Patients who stay

For Freud, the ideal goal of a successful analysis is to resolve unconscious conflicts, gain insight, strengthen the ego, modify pathological defenses, contain irrational superego demands, and work through transferential distortions. Termination is based on a satisfactory approximation of these goals. However, there are certain patients who are unable to achieve these therapeutic goals. They include those with severe personality, psychotic, mood, eating, chronic posttraumatic stress, and gender identity disorders. For many of them, perseverance of symptoms, impaired functioning, and maintenance medication preclude termination, necessitating ongoing or intermittent treatment. On the other hand, there are those patients who make significant therapeutic progress, but remain in treatment indefinitely. Many of them approximate the criteria for termination, but maintain a therapeutic relationship for a variety of reasons. These include: unresolved transference-countertransference issues, avoidance of separation, chronically stressful situations (work, interpersonal, illness), lack of an external support system, and gratification from ongoing intrapsychic processing. Although nontermination may be associated with pathological dynamics for both patient and therapist, it may also be connected to non-neurotic, realistic factors. In some cases, indefinite treatment may be preferable. A clinical illustration is provided.