At Death's Door: Therapists and Patients as Agents

Irwin Z. Hoffman

[Paper presented on June 9, 2000, at the Annual Meeting of the Rapaport-Klein Study Group]



An earlier version of this paper was originally presented at the annual Chestnut Lodge Symposium on October 1, 1999 in Rockville, Maryland. In February 1999, David Feinsilver, my sister's husband, and my good colleague and friend, died at the age of 59 of cancer. He had been on the staff at the Lodge for more than 30 years. This all-day conference on therapeutic action was dedicated to his memory. As one who had been close to him, and with whom David had shared common psychoanalytic interests and -- increasingly toward the end of his life -- common ideas about the analytic process, I was invited to be one of two plenary speakers. Thus, the context of the original presentation was one in which my sister and her grown children were present along with many others who knew the family well. Presenting the paper was itself a highly personal act of "affirmation" in the face of loss and mortality, part of a ritual of memorialization and rededication. The reader is invited to consider the context-dependent meaning of that moment, in which aspects of the content of the paper were paralleled by aspects of the process of presenting it.

Rising to the Occasion

My brother-in-law, David Feinsilver, was a champ when it came to living to the fullest whatever the obstacles. He came to Chicago with my sister and with both of their grown children in April 1997 to attend my younger son's Bar Mitzvah. That was a brave and generous feat considering the amount of discomfort, pain, and fatigue that David was experiencing from his cancer and chemotherapy treatment. David always pushed himself, though, to try to do whatever was necessary, or more than that, the maximum that was possible. That attitude generated some outstanding writing in David's last years and months. In one of his last papers, "The therapist as a person facing death: the hardest of external realities and therapeutic action" (Feinsilver, 1998), David defined the term "mentsch" in a manner that could so readily apply to him: "a person who confronts, clarifies, and overcomes what frustrates him, internally and externally, and then acts morally, ethically, and with compassion, to do what the situation calls for; in essence a person who rises to the occasion on difficult occasions to do 'the right thing'" (fn. p. 1148). So, considered in a secular way, there was David at the Bar Mitzvah rising to the occasion, despite his illness, to celebrate my son's emergence in the community as a responsible agent, as a contributor to the uniquely human project of socially constructing and maintaining a world of meaning and value against the backdrop of mortality and of a brutally indifferent universe.

Acts of Will and Imagination I: A Patient at the Analyst's Door

Two and a half weeks after the Bar Mitzvah, my 18 year old son stood at the side of my bed. I'd been home from the hospital for just a few hours, recovering from triple coronary bypass surgery, an operation David himself had had more than 20 years earlier. Since David and I were somewhat competitive, perhaps he was right to needle me with the suggestion that some part of me was loathe to concede bragging rights to him with regard to dealing with life-threatening illness. It had all happened very fast. A stress test in the course of a routine physical examination revealed an arrhythmia leading to further tests and an angiogram [6 days after the Bar Mitzvah] in which the entirely asymptomatic arterial blockages were unmistakably evident. The location of one of the blockages precluded angioplasty and made the surgery several days later the only viable option.

I'm not sure when I was in the most danger: in the period before the surgery when I was working out strenuously oblivious to my coronary artery disease, while listening somewhat nervously as my son gave his Bar Mitzvah speech in the temple, while I gave my own at the reception, during the surgery itself, or recovering in the hospital in the aftermath when I thought I'd die of starvation, lack of sleep, or boredom. In any case, it was great being home after the five day hospital stay. My wife was outdoing herself trying to make me comfortable; she had prepared something for me to eat that I actually enjoyed, and I felt more relaxed than I had felt since the surgery. But now my son at the side of the bed was saying, "Dad something very weird just happened. I opened the door for my friend who was dropping off some flowers and a card for you. An older man was behind her, and as she left this fellow approached and asked, 'where's the body?' I was a little thrown as you can imagine, but after a moment, I said 'if you mean my Dad, he's upstairs resting.' The guy said, 'OK, please give him this' and he gave me this check." My son handed it to me, and I was rather startled as I looked at it and at the accompanying note from Manny, an 86 year old patient I'd been seeing in analytic therapy for 12 years and whom I had written about extensively in the last chapter of my book which was then nearing completion. The discussion of the work with Manny centers largely on the issue of mortality. In the note Manny explained that he thought that in this difficult time I might appreciate the payment for the not-yet billed recent sessions.

I had a mixture of feelings: a combination of amusement, appreciation, and rather intense annoyance. I thought and mumbled something like "Jeez, this man has been in analysis for over 50 years (encompassing two analysts before me). He knows better than to show up at the house on a day like this. And what in the world did that remark mean: 'where's the body'?"

A few days later I was making phone calls, thanking people, including patients, for their cards and calls and gifts, letting people know I was doing well, and informing them of the time when I'd likely be returning to work. Manny was among the first people I called. Not only had he made the effort to come to the house with that check, he had also come to the hospital and delivered an orchid the first day after the surgery, leaving it with a receptionist in the lobby. So I wanted to thank him. Yet I also knew it was likely that I would express some displeasure about his coming to the house. I knew I was angry about that. It seemed impulsive, intrusive, at least poor judgment on Manny's part. I can't say I remember exactly what my expectations were as I made the call, whether I "planned" to say anything about those negative reactions or just had a readiness to say something and thought I'd play it by ear. I began by thanking Manny for the orchid and for the check and telling him that the surgery was a success and that I was recovering well. At some point Manny began talking animatedly about the money, why he thought it might be useful for me to have it as soon as possible, etc. He said he'd gone to the hospital first, but finding I'd been discharged he decided to just drive straight to my house. At that point I said, "You know Manny I don't think coming to the house was such a good idea." I don't recall exactly what was said after that. I know we didn't get into it very much on the phone. He may have asked why and I believe I said because it's my first day home, I needed a little privacy, he didn't know who he would encounter at the door, and so on. I mentioned that even close relatives and friends were not visiting on that day. He was polite about it as I recall. Said something like "OK sorry, just thought you might be able to use the money. Hope your recovery continues to go well."

We can pause for a moment to consider my comment on the phone. The time to judge it is at this juncture because we are always acting in the analytic situation (and in life in general for that matter) without the benefit of hindsight. Moreover, even hindsight hardly tells all that we would like to know, because we can never know just what would have happened had we chosen a different course. Even another similar moment with the same patient, not to mention a different patient, would not afford an opportunity to find out because there are countless factors that would not be the same. So the moment is unique. I could consider the circumstances, the patient's vulnerability, the patient's history, how the patient responded in the past if I said something that might have been narcissistically injurious, the possible unconscious meanings of Manny's gesture. All of these factors undoubtedly "enter my mind" and influence my choice. But there are other considerations which are simply my own feelings and my wish to relate to Manny in an honest, authentic way. By that time I had given a lot of thought to the importance of the analyst's authenticity and spontaneity in the process considered in dialectical interplay with psychoanalytic discipline and ritual (Hoffman, 1998). It seemed to me that it was important for the health of the relationship, and therefore for the patient's health, that the analyst or analytic therapist (terms that I am using interchangeably in this paper) not regularly bury intense countertransferential feelings. Apart from the fact that there is a danger that they will build up and get expressed unconsciously, and apart from all we've learned since Racker (1968) about the "meanings and uses of countertransference" as an avenue for exploring the patient's intrapsychic life, part of the patient's need developmentally is for a real relationship with a real person, notwithstanding the many contrived aspects of the analytic arrangement.

The importance of the analyst's honesty and authenticity is just one major consideration though. It doesn't provide a sacrosanct prescription for action any more than does the rule of abstinence. Honesty is not always the best policy. There are times, particularly in our roles as analytic therapists, when other considerations may take precedence. So there is no way to wring the disturbing element of choice out of my action when I am deciding what to say to Manny. In this instance, what pushed it over the edge for me were Manny's elaborations on the value of his visit. He seemed to be protesting too much as it were, thereby seeming to betray a bit of his own conflict. Meanwhile it made it that much harder for me to go along since my silence combined with "uh huhs" in a friendly tone could be misconstrued as mere agreement and gratitude.

With regard to the issue of choice on my part, I should add that the counterpart, as I see it, is choice on Manny's part. Whatever the dynamics governing his action, I regard him as a responsible, free agent, not merely an organism responding to internal and external pressures. He did not have to come to the house. He could have noted the impulse to do so, and taking the totality of the situation into consideration, he could have decided to put the check in the mail with a note or a card. From my perspective at the time, that would have been the wiser course. We are so used to thinking of anything our patients do as psychically determined we end up contradicting ourselves whenever we treat them as free, responsible, and not fully predictable agents. Although the ideology of psychic determinism presumably covers all human functioning, including that of the analyst, Freud's paradigmatic "person" was decidedly the patient not the analyst. Thus, the patient's freedom was precluded by the combination of forces acting upon his ego. But the analyst's freedom was also virtually eliminated by the requirement that he or she follow whatever scientific method was necessary to explore and discover the truth about the patient's unconscious uninfluenced by the analyst. As Otto Rank (1945) wrote: "In Freud's analysis, the will apparently plays no particular part, either on the side of the patient or on the side of the analyst" (p. 11).

Without attempting to solve the conundrum of free will that philosophers have been struggling with for millennia, please allow me this one philosophical reflection. Determinism is no more satisfying intellectually than is free will since it merely begs the question of origins. If what I am writing right now is determined entirely by causes other than my will, what were the causes of those causes, and so on ad infinitum? There is nothing any more or less unfathomable about how a person could be a choosing subject or agent than there is about the origin of the universe. Moreover, ultimately, we act as though we believe people are responsible agents and to act differently would create a very different world. Then the question would be whether we want to "choose" to create that world in which human beings are not held responsible for their actions. I think most of us would be averse to creating much less living in such an environment.

Regarding the human will as opposed to psychic determinism, Rank (1945) offers the following:

The causality principle means a denial of the will principle since it makes the thinking, feeling, and acting of the individual dependent on forces outside of himself and thus frees him of responsibility and guilt...  Only in the individual act of will do we have the unique phenomenon of spontaneity, the establishing of a new primary cause...  So one sees why a natural science psychology denies will and consciousness and in their place must introduce the unconscious Id as a causal factor which morally does not differ at all from the idea of God, just as sexuality as a scapegoat is not different from the idea of the devil. In other words, scientific psychoanalysis gives the individual only a new kind of excuse for his willing and a new release from the responsibility of consciousness [pp. 44-45]. [Footnote 1: Ranks' conviction about the central role of the patient's will seems to have developed partly as a reaction to its complete absence from Freud's theorizing and from psychoanalytic theory in general. In the context of that reaction, Rank was zealous about the analytic process fostering the emergence and development of the patient's autonomous self. In that spirit, he abhorred the analyst's moral influence except insofar as it facilitated the patient's autonomy (e.g. see Rank, 1945, pp. 66-68), a view that is quite contrary to my my own. The perspective I have called "dialectical constructivism" (Hoffman, 1996, 1998) calls for recognition of the inevitability of the analyst's moral influence and the desirability of its being exercised in a reflective, self-critical, and judicious way. In Rank's "constructive therapy" the analyst aspires to promote the patient's achievement of an unencumbered agency and freedom which is decidedly in the spirit of an enlightenment, "modern" sensibility and is wholly lacking in the postmodern appreciation of the individual's inevitable social-cultural embeddedness, as well as the influence of unconscious dimensions of the transference and the countertransference. Those factors, however, can be regarded as powerful influences without being wholly determining of the patient's experience and behavior so that "space" is still left for the individual will as a "primary cause." In effect I am advocating an integration of modern and postmodern perspectives on human agency (see Margulies, 1999).]

So I see Manny as responsible and as capable of having chosen a different course, just as I am responsible for my conduct on the phone. This perspective is important because it has practical consequences for how I relate to the patient and for how I reflect on my own participation. I think there are still many indications that analysts are very much encouraged to think of what they are doing as akin to the treatment of a disease or disorder, such that , if only enough were known, there could be a "treatment of choice" for a condition or for a state of mind at a particular moment. The condition or the state of mind as well as the treatment in this model are, for all practical purposes, homogeneous across all analytic dyads. So if we had a diagnosis for Manny complete with a developmental assessment or an assessment of his state of mind at the time of the visit to the house, maybe the analyst would know what to do. What is most unlikely in this model is that the patient would become the object of any sort of criticism since his or her behavior is merely a reflection of an illness which, of course, is not the patient's fault. So the patient behaves in some way and the analyst makes the appropriate, prescribed "intervention." Neither party in such an interaction is seen as a freely participating subject, heavily influenced, to be sure, by internal and external factors, but free nevertheless. Instead, both parties are seen as doing what they must do, given the pressures that are impinging on them. [Footnote 2: The disease model does, of course, apply best to certain conditions in which biological causation of symptoms has been demonstrated, such as manic-depressive illness, and schizophrenia. Even in those conditions it is quite possible, however, that the role of the individual's will may be underestimated or denied by both caregivers and patients.]

A few days later I received the following e-mail from Manny. Would anyone care to guess what he said? A suspicion, by the way, that he might say this or that is not the same as knowing what is coming, even though with hindsight we often feel we "knew" all along what was going to happen. The hindsight often transforms the mere "inkling" that was there before the fact into an absolute conviction in the way we remember it after the fact. "I knew it," we say, "I just knew it!!"

So here are some excerpts from Manny's e-mail:

Dear Irwin: I trust you are recovering rapidly. I hesitate to even write this because I am angry at your reciting Emily Post to me. I did not deserve it and it only shows your affection is only skin deep. I am aware about visiting uninvited and am meticulous in following this because it is the only respectful and decent way to operate -- but there is such a thing as extenuating circumstances… 
I always wondered how you could learn to care for clients with troubles including yours truly.
You put on a good show, and it probably was helpful. But I am not looking for a "show." I could go on to the reality of my visit and [tell you] that it wasn't to invade your family. In fact, I have tried to keep our relationship in as classical a manner as possible. Perhaps you are too arrogant in your interpretation. Konfused.

My reaction to the letter was one of shock and injury. I was quite hurt by it considering the years of work and the genuine feelings I had developed for this man. I think he knew how much value I placed on the sincerity of my attitude toward him so he knew he was getting to me at a very deep level. And he knew also that it was a time of heightened vulnerability for me. At the same time I had to recognize how incredibly hurt he must have been by my remark for his reaction to be so extreme. "I don't think coming to the house was such a good idea." Was that such a terrible thing to say under those circumstances? Why wasn't Manny more forgiving or even apologetic himself, or at least more balanced in his response? Was it incumbent upon me now to soul-search, to consider that I should have felt differently or at least handled how I felt differently? Maybe I could have emphasized more how thoughtful a gesture it was and still registered some reservation about the "house call" to be taken up when we resumed our regular meetings. If my affect were different maybe my tone of voice would have been different so that both what I said and how I said it would have been different. In any case, I responded to Manny's email with a rather long one of my own several days later which read, in part, as follows:

Dear Manny, I am very upset by your note. Whatever it means that I objected to your coming to the house, it doesn't mean that my affection for you is only skin deep. How can years of knowing each other be nullified by one moment like that. You mean a lot to me and what you feel toward me means a lot to me. And you do have the power to hurt me, as I know I have the power to hurt you. I doubt that would be the case unless we had some pretty strong personal connection.
Our relationship is based on honesty. Ironically I think it would have been more in an Emily Post spirit of "correct" analyst manner on my part to just say everything was fine when I didn't feel that way. . . .
I can understand your feeling hurt by my saying I didn't think coming to the house was such a good idea, but I really don't think it's fair (or true) to say that it proves that all the rest was "just for show." There's nothing I can do, of course, to "prove" that my feelings for you are sincere. For the moment all I can do is appeal to you to at least consider that you MIGHT be wrong in your conclusion that they're not.
Maybe there's reason to trust a person's affection MORE when they are prepared also to tell you what bothers them. That's at least another way to look at it.
My thought is actually that we are really close enough and you know me well enough so that, feeling as hurt as you felt by me, you wanted to say something that you knew would get to me because you know that for me there is hardly anything more important than trying to be honest and genuine. So what would cut to the core more than to call me a phony? Well, you're right. It does.
I do appreciate your writing the note and letting me know how you feel. I realize that you might have been tempted not to bother, to just say "to hell with him" and write me off. So I take your note as expressing something of an interest in trying to develop more mutual understanding and give us a chance to work things out. Like bypass surgery, one wishes it didn't have to happen at all, but once it happens what's there to do but try to make the best of it? With this event between us, maybe we both wish it didn't happen, either because I would have reacted differently or you would have reacted differently, or something. But since it did happen maybe we can use it in a way that will actually deepen our relationship and from which we can both learn. I hope so. Love, Irwin

Although the letter is certainly very expressive my feelings, I think it's important to emphasize that it is also carefully written and consistent with what seemed right to me in my role as Manny's analyst. Among other things, in the letter I try to impress on Manny the importance of keeping an open mind on the meaning of my response to his coming to the house, one that I appeal to him to regard as at least ambiguous in its implications. Thus, even though the letter may seem, in the foreground, to illustrate "spontaneity" and "expressiveness," it also, hopefully, reflects my understanding of the risks and potentials of the situation and of proportional analytic restraint. In other words, I see it as emerging, not from a striving for "authenticity" viewed in isolation from the analytic context, but from the dialectical interplay of "expressive participation and psychoanalytic discipline" (Hoffman, 1998, chapter 7).

I heard back from Manny that he was certainly interested in continuing the analytic work and that he looked forward to resuming when I returned to the office. I did not take for granted that he would continue, and felt relieved when he indicated that he would. The resumption itself was a generous, forgiving act on Manny's part, responsive perhaps to my very personal letter. If he stopped abruptly by his own choice, or if he fell ill or died, my own action in disapproving of his visit to the house could readily have taken on a much darker coloring in my own eyes as well as the eyes of others. The patient's response co-constructs the meaning of our participation. Therefore, exactly the same actions can become sources of guilt or of pride, and everything in between, depending on what the patient decides to do in response, and/or depending on contingencies outside of anyone's control. In a sense a great deal of luck is involved in determining the value we place, perhaps unfairly, on what he have done. In this connection, Thomas Nagel (1979), the philosopher, writes about "moral luck" (following Williams, 1976), suggesting, for example, that exactly the same moment of inattention on the part of a driver of a car can result either in catastrophe (such as hitting and killing a child running out into the street) or in nothing noteworthy at all (pp. 28-29). Perhaps the inconsequential moment wouldn't even register in the driver's memory.

But as it turned out with a little bit of luck and Manny's generous effort we did a lot of useful work on this episode at the house once we resumed our regularly scheduled sessions. Manny was embarrassed about having come to the house although he also wanted me to appreciate his good intentions which I did. He was especially mortified by his peculiar statement to Mark ("where's the body?") and very apologetic about it. We understood it at least in part as an expression of his anxiety about my well being, a condensed version of a statement such as "where is your father who I have been so terrified might die." Manny had been emphatically opposed to my having the surgery altogether, believing it would surely kill me. He had written to me before the operation to say that since I was asymptomatic I would be much safer if I resisted the recommendations of the medical authorities whom Manny regarded as engaged in nothing short of a nefarious racket of expensive, unnecessary, and dangerous procedures. Since I didn't follow his advice perhaps his remark could be understood as shorthand for "where's that father of yours who by all rights should be nothing but a corpse by now since he was fool enough to ignore my wise counsel?"

Manny rightfully pointed out that there were several factors that mitigated, for him, the sense of inappropriateness of his conduct in coming to the house that day. First of all, his first analyst (of the two before me) was prone to blurring the boundaries between analytic life and everyday social life in that he would often invite Manny and other patients to his house along with other friends. This was a well known analyst in the early period of psychoanalysis in Chicago when there was apparently an inner circle comprised of devotees of the new discipline, some of them patients some not. I admitted that I had completely forgotten about this precedent that Manny had for his own inclinations. Second of all, I had myself done my share to encourage Manny to think of himself as part of my family. Over the years he had introduced me to his interest in orchids and had given me a couple of them purchased at a huge and nationally known orchid nursery in the Chicago area. I had taken them home and told Manny that my wife's interest had been sparked enough so that she was reading about the subject and had gone out to visit this nursery with a friend. So his feeling that he had a place in my home was not without support from me. When we consider the positions patients are in when confronted with life-threatening illness in their analysts -- and some of us have been in that place ourselves as patients -- sympathetic understanding is certainly called for. The analytic situation as I and others (see, for example, Davies, 1998; 2000) have written lends itself to being construed as one of seduction and abandonment. And when is that aspect of it more salient than the moment when the analyst is a "person facing death" and the patient, who is so attached and to whom the analyst means so much, is so thoroughly excluded from normal channels of connection, including contacts with others with whom the analyst is close.

And yet we also had to consider other less benign meanings of the visit. My annoyance was not without foundation. There was something intrusive and entitled about Manny being at the door at that time. In the background there was the history as I reported it in chapter 10 of my book (Hoffman, 1998):

There is little doubt... that embedded within the existential, universal predicaments of life with which Manny struggles, we can find an idiosyncratic neurosis. Manny was abused as a child, given forced enemas to empty his bowels, probably before he was old enough to control his sphincters. His mother was overbearing, controlling, intrusive, and even violent. She would beat his father who would cower before her fits of rage. The patient remembers not one single occasion when his father stood up to her. And she would bad-mouth her husband to her son, offering Manny the sense that he was special, at the center of her life, a "gift" that did more to suffocate him than to build his sense of self [p. 252].

With this background how could that visit to the house not reflect some element of identification that Manny had with his intrusive mother, a readiness, absorbed through his relationship with her, to overstep boundaries, to feel entitled to enter the private space of the other, indeed especially the private space of the most intensely valued love object, and to do it, that invasive act, under the guise of it being exactly what the loved one needs.

Manny had his own elaborations to confirm this interpretation. When I suggested that perhaps he would have simply dropped the check into the mail slot had the door not been open at the moment he arrived, Manny volunteered that in fact he had the fantasy of visiting me all along, one which struck him as unrealistic as soon as he saw Mark. He thought he was acting very much like his mother who had a habit of bringing gifts and food to anyone in the neighborhood who was sick whether they wanted it or not, and always with strings attached. That is, she was frequently angry with others for not extending themselves to her as much as she did to them. Also, Manny wanted me to know that when he delivered the orchid to the hospital, he had similarly imagined a visit to my bedside, an admittedly unrealistic fantasy during the recovery period immediately following the surgery. He was brought back to reality -- at the same time that he was able to make close contact indirectly -- through a conversation on the phone with my wife who was in the recovery room. She advised him to leave the orchid with the receptionist in the lobby.

Finally, Manny wanted me to know that he was very conflicted about coming to the house and that he was actually in "a sweat" about it as he was driving down. He knew it might not be the best thing to do and had grave misgivings about it. As he anxiously drove around the neighborhood, having difficulty finding the address, he felt a very powerful internal pressure to go through with the plan despite his very strong reservations. His own awareness that his action might not have reflected his best judgment, however, made it, not easier (as I had hoped would be the case), but harder to absorb my disapproval because he felt I was failing to take for granted that he knew about all those considerations but had come to the house anyway because of some overwhelming compulsion.

Reinterpreting a Dream: The Coconstruction of New Meaning

Manny's visit turned up the volume on a possible meaning of a dream he had reported months before, again a dream and discussion that appear in chapter 10 of Ritual and Spontaneity. At that time he had returned, temporarily and briefly, from a winter vacation, one that had been open-ended so that it simulated a quasi-termination. I quote now from my book:

Manny could be gone a month or two or even more. It did not make sense, therefore, for me to hold his times. He said he'd call me when he returned and take his chances. So we were faced with an ambiguous interruption, neither quite a vacation in the usual sense, nor a full termination. I decided it afforded an opportunity to construct a benign kind of semi-ending, one the patient had never been able to experience before in analysis. In the "last session," I presented him with a gift, two books dealing with questions of origins, the beginnings of the universe and of life, and evolution, all questions I knew Manny was interested in. Accompanying the gift was a card on which I had written, in part, "Congratulations on your 'graduation.' If these books don't answer all your remaining questions about the meaning of life, you will definitely need more analysis (the advanced, post-graduate kind of course)." Manny was moved and delighted. He appreciated my turning this juncture into something of an ending, even though he thought he'd surely be back if he didn't die in the interim. He joked that he'd write or call to give me his address and phone number (unknown at the time of the meeting) so that I could call him in Palm Springs if I needed him. The next day he left an envelope for me in the waiting room containing two tickets to a concert in town that he couldn't attend while he was away. Several weeks later, he returned for a few days for business reasons. In the first of two scheduled sessions he spoke with elation about one of the books I had given him (Shadows of Forgotten Ancestors by Carl Sagan & Ann Druyan [1992]), which he said he was enjoying as much if not more than any he had ever read. He was thrilled with the ideas and conveyed them to me in a manner that was unusually animated. He seemed stronger and healthier than I had ever seen him, reporting that he was having a great time with his wife in Palm Springs, although he missed our meetings. He said he'd be back in Chicago in mid-spring and would like to resume the therapy. But he was rather unfazed when I told him I had given away his times. He said he understood and he'd just take whatever was possible when he got back. In the second of the two sessions, after speaking with some pride and satisfaction about the pile of business matters he had been tackling, he reported the following dream:
"I was heading for my first analyst's office. But in front of his building a huge crowd of people had gathered and I had to struggle to get through. A crowd of people was also in the lobby. So I decided I would just scale the outer wall, which I was able to do with ease, like Spiderman. I went in then through the bathroom window and got to his office. I said, 'I know I'm late.' He replied 'yes I know. You understand that it will cost you 3 hours at $11.00 per hour'" [pp. 259-260].

Continuing now with my original commentary on the dream:

He said his first analyst reminded him of me, in that he was warm and very human. He thought the people in front of the building represented my other patients, including whoever had taken his old times, and that his "lateness" referred to the duration of his trip, which meant leaving his times open. The penalty of three hours at $11 corresponded, he guessed, to what had been our frequency of meetings for a long time and to what was an obvious fraction of the fee, one-tenth to be exact. In the time-machine of the dream perhaps he was taking us back to a pre-inflation era. Being charged for three hours might allude to his discomfort and maybe to his guilt over the possibility that I had neglected my self-interest in not charging him for any of the missed time. He wasn't sure what scaling the wall meant and had no associations that illuminated that image for us. I suggested that it might be a whimsical way of representing his recovery of a sense of youthful vitality. The fact that in the dream it's his first analyst who appears, which takes the patient back 50 years, might also refer to his sense of himself as having youthful strength and energy. I suggested, also, that the image of scaling the wall might refer to his feeling special to me, so that he felt confident that he would have access to me eventually, even if something unusual was required and even if it did worry him that I might overextend myself. After all, I'd just given him a gift, which is not the standard kind of analytic interaction. The scaling of the wall might also allude, specifically, to the books on evolution, to his own adaptability, to the "survival of the fittest." Although I did not think of it at the time, it might well be relevant that the other book I gave him was "Climbing Mount Improbable" by Richard Dawkins (1996). What seems evident is that the quasi-termination, buffered and enhanced by the use of various transitional objects, was a powerful catalyst for Manny's development in terms of his capacity to feel confident about his own resources as well as the enduring aspects of his connection with me and with the analytic process [pp. 260-261].

Needless to say it makes no sense to think of events subsequent to a dream as though they were day residues for the dream itself. And yet possible meanings that are obscured by features of the transference and the countertransference at the time the dream was reported may be illuminated by features of the analytic relationship that emerge later. These meanings can be understood as also active preconsciously at the earlier time although resisted by both participants. And there are contingencies, such as my surgery, that may evoke feelings that would not have been evoked otherwise. The transference and the countertransference do not simply "unfold" over time according to some predetermined blueprint. Perhaps a kind of blueprint exists but it is for many different things only some of which will emerge in the course of an analysis. Which facets emerge is decided by a complex interplay of contingency and choice. The choice of either one of the parties, incidentally, can be construed as a contingency from the point of view of the other. So, for example, Manny's decision to come to the house is an unpredictable contingency from my point of view and my disapproving remark is an unpredictable contingency from his point of view. Each of us may be influencing the other and creating part of the context for the other's experience and for the other's choices. But influence is a far cry from total determination. Thus, even if an analyst knew fully the nature of his or her contribution to a patient's experience (which is never possible) he or she could not know -- at most could only suspect -- how the patient will choose to respond.

Returning to the meaning of the dream, in this instance the interpretations of Manny's sense of entitlement in scaling the walls of my building, of his intrusiveness, and of the element of identification with his invasive mother do not occur to me or to Manny at a juncture when we are both delighted by his progress and eager to recognize how much each of us has contributed and is appreciated by the other. But when Manny comes to my house and I experience some sense of violation of my space, those aspects of his motivation impress themselves on me and I can reflect retrospectively on their relevance to the dream and on the reasons for missing that interpretation earlier. Neither the positive countertransference nor the negative countertransference promotes grasping the whole truth of the meaning of the dream. An understanding that is more complex and integrative, although still not comprehensive (because none ever is), is one that combines what each quality of countertransference illuminates. On the one hand, against the current of the positive countertransference at the earlier time, there was probably something grandiose and presumptuous about Manny's idea that he was so special that he could bypass all other patients if he wanted access to me after his winter break, On the other hand, against the current of the negative countertransference at the later time, there was something loving, generous, and understandable about his wanting to be close to me after my surgery, his wanting this unusual "extenuating circumstance" as he refers to it in his email, to afford the opportunity to live out the fantasy of being part of my immediate family, like a son, or a father, or a wife. In the context of the analysis the act is hardly reducible to a repetition via identification with his abusively invasive mother. Perhaps it has some of that coloring, but it is also an act of will and of imagination, expressive of vitality, of love, and of intimate connection. In fact, in light of the template of the history, including the forced enemas, Manny's offering could be viewed as akin to the child's freely offering a bowel movement as an act of proud generosity as opposed to either compliant submission or defiant withholding. Rank (1945) writes that we must recognize that the patient in analysis

"suffers... from a situation in which a strange will is forced on him and makes him react with accentuation of his own will," and that "this negative reaction of the patient represents the actual therapeutic value, the expression of will as such, which in the analytic situation can only manifest itself as resistance, as protest, -- that is, only as counter-will" (Rank, 1945, p. 13).

So Manny's "counter-will" expresses itself as a spontaneous act of love that defies analytic decorum. The current of repetition is joined by a current of growth, of differentiation of the present from the past. The negative countertransference blinds me to what the positive countertransference illuminates and vice versa. But the dream is irreducibly ambiguous and holds an indeterminate potential for meaning. Just as my surgery and Manny's visit to my house bring out meanings that were unanticipated so might other eventualities bring out yet additional unanticipated meanings. And for every meaning that is brought out in this way, there are countless others that are left dormant, unknown, and unexplored.

Acts of Will and Imagination II: An Analyst at the Patient's Door

Now consider this scene as described by my brother-in-law David (Feinsilver, 1998) in his paper "The therapist as a person facing death." For six years David had been working with Wally, a young man in his early twenties, and a patient at the Lodge. Wally knew of David's cancer and sobbed at learning of its recurrence. The following is excerpted from David's paper:

One day, before Wally's hour, I began to receive concerned phone calls from various quarters of the hospital saying that Wally was acting strangely and had not shown up for his regular appointments. I became concerned. But when he did not show up for his hour, nor answer his phone, I started to become furious over his pulling his self-destructive routine of abandoning me as he felt I was doing to him. So when I got to his house a block away and he did not respond to my ringing the bell and knocking, I told him that I knew he was in there and he had two choices: either he opened the door or I was calling the police to have him committed back into the in-patient unit because I was not going to let him continue down this self-destructive path of cutting me and everybody off as a way of trying to handle his anger about my illness. I told him I didn't know how suicidal he was but I wasn't about to take any chances (and I meant it). He answered the door immediately and pleaded, as we walked back to my office, that although he was certainly feeling like wanting to do away with himself I didn't have to worry. He wouldn't [pp. 1136-1137].

A little later in David's paper we learn that, back at the office, Wally began to clarify what had "set him off":

[He spoke] of his rage at starting to get excited about the prospect of seeing me two times a week but then [started] to think about what good it would do to increase the time to two times a week if he were just going to lose me soon anyway. In the next session Wally proudly announced that he had worked out with his family that they could afford the increase and he wanted to start as soon as possible.
This sequence turned out to be a turning point in the work with Wally, enabling us to begin to work through the fears underlying his rageful protestations about going forward in life in general and "taking in all that new stuff," while also beginning to articulate the elements of the self-destructive, "negative therapeutic reaction" that has been precipitating his breakdowns and doing him in throughout his life [p. 1137].

David later comments as follows:

I believe Wally experienced my confrontation of his suicidality as a concrete expression of caring from the person who had abandoned him. He probably heard words to the effect that if somebody who is dying still feels there is "work of noble note" to be done [quoting Tennyson as David does at the beginning of his paper], then maybe the least he could do was show up. Since this sequence Wally has started to become more involved in working with me psychotherapeutically in our hours on the problem of his retreating from success, as well as working outside the hours on the very practical manifestations of this in developing close friends and maintaining a job [p. 1137].

Wally comes out of his self-destructive retreat because as David says he feels it's "the least he can do" in light of David's illness and David's effort. I think this aspect of Wally's motivation and of the motivation of the other patients David tells us about is underemphasized by David in his formal discussion of the principles of therapeutic action that emerge in the context of his terminal illness. I believe these patients get better partly because the factor of their malignant envy has been much reduced. The sense that the analyst already has his fill of narcissistic supplies combined with the sense that what he offers is by far too little and too late, can result in patients begrudging the analyst the satisfaction of having the power to make a difference in their lives. But now David is dying. The patient becomes the fortunate one, the "have" rather than the "have not," the one whose situation is enviable. Now the patient is able more readily to "give" David his or her progress as, in effect, a gift. It's "the least [the patient] can do" under the circumstances, to stop withholding on the grounds that David already has so much, whereas what he offers is barely a drop in the bucket. Now, what David offers to his patients is perceived as much more, relatively, because he has so much less for himself.

It doesn't always go that way of course. Ann-Louise Silver (1990) has documented beautifully a range of different reactions and adaptations that characterized her patients at Chestnut Lodge when she was afflicted with a life threatening illness in the early eighties In terror of abandonment, for example, some seemed to get more disturbed and disorganized. But despite the variations, and in keeping with David's experience, Silver also writes:

I do remember vividly that my patients were striving to work with me.... That is, they worked to rebuild the holding environment and I struggled to assist them. I observed their efforts gratefully, and I am confident that they perceived my being grateful. I have special fondness for those patients who saw me through those months. We are like veterans who fought together at the front lines [p. 164].

So now picture if you will, David at Wally's door and Manny at mine. Two very different scenes of course. In one, it's the therapist at the door, in the other it's the patient. In one it's a patient who is the object of a therapist's concern, in the other it's the therapist who is the object of a patient's concern. And yet the points of commonality are also striking. David is facing his own death as is Manny in his old age and both are at the door of someone they love who they fear could die even before they do. Four human beings facing death, their own and each other's. David says, and Manny says: "Look these are extenuating circumstances. I will not proceed as though this were business as usual. I will do what it takes to offer something. I will try, in accord with David's definition of a mentsch, 'to rise to the occasion on a difficult occasion to do the right thing.'" To be sure, David's action seems the wiser of the two and it elicits a much more positive response than what Manny gets from me. But Manny's intentions certainly include a desire to reach out, to be close, to offer something. Perhaps he felt, like Wally, that it was "the least he could do" under the circumstances. We are in this together, he and I, "on the front lines." And under these conditions he has the opportunity to allow his emotional attachment to override the usual constraints of the analytic situation, to show me more directly what he feels about me and to search out my personal feelings about him. However awkward and stumbling, and even ill-advised, Manny is reaching imaginatively here for something new, for something different. It's no wonder that he experienced my disapproving response as so injurious and as so jeopardizing of his sense of the authenticity of my interest in him. And given how hurt he was, his continuing in the analysis with me and his willingness to collaborate with me in exploring the meaning of this episode, including his own contribution, reflects his effort to integrate his autonomous, creative participation with responsiveness to my needs as his analyst and as a person.

From Idealization to Identification: The Patient's Progress as a Reparative Gift

David wonders toward the end of his paper whether the catalytic power that his terminal illness seemed to generate "can occur under ordinary circumstances." He asks: "Can we bottle it for export, so to speak, for everyday analytic work?" (p. 1148) His answer is definitively yes, believing that the key factor is the optimal emergence of the analyst as a person in order to facilitate differentiation of transference-based fantasy and reality. But maybe we need to go further and recognize that the emergence of the particular reality of the analyst's mortality is not just one of many realities that might emerge and facilitate differentiation. It is the ultimate reality, the core of the analyst's being, and at the same time, the deepest common ground with the patient. Yet it is the most difficult of realities to bring into the foreground since, as Ernest Becker (1973) demonstrated so compellingly in his book The Denial of Death, its denial is so common and its acknowledgment so universally horrifying. Becker suggests that the disillusioning power of the primal scene inheres in its exposure of the parents' corporeal existence, of their need-driven animality, and of their mortality, at a point when the child has a need to see the parents as superior, as transcending of materiality, as, in effect, more godlike.

In continuity with that facet of childhood, therapeutic action depends partly on the jointly constructed impression that the analyst is a superior power, an impression that is cultivated by the ritualized asymmetry of the analytic situation, even as it is challenged and rendered ironic through the analysis of the transference. With that power, which is associated with a kind of selflessness, the analyst is in a position to affirm the patient as an agent, as a contributor to the co-construction of the reality of the community, the culture, and the network of relationships in which the patient lives. It's a power that has as its precursor that of parents in their relationships with children in their innocence. When children absorb, uncritically, destructive attitudes that leave them profoundly flawed in their capacity as agents, they subsequently, as adults, need a specially designed arrangement to elevate a human authority to a status that can compete with the malignant influence of the original caregivers. In that respect, the analyst, as I've discussed elsewhere (Hoffman, 1998, chapter 1) inherits functions that used to belong to the gods or to the priestly mediators of divine authority.

But the therapeutic benefits of the analyst's status as a superior, benevolent, relatively selfless being can be offset by the factor of malignant envy referred to earlier along with the deep resentment that, in the cosmic order, what is being offered is much too little too late. The patient feels cheated and withholds the best that he or she could potentially give. He or she holds out for a better deal, for justice in a cosmic court, for a new start, for rebirth. At some level the patient, since he or she is indeed not a naive infant, but a discerning, interpreting adult, is always aware of what I've referred to as the dark side of the analytic frame: the way the arrangement serves the analyst's all-too-human needs, narcissistic and monetary. It is "a strange will" indeed, as Rank says, that is forced on the patient via the analytic situation. Money for love hardly comes close to having love bestowed simply in response to one's being born into the world, to the mere fact of one's existence. Moreover, there is a thin line, surely, between the patient's need for an idealized object and the patient's resentment of the analyst's privileged position. If there is to be any therapeutic benefit, in the end the patient must forgive the analyst for the reality that he or she is indeed simply a person like the patient. The patient must choose to forgive in order to choose to take whatever good the analyst has to offer. What seems anomalous as a basis for that forgiving attitude, the emergence of the reality of the analyst's mortality, refers, of course, to the most common thing in the world, the universal certainty that applies to everyone. It's only denial that keeps that fact of life in the background, hidden from the participants' view.

Overcoming that denial is not easy nor is it obvious how it can be translated into a form of action that can practically apply to the analytic situation. Unfortunately, life-threatening conditions come into play often enough as catalysts, but when they don't we need to find ways of bringing ourselves and our patients more in touch with our common humanity. To speak of death could seem contrived at times but it's also possible that we are not alert enough for occasions when it would be important for the subject to be raised. It is inescapably the case, after all, that in living, however passionately, however expansively, we are, all of us, at every moment, also dying. Some have noted (Cohen, 1983; Garcia-Lawson, 1997) that it is all too rare that analysts, regardless of age or state of health, explore with their patients how they might feel and what they might do in the event of the analyst's death. But I think more generally, in keeping with David Feinsilver's view, what brings the patient into contact with the analyst's mortality and hence with the sense that the analyst and the patient share a common plight is attention to the analyst's limitations and vulnerability in all the ways that they may spontaneously come into play in the course of the work. It is then, perhaps, that our patients can integrate the need for idealization with acknowledgment that we, as analysts, are also patients; that we are, indeed, vulnerable enough, threatened enough, suffering enough, deprived enough, bereaved enough, traumatized enough, flawed enough, and yet also good enough, to earn the patient's empathic identification and reparative concern. Then in that reversal recognized by Searles (1975) as essential to therapeutic action "the patient [becomes] therapist to [the] analyst" and can choose to offer him or her the most meaningful of gifts, evidence of an enhanced capacity for responsive and creative living. The analyst, in turn, can absorb the patient's movement in that healthy direction as testimony to the analyst's worth, despite all his or her limitations, as a powerfully constructive influence in the patient's life.


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[Note: This paper appeared in Psychoanalytic Dialogues, 2000, 10, 6: 823-846. Hillsdale, NJ: The Analytic Press. European distributor: Eurospan. We thank for the permission. This paper is partly a kind of epilogue to Irwin Hoffman's book Ritual and Spontaneity in the Psychoanalytic Process: A Dialectical-Constructivist View. Hillsdale, NJ: The Analytic Press, 1998/2000 (particularly in regards to the case of Manny who is discussed in Chapter 10).]

Irwin Z. Hoffman, Ph.D.
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