleague
of his. She did so but was not willing to transfer to the colleague. She
continued in analysis with Klauber at decreasing frequency of sessions
and he was able to say that the analysis achieved ‘some success’.
Working with her led to a constant confusion and anxiety in the analyst,
yet Klauber points out that paradoxically the analyst usually wants to
keep such patients because of the power of the libidinal connection
between them, however negative that might be. He concludes, like de
Simone (1997), that analysts should not end analysis but should wait
until the patient is ready. Anything else leads to trauma for the patient
and possibly for the analyst too.
Klauber makes the vital point that the therapist must suffer the illness
of the patient but that the therapist must get better first. This is an
immensely important aspect of analytic therapy. The therapist must
certainly make every effort to understand and overcome the difficulties
that the patient inevitably imposes on him or her as a communication of
the problem. The therapist must use his or her own therapy and
supervision or consultation to the utmost. A cardinal virtue needed for
this work is patience. Nevertheless, there are times when an ending is
indicated and may be the only way in which the therapist can recover
from the spell cast by the patient. If reasonable notice is given, the
patient may well be able to use the therapist’s recovery to good
advantage, provided that the therapist is genuinely not being sadistic,
careless or impatient but has taken every step to ensure that the process
is responsible and in the patient’s best interests.

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References

Balint, M. (1968) The Basic Fault, London: Tavistock.

de Simone, G. (1997) Ending Analysis, London: Karnac.
Drayton, M., (1975) in Gardner, H. (ed.) Oxford Book of English Verse,
Oxford: Oxford University Press.
Freud, Anna (1968) ‘Acting out’, International Journal of Psycho-analysis
79: 165.
Freud, S. (1918) ‘From the history of an infantile neurosis’, SE 17.
Khan, Masud (1989) ‘The empty headed’, in Hidden Selves, London:
Maresfield.
Klauber, J. (1986) Difficulties in the Analytic Encounter, London: Free
Association Books. (Originally published 1981.)
Kohut, H. (1977) The Restoration of the Self, New York: International
Universities Press.
Leigh, A. (1998) Referral and Termination Issues for Counsellors, London:
Sage.
Murdin, L. (1994) ‘Time to go – therapist induced endings in
psychotherapy’, British Journal of Psychotherapy 10 (3).
Schacter, J. (1992) ‘Concepts of termination and post termination in patient–
analyst contact’, International Journal of Psycho-analysis 73 (1).
Searles, H. (1965) Collected Papers on Schizophrenia, London:
Maresfield.
Winnicott, D. W. (1985) The Maturational Processes and the Facilitating
Environment, London: Hogarth.

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 6
WHAT IS TRUTH?
Values and valuing endings

As soon as I ask the question ‘when should a therapy end?’ I am in the

realm of values. The ending very often occurs as a consensus when the
values of patient and therapist coincide sufficiently. When there is conflict,
whether hidden or overt, the therapist must consult his value system as
well as his intellect. In this, as in all that we do, the therapist is limited with
knowing only her own conscious part in what happens. The analytic
therapist does her best to listen to the patient and to allow for her own
unconscious. In Chapter 1, I considered the way in which the theoretical
model might determine the therapist’s image of a good ending. In addition,
the therapist’s conscious attitude will be formed by personal values and
by personal moral development. There are also some professional values
which might achieve a consensus: all therapists, for example, share a
concern for truth.
Each therapist attaches meaning to the words values, morals and ethics
and each area will be relevant in the ending process. This chapter will deal
with the broad issues of the underlying values that will enter into the
therapist’s decision to end and the conduct of the ending phase. This will
involve a consideration of underlying goals which may not be consciously
formulated for therapists and patients. Chapter 7 will look at the ethical
principles and codes that govern the process of therapy for individuals
and the profession as a whole. Ethics and the science of ethics has a
public implication. Morality is usually defined as the personal value system
that sets out the distinction between right and wrong or good and evil. A
discussion of the values underlying the ending process will inevitably
also have to address the way in which the therapist makes use of his or
her values in choosing how to apply theory and technique to an individual.
In other words, valuing in practice may not always accord with stated
values.

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Are there any values that all psychotherapists might accept? This is a
difficult question. Positivists would deny that there are any universal
truths in the realm of values. ‘Goodness’, ‘rightness’, etc. are always
relative. Most of the debates within the profession arise from matters of
values rather than of fact. The process of seeking to establish agreed
national vocational qualifications for psychotherapy has led to an
acceptance of the differences that divide the profession and also to a
search for underlying common values. Although some do not accept that
psychotherapy can be described in terms of behavioural objectives at all,
for those who experimented with such descriptions during the
consultation process, there was general agreement that we all seek, and
therefore presumably all value:

• a model of the mind and of its functioning

• a model of human development
• a model of change.
None of these models is without controversy. Even if all three are
necessary to the practice of psychotherapy, each therapist is likely to
emphasise the value of one area more than another. Many therapists are
looking for a greater understanding of the patient and for the patient to
have achieved this for himself. Lacanians may emphasise living with the
emergence of the unconscious, and will devalue rational control as the
supreme good. Some models will place greater value on structural change
in the mind while others will value the capacity for relationship and
interaction.

Valuing development

Therapists look for change. This may be seen in terms of a developmental

metaphor. In other words, patients will be seen as having been arrested in
their mental development at a point of fixation, and value will be attached
to helping them to move beyond this point at least to another stage. A
more sophisticated version of this view will be that the patient should be
able to achieve a flexible level of functioning which will include and allow
for forms of thinking, feeling and behaviour that relate to various phases
in the developmental metaphor. Another approach to valuing development
may be to look for differences in relating. The therapist who values object
relations theory will be likely to look particularly for a patient to be able to
develop more mature relationships with appropriate dependency and
intimacy within the transference relationship or in the therapeutic alliance.

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Accounts of relationships outside the therapy may be taken as the

touchstone for improvement.

Valuing happiness

In developing a value system as a psychotherapist, each individual needs

to examine his or her personal moral system which will have been formed
by internalisation and identification. These values will be old family and
parental injunctions such as ‘always be considerate’ or ‘always be
truthful’. As a member of a Western society and culture, I am likely to pay
at least lip-service to some of the accepted value words and phrases such
as reason, autonomy, relief of suffering and resolution of conflict. Freedom
is also a value that needs to be considered in any discussion of the aims
of psychotherapy. Happiness may no longer be widely regarded as an
acceptable aim in psychotherapy, although it formed the basis of early
nineteenth-century utilitarianism and has occupied an important place in
twentieth-century value systems. If we do dispense with happiness we
had better be able to justify such a move, as many patients will expect that
they are going to find at least a degree of happiness.
Freud made it clear from the beginning that analytic work would not
necessarily lead to greater happiness. In ‘Beyond the pleasure principle’
(1920) he wrote that the organism seeks to reduce the level of excitation or
at least keep it stable, making it a special case under Fechner’s principle of
the tendency towards stability, and equated lowering of excitation with
pleasure (German: lust). He pointed out that:

there exists in the mind a strong tendency towards the pleasure

principle, but that that tendency is opposed by certain other forces
or circumstances so that the final outcome cannot always be in
harmony with the tendency towards pleasure.
(Freud 1920: 4)

What opposes the working of the pleasure principle which always

seeks to discharge any tension or excitation immediately, is the prohibition
and demand of what might be called conscience or the part of the ego
known as the super ego. This causes most trouble when the commands
are not conscious but are operating from hidden depths. The self-
preservative and thinking function of the ego may also encourage waiting

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for gratification or shelving the demands of the pleasure principle while

the hidden voices are being obeyed. If the death instinct has any power,
it is opposed to any pleasure except stasis. Freud believed that analysis is
on the side of life. It should reduce neurotic misery, but he understood
that any process which increases the degree of consciousness and the
extent of the relationship to reality is bound to lead to much pain and
difficulty.
Freud was writing in the context of nineteenth-century thought and
was therefore likely to consider the importance of happiness or pleasure.
The two words have slightly different connotations in English but both
do have definitions that relate to the enjoyment of what is considered to
be good or desirable, and the avoidance of pain. Happiness is perhaps a
broader word than pleasure, with more possibility of a spiritual dimension
and less emphasis on sensation. Therapists might put other goals first
but most patients would rate the increase of happiness and the avoidance
of pain as high on the list of their conscious goals. The theory on which
most psychotherapy is based accepts that neurotic disturbance is the
result of an attempt, either conscious or unconscious, to avoid pain,
therefore any therapy that seeks to change the defensive structures must
be concerned with the balance of pleasure and pain and must be concerned
with altering the way in which the individual deals with pain.
When a prospective patient enters the consulting room, she may
therefore be seeking something quite different from the purposes that the
therapist may entertain.

Mrs S comes to see a psychotherapist. She has been referred

by her family doctor because he considers that she is suffering
from depression but does not wish to take anti-depressants.
She is constantly visiting the surgery and complaining of minor
ailments. The GP’s referral letter sounds irritated and clearly
he wishes to have her taken off his hands. When she arrives
for an assessment session she is smartly dressed in a suit,
with a noticeably short skirt. She plunges straight in: ‘I do
not want to waste my time or your time and I would like to
know whether you can be any help to me. I just needed a
little bit of consideration from Dr T, but he is always too busy.
I shall not want to be here for a long time. You hear about
people who go to a therapist for months or even years. Well,
I’m not going to do that. I just want to know what you do so
that I can decide whether you can help me.’

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Many things willl be passing through a therapist’s mind at

this point about the way in which this woman relates to people
and her businesslike desire to be on top of things. This has a
perfectly rational side to it, but also of course there are various
other messages which will be interpreted according to the
theoretical model of the therapist.
Mrs S continued, when invited, to talk about her past and
current situation. She had a job as a publisher’s proof-reader
which she did not much like as it was ‘only reading other
people’s books’. She had been married for about a year, to a
man whom she had known since she was a teenager. She
had felt that this marriage was a mistake and that it had
limited and confined her. Her husband was not a very powerful
man, she said, and she found herself managing everything
for both of them. Now she had come to despise him. ‘He
clings to me. He thinks that just because I married him, I will
stay with him. Well, he’s wrong. I need my independence.
I’ve heard that therapy helps you to find yourself and take
more for yourself. That’s what I want. I’m tired of giving so
much to him. It was the same with my parents. They were all
right I suppose but they always left it to me to have all the
ideas and I got fed up with them. I left home when I went to
university and I hardly ever go back. They just bore me.’
In response to a question from the therapist about what
she hoped to gain from therapy, Mrs S replied, ‘I just want to
be happy. I suppose I want you to help me to be more selfish.’
At this point, the therapist was thinking that there was indeed
much work to be done, but that it was along the lines of
making Mrs S more aware of her existing selfishness than of
helping her to increase it.

This therapist is therefore confronted by ethical problems in deciding

whether to work with this patient and technical questions about how to
work if both wish to begin. The situation also raises questions about the
divergence of values. At least in the present, the therapist was not able to
accept the patient’s valuation of the situation and of the use that she
wanted to make of therapy. I shall return to this patient later.

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Measuring happiness

John Stewart Mill addressed the difficulty of taking happiness or pleasure

as an overriding goal in establishing the system of utilitarianism. He put
forward the following criterion by which actions could be judged as moral
or immoral:

The creed which accepts as the foundation of morals, Utility, or

the Greatest Happiness Principle, holds that actions are right in
proportion as they tend to promote happiness, wrong as they
tend to produce the reverse of happiness. By happiness is intended
pleasure and the absence of pain; by unhappiness, pain and the
privation of pleasure.
(Mill 1861)

The utilitarians worked from Jeremy Bentham’s view, stated at the opening
of his Principles of Morals and Legislation (1789): ‘Nature has placed
man under the governance of two sovereign masters, pain and pleasure.’
All actions are to be judged as useful or not according to the extent to
which they augment or diminish the sum of human happiness. Bentham
invented the Felicific Calculator which sets out to measure units and
increments of happiness. Perhaps if we could agree on how to measure
happiness we might be more able to use it as a guide to the patient’s goals
and therefore to a person’s desire to be untroubled by the process of
psychotherapy.
Mill, however, did not accept that happiness alone is enough to define
the good. He added the view that there are different qualities of happiness
to be considered. We might all have moments of happiness in doing
something fairly basic like eating an ice-cream or listening to a sentimental
song. We might value the ability to enjoy small things but would not
elevate these pleasures into a definition of happiness. We might also be
aware of more disreputable pleasures that we would not wish to admit to
in public and which we would certainly not wish to include in a statement
of what constitutes the good. Such a viewpoint implies that there are
valid judgements that can be made over which kinds of pleasure or
happiness are best. Mill was clear that such judgements are appropriate
and can be made by some people better than by others:

It is better to be a human being dissatisfied than a pig satisfied;

better to be Socrates dissatisfied than a fool satisfied and if the

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fool or the pig are of a different opinion, it is because they only

know their own side of the question. The other party to the
comparison knows both sides.
(Mill 1861: Chapter 2)

Socrates would be satisfied only by an offer of happiness that had a high

degree of rationality and morality in it. Mill put the point that there is more
to the idea of what is good than simple pleasure. He added the view that
those with the knowledge of many pleasures and possibilities are in a
better position to judge what is good than those who have only very
limited horizons.
The psychotherapist has experienced not only his or her own training
which usually includes intensive therapy of the sort being practised. The
question is whether this gives enough expertise to allow the therapist to
decide, for example, in the case of Mrs S, that he has a better idea of what
she ought to want. There is a difficulty in that if the therapist goes ahead
in working towards the goal of greater self-awareness, he may be doing
something that the patient does not want and is therefore infringing her
freedom of choice and her autonomy. In fact, we would not be surprised if
greater self-awareness made her more unhappy at least in the short term
and therefore was directly contrary to her consciously expressed wish.
For these sorts of reasons, psychotherapists have generally preferred
not to deal in terms of happiness and unhappiness. A more promising
field in which to seek the values that we could all accept and hope for
patients to attain has been seen in the concept of autonomy. The argument
for it is that if we cannot agree on specific goals or outcomes, the best we
can offer to our patients is that they should achieve increased autonomy
and be able to go away making more use of choice and self-determination.
We should in fact be freeing them from any dependence on our views of
what the greatest good might be.

Valuing autonomy

Holmes and Lindley (1989) accept Mill’s view that happiness is not a
sufficient description of the good. Mill’s view is that true happiness is
that which an individual would choose if his choices were not constrained
by irrationality or ignorance. Being autonomous implies being able to
choose for oneself what is good. They go on to assert that autonomy is

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‘an essential part of human well being . . . a reasonable level of autonomy

should be regarded as important in the same way as basic forms of physical
health care, (1989: 65–66). For those who do not have autonomy in this
sense, psychotherapy is ‘the best and, in many cases, the only remedy’
(1989: 66).
If autonomy is a central value, it might help us to assess readiness for
ending therapy. We could look at the degree of autonomy achieved. This
argument has several flaws in addition to the ones mentioned above. One
is stated by Erwin (1997), who argues that autonomy should not be the
only or even the primary goal of psychotherapy for several reasons. First,
it may not be the patient’s goal. He gives an example of a scientist who
presents with a problem in sleeping. The scientist does not seek to have
increased autonomy but does wish to sleep in order to be able to work.
Erwin seems to be implying here that it would be possible to be setting
out to increase the autonomy of the patient without at the same time
taking note of his own wishes for control of his sleep problem. A response
to this requires a discussion of theoretical model and technique.
We would be greatly helped with the difficulties of deciding the goals
and the degree of achievement of a patient in therapy if we were able to
take the patient’s wish as expressed in the presenting problem or at any
stage in therapy as the absolute arbiter of decision making. In fact of
course, in many cases, the patient does not give the therapist an
opportunity to affect the decision. In a majority of cases, however,
therapists claim that the decision is a matter of mutual agreement and the
therapist’s viewpoint has at least some weight. If the therapist does not
accept the patient’s view because of an underlying judgement, this is
likely to have an impact on the patient’s decision and the experience of
ending. The therapist at least should try to be aware of the processes
leading to his or her viewpoint.
If the therapist can accept the patient’s view, this would appear to
solve some of the problems in a democratic and morally acceptable way.
On the other hand, it creates great difficulties for anyone working
psychoanalytically. In the first place, how can a patient in the early stages
of therapy who is wishing to take a flight into health, or just plain flight, be
expected to assess the value of continuing with work that will take years
and will follow an inherently unpredictable shape? Second, and much
more crucially, there are difficulties that arise from the structure of the
mind implied by psychoanalytic theory. The theory of repression implies

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that the conscious part of the mind does not know what is repressed. If a
large or significant part of what could be known is not known, how can an
individual be free to make responsible and informed choices?
The difficulties of working from the principle of autonomy towards
conclusions about what should be done in psychoanalytic work are
discussed by Hinshelwood (1997). The model that lies behind the
psychoanalytic method of treatment is the medical model, and medical
ethics and values are bound to be important whether they are accepted or
rejected. Hinshelwood considers the decision-making process and
recognises that ‘at times in our work we sense that we must proceed in
spite of the patient, and this does not bring us – doctor, nurse or
psychoanalyst – into the category of torturer or brain-washer (1997: 20).
If we accept that there are times when we have to proceed against the
conscious wishes of the patient, then we are clearly elevating something
else above the value of autonomy. The clinical situation might develop as
follows for Mrs S:

Mrs S has been attending therapy for six months. During

that time she has talked about her difficulties with her
husband. The therapist has continually tried to encourage
her to consider the part that she plays in causing him to be
as he is. These attempts have been somewhat muted because
the patient seems to be always on the verge of leaving and
the therapist has decided that it would be best to go slowly
and encourage the development of a useful therapeutic alliance
before making too much challenge or confrontation.
Mrs S then came to a session telling of a dream in which
she was outside a window trying to get into the therapist’s
room. She could see someone else in the room but could not
make herself heard. The therapist interpreted this as her desire
to allow herself to be inside the room and therefore inside the
therapy instead of hovering about just outside. This of course
omitted to deal fully with the guilt over her incestuous wish to
come between the therapist and another patient as she might
have wished as a child to come between her parents, or, on
the other hand, the wish to be outside and to have someone
else be the patient. The following week the patient said ‘I’ve

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decided to leave now. This has helped me to see that I really

need to leave and stop bothering about what other people
think. You were wrong about that dream. I don’t want to be
inside. I just have to act for myself. Do you think that’s right?’

The therapist is confronted with the problem of whether or not to accept

the patient’s conscious wish to leave. There are all sorts of questions to
answer here about the possible meaning of the dream and the patient’s
unconscious messages. For example, why does the patient say she doesn’t
care about other people’s views but then asks the therapist for her view?
This paradox needs to be addressed at some point, but a more fundamental
question is whether the therapist’s values are in conflict to the point
where they need to be acknowledged at least internally and perhaps also
to the patient. For example, the therapist might be thinking that this patient
needs to continue in therapy in order to sort out the conflicts about
intimacy that could be seen in the dream and in the patient’s views of it. In
other words, the therapist might consider the paternalistic position which
would be to tell the patient that she thinks that she has more useful work
to do and should stay in therapy and struggle with the demands of an
intimate relationship. Clearly there is no guarantee that this would be
accepted by the patient and it might lead to a hostile ending in which the
patient would simply walk out.
The example of Mrs S is certainly one in which there is some ambivalence
in the patient which she has shown in her question to the therapist as well
as in her dream. The therapist, if following an analytical model, would
make at least some attempt to explore the ambivalence rather than simply
allow the patient to walk away. The medical model allows the doctor to
choose for the patient if the patient is not considered to be in a position to
make rational choices for him- or herself. Psychotherapy is in a particularly
difficult position here because people come to a therapist for the very
reason that the decision-making process in some area has become
problematic. The analytic model would say that there is a problem in the
patient’s mental processes arising from a hitch in a developmental process
or an illness in the faculty for remembering and forgetting or a failure to
achieve an adequate sense of self and other, or even not being sufficiently
in touch with his own unconscious processes. Wherever one places the
emphasis, the process of psychotherapy will be designed to change
something that will make the patient more capable of thinking in a healthy
way. In other words, we are dealing with what has been perhaps the
greatest value of Western culture in the twentieth century: rationality.

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Valuing rationality within autonomy

There have been endless papers written and debates conducted about
whether psychotherapy is a science or an art. Wherever we might decide
to place it as a discipline on that spectrum, we cannot escape from the
cultural valuation of rationality that has so far survived the postmodernist
critique. We deal with the demand that patients should be able to function
well rationally as well as emotionally. Disturbance of thought in terms of
obsessions, phobias, depression, fear of intimacy, is the basis of the need
for psychotherapy and patients will be at various stages of improvement
during the work. The therapist will make a judgement, when ending is
mentioned, about the position that the patient has reached in relation to
the capacity for thought, and this judgement will of course depend on the
therapist’s own capacity for thought.
A model of the mind that emphasises defence will invite a consideration
of splitting and the consequent valuing of wholeness or self-awareness.
Splitting as a defence is defined by Kleinians as the ability to avoid pain
and conflict by attributing certain thoughts and feelings to an agent other
than the conscious self and thus to avoid having to own whatever is
expected to be painful. If splitting is operating at a high level, the patient
will attribute her own feelings or thoughts to another, possibly to the
therapist, and therefore will not be in a position to make a judgement from
herself as a whole. The question is whether the patient’s decisions are
honoured in such circumstances.
To return to Mrs S:

The therapist replied to Mrs S’s question as follows: ‘You are

perhaps telling me that you have some doubts about me and
the therapy but you still want to know what I think, as if you
might not be quite sure that you want to leave.’ Mrs S then
got angry and said, ‘You therapists are all the same. You just
want people to stay in therapy for ever so that you can have
a nice fat income. You’re just like him [her husband].’ The
therapist was taken aback by this attack, but recognised
that a process of splitting at this point could perhaps be made
conscious. ‘I understand that you see both your husband
and me as making huge demands on you. If you see me as
just doing that, then no wonder you would not want to continue.
Perhaps you tend to see one person as making all the
demands and the other as the victim of that. Of course you
are right and I do demand money and words from you, but

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maybe we can look at the demands that you might want to

make on me.’ The patient looked surprised and said, ‘Well
you’re right; if I was going to stay I would want some things
changed. It wouldn’t just be me that would have to change.’
There is still not much hint of co-operation or mutuality here,
but there is a beginning of some sort of thought process about
what goes on between two people.

The therapist is valuing relationship and thinking with more than a

simplistic view of autonomy. If the goal were merely that the patient could
make a decision to leave, she could have greeted the patient’s
announcement with encouragement and wished her well. On the other
hand, to take autonomy at such a level would be to ignore its rational
component. Erwin (1997: 30) defines autonomy as:

• the capacity for rational reflection

• the tendency to eliminate defective desires
• the capacity for self-control.
It is of course possible to hold a simplistic view of autonomy which says
that being able to leave the therapist might be the patient’s major act of
freedom. Erwin’s definition allows for the need of the patient to be able to
decide when to leave, but adds to that the idea that the patient who has
achieved sufficient autonomy will be right in wishing to do so, because
the effect of therapy will have been to remove defective desires. This may
well be the case with successful therapy, but how do we know whether
the therapy has been successful? The difficulty is that the patient is
unlikely to know that his desires are defective and the therapist will have
to decide whether he or she knows better. In practice, this is done through
counter-transference responses in the therapist which indicate how much
anxiety and hostility remain, as well as from accounts of changes in the
external life situation. In Bion’s terms, the therapist will have enabled the
patient to reach a point where the processes of introjection and projection
have successfully diminished the infantile terrors and rages to the point
where the patient can allow ideas to come together and create new thoughts
(Bion 1967).

Valuing the therapist’s views

When the patient expresses a desire to leave which the therapist finds
premature, in that this stage of integration has not yet been reached in his

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view, we return to the question of whether or not the therapist might claim
a privileged status in that he has some knowledge that the patient does
not have. Psychoanalysis in the early days would probably have had no
problem in claiming this status for the analyst. Subsequently, writers
such as Carl Rogers (1951) have emphasised the patient’s conscious
knowledge and have taken the view that the patient does have both the
knowledge and the authority to make the most useful choices.
Nevertheless, the therapist needs to maintain the view that he has some
expertise, even if he embraces the view that we are working with two
subjectivities in the room. There is still a need to claim some skill or
knowledge for the therapist, or why, as Gabbard (1997) points out, are
patients bothering to pay us and attend sessions? He also argues that
patients want the therapist to know more, and to see what the patient
himself misses.
The therapist cannot become the desired wise parent and may indeed
wish to enable the patient to move to a more self-activating state, but it
would be difficult to argue that the therapist is wrong to use such skill and
knowledge as he does have. Using experience might entail saying
something different about ending and not accepting the view of the patient.
This can still stop short of the objective view, that the therapist is always,
by virtue of skill and training, more objective, and therefore right. Hanly
(1995) believes that we must integrate objectivity and subjectivity so that
the therapist may have perhaps more objectivity in his subjectivity. On
the other hand, an element of subjectivity reminds us of the fluidity of the
analytic situation. The possibility of any kind of certainty eludes us.
Because we are always likely to be caught by our own subjectivity we
must retain a view that the therapist, because of his or her own training,
therapy, supervision, experience, etc., is still in a privileged position and
therefore sometimes more able to see what is needed than the patient, but
equally must always be tentative and willing to be convinced otherwise.

Hinshelwood (1997) deals with a specific case in which he

had a patient who decided to marry soon after she entered
analysis. She had a satisfactory intellectual relationship but
was not attracted to the man sexually. The question for the
analyst was whether to advise her, as Freud might have done,
to suspend her life for the time being, and not to embark on
marriage while in the turmoil of the early stages of analysis.
He decided that he would not do that but was also grappling
with the question of whether she was effectively ending the
analysis: telling him that she had found her own cure, by

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avoiding the issue of sexuality altogether. In fact she chose

to continue to come to the sessions, and a way was
discovered to enhance her ability to live her life while remaining
in analysis.
(Hinshelwood 1997: 90–91)

The choice presented is not only whether therapy enhances life or

precludes it, although that is an important issue for those who do long-
term work in particular. The therapist will have to judge the extent to
which the patient is capable of making a rational choice with a large
degree of consciousness that takes into account external reality and is
not driven by pathological defences. Because therapy may disturb the
existing defences, it may bring a period of chaos in which making major
life decisions is not a good idea. On the other hand, patients who get
better will show this by being able to move forward. Fortunately, the
decision does not always depend on the therapist’s judgement, although
a comment may turn out to be very powerful.

Valuing mutuality

If autonomy is not just a matter of making decisions for oneself, but does
also include being able to make decisions from a position of as much self-
awareness as possible, it must also include being able to see the other as
a separate individual with views that may or may not be valid. This implies
a change in the patient’s valuing processes such that the ending can be a
matter of negotiation and discussion. The very fact that a patient does
not make absolute, unilateral decisions is itself a criterion for readiness to
leave. In the case of Mrs S, there is only a hint of that faculty developing.
The therapist would be led both by counter-transference feeling response
and by a process of rational thought to conclude that she has not yet
reached a level of functioning that can be considered to be truly
autonomous.
Mutuality cannot be left to the patient’s developmental process alone.
It is an area in which the therapist must also change to a position in which,
without abdicating from the necessary degree of responsibility for the
therapy and what happens in it, he begins to see a greater possibility of
accepting the patient’s ability to judge his own functioning. This involves
not only being able to overcome his own disinclination to allow the therapy

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to end but also being willing to accept that the patient may be right in
wishing to leave, even when the therapist is not sure or believes the
contrary. This can happen only when the overall functioning of the patient
has reached a point of stability and self-awareness that the particular
therapist can recognise as healthy. It therefore depends on the therapist
being able to change the boundaries of his own faith and confidence with
each new ending.

Valuing difference

Whatever the therapist’s values, he is likely to seek convergence from the

patient in order to judge her ready to leave. The therapist must also be
prepared to learn how to work with the patient who is clearly different
from herself. Not surprisingly, overt differences in the perceived physical
body, such as skin colour or disability, or the more diffuse areas of culture
or sexuality, may be a genuine difficulty for either or both people.
Alternatively, overt differences may be used as the vehicle for conveying
other hidden difficulties. There is no doubt that most therapists will have
difficulty with some aspect of difference. Conscious values might not
always be reflected in actions. In working with a patient when there is a
noticeable difference in, for example, age, the difference must be recognised
overtly and be part of the therapeutic dialogue. In that way it is less likely
to form a potential reason for a sudden ending.
Therapists might prefer that the problems were all in the patient, but
few would deny that there will be areas of difference where they find it
particularly hard to face for themselves what the meaning of the difference
might be. There will be some inevitable difficulties in understanding each
other which may be enough to bring about a premature ending if they are
not addressed. There may be times when a therapist is simply not able to
understand enough and the patient needs a referral to another therapist
where the differences will not provide such an initial obstacle. An even
more difficult crisis will arise when the perceived difference is in the
therapist. For example, if the therapist is visibly disabled or blind, the
patient may find it very difficult to say how he or she feels about it and
may simply not come back. Yet this is an ending that could sometimes be
avoided, and therapists who know that they are seen as different are
likely to confront it immediately. Therapists with less obvious
characteristics will have a more difficult time because they will not know

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how much they are affecting any given patient. Lack of shame in the
therapist is one of the most important qualities in this context, where early
acknowledgement is usually the only way to avoid a precipitous ending.
Patients may be extremely anxious about the therapist’s values in any
given area. There may be particular difficulties over sexuality, which the
assessment should bring to the surface. In an analytic setting, the patient
may have questions which remain unanswered and he will have to put up
with assumptions about the therapist’s sexuality which may not be
confirmed or denied. Both patient and therapist will try to discover each
other’s values, although the therapist has the advantage in the assessment
session of discovering more overtly what the patient thinks and feels.
Patients try to deduce what they can of the therapist’s values from any
available hints.
Attitudes to the value of life and death are also of central importance
where conflicts need to be made overt. In reinforcing the choice for life or
in accepting death for another, the therapist may have absolute values
that life is always the right choice or may have criteria for the quality of
life. The therapist’s views of what is right may have to change during the
course of a therapy or may be so rigid that the patient leaves in despair.
Patients will often deduce conclusions about the therapist’s values which
may or may not be right, but may come up against genuine differences
which prevent suicide and death from being explored as the patient needs
them to be. The therapist’s attitude towards suicide is further discussed
in Chapter 7.
The patient who threatens suicide out of anger provides that therapist
with a potentially difficult ending and tries to force the therapist to choose
between struggling on with work that might have become counter-
productive and an ending that might be full of anger and hostility. Ethical
difficulties arise when the borderline or narcissistic patient creates an
intensely negative transference and, like the child in a dysfunctional family,
cannot leave. The therapist may have been enduring intense hate or
erotic demands for some time and may strongly wish for an ending.

Ms U was a patient who formed a passionate erotic

attachment to her therapist. The hatred that the protestations
of love were intended to conceal was never acknowledged,
and the gifts, hanging about outside the consulting room,
etc. that constituted constant attempts to act out over many
months did not diminish, even though the therapist was patient
and empathic while making a steady effort to interpret the
controlling omnipotence that seemed to be developing. When

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the therapist finally said, ‘I do not think that you are able or
willing to work with me and therefore I think we must fix a
time to finish,’ the patient immediately threatened to kill
herself. The therapist had to exercise considerable courage
to try to say that in spite of this threat, there would still have
to be an ending. In this case the therapist’s courage was
rewarded, and the ending phase, although tempestuous and
frequently frightening for both, did lead to some fruitful work
and a parting between two living people. In this case, one of
the functions of the threat of suicide had been to deprive the
unsatisfying therapist of a satisfying ending.

There is a second group of patients who themselves threaten to end both

therapy and their own lives without the therapist having mentioned ending.
These are likely to be patients who are depressed and who are therefore
seeking oblivion, fusion with a mother at such a primitive level that she
would have no chance ever to reject. There are difficult technical questions
here about how to do the work, but there are also questions about how
the therapist values the patient’s view of the desirability of death and
ending. Sometimes a patient wishes to die, and no matter how much a
therapist may wish it were otherwise, nothing can prevent the death.
There is a third group of suicidal patients who choose suicide as an
ending to unbearable suffering. Therapists who work with the terminally
ill are often needed to work with a patient over the question of whether
death can be left to come naturally or whether it will be chosen. No therapist
is likely to wish to set rules for every case, and sometimes we will be
profoundly moved by a patient’s need to reach an end.
In all these cases, the therapist has to work with the need to value the
patient’s right to choose death, but will also have to struggle with profound
feelings about the question.

Mr V, a man aged 75, came to therapy, having been referred

by his GP for depression. He had taken every kind of anti-
depressant in the pharmacy but was apparently untouched
by them. He was a sensitive, intelligent man, a writer who
was no longer able to write. He said that his one longing was
to die. He thought about ways to kill himself every day and
said that he had the correct combination of drugs for certain
death when he chose it. In the meantime I was to be given a
chance, once a week, to convince him that life was worth

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living. His history involved a powerful, controlling mother who

had not valued his father at all. Mr V had become a bomber
pilot in the Second World War and had conducted many
successful bombing raids on Germany. During one of these
his fiancée had been killed in a German bombing raid on
London. He said he had convinced himself that he had killed
her, although this was not a psychotic delusion and rationally
he knew that he had not.
The first part of the therapy was spent in an attempt to
analyse away this guilt. This was completely fruitless and at
the end of every session he would say, ‘See you next week –
if I’m still alive.’ I felt great pressure to come up with whatever
it was that he wanted from me, but of course neither of us
knew what that was. I did begin to understand that the first
requirement was that I should stay alive and not let him kill
me off in despair. There were times when I was very angry
with him and felt like saying that he should just get on and
kill himself, but mostly I felt a great desire for him to stay
alive. This I interpreted as his own split desire for life versus
the longing for death as a respite from the whole struggle.
When I acknowledged that I experienced these two sets of
feelings, something changed, and he was able to talk to me
about death in a way he had not before. He told me that he
knew it was his way of trying to get me to see that he had
some power. In other words, his mother had seen him as
weak and I must see him as powerful, even if only in the
ability to make me feel that he might kill himself.
There was another part of him that needed attention. He
had been a bomber pilot, and one of his most powerful
memories was of flying a small fighter plane under a bridge
just after he had learned of the death of his fiancée. He knew
this had been a very dangerous act, both for himself and
others, and he thought that he had wished to kill himself then
but had not put it into words. We established that the pilot in
him was his rational self, extremely perceptive and skilled
but at times hijacked by his powerful anger and
destructiveness. Gradually his depression changed to anger.

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My fear that he could never end therapy without killing himself

diminished, and after three years he did decide to stop. He
was still inclined to depression but was no longer threatening
suicide. He said that therapy had not done much for him but
at least he was able to see that the pilot in him could be of
some value and use. I received a card from a friend of his
some years later to say that he had died of a stroke after
writing his autobiography.

This case illustrates both the difficulty for the therapist of working with
a very suicidal patient and the importance of achieving a kind of autonomy
in which there is some reduction of omnipotence. The pilot in Mr V was
unstoppable to begin with and was totally isolated in his cockpit. It was
only after the acknowledgement of some dependence that a more useful
autonomy was achieved in which he could manage to fly on his own.

Conclusion

In practice, therefore, therapists find that there is not one truth for all, but
many different aspects of truth. Autonomy is a criterion for ending insofar
as it shows the patient arriving at a kind of truth for himself. Where the
patient is sufficiently independent to consider ending, but wishes to take
the therapist’s view into account, that will in itself indicate that the patient
may be functioning at a more mature level. In some cases, the patient will
end in an omnipotent, unilateral way, either through leaving or sometimes
through death. In any case, the therapist’s job will be to seek the truth of
what is happening, as far as that is possible. If the truth is that the therapist
is following selfish needs of her own, that must be faced and dealt with.
Mrs S (p. 107) suspects that her therapist is valuing her own economic
welfare above that of Mrs S. Sometimes such factors are bound to enter
into the therapist’s attitude. Even if personal desires for money or status
were to be eliminated, the therapist’s task in assessing readiness to end is
not an easy one, and each therapist will have to work out what is true to
the best of her ability. In Chapter 7 I will examine the way in which ethical
codes relate to values and govern the ending process.

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References

Balint, M. (1968) The Basic Fault, London: Tavistock.

Bentham, J. (1789) The Principles of Morals and Legislation, (Reprinted
1988) New York: Phoenix Books.
Bion, W. R. (1967) Second Thoughts, London: Karnac (Reprinted 1984.)
Erwin, E. (1997) Philosophy and Psychotherapy, London: Sage.
Freud, S. (1920) ‘Beyond the pleasure principle’, SE 18.
Gabbard, G. (1997) ‘A reconsideration of objectivity in the analyst’,
International Journal of Psycho-analysis 78: 15.
Hanly, C. (1995) ‘On facts and ideas in psycho-analysis’, International
Journal of Psycho-analysis 76: 5.
Hinshelwood, R. D. (1997) Therapy or Coercion, London: Karnac.
Holmes, J. and Lindley, R. (1989) The Values of Psychotherapy, Oxford:
Oxford University Press.
Mill, J. S. (1861) Reprinted in Utilitarianism, London: Fontana.
Rogers, C. (1951) Client Centred Therapy, London: Constable. (Reprinted
1987.)

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 7
ENDS AND MEANS
The ethics of ending

Psychotherapy has a body of knowledge about human nature and sets of

techniques that are derived from theory or sometimes are simply pragmatic.
Some work and others do not. Sometimes the achievements of
psychotherapy are brought about by the charismatic force of the
therapist’s personality and faith and sometimes by a very routine
application of well-known and tested methods. The necessary existence
of the former element, the power of the individual therapist, in both the
relationship and the process, is such that ethical thinking and the restraints
of ethical codes are always necessary, although not always sufficient. As
soon as ethical principles conflict, codes become useless and we are
thrown back on individual morality.
Ethics is in the public arena where morality becomes the law that must
be followed. Therapists must adhere to these rules but must learn how to
apply them to the individual who will make unique demands. Psychotherapy
is about setting boundaries and changing the ones that are inappropriate.
These are not only the boundaries between individuals in a given society
and culture, but also the boundaries within the individual that prevent the
free movement of thought and feeling within the psyche. The therapist
may be allowed a privileged position, in that the normal social fences
have to be taken down so that a stranger may be told the most intimate
details of a patient’s life, love and sexuality. This freedom of movement
implies a particular need for restraint. The lack of normal boundaries
paradoxically implies a particular need for specific and strong boundaries
in the therapist. It is often the failure to establish boundaries that are
appropriate to the therapeutic process and to a particular individual that
leads to untimely and contested endings in therapy.
Therapists using models that seek to analyse a transference relationship
have particularly difficult ethical questions to answer, usually about
boundaries, and they will very often find only minimal guidance in ethical

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codes, since these can legislate only for behaviour that is clearly and
grossly harmful. Where there is a question of competence or dubious
technique, the codes are often of no help. In this chapter I will also look at
the therapist’s use of self and the degree of opacity or openness that is
used in the ending phase. Other areas of technique with ethical implications,
especially for ending, are connected with the degree of confidentiality
both during the ending and after it. In different ways, these are implied by
theoretical models and are certainly used in different ways by individual
therapists.
The ending process is subject to strife between patient and therapist.
The number of complaints and appeals received by the United Kingdom
Council for Psychotherapy (UKCP) and the British Association for
Counselling that are connected with an ending that went wrong provides
adequate testimony to the importance of considering the ethics of the
therapist’s behaviour in this area. At the time of writing all the members of
the United Kingdom Council for Psychotherapy are organisations, each
of which must construct its own codes of ethics and practice to suit its
own model of psychotherapy. These codes must be written to comply
with the basic requirements set out by UKCP. The reason for not having
one single centralised code has been the need for different working
practices required, for example, by those working with children and those
working with couples or groups. In these modalities the need for different
codes of practice is obvious. Children may not be able to make a necessary
complaint for themselves, and third-party complaints will be both
reasonable and necessary. In work with adults the question of whether,
for example, partners are entitled to complain about treatment which has
caused them problems is much more debatable. They would often wish
for the therapy to end. Such complaints cannot usually be heard without
breaking the confidentiality of the patient, and most organisations refuse
to hear them on those grounds. Such complaints are likely to relate to
endings outside of therapy such as the breakup of families or partnerships
where the therapist is thought to have great influence and has not stopped
the work. In cases where relationships outside are ending, the therapist
has responsibility to work at the patient’s understanding of the issue, and
not to try to impose his own agenda.
Different models of psychotherapy may also need different codes of
practice. In some models the contract has a time-limit and the ethical issue
is to keep to the contract. This in itself is not always easy, as there may be
the temptation to prolong the work into private practice (see Chapter 9).

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Each model has its logic. A humanistic therapist will be placing great
reliance on the autonomy of the patient in making the decision to end (see
Chapter 6). An analytical therapist hopes to convert the resolution or
solution of the imaginary relationship into something more mutual.
Particular codes will be required for those who use massage or other
forms of touch. Behavioural therapy and paradoxical therapy need to
make clear what informed consent might mean for them and what must be
said in making a contract.
Analytical therapists who have been working by means of interpreting
current events as transferred from the past to connect them overtly or
implicitly with the patient’s mother, father, siblings and significant others,
not to mention parts of the self, will become intimately involved in the
patient’s life and emotions. The delicate balance that allows the patient to
feel disappointed, frustrated, angry and yet stay in therapy may not be
maintained, and the patient may tip over into psychosis or leave and make
a complaint. Complaints often focus on the therapist’s sudden or
apparently sudden decision to end the therapy when the patient is in the
midst of powerful feelings. There will be questions about whether adequate
provision was made for other referrals or at least contact with the general
practitioner or psychiatric service. Investigators may be faced with the
question: Was the therapist behaving competently and ethically or not?
If not, there will be the possibility of sanctions, the most extreme of course
being the loss of registration and the ability to practise under the auspices
of the professional body. As we do not have statutory regulation of the
profession at the time of writing, anyone may continue to practise as a
therapist no matter what complaints have been made and substantiated,
but to do so would be difficult.

The ethics of technique

Klimovsky, Dupetit and Zysman (1995) have written on the question of

whether there is a logical connection between the ends of psychological
treatment, its techniques and its ethics. We must have good reasons for
the rules that we impose on ourselves and our patients. Klimovsky et al.
look at the chain of reasoning that lies beneath an ethical statement.
Statements of fact and ethical statements can be mixed in a way that is
confusing. For example, ‘The unjust is ethically bad’ is a purely ethical
statement, whereas ‘An unjust action committed by a man towards another
results in a particular kind of conduct or symptom’ is a mixed factual and

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ethical statement (Klimovsky et al. 1995: 981). If we mix these sorts of

statements unintentionally we are unlikely to be able to arrive at clear
conclusions about what is the case and what we should do.
These authors point to the difference between the two uses of the word
must. It can be used to imply that a certain course of action is necessary
in order to achieve a certain end or goal. Alternatively, it can be used to
convey an ethical imperative. They look in particular at the importance of
ethics in interpreting what is considered in analytical work as patterns of
behaviour transferred from the past. They construct the following chain
of reasoning:

• The transference is the expression of an unconscious tendency to

repeat forms of behaviour from infancy brought into the present in
the relationship with the analyst (theoretical statement).
• Transference manifestations are observed in every psychoanalytic
treatment (a factual statement).
• The analyst must analyse the patient’s transference manifestations in
order to understand his past (a mixed ethical statement).
• It is good for the analyst to analyse his patient’s transference (an
ethical statement).
(Klimovsky et al. 1995: 981)

Freud’s view was that understanding the hidden roots of a neurosis was
an intrinsic good, as in the last statement, and although he abandoned
the technique of hypnosis as a tool to discover what the patient had
hidden in his psyche, he nevertheless advocated a powerfully silent
therapist sitting out of sight and waiting for the patient to reveal himself.
This technique is based on a logical sequence which says that it is curative
to come upon the memories or desires that are hidden and to admit them
to consciousness. The technique of a silent analyst encouraging free
association allows unconscious memories and wishes to surface or to
make themselves known in the gaps, the patterns of repetition, the faux
pas, etc.; with this basic premise, the logic of ethics would lead to the
conclusion that the technique is good. Nevertheless, many patients who
make complaints cite a therapist who was not sufficiently ‘warm’ or ‘human’.
The argument of the end justifying the means does not seem to be valid in
this case, because if the patient cannot endure the deprivation of the
method, the end will not be achieved anyway.

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A depriving analytic attitude contrasts with the current view of many

analytical practitioners that the process of therapy involves the meeting
of two subjects and their effect on each other. Jung’s alchemical metaphor
has long since emphasised the need to be open to the melting down that
occurs when two people meet over a fairly long period. Increasing interest
in intersubjectivity has now entered into mainstream psychoanalysis.
Roger Kennedy in his book on the nature of subjectivity (1998) emphasises
that the therapist may be natural or spontaneous, that being neutral is not
being neutered. He points out that the therapist may succumb to the fear
of seduction. The therapist suffers not only from the fear of sexual
seduction but also from the anxiety of being deceived, duped, ‘taken for
a ride’ by the patient (1998: 113). This is the sort of fear that can lead to the
practice of defensive psychotherapy in which the therapist’s main concern
is not to get into trouble (Clarkson and Murdin 1996).
Clarkson has also written on the temptation of the psychotherapist to
stand aside from anything that is difficult in the social, cultural or political
context. She points out that the whole profession suffers from an unhealthy
narcissism if it is absorbed by its own image to the extent that therapists
ignore both what is going on outside the consulting room and also at
times some of what is going on inside it. She adds that in some political
situations, such as recently in South Africa or earlier in Germany, one
might understand that active involvement would require extreme personal
bravery. Usually we are called upon only to be willing to enter into the
struggles that are going on in the room. Being in the room can be dangerous
enough however, so it is not surprising that therapists are sometimes too
zealous in obeying the rules. Too much preoccupation with the technical
rules may at times be as dangerous as ignoring them. Clarkson and Murdin
(1996) wrote about the importance of the spirit of the law rather than the
letter. When it comes to subjectivity and to deciding what is permissible
in the therapeutic situation, we may have to observe the spirit of the law
rather than the letter.
An ethical question arises if a patient is finding the silence of an analytic
approach difficult. A technically correct approach might mean that no hint
can be given that the analyst cares how the patient feels or whether the
patient gets better. Of course, too much emphasis on getting better can
lead to a risk of the patient trying to please the therapist or alternatively
trying to frustrate him. On the other hand, the therapist may sometimes be
the only one who can maintain some hope, and at times this may need to
be conveyed to the patient. In the ending phase this may require particular

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attention because after a long therapy, most people will go through various
different degrees of doubt, hope, optimism and despair. Some therapists
consider that they should become more open and deliberately remove the
veil of mystery that has surrounded them. This would imply a deliberate
and planned attempt to dissolve parental transference and become more
ordinary.

Passionate attachment and the destructive ending

The process of therapy may be regarded as the process of finding and

dissolving transferred feelings that are not appropriate in the present. If
this is not done continuously or if the patient has developed the kind of
embedded erotic feelings described in Chapter 5, the therapist would
have to find a way of ending that is ethical. A transference of this sort is
as likely to be strengthened as dissolved by revelations by the therapist
about his or her personal life or beliefs. An equally dangerous alternative
is for the therapist to withdraw. Sometimes the patient offers gifts and
allurements which the unwary may accept. When the whole thing gets
out of hand and the supervisor says it should stop, the patient may well
feel totally rejected and unable to cope. In this situation the therapist may
bring about the ending of the therapy either overtly or indirectly through
fear. Patients often make complaints about these endings. In such a case,
it is the initial encouragement of the transference that went too far and
became at least unwise if not unethical. Assessment of the potential for
such lethal passionate attachments is not infallible, but must be attempted
in order to protect patients and inexperienced therapists.
Psychotherapy organisations have great difficulty in dealing with the
aftermath of such endings. Patients are profoundly hurt and wish only to
prolong the relationship with the therapist. They do this through a long-
drawn-out complaints and appeals process. The therapist fears litigation
or the risk of losing professional credibility or even registration, and
refuses to have any further contact with the patient. This absolute
prohibition infuriates and frustrates the patient even more. No one is very
good at dealing with these situations. Perhaps the only answer is to
provide some sort of mediation or couple therapy for a therapeutic
relationship that is in this sort of difficulty before it ends disastrously. At
least there might be some way of helping the patient to find another
therapist with whom the connection might be less dangerously passionate.

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Therapists know they need to be consistent, and yet that knowledge

has to be balanced against the need to learn from the patient and change
when appropriate. The change has to be carefully planned and thought
through. The necessary change that comes from learning during the
process is very different from the sudden change imposed in an attempt
to improve or facilitate the ending process. The case of Mr W illustrates
the difficulty of sudden change at the end:

A therapist, Mr W, was seeing a woman aged 34, Ms X. She

had been coming to him for four years and had done some
very useful work on her difficulties in relating to men. Her
presenting problem had been sexual abuse by a step-father
when she was about 8 years old. Ms X had been overtly
erotic in her behaviour in the therapy and Mr W had felt the
need for very rigorous boundaries which he had held
successfully. As a result, Ms X had ceased to try to seduce
him or to complain about his hardness of heart. Mr W thought
that she was much better and when she spoke about the
possibility that she might marry a man she knew at work
who wished to leave the area for a promotion in the next year
or so, he suggested that they should end the therapy.
Ms X agreed that they should end in about six months’
time and before she got married. After a few sessions, she
began to show signs of regretting the decision and became
more and more depressed. She was failing to meet deadlines
at work and was turning up late for sessions. Mr W said that
he supposed Ms X might be frightened about how she would
manage without the sessions. She agreed and said that she
would not be able to manage without Mr W. She had changed
her mind about her engagement and did not think she could
marry her fiancé after all.
Mr W then grew worried that Ms X had more powerful
feelings for him than he had recognised. In something of a
panic, he decided to stick to the ending date that had been
arranged and in the sessions decided to make her more aware
of his failings and weaknesses so that she would not idealise
him so much. He began to say things like ‘I understand that
you feel attached to me but of course you do not know what
I am really like.’ She mentioned on one occasion that she
liked the way he could speak so decisively. He then said,
‘Oh well, I do not always make good decisions. The other

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week I decided to paint the outside of the house, as you can

see [many comments had been made about the painting by
most of the patients], but I am already regretting the colour
and I don’t think I chose the best people to do it as they
haven’t finished yet.’ Ms X seemed somewhat shocked by
this departure from his usual restraint but said nothing for the
rest of the session.
At the next session Ms X handed Mr W a piece of paper on
which she had written the name of a firm of decorators run by
her brother. Mr W said that he was grateful for the suggestion
but did not think it appropriate that he should change
decorators. Clearly this was an avoidance. What was
inappropriate was that he should discuss decorating in a
connubial way with a patient. His intention to make the ending
easier was simply digging him a deeper hole from which to
escape. He had to acknowledge that talking to Ms X about
the decorating was speaking in a way that he had not done
before, and that she might have experienced it as his
encouragement to change the nature of their relationship.
She agreed that she had. He then said that he intended to
maintain his position as her therapist and any improvements
in the future would have to be those that she carried out on
herself.

In this case, ending therapy is very difficult for the patient who has fallen
in love with the imaginary therapist. Inexperienced therapists may well
encourage this kind of adoration and may themselves be excited by it. On
the other hand, an inexperienced therapist may not notice that it is
happening until he or she is in the thick of it. As Mr W pointed out, the
patient does not know the therapist as a whole person and is in love with
an ideal, tolerant, non-retaliating father or mother. Clearly this imaginary
relationship should have been analysed throughout the work, if that were
possible. The feeling and its intensity is totally absorbing to the patient
and is likely to send the therapist into a panic when he or she realises the
degree of intensity of feeling.
Ethical codes cannot specify technique: they usually say only what we
should not do. There are no universal rules about how to deal with the
patient who falls in love or in hate. Each model of psychotherapy will
have its own solutions or recommendations. The bottom-line statement is
usually that the therapist must not exploit the patient. Exploitation implies

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using power inappropriately. Even attempts to dissolve the kind of

relationship that has developed may turn into an inappropriate use of
power. The most important way for the therapist to decline to take on too
much power is to be honest with the patient. This does not imply too
much self-revelation but does imply a complete lack of pretence. Whatever
is said must be genuine. The ideal must be that the therapist helps the
patient to stay in a fluid state in which love and hate are available but
there is still some understanding that the therapist is not the beloved
mother or father or potential partner, while allowing the kind of exploration
that Freud referred to when he said that the patient shows what he or she
is like in love and the doctor shows the patient this image (Freud 1914).
The only hope is in the skill and humanity of the therapist who can keep
the balance and enable the patient to do the same. A total refusal to take
on the role of the beloved is essential and, as for Mr W above, this
sometimes means falling into traps, but always trying to put into words
what is happening and what has happened. The ending cannot be forced
or made into an ideal resolution. It will often remain messy and
unsatisfactory, and no amount of making oneself ordinary at the last
minute will help if the therapist has not been ordinary all along.

Confidentiality

One of the main values in psychotherapy is the confidentiality of the

therapeutic relationship. The great majority of patients would not be able
or willing to unburden themselves of the kinds of problems they bring to
a therapist if they did not believe that the problems would remain within
the relative safety of the minds of the two people concerned. Many
therapists also seek supervision or consultation, and will let patients
know that this aspect of the work is also confidential but does extend the
boundary of who knows about the work. For most patients supervision is
welcome and reduces the fear of abuse. Where there is only one parent
there can be a secret and abusive relationship, but the second parent may
be able to control and make the other safe. The supervisor is often seen to
adopt the role of the other parent (see Chapter 9).
In the ending process, supervision or consultation often becomes a
necessity if there is doubt about the appropriateness of the ending. As
long as this is provided in the contract, it is perfectly ethical. There may
however be other aspects of the ending process where confidentiality is
threatened by the therapist. In the United States, confidentiality is under

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constant threat because of legislation that requires therapists to report

sexual abuse as well as any possible involvement with criminal activity or
any predictable crime. There are therefore many situations in which a
therapist may have to stop a patient and point out that the information
that he or she is giving may make it necessary for the therapist to speak to
a statutory authority. Bollas and Sundelson (1995) have written about the
problem this poses for the future of this profession which depends on the
possibility of privacy.
In the UK at present, there is less pressure to report except in the case
of ongoing abuse of children or of a potential act of terrorism. We are not
likely to encounter the case where a therapist says, ‘If you tell me about
that, I shall have to report what you say to the police, social workers, etc.’
Yet there are certainly cases where a therapist may need to deliver some
sort of ultimatum. For example, if a patient were to tell the therapist that
she felt in danger of hitting her children, the therapist might be torn
between two ethical imperatives. On the one hand, the children might
need protection. The mother might not want anyone to know of her
predicament because she is afraid that the children will be taken away
from her. Yet the therapist now knows. He or she must decide whether the
children’s potential danger weighs more heavily than the needs of the
patient and the potential to help her if the therapy is preserved. If the
therapist insists on breaking the confidentiality, the therapy may come to
a premature end. The ideal solution is that the therapist can work with the
patient while helping her to seek the support of an agency because practical
help may well be needed. On the other hand, it is also true that any
admission of the sorts of violent feelings that might be problematic will
also be quite likely to lead to children being put on the ‘at risk’ register
and possibly removed or given to the care of a partner. The Code of Ethics
of the British Association for Counselling is very clear and explicit about
the priorities in making these boundaries. Although there may be a legal
duty to report ongoing sexual abuse of minors, the patient’s confidentiality
must never be broken and an ending risked without extremely good reason.
Publication of material about patients is another area of ethical difficulty.
Most therapists would probably prefer to write about ongoing or recent
work in which the atmosphere, the detail, is fresh in the mind. On the other
hand, the mere fact of asking the patient’s permission and having the
therapist’s thoughts and the patient’s material set out in print for all to see
will have an effect on the ongoing work, which is undesirable because it
is introduced purely to satisfy a desire of the therapist. The alternative is
to wait until the work is ended and then ask for permission to publish.

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This leads into a grey area when the patient cannot be found and therefore
permission cannot be obtained. In most cases disguise is sufficient,
especially where publications are likely to be read only within the
profession. Nevertheless, therapists must adopt the principle that a patient
is always a patient in the sense of being entitled to privacy. Even when
the work is ended, the therapist does not own the experience.
The threat of suicide is another situation in which questions of
confidentiality must be faced. I have discussed the conflict of values that
it raises in Chapter 6. Robert Firestone (1997) has written of the indications
and possible treatment of suicidal patients. He points out that the therapist
is likely to experience strong feelings when with a suicidal patient. This
will come as no surprise to most of us:

suicidal patients often provoke feelings of dislike, discomfort, even

malice in therapists. Negative feelings that suicidal patients feel
towards themselves are evoked in the therapist during sessions
or interviews.
(1997: 237)

Firestone considers that such feelings in the therapist should alert one to
the possibility of suicide if there has been any suicidal ideation already or
if there are other factors leading to a suspicion of suicidal intention. We
may all arrive at the conclusion that a particular patient is at risk. A much
more difficult problem arises if the patient is not willing to talk about a
suicidal intention or is willing to talk to the therapist but to no one else.
Firestone does not take this to be a particularly serious problem, as he
is writing in the context of an open and family-orientated approach to
psychotherapy. He says:

Clinicians should warn the patient’s family and significant others

of the patient’s suicidal potential and enlist their involvement in
management and treatment unless such involvement is contra-
indicated by toxic family interactions. Providing information during
the course of treatment can lead to active collaboration and help
in monitoring the patient’s and family’s distress. In terms of the
legal aspects of suicide the family is less likely to bring suit against
clinicians who have previously established good relations with
them.
(1997: 241)

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Firestone also points out the importance of keeping notes of the work:

Defensive clinical notes written after the fact may help somewhat
in damage control but there is no substitute for a timely thoughtful
and complete record that demonstrates . . . a knowledge of the
epidemiology, risk factors and treatment literature for the suicidal
patient.
(1997: 240)

Not all therapists would agree with the importance of keeping detailed
notes of the sort recommended here, but although the choice will reflect
the personality of the therapist and will therefore have a part to play in the
therapy, it is not likely to affect the course or speed of the ending itself. In
the event of actual suicide or a sudden conflicted ending, it is certainly
possible that the therapist will be required to produce a record of the
treatment and might be accused of negligence if no such record is available.
Therapists working with patients who refuse to speak to their families
and do not wish the therapist to do so will be in the difficult position of
having to hold confidentiality as a value to be preserved if at all possible.
Against this will stand the possibility that an insistence on informing
others of the danger without the patient’s consent or in direct
contravention of his wishes may lead to the end of the therapy. Hidden
within this dilemma may lie the therapist’s response to the patient’s hate
and anger and his wish for the patient to die. Being told that you are not
good enough to prevent someone from wishing to take his or her life is
bound to arouse in the therapist feelings of anger and a wish to retaliate.
Retaliation can take many forms, but one might well be the betrayal of the
patient through unnecessary breaches of confidentiality. Another aspect
of the same response could be the desperate need to enlist others in the
blame, hate and anger that surrounds, if only at an unconscious level, the
threats of suicide. Rejection is bound to be in the therapist’s feelings
somewhere because suicidal potential is always a rejection of the living.
This rejection needs to be explored in the therapist, and in the patient’s
own experience, rather than acted out by the therapist.
Firestone (1997) cites as an error committed by a therapist the delivery
of an ultimatum along the lines: ‘If you make an attempt at suicide, I shall
discontinue the treatment.’ This is a clear acting out of the rejection that
the patient has no doubt experienced at some time in the past and wishes

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to impose on the therapist who rejects it and hands it back. There may be
times when it is possible and necessary to hand it back in the sense of
talking to the patient about this rejection and what it implies. After the
patient has been given a chance to make use of opportunities to work on
these memories in the therapy, he or she may still persist in suicide attempts
and the therapist may eventually decide that the anxiety is unbearable
and the hostility cannot be reduced in that therapy. Therapists have their
limits and may not be able or willing to continue, although ending in such
circumstances should always be a last resort.
Referral to someone more experienced or to an agency such as a hospital
may be all that is possible. Firestone cites a case in which a referral to
another therapist was made, but before contact was arranged with the
new therapist, the patient shot himself after being sent home from hospital
(1997: 244). Referral to another therapist may work, but it is not an easy or
obvious solution. The loss of the previous therapist may be too much to
bear. Referral to hospital may be easier because the therapist may be able
to continue to see the patient at least when he or she is discharged, and
because there will be a much safer holding environment while it lasts.
Referral is a process which inevitably raises the problem of the patient’s
consent to it and to information being passed to the next therapist. Is it
ethical to refer a highly suicidal patient to a colleague without telling the
colleague about the problem? If the patient does not agree to the release
of information, the therapist will again have to decide between conflicting
ethical imperatives because the possible outcome of a new therapy may
depend on a certain amount of information being passed on. GPs and
psychiatrists will often not require or use information from
psychotherapists even if it is available. Unfortunately, hospital stays are
harder to obtain and often shorter in duration than we might wish, and
there may not be time to discover what the problems are, even if there are
staff qualified to do so.
When there is a risk of ending through suicide, supervision or
consultation is essential and it is difficult to see how one could argue
against it in these cases, but discussions that go outside that area without
the patient’s permission might sometimes be an avoidance of confronting
negative emotions in the patient. For example, the therapist may well feel
in need of extra support and may find it tempting to talk to colleagues
more freely than is appropriate or may talk to the patient’s family without
obtaining consent in an attempt to gain support and get rid of the feelings

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of isolation and rejection which must in fact, as far as possible, remain

within the therapy as part of the work.
Firestone (1997) looks at the possibility of forming an anti-suicide
contract with a patient. He sees such a contract as potentially useful in
assessing the patient’s motivation and willingness to accept a degree of
responsibility for the treatment. It is a comfort to the therapist in all sorts
of ways: it implies safety for the therapy as well as a formal alliance with
the patient. It may provide for the ending of the therapy if the contract is
broken and this will salve the therapist’s conscience if the work becomes
unbearable. There is nothing unethical about such a contract if the patient
understands it clearly, but there is a question about the morality of
abandoning the person whose problem is so severe that he or she cannot
keep to a contract that was presumably made in good faith. A second
problem with such contracts is that, as Firestone points out, it may lull the
therapist into a false sense of security. Indications of change in mood or
intention should be carefully monitored at all times.
In this section I have looked at some of the difficulties raised by the
suicidal patient in the constant threat of ending that they pose to the
therapist. They can induce the therapist to make a premature ending
either deliberately or through actions that lead the patient to walk out.
These difficulties are of course intensified with the suicidal patient but
are not unique to these cases. All therapeutic work is subject to the
dangers of the therapist who acts out of counter-transference emotions
rather than bringing them back to the work and making them available to
thought and to language.

The patient deserves an ending

The ethical practice of psychotherapy implies the kind of endings that

must be avoided and also implies that therapists have an ethical obligation
to keep ending in mind and be prepared to help patients to end
appropriately. The British Association for Counselling Code of Ethics for
Counsellors, as revised in September 1997, states that:

Counsellors work with clients to reach a recognised ending when

clients have received the help they sought or when it is apparent
that counselling is no longer helping or when clients wish to end.
If an ending is enforced because the work appears not to be
therapeutic, counsellors must make arrangements for care to be
taken of the immediate needs of clients in the event of any sudden

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and unforeseen endings by the counsellor or breaks to the

counselling relationship.

The therapist’s holidays and absences for whatever reason are seen as
important in the patient’s experience both because the therapist has
inevitably become important and because it is in this area that the
difficulties of the ultimate ending can best be foreseen and worked through.
Counsellors are required to take care to prepare their clients ‘appropriately’
for any planned breaks from counselling. They should take any ‘necessary
steps to ensure the well-being of their clients during such breaks’.
These clauses are in addition to the existing codes in that they recognise
the special need for ethical behaviour in relation to endings. They are
welcome in that ending does require awareness of its specific ethical
questions. On the other hand, it is difficult to legislate for all the potential
situations that may arise. Spelling out some requirements leaves others
uncovered and creates more difficulty in the long run. There are many
questions about the judgements implied, especially the decision about
when steps need to be taken and what the ‘necessary steps’ might be
seen to be. The United Kingdom Council for Psychotherapy has a set of
ethical requirements which must be incorporated into the codes of all
member organisations. These codes do not usually mention ending as
such, but all therapists must be aware of the specific problems of ending
therapy in a way that is ethical and must also apply the requirements that
are in the existing codes for all their behaviour when there are no specific
requirements for ending.

Conclusion

Ethical behaviour is required of therapists at all times. The ending process

imposes particular strains because in some ways it involves departures
from what is ordinary. By definition it is about change, and very often it is
brought about by change. It demands the most of therapists in flexibility
and willingness to accept what is different, and mainly of course to accept
loss. Even where the therapist seeks the ending because the work has
become impossibly difficult, he or she must recognise both the loss to the
patient of a hope that therapy could be valuable and also the loss of the
narcissistic satisfaction of achievement. While working with these
difficulties and the strong feelings they arouse, the therapist must still
consider the patient’s needs and as far as possible make the ending useful
for the patient.

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References

Bollas, C. and Sundelson, J. (1995) The New Informants, London: Karnac.

Clarkson, P. (1996) The Bystander, London: Whurr.
Clarkson, P. and Murdin, L. (1996) ‘When rules are not enough: reflections
on the spirit of the law in ethical codes’, Counselling 7 (1): 31–35.
Firestone, R. (1997) Suicide and the Inner Voice, London: Sage.
Freud, S. (1914) ‘Observations on transference love’, SE 12: 157.
Kennedy, R. (1998) The Elusive Human Subject, London: Free Association
Books.
Klimovsky, G., Dupetit, S. and Zysman, S. (1995) ‘Ethical and unethical
conduct in psychoanalysis’, International Journal of Psycho-analysis
76: 977.

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 8
ENDGAME
Last sessions

Every therapy eventually reaches a last session. The ending phase may
be a matter of minutes or seconds for the patient who walks out abruptly
or it may be as long as a year. The therapist’s ending for reasons such as
moving away as described in Chapter 5 may also lead to long ending
phases. However long the ending is, each therapist will need to decide
whether there are specific techniques that are appropriate for the ending
phase and what may be the theoretical rationale for any difference that is
made. De Simone (1997) considers that in a therapy that has gone
reasonably well, there should be no particular problems and no change of
technique in the ending phase. Readiness to end will ideally involve a
willingness in the patient to negotiate and discuss the ending. The
therapist’s own feeling that ending now will be all right is another important
criterion and will contribute to the possibility that the ending phase will
be of value to both.

Change to the sense of time in the ending phase

In order to reach a point at which ending is accepted and even desired,

the patient must have changed and so must the therapist. One of the most
important and least noted changes is the way in which the sense of time
has altered. The sense of time is a candidate to be our sixth sense. It
follows self-awareness and yet it is variable and changes as the patient
changes. The sense of time varies developmentally, culturally and socially.
The patient arrives in therapy with no time to spare or without knowing
how to use time. The sessions are treated as precious short stretches of
time, or are endless deserts. The end of each session is a deprivation or a
punishment. Alternatively, the sessions are grabbed and smashed or
crumpled up and the patient cries out for more time, but good time instead
of bad.

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The therapy session shares in the cultural changes in our attitude to

time. Time has been deconstructed in the arts. We have been taught to
accept the novel or film that begins with a flashback or a scene in the
present which frames a story from the past. We used to need time machines
or space travel to explain such time changes, but we have become so
accustomed to them that we no longer find such artificial aids necessary.
Time travel is an acceptable fiction and of course all therapies are likely to
include a certain amount of it. We also know now that what happens in
therapy is also a construct. There is a historical past and there are truths
that can be verified. Nevertheless, the story that is told to the therapist is
bound to be coloured and shaped by the present. As in a film, for example,
The French Lieutenant’s Woman, we see the past from the point of view
of the present. In this film, the story is set in the eighteenth century, but it
is framed and interspersed with the story of the actors who are playing
the parts. Their story echoes and interweaves with the story from the
past. The end of the film is in the present when the film within a film has
finished. Much the same thing will have happened in therapy. What we
need to know is that the story ends in the present. The actors will have
been affected both by what happened in the past and the way in which it
has been remembered in the course of the therapy, but a good ending
needs to be in the present.
The change to an ability to live in the present is one of the main
improvements that can be derived from a therapy that is good enough.
Living in the present in this sense implies being able to remember the past
without letting it dominate thoughts, feelings or patterns of relationships.
When people arrive in therapy, they find the past, present and future are
all unbearable for one reason or another. For the manic depressive, the
future is either greeted with careless insouciance or a depressed certainty
that it will be bad. The schizoid may believe that it will be lonely and the
paranoid that it will attack with worse strokes of fortune than the present
or the past. Getting better in all these cases may mean that the sense of
time allows for an awareness of the future, but does not let it overshadow
the importance of attention to what is happening now.
Michael Eigen describes the importance of allowing time to move at
whatever pace is needed for the moment in a session:

Let’s relax into giving time a chance to develop its own flow, and
allow that there should be a ‘later’ or a ‘then’, or enough room or
enough of a gap so that some kind of approach of movement from

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here to there is possible. So that analysis can be possible and

develop over time. . . . In this sense you might want to help a
person view therapy as a kind of psychic gymnasium, to build up
tolerance, at certain times, for just seeing a moment through.
(1997: 114)

‘Seeing a moment through’ implies being able to allow what is potentially

painful to take its course before the customary defences click in. It is
above all an experience that is provided by almost any model of
psychotherapy for anyone who can tolerate it at all. Therapy has its own
time zone. In the postmodern era we are fragmented in many ways, and we
recognise to some extent our fragmentation. In therapy, time can stretch
or condense. It can speed up or slow down, sometimes achieving the
point where rushing on to the next thing may not be necessary.
Therapy is a process that may change the sense of time. In almost all
models of psychotherapy, people are seen to present with a disturbance
in the sense of the passage of time. There are disturbances also in memory
and these imply a difficulty with letting the past go and with living with
what there is. There is also often a difficulty in accepting the rate at which
time passes. Either it moves too fast, taking away one’s time in a persecutory
way, or it moves too slowly and each moment is too full in the senses of
both being too long and not providing enough. Personal time is variable
and elastic and may change dramatically for the patient during the course
of therapy, and requires the therapist to have the same experience, moving
perhaps from boredom or anxiety to a calmer acceptance of the rate at
which time passes. Whereas at the beginning of therapy the fifty-minute
hour may seem much too long, a great space to fill, or much too short,
never giving enough time to say everything, by the end of therapy, the
session, both in itself and as a template for most other stretches of time,
may have become more comfortable, with the patient more able to fit it to
him and to fit into it.
There is of course value in recognising fragmentation which may in
itself imply the ability to change. One of the ways in which patients can be
helped to bear whatever pain they have is by gradually developing
understanding that whatever there is in the present is not all there is. I can
feel or know something different from what I feel or know now. We could
call this a sense of something more, something that continues, a core self,
or simply a knowledge that the different selves that make up myself will

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not cease to be available. In any case, there is a change that can take place
which allows a greater tolerance of whatever there is.
The paradox of leaving therapy begins to make sense if we see it in the
context of both continuity and a tolerance of discontinuity. The present is
valued, and a vision of the future that includes separation can be faced,
but without undue anxiety. This attitude allows for the stage in which
ending becomes part of the discourse that makes up the therapy but is
neither dreaded nor desired to an extent that creates unbearable anxiety.
The level of anxiety over time is an indicator of whether it is yet time to
end.
Time can be conceptualised as a circle in which we always return to the
beginning, or an arrow moving only in one direction. Angela Molnos
(1995) writes that in the twentieth century we have become more aware of
time as an arrow. The image of time’s arrow flying in only one direction is
a symptom of the anxiety of our age, in which we feel ourselves to be
shooting helplessly forward at a frightening speed and with an implication
of destruction at the end. Medieval images seem more comfortable in that
the closed universe provided a container. The planets moved in closed
circles round the sun, and beyond the solar system the stars were safely
fixed. Time was conceived as a cycle. Human life followed its destiny and
returned to God from whence it came.
In order to end therapy or any relationship in this age, we have to
achieve the recognition that time is irreversible: we cannot have the past
back, not even in memory, since memory continually makes changes. We
have to move forward and that does mean facing the unknown. Therapy
may help in the discovery that moving forward need not imply
abandonment of the past and of what has been of value in it.
Readiness to end entails willingness to remember and willingness to
forget. Time can be allowed to move fast or to slow down. There are
observable cycles and yet overall a movement that is forward and
irreversible. At the beginning of therapy some patients may have been
unable to allow any return to the past. References by the therapist to what
happened with the parents are regarded as avoidance of the therapist’s
own role in the pain and discomfort of the present:

Ms Y came to see a therapist because she had been raped,

and was advised by the police and also a friend whose mother
was a therapist that therapy might help her ‘to come to terms
with the experience’. She appeared to be very reluctant to

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talk much about the rape or anything else, but Mr Z, the

inexperienced therapist who saw her, thought that she was
suffering from post-traumatic stress and that she would soon
learn to trust him and tell him more. In fact she never told him
much about her history other than that her father had left her
mother when she was 5 years old. Occasionally he sent her
parcels of completely unsuitable presents. She remembered
him sending her a teddy bear when she was 14 and a copy of
Chaucer in the original when she was 7. Both of these things
could be seen as quirky but perhaps well meaning. She saw
them as deliberate attempts to show that he did not care
how old she was or what she was like.
Mr Z soon found himself at the sharp end of some very
negative transference. His interpretations were met with a
stony silence, or loud shouting along the lines that he never
understood a word she said and all that he said was
unbelievably naive. She had read a great deal about
psychology and psychoanalysis herself and was inclined to
say, ‘If you’d read any Klein at all you’d know better than to
say that.’ Mr Z had read Klein and was hurt by this constant
swarm of stings. ‘What would you say if you were me?’ he
asked. She replied, ‘You can’t get out of it that easily. That’s
pathetic escapism.’ Mr Z also said, ‘You treat my words as if
they were unsuitable presents from your father. The difference
is that with me you can send them back.’ This produced
even more fury: ‘You think you can talk about my father and
that lets you off the hook. You know nothing at all about my
father.’
This went on for some time before gradually, with the help
of intensive supervision, the therapist fed back the double
binds that the patient produced for him. He could not speak
of the past and he could not be tolerated as himself in the
present. He did, however, survive in the time-honoured way
that therapists usually do, by a mixture of empathy, humanity
and enough interpretation to keep himself from going mad.
Gradually, the barrage of hate and hostility lessened and,
with many relapses, some progress was made towards a
state in which the therapist himself was tolerated better and
was acknowledged to be not totally useless.

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Ends of sessions had been particularly difficult times in

which Ms Y had fought against the inevitability of the end of
the session with various weapons, including refusing to leave
and all the gamut of reasons for staying just a few minutes
longer. Mr Z had worried greatly about how to deal with this
and certainly despaired of being able to end the therapy in a
mutual and constructive way. Nevertheless, after five years,
Ms Y decided that she wished to train as a psychotherapist;
she was already working in an allied profession. To Mr Z’s
astonishment, she was accepted for training by one of the
London organisations and she was told that she would have
to change therapists. He was therefore both relieved and
chagrined when she told him she intended to finish working
with him in six months so that she would have her new therapy
in place in order to begin the training.
There was therefore a six-month ending phase in which
some of the changes that had been developing in secret were
allowed to appear. Mr Z had some inkling that things were
not as bad as they had been in her personal or work life, but
he had had no idea of the extent to which she had concealed
from him her improvement. She said to him about six weeks
before they finished: ‘you have made a difference to me. I
don’t know how or what you did, because you never said
anything very brilliant, but you seem to have let me feel that
I could take my time. Now, I know that I have a lot to learn but
there’s a lot that I can’t tell you. I may not tell anyone or
perhaps I may now. I don’t know whether I’ll be any good as
a therapist but I’ll be able to have a try at it.’ She told him one
or two things more about her mother and her memory of her
father, but most of the story remained untold in the therapy
with Mr Z. They ended with warmth and a sadness that
surprised Mr Z, who had at times longed for the ending.

By the process of putting up with an intimate relationship with someone

who was very difficult to endure, Mr Z had somehow helped her to be less
persecuted both by him and by herself. One of her major changes was the
improvement in her ability to use the time available. She had been injured
by her father’s departure to such an extent that she would never let him
repair by giving her presents. Mr Z had somehow managed to repair

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something by continuing to be there week after week, even though she

rejected everything he offered. The desperation at the end of sessions or
holiday breaks never disappeared but it diminished as her acceptance of
his ordinary, dependable, if not brilliant self enabled her to achieve
something like object constancy. Why she chose to train with an
organisation that would not accept Mr Z as a training therapist is an
interesting question and one that he never fully addressed. What he did
say was that it seemed as though she wanted to make clear that he was
not very important and could be supplanted by another person, in this
case a higher status training therapist. He added that he suspected that
she would have wished her father to have been less important to her. She
did not greet this with her usual scorn, although she reiterated that of
course it was just to do with stupid training requirements and nothing to
do with her father. One would hope that the next therapist or analyst was
able to make use of the groundwork laid by Mr Z and that good work
might have ensued.

Loss and grieving in the ending phase

In this case, the interminability of analysis, as Freud put it, was made very
clear. The ending was made less intense because there was very definitely
somewhere else to go. There was more emphasis on the future, and the
importance of the therapy being ended was to some extent denied.
Nevertheless, the sense of time had clearly changed and the last six months
became more constructive. Ms Y could not acknowledge the importance
of the loss of her father and it could not be evoked. Because so much of
the work that is done in therapy relates to losses and the way that we face
them, the ending phase provides an opportunity that most people find in
no other context to live through an ending that has all the measures of
sadness, anger, disappointment, gratitude that go with bereavement and
loss in other contexts. These emotions should have been faced before the
end, and at the last minute they may be fleeting and easily missed because,
if the therapy has gone well, the ending will be a celebration as well as
being a loss. The feelings that relate to death and dying may be repressed
when the patient is much better and is approaching the end with outward
success and perhaps new relationships or a marriage.
The work that has been done on death and dying by Parkes et al. is
relevant and helpful in considering the processes of ending. Once an
ending date is set, the therapist listens for the way in which the patient

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deals with the inevitability of change and therefore of loss. Birth is a

difficult process for the baby, as we all know, but recent thinking implies
that the baby may actually be ready to be born. The womb may have
become a cramped space. The analogy with therapy is obvious and
optimistic. We cannot, however, ignore the analogy with the other end of
the life span. Jung emphasised that achieving readiness to die is one of
the tasks of adult life. How we make ready is an interesting and difficult
problem which each individual will have to solve. All that therapy can do
is to provide a context in which the question is raised and there is time to
look for an answer.
Nina Coltart is a psychoanalyst who took her own life. This event
shocked the analytic world, or at least those parts of it that were not close
enough to her to know her mind. On reading her last book The Baby and
the Bathwater (Coltart 1996) and her interview with Anthony Molino in
Freely Associated (Molino 1997), one has the opportunity to see how she
was prepared for death. Speaking in the context of her study of Buddhism,
she wrote:

Now this of course has considerable impact on what was let’s say
already an interest of mine; namely the idea of one’s own death. If
one is not a self, if the ego is a construct, the result of a
conditioning, we come to accept, well then, what is there to fear?
In any case, it’s always been my impression that people fear dying
much more than death. . . . But that too hasn’t been much sorted
out in the West. I mean it does require a lot more contemplation
and attention.
(Coltart 1997: 193)

This is far from being a nihilistic view of the self. Coltart also emphasises
that meditation is a strenuous process and that an understanding of what
is meant by no-self or anatta is not acquired quickly or easily. It is certainly
not the destruction of the ego (1996: 134). In the same way, the truths that
are reached in therapy may enable the individual to end, to face his or her
death, but are not quickly or easily available. The Buddha sat under the
bodhi tree for seven days and seven nights at a time in order to arrive at
some element of enlightenment. For most people, several years of therapy
are needed to reach a state in which we can give up and leave behind
some of the unwanted aspects of ego.
Coltart herself says that she does not see the Buddha dismissing all
aspects of ego as illusion or what Lacan would call méconnaissance. As
a therapist, she concludes that there is some value in the concepts of true

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and false self that Winnicott propounded in his paper of 1960, because
the true self can allow for stillness at the centre. There is time and space
when one reaches this centre for both attention and detachment. I find
this view of Winnicott’s concept of true self greatly preferable to the
wilful unadapted baby that it seems to imply for some.
Coltart found that she could contemplate death as exciting, ‘an awfully
big adventure’ rather than as a terror. She wished to face death consciously,
and was only sorry that she would not be able to write a paper about it:

Mostly I think it will be extremely interesting and it seems to me as

if almost the greatest blessing that life can hold is to go consciously
into one’s own death. It is maddening not to be able to write a
paper about it afterwards. But to greet one’s death to observe and
inspect it would feel like a fitting ending – particularly in a
psychotherapist’s life.
(1996: 143)

Therapy allows for leaving and parting to be consciously faced. Some

patients seek to reduce the frequency of their sessions in order to test
their ability to manage without the therapist. Allowing a reduction in the
number of sessions per week or month is understandable, but will reduce
the intensity of the ending phase and deprives the patient of the most
intense and therefore perhaps the most valuable time of loss, of letting
someone go with all the anger and sadness that loss entails. On the other
hand, a gradual reduction in frequency may enable some patients to face
leaving when otherwise they would evade it altogether. If loss is faced,
there may be echoes of both birth and death in the experience. In this
paradox lies another: the contemplation of birth and death allows both for
greater strength in being able to contemplate separation and leads towards
a point at which there is less isolation either internally or from the other,
although there is separation.

Is there life after death?

We bring ourselves to contemplate ending for a short time, but we revert

quickly to optimism and emphasis on the positive. Patients in the ending
phase may wish to find manic defences which allow them to believe in
new relationships or to deny the ending of the current one. There are

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often questions, overt or veiled, about the possibility of continuing to

see the therapist as a friend or colleague. Trainees do not have to lose
contact with their training therapists and analysts in the way that we
expect our other patients to manage to do. Therapists vary in the extent of
absolute finality in ending. Not many would refuse to allow the possibility
of further therapy if it were sought, but most would wish the ending to be
final for now.
Becoming a friend or partner is an option that is sometimes taken. Love
affairs or sexual relationships with ex-patients are discussed in Chapter 7.
Lisa Alther in her novel Other Women describes a therapist allowing her
former patient to meet her for lunch when they have finished. The patient
is delighted, but describes vividly her disappointment at the change from
therapist behaviour to behaviour as a friend. The friend says, ‘Yes, and I
have my problems too,’ and does not necessarily wish to listen patiently.
These are obvious superficial difficulties. What is much more problematic
is the change that this causes to the internalised therapist who is no
longer available in the same way as an image or after image. The reality is
liable to supervene and remove what went before.
An argument on the side of allowing friendship might be that there is
no need for the therapist to seem superhuman. A change to being an
ordinary person should not destroy the work that has been done. The
aims described in Chapter 1 for almost all analytic therapies imply that
therapists would deliberately set out to ensure that they cannot be seen
as superhumanly wise or tolerant or restrained. For this reason, many
therapists would accept a hug or a handshake at the end of therapy
although they might not initiate such a change to physical contact
themselves. They would allow themselves to be natural in response, and
this does not necessarily invalidate the rigour of what has gone before. It
may still be consistent with the wish not to be the one who is supposed to
know nor to be adopted as the ideal. A refusal to be idealised is a continuing
process or attitude in the therapy. What is likely to be problematic is a
sudden change in the final phase of the therapy if a certain amount of
idealisation has been tolerated up to that point. Sudden changes are not
desirable for a number of reasons. One of the most obvious is that it
brings the genuineness and sincerity of the whole therapy into question
if the therapist in effect says, ‘OK, now we are finishing, you are grown up
enough to know that there is no Father Christmas, although I thought it
was good for you to believe in him for a while.’ Such an attitude to the
whole process is clearly likely to be damaging because we are not dealing

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with children and, although fairy tales have an honoured place in therapy,
we are not in the business of telling them as if they were the truth and then
recanting later.

The last session

If the therapist is firm about the finality of ending, the patient is faced with
a parting and a separation but not with the total loss of the therapist
because the therapist can continue to be kept in mind as therapist. Even
so, the separation process is bound to bring fear and anxiety insofar as it
is experienced as loss. Masud Khan was able to say about his analysis
with Winnicott:

One of the most valuable contributions of DWW’s long protective

care and coverage over the past twenty years of my growth and
development as a person has been that he has changed a
catastrophic threat of loss of object into separation anxiety.
(Cooper 1993: 21)

The actual analysis lasted fifteen years, but as fellow members of the
British Psycho-analytical Society their relationship continued after the
end of formal analysis. For patients who are not colleagues, the ending is
different. The patient may panic and wish to change his mind and not part
after all. Even when the feelings in the therapeutic couple have reached a
point when ending is in view, reverses upset the smooth passage to an
ending. This may be the phenomenon known as negative therapeutic
reaction which is usually understood to mean that there is anxiety aroused
by any improvement of symptoms or state of mind. The anxiety is caused
partly by the fear of losing the therapist and partly by much less conscious
phenomena described by Sandler et al. (1992), and Limentani (1981), for
example, as guilt at getting better or envy of the therapist who cannot be
allowed the satisfaction of healing. Guilt is caused by the inner voice
which demands suffering and exacts continuing reparation.
Whatever the reason for the negative reaction, we all see it happening
when there has been a particularly good session or a particularly good
therapy which may be about to end. This happens at various points in the
process, but is a common experience in the very last session.

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Mrs AA is a woman of 78 years old. She had Jungian analysis

in her twenties and later trained as a counsellor, having had a
considerable amount of further therapy of her own. She came
to her last therapy because she had experienced what she
saw as a series of dreams about her little brother who had
died at the age of 5. Both she and her brother had been
beaten by the nanny who was looking after them when their
mother had died. Her little brother always appeared in the
dreams as an innocent child who was helpless in the grip of
the cruel woman and was imploring rescue. In the early dreams
he was standing on a chair. Mrs AA would interpose herself
between him and the woman who was trying to hit him, but
she fell down or tripped and was unable to prevent him from
being hit while he screamed and cried. The dreams were
extremely vivid and distressing. At the same time, Mrs AA,
whose husband had died twenty years before, was struggling
with a relationship with a man of about her own age, and who
wished to come and live with her. She had known him for ten
years or so but had never wanted to commit herself to anything
more than friendship.
In the course of therapy, which lasted about eighteen
months, she explored her feeling of guilt and helplessness
over her little brother. She had no children of her own and felt
that she was unfit to have been a mother and in fact that she
carried the burden of all women who are harmful and
destructive to men. With the woman therapist she was able
to acknowledge how difficult she found it to allow anyone
close to her at all. She had a dry wit and great intelligence
and therefore she had many friends, both men and women,
but no one was allowed inside the secret garden of her
innermost feelings. She was also an artist with a loom, and
she could convey a great deal of pain and separation in the
images that she wove.
In therapy she could be savage in her attacks, but she was
also able to invoke great affection and attachment in the
therapist. She was able to allow that she also loved the man
she knew, but she could not risk having him come to live in
her house. She reached a sort of compromise with this, and
decided to end her therapy in the understanding that she had
done as much as she could. She agreed with the therapist to
have an ending period of about three months. They worked

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on, dealing with the image of the little boy, seeing in him both
the hope and purity of the puer aeternus or the eternal child,
the saviour, and also the contrary figure of the helpless child.
She had seen men as both, and was therefore, not surprisingly,
afraid that she could have a great effect, largely damaging,
and also that she could have no effect at all on the man who
was to be the saviour of the world.
When the last session came, the therapist was very sad in
anticipation of ending what she had found to be most
illuminating and challenging work. She was also sad that
she would not be seeing this brave and lonely woman any
more. The session began with Mrs AA saying in great agitation
that she had quarrelled with her friend and that he had said
he was tired of her prevarication and would not want to come
and see her any more. The therapist immediately thought,
‘well, we can’t end the therapy. She’ll be completely on her
own and there is obviously much more work to do now.’ She
waited, however, and on reflection decided that this might be
a last-minute panic and that she should persevere with the
ending, rather than respond to her own wish to continue to
see this patient. She therefore said: ‘I know that you are
describing a bad quarrel and I don’t know whether you will be
able to mend it. I also know that we are ending our sessions
today and we might both be aware that the end of our meetings
is sad and in a sense not to be mended, and yet perhaps
there is still something important for you in having the courage
to face this final session.’ Mrs AA was able to acknowledge
in tears that the ending was very important to her and that
she would greatly miss the therapist. Nevertheless, she
wished to end as they had planned. Her last words were, ‘I
shall weave something for you and send it so that you will not
forget me.’ In this way, we could say that she evaded the full
force of the ending, and yet, in her sadness and her
unprecedented acknowledgement of someone’s importance
to her, she had faced it as much as anyone does. The
therapist heard that she had died within a few months of ending
the therapy, so the wall hanging was never finished.

Persisting with the ending when the patient brings an emergency into
the last session may not always be the appropriate response, but it is

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always important to check it in one’s own need for the patient and one’s
own defences against death and the end. Another therapist was faced
with a patient whose mother died the day before the last session. This
was a sudden, unanticipated death from a stroke. The patient asked
whether it would be possible to have more time, and in that case the
therapist decided to give another three months to the therapy. The rationale
would be that the death of one’s mother is a difficult experience to survive
for most people. It was not a reparable loss like a quarrel, and it meant that
the ending of the therapy could not in any case be fully valued because
the patient was in a state of shock. For all these reasons, the change of
mind seemed the best choice and in fact the therapy ended on a sad but
constructive note at the end of the three months.
Not all therapy ends with sadness. Perhaps a more usual ending would
have a celebratory note and would have optimism and energy as the
conscious tone. In these cases, the therapist must remember the themes
of loss and death. This is usually achieved by making some sort of
summary of what has been done and what has not been done. There are
bound to be disappointments and areas that have not been touched. The
whole journey may have been to an unforeseen destination, and in any
case, the person who is arriving is not the same as the person who set out.
Both the patient and the therapist will have ideas about what has been
missed, although they may be different. Patients can be encouraged to
say what they have missed or not been able to change. Therapists are
less likely to say what they think has not been done unless it relates to
what the patient has already said. To raise something that has not been
discussed already as a lack seems cruel, and would be a poor reflection on
the work of the therapist. On the other hand, to recapitulate what both
agree has not been possible or only marginally achieved is to face as far
as possible the reality of the relationship and its shortcomings.
One thing that is often missed by therapists is the importance of the
patient’s gratitude. We are so used to hearing and acknowledging negative
transference that it can be quite difficult to hear and accept genuine
gratitude. Yet even a superficial knowledge of Klein suggests that gratitude
is the antidote to envy, allowing a person to be at peace with himself and,
even more importantly, allowing that another can have something good
which may in part be given or shared but which does not have to be
destroyed. This in itself implies that the therapist can be left and can be
allowed to keep whatever good she still has in the patient’s mind.
Hinshelwood refers to a patient who spoke in images of planting and
growing:

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He knew that getting the sweet peas was connected with my having
sweet peas in my front garden. Also, when he was a child there
were sweet peas in a wild part of the garden at home, and he loved
them, they meant a great deal to him.
(1994: 218)

There may be idealisation in this image, but as Hinshelwood points out, it

is connected to the earth and suggests that something may be growing or
at least able to grow in the patient. In a last session, such an image of
growth can be greeted with hope because, although it may be defensive,
it is the patient’s last word.
Therapists may also wish to give something to the patient. Melanie
Klein, in her account of therapy with Richard (1989), said to him in his last
session when he took a drink of water that, since he could not have the
good breast, he now wishes to take the good penis of the father into him.
The material does not obviously lead to such an interpretation. One might
say that it is consistent with her whole pattern of discourse with Richard
in which she makes a commentary on all his simple, everyday remarks in
terms of her theory of the child’s concern with the bodies of the parents
and with his own body. Nevertheless, in the context of the last session,
she is giving him a gift of the good penis. Will he be able to use a penis
that she gives him, or is it an addition, an extra, not his own? Apparently
he became a travelling salesman, with a suitcase of objects to display and
to offer to others.
This example merely illustrates the uncertain trajectory of all that we
offer. We cannot know where it goes or what it might effect. When we are
in the endgame, we may be tempted to try to give something extra. It is the
last chance, and the patient will no longer be there to repair our sense of
ourselves as therapists. Perhaps it is this loss on both sides that leads to
the ultimate desire for a return to the real or physical contact at the end. It
is a very private moment and we do not know much about what happens,
although it is likely that there is often a wish on both sides to express the
inexpressible at the last moment.

References

Coltart, N. (1996) The Baby and the Bathwater, London: Karnac.

Coltart, N. (1997) ‘Interview with Nina Coltart’, in Molino, A. (ed.) Freely
Associated, London: Free Association Books.

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 HOW MUCH IS ENOUGH?

Cooper, J. (1993) Speak of Me as I Am: The Life and Works of Masud

Khan, London: Karnac.
de Simone, G. (1997) Ending Analysis, London: Karnac.
Eigen, M. (1997) ‘Interview with Michael Eigen’, in Molino, A. (ed.) Freely
Associated, London: Free Association Books.
Hinshelwood, R. (1994) Clinical Klein, London: Free Association Books.
Klein, M. (1989) in Steiner, J. (ed.) The Oedipus Complex Today: Clinical
Implications, London: Karnac.
Limentani, A. (1981) ‘On some positive aspects of the negative therapeutic
reaction’, International Journal of Psycho-analysis 62: 379.
Molino, A. (ed.) (1997) Freely Associated, London: Free Association
Books.
Molnos, A. (1995) A Question of Time, London: Karnac.
Parkes, C. M. (1995) Recovery from Bereavement, London: Karnac.
Sandler, J., Dare, C. and Holder, A. (1992) The Patient and the Analyst,
London: Karnac.
Winnicott, D. W. (1960) ‘Ego distortion in terms of true and false self’, in
(1985) Maturational Processes and the Facilitating Environment,
London: Hogarth.

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 9
IN MY BEGINNING IS
MY END
The time-limited solution

If it were done when ’tis done, then ’t were well

It were done quickly.
(Shakespeare, Macbeth I, vii)

How loss is used

Much of this book has been about reconciling the conflicts of patients
and therapists over how long therapy should be. Therapists in private
practice are consciously highly motivated to make therapy last as long as
possible both because their income depends on a regular number of
sessions and because of innate conservatism as well as resistance to
loss. Patients have the opposite motivation. In most cases, they want to
spend as little money and time as possible in order to leave therapy
feeling better and with their lives changed. These two streams of thought
have to meet in making a contract and in planning an ending. When the
contract has a time-limit, the patient will have to change a great deal in a
short time, but paradoxically, the therapist may not have to change as
much as in open-ended work.
In some cases the therapist makes a time-limited contract reluctantly,
bowing to practical necessity. Working for agencies, many therapists
have accepted that six or twelve sessions is what the agency offers or can
afford and that if they wish to work for the agency they must keep within
the time-limit. In some cases, they would prefer to be seeing the patient
for longer if they could. Research has indicated, however, that gain in
reported improvement continues with increased length of therapy only

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up to twenty-six sessions. After that the gains reduce until the longest
therapies show little if any continued gain (Howard et al. 1986). A study
comparing eight sessions with sixteen found that only very disturbed
patients benefited more from sixteen sessions than from eight (Shapiro
1995). There is therefore good reason to regard time-limited therapy as a
treatment of choice in many cases. Therapists have been inclined to see
long-term work as their treatment of choice, and it is often necessary to
educate the therapist into believing that much can be achieved with
specialist training and supervision for the shorter periods of therapy.
There is now some excellent training in time-limited psychotherapy.
The most obvious advantage of time-limited work is that both patient
and therapist know exactly how much time there is and can adapt their
pace accordingly. Time-limited contracts are not necessarily very brief.
Although they may be as little as one or two sessions, they may equally
be for a year or two years. The end is built into the contract and there is no
way that the loss can be avoided or denied if the contract is followed
rigorously. There are of course various models of time-limited work and
the more cognitive models may be less inclined to deal with the ending of
the work overtly. For example, a systemic model of six sessions involves
bringing up the idea of ending in the fourth session. The patient is reminded
that there are two more sessions and the question of further work to
continue or extend what has been done is raised. At this point further
referrals may be made or lists of appropriate agencies, including perhaps
those for long-term therapy, may be offered. The end of the current work
is clearly set out in front of the patient, although feelings about it may not
be directly addressed unless the patient shows distress or raises the
ending as a problem. In the last session, the patient will be invited to say
what has been achieved by the therapy and what has been missed. This
will often lead to an opportunity for the patient to speak about the feelings
aroused by ending although, again, the therapist will not directly ask
about feelings. The emphasis will be on what the patient will do next and
how the improvements achieved may be maintained. In a systemic or
cognitive model the therapist can stay with known and tested techniques
and schemas and may not need to seek resolution through his own
change.
In a more psychodynamic or analytic approach, the patient’s transferred
feelings about the potential loss of the therapist and the therapy may be
more directly raised by the therapist. This has to be done carefully, because
a danger in time-limited work is that the patient uncovers feelings and

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memories which are transferred to the therapeutic context and are so

profound or disturbing that they cannot be processed or resolved in the
time available. Many therapists who have trained in open-ended
psychodynamic therapy will find that they think in terms of what is being
transferred from the past and what part they find themselves playing for
the patient, but will use a great deal of skill in not opening up too many old
wounds that cannot be healed in the time that remains.
Mohammed and Smith describe their work for the Women’s Therapy
Centre as ‘neither psychoanalysis nor counselling although it contains
elements of both’ (1997: 112). They make use of David Malan’s three-
pointed approach to psychodynamic work to achieve insight by linking
accounts of past relationships with the present outside the therapy and
the present in the room with the therapist (Malan 1979). If these three
points can be linked during the therapy, which is commonly a contract of
twelve weeks, the ending may be experienced with acceptance rather than
a sense of persecution. Mohammed and Smith have found, like most
others in the field, that there is often a crisis in the last few weeks of such
a contract, and this crisis raises the whole question of whether there can
be any autonomy and self-confidence without the therapist and the
therapy, but, by surviving this moment, the patient can gain hope and
belief in himself. The therapist must keep faith at this point and not change
the ending date, because that would imply doubt.
The therapist is not the only one in the room who thinks differently
because of the time-limit. The patient also knows both consciously and at
a deeper level that there is just so much time to use. The therapist reinforces
this by reminding the patient of how much time there is left and encouraging
the patient to think actively about how to use that time. Outcome studies
by the Westminster Pastoral Foundation’s time-limited project in
Counselling in Companies indicate that patients report surprisingly great
improvement in just six sessions and one explanation for this is that there
is a self-regulatory mechanism in the psyche which enables the patient in
most cases to avoid too much regression and to use the time in therapy to
change patterns of behaviour, with the reinforcement and encouragement
of the therapist acting as catalyst.
Davanloo (1980) is a charismatic therapist who works in a model which
depends greatly on his own powerful personality. He makes a judgement
about who can use his approach and then breaks down resistance and
defence by persistent questioning in which the patient is allowed no
escape. He insists on knowing exactly what the counter-productive

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behaviour is, when it happens and how it happens, and the patient is
allowed no avoidance, no hiding-place. He forces the patient to become
aware of strong feelings in the present which cannot be avoided, because
Davanloo will not let them be concealed. He achieves his aims, or the aims
of the patient, by means of connecting the powerful feelings that arise to
a sense of discovery, so that the patient is aware that he or she can
change and behave differently from the way he or she has behaved before.
He sets up an expectation that change can be exciting and liberating. In
other words, he enables the patient to see that time’s arrow may be moving
towards the achievement of goals and strongly suggests that this need
not be feared.
One of the most important elements of the therapist’s work when it is
short term is the warmth and concern that is conveyed by the voice and
attitude of the therapist so that the patient knows that the challenging is
for his or her own good. Molnos (1995) refers to the healing anger that the
patient experiences when the resistance is challenged to such an extent
that there is nowhere left to hide. At the moment when the patient is able
to be angry at the pressure, and the laying bare of the defence, he or she
is able to be free of the defence. Compliance and pleasing the therapist are
no longer possible, and although what is experienced is anger that relates
to all the compliance and acceptance of the past, the anger itself is
nevertheless a moment of separateness in which the patient is free from
his or her neurosis and is able to contemplate a less dependent existence.
Davanloo’s approach is in some ways very authoritarian, but Molnos
(1995) argues that part of its beneficial effect is that it enables the patient
to be separate and to experience not needing to be so defensive. Davanloo
generally works in only one or two sessions (although he has also worked
for up to twenty sessions), and carefully monitors the extent to which the
patient can survive his challenge. Most therapists will be less challenging
than he is but we can perhaps see a similar rationale for other forms of
brief therapy. The therapist can set up a dependency if she is seeking
admiration for her wisdom or is too inclined to enjoy being idealised.
There would be some danger in such a therapist using the reminders of
the approaching ending to tantalise the patient, to say in effect ‘aren’t
you sorry that you have only two more sessions with me?’ The implication
of speaking of ending is the possibility of independence: ‘We have only
two more sessions and you will be able to use the time to develop tools
for yourself that you can use on your own without me.’
In ‘Mourning and melancholia’ (1917), Freud wrote of the difficulty of
losing someone through death or other means. In one of his most
memorable pieces of writing he said that ‘the shadow of the object falls
upon the ego’. He was speaking of the way in which, through depression,

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the sufferer feels worthless and treats himself as the useless, powerless
one, because the alternative would be to think this of the dead person.
Therapists have to be aware that they can become in fantasy the lost
person whose shadow falls upon the patient’s ego and disables it. There
is particular danger of this in long-term therapy, but in short-term work the
therapist risks this happening if he is too brilliant and charismatic and
allows the patient to see him as the one who knows. Davanloo, for example,
guards against this to some extent by using Socratic questioning. The
patient must find his own solution, although he is brought to the necessity
of finding something by the persistence with which Davanloo pursues
him into his avoidance and delays.

Ending: do we really mean it?

One of the most painful questions facing therapists in time-limited work

arises when a patient wishes to continue beyond the time-limited contract.
Most of the agencies who provide this kind of therapy have strict rules
prohibiting therapists from seeing patients after the end of the contract.
Like marriage after therapy, however, the continuation of the work is not
always seen as impossible. Many GP practices have counsellors or
therapists working for them who may choose to see some patients for
open-ended contracts or in some cases may take patients into private
practice if the patient is willing and they wish to do so. There are obvious
arguments for and against these continuations. The therapeutic argument
will be that the patient has begun to uncover some part of himself or his
past which is now raw and open and must be given more attention before
it festers. The therapist will be experiencing the counter-transference effects
of being loved and possibly idealised in the transference, even though
the time together may have been short.
Clearly, therapists in such a situation need to search themselves and
their own motivation carefully. There is likely to be some sort of particular
attraction in this patient which relaters to a son/daughter or mother/father
transference for the therapist. These Oedipal connections will make it
very difficult to let the patient go. No doubt they will affect the extent to
which both the patient and therapist wish to continue beyond the contract
but they may not make a sound basis for deciding to ignore the contract
and postpone the ending. At the very least, they mean that the ending
that was agreed in the contract should be carried out and that if work is to
be resumed it must be under a new contract. An understanding that there

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will be a new contract does remove from the patient the experience of
letting go of a person who is valued. There is some Oedipal triumph in
managing to seduce your therapist into continuing to work with you, and
although this may not necessarily be a bad thing, it needs to be recognised.
Developmentally, the adolescent seeks to have the parent all to himself,
but needs to fail and be compelled to seek relationships of his own.
Clearly, this aspect of continuing therapy can be recognised and used.

Ending from the beginning

Because the patient knows that there will be an ending at a specific time
as the distinguishing feature of time-limited work, he is unlikely to stay in
a childlike state of timelessness, but always seeks to be in a more adult
mode with awareness of what is happening to him. This very awareness is
part of maturity and is presupposed by the therapist to be possible. If it is
not, then time-limited work is contra-indicated, as are some other forms of
psychological therapy. If the patient is not able to think or speak
articulately, talking therapies are not likely to be able to help unless there
is time for the patient to learn to use the therapist. Long-term therapy can
allow for regression to some aspects of childhood, but time-limited work
requires thinking from the beginning.
Patients who seek time-limited work are achieving the safety of knowing
that work will be done at the conscious level. Whatever is going on
beneath the surface, something will happen that can be known and
understood. There will be an ending, and we can be sure of that at least if
nothing else. On the other hand, they are missing out on the middle stage
of therapy. John Rowan (1997) writes:

It seems to me that brief counselling or therapy ignores the middle

phase and in effect cheats the patients of the potential hidden
within their crisis. It sticks to the easy part where some immediate
results can be seen and ignores the more demanding parts where
there may be difficulties with the therapeutic relationship itself. It
is in the second phase that higher levels of skill and deeper levels
of self knowledge are called for on the part of the counsellor.
(1997: 193)

The second stage to which Rowan is referring is the middle part of the
therapeutic process. He describes the beginning as dealing with the

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presenting problems or symptoms. The second phase is entered when

these initial difficulties have been removed and the patient begins to look
more deeply at the causes of the problems and the repeating patterns
they have made in the past, perhaps from childhood. Time-limited work is
not intended to upset deeply held convictions about childhood or other
aspects of life unless that is essential to deal with the present. An adult
finishing time-limited work may have solved an immediate problem and
may have acquired tools for the future but will not usually have faced
fully the fear and anxiety of childhood.
The third phase of time-limited work involves applying the learning of
the second phase to the everyday life of the present. These phases in
practice are often blurred and overlapping. Nevertheless, Rowan makes
clear that the patient who has to move straight from dealing with the
presenting problem into the ending does miss an opportunity. In analytic
work, the opportunity that is missed is the possibility of entering the time
of childhood where one can just mess about with no specific aim or end in
view. Such apparent idleness does have a purpose. There is a risk of
boredom and anxiety but it can also achieve changes at a fundamental
level, as a reading of Winnicott’s clinical work shows.
Something is lost and something gained which ever mode of work is
chosen. One thing is very clear: in time-limited work, the therapist must be
prepared to work for an ending right from the beginning and must not
waver in the view that an ending is desirable. Time-limited work requires
the therapist to be much more active in technique, even if not as active as
Davanloo, for example. Feltham (1997) lists some questions that the
therapist should ask after a session:

• Have I generally established a sense of urgency, expectation and

hope?
• In this session did I sensitively apply a degree of temporal
pressure?
• Exactly what did I do in this session that helped to move matters
forward?
• Did I at any time inappropriately hurry or pressurise the patient?
(1997: 139)
To these, I would add

• Did I remind the patient of just how much time there is left before
the ending?

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One aim of the therapist in reminding the patient of the ending is to

prevent aimless dawdling. The patient has set himself a goal and the
therapist’s job is to help him to move towards it. Of course the goal may
be changed, but there will have to be a replacement goal. Sometimes the
goal may be to find a goal, but that can then be delineated as the very
important need to discover what the patient wants. Because of this
pressure, the ending of such problem-solving work is bound to relate to
the problem. There will be an element of success or failure that may be
tackled less punitively because of the effect of the therapy, but will still
be part of the atmosphere of the ending. Sometimes, the main achievement
of a patient is to be able to forgive him- or herself and the therapist for
not having achieved the goal that was set or for achieving it only partially.
Therapists have taken varying positions about the need to specify
the ending date in time-limited work. One approach is to offer up to six
sessions and allow the patient to decide what number will be best. This
gives the patient complete control but does not always allow sufficiently
for deference and feelings such as: ‘You must have to see many people
who are much worse than me.’ Some therapists say that there will be six
sessions in total, but allow for them to be spread over varying intervals
according to the progress that is made and the type of problem brought.
In this model, the amount of contact is known and agreed but the final
ending date is not known. Mann (1979), on the other hand, is very clear
that in his twelve-session model, the date of the final session will be set
in the initial contract and will not be varied. He is telling his patients that
he is confident that they will be ready to go by then. This approach
emphasises the extent to which the time-limited model shows the
necessity for action and for change. Loss is inherent from the beginning,
but ‘The stimulus of loss makes all possession mean’ (Emily Dickinson).
The stimulus of loss may also bring to the forefront feelings of being
displaced, jealousy of patients who will follow, anger with the therapist
who gives just so much and then disappears. These sorts of feelings
may be painfully aroused but may be dealt with only indirectly as part of
the presenting problem. The therapist may be aware of the deeper
significance, particularly in terms of the relationship between patient
and therapist, but will keep such thoughts to himself. Psychoanalytic
interpretations will be made only if absolutely essential to remove a
block that is preventing dealing with the present task.

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From the therapist’s point of view, restraint is essential. He must not

draw feelings towards himself because he must not make the ending more
difficult. Taking into account the possibility of sometimes ending therapy
that has not achieved its agreed goal, the therapist also has to be prepared
for some disappointment. Analytic therapists are particularly likely to feel
dissatisfied because they have rightly resisted the temptation to encourage
transference. There will usually be other achievements to outweigh this
frustration. There may sometimes be minimal achievement or none that
can be recognised. Of course it often happens that the patient who achieves
little was not well motivated in the first place.
One of the causes of failure is the patient’s lack of motivation; for
example, if he attends therapy only because he has been sent by an
employer, partner, etc. Without the desire to make changes for himself, the
patient is likely to go away much the same, and the end of the therapy is
likely to be half-hearted and full of ‘not much’. The patient who finds
good reason to want to change and has the courage to see that he or she
needs to change, and does not simply wait for the rest of the world to
change first, is likely to participate in the high success rate reported by
Feltham (1997: 140), who quotes a study showing that 53 per cent of
patients reported improvement by the eighth session and 90 per cent by
the 104th session. Outcome studies show results to be as good for short-
term therapy as for long-term therapy. The benefit that is attained after a
hundred sessions seems to be increased self-understanding or in the
continuing support of a therapist rather in improvement to symptoms or
problems.
Some endings in brief therapy can be startling in the extent of
improvement that is reported:

Ms BB is a woman aged 23. She came to a GP surgery

counsellor reporting panic attacks and seemed listless and
uninterested in anything. She had a small child of 3 whom
she barely mentioned, except as a nuisance to be palmed off
on someone else if possible. She had a partner who was
reported as neglectful, often out in the evening and not willing
to help with the child during the day, even though he was
unemployed. Ms BB herself was very attached to her mother
and said that she would like to take a graphics design course
but could not leave her mum as she would have to do if she
were to travel to the nearby town to take the course.

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In the six sessions that were agreed, Ms BB came to life.

The therapist showed little interest in the panic attacks but
concentrated on the focus suggested by the patient that she
would like to be able to enrol in the graphic design course
that might lead to a job. The patient was able to express her
anger with both her mother and her partner and to plan what
she needed to say to each one. She discovered that her
panic attacks took place when she was out shopping with
her mother and related to becoming like her mother with no
life of her own.
As a result of facing her difficulties and finding ways of
talking about them, she found that she was able to take more
of an interest in her little daughter. She arranged for childcare
and discovered that her mother could actually do without her.
She enrolled for the course. All went so well that the therapist’s
concern became: ‘is this too good to be true?’ The
improvement was maintained however, and in the last session
the therapist decided to voice her anxiety that difficulties were
being kept hidden. The patient showed some relief at this
and said that she was afraid to seem ungrateful but she was
anxious about how well she would be able to manage the
requirements of the course in graphic design. Between them,
they were able to establish that Ms BB should be allowed to
do her best, even if that did not always bring success. The
therapist was reassured by this element of real anxiety and
in the follow-up session six months later found that the
improvement had continued.

Such improvement as this is by no means rare, although of course we

suffer from the lack of any way of controlling for the comparative effects
of other possible models or lengths of therapy. In the absence of research
that can look at differential outcomes for one individual, we have to accept
provisionally that working with a time-limit and hence an ending in view is
beneficial for most people. Nevertheless, it is very different in kind from
the long dialogue with another mind that is possible in long-term analytic
work and to make a comparison is hardly comparing like with like. For the
moment we can be thankful that both kinds of work still exist, and that
endings must play an important role in any kind of therapy.

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References

Davanloo, H. (1980) Short Term Dynamic Psychotherapy, New York: Aronson.

Feltham, C. (1997) Time-limited Counselling, London: Sage.
Freud, S. (1917) ‘Mourning and melancholia’, SE 14.
Howard, K., Kopta, S., Krause, M. and Orlinsky, D. (1986) ‘The dose–effect
relationship in psychotherapy’, American Journal of Psychiatry 146: 775.
Malan, D. (1979) Individual Psychotherapy and the Science of Psychodynamics,
London: Butterworth.
Mann, J. (1979) Time-limited Psychotherapy, Cambridge, MA: Harvard University
Press.
Mohammed, C. and Smith, R. (1997) ‘Time-limited psychotherapy’, in Lawrence,
M. and Maguire, M. (eds) Psychotherapy with Women, London: Macmillan.
Molnos, A. (1995) A Question of Time, London: Karnac.
Rowan, J. (1997) ‘Transpersonal therapy’, in Feltham, C. (ed.) Which
Psychotherapy?, London: Sage.
Shapiro, D. (1995) ‘Finding out how psychotherapies help people change’,
Psychotherapy Research 5 (1).

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 10
ENDINGS IN TRAINING
AND SUPERVISION

Endings in training

Training in psychotherapy must vary according to the model and modality

being taught. Traditionally, the model has been something like an
apprenticeship, and something like an initiation. Recently there has been
a strong movement to make psychotherapy into a profession, and this
has resulted in codes of ethics and practice and in training requirements.
Most training in analytic psychotherapy is designed to encourage long-
term or open-ended work. Trainees are required to have personal therapy
of the appropriate kind for the duration of the course and do not end with
their own therapy, unless something goes wrong, until after they have
finished training. They may think that training is interminable and wish
for it to end, but the effect of training is to make the ending of the work
into an idea but not a reality.
The traditional requirements for training in psychoanalytic
psychotherapy, analytical psychology or psychoanalysis go something
like this:
All candidates must see as a minimum:

• one patient three to five times a week for two years;

• one patient two to five times a week for eighteen months.
After the second training patient has been seen for long enough, the final
paper may be written with the supervisor’s approval. Everything depends
on being able to see two patients for the required length of time, and of
course doing so in a way that the supervisor can approve. Most training
requires two individual supervisors, one for each patient, so that two
ways of working are experienced and also so that assessment is not
restricted to one person’s viewpoint.

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Counselling training on the other hand is much more likely to have

requirements in terms of numbers of hours. Thus the British Association
for Counselling requires 450 hours of supervised case work as a minimum
to be completed before a counsellor may seek accreditation. Many other
training organisations have chosen a middle path between the two, with
some requirements being stated in terms of hours and some in terms of
numbers of patients seen.
We can easily see the difficulties that the training organisations face.
How can you tell that someone has done enough work to be able to use
their experience constructively? How can you assess someone unless
they have done a good deal of the kind of work that they are training to
do? Training in long-term psychoanalytic work clearly requires that
trainees should have worked in at least the middle stage of analytic work
so that the transference has been faced in various forms and the candidate
has shown ability to tackle whatever the two patients bring. At the other
end of the spectrum, many counsellors are increasingly likely to do only
short-term work and they need experience of that. They will therefore
experience many endings but may be able to avoid the pain and anguish
of these more frequent endings and also their value in therapy.
All training needs to be clear about the reasons for the amount of
experience required of trainees. The current lack of statutory regulation of
counselling, psychotherapy and psychoanalysis means that trainees reach
the end of their training and qualify with very different levels of experience
behind them. Deciding how much training is enough is done by individual
training committees or, increasingly often, by university committees.
The thoroughness and therefore the volume of case work needed in a
training seems to me to be determined by the difficulty and responsibility
of the undertaking. All those who work in this field are likely to be in a
position to do good and therefore also to do harm. They may be influencing
people’s lives for better or for worse. There seems to me to be no excuse
for a training that ends after a brief encounter with clients or patients. No
training in counselling or psychotherapy should, in my view, allow people
to finish until they have studied a theoretical rationale and worked
satisfactorily with clients or patients for at least four years part-time with
concurrent personal therapy.
Length is essential in training because the theory must not just be
learned but must be assimilated thoroughly through supervision of
practice. The nature of the practice, on the other hand, may well need to
depend on the kind of work that will eventually be done. Teachers have a

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duty to ensure that the training is fitted to the work. Thus a counselling
training should logically ensure that it includes the skills of brief work,
and if its trainees are not being required to include long-term cases in
order to qualify, they must be aware that they are qualified only to specialise
in short-term work and to refer on for long-term work. A training that
equips someone to work in all temporal modalities is necessarily long and
arduous and not everyone would wish to do that. On the other hand,
everyone needs to be clear about what they are trained and equipped to
do. This is vital for the ethics and professional standards of both
counselling and psychotherapy.
Endings are problematic for training in all areas of counselling and
psychotherapy. In Chapter 9, I examined the importance of endings in
time-limited work. Although time-limited work requires great skill it does
have schemas, particularly in systemic and cognitive approaches which
can be taught and learned. Trainees can develop micro-skills which will
enable them to work within the time pressures of a six- or twelve-session
model and to make constructive use of those pressures. If a training does
genuinely teach people to work in this way, it is bound to address the
matter of endings, probably by means of exercises and role play and also
by supervision of case work in which endings will occur.
In analytic psychotherapy training there is a greater problem. Trainees
are specifically required to carry out ongoing long-term work and will
hope not to have to deal with an ending in their training cases. A difficulty
that supervisors will have to address is the tendency of trainees to practise
defensively and to collude with patients because of their anxiety not to
lose a training case. Thomas Freeman wrote about the projections that
arise in the trainee’s view of the patient who is wanted and needed and
takes the place therefore of a parent who had to be pleased, mollified and
reassured (1991: 204). Freeman makes the provocative suggestion that
there is an advantage in having the analysis and supervision done by the
same person so that such projections can be recognised and understood
at depth as part of the analysis. This would be a very controversial view
because it risks confusing the management of the patient with the
transference to the analyst. Freeman is in any case speaking pragmatically
of the situation in Northern Ireland where there was a shortage of possible
analysts and supervisors.
Nevertheless, if future practice is to be in the profound and moving
long-term work that is being supervised, ending cannot be addressed
except from the supervisor’s challenge to collusive tendencies and from

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other contexts such as the personal experience of the candidate or through

reading the theory. Many trainees are experienced workers, perhaps already
qualified counsellors, and will have other supervision where ending may
well be addressed. There is some research that has shown that outcomes
as reported by clients are not affected by whether or not the therapist is a
trainee or by whether or not the therapist approved of the timing of the
ending (Macdonald: 1992). Perhaps the patient will make an ending anyway
if he needs to do so.
One of the most difficult tasks for a training supervisor and for the
organisation is the assessment of patients before they are seen by trainees.
The trainees provide a valuable service in that they work with their patients
with great energy and devotion. They are having the most minute and
detailed supervision that is ever given, in that each patient is individually
supervised once a week. The trainees are encountering theory for the first
time and are thinking about and discussing it continuously. They have
faith and commitment and are also in the middle of their own therapy. For
this reason too, they provide patients with the best that they can possibly
give as long as they are consistently challenged over the need to placate.
For all these reasons, one could argue that patients are gaining a great
deal if they are accepted into a training scheme.
On the other hand, patients are assessed for, among other things, their
staying power. To benefit from the work, the patient needs to be willing to
stay for at least two years. What may not be said in so many words, but is
usually clear to both parties, is that this length of stay is needed for the
trainee as well as for the patient. The temptation that the patient may or
may not avoid from then on is to use the threat of leaving. The patient will
suspect that the one thing his therapist least wants is for him to leave.
The trouble for both is that this is of course true. Some training courses
will send a trainee back to begin again if a patient leaves after twenty-
three months. Such a requirement will exacerbate the difficulty with ending
and most of the training bodies are, in practice, willing to consider a case
on its merits. Because of the reality of the disaster that stringent application
of the requirement could imply for a trainee, he or she is least likely to be
able to address the possibility of ending in a way that makes it a constructive
part of the work. Yet that above all is what the patient needs.
In counselling training the difficulty with ending may lie in the opposite
direction with the trainee’s inability to address the client’s wish to end at
a time that seems premature. In any profession, trainees are likely to be
tentative, and in counselling there is a strong tendency to value the

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client’s ability to decide what is right for himself. Without denying this
ability and right to decide, the psycho-dynamic school would be likely
to urge the trainee to pause long enough to discover whether the client
has hidden from himself an anxiety which could be eased by
understanding it in the counselling relationship. Supervisors have the
difficult task of helping trainees to work with balancing a necessary
scepticism about readiness to end with a willingness to end well if that
is what the client is determined to do.
A clear contract at the beginning needs to include the overt information
that the trainee is on a training course. If this is made clear, the patient’s
temptation to use the power that this gives may be overtly addressed. It
may well echo the power that the child tried to find to attack parents
who seemed all powerful. It may be a more subtle wish for revenge on
the parent who did not seem to be powerful enough. The child in the
patient wishes the therapist to be the one who is supposed to know and
the one who is powerful enough to make everything safe. All therapists
will be familiar with the testing that goes on in the early stages of therapy
to discover whether the therapist can cope with what the patient needs
to bring. This testing will often include challenging the boundaries of
time and sometimes space. Therapists are well used to having to manage
and interpret infringements of the expected timekeeping and sometimes
the keeping to the appropriate space. Part of the skill of the work is to
decide when and how to take up these infringements and how firmly to
make the framework of the therapy clear and inviolable.
A trainee has the added task of taking up, and at some point
addressing, the patient’s fear that she does not have sufficient skill or
knowledge to deal with what the patient believes are uniquely appalling
problems. This fear may be expressed in any of the ways in which ending
is used as a threat. The threat is usually well concealed behind the
rational problems of the external world: ‘I will have to leave in a few
months because I am beginning a new job/course/relationship, etc.’ Or
‘I have to leave because I cannot afford the fees.’ The first group of
reasons relates to the patient achieving power and status and may be
thought about in terms of what cannot be entrusted to the therapist but
must be assumed by the patient for himself. Such premature
independence is often a defence against the suffering of loss. Some
loss may confront the trainee therapist and will have to be endured,
even though it is particularly difficult to face the loss of a patient when
the trainee’s own therapy has not yet reached the ending stage. Patients

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are afraid of being held in therapy for ever and the trainee therapist has
to reach the internal conviction that the patient may leave and that will
not be the end of the world. If this cannot be achieved the patient may
feel too much needed, and this will often resurrect conflicts with needy
parents.
The second group of reasons related to money and time for therapy
connects with what the patient is willing to give the therapist. Again, this
is not unique to training therapy but in that context has a particular
relevance to the patient’s fear that he is being seen only because the
trainee needs a training patient. This fear leads to defence and resistance
connected with what can be given to the therapist. The patient in effect is
saying, ‘I am already giving you too much and will not give you any
more.’ This is as useful as any other information that the patient gives
about his greatest fears. If the therapist feels secure enough about being
a trainee, attacks on this front can be used, even though they have the
difficulty of being based in knowledge of the therapist’s actual situation.
The trainee’s ability to work with such feeling in the patient will certainly
be affected by his or her confidence that being a trainee can be discussed.
It is not a shameful secret that needs to remain hidden if possible.
Macdonald’s research is an example of a study which shows that trainees
have outcomes that are as good as those of more experienced therapists
(1992). The trainee needs to face her narcissistic need to be successful
immediately and with this patient, and then to put it behind her enough to
accept that if that cannot be achieved and more time is needed, then so be
it. This inner freedom is essential if the patient is to be free to choose to
either go or stay. If this kind of freedom can be achieved, the patient may
be helped to become aware of all the envy of the parents’ satisfaction
from having him as their child. Parents certainly get a great deal out of
being parents in most cases, and therapists get a great deal out of being
therapists, both in terms of learning and in terms of satisfaction. Why
should the trainee not get something out of seeing this patient? Likewise,
why should the patient not envy the trainee for the training, and for the
satisfaction and achievement that it might bring?
Patients who are ambivalent are likely to find all sorts of reasons to
leave. Faced with an ambivalent patient who is complaining, for example,
about the fee, a trainee may be tempted to comply and reduce it to a point
at which he becomes resentful of the patient. This is obviously counter-
productive. Some reduction may be reasonable because trainees are likely
to be seeing people who do not have much income. On the other hand,

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Symington (1986) discovered that his patient benefited when he realised

that the low fee he was charging her represented his low expectations and
even lower opinion of her. He understood then that the patient needed
higher expectations in order to achieve more. In fact, he discovered that
she was already capable of more than he had thought possible. Trainees
need to have high expectations of their patients and to expect patients to
have high expectations of the therapist too. This does not mean being
unrealistic about fees. There are times when a reduction is possible and
does enable someone to stay in therapy when necessary. Both patient
and therapist may need to achieve a state in which they have higher
hopes of each other.
Trainees have to end their own personal training therapy. Some choose
to go on long after they have finished the training. Others leave at the first
available moment when the training requirements are completed. Training
committees have no jurisdiction over this choice and it is usually thought
to be the trainee’s own business. There are, however, unique difficulties
to negotiate in that ex-therapists may become colleagues, and this will
have to be negotiated as a future possibility during the ending phase.
This may add to the difficulty of ending, often as much for the therapist as
for the trainee. On the other hand, some trainees may have been in therapy
for many years and have reached a natural stopping place before the end
of a long training, and might benefit from experiencing an ending. Those
who are able to stop therapy very precipitously at the end of training raise
some questions about the value of what they have been doing before,
although there may be practical reasons to end soon. There may be
financial difficulties, as training often necessitates taking out loans. If
this is the case, the ending may well have been planned before the actual
qualification takes place. For those who are not in such urgent need to
stop, the value of a considered ending needs to be taken into account.

Ending supervision

For trainees even more than for other therapists, supervision is a vital part
of the work. Trainees learn both from what the supervisor says and from
what the supervisor does. That is why supervision may be the only place
in which trainees can think constructively about endings; it can also be
the only place in which they can hear about the way in which an
experienced therapist thinks about endings. The supervisor is also a role
model and can demonstrate his or her own attitude to contract making

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and to the opening up of the ending process. Supervision, like therapy,

has to reach its own ending in due course. Like everyone else, supervisors
have to struggle with their own resistance to endings.
The supervisor of a trainee has a double problem when a patient wishes
to end therapy, in that he or she is likely to prefer the trainee’s work to
continue smoothly if it is intended to be open-ended and will also wish
the trainee to have the opportunity to succeed in the training. The
supervisor’s concern to demonstrate professional competence is
somewhere in the background too. If the supervisor presides over the
sudden departure of a training patient, does that not in some way reflect
on the skill and experience of the supervisor? Some people might think so.
In any case, the patient’s struggle to bring to the session his or her
wish to leave is likely to be difficult for the supervisor to hear as well as for
the trainee:

Ms CC had been assessed as a patient for a training therapy

scheme. She was a student taking a course in fine art and
had little money. She came from a family background in which
her mother had been schizophrenic and had eventually killed
herself. Her father had left the home and she had been brought
up by her aunt and uncle. She was articulate and had read a
considerable amount of psychology and self-help literature.
She was strongly motivated and had friends who were in
therapy. She had a conflictual but three-year-long relationship
with a male partner. Although she had a very disturbed
background, she was thought to be sufficiently motivated and
psychologically minded to be a suitable training patient.
She was allocated to Mrs DD, who met her for four sessions.
In this time Ms CC was rather withdrawn and, although she
told something of her history, Mrs DD found it very difficult to
make contact with her. The supervisor was expecting some
difficulties to arise in the transfer from the assessing therapist,
and encouraged interpretations about the problem of having
to make do with an aunt when one would rather have one’s
mother. What was not said was that the mother was not to
be relied upon. After the fourth session, the patient wrote to
the therapist saying that she had not felt comfortable at all
with the therapist and would not be returning.

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The therapist was taken by surprise, and was very upset

that there was to be no opportunity to put right or repair what
might be wrong. She telephoned the patient and said that
she thought the patient should come back to discuss her
difficulties in another session. The patient responded angrily
that she had already made up her mind and would not return.
The trainee then told her supervisor what had happened.
The supervisor’s first response was anger. Why had the trainee
not been able to get the patient back, and why had she not
waited until after supervision to make a move? The telephone
call seemed hurried and ill advised. She was rather brusque
with the trainee, who burst into tears, saying that she had
done the best she could but had felt a great sense of urgency
to get something done before supervision. Both the trainee
and the supervisor then began to look at the parallel processes
that were involved. The trainee was feeling like leaving the
supervisor. She had clearly been experiencing some of the
same feelings as the patient, in that both were afraid of the
unpredictable and terrifying mother who would have no ability
to understand feelings of fear or inadequacy but would snap
destructively at any weakness shown.
There was no possibility at this stage of reviving the
therapeutic relationship, but the trainee and supervisor were
able to deepen and develop their own relationship because
some of the inevitable fears that go with training and
assessment were exposed and expressed. They were also
able to discuss the question of how to deal with a sudden
ending or, more usefully, with talk of an ending.

In the case described above, the supervisor managed to recognise her

own part in the difficulties that the trainee was experiencing. She had
been angry and had felt that the trainee should have done better. This
might be true, but it is a judgement that needs to be mediated by an
attitude of shared responsibility. The supervisor might well have been
angry with herself and displaced her anger on to the trainee. After all, the
supervisor had not seen and pointed out the patient’s terror of the
therapist’s power to be like her mother.
Supervisors can be powerful and terrifying to trainees and need to
recognise the responsibility that goes with power. In the training situation

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it is tempting for trainees and supervisors to set up a collusive atmosphere

in which everything that is difficult is caused by the patient’s pathology.
Sometimes the supervisor blames the trainee’s pathology for anything
that goes wrong, and although, of course, this may sometimes be the
source of problems, the supervisor is often slow to recognise the extent
to which problems tend to echo up and down from patient to supervisor.
A balanced view that takes external reality for the patient into account as
well as the pathology of all three – patient, therapist and supervisor – is
never easy to achieve. The supervisory relationship is likely to encounter
its own difficulties and, if it is to reach any depth and value, both supervisor
and trainee will have to work through some troubles and disagreements
before the trainee can qualify or the relationship can end.
Stoltenberg and Delworth (1987) have a developmental model of the
process of supervision in which they describe the supervisee as passing
through stages from narcissism to independence or mature dependency.
In Stage 1 the trainee focuses mainly on himself and is motivated by
anxiety to perform well. The supervisor’s comments are likely to be taken
too literally and are not subjected to sufficient internal processing. The
main concern is ‘How am I doing?’ At this stage the supervisor is tempted
to be the charismatic one who knows all the answers. She is required to
work with this idealisation both of herself and of the process of therapy,
as is the therapist for the narcissistic patient. At the second stage or
‘level’ of Stoltenberg and Delworth’s model, the trainee becomes more
doubtful both about the supervisor and about the possibility for therapy
to solve all difficulties. Patients have not always responded well, and the
trainee has many storms to weather. Finally, the trainee may move on to a
more independent stage in which he judges his own competence more
accurately and is also better at assessing patients and their needs. He is
able to take something from the supervisor and also to reject. The reflection
of all the processes in each other means that the supervisor has to change
with each supervisee, just as the therapist must change with each patient
in order to accommodate the development towards the ability to end.

Leaving the supervisor

Once the trainee becomes a qualified therapist, in some organisations

supervision becomes optional. Even if it is expected that therapists
continue in supervision after training, there is a case for changing
supervisors from time to time in order to avoid falling into ruts and

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complacency and to learn what others have to teach. How does one
broach the need to leave the supervisor? Some make it possible by
enquiring each year whether the supervisee wishes to continue for another
academic year. Others take continuing for granted and made it extremely
difficult for the supervisee to finish. In therapy, there is at least a task
which can be said to be completed or as near to complete as it will get. In
supervision, there is an ongoing process.
Supervisors who are alert to the difficulty that there might be for the
therapist will usually make an ending possible. Supervisees nevertheless
enhance a therapist’s status and reputation. The work of supervision is a
welcome change of pace from therapy itself and it is not surprising that in
some cases, a therapist’s desire to end or change supervisors might feel
like a blow to the narcissism of the supervisor. An extra difficulty arises if
the supervisor suspects that the reason for the ending is the supervisor’s
own incompetence or boredom or a disregard of boundaries. Supervisory
relationships can become collegial and very enjoyable. The boundaries
need to be maintained but can be more flexible than in therapy, and some
supervisors do not maintain a sufficient regard for the need to do the
work professionally. The tone of supervision is naturally different from
that of therapy, and the supervisor may relax too much and be too expansive
about herself. If there is an uneasy awareness that all is not well, then the
supervisee’s wish to end might well be a criticism.
A supervisor who is growing old or ill or depressed is likely to cease to
be useful. Yet a therapist who does not wish to be destructive or to
acknowledge destructive impulses will feel anxious about leaving or
suggesting an ending. Supervisors in this situation may seem to need
their supervisees, and common humanity will make it difficult to say in
effect: ‘You are too old, or too ill.’ Therapists will stay with elderly
supervisors to keep them alive, just as patients will stay to heal and repair
and keep their therapists going. The supervisor has the responsibility to
watch for this and to make sure that an ending is possible when it is
needed. In this he is modelling good practice which is essential in all
aspects of training and supervision. We have a profession which works
at many levels and has theoretical and practical aspects, but above all,
training still needs to be a kind of apprenticeship in which supervisors
should be master craftsmen, and should try to demonstrate the kind of
responsibility and restraint which they demand from their trainees.

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 ENDINGS IN TRAINING AND SUPERVISION

Therapists in any of their roles have to be prepared to give up

relationships that they have come to enjoy and that they have used for
satisfaction, for income and for validation as a worthwhile human being.
This is a hard task and is often too difficult. No wonder we need help from
each other as colleagues and from present and past teachers and
supervisors to bear in mind that the ability to let go when the time comes
is one of the primary achievements of any kind of therapy.

References

Clarkson, P. (ed.) (1998) Supervision, London: Whurr.

Freeman, T. (1991) ‘Hobson’s Choice: personal analysis and supervision in the
training of psychoanalytic psychotherapists’, British Journal of Psychotherapy
8 (2): 204.
Macdonald, A. (1992) ‘Training and outcome in supervised individual
psychotherapy’, British Journal of Psychotherapy 8 (3): 237.
Stoltenberg, C. and Delworth, U. (1987) Supervising Counsellors and Therapists,
London: Jossey Bass.
Symington, N. (1986) ‘The analyst’s act of freedom’, in Kohon, G. (ed.) The
Independent Tradition, London: Free Association Books.

171
 THE GOOD ENDING

All therapists need to envisage ending their own work as therapists and
supervisors. We all need to make a therapeutic will which will allow for the
safe care of our patients and supervisees in the event of an accident or
sudden death. Even more difficult for many is to plan retirement and put it
into practice. Like our patients, we also need to be able to let it all go and
say that we have done enough before that recognition is enforced by
illness or debility or incompetence. Working in the field of psychotherapy
is one of the most fascinating and rewarding experiences that anyone can
have. Yet we all come to the end of a useful working life sooner or later and
can learn to exist without patients to help us. It is therefore essential some
day to be able to choose to say that I have done my share, had my turn
and now I shall leave it to others.

172
 INDEX

160–1
abuse: sexual 5, 31, 66–7, 73, British Psycho-analytical Society
123–6; in therapy 125 65, 143
aim 12, 17–18, 20, 63; autonomy Brunswick, R. 94–5
99, 103–10, 119; clinical
Casement, P. 39
symptoms 12; independence 4;
castration 37, 41, 47
happiness 99–103; reason 99,
catharsis 14, 16
106; relief of suffering 99;
change 6, 9, 12, 14–16, 23–4,
resolution of conflict 99; in time
26–7, 38, 47, 51–2, 56, 63, 71,
limited wish 155–6
73, 84–5, 93–4, 106, 110, 131,
Akhtar, S., Kramer, S. and
146; in ending phase 133–9;
Parens, H. 40
model of 98; mutuality in 4,
Alther, L. 142
108–10, 199; therapist’s 7, 17,
anatta 140
19, 95; in time limited therapy
anxiety 51, 129; patient 37, 61,
149–52; sudden 123–5, 142;
64–5, 70, 72–3, 84, 108;
supervisor’s 169
therapist 4, 11, 37, 39, 91–2,
Clarkson, P. and Murdin, L. 121
95, 121
cognitive approach 7, 10
appeals 118, 122
Coltart, N. 38, 56, 140–1
Appignanesi, L. and Forrester, J.
complaints 9, 11, 86, 118–19, 120,
72–3
122
assessment 47, 71, 112, 122, 160,
confidentiality 49, 118, 125–8
163
contracts 21, 25, 118–19, 125,
autonomy 59, 64, 99, 103–5,
130, 149–51, 153–4, 156, 164,
107–8, 110, 115, 119, 151 ; see
167
also aim
convergence 4, 10, 15
Balint, M. 87–8 Cooper, J. 143
Bentham, J. 102 counter-transference 11, 108, 110,
Bettelheim, B. 13 130, 153
Bion, W. R. 108 criteria for ending 13, 29, 35, 41
Bollas, C. and Sundelson, J. 126 damage 5, 12, 17–18, 41, 54–5,
Bowlby, J. 17 61, 82, 86, 128
Breuer, J. 14
Dare, C. see Sandler, J.
British Association For
Davanloo, H. 151–5
Counselling 118, 126, 130,
De Simone, G. 11, 95, 133

173
 HOW MUCH IS ENOUGH?

death 8, 37, 61, 139, 146, 152, Gabbard, G. 109

172; attitude to 112–3, 140–1; Gellner, E. 24
Freud’s view 62–3; instinct 61, goals 12, 20, 97, 100, 102–4;
70, 100; Lacan’s view 41, 63–4; achievement of 4, 152
of therapist 82 grandiose self 51
Delworth, U. see Stoltenberg, C. gratitude 17, 35, 41, 57, 62, 87,
dependency 9, 29, 46, 55, 94, 99, 139, 146
103, 152, 169 Guntripp, H. 77
depressive position 17, 18
deprivation: in transference Hamilton, D. 77
120–1 Hanly, C. 109
development: metaphor of 8, Hartmann, H. 39
45, 59, 169; theory of 17–19, Hinshelwood, R. 105, 109–10,
40, 47, 51, 54, 63, 65, 71, 146–7
88, 97–8, 106, 110, 133, Holder, A. see Sandler, J.
154 Holmes, J. and Lindley, R.
Dickinson, E. 156 103
difference: recognition of 111 Howard, K., Kopta, S., Krause, M.
Dinnage, R. 8, 68–9 and Orlinsky, D. 149
Dupetit S. see Klimovsky, G. hypnosis 15, 120
Dupont, J. 34–6 hysteria 14, 72

Eigen, M. 134–5 idealistion 70, 147; of therapist

ejaculatio retardata 38 74, 142, 169
envy 2, 17, 20, 36, 62, 143, 146, impasse 8, 11, 27–8, 38, 52, 54,
165 56, 71, 93
Erwin, E. 104, 108 internal objects 18
eternal child (puer aeternus) jouissance 63
145 Jung, C. 13, 121, 140
ethical codes 65, 97, 117–19, 124,
131, 160 Kennedy, R. 41; 1988 121
Kernberg, O. 18, 50–1, 74–5
failure 19, 28, 51, 78, 156–7 Khan, M. 93, 143
Fairbairn, M. 17 Klauber, J. 95
fees 164–6; difficulty with 58, Klein, M. 17–18, 35, 54, 62, 146;
65–6, 1989 147
Feltham, C. 155, 157 Klimovsky, G., Dupetit S. and
Ferenczi, S. 34–6, 88 Zysman, S. 119–20
Firestone, R. 127–30 Kohut, H. 18, 54, 74, 75, 81
Fordham, M. 13
Kopta, S. see Howard, K.
Forrester, J. see Appignanesi, L.
Freeman, T. 162 Kramer, S. see Akhtar, S.
Freud, A. 69, 92 Krause, M. see Howard, K.
Freud, S. 9, 10, 12, 13, 16–7, 23,
Lacan, J. 5, 13, 14, 25, 29, 37,
30–37, 44, 46–7, 50, 81, 120;
41–2, 45–7, 59, 62, 73, 98, 140;
Dora, 72; Rat Man 9; 15, 25,
45, 52, 125; 15, 152; 93–4; see also death
1920 99–100; 37; 20; see also Leigh, A. 88
death Limentani, A. 143
Frosh, S. 24 Lindley, R. see Holmes, J.

174
 INDEX

loss 2, 4, 14, 17–18, 31, 37–8, Philips, A. 31, 65

41–2, 46, 56, 78, 95, 131, projection 17–18, 44, 55, 108,
139–41, 143, 146–7, 149–50, 162
156, 164 psychosis 30, 38, 119
Macdonald, A. 3, 163, 165 Ragland, E 63
Mahler, M. 40, 54 referral 65, 82, 88, 91, 93, 100,
Malan, D. 151 111, 119, 129, 150
Mann, J. 156 regression 82, 87–9, 151, 154
meconnaissance 140 repetition compulsion 28, 63–4,
Melzer, D. 18, 52–4 70, 73, 120
memory: as cause 12, 28, 135–6; repression 15, 30–4, 104
generation of 29; recovery of resistance 5, 16–7, 33, 36–8, 55,
13, 24, 32, 38, 92, 120; 149, 151–2, 165, 167
redescription process 31 Rickmann, J. 20
Mill, J. 102–3 Rowan, J. 154–5
Miller, I. 37–8
Mohammed, C. and Smith, R. Samuels, A. . 13, 66–7
Sandler, J., Dare, C. and Holder,
151
A. 143
Molino, A. 140
Schachter, J. 80
Mollon, P. 47, 75
Searles, H 19, 30, 89
Molnos, A. 136, 152
self-concept 81
Murdin, L. see Clarkson, P.
self object 18, 54, 81–3
nachtraglichkeit 30 sexuality 18, 67–8, 73, 94,
narcissism 44–60; and religion 50; 111–12
therapist’s 6, 28, 30, 45, 121, Shapiro, D. 150
169–70 Smith, R. see Mohammed, C.
negative therapeutic reaction Spence, D. 16
143 Steiner, J. 18
Nemiah, J. 73 Stern, D. 54
normal symbiosis 54 Stoltenberg, C. and Delworth, U.
169
obsessions 73–4, 107 subjectivity 29, 33, 109, 121
Oedipus complex 18, 19, 26, 30, suggestion 10, 16
34, 36, 73, 83, 153–4 suicide 8–9, 38, 112–15, 127–30
omnipotence: therapist’s 19; Sundelson, J. see Bollas, C.
patient’s 38, 55; and narcissism supervision 2, 9, 91, 95, 125, 129,
47–8, 50–1; relinquishment 62, 160–71
113–15 symbolic 41–50, 55, 87
Orlinsky, D. see Howard, K. Symington, N. 54, 71, 166
outcome 3, 6, 12, 15, 20, 28, 44, 99, symptoms 2, 12, 14–16, 20, 30,
103, 129, 151, 157–8, 163, 33, 74, 94, 143, 155
165
time limited therapy 20, 118,
paranoid schizoid position 8, 149–56; short term therapy
17–18 10
paraphrenics 52 training 2, 70, 142, 150; analysis
Parens, H. see Akhtar, S. for 56–7; ending therapy in
Parkes, C 139 160–71

175
 HOW MUCH IS ENOUGH?

transference 23, 29, 32–41, 63, 70, values 2, 10, 38, 97–106, 111–5,
99, 112, 146, 153, 161–2; 127
acting in 28 ; boundaries in Voltaire 59
117; encouragement of 122,
157; ethics of 120–2; love 25; Westminster Pastoral Foundation
maternal 89; resolution of 35; 151
see also deprivation will: therapeutic 82, 172
Winnicott, D. 1986 40, 54,
unconscious 6, 14–16, 29, 31, 33, 65, 143, 155, 141; 1985 87,
37, 41, 61, 63, 68, 97–8, 106 68
United Kingdom Council for
Psychotherapy 118, 131 Zysman, S. see Klimovsky, G.

176