Long-Term Effects of Psychotherapy: The Internalized Therapeutic Relationship

April 1, 2007

As I approach retirement, I have been looking back over the patients I have seen. Although I was trained as a psychoanalyst, most of the therapeutic procedures I have engaged in have, of necessity, been adaptations of my analytic skills in order to meet the needs of particular patients.

As I approach retirement, I have been looking back over the patients I have seen. Although I was trained as a psychoanalyst, most of the therapeutic procedures I have engaged in have, of necessity, been adaptations of my analytic skills in order to meet the needs of particular patients. What emerged is that, regardless of the mode of adaptation-be it work with a recovering psychotic or a well-functioning woman doing once-a-week analytic work for a crucial interpersonal problem-all the therapies had proceeded on the strength of the therapeutic relationship.

I have no way of knowing how most of my 231 patients have fared. But from the words of the patients who have remained in contact with me, we can glimpse not only the importance that the therapeutic relationship played in their therapy, but how-internalized and assimilated into their own ego functioning-it remains vital to their present-day personal and professional lives.

Centrality of the therapeutic relationship
Annette was totally unaware of this internalized voice. When she was in the city visiting her ill mother, she came by to have lunch with me. She was recalling how desperately depressed she had been when she came to me 20 years before. I asked her if she had any idea how she continues to make use of her therapy. Her immediate association was to her daily talks with God. Holding the Bible in her hands, she thinks about decisions she needs to make and feelings she has, and God talks back to her. Suddenly she turned to me and exclaimed, "He talks to me just like you used to do!" We looked at each other in astonishment and burst out laughing.

Seriously ill people may have trouble hanging on to my internalized voice, and return occasionally to have that voice reinforced. I started working with Jim in the VA Hospital when he was just beginning to recover from the deep depression that had followed his first episode of mania. Discovering the 2 events that had led up to his illness: the loss of his boss, of whom he was fond, and a breakup with his girlfriend, we developed a mantra for him to use when his mood began to go high: "What have you lost?"

Two years after his discharge, he came to see me in my office. He told me that when I had given him his first pass from the hospital he had hanged himself in his mother's attic. Then he recalled my voice saying to him when he was in despair, "But Jim, you can still eat and sleep." With great difficulty, he got himself down.

After lithium became available, I learned from Jim enough about his childhood to understand why he had no pause between impulse and action. Semiconsciously, he was aware of the very real danger that he might kill someone when he felt abandoned. (He had actually killed a goose with his bare hands at the time of his father's death.) The hypomanic state seemed to be a signal alarm that his rage was about to go out of control. Throughout his life, he knew to contact me when he was hypomanic so that we could figure out what it was that he was perceiving as a serious loss. With this kind of working-on-the-surface support, Jim managed to marry and have a daughter of whom he was justly proud. On one of his last visits, several years before his death, we discovered that the loss triggering his most recent crisis was his daughter's graduation from medical school and prospective marriage. As proud of her as he was, each step in her growth had reawakened his primordial outrage at loss. Seeing this, he calmed down and lived to enjoy his first grandchild.

Patients retain the internalized presence
Most of the patients who needed support but could tolerate some exploratory work managed to retain my incorporated voice. Many were depressed or bipolar. Theresa is still aware of my internalized presence after 30 years. In answer to my inquiry, she wrote: "You have been a guide through many tough spots as a felt presence: I imagine, 'what would Dr Young say about this?' No, I don't hear your voice; I don't need to. I have heard myself counseling students, patients, friends, and family in a way I know reflects what I have learned from you. It is pleasing to hear my graduate students, many years after I've taught them, say to me they always feel my presence when they have to make professional and personal decisions. Good therapy keeps on giving!"

Patients know that therapy helped them
Many of the people who required the frequency and intensity of classical analysis were hopelessly caught in obsessive-compulsive disorder or phobic anxiety and depression. When analysis was successful, they felt that they had been given life for the first time. Ed, who suffered with a severe obsessive-compulsive disorder, looked back almost 40 years. "I talk to my wife about you, particularly at moments of pleasure and/or joy. . . . My manner of paying attention to my students at the university during those many years of teaching was rooted in the way both my mother and you listened to me, in contrast to my father and the father figures in my life."

Maura had been chronically depressed most of her life. In her analysis she became severely anxious and had episodes of frozen panic as she explored the hate and venom she was feeling toward those she loved. She eventually left her marriage, went back to college, and obtained her PhD in psychology.

Thirty years after she finished analysis, she wrote, "I love my work as a therapist. I think of it as a way to repay all those people who have so lovingly mothered me back to health and aliveness. I am the vehicle like they were, for the growth and development of other people who, like me, never quite had a chance to experience their own uniqueness."

Modified analysis: the highest success rate
In more recent years, a number of well-functioning young women have come for help with a particular problem and have been successfully analyzed on a once-a-week schedule. It is interesting that this modified analysis had the highest success rate of all the modes of therapy. Gail was not totally restricted as Ed and Maura had been, but she was "miserable" all the time and had problems in relationships stemming from her parents' separation when she was young. Her mother had been depressed and her father had distanced himself when she came to visit. After we circled deeper and deeper into this devastating problem with her father, we began to wonder if he was aloof because of the pain at having lost her rather than our earlier assumption that he was an inherently withholding person. Taking courage, she put him to the test. He responded positively to her gaze. She actually retrieved the love of her father, and he his long-lost daughter.

In her reply to my inquiry, she wrote, "Barbara Young's willingness to simply be with me in that darkness is one of the greatest gifts I have ever received. I believe I have incorporated her approach into myself so successfully because she always made sure to hold me exactly where I was, and because she never tried to fix me or help me 'manage.' Over time, it was her presence and her own humanity, which she let shine through, that I internalized." As she approached the birth of her first child, she rejoiced: "My child is not doomed to endure my unhappiness."

"Good therapy keeps on giving"
After I completed an informal survey of my former patients, I found myself wondering how I could justify all my years of training and the investment of 55 years of intensive work when I had treated only 231 people. Then I remembered the students, the clients, the patients, the children, now the grandchildren-all whose lives have profited from the therapy the patients had received. I was comforted by Theresa's words, "Good therapy keeps on giving."