Shrinks, Once More, Again

Yes, I thought I was done with Jeffery Liebermans's, Shrinks: The Untold Story of Psychiatry, but it was not to be.

Clinical Psychiatry News asked me to write a shorter review than the one on my blog, from the angle of whether it would be a good book for a psychiatrist to recommend to patients.

So how could I resist? This one is much shorter, and less of a rant.

So please surf over there and check it out. It feels good to have my opinion expressed beyond these confines. I think the site is free but you may have to register. Also, the print version will be out in a few weeks.

Enjoy, and come back here to comment, if you like.

Summing Up 2015

Here we are at the end of the year. A lot has happened in the world of psychiatry in 2015.

Collaborative Care is alive and scoring a 0 on the PHQ-9. The Clozaril REMS deadline was extended. Tom Insel left NIMH for Google. Mandatory E-prescribing was postponed until this coming March. EHRs continue to disappoint. Meds long past patent have had their prices jacked up 5000%. The FDA is looking to appoint a new head, and Robert Califf, a cardiologist with strong ties to the pharmaceutical industry has been nominated (See NY Times and David Healy).

On the upside, Dinah at Shrink Rap came up with a brilliant way for people to access psychiatric care in Maryland. I hope this approach is replicated more broadly.

I was perusing my posts from this past year, and I made a list of some of the major topics, and their respective posts, both general and personal:

Maintenance of Certification

I studied for:
The Montillation of MOC
Percentages

And passed:
Done
There and Back Again
Framed
Signed, Sealed, Delivered
Switching the Labels

my board recertification exam.

And I was certified by the NBPAS, as well:
Another Board

The ABPN refused to make any significant changes to MOC, especially Part IV:
I Really Should be Studying, But...
An MOC Step?
Follow the Money

Although the Part IV Feedback modules are now optional.

And I developed my own Psychoanalytic PIP Module:
Fascinating
Here Goes Nothin'
A Monkey's Uncle

The best part about all of this is that I've written enough MOC posts that I now misspell "Maintenance" only about 5% of the time.


Affordable Care Act (ACA)

The ACA has kicked in:
Out of Network Benefits in NY

And pushed me over the edge into the realm of blog ads:
Adding Ads and the ACA


Psychoanalysis

I terminated my analysis:
Termination
Blessings

And wrote some other posts about psychoanalytic evidence and topics:
Analytic Evidence
AA Brill
The Blank Screen
Narcissism, Part I
Narcissism, Part 2


Jeffrey Lieberman

His book, Shrinks was published:
"Shrinks" Review: Introduction
Shrinks: The Untold Story of Jeffrey Lieberman's Oedipal Victory over Papa Freud
Shrinks Links, Etc.

And a torrent of posts followed, culminating in the one about his fiasco of a presentation at the White Institute:
Lieberman Speaks


Addyi

The FDA approved a drug that could hurt you but can't help you:
They Caved

That was immediately sold for $1Billion:
Addyi-dendum

And then the FDA and Valeant pawned off responsibility onto the doctors who prescribe it, and the pharmacies that fill the prescriptions:
Addyi REMS-A Shanda


Paxil 329

Finally, and perhaps most importantly, the restored version of Paxil Study 329 was published, with disturbing conclusions:
329


Do I have a favorite post from the year? Not really. The Lieberman posts, especially the reviews and the one about his talk at White took the most out of me. But in terms of content, I think the Analytic Evidence and 329 posts are the most important.

On to pastures greener.

Couch

I notice that after I've written a post, or a series of posts, that required a large investment of time and emotion, I get blog burnout. It's not that I'm not interested in posting as much as I can't think of anything I want to write about.

So instead of just waiting around for several weeks, I thought I'd try doing something light.

The thing is, I hate my analytic couch. It's not the one I started with. That would be this one:

The Barcelona Daybed by Mies van der Rohe. Mine was a knockoff, but it basically looked the same. It's comfortable and it looks good, but a couple years ago, I had to make a last minute move to a new office because the people I was subletting from didn't realize they had a demolition clause in their lease. Long story.

I found a new office quickly. It's quite small, but otherwise, I love it. Great neighborhood, great building, great office setup, great office-mates. It would be perfect if it were a little larger.

But it isn't, and I had to get a new couch because the old one was too big for the space.

What I got was something I think of as a placeholder, even though I've had it for four years. It's a modern curved chaise with a chrome base in a whitish, tufted synthetic leather. I had very specific dimension requirements, and it was the best I could do at short notice, but I just don't like the thing.

Still, I haven't been able to find a suitable replacement, which hasn't stopped me from looking and virtual window-shopping. I've found a lot of beautiful couches, but thus far, nothing that will work in the space. Still, a girl can dream.

Here are some of my favorite couches, and I'll save the best for last:

The DWR Midcentury Modern Lounge

The Maxime Daybed from Jonathan Adler

The Danner Chaise, also from Jonathan Adler

This 1950's number by Paul McCobb

This very simple piece I found on Flickr

This Adrian Pearsall that sold on ebay

This one that sold on 1st Dibs

This beautiful William Haines Piece

This Ash Lounge Chair I found on Overstock. It's too red, but I still like it.

This lovely and conceptually simple piece.



And finally, the big reveal of my absolute favorite:

The stunning Ash Crescent Lounge from Vonnegut Kraft.

A Monkey's Uncle

I had a hard time naming this post. Everything I thought of had some kind of expletive in it.

Holy ____! 

____ me dead! 

l'll be ____!


I'm not averse to this kind of language in my speech, but I try to keep it out of my writing unless there's a good reason for it. Like if I'm quoting someone. Or if I'm writing about having witnessed a potted tulip fall from space and say, "Not again!"**

Suffice it to say, I'm surprised. I got a response today from the ABPN about my proposed PIP Clinical Module on the "Suitability for Psychoanalysis". Here it is:

Thank you for submitting an individual PIP for preapproval consideration.

Your PIP Clinical Module on the ‘Suitability for Psychoanalysis’ has been preapproved, provided you use your own patient charts/data for the initial and follow-up reassessment.  The patients that you use for the reassessment can be the same or different patients from the initial assessment.  This module will count for the PIP Unit that you need for your 2016-2018 CMOC block.

Please retain this preapproval in the event of an audit.

Let me know if you have any other questions.


I did have questions, so I responded:

Thank you for your prompt response. I will certainly use my own patient charts and data.

I have 2 questions:

1. Does "preapproved" mean it's approved, or is there something else that has to happen?

2. Are others allowed to use this module for their own patients?

Thank you for your attention to this matter.


I just sent off my response, so I don't know what will come of it. I'm a little worried that it's too good to be true, and I should have left well enough alone and not asked my questions because now they'll change their minds. But I'd like for other people to be able to use the module, and I wasn't sure if, "provided you use your own patient charts/data for the initial and follow-up reassessment," means that for some reason, they thought I would use someone else's patients' data, or if it's only approved for my use. Maybe that's what "preapproved" means.

So for now, Odds Bodikens!, Zounds! Holy Mackerel! I'll eat my hat!, and I'm a Mongoose! And remember, if I can make up a PIP Module that gets "preapproved", anyone can.

Addendum: 

Wow! While I was previewing this post, a response from ABPN came in:

1.        Preapproval means that your PIP meets the criteria, although you are still subject to auditing.

2.       Preapprovals are done on an individual basis; but, yes, if you’d like to share your outline with colleagues, they could submit it for preapproval as well.


So I guess anyone can use it, provided he or she submits it for preapproval. Here's a link to it in pdf form. I hope it's helpful.

Addendum #2: If you happened to download the pdf before 11.17.15 4:55pm Eastern time, please disregard it and use the currently linked form, which includes the practice guideline source.

**“Curiously enough, the only thing that went through the mind of the bowl of petunias as it fell was Oh no, not again. Many people have speculated that if we knew exactly why the bowl of petunias had thought that we would know a lot more about the nature of the Universe than we do now.”― Douglas Adams, The Hitchhiker's Guide to the Galaxy

Here Goes Nothin'

I did it. I just now submitted an application to the American Board of Psychiatry and Neurology (ABPN) for approval of an Improvement in Medical Practice Clinical Module. That's the notorious, MOC Part IV Performance in Practice (PIP) module.

I don't expect much to come of it, although I was inspired to make the attempt by Jim Amos at The Practical Psychosomaticist, who submitted his own CL module. Brave man.

Let's review. In order to maintain board certification by the ABPN, psychiatrists no longer need to submit the Part IV feedback modules, which asked for reviews from 5 peers, and from 5 patients. But, we still need to do those idiotic practice improvement modules, one every three years. You take 5 patient charts. You go through them to see if you're meeting "evidence-based" practice standards in a specific area, like depression, for example. And they HAVE to be based on some "evidence-based" guideline.

If you're not meeting the standards, you implement the suggested "evidence-based" changes, which mostly involve questionnaires like the PHQ-9, and then two years later, you do another chart review to see if you've gotten your act together by then and have been using PHQ-9's with all your patients. Then you've demonstrated improvement.

Of course, if you were doing things "right" to begin with, then two years later, you will have failed to improve because you haven't implemented any changes. It's my understanding that some people understate what they're doing in the initial review, or outright lie about it, so they can demonstrate improvement two years later. I didn't do that. I just documented that I made none of their recommended changes because they weren't clinically appropriate.

My version is a Psychoanalytic PIP. I considered starting it back in a post I wrote in July, Fascinating, but I had trouble finding a suitable Practice Guideline. Well, I subsequently found one, the American Psychoanalytic Association's (APSaA's) Practice Bulletin 7: Psychoanalytic Clinical Assessment. This is an interesting document, with a lot to say about the limitations of the DSM system, and the risks of diagnosing a patient:

The current DSM system does not include information derived from psychoanalytic
research methods and, with a few notable exceptions, ignores the accumulated
knowledge from a century of psychoanalytic clinical experience...For example, the DSM-IV system does not account for unconscious aspects of mental functioning that are at the heart of the psychoanalytic treatment process. The DSM-IV perspective aims to confine its data to experience and behavior at the level of phenomena that can also be observed outside a therapeutic context. In contrast, a psychoanalytic perspective recognizes unconscious processes and unconscious meanings of experience and behavior as these become observable over the course of treatment. Some examples are intra-psychic conflict, defenses and their associated internal object relations, ego functions, the cohesiveness of the sense of self, the patient's subjective inner life experience, etc....

Clinical use of "official" diagnostic labels tends to act as a suggestion that might become a new guiding aspect of the patient's sense of self and might serve to alter the treatment process. In some cases, this suggestive technique might help a patient who feels fragmented to organize his or her sense of self enough to participate more effectively in treatment. However, the experience of being labeled with "the diagnosis" may create new defensive barriers that can block free psychoanalytic exploration and obstruct the treatment process. 

It has a section about assessment of strengths, to determine a patient's suitability for analysis, and this is what I used for the PIP module. The relevant parts of the module application look like this:

I chose "Type of Treatment" as my category, and I listed the practice bulletin as the guideline to be used. As it turns out, the bulletin has exactly four clearly delineated categories in the assessment of strengths section, so that worked out well.

1. Motivation: How clearly and seriously does the patient see the presenting problem(s) and how does this relate to the patient's determination to pursue an analytic effort at self-exploration? How stable is the patient's current life situation and how strongly is the patient willing and able to invest the effort, time, and financial resources necessary for successful psychoanalytic treatment?

2. Potential for self-observation: How strong are the patient's capacities for introspective self-reflection, cognition, verbal communication, and expression of thoughts, feelings and fantasies?

3. Potential to withstand the tensions of analysis: How strong is the patient's capacity for impulse control and frustration tolerance? How effectively has the patient utilized prior treatment opportunities?

4. Potential to work analytically: To what degree does the patient show abilities for adaptive internal conflict resolution (e.g., via sublimation, grief and mourning, etc.), for maintaining a loving, caring investment in a human relationship in the face of some frustration (object constancy), for recognizing and experiencing others as both similar and different from oneself (e.g. self-object differentiation), and for reliable recognition of the difference between reality and fantasy (reality testing)? How strongly does the patient show the potential to analyze rather than avoid or mal-adaptively enact the anticipated powerful feelings, wishes, and urges that emerge toward the analyst?
I included only the headings in the application, and I attached a form I made up that delineates the specific details under each heading.

Then I included this description of procedure:

Chart review of 5 patients to determine suitability for psychoanalysis. Patients may be in psychoanalysis currently, or in another modality of treatment. See attached pdf of module questionnaire. If patients are suitable for psychoanalytic treatment, then either continue with psychoanalysis if already in progress, or switch them from their current modality to psychoanalysis. If patients are not suitable for psychoanalysis, then switch them from psychoanalysis to another suitable modality, if they are currently in psychoanalytic treatment, or continue with current treatment. Follow up in 2 years to determine if patients are being properly assessed for appropriate treatment.

And that was basically it, aside from attaching a pdf of my nice form, modeled after the PIP modules I've done already:

What this module addresses is the question: Is the patient suitable for analysis?

It doesn't address the question: Is analysis suitable for the patient? So you can't really jump directly from noting that a patient is suitable for analysis to starting an analysis.

I thought about including this question in another section, but I didn't for several reasons. First is that the practice bulletin doesn't directly treat this topic. It makes reference to it, but not as clearly as the four topics under "Strengths". And while determining whether a presenting problem is suitable for analysis is part of analytic training, I wanted something simple and boldly stated, so that whoever evaluates this doesn't have an excuse to reject it.

Also, the application asks for a minimum of 4 measures, so I gave it 4 measures. I'm not doing any extra work for this nonsense. I don't really expect the application to be approved, so I didn't try all that hard. I assume the ABPN won't think the practice guideline is "evidence-based" enough. Or perhaps my phrasing is not in line with what they think of as measures of quality. But who knows? If they approve it, I might actually do a PIP module and consider maintaining my certification status. I'll just have to wait and find out.

Narcissism, Part 2

Picking up where I left off in, Narcissism, Part 1, we were about to discuss narcissism by way of self-psychology and the Kohutians.

Heinz Kohut (1913-1981) started his professional life as a traditional analyst, but gradually moved away from a focus on drives and conflict related to the oedipal period to earlier developmental stages, and the establishment of the self. Kohut characterized narcissism by a:

lack of genuine enthusiasm and joy
sense of deadness/boredom
frequency of perverse activities

He believed there is a developmental need for the infant to endow caretakers, particularly the mother, with idealized capacities for power and omniscience which the infant can then identify with and borrow from. There is also the primitive need to be noticed/admired/approved in ones grandiose aspirations.
These developmental aspects of the self precede the development of drive. In pathological narcissism, there is a deficiency, an arrested development of adequate psychic structure, due to the failure of the caretaker to meet these needs, so that a crucial developmental task is left uncompleted . Traditional psychoanalysis (PSA), according to Kohut, prevents the emergence of this deficit, with its focus on conflict and the oedipal period. Further, in more traditional PSA the analyst’s muted responses repeat experiences of early deprivation.

Kohut's approach to treatment was to allow the idealizing and mirror (i.e. need to be noticed/admired) transferences to emerge in the early phases of treatment. For example, when a patient would start to say something along the lines of, "Dr. Kohut, you are the best doctor in the world," instead of questioning the need for the patient to think of him that way, or pointing out the denial of aggression and envy in such a statement, he would just let it ride. In fact, for Kohut, the emergence of such a transference early in the treatment was diagnostic of narcissistic pathology.

He also employed reconstruction, in which the inevitable failures of empathy by the analyst could be used to reexamine the original failures of empathy in the patient's life.

In this way, he believed the developmental task that had been uncompleted in childhood, the establishment of a sense of self, could now be completed in adulthood, and the patient could then go on to address less narcissistic issues.


A contrasting view of narcissism is that of Otto Kernberg (1928-).

Kernberg characterizes pathologic narcissism by an incapacity to depend on internalized good objects. These patients look depressed when they're abandoned, but what they actually feel is anger, resentment, and vengeance rather than real sadness over loss. They lack true emotional ties to others, and there is an overall sense of emptiness, and absence of genuine feeling. They lack positive feelings about their own activities. They think of themselves as denigrated, hungry, weak, enraged, fearful, and self-hating. They lack the ability to sustain relationships except as sources of admiration, and they have a tenuous hold on their self-esteem, maintaining it by depreciating others and avoiding dependency. They also experience destructive rage and envy towards those they depend on.

Etiologically, Kernberg views the self as a vital aspect of the early ego, developing originally as a fused self/object internalization. That is, the very young infant views itself as undifferentiated from the primary object, in most cases mother. On the way to thinking of itself as a separate entity, the infant internalizes this idea of itself as fused with the mother, in order retain a sense of omniscience in the face of the helplessness of being a little child. Later, in normal development, the child is able to relinquish the fusion, and can ultimately perceive both itself and the object as separate entities, each with inherent strengths and limitations.

(I'm leaving out a lot of stuff about normal internalization of, as opposed to fusion with, the object and subsequent development of the superego, but suffice it to say that Kernberg sees superego distortions in narcissistic pathology, and feels that antisocial character disorders are a subgroup of narcissistic ones).

In Narcissistic Personality Disorder, stable ego boundaries have been established, (i.e. reality testing is intact, unlike in more primitive pathology), but there is a refusal to accept the differentiation between the idealized object and the self. It's like saying, “That ideal person and my ideal image of that person and my real self are all one and better than the ideal person whom I wanted to love me, so that I do not need anybody else anymore.” These patients are often raised by parents who are cold and aggressive.
Cooper, A. M. Narcissism (1986) in Essential Papers on Narcissism, Andrew P. Morrison Editor, pp. 112-143. New York University Press

For Kernberg, the goal of treatment is for the patient to give up his yearning for perfection, accept the terror of intimacy and the reality of the other person as genuine but flawed. This is where he fundamentally disagrees with Kohut. Where Kohut encourages the idealizing and mirroring transferences, Kernberg sees the goal as undoing pathological idealizations, not encouraging new ones with the analyst. Kernberg views these idealizations as defenses against rage, greed, and emptiness, which need to be interpreted.

It's basically that Kohut and Kernberg have different ideas about the developmental problem that causes narcissistic pathology. Visually, it's like this:

Where the dotted arrows represents normal development, and the solid arrows represent narcissistic pathology. For Kohut, development has been halted at the point of establishing the sense of self, and if it can just get past that barrier, normalcy will ensue. For Kernberg the self has been established, but in a distorted way, so treatment is very different.

Clinical examples are always helpful in elucidating theoretical concepts, and I use them in my class, but unfortunately, I can't do so here, so my apologies for that. But I hope there's at least some information that may be useful.

Lieberman Speaks

Last night, I went to hear Jeffrey Lieberman (JL) speak about his book, Shrinks, at the William Alanson White Institute. He spoke on a panel, along with Andrew Gerber (AG), Medical Director and CEO of Austen Riggs, and Jack Drescher (JD), a training and supervising analyst at White (among many other impressive credentials). Each gave a brief talk in reference to the book, then they commented on each other's presentations, and then there was a Q&A. The moderator was Sue Kolod (SK), another training and supervising analyst at White.

A little background. The White Institute was founded in 1943 as an alternative to "mainstream orthodox Freudian psychoanalysis". It's known for its interpersonal point of view, and for an interdisciplinary approach. It was only very recently (like, last year) admitted to the American Psychoanalytic Association. I don't get all the politics involved. Frankly, I don't care. But I think the delay had to do with the less traditional approach, including differences in required frequency of analysis (3 times per week vs. 4 or 5), and other stuff I also don't get. In any case, I'm not affiliated with White.

The institute I am affiliated with, NYPSI, is more traditional. At least, that's its reputation. It's a lot more relaxed than it's given credit for, but it's not great at broadcasting that fact. Now, when Shrinks was published, NYPSI invited JL to speak. He declined. Well, no, actually he never responded. Even after several attempts by the chair of the program committee.

I had given up on seeing him address an analytic audience when I learned he'd be speaking at White. So I went. Maybe it was a good idea for me to go, maybe it wasn't. I took notes. I didn't get everything down. Sometimes I got most of a part down but missed a few points and interpolated. I'll try to indicate when that was the case.  I'm sure I got some things wrong, too. Unless otherwise indicated, I am quoting or paraphrasing the speaker being described. Here's what happened:

It was an oversold event, so they moved it to a larger location, a synagogue near White, with a moderately sized auditorium-not the main prayer space. Early in the event, someone asked the audience how many had read the book. Very few raised their hands. There was a pile of copies of Shrinks on a table in the back. By the end of the night, the pile of Shrinks had not shrunk very much.

SK introduced everyone. She said she had the idea of setting up this talk after reading Shrinks. She agreed with most of it, especially the parts about psychoanalysis' history of homophobia, rigidity, rituals, and a non-scientific approach. She had two goals. 1. To recognize that in his book, JL helps us to see how the general public sees us; and 2. To introduce JL to modern psychoanalysis, as it's practiced today, and hope to change his point of view.

Jeffrey Lieberman

JL spoke first. He said that even though we were in a synagogue, we had dispensation not to wear "yarmulkas or tallits" (skullcaps or prayer shawls). He was pleased to have 2 of his favorite colleagues as co-panelists.  He announced, "My analysis failed!" and said no more about it. I like to think that validated the hunch I mentioned back in my review of Shrinks:

Lieberman, (or maybe it's Ogas) writes with particular vehemence about the period when most psychiatrists did analytic training. It made me wonder if he was rejected from a training program at one point, or if he was in an analysis that he quit because he found it intolerable. I have absolutely no basis for these thoughts- they're just conjecture.

JL said that his concern about the stigma of mental illness is what prompted him to write the book. It's like the sign of Cain. or the Scarlet Letter. Or the gold star Jews were forced to wear in the holocaust. Why should mental illness be stigmatized? He asked, "Would you prefer to say you were missing a (something) because you threw your back out, or because you were depressed?" That, he said, is stigma.

He reminded us that there is no anti-cardiology movement. That the stigma of mental illness is woven into popular culture. That it is vestigial, and in contrast to the scientific research of the last 50 years, which demonstrates that mental illness is in the brain. Stigma denies the array of available treatments. He said something about the brain being more complex than the heart, and that it's taken a long time to understand how the brain works and gives rise to mental illness, and that we're just starting.

He pointed out the stigma that existed with AIDS early on, but then came the ACT UP movement which made sure there was money for research, and then came AZT, and now we manage AIDS like diabetes or hypertension.

He said that in the past, there was little treatment available for mental illness, but now things are different. He spoke about an anxious patient he had seen that day, who is now treated for his anxiety, and can't believe how different he feels.

He had a patient, Sarah, who suffered from (I didn't hear this but he must have said, "agoraphobia"). He had to see her in her home. But after initial introductions, followed by appropriate medication, she is doing well.

He said there are failures. He recalled a borderline patient, L, who he had seen as a resident, before there was DBT. His goal was just to keep her alive. She dropped out of treatment, and he didn't know what happened to her.

He said there is an indisputable difference between now and before the mid-20th century. Back then, the barrier to care was lack of treatment. The new barriers to care are: stigma, lack of awareness, and lack of access. He emphasized the need for early detection of mental illness via screening in primary care settings, schools, and the workplace. Like for TB. Also the need for coordination of community care in advanced disease. He mentioned that there is a 7 year delay in treatment for depression, and that women should be routinely screened pre and post-partum, and children routinely for LDs and ADHD (I think he said ADHD).

He claimed all this would reduce homelessness, jail populations, and violent episodes. He mentioned, among others, Adam Lanza (the Newtown, CT shooter), who had clear signs of mental illness for years and could have been treated. (Please see my post, Behind the Violence, for a more nuanced discussion of the matter). They were all shunned, no one reached out to them. We need to trade "don't ask don't tell" for "I am my brother's keeper".  We shun people who look weird or menacing, but we need to be proactive.

JL spoke about a piece he wrote following Robin Williams' suicide (BTW, did anyone else see the thing about Williams having Lewy Body Dementia?). He got a letter following its publication from a psych-nurse who turned out to be the borderline patient, L, now doing well, and grateful to JL for genuinely caring about, and not judging her.

He ended with, "End Stigma!"

Andrew Gerber

(I'm going to skim through this one) AG thinks JL is a great guy and a great chairman. He broke the book down into 3 parts:

1. What analysts need to hear-JL just wrote things we say to each other anyway, that analysis has a history of intolerance, of who's in and who's out. We need to think about how to test our ideas. We have a history of being anti-meds, of excluding non-MD's, of ethical violations. He mentioned the Central Fact-Gathering Committee of the American Psychoanalytic association which, back in the '50's (?) suppressed data about the limited success of analysis.

2. What we can teach JL-analysis is not the same today. White and Columbia are responsible for vast changes, there are >100 trials showing the effect of psychodynamic psychotherapy.

3. What can we do together? Teach each other about the mechanism of action in therapy, exposure/response prevention, modeling relationships, interest in the patient's narrative, EEG's, biomarkers, case studies. We need to tackle healthcare funding together.

Jack Drescher

JD noted that he is not a cheerleader for PSA (psychoanalysis). He has written extensively about, for example, homosexuality in analytic history. He is not opposed to the DSM (he was a member of the DSM-5 workgroup on sexual and gender identity disorders), or to ECT or meds. But he felt the book was an anti-PSA polemic. That you can't lay the low status of psychiatry at the foot of PSA. He noted the links between psychiatrists and big pharma. He had 4 main points (I wasn't really clear on what they were trying to accomplish but here goes):

1. How to tell a story-addressing a popular audience. There was early approbation of thorazine for relaxation, nausea in pregnancy, and hiccups. TD is not mentioned in Shrinks.

2. The limits of rationality-he was taught as a resident that patients will take their meds if you simply explain to them that they need to. There is a need to empathize with irrationality.

3. Attributing motives-JL accused PSA of folding everyone into its net, with no clear demarcation between normal and abnormal, but JD noted that if it was done, it wasn't malicious.

4. Again, PSA not responsible for the low status of psychiatry, and most people don't know anything about PSA, certainly not in its contemporary form. We don't look to the Schreber case to treat psychosis today. The stigma of mental illness may be transferred to the profession that treats it. The book doesn't improve things by taking pot shots at PSA.

Now the mutual comments:

JL: The idea of writing the book was to gain credibility by fessing up to the history of psychiatry. When I included the quote (p.200) that, "Freud's ideas, which dominated the history of psychiatry for much of the past century, are now vanishing like the last snows of winter, " I just meant that Freud is not as influential. The therapeutic relationship is always important when you talk to people.

JD: We argue among ourselves about ideology.

There was quite a bit more, including comments by AG, but I was distracted thinking about JL's "fessing up".


Then came the questions.

The first to speak was Leon Hoffman, who disclosed immediately that he had written a review of Shrinks in JAPA. He reiterated some of the things he had noted in the review, like the way JL's lack of ability to establish a rapport with patients' families (the two he describes in the book) doomed the treatments to failure. Hoffman said he was pleasantly surprised to hear that JL did value the therapeutic relationship, because that wasn't clear from the book. To which JL replied, "I'm not sure you read my book." Hoffman asked if JL thought psychiatrists should be trained in therapy at all. JL responded, "If that didn't come through in the book, then I failed."

There was another interesting exchange with a brave man whose name I didn't catch, he's a psychiatrist and analyst who treats mainly schizophrenia. He uses therapy and meds. He says his patients are mostly people whose mothers never gave up on them. And he has helped them extensively. He pointed out that stigma is decreased by understanding the meaning and significance of the illness, not by making it the same as diabetes. JL said, "All illness has meaning." The man replied, "Not the primary meaning." Then JL, with an incredulous look, said something to the effect that this would imply there's something different or exceptional about mental illness, as compared to other types of illness. And most of the audience went, "Yeeees."

I think this was when JL started yelling. Truly, he was yelling. He said, "Your opinion doesn't matter! Cases don't tell you anything! You need evidence!" He sounded really mad. He also said something like, "I'm sure you mean well, but..."

The guy started mentioning some of the evidence that's out there, and JL just talked over him. I heard someone near me use the phrase, "Used car salesman".

Once JL was done, JD said something about how the meaning might reduce the stigma for the patient, but not for everyone else.

There were a few more questions, with audience members starting to file out. One resident asked about how he can make a decision about where to direct his career with all this sectarianism. This elicited long responses from all three panelists, a kind of, let's take this opportunity to educate the young'uns.

I missed a lot of the Q&A because I was so disturbed by the "fess up" comment. So I did something atypical for me, and I got in line to ask a question. The gentleman in front of me had more of a comment, to the effect that JL is not helping the profession by dissing analysts.

I'm a little confused about the sequence of events, but I think JL said something here about the complete lack of evidence for PSA, except for a few little studies (with a hand wave), and how you can't expect to be reimbursed for something that has no evidence.

Then it was my turn, and I was the last questioner, which suited me fine because the room had cleared out a lot by then. I'm a pretty comfortable public speaker, so I was surprised to note how much my voice was shaking, until I realized it was rage, not stage-fright.

I told him I had read his book, that there's a lot more evidence for PSA than he's allowing for, and I paraphrased the passage where he states that if Willem Reich's patient were alive today, she would be diagnosed with an anxiety disorder and treated with an SRI and CBT, which made it sound easy. I pointed out that he was concerned about gaining credibility by fessing up to psychiatry's history, but the fessing up was selective, and that nowhere does he mention the difficulties with treatment, including things like metabolic effects of antipsychotics, or Paxil Study 329, and how does he mean to engender trust in the public by omitting those kinds of facts?

I know I was far less eloquent in my phrasing, and what I just wrote is not so great to begin with. I think he cut me off towards the end, because I never said anything about the severe limits of what we actually know about mental illness. He rolled his eyes and said, "Medications have side effects. Am I supposed to list every side effect in the book?" I have the impression he was still yelling something, but I could be wrong.

Some poor soul got up then and tried to talk about research by Jonathan Shedler, but he got steamrolled. I think JL said something about adding that to the next edition.

I was going to do a lot of editorializing, but this post is already really long, and in any case the facts speak for themselves.

Narcissism, Part I

Long time no see!

I've been busy teaching. And it's been  a lot of work. I'm assistant-teaching an analytic class on Affects and Affect Pathology, and I just finished solo-teaching a psychotherapy class on Narcissism. This hasn't left a whole lot of time for blogging, or doing research for blogging, so I thought I'd attempt to combine the two by sharing some of the ideas from the Narcissism class.

If you think about it for a minute, you'll realize that "narcissism" is one of those words that has so many meanings, it's meaningless.

In the early analytic literature, narcissism was used in at least four different ways:

1. To denote a sexual perversion characterized by the treatment of ones own body as a sexual object

2. To denote a stage of development

3. To denote two different phenomena in the realm of object relations:
    a. a type of object choice in which the self plays a more important part than the real aspects of the object
    b. a mode of relating to the environment characterized by a relative lack of object relations

4. To denote various aspects of the complex ego state of self esteem
(Cooper, A. M. Narcissism (1986) in Essential Papers on Narcissism, Andrew P. Morrison Editor, pp. 112-143. New York University Press)

For those not familiar with the jargon, and ironically, in psychoanalytic-speak, people are referred to as, "objects".

Importantly, we can differentiate (Freud, 1914, "On Narcissism")  between primary narcissism, in which libido is invested in the now-differentiated ego, prior to the formation of object ties, and secondary narcissism, the withdrawal of libido back into itself, after object ties have been established. These are somewhat archaic descriptions, but the bottom line is that there is a normal, healthy type of narcissism that is part of development, and there is an abnormal, unhealthy type of narcissism that forms when something goes wrong developmentally.

Why is it important to know about narcissism? Because we see it all the time. There are the blatantly obvious cases, such as the super-entitled patient with zero empathy, or as a specific example, Richard III, about whom Freud writes in, "The Exceptions".

But there are also the more subtle cases: The patient who has been unemployed for years because he is unable to give up an unrealistic dream in favor of a potentially fulfilling and attainable but less grand goal; The perfectionist who can't differentiate between a minor mistake and a paralyzing, life-ruining humiliation; The patient who is unable to view others as anything but an extension of herself, who cannot understand why her friendships and romantic relationships never last; The highly somatic patient whose concerns with his body reflect his worries about the disintegration or annihilation of his sense of self.

And finally, there are the ones who do not have a primarily narcissistic pathology, but who suffer some sort of major narcissistic injury (e.g. loss of job, spouse, friend), who in response, regress to a more self-focused, withdrawn state, sometimes in the form of depression, and who need help re-establishing ties with the world.

Some of the qualities of Narcissistic Pathology:

sense of vague falseness
shame
envy
incompleteness
ugliness
inferiority
self-righteousness
pride
contempt
defensive self sufficiency
vanity
superiority
perfectionism

Fear of fragmentation can be displaced into preoccupation with physical health
Denial of remorse and gratitude
Guilt or dependency is shameful
(McWilliams, N. (1994) Psychoanalytic Diagnosis. New York: Guilford Press)

defensive self inflation
lack of integration of the self concept
inordinate dependence upon acclaim of others
poor object relations
vulnerability to feelings of rage, shame, depression
entitlement
relentless pursuit of self perfection
impaired capacities for concern, empathy, love for others
Defenses:
self aggrandizement/omnipotence
idealization/devaluation
(Auchincloss, E., and Samberg, E. (2012) Psychoanalytic Terms and Concepts. Yale University Press, pp. 162-6)

And here are DSM-IV (left) and DSM-5 (right) criteria for Narcissistic Personality Disorder:

Interestingly, DSM-IV is more focused on presenting symptomatology, while DSM-5 harkens back to a more etiologic conception, with emphasis on impairments in sense of identity and self.

There is a rich literature about the role of the "self" in narcissistic pathology. Sullivan writes about "self-dynamism" formed by notions of the "good me", the "bad me", and the "not-me". Rado writes about the "action self", a gauge of a person's emotional stature.

Horney describes the loss of the "real me" under conditions of parental coercion, resulting in unproductivity, excessive expectations, grievances and hostility.

Winnicott writes about the "true self" vs. the "false self":

A True Self begins to have life through the strength given to the infant's weak ego by the mother's implementation of the infant's omnipotent expressions. The mother who is not-good-enough is not able to implement the infant's omnipotence, and so she repeatedly fails to meet the infant gesture; instead she substitutes her own gesture which is to be given sense by the compliance of the infant. This compliance on the part of the infant is the earliest stage of the False Self, and belongs to the mother's inability to sense her infant's needs.
(Winnicott, D.W. The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. New York: International University Press, 1965, p. 145.)

For narcissism, in its pathological form, development of the self is where it's at. Which brings us to self-psychology, or the Kohutians, my preferred term because it sounds science-fiction-y.

To Be Continued...

Does Talk Therapy Work?

Take a look at the article in today's NY Times, Effectiveness of Talk Therapy Is Overstated, a Study Says.  

It's about a study published in PLOS one,

Does Publication Bias Inflate the Apparent Efficacy of Psychological Treatment for Major Depressive Disorder? A Systematic Review and Meta-Analysis of US National Institutes of Health-Funded Trials

Well, it's all very interesting. They were trying to look at publication bias in studies about talk therapy, and they found it. Of the 57 studies that met their inclusion criteria, 13 were never published-they learned about them by contacting the study authors.

And by their estimation, talk therapy is 25% less effective than previously believed.

The study looked at NIH grants between 1972 and 2008, and tried to match the grants to published studies. They were pretty thorough in their search terms:

(1) “depression” (depression, depressive, major depressive disorder, mood disorder, affective disorder, melancholic, melancholia) and (2) “psychological treatment” (cognitive therapy, behavior therapy, behavioral therapy, interpersonal therapy, psychodynamic therapy, dynamic therapy, humanistic therapy, therapy, supportive therapy, experiential therapy, [self-] control therapy, [problem-] solving therapy, [supportive-] expressive therapy, family therapy, group therapy, marital therapy, couples therapy, aversive therapy, exposure therapy, psychotherapy, psychotherapies, psychotherapeutic, counseling, disease management, psychoanalytic, behavioral activation, cognitive behavioral analysis system, desensitization, relaxation techniques, and progressive muscle relaxation). 

Of note to me is that they included "psychoanalytic", but not "psychoanalysis".

Inclusion criteria were:

(1) a randomized clinical trial examining (2) psychological treatment for (3) acute depression in (4) adults

This is a diagram of how they selected studies:

It bothers me a little that they started out with 4073 studies, and ended up with 57. But they seem to have been pretty thorough in how they went about it.

This is the table of the 57 varieties of studies they looked at:

Sorry,  I meant:

Of note again to me is that 5 of the studies are in Short Term Psychodynamic/Psychoanalytic Psychotherapy (STPP).


I'm not terribly surprised by their results. I don't put that much stock in the long-term effects of short term therapy. You may recall my post, Analytic Evidence, probably worth a shifty in this context. I've never been a big fan of CBT, except in very specific presentations, but admittedly, I think my CBT training was inadequate.

What I don't like about the study, and the Times article, is the overall message to the uninitiated. These were short-term treatments, and they were heterogeneous in type. These limitations are not addressed in the discussion section of the study. So the message is that all "Talk Therapy" doesn't work as well as we thought, with no differentiation between type or duration of therapy. And this is misleading and may keep people from seeking help.

Blessings

City Bakery Melted Chocolate Cookie-Part Cookie, Part Chocolate Bar

I've gone back and forth on whether to write about the termination of my analysis, after the fact. I did write about it in Termination, before it happened. Somehow, this is harder.

So, my analysis ended. The last session was difficult and confusing, and probably will remain confusing for a long time.

First, there was the cookie saga. I decided to get my analyst a parting gift, and since it's impossible to encompass the entirety of an analysis in one object, I decided on cookies. I wanted a specific kind of cookie from a specific bakery (the melted chocolate cookie from City Bakery), but then I wasn't sure I'd be able to get that kind of cookie, so I baked my world-famous-awesome brownies (see This Post for the recipe), but then I felt uncomfortable giving her something I baked myself so I went back to the original cookie idea. And all of this got experienced, acted out, and narrated in the last few days of my analysis.

Another thing I did in the last few sessions was talk about all the things that made me uncomfortable about the process of terminating. Like which words my analyst would choose to end the last session, and how I felt about the intimacy of shaking her hand when I left.

Yet another thing I did, as a larger gesture, was make a blessing. Having been raised as an Orthodox Jew, many, if not all of my fundamental references are Judaic. And one thing observant Jews do is make blessings, which follow the specific formula of, "Blessed are you, lord our God, king of the universe, who is/does something." The italics are the part that varies.

There are blessings for all kinds of things, from rainbows to acknowledging scholarship to thunder to hearing bad news. There is a blessing for every type of food, categorized in very specific ways, of course, but pretty much everything is covered: bread, wine, potato chips, strawberries, and yes, cookies. And even though I'm not as observant as I was growing up, I still make blessings over food. It's a way of reminding myself that I am privileged enough to have food.

In the last few weeks of my analysis, I tried to think of a suitable blessing to make over termination. It was tough. One idea I had was the blessing parents make when a child becomes a Bar or Bat Mitzvah, which goes something like, "Blessed are you....who has removed this one's punishment from me." It sounds awful in translation, but simply means that the child has attained an age at which one begins to take responsibility for ones own actions. That has something of the right idea for a termination, but I told my analyst it seemed more suitable for her to say about me, than for me to say about her.

A friend suggested a blessing about healing a broken heart, which was pretty good, but not quite right.

In the end, I invented my own blessing. It's based on the prayer that's said at funerals and other types of memorial events, such as a Yahrzeit (anniversary of a death), which seemed suitable, since termination has an element of death to it. The end of the prayer translates to something like, "...May he rest in his resting place in peace..."

The Hebrew word that's translated as "resting place" is Mishkav, which literally means, lying-down place. Like a couch. So I used the same word but tweaked it a little to, "Blessed are you, lord our God, king of the universe, who raises (me) up from the couch in peace."

For me, it captures the idea that I leave not "cured", but in more peace than I was in when I started.

So the last session went something like this:

I came in and handed my analyst a bag with the gift. She laughed and asked if these were the brownies or the cookies. I told her they were the cookies, but then I felt bad. Maybe she really wanted to try my world-famous-awesome brownies, and I could have brought both those and the cookies. Oh well. There went that opportunity.

I felt like I should say something momentous that encapsulated the entirety of my analytic experience, but all I could think to say was that my analyst had been very kind. I felt like she should say something broad to summarize our work together, but she just said she'd enjoyed working with me. She also said the door is always open, should I wish to return. I felt like that was decent of her, but it made me wonder if she thought I might not be able to manage on my own.

In the middle of the session, I silently made my blessing, then told her I had made it.

All the old doubts were right there. Have I done enough? Can I manage on my own? Does she like me? Can I share the things I'm inclined to keep to myself? Is she disappointed that I didn't bring her brownies? Can I tolerate the pain of this separation?

It was like a miniature version of my whole analysis, reliving all these feelings that I had grappled with over the years, and made some kind of peace with, only to re-experience them right at the end.

There was a lot more laughing than I had expected, on both our parts. I felt like my preemptively bringing up my discomfort with her final wording, or with shaking her hand, had lessened the pain of those experiences, but also lessened their power. They became more awkward than sad, and I wondered if she was feeling sad too, but was uncomfortable showing it, or felt it was inappropriate to let me see her feeling that way, and maybe the laughter was more nervous than fun. I was disappointed that she wasn't obviously sad. I might have been more disappointed if she had been.

In the end, she said, "We do have to stop." And she laughed. I smiled. I got up, walked to the door, and we shook hands with a quiet, nervous laughter. And then I left.

It wasn't our best session. It wasn't our worst session, either. It was just one of many sessions. I'm grateful for my whole analysis, and I'm also glad, and sad it ended.

So, cookies for closure, discussion for honesty, and a blessing for peace.

Amen.

Fascinating!

The idea for this post is based on a post by Jim Amos, The Practical Psychosomaticist, entitled, Getting Small Again About MOC. At least, that's how it started.

Dr. Amos wrote to someone at the ABPN to find out if instead of doing PIP modules, often at substantial cost, a diplomate's use of PubMed could be tracked by the Board. He was informed that PubMed use was not an option as a PIP alternative, but that, "You have the option of seeking individual preapproval for either one (PIP) that you develop, or one that you may already be doing as a QI project in your hospital/institution."

And he was given a link to the Individual Part IV Improvement in Medical Practice Approval Request.

So I started to think about the possibility of designing a PIP for the practice of Psychoanalysis.

This is how it works:

Clinical Module: A clinical module requires that you do a chart review of at least five patients in a specific category, (for e.g., diagnosis or type of treatment, treatment setting). You must then compare data from the five patient cases, utilizing a minimum of four quality measures, with a standard specialty practice guideline. Based on the results of the review, develop a plan of improvement, carry out the plan, and in no more than two years, do a second chart review utilizing the same guideline to see if improvement has taken place. The charts may be the same or different patients but must be in the same category utilizing the same guideline and quality measures. (boldface mine)

Where do I get a standard specialty practice guideline for Psychoanalysis? I started looking online, and that's when the idea for this post changed. Because I found an Evidence Based Guideline for Psychoanalysis from BlueCross BlueShield of North Carolina.

This is a short but fascinating document. How to explain?

It has a nice, brief description of Psychoanalysis as a "procedure or service". A bit about theory, how it can be helpful, the logistics, what kind of patient is suitable for analysis, and how analysts are trained. Really quite nice.

Then it goes on to describe the "Evidence Based Guideline", and completely contradicts everything in the preceding section.

For example, in the first section, there's this paragraph:

The person best suited for psychoanalysis is one who is generally successful in most aspects of his/her life but is still unhappy. Psychoanalytic therapy is said to be beneficial for those with troubled relationships, poor self-esteem, anxiety, chronic irritability, unresolved grief, phobias, and many other conditions where they want to understand themselves and see how their own thoughts and behaviors contribute to their difficulties. Psychoanalysis is thought to promote self discovery, personal growth and development. (boldface mine)

But then, in the guideline section, it states, "Psychoanalysis is not recommended for...treatment focused on increasing self awareness, self discovery, or personal growth."

I get that they're saying self-discovery shouldn't be the purpose of analysis-not an analysis they're paying for, anyway, but really, at least change the language so it's not identical.

The guidelines are antithetical to everything an analysis is supposed to be. The "A" criteria are:

Psychoanalysis (PSA) may be appropriate if nothing else has worked.

The patient needs some kind of problem that corresponds to a diagnosis
AND
The patient has distress in work/school/social
OR
an ongoing disorder that requires "behavioral assessment to maintain symptom relief and/or function"
OR
"additional treatment sessions are needed (documented by clinical evidence) to prepare for termination of therapy consisting of a clear treatment plan with well defined goals, methods and time frames to support discharge from therapy"
AND
The patient doesn't need to be in a locked unit.

"Well defined goals, methods and time frames" in an open ended, free associative psychoanalysis. How does that work?

The "B" criteria are even worse. I'm just gonna cut and paste and highlight the phrases that particularly annoy me:

B) All of the following criteria are met;
1. There is documentation of a mental disorder diagnosis, AND

2. There is a medically necessary and documented treatment plan or updated plan
individualized for the patient with at least one of the following outcomes;

a) focuses on alleviating the patient’s distress and/or dysfunction in a timely manner, or
b) pursues achieving maintenance goals for ongoing conditions, or
c) focuses on discharge from therapy, AND

3. The individualized treatment plan includes all of the following:

a) the status of the patient’s dysfunctions being treated and documentation shows
progression toward the treatment goals, and
b) the current treatment is focused on each psychiatric symptom, and
c) treatment framework, and
d) modality of treatment, and
e) frequency, and
f) estimated length of treatment, and
g) the status of the involved family or friends in support of the patient, and
h) the status of any necessary community resources, and
i) an alternative plan if the patient does not make sufficient progress in the time frame
specified, AND

4. The treatment must be rendered by a "certified psychoanalyst" from a nationally recognized
institute for psychoanalysis.

And now my corresponding comments:

How do you define "medical necessity" for PSA?

PSA often increases the patient's distress in the short term

Timely?

Focus on discharge: You better hurry up and change a lifetime's worth of patterns so we can terminate!

Status of dysfunctions?

Symptom focus? That's not PSA.

What do they mean by "treatment framework"?

The modality is PSA, duh!

You don't do family meetings in adult PSA

By their own description, PSA is appropriate for people who are generally successful. What kind of community resources are they talking about?

Define "progress"!


It sounds to me like they just took guidelines for some other kind of psychotherapy and pasted them in.

Now the worst part. The evidence.

There are 4 reference sources listed. The first is:

Dewey R. (2007). Psychoanalysis. Retrieved 7/10/2008 fromhttp://www.intropsych.com/ch13_therapies/psychoanalysis.html

This seems to be some kind of online Psychology Intro text. Psychoanalysis takes up one page. One very short page. It includes no information that would constitute a guideline, evidence based or otherwise. It describes what I consider a misinformed and outdated notion of PSA.

The second source is the "About Psychoanalysis" page on the website of the North Carolina Psychoanalytic Society. It's just a brief blurb about psychoanalysis, the couch, frequency of meeting, and the like. Nothing here in the way of guidelines.

The third source is the American Psychoanalytic Association's Standards for Education and Training in Psychoanalysis. This is a 23 page document that describes requirements for training in PSA. Like, who is eligible to be a candidate. How many case write-ups do they need to complete. It has nothing to do with guidelines for practicing PSA.

The last is the DSM-5. We'll ignore that, since it's just about diagnoses.

What we have is a completely bogus "guideline" that has no evidence base whatsoever, nothing to do with PSA, and everything to do with not wanting to cover the cost of an analysis. If you're an insurance company and you cover mental health, then you really can't afford the cost of an analysis for everyone who would benefit from one. And I guess they can't just outright state that they won't cover PSA because it's too expensive. I get it.

And in case you were wondering, this is not an out-of-date document. It was written in 2008, and reviewed in 2010, 2011, 2012, and last updated a year ago, when some (unspecified) references were removed, and others added. No changes were ever made to the guideline statement other than wording. It's up for another review this month.

I wonder if the ABPN would accept it as part of a PIP module.

Actually, the title of this post is wrong. Mr. Spock says, "Fascinating," when there's something interesting that he doesn't understand. If he does understand it, he just says, "Interesting."

Termination

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.