Shirah Vollmer MD

The Musings of Dr. Vollmer

Intensifying Treatment: Who Decides?

Posted by Dr. Vollmer on March 29, 2016

Springtime is time to teach, for me. Tomorrow starts my class entitled “Building A Psychoanalytic Practice”. Our first reading, by Stephen Bernstein MD, discusses the process in which patients begin coming once a week, and for some, there is a transition to more intensive work, meaning twice, three, four or five times a week. To people unfamiliar with psychoanalysis, this might seem to be an absurd amount of psychotherapy. Yet, for those in psychotherapy who feel a sudden or gradual  sense of being understood, of being heard, of feeling significantly less anxious, intensifying treatment makes a lot of sense. Yes, yes, there is significant time and money involved in such a commitment, but let’s put that aside for the moment. The relationship, as Bion famously said, provides a containment,  meaning a psychological enclosure in which difficult and painful feelings can be processed. Outside of psychotherapy those feelings can lead to panic attacks and generalized anxiety, but in the context of a therapeutic relationship, the opportunity to process those feelings often leads to diminishing anxiety, and hence the person feels contained. The inability to contain a patient is seen as a therapeutic challenge, and not necessarily a reason to refer for anti-anxiety medications. The referral, Bion might say, sometimes implies that the patient’s anxiety has overwhelmed the therapist, leading to greater hopelessness in the patient. The struggle to contain the anxiety is the work of the therapy, and sometimes that work requires greater muscle power which can only be achieved by adding more time, which increases the focus on the anxiety, and shortens the intervals between sessions. Like all relationships, the more they are nurtured, the more rewarding they feel, so too, with psychotherapy, that the more the dyad can focus on the issue, struggle with verbal play to understand the psychic pain, the more likely there will be a sense of understanding and psychic relief. The “break it to fix it” model applies here. The patient must experience the pain, intensely, in order to put himself back together in a way which feels both more expansive and more peaceful. Working with patients to increase the frequency of visits, like all aspects of psychoanalysis, is a very delicate process. Some patients may feel that they are “so sick” they need more therapy, whereas others might feel flattered by the desire to spend more time together. Understanding the meaning of proposing a different treatment is the first step towards testing the waters as to whether a deeper relationship makes sense. Therapeutic regression is expected and so both parties are naturally fearful of the outcome. The more time people spend together the more their blemishes are revealed, the more shame both parties can feel, possibly resulting in rage and disappointment, either with themselves or the other. The stew of feelings is expected, but working through them, containing them, examining them, is the work, the art of deep treatment. For some, this will be a life-changing endeavor, again for both parties, but particularly for the patient. For others, the therapeutic regression will cause a stalemate, and there will be a terrible sense of spinning one’s wheels. To enter takes courage. To learn how to enter also takes courage. And so our class will begin.

2 Responses to “Intensifying Treatment: Who Decides?”

  1. Shelly said

    But you haven’t answered the question you asked in the title of this blog: “Intensifying treatment: who decides?” You’ve described the process as being painful on both sides. But truly, who does decide? The patient? The analyst? Does the analyst ever say, “I think we’ve come a long way and I think we’re done?” Have you ever said that?

    • The answer, like deciding to get married, is mutual, initiated by one party, but agreed by both. As for ending treatment, this is also a mutual decision, usually initiated by the patient, as the internal state of the patient determines when the work can be scaled back and then terminated. So, the short answer is no, I have never said that. The long answer is that the journey is one of an infinite quest to discover the workings of the mind, and so termination, which is another class I might teach, is based on the issue that the effort of continuing in treatment no longer seems necessary given the improved state of mind. This decision comes from the patient, as the cost/benefit analysis is theirs to make. Thanks.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: