“I stop somewhere waiting for you”: Unplanned Interruptions in Clinical Processes.
Jactina Frawley
Trained as a Jungian Analyst in Zurich, Switzerland, and is a Training Analyst with the Australian New Zealand Society of Jungian Analysts (ANZSJA). She is a former Director of Training, C. G. Jung Institute, ANZSJA and is currently Convenor of Ethics. Originally trained as a social worker, Jacinta has practiced for over forty years in Australia, the United Kingdom and Switzerland. She has been in private practice in southern Sydney since 2001.
Introduction:
Before beginning, I acknowledge that many in the audience will have experienced ‘unplanned interruptions’ in clinical processes and that this topic may stir deep feelings and deep defences around a difficult topic. Today, I will refer to ‘therapist’, ‘patient’ and ‘clinical process’ and trust that my thoughts may be useful across a wide range of clinical styles.
Text:
All depth psychologies prioritise the importance of the therapeutic frame. Therapist and patient meet regularly, consistently, predictably to shape a holding container into which all manner of thoughts, feelings, experiences, and hopes can be poured, accepted, considered, and transformed. Recognising the importance of the transferential relationship, breaks of all kinds are carefully planned, and therapeutic endings are anticipated and carefully tended too.
Yet therapists are human beings too and can become ill or even die suddenly. In recent times Ethics Committees have drawn attention to the need for professional wills and clinical executors to support therapists and patients in the face of the therapist’s sudden unavailability. This paper will explore beyond these necessary practicalities into the lived experience of unplanned interruptions for the therapist, patient, and wider training and organisational group.
Before I consider how we might experience unplanned interruptions within long term therapeutic work, I will clarify what I am not discussing.
Ideally, therapeutic work pauses regularly for planned breaks (such as holidays) and concludes by mutual agreement when the time and situation are right for both parties. This is more an ideal than a reality. For instance, planned termination due to retirement of the therapist may not suit the patient or the patient concludes the process before the therapist is ready. I have been on both sides of this experience--once giving a year’s notice as I closed my practice to relocate internationally and on a different occasion receiving a year’s notice of an impending retirement. Yet such conclusions are usually planned, and the ending phase may be tremendously fertile and rich.
Causing more distress are abrupt terminations due to significant events in the therapist’s life. Writing this paper has re-membered the abrupt, and very dis-membering, termination of my own analysis when my then analyst closed her practice soon after the sudden death of her husband. Though this is now almost 30 years ago I was surprised how these almost forgotten memories still move me. I will not be discussing abrupt terminations due to the therapist’s ongoing unavailability or even death today but do encourage you to review the excellent articles in Psychoanalytic Dialogues from earlier this year. I will provide a short list of references.
So, this paper is not about planned breaks or unplanned termination of clinical processes rather about ‘unplanned interruptions’ which allows us to consider what happens on the other side of the interruption—the return to clinical practice.
For many reasons, including the expense and length of training, therapists tend to be of an older demographic. Being human, perhaps we prefer to claim the wisdom of age and overlook the vulnerabilities of the ageing therapeutic body.
When we do suffer a serious illness, -- a cancer diagnosis, an incapacitating accident, concussion, stroke, increasing disability due to chronic illness—all of which become more common as we age, the physical body of the therapist with all its human vulnerabilities crash lands into the therapeutic encounter and abruptly pauses the therapy. At the time of a serious diagnosis, it is seldom clear how long the unplanned interruption may be, how incapacitated the therapist, and when they might be able to return. Many duty-of-care questions are raised, especially in private practice. Ethics Committees have guidelines to meet the practical requirements, and it is worthwhile to be acquainted with these.
A review of the literature on the impact of the therapist’s illness or death raises familiar and useful themes. The realm of ‘forced disclosures’, that is, self-revelations which might be unwillingly required from the therapist, can be very challenging. I experienced this first-hand when I informed one of my patients, necessarily by phone from a hospital ward, that we could not meet again in the forceable future. He burst into tears, refused the contact details of my clinical executor, saying he couldn’t go through this again. Consciously, he was referring to the death of his father and retirement of his previous therapist, unconsciously perhaps to his own ever present murderous fears. We managed to repair the connection somewhat, and thoughtfully concluded our work together, but he never did return to working with me. His parting communication was: ‘I am so needy; I can’t care for you too.”
Yet, a friend of mine speaks lovingly about the reparative journey of being one of the last patients to continue working with her therapist until his necessary retirement. He was dying of the same illness that had taken her father. Now retired from therapeutic practice she continues to contribute as a uniquely talented volunteer supporting both cancer patients and medical students.
The therapist’s illness challenges notions of ‘abstinence’, the therapeutic container, and frame. Assumed roles are disrupted as the role of ‘sufferer’ moves from patient to (absent) therapist with all the attendant anxieties.
Do we break the therapeutic frame by even imagining the therapy continuing without the therapist’s physical presence? Is the therapist’s sick body an affront to the fantasy of the therapist as healer and the patient as ‘sufferer’.
Recalling that the etymology of ‘patient’ is ‘to suffer’ and the etymology of ‘therapist’ is ‘to heal’, illness throws us into a topsy turvy world. Who is now caring for whom?
My own experience of having a gynaecological cancer activated traumatic fantasies for some patients. Were they the malignant, devil-child, the “changeling” that had got inside me and poisoned me? Were they too much for me, a burden beyond bearing? As one said to me “and you would be too nice to tell me, even if I were!” Would my cancer infect them and kill their therapy and emerging Self as well? Others feared that a gynaecological cancer robbed me of my ‘fertile’, nurturing, maternal aspect, leaving only a wizen, dying grandmother. Dreams of stagnating pregnancy were counted by broom-wielding witches. For some I/they/the therapeutic container was a burden, for others I/they/the therapeutic container was barren.
This reminds us to hold in mind and body what is lost for the patient when the therapist is sick. Not simply a holding container, a meeting time and space, though this is tremendously important, but also a loss of the connection to the inner and outer self, the self-in-becoming that the therapy holds. The space in between is stretched, distorted, and de-shaped, chaos ignites in the once familiar space. Transference and countertransference distend to include a malignant other.
No matter how knowledgeable we are, how much clinical experience we have, or how many hours of personal analysis we have done, nothing constellates attachment styles so much as abrupt, one-sided interruptions to significant relationships, except perhaps confrontation with one’s own mortality. If you take only one thing from this paper, I hope it is this. If ever you are in a similar situation or are the clinical executor for a colleague, I recommend modelling a secure attachment to the medical treatment team and process. This does not mean being overly optimistic, reassuring or lying about treatment, rather I recommend expressing complete confidence in your medical team. Patients are owed truth and honesty but not our fear and uncertainties. Thus, when the transference and countertransference distend to include the malignant other, modelling a secure attachment to the medical team creates an imaginal space for the healing other.
These ways of considering interruptions to clinical practice: ‘forced disclosures’, abstinence, therapeutic container, frame, transference, and attachment styles appear frequently in the literature and are often the grist for supervision. Yet, all emerge from some version of the consciously ridiculous fantasy that the therapist is impervious to the world outside. I offer an example from Salman Akhtar’s “Turning Points in Dynamic Psychotherapy’, the chapter on disruptions:
‘ . . as a commonsense phrase, the expression of ‘disruption’ is a daily guest in the chamber of clinical discourse. It is used loosely for interruptions of treatment due to reality reasons (e.g. money, relocation, finishing college) as well as for miscarriages of dialogue due to psychological reasons within the therapeutic dyad . . . I suggest that we restrict the use of the term to the latter situations.”
I argue that such statements perpetuate a fantasy of therapeutic omnipotence and immortality. We do neither ourselves nor our patients any favours by ignoring interruptions to treatment due to the reality of the therapist’s vulnerable human body. I would like to offer another way of thinking about unplanned interruptions, not as aberrations, but as the most normal aspect of human experience.
Let’s ask ourselves: are there existing narrative structures, what Jungians might describe as archetypal patterns, that may assist us to see our illness or the illness of our therapist as part of a greater human story. If we do indeed ‘contain multitudes’ how might these multitudes be organised. I would like to offer a familiar narrative called “Voyage and Return” stories, a variant of the Hero’s Journey as a way of ordering and normalising our experiences of ‘unplanned interruptions’.
Voyage and Return
The essence of the Voyage and Return narrative is that the main character travels out of their familiar, everyday normal life, into a ‘foreign country’, completely cut off from the first, where everything seems disconcertingly abnormal. At first the strangeness of this foreign country with its shocks, challenges, new knowledge, unique personalities, and marvels, may seem diverting, even exhilarating, if also highly perplexing. But gradually the main character feels increasingly trapped, until eventually they are released and can return safely to the familiar world where they began.
Many classic stories: Alice in Wonderland, The Prodigal Son, The Hobbit, and the first ever recorded story, the Epic of Gilgamesh, belong to this category. And of course, nearly all cancer memoirs.
There are some characteristics which make this narrative style so helpful for considering unplanned interruptions.
It is a characteristic of the Voyage and Return that the main character does not choose the journey (it is not a quest). Often it is through boredom (Alice), naivety (the prodigal son), complacency (Bilbo Baggins) that the character unwittingly enters the ‘foreign country’. We recognise this in so many stories of sudden illness. It is part of the trope ‘that I was living, my best life”, ‘never been so well’, “took me without warning’. Hubris and ‘busyness’, distract us— ‘I don’t have time to be sick’.
A signifier of these stories is the shocking, sudden and violent entry into the other world: Alice falls down the rabbit hole, assailants steal the prodigal’s money, the dwarves burst into Bilbo Baggins’ very private home. A colleague slipped and fell in the garden, the resulting concussion interrupted his practice for six months. Another, with vague feelings of fatigue visited her GP on the Friday, was immediately referred to Emergency, had major surgery on the Monday morning, commenced chemotherapy two weeks later and slowly returned to her practice only after a long hiatus. The Voyage and Return narrative normalises being wrenched out of our familiar world where everything we know is challenged and changed.
Yet the foreign country of diagnosis, medicine and our own bodies is also fascinating and enthralling. We can learn a great deal through illness.
How then do we bring this unwelcome, unsought, new-found experience of illness back into our familiar life. The narrative purpose of Voyage and Return stories lies in two potential resolutions: the central character returns to their own world either transformed or not. Alice is not transformed by her adventures in Wonderland –‘it was all a dream’. The prodigal son and Bilbo Baggins are changed forever. And so, it is for us as we return to our clinical practices after an unplanned interruption, are we transformed or are we not?
I notice in my return to clinical practice there are patients who wish to wake up like Alice and it all to have just been a dream. They do not welcome any invitations to consider mortality, mine or theirs. Grief is an anathema. Evidence of treatment or vulnerability or ongoing treatment side effects are ignored or at best treated as a social faux par, like farting in public, to be forgiven and quickly skipped over. And these are sustaining attitudes that I respect. It is not for me to pull anyone into my Voyage, their own unique ‘foreign country’ awaits them.
And sometimes too it is very difficult for me to leave the perceived safety of oncology treatment. Like many medical patients I long to be discharged but also fear the abandonment of access to my oncology team. So, I too, am not immune to wishing to return to ignorance. When my oncologist recently tried to discharge me, I had a dramatic recurrence of symptoms, which, even though he and I suspected were psychosomatic required the full battery of invasive and expensive medical tests. When I tell this story to other cancer patients, they laugh and nod in recognition.
The Voyage and Return narrative normalises those times when our conscious and unconscious habits are completely disrupted, our crucial sense of identity and reality taken away.
In my clinical practice other patients, are reluctantly, tentatively inviting us to think together about imagining life without each other. Mortality, illness, death or even simply and consciously concluding long term therapeutic work are powerful themes. One subgroup of patients, those with significant chronic illness, have perhaps offered me the most generous education. They do not wish illness on anyone; suffering and the medical world are all too familiar. They have a stoicism from which I have learnt, and several are making use of my ‘return’, “now that you are one of us”, as one commented, to explore further into their own chronic conditions, not as a ‘foreign country’ to be repudiated but as their home territory.
Long ago, at the beginning, my oncologist said he wished for me a time when I would look back and see this “only as a bad dream’. So, I have permission to be ‘Alice’ who voyaged to Wonderland and returned unchanged, yet I have the scars and the (admittedly now vague) memories which would make it seem a denial of suffering to wish my voyage away as ‘just a bad dream’. As one young patient poetically said of her own life-threatening illness, “once you have been to the mountain, you can never not have been to the mountain, even if you return.’
Clinically, we must listen for material that relates to the unplanned interruption, a delicate dance of being attentive to references to our absence yet not imagining ourselves the centre of every therapeutic communication. And managing our own complex countertransference—how much do we long to use our patients to care for us and process our own illness. In my own experience I found that the Covid pandemic provided a useful background parallel process. The pandemic gave us all unique permission to talk about ill health and normalised abrupt withdrawals from social or clinical life. We have social permission to bring bodily vulnerabilities, in fact our real actual bodies into therapy, we no longer offer simply mindful spaces but also bodily spaces. In my reverie I quietly listen for “cancer” along with ‘covid’ and so feel into multilayered transferential communications.
Organisations:
Before my concluding remarks I would like to speak briefly to the impact on organisations of sudden interruptions due to therapist incapacity.
Most psychotherapy communities are small, many therapists play significant roles within their communities and so the unplanned absence also disrupts the organisation. We know there are complex therapeutic and supervisory relationships within organisations, especially those that offer training. Unplanned absence of a member can be organisationally problematic, as others are required to suddenly step into new roles, institutional knowledge can be forgotten, passwords lost. Colleagues and organisations are confronted with their vulnerability and mortality. And they are not always happy about it, because it is a burden! Organisations do, of course, need to have administrative contingency plans, but I would also encourage psychodynamic and psychoanalytic groups to embrace the ‘voyage and return’. Culturally there is a collective dissociation around mortality, but surely groups such as ours are well placed to offer alternative narratives and model the importance of consciously facing our mortality.
So, what do I hope that you will take away from today?
Practically, I encourage you to engage with your Ethics Committees and develop your personal strategy for managing an ‘unplanned interruption’
If you are ever in such a situation of forced withdrawal due to illness, model a secure attachment style in your communications to your patients
I encourage organisations to normalise the inevitability of unplanned interruptions especially as members are often of an older demographic
I offer the Voyage and Return as an archetypal ordering story to place these ‘unplanned interruptions’ into the broader context of human experience.
And finally, we have voyaged far today, and in concluding I will return to the inspiration of the conference. Walt Whitman’s “Song of Myself” is a poem of transcendent joy in human connection. He celebrates ‘sharing atoms’, ‘containing multitudes’, and when all is said and done and we seem lost to each other, his last stanza reassures and enjoins us to:
. . . keep encouraged,
Missing me in one place search another,
I stop somewhere waiting for you.” (Song of Myself. Lines 1344-1346, 1881.)
Suggested Reading:
Akhtar, Salman. Turning Points in Dynamic Psychotherapy. Karnac, London, 2009
Psychoanalytic Dialogues, 2024, Vol. 34 No1 includes two excellent articles by Kirsten Lentz and Rachel Kozlowski on the death of the analyst, plus two responses to these articles by Jeannie Blaustein and Stephanie Brody.
Voyage and Return:
Booker, Christopher. The Seven Basic Plots: Why we tell stories. Continuum, London, 2004.
Carroll, Lewis. Alice’s Adventures in Wonderland. 1865.
Hartley, L.P. The Go-Between. Penguin Books, 2010.
Tolkien, J.R.R. The Hobbit. Collins Modern Classics, 2012.
Cancer Memoir:
Goldsworthy, Peter. The Cancer Finishing School. Penguin Random House, 2024.