Patients Who Stay

Abstract

For Freud, the ideal goal of a successful analysis is to resolve unconscious conflicts, gain insight, strengthen the ego, modify pathological defenses, contain irrational superego demands, and work through transferential distortions. Termination is based on a satisfactory approximation of these goals. However, there are certain patients who are unable to achieve these therapeutic goals. They include those with severe personality, psychotic, mood, eating, chronic posttraumatic stress, and gender identity disorders. For many of them, perseverance of symptoms, impaired functioning, and maintenance medication preclude termination, necessitating ongoing or intermittent treatment. On the other hand, there are those patients who make significant therapeutic progress, but remain in treatment indefinitely. Many of them approximate the criteria for termination, but maintain a therapeutic relationship for a variety of reasons. These include: unresolved transference-countertransference issues, avoidance of separation, chronically stressful situations (work, interpersonal, illness), lack of an external support system, and gratification from ongoing intrapsychic processing. Although nontermination may be associated with pathological dynamics for both patient and therapist, it may also be connected to non-neurotic, realistic factors. In some cases, indefinite treatment may be preferable. A clinical illustration is provided.

When psychotherapy is indefinite and there is no final outcome: Case study of a community mental health clinic.

“…Although results of this case study may be unique to one community mental health clinic, we suspect that the present qualitative themes will resonate with the experience of many psychotherapists, particularly those who work in comparable low-income clinics and those who have a large percentage of chronic patients in their caseload. Interestingly, despite major differences in setting and treatment approach, the kinds of patients described by our participants closely reflect those whom Glucksman (2011) described as “patients who stay” in psychoanalytic psychotherapy. That is, similar to Glucksman, our participants see patients indefinitely when they have a severe mental illness, including a personality disorder, are generally low functioning, have few external supports and multiple life problems and stressors.…”

Retirement, Illness and Death of the Analyst

“…Talking with colleagues prior to writing our report we heard of instances of denial, role reversal, and at worst, some serious breaches of boundaries. In a paper written more than 45 years ago, Eissler (1975) warns of the danger of patients becoming more important to the elderly analyst as his or her contemporaries retire or die, and Glucksman (2011) warns of the vulnerability of the elderly analyst to countertransference love. Chessick, one of the few men writing on this topic, considers the special problems for the elderly psychoanalyst in the psychoanalytic process.…”

Special Problems for the Elderly Psychoanalyst in the Psychoanalytic Process

“…This can cause problems because, as patients sense they have become important love objects, or in rare cases the analyst's only love objects, the situation is so gratifying that they wish to continue in treatment forever. As Glucksman (2011) puts it, "Therapists who have suffered from early losses, or who have been narcissistically injured developmentally, through illness, aging, and unsatisfactory love relationships, are vulnerable to countertransference love. Consequently, they too find it difficult to terminate with their patients " (p. 191).…”