“Why should I come more than once a week? And why should I use the couch?” These are familiar questions for many psychoanalysts.

How can a resistant patient in once-a-week therapy be helped to make the transition to psychoanalysis ?

I believe that it is in allowing for the developing transference and interpreting it that the psychoanalyst is most helpful. Understanding transference and resistance and interpreting it for the patient in a way the patient can accept and understand are invaluable, even in once a week psychoanalytically informed psychotherapy.

Patients will usually resist psychoanalysis when at the same time they claim to be quite open to once-a-week psychotherapy.

To illustrate, here is a brief description of a psychotherapy which became psychoanalysis in a patient who was initially very resistant. Although patients, of course, differ in their presenting problems and dynamics, I feel that in this particular case, continuing to come once a week, allowed her to appear motivated and compliant (which she was), but maintain control and emotional distance and avoid deep-seated change.

Initial Session and Presenting Problem:

What impressed me most at our first meeting was Ellen’s obvious anxiety. She was a slim, attractive, but very tense-looking young woman who sat at the edge of her seat during much of the session. I noticed that she was dressed in a dark conservative loose-fitting skirt and jacket and wore no makeup. Her hair was stylishly cut and spoke to me of a lighter, brighter, more daring side. Her face was pale and tense and she held herself stiffly. She was obviously guarded and watched me carefully, appearing to be waiting to be told what to do. She answered my questions in a thoughtful, deliberate manner and appeared to have prepared for the session.

For example, when I asked her to tell me what brought her to therapy, her reply was striking to me in that it was almost word for word the same statement given to the intake interviewer. She said:

“I never had a boyfriend. I wonder if it’s me. I’m now 30 years old and feel really embarrassed about it.”

I wondered about her need to be prepared. I also noted for myself the word “embarrassed” and kept in mind to try to find out more about this later.

For now, I attempted to clarify what she meant by “never had a boyfriend” and she told me that she had had single dates with men, and sometimes two dates with the same man, but she had never had a dating relationship beyond two dates. She added:

“I wonder if there is something wrong with me. I feel like a freak in front of friends who are married or have steady relationships.”

In fact, although she had several female friends who she considered close she had never told any of them that she’d never had a relationship.

Diagnosis

The DSM V diagnosis that comes closest to describing Ellen’s symptoms is Mixed Personality Disorder ( Obsessive-Compulsive /Dependent) with the obsessive-compulsive features dominating and with mild paranoid features. When she started treatment the paranoid features, such as guardedness, hyper-vigilance, and fear of being hurt, were more pronounced and decreased considerably as the treatment continued.

Compulsive features dominated, such as indecisiveness, fear of making a mistake, preoccupation with details, rules and schedules. Dependent features included lack of self-confidence, fear of jeopardizing relationships by making demands and being left alone as a result. These dependent features also decreased as the treatment continued.

Initial phase of treatment

Over the next weeks, she would be startled if she found herself departing from what she intended to report and would become guarded and appeared to be suspicious of me on such occasions as if I had tricked her. It was clear to me that she felt a need to protect herself from intrusion, that she feared letting down her guard and trusting me. In fact, her dutiful preparation for sessions, while perhaps on one level indicating her motivation to use therapy specifically to resolve her problem around men, was also seen by me as a defence against revealing her inner self. She attempted to “fix” the problem on a behavioural level by getting “expert advice” but keeping me at a safe distance.

Overall, my impression in the first few months was that she used distance in a dyadic relationship as a rigid defence to ward off paranoid-like fears. It appeared to me that in a two-person personal relationship she was very scared. She was dutiful and compliant on the surface but was quite resistant underneath.

Engaging her trust was a priority at this time. I paid attention to her need to move at a pace that felt safe to her, and to feel in control. One session a week appeared to be the maximum she could handle at this time. Because of the rigidity of her defences my decision was to work on building her ego strengths first so that she could be more trusting and feel safer with me.

She appeared to be motivated and although she did tend to blame others for her situation she also began to express her feeling that she might have a part to play in the problem herself. In fact, I kept in mind one of the statements she made in our first session that she might be “scared of men”, and as she described the various men she had dated, as well as her father and brothers, I strove to explore with her what was so scary.

She expressed her feeling of inferiority and rejection by men. She felt that she was not “the type” or she didn’t have the “mindset” to have a relationship with a man.

She also talked a good deal about her father and was able to connect her feelings about her father with her fears about men. She expressed anger, resentment and sometimes cried as she described her father as

“domineering bad-tempered, unpredictable, not knowing when he is going to lose his temper and blame me for something I didn’t do”.

During this period of therapy themes of pleasing me began to manifest themselves in the transference, as well as anxiety about the consequences of not pleasing me.

For example: Ellen looked a little tense when she first came into the room, and when I commented on this she said she had a stomach-ache which she gets sometimes. She had been trying to decide whether to go to the bathroom before the session but assured me that it was okay and that she could wait. She then proceeded to tell me how pleased she was with our sessions and how helpful it was to be in therapy.

At the time I wondered about the “holding in” and not going to the bathroom. Later on, in the work I discovered that as a child she was expected to be ready to go to services when her father was, and there had been instances when she wanted to go to the bathroom but was not allowed to keep her father waiting, so had to sit through the service holding it in. The implications were clear in the transference. In order to please me, she was striving to be a good toilet-trained child for me as she was for her father.

She would tell me in detail about social events where she encountered men she might be interested in dating. She became very passive in these situations and it became clear in our sessions that any assertiveness on her part was not acceptable and would drive the interested man away. Over time she allowed herself to show more interest and be less passive in these situations and started to date.

Movement towards psychoanalysis

As she started to date a particular man, L on a regular basis, there was still a good deal of anxiety. As she continued to see this man, fear of losing control and being dominated were again activated. However, now that these fears were more out in the open, and she could observe them in her reactions to J. she was more conscious of the part she played.

In her sessions, she continued to come prepared with an account of what happened in her interactions with this man and sought “advise” from me.

I suggested at this point that it would be helpful if she come in three times a week and use the couch, in order to better explore her fears as she became more involved with L. She was very startled at the thought and said it would mean too much commitment. Her associations were to a friend who had been in analysis whose parents paid. She recalled that the parents and the analyst were in contact about payment issues.

I understood that it felt to her that coming three times a week would be like having the parents in the room with us. Furthermore, that her old fear of me as the harsh authority figure was activated – that I would become her father. I would be totally in control.

I felt at this point that to pursue the issue would be counter-productive, since her anxiety was so intense, but expressed the belief that the work would be enhanced if she came in more often. She agreed after much discussion over a period of about 2 months to try coming in twice a week, with the understanding that she could return to once a week if she wished.

This was difficult for her at first. She felt that she had “nothing to talk about” for the second session of the week. In fact, she could no longer spend the second session of the week reciting the events of the past week-end and this was anxiety-provoking for her. She was willing to cautiously test more closeness, but clearly wanted to still keep me at a safe distance.

She did, however, continue the twice a week sessions, and agreed to “try out” the couch, again with the same understanding that if she didn’t like it she could discontinue.

As the sessions on the couch continued, at first, she was passive, a compliant patient. I was the controlling authority figure. This transference, which had been present in the past became stronger. There were mild complaints, of not getting through her list of items to discuss.

As the sessions continued, a transference emerged where I was seen at this time primarily as the pre-oedipal mother, who could be a benevolent provider, but could also just as easily be depriving. In time she was able to express her emerging concerns, that I might not be able to focus on her issues since I saw so many other patients, that her needs might be “too much” for me.

Over time she became more assertive in expressing her needs in her relationship also, and less passive in general.In addition, her fear of not being “perfect” – related to her harsh superego began to relax.

“Why should I come more than once a week? And why should I use the couch?” These are familiar questions for many psychoanalysts.

How can a resistant patient in once-a-week therapy be helped to make the transition to psychoanalysis ?

I believe that it is in allowing for the developing transference and interpreting it that the psychoanalyst is most helpful. Understanding transference and resistance and interpreting it for the patient in a way the patient can accept and understand are invaluable, even in once a week psychoanalytically informed psychotherapy.

Patients will usually resist psychoanalysis when at the same time they claim to be quite open to once-a-week psychotherapy.

To illustrate, here is a brief description of a psychotherapy which became psychoanalysis in a patient who was initially very resistant. Although patients, of course, differ in their presenting problems and dynamics, I feel that in this particular case, continuing to come once a week, allowed her to appear motivated and compliant (which she was), but maintain control and emotional distance and avoid deep-seated change.

Initial Session and Presenting Problem:

What impressed me most at our first meeting was Ellen’s obvious anxiety. She was a slim, attractive, but very tense-looking young woman who sat at the edge of her seat during much of the session. I noticed that she was dressed in a dark conservative loose-fitting skirt and jacket and wore no makeup. Her hair was stylishly cut and spoke to me of a lighter, brighter, more daring side. Her face was pale and tense and she held herself stiffly. She was obviously guarded and watched me carefully, appearing to be waiting to be told what to do. She answered my questions in a thoughtful, deliberate manner and appeared to have prepared for the session.

For example, when I asked her to tell me what brought her to therapy, her reply was striking to me in that it was almost word for word the same statement given to the intake interviewer. She said:

“I never had a boyfriend. I wonder if it’s me. I’m now 30 years old and feel really embarrassed about it.”

I wondered about her need to be prepared. I also noted for myself the word “embarrassed” and kept in mind to try to find out more about this later.

For now, I attempted to clarify what she meant by “never had a boyfriend” and she told me that she had had single dates with men, and sometimes two dates with the same man, but she had never had a dating relationship beyond two dates. She added:

“I wonder if there is something wrong with me. I feel like a freak in front of friends who are married or have steady relationships.”

In fact, although she had several female friends who she considered close she had never told any of them that she’d never had a relationship.

Diagnosis

The DSM V diagnosis that comes closest to describing Ellen’s symptoms is Mixed Personality Disorder ( Obsessive-Compulsive /Dependent) with the obsessive-compulsive features dominating and with mild paranoid features. When she started treatment the paranoid features, such as guardedness, hyper-vigilance, and fear of being hurt, were more pronounced and decreased considerably as the treatment continued.

Compulsive features dominated, such as indecisiveness, fear of making a mistake, preoccupation with details, rules and schedules. Dependent features included lack of self-confidence, fear of jeopardizing relationships by making demands and being left alone as a result. These dependent features also decreased as the treatment continued.

Initial phase of treatment

Over the next weeks, she would be startled if she found herself departing from what she intended to report and would become guarded and appeared to be suspicious of me on such occasions as if I had tricked her. It was clear to me that she felt a need to protect herself from intrusion, that she feared letting down her guard and trusting me. In fact, her dutiful preparation for sessions, while perhaps on one level indicating her motivation to use therapy specifically to resolve her problem around men, was also seen by me as a defence against revealing her inner self. She attempted to “fix” the problem on a behavioural level by getting “expert advice” but keeping me at a safe distance.

Overall, my impression in the first few months was that she used distance in a dyadic relationship as a rigid defence to ward off paranoid-like fears. It appeared to me that in a two-person personal relationship she was very scared. She was dutiful and compliant on the surface but was quite resistant underneath.

Engaging her trust was a priority at this time. I paid attention to her need to move at a pace that felt safe to her, and to feel in control. One session a week appeared to be the maximum she could handle at this time. Because of the rigidity of her defences my decision was to work on building her ego strengths first so that she could be more trusting and feel safer with me.

She appeared to be motivated and although she did tend to blame others for her situation she also began to express her feeling that she might have a part to play in the problem herself. In fact, I kept in mind one of the statements she made in our first session that she might be “scared of men”, and as she described the various men she had dated, as well as her father and brothers, I strove to explore with her what was so scary.

She expressed her feeling of inferiority and rejection by men. She felt that she was not “the type” or she didn’t have the “mindset” to have a relationship with a man.

She also talked a good deal about her father and was able to connect her feelings about her father with her fears about men. She expressed anger, resentment and sometimes cried as she described her father as

“domineering bad-tempered, unpredictable, not knowing when he is going to lose his temper and blame me for something I didn’t do”.

During this period of therapy themes of pleasing me began to manifest themselves in the transference, as well as anxiety about the consequences of not pleasing me.

For example: Ellen looked a little tense when she first came into the room, and when I commented on this she said she had a stomach-ache which she gets sometimes. She had been trying to decide whether to go to the bathroom before the session but assured me that it was okay and that she could wait. She then proceeded to tell me how pleased she was with our sessions and how helpful it was to be in therapy.

At the time I wondered about the “holding in” and not going to the bathroom. Later on, in the work I discovered that as a child she was expected to be ready to go to services when her father was, and there had been instances when she wanted to go to the bathroom but was not allowed to keep her father waiting, so had to sit through the service holding it in. The implications were clear in the transference. In order to please me, she was striving to be a good toilet-trained child for me as she was for her father.

She would tell me in detail about social events where she encountered men she might be interested in dating. She became very passive in these situations and it became clear in our sessions that any assertiveness on her part was not acceptable and would drive the interested man away. Over time she allowed herself to show more interest and be less passive in these situations and started to date.

Movement towards psychoanalysis

As she started to date a particular man, L on a regular basis, there was still a good deal of anxiety. As she continued to see this man, fear of losing control and being dominated were again activated. However, now that these fears were more out in the open, and she could observe them in her reactions to J. she was more conscious of the part she played.

In her sessions, she continued to come prepared with an account of what happened in her interactions with this man and sought “advise” from me.

I suggested at this point that it would be helpful if she come in three times a week and use the couch, in order to better explore her fears as she became more involved with L. She was very startled at the thought and said it would mean too much commitment. Her associations were to a friend who had been in analysis whose parents paid. She recalled that the parents and the analyst were in contact about payment issues.

I understood that it felt to her that coming three times a week would be like having the parents in the room with us. Furthermore, that her old fear of me as the harsh authority figure was activated – that I would become her father. I would be totally in control.

I felt at this point that to pursue the issue would be counter-productive, since her anxiety was so intense, but expressed the belief that the work would be enhanced if she came in more often. She agreed after much discussion over a period of about 2 months to try coming in twice a week, with the understanding that she could return to once a week if she wished.

This was difficult for her at first. She felt that she had “nothing to talk about” for the second session of the week. In fact, she could no longer spend the second session of the week reciting the events of the past week-end and this was anxiety-provoking for her. She was willing to cautiously test more closeness, but clearly wanted to still keep me at a safe distance.

She did, however, continue the twice a week sessions, and agreed to “try out” the couch, again with the same understanding that if she didn’t like it she could discontinue.

As the sessions on the couch continued, at first, she was passive, a compliant patient. I was the controlling authority figure. This transference, which had been present in the past became stronger. There were mild complaints, of not getting through her list of items to discuss.

As the sessions continued, a transference emerged where I was seen at this time primarily as the pre-oedipal mother, who could be a benevolent provider, but could also just as easily be depriving. In time she was able to express her emerging concerns, that I might not be able to focus on her issues since I saw so many other patients, that her needs might be “too much” for me.

Over time she became more assertive in expressing her needs in her relationship also, and less passive in general.In addition, her fear of not being “perfect” – related to her harsh superego began to relax.