Sarah Goldberg dissertation

Institute for Clinical Social Work

Fresh Sufferings: Psychoanalysts in the Retirement Phase

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Sarah Goldberg

Chicago, Illinois March, 2021

Copyright © 2021 by Sarah Goldberg All rights reserved

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Abstract

This phenomenological study provides an in-depth exploration of the lived experience of nine aging clinical psychoanalysts during the retirement phase. The study offers greater understanding on how aging psychoanalysts negotiate issues of the self and later life during their final years in clinical practice. The study presents the lived experience of psychoanalysts using the theoretical lenses of self psychology and fifth individuation to examine the experience of the psychoanalyst’s self during the retirement phase.

The study has five major findings: 1. Practicing psychoanalysis provides a strong professional identity.

2. Concepts of “age” and “aging” are uniquely complicated in psychoanalysis.

3. There is real confusion among psychoanalysts regarding correct clinical protocols.

4. The necessary tasks of the fifth individuation and other developments of “time-sense” may be delayed or thrown off in psychoanalysis.

5. Practicing psychoanalysis over a lifetime provides steady selfobject experience which is ruptured when confronting old age.

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For all the healers who see in us what we need to be true.

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If you want to endure life, Prepare yourself for death ~Sigmund Freud

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Acknowledgements

This project began almost a decade ago and many people have helped it come to fruition. My parents’ enduring support is foundational and I wouldn’t know how to account for all the ways it has allowed me to flourish. The support of ICSW throughout my training, as well as their tremendous faculty, gave this project a home. My committee chair, Dennis Shelby, believed in this project from the beginning and understood my ideas before they made sense to me. This final dissertation exists thanks to the enduring commitment, guidance, and patience of my committee: Dennis Shelby, James Lampe, and Denise Duval Tsioles.

SG

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Table of Contents Page Abstract…………….……………………………………………………………………iii Acknowledgement….……………………………………………………………………vi Chapter I. Introduction………………………………………………………………………1 General Statement of Purpose Significance of the Study for Clinical Social Work Statement of the Problem and Specific Objectives to be Achieved Research Questions Theoretical and Operational Definitions of Major Concepts Statement of Assumptions Epistemology Foundation of Project Foregrounding II. Literature Review………………………………………………………………11 Introduction Termination Illness and the Analyst Death and the Analyst Aging and the Analytic Institute Recent Literature Contributions

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Table of Contents—Continued Retirement Studies in Related Fields Theoretical and Conceptual Framework of the Study Chapter

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III. Methodology……………………………………………………………………40 Study Design Scope of Study, Population, and Sampling Data Collection Data Analysis Ethical Considerations Issues of Trustworthiness The Role and Background of the Researcher IV. Results………………………………………………………………………..….54 Results of Participant Sample: Demographic Overview “Halcyon Days”: Competence – The Good Fit “Being an Analyst Opened So Many Doors”: Self-Expansion “I've Dodged a Lot of Bullets”: Experiences of Illness “I Feel I'm at the Top of My Game”: Mastery in Later Years “Not as Good as They Used to Be”: Facing an Uncertain Future V. Discussion and Conclusions…………………………………………………....69 PSA Identity Aging as PSA Concept

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Table of Contents—Continued Culture of Confusion Findings in Terms of Fifth Individuation Perspective Findings in Terms of Self Psychology Conclusion and Other Remaining Thoughts Appendices

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A. Flyer…………………………………………...……………………..……….98 B. Open-Ended Questionnaire………………………………………………..100 References…………………..…………….………………………...………….103

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Chapter I

Introduction General Statement of Purpose The purpose of this phenomenological study is to explore how clinical psychoanalysts understand and experience the retirement phase within the context of their clinical career.

The study will examine the lived experience of clinical psychoanalysts as they face aging and the retirement phase of their practice. For the purposes of this study, a psychoanalyst, in the retirement phase, is defined as one who is over 75 years old and still practicing clinical psychoanalysis. Using the method of interpretative phenomenological analysis, the study’s primary object of interest will be to investigate the range of lived experiences for clinical psychoanalysts as they enter the retirement phase and approach the end of their clinical career. The study will access lived experiences through the stories, anecdotes, and reflections of the participants. The goal will be to gather a sense of the lived phenomena of an aging psychoanalyst through eliciting their understanding, experiences, and sense-making directly within the specific context of being an aging psychoanalyst (Smith, 2009).

The study aims to illuminate the subjective experiences of the aging psychoanalyst as they approach the later stages of their clinical practice and gain greater understanding of the psychoanalyst’s relationship to their clinical work during this period. The study will

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look to explore the aging psychoanalysts’ subjective experiences including: the meaning of the work, their fears and fantasies of aging, how the nature and qualities of relational and affective ties shift with aging, how the meaning of the patient and psychoanalytic work changes with age, and how one’s role in the psychoanalytic field changes with age.

Significance of the Study for Clinical Social Work The significance of this study for clinical social work practice lies in the responsibility of social workers to our clients. The National Association of Social Workers (NASW) Code of Ethics 1.01 states that social workers’ principal interest is to promote the wellbeing of clients and that clients’ interests are primary (NASW, 2014).

Social workers who receive psychoanalytic training, or who chose to work in a psychodynamic or psychoanalytically informed way and enter private practice must keep in mind this initial contract with the patient. One can work as a clinical social worker, with long-term clients, in private practice, well into one’s later years. Often, because of this flexible framework, the career is conducive to clinicians working while suffering through illnesses or major declines (Fajardo, 2001; Morrison, 1997). There is an interest on the part of all social workers to confirm that one’s personal rationale for continuing to work is in line with the NASW ethical code and demonstrates a primary commitment to client’s best interest. This study could potentially impact how psychoanalysts negotiate this ethical bond to their patients.

The significance of this study, for social work policy, is that it will illuminate the process of aging in clinical practice and have future implications for examining current policies of aging as a clinical psychoanalyst. The significance of this study for social

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work research is to open up the phenomenon of aging as a topic for examination. This study may potentially help indicate the areas that require further research and exploration.

Statement of the Problem and Specific Objectives to Be Achieved According to the International Psychoanalytic Association (IPA), the average age of a psychoanalytic member is 65 years old, and the average age of a training analyst is 73 years old (International Psychoanalytical Association, 2011). There is a need to better understand the experience of aging psychoanalysts and to explore various approaches to ending one’s clinical practice. As the field of psychoanalysis ages, and an increasing number of practitioners in the field approach the retirement phase, the need for this exploration is even more timely. Neither private practice psychotherapy nor psychoanalysis has a mandatory retirement age. Decisions about clinical practice are left to the discretion of the individual psychoanalyst. The professional societies, such as APA, NASW, and APsaA do not have oversight boards that track or monitor aging clinicians, nor do they formally recommend courses in preparation for aging or end of practice as part of psychoanalytic training (Weiss, Kaplan, & Flanagan, 1997). The lack of established institutional guidelines suggests a long-running absence of thought and consideration to issues of decline and aging in psychoanalysis.

Despite more recent attention to the field of aging in psychoanalytic literature and training, the efforts have been anecdotal and spotty (Junkers, 2013). There have been few institutional efforts to think systematically about or begin to incorporate aging into the psychoanalytic training curriculum. There are no standardized protocols or trainings that speak to the experience of aging or ending a practice as a psychoanalyst. Because of this

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absence, there is much uncertainty how to manage the aging process, not only for the analyst and their patients, but for the field of psychoanalysis itself (Galatzer-Levy, 2013).

From the beginning, psychoanalysis has been a profession that one could practice late into life. Sigmund Freud practiced throughout a long battle with cancer and only ceased seeing patients close to death when his cancerous lesions became intolerable. This model of practicing until death carried through the early decades of the profession and perpetuated the myth of the therapist that can practice forever (Fieldsteel, 2005). This framework was based on the early theoretical foundations of psychoanalysis. The theoretical assumptions of the one-person model, and a completely interiorized psychological life, supported an analyst working into later life without affecting the patient and the treatment. As the field developed, the theoretical understanding of the therapeutic relationship has deepened. Many theories emphasize that the majority of psychological work takes place within the context of the therapeutic relationship. For the work to be useful, both parties need to be informed and consenting on every level.

Currently, decisions about aging and end of practice take place behind closed doors and are often kept between colleagues. For example, there can be knowledge of a declining clinician yet no one will interfere, out of a mixture of loyalty and friendship to their colleagues or discomfort with a confrontation (Galatzer-Levy, 2004). Galatzer-Levy (Galatzer-Levy, 2013) suggests that analysts will passively allow these circumstances to protect their colleagues and the analytic community, and to deny their own sense of vulnerability. As he further suggests, this situation does not respond to the patient’s best interest, and over time, has eroded faith in the field at large (Galatzer-Levy, 2013, p.

185).

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There is a need to know more about how clinical psychoanalysts think about ending their practices and their understanding of this retirement phase. What considerations come into play when thinking of taking on a new patient? How do they understand how aging has impacted their clinical work? What hopes and fears do they have for their continuing clinical work? How do they think about planning for an ending with their patients and how do they prepare themselves? Are there any protocols or supports which aging psychoanalysts think would aid in their consideration of ending their practices?

What would they recommend for future consideration?

Research Questions Central Research Question: How does the aging psychoanalyst experience clinical work and how do they experience their own aging in clinical practice?

Sub-Questions: 1. What is the aging psychoanalyst’s relationship to work and how does the meaning of the work change with age and as they plan for the end of their practice?

2. What are the fears and fantasies the aging psychoanalyst has in relation to their clinical work?

3. How does the aging psychoanalyst experience their relationship to their patients as they plan for end of their practice?

4. How does the aging psychoanalyst understand their role in the field and how does their understanding change with age?

5. How does the psychoanalyst’s age exist as part of the clinical work?

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Theoretical and Operational Definitions of Major Concepts Psychoanalyst: The term “psychoanalyst” is understood as someone who has completed the education requirements and received a psychoanalytic certificate from an accredidated analytic institution. The term “clinical psychoanalyst” is anyone who practices as a psychoanalyst by seeing patients in analysis. An “aging psychoanalyst” is understood as any psychoanalyst over the age of 75, who continues to maintain a clinical practice.

Statement of Assumptions 1. The study assumes that independent clinical psychoanalytic practice is a distinct profession that occurs primarily in a private space without oversight. Any decisionmaking about competence and aging are made outside of any official/institutional process.

2. The study assumes that being a psychoanalyst is not just a vocational identity but informs an ongoing understanding of the self, and that will be affected as the end of clinical practice approaches.

3. The study assumes that part of the unique vocational identity is formed from the longevity and intensity of the relationship of the patient, a relationship that differs from other helping professions.

4. The study assumes that psychoanalysts experience a specific phenomenon in relation to their identity when it comes to aging and ending their practice.

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5. The study assumes, through engagement with aging psychoanalysts, that some of the particulars of the lived experience of being a clinical psychoanalyst and the possibility of not working will be illuminated.

6. The study assumes the researcher will be able to use IPA methodology to develop relevant themes about the phenomenon of aging and experiencing the retirement phase as a clinical psychoanalyst. The researcher will also be able to make meaningful statements as a result of my data analysis about the unique qualities of the experience of an aging psychoanalyst. The study assumes that relating these developed themes back to the available literature will potentially illuminate the phenomenon of what it means to be an aging psychoanalyst nearing the end of their clinical practice career.

Epistemological Foundation of Project This phenomenological research project is located within the hermeneutic tradition of inquiry and relies on an interpretivist worldview. Given this interpretivist standpoint, the study assumes that all meanings of aging and end of practice concerns are created subjectively and dependent on the participants’ life experiences. This interpretivist view assumes that there is no single, absolute truth, but rather, the knowledge is constructed from the participants’ subjective experiences and interactions with the world (Bloomberg & Volpe, 2012).

The purpose of this phenomenological study is to explore the experience of the aging psychoanalyst. Phenomenological studies use an interpretative approach to narrative data to explore and gain access to the participants’ world of meaning. The goal of the study is

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to understand the lived experience of the aging psychoanalyst in the retirement phase and to provide an enriched understanding. Within the interpretivist viewpoint, the researcher acknowledges the importance of her own interest in the topic and works to examine how her values shape the conclusions of the study.

Foregrounding For the past several years, I have had a growing interest in aging and retirement within the psychoanalytic community. From an early age, this community has been important to me and has had an impact on how I understand the world. I grew up within the psychoanalytic community, with a father who is a psychoanalyst, and a mother who is a psychotherapist.

My understanding of psychoanalysis deepened when, at the age of nineteen, I entered psychoanalytic treatment. In the tenth year of my analysis, as my life was getting busier, my psychoanalyst told me that he needed to surgery on his back. He said he was uncertain about the exact timeframe because his doctors were discussing the risks and wanted to make sure it was the right choice. I remember little discussion about this topic with him. He did not seem worried, and I was familiar with the type of surgery. However, months went by and there was no news. I may have asked once or twice when he was expecting to be gone out of an interest of scheduling and preparing my calendar for his absence.

I vaguely remember wondering what was taking so long and why he was not able to go ahead and have the surgery. But, primarily, I remember thinking about myself insession and not having much concern for him. One fantasy that existed throughout

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treatment was that he would live forever and, most importantly, be there for the death of my parents, during which I imagined I would need his support. Truthfully, he was the same age as my parents and had been in ill health. I add these facts to indicate that my relationship, my transference, and my understanding of him were all components of a fantasy. There was no logical evidence to indicate that he would outlive my parents, and data demonstrated that he was unwell. I recognize all this only in retrospect; at the time, I thought he was immortal.

Following his surgery, we had several months of sessions on the phone. He did not always seem to be himself, but I did not give the change serious thought. One night, while away on a vacation, I got a message from a colleague of my analyst, saying that my analyst was terribly ill and unlikely to recover. I found out five days later that my analyst had died. I had a strong defense against grieving and even thinking much about his death.

Perhaps, to protect my idealized image of my former psychoanalyst, I wondered if he might have handled the situation differently had he discussed the risks of the situation more openly, if more thought would have been given to the concerns of analysts’ mortality, and the impact sudden termination has on a patient. I wondered, if he had not been trained or prepared to manage this final ending and, thus, let events happen. As I talked more and more about this with fellow patients and psychoanalysts, I learned that my experience was not uncommon. Few psychoanalysts plan for the ending of their career or what to do in case of severe illness. I have heard of patients not being notified of their psychoanalyst’s death, and not being encouraged to think, within the treatment, about loss, effectively colluding with their psychoanalyst’s a fantasy of immortality.

Unlike many fantasies in psychoanalysis, immortality and a never-ending treatment are

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often left unexplored. Losing a psychoanalyst is a special category of mourning. There are few places you can go to understand and explore this loss. Yet it is precisely this type of exploration, one that is unique to the psychoanalytic process, which could be employed to think with patients while in treatment about the meaning and impact of losing such an important figure.

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Chapter II

Literature Review Introduction Since Freud’s invention of psychoanalysis, there have only been a few research studies (Tallmer, 1992) and personal essays (Eissler, 1975; Eissler, 1993; Abend, 1982; Bolgar, 2002) that explore the experience of aging as a psychoanalyst. Until recently, there were no discussions or research studies of the retirement phase for psychoanalysts.

These few contributions to the literature regarding the experience of aging have failed to spark an ongoing conversation in the psychoanalytic field about what it means to age, as a practicing psychoanalyst, and encounter the retirement phase. In the past ten years, there has been an increase in publications discussing aging and retirement for psychoanalysts. Around 2010, there was a change in the literature on aging and retirement. Until this point, efforts had been scattered and rarely built into a dialogue; there were attempts throughout the years but, because of scarce supporting literature, these articles were not able to build off of one another in a way that could command the attention of the psychoanalytic field. And, these articles were primarily personal exploration, which rarely examined what aging meant for the field of psychoanalysis. A profound shift in the quality of the literature is apparent around 2010, demonstrated by dialogues in the literature and an emphasis on the meaning of aging psychoanalysts for

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the field at large (Fonagy, 2009; Elise, 2011; Galatzer-Levy, 2013; Junkers, 2013; Power, 2016). This review will examine trends in the literature on aging and retirement in psychoanalysis and will consider how these trends reflect the dominant thinking of the time.

Along with the shift in the literature exploring the experience of aging as a psychoanalyst, there have been developments in the psychoanalytic field reflecting an increase in thinking about aging and retirement for psychoanalysts, such as the committee on aging in the IPA. Increased literature relating to the experience of aging and retirement, as a psychoanalyst, parallels a similar emergence over the past several decades relating to surrounding topics such as illness/impairment, ending one’s practice, and how an aging population affects the field of psychoanalysis. This literature review will examine these related topics and will be broken up into several sections each of which contains a summary of the available literature on these themes and their bearing on the research question; the sections are: termination/end of practice, illness and the analyst, death and the analyst, personal reflections on retirement and aging, and aging and the analytic institute.

Termination The first topic that is generally mentioned in the literature on clinical endings is that of termination. It is a small thing to note, but most articles that explore clinical endings begin with a summary of the current theories on termination. The tension between theoretical paradigms of termination versus the practical conditions of less-than-ideal clinical endings is played out within the texts. These articles frequently begin with

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Freud’s original vision of the psychoanalytic process that would end when the symptoms had abated, and the patient had increased their ego capacity. However, Freud had no formulated termination policy and forced some patients to end their treatment to make room for incoming patients (Novick & Novick, 2006). As psychoanalysis has developed, clinicians have grown to see the importance of working through the termination process and allowing a full processing of the meaning of the ending. Responding to this developed sense of significance regarding termination clinicians from various theoretical leanings have written texts to describe types of terminations, its stages, and how to assess early in treatment if there might be trouble terminating.

A classic text, in the psychoanalytic field, on termination, is Stephen K. Firestein’s Termination in Psychoanalysis. Written in 1978, it mainly contains case histories that demonstrate the various outcomes on proper termination techniques being developed in the field at the time and is cited frequently. More recently, Jack and Kerry Kelly Novick’s book, Good Goodbyes, is heavily influenced from the tradition of ego psychology and represents current termination theory within this psychoanalytic tradition.

The discussion is purely analytic in its foundation, yet it aims to speak to a crossover audience of psychotherapists who hope to practice with a psychoanalytically oriented model. Another text with a strong discussion of analytic termination procedure is Alma Bond’s chapter, “Preparing for the Termination of Analysis,” in Is There Life After Analysis? (Bond, 1993), which develops theoretical concerns to consider in long-term treatment, including an overview of analytic thinking on the topic.

There are many additional texts that can speak to both analytic and psychotherapeutic audiences on termination such as Endings and Beginnings: On Terminating

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Psychotherapy and Psychoanalysis (Schlessinger, 2005); a thorough book, which, despite including a chapter titled, “Vulnerable Patients,” has no discussion of aging or retirement.

Another psychotherapeutic text on termination, Endings in Clinical Practice (Walsh, 2007), offers practical advice and case studies for terminating in a variety of clinical settings. Finally, Gabbard, in Long-Term Psychodynamic Psychotherapy, breaks down termination into nine potential category types (Gabbard, 2010). Gabbard continues his discussion in his 2009 paper, “What is A Good Enough Termination?” and attempts to break apart the myth of an ideal termination, suggesting it is an illusion. Instead, he seeks to define what the tasks of termination are and what new lessons might be learned (Gabbard, 2009). None of these articles or books discuss aging or retirement. The concept of termination is primarily considered to be a patient-initiated phenomenon.

The closest these writings get to dealing with the issues of a premature ending is through the discussion of a forced termination (Gabbard , 2010; Novick, 2006), in which the treatment has to end due to relocation, therapist-reassignment, or insurance disruption. This disruption can be initiated by the patient, the therapist, or by a thirdparty, such an the insurer, but these texts do not consider the concerns of retirement or aging. Much like with other topics, the literature that most closely touches on the issue of termination and death are personal reflections written by candidates or fellow therapists from the position of the patient (Rendely, 1999). Indeed one of the few recent research studies around termination practices focuses on the experience of termination for canididates only and laments the lack of available information of termination for “ordinary patients” (Craige, 2002). In another article, Craige follows up and suggests,

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Analysts should reevaluate their termination and post-termination practices in light of their potential impact to strengthen or destroy a sustaining, good-enough internal object relationship within the patient. Because standard termination technique grew out of a one-person psychology rather than a two-person model in which the analyst's role in shaping the process of treatment is more fully appreciated, our techniques and expectations about termination should be systematically reconsidered in the light of newer theoretical models. (Craige, 2003) A recent contribution to the literature of forced endings, which attempts to do as Craige suggests and update the termination model, is Anne Power’s book, Forced Endings in Psychotherapy and Psychoanalysis (2016). In this book, Power expands beyond the previously explored types of forced-endings to those endings caused by retirement or illness. She researches the impact of forced endings, due to retirement, illness, and moving on seventeen psychotherapists and psychoanalysts in Britain. She uses the lens of attachment theory to explore the experience of ending one’s practice. Her book presents the unvarnished experiences of clinicians who are forced for various reasons to close their practices in their own words. Power’s book is only one of the texts that engages and explores this idea of a “forced” termination or ending, and it represents the recent uptick in interest surrounding the topic of aging and endings in clinical practice.

Illness and the Analyst There have been separate contributions on endings in clinical practice from clinicians who have practiced with illness and various impairments. These texts pertain to the

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overall research question as they explore changes in the psychoanalyst’s capacities as they practice. There is sufficent overlap in the concerns of ill and aging psychoanalysts, as well as the previously mentioned dearth of texts relating purely to aging, that these writings on illness and impairment have relevance for considerations of retirement and end of practice issues.

The most common form of literature, speaking to the difficulty and complexity of practicing as a psychotherapist with a deadly-illness, is the personal reflection.

Beginning in the late 1960s and through the 1970s, brief mentions of illness and its impact on clinical practice begin to be published (Little, 1967; Chernin, 1976). In 1982, Dewald wrote Serious Illness in the Analyst: Transference, Countertransference, and Reality Responses, in which he discusses his experience with a sudden illness that required him to suddenly take several months off of work. Dewald explores his own discomfort in terms of communicating information about his illness to his patients, the various reactions to his illness by his patients, as well as the lingering consequences from the rupture. The article included a review of the very limited, available literature and calls on psychoanalysts to recognize and consider the importance of illness in the context of clinical practice.

Responding to Dewald in 1982, Abend writes about his own illness and its impact on clinical practice (Abend, 1982). In these articles there is a lot of consideration of “technical decisions” around disclosure (Abend, 1982, p. 365) and transference and countertransference experiences. Abend explores his initial instinct to convey no information about his illness to his analytic patients, to adhere to the classical frame of the analymous analyst, but found that he felt compelled to share more than he had

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planned. Abend considers both the costs and the benefits discussing with colleagues and how their “bonds of friendship” might impede their capacity to be truthful. He concludes by stating, “What I wish to emphasize is that we sorely lack reliable data to guide us in making assessments and decisions in managing these situations” (Abend, 1982, p. 378).

Another contributor to the literature on analysis and illness was Barbara Fajardo, an analyst who practiced throughout a long battle with cancer. She wrote “Life-Threatening Illness in the Analyst,” an article about how her practice was impacted in multiple theoretical and personal fronts as she practiced with a terminal illness. In her review of the literature, Fajardo separates the writings on illness into two camps: one-body and two-body, by which she means to distinguish those analysts who hold to a one-person, purely transferential view of the analytic process, with those who hold a relational frame, (Fajardo, 2001). Fajardo talks about how her “anxiety was palpable” to her patients and felt a need to explain the change in her subjective reality brought about by her diagnosis (Fajardo, 2001, p. 577). She breaks down the experience of the illness into three phases and acknowledges that patients' need to process the illness, in an ongoing way, can threaten the analyst who may hope to deny its existence. Fajardo discusses the common error of responding “to the patient's allusion to my illness with matter-of-fact reassurances that I am fine” (Fajardo, 2001, p. 582), instead of exploring the meaning of their concern. She notes the need for the ill analyst to find a, “professionally objective person” (Fajardo, 2001, p. 585) for consultation as well as an examination of selfobject needs. Despite potential pitfalls, Fajardo concludes, “It is possible to work through the phases of a life-threatening illness, and with most patients careful and deliberate selfdisclosure can deepen and facilitate the analytic process” (Fajardo, 2001, p. 584).

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Coming around the time of Fajardo and echoing similar sentiments, Schwaber offers another contribution to the literature on practicing psychoanalysis during an illness (Schwaber, 1998). She again focuses on the technical considerations of how to disclose and manage the information in her practice. She explores the desire to keep the details of her cancer away from her patients and states she, “Was motivated by a wish to protect my patients from the unnecessary and perhaps continuing anxiety that might be evoked (Schwaber, 1998, p. 1047).

Along with these singular reflections on illness, a book compilation titled Illness in the Analyst: Implications for Treatment (Schwartz & Silver (Ed.), 1990), brought together various opinions on the subject of illness and offers deeper insight into the experience of practicing psychoanalysis with an illness. The book is primarily made up of personal reflections from analysts who experienced illnesses while practicing. As with the other literature, the primary goal of the texts seems to be to examine what the proper self-disclosure is in the case of illness. Sparse discussion is given on the concept of informed consent, and all of the analysts, in this collection, take an abstinent stance, sharing as little information as possible. Patient welfare in the face of an analyst’s illness is barely discussed. It seems that there is a fantasy where the analyst can insure their welfare by continuing to practice, and through maintaining their practice, any concerns from the patient can be interpreted away. The idea that this will be a permenant and potentially traumatic loss for the patient is strikingly absent.

In most of these articles about practicing while ill, from the 1980s and 1990s, the writer spends a great deal of time and reflection imagining and managing the transference and counter-transference experiences of the illness, but, in the end, maintains that there

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always remained the capacity to do thoughtful analytic work despite the illness. As discussed, there is very little thought given to the actual death itself and the experience of the permanent loss of the analyst for the patient. Rather, the focus in these texts is about maintaining the analysis under the strain of the illness. In the early 2000s, slowly developing into the significant uptick in literature we see now, articles that look at the experience from the patient’s point of view and significantly questioned the long-held belief that practicing while ill was ethical started to surface.

Some of the sentiments leading to this shift can be seen in the last section, Illness in the Analyst, which deals with the subject of death. Most of the literature, up until this point, relates to handling illness and primarily represents the belief that illness presented little problems as long as one remains within the analytic stance. However, the final section of Illness in the Analyst: Implications for Treatment is titled “Death of the Analyst” and includes some of the only literature that deals directly with the issue of a psychoanalyst’s death. This section includes two personal reflections from analysts who experienced the death of their analyst as well as a short paper by Firestein that deals with various considerations for the patient following the death of analyst. Firestein’s paper, Death of the analyst: Termination, interruption, what?, offers certain questions to keep in mind regarding the death of analysts, such as how the patient found out about the death, what stage of the analysis the patient was in, and what comminucation had been provided to the patient. Firestein offers the suggestion that every analyst, “Develop an understanding with two trusted friends that will intervene if the analyst (a) shows signs of impairment in his work life; (b) experiences sudden total incapacitation or dies” (Firestein, 1990). Reading this section, it is easy to wonder how these practices developed

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and where Firestein derives his formulation on how to act. Which traditions around death, such as sharing a list of patients with a colleague, came from analytic training and which are ad-hoc compensatory practices that evolved where no training took place. Firestein notes that despite death being the ending we all have in common, few seem to prepare.

Firestein laments that the data, “Suggests there was a time in which to do useful things for the welfare of patients, this occurred but rarely. Analysts tended to deny the seriousness of their condition, or rationalized delay in informing their patients” (Firestein, 1990). Due to this denial, patients are rarely given the opportunity to fully explore and discuss mortality and its meaning for them.

Death and the Analyst Due to the aforementioned complications, the subject of death is rarely dealt with head-on in the literature. It is referenced but rarely fully engaged. In her book, Forced Endings, Anne Power has two brief discussions on mortality, she begins with Freud’s thought that, “Our own death is quite unimaginable” (Power, p. 125). In these sections on mortality, Power notes that ending one’s practice can feel like a death itself and, the loss of a professional identity, can force one to grapple more closely with issues of aging and death. Power reports that there is isolation for many analysts when closing their practice.

Power writes, “Several contributors did not know any other therapists who had retired and this meant they were quite alone with whatever feelings came up” (Power, p. 125).

There is the feeling that the participants in Power’s book experienced a wish for more leadership and support from their analytic community.

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The earliest piece of literature to directly grapple with the consequences of the death of an analyst is a research study in 1978 examining how patients reacted to the unforeseen death of an analyst. It was an exploratory study of twenty-seven people to examine how patients reacted to the death of an analyst (Lord, Ritvo, & Solnit, 1978).

The study found that ten of the twenty-seven patients who lost their analysts demonstrated complicated and prolonged mourning. The study found that this type of mourning often related to deprivations and loss in early childhood. The study stated, “The most striking feature of this group of patients with complicated and prolonged mourning was their high incidence of early loss, deprivation, abandonment, or all three” (Lord, Ritvo, & Solnit, 1978, p. 193). Because there are so few research studies around the loss of an analyst, this one is frequently cited as an early call to arms. The literature review of the article bemoans how little interest in mortality analysts have taken and called for more research focusing on patients’ reactions to the end of treatment and how earlier losses figure into termination.

Even with the warning sounded, the topic had little writing until Galatzer-Levy's follow up in 2004. His paper adds to the Lord, Ritvo, and Solnit study with reflections from his work with ten patients whose analysts died while they were in treatment.

Galatzer-Levy aims to understand the dynamics of mourning for these patients who lost an analyst in the middle of their treatment and then sought an additional analysis (Galatzer-Levy, 2004). The study elucidates how the unexpected loss reawakened earlier traumas and often caused the hard work of the analysis to fragment under the stress of the unanalyzed rupture (Galatzer-Levy, 2004). Galatzer-Levy uses the topic of the death of the analyst to survey how the psychoanalytic community responds to impaired

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practictioners. He explores the overarching element of denial of death within the psychoanalytic community as a failure to engage and handle ethical complaints, the inability to plan for end of practice and lack of informed consent when the circumstances of treatment change. He challenges the notion that it is ethical for a terminally-ill analyst to continue to practice and calls the assumptions from the illness papers into question. He cites Firestein as saying, “That once the illness is known to the analyst, the treatement should be considered terminated” (Galatzer-Levy, 2004, p. 1018). The paper ends with the sudden deaths of analysts and the harm it does to patients with a call for greater oversight, greater retirement planning, and greater training on this issue in the psychoanalytic community (Galatzer-Levy, 2004).

Despite Galatzer-Levy’s implicit call for engagement and thought around illness and death of psychoanalysts, as seen from the trends in the literature, it took a few more years for a larger discussion of the topic to take place. In 2013, in another paper on the topic, Galatzer-Levy offers a more forceful attack on the failure of individual analysts and, particularly, the failure of analytic institutions to properly manage the end of practice for ill and aging psychoanalysts. In “The Death Analyst, the Death of the Analytic Community, and Bad Conduct,” Galatzer-Levy paints a darker picture of the costs of practicing while ill or impaired. He directly challenges Barbara Fajardo’s claim that she was able to work effectively while dying from ovarian cancer. He says those types of rationalizations offer “attractive” explanations but do not hold much truth when contrasted with personal experiences of patients whose analysts had died. This article holds the analytic community and its institutions to blame for the systemic failure to consider the importance of boundary issues surrounding life and death. He further

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connects the psychoanalytic field’s inability to mourn its losses as a community with a lack of generativity, and as a failure to consider the future of and potentially mourn the decline of psychoanalysis itself. This strident language and plea for action is more common in literature from the last ten years as the topic has gathered steam.

Despite the momentum gathered in the literature in the last ten years, a careful overview shows that, in practice, the debate over when to close one’s practice and how to do it has been ongoing. Some clinicians align with Galatzer-Levy’s position that one cannot practice while terminally ill and have ended their practices while they still felt able to control their own and their patients’ fate. These psychoanalysts ended their practices while vital and well, wishing to step back from their career prior to any serious declines. There is a good deal of literature representing personal reflections about the desire to retire from psychoanalysis or psychotherapy and the internal struggle to do so while maintaining dignity between self and others (Fieldsteel, 2005; Nass, 2015; McKamy, 2015). Robbins and Sands offer similar reflection essays on the complicated feelings that come to drawing a vital part of one’s life to a close particularly when it involves close and powerful attachments to other people (Robbins, 2006; Sands, 2006).

Through these different writings one can feel the need for a deeper engagement with a community of peers.

Aging and the Analytic Institute Over the years, along with literature on termination and illness, there has been some emerging literature touching on the issue of aging and how to think about it within the psychotherapeutic and psychoanalytic communities. In the Menninger Clinic Bulletin in

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1997 and 2000, Weiss and Kaplan wrote about both the needs and the barriers to instituting aging reforms within psychoanalytic training institutes and communities. They cite structural impediments such as the late start that many analysts get in their practice due to the long training as well as resistance to oversight throughout the years. Their two papers offer a good summary of how the field has developed thus far with little intervention (Weiss & Kaplan, 2000; Weiss, Kaplan, & Flanagan, 1997). They echo many of Galatzer-Levy’s sentiments.

Finally, the outline and sample vignettes in Ethics Case Book: Of the American Psychoanalytic Association regard how difficult cases are in terms of clinician aging and of impairment, and that they are not black and white. The book begins with ten “guiding general principles” (Dewald & Clark, 2002). The eighth is, “safeguarding the public and the profession” which lists guidelines for difficult situations (Dewald & Clark, 2002). For instance, one guideline suggests that in the case of an analyst with a “serious illness . . . or whose analyzing capacities are impaired should consult with a colleague and/or medical specialist to clarify the significance of his or her condition for continuing to work,” according to the book (Dewald & Clark, 202). From other texts in this review (Galatzer-Levy, 2004; Weiss, Kaplan, & Flanagan, 1997), it is clear that peer consultation, in this insular community, is rarely effective, yet the book continues to offer it as a remedy.

Another guideline says that, If a psychoanalyst is officially notified by a representative of an institution or society that a possible impairment of his/her clinical judgment or analyzing ability exists, the psychoanalyst must consult with no less than two colleagues, one of whom may be a

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non-analyst medical specialist, each is acceptable to the notifying body. If impairment is found, remedial measures must be followed by the psychoanalyst in order to protect patients from harm and to prevent degradation of the standards of care in the profession. (Dewald & Clark, 2002) Despite these suggested protocols, the previous literature review demonstrates that there are no institutional enforcement mechanisms for such a guideline to be effective (Weiss & Kaplan, 2000; Weiss, Kaplan, & Flanagan, 1997). Junkers summarizes these paltry and failed efforts over the years and concludes, “(T)he only conclusion we can draw from that is that here a multiplicity of unconscious wishes comes into conflict with perceiving reality and that personal/institutional denial is at work” (Junkers G., 2013).

As it currently stands, psychoanalysis is a field with good intentions regarding termination, practicing when impaired, and planning for retirement and aging, yet there remains no planning or training efforts to implement or enforce any cohesive vision. In addition, according to the literature there seems to be an ongoing denial of the severe need to consider and plan for aging and endings.

Recent Literature Contributions Responding mounting need, there has been an influx of literature in the past five to ten years that relates to aging and ending one’s clinical practice. In 2009, George Moraitis wrote a reflection on closing his practice that discusses the tenuous professional identity of the psychoanalyst and the comfort a full caseload can provide. Moraitis explores termination practices and shares that he, personal, closed his practice by refusing

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to take on new patients, only allowing his remaining cases to complete “their analysis by mutual consent” (Moraitis, 2009, p. 157).

In 2011, psychoanalyst Robin Deutsch wrote a poignant paper discussing the death of her analyst while in the middle of her treatment as a psychoanalytic candidate. Deutsch explores how the loss of an analyst means the loss of the analytic space and the “analyst and self” that exists within the dyad. The journal, Psychoanalytic Inquiry, published two discussions of Deutsch’s paper, one by Adrienne Harris and the other by Dianne Elise.

The discussion by Adrienne Harris notes that Deutsch has offered one of the few available narratives on the loss of an analyst. Harris writes, “The voice of the analyst and who is left bereft by the death of the analyst is not at all well known. This voice has been almost inaudible until now” (Harris, 2011). Harris’s discussion includes a section subtitled, “The Analyst’s Vulnerability,” in which she discusses some of the issues of illness and impairment that were reviewed earlier in this chapter. In consideration of how to handle these concerns she notes, It is an oversimplification to simply decree that however one handles life crises and the maintenance of health in practice, there is some imperative on bringing such material into the room in an analysis. The right path through problems and issues of analytic subjectivity is not quite so easy to proscribe . . . There are no easy obvious rules of procedure here. (Harris, 2011, p. 540) These three papers provide a sense that the community is beginning to engage issues of aging psychoanalysts in a deeper and more thoughtful manner.

This trend continued in 2013 with the book The Empty Couch, a compilation of essays edited by Gabriele Junkers, a psychoanalyst and gerontologist. The book is

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divided into three sections: growing older as psychoanalysts, illness and ending, and institutional parts of ending. These three sections cover most of the same territory as discussed in previous literature, while expanding on some themes. The section on aging as a psychoanalyst provides richer personal reflections on why psychoanalysis might be a difficult profession to give up, with reflections about how psychoanalysts organize much of their identity around the profession. The section on illness and ending offers some of the same voices from the past such as Fajardo, but also includes a reflection from a psychoanalyst about her training analysis with an esteemed senior psychoanalyst who became increasingly ill and demented throughout her treatment. This inclusion of the patient’s perspective, although it is one of a candidate that has now joined the ranks, marks an expansion of the discussion to include other voices.

In her essay, “Later, Perhaps . . . ,” Junkers argues for what seems to be the overarching hypotheses to this collection, It is in my view because we as a group, as if under the sway of a taboo, are unable to share with each other an internal representation of the significance for us of old age and the end of our professional and biological lives . . . This scotomisation of a fact of life helps us to understand why, on the one hand, we have problems with bidding farewell to working behind the couch, and, on the other, why we have been unable to address this changed life situation institutionally. (Junkers, 2013) Through the essays in The Empty Couch, Junkers is able to begin and deepen a muchneeded conversation about psychoanalysts and aging.

Following on the heels of The Empty Couch, there has continued to be individual contributions to the literature primarily in the form of personal reflections on aging. One

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example is Chessick’s 2013 article, “Special Problems for the Elderly Psychoanalyst in the Psychoanalytic Process,” which offers an updated picture of practicing as an older psychoanalyst. Using case studies, he illustrates some of the clinical issues that can arise as one ages (Chessick, 2013). In 2015, Elizabeth McKamy wrote “Closed for Business: Reflections on a Psychoanalytic Psychotherapist’s Voluntary Retirement,” in which she frankly discusses the difficulty of ending one’s practice. The increase in contributions is promising but, as every writer and every paper has acknowledged, this field of study continues to need a significant investment of resources and attention.

Retirement Studies in Related Fields In following the trend to examine the any related studies of importance pertaining to endings within the psychoanalytic fields, it is necessary to consider the literature on retirement. There have been a few studies that directly look at retirement implications for psychoanalytic clinicians. Some of the more recent literature, such as The Empty Couch and Forced Endings, touch on aspects of retirement but are not directly focusing on a planned retirement. The studies on retirement that are available have been done either in the United Kingdom, New Zealand, or Australia and primarily examine retirement for medical doctors. For instance, Australia instituted a study called The Medical Masters Study, which aimed to look at adaptive aging in some of the top doctors in the country as identified by their peers (Peisah, 2009). In 1999, Australia and New Zealand conducted a three-part study on 629 aging psychiatrists to examine various aspects of their retirement plans and attitudes towards retirement (Draper, Gething, Fethney, & Winfield,1999; Draper, Gething, Fethney, & Winfield 1999a; Draper, Gething, Fethney, & Winfield,

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1999b). Each portion of the study attempted to examine a different aspect of retirement practice. The study charted indepth demographics as well as what created positive associations to retirement for these psychiatrists, what helped them transition to the next stage of their life, and how they chose to define that stage.

Along with these studies, the United Kingdom has produced several studies examining retirement concerns for psychotherapists. Some are along the lines of the personal reflections and examine clinicians’ personal struggles to find the right time.

When is the Right Time to Retire? is a qualitative study that looks at the decisions of four clinicians and their plans for retirement (Pointon, 2004). It comes with audio and provides an indepth analysis of their decision-making and the balancing of needs between the patient and self that such retirement decisions entail. Additionally, an article in the British Journal of Psychotherapy (2012) details four new courses that have been established in Britain in the past decade to focus on retirement concerns and training (Barratt, Kegerreis, & Wetherell, 2012). The courses grew out of discussion beginning at a conference in 2003. The attendees noted that although many clinicians were expected to be comfortable discussing issues of the retirement phase with their patients they themselves may not be doing the critical and necessary preparation work. The timing of this study parallels the increased interest and writings within the last fifteen years.

In the United States, a survey study of the Texas Society of Psychiatric Physicians focused on how the members were planning for retirement, their leisure activities, and financial planning (Baker, Warren, Muraida, & Muraida, 1993). One of the authors of that previous study completed a later retirement study with the active members of the Black Psychiatrists of America (Baker, F. M., 1994) and examined the same concerns.

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Studies examining retirement within the mental fields have been few. Unlike their counterparts in the Britain, there has been no collective voice speaking to training and planning concerns for aging medical professionals.

Theoretical and Conceptual Framework of the Study This research study uses two theoretical models to frame and analyze the data: Colarusso’s concept of the final stage of life or what he terms, the “fifth individuation”; along with self psychology theory and its concept of a selfobject experience. The fifth individuation helps frame the data in terms of the developmental and contextual meaning contained in the last stage of life. While self psychology provides a conceptual framework for exploring the subjective meaning that participants derive from this phase of life.

The fifth individuation.

This research uses Colarusso’s concept of the fifth individuation, described in his paper, A Developmental Line of Time Sense: In Late Adulthood and Throughout the Life Cycle (Colarusso, 1998), because he is one of the few modern psychoanalytic researchers who has built upon existing psychoanalytic developmental literature to explore development throughout later phases of life. Reflecting previous psychoanalytic understanding of development (Erikson, Emde, Pollack), Colarusso bases his work on the idea that development is an ongoing experience throughout life. Using Mahler’s separation-individuation framework, he offers expanded views on the developmental tasks of early, middle, and late adulthood. Despite using Mahler’s framework of

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separation-individuation, Colarusso is explicit in differentiating the tasks of the adult from the more simplistic individuation that takes place within the first individuation period with the mother and baby.

For Colarusso, the primary way that adult developmental tasks are differentiated from the tasks of childhood development is “the degree to which the intrapsychic experience is one of separation and individuation from aspects of the self” (Colarusso, p. 1472). This gradual leaving culminates in death. The awareness of our impending mortality, according to Colarusso, is what shapes the time of the Fifth Individuation. Along with the lifelong stages of individuation, Colarusso focusses on a developmental theory of “timesense” and how attitudes toward time greatly influence the separationindividuation process throughout life, but particularly in middle and late adulthood, as individuals gradually change their perspective from, to use Neugarten's words, timesince-birth to time-left-to-live. This shift in time perception leads mid- and late-life individuals to focus on, process, and gradually accept the inevitable separations that occur, both intrapsychically and in the real world, from others and from no-longerauthentic aspects of the self (Colarusso, p. 1485) Through his theory of time sense, Colarusso builds an understanding of the fifth individuation as period of time shaped by the awareness of death in which one also desires generative symbiosis. He states, The fifth individuation is characterized by two contradictory trends: the intraspychic shift from being left to leaving as one contemplates and accepts the nearness of death and the loss of all human relatedness; and the simultaneous desire, stimulated by the acceptance of a personal end, to fuse with loved ones, community, culture, and

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the broad expanse of humanity by giving, without restraint or expectation of return, of one's wisdom and possessions. (Colarusso, p. 1471) This research study uses the framework of the fifth individuation to consider the meaning of this period of life for the participants. Using Colarusso’s understanding of the tension between an awareness of death and a desire for generativity helps frame the challenges for this period of life. Colarusso also speaks briefly to the impact of retirement on the fifth individuation. He notes that retirement can often prompt a mourning process and the need to individuate from unrealized hopes and dreams for the self. Colarusso describes, Retirement produces a growing awareness of redundancy, of no longer being in the center of a world which rapidly, even frantically, rushes past the retiree, embracing and integrating new knowledge and technology. The retiree must struggle with the realization that he or she is separate from the younger generations: on the other side of an ever-widening chasm of time, knowledge, energy, and technology. The loss is made narcissistically tolerable, even enjoyable, through a combination of generative activities, identification with the young, and an understanding and acceptance of the human life cycle. (Colarusso, p. 1479) Colarusso sees the paradoxical tasks of mourning for a fading mastery while investing in the community of the future as the characteristic tension of the fifth individuation.

Self psychology theory.

Self psychology is a theoretical perspective developed in the 1970s by Heinz Kohut.

It moves away from classical drive theory and offers a distinctive view of narcissism and

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of the development of the self. Self psychology formulates an experience understanding of patients using empathy as the primary data collection tool and uses the hermeneutic tradition to deepen the exploration. Self psychology posits the idea of a nuclear self that exists as a tension gradient of its constituent parts between two poles, the grandiose self, and the idealized parent imago with the aim over time for the self to achieve a narcissistic homeostasis and cohesion (Siegel, p. 66).

Self psychology describes the formation of the self by demonstrating how interactions with caregivers develop the structure of the self. A lack of attunement from caregivers and a failure to respond to the developing self causes deficits in the self structure. Self psychology theorizes a nuclear self, a structure that emerges during the second year of life (Kohut & Wolfe, 1978), which is the foundational part of the personality that endures over the life course. It is the core, nuclear self that accounts for the sense of the self as a continuous subjective entity over its development and provides a sense of continuity and cohesion over time (Elson, 1986). The nuclear self contains the constituent parts of the personality with talent and skills that are impacted and developed in response to ambitions and ideals. In self psychology, the concept of the self is not meant to describe agencies of the mind, as ego, id, and superego do. Instead, the self is a structure in the mind that allows for the reflection of experience and encompasses all agencies of the mind. Kohut sets up a flexible theoretical framework for how the self develops individually and uniquely for each person. This framework provides the basis for the contextual root metaphor because every self is different and every individual context will develop a different self. Each self will have a different set of talents and skills which

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interact in an unique way with the two poles. A healthy self is one that is well-balanced and well-regulated.

Kohut describes the self as a nuclear self that exists as a tension gradient of its constituent parts between two poles, the grandiose self and the idealized parent imago (Siegel, 1996). According to Kohut, the pole of the grandiose self is related to our fantasies of a perfect self. The grandiose self contains the experiences of our omnipotence, expansiveness, and our wish to be admired. The other pole, Kohut describes as the idealized parent imago, which is related to the desire to merge with the idealized caregiver. According to Kohut, this desire for merger offers tension regulation and the feeling of union with omnipotent source.

One of Kohut’s most important and expanded upon theoretical contributions is the concept of the selfobject. Kohut introduced selfobject as a way to describe a particular relationship between the self and others. Selfobject functions are essential psychological needs which one uses and internalizes through consistent and empathetic responses from the others (Bendicsen, Koch, & Palombo, 2010; Elson, 1986). Selfobject needs represent mental states that are not developed in the self and require others, the selfobjects, to provide them. Selfobject experiences begin in utero and although they change in presentation, people need them across the developmental lifespan. A baby needs a caregiver to provide concrete and active selfobject functions such as feeding, changing, and rocking because the baby is not yet able to manage these tasks for himself. Yet, as we grow, our selfobject needs are less concrete and are increasingly provided in symbolic experiences. Selfobject experiences provide feelings of cohesion, homeostasis, and

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integration. Kohut felt that without ways to fulfill selfobject needs in our lives, particularly in periods of change, there was often internal disorder and fragmentation.

Using clinical material, Kohut found that there were specific types of selfobject needs that corresponded to the psychological structures of the grandiose self and the idealized parent imago. The selfobject functions aligned with the grandiose self are having someone to mirror one’s own internal state. The grandiose self being responded to by excited and enthusiastic selfobjects, provides a sense of value, confidence, and narcissistic homeostasis. Over development, mirroring selfobjects help to instill a sense of self-esteem and confidence. The selfobject functions for the idealized parent imago are to provide a sense of self-control and calm with which one can connect. The idealized parent imago is able to share in the selfobject’s strength as well as have affect contained and understood. These selfobject functions develop into a sense of self-regulation and life values. Later in his writings, Kohut offers a third selfobject function, that of twinship or an alter-ego. These functions were originally part of the mirroring function, but Kohut chose to give them a distinct status. The alter-ego selfobject functions are defined as providing a sense of likeness with others and a bond with others. The alter-ego selfobject function gives one a sense of belonging and cohesion in a community. These three selfobject experiences are essential throughout life.

Kohut’s theory of self psychology did not offer a clear course of development, rather Kohut described an outline of a lifelong interplay of the structures of the self with their environment. Kohut offers, More substantial than the terminological questions are those concerned with the development and dynamic position of the principal narcissistic configurations. The

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central mechanisms (“I am perfect.” “You are perfect, but I am part of you.”) which the two basic narcissistic configurations employ in order to preserve a part of the original experience of the narcissistic perfection are, of course, antithetical. Yet, they coexist from the beginning and their individual and largely independent lines of development are open to separate scrutiny. Under optimal developmental conditions, the exhibitionism and grandiosity of the archaic grandiose structure are gradually tamed, and the whole structure ultimately becomes integrated into the adult personality and supplies the instinctual fuel for our ego-syntonic ambitions and purposes, for the enjoyment of our activities, and for important aspects of our selfesteem. (Kohut, 1971, pp. 27-28) Palombo, Bendicsen, and Koch call self psychology’s approach to development, “A hybrid nonepigenetic organismic model that incorporates a narrative perspective” (Palombo, Bendicsen, and Koch, 2010, p. 262). Palombo, Bendicsen and Koch use the Self Psychology theory and framework to build a developmental model, yet it only extends through age 26, a stage they label “Entry into adulthood.” Cohler and GalatzerLevy (1990) offer an expanded exploration into selfobjects and their functioning in adult life. They argue that there is a need throughout life to have relationships that provide selfobject functions and they examine three: mentorship, parenting, and reminiscing in old age. Cohler and Galatzer-Levy argue, It seems reasonable to extend the idea of selfobject function to include not only mental representations that stabilize and vitalize the experience of the self, but also those that promote development by, as it were, holding the person through the periods

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of instability and change that are necessary for psychological development.”

(Galatzer-Levy and Cohler, 1990, p. 93) Cohler and Galatzer-Levy conduct explorations into the selfobject experiences in adulthood and later life yet note that more work is needed to examine the selfobject experiences of adulthood, especially “friendship and work” (Galatzer-Levy and Cohler, 1990, p. 106).

Like Galatzer-Levy and Cohler, Miriam Elson argues that “Selfobjects are required for the creation and the consolidation of the self throughout life” (Elson, 1986). Elson discusses selfobject experiences in adulthood as necessary for maintaining cohesion and self-regulation. She writes, As the individual grows to mature years, there are many transitions which severely test the cohesiveness of the self, resulting in periods of lessened vigor, loss of purpose, discontinuity. Selfobjects play a role both in sustaining an individual during a period of such reverses and in tempering the excitement of success…As we mature the selfobjects we seek for sustenance will include not only individuals, but also one’s profession and vocation. (Elson, 1986, p. 19) Elson does not offer much further on this idea of work or one’s profession as a selfobject, yet this research framework will use this understanding of one’s profession or work as providing a selfobject experience.

Although self psychology does not offer specific theory that speaks to late life development or aging, Kohut speaks about transience and offers that, Man’s capacity to acknowledge the finiteness of his existence, and to act in accordance with this painful discovery, may well be his greatest psychological

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achievement, despite the fact that it can often be demonstrated that a manifest acceptance of transience may go hand in hand with covert denials. (Kohut, 1966, p.

263) This study uses the self psychological lens that believes our experience with others and the meaning of those experiences shape and develop the self throughout the life course. Self psychology labels these experiences of mirroring and idealization selfobject experiences. A great deal of work has been done around exploring the selfobject experiences of early life, but much less so on later life selfobject experience. This study will use the framework of the selfobject experience to further explore the experience of aging psychoanalyst and the selfobject experiences contained within the professional identity.

Summary of Theoretical Framework This research study uses two theoretical concepts: Colarusso’s the fifth individuation and self psychology selfobject experience to structure and further explore the data. The concept of the fifth individuation helps frame this final stage of life within psychoanalytic terms. It is the last period of life in which Colarusso argues the task is to work with one’s impending mortality to shape lasting investments in others through love. Colarusso presents the fifth individuation as a time in which one individuates from and mourns lost potentials for one’s self. Self psychology tells us that in period of fluctuation and change, such as the mourning of the fifth individuation, there will be disruptions in the selfobject experiences that help sustain one’s narcissistic homeostasis.

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Conclusion Despite powerful claims of commitment to patients and to the psychoanalytic process of exploring and understanding, for years psychoanalysts ignored or sidelined questions of how to manage aging in clinical practice. Despite the growing acknowledgement that psychoanalysts have many clinical considerations as they age, there seems to be difficulty field-wide to any sustained formal discussion, retirement planning support, or professional oversight. Psychoanalysis is a field of primarily private practice clinicians who enjoy their ability to practice freely while belonging to a loose community of members and there has been little interest in community-wide or insitution-wide policies around aging.

It is a field with tremendous pride in its professional integrity yet one that is often unwilling to take steps to limit a colleagues’ ability to practice freely when there is a conflict between a patient and a colleague. There has been a feeling, for many years, that what went on behind the treatment room’s door was no one’s business and that the guidelines were just those, guidelines, but not to be enforced. Yet, as the impact of bad terminations and treatment with impaired clinicians gets born out in the literature, clinicians are gradually revisiting these old ethical precepts. Studies demonstrating the permanent loss when an analyst dies or the narcissistic considerations around the impact of aging with your patient, bring attention to new sets of issues. As the population grows older and aging concerns increase, we must tune in to these new ethical situations we can expect in the treatment room.

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Chapter III

Methodology Study Design The purpose of this study is to discover how aging clinical psychoanalysts think about the end of their clinical practice and how they understand the retirement phase within the context of their clinical career. For the purposes of this study, clinical psychoanalysts are defined as those who have graduated from an accredited psychoanalytic training program and work clinically for at least 50% of their work week. This is a phenomenological study that explored the lived experience of how clinical psychoanalysts understand the meaning of the retirement phase of their career. The study then interprets the data of the lived experience with Colarusso’s theory of time-sense and the fifth individuation as well as self psychology theory.

I located this research project within the hermeneutic tradition of inquiry, relying on a hermeneutic interpretivist worldview. According to Creswell, the choice for a research method is based upon the worldview of the researcher and the perspective through which they frame the research question (Cresswell, 2014). In this way, the hermeneutic interpretivist world view embraces a “context-specific perspective” (Bloomberg & Volpe, 2012, p. 29) and, most often, uses qualitative research as a method to explore and understand specific contextual experiences. This hermeneutic worldview fits with the

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perspective of contemporary clinical psychoanalysis and the object of study, which uses the hermeneutic method to examine potential personal meanings within co-constructed experiences. Using this hermeneutic interpretivist standpoint, I assumed that all meaning of the experience around ending one’s practice is created subjectively and dependent on the participants’ life experiences. This worldview assumes participants will form a distinctive personal meaning of the experience of ending their practice due to their individual subjectivity.

I chose a qualitative research method because it is a study that aims to explore the experience of ending a practicing clinic for psychoanalysts. A qualitative approach to research is used in order to “explore and understand the meanings that individuals ascribe to a social or human problem” (Cresswell, 2014). In contrast, a quantitative research approach is used “for testing objective theories by examining the relationship among variables” (Cresswell, 2014,). While a quantitative research approach is used to describe conditions as they are and assumes that there is a type of knowledge that is measurable, qualitative research believes that there is a multiplicity of potential meanings and experiences that can be true within any lived experience.

For the particular phenomenological research method, I chose the investigative research method of interpretative phenomenological analysis (IPA). IPA is a specific method for using a phenomenological approach to research. The goal of any phenomenological research is to examine the participants’ personal experience with a phenomenon and how they make sense of that experience. The emphasis in phenomenological research is on the “life-world” (Moustakas, 1994) and all the complexities within it. There is no attempt to formulate objective facts but, rather, the

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focus is on each participant’s personal understanding and meaning of the event.

Moustakas stresses that phenomenology is “a return to experience” for data. This emphasis on the experience itself as holding knowledge is fundamental to all phenomenological research approaches and aligns well with the understanding in psychoanalysis that data is contained in experience (Ricoeur, 1970).

Unlike with grounded theory, my aim with this research approach is not to develop a theory around the end of practice and psychoanalysis, nor does it seek to merely describe it in detail, as an ethnography might do. Instead, as Van Manen states, “Phenomenology does not offer us the possibility of effective theory with which we can now explain and/or control the world, but rather it offers us the possibility of plausible insights that can bring us in more contact with the world” (Van Manen, 1990). Instead, this study attempted to gain greater understanding about the meaning of the end of clinical practice for psychoanalysts and to bring greater light to this experience, both of which are goals that directly align with a phenomenological approach to the research.

The hermeneutic interpretivist underpinning of this research study are in alignment with the theoretical tenets of IPA in privileging subjective meaning above objective fact, which allowed the lived experience to come through in the data. IPA brings together the philosophical traditions of phenomenology and hermeneutics to form a research method that acknowledges any attempt to observe a phenomenon will necessarily be an interpretative one in which there is a hermeneutic effort to make meaning (Smith, Flowers, Larkin, 2009). IPA is a method for conducting phenomenological research that emphasizes developing a detailed understanding of the individual experience and placing it within particular social contexts (Smith, Flowers, Larkin, 2009). IPA is ideal, “When

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one is trying to find out how individuals are perceiving the particular situations they are facing, how they are making sense of their personal and social world” (Smith & Osborn, 2008). IPA’s considerations of the intersection of the individual and the social proved vital in the data analysis.

I explored the everyday experiences of aging psychoanalysts in clinical practice with IPA’s focus on “human lived experience” which “posits that experience can be understood via an examination of the meanings which people impress upon it” (Smith, Flowers, Larkin, 2009). The commitment of IPA to sense-making fits well within the goals of this research study which aims to develop some understanding of the meaning of ending clinical practice for psychoanalysts.

Because there is little existing research regarding the experience of ending practice for clinical psychoanalysts, the IPA method helped explore the phenomenon and draw out some of the key elements of the experience. IPA allowed for a deep exploration of particular experiences as the primary aim of the method is to “explore, flexibly, and in detail, an area of concern” (Smith & Osborn, 2008,). IPA offered a type of phenomenological precision that helped illuminate the experience of the participants.

I aimed to offer a descriptive picture of this final career phase for clinical psychoanalysts in this study and, by doing so, help the psychoanalytic field think deeper about what policies and training might be useful to build greater trust in psychoanalytic field for both patients and practitioners. In the attempt to understand the phenomenon of retirement in psychoanalysis, the study focused on one main research question: What is the meaning of the end of clinical work for clinical psychoanalysts? There will be five additional sub-questions which will be used to help further the elucidate the main

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research question: (a) How does an analyst describe and understand the end of practice phase? (b) What meanings does a clinical psychoanalyst makes of ending clinical work and terminating the relationship with patient? (c) What does planning for ending one’s practice as an psychoanalyst entail? (d) What is the impact of retirement on the psychoanalyst’s sense of self? (e) Are there any recommendations for training curriculum or institutional protocols that might be indicated as a result of the findings?

Scope of Study, Population, and Sampling In order to adhere to the sampling strategy recommended by the IPA method and create a sample of psychoanalysts over 75 years old currently practicing clinically, I began the study using a type of purposive sampling called criterion-based sampling, a strategy to ensure that all participants fit within the inclusion criteria (Bloomberg & Volpe, 2012). IPA recommends the use of a purposive sampling method to find a homogenous group that will represent the phenomenon being studied (Smith, Flowers, & Larkin, 2009). Unfortunately, due to limited responses through purposive sampling, I moved on to a snowball sampling method. Snowballing is used by asking current participants or stakeholders in the community to help identify other potential participants.

The research sample for this study is meant to be small. IPA method indicates the ideal number of participants is between 4-10. (Smith, Flowers, & Larkin, 2009). IPA states that the sample size should be small because the goal is to develop a deep understanding of a certain group or phenomenon, not to reach generalizable claims. My initial goal was to find between 7-10 participants, I had nine participants in the end.

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My first outreach methods included emailing psychoanalytic institutes listed on the APsaA website to ask them to post my recruitment poster, which directed any interested person to reach out via email or phone. I emailed 30 institutes and received 3 replies from administrators agreeing to post my flyer. I found a psychoanalytic blog that agreed to post my flyer. Additionally, I recruited through professional contacts by asking colleagues if they knew anyone who fit the following inclusion criteria: 1. The participant must have graduated from an accredited psychoanalytic training program.

2. The participant must be devoted to practicing psychoanalysis clinically at least 50% of their work week. Other activities such as teaching, research, and administrative work will not be thought of as clinical practice.

3. The participant must be over the age of 75.

Through the posting on the blog, I found five participants and began interviews with them. Over the course of the following year, I continued to use my professional network to build the sample up to the total of nine participants.

Once I received word from a potential participant (all initial contact was email), I reached out to assess if they matched the study criteria and had a willingness to discuss the research topic.

Data Collection I will describe the data collection process of the study. The study used one interview with each participant. The struggle around sample recruitment and the extended timeline it caused for the project made me stick with a single interview for each participant. The

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interviews used semi-structured questions as they are the preferred type of questions for the IPA method. Semi-structured interview questions provide a “flexible data instrument” and Allows the researcher and participant to engage in a dialogue whereby initial questions are modified in the light of the participants’ responses and the investigator is able to probe interesting and important areas which arise. (Smith & Osborn, 2008) The interview guide followed these suggestions and provided only an outline for guiding the interviews.

Each participant was told to expect the interview to last 60-90 minutes and all interviews fit within this timeframe. Because the participants were scattered throughout North America, I used a variety of interview and recording techniques. Whenever a participant was local, I attempted to do the interview in person and, with all local participants, I was able to conduct the interviews in person using a phone as a recording device. For the other participants, I offered a phone call or a virtual call/Skype. Most participants chose the phone and I used an app to record those interviews. Two participants agreed to a Skype interview and I attempted to record those interviews through Skype; unfortunately, the Skype data was corrupted. I was unable to access those interviews and did not use the data from those participants. All interview recordings were professionally transcribed.

Throughout the interview process, which was extended due to difficulty around recruitment, I kept a journal around for field notes and memos to discuss with my chair.

This journal served to track my own reactions as the data developed, this also tracked thoughts and reactions that could be used for the data analysis phase.

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Data Analysis The data analysis began once all the interviews were transcribed. The IPA method calls for the researcher to enter the participant’s world by deeply involving themselves in the data (Smith, Flowers, & Larkin, 2009). IPA specifically calls for a slowing down during the initial engagement with the data in order to fully immerse onself in the world of the participant. In order to allow for this thoughtful engagement with the participant’s experience IPA states that each interview should be analyzed extensively as an individual entity before drawing connections between interviews. I used this understanding to guide my data analysis.

To begin, I listened to the audio tape of the recorded interview, alongside the transcript, and recorded any general impressions or memories that emerged. After that replay and notation session, I read through the transcript, making additional notes of any initial thoughts that came to mind. IPA method calls this beginning notation step, “Close to being a free textual analysis” (Smith, Flowers, & Larkin, 2009). IPA suggests that the researcher examine the text on three levels, descriptive, linguistic, and conceptual, in order to draw out various dynamics in the textual analysis. The goal of this initial analysis is for the researcher to emerse themselves in the participants’ world and have an active engagement with the data (Smith, Larkin, 2008). In other phenomenological methods this stage is described as horizontalization (Moustakas, 1994), a method which “procedures include horizontalizing the data and regarding every horizon or statement relevant to the topic and question as having equal value” (Moustakas, 1994).

IPA method assumes that the researcher has some familarity with the material following the initial round of listening, reading, and notating the interview transcript.

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This was the case for me as I had a greater understanding and felt ready to move forward with data analysis. The next step in the data analysis process is to bring the horizontalized data taken at each stage and to look for emergent themes or clusters of meaning in this larger set of information. Emergent themes are formed by attempts to summarize and capture the “psychological essense” of the initial notations. These emergent themes should capture not only the reality of the interview but they should also reflect the original interpretive analysis of the initial notations. Moustakas labeled the data that follows the horizontalization of data as clusters of meaning. The goal, for the emergent themes, is to clarify and strengthen the reflections made in the initial notation step. I used journaling from field notes, memos with my chair, and some material from the literature review to begin to draw out clusters of meaning and emergent themes from the each interview.

After developing the emergent themes for an interview, I looked for connections between the emergent themes within the interview. According to IPA, it is up to the researcher to engage with the themes and explore various connections and relations between the themes of each interview (Smith, Flowers, & Larkin, 2009). Using the emergent themes as meaning units, I went back through the transcripts finding all data around each unit. I revisited each theme using IPA framework of descriptive, linguistic, and conceptual levels (Smith, Flowers, & Larkin, 2009), which helped me consider the themes through in different lenses. I spent time exploring themes through the descriptive, linguistic, and conceptual level and then going back to the interviews to add textual depth. Eventually, through a deep exploration of these meaning units or emergent themes, I was able to create several superordinate themes for a whole interview. I then repeated

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the same coding process for all of the interview transcripts.

Once all of the interviews were coded with emergent and superordinate themes, I looked for connecting points and patterns between the superordinate themes across the interviews. IPA does not prescribe a particular process for finding superordinate themes across all interviews and I used a similar approach to the analysis of the individual interviews. I gathered each interview's emergent themes and looked for relationships, patterns and connections between them as suggested by the IPA outline (Smith, Flowers, & Larkin, 2009). There was a good deal of commonality around the emergent themes of each interview and, therefore, some clear categories and concepts came through when I was analyzing for superordinate themes. I was able to draw out several themes and checked with my chair to see if they seemed to track with the study. I then used superordinate themes to go back through each interview and look further for any related passages. l checked each transcript to locate all areas where superordinate themes were identified and made a list of the particular phrases that connected to each theme.

Following the coding into superordinate themes, I moved to writing up the results using the framework of the superordinate themes. The intial goal of IPA is to develop the participants’ meaning behind the themes into a narrative account. With that narrative account, I elaborate and unpack the superordinate themes through the use of the participants’ own words and my own interpretations (Smith & Osborn, 2008).

IPA recommends four criteria for evaluating research: sensitivity to context; commitment and rigor; transparency and coherence; impact and importance (Smith, Flowers, & Larkin, 2009). The research study considers this criteria as part of the final discussion.

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Ethical Considerations All participants completed an informed consent form prior to the interview. Clinical psychoanalysts are not a low-risk population and researching them poses little threat. The only potential ethical dilemma was around sharing confidential patient material.

Therefore, any clinical info was omitted or heavily disguised.

Issues of Trustworthiness Concerns regarding trustworthiness are addressed in three categories: credibility, dependability, and transferability. Credibility concerns whether the researcher’s representation of the participants’ understanding is accurate, (Bloomberg & Volpe, 2012). In order to attempt to have a credible representation of the participants, the study uses several techniques. Along with field notes, active use of the existing literature, and the researcher’s long-standing relationship with the psychoanalytic field, this study used member-checking by going back to the participants and affirming that the themes and the statements align with what they intended to represent. Additionally, all material was reviewed with the dissertation committee to check for researcher bias at several points throughout the data analysis and write-up.

Dependability in qualitative research is whether the research process and data collection efforts are understandable and known. To provide dependability, the researcher will keep a field note journal, provide a detailed account, and schedule the data collection process. To account for the dependability of the development of themes, the researcher will work closely with a member of her committee to check the themes and see if the process of the theme development is intelligible and adheres to the IPA method.

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Qualitative research studies cannot expect to have generalizable results; however, there is the potential for transferability. Transferability is measured by whether there is a good fit between the research project and other potential projects (Bloomberg & Volpe, 2012). Transferability is measured by the richness of detail provided about the phenomenon and the amount of detail provided. This study will aim to provide extensive details of the experience of the retirement phase for clinical psychoanalysts.

Evaluation Criteria IPA recommends four criteria for evaluating research: sensitivity to context; commitment and rigor; transparency and coherence; impact and importance (Smith, Flowers, & Larkin, 2009). This research worked to address these four criteria throughout the project. IPA describes sensivity to context as something that takes place from the beginning of the project through attention to factors such as the socio-cultural milieu of the participants, the interactional nature of the interview situation, and a strong grounding of the data in the participants’ voice. This study attempted to keep the specifics of context in mind in several ways. The literature review was ongoing throughout the project in an attempt to capture the evolving nature of the topic of aging in psychoanalysis. I also used field notes, journaling and frequent communication with my chair during the interviews to help situate the data.

The second evaluation criteria is commitment and rigor. IPA describes commitment as the researcher’s personal investment, which IPA says has overlap with the ideas of sensitivity to context. IPA defines rigor as a type of depth and thoroughness for the study as well as the capacity to address the topic on both an individual level and a broader

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thematic statement. I think this research study meets that criteria as there is a rich picture of each individual that is expanded out to themes shared among the participants.

The third evaluation criteria is transparency and coherence, which IPA judges on how well the study holds together around complex data and how reflective the study is of IPA’s hermeneutic and phenomenological underpinnings. The study attempts to work in the contradictory nature of the data and work it into a larger thematic analysis. The study aims to stick close to the participants’ language itself and use it to build out and deepen understanding. IPA’s openness towards complexity helped the study to work with paradoxical realities and to build a larger, thicker picture that is reflective of the phenomenological underpinnings. That the results continue to create new questions and open up future areas of study reflects the hermeneutic underpinning.

The final evaluation criteria is impact and importance, which IPA states is hard to judge. Rather it is suggested that the research can be evaluated on if it tells the reader “something interesting, important or useful,” (Smith, Flowers, & Larkin, 2009). A criteria that seems out of the researcher hands. However, given the literature review, this study reflects current concerns within the psychoanalytic field and offers information that does not seem to be available.

The Role and Background of the Researcher As the researcher, I played a crucial role in this study as the instrument of data collection. IPA understands the researcher to be operating within a “double-hermeneutic” in two ways. First, the double hermeneutic of IPA describes how the researcher is making sense of the participant, who is making sense of the phenomenon (Smith, Flowers, &

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Larkin, 2009). Secondly, the double hermeneutic describes the dual positions of empathy and questioning, which is the suggested stance for IPA research.

The dual positions of empathy and questioning fit well with my long-standing interest in the psychoanalytic field as mentioned in the foregrounding section. These dual positions are also widely held within the therapeutic fields and overlap with the attitudes I and the participants already have. This shared framework of empathy and questioning is held between me and the participants, psychoanalysis overall, and contributed to the study.

The background of the researcher is relevant because IPA method acknowledges the researcher as a direct participant in the research study. IPA believes that, within the analytic process, it is impossible to create a pure account of the participant’s experience, and the developed understanding will always be co-created by the participant and the researcher (Larkin, Watts, & Clifton, 2006). The interpretative emphasis, within IPA, allows the researcher to take a critical view of the participants’ statements, thus this dialectic engagement helps develop a co-constructed meaning of the phenomenon.

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Chapter IV

Results Results of Participant Sample: Demographic Overview To protect the individual participants’ confidentiality, I will describe the sample as a group. There were nine participants included in the study: six men and three women.

Eight participants were over the age of 75, an exception was made for the ninth who was 74 at the time of the interview. The ages of the participants ranged from 74 to 89. Two participants were born in Europe, the other seven were born in the United States. All participants were trained in the United States and all participants are Caucasian. They had been practicing psychoanalysis for an average of 45 years.

“HALCYON DAYS”: Competence–The Good Fit The aim of this research project was to better understand the lived experience of psychoanalysts as they age and potentially consider retirement. The central research question of this project is “how does the aging psychoanalyst experience clinical work and how do they experience their own aging in clinical practice?” To answer this question and the sub-question of “what is the aging psychoanalyst’s relationship to work and how does that meaning change with age?”, the interview began by inquiring about the participants' early years as a psychoanalyst and how they had experienced the field

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when they began their careers. Universally, across all interviews, the participants describe a strong and positive feeling regarding their choice to become a psychoanalyst. Every participant expressed enjoyment with their early years in the field and the feeling that psychoanalysis was a good fit for them.

The positive sentiment is shared across all participants. The participants’ language is striking, and the similarity of descriptions was one of the first themes that struck me when I did the interviews. P#2 said, of his analytic training, that it was, “An absolute dream.” P#5 called her training, “Halcyon days.” P#3 also stated, “Those were easy, good days. I have never had problems getting analytic patients. I had no interest in doing anything other than analysis.” P#4 added, “The early years in clinical practice were very successful.” The positive, early regard for joining the psychoanalytic field was shared across the sample. There was an overwhelming feeling from each participant that they had landed in an enlivening and stimulating career.

The participants’ descriptions of their early career experiences, as psychoanalysts, included stories of training and learning at the peak of psychoanalysis’s popularity. P#2 states, In the early years it was the heyday of psychoanalysis, so I was lucky to have been trained in (local institute) with all the great leaders . . . so this was a really exciting period for psychoanalysis, so I would say the training was unusually enjoyable and productive.

As P#4 notes, psychoanalysis was the thing to do if one was interested in mental health by stating, “If you were smart and really wanted to do good work, you would be an analyst.” The participants describe psychoanalysis in the mid to late 20th century to be a

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vibrant and expanding field in which they found themselves right at home and flourishing. P#8 explains, “I don't think there was reason to worry in those days. It just fell into your lap when you finished [training] . . . I was very optimistic, very excited about learning and growing . . . the heyday was really different.”

P#5 echoes the experience of falling right into place as a psychoanalyst following her training. She says, “I graduated, and somehow I wound up having people who wanted to be in a study group with me, who wanted to do analysis, and I had all these therapists who signed up for analysis.” All the participants reflected how their early careers flourished and that success provided a powerful personal reassurance. P#7 emphasizes this experience of discovering his own competence, “I loved learning how to become a psychoanalyst. I felt like I was good at it from the beginning, as if I had some natural skills with the damn thing.” The theme of psychoanalysis feeling “natural” is repeated by P#6 who states, “I was told I was a natural . . . and I felt like a natural in the sense that it all came very easy to me.” The research data shows a strong alignment between self and early career.

Every participants' early experiences practicing psychoanalysis were fulfilling and offered wide open possibilities in a flourishing field. P#3 shares the bounty of their early career saying, “It was just wonderful. And if a patient went to terminate, I instantly panicked I’d never get a referral, but I would put the word out and I would be able to choose which patient I wanted.” There was the shared sense across the sample that the psychoanalytic career was a good fit and one that provided potential outlets for a variety of interests. P#4 speaks to the thrill of early career, “I got very involved with my patients.

I loved the connections and I loved the learning. And I loved everything about it.” P#6

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agrees stating, “It was a very rich practice, always . . . we were lucky because we were both getting a lot of referrals; I had supervisors, friends, and colleagues who kept referring to me.” P#9 summed up this early career thrill, It’s largely built on my character and their character, so nobody else in the world makes the same contact as we do. But when it happens it is like finding gold. You know, you’re digging for gold and gold, look at that. It’s that rich.

Being an Analyst Opened so Many Doors: Self-Expansion After exploring the participants’ initial experiences of training and beginning to practice as psychoanalysts, the study attempts to understand how the middle years of their psychoanalytic practice develops and their experience of practicing psychoanalysis. The main theme from this material is the way in which being a psychoanalyst allows for selfcohesion and expansion. In different ways, each participant notes how they were able to grow within the field, whether that be to explore other academic disciplines, travel, get involved in conferences or publication, or to shape their schedules along with other life commitments.

One common theme among the participants is the way in which being a psychoanalyst created opportunities to indulge other interests such as travel or writing.

P#2 said that when starting out as a psychoanalyst, “I really had no idea what the career would go because I happened to have been trained with an unusual interest in literature, the visual arts, and music.” Over the years they had been able to use a psychoanalytic lens to explore his interests, stating, “I wrote on movies, James Joyce, I wrote on Faulkner, I wrote on quite a few plays, quite a few papers on Shakespeare.” P#2 summed

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it up by saying “I have a closet full of interests, which allows me to expand my interest in literature and psychoanalysis.” P#1 echoes this expansive capacity of a psychoanalytic career by stating, “I feel I’m much busier, more engaged . . . because I have so many other things I am doing, like teaching in China, doing my writing, editing, and publishing.” P#5 notes the ways in which being a psychoanalyst presented professional opportunities such as planning conferences and being involved in programming and community events. P#5 says, It was a position where I did a lot of work. And I loved the work. I put on conferences and programming that made a profit and brought people to the institute. I can tell you being an analyst has opened so many doors for me. I would never have had the opportunity to run (the program) without that.

Another way in which practicing as a psychoanalyst allows for self-expansion and growth is in meaningful, relational contacts with patients. P#3 speaks to this phenomenon by saying, “I developed a certain prestige and status so that through the years, I’ve gotten to know people, very special people, I would have never gotten to know them socially.

Such achievement.” P#8 echoes this sentiment saying, “I’ve had a lot of good referrals.

So I could be fairly choosey. It’s fun for me. I feel, I enjoy patients, I enjoy the intimacy.

I enjoy what gets evoked in me.” P#4 agrees sharing, “As I’ve gotten older of course my practice has been more and more psychotherapists who want training, which has been very enjoyable.”

The participants noted the benefit to setting one’s own schedule and how that allowed them to adapt to different phases of their lives. They shared that they had been able to shape the practice to fit their needs at various points throughout the career to respond to

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childcare or other responsibilities. One participant had a different schedule while their children were younger, while another participant mentioned working longer hours when their children were in college and the tuition costs were high (these anecdotes included personal data so I am summarizing rather than quoting). For the most part successful clinical psychoanalyst can shape their work schedules and the interviews reflected that benefit. However, sometimes the success of the clinical work became problematic as the psychoanalyst ages. P#6 reflects this difficulty, “. . . so it was a very rich practice, always. And I would say, only in the last three or four years, that we have tried very hard to really not accept new patients, with great difficulty.” P#6 reflects the difficulty many successful psychoanalysts have as they approach the retirement phase and consider cutting their practice down. The benefit of being able to adjust the schedule can present new challenges in the later years when the clarity of working for tuition or taking time off for the kids is no longer the guiding force.

The Institute Right Now is Not a Happy Place: Institutional Unrest In contrast to the nearly universal positivity for their choice of career as a clinical psychoanalyst, the participants’ responses and feelings towards their respective psychoanalytic institutes is primarily negative. Some participants detail long-standing difficulties with their institutes while other participants speak of more recent slights that they felt was a type of ageism. Overall, there is a tension for people who enjoy the structure of private practice life to come together and create community effectively. Each participant spoke to aspects of that tension.

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As P#3 notes, “I have not been part of any analytic institute or society for at least 35 years. I am just an outsider by choice and grouchiness.” This was a common refrain by a few participants, namely that they are not cut out for the communal efforts of psychoanalysis. P#7 offers, “I didn’t want to be a part of corporate psychoanalytic life, if you know what I mean. I didn’t go to meetings, I didn’t join groups, and I’ve been that way for the last 50 years, really.” These statements show how the type of person who gravitates toward clinical psychoanalytic work might be at odds with institutional structures.

These differences of temperament were only the beginning of the ways in which the participants felt estranged from their institute. Several participants recounted how their long-standing teaching assignments were changed at the last minute or unceremoniously dropped without any notification. P#5 detailed how a long-standing workshop they ran was suddenly taken away by the institute. P#5 states, “What happened was, after 13 years, there was a coup in which my throat was slit . . . This is actually the worst thing that ever happened in my life, the coup.” P#1 notes, That’s the way it works. It’s a club. And, if you’re not part of the club, then . . . the problem is that we have to give the younger people a chance because they want power, they want to run the show. But that, I think, is a big mistake, and it leads to disaffection. And it’s very important that an institute keep their older people involved.

P#1 felt that his experience with rejection from his institute was related to his age and place in the field. P#2 also recounted how his institute changed and removed teaching assignments for many of the older members in the past years. P#2 describes,

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I think there are a lot of power issues. As an individual they’re fine, as a group they’re rather insensitive, and they behave very badly in a couple of instances. And so it isn't a very collegial way of proceeding. So that’s how our institute works. They’re not always sensitive to people’s feelings and don't even evaluate an issue properly before making a decision.

Even when participants had not personally been harmed by their institute there was a sense of disappointment. P#8 shared, I've become disappointed in the quality of the candidates. So that when I go in there [to teach], I'm well prepared. And it won't be like in the old days where people were eager to talk about their clinical experience with the cohort that they became attached to. There'll be a lot of silence that I have to work to get things rolling.

P#2 echoed this sentiment saying, “The institute is not a happy place.” Some of the disappointment with local institutes overlapped with concerns and disappointment among all participants with how psychoanalytic institutes deal with the issue of decline and impairment with its faculty.

In each interview, the participant themselves brought up the Analytic Assistance Committee, experiences they had with the committee, and with declining colleagues. The universal consensus was that the committees are unhelpful at best and often quite harmful. Many participants offered hesitant and hedged reflections on committee processes that had estranged colleagues and failed to protect patients. However, all participants agreed that they could not imagine a better process. All of the normally eloquent participants struggled to formulate what they felt comfortable sharing around the confidential processes of the Assistance Committees. In bits and pieces participants

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painted a picture of a well-intentioned effort towards impaired fellow clinicians that, unfortunately, causes more paranoia and uncertainty.

“I’ve Dodged a Lot of Bullets”: Experiences of Illness As mentioned in the literature review, experiences of psychoanalysts and the psychoanalytic community navigating illness and its effect on clinical practice are related to this study. Illness is one of the only times when the psychoanalyst may have to pause, postpone, or terminate clinical treatment. Illness may be one of the only times when the psychoanalyst’s health and physical reality intrudes upon the analytic process. Therefore, experiences and reflections of illness within psychoanalytic literature often inform how psychoanalysts approach their health in the clinical frame. This study directly asked participants for their experiences of practicing during an illness and how they had shaped their practice around any disruptive illnesses.

The responses were split into two groups. There were three participants who reported having an illness serious enough that it required them to make some change or adjustment to their clinical work over the course of their careers. For one participant, this illness was decades ago at the beginning of their career, yet the illness had shaped their outlook and contributed to a deep fear of “moving to the world of well to the world of sick.” Another participant lived with and through several illnesses throughout their life and felt those experiences provided some familiarity with incorporating their clinical practice around disruptions. That participant mentioned the important role of supervision in helping them to manage some of the clinical situations that came from their illness and its disruptions.

The third participant with a clinical disruption due to illness experienced their episode

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within a year of the interview and was still reflecting on how it might impact future clinical decisions.

The other six participants experienced some brief illnesses but nothing that had affected their clinical practice. Several of these participants mentioned scheduling treatments or brief operations around their clinical schedules to minimize disruption and disclosure. As P#1 shares, “I’ve been lucky. I’ve dodged a lot of bullets. I’ve had all these illnesses, but I always escape. I should say in my practice I probably… haven’t canceled more than a week, other than that, in my whole practice.” This pride in one’s work ethic was reflected in many anecdotes. As P#8 states, So when I had the ------ done, it was done on a Thursday, went home on a Friday.

And the ------ was replaced. And I started back to work on Monday. Now that isn’t unusual for me, I'm a tough guy in that regard.

P#6 shares a similar story of an operation done without clinical disruption, “I have been very lucky. The only surgery I had was in August . . . usually I take four or five weeks in August. So, I had the operation during the day, went home at night. And I was fine.” There was a profound commitment to showing up and doing the work evident in each interview. Some participants reflected on this commitment by making genetic interpretations. Several participants offered stories of sick parents and how that led to a personal significance in showing up. Other participants spoke of the deep commitments to their particularly ill patients and how that shaped their work life. One way or another each participant reflected how they had adapted around illness and other circumstances to maintain their clinical work.

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“I Feel I’m at the Top of my Game”: Mastery in the Later Years Despite the previously noted irritations of institutions and illness, every participant noted increased satisfaction with clinical practice in their later years. Much as with the shared positivity of the early years discovering the psychoanalytic career, there was also a shared joyful sentiment regarding clinical practice in the later years. Each participant noted the benefits of the profession increase as one relaxes and feels confident in their own clinical style. P#1 explains, “. . . When you get into training there are a lot of rigidities that you have to escape from. Because you become more of your own person.

You learn a lot from experience.”

Most participants echoed the pleasure of coming into their own as a clinician and enjoying some theoretical independence in their later years. The word “fun” was used in a handful of interviews, with P#3 stating, “I have more fun with it than I used to have.”

While P#8 shared how the work had become more meaningful with age, “. . . That’s why I’m working now. It’s gratifying to enjoy it. Little less busy than I used to be . . . it’s fun for me. I enjoy patients. I enjoy the intimacy.” Several participants spoke about the enjoyment of practicing outside of professional and financial pressures. P#7 said, “We used to talk, once upon a time, should we really retire together. I have never been for that idea because we love the work we do.”

All participants spoke to their enjoyment of clinical work in later life and, all but one, stated they planned to continue to work for the foreseeable future. P#2 states, “As long as my marbles hold on and I don’t have too many memory defects, I have no plans of retiring.” P#5 agrees, “As long as I can sit in a chair and remember what they tell me, which at this point I can, I’ll be very, very happy to keep on doing this work forever.”

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Several participants spoke of a desire to cut back on clinical hours but noted a difficulty in doing so. P#6 said they would ideally like a reduced schedule of 4-5 patients/4 days a week, saying they, “Just want to cut back a bit and have a reduced schedule.” P#8 speaks about the bind around reducing clinical hours, “I'd like to do something with it [the clinical schedule]. It's hard to do. I have a practice. I have patients that I've made commitments to.”

Additionally, as noted, the career allows for the flexibility to shape one’s practice to explore new subjects and branch out from clinical practice. Many participants spoke about how they have sought out new interests, while maintaining their clinical practice.

As a listener, I often felt overwhelmed by the projects and interests listed off by the participants. There were teaching endeavors across the world, all types of writing and publishing, book clubs, new hobbies such as art and music, etc. (I do not quote these interests as they may be too identifying). There was a feeling of thriving for most participants, with these later years being especially fruitful for personal clinical development and expression.

“Not as Good as They Used to Be”: Facing an Uncertain Future As the interview questions moved to examine each participant’s individual approach to the end of their career, the answers were less organized, more open and searching. This delivery stood in contrast to the clarity and pride that filled other interview portions.

These questions regarding end of career are in conversation with the earlier sections on illness and institutional unrest. Given that the main objective regarding working with illness in the clinical setting was to avoid minimal disruption to the frame, there is no

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model for how to incorporate the reality of analysts’ body and its inevitable decline.

Similarly, as psychoanalytic institutions avoid and deny issues of aging, they fail to provide training or models for what this period of a psychoanalytic career can look like.

Only one of the participants had plans to retire entirely from clinical practice. All other participants had cut back or adjusted their practices as mentioned but had no plans to retire.

Every participant spoke to the enjoyment of the work and their reticence to give it up. As P#5 stated, The only thing that I could see that could happen is if I start losing my memory, and that’s the thing that scares me the most. I don’t ever want that to happen, because then I won’t be able to work. If people start telling me things and I don’t remember them, then I can’t do this work, even if I can sit in a chair. My two criteria, sit in a chair, remember what I’m told.

P#3 spoke openly about trying to adjust their schedule following a recent health scare, “I cut down to four days a week a few years ago, then down to three days a week after that March scare. The scare scared me enough that, for the last year, my life has been different.”

All participants spoke to the need for one’s memory and the ongoing need to attempt to evaluate it. P#2 described, “The only disruption I’ve noted is an occasional loss of appointments, that I’ve caught. So, I had to take serious measures to make sure it does not happen.”

Some participants talked about the importance of a fit mind through examples of colleagues. P#1 stated,

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My concern, frankly, is that some people I know that should be retired, they’ve lost it, and yet they continue to practice. The impaired analyst. That’s a problem . . . it’s very hard to get a person to recognize their impairment, accept it, and act on it.

P#5 offered, “Well, a lot of people are not as good as they used to be.” P#4 agrees stating, “I saw a lot of people around me who were old and falling asleep in meetings, yet still seeing patients. I don’t want to be cognitively impaired and use the patients to feel better, which is essentially what they’re doing.” Alongside this worry for declining colleagues, there were also many examples of analysts who had worked well into their later years and had done so well according to participants. Most interviews were filled with conflicting examples of colleagues who worked successfully late into life alongside examples of severe decline in psychoanalysts who continue to practice.

In every interview, except for P#2, at the point in the interview when I addressed the questions of retirement and decline, the dynamic in the interview shifted. The confident, well-trained psychoanalyst faded, and a more uncertain participant came forward. As we discussed issues around the end of clinical practice many participants looked to me for my thoughts and asked what I thought could be done. In every interview, except for P#2, at some point, I mentioned The Empty Couch and the IPA suggestion of a clinical consult for psychoanalysts over the age of 75 (Junkers, 2013). P#9 offered a spirited version of the usual rebuttal saying, I would be so angry that they could design such a test that would feel fair. I don’t trust it. Well, you could see how paranoid I was when you called, you know, and that was just . . . and you’re a nice person. But can you imagine how paranoid I’d be if

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such a thing was instituted? At the age of 80, we’re going to start testing you. That’s practically a way of saying retire.

The sentiment of impossibility was a common theme when asked for thoughts about what might help psychoanalysts in the retirement phase. P#2 stated, “I’m afraid there is no better approach.” P#1 concurred, “I don’t know. It’s very difficult. It’s almost impossible. We have committees, we try and so forth, but it’s very hard.” P#8 offered, “I think people go until they get sick or demented. Or depressed.” P#4 explains, “Because it’s such an overall identity, and such a crisis for somebody when they can’t continue.”

Many participants spoke openly of the need for models as they consider the end of their psychoanalytic career. P#5 asked, Do you have people to talk to for older therapists? Because one of the things I really want to know is what other analyst could I go to at this point? I want an older analyst who can talk to me, and I don’t know where the hell to find one.

In keeping with the search for models, P#3 offered, “Death was present in my house from . . . but aging and retirement were not. They were never realities. And that’s making it harder for me because I just can’t imagine what it’s like.” The difficulty of imagining a good retirement was a running theme. In every interview I asked if the participant knew of a fellow psychoanalyst who had a “good retirement.” No one answered affirmatively.

P#2 offered, “I would say the majority of the retirements I witness are bad.” The single participant who is planning to retire said that every single colleague had warned them against retirement, “I cannot tell you how many people say don’t retire.”

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Chapter V

Findings and Implications PSA Identity One initial finding was the powerful way in which practicing psychoanalysis evolved alongside and helped shape the participants’ identity. The sample for this study is typical of psychoanalysts from their era in that they all received psychoanalytic training early in their careers (one participant practiced for 15 years before their psychoanalytic training).

Therefore, most participants had spent 40+ years practicing psychoanalysis. This longterm relationship with a career meant that it had integrated into their overall identity and the data reflects that deep integration of career with self.

The research demonstrates how a career practicing psychoanalysis provided rich professional and personal meaning for this sample. The results show how every respondent felt psychoanalysis provided a good match for their intellectual skills and curiosities at the beginning of the career. The results further detail how practicing psychoanalysis was a skill that evolved along with their adult interests and adapted to developing life conditions, such as evolving intellectual endeavors or illness. In the mastery section of this study’s research results, all participants spoke to the satisfaction their work provided into their later years. The capacity of psychoanalytic work to grow along with the clinician and adapt to various life stages makes the psychoanalytic identity one that gets woven in throughout one’s life. The psychoanalytic identity becomes a

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constant against change and loss. Thus, one finding of this research study is that the professional psychoanalytic identity gains potency through its flexibility and longevity.

The research draws a picture of how practicing psychoanalysis in the 20th century was an effective vehicle for many practitioners to realize professional and personal satisfaction. There have been efforts in psychoanalytic literature to discuss what it means to be a psychoanalyst and the significance provided from the work, but few of those ongoing efforts speak to what to do once some of the data is in, once it seems clear that practicing psychoanalysis does give something special. As noted in the literature review, The Empty Couch, is one of the few psychoanalytic texts outside of personal reflections to openly speak to the deep satisfaction many practitioners of psychoanalysis feel. In the opening of her essay, Later Perhaps, Junkers notes the common sentiment, “Being a psychoanalyst is not a profession; it’s a passion!” and states there is, “No other occupation that calls for such a combination of theoretical understanding and practical learning with the involvement of one’s individual identity” (Junkers, 2013). Following these proclamations, later in the essay, Junkers shares another common uttered phrase “I’d really like to die behind the couch” (Junkers, 2013). This is an idea we heard echoed

by P#5, saying, “I’ll be very, very happy to keep on doing this work forever.” There is a feeling that the meaning provided by practicing psychoanalysis is one that is important, perhaps vital, to one’s sense of self. Therefore, it is difficult for many to imagine a future without it, which may account for why no one is able to consider alternate ways of addressing issues of aging and decline.

A review of the research around professional psychoanalytic identity and the meaning of the profession, once again, brings up many personal career reflections, but few broader

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examinations. There are considerable literature contributions on how psychoanalytic education and supervision help shape early psychoanalytic identities but, as with the literature overall, we continue to see a bias toward early career formation, and there is little material beyond personal memoirs focused on the later career. Additionally, there are several institutional studies focusing on the experience of psychoanalysts in the years following candidacy but far fewer studies following graduates over the course of their career, and into their later years. One of the few studies on post-graduate development from the Chicago Psychoanalytic Institute attempted to reach out to all of its living graduates concluded with a recommendation toward the development and enhancement of current training around “psychoanalysis as a professional identity and career” (Schneider et al., 2014).

One of the sub-research questions of this study considers how and if the meaning of the work changes with age and moving into the retirement phase of the career. From our interviews, the later phase of the career is where great meaning and personal satisfaction is derived from one’s mastery of the practice of psychoanalysis and from the long-term intimacy with their patients. This stands in contrast to the fact that it all will end. We see, in the declarations, that Junkers and our sample, offer how it is complicated to imagine how and when to decide to pull away from one’s passion. The capacity of the psychoanalytic career to grow along with the participant and to respond to life changes seems to be part of what makes the professional identity so powerful at the end of one’s career.

As early as 1956, Erikson warned of the difficulty of thinking through questions regarding the nature of psychoanalysis stating,

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Some search in this area may clarify the fact that some of the most heated and stubborn answers to the question of what psychoanalysis is or is not originate in another question of great urgency, namely: what psychoanalysis must be (or must remain or become) to a particular worker because a particular psychoanalytic identity has become a cornerstone of his existence as a man, a professional, and a citizen, (Erikson, 1956).

The literature review of this study, as well as the material from the interviews, indicate many of the same challenges Erikson’s describes still exist; namely that it has been difficult for psychoanalysis to think beyond the experiences and passions of individual psychoanalysts to consider how their career choices are shaping the field of psychoanalysis as a whole.

Aging as PSA Concept The second finding of the study is how the concepts of “age” and “old age” prove difficult to describe or hold on to in the psychoanalytic world. Working with the data, I began to identify a certain type of slipperiness at the heart of how the understanding of age functions in psychoanalysis. We know that psychoanalysts are getting older, the average age for members of the American Psychoanalytic Association is 66. We know there is a long training and practicing timeline with the delayed experience of mastery at its conclusion. But there seems little thought about how these facts may all come together and what their meaning may be for the aging psychoanalyst.

The concept of aging and how it functions in psychoanalysis is at the heart of this research. The research question asks how psychoanalysts experience their age in clinical

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practice and a sub-question delves further in asking how a psychoanalyst’s age exists as a part of the work. The literature review touches on how the field of psychoanalysis is beginning to think about aging and how it plays out in psychoanalysis. We explore how Junkers and Fonagy attempt to untangle the resistance and the taboo around discussion of aging in psychoanalysis. In the participants’ material, the role of aging and how it plays out in clinical work is tricky. As age consistently came up in the interviews, I began to hear it as participants’ ways of thinking through the often-conflicting messages around aging as a psychoanalyst.

As I mentioned, in the results, only one participant had any plans or thoughts around retiring. This lack of thought regarding aging or end of career issues was shared across the remaining participants. A common response among participants was that they never considered how long they would practice and that they knew of analysts who practiced late into life. Several participants offered the same examples of psychoanalysts who practiced until into their 90s and 100s. P#1 shares, “I never really thought about how long I would work. I never thought about that, ever.” He then mentions a colleague who worked into his 100s. P#6 concurs, “It didn’t even occur to me. I never thought about it until more recently. I had a friend who's still practicing. I think he’s had a huge practice.

He’s 93.” P#7 echoes, “I saw time as an unending carpet rolling out ahead of me. I can’t say I ever thought of what it’s going to be like when I’m 79. Maybe I always felt like a young man. Still do, I think. I do have colleagues who are working in their 90s, and they seem to be pretty capable at what they’re doing.” Again and again, the pattern of response is that the length of career or aging in their career was not given much

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consideration, but there was some understanding that psychoanalysis is a career that can be practiced late into life.

Along with the lack of planning or training around later career considerations in psychoanalysis, we add the feelings of mastery and wisdom that accumulate after many years of practicing psychoanalysis clinically. The research results demonstrate the many rewards of practicing psychoanalysis later in life and yet we see how this mastery is often without a fully developed framework. The result has been for older psychoanalysts, who retain a great deal of power, to have an expectation that they will continue to guide the field for decades and decades, as they feel they have a great deal to provide and will for some time. Several of the recent texts examining aging in psychoanalysis question whether this lack of development framework, that includes our later years, is partly responsible for some of the inter-generational strife within institutes. Fonagy argues, Aging is the prototypical taboo for psychoanalysts . . . a profession that has at its core the legend of Oedipus is condemned forever to idealize seniority and experience. It is all too easy to see the actions of young colleagues as derivative of a poorly analyzed wish to displace the parent . . . the failure of the profession to develop appropriate systems to deal with incompetence associated with ageing might be directly linked with our clinical immersion with intergenerational hostility. (p. 221) In addition to this confused picture of age and development in the psychoanalytic field, the demographic fact that the entire field of psychoanalysis is getting older. The age of candidates who enter training is increasing along with the noted longevity of psychoanalysts in the field, such as our participants. This leads to basic uncertainty about what the normal timeline for psychoanalytic career development is and what constitutes

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an older psychoanalyst. When I was planning my sample for this research study there was a great deal of debate as to how old the participants should be to correctly represent “older psychoanalysts.” The interview material captures the confusion regarding who is old and what age means in the psychoanalytic context. If one knows someone who worked successfully into their 90s or 100s, how can they call it quits, especially since they enjoy the work and felt good doing it? There was a shared understanding that, at some future point, the work might no longer feel good, but no one gave an actual age as to when.

Several participants tried to tackle the slippery task of tracking oneself as an aging psychoanalyst with the reality that the psychoanalyst’s age in often co-constructed in the psychoanalytic context. P#5 shares, “I don’t feel any different at 74 than 54. And, because I actually don’t look my age, people think I’m 54. I want to be the age people need me to be. Right now, people do not need me to be 74, I’ll tell you that.” P#7 speaks to the temptation to distance from the corporeal, “I feel old in body, to be sure, but my mind feels as young as it ever felt. But I think one has to. You have to remind yourself that, even though it might feel like it’s true, there still is an aging process.” P#3 agrees, discussing a sense of self that is on the line in these engagements, “The feeling is you don’t want to be dismissed just because you’re chronologically old. My body’s lost its energy, but I’m sorry if I’m misjudging, I don’t think my mind has lost its sharpness.”

The data shows the participants exploring what is required of mind and body in order to practice psychoanalysis, often within the clinical encounter, and not having much to go off of other than intuition and examples of colleagues.

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In both the literature and in the interviews, a complicated picture of psychoanalytic aging emerges. There is difficulty in the psychoanalytic field tracking the meaning of age and decline for the practice of psychoanalysis. The data shows how individual psychoanalysts attempt to formulate understanding around their experience of aging. Our research data reflects that without larger institutional or systemic forces helping to organize and think through the phenomenon of aging it will likely remain as each psychoanalyst’s individual conflict.

Culture of Confusion The third finding of the study first emerged as a feeling in the interviews and then was clarified through coding. What I felt from the interviews was a sense of uncertainty when discussing the retirement phase. The participants who had been so wise and knowing when discussing their earlier careers were more searching and less organized.

The data showed significant concerns around shaping and caring for a psychoanalytic practice in the retirement phase. The lack of organized institutional guidance, and the lack of effective mentoring or modeling, leads to a patchwork of individualized practices in the retirement phase, which in turn fosters suspicion and paranoia.

The research confirms what the literature and early hypotheses considered, namely that there is little guidance around how to practice as an aging psychoanalyst. The research finds that given the absence of any institutional approaches or trainings on how to handle aging and end of practice issues, each psychoanalyst developed their individual approach. The interviews revealed a patchwork of protocols that have developed over the course of psychoanalysis through word of mouth. Several of the research sub-questions

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addressed how participants thought about planning for retirement and, in every interview, I asked for whatever plans the participant had made. These questions were complicated, all but one participant did not see retirement in their near future and had little, direct planning for it.

The participants did; however, describe tailoring the hours of their caseload and, often, the decision to no longer accept analytic patients. Four participants stated they would no longer accept analytic patients as a policy they established on their own. P#1 had decided to no longer take analytic cases and described that decision, Well, the idea about analytic patients is that you can’t make a commitment to someone given your age. That’s the issue with analytic patients. I mean, psychotherapy patients are not the same. You have to think about any patient that you start with at this time. You want to be sure that you’ll be around long enough that you can provide what they need, so you make that judgment in each particular case.

P#4 shares, The last analytic patient I took when I was 72. I told her how old I was and that I couldn’t guarantee . . . And then, probably since age 77, I have not taken any referrals except for, you know, you get your arm twisted.

P#4 speaks to the idea that, even for the participants who had made the decision to stop accepting patients, there is a continued temptation, even if by others twisting your arm.

Although practicing psychoanalysis provided scheduling flexibility throughout the participants’ careers, the data shows it is complicated to adjust for age-related reasons. In the Results section, P#6 spoke to the “difficulty” around trimming down a practice and

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the loss regarding the decision to no longer accept analytic patients. P#3 expands on this difficulty, stating, That is the hardest of the problems for me. I later got a call from the [referral source].

I was the only one he wanted to work with. But that’s seduction. You know what that is. It seemed to me to start practice with a case, work with him, even though now I’ve lived long enough that we would have had five years together, it’s malpractice. I think it’s an ethical issue. I don’t think a person has that right.

P#8 shared their feelings around a recent, declined analytic case, The older I got the more cautious I became. I am eighty years old now. I am not taking on new patients . . . I had somebody refer a very nice person to me recently and I said no. I met with them. I didn't charge them. I told them that he would do better because he needed analysis with somebody else. And then I tossed and turned all night thinking of the fact that I wasn't going to be able to continue at this pace.

Four participants were more ambivalent around the idea of accepting a new analytic case, stating that they preferred to make the decision on a case-by-case basis. One participant of that group described a recent decision to take on a new analytic case that was made in consultation with three other clinicians with the analyst’s age being the central concern. One final participant was not ambivalent and stated, “If I got a referral today, I would accept it. If it was an analytic referral, I would still accept it knowing it’s long-term. So that hasn’t changed.” All these clinical decisions, including the threeperson consultation around accepting a new analytic case, were individual choices. Once again, the research shows how the participants have been able to mold their psychoanalytic career to their individual and developing needs even in these later phases.

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Another theme, that came up unexpectedly in the four interviews, was the issue of post-termination contact with patients and how to handle it. Post-termination contact was not an area that I had planned to cover, and the open-ended questionnaire did not include any reference to the idea. However, in discussing the idea of cutting back on clinical hours or deciding to no longer accept analytic patients, several participants mentioned uncertainty around how to approach post-termination contact with patients if they were to retire. P#5 stated, “I want to just be sure and mention this for you to think about. After retirement, what if the patient wants to have coffee with you?” Another participant detailed a complicated and unresolved termination with their training psychoanalyst which led to personal and professional confusion around termination. It was clear that there were many questions and concerns lurking around the idea of retirement with few outlets available to process them.

Other than restructuring their time and caseload, most of the participants had a few other protocols in place to address aging and potential practice disruption. The most common of these protocols is some version of the professional will–a document listing one’s current patients and their contact information that is left with a trusted colleague in the event of any unplanned crisis. Three of the participants, P#1, P#6, and P#7, are married to psychoanalysts, and said their plan for any interruption in their practice would be for their spouse to notify all patients with information left for them. Another participant’s plan was also for their spouse to handle their patient notifications despite not being in the field (P#2). Several participants spoke about how they were following recent guidelines on establishing professional wills that came through the professional

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associations. P#3, who notably spoke about their open preoccupation with death and mortality, described their protocols as such, I do have one, and I wish every analyst has one. In the upper left drawer of my desk, I have a page printed out, maybe from The American, about how to approach and handle patients about a dead or dying analyst. I have, attached to that, a list of each of my current patients and their phone number. And, someone else in my office knows, if I go, they're to get that envelope and call the patients.

Other participants mentioned their local institutes’ newly-released protocols regarding professional wills and were unsure how to comply or felt it was an intrusion into their personal practice.

The other practice that every participant mentioned was one of an informal “buddy system” in which they had a designated colleague or two with whom they had agreed to inform the other if they felt one was becoming impaired. I asked every participant where this practice originated or how they had decided to adopt a buddy system, and no one was clear. P#8 describes, “I think that it's pretty much agreed upon with a couple of friends.

We talk about it. We joke about our mental functioning. If we can't remember a name, we tease each other about it.” I generally followed up by asking how realistic the participant felt the buddy system was. P#8 offered a typical response, “I think it would be hard. I would have to push myself to do it. But I would do it. I might try to rationalize that, well, he's not seeing anybody more than once a week.” P#3 agreed stating, I know, from observation, when analyst friends, ask each other to tell the other when it’s time to stop, and that they're not really working on all cylinders at best, they don’t

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do it . . . I’m kind of hoping my friends will tell me but, having observed people who have done that, their friends don’t do it when the time comes, for multiple reasons.

Despite being very open about the limitations of a buddy system, the participants all had one, even if only with a spouse.

The finding of this patchwork of informal protocols ties back in with the lack of general regard and institutional leadership for aging at psychoanalytic institutes. These individualized practices, while demonstrating the adaptability of the autonomous psychoanalytic career, also exposes the failure of institutions to consider how ad hoc practices of aging psychoanalysts would inevitably shape the field. This research tracked the denial or disavowal of the reality of aging throughout the history of psychoanalysis.

Only recently has there been literature explicitly speaking about this theme. As such, one of the questions I returned to, again and again, was how that lack or absence had been experienced by the sample. This was a sample of studious, life-long learners who had been given little to no guidance on this important life transition. Can we understand some of the alienation from institutes reflected in the results as the understandable outcome for a sample whose profession has run out of guidance? Otherwise, how are we to understand that this sample of successful, flourishing, yet aging psychoanalysts didn’t include a single positive word about a psychoanalytic institution? Can we see some relationship between the disappointment of this entire sample of older psychoanalysts with their institutes and the fact that the institutions have split off this period of development and clinical practice?

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Findings in Terms of Fifth Individuation Perspective This study uses the Colarusso’s concept of the period of time of the fifth individuation in order to consider the findings that relate to aging (Colarusso, 2000).

According to Colarusso, the fifth individuation consists of our final years of life and is the last period of development. Following the individuation-separation framework, Colarusso theorizes that the tasks of the fifth individuation are to separate and mourn aspects of the self. For Colarusso, what is crucial to this period, is one’s development of "time-sense" and the growing awareness of death. Using Colarusso’s framework, we can more deeply examine some of the comments and confusion on age, time, and the slippery nature it had in the interviews.

Colarusso views the time-sense as part of development and believes that a necessary part of aging is coming to terms with one’s growing proximity to death. The data shows consistently that participants did not expect to live or work as long as they have. Not a single participant entered the field with any psychic preparation around “time-sense” for their career. The interview guide suggested, and each interview included the question of whether the participant had any sense of the length of their career when they started out.

No one answered that they did. P#1 offers a typical response, “I didn’t ever expect to live so long.” P#4 concurs, “I never thought about old age. You understand both my parents died way younger than I am, so I had no models, really.” P#5 offers the most impassioned version of this by stating, “I just assumed I would be an analyst forever, and that’s my intent.” The emphatic, across-the-board nature of these responses helps to demonstrate the failure to build out a time-sense within the training of psychoanalysis.

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Colarusso examines how work and one’s profession can help build and instill timesense in middle adulthood. He states, For some the comfortable, predictable, routinization of time and domination of the time of others becomes so narcissistically gratifying that work becomes the primary source of emotional sustenance and temporal stability. Such investment in work may block the engagement of a related, temporally driven developmental task; namely, planning for retirement and replacement by the next generation. The awkward juxtaposition of maximum achievement and power in the workplace and the realization of time limitation and the inevitable loss of power and position is at the core of the mid-life worker's intrapsychic and real predicament.” (Colarusso, 1998) Due to the extended professional years of psychoanalysts, it is reasonable to consider that these middle life tasks around the development of time-sense do not get addressed until later in life and are often pushed into the fifth individuation.

The research shows there were attempts by participants to study and consider their own time-sense. P#3 shares, I paid a lot of attention to the concept of aging since I wasn't able to do it at home, to watching older people die—age more than die. I had no idea how to do it. I watched a number of colleagues . . . Death was present in my house but aging and retirement were not. They were never realities and that’s making it much harder for me because I just can’t imagine what it’s like.

This statement shows the seeking for a framework to clarify the time remaining. This is the time-sense and an awareness of it that Colarusso believes is necessary for a smooth transition through adulthood.

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P#7 offers a similar struggle around their understanding of time. They state, I saw time as an unending carpet rolling out ahead of me. I can’t say I ever thought of what it’s going to be like when I was 79. I always felt like a young man. Still do, I think . . . I’m doing something more like 25 hours a week. So, that’s a huge shift.

And, I would say that shifted over in the last ten years . . . it sinks in after years of denial. In my case, I think an actual illness, or just the sense that one is truly getting older. I mean, there must be some capacity to not disavow everything, to let reality seep in a bit . . . I don’t really feel that way at all. I feel old in body, to be sure, but my mind feels as young as it ever felt. But I think one has to remind themselves that even though they may feel like it’s true, there's still an aging process.

P#8 offers a more resistant take when discussing a colleague who had retired, I'm not sure that his life would be my life. I told him once, that the thought of getting off the train was not appealing to me; meaning to die while the rest of my family continued living. He seemed rather resigned to the fact of his own death. Well, I ain't there yet. I ain't resigned to it, yet. Although I know it's coming.

These offer different examples of the struggle with time-sense and attempts to understand one’s own aging. It seems to be a special challenge to understand the aging process in a psychoanalytic career that can delay and distort time and time-sense development.

One of the practical implications of this issue of uncertain time-sense is the question of whether to accept new psychoanalytic patients, which necessarily involves engaging one’s time-sense to judge whether to make a commitment to the treatment. As P#1 explains, “You have to think about any patient that you start with at this time. You want

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to be sure that you’ll be around long enough that you can provide what they need, so you make that judgment in each particular case.” Time-sense and judgment around it are vital tools of the psychoanalytic trade. These tools only become more important as a psychoanalyst ages and their capacity to judge time-sense in terms of potential new cases is crucial.

An important part of the fifth individuation, according to Colarusso, is generativity and using the growing awareness of one’s mortality “to fuse with loved ones, community, culture, and the broad expanse of humanity by giving,” (Colarusso, 2000).

Considering these tasks of generativity, in light of the data on psychoanalytic institutes and the many discontents with them, there may not be sufficient institutional structures that offer opportunities for generative engagement. P#1 offers one explanation, The problem is that we have to give the younger people a chance because they want power, they want to run the show. But that, I think, is a big mistake, and it leads to disaffection . . . I think it’s because sooner or later you have problems and you feel rebuked by someone or other, so by the end of your career, you’re angry with your institute and you won’t leave them a penny.

This is just one example of the unhappiness with psychoanalytic institutions that has been discussed previously. This disappointment will also be considered from the self psychological position, but for the purposes of the fifth individuation we can understand that institutes would be the site for many of its necessary tasks. Therefore, the diminishment of institutions leaves a gap in how and where to address the vital tasks of the fifth individuation.

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Findings in Terms of Self Psychology Perspective The study uses concepts from self psychology to examine the self experience and understand the subjective meaning around practicing psychoanalysis as an aging psychoanalyst. Self psychology provides a framework for thinking about experiences of the self and to explore some commonalities among the participants. The discussion will use a self psychological lens and self psychology’s concept of the selfobject experience to explore aspects of the psychoanalytic professional identity. Our participant sample developed and sustained their psychoanalytic identity over the course of their adult lives and there is reliable set of selfobject experiences within that identity that might benefit from consideration. Then, using the selfobject experience around mentoring, self psychology will provide another way to think through the data around building and sustaining a regulated self as one ages. Finally, we will again use the idea of the selfobject experience from a communal or group angle to consider how the disappointment in psychoanalytic institutions and the field of psychoanalysis shapes the participants’ experience.

There is an agreement, among the theorists cited, that moving into the retirement phase of life brings about a change in identity and self-understanding (Colarusso, 2000; Chessick, 2013; Junkers, 2013). The data reflects our participants working through that shift. Using a self psychological framework and the concept of the selfobject experience provides another way to think about the meaning of this shift of professional identity as a disruption in the selfobject experience without a potential replacement for one’s primary sense of self-cohesion and narcissistic homeostasis, which Kohut theorized was the primary goal for the self (Palombo, Bendicsen, & Koch, 2009; Elson, 1986). “The ideal is

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not to be freed of reliance on selfobjects but rather to accept our need for others as integral to our humanity” (Palombo, Bendicsen, & Koch, 2009). If the primary motivation of the self is to maintain cohesion with help from its selfobject milieu then the disruption of the professional psychoanalytic identity could pose a threat.

As discussed in the results, the psychoanalytic identity was a strong fit for all of the participants. Using the self psychological lens, we can see this good professional alignment as one that likely provided a strong sense of narcissistic homeostasis and selfesteem over most of their adult years. Throughout previous stages of their adult lives, the career was able to evolve with the changing needs of the self, such as with childcare, vacations, new interests, and illness. Therefore, the retirement phase may be the first time when psychoanalysis can no longer adjust alongside the analyst. For Kohut, “A healthy self is not only an experiencing self. It also has aspirations, it has ambitions, it has ideals” (Kohut, Chicago Lectures, lecture 14). Thus, the retirement phase calls for a potentially large restructuring of the self’s organization of ambition and ideals.

As Galatzer-Levy and Cohler emphasize, “Work also goes a long way in determining who we are in our own eyes: work is central to the experience of identity in society” (1993). Several participants spoke directly to this struggle around giving up clinical work.

P#4 stated, “Psychoanalysis is such an overall identity.” P#5 expands on this by reflecting on how becoming a psychoanalysis led to a transformation in her selfunderstanding, I thought being an analyst was for boys and for doctors. I thought that’s who I was going to be watching forever. I was always going to be in the audience and they were

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going to be up there presenting. It never occurred to me I would ever get to switch roles.

P#9 offers a story of self through the frame of their psychoanalytic career, I can look back and see my own personal growth. I can see myself as a callow youth, superficial, in a hurry, trying to dig down, seeing the job as getting beneath the surface, getting to the unconscious, particularly getting to the Oedipus. That’s all changed. It’s more of a passive stance now, what can they bring to me, and then what are they not bringing to me . . . It was not that rich when I was younger because I was in a hurry to prove myself . . . As I got older and had a lot of experience, some people cannot go there with me, but many persons can go there with me, and it’s really, it’s amazing.

Either through describing the capacity of the psychoanalytic career to evolve along with changing interests, or to offer expansive experiences of the self, participants spoke to the power of their psychoanalytic identity to provide a steady selfobject milieu throughout adulthood. The participants’ language and affect when describing their careers called to mind Kohut’s description of “pride” as “all those experiences that nourish a sense of a securely positive sense of one’s self” (Ed. Tolpin, lecture 16, Chicago Lectures). Kohut connects pride to a bodily and exhibitionistic self, “A pleasure surface glow [of a] good narcissistic balance.” Kohut speaks to how one’s presentation and affect often shift with expressions of pride, this tracks with our participants’ affect and presentation when discussing their psychoanalytic work. The data shows that psychoanalytic careers provide a steady selfobject milieu, offering integrated experiences of mirroring and idealization, leading to narcissistic homeostasis and self-cohesion.

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Another piece of this selfobject experience that all participants spoke to is the importance of the interpersonal contact with patients. Several participants remembered early enlivening cases and spoke openly about their appreciation of these relationships at the outset. P#4 states, “I got very involved with my patients. I loved the connections . . . I loved everything about it.” P#7 exclaims, “You’re dealing with wonderful people.” P#8 describes a past treatment stating, “She was very devoted and appreciative. It was a very lovely experience.” P#9 shares, If we both do our part and we have a partnership, a therapeutic alliance. If we have a partnership, it's so fulfilling because just forming it is fulfilling. And then there's the way you can use it. Now, it’s largely built on my character and their character, so nobody else in the world makes the same contact as we [psychoanalysts] do.

Part of the good fit of the profession seems to be the selfobject experience provided by the patients. P#3 openly speaks to their experience of this, “One of the problems with aging and with retirement is a loss of those conversations. Analytic conversations are honest in a way that even a marriage conversation isn’t.” The truth of this claim may be debatable; however, it captures the feeling throughout the interviews that the experience with the patient is a vital part of the selfobject experience of being a psychoanalyst.

Toward the end of our interview, P#6 shared a recent experience of running into a former patient, “I felt very proud of her, we need another word to talk about the kind of pride or connection you feel around that kind of moment.” Within this spontaneous story, and the unprompted questions around post-termination contact with patients, it seems that there are questions around how to transition away from these selfobject experiences and identities that provide such a powerful sense of self.

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Having sketched out the vital relationship between the psychoanalytic identity and one’s sense of self, the stakes of retirement become clear. As we see, with the reactions to the retirement plan of our single participant, retirement is unthinkable as it seems to entail the destruction of vital experiences for the self and threaten the loss of one’s narcissistic homeostasis and self-cohesion. P#3 clearly states, “To stop seeing patients is to give up an essential part of life.” This sense of impossibility is complicated by the continued satisfaction of practicing psychoanalysis later in life. Not only did the participants emphasize the way in which psychoanalysis had been a good fit over the course of the career, as mentioned in the Results section on mastery, many participants continued to have meaningful experiences of the self while practicing in their later years. P#8 shares, “It's fun for me. I enjoy patients, I enjoy the intimacy, I enjoy what's evoked in me. I like to monitor that.” P#9 agrees with finding enjoyment during their later years of practice, “There's more of a feeling that I am an analyst. I don’t have to prove I’m an analyst all the time.” Expanding and opening up on what is at stake, P#3 explains, "This is why talking with others and retiring are the two hardest parts of it, other than losing the discretionary income which, at this point in life, isn’t an issue. It's losing the conversation and defining who are you." These statements reflect a deep alignment of self-identity and self-cohesion with one's psychoanalytic work and professional, psychoanalytic identity.

Self psychology also provides a framework for considering the theme of models, examples and mentors. In every section of the results, the participants have developed Colarusso’s time-sense to shape and plan their narratives. Most participants mention parents’ or caregivers’ life spans when planning out their careers. Following that initial calculation of time, we see, in the data, how the participants relied on examples from

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their own psychoanalysts, supervisors, and friends to try to guide their decisions around aging, and what a hodgepodge of information that brings. Galatzer-Levy and Cohler's discussion about the importance of mentors in terms of self psychology provides further understanding on what the research shows. Galatzer-Levy and Cohler explore the ways in which being a protégé in young adulthood, and being mentor later in life, are powerful experiences of the changing self in adulthood. In early adulthood, when understandings around the self and work are developed, Galatzer-Levy and Cohler describe how, “Through his achievements and ways of living, the mentor becomes an exemplar whom the protégé emulates” (Galatzer-Levy & Cohler, 1993). The data reflects the importance of mentors and teachers on the developing, professional self. Every participant mentioned at least one teacher with whom they had studied and been influenced. In an effort to protect identity and maintain confidentiality I do not want to quote direct names. This statement from P#1 will give a sense of the excitement around early career teachers. P#1 describes, The great leaders that were teaching us were the generation after Freud, so some of them knew Freud, had had contact with Freud, and they were very charismatic . . . they were exciting teachers, and they were really great lecturers.

As Galatzer-Levy and Cohler suggest, these early career experiences of being a protégé were vital to the formation of the participants’ professional, psychoanalytic selves.

According to Galatzer-Levy and Cohler (1993), “Internal images of the mentor often provide psychological support across a working lifetime.” The data reflects this as we see the participants repeatedly attempt to use previous internal models to work through the

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problems of aging. As noted in the Findings section on age, there were ongoing mentions of psychoanalysts who practiced late into life. These anecdotes (too specific for quotation) included models of both success and failure in late-in-life practice. Several participants mentioned the same person, which suggested that there is a field-wide attempt to search for aging models and mentors to guide their transition of the self to later life.

The data reflects a rupture around the participants’ experience of their professional self as they age due to lack of mentoring and modelling around the transition to later life.

Each participant tells a similar story around the formation of their professional, psychoanalytic self, and how their teachers, and the field at large, provided a structured environment in which very different individuals could flourish professionally. In contrast, at the end of their careers, the participants are without any material or guidance on how to make professional decisions. This leads to a fragmented sense of self and difficulty making generative choices.

The research data also reflects how disappointment in psychoanalytic institutions, and the field at large, had led to ruptures in the participants’ sense of a professional self. The bulk of this data was explored in the Institutional Unrest section in the results. That section demonstrated the pervasive disappointment and alienation around psychoanalytic institutions. The feeling in the early years of career, that it is exciting and meaningful work, which aligns with a strong sense of self, is no longer. The selfobject experience of being a psychoanalyst had been one of doing meaningful, well-paying work in a highly regarded field. However, the status of the field changed over the course of the

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participants’ careers and the self experience of being a psychoanalyst has as well. P#8 shares, I've become disappointed in the quality of the candidates. I challenged myself by thinking that maybe I'm just an old man. Guys do the “It's never as good as the good old days” but I think that there's some truth to it . . . Although, personally, I haven't suffered as much as the profession as a whole, professionally, but I see it decaying around me.

P#2 agrees, stating, “Now, most of the people who are in power don’t have that charisma, don’t have that breadth of vision, and are not terribly interested in culture.” The participants experience the failure of psychoanalytic institutions to adapt to the needs of their aging populations as a rupture in the professional selfobject experience. The institutes are disavowing systemic approaches to aging and career transitions which leaves psychoanalysts on their own, grappling with a fragmenting understanding of self and the loss of vital professional selfobjects.

Study Limitations/Suggestions for Future Research The research study has several limitations, the first being that there is only one interview with each participant and there is not a complete response for the member check. Another limitation of this study is the use of only two theories, one theory of life course and one theory of self, to examine the data. The use of additional theoretical approaches, particularly other theories of aging and old age, may offer expanded interpretations. As such, this is a specific sample of psychoanalysts, representing their cohort of late-twentieth century American psychoanalysts. One thing the study shows is

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the changing nature of the field of psychoanalysis. The final limitation is that this data is specific to this cohort and more research will be needed to understand the developing landscape for younger psychoanalysts as they approach and move into the fifth individuation.

Given that type of limitation, this research study opens up many potential future areas of study. Future areas of study could include further research with psychoanalysts as the object of study such as: research of psychoanalysts after retirement, younger psychoanalysts’ contemplation of the retirement phase, study of psychoanalysts who do not plan to retire, and etc. There may also be potential research with institutes to understand how they understand their relationship to this topic and think through why there seems to be so little institutional training or support for psychoanalysts during the retirement phase.

Conclusion and Other Remaining Thoughts Despite ongoing claims of its imminent demise, psychoanalysis continues to compel and influence clinicians and academics. It is perhaps a practice that has been too consumed with fears to recognize the influence it has had and continues to hold. For all the conversation over the past decades regarding the destruction of classical psychoanalysis, many practices from the psychoanalytic model are influential in shaping current psychotherapy and counseling. Most contemporary clinician practices, whether they be psychoanalytic, psychodynamic, or behavioral, are modeled on the outpatient, 45minute session. In all forms of psychotherapy, clinical practices are handed down through supervision and training. Yet, we know that psychoanalysis has only recently given

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thought to issues of retirement and aging; therefore, this absence of consideration in the field may have led to absence of influence in related fields.

To address this gap, this study explores the lived experience for clinical psychoanalysts as they age and plan for the retirement phase. The study uses open-ended interviews to examine the lived experiences of nine clinical psychoanalysts with an average of forty-five years practicing psychoanalysis. The sample experienced the height of psychoanalysis in the mid-20th century as well as its cultural diminishment since. The research study used the method of interpretative phenomenological analysis (IPA) to code and analyze the interviews. It then considered the data through the lens of Colarusso’s fifth individuation and self psychology theory.

The study finds that similar themes for the sample regarding their experience of being psychoanalysts. The research shows that the psychoanalytic career has been a good fit for every participant and that each participant has been able to effectively shape their career across their adult years. The study reveals similar pleasures in the psychoanalytic career such as its flexibility, its expansive potential, and its relational gifts. Additionally, the study finds that the participants shared some struggles around psychoanalytic institutions and peer decline. The study then considers the resulting themes using Colarusso’s work on time-sense and the life period of the fifth individuation. Our research data suggests that the needed work of mourning the past to move forward in the fifth individuation may not be taking place. The study also interprets the data, with the aid of self psychology theory, to examine how the retirement phase threatens a major upheaval in the selfobject environment that contributes to narcissistic homeostasis and cohesion throughout adulthood.

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This study provides some clear policy implications and possible routes ahead for future research. As suggested by recent contributions in the literature review, it seems that there may be more comfort and willingness to discuss the taboos of aging and retirement in psychoanalysis. A larger and more robust discussion of the retirement phase in psychoanalysis is warranted. However, this research indicates that there needs to be some organization or structure for these conversations or else they risk recreating the current confused state of affairs in the field of clinical psychoanalysis. The research calls for greater training around aging and the integration of retirement as a necessary and meaningful stage of the career.

One of the continued refrains, in the interviews, is that the lamentation around aging and retirement in psychoanalysis cannot be fixed, another impossibility for the impossible profession. However, I think this study, and other examinations of its kind, provides a way around and above some of these thorny issues. Often the air of impossibility arises when considering concrete issues such as when a psychoanalyst ought to retire or when to stop accepting psychoanalytic cases. Once concretized and reduced to certain facts, the practice loses its depth and meaning. If psychoanalysis is the hermeneutic art of exploring each human’s individual mystery then, certainly, a universal age for work cessation may not be agreed upon. Instead of reducing these circumstances to reductive behavioral instructions, we must hold on to the perspectives of Colarusso’s fifth individuation and self psychology and ask deeper questions. How does one prepare to be a good psychoanalyst in the fifth individuation? What is needed to develop and evolve ‘timesense’ across a psychoanalytic career? Or, given the importance of stability in the selfobject milieu, how does one limit upheaval and plan for continued cohesion in

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selfobject structures as life changes? In other words, the tools for this impossible transition are contained in psychoanalysis and its method. I urge us all to dig deep and trust in psychoanalysis to help us do the work to protect the field.

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Appendix A Flyer

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Seeking Psychoanalysts

Sarah Goldberg LCSW 773-791-9571 Sarah Goldberg LCSW 773-791-9571

Age 75+

Sarah Goldberg LCSW 773-791-9571

Participants wanted for a research study exploring psychoanalysts’ experiences of aging and retirement.

Sarah Goldberg LCSW 773-791-9571

*Must be age 75 or above *Must have graduated from a psychoanalytic training program *Must be currently practicing psychoanalysis

Sarah Goldberg LCSW 773-791-9571 Sarah Goldberg LCSW 773-791-9571 Sarah Goldberg LCSW 773-791-9571

If you are a psychoanalyst age 75+ who is currently practicing clinical psychoanalysis and would be willing to give your time for research, please contact Sarah Goldberg LCSW. It is a qualitative research study which requires at least 2, separate, 60 minute interview sessions.

Sarah Goldberg LCSW 773-791-9571

More information:

Sarah Goldberg LCSW 773-791-9571

Call: 773-791-9571 Email: sarah.o.goldberg@gmail.com Institution: The Institute for Clinical Social Work

Sarah Goldberg LCSW 773-791-9571 Sarah Goldberg LCSW 773-791-9571

Sarah Goldberg LCSW 773-791-9571 Sarah Goldberg LCSW 773-791-9571 Sarah Goldberg LCSW 773-791-9571

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Appendix B Open-Ended Questionnaire

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Basic biographical data collection: Age now: Age when entered candidacy: Professional license: **These interview questions will guide the interview and provide prompts for conversation - Can you describe your early years in clinical practice?

(Prompts: What was important for you? What were you worried about? What did you enjoy most about practicing? What did you enjoy least? How did you imagine the length and scope of your career at the outset?)

- Over the years have your feelings on the length of your career shifted at all?

(Prompt: Have you moved towards wanting to work longer or retire earlier?

Why?) - Where would you consider yourself in your career right now in terms of development as an analyst and retirement?

(Alternate: If you had to describe your arch as an analyst how would you and where are you now?

- Have you structured your practice any differently over the years?

(Prompt: Do you take on different patients, work different hours, have a different theoretical focus?

- Do you spend your time differently than you did at the beginning of your career?

- Does practicing psychoanalysis in the later phase of life feel like what you expected it would?

- Have you experienced aspects of aging that have impacted your practice? Have you had illnesses or other disruptions that could be attributed to aging?

-How have you handled these incidents clinically?

-Were there any tools or other resources you used to consider how to manage these situations?

- What do you imagine your version of retirement would be?

(Prompts: Can you tell me about it? How did the plan originate? Has the plan changed at all over the years?)

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- Do you have any examples in your institute or in your broader circle of analytic colleagues and friends who had either a good retirement or a bad one?

- What are your thoughts about how the aging of psychoanalysts should be dealt with in the clinical situation?

(Prompts: What has shaped your beliefs on this issue? Have you witnessed experiences with colleagues that influenced your decisions for aging?)

- Do you have discussions with your colleagues or within your institute about how to manage aging in clinical practice?

- What has been the most helpful resource for you as you work with the dynamic of aging as a psychoanalyst?

- What is a resource that you wished might have been available? What do you think would be helpful for aging psychoanalysts of the future?

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References Baker, F. M. (1994). Retirement planning by Black psychiatrists. Geriatric Psychiatry and Neurology, 7(3), 184-188.

Baker, Warren, Muraida, J., & Muraida, G. (1993). A survey of retirement planning by Texas physicians. Journal of Geriatric Psychiatry and Neurology, 6(1), 14-19.

Barratt, Kegerreis, & Wetherell. (2012). Thinking about and planning for retirement.

British Journal of Psychotherapy, 28(1), 110-116.

Bloomberg, L. D., & Volpe, M. (2012). Completing your qualitative dissertation: A road map from beginning to end. Thousand Oaks, CA: Sage.

Bond, A. S. (1993). Is there life after analysis? Grand Rapids, MI: Wynwood Press.

Chessick, R. (2013). Special problems for the elderly psychoanalyst in the psychoanalytic process. Journal of the American Psychoanalytic Association, 61(1), 67-93.

Colarusso, C. A. (1998). A developmental line of time sense: In late adulthood and throughout the life cycle. Psychoanalytic Study of the Child. 53:113-40.

Colarusso, C. A. (2000). Separation-Individuation phenomena in adulthood: General concepts and the fifth individuation. Journal of American Psychoanalysis Association, 48(4):1467-1489.

Cresswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed methods approaches (4th ed.). Thousand Oaks, CA: Sage.

Dewald, P., & Clark, R. (2002). Ethics case book: Of the American Psychoanalytic Association. New York, New York: American Psychoanalytic Association.

104

Draper, Gething, Fethney, & Winfield. (1999). Senior psychiatrist survey II: Experience and psychiatric practice. Australia and New Zealand Journal of Psychiatry, 33(5), 709-716.

Draper, Gething, Fethney, & Winfield. (1999). The senior psychiatrist survey III: Attitudes towards personal aging, life experiences and psychiatric practice.

Australia and New Zealand Journal of Psychiatry, 33(5), 717-722.

Draper, Gething, Fethney, & Winfield. (1999). The senior psychiatrist survey I: Age and psychiatric practice. Australia and New Zealand Journal of Psychiatry, 33(5), 701-708.

Erikson, E. H. (1956). The problem of ego identity. Journal of American Psychoanalysis Association, 4:56-66.

Elson, M. (1988). Self psychology in clinical social work. New York: W.W. Norton.

Fieldsteel, N. D. (2005). When the therapist says goodbye. International Journal of Group Psychotherapy, 55(2), 245-279.

Firestein, S. K. (1978). Termination in Psychoanalysis. New York: International Universities Press, Inc. Gabbard, G. O. (2010). Long-term psychodynamic psychotherapy: A basic text.

Arlington, VA: Amercan Psychiatric Publishing, Inc. Gabbard, G. (2009, June). What is a Good Enough Termination? Journal of the American Psychoanalytic Association, 575-594.

Galatzer-Levy, R. & Cohler, B. (1993). The essential other: A developmental psychology of the self. New York, NY: Basic Books.

105

Galatzer-Levy, R. & Cohler, B. (1990). The selfobjects of the second half of life: An introduction. In A. Goldberg (Ed.), The Realities of transference: Progress in self psychology (pp. 93-109). Hillsdale: The Analytic Press.

Galatzer-Levy, R. M. (2004). The death of an analyst: Patients whose previous analyst died while they were in treatment. Journal of the American Psychoanalytic Association, 52, 999-1024.

Junkers, G. (2013). The empty couch: The taboo of ageing and retirement in psychoanalysis. Routledge.

Kohut, H. (1966). Forms and transformations of narcissism. Journal of the American Psychoanalytic Association, 14:243-272.

Larkin, M., Watts, S., & Clifton, E. (2006). Giving voice and making sense in interpretative phenomenological analysis. Qualitative Research in Psychology, 3, 102-120.

Lord, R., Ritvo, S., & Solnit, A. J. (1978). Patients' reactions to the death of a psychoanalyst. The International Journal of Psychoanalysis, 59, 189-197.

Morrison, A. (1997). Ten years of doing psychotherapy while living with a lifethreatening illness: Self-Disclosure and other ramifications. Psychoanalytic Dialogues, 7, 225-241.

Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks, CA: Sage.

National Association of Social Workers. (2014). Code of ethics of the National Association of Social Workers. Retrieved January 18, 2014, from http://www.socialworkers.org/pubs/code/code.asp

106

Novick, J., & Novick, K. (2006). Good Goodbyes. Lanham, Maryland: Jason Aronson.

Palombo, J., Bendicsen, H., & Koch, B. (2009). Guide to psychoanalytic developmental theories. New York, NY: Springer Dordrecht Heidelberg London.

Peisah, C. G. (2009). Medical masters: A pilot study of adaptive ageing in physicians.

Australasian Journal on Ageing, 28(3), 134-138.

Pointon, C. (2004). When is the right time to retire? Counseling and Psychotherapy Journal, 15(4).

Ricoeur, P. (1970). Freud & philosophy: An essay on interpretation. New Haven, CT: Yale University Press.

Robbins, J. H. (2006). A psychotherapist retires. Women & Therapy, 29(1/2), 189-203.

Sands, S. (2006). Less time ahead, more behind: Being a psychotherapist in the last third of life. Women & Therapy, 32(2/3).

Schlessinger, H. J. (2005). Endings & beginnings: On terminating psychotherapy and psychoanalysis. Hillsdale, NJ: The Analytic Press.

Schneider, J., Wilkerson, D., Solomon, B., Perlman, C., Tsioles, D.D., Shelby, D., Witten, M. & Sadow, L. (2014). Psychoanalytic training experience and postgraduate professional development: A survey of six decades of graduate analysts. International Journal of Psychoanalysis, 95(6):1211-1233.

Schur, M. (1972). Freud: Living and dying. New York, New York: International Universities Press, Inc. Schwartz, H., & Silver, A., (Eds.). (1990). Illness in the analyst: Implications for the treatment. New York City, New York: International Universities Press, Inc.

107

Siegel, Allen M. (2004). Heinz Kohut and the psychology of the self. New York, NY: Routledge.

Smith, J., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis: Theory, method, and research. Thousand Oaks, CA: Sage.

Smith, J., & Osborn, M. (2008). Interpretative phenomenonogical analysis. In J. Smith (Ed.), Qualitative psychology: A practical guide to research methods (2nd ed.). (pp. 53-80). Thousand Oaks, CA: Sage.

Tessman, Lora H. (2003). The analyst’s analyst within. Hillsdale, New Jersey: The Analytic Press.

Van Manen, M. (1990). Researching lived experience: Human science for an action sensitive pedagogy. London, ON, Canada: State University of New York Press.

Walsh, J. (2007). Endings in clinical practice: Effective closure in diverse settings (2nd Ed.). Chicago: Lyceum Books.

Weiss, S., & Kaplan, E. (2000). Inner obstacles to psychoanalysts' retirement: Personal, clinical, and theoretical perspectives. Bulletin of the Menninger Clinic, 64(4), 443-461.

Weiss, S., Kaplan, E., & Flanagan, C. J. (1997). Aging and retirement: A difficult issue for individual psychoanalysts and organized psychoanalysis. Bulletin of the Menninger Clinic, 61(4), 469-480.