A Psychiatrist Moves His Office H I N D R A N C E OR H E L P
IN PSYCHOTHERAPY?
D. R. F R E E B U R Y , M . B . , F . R . C . P . ( C ) * This
paper
oriented psychiatric ent
patients
namic
describes
a therapist's
psychotherapy floor react
implications
highlighted
experience
practice
of a busy to this
from
general similar
discussed.
and its implications
A
experience feature for
in moving
an exclusive
hospital.
| his
private
The ways common
Canada
analytically
setting
to the
in which
differ-
are described
psychotherapy
Toronto,
and the dy-
to most generally
patients
is
are
ex-
amined.
I t is not a rare event for a psychiatrist to move his office but despite the fact that i t might be expected to have considerable effects in the course of psychotherapy, i t has received scant attention i n the literature. This paper will examine and discuss the implications and effects of such a move on a small number of private patients. The Nature of the
Move
The therapist's practice was originally conducted from one of a group of four offices in an apartment dwelling. Access to the waiting room was through a private entrance and patients left by a door which led via a corridor into the foyer of the building. The planned move which was necessitated by the therapist's hospital position was to an office on the psychiatric floor of a newly built hospital. Access here was by elevator and the private waiting area was shared with several other therapists. There were a number of unexpected delays in the opening of the hospital. I n the meantime his original office was completely refurnished and redecorated during the summer vacation by the doctor who was taking over the lease. Although patients had been notified of the move and encouraged to express their views and feelings about it, only a few had been informed of the considerable changes in decor. Reactions to these changes were quite marked, with some patients confused and rearly disoriented. Responses ranged from disbelief and dejection to disappointment and anger, from feeling deceived to frank distrust and, in one patient, a paranoid suspiciousness. What had been expected to be a brief situation turned into a four¬ * Head of Outpatient Services, Department of Psychiatry, Mount Sinai Hospital, Toronto. Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario M5G 1X5, Canada.
567
568
AMERICAN
JOURNAL
OF P S Y C H O T H E R A P Y
months' experience, with patients gradually acclimatizing, overcoming their feelings that the therapist was not the same person in this strange setting, and then having to re-experience a repetition of the upheaval with the actual move. Reactions
to Being Notified of the
Move
A number of general responses were characteristic of all patients. Initially they were curious about why I was moving. What was my connection with the hospital? Would they be clinic patients? What would the office and the waiting areas be like? They also asked who would have access to their files? Would they see other patients or be seen by them? What steps would I take to ensure their privacy, and from there to whether I cared about their personal privacy? They wondered if their fears and concerns were of importance to me or was this whole trip for my personal aggrandizement, for personal advancement and financial gain? Aside from these initial responses which were not unexpected, patients tended to react to the situation in their own characteristic ways. The following case examples will serve to illustrate this, and the ensuing discussion will highlight an important common underlying theme. CASE l
The first patient, a thirty-year-old Jewish university professor, married, with two children, entered analysis because of an intense need to control minute details of his life, procrastination to the point of interference with his work, and a compulsive drive toward achievement which his successes could never relieve. He was the older of two children born to a strong, dominating and controlling woman, and a weak passive, ineffectual father. His younger sister was born at the height of his oedipal conflict and this event left him feeling inadequate in comparison to his father and unloved by his mother. The treatment which preceded the move fell into fairly distinct phases. The first phase was marked by the development of a part object relationship in the transference in which he expressed fears of loss in anal terms. My return from my first vacation during his analysis coincided with the birth of his second child and the patient increasingly related to me as a whole object, in the face of his wife's attention to their new child. As he then became aware of his wishes to rival, emulate, and even supersede me, he warded off the anxiety associated with this through fantasies of being in a passive submissive relationship with me, that is to say, he had fantasies of being loved as a woman, by a man as he had once wanted to be loved by his father. This was the climate in which the anticipated move was introduced, and it produced in the patient feelings of abandonment, betrayal, and of being displaced. The last session in the original setting took place on his sister's birthday and was followed by my winter break. His attitude to me at this time was " I f I can't rely on you to care for me then I ' l l have to care for myself," which was ac-
A PSYCHIATRIST MOVES
HIS OFFICE
569
companied by increased masturbation and other forms of self-indulgence at the expense of his object relations. He in fact viewed the move to the new office as a birth, and in the first session in the new setting he felt like an outsider, that I now had my colleagues who would come between him and me. Genetic interpretations of the connection between his current feelings in the transference and the feeling of betrayal by his mother at the time of his sister's birth and the consequent rage and retaliatory feelings, resulted in a feeling of enlightenment and a recall of how for years he had felt left out at Christmas time, as a Jew in a Gentile world, without appreciating the relationship of these feelings to his sister's birth. The new and unfamiliar exposure to the therapist in the hospital evoked primal scene memories and intense feelings of rivalry and jealousy. Greenacre (1), in cases of hers in which patients had had prolonged exposure to primal scenes described jealousy as becoming a strong ingredient. Later exposures were associated with feelings of exclusion and intense loneliness. This patient in fact recalled that he had spent a lot of time in his parents' bed and that they eventually gave him the message that he was unwelcome by rolling on him and elbowing him out. Outside his analysis he withdrew from his wife, rejected her amorous approaches, and had strong feelings of affection and closeness to me. I t was interpreted to him that this was a wish to assure me that he was not a dangerous rival to me, in the face of his emerging awareness of the rivalry to his father who had impregnated his mother. The move in the case of this man brought sharply into focus a number of important issues through a revival of the primal scene and of his oedipal rivalry with his father, his resentment of his mother for her unfaithfulness in having his father's child, and in turn permitting that child to take the patient's place in importance to her. He envisaged the new hospital as my baby, feeling he would lose something of the specialness in his relationship with me, as he had lost it with his mother. Outside the analysis, in his marriage, he exercised some control over these events by impregnating his wife and then arranging for her to have an abortion. However, from this period of his treatment on there did emerge an increase in stature and evidence of increasing ability to compete openly with his colleagues, which he revealed through his creativity and the publication of technical articles. CASE 2
The second patient, a forty-year-old mental health professional, sought psychotherapy six months after being hospitalized for what was considered to be a depressive episode. She described an unhappy life characterized by bouts of excessive alcohol consumption, accompanied by rage and poor impulse control. Very early in her life her father had left home after sexually molesting her older sister. The patient and her sister had been raised by a mother who was restless, footloose, and very much out of tune with the needs of her young daughters. The patient was frequently hospitalized and on one occasion was left with a total stranger for several days. As a consequence of these early experiences the patient developed a seductive
570
AMERICAN
JOURNAL
OF P S Y C H O T H E R A P Y
attitude toward people which resulted in at least one man attempting to molest her as a child. When she began to menstruate and to develop physically, how ever, she experienced deep shame about her sexuality and a great hatred of men. Her mother encouraged these attitudes and the patient became a lonely girl who preferred the isolation of the countryside to the company of her peers. Though she was a bright girl, she interrupted her education to join the U.S. Army where she had a homosexual interlude and was ultimately invalided after a "nervous breakdown." She eventually returned to school and obtained a college degree. After trying out nursing which was interrupted by an episode labeled as schizophrenia, she found a job in the mental health field and did very well here, progressing to a supervisory position in spite of her depressive episodes. She still held this position at the beginning of her therapy. This woman was not a readily likeable person, mainly because of the manifestations of seething rage and the potential for explosiveness. There was, however, a most courageous and determined quality in her personality which one could not help but admire. Her therapy began on a twice weekly basis and the early years were barely more than supportive, with drug treatment of the recurrent depressive episodes which were always accompanied by rage and destructive fantasies. In her relationship to me she either saw me as an all good, caring, loving person or as an all bad, depriving rejecting, and hateful man. The latter feelings were easily provoked by an occasional absence or even a failure to understand her intuitively. She saw me only as a need-gratifying object, since object constancy had not been achieved as a consequence of her mother's insensitive early handling of her. I f I was not available when she felt she needed me, she reacted to the frustration with great rage threatening me with destruction on the one hand and wanting to kill herself on the other. I anticipated that she would react unfavorably to the move, and when it was announced her dreams became increasingly violent and she felt helpless and vulnerable about the move along with concerns that she would have difficulty in controlling her rage and might do some serious harm to me. For this particular patient the first meeting in the new office was arranged before the therapist's Christmas vacation break. Shortly afterwards she telephoned me in an intoxicated state saying she must have taken too many sleeping pills the night before. The expressed concern and availability of the therapist at this point seemed to help her through this difficult period but in the first session after the vacation she was very disturbed and decided to leave, never to return. She revealed how deprived she had felt at the Christmas break and how embittered she was to receive my bill in the mail with not so much as a "Happy Christmas." She felt that she had been duped into a trust and then abandoned. " I used to think you understood me completely." I t was interpreted to her that she felt her needs had been sacrificed to my own as she had experienced so many times in her life with her mother. She had a fantasy of killing me and standing over me laughing. She warned me that I had better keep alert because she might come upon me at any time. She symbolized her destructiveness by tearing the T
A PSYCHIATRIST MOVES H I S OFFICE
571
temporary nameplate from my door and stamping on it at the end of one of her sessions. A two-part dream is of relevance here. I n the first part a butcher was selling horses tails for food and she had an association that supplies were getting low. In the second part of the dream she and her mother and sister were trying to escape from some devouring monster. She was clambering up a hill to safety, but her mother's heart was failing and she was about to be caught. Her sister was also lagging behind hindered by her own family. I t was felt that this dream illustrated the splitting of the therapist into a good and nurturing object, and the provider of food, and into a bad devouring persecutory object. As the supplies from the good object appeared to be waning so the fear of the bad devouring object and the reactive rage increased. For much of her therapy she had in fact idealized me and this idealization was an attempt to keep the ideal object as far as possible from the bad or persecutory object. The de-idealization of me forced upon her by the move of my office brought the idealized object into close contact with the persecutory object and hence into great danger. This could be viewed in Kleinian (2) terms as a regression to the paranoid schizoid position, the anxiety being that the bad persecutory object would get inside the ego and overwhelm both the ideal object and the self. The rage was handled for the most past by my interpreting it as relating to her awareness that she was not the most important person in my life, and that I in turn was not the ideal mother she had longed for, especially as she experienced the move as a repetition of the many earlier abandonments she had experienced at the hands of her mother. The rage did in fact gradually diminish and in its place came a severe depression which persisted but which did not prevent her from completing a masters degree—which she was working for at the time of the move—and returning to full-time work. She began to talk of the co-existence of intense rage and great love toward the therapist and it was felt that the depression at this point was the consequence of the patient coming to experience the therapist as a whole object with the consequent loss of the split-off idealized part. CASE 3
The third patient felt unwelcome and unwanted because the actual move brought back her memories of being isolated in an upstairs room. She thought that the therapist had younger, more interesting patients than herself. She recalled that as a child she had been banished to an upstairs room when her newborn brother was placed in her old room to be nearer to her parents. My interpretation was that her current feelings were a repetition of the earlier resentment of being displaced by her brother in her mother's affections, with the consequent anger, at which point she herself added that she expressed anger through withholding in her therapy. Shortly afterwards she recalled her own hospitalization and how, to punish her mother for doing this to her, had only wanted her aunt to visit her, totally rejecting her mother. For this patient the privacy of the office, with its private entrance and secret back exit had helped to sustain a fantasy that she had a very special private rela-
572
AMERICAN
JOURNAL
OF P S Y C H O T H E R A P Y
tionship with her therapist which was not subject to invasion by others. Because she never met him on the outside with other people she could sustain the idea that he existed solely for her. I n this instance the move seemed to have a salutory effect in bringing certain realities forceably to her attention, resulting in the recall of painful memories of childhood which could now be worked with. The result was a decrease in her inhibition, and an increase in her productivity at work. CASE 4
In some patients the announcement of the move resurrected old patterns of resistance. One woman responded to the announcement by saying that she would not be keeping her last appointment prior to the move and then called requesting an urgent appointment on an earlier day because of a marital crisis. When this request was met with the offer of her usual time she declined it and in the first session in the new office queried a bill which was by that time some four weeks overdue. She read a letter written in anger at the time of her urgent request and bitterly accused me of giving her nothing at a time when she needed me most. Her bitter recriminations along with her failure to pay her bill were not without effect on me and in retrospect it is evident that I took revenge through interpretation. I pointed out that her repeated failure to pay the bill within a reasonable time maintained a situation in therapy which was repeated over and over again. I also suggested that her feeling that she got nothing from her therapy was enhanced by her paying nothing for it—and that a relatively simple solution to the anger she felt at the discussion of the outstanding bills was to pay regularly. Her response was that this was her style and this session ended on a note of exasperation in both therapist and patient. As a child this young woman had never lacked admiration and applause from her idolizing family and she found the therapist's reserve almost intolerable. Prior to the move she steadfastly denied any concern about where she met with me, but following it she expressed an intense dislike of the new surroundings and resentment at the loss of the privacy she had enjoyed in the old office. Shortly afterwards the patient sought out a lay therapist whom she began to see concurrently, and she indicated that she viewed my failure to wish her a good trip before Christmas as evidence of a great lack of understanding; she also saw the bill as a punishment. Her new therapist was a very warm and understanding person, more giving, less exacting, and after several weeks of unsuccessful attempts to interpret what I considered to be an acting out of her wishes toward me it was agreed to terminate therapy. A good working relationship was never established with this patient and countertransference played a large part in the limited success of her therapy since her narcissistic need was so great and gratifications for the therapist so few. Interpretation, however accurate, will have little positive effect if its tone expresses the therapist's own negative feelings and his own injured narcissism. DISCUSSION
I t is certainly not a rare event for a psychotherapist to move his office,
A PSYCHIATRIST MOVES H I S OFFICE
573
but i t is so uncommon an event that its effects are seldom discussed. For the therapist i t is an occasion not without personal ambivalence, especially when he moves from a private to a public setting; for the patient i t is an event of considerable significance. For my patients i t evoked certain common feelings, for example, concerns about loss of privacy, fears of being exposed i n public waiting rooms, of being seen by people who knew them, of having other patients see their moods, and in turn witnessing the moods and reactions of my other patients. They resented at seeing me with other patients or with colleagues and feared the loss of confidentiality. Some patients thought I would be talking about them to my professional colleagues. The over-all feeling of losing a special place with the therapist was the most outstanding and common feature and brought to light some aspects of the transference that had hitherto not been evident, namely that the privacy and secrecy of the old office had i n fact provided a reality side to the fantasy of being special since I was really treating them as very private special people. The experiences described here lead me to believe that the setting for analysis and psychotherapy, particularly where there is great emphasis on privacy may lead to too much idealization of the therapist. There are many areas where idealization of the therapist may hidef, and the special nature of the private office is one of these. Other areas of course would be the therapist's professional reputation, his degrees, titles, and his public image. The counter transference is always important to keep i n mind i n therapy and analysis and i t is important for the therapist to be alert to his own needs to sustain the patient's idealization of him and the ways i n which he may unwittingly encourage i t . I t is not surprising to find that the threat of the move and the actual move brought to light intense feelings relating to sibling rivalry, highlighting the resentment against a new sibling along with the anxiety over reprisal. Memories of primal scene exposures with subsequent rivalries and fears were also stimulated. By some, the move was experienced as a narcissistic blow, a repetition of and confirmation of feelings that they were really not cared for with the ensuing rage and resentment and, i n one instance, with threats of retaliation. The experience of this move was generally a positive one. For the most part i t was incorporated i n an individual way into each patient's therapy and proved to be a useful experience. Even i n the most seriously disturbed patient the crisis i t created was resolved to the patient's advantage. I n one patient i t did seem to play a significant role i n the termination of therapy, but even there i t brought to light a therapeutic impasse which had probably existed for some time. f Greben, S, E . Personal communication.
574
AMERICAN
JOURNAL OF
PSYCHOTHERAPY
SUMMARY
When a psychotherapist moves his office it is a significant event for both therapist and patient. Some clinical vignettes reveal that such an event is incorporated and handled by each patient in his or her own characteristic way. I n this case, the particular nature of the move from a private to a public setting highlighted certain features of the transference which had not formerly been recognized. The nature of the therapist's office and his arrangements for privacy and secrecy may i n fact provide a basis i n reality for the patient's fantasy of a special relationship. The therapist may unwittingly be fostering and condoning an idealization of himself which might conceivably never be worked through. Attention is drawn to other areas in which idealization of the therapist may hide. REFERENCES
1. Greenacre, P. Problem of Overidealization of the Analyst and of Analysis. Their Manifestations in the Transference and Counter-transference Relationships. In Emotional Growth, Vol. I I . International Universities Press, New York, 1971. 2. Segal, H . Introduction to the Work of Melanie Klein. William Heinemann, London, 1964.
IN PSYCHOTHERAPY?
D. R. F R E E B U R Y , M . B . , F . R . C . P . ( C ) * This
paper
oriented psychiatric ent
patients
namic
describes
a therapist's
psychotherapy floor react
implications
highlighted
experience
practice
of a busy to this
from
general similar
discussed.
and its implications
A
experience feature for
in moving
an exclusive
hospital.
| his
private
The ways common
Canada
analytically
setting
to the
in which
differ-
are described
psychotherapy
Toronto,
and the dy-
to most generally
patients
is
are
ex-
amined.
I t is not a rare event for a psychiatrist to move his office but despite the fact that i t might be expected to have considerable effects in the course of psychotherapy, i t has received scant attention i n the literature. This paper will examine and discuss the implications and effects of such a move on a small number of private patients. The Nature of the
Move
The therapist's practice was originally conducted from one of a group of four offices in an apartment dwelling. Access to the waiting room was through a private entrance and patients left by a door which led via a corridor into the foyer of the building. The planned move which was necessitated by the therapist's hospital position was to an office on the psychiatric floor of a newly built hospital. Access here was by elevator and the private waiting area was shared with several other therapists. There were a number of unexpected delays in the opening of the hospital. I n the meantime his original office was completely refurnished and redecorated during the summer vacation by the doctor who was taking over the lease. Although patients had been notified of the move and encouraged to express their views and feelings about it, only a few had been informed of the considerable changes in decor. Reactions to these changes were quite marked, with some patients confused and rearly disoriented. Responses ranged from disbelief and dejection to disappointment and anger, from feeling deceived to frank distrust and, in one patient, a paranoid suspiciousness. What had been expected to be a brief situation turned into a four¬ * Head of Outpatient Services, Department of Psychiatry, Mount Sinai Hospital, Toronto. Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario M5G 1X5, Canada.
567
568
AMERICAN
JOURNAL
OF P S Y C H O T H E R A P Y
months' experience, with patients gradually acclimatizing, overcoming their feelings that the therapist was not the same person in this strange setting, and then having to re-experience a repetition of the upheaval with the actual move. Reactions
to Being Notified of the
Move
A number of general responses were characteristic of all patients. Initially they were curious about why I was moving. What was my connection with the hospital? Would they be clinic patients? What would the office and the waiting areas be like? They also asked who would have access to their files? Would they see other patients or be seen by them? What steps would I take to ensure their privacy, and from there to whether I cared about their personal privacy? They wondered if their fears and concerns were of importance to me or was this whole trip for my personal aggrandizement, for personal advancement and financial gain? Aside from these initial responses which were not unexpected, patients tended to react to the situation in their own characteristic ways. The following case examples will serve to illustrate this, and the ensuing discussion will highlight an important common underlying theme. CASE l
The first patient, a thirty-year-old Jewish university professor, married, with two children, entered analysis because of an intense need to control minute details of his life, procrastination to the point of interference with his work, and a compulsive drive toward achievement which his successes could never relieve. He was the older of two children born to a strong, dominating and controlling woman, and a weak passive, ineffectual father. His younger sister was born at the height of his oedipal conflict and this event left him feeling inadequate in comparison to his father and unloved by his mother. The treatment which preceded the move fell into fairly distinct phases. The first phase was marked by the development of a part object relationship in the transference in which he expressed fears of loss in anal terms. My return from my first vacation during his analysis coincided with the birth of his second child and the patient increasingly related to me as a whole object, in the face of his wife's attention to their new child. As he then became aware of his wishes to rival, emulate, and even supersede me, he warded off the anxiety associated with this through fantasies of being in a passive submissive relationship with me, that is to say, he had fantasies of being loved as a woman, by a man as he had once wanted to be loved by his father. This was the climate in which the anticipated move was introduced, and it produced in the patient feelings of abandonment, betrayal, and of being displaced. The last session in the original setting took place on his sister's birthday and was followed by my winter break. His attitude to me at this time was " I f I can't rely on you to care for me then I ' l l have to care for myself," which was ac-
A PSYCHIATRIST MOVES
HIS OFFICE
569
companied by increased masturbation and other forms of self-indulgence at the expense of his object relations. He in fact viewed the move to the new office as a birth, and in the first session in the new setting he felt like an outsider, that I now had my colleagues who would come between him and me. Genetic interpretations of the connection between his current feelings in the transference and the feeling of betrayal by his mother at the time of his sister's birth and the consequent rage and retaliatory feelings, resulted in a feeling of enlightenment and a recall of how for years he had felt left out at Christmas time, as a Jew in a Gentile world, without appreciating the relationship of these feelings to his sister's birth. The new and unfamiliar exposure to the therapist in the hospital evoked primal scene memories and intense feelings of rivalry and jealousy. Greenacre (1), in cases of hers in which patients had had prolonged exposure to primal scenes described jealousy as becoming a strong ingredient. Later exposures were associated with feelings of exclusion and intense loneliness. This patient in fact recalled that he had spent a lot of time in his parents' bed and that they eventually gave him the message that he was unwelcome by rolling on him and elbowing him out. Outside his analysis he withdrew from his wife, rejected her amorous approaches, and had strong feelings of affection and closeness to me. I t was interpreted to him that this was a wish to assure me that he was not a dangerous rival to me, in the face of his emerging awareness of the rivalry to his father who had impregnated his mother. The move in the case of this man brought sharply into focus a number of important issues through a revival of the primal scene and of his oedipal rivalry with his father, his resentment of his mother for her unfaithfulness in having his father's child, and in turn permitting that child to take the patient's place in importance to her. He envisaged the new hospital as my baby, feeling he would lose something of the specialness in his relationship with me, as he had lost it with his mother. Outside the analysis, in his marriage, he exercised some control over these events by impregnating his wife and then arranging for her to have an abortion. However, from this period of his treatment on there did emerge an increase in stature and evidence of increasing ability to compete openly with his colleagues, which he revealed through his creativity and the publication of technical articles. CASE 2
The second patient, a forty-year-old mental health professional, sought psychotherapy six months after being hospitalized for what was considered to be a depressive episode. She described an unhappy life characterized by bouts of excessive alcohol consumption, accompanied by rage and poor impulse control. Very early in her life her father had left home after sexually molesting her older sister. The patient and her sister had been raised by a mother who was restless, footloose, and very much out of tune with the needs of her young daughters. The patient was frequently hospitalized and on one occasion was left with a total stranger for several days. As a consequence of these early experiences the patient developed a seductive
570
AMERICAN
JOURNAL
OF P S Y C H O T H E R A P Y
attitude toward people which resulted in at least one man attempting to molest her as a child. When she began to menstruate and to develop physically, how ever, she experienced deep shame about her sexuality and a great hatred of men. Her mother encouraged these attitudes and the patient became a lonely girl who preferred the isolation of the countryside to the company of her peers. Though she was a bright girl, she interrupted her education to join the U.S. Army where she had a homosexual interlude and was ultimately invalided after a "nervous breakdown." She eventually returned to school and obtained a college degree. After trying out nursing which was interrupted by an episode labeled as schizophrenia, she found a job in the mental health field and did very well here, progressing to a supervisory position in spite of her depressive episodes. She still held this position at the beginning of her therapy. This woman was not a readily likeable person, mainly because of the manifestations of seething rage and the potential for explosiveness. There was, however, a most courageous and determined quality in her personality which one could not help but admire. Her therapy began on a twice weekly basis and the early years were barely more than supportive, with drug treatment of the recurrent depressive episodes which were always accompanied by rage and destructive fantasies. In her relationship to me she either saw me as an all good, caring, loving person or as an all bad, depriving rejecting, and hateful man. The latter feelings were easily provoked by an occasional absence or even a failure to understand her intuitively. She saw me only as a need-gratifying object, since object constancy had not been achieved as a consequence of her mother's insensitive early handling of her. I f I was not available when she felt she needed me, she reacted to the frustration with great rage threatening me with destruction on the one hand and wanting to kill herself on the other. I anticipated that she would react unfavorably to the move, and when it was announced her dreams became increasingly violent and she felt helpless and vulnerable about the move along with concerns that she would have difficulty in controlling her rage and might do some serious harm to me. For this particular patient the first meeting in the new office was arranged before the therapist's Christmas vacation break. Shortly afterwards she telephoned me in an intoxicated state saying she must have taken too many sleeping pills the night before. The expressed concern and availability of the therapist at this point seemed to help her through this difficult period but in the first session after the vacation she was very disturbed and decided to leave, never to return. She revealed how deprived she had felt at the Christmas break and how embittered she was to receive my bill in the mail with not so much as a "Happy Christmas." She felt that she had been duped into a trust and then abandoned. " I used to think you understood me completely." I t was interpreted to her that she felt her needs had been sacrificed to my own as she had experienced so many times in her life with her mother. She had a fantasy of killing me and standing over me laughing. She warned me that I had better keep alert because she might come upon me at any time. She symbolized her destructiveness by tearing the T
A PSYCHIATRIST MOVES H I S OFFICE
571
temporary nameplate from my door and stamping on it at the end of one of her sessions. A two-part dream is of relevance here. I n the first part a butcher was selling horses tails for food and she had an association that supplies were getting low. In the second part of the dream she and her mother and sister were trying to escape from some devouring monster. She was clambering up a hill to safety, but her mother's heart was failing and she was about to be caught. Her sister was also lagging behind hindered by her own family. I t was felt that this dream illustrated the splitting of the therapist into a good and nurturing object, and the provider of food, and into a bad devouring persecutory object. As the supplies from the good object appeared to be waning so the fear of the bad devouring object and the reactive rage increased. For much of her therapy she had in fact idealized me and this idealization was an attempt to keep the ideal object as far as possible from the bad or persecutory object. The de-idealization of me forced upon her by the move of my office brought the idealized object into close contact with the persecutory object and hence into great danger. This could be viewed in Kleinian (2) terms as a regression to the paranoid schizoid position, the anxiety being that the bad persecutory object would get inside the ego and overwhelm both the ideal object and the self. The rage was handled for the most past by my interpreting it as relating to her awareness that she was not the most important person in my life, and that I in turn was not the ideal mother she had longed for, especially as she experienced the move as a repetition of the many earlier abandonments she had experienced at the hands of her mother. The rage did in fact gradually diminish and in its place came a severe depression which persisted but which did not prevent her from completing a masters degree—which she was working for at the time of the move—and returning to full-time work. She began to talk of the co-existence of intense rage and great love toward the therapist and it was felt that the depression at this point was the consequence of the patient coming to experience the therapist as a whole object with the consequent loss of the split-off idealized part. CASE 3
The third patient felt unwelcome and unwanted because the actual move brought back her memories of being isolated in an upstairs room. She thought that the therapist had younger, more interesting patients than herself. She recalled that as a child she had been banished to an upstairs room when her newborn brother was placed in her old room to be nearer to her parents. My interpretation was that her current feelings were a repetition of the earlier resentment of being displaced by her brother in her mother's affections, with the consequent anger, at which point she herself added that she expressed anger through withholding in her therapy. Shortly afterwards she recalled her own hospitalization and how, to punish her mother for doing this to her, had only wanted her aunt to visit her, totally rejecting her mother. For this patient the privacy of the office, with its private entrance and secret back exit had helped to sustain a fantasy that she had a very special private rela-
572
AMERICAN
JOURNAL
OF P S Y C H O T H E R A P Y
tionship with her therapist which was not subject to invasion by others. Because she never met him on the outside with other people she could sustain the idea that he existed solely for her. I n this instance the move seemed to have a salutory effect in bringing certain realities forceably to her attention, resulting in the recall of painful memories of childhood which could now be worked with. The result was a decrease in her inhibition, and an increase in her productivity at work. CASE 4
In some patients the announcement of the move resurrected old patterns of resistance. One woman responded to the announcement by saying that she would not be keeping her last appointment prior to the move and then called requesting an urgent appointment on an earlier day because of a marital crisis. When this request was met with the offer of her usual time she declined it and in the first session in the new office queried a bill which was by that time some four weeks overdue. She read a letter written in anger at the time of her urgent request and bitterly accused me of giving her nothing at a time when she needed me most. Her bitter recriminations along with her failure to pay her bill were not without effect on me and in retrospect it is evident that I took revenge through interpretation. I pointed out that her repeated failure to pay the bill within a reasonable time maintained a situation in therapy which was repeated over and over again. I also suggested that her feeling that she got nothing from her therapy was enhanced by her paying nothing for it—and that a relatively simple solution to the anger she felt at the discussion of the outstanding bills was to pay regularly. Her response was that this was her style and this session ended on a note of exasperation in both therapist and patient. As a child this young woman had never lacked admiration and applause from her idolizing family and she found the therapist's reserve almost intolerable. Prior to the move she steadfastly denied any concern about where she met with me, but following it she expressed an intense dislike of the new surroundings and resentment at the loss of the privacy she had enjoyed in the old office. Shortly afterwards the patient sought out a lay therapist whom she began to see concurrently, and she indicated that she viewed my failure to wish her a good trip before Christmas as evidence of a great lack of understanding; she also saw the bill as a punishment. Her new therapist was a very warm and understanding person, more giving, less exacting, and after several weeks of unsuccessful attempts to interpret what I considered to be an acting out of her wishes toward me it was agreed to terminate therapy. A good working relationship was never established with this patient and countertransference played a large part in the limited success of her therapy since her narcissistic need was so great and gratifications for the therapist so few. Interpretation, however accurate, will have little positive effect if its tone expresses the therapist's own negative feelings and his own injured narcissism. DISCUSSION
I t is certainly not a rare event for a psychotherapist to move his office,
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but i t is so uncommon an event that its effects are seldom discussed. For the therapist i t is an occasion not without personal ambivalence, especially when he moves from a private to a public setting; for the patient i t is an event of considerable significance. For my patients i t evoked certain common feelings, for example, concerns about loss of privacy, fears of being exposed i n public waiting rooms, of being seen by people who knew them, of having other patients see their moods, and in turn witnessing the moods and reactions of my other patients. They resented at seeing me with other patients or with colleagues and feared the loss of confidentiality. Some patients thought I would be talking about them to my professional colleagues. The over-all feeling of losing a special place with the therapist was the most outstanding and common feature and brought to light some aspects of the transference that had hitherto not been evident, namely that the privacy and secrecy of the old office had i n fact provided a reality side to the fantasy of being special since I was really treating them as very private special people. The experiences described here lead me to believe that the setting for analysis and psychotherapy, particularly where there is great emphasis on privacy may lead to too much idealization of the therapist. There are many areas where idealization of the therapist may hidef, and the special nature of the private office is one of these. Other areas of course would be the therapist's professional reputation, his degrees, titles, and his public image. The counter transference is always important to keep i n mind i n therapy and analysis and i t is important for the therapist to be alert to his own needs to sustain the patient's idealization of him and the ways i n which he may unwittingly encourage i t . I t is not surprising to find that the threat of the move and the actual move brought to light intense feelings relating to sibling rivalry, highlighting the resentment against a new sibling along with the anxiety over reprisal. Memories of primal scene exposures with subsequent rivalries and fears were also stimulated. By some, the move was experienced as a narcissistic blow, a repetition of and confirmation of feelings that they were really not cared for with the ensuing rage and resentment and, i n one instance, with threats of retaliation. The experience of this move was generally a positive one. For the most part i t was incorporated i n an individual way into each patient's therapy and proved to be a useful experience. Even i n the most seriously disturbed patient the crisis i t created was resolved to the patient's advantage. I n one patient i t did seem to play a significant role i n the termination of therapy, but even there i t brought to light a therapeutic impasse which had probably existed for some time. f Greben, S, E . Personal communication.
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SUMMARY
When a psychotherapist moves his office it is a significant event for both therapist and patient. Some clinical vignettes reveal that such an event is incorporated and handled by each patient in his or her own characteristic way. I n this case, the particular nature of the move from a private to a public setting highlighted certain features of the transference which had not formerly been recognized. The nature of the therapist's office and his arrangements for privacy and secrecy may i n fact provide a basis i n reality for the patient's fantasy of a special relationship. The therapist may unwittingly be fostering and condoning an idealization of himself which might conceivably never be worked through. Attention is drawn to other areas in which idealization of the therapist may hide. REFERENCES
1. Greenacre, P. Problem of Overidealization of the Analyst and of Analysis. Their Manifestations in the Transference and Counter-transference Relationships. In Emotional Growth, Vol. I I . International Universities Press, New York, 1971. 2. Segal, H . Introduction to the Work of Melanie Klein. William Heinemann, London, 1964.
