When is a person ready to leave counseling? What do they need to learn or achieve or grow toward? — T.F., Detroit, Michigan
What a great question! I think termination (as it’s called in the trade) is another part of the art form of therapy. The willingness and skillfulness of your therapist in helping you end therapy are a competence people should expect from competent therapists.
Termination — funny moniker, yes? Ever since film director James Cameron gave us the now-iconic Arnold Schwarzenegger character (1984), I’ve had this zany fantasy that someday, during a last session with a patient, I would feign an Austrian accent and say, “You’re terminated.”
I have thus far resisted the temptation.
I’m going to answer your question in two parts. This column is Part One.
In the near 30 years I’ve been plying this craft, there are three basic ways a patient might employ a therapist. The first is as a resource consultant. These people come for one, no more than three, sessions to pick the therapist’s brain about a particular issue. For example, what can I expect as my children adapt to their parents’ divorce? What’s the latest research about the viability of marriages with significant age differences? Premarital counseling falls into this category.
When I’m deployed in the role of consultant, termination is no big deal. I’m appreciated perhaps, but there’s no significant bond. No more than with the knowledgeable, informative landscape architect who walked around your backyard with you for thirty minutes, talking possibilities and prices. Nice person. Knew his/her stuff. But that’s the beginning and the end of it.
The second use of a therapist is in crisis intervention. Triage. Assess and refer. The “intervention model” is most often two to six sessions. It’s intense. No psycho-freudian navel-gazing because there is no time. People need advocacy, protection and support right now! Or else someone is going to burn down a marriage. A family. A career. Go to jail. Or the hospital. Or the morgue.
In competent crisis intervention, a bond tends to be formed that is not dissimilar to the bond you’d form (assuming you were conscious) with the EMT tending you sprawled on a sidewalk. Or a firefighter on your front lawn at 2 a.m. You’re glad, even very emotional about having someone who knew exactly what to do and exactly what to say at a time you were lost, overwhelmed, terrified and feeling crazy.
But again, termination is “built in” to crisis intervention. It often reminds me of watching “The Lone Ranger” on television when I was a boy. He comes in, saves your life, and about the time you’re recognizing that the crisis is past and you’re going to be fine, all you see is the receding dust cloud trailing behind a galloping horse. “Who was that masked man?” the pilgrims would ask as the credits rolled.
Termination gets trickier — much trickier — in more classical therapeutic relationships lasting several months or even a year or more. When therapy works, these sort of therapeutic relationships have lots of energy. Big Medicine. Weighty indeed. Some patients just know when they are done. And they just plop in and announce it, with a typical shrug of the shoulders and a little shy, self-consciousness, as if they fear hurting my feelings.
Slightly more often, however, patients ready to terminate will become inexplicably busy. Suddenly, it becomes much more complicated to schedule them. Or, suddenly, they begin to be late to sessions. Or to forget them. Or to “no-show.”
In still other cases, they will find cause to be angry or disappointed in me. Or they will risk philosophical disagreements, even enjoin spirited arguments with me. Or they will become slightly belligerent, saying things not dissimilar to an adolescent: “I don’t care if you’re mad at me,” etc.
All of these can be signs that a patient is finding difficulty and discomfort in terminating.
Well, of course it’s hard. It’s a necessary loss. The goodbye we say to the therapist who helped us is an important goodbye. And usually a painful one.
My former therapist lives in Phoenix. I’ll never forget her. Intellectually, I’m aware that she is a regular human being with a life and a family and “ups and downs” just like everyone. But, to me, in my psyche, she also will always occupy the office of Mysterious Shaman. Occasionally, I still dream about her.
I wept during my last session. There were tears in her eyes, too.
The ground between us will always be holy.
When is a person ready to leave counseling? What do they need to learn or achieve or grow toward? What about someone who is in counseling for an extended period, longer than what should be needed for whatever issue they have?
— T.F., Detroit, Michigan
This is part two of my answer to this question. Readers can catch up to this discussion at www.reviewjournal.com/columns-blogs/view/anthem/there-are-three-basic-wa….
T.F., this question is a great challenge to any therapist who has a sensitive, personal investment in quality patient care — what it means to add real value to people’s lives, as opposed to wasting the patients’ time. Evoking a fostering protracted, contraindicated dependencies, etc.
Let me put it to you crassly: I’m very alert to the voice inside my head that occasionally says, “Is it OK to keep taking this patient’s money?” Put another way, is it ever the therapist’s job — hell, ethical duty — to suggest, initiate or even unilaterally decide upon terminating a patient’s course of therapy? If so, under what circumstances?
In the near 30 years of my professional life, I have unilaterally terminated a patient twice. And, on both occasions, the patients in question were given fair, extended and ample warning under what circumstances I would terminate. So, in a sense, it wasn’t unilateral. It was more like giving your teenager six separate warnings that, if certain conditions weren’t met, he wouldn’t be allowed to acquire a driver’s license on his 16th birthday. And the teenager decides to test your resolve on the matter. And he doesn’t get his license.
I’m saying that never have I unilaterally terminated a patient because I decided he/she was in therapy “longer than what should be needed for whatever issue they have.”
Not that I haven’t agonized over whether I should terminate. I am never not aware of the occasional patient who seems to be lingering (or malingering) in therapy. They are faithful in attendance. On time. But the conversations seem to be less focused. Past-timing. Even interesting. But more like two friendly neighbors chatting. In some cases, after several weeks, I admit to myself the conversations never have been focused.
I interrupt a lot in session. Because I’m a focused kind of guy. Especially with anxious, emotional types. The kind who, if left uninterrupted, tend to get stuck in a ping-ponging verbal intensity. This usually works. It helps this type of patient to feel the safety of my more direct, focused questions. It helps them look deeper.
But, sometimes it doesn’t work. No amount of my interrupting, looking confused, joining with empathy or strategic detachment seems to make a difference. Occasionally I even run a one-session experiment: If I don’t utter one word during this session, will this patient even notice?
And they never do. Hmm.
So, what do I do? What do I do when, in the privacy of my own heart, it never or rarely feels like we’re digging into anything of substance? Or, if while for months we did dig in and “make hay,” now it seems like we are coasting on a plateau? Or what about the patient who always digs in to substance, yet, frankly, doesn’t seem to get better? They just keep coming in, week by week, to bemoan the same sufferings?
Surely I’m not a Professional Friend. (Don’t laugh. Patients sometimes chuckle out loud, and say with great irony, “Do I pay you to like me?”)
Every one or two years, I’ll call my supervisor to say I feel guilty about taking someone’s money. That I don’t know why they keep coming back. That I wonder if I should refer them to someone better suited, trained and equipped to help them.
And — every time — my supervisor challenges me in the same way. He says my “guilt” is my own problem. My own neurosis. My own insecurity. An especially subtle countertransference.
He reminds me that some people are so badly damaged as to warrant ongoing support merely for the support. Others pop out the other side of effective therapy, greatly healed and more whole, and then desire to use therapy because they enjoy being in therapy! The way some people enjoy going to the gym. He says when in doubt, check in. Ask. “How has/is therapy helping you? … What goals are left unmet?” Or, the real zinger: “How will you recognize when therapy is over?”
But, beyond that, it’s part of therapy to respect the patient to decide when the work is over.