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Regular Article |
Received April 16, 1999; revised September 23, 1999; accepted September 30, 1999. From the Department of Psychiatry, Massachusetts General Hospital, WACC 805, 15 Parkman Street, Boston, MA 02114. Send correspondence to Dr. Shapiro at the above address.
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Abstract |
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 Top Abstract IntroductionREVIEW OF THE LITERATURETHERAPISTS' RESISTANCE TO THE...USES OF DOUBLE SESSIONSINDICATIONS FOR CONSIDERING...CONTRAINDICATIONSSUMMARYReferences |
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Key Words: Double Sessions • Psychotherapy, Psychoanalytic
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Introduction |
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TopAbstractIntroductionREVIEW OF THE LITERATURETHERAPISTS' RESISTANCE TO THE...USES OF DOUBLE SESSIONSINDICATIONS FOR CONSIDERING...CONTRAINDICATIONSSUMMARYReferences |
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In this paper I will focus on the double session as a particular example of expanding the time frame of individual psychotherapy. As part of this discussion, I will examine resistances to this temporal modification and potential transference and countertransference pitfalls, as well as reasons for maintaining traditional time parameters. I will also consider which types of patients may most likely benefit from double sessions.
Discussion regarding the expansion of the time frame in treatment is important because clinicians lock into a certain time schema that may be uncreative and not optimally responsive to a patient's problems. The evolution of our thinking about theory and technique since Sigmund Freud is profound; yet one hundred years later we may stop and reflect that with but a few exceptions,8,9 the concept of the "50-minute hour" has remained surprisingly unchanged, even sacrosanct. (Note: The change from 50- to 45-minute "hours" is not considered a theoretical change, but rather a practical decision on the part of the therapist.)
In case conferences where discussions of a patient's progress in treatment are examined, many variables such as frequency of sessions, technical considerations regarding timing of interpretations, or countertransference dilemmas may arise, but the length of sessions is almost never questioned. If the treatment is stalled, clinicians do not stop to wonder if the treatment rituals themselves are being used in a defensive manner to prohibit the resolution of inner conflicts.10
It should be noted that the following discussion of double sessions may be more applicable to private practice situations where patients pay for treatment themselves. Medical insurance rarely, if ever, reimburses for double sessions. Additionally, clinicians in health maintenance organizations and mental health agencies are often so pressed for time that their schedules seldom permit them to see patients for weekly 50-minute sessions, let alone double sessions. Obviously, if double sessions are employed in these other situations and settings, additional meanings and dilemmas that are outside the scope of the present article should be considered.
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REVIEW OF THE LITERATURE |
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TopAbstractIntroductionREVIEW OF THE LITERATURETHERAPISTS' RESISTANCE TO THE...USES OF DOUBLE SESSIONSINDICATIONS FOR CONSIDERING...CONTRAINDICATIONSSUMMARYReferences |
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a planned strategy and part of the basic contract between patient and analyst....By this I mean that the analyst informs the prospective patient in the initial interview that one of the conditions of the analysis will be scheduling of double sessions during the ongoing treatment, depending on the need for the therapeutic work to proceed at an optimal level. Either patient or analyst may initiate such sessions. The analyst must reassure the patient that scheduling of such sessions will not depend on how well the patient is doing but, instead, on the necessity for delving more deeply into certain issues. (p. 70)
The five goals that he describes are 1) acceleration of the removal of certain defenses, such as blocking, denial, obsessive trends, phobias, intellectualization, and isolation; 2) breaking down of ritualistic behavior patterns; 3) providing an opportunity to work through conflicts in the dependence-separation dimension; 4) providing a positive holistic experience in an interpersonal situation; and 5) providing adequate time within one session to make periodic assessments of the status of the analysis.
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THERAPISTS' RESISTANCE TO THE USE OF DOUBLE SESSIONS |
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TopAbstractIntroductionREVIEW OF THE LITERATURETHERAPISTS' RESISTANCE TO THE...USES OF DOUBLE SESSIONSINDICATIONS FOR CONSIDERING...CONTRAINDICATIONSSUMMARYReferences |
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Two bases of possible resistance to the use of the double session are historical and technical concerns. In a historical context, extension of the time frame of therapy might recall the excesses of the encounter movement in the 1960s, with its disregard for the importance of time boundaries and its indiscriminate promotion of emotional expression. Unfortunately, that movement dismantled defenses, promoted harmful regression, and produced casualties. In reaction, many have wanted to avoid any suggestion of an alliance with a movement that disregarded boundaries. In the process, however, they may have thrown out the baby with the bathwater.
From a technical perspective, many therapists adhere to the theory that extending the time frame is merely a collusion toward action. In their opinion, the extension of the time boundary signifies a failure to contain some complex thoughts and feelings within the 50 minutes. Although I believe that this perspective is important in helping the therapist make the decision about the use of double sessions, I do not believe that double sessions are necessarily collusions on the part of the therapist-patient dyad. I will address this further when discussing contraindications to the use of double sessions.
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USES OF DOUBLE SESSIONS |
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TopAbstractIntroductionREVIEW OF THE LITERATURETHERAPISTS' RESISTANCE TO THE...USES OF DOUBLE SESSIONSINDICATIONS FOR CONSIDERING...CONTRAINDICATIONSSUMMARYReferences |
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Case Report: Intermittent double sessions. A patient in therapy for several years moved two hours away. Her job and irregular access to a car prevented her from regular face-to-face sessions. The therapy continued through weekly phone sessions (another alteration in the frame). Approximately once a month she was able to come to see me in person. We discussed and agreed upon double sessions when our schedules would permit. These in-person double sessions provided a kind of refueling that in-person single sessions did not permit in that 18-month period. In the single sessions, she barely had time to become comfortable again in my physical presence and reengage in the transference before departing. Double sessions did not extinguish her felt deprivation of me in that 1½- to 2-year period, but the extended sessions did provide sufficient comfort for a focused exploration of two important areas: her feelings of deprivation and some of the reasons she had moved so far away from me in the middle of our work.
Case Report: Continuous double sessions. C. was a 39-year-old married man who worked as a business consultant. He and his wife were in the midst of a marital crisis precipitated by his wife's extramarital affair. C. was able to use the therapy to contain feelings that affected his capacity to concentrate on his work and to parent his three young children. The crisis resolved in the succeeding months. It was not until that time that C. was able to voice some additional concerns: a sense of not fully being in his life, a kind of vague dissatisfaction, and a passive feeling of waiting for something to happen. C. felt that he was not an agent of his own life. It was clear to me that this was a man with a great deal of ego strength who, despite his inhibitions, had many relatively healthy long-term relationships and was reasonably happy in his work.C. was the second oldest of four children in a family with a remarkable absence of overt conflict. C. described a pattern of changing his beliefs to conform with those of his mother and of adapting his experience to allay his mother's anxieties. When C. was 10 years old, he fell from a playground swing and had to get stitches. All he remembers is his mother feeling so awful that she had "let this happen." C. appears to have repressed any feeling he had about this incident and only remembers trying to reassure his mother that he was all right.
Therapy sessions were painful for C. He was particularly uncomfortable with the beginning of the hour and would implore me to begin it for him. He simply could not allow himself the freedom to think and feel in my presence without first knowing what I thought and felt. When I would try to have the two of us examine what was so painful for him, he could not do it. When I wondered aloud whether he was attempting to find out if it would damage me (his mother) if he initiated any behavior and did not accommodate to my (his mother's) needs and wishes, this fell on deaf ears.
Even after the session finally got off the ground, it often faltered. He found himself utterly blank and unable to proceed. C.'s inhibition bothered him tremendously, but he could not imagine how it was ever going to change. The idea of terminating occurred to him frequently, especially because his pain was now more chronic than acute.
In one particularly memorable session, C. talked about his feeling that he would be able to take risks only when he saw me taking risks. Later that session, I had one of those spontaneous ideas that I would normally sit on and mull over by myself or with a colleague. I imagined that in a double session we could work much more productively. After a speedy evaluation of this idea in terms of any likely countertransference pitfalls, and also because it felt intuitively right I made this suggestion on the spot to my patient. He eagerly accepted it.
In his associations the following week to the idea of double sessions, but before initiating any, C. for the first time told me about the nights when he was away on business. Alone in the hotel room, and immobile on the hotel bed, he was unable to initiate any activity, except perhaps watching television "like a blob." The revelation of this important information about himself and the attendant shame he was suddenly willing to endure suggested to me that the idea of double sessions was a good one. After some additional exploration—both in the hour and in my own peer supervision—we decided to embark on this experiment.
The results were quite startling. At the first double session he came in with a dream about his wife's and his daughter's aggressiveness. This dream pointed us in the direction of paying closer attention to his fear of unleashing his own aggression. Although initiating the sessions continued to be painful for him, he had more time in the double sessions to begin to have access to his aggression.
In these double sessions, C. had the repeated experience of his head "swimming." This sensation was something we had discussed before, but two aspects were different: the head-swimming occurred more often, and, most important, we had time within the session to unravel the underlying feelings. We discovered anxiety-provoking feelings about asserting himself. We analyzed what interfered with his valuing his own experience rather than simply deferring to mine. C. began taking some risks with me, telling me when things that I said or did were helpful and when they weren't.
Interestingly, C.'s friendships began to deepen, a consequence of his ability to tolerate separateness and difference. These increased capacities also brought him into more regular conflict with his mother. He began to feel intensely frustrated with his mother's inability to see what C. himself had been working on so diligently in his treatment On the other hand, his marriage moved in the direction of becoming more equitable, as he was less willing to allow his wife to hold all of the self-interest in the relationship.
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INDICATIONS FOR CONSIDERING DOUBLE SESSIONS |
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TopAbstractIntroductionREVIEW OF THE LITERATURETHERAPISTS' RESISTANCE TO THE...USES OF DOUBLE SESSIONSINDICATIONS FOR CONSIDERING...CONTRAINDICATIONSSUMMARYReferences |
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Need for the lifting of defenses. C. had already demonstrated to me his capacity to contain strong affect. Even under the biggest strain of his adult life, his ego had been able to mediate the pressure of enormous impulses sparked by the rage at his wife. In fact, because of the rigidity of his character defenses, he had spent most of his life—other than the time of the marital crisis—frustrated that he was not more aware of what he was feeling.
The ability of the ego to sublimate affect over time is fragile. When the boundaries of the treatment are widened in time, this intensity challenges the ego's capacity to stay in secondary process. For those patients, like C., who experience a great deal of inhibition of affect, the increased time with the therapist increases the likelihood that the defenses will lift, if temporarily. In the case of rigid character defenses, an overnight break, such as occurs when one increases the frequency rather than the length of sessions, may not be as helpful in uncovering the painful affect obscured by the patient's defenses.
Severe separation anxiety. The panic around separation is so intense for some patients that they cannot relax and focus on anything else. Extending the length of the session may put some of these patients at ease by temporarily diminishing the specter of separation.
Countertransference resistance. In retrospect, the case of C. exemplifies some of the more compelling reasons that the therapist may have for converting to double sessions. Attending to the intersubjective model, I became aware of feeling like a failure when the patient's difficulty in initiating the hour appeared so intractable, even in the face of multiple interpretations. Moving to double sessions did not immediately remove the patient's difficulty in starting the hour, but it eased both the therapist's and the patient's anxieties. We both were able to know that there would still be plenty of time to accomplish something in the session, even if it began each time with his paralysis. Not surprisingly, that paralysis became less evident as the double sessions continued (though it never disappeared altogether), and we were better able to understand it together.
Performance anxiety and self-consciousness. The double session relieves the therapist (as well as the patient) of the pressure that attends the 50-minute hour. How many of us have had the experience that if only we had a little more time, we might have been able to go someplace important with the patient? Granted, a consciousness of time does not disappear with a 100-minute session; but liberating oneself of the constraints of the 50-minute hour can yield a sense of new opportunities.
Potential for an increased sense of connection to the patient. There is a sense of adventure that comes with breaking the mold of the 50-minute hour. Both parties in the intersubjective matrix are aware that they are doing something different together, taking a risk. This experience of "breaking the rules" likely makes a patient feel special, as noted above; but it may also make the therapist feel special, by virtue of the patient's willingness to take the risk with the therapist, and also by virtue of this change in the frame being an unconventional strategy. Although there are many potential pitfalls in making this change in the frame, there is certainly the strong possibility that if it is done thoughtfully and under the right circumstances, the treatment will be enlivened. Old therapeutic patterns or habits that did not serve the work may be left behind. Finally, it is not the creation of specialness that could come back as resistance to haunt the treatment; it is the failure to analyze the meanings of lengthening the sessions and the decision to do so that could result in resistance.
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CONTRAINDICATIONS |
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TopAbstractIntroductionREVIEW OF THE LITERATURETHERAPISTS' RESISTANCE TO THE...USES OF DOUBLE SESSIONSINDICATIONS FOR CONSIDERING...CONTRAINDICATIONSSUMMARYReferences |
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The therapist should also consider that the patient may be "supervising" him or her if there is a great deal of acting out around the new 100-minute sessions. For example, if the patient arrives very late for the sessions, it is possible that she or he is trying to tell the therapist that the added time is too frightening, making the patient feel dangerously regressed.
Case Example: Contraindications to the use of double sessions. M. was a 32-year-old male musician who had a history of defending against his wish for merger by an intolerance for intimate relationships and repeated trouble holding a job. He did not use the 50 minutes, often coming late or even not showing up at all. He experienced great difficulty managing the separation with the therapist, often lingering when the therapist had told him the session was over. Nonetheless, his wish for merger remained deeply unconscious. After a hiatus from treatment, M. returned, requesting extended sessions. It seemed to the therapist that M. was looking for a magical solution to the distress that emerged at the end of each session. The therapist was tempted to gratify this longing but was concerned, with good cause, that it would cause M. to regress more. The therapist anticipated that the extension of the session would only leave M. even more profoundly disappointed by the disruption of the fantasied merger with the therapist. An alternative possibility was that granting double sessions in this instance would constitute an enactment through which an analysis of the patient's separation anxiety could be avoided.
When the therapist's countertransference has not been adequately examined. The potential countertransference motivations are myriad, and they deserve thoughtful and thorough examination. For me, countertransference motivations were fruitfully explored during peer supervision sessions prior to initiating the double sessions, and the impact of altering the frame on both patient and therapist was explored for several consecutive weeks after the double sessions first occurred. Such supervision or consultation allows a therapist the opportunity to reflect on the relationship to the patient in the presence of a more objective party, thus avoiding some potential countertransference pitfalls. The presence of countertransference motivation is not itself sufficient to rule out the possibility of double sessions, but if it constitutes the primary force behind one's decision, it is safe to say that the change should not be acted upon at the present time. Below is a partial list of the countertransference responses that would contraindicate the use of double sessions:
The thorny issue of enactments. Interestingly, a few colleagues have offered me some clinical vignettes of patients who had asked them for double sessions and whom they had denied the request: all of the patients had significant narcissistic problems. It appears that with these patients, the desire to be specially treated was paramount, and the way these particular patients believed they could be confirmed as special was to get the therapist to break the frame by extending the time boundary. I agree that in these instances, offering double sessions would amount to participation in a grandiose containment unless both parties are aware of and able to explore all aspects of that need.
Casement11 describes a similar instance where an adherence to the initial framework is indicated. He reports working with a woman who begins to remember important new details of a surgery at an early age. During the surgery her mother's hand slipped out of her grip as her mother fainted.
She said she was unable to lie down on the couch again unless she knew she could if necessary hold my hand, in order to get through this reliving of the operation experience. Would I allow this or would I refuse? If I refused she wasn't sure she could continue with her analysis. (p. 131)
There are two points of relevance to the present discussion of contraindications to the use of double sessions. The first is the delusional quality of her transference to Casement, with a blurring of the boundary between the patient's early experience of her mother and her current experience of her analyst. Although, as Casement suggests, the analyst/therapist need not rush to cling to a rigid adherence to the analytic rules, a thoughtful consideration with the patient of his or her wishes and the pros and cons of their being granted should likely lead to a maintenance of the initial frame. The delusional or quasi-delusional patient is likely to appreciate (consciously, if not unconsciously) what Casement calls "analytic holding under pressure".11
The second aspect of Casement's clinical sequence relevant to this discussion is the patient's urgent demand on the analyst to diverge from the therapeutic frame. The feeling this evokes in the analyst, of being pressed against the wall with no way out other than yielding to the patient's demands, is usually a clue that an enactment is taking place. This enactment will have to be experienced and understood for the work to succeed. Enactments are not necessarily to be avoided. In fact, their power is often such that they are not fully realized until they are fully experienced by both therapist and patient. The work of therapy is to understand the meaning of the enactment, and this, by definition, occurs after the fact of the enactment. Thus, it is always possible that the introduction of double sessions may constitute an enactment by the therapist and patient. It is the therapist's job to analyze his or her own participation in such an enactment and to galvanize the patient's capacity to reflect on the effects of altering the frame. When the therapist fails to use the occurrence of an enactment with deliberation and care, then it becomes a pathological enactment, which may subvert the therapeutic endeavor.
I would note here that most of the literature advises against any alteration of the frame with character-disordered patients, especially if the frame is unpredictably changed. This advice is well taken. What is different about what I am suggesting is that it is a planned modification of the frame for the purposes of furthering the work. Any such change must be examined thoughtfully, both before and after making the change. If there is not room in the treatment for such thoughtful examination, it is best to do nothing. In my work with C., we agreed only to try double sessions; if neither one of us felt them to be useful, we would have discussed that thoroughly and, most likely, reverted to single sessions. Ultimately, it is predictability and thoughtfulness that make for a good frame.
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SUMMARY |
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TopAbstractIntroductionREVIEW OF THE LITERATURETHERAPISTS' RESISTANCE TO THE...USES OF DOUBLE SESSIONSINDICATIONS FOR CONSIDERING...CONTRAINDICATIONSSUMMARYReferences |
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This treatment was successful—as were others where double sessions were initially used more because of scheduling convenience than a well thought-out alteration of the frame. Nonetheless, this method provided surprising and invaluable results. More thought might fruitfully be given to other types of patients who could benefit from intermittent or regularly scheduled double sessions. Case examples support the notion that there are several indications for using double sessions. I argue that the inhibited patient is a particularly good candidate for extended sessions. The alliance between patient and therapist needs to be well established before any alteration is made in the time frame. When the transference is intensifying and the patient is able to handle this intensification of feeling, double sessions can move the work along at a more rapid pace. Under the right circumstances, double sessions can resolve impasses, reduce countertransference resistance, and lessen performance anxiety and self-consciousness on the part of both the therapist and the patient, while furthering a sense of connection between them. Contraindications for using double sessions include the presence of labile affect, high levels of aggression, a psychotic transference, and an inability on the patient's part to use symbolic imagery. Additionally, the therapist's countertransference must be adequately examined before, during, and after the use of double sessions. Caution is indicated whenever one alters the frame. Nonetheless, in this paper I question the common wisdom that altering the time frame necessarily entails a pathological collusion on the part of therapist and patient that is destined to subvert the treatment. On the contrary, both sustained and intermittent double sessions can often revitalize and shed new light on the therapeutic endeavor.
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Acknowledgments |
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References |
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TopAbstractIntroductionREVIEW OF THE LITERATURETHERAPISTS' RESISTANCE TO THE...USES OF DOUBLE SESSIONSINDICATIONS FOR CONSIDERING...CONTRAINDICATIONSSUMMARYReferences |
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