Fresh Sufferings
On When Analysts Won’t Terminate
Sarah Goldberg
In 2010, the person I felt closest to in the world died of complications from a spinal surgery. Or at least that’s what I remember. His health had been declining for a little over a year and he’d had two prior surgeries during that time. Yet it never occurred to me that he could die. For over a decade, he was my psychoanalyst, someone I shared my life with four times a week, and suddenly he was gone. The analysis was terminated, but not by either of us.
I was wrecked with grief and confusion over the loss and its alienating solitude. The analytic relationship is purposefully siloed off by its protective confidentiality, but now I found myself trapped alone in my grief. The person I knew to turn to with these types of scary emotions and experiences was gone. I dreamed of finding his other patients and having a memorial service with them. I imagined finding his family and telling them how much he had meant to me. Then I felt ashamed for wanting this relationship—one that by design was confidential—to be recognized by those who knew him beyond the consulting room.
My psychoanalytic treatment had seemed like a clear success story until this messy ending, which left me alone with a complicated grief that no one recognized or appeared to understand. To add to this inevitable grieving, the field of psychoanalysis appeared not to have given much thought to the decline and death of its workers—let alone their patients’ possible reactions to their demise. After the initial period of grief wore off and I was able to function in everyday life, the question remained of why exactly the illness and death of my analyst were managed so poorly, or rather not managed at all. This became a scholarly question that grew out of a personal one, but it also derived from a demonstrable social fact and salient institutional problem. Psychoanalysts are older, by and large, and many are past what was once considered retirement age. According to the International Psychoanalytic Association (IPA), the average age of a psychoanalytic member is sixty-five, and the average age of a training analyst is seventy-three. The analytic method—otherwise so thoughtful, nuanced, and capable of approaching the mysteries of life—seems to have given little to no thought to a wide range of issues regarding the aging and death of the analyst. There was an apparent design flaw in the treatment that saved my life.
There was an apparent design flaw in the treatment that saved my life.
This problem of aging psychoanalysts, as I discovered, was deeper and more institutional than it first appeared. The vicissitudes of old age seem to have escaped the evenly suspended attention of psychoanalysis altogether. Too little is made of developmental trajectories beyond mid-adulthood, and there are almost no corollary policies for practitioners. There is a lack of curriculum regarding the developmental stages of late adulthood and older age, and an absence of frameworks for retirement. No psychoanalytic institution has a suggested or mandatory retirement age. There are no standardized protocols or trainings that speak to the experience of aging or ending a practice as a psychoanalyst. The professional societies—such as the American Psychological Association, the National Association of Social Workers, and the American Psychoanalytic Association—do not have stand-alone oversight boards that track or monitor aging clinicians, even if this may fall under the work of their ethics boards, nor do they formally recommend preparation for aging or the end of practice as part of psychoanalytic training. These lacks create much uncertainty in how to manage the aging process—not only for the analyst and their patients, but for the field of psychoanalysis itself.
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From its beginning, psychoanalysis has been a profession that one could practice late into life. Sigmund Freud saw patients throughout a long battle with cancer and only ceased when his cancerous lesions became intolerable toward the very end of his life. In many ways it is a profession built for an older, wise person who can sit and listen with a particular type of developed patience. It takes a great deal of time to even begin the work of being a psychoanalyst: at least a decade. Then there is the extensive supervised training within the field, so it can be years into practicing before a psychoanalyst feels equipped for solo mastery and is identified by their peers as being so. All this training is supposed to prepare the psychoanalyst to work with human experience throughout the lifecycle. And time is a tricky element in psychoanalytic treatment, as one tries to examine the past in the present to help guide the future. Their greater expanse of human experience gives older practitioners a leg up, given the need to understand and contain developmental stages within psychoanalytic treatment.
This model of the older psychoanalyst guiding and being idealized by the younger patient is captured beautifully by H.D.’s Tribute to Freud, in which time and their respective different places within it shape the treatment and their connection. In Tribute to Freud, H.D. returns again and again to Freud’s age: “the Professor had had shock upon shock. But he had not died.” H.D. describes Freud thus: “he is nearer to the grandfather and that religion, ‘an atmosphere.’”
The notion of an analyst who can outlast any shock, who can defy death, subtends the equally fantastical model of the analyst who practices until they die, treatment stopped only by that final end. Such a framework is based on the early theoretical foundations of psychoanalysis, particularly of the one-person model and a completely interiorized psychological life. Classical psychoanalysis theorized a contained intrapsychic system of meaning inside of each individual, whereas contemporary psychoanalysis has moved toward understanding experience as having a fundamental relational component and with meaning being co-constructed with others. Without an acknowledgment of psychosocial and relational factors, classical psychoanalytic theory supports the idea of an analyst working up until death without affecting the patient and the treatment. As the psychoanalytic field developed, the theoretical understanding of the therapeutic relationship has deepened. Most contemporary theories emphasize how psychological work takes place within the context of both the therapeutic and social relationship. For the work to be useful, a deeper understanding of informed consent for psychoanalysis is necessary—and this extends to the material, not fantastical, health of the analyst.
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The failure to think about the later years in life, both theoretically and logistically, is playing out within aging psychoanalytic institutes.
Today, institutional decisions about aging and ending a practice take place behind closed doors, and the reality behind the decisions is kept between colleagues. As Robert Galatzer-Levy, a Chicago analyst, has noted, there might be knowledge of a declining clinician, yet no one will interfere out of a mixture of loyalty and friendship to their colleague or discomfort with a confrontation. In “The Death of the Analyst, the Death of the Analytic Community, and Bad Conduct,” he suggests that analysts seek to protect their colleagues and the analytic community to deny their own sense of vulnerability. Galatzer-Levy explains the extreme deference to the professional judgment of colleagues with the need to maintain privacy and agency within one’s own practice. Psychoanalysts are reticent to meddle in colleagues’ affairs for fear that they will be the next practitioner to come up for questioning. Better to leave well enough alone. Such hands-off methods do not respond to the patient’s best interest, Galatzer-Levy contends, and over time, they have eroded faith in the field at large.
But what of the working lives of psychoanalysts over the age of seventy-five? I interviewed nine of them. Together, they reflect the shape and feel of psychoanalysis in America in the later twentieth century: their experiences were expansive, enlivening, and lucrative, and they had no idea what maturing or aging in the profession would mean. All participants described their training and early decades as psychoanalysts with exuberance. “Those were halcyon days,” said one. Another called training “an absolute dream. Those were easy, good days.” Each participant detailed supportive early mentoring, and this good feeling around the profession continued into their middle-career years. They especially stressed the benefits of setting one’s own schedule, their autonomy, and how that allowed them to adapt to different phases of their lives, shaping the practice to fit their needs and responsibilities. The psychoanalytic career provided a path to expand the self into adulthood.
Experiences in later years of their career were more ambivalent. On the one hand, their theoretical and clinical technique deepened, and they developed a greater sense of theoretical freedom. This was the “fun” of the work, as they frequently described it—enjoyable enough that only one person had plans to retire. On the other hand, their sentiments about psychoanalytic institutes, communities, and peers had soured. Every participant, without a specific prompt, spoke of feeling alienated from their respective psychoanalytic institutes, and their age was a salient factor. Many cited incidents they felt were ageist or examples of how the institutes tossed off older psychoanalysts to promote younger ones. Many spoke disappointedly of younger colleagues and of how the quality of the psychoanalytic field has diminished over the decades.
Beneath the nostalgic narratives of their younger years, a sense of intergenerational conflict brewed when they were confronted with aging and their sense of having diminished roles in institutes. Older psychoanalysts, who retain a great deal of institutional power, have an expectation that they will continue to guide the field for decades and decades, as they feel they have a great deal to provide, and they will for some time. Several of the recent texts examining aging in psychoanalysis question whether this lack of a development framework that includes our later years is partly responsible for some of the intergenerational strife within institutes. Peter Fonagy, the Hungarian-British psychoanalyst, argues that “aging is the prototypical taboo for psychoanalysts . . . a profession that has at its core the legend of Oedipus is condemned forever to idealize seniority and experience. It is all too easy to see the actions of young colleagues as derivative of a poorly analyzed wish to displace the parent.”
The failure to think about the later years in life, both theoretically and logistically, is playing out within aging psychoanalytic institutes. Nevertheless, some psychoanalysts were candid about the difficulties of maintaining a thriving clinical practice as one ages. Psychoanalytic cases often require a commitment of several years at three–four sessions a week in a sustained and intimate relationship with another person. When and how to stop analysis is at any time a difficult question, but its complexities are exacerbated when aging might precipitate a premature termination. Because they have to improvise without any network, training, readings, or mentoring to guide them, the analysts I spoke to offered their individual, and therefore idiosyncratic, approaches to this set of problems. Dr. M. shared that they “just want to cut back a bit and have a reduced schedule” but that they struggled to make those changes. Dr. H. agreed, saying, “I'd like to do something with it [the clinical schedule]. It's hard to do. I have a practice. I have patients that I've made commitments to.”
The analysis was terminated, but not by either of us.
Every psychoanalyst I interviewed had set up a “buddy system” in which they had recruited trusted colleagues to tell them if the quality of their work beings to suffer, although several admitted that they would likely have trouble believing that message. Dr. B. spoke of having some memory troubles around scheduling: “The only disruption I’ve noted is an occasional loss of appointments, that I’ve caught. So, I had to take serious measures to make sure that doesn’t happen.” From these examples, I was led to conclude that lack of institutional preparation for handling the situation of aging must contribute, in part, to the negative sentiment toward psychoanalytic institutes. Yet most analysts bristled at the very idea of institutional oversight intruding upon the privacy of the consulting room.
As we discussed issues around aging and the ending of clinical practice, the confident, well-trained psychoanalyst tended to fade, and a more uncertain figure came forward. Some of the psychoanalysts solicited my thoughts and asked what I thought could be done. I usually mentioned, in response, an IPA suggestion for a clinical consult for psychoanalysts over the age of seventy-five. Dr. H., an eighty-four-year-old psychoanalyst who had been the most reluctant to sit for an interview, offered a spirited version of the common rebuttal, saying, “I would be so angry that they could design such a test that would feel fair. I don’t trust it.” The possibility of this test unearthed misgivings about participating in my interview: “Well, you could see how paranoid I was when you called … can you imagine how paranoid I’d be if such a thing was instituted? ‘At the age of eighty, we’re going to start testing you.’” Dr. H.’s fear was of being separated from their profession. “That’s practically a way of saying, ‘Retire.’” All the participants acknowledged that there were issues to consider around the ethics and protocols of the aging psychoanalyst, yet “impossibility” was a common refrain. Dr. B. stated, “I’m afraid there is no better approach.” Dr. W. offered, “I think people go until they get sick or demented. Or depressed.” Dr. S. explains, “It’s such an overall identity, and such a crisis for somebody when they can’t continue.”
Psychoanalysis has long consorted with the impossible, and Freud himself left a powerful warning about the binds of the psychoanalytic profession and impossibility in “Analysis Terminable and Interminable.” In this paper from the last years of his life, Freud warns of how psychoanalysis can always bring about “fresh sufferings,” which recur in the analytic relation. The issues of aging and the death of the analyst are not exempt from generating their own binds and impossibilities that bring about fresh or renewable sufferings—no matter one’s age or circumstance. Freud’s call to address the impossible in the analytic relation ought to encourage us to face these fresh problems—institutional, social, and personal—about aging analysts, their deaths, and the patients they leave in their wake. There is, of course, nothing to do about death—the end of possibility and the beginning of impossibility—but all matters shy of deathly impossibility make up the terrain of psychoanalysis. We might call that terrain, after Dr. H.’s style, the “almost impossible” about which psychoanalysis can do something, if only it could work through what’s so impossible about it.