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Endings and Transitions of Therapy
137 Plays11 months ago
In this episode, Fara and Grant talk about the endings and transitions of therapy. They talk about why saying goodbye in therapy can be tough for both therapists and patients, highlighting the significant importance of the process. They share practical advice on how to navigate the challenges of therapeutic termination, providing an approach to closure that suits individual needs. It's an insightful conversation that encourages reflection on the various aspects of concluding therapy.
We hope you enjoy.
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Transcript
Internalizing Therapist's Role
00:00:00
Speaker
When we talk about, okay, internalizing, let's say, the therapist, that means that when you've worked with someone for long enough, a generally positive relationship with them, and they become a stable and predictable force in your life, you can probably anticipate what your therapist would say or do, even before you tell them what happened with your
Podcast Introduction
00:00:25
Speaker
boss this week. So that's... Hello, I'm Dr. Farah White.
00:00:29
Speaker
And I'm Dr. Grant Brenner. We're psychiatrists and therapists in private practice in New York. We started this podcast in 2019 to draw attention to a phenomenon called the doorknob comment. Doorknob comments are important things we all say from time to time, just as we're leaving the office, sometimes literally hand on the doorknob. Doorknob comments happen not only during therapy, but also in everyday life.
Expressing Deep Emotions
00:00:52
Speaker
The point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking, and experiencing.
00:00:59
Speaker
Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them.
Therapy Frequency and Termination
00:01:05
Speaker
Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves. And sometimes we surprise ourselves by what comes out. Hi, thanks for tuning in to Dornop comments. I'm Farah White here with my co-host, Grant Brenner.
00:01:21
Speaker
Today we're gonna talk about a topic that comes up a lot in our work as psychiatrists because we work with lots of people who are in therapy and collaborate with a lot of great therapists. And often we hear from our patients that they're looking to either change the frequency of their therapy or maybe leave it all together and they are struggling with
00:01:48
Speaker
to understand it for themselves and how to discuss it with their therapist. And there are some considerations here, things that have come up in theory and things that come up in practice that we think we want to share.
Termination Phase Importance
00:02:03
Speaker
I mean, the first thing I think is important is maybe not how everyone thinks and maybe not how it always plays out. But in a very, very basic way, it is
00:02:13
Speaker
the patient's right, absolutely, to decide whether or not they want to be in treatment and to decide how, when and how much time to take when they want to stop or end treatment. Absolutely. But I think as a lot of people feel that their therapist is someone who has helped them, someone who understands them, they value that opinion a lot. So what if a person says, you know, this is my right.
00:02:42
Speaker
I'm not gonna come back here. I don't have to come back here. You can't make me." And let's say that they don't.
Avoidance Behaviors and Ethics
00:02:48
Speaker
It might actually leave that person feeling really bad one day down the line because I think we all have some sort of like impulse to flee certain things or to avoid difficult conversations. And at least in my mind, the sort of wrapping up of therapy or they call it like termination of treatment
00:03:10
Speaker
is actually one of the most important parts of ending, right? So I think by the same token that the patient has a right to stop when, how, and whenever they want, and the therapist is obligated to respect that,
00:03:27
Speaker
Therapist is also obligated to say something if they think there's something important to be said, such as, I think it would be helpful if we met at least a couple of times.
Patient Autonomy vs. Harm Risks
00:03:38
Speaker
Or I've noticed sometimes in the past, when things get difficult, you want to pull away from other situations. I wonder if that could be happening here. Of course, it's your right to leave, but out of respect for you and out of a sense of wanting to help, I think I ought to say something.
00:03:56
Speaker
And I think it's worth noting that there are certain circumstances where physicians and other licensed clinical professionals are obligated to take steps to protect someone. So what we're talking about is different if the person is suicidal or homicidal than doctors, therapists, et cetera, obligated, or if there's abuse taking place to intervene. Otherwise, the most important principle is autonomy.
00:04:23
Speaker
Right, which means that we have to find a way to respect their decision. And sometimes I think patients will bring up this desire with their therapist, but they don't want to hurt someone's feelings. They might not understand at what point are they exploring this desire versus really saying, okay, we're going to meet
00:04:51
Speaker
weekly for the next month and our last session will be, let's say at the end of December, right? And I think sometimes patients are nervous to say like, I really want to have a practical conversation.
Reasons for Therapy Termination
00:05:05
Speaker
I want to open up my time and my energy and my finances to a different type of treatment, right? Because at least these days there are so many different types of treatments and most people can't do everything.
00:05:19
Speaker
Who are things other than treatment, you know? So I think, I think we're talking about psychoanalytic therapy, which is open-ended and where sometimes when people want to leave, it's indicative that there's something else to be explored. And the psychodynamic or psychoanalytic therapist has a certain obligation to wonder with the patient if this is worth holding off on and continuing therapy to see if something comes up.
00:05:47
Speaker
And in my experience, being a therapist for over two decades and being in therapy as a patient where I've struggled with wanting to stay or wanting to leave, I do find that it is helpful to have that conversation. And as you said, the termination phase conventionally is considered to be really important because it allows people to address things like loss and transition in a healthy way, in a quote unquote healthy way, which can be used in a heavy handed way,
00:06:16
Speaker
Sometimes by well-intentioned therapists sometimes by therapists who are using their power to try to keep people in therapy who they should let leave but in many cases the feeling of wanting to leave. Actually is sort of precursor to the next stage of exploration and actually ending therapy is a very important part of therapy that's the conventional thinking.
00:06:37
Speaker
Now, that doesn't always happen.
Timing and Method of Termination
00:06:40
Speaker
And the therapist may have an idea of kind of an ideal ending. You know, for example, I was taught, and I think this is fairly traditional, that for every year that you've been in therapy, you should take one month to work through the termination. That means if you've been in therapy for three years, you would take three months, which would be something like 12 sessions of once a week. What I have found is that once people decide to leave therapy,
00:07:05
Speaker
It requires a special effort of will to remain in therapy and it is more often than not very important work because the things that were addressed in therapy all return and can get work through sort of one final time as well as helping the person to consolidate their gains and know how to be resilient and also know when to seek help again.
Therapists' Challenges with Termination
00:07:30
Speaker
So I do think the termination phase is really, really important. That's what we're trained, but
00:07:35
Speaker
especially nowadays when authority is much more kind of leveled, doctors don't tell patients what to do. We sort of give people information and help them through make a decision that ideal health termination doesn't ever happen. Doesn't always happen and say it doesn't always, doesn't ever happen. Sounds like a Freudian slip, but it's, I think it's much rarer. Um, unless the person is in really traditional psychoanalytic therapy that they really are like, okay, it's really important to work termination. It's more like, like I'll see you later.
00:08:05
Speaker
Right. But, or at least like the ability to have a conversation about what termination would look like. So let's say, let's say a longtime patient comes in and says, Hey, listen, I think you've helped me a lot, but I've had enough of this and I am ready to leave. Would you share that information with them as part of like psychoeducation? Would you? I've had enough of what?
00:08:33
Speaker
had enough of therapy, you know, that I came in here to work on some issues. Well, I guess what you're saying, right, in not answering my question is that there's that is that you would explore it, right, you would explore that desire, and, and try to understand it. And so I think when therapists try to do that,
00:08:54
Speaker
a lot of patients feel like they're not being heard. Exactly. And I wouldn't say it that way, you know, in a clinical setting. But, you know, if that's the answer is kind of a defensive answer, what do you mean you've had enough of this? Or what are you, you know, talking about, I think your point is that therapists have feelings too. And, you know, a lot of us have had difficulties in our own lives that may make it hard for us to accept
00:09:19
Speaker
and ending. And so that would predispose the therapist either to try to hang on too long or maybe to cut things off perfunctorily. But we're taught to try to gently explore and encourage that option.
00:09:36
Speaker
But what are some good reasons to stop therapy?
When is Therapy Complete?
00:09:39
Speaker
How do you know when you think, you know, therapy is done? Because for me, it's the ideal reason to stop therapy is when you've done the work that you needed to do, independent of any external factors, right? In an ideal world, yeah, there's other things you want to spend your money on. But in an ideal world, you know, you would stop therapy when it's complete, whatever that means. Right. I think it's really hard for people to know
00:10:05
Speaker
when it's complete, because there are all of these other factors at play, such as attachment to the therapist, right? So people might feel that it's complete, but they might not be ready to say goodbye, or they might have these external factors or have some anger at the therapist or something that makes them want to say goodbye
00:10:29
Speaker
and the treatment prematurely. But I think... It can go both ways. People can hang on too long or they can be dismissive and leave too soon. But there's an idea of, okay, I've done the work I came here to do. And then there's another idea, which is part of that work might be to work through ending the relationship with the therapist.
Internalizing Therapy Experience
00:10:50
Speaker
Right.
00:10:51
Speaker
arguably in an ideal world again, would be important that the person internalize the ending and internalize the therapist and the relationship with the therapist. And you could make a case clinically that that's optimal in an ideal way. Yeah. Can we break that down? Because I think that a lot of people might not understand exactly what you mean by that concept. So can you?
00:11:14
Speaker
Yeah, well, I think there's a few key ideas. One of them is what does the idea of complete therapy mean? What are the goals that are done? I know myself well. I can cope. I don't require
00:11:28
Speaker
unnecessary support. I have other people in my life. I'm resilient. I understand myself well. I have greater freedom to make the decisions. I understand the patterns that I tend to repeat, and I have more options when they come up. So that's kind of the individual work. And then there's this relationship part of it that's important in therapy, but not as easily recognized nowadays
00:11:53
Speaker
that there's something that happens that's unique to a therapeutic relationship, that if you allow it to fully run its course has independent therapeutic benefit. Right. When we talk about internalizing, let's say, the therapist, that means that when you've worked with someone for long enough and you have, let's say, a generally positive
00:12:21
Speaker
relationship with them and they become a stable and predictable force in your life. It's something that you can probably anticipate what your therapist would say or do even before you tell them what happened with your boss this week. So that's something that happens a lot with patients that I've worked with for a really long time. They'll be like, I know what you're going to say. And the truth is they do know what I'm going to say.
00:12:50
Speaker
Yeah, and that's useful. I've had this experience personally and I've had plenty of people report it to me that they're facing a difficult decision and then they pause and they say, oh, I thought I had a dialogue in my head, right? I heard what my therapist would say was, well, make sure that you make make sure that you look after your own needs in this situation.
00:13:10
Speaker
And then so that internalization of this sort of healthy part of the self can sometimes come up as remembering what the therapist would say, though it can also be like, you know, that's what I think now. Right.
Therapist-Patient Dynamics in Termination
00:13:24
Speaker
Right. Because dialogue has shifted. Exactly. Exactly. And so that to me is
00:13:30
Speaker
one hallmark of a successful treatment and also a sign of readiness. When they don't need me anymore. That they might not need me anymore, right? Exactly. And so I think there's probably a whole spectrum of this, but I think we should touch on this question of do therapists want to keep their patients in therapy
00:13:53
Speaker
for sinister reasons, such as, well, I don't know who else I'm going to get to take this time, or it's a lot of work to take on new patients. Do you mean sinister, like, explicit, intentional, and manipulative? Or sinister, like, all human beings are subject to these
00:14:13
Speaker
self-oriented needs, the therapist's job is we're supposed to put all of the needs that we have into the frame of the treatment. So appropriate fees and collections, not working with patients for too short or too long for the wrong reasons. So what do you mean by sinister?
00:14:34
Speaker
Um, I guess we'll make it the second, we'll make the second one. I don't think that there are like that many diabolical
Therapists' Ethics and Bias
00:14:41
Speaker
therapists out there. I think usually when people have that sort of hunger, it goes into like a different, it usually gets channeled in a different place. I think most therapists are well-intentioned, but that people have their practices set up in different ways. Some people like you and I,
00:15:02
Speaker
have rather large practices. So if we're gonna lose one patient, it's probably not someone who we're seeing two or three times a week, right? There are therapists who have much fewer patients that they see more frequently, and that might be a little bit tougher, let's say, to replace in terms of time and income, right? And therefore, they might be
00:15:30
Speaker
I guess more vulnerable to a resistance or they might be more inclined to try to keep the patient in therapy. Right. They might unconsciously not even realize and they might with all good intention want to keep someone around and think it's for clinical reasons. It's been rare, but I've worked with a few therapists over the years who come on really strong and tell patients they can't leave, they shouldn't leave.
00:15:59
Speaker
And I don't think that they're doing it to try to keep their income up. Healthy therapists, though, will recognize that if they have difficulty with their income, it may affect the way they approach and deal with patients.
00:16:14
Speaker
Yeah, that's true. It's also how you're trained. We're trained in a tradition where you really always are paying close attention to your own potentially hidden motivations and trying to be held to a high moral standard and ethical and moral compass. Right. I think that's actually the majority of people and the majority of clinicians. And I will say that it's probably... I think that's true too, yeah.
00:16:41
Speaker
Yeah. But what I'm saying is that even if someone is well-intentioned, if they're not well-trained, their intention may not be fully realized. Yeah, that's a good point. We always have to be aware of our own motivations. We're supervised, right? It's good to have a supervisor who says, gee, I wonder why you're having so much trouble letting go of this patient. Right. Sounds like they're doing pretty well. Yeah. That you will miss them.
00:17:10
Speaker
Right. Or what about your own history of loss? Maybe it's harder to let go of a patient who you like a lot than someone who you feel more, you know, more equanimity toward. Yeah, for sure. I remember one time I asked my analyst what it was like to work with me if it was ever difficult. And he said, he said something like, sometimes I had to hold on to my seat.
00:17:35
Speaker
And I left analysis after nine years. And, you
Outgrowing Therapy
00:17:40
Speaker
know, he kind of said maybe you should continue, but he didn't try to stop me. Nor would it have been a good idea. Right.
00:17:50
Speaker
Right. So I think that's that he sort of handled it well. You know, I went back to see him a couple of times and I worked with coaches over the years that I found helpful and consultants. But I thought I thought I had done what I could do that may have been incorrect. Right. Right. Well, I think that's the other thing that I want to say as a therapist. Right. Like I will sometimes have this feeling
00:18:20
Speaker
like, well, I've taken this person as far as they could go with me. And that there's this hope that I have for all of my patients that like one day they're going to outgrow me and they are going to need or want a different kind of therapist. And that is probably a good thing because
00:18:42
Speaker
the person that they are, maybe when they're 19 years old and they come in and start treatment with me, is not who they are, maybe when they're 25. And you've changed in that decade. For sure. And there are also maybe some things that you're not
00:19:00
Speaker
well suited to work with for a variety of different reasons or some patients who aren't a good fit. And it's important to know like when you've done what you can do or when I've done what I can do. What I've also sometimes seen is there's a bunch of factors. It may be something like the gender of the therapist, like I'm a male therapist.
00:19:20
Speaker
And some people, there are certain things that they feel much more comfortable working with a woman therapist. And if I were trying to be too idealized as a psychoanalyst, I could say, well, it doesn't matter who the analyst is. It really doesn't matter who the therapist is. If you're doing the therapy correctly, everything will get analyzed. But that's really not true in the real world. Right.
00:19:44
Speaker
There's no such thing as what we call neutrality and anonymity. There's no way to be completely anonymous as a therapist. And it's not really true that if you do the process right, everything will work out okay, because it's not the same as surgery, where it really doesn't matter who's holding the knife, as long as the procedure is done properly, the care before and after is good.
00:20:12
Speaker
Right. I agree with that. And I think that when people bring it up to me, I will say, well,
Graceful Termination Strategies
00:20:20
Speaker
have you gotten everything out of this experience that you wanted to get? And what do you continue to get? What's keeping you there?
00:20:29
Speaker
Is it an attachment? Do you like the support? You want to review the work. When someone brings up, maybe it's time to stop, then if possible, you want to say, let's review what you have accomplished and what may be left to be done. And if the person does leave therapy, it's important to have that understanding, I think. Right. And I think that sometimes, I guess I'll speak from my personal experience as a therapist,
00:20:55
Speaker
I find it hard to say goodbye. So a lot of times, if I know that, let's say weekly therapy isn't right for the person anymore, or maybe they don't need it, or maybe they can't afford it or whatever, I will say, okay, well, why don't, yeah, we'll meet twice a month or once a month and I sort of taper it down and
00:21:19
Speaker
I think that's probably my own stuff because I don't want to have to say goodbye because the goodbye is hard. I mean there's a debate there as to what's best for the patient and in some cases I've had you know in some cases I think from a clinical point of view it's preferable for the patient to reduce the frequency
00:21:40
Speaker
and terminate more gradually i think for other people it seems you can make a case that it's better for their their mental health to pick a date and stop after that date it's also a little bit different as a psychiatrist because we're accustomed to working with people less frequently and it's it's a different model from the strict psychoanalytic right.
00:22:02
Speaker
For sure. And I think that both of us. Either you or I are strictly psychoanalytic. No, no, no. But we're also very fortunate. And I think most clinicians in New York probably feel this, where we're able to fill a practice. We're able to accommodate that because it's not, you know, that spot is going to get filled, right? It's also different because we offer more services than someone who only does therapy.
00:22:28
Speaker
because we medical treatments and so on i'm within the psychoanalytic idea that just coming back to what can we learn from when we think about stopping therapy whether whether we stop then or whether we say okay let's meet for another six months and see if something significant comes up.
00:22:46
Speaker
There's
Paternalism vs. Autonomy
00:22:47
Speaker
an idea that wanting to stop, and you alluded to it before as a kind of anxiety flight from fear, is that there's an idea that wanting to stop therapy sometimes is what's called resistance. And resistance is not a judgmental term. It was a term used by Freud, like in the original German, whatever that term was, maybe someone can email us the term or we can look it up. But the idea is that when people try not to do something that appears to be in their best interest,
00:23:16
Speaker
It's important to try to be curious about that. In psychodynamic therapy, resistance and analysis of what's called the transference, the relationships that people bring into therapy that they kind of project onto the therapist,
00:23:34
Speaker
analysis of both resistance and transference is very fruitful. And so, you know, you ask yourself if someone brings up stopping, is it time to stop? Or if there's more work to be done, could this be a reflection of resistance? If so, then the right thing to do clinically would be to try to analyze that and work with it. For sure. But I think where I take a little bit of an issue with this is it just has like
00:24:03
Speaker
a sort of paternalistic undertone, a patient is expressing a need. And then we're interpreting that maybe correctly or maybe not to be quote unquote, like resistance, maybe sharing it with the patient like, okay, this is something and that's where I really like. And that's why I wanted to talk about this because so why sorry, why paternalistic versus say authoritarian?
00:24:28
Speaker
And what would a maternalistic therapist do? So I think paternalistic, I guess to me implies that there is some authority and there's some, I know what's best. What's best is for us to work through this resistance together and have you stay in therapy.
00:24:45
Speaker
Yeah, I mean, I can understand why you might hear it that way. It may be true, but clinically, just for the clarity of the list, resistance does not represent a judgment that the patient is bad for avoiding something. It's a technical term that refers to when there is something that it would be useful to understand. Whether you try to force the person to do that or not,
00:25:13
Speaker
is an entirely different story. I would never try to force someone to do something. Right. Of course not. But I think that sometimes, you know, we share our interpretations with patients, right, if we think it's going to be helpful. And a lot of the times we don't. But when it comes to something like ending therapy, you know, scheduling, changing times, I think it's helpful for people to be able to see behind the curtain a little bit.
00:25:42
Speaker
I think it should be considered just good practice to share what comes up. On one hand, I hear that you feel ready. On the other hand, I'm wondering if this concept, and I'm going to explain it to you, makes sense right now. And if you feel, I want to make sure that I'm just
00:26:03
Speaker
providing the best possible care by not saying, like, sign R. Yeah, I agree
Long-term vs. Short-term Therapy
00:26:10
Speaker
with you. And if you remember when I was bringing up the idea of resistance, I was talking about that as one of the possibilities when people want to stop. The other one is either they need to stop even if they're sort of not done with therapy. That's totally valid.
00:26:28
Speaker
or they've completed their therapy. So I think it's particularly important for the therapist not to misuse their authority and particularly not to gaslight patients by saying that everything is a sign that they need to do more therapy.
00:26:43
Speaker
If that's happening, it's not good. If everything is like you need more therapy, then I think that's a good sign that you may be dealing with a therapist who has unresolved issues and in some less common cases is motivated for the wrong reasons. It's very tricky because I do longer term therapy with people and I'm always like, hey, really, whatever is best for you.
00:27:10
Speaker
Stopping doing something different trying different type of pharmacologic treatment stopping meds trying new treatments seeing a different therapist trying a different kind of therapy. I'm always open to those ideas and what i find is for some people they don't stick around they do find something else but there are some people for whom and this is a little more controversial longer term work is really helpful.
00:27:34
Speaker
Absolutely. And that's the sort of key question about termination, you know, short term therapies that are more cost effective versus being in therapy for some years. Like I was in therapy for nine years with my last psychoanalyst. Before that, I had had therapy for different periods of time, sometimes a year. So I know that shorter and longer term work can be helpful. But our society tends to frown upon longer term work.
00:28:01
Speaker
Right. Well, I think that the longer term work that people tend to really get a lot out of it and that it can obviously it's going to look different at year two and year seven and year nine. But I think for people who would like to have that experience,
00:28:20
Speaker
It's a great one to have. What's the value of that experience other than, you know, it's nice to talk to someone about yourself. And I remember Oliver Sacks, there was a video circulating, the famous neurologist and writer, after he passed away, he was, he was saying, I've been in, I've been in analysis for 43 years, not because I need it, but because I find it helpful to talk about things. But there is another idea that, you know, it can actually be therapeutic and the data shows that it's
Psychoanalytic Training Influence
00:28:45
Speaker
effective.
00:28:45
Speaker
and not only is longer-term therapy at least as effective as shorter-term therapies, like we were saying before with this idea of internalizing the therapy, the benefit continues to accrue after the therapy ends. So it changes your function as a person. So I wanted to ask you what your thoughts are pragmatically about why should I give up the two Lamborghinis that I might have bought in those nine years of analysis? What am I getting?
00:29:13
Speaker
Well, you could get a lot, right? And I guess that's in the eye of the beholder, right? What they believe that they're achieving. And I think there are a lot of people who feel like, oh, I was in therapy long-term and I feel like I was sold a bill of goods because I just feel better if I go to a yoga class, right? If people are looking to feel better quickly, long-term therapy is maybe not the best idea.
00:29:41
Speaker
if they're looking for a trusted outside source for someone to be on their team in their corner, a support over the duration of a very stressful period in life.
00:29:55
Speaker
I think long-term therapy is a way to assure that, right? I mean, I have or I partially agree with you because I do think in the short range, it's really important even if the therapy becomes long-term therapy to help people manage whatever crisis is coming up right away. And then once you're in a better place, you can think about whether ongoing therapy would be helpful. But I do think that even therapists who sort of do psychoanalytic work over the long-term
Measuring Therapy Value
00:30:23
Speaker
Want to be prepared to help people in the short run unless they really don't treat those patients but the patient has a right to know whether the therapist is gonna be able to help them with a crisis or not and You know if you don't do that, that's fine Totally fine, but I do think it's important for the therapist to be transparent about what they will and aren't able to do one of the things that's interesting to me is
00:30:43
Speaker
Some of the history here, Farah, is you know this, right? The way cognitive behavioral therapy was started, Aaron Beck, right, started CBT, was in psychoanalysis for quite a long time, decided it was a waste of time or worse, and started his own model of therapy, which has become wildly successful, CBT. And it's kind of ironic because
00:31:06
Speaker
You can see it however you want to see it. You could say, Oh, he was right. He left and he made something better. Or you could see it and say his psychoanalysis was very successful. He left, even though he left on bad terms, he went on to invent something that worked better. That helps a lot of people. And if you really dig into CBT, a lot of the same principles are in psychoanalysis, but just not as focused on goals and homework and concrete roles.
00:31:35
Speaker
Right. And so it may have been that his years in psycho, I mean, we don't know, but his years in psychoanalysis allowed him to distill out what he felt was the most useful, right? And so that's what we want for anyone who's in therapy long-term. It's like, what was the most useful part of it? Was it having that stability and having that support? Was it having
00:31:57
Speaker
someone to challenge you and help you grow or having to advocate for yourself and needing someone who encouraged that. So I think people should just know what they're getting. I think they should feel free to have those discussions. This is a sore point, though, because it's like, well, why won't you just tell me what will help me?
00:32:20
Speaker
I will. Why do you need me to play with you? Right. And but the thing is, I will share with people exactly what I think would be helpful. And I will share with them a timeline. If you're not better by this point of the year, you know, then I think we need to start exploring some other options. You know, I never I look at it like my job is to really show them
00:32:45
Speaker
everything that the field has to offer. Well, I couldn't quite do that, but everything that I know of that might be helpful, right? You can't do everything, but you have a knowledge. Or you can refer for an expert second opinion. So if something, and I do check in with people and make sure that. You have to know your limitations as a therapist, as a psychiatrist. Right. And I also think that sharing those limitations with patients is an important part of this.
Systemic Issues in Therapy Access
00:33:15
Speaker
And to be honest, that we can't always see our own blind spots and that everyone who does this work should
00:33:24
Speaker
somehow be processing it either with a supervisor. And that's something that patients can ask, right? Well, I think what you're saying is very concrete is like, you know, in medicine, we call it informed consent. This is what I do. This is what I don't do. This is how I think it will help. This is where it can cause harm. Here are the alternatives. And we'll check in periodically on how treatment is going.
00:33:46
Speaker
I think what's more problematic in terms of Freud wrote a paper called Analysis Terminable and Interminable, like ending and never ending. The problem is, I think, especially if by virtue of the model or the training, the idea is that you will be in treatment for years and years and years and years. And that's just what happens. And it's not really questioned. And I think that's rare nowadays. For sure.
00:34:12
Speaker
But I still also know people who have been in analysis for 14, 17, 20 years or longer and find it very helpful and aren't involved in any kind of coercive dynamics and have fitted into their economic planning and think it's well worthwhile.
00:34:30
Speaker
I want to ask you is, you know, as a kind of a notion here. Okay. So we have an idea that health is a basic human right. Great. If you had sort of a rough childhood, then it's not really fair to have to pay for a lot of therapy and we don't have a national health service that pays for therapy.
00:34:49
Speaker
And insurance companies are difficult to work with around therapy. And there isn't a good solution for people to get help when they need it in a way that's affordable. And so there's an inherent kind of injustice on the systemic level, where it's like, oh, really, I need to pay all this money and spend all this time to fix stuff that wasn't my fault. I think that's a fair feeling. People need to work through that. But how do you think about it?
00:35:14
Speaker
when someone is in therapy for a long, long time? And why are people willing to spend so much money on some things and not sometimes therapy? Right. Well, I think that people are willing to spend money on things that where they can see the value.
00:35:31
Speaker
So what if you found out that you were working with someone and they said they couldn't afford your fee and say you were giving them a reduced fee or something like that or not. And then you found that they were spending large amounts of money on something that at least to you didn't seem so valuable. It might seem frivolous or even self-destructive. They were spending money on material possessions they didn't need. They bought their fourth car or they were drinking a great deal.
00:36:00
Speaker
And they said they can't afford to pay your bill, but then they're telling you about the $900 bottle of 200 year old Scott bought. How do you deal with it as a therapist? My first thought would be to be curious about it. What would your first feeling be though? Well, I would never have a fee. I had really good supervisors in my residency and I learned
00:36:22
Speaker
to never accept a fee that I would feel resentful about. But what I'm saying is if, let's say you're taking like a reasonable fee, but the person is saying, you know, I think I need to cut back to every other week. And then you're like, okay, you know, that's fine.
00:36:37
Speaker
And then they're talking with you and they say, Oh, I just bought a bottle of 20 year old Macallan for $900. You know, and I think I deserve it, right? You've actually helped me come to understand that. And then you may have some cognitive dissonance as a therapist, like I'm cutting back and the person is spending all this money, but they say it's for financial reasons. Maybe, but I might see it as, well, I don't know about the scotch. Right. I might see it as, Oh, well something,
00:37:07
Speaker
good happened here. It depends on like, like, let's say the, the psychological thing of the person, because for people who tend to have trouble spending money on themselves, but they want to feel better. Um, that is actually like a really, really tricky thing to be able to do. And so to get someone to value their health or their education or their comfort and safety, that's like one of the main goals of therapy.
00:37:35
Speaker
The other things, right, if people are buying their fourth car or they seem like really, really attached to other material possessions, I would say maybe they see a value in that car and they're not feeling as much value here. And maybe we should look at that.
00:37:53
Speaker
And it's not for you to kind of judge how they spend their money. It's not for you to judge, no. But if it doesn't work for you, that's important for you to recognize. Right. And also, I think driving a car down the FDR, if it makes them feel good and it makes them feel happy, that's giving them something that I can't give them. That's valuable. The experience is valuable versus saying, why do you need another car? You should do more therapy. Right. It makes you happy. It can't be that bad.
Unique Therapy Relationships
00:38:21
Speaker
Who's that? I want to share before we stop, there's a paper that a famous psychiatrist, psychoanalyst named Glenn Gabbard wrote on termination. It's called
00:38:34
Speaker
What is a good enough termination? And I don't like the word termination, but for some reason that's how they translated Freud. So we say termination endings is a bit nicer. So he quotes Freud in that paper. He says, the analyst pursues a course for which there is no model in real life.
00:38:52
Speaker
And so therapy is a different kind of relationship than in the other relationship it's a relationship characterized by. Sort of endless curiosity even even when you stop you're always curious you're always non judgmental to the extent possible and you're always curious about yourself maybe i'm consciously non judgmental but i'm unconsciously very judgmental and so.
00:39:13
Speaker
One of the things that Gabbard mentions in this paper, which sort of fits with what the Freud quote about it being unlike any other relationship, he says, or he writes, in real life, of course, an intense relationship involving love and profound attachment is brought to an end only by death, by extraordinary rage, or by severe narcissistic injury. And so he's saying,
Emotional Aspects of Ending Therapy
00:39:39
Speaker
Therapy ends differently from any other important relationship because you choose to end it even though the person is still there. And you haven't had a major falling out presumably with a voluntary angle. So what are your thoughts about that at the end of this podcast? Well, I think it is sometimes very important for people to be able to say goodbye to people
00:40:08
Speaker
rituals, therapies that no longer, that they no longer need or that no longer suit them. I think if we want to get really like analytic, we could say, well, this is a rehearsal for like that ultimate separation, right? Between earth and, you know. You mean dying? Yes. Yes. Their fears of mortality get brought up during the termination phase of therapy all the time.
00:40:34
Speaker
Yeah, for sure. But this is, I think, one way that people can actually manage those fears. And you learn how to deal with fears of mortality by working through an ending rather than sort of jumping from therapist to therapist or stopping sort of unfinished and leaving that unfinished. Right. It's your choice. Right. For sure. I think, though, that ability to feel sad
00:41:02
Speaker
and to let go and to feel that this person really helped you. And maybe, you know, the door is open or maybe it's not, you know, but I, I always love hearing from former patients, you know, even a voicemail and email always feels great. And I know that it doesn't mean that they want to come back, but I know that there's this acknowledgement, like even though we're not working together anymore, you're doing well.
00:41:28
Speaker
They're doing well. And they're taking care of you by letting you know because you like to know. Yes. And most therapists, I think, would like to know that.
Podcast Conclusion
00:41:42
Speaker
There's also an example of kind of a clean termination, but I think it's not unusual and it's healthy and natural for people to reach out and say, hey, I'm doing well.
00:41:51
Speaker
Right. We're wrapping up now, but I also think that's something that can be discussed in the therapy. Like, well, what is it going to be like when we're not working together? Like if I call you or you're not going to call me back or are you going to get right back to me? That's exactly why it's important in an ideal world to have enough time to think through that and many other things.
00:42:12
Speaker
And a lot of people, they're like, this is not goodbye, this is see you later, you know, because it's hard to deal with death. And again, you can't force people to deal with things that are so uncomfortable, but you can kind of put it in front of them and talk about it evenly and give a choice. You can also avoid it, right?
00:42:32
Speaker
Here we are. We're not going anywhere. Stay tuned for our next episode of Doorknob Comments. You can find us on different social media channels at doorknobcomments.com. I think on Twitter it's at doorknobcomment with no S and our website www.doorknobcomments.com. We would love to hear from you. Let us know how you're doing after listening to this episode.
00:43:02
Speaker
Remember, the Doorknob Comments podcast is not medical advice. If you may be in need of professional assistance, please seek consultation without delay.