Good Goodbyes: Knowing How to End in Psychotherapy and Psychoanalysis (Book Review)

Author:  Novick, Jack and Kerry Kelly Novick
Publisher: Jason Aronson
Reviewed By: Fonya Lord Helm, PhD, ABPP, Vol. 26 (3), pp. 63-65

Jack and Kerry Kelly Novick have written a very interesting book that grapples with the difficult issue of termination. They state that termination has been called the “Achilles heel” of psychoanalysis and psychotherapy, because the kind of ending that is required is unprecedented and in everyday life, good relationships continue, and only death, hostility or disappointment causes such relationships to end (Bergmann, 1997).

The Novicks propose a new model of termination, based on their evolving ideas about the development of two systems of self-regulation (p. 6). Their “two-system model” of development describes two possible ways of responding to feelings of helplessness. In this model, one system of self-regulation is attuned to inner and outer reality, has access to the full range of feelings, and is characterized by competence, love, and creativity. They call it the “open system.” The other, which they call the “closed system,” avoids reality and is characterized by sadomasochism, omnipotence, and stasis. The sadomasochistic omnipotent system is closed, repetitive, and increasingly resistant to change. In a distorted personality development it can become a structure regulating feelings of control, safety, excitement, enjoyment, power, and self-esteem” (p. 7). They state that the open-system is an “effort to transform the self, in contrast to the closed-system aim to control, force, and change others” (p. 8). They propose to “recast the overarching goal of treatment as restoration of the capacity to choose between open and closed systems of functioning and self-regulation” (p. 8).

While the Novicks emphasize the idea of conscious “choice” between the open and closed systems, they also emphasize the importance of the relationship and how it helps a person learn more about how to relate with love, creativity, and competence. They conceptualize “each treatment [as] a unique relationship between two individuals, which takes place at a particular cultural, social, and historical time” (p. 6).

The sadomasochistic need to control others will become less salient, as the result of therapeutic work, including the internalization of the new object relationship. In my experience, how sexualized the need for control becomes varies greatly, depending on the history of the person. The use of the term “sadomasochism” is lively and dramatic, but has a disadvantage in that it covers so many aspects of functioning that it blurs the distinction between the real sadist or masochist and the more ordinary person who becomes controlling when anxious and hopes to change the people he or she loves in order to make them fit an old and familiar template. Another disadvantage of the concept of sadomasochism is that it sounds pejorative and therefore may encourage a negative mindset for the analyst or therapist, since the patient now is thought of as a person who needs to “choose” to avoid many aspects of his or her functioning. Toward the end of the book, however, they state, “a belief is never mourned or gone but set aside. The omnipotent belief remains a potential response, but therapeutic work has helped the patient find competent alternatives and so transform a pathological belief into a wish or fantasy, a delusion into an illusion” (p. 117).

The firmness of their over-arching view of the patient as needing to “give up” a closed sadomasochistic system and “choose” an open system, however, contrasts with their flexibility in the clinical work. Their reports of their work in the book are very sensitive and provide evidence that these analysts are thoughtful, patient and are getting good results. For example, in working with a patient who had great difficulty associating to her dreams and was extremely concerned about being humiliated, the analyst found a way to spend time discussing the patient’s writing and her creativity. During the treatment, the patient had begun to take writing classes and write short stories. Together they explored the inner life of the patient’s characters. A year went by, some stories were published:

Despite moments of doubt, I generally trusted a feeling of momentum generated by the joint attention made possible by the focus on fictional characters. We were working together, even if the focus was not always obviously on Mrs. T. Through the lens of transference, I understood Mrs. T’s use of stories as a hostile defensive resistance to experiencing her positive feelings directly. It was also clear, however, that Mrs. T turned any attempt to take that up into a sadomasochistic control battle. I understood that direct comment on Mrs. T’s closed system only made her more embattled, putting us both in a situation where Mrs. T would undercut herself for the sake of defeating the therapist. (p. 37-38)

Many analysts and therapists would not conceptualize Mrs. T’s use of her stories as a “hostile defensive resistance,” but instead would conceptualize her use of the stories as an attempt to regulate her anxiety and stabilize her sense of self.

The analyst continues to describe her clinical choice of interventions.

I made a technical choice not to interpret the closed-system functioning but to support open-system elements. With space to work together on understanding the stories, Mrs. T discovered a potential source of self-esteem in feelings of competence and efficacy from the work, rather than from controlling me. She began to track patterns of fluent thinking, constrictions, and fuzziness, which were noted, then altered and mastered. (p. 38)

This technical choice of focusing on the patient’s creativity and her self-states worked well, although the analyst did not use self psychological concepts in thinking about the patient. The analyst was thinking more in terms of allowing work on conflicts in the displacement, as in the kind of play allowed in child psychotherapy. The analyst began to feel that the work was back on track and soon the patient had her first dream in a year, and related the dream to her appreciation of her analyst’s patience in listening to her “practice” by talking about her stories of fictional characters, saying that she was now ready to tell her own story about herself.

This book is full of many practical and useful ideas, and one of them is the different stages of treatment. These stages are evaluation, beginning, middle, pre-termination, termination, and post-termination phases (p. 13). The Novicks emphasize that the idea of separation and loss, and the need for a good ending, needs to be addressed from the beginning.

I found their conceptualization of the pre-termination stage to be especially useful, as I read the book and thought about my own clinical experiences. I have found that people can take several years in the pre-termination stage working through the discoveries made in the middle stage and, by this time, the patient and I have developed a shared language. We know each other and can predict how we will be in the relationship. The Novicks conceptualize the pre-termination stage as the time when patients begin to think seriously about the end of the treatment and spend time analyzing their contradictory wishes both to be autonomous and to stay with their analyst forever. When that work is done, both patient and analyst feel comfortable setting an ending date.

The Novicks are very aware that the middle phase can be a destabilizing time. Because they do so much child and adolescent work, they are faced with the problem of unilateral terminations much more often than those who work with adults. They have made a good contribution in their idea of turning the patient’s attempt to terminate unilaterally into a pause or interruption, thus giving the patient the sense that the analyst want to keep a connection. In my experience, agreeing to a termination is always a rejection, and needs to be discussed as such with the patient in the termination phase, but patients who want to end unilaterally are already destabilized too much and are often unable to grasp that idea consciously. Unconsciously, though, they may understand the rejection very well, and so the idea of the interruption helps them know that they are invited back and that the analyst will be glad to see them. They also have made an important observation that a unilateral termination often reflects the adolescent style of leaving home (p. 18). Their recommendation of asking about these patterns early on in the evaluation stage is a very good one.

Another time they use the idea of a pause or interruption comes during the pre-termination when the patient and analyst cannot agree that the time for a termination date is at hand.

The patient may feel the analyst is holding him back, with or without cause; the therapist may feel the patient is blind to continuing problems or to the opportunities intrinsic to a planned mutually agreed termination. We acknowledge the patient’s wish or need to try things out on his own and appreciate the possibilities for consolidation that may offer. We use whatever time the patient will allow to generate together some criteria for self-assessment that the patient may use in deciding when to contact us (p. 92).

The Novicks also indicate to the patient that they welcome updates.

Another advantage of a pre-termination phase is the opportunity to discuss many different ways of terminating. The Novicks want the patient to express his feelings about the kind of termination that will be right for him, and they emphasize Craige’s research showing that “formulaic endings may be destructive and cancel out some of the gains of treatment” (p. 95).

The Novicks define termination as the period between picking the date and the actual ending (p. 97). They allow the patient to take the lead in setting the date, considering it part of the autonomous functioning that the patient has gained. They note that there is a wider range of approaches in the termination stage than in any other stages of treatment. One reason for this situation is that the termination is also very stressful for the therapist or analyst, and the pressure of sustaining the loss of the patient can lead to uncharacteristic behavior. They suggest that analysts monitor their feelings especially carefully during this time (p. 105). Therapists are not neutral about termination, and the older ideas about being well-analyzed and thus immune to feelings of sadness and loss have turned out to be untrue (p. 118).

Jack and Kerry Kelly Novick make a point of emphasizing the importance of pleasure as a motivator, because it has beneficial physiological effects and is “essential to counter the addictive power of sadomasochism. The genuine power of closed system gratifications—the addictive, sometimes ecstatic rush—has to be acknowledged by patient and therapist, along with the recognition that dependable, reality-based pleasures will never produce the same result” (p. 108). It seems to me, however, that this assessment is too gloomy overall. Those people whose need for control has been sexualized to an extreme degree will struggle with the addiction, but for many people, omnipotent and grandiose ideas of power can be sublimated in creative work and at the same time provide a lot of excitement and motivation. For many people, relationships with others offer opportunities for transformation of selfish desires into playful and loving ways of relating that include sensitivity to the other person’s needs. Sadomasochism is an early form of love developmentally and aspects of it can be transformed while keeping a connection with the excitement and involvement.

I highly recommend this book to both beginning and advanced therapists and analysts. It will give them many ideas about many different ways to think about termination.

References

Bergmann, MS (1997). The Achilles heel of psychoanalytic technique. Psychoanalytic Psychology, 14:163-174.
Craige, H. (2002). Mourning analysis: The termination phase. Journal of the American Psychoanalytic Association, 50: 507-550.

Reviewer Note

Fonya Lord Helm, PhD, ABPP

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