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 to keep our late-night appointments each week; we can grapple with our resentments about working so hard, work through our more difficult counter-transference reactions, soothe our distressed patient with silent tears running down our own cheeks, and struggle to stay present with our patients when our hearts are in our throats because our child, our mother, our sibling, or, we, ourselves, are sick or dying. Yet with these and so many other circumstances in mind, can we fail to ask if physical presence and availability necessarily go hand in hand? Or, for that matter, if physical absence can’t sometimes include great availability if the absent analyst holds a patient in mind so thoroughly that the patient feels cared for and held?
A number of years ago, during a “break” in my own analytic treatment because of my analyst’s terminal illness, and after my mother was diagnosed with a life-threatening disease and underwent surgery that went less than well, I decided that I was done with being a therapist of any kind. I felt I could no longer listen, analyze, understand and help. I had nothing left. Having already experienced the deaths of two analysts, and now fearing the impending death of another and, possibly, of my mother, I found myself utterly horrified at the prospect of seeing patients, and I did not believe that my feeling was temporary. At that moment, I felt that I had realized something that was unalterably true: I did not enjoy being a therapist and wanted out immediately.
I asked my (then current) supervisor if I was allowed to quit - to become utterly unavailable. Her answer was no. When you begin with a patient, you commit to that patient until the patient decides the treatment is over, however long that takes. Unlike marriage, there is no separation or divorce, unless the analyst becomes ill, dies, perhaps has children and stops working, retires, or moves. Taking on a patient, it seems, is a commitment that lasts as long as the patient sees fit. The analyst is available ad infinitum. Period.
At that time, I was in the midst of what felt like an ethical maelstrom: physically able to treat patients, yet desperately wanting to escape from them all. The experience made me wonder about availability - my own and my analysts’. Who was more available, me or my dying analyst, who tried to stay present with his patients despite his exhaustion, pain and missed sessions? Me or my first therapist, who denied his impending death and refused to legitimate my concerns over his extreme weight loss and obvious illness? Me or my very beloved, yet workaholic, second analyst, who came to our sessions despite her pain and frailty because she needed to focus on someone other than herself?
Life interferes terribly with the commitments we make when we sign on to be analysts. I thought at the time: I signed on knowing that analysis was what I wanted to do, yet I knew that before I actually practiced. I knew it before I actually spent multiple hours each week sitting with patients - before I knew what it felt like to hold so many people’s extreme trauma, anger, hurt, and distress even when I could barely hold my own. I had no idea of just how hard being an analyst would be - how humbling a job and how bumbling and ineffective I would sometimes feel as a clinician.
And when my now-dead analysts signed on, I very much doubt they thought about or could really know how they would handle their availability when it came to their own deaths. How could they fathom the strength of their own denial, how much they might need their patients covertly to take care of them - to understand and accept the missed sessions, to temper emotional upheavals according to daily pallor, to wait patiently, not knowing if the next session would happen or be missed, then missed again, until a final goodbye was said in person, on the phone, or not at all? What does availability even mean when an analyst is dying? With no frame left, what is an analyst or patient to do?
During that time, when I saw my patients each week, feeling as if I had one foot in the door and the other firmly, albeit metaphorically, out of it, what could my concrete presence have meant other than that I was sticking to a psychoanalytic frame of “available analyst” while actually feeling devoid of the vital aspects that make me an analyst at all? Indeed, can a standard of “good practice” or a definition of “too much” time away exist in a world filled with so many exigencies and psyches? Different dyads can withstand - even thrive with - different degrees of emotional and physical unavailability: some patients are fine with vacations, while others can tolerate no absence at all. Particular analysts know that, if they treat certain types of patients, they must be available 24/7, at least for a time. Others, wisely, do not take on these patients because doing so would be unfair to both the patient and analyst: the analyst cannot offer the required degree of availability.
In response to Lieberman’s piece, Joe Cancelmo quotes his supervisor as saying what many of us believe: “This is hard work, this always putting someone else first, always being available when you say you’ll be, unless it’s humanly impossible,” and we endeavor to show up unless faced with “acts of God” that are beyond our control. Yet unless analysts actively grapple with their conflicts - their desire to miss sessions to go (yet again?) on vacation, or on a date, or to a child’s school function, or even just home to read a novel in bed - their availability to their patient is only partial. What if an analyst functions best only when s/he builds into his/her schedule as much time away as s/he sees fit, whatever that may be? It may suit one patient just fine but not another. It may be that, while all analysts must have a frame, the frame will differ according to the particular degree of availability inherent in the psychoanalytic contract that each analyst makes with each patient. Perhaps having our own specific contract that we, as individual analysts, abide by consistently can help us avoid harming our patients when we tend to our inevitable needs and desires.
In the final analysis, availability is best viewed as a subjective phenomenon, which must be negotiated on an individual, case-by-case basis. Analysts must always strive to act in their patient’s best interest but whether conventional availability is always in that best interest is open to debate.
Claudia Heilbrunn, MA, received her BA from Columbia University and her MA from the University of Pennsylvania. She is an Advanced Candidate in IPTAR’s Adult Psychoanalytic Program.