An Ethical Dilemma – Discussed by Matt McArdle
Psychoanalysis Terminable and Interminable
Rise Becker
This comment was prepared for a panel at the Australian Psychoanalytical Society Open Day 2024: The Mind and the Body in Turbulent Times
Recently, I read an article on climate change: Cutting emissions and surgical incisions. It begins; You are sick. You have a choice: two treatments with even odds of making you well. If the treatment gave you a better chance of a slightly longer life, but its environment cost was far greater, what should be done? (Sydney Morning Herald 2024)
This question echoed an ongoing dilemma I have regarding resources and availability of services to treat mental illness and dis-ease. Should only those who can afford it receive optimal treatment, while others get little or no help? Is this the best use of resources for the population.
A colleague from the NSW Service for the Treatment and Rehabilitation (STARTTS) raises the point that she sees highly traumatises refugees and sees people from the general population who proportionally can afford multiple sessions of psychoanalytical psychotherapy weekly over a long time. She is one of us who bulkbills her refugee clients and can see them once a month. This work adaptation opens the question but also offers a resolution which can use clarification.
The Length of an Analysis
In his paper Psychoanalysis Terminable and Interminable Freud begins: Experience has taught us that psychoanalytical therapy- the freeing of someone from his neurotic symptoms, inhibitions, and abnormalities of character-is a time-consuming business. Freud wondered whether the process could be condensed.
Despite this, according to Janet Malcom writing in 1977, the consensus about what constitutes an appropriate time for an analysis has been on an upward trend. In the twenties, it was one to two years, in the thirties and forties two-four years, in the fifties and sixties four to six years and when Malcom was writing, six to eight years. Is this still the case?
Freud asks the questions: Is there a way of accelerating the slow progress of analysis? He then poses, a related question; is there a natural end to an analysis, and this leads to further debate. Freud’s paper revolves around the possibility that there is an end to an analysis. This is a complex and thought-provoking paper exploring multiple ideas including the issue of time and the timelessness, necessary to achieve the aims of the analysis. This aim may not be clear.
In Germany one can have three hundred sessions of psychoanalytic treatment on the national insurance scheme; the number of sessions is generous i.e. years not sessions, but there is a ceiling. Some clinicians believe that this treatment is sufficient for most people, but importantly it may bring into focus the idea about ending the analytic work.
In Psychoanalysis Terminal and Interminable, Freud cautions against the idea of limiting the duration of the analytic work as this could lead to constraining analysis by funding needs rather than the needs of the patient. However, he also acknowledges that some people remained in analysis beyond the time when it was valuable, and a final date might accelerate the work. This leaves the question; valuable for whom unanswered?
Freud also addresses this question in his paper and discuses patients who improve but remain in the analysis without further development. In a particular case Freud set a final date which he believed accelerated the work. An interrelated circumstance revolves around the patient who had made considerable progress in the work, feels more able to cope, but not ready to leave. It is possible that the analysis is required to maintain the patient at an optimal level for that person.
Who is the Patient?
Many contemporary critics view Sigmund Freud as an elitist, suggesting that his psychoanalytic treatment was primarily accessible to those with intellectual and financial advantages. However, Elizabeth Ann Danto in her book: Freud’s Free Clinics: Psychoanalysis and Social Justice presents a different picture of Freud and the early psychoanalytic movement. Freud, Wilhelm Reich, Erik Erikson, Karen Horney, Erich Fromm, and Helene Deutsch envisioned a new role for psychoanalysis. These psychoanalysts saw themselves as brokers of social change and viewed psychoanalysis as a challenge to conventional political and social traditions. Between 1920 and 1938, in ten different cities, they created outpatient centres that provided free mental health care. They believed that psychoanalysis would share in the transformation of civil society and that these new outpatient centres would help restore people to their inherently good and productive selves.
Danto also discusses the important treatments and methods developed during this period, including child analysis, short-term therapy, crisis intervention, task-cantered treatment, active therapy, and clinical case presentations. Her work illuminates the importance of the social environment and the idea of community to the theory and practice of psychoanalysis.
The proliferation of psychoanalytical therapies for different settings has made psychoanalytical work available on a broader scale. This hybridisation does make a version of work appropriate and available to people and should not be underestimated. There are avenues where psychoanalysis is available at modest charges. Furthermore, there are people who may require or respond to intensive psychanalytical work and in fact only this level of intervention will be helpful to them. More contemporaneously Lemma, Target and Fonagy responded to the need for a shorter analytic intervention in developing, Dynamic Interpersonal Therapy, (DIT), which adhered to the sessions offered through the National Health in the UK. Additional examples may be cited.
However, Freud’s ideas of free clinics and low-cost services only partially address the issue. It is still the case; despite our growing political and social consciousness that the bulk of intensive psychoanalytical work remains with individuals who can afford it.
And so, the idea of privilege conferring the responsibility to act fairly may be one way out of the dilemma. This does ask us to consider the other. Efforts to serve a broader population could lead to more positive outcomes.
The scope of these questions is extensive and would require further time and exploration beyond the scope of this short comment. However ongoing scrutiny of our professional behaviour and responsibilities is essential.
References
Danto, E. Freud’s Free Clinics: Psychoanalysis and social Justice, 1918-1938, Columbia University Press
Freud, S. Psychoanalysis Terminable and Interminable (1937). Standard Edition 23.
Lemma, A, M. Target & P. Fonagy, Brief Dynamic Interpersonal Therapy: A Clinicians Guide Oxford
University Press 2011
Sydney Morning Herald (2024)
RESPONSE TO THE ETHICAL DILEMMA “PSYCHOANALYSIS TERMINABLE AND INTERMINABLE” BY RISE BECKER
Matt McArdle
April 2025
“What has once come to life clings tenaciously to its existence. One feels inclined to doubt sometimes whether the dragons of primeval days are really extinct”
In asking about the labour intensiveness of psychoanalysis, Rise Becker poses important questions about mental health resources and availability of treatments for mental illness and dis-ease. She is not just asking one question, but many. She stirs up many ‘big’ questions up the treatment of mental illness, the practice and benefits of psychoanalysis and the place of psychoanalysis in today’s healthcare and society. She alludes to Freud’s 1937 paper Analysis Terminable and Interminable. Many of the themes of his paper are as relevant today as they were 100 years ago. Many of his questions remain unanswered. I suggest that many of these questions are unanswerable, but that we benefit from ongoing reflection and debate of the issues.
There is a risk in raising the labour intensiveness and length of psychoanalysis that fuel is given to those who wish to represent psychoanalysis. In the following discussion will make comment on a number of questions that emerge from Rise’s dilemma. These comments do not resolve the issues. But they may help us to keep thinking about this complex ‘beast’ of psychoanalysis. I will discuss the questions under the broad categories: the benefits of psychoanalysis, the practice of psychoanalysis and resource allocation as well as the place of psychoanalysis today.
The Benefits of Psychoanalysis
Is there evidence for the efficacy of psychoanalysis?
Psychoanalysis has rightfully been challenged in recent decades to show evidence for the effectiveness of intensive analytic psychotherapy and analysis as effective treatments for mental dis-ease . In our current age of evidence-based treatment, analysts and analytic therapists must show through evidence-based approaches that our treatments have efficacy. There is a commonly held and false belief in sections of academia, education and mental health service provision that psychoanalysis is a ‘thing of the past’ and has been ‘proven to be of no benefit’. However, there is a large body of evidence that supports the utility and efficacy of intensive analytic therapy and psychoanalysis (https://www.opendoorreview.com/). Despite this growing evidence, there seems to be little interest within psychoanalysis for us to strengthen the base of quantitative research for our discipline. Most analytic therapists prefer qualitative approaches and case studies. Outside the relatively ‘small world’ of psychoanalysis there is a commonly held and false belief that ‘psychoanalysis has been thoroughly debunked’. Yet, outside the ‘small world’ of our institutes it is questionable whether most of the general public have any real sense of what psychoanalysis is.
Can we measure the benefits of psychoanalysis?
Psychiatry aims to diagnose and treatment mental illness. Current Psychology has similar aims. Psychoanalysis has somewhat different and, difficult to define aims. Psychoanalysis does not actively focus on symptom relief. Yet, most measures of efficacy do focus based on symptom reduction. It is difficult to measure the effects and outcomes of psychoanalysis. How do we measure improvements in sense of self? Can we measure the capacity to bear and express painful and difficult emotion? What is the quantitative way to assess insight into one’s compulsion to repeat and a growing capacity to respond to situations in new and different ways? Can the reduction in rigid defensive and self-protective structures and the replacement by new and more adaptive methods of living and coping be measured by current quantitative research methods? Are there novel approaches to research that we can develop? Is there enough enthusiasm within the psychoanalytic community for this research to be done? Modern mental health policy makers demand evidence for our treatment approaches. Can analytic psychotherapy community present evidence that can be heard by policy makers? Do we recognise a need for further research in our field?
What are the aims of an analysis?
Freud’s aim for analysis began with the idea of making the unconscious conscious. He said that “where Id is Ego shall be”. The goal of conscious insight to previously unconscious defences and repetitions of self-defeating attitudes and behaviours remains. However, many analysts today would say that their aims in treatment are much greater. Probably most agree that fundamental to our treatment is the goal of alleviating human suffering through a deep exploration of things that were previously out of the awareness of the patient. This requires specific conditions, usually requiring the patient and analyst to meet multiple times a week and sometimes with the patient lying on the analytic couch. The unique conditions allow for an unlikely conversation between analyst and analysand that cannot and does not happen in other circumstances. When the patient is able to express what comes to mind as freely as possible and the analyst is able to be present in a state of relatively free-floating attention, previously unnoticed and new thoughts, feelings and experiences emerge. This becomes a unique ‘journey’ that can contribute to growth of the patients mind and the capacity over time to bear previously unbearable thoughts and feelings. This can lead to psychic growth and relief of psychic suffering. However, the journey and results of each and any analysis is unknown before it begins. The goals cannot be specific like other psychological and psychiatric treatments.
Are the effects of psychoanalysis restricted to the individual being treated?
I want to briefly make the point that in my experience the benefits of analysis are not ultimately restricted to the patient being treated. The measure of its effects in reality filter out into the lives of others in the patient’s orbit. A patient once described it to me as ‘ripples on a pond’ saying it seems to ‘start with changes in me that ripple out into the lives of my family and friends’. These are ‘added benefits’ that we may not often consider in a risk/reward evaluation.
The Practice of Psychoanalysis
How long is an analysis?
A new patient might ask ‘how long will this take?’ A somewhat dismissive response might be ‘how long is a piece of string?’ It is usually part of the analytic frame that an analysis is open-ended. However, there are circumstances that might place limits on how long an analysis can continue. Rise, like Freud more than 100 years ago, invites us to think about the possible advantages of placing a time limit on an analysis. Because we can never know at the beginning of an analysis what may unfold, develop and emerge. I think it remains most appropriate to not put time frames around the length of an analysis at the beginning. The patient and analyst can then know ‘we have the time we need’. This time inevitably varies. In a 2022 IJP paper by Werbart and Lagerlof called “How much time does psychoanalysis take?” they review the length of analysis in their native country of Sweden. In Sweden currently the average analysis is apparently 5.7 years with a range from 1.5 to 12 years. They discuss how over time analyses have tended to become longer, not shorter.
There are, also, cultural factors and factors relating to each particular patient and analyst. I suspect a similar survey in Australia would find much longer analyses. There is also evidence of analyses in Australia, Europe and the Americas that go over many decades.
I would like to suggest that with different patients the ‘goals’ of analysis become quite different over time and that some patients require a much longer period of analysis than others. (these are topics for someone to write a much longer paper on).
When does an analysis end?
Perhaps my real question is ‘does analysis ever really end?’ In many ways it does. Analysand and analyst at some point (often by mutual agreement, but not always) cease meeting regularly. This is an ending and a loss. However, in other ways, the analysand internalises the process. They can develop a greater capacity for self-reflection, hold good objects within them (including the possible new objects from analysis) and develop adequate alpha function (alpha function is the inner capacity described by Bion that enables a person to transform raw experiences into something thinkable and meaningful. Bion suggested that in the start an infant cannot perform this function alone and needs a parent to provide alpha function until the earliest raw experiences can become bearable and the infant can develop their own capacity for alpha function). Once this process is internalised analysis continues and develops throughout life, even in the physical absence of the analyst.
This does not mean that events will not occur that overwhelm the analysands capacities. They no doubt will. Traumas, losses, unexpected internal and external catastrophes in life are likely to overwhelm all of us. At these times, the analysand may seek a period of further analysis, or a brief contact with their analyst or another analyst. However, some analysands may not require further analysis and may seek out alternative means of growth through crisis.
Why are some analyses prolonged?
I cannot begin to pose a good answer to this question here and now. What I will say is that I think of two broad groups. The first group is those patients for various reasons that need a much longer period of analysis. The second group is those patients (and analysts) that struggle to allow and face an ending. Glen Gabbard discusses many of the issues with this second group of patients (and analysts) in his paper “Termination and persistence of the infantile” (IJP, 2021). Gabbard’s opinion is that infantile dread in many forms can be a serious obstacle to the healthy ending of an analysis. He says, “the persistence of this infantile dread may interfere with both our patient’s capacity to terminate and the analyst’s capacity to let their patients go”.
Resource Allocation and the Place of Psychoanalysis Today
The costs of analysis?
Analysis is a costly endeavour. Those that train to become psychotherapists and psychoanalysts dedicate many years of their lives to their own therapies and analyses. Also, they commit to years of theoretical and clinical learning. They can only see a limited number of patients at any time. And of course, the more intensively they work with these patients, the less patients they can see. Some would ask, as Rise raises in her dilemma, ‘why see so few patients more often, when you can see less patients more often?’ And this, I think is the unresolvable dilemma for psychoanalysis.
I have no doubt there are many more people in the community that could benefit from psychoanalytic treatment. However, I also have no doubt that to work ‘in the transference’, to reach the infantile and often previously unconscious aspects of the personality, to enable a patient to think what has previously been unthinkable, special conditions are required. Patients and analysts are all different. I accept that for some patients with a particular analyst that they can do depth therapeutic work with a reduced frequency of sessions. For some patients with a particular analyst treatment may not need to be very long. However, in my (limited) experience and from what I have learnt from others, this psychoanalytic usually requires an agreement between analysand and analyst to meet, at least, 3 days per week and usually 4 or 5. In my experience, and again from what I have learnt from others, this analytic experience needs years (sometimes many years) to develop and take its natural course.
Some will say “that is not cost effective!” Maybe so, but I think this is often said without considering the mental, social and often physical suffering of these patients. Also, the suffering of their families and loved ones is not adequately considered and that the long-term benefits of an analysis flow out to others. Finally, I would like to mention the costs, side effects and limitations of other treatments that are often not fully considered.
Psychotherapy and psychoanalysis take up a lot of time for both therapist and patient. The treatment places an emotional load on both. Whilst in treatment painful, raw and often archaic mental states are encountered. Some would call these ‘side effects’, while they are necessary aspects of the analytic process. However, other treatments may involve costly medications (often with many side effects), multiple clinicians, involvement of emergency services, emergency departments, allied health clinicians and hospitals. This would be difficult to measure, but many of us who work analytically will have examples of patients whose need for other treatments and other services and interventions reduces during (and after) an analysis.
I often wonder whether the mental health community and society at large feels more comfortable if we as patients rely on services, medications and a broad array of ‘support workers’ rather than a more focused dependence on a therapist or analyst. I think this fear of dependence is often an unknown factor in debates about the utility and intensive resource use in analysis.
Dependence has become a dirty word. To rely on another individual in the deep way an analysand may depend on their analyst is often seen as pathological and addictive, rather than a necessary aspect of the process of depth psychotherapy. Yes, pathological forms of dependence do exist, as does addiction itself. This behoves us therapists and analyst to have adequate therapy, training and ongoing peer and supervisory support to know the difference between what is pathological and what is healthy.
The limitations of analysis?
Finaly, I want to make a few brief comments about the limitations of psychoanalysis. Many of us, when we find this treatment (this deep process) that has such a powerful effect on our lives grow to idealise it for a period of time. We begin to think “everybody should have an analysis”. Maybe we can think “analysis is the answer to all our woes”. But it is not and not everyone wants or can utilise an analysis. There are factors about each analyst and each potential analysand that place limitations on what is possible. Sometimes it is better and more truthful to say no to offering a therapy or analysis. However, sometimes we do not adequately trust what can be achieved when a patient presents with what feels like overwhelming distress and dis-order. These are complex issues, and we all need to reflect deeply with and about each patient.
Then, there are the limitations of each analysis and each analytic couple. This brings us back to Gabbard’s thoughts and “the dragons of primeval days”. These dragons are part of the infantile world of each of us. I do not see it as my job as an analyst to expel or destroy these dragons, but to work with each patient to gradually become aware of their personal dragons. Perhaps we need not fear the dragons. Perhaps it is our defences against them that are harming us. Maybe these dragons have not had adequate space to grow and flourish. For each of us, for each patient, it is different. Whilst there are common dragons to humanity, we are also all unique.
Two of the dragons we must meet are our own omnipotence and omniscience. We (as therapists and patients) must painfully discover that we can’t control it all and we can’t know it all. Once we are able to bear this, we may be able to accept that our analysis and analyst will, also, have limitations.
In ending this discussion of Rise Becker’s dilemma, I want to advocate two responses that you might have. Firstly, and most importantly, that you take some time to sit down and consider your own thoughts on these matters. If possible, write these thoughts down and share then, so that the discussion on these matters continues. Secondly, that you consider reading or rereading Freud 1937 paper Analysis Terminable and Interminable. You may be surprised at how current many of his thoughts, questions and ideas are. At the same time, like me, you may be delighted to see that on some matters we have come a long way and that our thinking and discourse on certain matters has evolved enormously.
References
Freud, S. Analysis Terminable and Interminable (1937). Standard Ed. 23.
Gabbard, G. The ‘dragons of primeval days’: Termination and persistence of the infantile. (2021). IJP, 102, 3. p.595-602.
Leuzinger-Bohleber, M & Kächele, H, Editors in commission of the Research Committee of the IPA An Open Door Review of Clinical, Conceptual, Process and Outcome Studies in Psychoanalysis. Third Edition 2015. Prepared by the Research Committee of the International Psychoanalytical Association. (https://www.opendoorreview.com/)
Werbart, A and Lagerlof, S. How much time does analysis take? The duration of psychoanalytical treatments from Freud’s cases to the Swedish clinical practice of today. (2022). IJP. 103, 5 . p.786-805