Early in this century a completed and thorough analysis could be accomplished in six months. Toward the middle of the century, analyses were averaging five years, which meant a thousand sessions. When patients would ask, "how long is this going to take?", I would sometimes respond, sardonically or whimsically or arbitrarily, "a thousand and one sessions". I would try to gauge the motivation and capacity of the patient by how he or she responded to this paraphrase of the Arabian Nights.
In the sixties and seventies of this twentieth century, it was not unheard of to learn of analyses lasting over a decade. The explanation was 'negative-therapeutic-reaction', 'very resistant', 'ego-defect' or transference-countertransference impasse. It was said that some patients were so damaged by pre-Oedipal neglect, deprivation or trauma that lifelong analytic therapy was indicated and appropriate.
As time went by, into the eighties and nineties, long analyses became more and more suspect. The analysand was unanalyzable, the resistance was too great, analysis was not the appropriate treatment. We have learned that many severe borderlines and psychotics were not approachable by psychoanalysis, nor were manic-depressives and most obsessive-compulsives. Some of these conditions responded better to supportive therapy or cognitive-behavioral therapy and some experienced dramatic relief of severe intrapsychic distress and behavioral disturbance with appropriate medication.
In my own practice, now approaching forty years, I have experienced several extremely long analyses where the patient was making incremental progress approaching two decades and I began to explore other ways of understanding this unusual situation, where the patient seemed involved, conscientious and making progress, and was not pushing for termination. Exploring the reasons for this I found two basic dynamics operative, one negative and the other, positive.
The negative dynamics involved an underlying negativity and destructiveness in the patient. When we undertake to uncover, what we dig up is not always pretty. Sometimes we find a deeply hostile and sadistic nature. I recently heard the term, 'constitutional oppositionalism', where apparently the power and depth of the negativity implied a genetic defect which perhaps had a Darwinian explanation. Some people say that nice guys finish last, and deep down my patient was not a nice guy. He had introjected two hostile and destructive parents and no matter how much we understood it, his knee-jerk reaction was to oppose, to fight, to win, to destroy. His character structure and identity were reinforced by anger. Stanley J. Coen's book, "The Mis-use of Persons" (Pathological Dependency) describes this character and its resistance to working-through as a mutual avoidance of this seemy and sordid reality of life. Some people don't want to get well. They can act nice for a while, but continually revert to belligerence, hostility, nastiness and destructiveness. They get a certain kick out of being sadistic that is addictive. On the deepest level they don't want to give you the satisfaction of helping them. On another deep level they blame you for not magically changing them. No matter how much this is discussed and apparently understood, it does not change. These people have to be terminated, finally, as unanalyzeable beyond a certain point. There is a certain evil nature that defies working through or resolution.
The positive dynamics are similar to those inferred from Dr. Richard Chessick's case reported in the summer 1996 issue of this journal, "Failure and Impasse in Psychoanalytic Treatment". His case was that of a highly functioning but severely regressed woman whose therapy was well into the second decade with no end in sight. I did not think the case was a failure, far from it; the lady was improving and doing well on one level, while resisting integration and resolution on the deepest level, which was apparently split off. She denied that she was making any progress and said the therapy was not doing her any good. I believe she was talking from this deeply regressed level which emerged as the transference-neurosis, only the regression was pregenital and preverbal. She was looking to be nurtured, held and cuddled by the analyst-mother and instead, he maintained a professional detachment and took vacations and trips. To her regressed self it seemed that he callously rejected her by leaving, and she was inconsolable. Many patients are inconsolable because they were never consoled in infancy. Their basic physical needs and minimal emotional needs were met, but there was no affection, protection and nurturing that could be internalized as a 'good-mother'. (The mother was not a 'good-enough' mother). Therefore, on the deepest level, there was no self-esteem, no self-confidence, no lovable self-identity, and a persistent undercurrent of psychic pain that the analyst could not relieve. Dr. Chessick offered her medication, but she refused to take it. It is almost as if she wanted to suffer and only would accept personal, tangible, physical or magical relief. Since her psychic pain, re-experienced in the analytic situation, would not be relieved, the transference analyst-mother was blamed. And yet the patient would not terminate. This is pathological dependency.
In effect, the patient was addicted to the analysis and the analyst. From my own experience, a similar patient said to me, "I don't want to get well; if I did, I wouldn't be able to see you anymore". In reality, the therapy was the most gratifying situation in the patient's life. Miraculously, a parent-figure would give her his undivided attention several times a week, year after year. It was worth every penny, because in the session, with the apparent loving attention of the analyst, the psychic pain, the yearning to be loved and understood, was being gratified, albeit not completely. We have to face the fact that for some patients, there is no way not to gratify the patient's deepest needs without being negligent or cruel.
I was able to terminate three such patients by interpreting and discussing this impasse repeatedly and insistently, all the while being tactful, sensitive and empathic. In the end, I had to address the adult ego of the patient more and more, and be less and less sensitive and empathic, in effect weaning the patient from the therapy. A date had to be set for termination that was mutually agreed upon. It had to be understood that the analysis could not 'cure' the patient entirely, that certain deficits had to be lived with. They could be lived with as ego-strengths from the long analysis were integrated into a somewhat more mature and integrated personality.
A followup on these patients of two and five and ten year duration suggested that gains were maintained and functioning continued on a high level. There is a point of diminishing returns, and if the patient does not find it, the analyst has a responsibility to help the patient realize it and make the most of what analytic therapy can provide, which is, in the larger picture, considerable.