Ending therapy

lillypondTwo 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.

90 comments to Ending therapy

  • tracy

    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…

  • TK

    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.

      • Been There

        I began therapy in my early 20s. It was my idea to try it to address some issues (depression, confidence, etc)…I liked my therapist and she was helpful in some ways. After 6 years, I did a cut and run because I didn’t see an end in sight. The first time I told her I needed a break and was entitled to one, she was gracious about it. In the future when I mentioned needing a break, she would become frustrated and say, “you need this.” While I was trying to space the appointments further apart, she was trying to push them closer together. She even admitted at one session that we were both trying but things didn’t seem to be progressing. Once she mentioned, when I was “ready”, she would let me “fly.” I should have called her on that one and asked, “what has to happen with me so I can graduate therapy?”. I showed up at one session and she was lying half dead on the couch. Her eyes were literally half closed – she was sick but didn’t call ahead of time to reschedule. She conducted the session that way!! I didn’t stay long. While I was leaving another session and I said I needed a break, she said she needed to see me again – she acted concerned so I gave in. The very next session – she treated it like it was a social visit. I thought she’d say, “I want to pick up where we left off” but that didn’t happen. I was paying out of pocket the whole time and I have to admit, I was starting to feel a little “taken.” I mentioned putting an end to something that’s no longer working (meaning therapy) and she said she didn’t want to force me to come. But she would get annoyed and frustrated when I would mention I needed a break! And she seemed to change the subject when “leaving therapy” came up..The last hurrah: I called several days in advance to cancel my appointment because I booked a trip for a few days – a mini vacation. She left a message for me to re-schedule an appointment and I didn’t call back. It dawned on me that once I was “away” I could stay away. She left several more messages and wondered if I wanted to try “group therapy” with her conducting it, of course. I didn’t return her calls. I hate to say this but it feels like a power struggle between therapist/client. When you are in the therapist’s office or “grip” they seem to have the power. When you’re away, on your own – you seem to have the power. She always acted happy and in control when I kept my appointments. I noticed in her voice messages, she sounded more humble than she usually sounded!! A couple of months later she did reach me at home early one morning. I told her I had been very busy with work and school and some other things and she said she just wanted to see if I was okay. That was nice of her and she did not stay on the phone long at all. A year later, she sent a small note in the mail saying she thought of me and would love to hear from me to see how I was. I thought of calling her many times but I just couldn’t bring myself to do it. I was afraid of the cycle starting up again with no end in sight! In hindsight, I regret not sending her a note back to say hello – it’s been way, way too long now. I notice a recurring theme – therapists want therapy to end on their (the therapist’s) terms. I was young then and didn’t know how to leave, but sometimes you just have to go…And the therapist needs to let you go.

        • In my original post I wrote: “If the patient feels he or she must make a unilateral decision to end therapy, this [working] alliance has been damaged somehow, or was never strong in the first place.” That sounds like the case here. It was not my aim to defend the behavior of all therapists. There are many who let their own feelings distort therapy, who are too clingy, or who blame patients for wanting to leave. Your therapist may have framed this as a power struggle through no fault of your own. On the other hand… this could have been your dynamic instead, projected onto a therapist who wasn’t “wielding power” but merely trying to work with your mixed feelings about therapy. I wasn’t there, and can’t say.

          Ultimately it’s the psychotherapist’s job to work with your feelings, even if they incline you to stop treatment. Psychotherapies do end by mutual agreement all the time. But even more often they stop for pragmatic reasons — time, money, distance — or because such therapy stirs up intolerably unpleasant feelings. The latter is a challenge for both parties: The patient has to decide whether to continue on, and the psychotherapist has to decide how hard to advocate for continuing a process that is painful in the moment but apt to help in the long run. It’s hard to maintain a working alliance with someone who wants to leave, but that’s our job. Some therapists are better at this than others, and all of us are better with certain of our patients than with others. Thanks for writing.

  • TK

    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.

  • anonymous

    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.

  • anonymous

    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.)

  • TK

    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.

  • anonymous

    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…

  • TK

    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!)

  • tracy

    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.

  • TK

    @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.

  • tracy

    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…..

  • TK

    @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.

  • tracy

    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

  • 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.

  • TK

    @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…

  • tracy

    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

  • Catrenia

    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.

  • Catrenia

    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

  • Anonymous

    Dr. Reidbord, I was searching online for help with my termination dilemma and came across this blog, am not sure how blogging works but am hoping you might be able to make some suggestions, I’ve got a termination dilemma. It feels to me that my psychologist of almost 2 years has decided to terminate therapy. Our usual way of communicating for scheduling sessions was either in the session, by phone or email, and suddenly he stopped answering. At first he said he didn’t get my email, and would call about scheduling, but didn’t. It was hard to risk rejection again but I emailed again after a while, no answer; then I called and he emailed that he would call me when he got back, and gave the date he was expected to return, had apparently gone out of town. But there was no call. After several weeks I emailed again and explained how the silence was triggering many very painful issues etc. but got no response. I waited for a week then left a phone message that it was clear something was going on but having not had a session nor phone contact for so long I could not know, and asked if I could please get an explanation. There has still not been an answer. Although it seems clear to me that the therapist is terminating, I dont know how to handle the emotional issues this raises nor how to proceed. He is not answering emails or calls and I don’t know where to turn now. Aren’t there guidelines or rules or can a therapist just disappear. What makes it even more painful is that I had been in a serious work crisis and emailed that as a result I needed to find a different session time, and he called me to see how I was. He knew things were very tenuous for me, seemed concerned about me, and so it is even harder to know why he stopped communicating. Just so you know I have been very conscientious with sessions, always on time, never miss sessions unless mutually agreed to rescheduled, and even when there were big difficulties with issues or with how we interacted, I did not “act out” by not showing up or by coming late. I already had issues with trust, rejection and abandonment (not unique at all, I know), so this is very traumatic for me. I don’t know what to do, this hurts and adds new issues on top of my regular ones. I suppose another therapist could help me with this forced transition but don’t know how to find one other than doing a Google search in my area. How do I know from Google that the therapist would be appropriate? I don’t know that I have the strength right now to make myself vulnerable to an unknown entity, and if I did something to cause this therapist to act this way how do I not do it again? The pain and sense of betrayal and loss is pretty overwhelming for me. I don’t know what to do next, I need to makes sense of this and get some sort of closure but how do I do that when the therapist doesn’t respond? Do you or anyone have any suggestions? I’d really appreciate anyone’s point of view. Thanks very much/

    • Hi, and thanks for writing. As I wrote in the original post, a unilateral ending by the therapist, whether intentional or not, usually feels like a betrayal and abandonment to the patient. Of course, neither you nor I know why your psychologist is behaving this way. If you assume the worst, that he is acting willfully in a negligent and unprofessional way, you may feel inclined to report him to your state’s licensing office for psychologists (usually connected with the Medical Board of your state), and/or to the American Psychological Association, if he is a member. The APA and your state licensing office both forbid this kind of behavior in licensees, and will open an investigation. You may even consider legal action against him, i.e. a malpractice suit, to be compensated for your pain and suffering.

      However, I prefer to think well of people, unless the evidence won’t let me. Maybe he is ill, or has a family crisis. These possibilities do not invalidate your feelings, or the dilemma you are in, but they may suggest another approach. I suggest a letter to him (not email) briefly documenting his inaccessibility and how his silence is “triggering many very painful issues” (as you wrote above) — and that you regretfully assume he is ending his therapy relationship with you. In this letter ask him for referrals to another therapist.

      Meanwhile, look for another therapist yourself. Google is one way — many patients in the past few years found me through Google. But also ask your primary-care physician (or Ob-Gyn) for a referral. Contact the psychiatry department of your local medical school or major medical center, if you have one nearby, and ask if they have any psychotherapists on faculty who are accepting private patients. If you have health insurance, check your list of mental health providers on the insurance panel. Contact your local mental health association or any large mental health clinics in your area and ask about a referral. By going through these various institutions, you are more likely to get “vetted” therapists with good professional reputations.

      This is a hard situation for you right now, but there are probably many other therapists close enough for you to see. Starting with someone new is always hard, especially when the first order of business is the hurtful behavior of your last therapist. Hang in there, and good luck.

      P.S. It wasn’t clear from your comment, but I do advise regularly-scheduled therapy appointments, as opposed to scheduling one at a time. It’s a lot simpler and also helps the therapy work better. I also do not use email with patients for any purpose — yes, even though I blog and am online a lot. It is not considered a secure, confidential medium because it can be hacked and spoofed (technically, it is not HIPAA-compliant). It’s also hard to be sure the other person ever sees your message, or does so in a timely fashion.

  • Anonymous

    Thanks for such a prompt and very thoughtful reply, I found it to be simultaneously informative and comforting. You were very helpful, and gave me much to think about as well as many useful suggestions. I don’t think in my current state I could risk seeing a therapist blindly obtained through the options you listed(some are not options for me) – the referrals would all be unknowns, and in my professional experience, individuals found through those agencies are in theory “vetted” but are quite often less than ideal. Just contemplating seeing someone found through “cold calling” causes a degree of anxiety disproportionate to the circumstance. That, unfortunately, is because many years ago I had a very distressing experience with a psychiatrist who was sexually inappropriate and verbally abusive. I was able to end that relationship myself but not without lasting apprehension related to trusting therapists. It took years and a sudden life crisis for me to find the courage to place my trust in another therapist, the one I recently wrote to you about. So you can imagine that with the current situation, the thought of making myself vulnerable to a new therapist, in my current emotional state, produces more than a little PTSD. I’m in a pretty tenuous state these days. Nonetheless, I did take your advice and sent a short, half-page letter to my current therapist, because I share your view of believing the best in people (that, by the way, was one of the things that kept me in therapy with the abuser longer than I should have but I still have not abandoned my basic belief that most people really mean well). From here I have to take things one day at a time.
    Thanks once again for your kind attention to my question, for your blog, and for the thought-provoking discussions your posts elicit.

  • Anonymous

    Hi again Dr. Reidbord,
    I am writing now to give you follow up to the advice you gave me above; back in January, I had written about the sudden disappearance of my therapist. Thought you might like to know how the story ended. As you suggested, I wrote a letter to him asking for an explanation for his silence, telling him that his absence and silence was triggering very painful issues for me. I asked directly for an honest answer as to whether or not he was terminating. I got an email with 2 brief sentences saying that he had been away and only just now getting all of my messages, and that he would be away again for the next two weeks. The email ended there, with no clarification about the future or explanation as to his behavior. I never heard from him again.
    This was extremely painful. I couldn’t understand what happened or why and the emotional conflict was almost paralyzing. Tried to follow your instructions about finding another therapist. Initially I became panicked about finding a new therapist found on Google etc, thinking this new therapist could treat me as the other had, and didn’t think I would survive another rejection/betrayal. However, I re-read your response many times, got enough support from it to search on the APA website, and found a psychologist whose profile and statement seemed to fit for me. In addition, I called the APA but found my therapist was not a member, so they could not address the situation. An on-line search on the state’s licensing website did not turn this therapist’s name up. I followed some links on the website about ethical behavior and ultimately was directed to the Office of Professional Misconduct where they clearly list the guidelines for terminating therapy, particularly when a patient is in crisis. Submitted a complaint regarding inappropriate termination of therapy. After 4 months I had heard nothing so called to folllow up. The investigator called back to say that it appeared this therapist was practicing without a license so they could not do anything to address my complaint. Regarding practicing without a license, he told me it would be close to difficult for me to prove I had been in therapy with him unless I had some proof or unless the therapist himself admitted to it. I supplied the emails from the therapist scheduling and cancelling appointments, but was told it would be insufficient evidence because neither of us used the word “therapy”. I forwarded a copy of the letter I had mailed to the therapist after his disappearance. This, too, was insufficient, the investigator said, because I did not use the word “therapy” when asking about termination. In my original complaint, I had supplied all of the contact information, work addresses, phone numbers and email addresses that I had for the therapist, so the investigator said he would try to track him down.
    The end of this long story is that last week the investigator called to say that my being in therapy has been verified and as a result, my old therapist, a psychologist, will be prosecuted for practicing psychotherapy without a license, because it is a criminal offense.
    I have continued working with the new psychologist that I found on the APA website. It was extremely difficult in the beginning, overwhelming, painful and frightening, but this therapist is helping me to understand the effects of having worked with a therapist who terminated therapy suddenly and inappropriately, and is helping me accept that the termination was not because I was defective. He has pointed out to me that the previous therapist represented himself falsely, as he was not licensed to practice. As therapy progresses, I am for the first time having a positive experience and am seeing how therapy actually should proceed. The differences in how this current therapist conducts himself compared with the behavior of the other one are profound, as are the differences in how I feel about myself and therapy. There has been a lot of damage (I was in therapy with the unlicensed person for a couple of years), resulting in significant trust issues, so sorting things is quite hard – but it is a good struggle because I feel grounded and that I am working excellent and ethical therapist. Now there is a sense of safety and mutual respect, and there is positive, forward movement. I feel really fortunate that the leap of faith I took in choosing a therapist “sight unseen” from the APA website has turned out so well and feel optimistic about our future work.

    Thank you so much for your advice. Your input really helped tremendously. It is because of your answer above that I was able to take concrete steps towards figuring out how to handle what was an incredibly overwhelming situation. I felt validated, not so alone, and what you said helped to give me direction and ultimately find a solution. It also helped me avoid what could have been a more catastrophic result of being abandoned by my “therapist”.

    • Wow, that’s quite a story. I’m glad it worked out for you in the end. By the way, in some states (e.g., here in California) it’s legal to practice psychotherapy without any license whatsoever. But not to claim to be a psychologist, psychiatrist, or any other kind of licensed therapist if that isn’t true. Thanks for the follow-up.

  • Anonymous

    My psychologist has been on maternity leave for three months. She did set me up with a substitute, which pretty much sucked. My concern is that before she left.And the sub and noe before she’s returning asked me if I was going to continue therapy with her? I emphatically said yes. She knew it was going to be aweful for me while she was gone. She asked three times and by the last I told her to stop. She said it wasn’t because she didn’t want to see me anymore but that she once had a client not come back to therapy after a leave she took. I’ve been seeing my psychologist for around 4 years and am wondering if she just doesn’t want to see me anymore and is just dropping hints or putting the bug in my ear. I’m diagnosed with bipolar, bpd and ptsd so maybe she thinks with the new baby I’d be too much work. I gave her a gift for the baby she loved it and did send me a very nice thank you card also saying she couldn’t wait to see me in january, this was mid December she also said she would be calling in a few weeks to touch base. Then when she called she left a message asking if I still wanted to continue working with her and asked if an alternative date could be done for our sessions which was fine not a big change and she knows that I am available just about anytime. So my question is that is she hoping ill quit. She also gave me a hug on the last day before she left, which I thought was nice but now I’m wondering if that was supposed to be some sort of a goodbye thing. I’m seeing her tomorrow and very excited but don’t know if I should ask her if indeed she did want me to continue with her and why she the sub then she again asked me if I was planning on continuing working with her.

    [I removed your email address as requested — SR]

    • It’s always hard to know another person’s intentions. I suppose it’s possible your therapist was hinting that she didn’t want you to return to her. But it sounds a lot more likely that the opposite is true: She wants to make sure you’ll come back — because she is dealing with her own anxieties and insecurities about being rejected by you. That is, it sounds like your therapist fears being the “rejectee,” not the “rejector”.

      By the way, this may be a good illustration of why therapists should have their own therapy. A therapist who telegraphs insecurity, as yours may be doing, stirs up uncertainty and discomfort in his or her patients. Exploring one’s own vulnerabilities as a therapist helps make one’s communications clearer with patients, in addition to all the usual benefits. When you see her tomorrow I hope you’ll raise these issues, including how her comments made you worry. She should be able to clear up the misunderstanding. Thanks for writing.

  • AnnaL

    I had a horrible experience with this when my psychiatrist left, abruptly, for unclear personal reasons. I was seeing her in a clinic setting, and it was my first time seeing one and taking meds. We had had a very difficult session, and shortly before the next appointment, I got a call telling me she wouldn’t be in, and that I would be “seeing a new doctor.” That blew me away. I wrote her a note, as I really liked her and hated things ending that way, but I felt pretty horrible about the whole thing and still do. Seeing a new doctor (the one I was referred to originally) next week. Pretty nervous about ‘starting all this again.’

  • AnnaL

    p.s. This clinic only has a couple of doctors so it’s not like there is a lot of ‘choice.’ Finances prohibit me from looking outside. She was always very proper and ethical in her behavior, at least toward me, and while I don’t know all of the facts of her leaving, it wasn’t like we had time to ‘terminate.’ So yeah, I did feel ‘abandoned’ and bereft for weeks / months and only now can wrap my head around seeing someone new. Not sure how to begin again. The new one is very young (I’m an older woman) and my old shrink was closer to my age. Don’t know how this will work out and I really miss the old one.

  • unplanned

    To Steven P Reidbord, MD

    My therapist of 10 yrs is leaveing.
    I want to ask questions but I need to know if you still answer.
    please let me know.

    • The blog is up and running, and I still read all comments (like yours) before they appear on the site. If you post a question, I’ll try to answer as time allows — sorry, no guarantees. Other readers are welcome to reply too.

  • unplanned

    To Steven P Reidbord, MD

    I have been in therapy for 10+ years with one therapist. I have moved locations with her.
    I noted the mileage to have you understand how committed I am to seeing this therapist
    I started seeing her at an infertility clinic (55 miles)
    When she stopped working there she was able to bring some of her clients to her other place of employment, (69 miles). Then she moved to a different location in the same company (59miles)
    Then she changed jobs completely, after a stressful uncertain time I was able to keep seeing her there (50miles). This spring she changed jobs again into an administration job that did not include seeing clients. Several years ago she had set up a small private practice (53miles) and said she could see me there although not weekly as we had been. My insurance provider would not put her in network, we had to apply and then appeal for out of network coverage. It took about 2months and the verbal call from my family doctor to get 12 visits from May to Dec. At that time I planned to change to an insurance that she was in network.
    For 90% of the time I have seen her every week, since this last change it has been about twice a month, this is hard and different but I was adjusting.
    We have been through massive infertility treatment, 6 miscarriages, one was a life threatening ruptured ectopic, and thankfully one high-risk pregnancy and a wonderful healthy daughter.
    I have a list of problems that we have been addressing, with varying degrees of improvement/movement. The re-parenting of me as well as helping me parent my daughter is huge.

    On Wednesday with no warning or preparation no discussion nothing she informed me that she is closing her private practice and will not be able to see me any where at all.
    She said she thought she could do the new job take care of her kids and continue to see client, but now she says she can not.
    When all this stuff happened in the spring we talked a lot about therapist are not interchangeable,
    That the relationship and trust has to grow and for me that takes along time.
    I felt like no matter what happened we would work something out.
    We had also talked about my not having a strong foundation and all my pillars are unstable, cracked, pulling me down. She is the only strong pillar holding me up.
    We have been working on strengthening some the other pillars and my center foundation.
    Now I feel like the only strong pillar has been taken out from under me from the one person I thought I could trust.
    She says there is no option.
    I want to appeal; I want to find a way to continue some contact even if it is only monthly,
    I want her be open to trying to find another way.
    How can she be part of my life so intensely and then just end, “ end my private practice within six months “ why do I not get a say in it.
    What the hell am I suppose to do, I can not start over with anyone else.
    How do I get her to listen, to work something out, to not desert me abandon me,
    If I did something wrong I’ll try to fix it.
    What do I do?
    How do I keep living?

    • It sounds as though you understand intellectually that life circumstances eventually disrupt every human relationship. Psychotherapy is no exception. One or the other party moves away, the therapy becomes unaffordable or impossible to schedule, or the therapist retires. If nothing else ends the relationship first, then death, from old age or something else, intervenes sooner or later. Our lives, and everything in them, are finite. I’m sure you know that.

      You apparently feel your therapist is rejecting you personally. I sense a great deal of anger that you’ve bent over backwards to see her, and now feel she is discarding you in an uncaring way. This emotional impact is apt to be very helpful to discuss with her — much more so than complaining on the internet. Her upcoming departure is not happy or pleasant news, and I feel sorry for your anguish, but no one outside of your therapy can repair the relationship or your feelings. If I am reading correctly, she is giving you advance notice of up to six months, plenty of time to air your grievances with her, work through your loss, and make peace with reality. Please use this time to get what you can out of a psychotherapy that has served you well for so long, and take care.

  • William Y

    I too am not a therapist but found this article interesting as I was Googling around. I was sent to therapy when I was young (age 14-17) at a place called Ecker Center. They felt I was making more progress than I felt I was, (probably because I was quickly approaching age 18 where the school/law requirements that I attend the sessions due to my many absences due to severe anxiety/who-knows-what-else, and I had a decent bond with my first therapist.

    My appointments got spread out thinner as they felt my progress (age) dictated fewer visits. One day I went in, and found out that my therapist was no longer working there. I attempted to at least get a basic “what happened, where’d she go?” explanation, and the man at the front desk offered up no other explanation other that a “Kristen moved on to other things”.

    Wow. No warning, call, card, or anything? I since grew up. I realized the school/counselors/associated doctors weren’t in the ballpark of clueing me in on my conditions. I found out much later in life that I suffer from something much more severe than the symptoms of depression/social anxiety led on. I attempted to get myself help a couple times as an adult, but found myself up a creek with one drive-by 10 diagnosis + prescription after another.

    I have long sense wondered if Kristen was in the right to give no warning/formal goodbye to her clients, especially a vulnerable minor with severe abandonment issues and no clue what was really happening to my brain. The man at the front desk seemed like he’d think I’d be in the wrong to act hurt or confused, so I just left with my Dad and that was that.

    I found it very refreshing to read this that there are some in the field out there who don’t shelter themselves completely from their patients in the name of objectivity (believe me, i’d understand how difficult it’d be to get attached to so many emotional investments…it’s amazing some still can truly bond. I’ve studied various avenues of psychology since 1992 and while I don’t work in the field I have “played” intensive therapists for many I have encountered along the way, though I couldn’t imagine the strength it’d take to make a living doing this with multiple people on a daily basis and still not be completely removed.

    I admire Mr. Reidbord for taking the time to even acknowledge these comments over the years, let alone offer his valuable insight when so many others out there wouldn’t do so outside of an actual session.

  • S.J

    I would just like to add that I can see no rightand proper reason for a therapist not givng good notice of leaving or terminating therapy.

    They simply cannot have it all always – on the one hand setting themselves up as specialists, if you like, in terms of trust and emotional intelligence, and on the other, going by some of the accounts on here, acting like any other spiv.

    It is discounting the intellect and worth of the patient not to do this. I also do not know why Dr Reidbord insists on ‘thinking well’ of people. given that it is very easy to maintain contact with a client/patient, and the consequences of not doing so can be catatrophic for for them, why should any of us think well ofthose who will not even stretch to this elementary of tasks?

  • S.J

    P.S

    Even if the therapist is ill, or has afamilycrisis, it is surely a matter of competence in arranging contact to be made, of having plans in place for lsuch eventualities.

    The rest of us have to do this, in terms of our work obligations

    • Hi SJ,
      It sounds like you are responding to my 1/29/11 comment, the only place in this thread I said anything about “thinking well” of people. I don’t insist on it, either for myself or anyone else. I find it a good thing to strive for, though. If I didn’t “think well” of patients who often act in self-destructive or hostile ways, I wouldn’t be able to do this work. Since therapists are people too, I try to extend the same courtesy to them. All the same, I agree with you: There’s no good excuse for a therapist to abandon a patient or client without explanation. Even if the therapist suddenly dropped dead, someone (a colleague?) should have the courtesy to inform those affected. Thanks for writing.

  • Unqualifiedly advising all your unseen readers to submit an extended termination period well could be unrealistically idealistic and extremely destructive counsel to some.

    Likely some of your readers will leave therapy for self-preserving reasons–like ethical violations, strong erotic transference,dependency, stagnation, feeling subordinated or bullied, therapy taking an outsized role in life, to list but few scenarios. Unfortunately some of your colleagues handle react to these exits with extreme destruction, invoking their authority to inflict maximum damage to keep the patient in treatment or retaliate for wounded pride. Though this event seems scantly covered in professional literature, it widely is discussed among clients in forums.

    Nothing happens in the therapy room that immunizes client and doctor from ordinary responses and power dynamics. There’s a large danger for mental health professionals to lose themselves so deeply in theory they forgot that therapy is first is a commercial arrangement between two equal human beings.

    • The 5th and 6th paragraphs of my post did qualify my advice about “submitting” to an “extended” (your words, not mine) termination period. But if it really needs spelling out: I very much advise against even one additional session with a therapist who physically abuses, sexually molests, bullies, or financially exploits a client. Many types of ethical and legal transgressions call for fleeing the scene immediately and reporting the perpetrator.

      On the other hand, “strong erotic transference, dependency, stagnation, …[and] therapy taking an outsized role in life” are not ethical or legal transgressions, or even necessarily clinical errors. They are all matters usefully addressed in the therapy itself. In most cases it’s far better to deal with these in the existing treatment relationship than to leave without discussing them — and then finding them crop up again in one’s next therapy — or romantic, roommate, or work — relationship. Such issues are expected to arise in dynamic therapy, and should be dealt with sensitively and professionally by the therapist. Leaving the instant they appear, without talking about it, guarantees that nothing will change. Thanks for writing.

  • Sandy North

    I just quit therapy with a therapist I really liked, mostly because I felt that my issues cannot be resolved in therapy and therefore that staying in therapy was kind of abusive (to him).

    I didn’t realize that ending therapy usually takes more than one session. In my case, I phoned a few days ahead to let him know, and then we had our final session (in which my departure, after a year, was hardly mentioned) and I left. I certainly didn’t mean it as a criticism of him and hopefully he didn’t take it that way. This was my first time in therapy and he never mentioned anything about how it would end. He’s great. I’m not great but probably am doing as well as can be expected. I just assumed that therapists are relieved when patients move on, so that they can see new, interesting people.

    I miss him a lot, though. As I was seeing him for grief, it’s like another death. But, that just means that he was important to me and I see that as a positive thing even though I feel like crap right now.

    • I’m surprised your psychotherapist “hardly mentioned” your decision to stop treatment after a year. Particularly when your reasons were that you felt you were abusing him, that you imagined he’d feel relieved, and that you assumed he’d prefer to see “new, interesting people.” It is quite likely that none of these beliefs is accurate. A person suffering grief or bereavement, particularly when the feelings toward the deceased are mixed or complicated, may feel like a burden to others. One reason to discuss stopping therapy before doing so is to clarify your beliefs and assumptions the led to this decision. I can’t say whether this would have led you to change your mind, but it sounds as though you liked and valued your therapist, and at least had mixed feelings about stopping. If you feel there’s “unfinished business” between the two of you, it wouldn’t hurt to make another appointment and review it with him. Take care.

  • KT

    To Sandy North, I hope you will consider going back to your therapist! It certainly sounds like at the very least you have some unfinished business with him. That’s what therapists are for: working out unfinished business. Therapy is not always a straight road, and sometimes you end up going over stuff again and again, but with a different understanding each time. Wishing you well, KT

  • KJ

    Is it “professional” or ethical for a psychotherapist to call and leave a voice mail at 6pm to cancel your 7pm appt because their 6pm cancelled and they would “like to go home.” Then, 10 minutes later and leave another voicemail saying they ARE leaving the office and going home, and if “you get this message, you can call my cell phone but I wont be at the office.” I terminated my therapy with this therapist….it upset so badly. I felt as if my time…..as if my time wasnt important…I wasnt important.

    • It’s clearly unprofessional. Some psychotherapists are so selfish, tone-deaf to the feelings of others, or devaluing of their own work that they shouldn’t be in this field. I don’t know which of these applies to your former therapist. As you know, I normally advise talking it over with the therapist before quitting. In this case I’d understand if you considered that pointless.

  • KJ

    She wanted to “phone me” after I said I wouldnt be back. She wanted to “talk it over.” I said no….I felt it would just make the decision to terminate harder for me. Ive been with her for 5 years…5 years…so, it isnt “easy.” It was the “icing on the cake” for me though, and not the first issue. Two weeks ago she did something else that I felt was unprofessional. I let it go…she never even brought that up and I had told her how upset I was over it. She said we would talk about it “at my next session.” The session came and she acted as if she hadnt even remember what happened…or as if nothing DID happen.Then, she cancels on monday because she “wants to go home.” At least lie and say you are sick or something! I just wanted another opinion..so thanks for the response. I feel “better” about my decision.

    • I’m glad you feel better I guess. But a 5 year therapy is a big investment of time, money, and emotions. There must have been something keeping you there for 5 years. And if talking over your decision to stop makes it harder to carry out, then that says something too, presumably about your conflicts over quitting. I don’t disagree with your decision, but after 5 years working together putting feelings into words, it’s certainly a pity that you had to bear this alone.

      • KJ

        Five years IS a bigger “emotional” investment, more than anything.She has helped me sooo much…so much..She even worked with my daughter…watch her grow…she is now 12 yrs old. Helped me through childhood abuse issues…sexual, physical, emotional…but “things” just havent been right with the therapy, lately….it has kinda gone sour. I feel like she has gotten to “comfortable” with me…if thats possible…thanks again. The feelings of loss and sadness will pass…but my “gut” tells me Im doing the right thing by terminating….sometimes, even the right thing can hurt….

  • SF

    Hello
    I have been in therapy for just over two years, after a hospitalization for depression. I am doing well and on no medications right now. I have noticed my doctor nodding off in my sessions for several months. His eyes roll back in his head, and then he snaps awake suddenly..! it is very annoying. I want to end my therapy but do not want to pay him for more sessions while we “close out” the therapy. I would also feel very uncomfortable talking to him about seeing his eyes closing and then snapping awake during my sessions..
    Would it be totally unacceptable to make a polite phone call and telling him that I would like to end therapy? I feel we have not made any progress for quite some time, and While I do not dislike my therapist I do not feel all that comfortable with him either..I do not feel that I need to examine my decision to end therapy under the circumstances..I know that there is supposed to be a termination phase! but I really just don’t want to go through it…

    • It’s certainly “acceptable” to leave a phone message that you’re ending therapy and not coming back. After all, it’s your money. The question is what is best for you, now and in the long run. You built a relationship with this person for two years, investing time and money, trusting him with your private thoughts and feelings. It’s completely understandable that you’re very annoyed he’s falling asleep instead of paying attention. But what’s best for you now?

      Consider two scenarios: (1) You call and say it’s over. You spend no more money or time on this man who angers you for not doing his job. Perhaps you imagine this punishes him, although he may not know why you did it, and this revenge makes you feel better in the moment. He doesn’t get a chance to apologize or mend his ways, and you miss out on exploring your reactions to annoying people who let you down. You go forward with a story to tell of your offensive, useless therapist. (2) Since this has been going on for several months, you decide the incremental investment in time and money to address it may be worthwhile. You gather the courage to tell him his sleepiness really irritates you, that you feel like he doesn’t care, or that you’re boring him. You tell him you’re so ticked off you thought about quitting without even telling him why. Then you see what he does with it. Does he take your feelings seriously and ask you to elaborate? Does he apologize? Does he take active steps to fix the situation (coffee, moving your session earlier in the day, etc)?

      Choice #2 is a risk. Your therapist may deny everything, devalue your feelings, make you feel like a jerk for complaining. If so, the encounter will make you feel even worse before you leave, and you will have wasted the extra session or two. On the other hand, the outcome could be very good. Perhaps you’ve “not been making progress for quite some time” because you’ve been hiding negative feelings — a common situation. This would help release them. Perhaps seeing that your words matter to your therapist and lead to sincere efforts on his part would help you feel empowered. Maybe you’d decide to stay in treatment and get something more out of it. Or maybe even if you decide to end therapy, the discussion will leave you feeling your therapist was neither offensive nor useless.

      Obviously, I think there’s a lot to be said for taking the risk… but it’s your choice. Thanks for writing.

  • mary

    Hello,
    What do you think about the followibg situation? Is it healthy or not?
    I already passed by termination process several months age around 5 months ago.We had a great therapeutic relationship and without we expected, it was over: . I am still wishing being in therapy with my former therapists and frequently cry because I cannot find him.

    • You ended treatment about five months ago, but cry because you still want to see your therapist. In my opinion, this is not a healthy termination. I wonder if you thought it was a good time to stop five months ago, or if only your therapist did. Termination should happen when both people, the client and the therapist, feel the time is right. You should look forward to stopping as progress, a good step. If you had a great therapeutic relationship, you might consider calling him and explaining the situation. Perhaps a few more sessions focusing on your difficulty “letting go” would help. Or, as with losses of other people close to us, your grief will fade by itself in time. The loss of people we love and care about is an inevitable part of life. Thanks for writing.

      • mary

        thanks,

        but the termination wasnt neither my therapist decision nor mine. it happened because he was fired from the mental health clinic. we didnt spend it. even though we had about one month to discuss it, I still want another session with him again. the bid deal is that I dont know how to find him

        • I’m sorry I misunderstood your question. If you can’t find him, then you must mourn your loss and move on. It may be helpful to see a new therapist to continue the work you started with your former one, even though no one will be exactly like the person you lost.

  • Jenny

    I saw a therapist for seven years. It took me about three years to fully trust him and to open up and tell him about huge traumas in my life. I also struggled with suicidal thoughts most of the time. I think he kind of thought I would eventually end up killing myself. One session I told him about an abuse that I suffered just days before therapy. He was helpful and listened and I thought he cared and wanted to help me. I was struggling with ongoing abuse from a family member (I am not underage.) The next week on the day before therapy he informed me that he would not see me again unless I brought my husband in. I assumed he was going to tell my husband about the abuse. I don’t know. I absolutely was not going to do that. My husband is NOT supportive of me and I knew it wouldn’t help me at all. I explained this and he still wouldn’t see me by myself again. I begged and pleaded, but he refused. I never went back. He also never referred me to anyone. It was a horrible ending and I am very hurt and traumatized by it. I don’t know what I did wrong. I always showed up for appointments and paid on time. I was never ever abusive and didn’t threaten or harm him in any way. I tried really hard in therapy. I have had a lot of trauma in my life and have a lot of issues and I guess I was too slow in fixing them. I don’t know.

    I don’t know how to deal with this at all. I wish he had said he didn’t feel like he could help me anymore and we could have had a session or two to end things. My diagnoses were PTSD, Major Depression, OCD and I also struggle with eating disorders and self harm. I hate myself and feel like no one can help me. Like I can’t even pay someone to be there for me. I’m just kind of venting and don’t even know what I’m looking for. It’s just so painful. Thank you for listening.

    • Some therapists believe they can force patients to act in healthier ways by pressuring them. There was a discussion earlier in this thread about therapists who threaten to stop seeing patients who continue to drink or use drugs, to pressure them to stop. In your case, your therapist may have been trying to pressure you to include your husband in the conversation, or to unmask the abuser, etc.

      I believe such efforts usually fail. And even when they succeed in changing behavior, the patient can’t feel proud or take credit for it. People change when they feel safe and ready. I’m sorry your therapist tried to strong-arm you. He probably meant well, but miscalculated in a big way. I hope you can find another therapist you can trust, and who also will proceed at your pace. Take care.

  • Jenny

    Thank you for your kind thoughts. He probably did mean well. I do think it was the wrong thing to do. I mostly blame myself for being so slow and stupid.

  • Sam

    Hi there, interesting thread. I have been in therapy for just over a year and the vast majority of this time I have been experiencing what I understand to be a strong negative transference with my therapist. It feels like I am just going around in circles and I struggle not to verbally abuse him much of the time. Other times I am overcome by fear and struggle to talk. Needless to say, this is an unpleasant experience (probably for both of us). This week I asked my therapist if he was scared of me as I noticed his anxiety. He indicated he was at times. My question is how long should I allow this to go on before I just give up? I don’t feel like it’s going anywhere since I am too triggered to explore it in any real depth. I have often raised the issue of thinking about leaving but not discussed it in any depth. I am intending to leave a voicemail to terminate as I can’t see the point in discussing it with him since I feel no trusting connection with him.

    • Hi Sam,
      Dynamic psychotherapy often boils down to tolerating an unpleasant interpersonal experience for a long time, because the payoff is worth it. There is no concrete answer to how long to “allow this to go on.” Some clients quit after one session because the therapist isn’t warm and fuzzy enough. At the other extreme, I’ve seen therapy struggles go on a few years — strong negative transference, as you describe — and then either end up shifting to something much more collaborative, or terminate with the client later feeling it had been valuable and transformative. (Sometimes this is only apparent after stopping, i.e., when no longer struggling.) One question to ask yourself is whether your conflict-ridden therapy mirrors other important relationships in your life, i.e., whether it is really transference. If so, you have the perfect laboratory to study it, to lessen the chance it will happen in the future.

      Your timing makes me wonder if your therapist’s admission that he’s sometimes scared of you was the last straw, i.e., especially uncomfortable. I’m in no position to analyze or interpret that from here, but it may be worth bringing up with your therapist. Sometimes “the last straw” is the very thing that helps you turn the corner. I wonder more generally whether you’re able to “step back” and comment in therapy, for example that you struggle not to verbally abuse him. I don’t know if this is true for you, but it’s sometimes easier for people to discuss their therapy on a blog like this, than in the therapy itself where it’s much more likely to do some good.

      You won’t be surprised that I hope you don’t “terminate by voicemail” after a year of therapy. The time, expense, and struggle you already invested is worth more than that. Even if you decide to stop, please do it as a mature decision, with head held high, and not slink away defeated (or guilty). Of course, I also hope you don’t quit at all; it sounds like you’re working on something important. Take care.

  • Sam

    Thanks for your considered response.

    I think I was hoping to hear something about the therapeutic alliance being critical for success, that I should find someone I feel comfortable and safe with etc. In other words, I am still probably looking for permission to leave, and still somewhat ambivalent about it. My friends and family have consistently heard about my therapy difficulties over the past year, and I am almost embarrassed to keep speaking about it. To any person unfamiliar with this kind of a process (and used to the notion that there should be some kind of warm and supportive relationship between therapist and client), it seems absurd that I should continue to pay $600 a month to see someone I purport to dislike so much. Given that he comes from a psychoanalytic perspective, my therapist is non-directive (so won’t discuss these issues with me), and is about as warm and fuzzy as liquid nitrogen. Yet while every person I speak to (other than yourself)advises me to leave, for some reason I haven’t been able to. I am concerned that it is my masochism that keeps me going, rather than any actual benefit.

    My experience definitely holds parallels with some previous interactions, however I rarely stay in relationships which I find this triggering, and I will do my best to conceal my experience from the other person. I understand what triggers these responses, but doubt that it could shift. Every now and then I can step out of my experience while in therapy and just describe it, as opposed to being in it, but that is physically and emotionally exhausting to do. My experience is quite visceral – there’s a lot of nausea, sweating, heart pounding and feeling like I am being spat on (I can feel it on my skin even though I know it isn’t real). Due these experiences, I feel I am just trying to endure therapy, rather than engaging in it. If there is such a thing as a therapeutic window, I feel like I am stuck on the roof nowhere near it.

    You are correct to notice the timing, but I feel that was more around him giving me a note regarding a fee increase, as well as a list of his unavailability over the next 12 months, both of which triggered more rage. Perhaps I will just take a break, and leave the door open instead. There are parts of me which think I am a “failure” if I take a break or leave; I can recognise that whatever process is occurring is clearly not complete. It’s that shame, coupled with a fear that I will turn back on the decision if I try to carry it out face-to-face, which makes the voicemail option look more attractive.

    I don’t expect a response, just felt like rambling.

    Thanks

  • Oona

    I am stupid – I had growing fears that my psychologist was no good for me after repeated sessions being cancelled by her for childcare reasons, one attempt for not booking a room and others for legitimate holidays/leave within 4 months of working with her.
    Her not ‘having her hours yet’ and being ‘only part time’ in the NHS with no business card showing proof of who she is and her job status and filling me in with her own disfunctional situations with her ex’s family, as a way to normalize what I experienced as emotional abuse by an ex boyfriends and family – really didn’t help me feel secure either.
    Then it stated getting nasty – me accusing her of not caring – as she yet again gave me one session notice of an absence for childcare reasons – I have social anxiety and so only see her to talk to and one mental health worker who was also away in that week also – I don’t work or see anybody else during every week – she replied immediately to me with ‘Well, if you were on time?’ – I walked out and almost crashed my car into the wall on purpose but realised I was angry with her not myself and so stopped myself and took myself to a safe place to calm down for hours….
    The next session she briefly admitted she had had bad timing for that comment and then swiftly proceeded to talk all session again about me not being on time – totally deflecting and stopping me from talking about my feelings about her not caring about me (which is actually a known problem for me to assert myself) – by the way I was on time for that session – I made sure I was by nearly an hour – to make sure. This was the last session I had with her – I simply could not bring myself to be in the room with her and made excuses for the next three sessions not to go – I didn’t know what to do – the line manager was already on her side she had already told me so – then when I finally worked out she may actually have been correct about me being paranoid – she had terminated my therapy for the next session – siting that she felt I was not ready for therapy – no referrals and no discussion about it – it is all my fault.
    During the off and on sessions with her – I wasn’t on time all the time but I was there every time – at first I was baffled – because I actually felt I may have been close to being late but not bad late – I have had some serious battles with not sleeping at night until early morning due to self harming and this made it difficult alongside having to do certain things before being able to get out of my front door – but I still didn’t believe I was being really late – then when I thought I was actually making an effort – I really was baffled but checked my phone watch with hers and she was right – it was late by a good ten minutes – however I had been convinced that I was doing well prior to actually arriving on the floor of the office and looking at the phone – anyways she started saying things like my line manager is not happy etc…and if you are later than 15 minutes then I will have to terminate the sessions.
    I just felt ganged up on then by an unknown stranger and her – which triggered paranoia only I didn’t know it was paranoia – she told me I had paranoia about other things but I was convinced she couldn’t possibly be right – I was convinced she was out to get me – it was her she was insecure/ i would be neglected/ was too similar age to me, unprofessional and unexperienced – so totally unable to help or truely understand me – so my reaction shamefully – I dug my heals in during the sessions to her face and told her my lateness hadn’t been an issue with my other therapist who understood I had great problems and that it was amazing I actually got there at all (this is true – she would get on with her paperwork while she waited and I found her much more disciplined and effective and calm and relaxing to be with, more solid but she sadly retired). At the same time outside of my new psychologists view – I was genuinely much much more conscious to be on time for her sessions – yet some times it worked some times it didn’t???? – which did actually genuinely baffle and embarass me genuinely – I have found out this week by accident that the car clock was wrong by about 11 minutes – it never occurred to me – and this is the clock I was using while I sat in the car park before going up to the office not my phone as only I thought.
    So my question is what on earth do you do when you have been a really really bad patient due to your paranoia and social anxiety issues and with asserting yourself/your problems with the therapist and your much much needed therapy has been terminated? I have no money for more than one private therapy session – I was receiving free therapy on the NHS I am in the UK. What do you do? I hope you can read this and give me some advice because there is no one to ask – the mental health worker is now making signs she also wants to quit sessions with me and I am struggling trusting her also. There is no one else.

    • Oona,

      I’m sorry, but this is not a forum for lengthy, tell-all comments. I won’t be publishing your other 2 submissions. The question at the end of your comment is a hard one. I’m tempted to say that you need to behave yourself. If you repeatedly don’t show for appointments, you risk having your case closed. If you arrive late, your therapist is apt to say something about it. Free therapy is still worth something, so if you value it, you have to act that way. I appreciate that your therapist may have been inexperienced, so this may have felt to you like a “set-up.” I’m sorry you were put in that position, but you have to work with what you have — or ask maturely for another therapist. Good luck.

  • Tracey

    I feel so confused. I gave notice to my therapist 3wks ago after seeing him 7yrs. Had final session and I feel so sad, hurt and unsure. 18mths ago I lost my mum and then 12mths ago he lost his dad this along with festival commitments he had made for disjointed therapy so I opted not to do certain work as it was important I could rely on him being available weekly. He acknowledged this and understand how I felt and I did do other work just not as emotive. Over the xmas break I’d geared myself up for facing the issues I’ve avoided for so long I felt everything would be in place. I trusted him, I wasn’t seeing clients myself (as a psychotherapist taking a year out) the anniversary of his dad’s death passed that was important to me cos I knew how much being an orphan affected things I never felt he struggled but i guess I believe it changes a lot and time is needed to reflect and I was protecting myself also my fear was I’d start sharing and he’d give notice as he travels a distant to where I see him and has gradually been reducing his days whilst always reassuring me he’d “never give me notice I’d leave him”. Anyway first session of the new year he casually mentions he’ll be having more time off than usual as he’s doing a course in LA over the next 6mths, a yoga retreat and. 3wk holiday with his son, so basically off for 1to3 weeks every 8-10weeks. My heart sank I was gutted I said that wouldn’t work for me that I’d be waiting for consistent sessions as last year was so disjointed and I get he has a life so said I’d have to think about it. Next session gave notice he was surprised I explained I couldn’t do work I wanted that starting it with his planned breaks would just add stress and I didn’t want to feel abandoned, resentful with his first break coming up on 3rd feb that gave us 3sessions we agreed on that. I went home released my mistake 3 sessions not long enough to break cleanly emailed asking for extension explaining whilst caring for myself in ending I’d overlooked what having him meant to me that id not considered how id manage could I extend. He replied given notice for the room that day, only working one day isn’t no available evening slots possibility of afternoon but no times given and he’s truly sorry. I was flabbergasted he’d moved so quick did that mean he’d no other clients that day just me if that so surely he should have said something when I gave notice so I’d know coming back or extending wouldn’t be options. I know I assumed I shouldn’t have but I’ve forgotten about an op I need and the thought of going through that without his support scared me. I feel strongly he’s let me fall on my sword so to speak that he didn’t look out for me whether consciously or unconsciously my giving notice suited his plans and he neglected to question my decision or acknowledge my obvious use of our time as a major support . I can’t shake the feeling he was pleased I’d given notice he let him off the hook but I feel on reflection manipulated into that position I’ve always been honest he knew how unsettled I found breaks yet he made no allowances for this. I told him I felt angry that I’d made a wrong decision not in ending but in not agreeing more time that I find myself in the position I’d dreaded throughout therapy alone with a major event up and coming with no time to process my emotions look at coping.

  • I am embarrassed to even write something that may be just distorted thinking. I have had this therapist for a little over a year. She is wonderful, and has done so much for me. Well recently, I wrote a letter with the intent to tell her how I feel towards her, and an incident that I told her I did not mean to do, but truly did it anyways. The letter explained that I sometimes I think her therapy is stern, and she can’t be very abrupt at times. I saw it as growth, and felt that a year earlier, I would of never been assertive enough to let her know that I thought this. Well, after I read the letter she told me she felt emotionally attacked, and she had to stop all conversation with me because she thought I might take what she has to say the wrong way. She stated that she needed to seek supervision. A week earlier, I was attacked in my home and it was triggering incidences from my abusive past. Also, one of her mannerisms triggered a flashback during session. I left that day with no intention on coming back. I drove away and thought and recognized it as an issue with me, not the therapist. Now because of that and her feeling I didn’t trust her enough to tell her I was in crisis. She said I it made her loose trust in me. I went into crisis and called her like we had on our safety plan, well as I was calling her, and after I had decided it was enough, I felt bad that I had done what I did, and did not tell her I was in need. I ended up in the hospital under observation. Even after I told her it was not that I did not trust her, I was disappointed in myself for letting her down. I made a promise, and I broke that promise. I lost her trust because I didn’t tell her the truth. I am at a loss right now. I love this therapist, and I do not want her to terminate, because she feels that she was not truly helping me. She has helped me, and I am very saddened that this will be the end. What can I do? Please help!

    • Hi Wendy,

      As I’ve said before on this blog, sometimes it’s easier to write something on the internet for everyone to read, than it is to tell your own therapist. (It’s not that mysterious really: you care about your therapist’s reaction and her feelings toward you.)

      I wonder if you feared you damaged your therapist, who suddenly had to stop all conversation with you and seek supervision? I imagine your concern about her is why you left with no intention of coming back, and why you didn’t tell her you were in crisis. As I read it, you faced the dilemma of hurting her by expressing yourself, versus breaking your promise (the safety plan) if you didn’t. If so, you opted for her safety over your own.

      I also wonder if your therapist is still in training, or at least on the inexperienced side. This is just a guess. It sounds like she didn’t realize her reaction would worry you so much. If any of this rings true for you, maybe you can put it into your own words, and ask your therapist if she’d be willing to meet and talk with you about it. You can still change your mind after you left intending not to return, and she can reconsider trusting you again to stick to your safety plan. Best wishes.

  • european

    Hello Dr. Reidbord.
    Can I have a question? I’m really confused and don’t know where to start… And please forgive my English, it’s not my native language. I’m from Europe.
    Hours ago I was just kicked off of therapy.
    My therapy lasted one year. It was psychoanalysis twice a week, with an old and experienced analyst (and I believe, respected in my town)
    The last sessions I have felt strong negative countertransference towards me, and I just don’t know. Maybe I was deserving it? I’m really confused. My therapist told me numerous times that I’m just arguing with him, that I don’t respect any authorities and restrictions. This time he told me that he don’t want to deal with me anymore, that I’m so grandiose and that I’m really a bighead.

    I meet the criteria for NPD. I study psychology too, so I know – I really have it. I went to a psychiatrist once and he told me that I have characteropathy (the old name, still used in my country; I live in Post-Soviet country in Eastern europe).
    All my connections to people crumble… Days ago a friend told me that I’m “an evil creature” and removed me from all social medias.
    So.. I don’t really know. I realize I have many issues. It’s really desperating to realize that I AM the desease, that everything I feel, think, or do is wrong and twisted.
    But I just don’t understand. Shouldn’t a therapist be more tolerant of addictive behaviours such arguing, opposing his opinions, etc?
    I just don’t know, I’m really confused. I felt that he’s grandiose too and that I really piss him off when I’m doubting him. It was not discuseed in therapy, I was afraid to do it.
    I don’t know! I’m really confused. What if I’m just distorting and he’s perfectly sane and right all the time and I’m just disrespecting the frame and his authority?

    Today, when he kicked me, it all happen so sudden that I was shocked and I couldn’t ask why. He lost his temper, he raised his voice even, asking me who do I think I was dealing with. He clearly was angry, probably he feel very disrespected. Then he calm down and said to me that he just doesn’t want to deal with me anymore. That I’m very sick, grandiose and bighead.
    I asked him only if I could go back in therapy some other time, ever, and he said: “No, don’t come back, I don’t want to deal with you anymore.” And that he prefer to see people who want to work. But really, I tried my best to work… Or didn’t I? I’m REALLY confused if it’s ALL my fault or it’s mutual.

    So I don’t know. Should I call him and beg him to discuss why he reacted this way, given the fact that he doesn’t want to deal with me anymore? Or what?
    Am I really evil creature, impossible to be around and to work with.. I just don’t know. People always seem to dislike me, when they know me better, and to leave me…
    Please answer me! I’m confused!

    • Hello,

      The simple answer is: “not all personalities get along.” The reasons for discomfort are often obscure. Some psychotherapists find highly dependent patients especially challenging, others find dependency no problem at all. For other therapists it’s very angry or contemptuous patients. And the converse is even more true. Some patients want a warm therapist who acts like a friend, others seek cool and careful professionalism.

      Of course, effective therapists, and particularly psychoanalysts, must work well with a wide range of personalities. When I was in training, a professor reminded us that many patients will have difficult personalities — because that is exactly why they come to see us! Just as a dermatologist cannot recoil at the sight of ugly skin infections, and a surgeon must tolerate the sight of blood, psychotherapists must be able to work with personalities that others find difficult.

      If your therapist could not tolerate your attitude in sessions, I think this is his failure. (It’s different if the therapist tolerates the patient, but doesn’t believe the therapy is or will be helpful. Then it is a service to the patient to share this, so time and money will not be wasted, and there is no false hope. Perhaps the patient can be referred to a different kind of treatment.) It’s especially troubling when a therapist fails in this way, as it reinforces the patient’s hopelessness and feeling unlovable. It’s worse than never seeing the therapist at all. According to Freud, a psychoanalyst who reacts to this kind of countertransference needs more analysis himself.

      However, I want to contrast this with a patient’s intolerable behavior. No therapist is obliged to work with a patient who can’t keep the work contained to words, and who acts out in destructive or self-destructive ways. Repeated attempts to manipulate or threaten the therapist outside of sessions, frequent rule-breaking, failure to pay the fee, and many other behaviors may legitimately trigger a termination.

      I suppose there are situations on the border, when it isn’t clear where attitude stops and behavior begins. Psychotherapy is an art more than a science, and reasonable people can disagree where to draw the line. However, in my opinion, there’s still a very useful distinction between working with a wide range of personalities and attitudes, versus setting limits on behavior. Thank you for writing.

  • Barbara

    [Edited for brevity – SR]

    Dear Dr Reidbord,
    […]
    I’ve been seeing a psychodynamic therapist for four years now. […] I wanted help as I have some Autism Spectrum traits and tend not to make sense of fine points of some social interactions. I have become isolated and really don’t feel confident in society. I had some very painful experiences that ended with me being slandered and shunned and was unable to defend myself, and I wanted some support to get past the trauma I experienced.
    […]
    The therapist doesn’t understand me and I feel there is no connection. If I tell her I don’t agree with her she becomes irritated. I’m confused – I know the truth about me and she does not, yet she wants to tell me what I feel – and she’s wrong. She has told me that she doesn’t understand much of what I say – it’s “too cerebral”. I also find that her analysis is superficial and obvious, ‘though I don’t say so. It has become a maddening, meaningless experience to me.
    […]
    I would really like to be referred to someone else but when I asked, the therapist said she thinks I should deal with the issue of wanting to leave, and won’t refer me on. She wants to discuss how I feel about her but she hasn’t given me reason to feel anything much, and I want to leave because I dislike being told, erroneously, what I feel, and because I realize I’m not going to get any assistance understanding how social exchanges work, or reassurance after the trauma I experienced. I certainly don’t have any of the transference feelings I have read of in this blog. I suspect my lack of transference is because I just don’t make assumptions about people but look for evidence of their thoughts, tend to be very concrete and analytical, and am on the Autism spectrum. […] I don’t think I’ll look for help again if this fails as the consequences of being misunderstood are too uncomfortable and anxiety inducing. […]

    • Barbara,

      You clearly do have transference. Transference isn’t a special, unusual feeling. It’s a special name we give common, everyday feelings toward another person that arise in the setting of psychotherapy sessions. If you feel anxious, misunderstood, and unduly criticized by your therapist, that’s transference. Broadly speaking, it’s the job of a psychodynamic therapist to avoid provoking a specific transference, while encouraging transference in general.

      Your challenge as a patient is to decide whether your negative feelings are being evoked by a relatively neutral, benign therapist, or whether a wide range of people would hold similar negative views about her. For example, you mention you had trouble connecting with people and being isolated before seeing this therapist. Is the lack of connection in your therapy a pattern that you bring to it, or is this therapist especially hard for anyone to connect with? If the former, there is much to be gained by talking it over with your (errant, maddening) therapist. You’ll learn what irritates you — and possibly why — and you’ll also come to recognize and accept your own feelings more readily, which is particularly valuable for those on the autistic spectrum. On the other hand, if your therapist is simply an insensitive oaf, it’s best to leave and find another. Please do not let this experience deprive you of the benefit a better therapy relationship may offer. Thanks for writing, and take care.

  • Barbara

    [more editing for brevity – SR]

    If transference is the name for common everyday feelings distinguished by their having arisen during psychotherapy, how can they be distinguished from common everyday feelings that arise outside of psychotherapy? I imagine common feelings distinct from transference could also arise in the setting of psychotherapy? In the same way, can feelings provoked by the world at large be used to understand one’s inner world? […]

    I know the therapist misunderstands me because when she has repeated things back to me later they are often factually wrong: she tends to think things that have actually happened are things that I’ve imagined or guessed, and she ascribes feelings to me that I haven’t had. I have observed this as a fact, I don’t feel it as an emotion. Things are either facts or they’re not, and it’s possible to observe facts without having feelings about them. This is my experience, anyway.

    I do think a wide range of people would feel unheard, invalidated and not connected with her if this therapist, or any other, behaved this way to them. I don’t know if she would behave the same way with a wide range of people, however. I have to suppose I didn’t do it right. She once thought I was testing her, she said. I never had any such thought, but the week after I told her that I didn’t feel heard she told me she felt I was telling her that she was “bad at therapy and a terrible therapist and contempt! That you have contempt for me!” and she went on a bit more. She wanted me to know how she felt, she said. She said it feels more real now, but to me it feels out of hand. I have written to explain that I wish to finish. […]

    The question remains to be answered – what if one IS misunderstood? And held to answer for thoughts one does not have?

    • Transference can be described in broad strokes as feelings one has toward one’s therapist, particularly those feelings “transferred” as assumptions or suppositions from important prior, especially parental, relationships. Freud found that close attention to such feelings in psychoanalysis was illuminating, and he therefore wrote a great deal about “analyzing the transference.” However, such feelings also arise in everyday life, e.g., when we immediately like or dislike someone new, or when we have an “automatic” reaction to authority, whether obedience, competition, rebellion, or some other feeling. We don’t call it “transference” outside the therapy setting, but it’s exactly the same thing.

      Certainly non-transferential feelings can arise in therapy. The exact definition of transference is hard to pin down, but most would agree that feelings in reaction to actual features of the therapist, and that are unrelated to the patient’s important prior relationships, are not transference. This is why I asked whether most others would find your therapist difficult. If so, your reaction, i.e., finding her difficult, is better explained by her personality and not by yours. And certainly, feelings provoked outside therapy can be used to understand oneself — that’s how 99% of the world lives.

      The answers to your final questions are ultimately up to you. Some patients flee at the first sign they are misunderstood. Others strive to make their therapists understand. Some become quite frustrated, others do not. Being (or feeling) misunderstood, at least a little, is inevitable in all human relationships. It’s another matter if this occurs constantly, over four years, in a professional helping relationship. If your therapist’s “more real” feels “out of hand” to you, it’s important to respect your own feelings, and for your therapist to respect them too.

  • Barbara

    Thank you very much, Doctor. I appreciate all the time you’ve taken to answer my queries. In this correspondence I DO feel heard, which has been restorative!

  • Msrins

    My therapist is retiring and moving away to be near her grandchild. I don’t seem to be able to wrap my head around a smooth transition. She wants to talk about our relationship over the last 12 years. We have been through a lot. I have been through the death of both of my parents. I have been through the killing of 12 of my coworkers in my office building. I have been through another active shooter incident in the same building that turned out to be a false alarm. I am extremely overly sensitive. I am overly emotional when placed in stressful relationships. It looks like I am going to have to retire. So I am losing my work and my therapist at about the same time and don’t know how to get to closure and how to talk about the relationship I have had with the therapist. It has had its ups and downs. I have never really wanted to end it. Does anyone have experience with retirement for a long term therapist? II think I am way too attached to her and there is no one else out there that I can trust. I have issues with trusting people and approaching people. I don’t liker crowds, etc. I fear this loss of the therapist and loss of the job will completely take me over the edge and I have incredible amounts of worry, anxiety, negativity, iI don’t see the light at the end of any tune.

    • The transition may not be smooth, i.e., painless. There is often no ideal “closure” when a therapist makes a unilateral decision to stop treatment, even for a good reason like retirement. Just do the best you can, given the reality.

      An invitation to discuss your relationship over the last 12 years is your therapist’s way of reviewing the connection you’ve made, and probably a gentle nudge for you to notice the improvements you’ve made. This is helpful for most patients, including acknowledging the awkward ups and the downs in the relationship. But it’s your choice not to engage in such a review if you find it unduly painful. Part of terminating a long therapy is taking the time to loosen your attachment and to consider other sources of support, and people you can trust. Good luck.

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