The ACPE Research Network

Back to the Articles of the Month Index Page ]


 

August 2003 Article of the Month
 
This month's article selection is by Margot Hover, D.Min., ACPE/NACC Supervisor at Barnes Jewish Hospital, supervising the St. Louis Cluster's Community-based CPE program.
 
[Editor's Note: It is a goal of the Research Network to consider not only clinical and patient care concerns but the CPE educational process itself. Margot Hover's article selection, while it focuses on relationships in psychoanalysis, can be seen to raise issues regarding how CPE students may experience the ending of supervisory relationships and how that experience may be researched. The creative investigation of the CPE experience, including the refinement of methodology for gathering and assessing post-program feedback, is vital to the ACPE; and members of the Research Network are encouraged to contribute in this area by highlighting pertinent articles and reporting original research through this web site.]

 

Craige, Heather. "Mourning analysis: the post-termination phase." Journal of the American Psychoanalytic Association 50, no. 2 (Spring 2002): 507-550.

 

COMMENT AND SUMMARY: CPE supervisors routinely include in the curriculum didactic seminars and readings on the phases of group life, guiding students to pay attention to those phases as they emerge in the workings of each unique group. Apart from the surveys of alumni required as part of the accreditation process, little work has been done to study the post-termination phase of CPE units and residencies or to prepare participants for that phase. Although this article focuses on the post-termination phase of psychoanalysis in a population of candidates who had completed training analysis, it seems analogous to the relationship between CPE students and supervisors. While CPE supervision is clearly education-focused rather than therapeutic, both types of relationships involve depth and significance, trust, and duration. For that reason, I have selected this article as possible "grist for the mill" of student and/or supervisor discussions.

Background: The post-termination phase of psycho-analysis is not well understood or studied. Nevertheless, the assumption is that post-termination is itself a phase of the analytic process "during which the analysand mourns the loss of the analyst and creates internalizations of the analytic relationship that support the analysand's capacity for continued self-analysis." (p. 508) Theorists describe the process in terms of stages, in which the client misses the analyst and the analytic setting, then accepts the separation, then struggles for and finally achieves autonomy. Some theorists have linked successful mourning with whether termination is experienced as deprivation and loss or as emancipation and mastery. They also warn that even "good analysis" may sometimes be spoiled, as when a client's disappointment about the termination takes the shape of blame and resentment of the analyst.

Methodology: This study began with a questionnaire mailed to all candidate members of the American Psychoanalytic Association to develop an overview of the subjects' reactions to termination. The 47 item questionnaire looked at important issues during analysis, how the decision to terminate was made, the frequency and nature of thoughts about the analyst after termination, and the experience of significant loss, affection, and support from early childhood through adulthood. That was followed by in-depth individual interviews, to which 47% of the questionnaire respondents agreed. The 121 interview volunteers had terminated their training analysis. Sixty percent were female; 40% male, with a median age of 45 years, and a median length of training analysis of 5.5 years (1-16 years). The time since termination ranged from one month to 21 years, with a median of 2 years. Eighty-nine percent of the training analysts were male. Of that pool of 121 people, 20 were randomly selected for telephone interviews. Sampling was segmented; four interviewees were randomly selected from each of five groups representing a range of loss, pain, and disappointment, so that these smaller categories could be identified and more deeply explored.

Questionnaire Results: The majority of the subjects experienced a sense of loss that averaged between 6 and 12 months, with a lot-to-moderate degree of pain. Pain during the termination phase was the variable most highly correlated with pain after termination. Ninety-four percent of the candidates experienced a strong sense of "loss of the unique analytic relationship," even though 98% of the candidates "expected to see their analysts" in the future as professional colleagues. This loss was positively correlated with a positive overall experience characterized by success and warmth and achieving something valuable. It was also correlated with a "strong working alliance," but not with having an "intensely experienced transference." The author was surprised that pain and loss were not correlated with "significant emotional loss in childhood or adulthood" and wondered if therapy allowed the candidates to work through those earlier experiences. The author was also surprised that 28% of the candidates were "disappointed with the results of their analysis." Further statistical analysis of that group also linked lower degree of growth and integration, termination pain, and unilateral termination.

Paralleling models for dealing with grief and mourning, the author identifies four emotional tasks to be accomplished during the post-termination phase: facing and feeling the loss of the analyst as analyst, understanding on one's own the transference involved in the separation, holding onto a good-enough image of one's analyst, and assuming for oneself the analyst's functions. Complicated post-termination mourning stemmed from negative and/or unanalyzed transferences. The author identifies self-analysis as the most important skill in navigating the post-termination period; the client's capacity for independence, reality testing, and sorting through the left-overs helps him/her to avoid regression.

 

Suggestions for the Use of the Article for Discussion in CPE: 

As noted above, there may be a number of interesting parallels between termination at the end of a CPE unit, residency, or supervisory education period and termination of therapy. CPE students will recognize both the sense of freedom, particularly at the end of a residency, as well as the trepidation associated with "what next." Are there any differences? The article may be especially well suited for residents to reflect upon the ending of their initial CPE unit--and as they look ahead to the ending of their residency.

How do you imagine your current group will feel toward the end of your time together? What might contribute to a group or individual's sense of being "stuck"? What might "unstick" an impasse? What do the members predict their process will be like following the conclusion of their program? What factors impinge on that process in the realm of CPE and spiritual care?

While exit interviews are a standard part of most CPE programs, there is little research on the process of termination during the period following a program. How would you set up a research project to explore that area? What "educated guesses" do you have about the outcomes, based on your own individual and group experiences?

 

Other Items of Interest: 

The Journal of the American Psychoanalytic Association is a good source for research articles that may have value for CPE researchers. For instance, in the same issue of the journal, see Siegel, P., Josephs, L. and Weinberger, J. "Where's the text? The problem of validation in analysis." Journal of the American Psychoanalytic Association 50, no. 2 (Spring 2002): 407-428; which deals with the difficulties of research using case reports (i.e., verbatims) rather than transcriptions of recorded conversations. Pastoral care researchers exploring the character and effectiveness of a chaplain's interaction/intervention with patients may face similar methodological problems. The JAPA literature may speak to many such issues of research methodology, in addition to some related subject matter.

Also, readers are reminded that our December 2002 Article-of-the-Month took up a CPE-oriented theme as well (regarding Systems-Centered Group Therapy).

 


If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman (Network Convener) at john.ehman@uphs.upenn.edu .
Copyright 2003
The ACPE Research Network. All rights reserved.