I had been seeing a therapist for about a year for depression. She was fantastic and brilliant, and now I feel so much better. However, now that I feel good, she told me that I can’t come in anymore. I like to go and talk to her about my week because I don’t have any close friends to chew the fat with, but she said that she won’t see me anymore “unless I have something specific that I need to work on.” Is she right, or just a bitch?
This question coincidentally follows our theme of ending therapy, but the roles are now reversed. When is it appropriate for a therapist to terminate treatment? My first reaction to this query was “Damn straight Mark, she’s a bitch!” but then, on second thought, maybe not.
Psychotherapy, by definition, involves ameliorating some type of psychological or behavioral problem. If and when that mission is accomplished, the client ideally goes on his or her way and treatment is over. However, some clients, even when feeling better, can become “overconsumers of therapy.” That is, they become attached to the process and do not want it to end, despite not necessarily needing the therapy. This is generally not a good thing.
Therapist Rule: When you are no longer working on a therapeutic goal, addressing a specific problem or issue, or not helping a client understand himself or his life, then you are ethically obligated to end treatment.
This Therapist Rule, however, is quite broad and open to interpretation. I’ve worked with several clients for many years, people who have initially come in for a specific psychological difficulty (e.g. panic, depression, anxiety) and have felt much better because of the therapy. Some of these clients have enjoyed the work we have done and want to continue, even in the absence of psychological symptoms. In cases like these, I agree to continue working together.
This agreement, however, is contingent upon the clients’ willingness to understand themselves or their world at a deeper level than they already do. In other words, I will not serve as simply a Sounding Board or an ear for which a client can prattle on to for 45 minutes about nothing. That’s what best friends are for. Or at least drinking buddies. We need to be working on something related to the client’s psychology.
As an example consider Jill, an early 40’s woman with a good job as a banker, two children, and a husband of 15 years. Jill came to me early in my career due to work stress that was generating strong anxiety and sleep problems which she felt would impact her work. Over a few months, Jill responded very well to rudimentary muscle relaxation, lengthy discussions about whether or not she should remain at her job and coaching on how to better communicate her needs to her superiors during times of stress. When her symptoms remitted, I assumed we would stop our weekly meetings, but she insisted on continuing. I agreed, because as a neophyte therapist, I didn’t know that clients would use sessions for something other than therapy.
The next week, Jill wanted help in deciding which caterer to hire for her family’s next party. Then she wanted to tell me about her friend’s dog and how cute he was, “especially with the little hat and sweater that [she] had just bought for him.” She then moved on to the benefits of decaffeinated coffee over regular, and whether anyone had ever killed him/herself after reading one of Ann Coulter’s books. These conversational threads were unacceptable.
“Jill, I don’t understand why you are talking about all of these things. What is it that you need help with?”
“I don’t need help per se,” she said, “I just want to think out loud, to bounce ideas off of you.”
Clients often have a need to think things through, which is fine. However, she hadn’t actually asked for my opinion on any of these subjects, so she definitely wasn’t bouncing anything off of me.
“I see. I don’t understand, though, why you need to do that here, to pay your money on something that you could discuss with a friend or family member.”
“I just like to do it here,” she protested. “It’s my time, so I’m using it as I wish. I’m paying you, so I call the shots.”
Deep down I know that I’m essentially an employee providing a service, but being called out as such has a way of pissing me off.
“Let’s get something straight here. Yes, this is your time but, more correctly, this is your time for therapy. It’s not for whatever you’d like to do. I am here for specific reasons, and discussing canine outerwear or Republican propaganda are not some of them. I will assist you with any psychological problem you have, or if you need help in understanding yourself and your world better, I am here for that too. Catering fees and coffee grounds are not part of therapy though, so we need to come to an understanding about what we are doing right now.”
Taken aback by my “as close to confrontational tone as I can get” response, Jill paused, then smiled. “Fine. Did you know I slept with my assistant yesterday? My female assistant?”
My eyes widened. “Really?”
“No. I just wanted to see the look on your face.” She laughed.
Therapist Rule: When a client is jerking your chain, either help the client understand her behavior or verbally kick her in the teeth.
“Jill, you are either attached to me and/or the therapy, or simply don’t respect this time and feel that you can use it for whatever you want. The latter is not acceptable. Tell me what is going on.”
“Okay, I’m sorry. I’m really sorry. I don’t want to leave therapy. I love my husband, but he’s so busy, and I don’t have a lot of friends. It’s just nice to have someone to talk with. Is that wrong?”
Therapist Rule: Always educate your clients on the difference between therapy and friendship.
“Okay, now this makes more sense to me. Many clients become close with their therapists and begin to see them as people to have casual conversation with. But therapy is not happy hour, and we need to make a decision about where this therapeutic relationship is going.”
“You want me to go” she said, somewhat dejectedly.
“Not necessarily. But we need a valid reason for you to be here. Something I heard you say earlier is that you don’t have anyone that you can confide in about the daily grind of life. Do you have any ideas as to why that is?”
After a few seconds of mulling this over, she responded. “Probably because of all the time I spend at work and with the kids. But I don’t know. You’re the shrink, you tell me.”
“Well, you know yourself better than anyone, but that definitely sounds like a valid and common reason. Maybe we need to work on helping you find either the time or the people to have these conversations with. If you had that, do you think you’d still need to be here each week?”
Again, a pause (note: therapists love pauses, as it implies that you are in deep thought about what was just said to you). “Probably not. I feel good about life in general, and I’m not anxious anymore. I just don’t have enough regular friends, you know?”
Jill and I worked on this issue for several weeks. She ultimately decided that she and her husband needed to create more quality time for them, and she became more active in contacting friends and initiating social engagements. Work suffered somewhat because of this, but it proved to be nothing that she couldn’t handle. And when we put the finishing touches on this particular issue, Jill was ready to say good-bye, saving me the trouble of firing her.
Mark’s letter taps into a similar issue: why doesn’t he have friends to talk about the daily occurrences of life with? If he needs someone to confide in, shouldn’t his therapist help him to figure out the right resources? In other words, doesn’t Mark still have something to work on?
Mark’s therapist is actually right and a bitch, so gets both props and condemnation. While he does need to “have something to work on” if he wishes to continue, his therapist could help him to see if he truly has something else to address, rather than simply leaving him in the lurch with a pithy statement and a termination notice. I hate people like that.