The Dreaded Phone Call
Recently, a client of mine left the following message on my voicemail: “Hi Melissa, I just wanted to let you know I won’t be coming to my appointment tomorrow. I’m feeling fine now. I’m not coming back, but thank you for all your help. I’ll call you again if I need you.”
Of course, I called her back. It’s the age of caller ID, though, and not surprisingly, she did not pick up. Nor did she return my call, despite my delightfully supportive message wondering if we might at least have a wrap-up session.
Clients cancel appointments and leave therapy prematurely for all kinds of reasons. It’s not the first time I’ve been left by a client and it won’t be the last, but, admittedly, it had been a long time since I’d given much thought to endings.
The world of modern psychoanalysis does not put termination near the top of the training agenda. Most everything is looked at as a resistance to treatment. I like this a lot, actually—first because it puts the focus on studying the client’s unconscious, and second because it then puts the focus squarely back on mine. And it encourages studying emotional communications and unconscious obstacles to treatment with curiosity and interest, which is profoundly soothing to the part of me that tends toward self-attack and self-doubt. Looking more deeply at the challenges that get in the way of the work continuing is a good way to help the work continue.
Frankly, termination is not really at the top of anyone’s list in terms of training. In fact, much of the information out there focuses mostly on professional ethics, process, and client rights. There’s not a whole lot about what we therapists are left with when clients leave after a planned termination process, let alone when they drop out of sight without so much as a good old-fashioned goodbye.
“When clients leave suddenly, we have little recourse, but big feelings.” We pull out all of our training nuggets to help us try to understand what happened. We can figure that maybe they got what they needed; we can look back to the last session to see if we may have hit the wrong note; we can wonder if perhaps they are protecting themselves from something, or protecting us by leaving abruptly or without discussion. Perhaps they are protecting us from their rage, their hopelessness, or their discontent.
And we can think about our patients’ characters, history, patterns of functioning. Our clients might be letting us know finally how they have felt, being left in their lives—frustrated, discounted, ignored, worthless, abandoned or powerless, perhaps—which is often how therapists feel when clients leave without warning or discussion. They give it to us good over the psychic airwaves. Abrupt exits from treatment can be jarring, aggressive or even mean. The emotional communication is powerful, and while it can give us valuable information about the client, it also can be a window into our own psyches.
Therapists Have Feelings, Too
For good reasons, we therapists don’t often like to admit that we have feelings towards clients, let alone strong ones. We may be ashamed or embarrassed of our reactions, or even afraid—especially when we feel injured, abandoned, angry or stung.
Yes, of course we study the countertransference: we know we can go far enough, at least, to notice a feeling and give it a nod, to guess at where it comes from and maybe how to use it in session, for the benefit of the client. But beyond that, we hedge. Though we feel, deep down we think that we should not actually feel anything—not unless we are sure it’s in the best interest of the treatment. Not unless we have our professional head on—our dignified, composed, contained persona.
After all, we are trained to focus on the client, even when studying such ideas as subjective countertransference, when the emotional communications of the client trigger unconscious, unresolved conflicts in the therapist. For instance, when a client says that the therapy is not helpful, if the therapist has the impulse to be self-attacking or self-doubting, she may personalize the feelings, feeling anything from anger to hurt to worthless. And she may collude with the client’s desire to leave to avoid having to feel all those bad feelings.
Strangely enough, the fear that a client may leave, is, in some instances, really an unconscious wish—especially if that client brings us too many hard-to-bear feelings, or if we are burnt out or frustrated, or fear we are doing a bad job. And it’s possible that sometimes clients are onto something in us. Clients are often sensitive to emotional communication from us as well. Sometimes we may be sending the message that they are not wanted in some way. They may need much assurance that we are trained to welcome all their feelings, and help them do the same.
One client I work with wanted to stop coming because he imagined he was inconveniencing me with his weekend appointment. Another wanted to stop because she was fearful of how big her anger was. She believed I was frightened of her. Good discussions with these clients not only headed off ending the treatment, but led to all kinds of insights into their character, wishes, life experiences and patterns. And while it may be tricky to study the transferences, when it comes to endings everyone fares better when we do.
In the phone supervision groups I run, we talk a lot about termination. We debate all the ways to prevent abrupt exits, and avoid being stuck holding the bag of bad feelings. We talk about ways to help clients stay, to deal with difficult feelings differently. We discuss the merits and drawbacks of ongoing evaluation tools, professional protocol, policies, and termination letters. We wonder about preparing for discharge right from the start, checking in at each session to see how things are going in the therapy, having billing policies or not having them. But I think it’s also defensive driving. We do need to act ethically and we do want what’s best for our clients, but we do not want to be hurt. We do not want to be left. “Many of us do not think we are supposed, or allowed, to feel anything genuinely and deeply when it comes to our clients, and we most certainly don’t want to feel all the feelings that being left drudges up.” Some of us will do whatever we can to prevent bumping into abandonment, and its steadfast companion, inadequacy.
We can’t always attribute these feelings to the transference alone. Many desires are shared among therapists: to do good work, to sustain a solid income, to feel effective and accomplished, and, when possible, appreciated.
Therapists do lose sleep over these things. Our fears may get triggered when clients leave under any circumstance, but all the more so when they ditch us without so much as a “see ya.” Even planned and successful terminations can leave a therapist with a host of feelings, from loss to fear to doubt—especially if the therapist is not convinced it’s best to terminate, or does not feel that he has a real say in the decision, or if the client is leaving for external reasons like moving away or scheduling conflicts (and even these could potentially be worked out).
And if our practice is less than full at the time, or our personal finances are not what we’d like them to be, we may bump into financial fear. The fact of our business is that our livelihood is very much tied into getting and keeping clients. Many therapists fear their own financial hunger and, in an effort to prove they are not acting on their own desires, may join clients’ treatment-destructive resistance, and help them to go. I’ve seen therapists do this in a variety of ways, such as sending termination letters, bills, not returning calls when clients cancel or quit via voice message or email, or agreeing to termination without asking if the client would like the therapist’s thoughts on the decision or if the therapist has a say.
“In fact, in letting clients leave without attempting to discuss things, we may be rejecting them, or colluding with a pattern of rejection in their lives.” For some clients it may be therapeutic to help them stay; they may be relieved that they are wanted and not so readily let go of.
That’s not to say that we can’t ignore the unconscious if we’d like to, or that we don’t have and enjoy good endings, or feelings of satisfaction over good sessions and good therapeutic relationships. But let’s face it: in the volleying back and forth between occasional grandiosity and occasional inadequacy, clients who go AWOL can tip the slide downward for us fast.
"Am I Losing It?"
It’s hard to know when our feelings are safe and when they are on the edge. A friend of mine was recently angsting over some terribly good erotic feelings she was having for a client. She took it to supervision where her supervisor said lightly to her, “If they are not interfering with the therapy, enjoy them.” This permission to feel freed my pal up considerably. The erotic feelings faded and the work continues to be successful.
One therapist friend of mine says, “I feel like an emotional prostitute sometimes. I get to roll around in the all the intense feelings and then I get left alone in the chair.”
“That’s what we get paid for,” says another friend of mine. But we are so dedicated to staying contained, to reining in our feelings and our fears, that we may be cheating ourselves, not just protecting ourselves, the client or the work. What do we think will happen if we let ourselves go haywire? Not, of course with a client, but by ourselves or amongst our peers, in our supervision or personal analysis?
One colleague of mine did actually have his analyst go berserk on him. Upon my colleague saying that he would be leaving therapy soon (after 15 years and much good work) the analyst seemed to blow a gasket. He yelled, he screamed; he said that my colleague was in denial, was sick, did not even know how sick he still was. He told him to get out of his office immediately. Ungrateful lout!
When I first heard this story I hardly believed it. Perhaps my colleague friend was making it up. Perhaps he heard wrong or exaggerated, or even dreamt it? After all, this seems to be every client’s nightmare—and maybe every therapist’s. Would we really go crazy and let loose on a patient? Most likely not, but to that end, if we don’t allow ourselves to feel what we feel toward our clients, we may be missing out on a lot of good information that would benefit everyone.
But since many of us nurturers are not at all immune to self-attack, accessing our feelings may be easier said than done. Especially when clients leave us, we can be quick to accuse ourselves of all kinds of evil (especially if we ourselves are going through something difficult in our personal lives). Perhaps we really are (only and always) money-hungry, self-seeking, self-gratifying, selfish, poorly trained do-gooders? Or the opposite. What about our gift?! We most certainly could help them if they would just cooperate and let us! Why don’t they want this help? “It must be me” is the quiet tugging somewhere in our brains.
Maybe we are burnt out? Maybe we are losing our touch? Or losing touch? Maybe we are not actually helping anyone at all anymore. Maybe everyone is going to leave us. Maybe we need more training, a different approach, another certification. Were we not paying attention? Should we have been more confrontational, or less?
There may be some use in asking these questions, but it seems to me that we healers and helpers will go after ourselves in a schizophrenic loyalty to our trade before we will let ourselves have all our feelings about our clients.
Sometimes therapists tell me that they want to get rid of clients, especially the ones that are mean or demanding or frustrating, or boring, or are not making the progress they’d like them to make. On some level it’s hard for us to accept (and help clients accept) that talking itself is progressive and that we must be vigilant about not being too demanding of our clients or devaluing of our good ears.
After unpacking feelings with a therapist I work with who gives homework and advice frequently to clients, we came to understand how frustrated she feels in certain sessions—hence her urge to be more directive. While she continues to pride herself on giving resources, she is paying more attention to the words of one her patients who recently yelled at her (in itself a testament to their good relationship), “Would you stop trying to help me so much!”
Speaking Up, Pushing Back
A favorite story of mine is about an analyst I know whose patient called to cancel and “take a break” from therapy because she had to have surgery on the day of their appointment and would need a while to recover. The analyst asked if the surgery could be rescheduled for another day. At first take, this sounds ridiculous. Most of us would most likely offer up oohs and ahhs and “let me know how it goes.” But not this analyst: she works on the assumption that nothing is more important than the therapy and she does not want to give anyone’s unconscious the idea that being sick and needing surgery is ideal. She says by valuing the therapy above all else she is messaging the unconscious that it’s not okay take out difficult feelings on the body. Better to talk about them, learn to tolerate them, and live well.
The patient got angry at first. All kinds of aggression came out toward the therapist, albeit tentatively, about how the therapist was insensitive, mean, ridiculous, and odd. Funnily enough, though, the patient called back a few days later to say that the surgery was no longer necessary and she could keep her appointment.
Of course, we don’t attack someone’s defenses straight out, and sometimes a duck’s a duck, but it is interesting to consider how tightly or not we hold onto to the importance of valuing our sessions. Though we don’t always know how they will be received, our responses do send emotional messages. And since we therapists have to swim every day in the sea of a hundred feelings, we sometimes, unconsciously, may seek to avoid them by going along too readily with people’s disappearing acts.
Sometimes people really are not interested, ready, motivated enough, or are just too frightened to be in therapy. Do we forget that we have to go so very lightly sometimes, even for a while, to help people become real clients? In an informal survey among my clients who have had prior therapy, most tell me that they left without actually discussing their exit with the therapist. Some felt pushed. Many felt misunderstood and not helped, or they disliked the therapist’s style or something the therapist said. Very few recall discussing their concerns and feelings with the therapist before leaving.
A friend of mine, however, came to me for advice after doing just that. She felt her therapy was no longer helping her grow in the direction she wanted to go. She discussed it with her therapist and they agreed she should make a change. She changed, but felt that her new therapist was somewhat mean in his demeanor. She was thinking of canceling and not going back, but, reluctant to make yet another switch, she asked for my thoughts. I suggested she tell the new guy that she thought he was mean, which, bravely, she did. And in response, he told her she was right—he was mean sometimes.
My friend felt enormously relieved. It turns out her father was quite mean, but whenever she had tried to tell him so as a child, he denied it. In overcoming her fear of saying what she felt directly, and having her response validated and not denied, she believes she has made significant progress. She has decided that it’s okay to have a faulty therapist. She now takes great joy in pointing out each time she feels the therapist is being mean, and helping him to address it. And, she tells me, he is getting better. She is curing him.
The Failure Complex
When I supervise new professionals, I often find them to be blunt about their feelings, and I find myself encouraging them to say everything in supervision, and to become interested in their words and actions in sessions. When new therapists tell me, “He was so rude! I can’t stand him!” or “I’m furious with her,” I am delighted and respond by steering them toward curiosity about why they feel this way and what they may learn about the client and themselves. Seasoned professionals who I work with seem to hold back more, and are relieved to be reminded that they can have all their feelings, that clients are difficult (we ourselves may be difficult as clients), and that experience and expertise don’t negate our own need to feel our feelings and talk about our work.
And few outside the profession really understand this, I think: the constant meteor shower of feelings we encounter in our offices, this psychic holding we have to do of everyone’s feelings. Some of us fear that perhaps, even if a feeling is an inducement, we may act on it. Unfortunately, some of our colleagues do act on inducements–sometimes little ones, sometimes big ones. The number one complaint before ethics boards is for sex offenses, boundary violations. Acting on feelings. Most of us guard these borders vigilantly. “We know that erotic transferences in the treatment room are normal, and can be dealt with gently, with words and care and no action.” We may fear them, but we know they occur.
But murderous feelings? Rage? And abandonment and inadequacy? One analyst I know calls it her “Failure Complex.” Over her many years of experience she has learned that she will not be able to help everyone, that some clients will leave or punish her even when she has not made a mistake, because that’s what they do to survive. She knows that when clients leave and don’t say goodbye, it feels just like when she was a kid and her father would stop talking to her for days on end, blaming her for his reactions. She had no control over this feeling then, and felt for years that anything that happened in the treatment was her doing, her mistake. The psychic umbilical cord tying her to her father was like a straight shot back to her feeling like a lonely, misunderstood ten-year-old. Even with all her advanced training, she still wound up back there in the pit of that despair and rage. She berated herself for that, too.
After some time though, she says she has come to feel better. Her dad was just being her dad, she tells me now. And her clients are just being her clients. And she is just doing what she knows how to do. She wears it all a little lighter now.
I like the modern analysts’ idea of helping clients to say everything—at their own pace, of course—and I especially enjoy it when it translates into therapists being able to say everything in our own supervision and therapy. As another therapist I work with says, “I like to let my fear flag fly! Talking about my own stuff builds my resiliency, and then I can stay the course.”
From the Heart
Many seasoned therapists agree that part of staying the course means checking in with the client now and again, to see how the therapy is going, either with evaluation tools, or by helping clients to say everything to us about the therapy itself, and that doing so goes a long way toward preventing abrupt exits. But we have to be willing to bear our own discomfort, and keep our support systems active. When we do this, we are better able to negotiate the blurry line between discharging our own feelings in session and making good clinical interventions.
A few years ago I sat before a panel of professionals who run a regional referral service. I was hoping to be added to their referral network. I came in with my CV and my suit and took my seat. They asked a bit about my background, and then asked me what modalities I use. When one of the interviewers spoke up and asked, “What do you do with difficult clients?” I was quiet for a minute.
“I listen and I love them,” I said finally. “And I help them to talk.”
I do get referrals from them now, but I recall at the time feeling terrified. Who says that? I really was poised to talk about my training and about interventions and skills, and the things that we do that bring recovery and healing, but that’s what came out. Love. (I suppose I could have said that I get frustrated and I tolerate it. Either might be true at one time or another.)
“Here’s what I think keeps us up at night: the idea that we are not supposed to speak from the heart, the soul, or the depths of our psyches.” We may be so tied to what we think we are supposed to be, to know, to feel and to do, that we are afraid of what we really feel. And while most of the time we don’t have intense feelings for or about clients, certain clients and situations fire us up more than others (a nod to transference), like being left without a chance to know why, to heal something, or to at least say goodbye.
On top of this, many therapists imagine a domino effect: first a bad session, then one client leaves, then another, and then the unemployment line. Much as we might like to be, we are not at all immune to worry, doubt and insecurity. Even the most experienced clinicians have moods that are directly tied in to the state of their practice.
An old friend of mine who lives her life by her 12-step program likes to tell me that finding serenity, pleasure and contentment means practicing the ability to bear discomfort—that it’s ten ways to Tuesday. Whatever your discipline, training, experience or knowledge, success and satisfaction are about feeling what you feel (good and bad) without doing harm. We do get emotionally walloped once in a while in this business. Chalk it up to transference, to regression (ours and our patients’), or call it a bit of temporary psychosis when feelings get too intense.
One analyst I know continues to call her dropout patients every now and then. She leaves messages just saying hello or asking how they are. She told me that many years ago she used to worry that they would think she was just after their money or out to build up her practice. And maybe so. (“Why shouldn’t everyone make money and prosper?”) But now, she says, she thinks it’s just good practice to let clients know we are still interested, available, and open to a connection. She has a thick skin when it comes to rejection: it’s all grist for the mill. Pointedly, she tells me that some of her dropouts do return to treatment, happy that she had continued to hold open the door and hold onto the idea that they and the work were worthwhile.
Our work is fluid, frightening, fantastic, and filled with blind spots all at the same time. But I think that therapists sleep better when we allow ourselves to feel everything, to talk about everything in the company of good peers, and to find comfort in the idea that we really are not alone, no matter how crazy we sometimes feel. We can be interested, curious, and confident that we’ll be okay—and we can pass that freedom on to our clients, enriching the experience for everyone.
I am not suggesting that we never agree that it’s time for therapy to end or to pause. Certainly, there is a season for all things. But more often than not, if we are really honest, most attempts to leave treatment have some deeper meaning. And if we go along with the surface material, especially if we are only mildly in touch with what we ourselves feel, we may be helping our clients to miss out on the benefits of a meaningful therapeutic experience.
