The Availability (and The Responsibility) of the Analyst:  ‘Above all, do no harm’

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Janice S. Lieberman, PhD

Thank you to the Editors of The Candidate Journal for providing me with the opportunity to explore with the psychoanalytic community an uncomfortable topic, seldom discussed, but affecting all of us.  We at times discuss the patient’s availability to come to sessions, but not the analyst’s availability.  I would like to discuss the issue of the analyst’s physical availability and not so much his emotional availability or mental availability, even though these are all interrelated.

I pose the following question to debate: After having taken a patient into analysis, on the couch, 3-5 times/week, the process having activated a degree of regression in the patient, for how many sessions and for how many weeks of the year is it the responsibility of the analyst to be physically in his office and providing sessions on the agreed upon days and hours?  Similarly, for how many sessions and how many weeks a year must the supervisor of cases in analysis be physically present?  I do not think the answer to this is obvious and I have observed so many variations in practice that I think it worthwhile to consider.  I am going to raise many questions and do not have ready answers.

Little has been written about the analyst’s “work superego” and his responsibility to his patient other than analyzing.  The focus has usually been on the patient’s availability and the patient’s resistances to doing the analytic work, paying for missed sessions, and so forth.  I have not seen cases reported in the literature (with the exception of those writing about the disabled analyst and the pregnant analyst) in which the analyst reports when he was present, when he was absent, and for what length of time during the course of treatment reported.

We all agree that analysts need vacations (and patients need vacations too), but at what length and at what frequency?  What effect does too much absence on the part of the analyst have on the treatment?  We need to define “too much.”  Can “too much” create an iatrogenic illness or, for those patients whose parents travelled or were often separated from them, a retraumatization?  Do analysts regularly inform their patients that they will not have sessions prior to vacations large and small?  Do they provide sufficient time to analyze how their patients experience these impending absences?  Do they analyze the impact of vacations once they return?  There do not seem to be standards established around what is considered to be good practice.  The tradition begun by European analysts (before air conditioning was available) of taking several months off in the summer, then the hallowed month of August, has now for many become the taking of several short (one to two week) vacations scattered throughout the year.  We must examine the impact of these practices on the analytic work.

Some world-renowned analysts travel a good part of the year to give papers and workshops, to participate in national and international congresses and in governance.  Do their patients and supervises suffer from such absences?  Does the narcissistic gain from having a famous analyst or supervisor feel like compensation?  Is this analyzed?  In some fields, people say that in this age of computers and Skype, they can work from anywhere.  Can the analyst work from anywhere?

The variations that concern me have to do with my observations and reports of two groups in particular: (1) analysts who are starting their private practices (usually in their 30s and 40s) and (2) those who are older and long established (usually in their 60s and 70s).  Some of these younger analysts of child-bearing and child-rearing age take maternity (sometimes paternity) leave of three to four months.  Little has been written about the impact of these leaves of absence.  Those in this age group are sometimes the emotional center of “familial sandwiches” in which they are care-taking their own children, well and sick, and their aging parents, well and sick.  They are in training and/or trying to build their private practices.  At the other end of the spectrum are older analysts, who often have adult children and grandchildren.  They by now earn a comfortable income and have savings.  If they still have their health they feel entitled to “smell the roses.”  I have heard of some taking vacations of two weeks or more every few months often for travel.  What is the impact of this practice on their patients and supervisees?

I am questioning 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.  These analysts are in a position to work through the meaning of their absence to their patients.  I am not questioning those who are stricken with an illness suddenly and cannot work and often have to have someone else inform their patients that they will miss sessions, often for an indeterminate amount of time.  I am talking about what can be controlled, not the uncontrollable.

Other variations in analysts’ accessibility to their patients have to do with practices around providing access in between sessions, on weekends and on vacations.  Are patients who perceive themselves to be in crisis permitted to reach them on the telephone, by e-mail, by text, or are they made to wait until their next session to speak to their analyst?  Some analysts will do phone sessions if needed while traveling, while some do not provide an e-mail address or the name of a covering colleague.  Do these variations have to do with some notions of how analytic work should be conducted, do they have to do with a perception of the psychological needs or transference fantasies of each particular patient, or do they have to do with the personal limitations of the analyst’s psyche and how much accessibility he can tolerate?

I have heard anecdotes from colleagues and candidates of variations in access to analysts. Unfortunately this can differ according to the fee paid or the ease of working with the patient.  I have heard of practices in which analysts who need to cancel a few sessions in a day for personal reasons will cancel their low fee patients and see their full fee patients.  Or they will cancel those who are difficult to work with and see those who are easier.  Low fee patients (and supervisees) are sometimes not given a regular hour.  They are asked to call each week to see what cancelled hours the analyst has to fit them in.  They are what I would call “analytic step-children.”

The physical availability of the analyst is connected with both conscious and unconscious resistance to the analytic work. Certain patients may reactivate old buried conflicts and the fear of countertransference feelings may result in cancellations.

Another variation is that of the analyst who is bi-coastal or has practices in two geographically distant cities and spends several months at a time in each, doing telephone or Skype analysis with the patients who are outside of city of residence. Here the analysis is split into two distinctly different experiences that have a planned structure.  What is the effect on the analysis?

What do we do or should we do when we observe or hear about the work of analysts who do not seem to care about their patients?  On the other hand, how much do analysts have to “care” about their patients?

Analysts vary greatly in the number of patients they see each day and the number of hours they work each week.  This is not entirely voluntary, since some receive more referrals than others.  Some work as many as 60 hours/week, seeing 12 patients each of five days.  Others work 20 hours/week, seeing 5 patients over each of four days.  Analysts vary in energy level.  What is “too much”?  What is “too little”?  It takes a lot of cognitive and emotional capacity to process so many sessions daily.  On the other hand, the analyst who has too few hours may feel out of touch with the work, may feel badly that he has so few hours, may have financial worries and may have to sublet his office, reducing the hours he could be available to his patients. I have heard stories told of senior analysts who regularly fall asleep in their early morning sessions.  One patient who has since left her renowned analyst, was told upon awakening him that her associations were so defensive she made him sleepy. This obviously left a scar difficult to erase.

Is there such a thing as an “analytic superego”?  What subset of rules have been established consciously and unconsciously on the basis of the analyst’s training: through observation of the behavior of one’s own analyst(s), supervisors, and teachers, through what has been heard in lectures, seminars, and peer groups about the responsibility of the analyst to the patient? Recently the analyst’s ethical failures have been examined in the literature of boundary violations.  Do some of the practices in this discussion fall into the area of ethical failure?

One can ask about the relationship between the analytic superego and the personal superego?  Does the analyst who wantonly cancels sessions cheat on his taxes or his wife?  Does the analyst feel guilty about vacations and cancellations and, if so, how does his guilt (or lack of guilt) interfere with his ability to analyze?

I want to thank the Editors of The Candidate Journal for the opportunity to express these concerns.  I look forward to the discussion.

Janice S. Lieberman, PhD is a Fellow and Faculty Member at IPTAR, where she teaches The Contemporary Dream.  She served on the Editorial Board of JAPA for many years.  She is co-author (with Helen Gediman) of The Many Faces of Deceit: Omissions, Lies and Disguise in Psychotherapy and author of Body Talk: Looking and Being Looked at in Psychotherapy.  She has published and presented papers on deception, gender, body narcissism, greed and envy, the digital age, and psychoanalysis and art.

 

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.    

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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...

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