Two events prompt me to write about therapy endings. In the more abrupt and traumatic of the two, a local psychiatrist died last month in a tragic accident, leaving many patients suddenly without their doctor. The other event, far more commonplace, was the decision of one of my own patients to stop therapy. These events illustrate opposite ends of a continuum, as I hope to describe below.
I discussed typical features of open-ended dynamic psychotherapy in my last post. Timelessness, wide focus, relative freedom from protocol and direction, and promotion of transference all come into play when such a therapy eventually comes to an end. Since this type of therapy has no “built-in” ending, each ending is unique.
In the real world psychotherapy often does not feel timeless. External events like a job change, a move, or a change in insurance coverage may end therapy prematurely. Therapists retire or move their practices far away. These endings are not chosen by the patient. Any unchosen ending can feel like a loss, or even an abandonment. These events do come with advance warning, however, and can be discussed ahead of time. The emotional repercussions can be contained, reviewed, and comforted in what is termed the “termination phase” of treatment: the sessions between acknowledging that therapy is ending, and the actual last session.
However, sometimes there is no warning, for example when a psychiatrist or other therapist suddenly dies. Such events are emotionally traumatic. Patients feel the acute loss of a relationship they came to rely upon, and often there is a rocky transition to another doctor, facilitated by the colleagues, professional partners, or secretarial staff (if any) of the deceased therapist. This mini-community steps in, without advance preparation nor much knowledge of the patients affected, to make the best of a very difficult situation. I consider this one extreme of the continuum of therapy endings, the pole where it is not the patient’s idea or wish at all.
In my view, the ideal way to end psychotherapy is not the other pole of the continuum either, where the decision is entirely the patient’s. This was the case with my patient who recently decided to end treatment after making much progress over the past couple of years. Yet, in my opinion she had a long way to go. Obviously, it is the patient’s choice to spend time and money on therapy; I can’t keep anyone in therapy if they choose otherwise. And sometimes a patient’s unilateral choice to stop reflects progress: a newfound ability to assert oneself, or to make definitive life decisions. Nonetheless, it isn’t an ideal outcome because it isn’t collaborative.
Psychodynamic therapy relies, first and foremost, on a “working alliance” between patient and therapist. If the patient feels he or she must make a unilateral decision to end therapy, this alliance has been damaged somehow, or was never strong in the first place. In a therapy with relatively little protocol or explicit direction, and where transference is promoted as a therapeutic tool, the one bedrock that both parties can rely upon is their mutual aim to help the patient. Ideally, then, a time comes when the patient feels ready to stop, and the therapist feels likewise. This is the midpoint on the continuum of therapy endings, where it is neither the therapist’s abandonment of the patient, nor the patient’s defiant separation from the therapist. It is a shared understanding that the work is ending, the culmination of a shared exploration in therapy.
Yes, this does happen in real life, although not as often as anyone would hope. Yet even when it’s the patient who chooses to end therapy, and the two parties “agree to disagree,” it is still very beneficial to plan ahead and allow for a termination phase — the length being roughly proportional to the length of the therapy, from a couple of sessions to several weeks — to discuss the ending. Unexpected feelings can arise when time is short. By exploring these feelings, therapy can be therapeutic until the very end.
Hi Dr. Reinbord….i left a comment on “Parasuicide”….
Sadly, i lost a very good Psychiatrist to death…he had cancer, but told none of his patients…
If therapists would simply say this at the outset of therapy, there would be very few cut-and-run or don’t-show-up-for-last-session patients, and they would know why their patients are terminating.
“Before we go any further, I want to talk to you about the end of therapy. If at any time you have a strong desire to end our work, please tell me in advance. It’s important to talk about the end of work. It’s so important, in fact, that I won’t charge you for any final session.”
Believe me. If it’s the therapist’s dime? I’m happy to come in and tell him or her why I’m stopping, in full detail. If I’m paying for the privilege of explaining myself? I don’t necessarily think the same.
TK, thanks for writing. I like the idea of raising the issue in advance. However, luring patients with a free final session to explain themselves misses the point. Termination session(s) are in the patient’s best interest, not mine. If a patient is willing to stick with the process long enough to examine thoughts and feelings about stopping — a good idea in my opinion — he or she should pay for my time and expertise as usual. If a patient chooses to stop without such an examination, I consider it a pity for them, not me. No one owes me an explanation simply to satisfy my curiosity, free session or not.
Likewise, I do not owe any patient a “free shot” at me. “Happily” dumping complaints or dissatisfactions “in full detail” serves neither of us, especially when the patient has already decided there’s no hope of us repairing the rift. Inviting this would be masochistic of me even if I charged for the session, and doubly so if I didn’t.
Thanks for the quick response!
In making my suggestion, I was struck by what Dr. Ryan Howes had to say on his PsychologyToday blog eighteen months ago or so, where he wrote a four part series on termination.
http://www.psychologytoday.com/blog/in-therapy/200810/terminating-therapy-part-iii-the-not-quite-ideal-termination
He had this to say about abrupt patient-initiated endings:
“Cut and Run: Maybe it’s via voicemail or LMB [Last Minute Bomb]. Maybe the client just doesn’t show, doesn’t call and is never heard from again. For these endings, we never learn why they wanted to stop, can’t rectify or explain any problems within the therapy and are unable to say goodbye. As a therapist, these are the endings that sting.”
It seems like Howes is saying here that a final session is not just in the patient’s best interest, but in his as well. Do you think that’s e ever the case? Would it make one a better therapist to have a clearer sense of why the therapy is coming to an end? Or does it not matter, and the exercise in masochism is not worth the limited self-knowledge that might ensue?
Interesting questions, with no easy answers.
wow. i completely agree with TK and Dr. Howes, and it would seem that any professional who thinks that he is so good that he can’t benefit from a little constructive criticism might be able to do with some counseling himself. most professionals are thrilled to be able to get feedback from their clients, even when it’s not so good– it generally helps them to become better at what they do. your response to TK’s original comment only confirms in my mind how right i was in terminating my own relationship with my therapist.
Dr. Howes’ article (linked in TK’s comment above) is terrific. It’s well stated, and I agree with every word of it. However, I also agree that these are interesting questions, with no easy answers. In the regular course of doing therapy I get “constructive criticism” all the time; I certainly value it and benefit by it. We were talking about something more specific: Asking a patient, who has already decided to stop therapy, to come back for a final session ostensibly for my benefit.
Whether this request is to satisfy my curiosity, or even to make me a better therapist in the future, it is still misguided in my view. The therapy is for the patient’s benefit. I do my learning on my own time, or as a side-effect of trying to help my patient. It is not a patient’s job or obligation to teach me anything. It may be a subtle point, but expecting education or “feedback” from a patient is an unwarranted gratification on the part of the therapist, similar to a therapist expecting to be entertained by a patient.
In my comment above, I also took the opportunity to note that “constructive criticism” often has an angry edge. If a patient and I are in a therapeutic relationship, working together, it’s part of my job — and often quite valuable — to hear about how I’ve let my patient down, and to hear the anger that often comes with it. As Dr. Howes notes, this still leaves a lot to explore: The lapse could certainly be mine, but it could also be resistance on the part of the patient. In the middle of a functioning therapy, this is a very important discussion to have. However, when a therapy is effectively over, being a willing target serves no therapeutic purpose. I’m not a punching bag, even if it makes my ex-patient feel better in the moment.
actually, i didn’t think the question was whether to ask a patient back ostensibly for the therapist’s benefit. i thought the question was whether therapists should consider not charging the patient for that last visit, to encourage a patient who might otherwise be unwilling to come back to reconsider. but maybe i was focusing on a different part of the question than you were.
anyway, focusing on that part of the question, if the patient already believes that the therapist has fallen down on the job, why would the patient be willing to pay for yet another visit of substandard care?
the patient already knows that he will have to contribute his valuable time and effort to the final session despite his disappointment in the therapy and the lost time and money he has already contributed to the failed effort. eliminating the fee might allow him to come to the session with a more positive attitude toward the therapist and the therapy, rather than feeling that the therapist will be taking advantage of him one last time. as a result, he might actually be able to get something positive out of that last session.
and, however unsubtle the point, the therapist might be able to get some useful information from the session, because, as you note, the lapse in the therapy could certainly have been his. (the next time i have an unpleasant experience with my dentist/lawyer/dermatologist/investment advisor and i pick up one of his “how are we doing?” cards, i will hand it back after writing across it “asks for unwarranted gratification” and then explain kindly that i don’t want to hurt his feelings by making him feel like a punching bag.)
Good lord, look what I’ve started.
I have a slightly different take on this from Anonymous of 3/2/10, though his/her points are both well made and heartfelt. I am still willing to look at it from the patient’s point of view, and take at face value Dr. Reidbord’s assertion (it’s his blog, after all!) that he would still want that final session to be for the patient’s benefit, rather than in service of him.
I think that’s a point well made and well-taken too, though I do think that in terms of the overall patient-therapist relationship — one never knows whether the patient will come back in the future, after all — the therapist having a greater understanding the terms of the rupture can’t help but be of benefit to both parties in the room. Especially the patient’s, actually.
But let’s just look solely at the possible benefit to the patient of the therapist offering the final session at no charge. (And let’s assume that in real terms, the therapist has seen the patient no less than 10 times, at two hundred dollars per hour. Let’s say that’s two thousand dollars. So the therapist is essentially giving up, for this eleventh session, less than 10% of his overall fee. For a longer term therapy — thirty or forty sessions — the percentage is far less.)
Here are six specific patient benefits, over and above any benefit that the therapist might gain from this final session.
1. The therapist, via this act of generosity, might well be countering the patient’s pathogenic beliefs, and thus help the patient get to what the patient really wants to do, which is to stay in therapy. (Yes, the appeal to Joe Weiss’ control-mastery theory is deliberate!)
2. The therapist is modeling, entirely for the patient’s benefit, how to handle with maturity and generosity ruptures in one’s life. By his own actions, he is showing the unacceptability of cut-and-run, and a willingness to absorb some pain in the service of a greater good.
3. The therapist is eliminating the economics of the relationship for one specific session, which could be a major stumbling block for the patient, and might provide for a remarkable exchange in the room about something that that the patient had not previously considered. Yes, it’s a shift of the frame, but maybe it’s warranted.
4. The therapist models the notion of going the extra mile for the patient. I’m tempted to reference here one of my all-time favorite films, REIGN OVER ME, about the importance of going the extra, extra mile for people in pain. (Incidentally, this film was not universally critically acclaimed!)
5. The therapist is providing the patient one final opportunity, unimpeded by economics, to share his or her true feelings about the reason that therapy is coming to an end. It might be something deep and buried in the patient, but the therapist going the extra mile may give the patient the impetus to go the extra mile. Yes, this reason could be transferential, but it could also be here-and-now. Again, this could salvage the therapy at the last minute.
6. The therapist is underscoring how much he cares. Really cares.
It’s kind of like — yes, I’m influenced by what I watched at the Olympics this weekend — a team down by a goal pulling their goalie with a minute left to play. Yes, it could result in losing anyway. It could result in losing by two goals, instead of just one — the moral equivalent of the punching bag But it can also result in a last-second miracle for the patient. And who could say that they are opposed to last-second miracles?
(BTW, kudos to the Canadians for coming back in overtime!)
Thank you to Dr. Reidbord for providing this forum. BIG thank you.
I’m tempted to turn this into a post, but I’ll leave it as commentary for now. Anon, your most recent comment assumes the therapist is offering “substandard care” and is “taking advantage of” the patient. If this is really the case, the patient should not return at all; even a free session would be no bargain.
A patient who believes the therapist has fallen down on the job might pay for additional sessions anyway if he or she chooses to examine that feeling instead of immediately acting on it by quitting. One basic aim of dynamic psychotherapy is to encourage reflection over reflexive emotional reaction. Rifts in the working alliance are inevitable. After all, both parties are fallible humans and will at times miscommunicate, misperceive, get distracted, and so on. Ironically, these are often the most fruitful moments in dynamic therapy, as they can shed light on a patient’s dissatisfactions in other areas of life. (Even when the lapse really is the therapist’s, in which case he or she should apologize, allowing the therapy to proceed.) As I said earlier, it’s a pity if the patient decides to give up just then… unless of course the therapist is truly inept or dangerous.
Dentists, lawyers, dermatologists, and investment advisors are not psychotherapists. You will never see a “How are we doing?” card in the office of a dynamic therapist because the therapy itself is the place to ask, and answer, that question. These other professions have far fewer restrictions on the nature of relationships with patients/clients. You can play golf with your dentist, have lunch with your lawyer, and go camping with your investment advisor. Therapists are just therapists to our patients. This avoidance of dual roles and extraneous gratification is part of the “frame” that allows therapy to work.
Turning now to TK, I certainly won’t argue that no good could possibly come of such a meeting. You listed several possible patient benefits, all fairly plausible. But here are some possible patient detriments, over and above any drawbacks for the therapist:
1. The patient learns that by complaining enough, he or she gets things for free.
2. The patient now feels the therapist, and by extension other people in caretaking roles, are clingy and desperate.
3. The patient learns that psychotherapy, and a professional’s time and training, don’t really have monetary value.
4. Since the session is free, it isn’t really therapy, and therefore the patient need not reflect on his or her own contribution to the rift. Externalization (blaming others) is encouraged.
5. The therapist loses the chance to show that caring, really caring, sometimes means “tough love,” i.e., not always giving a person what they are asking for. The patient falsely equates caring with sycophancy.
6. The therapist has given up on therapy, why shouldn’t the patient?
I’m not saying my list is more plausible than yours. The point is, we don’t know. In the midst of therapy, these complex possibilities can be explored and reviewed. In a debriefing, they can’t be. Psychotherapists can’t hope for last-second miracles the way a hockey team can. Throwing caution to the wind is heroic on the Olympic rink, and malpractice (or foolish at least) in a professional office.
Either of you, feel free to comment further. But I think I’ll do a more formal post if I write more on this topic.
pay a therapist who a patient believes has fallen down on the job for additional sessions when there are so many other qualified therapists out there to choose from? would you pay any other professional who you thought had failed you to see them again for the same service? this is getting way too through-the-looking-glass…
What a thoughtful exchange this has been. Dr. Reidbord, it would be fabulous if you decided to post on this subject.
I do think, however, that in your response to me, you set up something of a straw man and then proceeded to efficiently and effectively flatten him, in your listing of patient detriments from a final no-charge session where the patient who might otherwise cut-and-run has a chance to discuss what’s going on internally, and where the psychotherapist would still get to do therapy, if only with a patient whose mindset coming in could be strongly negative.
You wrote, eloquently…
1. The patient learns that by complaining enough, he or she gets things for free.
2. The patient now feels the therapist, and by extension other people in caretaking roles, are clingy and desperate.
3. The patient learns that psychotherapy, and a professional’s time and training, don’t really have monetary value.
4. Since the session is free, it isn’t really therapy, and therefore the patient need not reflect on his or her own contribution to the rift. Externalization (blaming others) is encouraged.
5. The therapist loses the chance to show that caring, really caring, sometimes means “tough love,” i.e., not always giving a person what they are asking for. The patient falsely equates caring with sycophancy.
6. The therapist has given up on therapy, why shouldn’t the patient?
If the entire therapy had been at no charge, then (1),(2), (3), and (4) might have some greater validity. But this session is just one amongst many, presumably many where the therapy had been nicely renumerated. To me, it feels more like a section of a larger canvas, as opposed to the one thing that dominates all others. One gratis session, when the therapy has been ten, twenty, forty, eighty, or many more, all renumerated? It doesn’t feel to me like complaining is getting “things” for free, or that the therapist is clingy or desperate, or that therapy is of no value.
Nor does it make sense to me to think that if one session is gratis, it isn’t really therapy. Surely many mental health practitioners out there in the public sector, with poorer population cohorts, would strongly disagree with this assessment.
As for your positing that the therapist loses the chance to show some “tough love,” there’s some validity to this point, though I would never draw the equivalence of someone’s going the extra mile, or being generous, as sycophantic. However, everyone isn’t me.
The last point, that a gratis evaluative and perhaps restorative session is rendered giving-up by virtue of a fee waiver decision by the therapist himself or herself? Again, I don’t see it that way. There’s no true giving up on the therapy until the client stops coming. We’ve all seen the cases where clients will stop…and you’ll get a phone call two months, two years, or five years later. It’s one of the reasons that dual relationships, and even accepting referrals, from ex-patients is so dicey. Once a patient, always a patient. Even if the departure is with the moral equivalent of an F-bomb!
You do, though, make one outstanding point. As you wrote so well, “I’m not saying my list is more plausible than yours. The point is, we don’t know.”
The empiricist in me would say, it’s time for some empirical research! Not that I’m going to run it, but I’d love to see the results of a controlled study which compared the offer of a gratis final session to no offer, both from the points of view of the therapists and the points of view of the patients. I think I could guess the outcome, but guesswork is no substitute for science.
No matter what, there’s got to be a better way to handle the arena of termination. According to at least one empirical study, fully sixty percent of therapy patients think they either terminated too early or too late, and fully eighty-four percent say they were the ones to initiate the termination process.
http://www.sciencedaily.com/releases/2008/01/080109094351.htm
Those are not good numbers. We can do better.
Again, thank you for this forum, and for discussing these issues so forthrightly. (I’m not one of those people who insists on agreement as a forerunner of respect!)
What happens when you get “kicked out”?
I’m not sure what you’re asking, or even what “kicked out” means exactly. There are many reasons why your therapist may unilaterally end your therapy. All can potentially feel like being “kicked out.” Some reasons, like retirement, are not directed at you specifically, and can be discussed ahead of time. Others may be more personal. A therapist may feel you cannot benefit by the type of therapy offered, and may refer you to a different type of treatment.
Sometimes therapists end a therapy in reaction to unacceptable behavior. What counts as unacceptable varies from therapist to therapist. At one extreme are serious physical threats to the therapist or his/her family. For example, most therapists will refuse to see anyone who brings a weapon to the office. At the other extreme are behaviors that are self-harmful, for example active alcoholism or drug use. Some therapists pressure clients to stop addictive behaviors by threatening to end therapy if the behaviors continue. This is controversial and may backfire, but it is not uncommon.
If you feel you are getting kicked out of therapy, your therapist at least owes you an explanation (and usually a referral). What happens next is up to you.
@Tracy,
Sometimes you’ll get asked to leave therapy because a therapist’s countertransference to you — it can take the form of intense sexual feelings, intense hatred, intense anything, including love — is so strong and unmanageable that the therapist fears that s/he will cross firm ethical boundaries or be unable to do the work that you’re paying him/her for.
In all cases like this…hell, in all cases in general…you’re entitled to a full and detailed explanation from the psychotherapist, so you can use this information in your next therapy. Also, the therapist must fully comply with the relevant ethical standards about abandonment of clients. It’s worth taking a look at those standards.
One would hope that the referral process to another therapist(s) in the situation where the therapist is terminating you goes beyond merely giving you some names and phone numbers scrawled on a sheet of paper.
Dr. Reinbord and TK,
Thank you so much for answering my v e r y brief. question.
The reasons i was “told” not asked, to leave are many and varied, and hard to explain in this venue, some i still don’t understand. They have mostly to do with my behavior and the termination, while ultimately the Psychiatrist’ decision, was my fault.
In the couple of weeks before, i had chased sevaeal alcoholic drinks with an almost full perscription of Cymbalta. i did not end up inpatient, as the Psychiatrist “went to bat” for me, he knew inpatient does me no good and knows i am not trying to kill myself….just stupid, BPD manipulative acts…
At the next appointment, he demanded total sobriety from me as well as attendence at AA meetings. i was not ready to comply….i tried for a while and several meetings, however, i had been in this exact situation before, with another Psychiatrist, who demanded sobriety from Day One….i “loved” this doctor and was willing to do whatever he asked. (i also decided, during that time, i would never make myself that vulnerable again….)
So, long story…..got “the boot” about 1 1/2 weeks ago…Psychiatrist saying it would be wrong for him to keep me as a patient, it would be against his Professional Values.
Yes, i did this to myself. No referrals. i am alone. And afraid. And sooo sad. i have made one of the biggest mistakes ever….and boy, does it hurt. Stupid, stupid me.
Thanks for listening…..
@Tracy, I don’t know if Dr. Reidbord would agree with this, but I’m going to say it anyway.
From the chair in which I sit? Your psychiatrist demanding 100% sobriety from you as a condition of continuing therapy with him feels an awful lot like a psychotherapist demanding a 100% cessation of binging-and-barfing as a condition of continued treatment for a patient being seen for an eating disorder.
I think — I am being terribly blunt here, forgive me — that he just didn’t want to deal with a patient who could potentially (emphasis on the word potentially!) get drunk and swallow a full prescription bottle of something else that wasn’t Celexa. Potentially, something that could kill that patient.
TK,
Thanks for your comment. Interestingly, it brings up-no pun intended-two things.
i am bulimic and total cessation of bingeing and purging was never a condition of my staying in treatment.
And, just as you wrote, he did say to me, in a comment that sounds very much like your thought….”Tracy, i’ve never had a patient kill themselves.” You are definately right on in your comment! No need to feel like you were too blunt. i appreciate your being candid with me.
A somewhat weird comment he made, especially for a “kick out” session-i had recently gotten my hair cut (and hate it!). He said i looked like Katherine Zeta-Jones in “Chicago”. In-ter-esting……
(And, i wish!).
Thanks again, TK,
tracy
…..Annnnnnnnnnd, any therapist who stays in the business long enough, is going to have at least one patient, probably more than one, kill themselves. Sad as it is. Guess i didn’t get to be his first.
@Tracy, you wrote…
“A somewhat weird comment he made, especially for a “kick out” session-i had recently gotten my hair cut (and hate it!). He said i looked like Katherine Zeta-Jones in “Chicago”. In-ter-esting…”
Not just interesting. Potentially, a little flirty.
And now, back to USA-Algeria at the World Cup.
But before I immerse myself in The Beautiful Game…
That notion of having a psychotherapist requiring a patient to cease a certain behavior as a condition of ongoing treatment, when that behavior is the very thing that might need to be explored, or be the pathological symptom that will need long-term attention, or somesuch? I’ve heard of couples therapists requiring a cessation of contact for e.g. a wife with her affair lover as a condition of treatment of the couple.
I dunno. Makes me shake my head. Who is this serving? The patient or the therapist?
We’re off the “ending therapy” topic and onto something else: demanding behavioral changes as a part of therapy. As with several other topics you’ve raised, this warrants a whole post, not just a short reply. To put it briefly though, imposing changes in behavior first (and hoping feelings will follow) does serve the patient. It is the foundation of behavior therapy, cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT) and similar treatments, as well as the whole “12-step” approach to addictions. While this clashes with the position taken in traditional dynamic therapy, in my opinion it isn’t as suspect as you are implying. Maybe I’ll write more on this later, although I seem to be falling behind…
Dr. Reidbord,
Thank you for letting this conversation take place here on your blog. i really do appreciate it as well as your insights.
In appreciation,
tracy
Thank you for posting this Dr.Reidbord. I am a patient at one of The University of Pennsylvania’s outpatient clinics. I see a resident. I have been going there since 2005. I have been through about 4 therapists, and med management psychiatrists (always different doctors in the same clinic), because they graduate, and move on. I was just looking for information on ending therapy. I am 23, and have been in therapy on and off since I was 8, and I was in an RTC for a year. My current therapist is leaving in a year. I have been working with him for a year, and have made more progress than with any other psychiatrist in my adult life so to speak. His leaving, and my time ending is all I can think about. It’s very upsetting, and difficult to try and get that same connection with a new person.
I have become super anxious, and reluctant to go to appointments. We recently just overcame a “rift” as you put it. If I understand you meaning correctly. For some reason we just weren’t connecting on a certain subject. I do take responsibility in that. I was omitting certain things. Being resistant. Trying to get help with something with out saying what it was. Counterproductive I know, but I do not take full responsibility for it. I kinda felt like my therapist was being resistant himself to fully address the issue, and even a little close mined. Now he understands, and I am over my fear of talking about it, and he is helping me work through it. I know I have far to go. There is still so much about my illnesses I do not understand. Wanting to quit seems like an easy way to avoid further distress when he leaves. I know I will be distressed. Discussing the ending is important. It won’t necessarily make me feel less grief. I do feel like it is a little bit of a grieving process. However, it will make me feel less abandoned.
I also go to a DBT group once a week. All the modules will be completed in September, but I have the option to continue. The group leaders said that it’s not uncommon for people to do it twice. Two group leader just left. It was sad, and I will miss them. They knew how to handle me. Yes I do tend to need handling on occasion. My therapist has told me that I stress him out, and confound him. I admire that. I know I am not always easy to deal with.
I have cut and run with therapists before. That wasn’t easy either. I felt guilty about it. I did feel like I owed them some kind of explanation. Therapists are people too. I know I would be curious and a little concerned if my patient just stopped coming. There have also been situations where I terminated therapy, because I just didn’t like the doctor, and I did say something like we’ll give it a certain amount of sessions, and if I still feel that way you can refer me to someone else. I would definitely suggest this to anyone. It’s much more effective, if you are planning on continuing treatment.
I have a few questions for you on this topic.
What the longest time you have worked with one patient?
Is there a typical average time period for a psychiatrist/patient relationship?
Do you think that taking a break from therapy is a good idea? (Not terminating just a break)
If my current therapist was moving too somewhere close by, and it was feasible to keep seeing him, would that be wise? I know a year from now is a while and thing could change, so that is assuming I would want or need to continue therapy.
Would it be ok to ask to see him for med management if not for therapy?
Are these things considered acceptable, or are they kind of out of bounds?
Incase you are curious as to why I have been in therapy since I was 8. I have Bipolar I, I was diagnosed at 10. I was diagnosed with Borderline Personality Disorder about 4 years ago, but only recently started receiving treatment for it. I am considered recovered from Agoraphobia. I also have panic disorder, what they are calling a multi-phobic personality, and Somniphobia. I know I would be wondering what have you been doing in therapy for fifteen years. Is therapy ever a life long thing? I know it isn’t rally meant to be.
Thank you again for your post. This is a great opportunity to ask those question to a professional willing to talk about them.
~Catrenia
Hi Catrenia, and welcome to the discussion. You raise a number of good questions. Since you have a year to go with your current clinic therapist, you have time to discuss the pros and cons of continuing therapy with him after he leaves the clinic. Here in San Francisco it is not uncommon to continue therapy with a former resident once he or she enters private practice. For the patient, it can be much better than starting with someone new, and frankly it’s good for the new psychiatrist building a practice too. There are several issues to consider, including a possible fee increase, and whether the therapist plans to provide this type of therapy in private practice. Bear in mind that residents learn a wide range of psychiatric approaches, and very few will continue to practice all of them after training.
Your question about taking a break from therapy is a hard one. My first answer is no, it’s usually a resistance that is better talked out and resolved — even if the discussion eventually leads to a decision to quit. But on second thought I can imagine situations where a break might be beneficial. And then if I think about it some more, it seems to me that quitting and taking a break are on a sort of continuum. I’ve had patients stop therapy, and call me back months or years later to restart. Was that a “break” in one long therapy, or a “quit” and then a new therapy? Since we’re the same two people, and hardly starting over, I would call it an extended break.
I don’t know the longest time I have worked with one patient. I would guess about eight years, maybe ten. There is no “typical average” duration: Both psychotherapy and medication management can range from a single session to many years. Sometimes chronic conditions like schizophrenia require lifelong medication management. Is therapy ever a lifelong thing? “Ever” is a tricky word. I’d like to say no: Therapy aims to make itself obsolete. But I can’t guarantee it never happens.
Thanks again for writing.
Thank you for having me in the discussion.
I do understand that he may not continue providing the same type of therapy. I was actually planning on asking him in my next session. All the doctors in the clinic do psychotherapy and med management. This particular clinic doesn’t let you have the same therapist and med management doctor. He may just go on to do med management type thing or work in an institution setting. who knows til I ask him.
My Question about a “break” for me a break would be a set amount of time out of therapy. For example I tell my therapist I want to skip the next 3 sessions, because I am flooded with information, and emotions. I get what you are saying though. In any case It’s best to figure out if it is a resistance issue or not, and be a decision that has been talked about. It also may lead to the person not going back at all.
I know ever is a tricky word I try to avoid using it. Your answer on the duration of therapy was very helpful. I have been told that therapy isn’t meant to be lifelong. I know med management is a permanent part of my life now. That was a difficult thing to accept. Right now after almost 15 years of therapy, and still feeling like I need so much more help seems like it’s gonna be life long.
I think (you may disagree) since I have been in therapy as a child, and am just barely an adult therapy seems new in a sense. The dynamic is different there are new symptoms, and issues that are probably a result of just growing up. Coping as a child/adolescent is different than coping as an adult. So for me therapy has been almost life long. It’s just a part of my life. Is that a bad sign? A sign that therapy has gone on too long?
Thank you for such a quick and helpful response. The answer in regards to the duration of therapy, and how long you have worked with on patient was very helpful.
Thank you again,
~Catrenia