What about therapy breaks?

Two Chairs
Two Chairs

How is a break from therapy different from termination?

The same questions need to be looked at when a patient decides to take a break from therapy as when she decides she wants to terminate — Why now? Is there something being avoided? It is not that a break is a bad thing but, as with anything in therapy, the reasons and feelings behind it need to be explored. Because that is a big part of what therapy is about. In therapy every little movement really does have a meaning all its own.*

In most relationships, announcing you want to take a break usually amounts to ending the relationship. And my experience has been more often than not that patients who announced they wanted a break were actually wanting to end without taking the time to really work through an ending process. So it is important to be as clear in yourself what wanting a break is about for you and what your intentions are. Is a break really what is called for or are you avoiding something in the therapy? Are there issues with the therapist that need to be discussed, worked out that you would rather avoid? Be relentlessly honest with yourself about this so you can really make the best choice for yourself.

If it is really a break and not an ending, then  schedule a time to return. Because a break means a temporary suspension and thus carries a return date. Even if during that time you decide you do not want to continue, you should keep that appointment in order to complete the ending and say goodbye.

A number of years ago, after a long and very difficult period in my analysis, when it seemed that we were at an impasse that could not be resolved then, I took a break from analysis. Only I considered it an end, even knowing that I would return to analysis eventually. We spent 6 months winding down, spending time with what ending such a long relationship felt like, with reviewing what had happened, with gains I had made and what I saw remaining for me. It was 6 months very well spent and at the end of that time, I was able to say goodbye and feel good about going. BTW, I did return — 6 years later.

* I often wonder if anyone knows these kinds of references — this one refers to a song from 1910 – “Every Little Movement Has a Meaning All its Own”

When is it time?

We have talked about the beginning and some about the middle of therapy — and we will talk even more about them as time goes by — but today  what is on my mind is termination, or the ending of therapy. When it’s called for, what a good process looks like…how you know it’s different from a “break”. Maybe not surprisingly, much more has been written about beginning therapy than about the end because ending is not without its own issues.

Termination comes when the therapy has ended. That’s the ideal — when both therapist and patient feel that the work has been accomplished, that they have done as much, gone as far as they can go. 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 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 often 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 to make a good decision, whether it is to stay or to leave. 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.

Next, 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.

Millennials and Online Psychotherapy

labyrinth solid white bkgrd

A Tweet about this article caught my eye before the holidays: Millennials and the false allure of online psychotherapy. Just the term “online psychotherapy” can mean anything from Skype or FaceTime sessions to email. Not all therapists are comfortable with or accepting of therapy except when done face to face in the consulting room. So I am used to seeing articles here and there decrying therapy which occurs via telephone or Skype. And that is what I expected to read about in this article. To a degree, that is indeed what I found.

After describing factors that seem to make millennials “the most stressed out group in the country”, there is this brief bit:

With Talkspace, for just $25 per week, clients can purchase “Unlimited Messaging Therapy” that allows them to text with a therapist whenever emotional problems arise. The Web site for the app states, “just like texting with a close friend, you can now message your therapist every day, for an entire week, writing as many times as you want.” Initial sessions for In Your Corner cost as little as $25 dollars for “instant expert support when you need it.” That might include online therapy, written coaching plans and stress-reduction techniques from a meditation instructor.

I had only recently heard of these quick response options from my son, who is just starting out in private practice and considering what he might offer. When he asked my opinion, I asked him if he really wanted to work with anyone on that kind of uncommitted catch as catch can sort of basis, because in my mind, it is not therapy but more like a stop at a first aid station for a band-aid now and again. He tried to make a case for it, thinking maybe some people would want to convert over to more regular scheduled therapy. I told him that when therapy starts with such a haphazard frame and very little commitment, it doesn’t seem likely to change because in accepting it, the therapist is colluding with the patient in his or her belief that a quick fix, an encouraging word as needed is sufficient to actually deal with ongoing issues and problems. 

Years ago I had a copy of the fairy tale “East of the Sun, West of the Moon”. And there was a line in it that seems to fit the therapeutic process — the road is long and hard but when you get to the end, you will find great reward. Therapy isn’t about becoming happy or soothed but is about traveling the road inward and becoming more conscious about oneself and life experience so that a greater freedom of choice becomes a available. It isn’t a pacifier there for instant gratification. No matter how much any of us might like to have something like that.

It is ultimately, no matter the orientation of the therapist, the relationship, which can only develop over time, that heals, that fosters change. And that can’t come in texts or quick emails. And yes, it can occur over time talking with a therapist over Skype or the telephone.

Now to spend some time reflecting on how our children came to expect that “instant expert support when you need it” is the way to go.

Week 4: Jesse

Jesse rummages in his backpack as Paul asks how his week was. He says kind of weird. Then he tells Paul he got a letter from his birth father — Paul has a big sneeze which he says is an allergy. Paul asks when it arrived and Jesse says a few days ago. He says he married his birth mother. They got pregnant when they were 17, broke up and got together again after college and married. He says he wrote on Karen’s behalf because she is depressed that he has not responded to the phone call. He wants Jesse to respond and let them know if he will contact them. And he says he loves Jesse. Jesse is angry and says he thinks they may be assholes. And he may be getting a B in algebra, which he says is a miracle. Paul asks if he studied for the test and he says yes, Roberto helped him. Paul says Jesse must have told him about the suspension. He says Roberto thought it was no big deal. Paul says he thought Jesse was nervous about how he would react but Jesse says he was cool. He told him about Nate and why it happened. Paul gropes for the right term and Jesse mocks him. He says no he did not tell him what Nate was doing. He wants to know why Paul won’t leave it alone and let it be a nice thing that his dad helped him and he got a B.

Paul goes back to the letter. He asks what his father’s name is. Jesse says Kevin. He thinks it is inappropriate for them to contact him and to want in to his life when other people have raised him. He has one set of parents and that is enough. Paul asks if maybe they are seeking some other relationship like friendship. Paul asks if he told his parents about the letter. He says he wrote a response. In his letter he says Karen’s call distressed his parents and he does not want to be in contact with them and asks that they not contact him at his home and he signs it with his full name. He says he took an Adderall to write it and he thinks it came out well. Paul notes it is pretty formal. Jesse says he is smart and wants them to know it. He thinks Paul doesn’t like the letter. 

Paul asks what about the week was weird, besides the letter. Jesse says Marissa was weird. She didn’t get out of bed and when he asked, she said she was sick and asked him to close the door. He and she have not talked at all about Karen’s phone call. Marissa told Roberto and he blew up and said it was inappropriate and he wanted to call the cops. Jesse says he had never seem him that angry. Jesse says he used to try to make Roberto angry when he was younger.  Now Jesse claims to understand why Roberto withdrew a bit from him, that he was overwhelmed with work and family demands. Paul asks him what he feels about Roberto’s response to the letter. Jesse liked it because he feels he cares. Jesse is furious with the birth parents because they haven’t earned a relationship with him. And Roberto and Marissa have earned that. Paul asks if he thinks he was difficult to raise and he says yes, he has ADD and is a slut. Paul asks how did Roberto react to Kevin’s letter — Jesse says he didn’t tell him after the way he reacted to learning about the phone call. Jesse puts his head in his hands. Paul suggests he is feeling a lot of pressure — how is the static and Jesse says it is very loud.  Jesse thinks Kevin is left-handed like he is because of smudge marks on the letter. He shows the letter to Paul. Then he sees how similar the handwriting is on both. He is distressed and asks what he should do with that information. Paul asks how it feels. Jesse asks if Paul thinks Kevin looks like him. Paul says maybe you look like Karen. Paul says he thinks he is still interested in a private relationship with Karen and Kevin but Roberto’s reaction shows he cares about him and so he is caught between them — if he reaches out to the birth parents, he will lose Marissa and Roberto. 

Then he says Paul was wrong about Marissa and the Church. He went into Marissa’s room and saw Marissa in the closet on her knees and praying. Paul says she is scared. That she is afraid he is slipping away from her and she turns to her religion for comfort. Maybe she is afraid he will think she is choosing the Church over him.

Jesse says he can’t believe they married each other. What is their house like? Paul suggests they talk more about the letter next week. And think about he wants to respond to them.  Jesse says okay and that he thinks it will all be okay for some reason. Paul says good and Jesse leaves. Jesse asks him to keep the letters.  He is afraid Marissa would find it in his bag. Jesse leaves.

I don’t know about you, but I feel a lot of relief about Jesse this week. His bristly defensive anger was far less in evidence and he was able to allow Paul to see some of his vulnerability. It can be very difficult to make empathic connection with teenagers when they get caught in their very real need to assert their independence at the same time that they need to be cared for. Jesse allowed Paul in enough to be able to let down a little and we see the result in how he feels at the end.

What Paul was able to do this week was help Jesse to have a more nuanced attitude toward both sets of parents, to begin to entertain the idea that Marissa and Roberto care about him and their reactions stem from that caring and to begin to consider how he might want to connect with his birth parents. This is a big step from his very either/or thinking of previous weeks and early in the session. And this builds on the relationship Paul has with Jesse which we know began before we met Jesse this season. 

Jesse has yet to face squarely into how much it hurts to now know his birth parents gave him up and then married. that their lives have gone on without him, leaving him to wrestle with how it feels to be abandoned by his parents. Today is the first time we can see that he is attached to Roberto and Marissa, fragile though that attachment may be at times. In instances like this, there are psychic wounds all over the place — the adoptive parents and their inability to have a biological child and their fears about birth parents appearing and snatching their child away from them. The birth parents desire for the child they gave up and wanting somehow for that to have turned out well. And Jesse’s issues of abandonment  by his birth parents and fears that he cannot have a relationship with both the birth parents and his adoptive parents. And these wounds will not heal quickly.

I have no idea what the very first part of the episode is about, why Paul was sniffing the herb bottles but I trust it will make sense when we see the next episode with Adele.

Week 2: Issues

Photo of Paul

On the HBO forums there has been considerable discussion of the note-taking issue. And we saw this week that after seeing April, Paul sat down to write some notes. Which we know from what he said to Mia when they met to discuss the lawsuit taking session notes is not his usual practice. So why now?

The answer is simple — anxiety. 

The whole issue of session notes is related more to risk management and insurance company requirements than it is to good care and the best interests of the patient. In fact. until fairly recently, it was up to the therapist what kind of notes if any notes would be taken. And, depending on licensing requirements and whether or not one accepts third party payment, it is still up to the therapist on this issue. Some therapists document via a short notation the occurrence of a session combined with  billing records. Others take notes during the session. There is nothing in these approaches or any other that correlates to skill or outcome.

In a paper presented to the APA, Martin Williams explains how what starts as a way to manage risk morphs into standard of care — and sometimes into mandated requirement:

“Why wouldn’t you want to take notes about your session? …

Some psychologists—many more, I think, back a few decades ago and fewer today—do not think of what we do as medical, or as a treatment, or as something for which written documentation is appropriate. We see our work as forming relationships with patients, relationships that are unlike that of doctor-patient, but more like teacher-student, consultant, clergy-parishioner, or simply peers. Some of us believe that medicalizing that relationship by writing notes about how “the patient is progressing” or even about what happened during the session creates a barrier between the two people who are engaged in a personal journey together. Along those same lines, some of us eschew diagnosis and treatment plans.

It doesn’t really matter whether you agree with this Humanistic approach to psychotherapy. It serves as a good example of how risk management evolves to become the standard of care. Somewhere along the line, psychologists thought it would be a good idea to document what you did in therapy as a way of protecting yourself from certain claims, especially claims that you failed to do something. If someone claims you failed to ask your patient if he or she was still feeling suicidal, and your notes show that you did ask that question, bingo, you’re protected. If the patient later suicided, but after the session you wrote a note documenting the reasons that you believed the patient was not suicidal, and those reasons make sense to a later adjudicator, you have a degree of protection that you wouldn’t have had you just reconstructed that session from memory—subject to the skeptic’s view that your memory had been conveniently altered and rearranged to diminish your liability.

So it makes sense that those of us who want more protection would minimize their risk by taking notes, taking notes to document that we did all those things that someone later might claim we failed to do—a fine risk management idea. Fast forward to 2002 and we find that record keeping is no longer about risk management. It has become the standard of care…

One no longer keeps records to protect oneself. Now, one keeps records because not doing so is considered unethical in and of itself. Risk management evolves to become the standard of care.”

Ultimately each therapist has to decide where he or she stands on this issue. If one does not accept third party payment, it is a little easier because there are not then concerns about insurers demanding to inspect files, which they have the right to do for covered patients. The therapist must weigh duty to protect the patient’s interests and confidentiality vs. risk management. Consider also that patient files can be subpoenaed in other legal actions such as divorce cases and the confidentiality issue can be quite significant.

So Paul, now anxious about the lawsuit filed by Alex’s father, is taking notes after seeing April, not because it makes him a better therapist but because of his fears. It isn’t clear whether he is also taking notes on other patients. 

This is a difficult issue. Before therapy was routinely covered or expected to be covered by insurance, risk management and these kinds of records requirements were rare for therapists. And given the low incidence of lawsuits against therapists, the fear generated by risk management folks is disproportionate. Years ago in response to someone asking how he felt about insurance coverage for analysis, a well-known Jungian analyst said that we must remember that he who pays the piper picks the tune. We do well to bear this in mind as third parties become more a part of what we do.

“Psychoanalysis cannot be considered a method of education if by education we mean the topiary art of clipping a tree into a beautiful artificial shape. But those who have a higher conception of education will prize most the method of cultivating a tree so that it fulfils to perfection its own natural conditions of growth.” Jung C W, vol. 4, para. 442

Week 1: Oliver

Oliver picture

Oliver and Paul are sitting on the couch. Oliver asks if they have to wait for his mother and father. They decide to play cards while they wait. Oliver suggests blackjack and expertly shuffles the deck. He gives Paul the rules. Oliver says Paul sucks at the game and he wonders why if he sucks at it, why play? Oliver doesn’t really know why he is there. Paul tells him that his parents are getting divorced. Oliver denies the divorce — he says his dad has moved out but it doesn’t mean they are divorcing. He finds it annoying that his dad has moved out. Paul tells him they are meeting to help work out a solution to the problem that Oliver refuses to stay at his father’s apartment.

Oliver doesn’t like the food at his dad’s or his friends or that it takes longer to get to school. Paul says maybe they can help get things to change at his dad’s and make it easier for him to stay there. His mother arrives with Oliver’s snack and complaints about the father and where he lives. She doesn’t want to wait in the waiting room until the father arrives. We can see his mother is reluctant to have Oliver stay with his dad. 

The father arrives in a rush. The parents complain about each other to Paul. Paul asks Oliver to wait in the waiting room while he talks with the parents.

Paul tells the parents they need some ground rules and that Oliver doesn’t really know they are getting divorced. Each of them blames this on the other. The dad wants Paul to explain to Oliver but Paul refuses because it is important for them to tell him these uncomfortable things. Luke, the father, believes that by allowing Oliver to choose his own food from take-out menus he is teaching him self-sufficiency. Paul explains that what Oliver may be saying is that he is not getting enough nurturance.

Paul picks up that both parents are using Oliver to get information about the other parent and tells them this is not good for Oliver. Paul proposes separate meetings and both refuse because they want to know what the other says. Oliver creates a distraction and they invite him in. Oliver tells his dad that it’s hard when his friends come on school nights. And dad agrees to change that. They also come up with a solution for after school snacks. Oliver says he doesn’t want to stay with his father and the mother says he doesn’t have to. The father leaves. Then they all leave.

Oliver is around the same age as Paul’s youngest child so we have to wonder if Oliver’s unhappiness makes Paul think about his son and the effect of his divorce on his children.

In this case, Paul has a complex dance to do — helping Oliver and gaining the cooperation of the warring parents. This is never easy. The parents are not interested in being seen as a couple, which is too bad because they could perhaps become better able to work together as parents if they did. So he has to try to get them to make agreements while steering around their long standing conflicts. 

Parents are the hardest part of working with children.

I liked the way Paul let Oliver explain the rules of the card game to him. Playing games with a child in therapy is never about the game but what the game allows the child to reveal about himself and the issues he struggles with. So Paul pays attention the way Oliver explains the rules. And we learn something important about him when Oliver asks of Paul what is the point in playing something if you suck at it — we should not be surprised if we learn that Oliver feels he is no good at sports or other games that  maybe his father enjoys. And note that Oliver did not seem excited by the football his dad gave him when he arrived. It was when he was playing with the football in the waiting room that he knocked over the plant. It looks like Oliver is struggling with some things in addition to his parents’ divorce.

Week 1: April

April picture

A young woman, April, is sitting in the waiting area. Paul opens the door and invites her in.

Paul’s office has large bay windows and is comfortably furnished. April walks around looking and admires the office, mentioning she is an architecture student. She asks if he did it himself or used a decorator and when he says he did it, she congratulates him.

April tells him she is 23, a student in architecture and urban planning at Pratt. She is recently single, having just broken up with a long time boyfriend. Paul asks if that is why she has come and she says no, the breakup was fine. She says she found his name online because she wanted to see someone near Pratt who would take her insurance. She tells him no one had commented and she had assumed it was a new practice. He tells her he recently moved there. Paul tells her she needn’t apologize for questions and that she needn’t censor herself to spare his feelings. He asks if she has seen a therapist before and she says she had —  through student health. She speaks scornfully of the previous therapist. She felt that that therapist saw her as a complete waste of time. She  tells Paul that the therapist had told her the same joke twice. Paul asks about it and she tells him. April stopped going and never spoke to the therapist despite receiving many telephone calls from her. She says she did not return the calls or tell her because she didn’t ant to hurt her feelings. April gets angry and defensive at Paul’s questions about her previous therapist.

Paul reflects to her that he knows now that she doesn’t want him to tell her things twice, not to feed her platitudes, that if he fails to engage her she will leave him without telling him even if he calls her 87 times.

She likes that and asks how many people come to her because of something really big. He tells her she can tell him anything — a rape or death. She tells him she was not raped and she is trying to tell him. Then she asks if she can write it down and he says of course. She writes and she is clearly upset. She hands him the paper. She looks terribly ad and so does Paul. He asks how she feels  — she replies she is tired. He asks what type of cancer it is. She says she doesn’t want to talk about it. She just wanted to tell someone and she rushes into telling him all the things she has to do. He asks if she is getting sleep and she says no, she has terrible night sweats which are a symptom of lymphoma. He asks how she found out. She tells him she had a cough that wouldn’t go away. She went to the health center but what they gave her did not help. Her father is a doctor in the Army and she couldn’t reach him. Her symptoms got worse so she returned to the health center. Finally she was sent for further tests and she was diagnosed. She has a big mass behind her spine. She tells him to never get a bone marrow biopsy and describes how bad the experience was. She has met with an oncologist. He asks if she was alone when she did and she says she was. He asks if she has told her parents or friends. And she says she has only told him and a construction worker who harassed her on the street. She says she wanted to talk someone who is objective and won’t care what she does so she can talk about what she wants. She says her mother would become hysterical as would her father. Her brother, who is autistic, she says would become violent. Paul asks if she came to him looking for someone who would tell her it’s okay not to get treatment and she says no. Paul asks her if she really believes she has cancer, does she believe what she knows?

April tells him the oncologist said she was at stage 3 and she should start chemotherapy immediately. Paul challenges her resistance to starting treatment. Paul suggests to April that the other therapist told her the same story twice as a way to tell her it’s okay to need help. Paul says she needs to tell the oncologist what she is contemplating and that she needs to tell her parents as well. April gets angry and wants to leave. Paul offers her another time and presses to schedule another. She says she will call him. Paul is worried. She leaves.

April presents Paul with some interesting issues. He knows she will leave if he does not meet her expectations for his behavior, if she feels he has not listened and really heard her. And she is also in denial about the seriousness of her illness and the necessity to allow people to help her and to engage her in treatment. So he must find the line between listening and confrontation that will allow her to stay. The threat of abrupt termination is hanging over the therapy from the outset and Paul knows this.

Notice how Paul understood from what April told him about the first therapist and her scorn for her that she was telling him what would lead her to similarly reject him. And in fact she is primed to reject him because she is deeply ambivalent about getting help of any kind. It is not uncommon for patients to tell us how we will fail them, and we often do exactly that because it is an unconscious agenda for the therapy. The trick is in getting the patient to be willing to work through what they feel as a failure of empathy in order to see the greater complexity of the issue.

Paul is hoping April will come back. He stepped on the mine when he bluntly told her she needed to allow herself to be helped and to tell her parents. But he also earned some credibility in her eyes when he got what she was saying about the previous therapist. The odds favor her return. But it was a gamble he had to take on the chance that she did not return, a chance which was present from the very first moment of their meeting.