Overcoming the Pernicious Chronicle By Richard Makover, MD on 8/24/21 - 2:36 PM

Therapy stagnates when patients doggedly chronicle the events that have occurred since their last session or when they use all their therapy time to recite their grievances, bewail the injustice of their situation, and air their resentments. The therapy, in short, fails to fulfill a treatment plan. The misuse of these sessions can lead to “interminable” outcomes, where patients continue to catalog their problems but do not modify or alter how they deal with them. The therapist can be caught up in this paradigm, resigned to listening and sympathizing without making any meaningful headway in helping these patients recover.

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Worse yet, the therapist may become comfortable with this covert contract: “If you tell me your troubles and adventures, I’ll listen and make occasional wise remarks, I’ll even offer you some advice, but little will change in your life due to our therapy. You’ll be comforted, and I’ll be compensated.” This arrangement can go on for years, even decades, and only end if the patient can no longer pay, by the death of either party, or by the therapist’s retirement. A colleague of mine used to refer to these patients as “psychiatric annuities.” To him, they were an income stream providing steady payments that would support his earnings “forever.” The patient will never reach the therapy’s goals (if indeed there ever were therapy goals!) and instead become so dependent on the therapist that their lives will be diminished instead of enhanced by their treatment.

Some therapists feel comfortable with this long-term arrangement. Sessions with these patients are predictable and require little or no effort. They might even grow fond of this long-suffering patient and wouldn’t want to trade for a new case with all its uncertainties and hard work. And they’re getting paid for little or no work. If asked, these therapists might argue that they are providing “Supportive Therapy.” This rationalization adds insult to injury: The patient is incapable of change? Are they so damaged they need a weekly boost from a therapist to tell them how to live their life? Does the therapist need a therapy-dependent patient, hanging onto every word, to boost his or her own self-esteem? What is being supported? The status quo?

A real regard for the patient’s benefit, not to mention simple professional ethics, requires that all of us resist the siren’s call of these cases and, instead, interrupt the chronicle, reinstate active treatment, and forego the insidious pleasure of these unworkable, so-called supportive arrangements.

File under: The Art of Psychotherapy