After the title of this column came to mind, I recalled that I used “As Long As Ye Both Shall Live” as the title of a column last year. 1 Why was I so inclined to quote from the marriage ceremony? Is the psychotherapeutic relationship like the bonds of marriage? Not exactly, I thought. It lasts only as long as it is necessary for the purpose of treatment, although it may last forever in the patient’s mind and it places certain lasting obligations on the therapist as well. But there is a covenant—a commitment on the therapist’s part to preserve an environment for effective work in which the patient feels safe and confident that the therapist will stand by him or her until the work is done. Major life stresses such as marital problems and serious illness place this covenant under duress.
Mrs. A began to talk about her visit to the cancer center that was to occur later in the day. She would learn about the results of the biopsy that had been done on the newly discovered thickening in the area of her lumpectomy for breast cancer, which had been done 2 years earlier and followed by chemotherapy. A shot of adrenaline ran through her psychiatrist’s body. He was reminded of the prostate biopsy he faced that afternoon for a rising prostate-specific antigen titer. While mindful of Mrs. A’s anxiety, he became preoccupied with his own anxiety and had trouble attending to what he was hearing for a while...
How many of us have faced that situation when a patient’s issues touch directly on our own?
Like many cinema psychiatrists before him, in the recently released movie Antwone Fisher, Navy psychiatrist Davenport gets off to a good start treating Seaman Fisher for his outbursts of rageful assault. The clinical results turn out to be good in this portrayal of a real-life story, but along the way we psychiatrists in the audience begin to squirm as boundaries are stretched to the breaking point. A serious setback occurs as the patient is invited to the psychiatrist’s family Thanksgiving dinner and the psychiatrist’s father rudely interrogates the patient. The psychiatrist’s marital problems gradually emerge, and his withdrawal from his wife is finally explained: she has been diagnosed as being unable to bear children and he can’t handle it well. As Antwone recovers from the effects of massive deprivation and abuse in his childhood, the psychiatrist recovers access to his feelings and his love for his wife. The psychiatrist struggles against his own fatherly feelings towards Antwone and his Oedipal jealousy of his wife’s caring interest in the young seaman. In the process, his reaction-formation defense almost wrecks the treatment with an abrupt and harsh rejection that Antwone, through his life-saving strength of character and new-found ability to express his needs, manages to overcome. (Denzel Washington does a masterful job of directing the movie and acting the part of Dr. Davenport—take several hankies along to see this one.)
Sadly, in real life, such invasion of the treatment relationship by psychiatrists’ personal crises generally doesn’t turn out so well. Highly respected colleagues have wrecked their careers because of major ethical infractions following treatment for prostate cancer. Experienced therapists have been drawn into sexual relationships with seductive clients whose childhood traumata closely approximated their own. The private and caring environment of therapy can become powerfully gratifying to a therapist who is feeling inadequate, lonely, and rejected in the world outside.
What causes therapists to lose control and cross the boundary into abusive, seductive, or sexual relationships with their patients? Although one cannot know in any individual case without intensive exploration of the person’s motivations, treatment experience indicates a multiplicity of causes. Often there is an Achilles heel—an unresolved need or conflict that one wishes could have been resolved in earlier psychoanalytic work during preparation for a career as a therapist. A chronic sense of deprivation; a perceived lack of love from one or both parents; narcissistic vulnerability due to early failures of empathy and damage to self-esteem; long-standing doubts about one’s sexuality enhanced by present-day rejections, disease, or aging; loss of a compensatory mechanism such as an obsessive athletic activity—all can set the stage for a cataclysmic failure to maintain a therapeutic stance when under pressure from a current crisis.
A relatively passive or masochistic character structure can make the therapist vulnerable to patients who deal with their problems through aggression and domination. A highly developed sense of responsibility can deteriorate into pathologically guilt-ridden submission to needful patients’ exploitation of the therapist’s availability by telephone after hours. Similar processes may allow patients to take advantage of their therapist’s willingness to be accommodating about setting or collecting fees. Unresolved rage can lead to direct or subtle attacks on the patient’s self-esteem. Treatment is next to impossible if the therapist has, in effect, used the patient to meet his or her own needs or has allowed him- or herself to become a helpless victim of the patient’s psychopathology.
Severe illness or terminal disease imposes special demands on the therapist. Questions abound. How much does one tell the patient? What kind of commitments can one make to enter into a long-term treatment with a new patient? Should one see patients when one is not up to par? How does one handle the physical evidence of illness such as crutches, scars, or hair loss after chemotherapy, or unusual routines that one must undertake for treatment or comfort? How should one handle prolonged absences due to surgery or other treatment needs? How can one deal with the patient’s concern and efforts to help? When should one retire? How should one prepare for continuity of care for one’s patients after death or ceasing practice? Some examples of these dilemmas follow.
Miss B came for continued analysis after her analyst had died. He had seen her up to the end, which she learned about when she came to his door and saw a posted notice about his death. The analyst had terminated work with most of his patients but had kept Miss B on. She had been grateful for this. Near the end she felt that she was doing him a service by continuing work with him, that this kept up his spirits and self-esteem, and that in a way she was undoing her neglect of her father during his terminal illness, about which she had always felt guilty. During those final months, her analyst had kept a glass with ice and a liquid by his side behind the couch, and she thought she could smell alcohol. She never was able to address her own alcohol dependency during the analysis, nor could she confront her anger about the gradual decline in her therapist’s acuity and his anticipated death...
Was her analyst’s decision to continue to see her wise? Was it for her benefit or for his? Did it help her to work through her feelings about her father, or could this have been better facilitated by transferring the patient to another analyst? Was it a disservice to collude in not addressing the patient’s alcohol problem? There are no hard and fast answers to these questions. Fortunately Miss B had access to subsequent analysis that was successful.
Having seen a succession of therapists without making much progress, Mrs. C felt very fortunate to have found Dr. Z. He listened while she propounded elaborate theories about health and life, and he tolerated her reports of extreme measures to stamp out dust and mold, garbage-picking activities that filled her house with other people’s junk, daily measurement and weighing of her stools, rage at her husband’s garrulousness and insensitivity, and total domination of his activities—all of which I also heard about in great detail because her husband was my patient and she left lengthy diatribes on my answering machine. Dr. Z. patiently helped her calm down and reduce her intrusiveness and anxiety-driven controlling activities, and the messages to me diminished. She began to relax, sleep better, and get along better with people.
Then Dr. Z. came down with a fatal malignancy. During his final months, it seemed to Mrs. C that she was his therapist more than he was hers. He talked about his symptoms and distress. She suggested various herbal remedies from which he reported some beneficial effect. They undertook inspirational readings together. When he died after a short hospitalization, she leaned on me for support and referral to another psychiatrist. She called back later with much annoyance because the new psychiatrist had taken a very careful, detailed history and also listened to her husband’s views on her problem; I took it that she felt threatened by his professionalism and thoroughness...
No one could measure up to Dr. Z. and the degree of invasion of his private life that he had permitted. Was Dr. Z’s management of Mrs. C during his final illness beneficial or harmful to her? Only time will tell. His earlier treatment had clearly been helpful, but Dr. Z’s final act was very hard to follow.
It is not possible to supply definitive answers to the questions raised here. Truthful disclosure must be titrated against preservation of a treatment process. One shouldn’t make promises that one can’t keep. The therapist must be mindful of his or her special needs, anxieties, preoccupation with sadness and loss, diminished function, and inevitable narcissistic regression and vulnerabilities, and their impact on the treatment process. One shouldn’t hang on to patients or work in order to meet one’s own needs for support or validation. One shouldn’t indulge in the conceit that one is irreplaceable. Consultation with a colleague about these issues is invaluable. A collection of essays exploring the subject in depth, many of them by psychoanalysts who have been in this situation, makes good reading for anyone who wants to pursue the issues further. 2 It’s a sad subject and a sad time in an honorable career of service to one’s patients.
1. Clemens NA. As long as ye both shall live. Journal of Psychiatric Practice 2002; 8:116–8.
2. Schwartz H, Silver A, eds. Illness in the analyst: Implications for the treatment relationship. Madison, CT: International Universities Press; 1990.