New Ideas
in Psychology, Vol. 1, No. 2,
pp. 177-182, 1983
Printed in Great Britain
AN
INDEPENDENT SHARE IN THE WORK: SOME
THOUGHTS ON TIME-LIMITED PSYCHOTHERAPY. A RESPONSE TO MOSS
RICHARD L.
RUBENS
Teachers
College, Columbia University, New York, NY 10027, U.S.A.
In his article “A Therapy is Being Ended,”
Donald Moss presents an artistic, thought-provoking series of reflections on
the theoretical and ethical questions raised by the all too common practice of
blindly assigning patients to work in ersatz long term
therapy - blindly, because it is done without regard for individual
circumstances, and ersatz, because it is often simply a serially
contiguous succession of incomplete segments. It is clear that such practices
are irrational, negative, and anti-therapeutic. It is also true, as Moss
asserts, that the avoidance of termination somehow lies at the heart of the
problem.
The construction of the article contributes to
its power and its evocativeness, while simultaneously creating its most
problematic aspect: its discontinuity diminishes its sharpness, philosophical,
as well as clinical. Moss does not provide an explanation of his position with
sufficient clarity to permit the reader to interact with and further refine
some of the important concepts that he is raising. While his contention may be
true – that at a preliminary stage, “the issues resist the taming effect of
interpretation” - can it ever be too early to encourage co-participation in an
exacting psychoanalytic inquiry, be it between author and reader or patient and
therapist? It may be that this problem reflects a greater shortcoming in Moss’s
reading of the issues.
Moss invokes Freud’s description “The
interpretation of dreams” [ 1] of the reflex functioning of the psychical
apparatus. A more precise reading of this material reveals Freud’s contention
that the earliest form of psychic activity is that of the infant’s
hallucinatory cathecting of an inner image, associated with earlier experience
of satisfaction, in order to deal with the pressure of internal need. The
“bitter experience” which Moss cites is quite simply the lesson that wishing
doesn’t make it so- that hallucinatory wish-fulfillment does not satisfy
somatic needs. Action in the real world must be accepted as a prerequisite for
satisfaction.
It is most certainly true that central to
every form of psychoanalytic psychotherapy is the movement toward the
acceptance of reality as opposed to fantasy. Nevertheless, there is nothing in
this fact that pertains to the length of treatment. There is no sense in which
brief psychotherapy is more “blunt” in dealing with reality. In fact, it is
entirely possible for a treatment to be “brief’ for the very motive of denying
reality.
The aspect of reality on which Moss most
correctly focuses is that of loss. One of the most fundamental features of life
is that it is finite: to live is to die. There are no exceptions. Furthermore,
the very process of living, that of growth and change, implies continuous loss.
One cannot move on to a new stage of life without relinquishing an old one. It
is the desperate denial of this reality that lies at the heart of all neurotic
processes. In neurosis, an attempt is made to deny finiteness and loss by the
creation of a fantasy world in which
time does not exist and real action is not necessary. The same drama is
continuously re-enacted with the same players. It is the world of Keats’
“Grecian Urn” [2] where the lovers and their love exist for all eternity,
unravaged by the passage of time:
Bold Lover, never,
never canst thou kiss,
Though winning near
the goal-yet, do not grieve;
She cannot fade,
though thou hast not thy bliss,
For ever wilt thou
love, and she be fair!
The price of eternity is, unfortunately, the eschewing
of living.
This closed system, in which time and change,
ending and death, do not exist and in which real action is meaningless and
impossible, is reminiscent of the state of hallucinatory wish fulfillment described
by Freud. There are those of us who, following Fairbairn, would maintain that
the creation of and adherence to such a closed system are not reflective of the
primary state of human psychic activity, but rather of a schizoid alteration of
the self resulting from intolerably bad experience. In either case, it is clear
that nothing which is to be considered psychoanalytic psychotherapy may in any
way support, or even fail to challenge, the denial at the heart of any closed
system of experience.
Moss confounds the important question of the
role of recollection by linking it to nostalgia. Treated more simply, to
recollect is to remember, specifically in the sense of the gathering together
again of elements of past experience. In this sense, recollection is the very conditio
sine qua non for
the existence of the category of loss. There must be a matrix of past
experience against which loss can be recognized. Virtually all of
psychoanalytic theory has emphasized the need to supplant the timeless
re-enactment of neurosis with a differentiated awareness of history as past
experience (see Freud’s “Remembering, repeating and working through” [3]). I n
neurosis, there is an unconscious refusal to recognize the reality of the state
of being past, for to do so would mean to recognize the reality of loss.
To be nostalgic is to yearn to return to the
past. Psychotherapy is committed to the recollection of the past in such a way
as to make clear that return is not possible. When psychotherapy becomes
“dedicated to nostalgic recollection,” it ceases to be psychotherapy.
When amorists grow
bald, then amours shrink
Into the compass
and curriculum
Of introspective
exiles, lecturing.
(Wallace Stevens.
“Le monocle de mon oncle” [4])
Psychotherapy must be a real enterprise in the
present, with the life and vitality that comes from immediate experience. It
must offer, in its present reality, a taste of what makes it worthwhile to
relinquish the attachment to life in fantasy.
Any attempt to deny the finite character of
life and relationships is anti-therapeutic. The prolongation of a therapy
relationship becomes a denial of finiteness when it continues beyond the reason
for its existence. The “rotating” of therapists and the “handing on of
patients” also represent such a denial, in that-in classically neurotic
fashion- they are based on the fantasy that the eternal unchanging presence of
the loved one can be attained by refusing to recognize change and individual
difference. Then, too, the assumption that short term treatment is invariably
indicated is just such a denial.
Moss writes that “It only gets serious when
the possibility exists that it can end”. In truth, relationships can only be
real when the possibility is acknowledged that they can and do end. In
neurosis, one is deathly serious about the denial of this reality.
In this, therapy is no different from other
intimate relationships: there is no reality to the relationship unless its
finite nature is acknowledged. Friendships, marriages, family ties-each becomes
meaningless and life-denying if assumptions of interchangeability are made, or
if the bond exists beyond any reason for its existence. On the other hand, an
important conclusion can be drawn moving in the opposite direction:
relationships require a mutual commitment to be viable. A therapy in which the
two participants have not agreed to devote themselves to the pursuit of some
common undertaking cannot work.
It simply is not true that brief therapy is
“the only form of treatment in which patients can reasonably be expected to
suffer loss and thus to come to grips with Freud’s ‘bitter experience’ “. The
most open-ended and ongoing of long-term therapies can deal continuously with
the loss involved in the bitter experience of relinquishing the belief in
timeless fantasy and its denial of finiteness. And the end that does come
eventually is no less powerful for its having evolved naturally rather than as
an artifactual imposition.
There is no psychotherapeutic benefit inherent
in brevity. None.
There can be enormous benefit in the use of
time limits in therapy, however. It is an unfortunate feature of Moss’s paper
that it never states what specifically is meant by “brief analytic treatment”.
I shall attempt to be clearer about my assumptions regarding what I term
time-limited psychotherapy.
For it to make sense to propose a time-limited
treatment, certain criteria must be met. (1) There must be a clearly definable
problem, the importance and centrality of which must be mutually agreed upon by
therapist and patient. (2) The issue of loss must figure in this problem in a
way such that the real and present loss experience in the treatment will
resonate with the structural and historical issues involved. (3) Both
participants must be able to feel that it is reasonable to expect to make
significant progress on the defined central issue in the time to be allotted.
(4) Both must be convinced of the patient’s ability to carry on the work in
this area on his or her own after the termination. (5) Both have to believe in
the therapist’s ability to enforce the termination.
In practice, I do a series of evaluation
sessions (usually two to four in number). If the criteria are met (I cannot
emphasize enough that they involve mutual judgment, derived from the process of
evaluating the situation together), there is a very specific contract that is
formulated. It begins with an explicit understanding of the central issue, a
statement of the planned direction of the inquiry, a statement of the duration
of the treatment (twelve sessions, although this number is one that is somewhat
arbitrarily derived), the specific mention of the date of the final session,
and concludes with a statement that the goal is to make sufficient progress in
the work on the central issue so as to enable the patient to be in a position
to continue on his or her own. If this contract is accepted, and if it is
arrived at mutually during the course of the evaluation, the treatment is
begun. The termination date must be adhered to under all circumstances, and
extra sessions are not permitted.
When the criteria I have enumerated are met in
a particular instance, time-limited psychotherapy may well be the treatment of
choice. When they are met, it is at the very least, completely certain that it
is a viable option. To institute such a treatment when the criteria are not met
may represent as gross a denial of that “bitter experience” as do the abuses
catalogued by Moss on the other extreme.
When Moss insists that the institutional (and
personal) need to “pass on” patients rather than to terminate with them derives
from difficulties in dealing with loss, he is most assuredly on target. He is
closest to the mark in this when, spinning off from Freud’s conclusions about
the multiple perspectives simultaneously present in the fantasy discussed in “A
child is being beaten”, he concludes that, as therapists in the process of
ending a treatment, “We watch it, we administer it, and we empathetically suffer it” (emphasis added).
Why does Moss distance himself from the more
direct statement that we suffer it? It is an ending for the therapist as well.
It is a loss, an occasion for suffering. In fact, there is a covert theme
running throughout Moss’s paper that denies this particular reality. He writes,
“We prolong our therapies, in part, because we fear what will happen to our
patients without us. This fear. .
represents a reassuring
transformation of a wish to be rid of them”. Would not a more parsimonious
interpretation be that it represents a transformation of our fear of what will
happen to us without our patients? Moss describes patients as “the nearly
helpless”, yet it is clear that he is aware of the profound sense of impotence
in the statements of the therapists he quotes.
The extended discussion of the role of hatred
is similarly skewed. It is not, as Moss quotes Winnicott as saying, that “Hate
is expressed by the existence of the end of the hour”; it is reality which is so expressed. That this reality involves finite
limitations, separations, and even losses is part of the agreed-upon reality of
the structure of the relationship. While it is true that there exists an
“impassioned conviction” that pain “is always the result of intention”,
Fairbairn [5] is correct is asserting that this conviction represents what he
terms the “moral defense” in which one assumes guilt (or projects blame) in
order to avoid the deeper, more unbearable ultimate schizoid fear of
recognizing his or her helplessness. Clinically, feared helplessness always
lies at the bottom of grandiose omnipotence. This truth holds for patients,
therapists, and even the Grand Inquisitor.
The choice of the title of this review was
prompted by this covert denial in Moss’s article. The phrase, “an independent
share in the work”, comes from the
one major ellipsis in the lengthy
passage he quotes from Freud’s “From the history of an infantile neurosis”,
which I here quote:
His unimpeachable
intelligence was, as it were, cut off from the instinctual forces which
governed his behavior in the few relations of his life that remained to him. It
required a long education to induce him to take an independent share in the work;
and when as the result of this exertion he began for the first time to feel
relief, he immediately gave up working in order to avoid any further changes,
and in order to remain comfortably in the situation which had thus established
(emphasis added).
Freud is not referring to a case in which the patient was simply being
passively apathetic. Rather, this is a case in which considerable analytic work
has been done in order to mobilize the patient’s independent resources, which,
having come into play, were then actively withdrawn for the purpose of
reinstating the denial which is here under discussion. For, active
participation by the patient in an analysis involves the recollection of a past
in such a way as to create a free and active present, and in so doing, it works
contrary to the neurotic need to deny the finiteness of life in a changing and
growing present. This real activity on the part of the patient is what Moss
omits from consideration.
The only true community is not, as Moss
writes, “a community of true losers”, but rather of true individuals, who know
both the power and limitations of their separate and finite existences. When
individuals interact in such a way as to accept – and not to pretend to
transcend – the bounds of their own responsibility for themselves, their
relationships can be satisfying, intimate, and even curative.
This is the real power of time-limited
psychotherapy: it forces both participants to acknowledge openly and clearly
the terms of their co-participation. Curiously, this acknowledgement may be
more novel for the therapist than for the patient. It is possible in long-term
treatment; it is even required if the treatment is to have any real meaning.
But in time-limited treatment, it becomes more obvious that both participants
must have “independent shares in the work’. It is not theory, as Moss claims,
that becomes the crucial, orienting device; rather it is the open
acknowledgement of purpose and plan, and the explicit invitation to
co-participate in a joint enterprise in an independent way. “Brief therapies”
which do not involve this understanding run the certain risk of being no more
than a different manifestation of the denial that Moss decries.
Any treatment which does not respect
individual autonomy and the finiteness and separateness therein implied is an
attempt to deny the “bitter experience” which has been under discussion. This
infantile dependent fantasy is as present in the Grand Inquisitor who arrogates
to himself the “terrible freedom” of decision making as it is in the “cattle”
who long to have the suffering of confronting this freedom expunged from their
awareness. When “brief therapy” is offered as a repressive palliative for
problems that would be more amenable to a more sustained exploration, or when
it is indiscriminately offered to all because the financial resources are not
sufficient to provide what otherwise would be required, such therapy becomes
guilty of the worst sins catalogued by Moss. Just as when an unending
succession of ersatz long-term treatments avoids the need for the participants
to face the reality of termination, or when patients are “passed on” so as to
allay the fears of institutions about maintaining a “patient pool” for training
needs or financial income, the growth possible in such therapies is severely
limited by the neurotic shortcoming that underlies their very existence.
The proper use of time-limited treatment is in
a manner that takes advantage of its potential for bringing into focus the need
for definition and clarity of each participant’s “independent share in the
work”, making full use of its inherent highlighting of the finiteness of life
experience. When conditions so permit, and this modality is so employed, it
provides an excellent technique for doing what psychoanalytic therapy always
has been meant to do: it provides an experience in which one learns to live
life in the fullest and freest recognition of all its potential and
limitations.
The ubiquitous human fear of living in an open
rather than closed way- the fear of accepting finiteness, change, and the
reality of loss rather than hiding in eternal and unchanging fantasy-is
essentially the same as the fear of the “terrible freedom.” There is always a
temptation to submit to totalitarian authority rather than take an “independent
share” in confronting reality as it is. Psychoanalytic thought has always
maintained what the “prisoner” told all mankind in tales earlier than the
cynical one told by Ivan Karamazov: “The truth shall set thee free.”
1. Freud S. The
interpretation of dreams. In The Standard Edition of the Complete
Psychological Works of Sigmund
Freud (ed. Strachey J.), pp.
5655566, Vol. V. Hogarth Press, London (1961). (Originally published, 1900.)
2. Keats J. “Ode on a Grecian
urn.” In Selected Poems and Letters (ed. Bush D.). The Riverside
Press, Cambridge, MA (1959).
3. Freud S. Remembering
repeating and working through. In The Standard Edition of the Complete
Psychological Works of Sigmund Freud (ed. Strachey J.), Vol. XII. Hogarth
Press, London (1961). (Originally published, 1914.)
4. Stevens W. “Le monocle de
mon oncle.” In The Collected Poems of Wallace Stevens Alfred A. Knopf,
New York (1971).
5. Fairbairn W. R. D. A
synopsis of the development of the author’s views regarding the structure of
the personality. In Psychoanalytic Studies of the Personality. Routledge
& Kegan Paul, London (1952). (Originally published, 1951.)
6. Freud S. From the history
of an infantile neurosis. In The Standard Edition of the Complete Works of
Sigmund Freud (cd. Strachey J.), Vol. XVII, p. 11. Hogarth Press, London
(1900).