Jung At Heart

Every therapy comes to an end eventually. Under ideal conditions, therapist and patient arrive together at the decision to end and they take the time necessary to fully and respectfully end the relationship. It s a ritual of goodbyes -- taking the time to look back at what has happened, what has changed. It's time to look at what has been accomplished and what has not. It is an exit interview and a farewell all in one and ideally takes up a number of sessions. When this happens there are good feelings all the way around, along side the inevitable sadness at saying goodbye. 

I get upset when it is suggested, as it not uncommonly is, that therapists encourage people to stay in therapy because they want the money. I am certain there are some therapists like that. Like there are lawyers or accountants or plumbers or mechanics who place income above ethics. I have been in therapy with a number of therapists myself and I have never encountered this as in issue with any them. And I know that I and the people I have supervised have dealt with anxiety about money in supervision a lot in order to keep that anxiety as much out of the work as possible.  

Not all terminations are ideal. Someone asked me recently what it is like when a patient leaves abruptly. Well, it's hard. Sometimes a patient will call and leave a voicemail saying  they won't be back. Or send an email or a note. Or not show up and then not respond to calls. Sometimes this is part of a pattern in the therapy and the patient eventually returns. But more often, they do not and we end up not knowing why. And that is hard because it is in the nature of therapists to wonder and want to know what happened.

It's my job to challenge any changes in our work that patients bring up. It is my job to ask when someone announces they want to leave therapy to ask why now and to raise what I see as possible issues. It is not about wanting to control the patient or protect my income. It is my job. I ask at the beginning of therapy why they are seeking therapy now and we look at that. I ask at the end why they want to leave now and we look at that.  

I think it is hard to remember that the therapist is a person and that therapy is a relationship. It is a RELATIONSHIP. Patients and I spend an hour or so together every week and they live in my thoughts and occupy space in me beyond that hour. It's a relationship. So when a patient says to me, "I want to stop now", I ask why now and I ask that we look at this because it is part of our relationship, because I am a part of this relationship. And if that patient won't talk about it, won't look at why and leaves, maybe in a huff and full of mutterings about me, then she leaves. But she will still occupy space in my thoughts as I try to understand what happened and what might have led to this. And when she wants to return, as often happens, my door is open and we begin again and I do so without carrying resentment.  

It all comes with the territory.  

There are all kinds of reasons for ending -- money, time, dissatisfaction, discomfort with the process, dislike just to name a few. But it is the abrupt ones, with no chance to really say good by or talk through  what has happened and ending that are hard on therapists, and ultimately on patients as well. Ending well is important.  It lets us go forward without lingering feelings and resentments.

Ending is hard. It is hard no matter where in our lives we do it. And we tend to end in therapy in the same style we end other relationships. There are good endings and bad endings and healing endings and wounding endings. And they are all hard. And we can, all of us, learn to do them with more grace when we are willing to look at how we do it and what endings mean to us and have meant in our lives. 

A reader asked me to write about " termination.... when it's called for, what a good process looks like...how you know it's different from a break". Good questions and I'll do my best with them.

Termination is called for when the therapy has ended. That's the ideal -- when both therapist and patient feel that the work has been accomplished. In any kind of depth psychotherapy, it is hard to define when that time is and certainly it cannot realistically be set in advance, not in this kind of therapy. In the first session, it is not possible to know if this work will last 6 weeks, 6 months, 6 years or more. That all depends on how things unfold and how far the patient wants to go.

Maybe it helps to consider that therapy is a process, not a destination. It isn't like a graduate program with a diploma or certificate at the end. Because there is no defined end. The process begun in therapy optimally will continue for the rest of your life.

So, in a sense, therapy is over when you decide you've gone as far as you want to go. Cure is meaningless here -- what is it that would be cured? It helps to have in mind what you want from therapy, what it is about for you and to review that from time to time, with yourself and your therapist.

Now it is often the case the the urge to terminate comes when something difficult is in the offing. Why? Because it is human to want to avoid work that is difficult or painful. So if things have been going along productively in your therapy and you rather suddenly announce your desire to end, don't be surprised if your therapist asks why. Why now -- what makes you feel this way today but not last week or 3 weeks ago? What is going on?

Money is the most frequently cited reason for wanting to end. However if you ask these patients if they talked to the therapist about a fee reduction, they almost never have. When the patient and the therapist have a shared commitment to the work they are doing together, they can work out changes in fee to deal with changes in circumstances.  It is useful to ask yourself if you are using money as the reason what else is making you want to leave. Because it is almost certainly that that "something else" is something that needs to be dealt with.

So when your therapist starts challenging you on your desire to end, be willing to explore this with her. She is not trying to keep you from leaving, but trying to help you make a good decision, whether it is to stay or to leave.

The termination process is not about trying to keep the patient from leaving. It may come up in the process that the therapist feels some important unresolved issues remain on the table. But we cannot compel anyone to stay so the choice to leave, the power to leave always rests with the patient. What we hope for always is a good ending, but we don't always get what we want.

Tomorrow, in Part 2, we'll look at taking a break in therapy and how that differs from termination. 

And then in Part 3, we'll look at how to do a good ending.

We started the film series, Psyche Goes to the Movies yesterday by showing Don Juan De Marco. And it was a good beginning -- 24 people showed up, we had a good discussion and now to discuss it some more here.

I really enjoy this film. This is the third time I have seen it, though not for a number of years. Johnny Depp, Marlon Brando and Faye Dunaway all bring wonderful life to their characters. If you haven't yet viewed the film, I recommend doing so.

I enjoy the split we get to see between the biobehavioral model and psychosocial model in the staff of the hospital where Don Juan ends up. On the one hand most of the staff wants him medicated quickly and they believe he will end up a long term hospital patient. Dr. Mickler however wants to get to know him and see if he can discover why this young man has adopted the identity of Don Juan. This split was still relatively new when the film was released in 1994. We wouldn't se such a debate taking place at a staffing conference today nor would the initial involuntary hold be for 10 days.

Several other points that struck me:

We see in action here the notion Jung had that patient and therapist act on each other.

Don Juan has a youthful zest and romanticism that Dr. Mickler has lost and conversely, Mickler is better able to navigate the world than is Don Juan. In the process of their short time working together, we see them changing each other. There is a point even when Don Juan identifies the patient in Mickler -- a lovely moment illustrating this process.

I have seen Don Juan of this movie diagnosed as manic-depressive. But I would suggest that it is difficult even to establish him as psychotic because he is in fact oriented to time place and setting and is quite aware of what is happening. What we see is a young man who adapted the identity of Don Juan for himself in order to make some life following a series of terrible blows to him -- the death of his father, the loss of his mother and rejection by his fantasy love object. It is a detailed fantasy and a creative one, but it also works for him and gets him to where he needs to be. Do note that he cooperates with Mickler when he shows up.

Mickler wisely does not tackle the fantasy/delusion head-on, knowing that it would be fruitless to do so. So he steps into it a bit agreeing to be Don Octavio and thus is able to finally learn why the fantasy/delusion came into being in the first place.

So -- what do you all think? What did you notice?