To open this book, Reflections on Long-Term Relational Psychotherapy and Psychoanalysis, is to experience, however briefly, a sense of picking up some samizdat literature of the Soviet period. That may be an exaggeration, and in saying that, I mean no disrespect to those who lived through The Great Terror of Soviet communism. I have read Conquest's book and some of the memoirs and biographies of others who lived through that period and do not wish to diminish any of it by shallow analogies.
Nevertheless, the power of collective pressure, and even more collective disdain, even in "free" and democratic societies, is no small thing. Sustained to a high enough degree and for long enough time, such pressure and disdain can make otherwise innocent people feel highly suspect and force them to engage in splitting and cloaking, which one would not expect psychotherapists to do if they are trying to heal patients of those same phenomena! Nevertheless, here in the United States the pressure against, and disdain for, long-term psychotherapy has been widespread for a quarter-century and more now, requiring clinicians who believe in and practice long-term therapies to downplay or deny their involvement, discussing the same only with trusted colleagues under a cloak of secrecy to prevent the prying hands of "managed" health care apparatchiks from hauling them before some star chamber for "ethical" violations and/or "fraud."
As someone whose life was profoundly changed, and for the good, by long-term psychoanalysis in my native Canada (where American pressures at time-reduction of therapy are only slightly less advanced) I do not think my "bias" on this question is any great secret. I fully believe that in some (not all!) cases, some patients may well require long-term treatment.
At the same time, however, as someone whose intellectual formation in psychoanalytic thought has debts above all to Winnicott, Nina Coltart, and Adam Phillips, I am not--thanks to them--an ardent and unyielding ideologue about analytic therapy or its length. One thing I take from them in particular, and the British Independend/Middle school as a whole, is their pragmatism and avoidance of hidebound ideologies and practices, including about psychoanalysis itself (which Phillips well addresses in almost all of his works, but perhaps especially his recent book The Cure for Psychoanalysis). Stated positively, I believe people should find whatever theory and modality works for them, and pursue therapy at whatever length they need--short or long matters not to me if it aids in their flourishing and healing, which should remain the sole criteria for adjudging length.
In that light, then, and without fear of any contradiction, I have written sincerely and appreciatively about short-term therapy here. I have seen patients in my own practice who came with with otherwise good health and very highly functioning lives who needed assistance in one particular area and when some success had been achieved in that area, wanted to discontinue therapy, which I fully supported. It is, after all, their life and as someone who is also deeply indebted to Erich Fromm, I believe that therapy should aim at maximizing their freedom, above all--as Fromm said--from authoritarian figures, which some therapists certainly can be!
I have had, so far, two supervisors who had very opposing views on long-term therapy, and I respected, and respect, both of them and their arguments. The first, a licensed clinical social worker of longstanding, noted that perhaps if therapy is running on for years at a time then one needs to set two goals: to increase social skills and thereby to increase the likelihood of finding friends. As someone who has worked long-term in community mental health, he was rightly very wary of anyone engaging in services for too long and thus depriving someone who might desperately need them from accessing the same.
My second supervisor, a long-time clinical psychologist, has talked about his experience of long-term therapy in terms that authors in this book do also: as something that may sometimes be indicated by the patient's manifest needs and in the patient's interest, and perhaps even requested by the patient him/herself.
The editor, Susan A. Lord, makes those arguments herself, and other contributors do too. Lord gets right down to business in opening her book Reflections on Long-Term Relational Psychotherapy and Psychoanalysis with a frank acknowledgement of the discomfort many experience in even talking about the topic of long-term psychotherapy. How strange and sad that we are made to feel like quasi-criminals!
But before that she gives us a startling epigraph, revealing a fact about two people whose books I have admired, but whose relationship I did not know of: the late neurologist Dr. Oliver Sacks was in a half-century-long psychoanalysis with Dr Leonard Shengold which ended only with Sacks' death in 2015 (Shengold died in 2020. He is perhaps best known for his searing book Soul Murder: The Effects of Childhood Abuse and Deprivation). Sacks wrote about his analysis in part in his memoir, On the Move: A Life. No doubt this revelation of a 50-year analysis has caused all kinds of recoiling in readers.
Admittedly, that is perhaps a world-record and not a normative standard that anyone else should necessarily imitate. So what do the authors and editors of this book mean by "long-term" therapy?
Most of them adhere to what seems to be something of a semi-accepted standard of any treatment that goes beyond six years. But many of the contributors talk of patients they saw for 15, 20, 25, and in one case 30 years.
To admit to such length is at once to raise a whole series of serious questions, and the various authors in this highly valuable collection do an excellent job at that. One must ask, inter alia, such things of oneself and one's patient as:
- what does an ending look like?
- why do we require an ending? Do we, in fact, require one?
- does having an ending facilitate therapy or inhibit it?
- does having a time limit enable growth or inhibit it?
- how long is long-term?
- how much/long is "enough"?
- why does talking about long-term therapy, and admitting to conducting it, seem like a "shameful secret"(p.xiv)?
In her introduction, Lord suggests--as other contributors do--that "we should leave the decisions about length of treatment to our clients."
The second chapter, by Patricia DeYoung, continues the exercise of raising excellent questions and challenging assumptions. She begins by flatly and rightly insisting that "sometimes brief work is exactly what's needed" and therefore, for such patients, one can safely conclude long-term therapy is not needed.
What about other patients, however? What about those with major long-standing developmental trauma? For them, she says, long-term therapy is justified and should be seen as such. She then spends most of the rest of her chapter on a 15-year (and counting) treatment with a young man whose life had totally collapsed (into what some might consider near-psychosis, though DeYoung avoids all such language because her patient found diagnostic terms profoundly demeaning and unhelpful).
Jean Kotcher, in her chapter, offers some helpful reflections on what therapists need to be able to conduct long-term therapies, noting that not all therapists are cut out for such work. Drawing on a definition from Norman Doidge et al that defines long-term work as averaging six years in North America, she notes her own experience is considerably longer: 15 years in some cases she discusses, including with patients who were massively abused as children. To work over the long haul requires, Kotcher says, that "long-term therapists have patience and self-esteem that does not rely upon a timely 'cure,'...comfort with uncertainty..., and an ability to commit to and be energized by long, mutually caring professional relationships, sometimes for decades" (p.32).
She further notes that sometimes in long-term therapy not much appears to be happening because in fact not much is happening directly or consciously. Instead, there are stretches where gains are being quietly and undemonstratively consolidated and integrated. The temper of such therapies is, she later says, "relaxed" and allows patients the ability to engage in "unfreezing themselves from destructive and unsatisfying patterns and relationships, past and present, to arrive as more fully evolved people who are supple and more capable of living fuller lives" (35).
William Meyer, a just-retired social worker, has two chapters in this book. It was, in fact, in search of his writings that I was led to Reflections on Long-Term Relational Psychotherapy and Psychoanalysis in the first place. Both of these chapters are very helpful. He starts off chapter 4 by noting something that might be obvious and for that reason overlooked: "the similarities between the role and functions of a good therapist and a good parent" (37). A parent is a parent for the long-haul. There is usually no "termination" in that relationship, raising the question: why must there be one in therapy at least for some people?
There are, he notes, some people for whom brief therapy is indicated, and he reviews some of the standard criteria here: a relational capacity, psychological mindedness, motivation, and evidence of adaptational ability. This is not an exhaustive list, but if your patient is lacking one or more of these, considerable caution is in order before recommending brief therapy.
Much of the rest of the chapter is given to talking about cases, and in one of these he notes that for a sometimes-suicidal patient who went through bouts of despair he had to show her that "I will carry the hope until she feels stronger" (45).
He ends by returning again to Winnicott and the latter's observation that "we can actually alter the patient's past" so that the therapist who now provides a holding and maternal environment can in fact contribute to the patient's growth even if it arrives later in life than for those who had good maternal environments.
In his next chapter, he raises an absolute humdinger of a question: "If an individual was on a psychotropic medicine that provided symptom relief, would anyone suggest that the person stop taking it?" This question becomes all the more acute when, "for many patients, the therapeutic relationship is the best love relationship they have ever experienced" (54). If that is so (and in my case it was--at least prior to getting married), then who are we to prescribe artificial limits to that in advance? Is it not utterly perverse (in that way only advanced capitalism can justify) to say that you can have a life-long relationship to a pill for its therapeutic alleviation of symptoms, but not to another human being?
Yes, but....I can hear you splutter. But what about abuses? What if the therapist is extending treatment for unhealthy reasons of his own pathology? What if the therapist is dragging things on to line his own pocket? These are all crucially important questions and if such things happen then (as Superintendent Hastings might say) the professional associations and legal authorities should throw the book, and bookshelf, at the perpetrators. But surely we should not let these abstract and rare problems inhibit therapeutic practice unduly? Why allow the bogeyman of a lazy or fraudulent therapist inhibit the rest of us? For a profession that likes to self-soothe by endless repetition of the mantra of "evidence-based," where is the evidence for massive and widespread fraud committed by corrupt therapists dragging on treatments for decades without justification or results?
Carol Ganzer's chapter, "Mourning the Melancholy Object: Giving Voice to Traumatic Experience" is also very substantial. Parts of it put me in mind of the recent book of Madelon Sprengnether, Mourning Freud. Ganzer notes that much of therapeutic work has to "deal with ghosts from the past" and that such ghosts often represent the "melancholy object" which (in a definition borrowed from Stephen Frosh) is "one that is never fully acknowledged and consequently can never be properly mourned." Such objects form a "present absence."
Ganzer's chapter is useful in illuminating the clinical phenomena of enactment and impasse. About the former she says that she can detect one beginning or happening when "I find myself behaving differently from my usual patterns with patients, or I am surprised and caught off guard in some way" (p.66). The latter she says (here drawing on the work of J.M. Davies) may be linked to incomplete mourning: "an impasse in the treatment is linked to an impasse in mourning in the analyst" (70), a point she then illustrates with a case study of one of her patients.
Natalie Peacock-Corral has an interestingly titled chapter "It Takes a Long Time to Grow Young." In it she talks about how learning psychoanalytic theory on sadomasochistic dynamics helped her understand the self-destructive drive and practices of one of her long-term patients. She recounts her experience of a long-term therapy with a man in his 30s, and how this showed her what Winnicott was on about when he wrote of the therapist/parent needing to be able to tolerate the rage of the patient/child without retaliation. It took this patient 12 years of treatment before he could properly mourn his mother, and in the meantime Peacock-Corral learned a further lesson first discussed by Nancy McWilliams (in her superb book Psychoanalytic Psychotherapy: A Practitioner's Guide, about which more another day): that the patient needs the therapist to be a worthy opponent.
Perhaps the central insight of her chapter is one she derives, as a relational psychoanalyst, from Winnicott: there is no such thing as a patient. (DWW had phrased it as "there's no such thing as a baby.") In other words, as she continues, "there is the patient and the therapist." Just so.
Speaking of babies, this author recounts what her two pregnancies, and a miscarriage, provoked in her long-term patient Robert. The latter experience especially allowed him to appreciate her in a vulnerable state and so be helpful and even somewhat of a healing presence. In doing so, he was playing the role that Harold Searles described in his very memorable and insightful 1975 paper which I have referred to before: "The Patient as Therapist to his Analyst."
Skipping over several chapters in the interest of keeping this review to somewhat manageable length, let me, in concluding, turn to the final chapter by Anthony Bass, "The Longest Goodbyes: Analysis Everlasting." He begins by noting how often and how long patients have conversations in their mind with their therapists during vacations, separation, and even after the death of the therapist, noting that "an analyst's voice is often a lifelong companion." (To his credit he notes that this is not always salutary for not all analysts may have been a helpful and healing presence.)
In this chapter, we see Bass fully inhabit the so-called two-person psychology that developed after Freud and is especially prominent among relational analysts/therapists (the terms are used interchangeably throughout this book). For Bass, "the learning curve for an analyst often continues for a lifetime." This should be at least a partial rebuke to the slanderous prejudice which assumes long-term analytic (or other) therapy involves no effort by the analyst beyond lining his own pocket. You are always learning, always being challenged, because no patient is ever the same during treatment; nor are any two patients alike. Equally, however, no therapist is ever the same in treatment with one patient, or across treatments with multiple patients. As he puts it, "in any analysis worth its salt, both participants change as a function of their encounter with one another."
Moreover, the process of arriving at change (and the agreed-upon landmarks of what change might look like) is never the same, nor even necessarily stable and constant inside one treatment. Here Bass charmingly used a reference to that voice that most of us have heard at least once in the last two decades of driving: the voice of our GPS when we miss the turn (whether by design or accident): recalculating. In therapy, he says, the route and destination are always recalculating.
In the end, then, this very rich book has brought out into the open an unnecessarily and unhelpfully hidden discussion about the fact that late capitalism's fetish for brevity and efficiency is, in therapy at least, highly unwelcome and often highly deleterious. Does all therapy have to be long? Does it all have to be short? Therapists and patients alike should have the freedom to decide. The answer is always going to be: it depends on the patient's needs. All other considerations should be otiose.
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