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”  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” ). 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” )
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  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.”
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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).