Christopher BollasCatch Them Before They Fall: The Psychoanalysis of Breakdown

Routledge, 2013

by Tracy D. Morgan on March 26, 2013

Christopher Bollas

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What if analysts took steps to keep their analysands out of the hospital when they were beginning to breakdown? What would that look like? In Catch Them Before They Fall: The Psychoanalysis of Breakdown (Routledge, 2013), the eminent psychoanalyst Christopher Bollas, walks us through that process.

Beginning with his treatment of psychotic and manic depressive patients in the 1970s in London, Bollas sought to increase patients psychoanalytic sessions and to work with a team of psychiatrists and social workers who were analytically savvy. When these fragile patients disturbances became heightened, Bollas et co. worked in such a way that none of his patients needed to endure the shock and awe of hospitalization. Now, 40 years later, he has published a book that looks deeply into a way of working that confidently declares psychoanalysis to be THE treatment of choice for the person breaking down. By expanding sessions from five times a week to twice a day seven days a week or from morning to early evening, he discusses with us how breakdowns attended to in this way can become their antithesis: a breakthrough. He is passionate and as always, an intelligent maverick.

This interview promises to give analysts and analysands cause to pause regarding our relationship to the frame and the doing of business as usual. His belief in the human need to find a human other to hear us in our darkest moments, an other especially attuned to unconscious meanings, is convincing. For Bollas, being with a person breaking down demands we change our modus operandi. A breakdown is in a way an opportunity that can be dealt with by psychoanalytic means. To not attend to a breakdown is to put the analysand at risk of simply and devastatingly sealing over the elementary forces that brought the breakdown to the surface in the first place. Always thought provoking, in this interview Bollas weds theory and technique, expanding the reach of psychoanalysis with great creativity.

{ 23 comments… read them below or add one }

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tracy morgan May 1, 2013 at 8:18 pm

Dear listeners and readers,

Thanks to all for your enthusiasm for and participation in our time spent thinking through Christopher Bollas’ challenging ideas regarding the treatment of breakdown. Many great questions have been asked and cases shared. Bollas has responded as promised today, May 1, giving us a full six course meal of an essay, taking in what has been expressed, in some cases elaborating and in others metabolizing the many words put on offer. As this was a limited event, with a beginning, middle and an end point, I wanted the audience to know that this is, as it were, the end of the session with Bollas. He will not be engaging in an ongoing conversation here any longer but of course, reactions to his words and his gesture are welcome and encouraged. I think it was a rich exchange and going forward on NBiP you can look forward to more participation with authors in a similar fashion. Tx as always for tuning in.

Warmly yours, Tracy D. Morgan
Host, New Books in Psychoanalysis

christopher bollas May 1, 2013 at 2:07 pm

New Books In Psychoanalysis

I appreciate those who have contributed to this discussion. It is not easy to post a comment or a question. One has to distil a lot of thoughts into a brief communication with no idea if this will have been sufficient to get one’s views across.

I agree with Evan Malater that extending psychoanalysis does indeed challenge our notions of time. Bearing in mind that Freud himself wrote about extended sessions, that Winnicott made this famous, and then Lacan infamous, why are we shocked by temporal alterations? There is a difference between chronologic and psychic time. Five minutes can feel like hours, an hour like five minutes. Analysts regularly discover that they have inadvertently gone over time with a patient–usually by a few minutes–because on occasion crucial material seems to arrive only after the hour is over. Sometimes, however, an analyst may elect to end a session early, guided by clinical judgment that responds to psychic time.

A few days ago a patient said to me “I can’t talk anymore. Do you mind if we stop?” and I said “If you wish, why not?”. We stopped. This has happened ten or twelve times over eight years and each time she says this to me I believe she actually does need to stop as she has reached a point of such personal pain that she does not want to hear anymore from herself.

Another patient, early on–very compliant–was struggling after twenty minutes. I said to him “it seems to me you have left the session” and he agreed. “My feeling is you would like to stop now, as you have ended” and he said that was correct. We stopped. Over the years, my accepting his ending of the time was critical to his feeling that these sessions were for him–not for me, not for psychoanalysis–but for him. These days he uses the sessions and it has been years since we ended before time.

A schizophrenic patient shows up for sessions but often disappears in meaningless abstractions followed by painful silences. It is clear that he does not want to be in the session. I say to him “why should you have a session if you do not wish to?” and he makes excuses: he forgot, he was confused, and so forth. Eventually he can say that on the day he did not feel like talking. “If you do not feel like talking, then why force it”? He said he would email me or phone ahead if he would not appear. I said this was unnecessary. Why burden himself with that? I was not going anywhere and if he did not appear after his hour I would assume he was not coming. The fact is that I support those analysands who have had enough with the process, who for many reasons may need to bunk off, for a session, for some months, indeed for some years.

Now of course in making these points, especially and unfortunately, in the world of psychoanalysis more often than not one hears the following sort of response. “Well, so if your patient says he needs to talk for twenty more minutes, you just force the patient who is waiting to hang out in the waiting room”? Or, “so if your patient seems glum after five minutes you just say, ‘why not leave if you don’t like it here’?.

A problem with trying to get to certain levels of serious discourse in psychoanalysis is the tendency for some respondents, to dumb down the level of discussion, reducing potentially interesting issues to a type of concrete gamesmanship.

Evan’s point, that we could rethink time–a passion of Andre Green’s–is pertinent. So far as the unconscious is concerned, says Freud, there is no difference in time. And he points to the dream as his example. I mention the above clinical examples because for some people fifteen minutes feels like hours if they are suffering and demanding they remain put until the end of the hour, or in effect trying to accomplish this through a supposed analytical investigation of why they feel a need to stop can be a form of coercion.

Perhaps the psychoanalytical experience is timeless. That is, although the analyst and analysand impose an end to the session, this is of course a matter of social convenience. Yet, inside the experience, both are amidst a timeless state of mind, ruptured by the reality of necessarily imposed human requirements.

It may well be that the analysands who move quickly into breakdown and whose clinical requirements demand more time are quite simply moved by the logic of analytical time: that the timelessness of its promise is accepted.

Some comments were directed towards why I waited so long to publish my views. I do address that in the book. It was not until the mid 1990′s that I realized I was working, on occasion in a different way. I knew that I needed time to see how it went and that I would also need time to discover what I really thought of it all. I have discussed in the book why I did not discuss this work with my colleagues, but I should add that I do not think people would have been shocked or disapproving. An entire tradition of analysts from Winnicott, Balint, Khan, Laing, and Coltart to many others, less well known, extended sessions in order to help people through breakdown. I needed, however, to digest these experiences over a long period of time. I was privileged to work with a great team of people, all of us knowing we had a job to do, including leaving each to his or her own private reflections. I owe more than can be said to the freedom of thought imbricated in English culture and I would never have developed this way of working without the modest and just-get-on-with-it frankness of those with whom I worked. The psychiatrist with whom I worked for over 30 years is now deceased. He is named in the book as Dr. Branch. I could not have forged these relations without him.

What we did in England was less well known in the United States and when I first presented my work to a clinical seminar at Columbia University in the 1990′s, those present were without exception shocked and disapproved. Perhaps this is why I was mildly surprised by Tracy’s comment about those who were in a state of envy upon hearing about my book. Why did I not realize the significance of this? I suppose because the responses I have had in the United States have often been dismissive. On the other hand, when I presented my work to the Finnish Psychoanalytical Society in May of 2012 there was a thoughtful and encouraging discussion of this way of working. Tracy’s reception to this book and that of many of her colleagues as well as many of those making comments is a new experience for me insofar as presenting this work in the United States and I hasten to add that when I presented this way of working to the Chicago Workshop in Psychoanalysis over a period of two years a lot of thought and consideration was given to this topic.

As to the envy an analyst might have towards a patient who is receiving from that analyst the sort of care the analyst did not receive when he or she was in analysis, well I expect this is so at times. I would say, however, that I learned much about how to do psychoanalysis from the mistakes of my analysts as from their good interventions and I was pleased to be able to give something to my patients that I had not received. It may be a bit like becoming a parent. Many parents learn how to be better parents for their own children by not repeating the mistakes of their own parents and more often than not, I think, such parents feel good about creating a better relational space for the children.

I think Christopher Bandini’s response is good humored and his ironic rejoinder allows us to address some of the problems posed in writing this book and how some people will, of course, choose to object to it. First, one has to read the book and if so I think the question of the time-limit is addressed in full and the notion that if one offers an 8 hour day, why not 12, or more, or even have them stay with you in home; well, that’s good for a laugh perhaps, but it is as Bandini says, quite absurd. Readers of the book will note that I regard one of the crucial features of extended sessions to be the analysand’s resistance to this recommendation. That resistance is crucial, prognostically in my view, because the patient–although breaking down–wants to get back into their life.

By the end of the 1990′s I had arranged to work a 4 day week, 10-12 hours a day. That way I could have a long weekend with my family, sometimes do a bit of writing, or just enjoy the varied pleasures of life. Every year or two, however, that Friday and the weekend would be taken up looking after a patient who was breaking down in what was to become the 3 day session. None of my other patients knew about this, there were no cancelled sessions, and like Bandini, I enjoyed my weekends very much as well. The point is that the 3 days sessions are a rarity. I certainly do not recommend it as a way of life. It is true that I think sending a patient off to hospital when they are breaking down is a tragedy if extended sessions would offer the analysand a meaningful and transformative holding environment that saw them into a breakthrough.

To be sure, in the book I maintain that when I offer the all day sessions I have never known how long it would take; indeed, that this not knowing–this suspension of time as it were–is a crucial background to the analyst’s clinical effectiveness. One has to entertain the illusion that this could go on indefinitely, as long as it proved efficacious. In the back of my mind, when I did this the first two occasions I thought it might take one or two weeks. That it never did was at first a surprise and now having gone through this enough times I only wonder why it is just three days.

A London friend and colleague, who was surprised to hear I had been doing this all these years, correctly challenged me by stating, “but you underplay just how incredibly difficult this is. You make it all sound so easy, and it is not!” I agree that the double sessions a day, seven days a week, for two weeks or so is very, very, demanding. So too is working with a severely disturbed person every day, four or five days a week, for years. Our work, ordinary analytical work, can push all of us to our limits. I do have to say, however, that I have never experienced the three day sessions as in the same category. Intense, yes. Harrowing at times, yes. Like living in a totally different spatial and temporal reality, yes. In some ways utterly bewildering, yes. But the three days are amongst the most moving moments of my psychoanalytical life and to see people enter this process, use it with some extraordinary intelligence and courage, is profound. I accept, however, that I am unlikely to understand why three full days works as it does. Not knowing why it works as it has was one reason in my mind, at least, against writing the book in the first place. I decided that even if I could not know the answer to this question I should nonetheless push on and live with the consequences.

Do I think that analysts who refer their patients to hospital, rather than elect to provide additional sessions, care less for their patients than do I? Of course not.

Hospital care, however, is usually brief (a few weeks or months at most) and the patient is then returned to his or her life, but has not received anything like psychoanalysis during their stay. I was privileged to work at The Austen Riggs Center in Stockbridge Massachusetts for some years, but as most people know Riggs is a residential treatment center and set up to offer long term therapy for people who are, if not psychotic, then borderline and so forth. For the most part, hospitalization, however, is experienced by the patient as a rejection by the clinician, often at a crucial time in the patient’s psychic life when the very thing they need is analytical care.

Indeed this may be occasion to applaud Dr. Hoffman and her husband who are providing residential treatment for people in the United States. This is very good news. There is a long tradition of such practice in the United Kingdom, beginning with Kingsley Hall and Laing’s exhausting work with people who were quite ill. Today, both the Philadelphia Association and the Arbours Association offer therapeutic houses where patients live attended by a live-in clinician and are offered both group and individual psychotherapy. The cost is modest, patients usually stay for a year or two, and readers of our conversation would, I think, profit from looking up those groups on the internet. North American clinicians exploring treatment options for patients who cannot afford the high fees of a place like Austen Riggs might want to explore the English alternatives. Many Americans have arrived in England and become patients at the PA or at Arbours.

I have copied and now paste the Arbours Association description of its home centers for patients. If I simply offered a link I am not sure people would actually have a look. So, here it is:

The Arbours runs three residential Therapeutic Communities where people in emotional, psychological and social difficulties can live in a supportive therapeutic environment.
All of the houses are situated in quiet residential areas of north London. They are comfortably furnished and can accommodate up to eight residents in single rooms with communal rooms shared by everyone. When possible we try to ensure an even balance between male and female residents and we attempt to provide as wide a range and diversity of cultural and ethnic backgrounds as possible.

• aims and objectives
• user participation
• staff support
• referral criteria & assessment procedures
• community support & therapy programme
• families and partners
• moving on and after-care
• practical support
• fees
Aims and Objectives
We aim to maintain a nurturing, non-institutional, home-like atmosphere where respect for the freedom and unique potential of each individual is honoured. We see it as our task to help residents face and work on the difficulties that may be impeding their growth, and to motivate them in the direction of achieving a more satisfying way of life so that they can live as viable members of society.
The umbrella of therapeutic and practical support provided by Arbours fosters a climate that provides the necessary freedom for residents to find their own identity and take responsibility for their lives. Our long-term aim is for each resident to overcome his or her emotional and psychological dependency and to gain a more independent way of living.
User Participation
User participation is a vital component of our therapeutic approach. We expect each person to contribute to the running of the house, and to help with cooking, cleaning, shopping, financial management and maintenance, as well as with choosing new members and with attending on-going discussions of house policies.

Staff Support
Arbours has always been concerned about the alienating aspects of “staff-patient” relationships often found in institutional settings. In order to counter-balance such alienation we have developed a careful programme of staff support that has proved to be both therapeutic and effective. During the past over thirty years, our experience has been that this supportive therapeutic programme had made it easier for residents to resolve their difficulties.
Two co-ordinators, both experienced psychotherapists, have overall practical and therapeutic responsibility for each house. They are on call for advice and support and lead house meetings in each house every week. Residents see their own individual psychotherapists twice a week and attend art and movement therapy groups once weekly.
In addition to the above, we have established a policy of having in each house, residential community facilitators who share living in the community. In addition, our trainee psychotherapists and volunteers do visiting placements.
Referral Criteria and Assessment Procedures
Referrals to the communities may come from individuals, psychiatrists, GPs, social workers, psychologists, and psychotherapists, and from statutory and voluntary agencies.
Each potential resident has an interview with an experienced psychotherapist who assesses the applicant’s psychological and emotional needs, and suitability as a community resident. This also provides an opportunity for the potential resident to raise any questions they may have and to get information about the communities.
The next stages in the assessment procedure are interviews with each of the house co-ordinators and an informal meeting with the present residents. If all goes well, the potential resident is invited to spend a weekend in the community. The whole procedure usually takes from four to six weeks.
Community Support and Therapy Programme
Throughout their stay in the communities, residents are required to attend:
1. The twice-weekly group meetings, which are led by the house co-ordinators, where the residents can explore and clarify both personal and inter-personal issues. The group may also offer an experience of belonging that is often lacking in individuals who have been isolated by their problems.
2. Two individual psychotherapy sessions a week with a trained and experienced psychotherapist where residents can explore the meaning of their problems and difficulties in a trusting one-to-one relationship.
3. Art and movement therapy groups (one of each a week) where residents can explore their experiences and feelings in a medium other than words: through painting, drawing, sculpture and movement.
In addition the residents are living in a therapeutic milieu in which they can learn, with the support of the co-ordinators, the community facilitators and their peers, to take responsibility for themselves and others and to learn relational, social and domestic skills. Any difficulties experienced in meeting these responsibilities can be discussed in the regular house meetings.
Our experience shows that it takes time for a person’s psychological repertoire to unfold. Therapeutic programmes cannot, therefore, be static. Residents’ progress is assessed on an ongoing basis, and changes may be made at any time to meet their needs. In addition, formal internal reviews of residents’ needs and progress take place approximately every six months.
The Communities provide outings and day activities and residents are encouraged to explore and create links with the outside community, working towards eventually making use of courses and other activities.
Families and Partners
The families, partners and other individuals in the resident’s social network may be in need of emotional psychological support. Where appropriate, we are able to see residents with their partners or family. It may, however, be more therapeutic for families and partners to receive individual psychotherapy, which we can provide directly by means of a referral.
Moving On and After Care
When moving-on is indicated, appropriate support is provided and residents are able to discuss their anxieties and practical difficulties of moving on with the house co-ordinators and in the house meetings. Residents are encouraged to take courses, to train and to find employment before leaving the community.
Practical Support
The Arbours office provides assistance with DWP (Department of Work and Pensions) and Local Authority payments, and advice about rights, training courses and any other issues throughout the resident’s stay.
The office staff visit the communities regularly to impart useful information and to offer practical help, particularly with problems related to social security and with maximising income. The office staff are also available to try to provide help with move-on accommodation and any other practical issues.
Fees
Please contact the main office to ask for a breakdown of costs for any of the three communities.

So that is Arbours. Have a look at the Philadelphia Association for news of a similar situation.

I should make it clear, however, that my book is not about the sort of treatment offered by either therapeutic communities or as I understand it by Hoffman. I do not accept analysands who seek analysis in order to have a breakdown. Nor do I encourage, foster, or facilitate a breakdown. The book is about what might show up
in a seemingly “ordinary” if vulnerable analysand whose regression is more intense than in an ordinary analytical regression; indeed, in some cases may be acute and without any prior indication this was going to happen.

A European colleague has written to me concerned about my position on hysterics and I have re-read the passage in the book where I have written about not taking “malignant hysterics” into regression. It is not the case, however, that I would not respond to an ordinary hysteric’s breakdown, and the case of Anna is an example of working with an hysteric. Time does not permit discussing malignant hysteria, but suffice it to say that for a few people breaking down is sought as an end in-itself, the experience affording considerable secondary gain, and extracting an implied license from the analyst for unending care. I consider this to be rather disastrous and in my view some of Winnicott’s clinical failures were in his work with patients whose hysteric demand he agreed to try to meet. I did not know Winnicott personally, but I did know his wife, Clare, very well and we often discussed this one area where DW had a blind spot. I also inherited several of his analysands, one of whom was in that realm, and I could see how she envisioned psychoanalysis as an endless promise to fulfil her wish that she have a witness-accomplice to her cumulative deconstruction of her personality, to some imaginary O point.

On the other hand, I have discussed at length over a number of years Winnicott’s way of working with three of his analysands all of whom were qualified psychoanalysts. They found his facilitation of regression to dependence transformative in ways that simply could not be put into words. Elsewhere I have written that Winnicott actually did not psychoanalyze his patients and in in his own way neither did Bion. Both personalities created more of a very special type of atmosphere in which experiencing in the here and now took precedence over interpretation of inner life or projective processes.

I appreciate Jane Goldberg’s passionate description of a year’s work with her patient. It is also kind of her to credit the interview with helping her to report her work.

I am not, of course, in any position to comment on the course of this analysis, but as Jane Goldberg likens it to my own way of working, I think I should make some rather tentative comments, lest there be confusion about my own thinking.

I do not agree to a patient’s wish to have extended sessions. In the book “Catch Them Before They Fall…” I have written why this is so and I cannot recreate the argument put there. In brief, I offer extended sessions when it is clear to me that the analysand is beginning to break down and that ordinary 4 times or 5 times a week analysis will not be sufficient. That is a rare moment because usually ordinary analysis is able to hold and process regressive breakdowns.

I have emphasized in the book that a prognostic indication for extending sessions is the analysand’s resistence to such an offer. That resistence is an ego-indicator that the patient’s life instinct does not want to enter regression, that it wishes to remain connected to the ordinary object world, and therefore resists the interpretation that the self is being guided into more regression than one would ordinarily accept. The breakdown, however, is so compelling that the resistence is eventually overcome by the power of the breakdown and the psychoanalyst’s assurances. One of those assurances is that usually extended sessions will last for a limited period of time–a few weeks or so–and then patient and analyst will return to ordinary sessions.

If the psychoanalyst, in my view, has assessed the clinical requirements correctly then that is what will happen. If the extended sessions were to endure for more than a few weeks, indeed were to be for months; further, if they were to be episodic (a few weeks like this, a few weeks or ordinary work, a few weeks like this) then the analyst has either not provided the correct amount of time or the analysand is not the sort of patient for whom this technique is suitable. I have discussed earlier in this essay that I do not, for example, offer extended sessions to malignant hysterics.

In my book “Hysteria” which is not so well known in the United States I discuss the complex problems presented by male or female hysterics to practicing psychoanalysts. A chapter is devoted to the perils of facilitating an hysteric’s desire for regression, in which enactment becomes the-thing-itself. As I read Jane Goldberg’s case–and again my apologies for cloning a response from a snippet of reported material–I would want to be sure that her analysand is not a malignant hysteric. In thinking about these issues further “Catch Them Before They Fall” cannot, I realize, be adequately understood without first reading “Hysteria”(Routledge, 1999). I think after reading that work then my arguments in “Catch” will be clearer.

I am concerned that it is the patient who has asked for extended sessions. Her patient’s presentation seems highly dramatic and enactment based. She contains vivid scenes in her mind and through an open-ended regression agreed to by the analyst may move towards an endless presentation of fantasy-driven memories of childhood. As with Freud’s hysterics in Studies in Hysteria the secondary gain achieved by the production of ever-new scenes for analyst and patient to view is impossible to end. Freud’s patients were not borderline, as many have maintained. They were not schizophrenic either, in my view. They were malignant hysterics.

Here the “talking cure” is transformative as opposed to the “showing cure” which is not. The malignant hysteric will aim to substitute presentation in the imaginary order in usurpation of representation in the symbolic order. The difference in the direction of the cure, so to speak, is huge. Winnicott made serious mistakes in his treatment of hysterics because he took the showing self to be indicative of a repetition compulsion presenting the raw materials of early trauma to the psychoanalyst. I think he was taken in by the powerful dramatic dimensions of these showings (not tellings) and this is unfortunate.

In part I wrote the book on hysteria because after supervising many cases in the United States, South America, Europe and Israel I was aware of a common problem posed by patients who demanded that their clinicians give them more time. Often they would telephone out of the blue or show up in the clinician’s waiting room aiming to get another session. One of the concerns about publishing “Catch” is that some patients might read this book and in its name demand more sessions from their analysts: i.e. “Well, why don’t you do what Christopher Bollas says”! That may sound unlikely but a book of this kind can and will, unfortunately, elicit that kind of demand from certain kinds of patients.

Of course I would have no way of knowing how and in what ways this relates to Jane Goldberg’s patient, and online publication prohibits any detailed discussion. Psychoanalysts work in differing ways with differing patients and there is no “royal road” to the correct treatment. I believe if some folks decide to read my book they will then discover quite a bit more than can be discussed here. And I reckon that some of the writers who kindly commented on the interview will find some of their questions answered, even if–as one would expect–they disagree.

We are all indebted to the courage of a Jane Goldberg who has stepped into a difficult space to share her work with an unknown audience, not knowing what kind of response she might receive. That I cannot validate her approach should not be taken as an informed view, because it simply cannot be. One day, perhaps, she will write about her work with her patient. Her prose style indicates a high degree of skill as a writer who can communicate with passionate intelligence her own view of how to help her patient. If so, I look forward to reading her work and wish herself and her patient the very best.

Steve Poser’s thoughtful meditation on the patient whom he has seen points us in a different direction. Let me quote from a brief part of his comment:

“The second time the patient came with her fiance and aunt. The patient asked that her fiance and aunt leave the room and became frankly psychotic, paranoid, and thought-disordered. She thought her aunt and fiance were plotting to have her put away in a mental hospital but that in fact she suffered from neurological problems in her brain owing to what she claims was a mild case of cerebral palsy when she was a child. She never came back for her third session, but the boyfriend did come in her place and said she had been hospitalized by a psychiatrist near her family home and could conceivably be there for several weeks.”

The first time the patient came she attended with her finace. The second time with fiance and aunt. She now asked that they leave the room and then thought they were plotting against her. Well? Perhaps. It seems plausible that they thought she should be in hospital. But the beauty, to my way of thinking, is Poser’s unconscious attention to a psychic evolution. The patient comes with her fiance, and it seems to go well. The second visit is with an aunt and she dismisses them both on the grounds that they are plotting against her. She claims that she is not psychotic but suffering from a “palsy”. In that word are several phonemic possibilities. I heard “pall” and then “see”. I also imagined something that gave rise to a pause, a pall that stops expression. What might she want the analyst to see? What would give rise to a slowing up of things? Steve then intuitively changes his narrative. The fiance is now a “boyfriend” who comes in her place. Both have been demoted. What does this mean? Who knows? But Poser’s receptive intelligence has conveyed to us a complex that is certainly communicated by the patient. The analyst, in my view, is not obliged to know; indeed, how could he? What is he to make of the shift, from a fiance and his wife (to be disturbed), then a triad involving an aunt, then the vanishing of the patient, the regression from fiance to boyfriend, and then the guy standing in her place? What has happened? I have no idea. And perhaps Poser also does not know what has happened. But if she were to return alone and unattended, who knows what she would say? Would it make any difference? Or does she need to disperse her self through a presumed marriage to be, that is thwarted by marriages in the family of origin?

Poser is correct that none of my patients in breakdown have been psychotic for long. No voices heard, but visually intense phenomenon, yes. I reckon that in the course of the three day sessions my patients are in deep eidetic territory but as they are not speaking I am not privy to their thought process.

He asks if it is possible, in my view, for him to set up an outpatient treatment setting for this patient and I think, yes, it is possible. Establishing psychiatric colleagues to be part of that team is crucial, as he indicates, and he implicitly conveys that were the patient not hospitalized he thinks he could have reached her. There is something in the emotional communications latent to his writing that seems to me clinical evidence that he should pursue this possibility. I have worked with people who begin analysis having come from hospital and although much may have been lost in the process, we have to accept the very different terms of engagement.

In 2014 I hope to conclude a book on schizophrenia which has been occupying much of my time these last few years. In that book I indicate how I work with psychotic analysands and indeed it will be clearer how different this is from working with those people described in “Catch…”.

Sacha Bollas has also brought to my attention that my April comment could be construed as stating that clinicians had to be in full compliance with all regulatory requirements before providing extended sessions. I can see how that comment could create that impression. In fact, provided one has a psychiatrist in the picture, assuming clinical responsibility, then I think there should be little problem in setting up this treatment paradigm. I do think one should, however, make one’s practice position clear to appropriate groups, not to ask permission, but to indicate a change in the ordinary way of doing things.

I should also take this moment to add that Sacha Bollas’ interrogation of me at the end of the book was his collation of objections made to my lectures on this topic in the United States. We decided to put them into a dialogic format. While he has a positive regard for cognitive behavioral therapy and other modalities, he is a psychoanalytical psychotherapist and not a CBT or DBT practitioner.

I would like to thank Tracy Morgan for her thoughtful interview and those of you who elected to take part in this extended discussion.

Steven Poser April 29, 2013 at 10:47 am

I have recently seen a young woman twice who has had two previous hospitalizations in the past few years, hears voices, and has a diagnosis of psychotic disorder. She was working a part-time job, planning to go back to school, and had recently moved in with her boyfriend to whom she is engaged to married, after living in a family home peopled by her aunt, father and various cousins. She came first with her fiance and had an immediate and powerful transference to me and wanted me to be her therapist. I wanted to take her on and immediately went about getting a support team around the prospect of treating her, including securing referrals to two psychiatrists with clinical affiliations to nearby hospitals who I am planning to approach should the treatment begin. My thinking was that if I could get a real support team around me and if I could get someone to both bring her to the office and take her home after the session, I could go ahead and see her for 50 minute sessions. The second time the patient came with her fiance and aunt. The patient asked that her fiance and aunt leave the room and became frankly psychotic, paranoid, and thought-disordered. She thought her aunt and fiance were plotting to have her put away in a mental hospital but that in fact she suffered from neurological problems in her brain owing to what she claims was a mild case of cerebral palsy when she was a child. She never came back for her third session, but the boyfriend did come in her place and said she had been hospitalized by a psychiatrist near her family home and could conceivably be there for several weeks. She has been heavily medicated and I don’t know where she is, though the hospital called to ask if I would be willing to see her when she was discharged and whether I had a psychiatrist who could look after her if she were to return to where she resides with her boyfriend.

I would like to treat this woman and have had some significant experience with schizophrenic patients in long-term hospital care. I have also treated a frankly psychotic man as an outpatient for six years and never had the experience of his ending up in an emergency room, hospital or police station.

I understand that the criteria you propose in your book evokes a very careful and sensitive picture of what the onset of a breakdown looks like, feels like, and sounds like. Also, that this kind of perception and judgement is predicated on having known and treated the patient for some significant amount of time previous to the onset of signs of breakdown. So the case I am describing I believe would fall way outside the bounds of what you are describing and would also probably not be a candidate for anything like the extension of the analytic frame to encompass an incipient breakdown before it happens. After all I hardly know the patient and the breakdown ( or breakdowns) have already happened in a big way.

But what if there were the unfortunate development in a case conforming more closely to the ones you describe in your book, where the patient did indeed become psychotic in the course of the session? I am thinking of beginning to observe such symptoms as delusional ideation, catatonia, auditory or visual hallucinations or picking up the feeling of some kind of imminent violence? I know one can “see these things through” without taking any action to restrain the patient most of the time, and so I find I am wondering how your thinking would be affected by such an eventuality.

Jane G. Goldberg April 28, 2013 at 2:36 pm

I have been working with a patient for a year who has been in what Bollas calls “break-down” for the entire analysis. She is a frighteningly smart and sensitive patient, who struggles mightily in sessions to even talk. It is as though she has a clamp on her mouth whilst simultaneously her psyche is screaming out, to be seen and heard. But once she gives herself license to talk, it becomes clear that she has been having an ongoing internal dialogue of the richest kind for years. In fact, I believe her internal dialogue is what has saved her from hospitalization multiple times during particularly difficult moments.

Her sessions with me are routinely extended beyond 50 minutes. It was her idea to have sessions every day, and, at times of most dire need, to have sessions more than once a day. I have accommodated her as best my schedule permits. Due to the frequency of the sessions and her particular need for this frequency, as time went on, she would timidly allow herself to open up a little bit at a time. She would even periodically allow herself to cry out in the pain she was experiencing in her life — something she had never done so openly before her treatment with me began.

Because sessions are this frequent, we enable her life to be laboriously rerouted – and lived – through an inner psychoanalytic (safer) netting that has become the basis for her inner emergence. Through this model, some tremendous milestones on her inner roadmap have been attained. Largely, this has come about as the result of an emotionally trying experience in her personal life – and often times emerging in her relationship with me – in which she regressed to a state of poised and verbal external presentation, but (undetectable to those around her) extreme internally-bound silence.

Yet in those times, seeing her as often as I can, we work hard to undo the threat that has muzzled her and get her to a more internally functional state. Providing frequent sessions and “catching her” as the fall happens, I have noticed great improvement in her treatment in general. Her intense resistance to talking has taken on a new consistency: she is learning to identify the analytic environment and is able to pull out of intense regressions with greater ease and at a more functional pace. The pacing of her “come-backs” to our present relationship has become significantly shortened — from being frozen for 3 weeks to thawing out in a mere 3 days. All this, to enable her to be suitably treated in the psychoanalytic approach. In working with her, and identifying the causes of her “fall-and-break” experiences, I have developed strategies to “catch her before the fall” and it has proven to – at best – completely avoid, and – at worst – lessen, an internal regression into inner prison-like silence. It is clearly evident that there is a concrete positive effect – in both short term and long term perspectives – on my patient from these frequent (and at dire times, the twice-daily) sessions.

I have spoken to no one about this unusual psychoanalytic treatment. I thank Christopher Bollas for giving me “permission” to conceptualize this treatment as being within the framework of my beloved chosen profession. I thank him as well for making an argument for the usefulness of frequent sessions as a way to not only prevent and/or curtail a potentially damaging experience, but as a way of working that practically helps treat patients who are in long term analyses.

Marie Hoffman April 23, 2013 at 8:04 am

What a delight to hear of such passionate work being done. Almost despaired that anyone was going to these lengths to mend souls.

My husband and I are psychoanalysts and have a 13 acre retreat site where we and our associates practice. Before even reading the book, we have been preparing to utiliize a farmhouse with five en-suite bedrooms next door where we hope to have time for intensive work with people in this setting, as well as our regular practice. So, you can understand our delight when we read your stirring book.

In addition to the very practical and important comments on a professional support team and ethical concerns, we’d love any ideas on how to incorporate this milieu and intensive practice with the more normal two to three times a week psychotherapy/psychoanalysis. Our ideas involve offering rooms in which to retreat after difficult sessions; a video/book library to utilize; a meditative/contemplative space; doctoral students who may do follow-up later in the day when patients are struggling; groups, etc. How do we conceptualize a non-hospital haven for those who could benefit from such work.

Sara Beth April 16, 2013 at 11:28 am

Do you have any experience with treating mild anorexia or eating disorders NOS with psychoanalysis? I have been with an analyst for almost 2 years now and though we have a good rapport, I find it hard to approach this topic that I struggle with, with my analyst. I assume that this must be the reason why my issues have not been resolved and why I still painfully struggle in an islolated way with periodic eating issues. I was wondering how – and if at all – you have any experience or knowledge on dealing with eating issues through analysis.
I eagerly await an answer.
Thank you,
Sara B.

christopher bollas April 15, 2013 at 4:22 pm

I thought I would jump into the discussion at this point because important questions have been raised about how one might go about working with people in breakdown in the United States where there are issues involving one’s professions point of view, licensing board dimensions, and other matters.

First, although the interview with Tracy was detailed and allowed me to discuss many of those issues it is not equivalent to reading the book itself and I urge people to do that as a first step. Some of the comments seem to suggest that working in this way is simply a matter of providing a loving therapeutic relation, or practicing more-or-less in one’s ordinary way, just fine tuning things a bit. If that is the view then my book has failed to convey that the persons I am describing are strikingly more disturbed than would ordinarily be the case and would initiate steps in almost any country that would lead to an immediate hospitalization. Like all of us I have worked with very disturbed patients who have slowly broken down in the course of analysis but the structures of the analysis was adequate to see the person through their breakdown. This book addresses those few cases where such an approach will not work.

That said, what do I recommend one do in the United States?

There are several steps that need to be taken rather simultaneously. I would first find a psychiatrist who, if not a psychoanalyst, is analytically informed. I have done that in Los Angeles by using the LAISPS list serve and simply described the sort of situation I anticipated and asked colleagues if they could recommend people and I had a reply from about 10 analysts providing the names and phone numbers of psychiatrists who had worked in this way or who would be prepared to do that. It is then a matter of interviewing people on the phone and then making a choice and meeting the psychiatrist in person. You are, hopefully, establishing a working relationship that could last for many years or decades. So, if you are in your 30′s or 40′s you would want to find a psychiatrist who is of similar age.

Although cities usually do not provide the sort of social services that deploy social workers to help out in these situations, it is not difficult to find a social worker who could become part of the team you are forming. In some states (North Dakota) one could ask BA Social Workers to help by home visiting the patient to assess the person’s state as well as to help with the necessary ordinary provisions in life, such as grocery shopping, laundering, and so forth. In other states (New York for example) that social worker might have to have an MSW. Naturally not only would one interview that social worker but also introduce the psychiatrist and social worker so that one now had the nucleus of a team.

However, one should write down one’s practice guidelines and then write to one’s own psychoanalytical society. The aim here is to disclose that this is the way one is going to work and should the ethics committee wish to discuss this you are pleased to do so and indeed to have their views.

One should also contact both one’s own profession’s ethics committee and if need be the state licensing board. In some cases one is mandated by one’s profession to insure that patients in, say, a depression are medicated and it is important to point out that one is working with a psychiatrist, that the patient will have been assessed by the psychiatrist, and that the patient will have been fully informed that medication was on the wait-list to see if a week or a bit more of extended psychoanalysis was sufficient to meet the patient’s clinical needs. One’s malpractice insurance company will not, usually, require that you inform them of extended sessions–how would they know in any event?–but it is a professional courtesy to write them to let them know that one is proceeding to consider doing so with a particular patient, and again, it is incumbent to be quite detailed about the clinical team one has assembled, and also to indicate that one has informed one’s own society, and the professional and licensing board agencies in one’s state. My experience is that if you have done this, and bearing in mind you have a paper record of informing the company, that the company will only wish to establish that you are practicing in accord with the ethical standards upheld by your profession.

Assume for a moment that one’s societies ethics committee states that it does not approve of what it deems a “breaking of the frame” or some such critique. This may lead to a somewhat lengthy correspondence or indeed appearance before the committee, because people often distort what one has stated and easily forget the other dimensions. For example, the fact that clinical responsibility rests with the psychiatrist and not with the psychoanalyst–(see the argument for this in “Catch Them Before They Fall…)–it may be lost on one’s society, and other bodies, that one has actually provided for the psychiatrist to assume clinical management.

The point of the above is that the clinician has not only set up a fully functioning team but has also provided professional, regulatory, and insurance companies with limited indication that extended psychoanalysis is a thoughtful and considered decision and not an idiosyncratic and impulsive action on one’s part then one has acted in an effective and professional way.

I recommend against anyone extending sessions or adopting any of the procedures recommended in my book without fully implementing those guidelines discussed in the book and taken into full account the measures I have discussed here.

I may be leaving out certain issues that are important to practice in the United States and if so perhaps people will write in and let me know and in the concluding discussions at the end of this month I will do the best I can to reply.

Evan Malater April 9, 2013 at 12:10 pm

Along with Jamie Katz, I am interested in the way we can come to a psychoanalytic understanding of time through this discussion. Dr. Bollas has extended the use of the object in fascinating ways through his discussion of the evocative object, for example. How can we see time as an object through this discussion?What kind of object is time? Lacan provoked his own scandal by questioning the use of time in sessions and here too we see that there is a strong reaction to asserting a variation in time. And yet, it is not that anyone is suggesting that a patient in (real as opposed to acting out) breakdown does not need more time, rather it is often the case that we are saying that others should be the ones to provide the necessary additional care. So for example, we assume that we are talking about the frame and how to extend it or not. But the concept of the frame is itself enframed. How are we being in and with time to carry time with us as an object in a frame/template? Rather then see this through the lens of a frame, is it possible that the process described is itself something that throws the concept of the frame into question? Maybe time never belonged in a frame to begin with – or at least we can say that perhaps its most essential aspects are not captured by the notion of the frame.

Neil Herlands April 7, 2013 at 12:10 pm

What a joy to hear this extended interview with a master. The controversial technical choice he elucidates in his book is fascinating. My favorite detail is how he advocates working within the Freudian paradigm in these cases, and makes the distinction from interpersonal/relational models in which the Analyst is more actively involved with frequent Transference interpretation, rather than using Freud’s free floating attention or Bion’s “reverie” to allow the unconscious narrative to be told. This difference is sometimes blurred and often gets lost in today’s analytic discourse. It was heartening to me that it is alive and well!.

Neil Herlands

Lynne Laub April 5, 2013 at 9:32 am

I certainly like the idea of keeping patients out of the hospital and I can embrace the technique of giving the patient more time in order to “Catch Them Before They Fall”, but I cannot discount the 50 minute hour as a technique that helps to develop a psychic structure that could be compared to a ‘holding’ environment…I like viewing each patient individually and developing a treatment plan that is specific to the individual which includes not overwhelming the patient with too much stimuli…The Modern Analytic Theory of balancing frustration/gratification and using the Contact Function is an important aspect of treatment that helps the analyst observe the amount of time the patient can tolerate the regression necessary to reach the unconscious…It is also just as important to bring our patients back to consciousness in order to leave the office and function…Sometimes more is better and sometimes less is more.

Teresa Solomita April 5, 2013 at 6:34 am

As a big fan of Tracy Morgan’s new books in psychoanalysis, I have to say this interview stirred up more for me than most. I am particularly taken by the generosity that Christopher Bollas exhibits towards his patients, listeners and readers. I also feel vindicated by the times I have secretly broken the frame to instinctively provide more to my patients. I find myself thinking – how could I possibly set up this arrangement in my work, who would the players be, what might my colleagues say? I worry about my other patients – what of their vulnerability? Do my new patients have enough ego strength to stay with me when I’ve cancelled their hour? What of my income? Do I have enough faith in the process to sit with a patient for that many hours, that many days? And yet, the thought of taking a patient through crisis without the poor care that hospitals in our culture are able to provide, to “catch them before they fall” is rather enticing. It stimulates a sense of longing in me and a feeling of hope for my patients.

Chris Bandini April 4, 2013 at 2:50 pm

I commend Christopher Bollas for raising the idea of increasing session frequency in the light of a patient’s breakdown. It has certainly made me consider my own thoughts. I do wonder however, about the analyst…I can see myself seeing a patient everyday, even twice a day perhaps, but 8 hours a day? How does the analyst set a limit? In reductio ad absursdum, why not 12 Hours seven days a week? Or inviting the patient to my home for a few hours? We all know that this is/has been done in our past, but it demands heroic measures of the analyst. Am I less of a human being or analyst if I priortize my own time(I like my weekends) and refer a patient to a hospital? I’m also not sure my other patients should be understanding of such an arrangement. Even if their problems are “smaller” should they be given second priority?

Barbara D'Amato April 4, 2013 at 9:24 am

( as copied from Facebook post on March 26th) “Listening to your interview with Bollas yesterday, I realized how important it is for us to not only know what other psychoanalysts are doing – as we are always trying to – especially ground breaking work like Bollas has done, but to also hear from them. Listening to a speaker obviously has a much stronger impact than reading their work in print. There is something dramatically nurturing in the experience of absorbing the words of the author as they are spoken, directly. Analysts spend a great deal of time listening to patients. This is our work. It was quite a treat to hear, and to be given to by someone like Christopher Bollas, whose core ideas very much resonate with our own. Thank you Tracy, for bringing this in vivo experience to us. Invaluable!”

Since listening to the interview I have been reconsidering a patient who has been in breakdown mode for several months now. I am seriously considering a dramatic increase in the session frequency, not something I would have done prior to hearing from Bollas. The patient may or may not agree but I am in a different frame of mind about the case and the offer of increased contact feels not only “right” but imperative!

Kate Minolta April 3, 2013 at 9:49 pm

Theoretical frameworks have often been used to justify what basically comes down to loving care and human decency. It’s a shame that in our modern Western culture these are not readily available from family members and friends. We have had to subordinate them to a science, with theories and techniques. We should applaud Bollas and others who find intellectual, and even Freudian excuses to listen lovingly to people and say the things that help them the most when they need them the most frequently and desperately.

Jamie Katz April 3, 2013 at 9:29 pm

Thank you for the excellent work, both Christopher Bollas and Tracy Morgan. Your (Dr. Bollas’) ideas seems to be to modify the frame when circumstances call for it. This reminds me of Lacan’s “scansion” whereby the length of the session is adjusted on the spot to help punctuate some aspect of the analysand’s communication. This changing of the frame contributed to the IPA being in dire conflict with Lacan. My training center generally advocates for 1 session/week — another “frame” issue about session frequency that has pitted other institutes (who insist on more sessions/week) against the one where I’m in training.

The frequency and length of sessions — and perhaps all frame issues — are not a sacrosanct “given” that we have to follow. It’s possible that there are benefits to a certain arbitrarity of the structure of the frame — the frame might be useful for it’s static, solid, predictable qualities, regardless of other qualities it may have. E.g., it might be difficult to argue that 50 minute sessions are “better” that 45 minute ones in a qualitative sense; but the fact that a length is fixed might add something. On the other hand, sometimes the benefits of parts of a frame come from those qualities that have meaning beyond their arbitrariness: some might argue that a couch is better than a chair because it is more relaxing, or that dim lights facilitate reverie more than bright florescent ones do.

In a way, “the frame” contains those elements of an analysis that are unanalyzed, the edges where the analyzing stops. Once they begin to be thought about, not in the general sense, but in their specifics, relating to this particular analysand, they can become part of the analysis, adjusted, experimented with, discussed, etc.

We didn’t arrive at the 50 minute hour because it was determined as being optimal for the greatest number (and what sort of psychoanalytic standard would that be anyway?) — most frame elements have been passed down to us, created by accidents of history. This doesn’t make them “bad” but it certainly doesn’t make them a component so vital as to make a pariah of anyone who changes them.

Bollas has often sounded the alarm at the destructiveness of the pressure to conform to various psychoanalytic “givens.” It upsets me greatly that he hesitated for many years before sharing with us his very interesting and well-attended-to techniques. My question: was this hesitation (fear of being misunderstood or attacked by colleagues) an inevitable part of doing something bold and new? Or do we need to spend more energy making our “community” a more honest, open, and thoughtful one?

Tracy D. Morgan April 3, 2013 at 8:28 pm

Dear Listeners and especially to those inclined to respond to this interview here on the webpage,

The book raises very legitimate concerns about how to put into practice what is discussed herein. Christopher Bollas is following the comment discussion on line and if you have particular
issues that you wish he would address, do not hesitate, but rather write in your
comment! By the first of May, (May Day) he will read through all commentaries and address some of
the issues that have arisen from the interview, in what will, in effect,
be a short essay published in the commentary section.

This is a terrific moment for listeners and NBiP responders to hear back from Christopher Bollas as regards their concerns and fascinations with his approach to the patient breaking down. Engagement and, perhaps as a result, some gratification, approaches.

All best from your devoted host, Tracy Morgan

Angela Ursery April 1, 2013 at 5:36 pm

This was a splendid interview; I thank Tracy Morgan for her insightful questions. I was especially taken by her query re analysts envious of the care and attention Bollas provided his clients, care that some analysts wished they’d received (but did not) as analysands in distress. Bollas didn’t spend much time on it (and seems to have assumed Morgan was referring to envious responses from the author’s peers and colleagues), which was a disappointment. After all, how can an analyst provide something to a client the analyst her/himself has needed yet never received? And would the analyst resent the analysand for making that need known? If so, what would be the outcome for the therapeutic relationship, the analysand, and the analyst?
Another chewy bit was that relationships among the various providers in the American health care system and related services are in no shape to support the framework of care Bollas created and used so effectively in London (and similar to the methods used by one group of Finnish psychiatric services providers and captured in the film, “Open Dialogue”). In the U.S., as Morgan points out, GPs don’t even call to confer with the psychoanalysts treating the patient they have in common, much less work in partnership with one another.
Thanks again.

Angela Ursery April 1, 2013 at 3:07 pm

One of the challenges (for the analysand, anyway) is that most analysts have no idea whether they have the ability to attend to an analysand’s breakdown until facing one. That’s usually the worst time to find out, of course…

Michael Weinstein March 30, 2013 at 5:10 pm

Tracy Morgan is an outstanding radio host who knows how to ask her guests hard, probing questions, that are well researched and highly provocative in nature. While her series is a treasure chest of psychoanalytic insights, this episode might be her best ever, as she gets Christopher Bollas to tell all about the importance of properly managing “breakdown”.

To what degree is the modern analytic professional capable and prepared to take on the challenges of the patient “on the verge” of breakdown? As a non-analyst, I always thought the analyst was equally ready for all cases that land in the treatment room. This episode shows the complexity of successfully dealing with disintegrating patients as part of “professional team”, working with psychiatrists and social workers to plan out medical interventions and the “extension of sessions” that could require more intensive time spent with the patient.

“To lose the meaning of this pivotal event (the break down), is a tragedy” according to Bollas. This episode will help other analysts reflect on whether or not they are up to the challenge of dealing with patients on the brink.

Thanks Tracy for this great reflective work. I am happy to hear your exploration of this exceedingly difficult issue!

Your show has always been inspirational to me!

Aarthi March 28, 2013 at 5:16 pm

This approach as proposed by Bollas is a very thought provoking as well as a difficult procedure as I can see. Perhaps over some years of implementation it can be made more accessible to every other psychoanalyst in the world and to people who deal with severe psychotic patients on a regular basis.

Neil Friedman March 28, 2013 at 7:47 am

Bollas’s approach to the treatment of individuals on the “verge of a breakdown” which focuses on the patients intrinsic ego strength is reminiscent of what Mark Epstein wrote about in his book: Going to Pieces Without Falling Apart. . .in which he suggests that “the happiness we seek depends on our ability to balance the ego’s need to do with our inherent capacity to be.” What I hear Bollas saying, is that the patient needs to be in a safe enough space in which (s)he can discover his/her capacity “to be” while (s)he finds the strength to “let go”. It’s okay to go to pieces if you “know” that you won’t fall apart. . .

Carl Jacobs March 26, 2013 at 1:47 pm

I found the discussion of what Bollas calls the “lucid object” the fulcrum of what he is trying to get thru to his audience. A sort of extension of Loewald’s concept of “internalization” as a health provoking process, which allows for a re-integration of self and self/sameness to then provide the requirements for a completion of the process of internalization. As Loewald extended Freud, Bollas extends Loewald’s concepts without circumventing the Freudian paradigm. Only a close reading will suffice.

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