Abstract
This paper about patients who return to treatment several years after their analyses ended explores a few of many questions that arise for most of us. First: out of what conscious and unconscious needs do some patients come back while most resist the universal temptation to do so? Second: what has the unexpected experience of renewing a treatment and relationship with particular individual patients meant to me after an absence in which both of us may have moved on to different stages of our lives? We analysts and therapists at work are solitary people, and need the corrective of sharing our experiences and the kinds of feelings we tend to keep within the confines of our private offices. This essay is such an attempt.
I will begin by quoting parts of a recent clinical presentation of Ms. X that focused on how my fantasied relationships to the patient’s central objects may have affected the outcome of a very long, terminated analysis:
What remains unanswered is: Did her alliance with me, partly based on my significant degree of support for her perceptions and feelings about her objects . . . advance or hinder her becoming able to experience erotic desire imbued with trust and intimacy toward a male love object of her own? . . . In the course of years her insatiable need for an external mother figure became more and more our focus. The prospect of termination was painful and frightening, even though her ability to deal with the demands of her life, to use her mind thoughtfully and effectively, to become an appropriately loving and steady mother to her children have become easily available and gratifying. However, conflicts over sexuality and her relationships with men remained. Her wishes to castrate phallic-exhibitionistic, sadistic men, the ones she was most attracted to, the theme of numerous dreams, remained at least partially unresolved at the end.
I concluded in that earlier presentation that
my feeling that she needed something concrete to cling to at the time of termination, namely, my assurance that I would see her if she needed to see me, expressed my distrust that she could retain a relatively constant representation of me and of our working relationship in the face of loss; my anxiety that rather than mourn, she would become depressed.
Three years later, this divorced patient with two teenage children asked to return to therapy, and we have been meeting, sitting face to face, twice a week for several months. She looked somewhat more worn than I remembered her, and somewhat sad. As had always been true, her clothes were expensive, fashionable and carefully assembled; the riding breeches she often wore conveyed a somewhat masculine athletic image that might warn an approaching, interested man that, to paraphrase Freud’s famous dream symbol, “This shop is closed.” She told me she was generally happy in her life, felt fulfilled as a mother, and had made advances in her profession, which gave her pleasure, but she realized she would soon be turning sixty, and her older daughter was about to leave home to enter college. She would now be free, after many years, to participate in an accessible, socially desirable world. In the three years, she added, she had been unable to form a relationship with any man. She found disqualifying deficiencies in all of them, including internet respondents, and had become aware that she stiffened with fear and rage whenever an interested man approached her physically. She hoped we could work to understand and lessen these conflicts, which now augured a lonely and bitter old age.
I will use this clinical example to suggest a few tentative conclusions about a number of patients who have returned in recent years and to examine what precipitated their decision to call, and some of what the renewed contact has offered them—and me.
Several of my patients, including Ms. X, have returned just following, or in anticipation of, major losses—of particular objects who have supported their often shaky sense of self, of wholeness, of being needed, of having something good at the core of their being that enables them to believe they can love and be loved. Such individuals, as one would expect, are particularly vulnerable to the undeniable internal changes that time confronts them with, unprepared for the realization that life rushes relentlessly on. They tend to feel unable to mourn and to overcome the consequent inevitable losses. They fearfully anticipate impending future separations, expecting a return of painful aloneness that harks back to their early lives and to a conviction that the world has no loving stake in their well-being or even their existence. The inability to hold on to a secure and rich internal structure of self- and object representations seems traceable to very faulty early attachments with primary objects. These lacks may make it increasingly urgent to restore the steady presences we analysts have been to them.
I have often found that coming back brings an immediate, reassuring effect. Evidence of my continued existence as more or less the same person I was, my remembering them and our shared past, quickly restabilizes a number of such patients. In long analyses extending through sequential life phases, the meanings we and our patients develop toward each other are deep and abiding. Our daily meetings will usually have become precious in my life too. In the next part of this essay I will offer some thoughts about the meanings to me when a patient returns. But now I would like to tell you about Ms. X’s return to therapy.
What I have just suggested about the origins of feeling like an oddity in an unwelcoming world fully applies to Ms. X. At her birth her too young, unprepared mother suffered from postpartum depression and felt her baby was ugly and should not be photographed, as her slightly older sister had been—voluminously. When Ms. X was just a few months old, her mother used her doctor’s permission as sanction to get away on a long vacation trip.
Such “facts” about Ms. X’s babyhood and early childhood had moved me, I think, to emphasize her dyadic, preoedipal needs in her first treatment, and to minimize analytic attention to the still powerful oedipal conflicts built on them. These have become much more our focus in the current period of treatment.
When she returned, Ms. X asked to be able to look at me during her sessions—to keep me on her radar, she said. On the couch she felt too alone; I seemed cold and distant, and only sporadically could she shake off the belief that these feelings were realistic and immutable. Though I believe they reflected revived memories and affects associated with her mother’s coldness and neglect, recent sessions have clarified that they also warded off any responsible awareness of erotic and aggressive transference.
In our renewed therapy, Ms. X was aware of work still to be done. She conveyed, and/or I was able to hear, that she sensed she needed to revisit our work together to move deeper into an exploration of triangular desires and conflicts. When in a recent session she recounted, as she had so often in years past, her husband’s cruel, insensitive, and potentially damaging behavior with her children, I felt a familiar empathy, a wish to support her efforts to shield her children. But, I realized this time, she had also fought to hold on to them as hers, not his. We were now sitting together facing each other, reading our responses to each other. This new perspective and other changes in both of us, thanks to our past relationship of many years, made me freer to reveal more of my self-reflections to her. So in this hour I reminded her of why she had said she wanted to return, and wondered aloud if by telling me about her husband’s cruelty, she was repeating the way her mother had used her as a child. Her mother had confided to Ms. X, even as a very young girl, her complicated efforts to avoid succumbing angrily to her husband’s perverse, often sadistic sexual demands. Rage, but also excitement, was aroused in both mother and child, I suggested. In a series of interventions I referred to examples of her own initial attraction to several similar tyrants. She thereby identified with her mother, and in this sense held her inside, but she also triumphed over her aging and envious mother. She could now conquer men who also excited her mother. Initially Ms. X would surrender to them, body and mind, but then would feel demeaned and enraged, find them physically repellant, and refuse their sexual advances. Finally, she would feel victorious in reducing them to impotent rage. In past years she had told me several dreams in which her former husbands and boyfriends were undisguisedly castrated. And in one recent dream she excitedly witnesses her father abusing her mother verbally during sexual intercourse.
I believe my patient has been able to take in these interpretations and work with them, and that attending more fully to her Persephonal conflicts is promoting a valuable deepening of our work. In her earlier treatment she had tried to keep me as an asexual nurturing mother, warding off the sexualized seductive mother she had grown up with. At the same time, she made me in fantasy the aroused child witness to the sadomasochistic primal scenes she had experienced. And/or she lived out the position of the child whose neglectful mother regaled her with descriptions of fantastic sexual atrocities committed by men (her father). And/or in her resistance to change, she could keep me indefinitely as a “castrated” man who can never satisfy her, hard as he tries. Does the very fact that she needed to return not drive home my failure as well as hers, while also arousing the hope in both of us that change may now be possible? My patient expresses gratitude that I’m still here with her. It feels sincere. She also expresses a new level of anxiety about the possibility of discovery and change, a possibility that would require her daring to glimpse positive oedipal transference desires that would disrupt her unreliable, unstable bond with her mother.
“I’m frightened here,” she said unexpectedly one day toward the end of a session.
“Why?” I asked.
“Just because you’re a man.” A telling look flashed between us. It was an impressive moment for both of us. Ms. X responded to my different kind of interpretation with new material. It concerned her father’s having opposed cosmetic surgery her mother pushed for when she was eighteen because, he said, she “should wait to learn what her future husband would like.” His reaction enraged her. It was clear to her that both her father and her mother were expressing their own sexual preferences and their erotic involvement with their daughter. There is abundant evidence that her father treated all his daughters as if he were the “Urfather” of a horde of females. She realized that he believed that the man has the right to possess erotically charged parts of her body as his own, that he would regard any future lover of hers as a surrogate for him, forever the first male. As I noted earlier, she in turn found herself bound to seek and find this father again and again, initially to surrender to him, and then vengefully to resist, to entice him but spurn him as an enemy. We had worked on some of this, especially the paralysis of thinking and articulation in speech her stifled rage produced in fierce struggles with her husband and other men. But interpretations about the emergence of stages of this sequence in the transference were accepted only weakly, and without conviction.
Defying her father, the teenage Ms. X had the surgery, in a sense choosing her mother. But the fantasy of temporarily yielding to the sadistic male and then exacting endless revenge was played out in two marriages and, we can infer, in the meaning to her of being operated on, as well as in her persistent inability to experience and communicate an emotional awareness of her erotic transference. This, I felt, had remained tantalizingly out of our reach for many years. She now came back to me, to an “old” object, hoping to become able to create a new object she could welcome into her with more love than hate, more pleasure than fear. The outcome of our renewed work remains to be seen, but there are real indications of progress.
What it Means to Me Now When a Patient Comes Back
Since I have not begun analyses for some time, my practice has inevitably changed. I have loved doing analysis. When a former patient returns after an interval of years, he or she brings something back to me which is no longer available as a core source of meaning and pleasure in my professional life. Our patients often are intelligent, self-aware, interesting people who offer us privileged views of others’ lives. Even though we acknowledge that these pleasures in working together should be, and are “analyzed,” when some patients return to me I experience unmistakable pleasure, which I am sure I convey. It is unclear whether the quality of my greeting and my relatively more relaxed openness as we begin our reengagement helps or hinders our efforts, but it feels right to me. Although my work with returned patients now takes different shapes, it soon builds on, and further develops, earlier work, and quickly confronts earlier resistances anew. The language we have developed together—a form of analytic third—quickly comes back to life. For me today, I feel a kind of rejuvenation in this renewal of our interaction, and clearly this presents countertransference dimensions. My attempts at self-reflection do seem to work, but who can say with certainty how completely, or to what effect?
Sometimes the return of a patient feels to me like the coming back of a son or daughter after a long time away. I am curious to learn what life has brought them, and curious of course to learn if the years of analysis have worked, and how, in influencing the direction and meaning of their lives. Each patient reawakens in us fantasies and memories about emotionally important people in our past lives, our significant lost objects, some of whom have been represented in countertransference relationships. Ghosts of our past may be awakened by the blood of revived countertransferences when patients return, fulfilling in displacement our wished-for hope that in our relationships with them we may lessen some of the impact of our past losses, and recapture time lost as well. The temptation to cling to the renewed contact, to hold fast to returned patients, especially toward the end of our active professional years, can be strong, and may require strong efforts to resist.
I have worked with several former analytic candidates who have terminated training analyses with me or with others, and return as colleagues, or who have left the profession, or, in a few instances, come to me because their former analysts are ill, have retired, or have died. These patients tend to begin with idealizing transferences toward their former analysts, in some instances, I suspect, because idealizations of them and of analysis have been left unresolved under the circumstances of how their earlier treatment ended. Sometimes this lingering idealization will have been insufficiently resolved toward me as well. Soon it becomes evident that they have saved up their aggression, and, for a while, they direct it fiercely toward the former analyst. Or, if they are former patients of mine, they may, in a gesture of appeasement, suggest that I am now a better analyst than I was in the past—more relaxed, open, smarter—and that, like Mark Twain’s parents, I have grown wiser in the years they were away.
They, like everyone I work with, are conscious of my age—as am I. And this shared awareness plays a crucial role in determining how the work proceeds, lending a valedictory quality to our meetings—a recognition of what has been achieved mingled with the poignant immanence of farewell. I sense a special scrutiny as we greet each other. “How are you?” has a weightiness to it.
As I have indicated, a number of patients who have come to me in recent years were in treatment with analysts who became seriously ill and were functionally impaired. Some died. A major reproach these patients have brought in centered around their analyst’s inability to help them speak about their perceived sense of what the analyst was facing, and what it meant and would mean to the treatment and, overwhelmingly, to the relationship itself. They felt prohibited from connecting their sadness, anger, and fear about these realities with the transference awareness they had thus far achieved. They guiltily reproached their analyst for being unable to remain analytically “neutral” in their interest in the face of the coming tragic loss to each of them, to confirm and clarify their observations and reactions when there was evident physical and/or mental deterioration. I realize that these patients had often needed to protect their analyst, to maintain idealizations and collude in denying what was happening at the time. However, they also believed, as do I, that they needed their analyst to break into these denials. And while some therapists and analysts could do this, it was humanly impossible for others to affirm the perception of such cruel realities to their patients.
What such patients have been unable to do in their treatments with past therapists, they needed to use me to do. My current patients therefore need my reassurance that they are permitted to criticize, to derogate, to label me diminished, to test my memory, to assess my errors, to feel sad, to begin to grieve in my presence. They need to be helped to believe I can take it. They need to find in me someone who can enable them to continue the aborted work of mourning for their “lost” analyst, including me when I was younger, and through this process, also to mourn for other, long-ago losses of their own, including the people who had been crucial in the origins of their difficulties creating stable, growth-promoting internal objects and self-representations. How well I can do this, and especially how well I’ll be able to do this in the future, I can’t be sure. I think no analyst can be.
I do think it is incumbent on me to let returning patients know at the outset that what I can offer will be therapy rather than analysis. We both know that this period of our work will likely be time-limited, and that it probably will be our last encounter: that this time when we separate, it may well be permanent. I have indicated that in a number of instances patients who return have failed to maintain neutralized, stable internalizations, and come back with powerful feelings of incompleteness of the self, emptiness, separation anxiety, and intense longing for a palpable renewal of our relationship. I believe these returning patients can be helped only by someone who does not hide from the reality that some of his capacities will inevitably diminish in time. Future endings may be dictated by natural forces beyond my control. Simultaneously, people of my generation must live with our own multiplying losses of beloved contemporaries, inevitable at my stage of life. It seems to be only human to want to cling to our valued present objects under these universal circumstances. Yet it is our task, and I would say our form of love, to try to enable our patients to exist and thrive as Other, and eventually without us. With all patients, but especially those who return because they could not endure separation from us without severe pain and decompensation, it is vital that we are able to let them go.
Facing Each Other Means Facing Reality
Perhaps for some of our patients, unresolved conflictual transference fantasies, powerfully imbued with erotic and aggressive drives, become more intense and feel more real in the absence of actual contact, rather than being held internally as memories and fantasies whose affective charge fades in the noisy traffic of ongoing life and its changes. But the need to see us, to experience us in person, becomes urgent, both in those for whom our internal representation threatens to become attenuated or lost, and in those in whom it becomes dangerously reinstinctualized. All these patients seem to find that our sitting up and facing each other has been important and helpful.
A number of returning patients have stressed the importance of my visible presence in our sessions. Distinguishing between my actual appearance and their internal image of me becomes sharper and more convincingly real. Some vividness of transference fantasy may be sacrificed; but this loss is countered by greater and stronger apprehension of denied aspects of reality. I have realized that making my responses relatively transparent—conveyed visually but also by tone of voice, occasional humor, an escaped tear—seems to help move a process forward. I think it aids the “taking in” (introjection) that is so necessary to these patients. For Ms. X it has diminished her feeling of inner loneliness, which can give way to persecutory fantasies or an expectation of total abandonment. Seeing me as a reactive, emotionally open person allows her to be less self-conscious, less focused on being looked at. Our gazes back and forth diminish her need to conceal herself; we seem to be able to be more alone while being together.
Sitting together also lets returning patients, immersed in the pain and frustration of thwarted, blocked mourning for past and impending losses, find access to this necessary, ultimately liberating process. I believe the process of mourning a lost object requires a sense of connection with living, present, interactive others. In some of my patients, tears long held back begin to flow when a true connection is made with a responsive other. Societies and religions “know” that those who mourn need to share their experiences and memories with one another. Eating together, a genetic forerunner of internalization, or its opposite, shared fasting, is a common ritualistic restorative experience for mourners in many religions and societies. In fact, many grief-stricken but solitary patients have said they could not weep when alone. One patient who returned after a few years felt “forbidden” to speak of or show her grief about the death of a family member years ago. As if her memory swept past the intervening years to the present clinical moment, she said, using the present tense, “My tears feel strangled in my throat.” She has also said this: “I couldn’t end my analysis without looking at your face, and you, mine.” What she needed to see was that my face, unlike her mother’s, was not blank, unrelated, excited, rageful. Taking me in with her eyes, she could anticipate being able to find release in the sleep that often eluded her.
I think of two other patients who returned when their first child left home for college. The child’s efforts to detach from them felt hurtful and cruel, evoking depressive affects, anger, disturbing shifts in intrafamilial dynamics, and a painful new focus on the transience of their lives. Characteristically, these patients had quite disturbed mothers, sometimes vacant, depressed, and narcissistic, who related to and clung to their children only as parts of themselves, and emotionally absent fathers whose unavailability, as in the case of Ms. X, was shattered by recurrent episodes of rage and sexual seductiveness to the point of abuse. Almost always these patients felt deprived of the experience of childhood; their caretakers could not appreciate and love what was childlike about them. In a way, these patients mourned the childhood they had missed, like Masha in Chekhov’s The Seagull, whose father refused to recognize her as his child, who always wore black because, she said repeatedly, she was in mourning for her life.
These patients’ wishes to move away from primary objects were powerfully conflictual and engendered guilt and even fears that these objects might actually die, or that they themselves, lacking the structured internal representation of a stable “good, loving” parental object, would succumb helplessly to the power of a malignant parent’s curse. The efforts of a number of these patients as children to move from self-object merger to object-relatedness were met in varying degree with parental rages, threats of suicide, terrifying warnings about a dangerous world outside the parental “womb,” agitated depressions, or seductions meant to create unbreakable bonds. Ms. X clung immobilized, close to her alternately hysterical, self-dramatizing, and depressed mother. She didn’t talk until age two, and didn’t walk until almost three, and at these ages she would sit on a blanket next to her mother when they were away from home together visiting friends and relatives—silent, motionless, undemanding for hours. Other patients worked tirelessly to achieve an often unstable self-image of autonomy, or attempted to create acceptable selves by dedicated efforts to reinvent themselves in order to prove their unrelatedness to their parents. Some of these children insinuated themselves into families away from home, and lived out wishful dreams of being “adopted” by idealized parents who replaced their own, fulfilling family romance fantasies. But the need to seek nurturing substitutes for primary objects, manifest in the need to return to treatment, never left them.
When these patients return, just seeing me, my familiar bodily stance, the sameness of my office, my fifties furniture and old pictures was immediately reassuring to them. These cases include some current patients, so I cannot say that the next terminations will be more complete—that they will persist as internal processes and not just conscious passive acceptance of necessity. But I have the hope that our leaving each other this time after facing each other for a year or more will mark the mutually agreed upon, understood, chosen acceptance of present-day realities rather than the unmastered repetition of forced renunciations linked to the traumatic past.
Conclusion
I have received letters from former patients who, in contrast to those I have discussed, have not returned, in whom the internal representation of the analytic relationship has held and in whom, therefore, self-analytic efforts work effectively. These letters have pointed to the continuation of the process. One moving letter said, “I can add that the old saw about the treatment continuing after doctor and patient have stopped seeing each other is unquestionably true. The ‘process’ remains part of me and in that sense you are still here, for which I’m repeatedly grateful.”
We hope that we and our patients can achieve the recognition that analytic processes do have an interminable vitality. Freud knew that every significant object relationship leaves a permanent imprint. Loewald deepened our appreciation of the creative potential inherent in internalization of the analytic relationship. However, in some, as time and life go by, such internalization loses its power to stabilize the person. This regression is more severe in those more undone by the stresses of loss. I have focused here on those with the kind of early relationships and constitutional vulnerability of someone like Ms. X, in whom the capacity to mourn is limited and grief threatens to be overrun by empty depression. Those whose constitutional tendency in the face of losses is to withdraw from human contact rather than reach out suffer longer.
However, the number and variety of patients who return give testimony to the idea that termination, like mourning, is never completely over. Transference is not dissolved. The patient-analyst relationship, once established, encompasses both relative autonomy and a nagging need for what, somewhat euphemistically, has been called “refueling” or a “tune-up.” While most do not choose to act on these needs, all patients who have lived through profound analyses and genuine termination processes with us retain a wish—a belief? a hope?—that we are alive in the world and remember them; that we are potentially available, not having been destroyed by their anger, disappointments, and grievances, or by what some of them regard as their subsequent infidelities to us with other therapists. While many, including analysts, “check in” or return for more, for everyone the needs I have written about here are laws of existence that apply qualitatively to high-functioning patients, as well as to more troubled ones like Ms. X. They in fact apply to us all.