Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Tuesday, July 7, 2015


Nothing has distracted me from getting things done lately more than the fact that I'm terminating my analysis at the end of the month. This is not new information for me. I started talking about terminating last Fall, and the date was set at least six months ago. But none of that prepared me for the extent of the mourning involved.

Or the craziness. What other human relationship do you end just when it's starting to go well? And the real point is, I'm the one who's ending it.

This is supposed to be a good thing. And that's how it felt when I started discussing it last Fall. I came in one day and said, "I think I'm done." Not in an angry way, as I've felt in the past when something had come up that was upsetting or hard to think/talk about, or I felt like I was being criticized, and I just wanted to leave. And not in a hopeless way, as though there was no point continuing because nothing was ever going to change.

It just felt like I'd gotten a lot out of the experience, including the fact that I could take it from here. I certainly didn't feel "cured", or no longer neurotic. I just felt like I wouldn't be overwhelmed by expectable life circumstances, or even unexpectable ones that aren't too horrible, and I could handle my anxiety and my weird worries on my own.

Or well, not quite on my own. It's like my analyst has become part of me, so I don't need to go to sessions anymore to do the work, and I can manage my own reality checks.

Yeah. A good thing. Exciting, even. An accomplishment.

And let's not forget about the tangible benefits. Like more time freed up, and more money, both from not spending it on sessions, and not taking time for sessions, and the commuting to and from sessions, that could be spent seeing patients.

And what about the relief? Analysis is painful. It forces you to look at things you've been hiding from your whole life. Four days a week.

These are the things that make termination appealing, aside from the fact that termination is the ultimate goal of the treatment.

I want to share a few quotes from a paper by Glen Gabbard, What is a "Good Enough" Termination? (2009. Journal of the American Psychoanalytic Association, 57:575- 594):

...we lack a paradigm for termination. This is as it should be. There are multiple scenarios that are “good enough.” (p. 591)

“Termination,” as opposed to the ending of an analysis, generally implies that the analysis has come to an end through mutual agreement and negotiation by patient and analyst rather than by a financial setback or an unplanned relocation of the patient. There is also the implication that patient and analyst must allow sufficient time to work through the patient's feelings regarding the loss of the analyst and the changes that have been made in the course of the analytic work. (p. 578)

...the interpretive resolution of the transference neurosis, the eradication of symptoms, the achievement of “full genitality,” the modification of the superego, and the ability to love and work are often clustered together as indications for a termination process that will take several months and be mutually agreed on... [However]...terminations are based not on predictive theories, but on permissive models that are reinvented each day.

We must accept that no analysis is complete—rather, a process is set in motion. Orgel (2000), in a thoughtful contribution on the reality of termination, asks poignantly if any analysand ever ends analysis with an emotional conviction that it is complete. Kogan (2007) notes that “there is no such thing as an ideal termination; the symptoms never disappear completely; the patient does not achieve all of the structural changes one would like; nor does he manage to acquire a totally integrated personality”...The terminated patient is not “fully analyzed”—he or she is simply embarking on a life of self-analytic reflection that offers depth and richness to one's existence. Suffering, intrapsychic conflict, and problems in work and love will continue. A tragic vision is central to the psychoanalytic journey. (pp. 585-6)

...both analyst and analysand must disentangle themselves from a significant connection with another human being that has shaped their lives. To some extent analyst and analysand lose themselves as separate individuals in the analytic experience, and it is only through termination that each “retrieves” a sense of being a discrete mind (Ogden 1997). Both parties are different from what they were when they set out on the analytic journey, however, and the mind retrieved is not quite the same as the mind that began the analysis. (p. 587)

Excitement and accomplishment are all well and good, but still, I'm in mourning. Analysis has structured my days and weeks for a very long time. Even my years-the August break is always there, along with some time off at Christmas/New Year, Spring break, Thanksgiving, etc.

The sessions are clearly delimited, and almost always end with the statement from my analyst, "We do have to interrupt," which I find pretentious, although I understand it makes the point that an analysis is really just one very long session with lots of commercial breaks. I'm dreading what she's going to say at the end of the last session. "We do have to terminate," maybe? "It's time to terminate?" "It's time to stop?"

Whatever the phrasing, it's a little bit heartbreaking.

I'm losing the place I go to deal with all the built up frustration and pain. And even though I often clam up when I'm there, I still know it's my time, set aside from the rest of the world.

I'm losing the place that taught me it's okay to look at anything about myself and not feel ashamed or guilty in doing so.

I'm losing an important person in my life. I don't really know her. I know just this one aspect of her. But there is still tremendous intimacy, and I leave with the conviction that, to quote a friend who finished his analysis several years ago, there's someone in my corner. And that someone cares what happens to me.

Of course, there's the weirdness that I'm ending this intense, intimate relationship with this person, but I'm still going to see her at meetings, etc. Only there, she'll be an unapproachable stranger. This is not conjecture or possibility. It happened just last week. But unlike last week, I won't be able to talk to her about the weirdness the next day.

So it's not a death. She'll still be around. It's not a divorce. We're not ending because we can't get along. It's not the gradual drifting apart of a once strong friendship. If anything, it's grown progressively more comfortable , and we've developed our tropes and can even joke around at times.

During one recent session, thinking about endings and "nevermore", I brought up the poem, The Raven. It's a terrible poem. Poe is a terrible poet (though I happen to think he's a master of the short story). The content is all sad and morose, but the sound is jaunty. Silly, even. He uses ridiculous words like, quaff and nepenthe. And the rhymes are too perfect. When I mentioned this, my analyst laughed and told me about a New Yorker cartoon with Poe scribbling phrases like, "Shut the door," and "Sweep the floor."

This exchange would not have happened early in my analysis. This kind of relaxed jocularity. Or if it had happened, it would have upset me, as though a boundary had been inappropriately crossed, and my analyst had behaved, "unanalytically". But the boundaries are now long since established, and I've learned that if one of us occasionally puts a toe across, we'll both survive. That it's possible to survive disappointment or discomfort or ambivalence without losing a relationship may be the greatest lesson analysis has taught me.

Which is why it's okay to lose this relationship.


  1. This is beautiful. Thank you for sharing it. I hope you share it with your analyst, or perhaps leave it as a parting gift.

    1. Thanks. I might share it with her. I'll have to think about it. But it's nothing we haven't discussed, in any case.

  2. I thought that the difference between analysis for normal paople and the analysis of analysts was that analysts often did wind up interacting with their own analysts - not just seeing the former analyst in meetings but even serving on the same committees.

    Much like in families, you found a way to live with people who knew a lot about you and engage with them in a different way. You would never be friends, but you would be colleagues. A similar process occurs when a resident is hired by his/her institution, then gets promoted and becomes the colleague of former teachers.

    1. I think there's institutional variation I this, and as it happens, I am on a committee with my analyst. But it's a large committee, with little likelihood of direct interaction. If and when it breaks up into subcommittees, everyone will be careful not to put analysands with their analysts.

      I know there are some institutes that allow candidates to take classes with their analysts. Most opt not to do so.

      I see the analogy with becoming an attending where you did your residency. Having done just that, I can vouch for the fact that it's not the same.
      That's more like developing a friendship with a supervisor. The relationship evolves. Same with family.
      But the relationship with an analyst, or a therapist, can't evolve into a different kind of relationship. Aside from being a horrible boundary violation, it doesn't take into account the possibility of returning to treatment in the future. It's not unusual for former analysands to "check in" with their analysts from time to time, especially in the context of a crisis. Unfortunately, analysis doesn't life proof you. Or sometimes analysts will continue to prescribe medication.
      But even in the absence of any return to treatment, your analyst is always your analyst. the role doesn't change.