Endings and Beginnings: On Terminating Psychotherapy and Psychoanalysis (Book Review)
Author: Schlesinger, Herbert
Publisher: The Analytic Press
Reviewed By: Edwin Fancher, MA, Vol. XXVI, 4 (Fall 2006), pp. 45-46
In his 2003 textbook, The Texture of Treatment: On the Matter of Psychoanalytic Technique (see my review in Psychologist-Psychoanalyst, Spring 2004) Schlesinger omits the requisite chapter on termination, but mentioned that he was planning another book specifically about termination. This book is the promised continuation of his earlier work and provides not a chapter, but eleven chapters on various endings and terminations of treatment and how they evolve from beginning phases of diagnosis and therapy. Although it is based on the theoretical foundations explicated in the 2003 book, this new book stands on its own.
Schlesinger brings 50 years of experience as a practitioner, teacher, supervisor, and author to this task. He is interested in the clinical theory of both psychodynamic psychotherapy and psychoanalysis, and he is able to switch back and forth effortlessly between the technical problems of beginning and ending in each of these two modalities of treatment.
Schlesinger recognizes that there are many kinds of endings in psychotherapy, but is eager to distinguish “ending” from “termination” in treatment: “By reserving ‘termination’ to refer to the unique aspect of a beneficial ending of a psychoanalytic treatment, whether psychoanalysis or psychotherapy, we can focus on the special concern of analysts, that when a patient leaves treatment, he should own the achievements he has made and take them with him” (p. 3). Thus, termination is defined as a phase of planned, mutual working through of a phase of separation between the therapist and the patient, which may be the end of a long therapy or analysis, or may even be recognized in particular phases in a long treatment.
His treatment model is an ego psychology one with emphasis on the ego autonomy of each patient. He regards treatment as: “. . . an instrumental relationship that each party enters to accomplish a purpose external to the relationship. When that purpose has been accomplished, or it becomes clear to one or the other that it is not likely to be accomplished, we expect them to end their meetings” (p. 4).
He is harsh on the common practice of mental health clinics exploiting patients in the service of providing clinical experience to students. He accuses them of not training therapists in techniques of terminating treatment, and of holding on to patients without any consideration for whether or not they have received the help they came into treatment for:
“[The] therapist should neither want to hold on to the patient nor hope to extend the treatment by preventing the patient from dropping out. Rather the therapist ought to provide an opportunity for the patient to test out (that is, discuss) the alternatives he faces and to choose whether it would be useful and safe for him to stay on or whether it would be in his best interest to leave” (p. 33).
He is particularly critical of clinics that assign interns to see patients for training purposes for a limited number of months before being reassigned to new interns, without planning for at least a mini-termination phase so as to reduce the trauma of loss with each change of therapist.
Schlesinger insists that consideration of ending should be in the mind of the clinician at the beginning of every treatment. Concern about how the treatment will end or be terminated should be included in the initial interview and should continue to be considered in each phase of treatment. Some patients may arrive having analyzed their own problems fairly successfully, and only want a professional’s validation, in which case therapy might even be conducted in only one session. Other patients arrive with deep-seated neurotic character problems that will likely yield only to full-scale psychoanalysis over an extended period of time. Every patient comes to the initial interview having failed in a self analysis, an impasse in resolving his inner conflicts by himself, which has probably led to a mess in his life for which he requires help. Both psychotherapy and psychoanalysis involve a series of phases where the patient tackles one conflictual problem at a time, with a beginning and a termination in each phase of the work. Normal working through is regarded as a series of mini-endings where a particular problem may have been resolved and the patient pauses to get his bearing before plunging into the next frightening issue.
Schlesinger is committed to establishing treatment goals and evaluating progress toward them as therapy progresses. He is particularly concerned with the effectiveness of psychotherapy. If the therapist “would like to keep psychotherapy efficient by assuring that it takes no longer than it has to, he will have to know when the patient has accomplished enough so that he can get along without treatment” (p. 41). Psychotherapy is seen as a series of working through of specific tasks, each of which has a beginning and an ending. The completion of each task is signaled by markers that the therapist must be sensitive to before proceeding to the tasks of the next phase.
In the chapter “Beginning from the Vantage Point of Ending,” he outlines the values of starting each evaluation interview as if it is the initial phase of treatment, with the eventual ending in mind. He gives excellent advice for both beginning and seasoned therapists on conducting the initial evaluation, and provides vignettes on eight patients, illustrating different clinical problems in the evaluation phase of each. In the following chapter, Schlesinger returns to these eight cases to show how each ended or terminated his psychotherapy or psychoanalysis and how it was consistent with diagnostic markers present in the initial phase. He also demonstrates the important and subtle theoretical and clinical differences between ending psychotherapy and terminating psychoanalysis.
In his chapter on vulnerable patients, the diagnostic challenges of the so-called borderline patients are discussed. He distinguishes between those patients who can profit from treatment and end or terminate psychotherapy from those patients who may require long-term supportive therapy and medication for life. Again, he illustrates his theoretical points with several extensive cases.
One of Schlesinger’s most provocative chapters is “Impasse or Stalemate: the Problems of Ending and Terminating.” He regards the impasse as “an unsettled disagreement or argument between therapist and patient” (p. 152). The problem then, is to determine what this argument is about, why it emerged at this moment in therapy, and how to resolve it or end it. The impasse involves not only the negative stance of the patient, but almost always the therapist’s collaboration. It is important to distinguish stagnant impasses based on rigid transference-countertransference fixations from the appearance of an impasse reflecting a phase in the treatment following a productive achievement, which is like getting a “second wind” before tackling the next therapeutic task, or may even be a prelude to termination.
In the chapter “Interminable Analysis,” Schlesinger asserts that “My argument can be restated to the effect that an impasse in analysis can be, and I believe usually is, an expression of the transference neurosis. If not recognized as such and if allowed to continue, such an impasse eventually may be renamed interminable analysis” (p. 173). A transference neurosis is analyzable, and is to be distinguished from those interminable treatments where the goals of change are no longer relevant, but an attachment by both therapist and patient maintains the relationship: “To invite into a continuing attachment someone who may already have accomplished his therapeutic goals, but who has strong relationship needs, is to invite the possibility of an interminable relationship—but probably not a therapy” (p. 39). This is in contrast to the normal, but painful, separation anxiety of patients approaching termination, and the parallel anxiety in the analyst, who may also be reluctant to separate from a relationship with a long-term patient with whom his work has provided a rewarding experience to him.
In the chapter “Ending, Termination, and the Life Course of the Analyst,” he emphasizes the importance of “function pleasure” experienced in the practice of analyzing, which provides the analyst’s enjoyment of his work. The analyst must also have a sense of humor and be able to laugh, and his mind should ideally function close to the “play” mode as Winnicott (1971) described it. Burnout occurs when pleasure in the work and the playful attitude to it is lost.
This work fulfills the promise of the previous book, Texture of Treatment: On the Matter of Psychoanalytic Technique. These two books provide a new textbook of psychotherapy and psychoanalysis. Both are clearly written, theoretically consistent, jargon free, and brimming with clinical insights. Schlesinger has produced two volumes appropriate for both advanced and beginning therapists—no easy task. Although each book can stand alone and be read separately, I would hope that at some time in the near future the publisher will integrate them into one volume and issue it in a paperback edition so that it will be available to a wider professional audience. Until then, I recommend them in their present form.
Schlesinger, H. J., (2003). The texture of treatment: On the matter of psychoanalytic technique. Hillsdale, NJ: The Analytic Press.
Winnicott, D. W. (1971). Playing and reality. New York, Routledge.
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