:: Leaving therapy – so what’s the problem?

By at least a ten to one margin, the most read and commented-upon post to this blog is my August 1, 2007 End times: Coming to the end of psychotherapy. I had not expected this, when I published the piece.

Originally written to help one of my clients sort out their thinking as they came to the end of their time working with me, I had posted it because I did think others might find it useful. It appears, now, that it addresses a real and persistent problem. Well, such problems are what we deal with in psychotherapy, and sometimes in our blogs as well.

So, “what’s the problem”? There appear to be two of them: psychotherapy clients, and their therapists. That’s simply what the data appear to support. Let me address each, in light of the continuing comments to the blog entry, and in relation to one in particular (which was withdrawn by its author, so you cannot find it there).

THERAPY CLIENTS AND THEIR ISSUES

Clients appear to have trouble with leaving for several reasons, among which are:

• They cannot decide if it’s time or not. They don’t know how to arrive at  a decision they can feel comfortable with.
• They have to leave, and don’t want to, and it’s disturbing them.
• They’re ready to leave therapy, but don’t want to lose contact with their therapist.
• They want to leave therapy, but their therapist is objecting, or advising against it.

I think you’ll agree that that covers a lot of ground.

THERAPISTS AND THEIR ISSUES

From the report of people writing comments to my blog entry, it appears that therapists also have trouble with therapy termination for a variety of reasons, among which are:

• They think their client is making a poor decision, and really isn’t ready to leave.
• They think their client is being “resistant” to therapy, and is basically “fleeing” therapy.
• They appear committed to a long term relationship with their client, for reasons which (to me) appear suspicious, and object to a client’s attempts to break free.

I want in this post to comment about therapists and their problems, mostly, since the clients’ side of the picture has been commented upon by me extensively in my original post, and in my responses to readers’ comments.

When therapists think their client is making a poor decision, and really isn’t ready to leave. In a hospital, if the doctor treating you isn’t ready to discharge you and you leave anyway, which is certainly your right, unless you’re being held there under court order, you’re advised that it will be noted in your chart that you’re leaving “AMA” – again medical advice.

In other words, it is customary to tell you that we think (I used to work in a mental hospital) that you’re making an ill-advised decision. Partly this is to protect ourselves legally, but it’s also a last chance to ask you to think things over. Warning you about an “AMA” discharge seems good practice for both parties, and it’s usual and customary practice.

Such circumstances certainly occur in outpatient practice as well, and the same justifications for voicing and recording objections of the treating professional to the departure of the client hold weight in this context. In other words, we are almost certainly remiss if we DO NOT give this warning.

So, clients, you do well to consider the larger picture when you find that your therapist does not support your leaving. The disagreement likely has in it an element of real concern for your welfare.

Yet some clients come to therapy with the expectation (which can escalate to a demand) that their therapists “support” them, period. This is both unreasonable AND reasonable, in the following senses:

• Reasonable: Our first obligation to you is to support the promotion of your health. It’s the oldest admonition in the healing arts. This means that we need to be able to offer you an informed opinion about your condition, AND that we actually make you that offer. But…
• Unreasonable: There’s no guarantee that you’ll like what you hear  when we offer you this kind of support. Making you immediately happy is not the purpose of such support. Assisting you to be healthy in the long run IS.
• Reasonable: “Support” is a favorite word women use in talking about their close social relationships, and with good reason (men seem not to talk about this). It’s a high value for most women, and by “support” they mean what I would call the offering of emotional congruence. That kind of support is appropriate in therapy as long as it supports (in the other sense!) your health. Such support can very meaningfully help a client learn to value their own feelings and viewpoints, for example. But…
• Unreasonable: Do not expect us to support you emotionally while you make what appears to us to be a bad decision. That’s like praising you for staying on road while driving, as you drive across a washed out bridge.

So, can we do both at the same time? Can we support your “personhood” while disagreeing with your decision to leave? Of course, and I think we must.

I think that at all points in the therapy relationship we need to support our clients’ thinking for themselves. This, fundamentally, is about self respect. But, we also need to MODEL this behavior, which is what I do when I disagree with a client’s decision to leave. How can I advise you to respect your own thinking if I do not respect my own? Therapists are in many ways like parents: they cannot be, or act like, “friends” or “buddies”. We are coaches,  sources of expert opinion and intervention, and most definitely models. Any other understanding is almost always ill-informed and ill-advised.

Basically, our being both supportive and unsupportive of a client, when we find that that is our true position,  is asking a client to be an adult. We’re saying “It’s important that you make your own decision, and do what you think best. Nothing else will really work for you, howsoever scary it may be at the moment.” And then we may also say “And I do not agree with your decision to leave therapy at this time. I think it’s ill advised.” And then, finally we say (at least I say this, because I think it’s very important): “Now you have to make a lonely decision. I’ve given you my best thought, and the most important part of it is that it’s up to you to decide, just as it’s your fate to meet up with the consequences of your decision. This is the way life really is, and I’m here to help you with this little piece of it.”

Some clients have trouble with this, in large part, I think, because we therapists don’t work hard enough making clear what our purpose is: not to make life easy, but to make it better. Often, that means “no pain, no gain”. Some clients really kick and scream about this. I consider that a normal part of their life development. We’ve all done it at one time or another, believe me! And we therapists must remain adult, hold our ground, and hold out for the overall improvement of our clients. We, too, have a lonely decision to make: just as you have to do what you think best, and no one can really take over for you, so do we. It’s part of our ethical commitment to you.

(I’m laughing to myself right now…recalling how many times I know of parents who truthfully told their kids “You’ll thank me for this some day.” What a day of true joy THAT is – ha!)

When therapists think their client is being “resistant” to therapy, and is basically “fleeing” therapy. Well, some clients ARE resistant, and they do flee. The “resistance” is typically based either on a failure to understand what therapy is actually about (“What? I have to walk TOWARD my pain? Are you NUTS?”), or on fear, or both. The “fear” is more serious, more complex, and more difficult to deal with.

Just to give one example: a client I had once basically had never, as a child, had an emotionally supportive, protective relationship with an adult she could trust. I was probably the first person who’d ever invited her to trust herself (AND me) as we looked back at the painfulness of that childhood. She’d thought that therapy would be like a magic pill, and that we’d quickly and permanently anesthetize large parts of her memory.

When I advised her that that wasn’t quite accurate, she simply couldn’t trust that I knew what I was talking about. I think that she also couldn’t trust that she could survive contact with her feelings. She ran, against my advice and in spite of my best efforts to calm and reassure her. I believe her departure was due both to her mis-perceptions about how therapy works and her fear of herself and all other adults. A tough story, for both of us.

On the other hand, some therapists call any client who want to leave before the therapists deems them ready “resistant”. I strongly object to this. First, I don’t think it’s helpful in any way. Second, I think it a poor characterization of what’s actually happening.

Resistance can be a very good thing. I will resist your picking my pocket, for example. But it also can be a completely wrong word. If I resist having a perfectly good meal with you, because if I do so I’ll miss my train, “resisting” your invitation is simply rational. So is it rational if my client evaluates her situation, listens to me and anyone else she cares to listen to, then decides that what she want to do is leave? In that case, her leaving is the only sane, rational thing to do, and I would strongly support her leaving for that reason.

I have in fact most certainly told clients who I thought were leaving therapy prematurely (I do get a few!) that I thought all in all they simply had to go, that not to go would be wrong because it would be an act of self-disrespect. And I said this after telling them that I was convinced that therapy would be good for them, and  thought they needed it.

Again I say: I know this isn’t simple. But it IS true, and telling the truth is my first interest and first obligation. The challenge of understanding this truth is a completely separate issue.

WORKING TOGETHER TO MAKE THIS EASIER

From the moment I began addressing this topic, over a year ago, I knew that often it’s a difficult one for all concerned. I have, at all points, felt most concerned about the difficulties clients have with ending therapy. They are the more vulnerable, less informed, less experienced of the two individuals involved. I think we therapists need to help them with this issue just as we do with others.

Therapists get in trouble with this issue just as do their clients, sometimes for the same reasons! Sometimes their troubles are of their own making, and sometimes they are due simply to the nature of the problem. A fundamental objective of my writing on this topic is to raise awareness by both therapy clients and therapists both of the pervasive existence of this problem and of its nature.

We need to talk more with each other about this matter, preferably from an informed point of view. We certainly also need to respect each others difficulties in dealing with therapy termination. All in all, this problem isn’t going to go away, and isn’t likely to get much easier over time. It will just be there, waiting for us.

When therapy termination time comes, we need to do with this what we do with other problems in psychotherapy, turn toward it, look it in the eye, see its parts, feel our feelings, talk to each other, and, while as fully alive and functional as we can be, simply walk through the fire. It’s what we do, and it’s what we’re good at – or trying to get good at! It’s just another part of a life which isn’t always easy but which IS manageable.

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