Posted by Dr. Vollmer on January 24, 2014
According to Webster’s definition, an impasse is a “predicament from which there is no obvious escape.” “I felt held at an emotional distance,” Judy Kantrowitz MD writes in her paper entitled “Impasses in Psychoanalysis” which we will discuss in my class next week. Like M& M, morbidity and mortality rounds, in Internal Medicine, reflecting on what went wrong is, by my way of thinking, an admirable part of my field. Learning from our mistakes, on the one hand, seems so elementary, but on the other hand, is an intense act of humility, and sometimes shame. Bila, forty-one, female, enters my mental space as I think about therapeutic impasse. One day she comes in sleepy and disengaged. She moved from topic to topic, all relevant but with no affective charge. She felt lacking in curiosity about anything. “I wonder if you are afraid of the closeness in our relationship, so you have shut down,” I said, hoping to put us on a path of meaning and interest. Instead, Bila responds, “I think it is time to end our treatment,” with a flatness and detachment in her voice. “I wonder why that is coming up now,” I say, thinking that Bila and I had just been discussing her frustrations with her romantic relationships. “You don’t seem to listen to me,” Bila said with intense anger. ” I can hear that you are disappointed with me and I would like to understand that better, ” I say, hoping to understand the shift from deadness to anger. “I just don’t think I can go anywhere with you. I think we have done all that we can do. I think I am limited in how far I can take this therapy.” Bila says with sadness and frustration. “It seems like you started to get angry with me, but now you are angry with yourself,” I say, reminding her of her familiar dynamic where her angry feelings, almost always, turn back on herself. This was a brief impasse, as she quickly said “yes, that is what I do, and I am angry with myself all the time, and I don’t want to stop treatment.” Bila says, with tremendous relief that she could backtrack and feel more authentic about her narrative. Her initial deadness transformed into anger towards me and then anger towards herself, leading us to understand that she was afraid of her anger, so she became flat, and then she gave herself permission to express anger towards me, and with the safety of our relationship, she could then own her anger, as a chronic state of unhappiness with her decisions. In this case, the therapeutic impasse was a means to deepen our work. Of course, therapeutic stalemates do not always lead to such happy endings, but it is nice when they do.