The Analyst’s Availability: A Discussion
Joe Cancelmo, PsyD
I am grateful to the Editors of The Candidate Journal for inviting me to discuss Janice Lieberman’s essay, “The Availability (and Responsibility) of the Analyst.” Janice’s writings, both academic and in popular press, are wide-ranging – from the external world of society, culture and art, to the internal, visceral world of body and character development and their intersections. This complexity comes through in her creative musings in the form of questions about the curious absence of discussion on shifts in the analyst’s “availability” to patients.
I will offer some general impressions, my own musings about this area of analytic scrutiny. Then, I will briefly discuss Janice’s questions in the context of cultural shifts, both societal and psychoanalytic, and how the two may intersect to create what are noted here as “availability” issues. Along the way, I will pose some of my own questions that occurred to me as I read her essay.
I’ll start with a personal vignette from back in the day I saw my first therapy patient. I vividly recall a dilemma that has stayed with me, perhaps a nascent formation of a professional "ego ideal": I saw this young man at 7:30PM, which fit his schedule, and mine as well. All was well until about three months into his treatment. A good friend had invited me to a VIP cocktail party, a prominent magazine’s anniversary celebration at a trendy club. Passed Hors d’oeuvres, a buffet and "top shelf" open bar. My favorite band was performing (the club and the band will not be identified, as this will date me). The only hitch: I needed to meet my friend at 7PM sharp to collect my VIP Guest Pass. As an overworked and seriously under-gratified graduate student, the gravitational pull of this conflict was excruciating. I turned to my supervisor, while knowing full well the "right" thing to do. My supervisor, an analyst, empathized with me, put words to my dilemma that I still recall: “This is hard work, this always putting someone else first, always being available when you say you’ll be, unless it’s humanly impossible, of course.” She went on to offer qualifications, saying things about sickness, storms, acts of God and the like. The die was cast but echoes of this struggle can still be felt, even after many decades of work. I suspect I am not alone with this. It is far easier for analysts to talk about sex and money than it is to discuss the deprivations and gratifications, our subjective countertransference, or questions about the psychoanalytic position and its operational face, the clinical frame. Janice is including us all in these questions about availability – from beginners to seasoned analysts – and we would all do well to take note.
Janice frames the debate for us with a series of interrelated questions about the state of the contemporary psychoanalytic position or contract. I will extend this metaphor to the psychoanalytic frame – the operational face of the psychoanalyst’s position – as it seems a central thread, the core of the questions raised here. The idea of frequency, of bounded time and space, of the inherent promise of availability and consistency from the analyst’s side are irrefutable aspects of the frame as representation of the psychoanalytic contract. Janice wonders, are there, and if so, what are the limits of this availability?
As Janice notes, there is not much assistance to be had from the literature when looking for guidelines regarding the “work superego” or analytic “ego ideal.” But what is there is interesting. In these mostly older articles, the focus is on the analyst’s identification with their training analyst’s norms – like my analyst did thus and such when dealing with absences or vacations. Also of interest are papers that address the harshness of the analyst’s ego ideal, the dangers of unrealistic expectations of themselves in the work, and how this translates to their view of the efficacy of the work itself. These ideas seem to fall under the heading of therapeutic zeal and overlap somewhat with the notion of what termination should look like, and what should have been accomplished in an “ideal” analysis. In other words, the question of availability was a given; we had to be wary of overzealous behavior.
As I dug deeper into Janice’s questions, I kept thinking about her other writings, on narcissism, on deceit, on cultural shifts in social norms (as she is a social as well as clinical psychologist and psychoanalyst). I see some intersections here between the suggestion of an erosion of accepted standards for conducting analytic practice and cultural shifts as the two inevitably emerge in our treatment rooms: the downsizing of frequency, opting for other short-term treatments, and of course the tide of SSRI’s that enshrines the shifts in cultural views on how to transform roadblocks to meaningful work and love relationships. I will add two normative items here: the shift to a 45 minute consultation hour, and its first cousin, the back to back session.
Psychoanalysis as a profession has been responding to these cultural shifts, beginning in the late 1930s with Kurt Eissler’s (now quaint seeming) paper on “parameters” and the groundbreaking work of Leo Stone in the early 1950s on the “widening scope” of psychoanalysis. Both papers suggested that the frame and what happens within it would have to shift more flexibly in order to best fit the treatment needs of patients who were starting to fill our practices (that is, patients with characterological problems, in particular, narcissistic and borderline difficulties). What quickly followed over the ensuing decades were parallel movements away from a strictly one-person, intrapsychic conflict model to a two-person model and intersubjective theories and techniques. These developments also gave more weight, and for some, central attention, to countertransference phenomena, both subjective (in the classical sense) and objective (as induced and providing information, a kind of emotional resonance). These conceptualizations reflected real shifts in who we treat and how we treat. Our literature has grown exponentially to reflect our clinical charge – to make an analytic space anew for each patient, as Ogden recently noted. But again, direct discussion of systemic, de facto changes in the way analysts make themselves available in contemporary practice has been curiously absent; perhaps the only references to be found are in clinical reports of countertransference acting out by the analyst or enactments around the frame in the face of work with more challenging patients. Here too these are considered aberrations or technical glitches, not accepted (or acceptable) norms.
It seems plausible that along with these shifts in clinical practice, aspects of our standard practice model such as professional availability may have shifted as well. Janice notes, for example, that the standard August summer off, now that we have air conditioning, is not universal. The realities of developmental needs with family schedules and obligations are also in the mix as we navigate our increasingly complex world, a world much more hectic and pressured than our analytic ancestors could have envisioned. Back in Freud’s day, analysis was also shorter, often conducted in intense bursts of treatment over circumscribed periods. Was it easier to stick to the availability Janice describes here as a basic frame and agreement back then – when travel was harder and more of a project, before air travel, the Web, and Airbnb?
We now hear of treatments that last several decades, or a near lifetime, and also change over time in frequency, with intermittent lapses as well. Does the analyst’s availability go through changes over the course of such treatments, and if so, how and why? As Janice notes, there also are evolutions in how analysts take their (necessary) breaks and travel for conferences. Are these, too, reflective of cultural shifts, perhaps some widening scope of the frame from our side of the couch? Or, could there be some emerging breakdown of ethical structure or sense of obligation that has eroded our professional position outside of our awareness? Are there pressures to write and present publicly at conferences so we can jockey for a better spot when analytic referrals are harder to come by?
Janice rightly wonders whether and how we deal with these periods of unavailability. One would hope that they are analyzed, but here too, what does this mean? This begs yet other questions, like how much of a real object we are to our patients; are we simply objects of transference of early relationships? Depending on one’s theoretical/clinical perspective, the patient’s reactions to our unavailability may be interpreted as transference. From another perspective, the impact is at least first seen as a “real” intrusion. Do our views of transference skew how we see patients’ reactions to our unavailability (i.e. is it simply grist for the mill, or are we, as real objects, failing them in some concrete way?) And, at the other extreme, but not unrelated to the issue of availability: when the analyst goes outside the frame to attend a patient’s play, art show, or musical performance – is she making herself unavailable (as a transference object) by concretely meeting some transference need?
Janice also gets into some important new territory on the impact of technology in our cyberage. Our field has been attentive to this theme in recent years. Analysts are talking to each other about how our practices have shifted due to digital communication. Access via email or text, the stretching of the frame (or again, depending on one’s vantage point, an accommodation of the frame, an evolution of the dyad for this digital age), are topics making their way into analytic discourse, in print and at conferences (and of course on the internet). Janice questions what is reasonable for patients to expect from analysts in this new era; it is one thing to try to accommodate a Millennial’s texting to reschedule an appointment and quite another it seems to conduct more detailed clinical exchanges on an iPhone or to treat people remotely by phone or Skype.
It is troubling to consider Janice’s report of analysts who cancel low fee patients or make such patients or supervisees wait for an appointment from week to week. This seems an availability issue of another magnitude, more a breaking of the frame, a kind of betrayal of certain ethical commitments that we make when we put out a shingle to practice. I found myself wondering if our rapid technological advances have begun to affect our sense of attachment in ways that we are likely only to discover once well underway. It is safe to say that many analysts are not “digital natives” but even older generations have adapted – using email, text, smartphone apps, and social media. Some of us struggle with internet usage and distractions from tech devices. What insidious effects might the impingement of technology have on our analytic position when seen in the context of questions about availability and the frame? This begs yet another question: do analysts struggle with the urge to look at their iPhones in session, waiting for some important text for example, even if only silently monitored, or worse, contemplate responding to a text with a word or short phrase? Even if such impulses are not acted upon, they undoubtedly create moments of unavailability, at the very least.
Finally, I kept thinking as I wrote these last words how useful it would be to conduct an anonymous survey about these analytic behaviors – and maybe to expand such reflections in a longer paper. I imagine the title as something like: A Plea for a Measure of the Analyst’s Availability (and Responsibility) in Contemporary Clinical Practice – with apologies to Joyce McDougall.
Eissler, K. R. (1953). The effect of the structure of the ego on psychoanalytic technique. J. Amer. Psychoanal. Assn., 1:104-143.
MacDougall, J. (1980). A plea for a measure of abnormality. Madison, CT: International Universities Press.
Ogden, T.H. (2016). Reclaiming unlived life: Experiences in psychoanalysis. NY: Routledge.
Stone, L. (1954). The widening scope of indications for psychoanalysis. J. Amer. Psychoanal. Assn., 2:567-594.
Joseph A. Cancelmo, MSEd., PsyD, FIPA is Past President, Training and Supervising Psychoanalyst (Fellow), Faculty member and Chair of The L.J Gould Center for Systems-Psychoanalytic Studies of IPTAR.
Thoughts on Availability
Claudia Heilbrunn, MA
In her piece “The Availability (and the Responsibility) of the Analyst”, Janice Lieberman questions the practices “of those who electively take vacations or cancel blocks of sessions, not those who must take time off due to planned surgeries, cancer treatment, and the like” - those absences that are “uncontrollable.” But how much do we really control when it comes to our availability? Is not the distinction between physical and psychological availability in some ways false? Sure, we can skip vacations and days off, take emergency calls when needed, say no to an event...