This week I want to discuss something that happens in the course of every psychotherapy work, (possibly more often than patients would like), something that has a major impact on the therapy and the therapeutic relationship.
Everyone who has been in psychotherapy or counselling will know that therapists tend to take breaks (holidays, pauses, vacations, etc) several times a year. Every interruption, be it previously announced or unforeseen, bears a major effect on the psychotherapy work.
The therapist may try to plan the breaks as carefully and thoughtfully as he can, but there is no running away from some powerful dynamics that will take place in and around the inevitable pauses in psychotherapy. However, far from undesirable, the experience of a break will provide an important opportunity for the patient to understand and work through the ways he/she handles some of the facts of life, things like disappointments, dependence, frustration, neediness, separation, abandonment, etc. Therapy breaks will also mirror dynamics and stir up feelings linked to the patient’s early relationships, more specifically with those they had to depend on in their life.
So I will now highlight and explore some of the aspects that a break in the psychotherapy treatment will most likely bring about.
Abandonment and separation: perhaps the most obvious experience that a pause in therapy will bring about is the experience of abandonment and separation. Throughout the psychotherapy work, patient and therapist will form a strong bond, an intimate relationship that is to be the springboard for the therapy to take place. In order for psychotherapy to work, the patient will learn to trust and rely on the therapist. So when a break happens, the bond is disturbed. The way patients acknowledge and react to the experience of abandonment and separation in a break varies greatly. It depends on how defended the patient is against the powerful feelings that will arise. You may say that a break in psychotherapy is not really an abandonment, as the patient normally knows that the therapist will be back. But in the closeness of the therapeutic relationship, a break will very likely bring up early experiences of separation and abandonment, whether the patient remembers them or not, and so feelings like anger, anxiety, envy and sadness will take place. Whilst some patients may be quite detached and dismissive about it, others will perhaps worry about having such negative feelings towards the therapist. As much as possible, it is helpful for therapist and patient to stay with the feelings, that is, to acknowledge them and try to contain them in the context of the relationship.
The feelings: as I mentioned above, the experience of abandonment stirs up very intense feelings in the one who’s being left. Well, I agree that being left by a therapist who goes on holiday is not the same as being abandoned by a parent, or left by a partner. But as it is, psychotherapy is about understanding and living through experiences, feelings and dynamics that belong elsewhere, but are made present in the context of the therapeutic relationship. In this way, it’s important to notice the feelings that are around when the therapist interrupts the work by deciding to go away. Some feelings are more obvious, such as anger, sadness or anxiety. Others are not so much, such as hatred, envy, jealousy, inferiority. A break then can provide an excellent opportunity for patient and therapist to understand and work through powerful but important feelings.
Acting-outs: feelings and experiences that can’t be thought about and put into words, perhaps because they are too unbearable, are often discharged in the way of acting-outs. This is not different around breaks. For instance, it’s not uncommon for patients to suddenly make life-changing decisions (e.g a break-up, a break-through, a career change, etc) around the pauses in the therapy. These decisions may be well meaning and genuine, but they can also take place as a defense against the patient’s dependence and neediness as the therapist is experienced as cruel, insensitive or reckless for going away at such crucial moments. It may mean that the patient is ditching the therapy, downplaying the therapist’s helpfulness with contempt and with that saying that he/she can take care of themselves, never to feel abandoned again. This is the same for another kind of acting-out that I often observe around interruptions in the treatment, when patients decide to end the therapy. Whilst some care to discuss this in the sessions, others just never come back from the holidays. Again, how much of it is the patient showing contempt towards this selfish therapist, stating that he/she does the abandoning, not the therapist. When the psychotherapist goes away on a break, it highlights the patient’s dependance and need for help. In this sense, the patient trying to show who needs who can be an important message on how he/she handles experiences like being left. Other acting-outs include cancelling sessions just before or after the break, or not turning up, or messing up their session times. Some patients will dismiss it all as meaningless, but as psychoanalysis believes that everything has a meaning and that in life there is no act without intention, consciously or unconsciously, such acting-outs can provide a great source for thinking and understanding. Whatever it is, acting-outs are important expressions of feelings that the patient can’t put into words, so it’s down to the psychotherapist to interpret, to name and contain such experiences, providing meaning and promoting a truly therapeutic experience.
Guilt: some patients will experience what I described above, the abandonment, the intense feelings and reactions, the anxiety and so on, and become overwhelmed with a sort of unconscious guilt for having had destructive feelings towards a process that has meant a lot to them, a therapist that has helped them during perhaps some very difficult times. This is important, as it mirrors the development that happens when we are babies, in the experience of depending on a mother who can look after us and feed us, but then having to deal with destructive feelings towards her when she is absent (even if for a few seconds when baby is distressed). In this way, therapy breaks give rise to very primitive anxieties, but the guilt can hopefully prompt reparation and development, as it does in early life.
I believe that it’s clear now that breaks, holidays, pauses and interruptions in the treatment will very likely stir up feelings, experiences and dynamics, some more unconscious than others, providing a great opportunity for therapy to happen. As patient and therapist become aware and work through the equation of abandonment, intense feelings, defenses and guilt, the patient has the chance to come to terms with the ambivalences and complications of real relationships. We will have to lay down our defences and, to a degree, become dependant and vulnerable if we want to establish meaningful relationships in life. And for that we will be disappointed, heart-broken and frustrated, but we will also open up to the beautiful exchanges that real relationships can bring over. And so therapy breaks can provide the chance to work through this.