The Delicate Balancing Act of Once-a-Week Treatment
The patient strides into my office, intense, determined. He’s speaking before either of us has had a chance to sit.
P. It’s been a bad week. Saturday night was terrible. I woke up with one of those death dreams. I haven’t had one for awhile. I had to wake Danielle [his wife] up. I asked her if God loved me. I couldn’t believe it when I heard that coming out of my mouth. It took me hours to get back to sleep. And then I couldn’t shake it. Not until I went mountain biking with my friend on Sunday -really driving myself- could I shake the feeling. It was a bad week. I’m burning the candle at both ends. I’d been doing fine juggling the new business and Danielle’s pregnancy, but going back to do some work for my old company has been too much. It’s tearing at my guts. And I’m trying to get it done as quickly as I possibly can, so I’m going all over the state just trying to get it done. And then Danielle is calling me and asking me when I’m going to be home and I’m trying to tell her that of course I’d rather be home with her, but I just need to get this done.
T. Do you remember the dream?
P. Oh yes. There were two dreams actually, although they’re not connected. In the first dream there’s a woman who’s cut off from under her breast on and she’s like walking around on her arms. She’s naked. And there are all these people in the room and everyone is ignoring her. I keep looking at her and not looking at her. I feel like I should help her, that I should do something. But there are all these other people trying to get my attention. I don’t do anything. I don’t know what I should do. Then the second dream I’m driving very fast in a sports car. It’s not my car. I’ve borrowed it. It’s a winding road. Suddenly there’s water on both sides and I’m still going very fast and then the car is turning over and I wake up just as I’m about to go in the water. I was a wreck when I woke up. I had to wake Danielle. I felt bad about that since she’s not sleeping all that well these days. I can’t believe I asked if God loved me.
The patient, whom I will call Bill, is a 35 year old computer consultant who had been in once-a-week, face-to-face psychoanalytic psychotherapy with me for a little over a year at the time of the session. He is the oldest of three children and the only boy. His mother and sisters are severe borderlines who are variously self-destructive. Bill is closest to his relatively stable father, although he was intensely disappointed when his father lost his business and disrupted the family’s standard of living. Success and achievement are extremely important to Bill. He has done well in establishing himself in his career and now has a lucrative, independent business. He has been happily married for 10 years. His wife, a professional woman, is expecting their first child who they know will be a girl.
The patient came into therapy after spending time with his family of origin and feeling “tied in a knot.” He felt powerless in the presence of his family’s “craziness” and also expressed concern about passing the “craziness” onto any children he and his wife would have. Bill also told me about having what he called “death dreams” in which he would know that he was going to die, be totally terrified, and try, in the last seconds remaining to him, to think about what his life had meant and to grab hold of the people who had been important to him. He did not like the idea of coming for therapy, considering it a weakness that he could not solve his own problems.
My initial impression of Bill was of a bright, driven man who, because he could not tolerate feelings of powerlessness, relied on fantasies of omnipotence and control which then proved extremely burdensome to him. He strove for perfection, convinced that if only he did everything right, he could make things turn out as he wished. When confronted with the human limitations of his power, he would drive himself all the more, determined that he could right the ills of his world if only he tried a little harder. His own feelings of neediness and dependency were denied, kept at bay, to surface only in his dreams and in an overwhelming depression he felt when someone he loved disappointed him.
Bill would only agree to come for once-a-week treatment, although I encouraged greater frequency. He said that he did not feel he had the time or the need to come more often.
The Session Continues
When I asked Bill what came to mind about the dreams, he spoke again about Danielle wanting him to be at home and his continually telling her that he was doing the best that he could. I told him I thought the woman in the dream represented Danielle and that he felt angry with her for pestering him and then guilty about both his anger and his inability to help her. He felt so guilty that he drove himself to the point of killing himself and then wanted to know if God loved him. These interpretations rang true for Bill. He described feeling that the woman was “like a little dog pawing at me, a dog that I’d pat on the head but then want to go away.” He called the woman a “gimp,” and then felt even more guilty. I said that perhaps the woman in the dream symbolized not only Danielle, but his mother and sisters as well; women who bothered him but who he could not help. Again, Bill responded positively, commenting on how nothing he did helped the women in his family of origin. I asked if I was another of the damaged women, but he vehemently denied that I was.
Bill went on to talk about how Danielle did not always appear damaged to him, but that her pregnancy had made her seem fragile and unavailable. This led me to ask both about Bill’s anger with Danielle for being pregnant and about his jealousy of the baby. He said that he hated admitting to feelings of jealousy because, unlike anger, jealousy and envy felt like “female emotions” which were “weak.” I questioned if the woman in the dream might also be the feminine part of himself, the part for which he felt contempt; and if he had to go from the damaged female part of himself to the borrowed male part that drove fast and hard. Bill did not respond to this interpretation, but returned instead to his greater comfort with anger. I reminded him that although he was more comfortable with anger, it also made him feel guilty and frightened of his destructive powers. I asked whether he might want to damage the baby and make it go away. Bill emphatically denied this possibility, even when I referred it back to a possible childhood wish to do away with his sisters. Bill became very distressed, insisting that he felt incredibly protective of his unborn child, even to the point of not wanting to have sex with Danielle for fear of harming the baby. He felt the baby was a tremendous burden for his wife and said both that he wished he could take the burden from her and that he had told her this was the last child. I asked if he was envious of his wife’s ability to have a child and although he agreed, he seemed so shell-shocked at this point that I was no longer sure if he was clear about what he was agreeing to. As he left he said, “This is so much stuff! I’m wiped out.”
The patient is right, “This is so much stuff!” As an analyst, I am thrilled to have all this material, material that perhaps speaks to the deepening of the treatment and to my continuing hope that the patient will agree to come more frequently. The patient, however, is understandably overwhelmed. I have offered one interpretation after another, allowing for some free association from the patient, but not a great deal. These interpretations and the ensuing dialog have covered issues of guilt, anger, punishment, reparation, jealousy, envy, masculinity-femininity, and murderous destructiveness. No wonder the patient is “wiped out.” How is it that I have thrown so much material at this patient?
It is possible to begin answering this question in terms of the patient’s dynamics, projective identification, and the transference/countertransference paradigm. I am, in fact, responding to Bill as he typically responds to himself- pushing, prodding, allowing himself little time for thoughtful reflection or peaceful relaxation. From a very young age Bill felt that he could rely only on himself. His mother felt, at best, “incompetent” and, at worst, “evil.” In response to the lack of good-enough mothering, Bill became super-independent, determined not to need anything from anyone, and to prove his capabilities to himself and the world. And, on the surface, Bill did achieve his aims. Unfortunately, the scared, needy little boy underneath has been ignored and squelched in the process. He has no time for his “weakness” and is contemptuous of the part of himself that craves love and caretaking.
It is easy for me to understand how this patient’s dynamics became interwoven with my own and led to an enactment of the pressure to succeed. Although for different reasons, the patient and I both felt the pressure to be smart and accomplished, regardless of the cost. In Bill’s session, my “smartness” was demonstrated by the depth and quantity of my interpretations; the patient’s was demonstrated by his capacity to hear, understand, and respond to the onslaught of these interpretations. We were both driven. Although overwhelming, this was also a place that felt very comfortable to Bill; it was a world he knew and could easily negotiate. This, then, was the transference/countertransference enactment. We were keeping the therapy in a familiar and, therefore, safe place where Bill would not have to experience me as a new object or himself as a new self. Although I do believe this enactment took place because of the confluence of the dynamics between patient and therapist, I also think that this is only a piece of the puzzle and that for the other pieces we need to look at the delicate balancing act of once-a-week treatment.
Oremland(1991) excludes once-a-week treatment from the realm of psychoanalytic psychotherapy, maintaining that such treatment is only “a weekly request to bear witness to, or to correct, the events” in the patient’s life. This was not, however, the difficulty in Bill’s treatment. Bill did not only present the week’s events and I did not merely provide suggestion and guidance. Quite the contrary. We focused on his conflicts and looked to his past to provide understanding of his difficulties in the present. But I was far too eager, in too much of a hurry. I over-interpreted, throwing everything available from my psychoanalytic arsenal, without regard to what this bombardment might mean for Bill’s psyche. What was missing in this once-a-week treatment was not my ability to interpret or analyze, but rather my capacity to be sufficiently supportive; to fully listen to and hear the patient’s expressed and unexpressed anxieties; to be patient so that he could find his own voice and come to his own insights. What was lacking in this treatment was not the rigors of psychoanalytic technique, but rather the supportive features inherent in all good-enough psychoanalytic processes. And these supportive features need to be understood not in terms of advice, suggestion, and practical help, but rather as the holding environment elucidated by Winnicott (1963) in which the therapist provides a sense of safety and protection and conveys his or her understanding of the patient’s deepest anxieties. In the rush of this once-a-week treatment, I had forgotten the value of this feeling of being “held.”
In psychoanalysis time can feel almost infinite. There is no rush. What is not examined today, can be dealt with tomorrow. A dream not fully explored can be continued tomorrow or will appear in different form some time in the future. Referring to psychoanalysis, Schlesinger (in Wallerstein, 1995) wrote, “Where else does one have the opportunity – day after day, and for as many years as both parties deem it worthwhile – to unburden oneself to another human being devoted totally, during that time together, to listening, understanding, and conveying that understanding without moral judgment, bias, or ulterior motive.”
Such luxury is not possible in once-a-week treatment. Time is ever-present, short, always running out. So much happens to the patient in the week that intervenes between sessions. Getting back to where one left off is often difficult if not impossible. The patient’s emotional state may shift radically from one week to another and may well have more to do with experiences occurring outside the therapeutic setting than feelings generated from within the sessions. These issues place an urgency on the process of once-a-week treatment that is not present is psychoanalysis or even more frequent psychoanalytic psychotherapy and can, all too easily, result in excessive and premature interpretations. Because of the time limitation, once-a-week treatment is inherently the least supportive treatment and is therefore the treatment where it is most crucial for the analyst to remain cognizant of the patient’s need to feel safe and protected. A longitudinal outcome study in Sweden found that supportive elements such as kindness, warmth, and openness were imperative for effective psychoanalytic psychotherapy, but not crucial for effective psychoanalysis (Sandell, et. al., 2000). Thus, the major pitfall in once-a-week treatment is not that it is inherently unanalytic, but rather that it can too easily become insufficiently supportive.
This is not meant to imply a strict dichotomy between interpretation and support, for an interpretation that conveys to the patient that he is understood is one of the most supportive aspects of the psychoanalytic process. We have all had the experience of having a patient relax into an interpretation or burst into tears in appreciation of finally feeling understood. In addition, in once-a-week treatment there is not the time to allow for the full development of the psychoanalytic process; to allow for a free flow of associations, a therapeutic regression, and a transference neurosis. As such it is necessary for the therapist to take a more active stance. As described by Weinshel (in Wallerstein, 1995), “In psychotherapy there is likely to be more activity on the part of the therapist, with less neutrality and systematic exploration of transference and resistance with the therapist taking the lead and using more suggestion to focus on topics. In psychotherapy there tends to be less exploration before interpretation, more focus on dream content than associations and resistances and, as a result, more construction rather than reconstruction via transference understanding.”
Any good-enough psychoanalytic process must always involve both interpretation and support. In once-a-week treatment this necessitates a delicate balancing act, one that involves moving between support to interpretation and back again. The therapist must not get so caught up in the feeling of urgency that the necessary supportive aspects of the psychoanalytic process are forgotten. Interpretations must be offered as hypotheses that open up new pathways of the patient’s thinking, not as weapons with which to bludgeon the patient. Bombarding a patient with “brilliant” interpretations is not psychoanalytic; it is simply not good treatment. My treatment of Bill illustrates the danger of over-interpreting to the point of overwhelming the patient and thereby joining forces with his negative, punitive, critical self.
On the other hand, the time constraint of once-a-week treatment also means that the therapist cannot allow the patient to meander totally on his own without interpretations that guide the flow of the treatment. Such lack of focus could feel equally unsupportive to a patient who would be left swimming alone in uncharted waters. In other words, in once-a-week treatment, the analyst must be a skillful high-wire artist, ever-watchful of the timing and carefully balancing between interpretation and support.
Bill’s Treatment: The Conclusion
For the next three sessions, Bill reported that he was not doing well. He felt both driven and alone. He felt that he carried the burden of the world on his shoulders and that there was no one who could help him. He told me that he had beaten up the voice in his head that said he was lovable even if he did not do anything. He denied feeling that I was the voice he had beaten up. He did, however, acknowledge that he had lost all positive voices in his head, including me. By relentlessly bombarding Bill with a multitude of “deep” interpretations, I had joined with the part of him that demanded accomplishment and perfection. I had ceased being the good object and, as a result, he felt all alone. This, in turn, led to his feeling worthless and unlovable unless he could prove himself by jumping through yet another hoop. My attempt to focus Bill on his feelings of anger or disappointment in me led only to denial. My attempt to return to his experience of the session in which we explored the dreams, met with only slightly greater success, since the passage of time made it more and more difficult for him to recapture those feelings.
Bill canceled his next session and then, the following session, came in completely elated. His wife had given birth, everything went “super,” Danielle was amazingly strong during the entire process, the baby was healthy and a delight, and he was going to terminate therapy today. I was stunned and felt immediately guilt-ridden. Bill recognized that he was on a “high” because of the birth, but felt that he had accomplished his goals and was ready to end. I made an instantaneous decision not to pressure Bill to change his mind, perhaps because I felt guilty about the pressure I had already put on him. He did consent to come for two more sessions to say good-bye. In those final sessions, Bill expressed a great deal of gratitude towards me. He said that he felt sad about leaving, but also excited, like he was graduating. He could find nothing negative to say about me or the treatment. I felt the termination was very premature and continued to feel guilty about my part in precipitating it. I still did not encourage him to change his mind, but did make it clear that he could return at any time.
Several months after Bill’s termination, while working on this paper, another thought occurred to me as to why Bill may have ended so abruptly. When Bill began treatment he explicitly stated that he did not want what was “crazy” in himself or his family to damage any future children he and his wife would have. I now realized that Bill may have meant this quite literally. Bill was very concerned about his own destructive powers. Much of his life was geared to atoning for his presumed evilness which he feared could destroy his wife and/or child. But they had survived. Danielle had given birth and both she and the baby were thriving. He had indeed accomplished his goal. He had hurt no one. Free from that tremendous fear and guilt he may no longer have felt the need for treatment.
Of course there is no way of knowing definitively how my intemperate interpretations did or did not contribute to the premature termination. I do know that the interpretations were overwhelming to the patient and did not conform to the supportive holding necessary in any good-enough psychoanalytic process. I also think that during the year of treatment, I failed to help the patient appreciate how therapy could have contributed to his sense of comfort and support, of feeling less alone and less burdened. If I had been less interpretive and more supportive, he might have come to appreciate the holding nature of the treatment and perhaps been less afraid of increasing the frequency of his sessions. My hope, of course, is that Bill will return so that I can do it over and do it better, my own kind of atoning. But if he does not return, perhaps I should take comfort in that fact alone and realize that even this flawed, once-a-week treatment was good-enough to bring Bill sufficient peace and freedom from his internal demons.
Oremland, J.D. (1991) Interpretation and Interaction: Psychoanalysis or Psychotherapy? Hillsdale, N.J.: Analytic Press.
Sandell, R., Blomberg,)., Lazar, A., Carlsson,)., Broberg,). and Schubert,). (2000) Varieties of long-term outcome among patients in psychoanalysis and long-term psychotherapy: A review of findings in the Stockholm outcome of psychoanalysis and psychotherapy project (STOPPP). International journal of Psychoanalysis, 81:921-942.
Wallerstein, R.S. (1995) The Talking Cures: The Psychoanalyses and the Psychotherapies. New Haven, CT: Yale University Press.
Winnicott, D. (1963) Psychiatric disorder in terms of infantile maturational processes. In: The Maturational Processes and the Facilitating Environment. New York: International Universities Press, 1965, 230-241.