How to process and make sense of abrupt termination of psychotherapy by a patient
Journal of Psychiatry Reform Vol 9 #13, August 2022
Caroline Giroux, MD, FRCPC
Professor of Psychiatry, Psychiatrist, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA. [email protected]
As a psychiatrist, I have been fortunate to be able to offer psychotherapy in my clinical setting for a while. My colleagues and I have the privilege to work closely with patients weekly and sometimes, such a therapeutic dyad can last years. Such a bond promotes the necessary conditions (safety, mentalization skills, emotional processing though the here and now) for a patient to learn and practice new, healthier templates of attachment, and it is also a learning experience for the psychotherapist. I have said countless times that my patients have been my best teachers. A recent situation only proved this to be true once again. Except that the learning occurred in the most unexpected ways for me, in the interstices of the weekly sessions, behind the scenes of what I thought was an inalterable psychotherapeutic alliance: during the transition, the void left by the patient’s abrupt decision to terminate our work together.
Ironically, years ago, I had offered a time in my schedule to this patient after a younger colleague I supervised with whom he had been working decided to not continue. This was due to discomfort experienced from the patient’s exuberance, disinhibition and poor boundaries. I wanted to prevent feelings of institutional abandonment in him. I wanted to protect his vulnerabilities and see if I could be a catalyst for his self-understanding. There had also been some interference by a more senior colleague who disagreed with my professional opinion and who seemed to make this patient sicker than he really was. I have enough perspective now to say that this patient had only mild symptoms compared to most of the trauma survivors I work with, but the fact that he seemed so motivated and engaged made me want to give him a chance and support him in his desire for personal growth. Six years later, after having experienced the recurring frustration of a few canceled appointments or being a little late due to my own chronic personal stressors, the patient asked me to decrease the frequency of our sessions to monthly. Then, after I asked him to start the session 15 min later one day (by ensuring him we would do the full 50 min) due to a phone conference that was scheduled on short notice and that I could not postpone, he sent me a message requesting a new counselor. A wave of overwhelming emotions destabilized me. I didn’t expect this. It burned like a cut reminiscent of a breakup. I hate to say I felt abandoned.
Then, as I unpacked the evolution of our bond, this made sense. At least a little. Throughout almost all our sessions, he was showering me with compliments and superlatives. I knew with my head that this was idealization, that this could also lead to devaluation sooner or later, but I preferred to enjoy the positive experience of having a patient appreciative of my interventions. Especially in the midst of a busy day saturated with menial tasks, pressure from the administrators, dissatisfied patients and other frustrating duties.
Given his temperament and personality configuration, his high pleasure-seeking tendencies also had the flip side of generating a low tolerance for frustration and delays. Even though on the surface he seemed empathic and understanding about schedule changes (statistically more likely to occur with a patient with weekly sessions as opposed to every 3 months), some of his ego or image-related aspects (as manifested by a tendency to be seductive and wanting to please and be applauded by crowds of strangers whenever he would brighten up the atmosphere in a store or at a bar) most likely made him limited in his ability to really look at the discomfort or old wounds reactivated by my own relative unavailability. I am certainly guilty of not having always been 100% emotionally present during sessions when he alternated between entertaining monologues of his life and intrusive questions about mine. I had severe life stressors that most likely reduced the quality of my care, but regardless of my daily emotional burden, I still felt like I genuinely cared about him and gave my best, just like I try to do with each patient.
The fact that he wanted another counselor made me realize that just like in so many other areas, doctors are not spared of being seen as disposable resources. It saddened me, as I reflected on our 6 years of deep insights and shared laughter during what I tried to offer as supportive therapy. I wondered if this had all been a lie.
I tried to remain detached as I offered him, as it is my usual practice, a last session for closure (to facilitate transition, exchange feedback, voice gratitude etc), and as I expressed the fact that I was respecting his decision. In sharp contrast with his jocular nature, he coldly requested 24 months of medication refills instead. I put my hurt feelings as a yet again instrumentalized doctor aside and explained the rationale for having at least medication management sessions every 3 or 4 months, as a patient safety and professional responsibility issue.
I wish I had received rupture resolution training or some form of supervision . I was unable to feel comfortable processing this new experience with anyone except with a friend and colleague I had also mentored during a physician wellbeing fellowship. She validated my parallel with a breakup. She told me maybe it was for the best. A few days later, I even considered no longer doing individual therapy for a while as I wondered if this was a sign that I needed to explore new venues in my practice.
Maybe it was meant to happen, sooner or later. After all, psychotherapy is not an end in itself. It is a bridge that we help the patient cross. For many months, I had been caught in the dilemma of reducing the frequency of visits, because I didn’t consider him functionally impaired enough to justify weekly visits. But since I had the openings in my schedule, I thought there would be no harm. Maybe he did sense that at some point. Therapy is more than just talk therapy. It is all in the subtext. The alliance is continually negotiated within the dyad at both conscious and unconscious levels . And maybe he eventually reached a threshold of internalization of my perception of his own readiness to be weaned.
I am thankful for him letting me be part of his journey, of his life. I cared as much about his family as I did him. This has been a very eye-opening experience. Psychotherapy is not only a bridge, it can look like a mother-infant dyad. Some mothers decide their baby is ready to be weaned off the breast, others have to stop breastfeeding due to other contingencies. And I have also heard mothers say, with a sense of nostalgia or prolonged grief, that their toddler had suddenly decided to wean himself or herself of their breast. A mother often finds her relevance and reason to exist in being needed, and suddenly seeing her child spread their wings can be an adjustment if she is not mentally prepared. My patient had reached a stage where he needed to express a sense of agency, even if it was reactive or part of an acting-out to the disruption from my stressors on my schedule. I can and should examine and hold in the same mental space my own needs for gratification (feeling needed as a therapist who wants to feed or nurture the patient, like a mother her baby) and my mission to support his own path, at his own pace, just like when toddlers feel safe enough to go explore the world on their own, make mistakes and learn from others. In order to accomplish that, they must leave their mother’s breast. I am left with a sense of unfinished business due to the pending closure, but part of our role as a psychotherapist is being able to tolerate uncertainty and follow our patients’ pace. Sometimes they return when there is a new stressor, sometimes they don’t. But we should never view this as failure, for we brought each one of them a little further on the path of self-awareness. At least this is my hope.
Shortly after writing this essay, I received an apologetic message from my patient who explained he had been off his medication for 10 days and was requesting to resume monthly sessions. Too swayed by my own emotional storm, I had forgotten to inquire about his medication adherence, since in the past he had been irritable upon attempting discontinuation. Yet, I was glad I had decided to pause and pay attention enough to my experience and learn from it. It made me more serene in accepting any outcome. Now, I am looking forward to this new therapeutic phase as we work on repairing our alliance. And I intend to be more regular in my mindfulness practice to cultivate greater awareness in the therapeutic relationship. Ruptures are apparently inevitable , so what matters is our attempts at repairing by engaging our patients with compassion and welcoming their return if they are willing to rekindle a dialogue.
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- Safran JD, Kraus J. Alliance ruptures, impasses, and enactments: a relational perspective. Psychotherapy. 2014 Sep;51(3):381.