Monthly Archives: May 2016

Termination

There is not much written about termination in the ISTDP literature (with the exception of Patricia’s 1996 book). With students I usually offer my own “integration” of different sources. I describe typical criteria for termination: the review of patients’ presenting complaints, their understanding of the therapy process, the importance of helping them “own” their changes and prepare for the future, planning follow-up interviews, and facing all feelings that come up in the termination process. In practice, however, I find that the termination and follow-up process “looks and feels” quite different from patient to patient depending on their capacity at the start of therapy, the length of the treatment, complexity of the problems, etc.

Could you post something about the termination process in general and discuss issues specific to ISTDP?” Thanks to Peter for offering this question!

Peter has offered an excellent summary of the issues raised during termination. Traditionally, it was thought that termination would not arouse many feelings because the therapy was brief and the transference had not been allowed to develop as a defense. In fact, however, ISTDP is not always brief, and a therapy that changes a patient’s life will trigger many feelings that will arise during the termination.

In brief therapies with low to moderate resistant patients, there are not many complex feelings that arise toward the therapist during termination except for gratitude for a helpful result.

However, once we are working with highly resistant patients where the work has been deep, lasting forty sessions or more, or with fragile patients whose restructuring could take 50-150 sessions, or severely fragile patients who need more time, many deep feelings will be aroused during the termination process. All the issues Peter described will arise and must be dealt with. In addition, any time we are working with a patient who has overcome superego difficulties, we should be on the watch for any return of symptoms as a defense against loss and complex feelings toward the therapist. This is the same issue that arises in other therapies as well. The longer the therapy, the longer the termination that may be necessary to work through those complex feelings and work through the feelings of loss of the therapy which connect to all the past losses in the patient’s life.

Of course this looks different from one patient to another. Not every patient has the same self-reflective capacity, verbal skills, cultural expression of affect, or genetic endowment. Thus, their ability to describe the process will vary in sophistication and depth. Their ability to bear and express feelings openly will vary according to their capacity and cultural background. That’s why it’s important to respect the strengths and capacities of the patient, accepting this variety of response during termination. Otherwise, our perfectionistic ideals may fail to give credit to the accomplishments the patient has made, even if he or she doesn’t look like some ideal image.

Progress is progress. And the therapist’s ideals can be a defense not only against termination but against recognizing the real limits of life. Our perfectionism at termination shows how we accept neither the patient nor ourselves. How can we ask for perfection in our patients when we cannot deliver it ourselves? It’s also important to remember outcome research findings. Patients in psychodynamic therapies continue to improve after therapy. Our task is not to “cure” a patient, i.e., purify them of their pathology. Rather, our task is to get them back on a progressive direction which they can follow the rest of their lives.

If we look at ourselves, many of us have had a variety of therapies and gained (hopefully) from each one. Yet each day we are learning something new about ourselves. Every day we are growing a little bit. Never perfect, but every day a little bit better.

Thus, when thinking of termination of a therapy, we must face the limits of what we can do in the time we have. And we must accept those limits rather than browbeat a patient to live up to some ideal. In saying our goodbyes, we must accept the limits of the patient and of ourselves, trusting the patient to grow and develop once he or she has left our “home”. Thus, termination, in a certain sense, is an expression of our faith in our patients, in others, and in life itself. “You can grow without me.”

And in letting go of one patient after another, we face death. A patient early in my career asked me, “So I’m supposed to get close to you so then we can say goodbye!!?” It’s not that we are “supposed” to do that. That is just how life works. We get close and either we die or our friends die. Love and death are inextricably tied together. Sometimes the pain of so many losses can lead therapists to detach from the pain of these losses after deep involvements. That is our struggle: to bear our feelings during terminations, our mixed feelings, our limits, our own impending deaths.

 

 

I hate to cry!

“I have a patient who becomes weepy and cries when I ask her how she feels. She begins to cry almost every time and then attacks herself for crying. She says she hates to cry and believes herself to be weak. She puts a lot of effort into not crying, which makes it hard for her to say what she needs in relationships.

When I asked where she learned tears were bad and to be resisted she recalled her father. She often got what she wanted from him when she cried. But he criticized her, saying she was too soft and needed to stop crying over everything. He told her having too much emotion was for stupid. She has struggled with this problem her entire life. However, she learned to hold it in better as her life went on, and now she attacks herself when she cries. In this case, does weepiness represent something other than a regressive defense? Thank you for your time and I would very much appreciate your input on this.” Thanks to one of our community for raising this important question!

Let’s take the last question first. Yes, this is not merely a regressive defense; it is the resistance of repression. When you explore feelings with patients, you invite them to become emotionally intimate with you. This triggers feelings toward you. Some patients have learned that when they have mixed feelings, they should protect other people from those feelings by turning the love and joy toward the other person and turning the anger upon themselves.

People who use the resistance of repression turn the anger upon themselves by self-attack, depression, tiredness, weakness, somatic symptoms, and weepiness. Simply pointing out the defense offers intellectual help and understanding to the patient. But this does not change the patient’s strategy of handling feelings: turning on the self to protect the therapist.

As a result, the therapist needs to do two things: 1) help the patient see the defense; and 2) invite the patient to face the feelings toward the therapist that are under the defense.

Th: What is the feeling toward you father for criticizing you?

Pt: [becomes weepy] [Defense]

Th: Notice how the tears come in right now? Could that be making you depressed? Could we look under the tears and see what feelings are coming up here toward me right now?

Pt: I hate this crying. [Defense: self-attack]

Th: Sure. It sounds like these tears have been getting in your way. So could we look under the tears and see what feelings are coming up here toward me?

Pt: These tears are so stupid. [Defense: self-attack]

Th: Could that be a critical thought?

Pt: Yes.

Th: So if you don’t hurt yourself and if you don’t protect me, can we see what feelings are coming up here toward me underneath the self-criticism? If we look under the self-criticism, what feelings are coming up here toward me?

Patient meta-communication: “I realize I must turn my anger toward you onto myself in order for you to love me and to maintain this insecure attachment.”

Therapist meta-communication: “You don’t have to protect me from your feelings. I am willing to accept all of your feelings so we can form a secure attachment.”

We always redirect her anger away from herself back onto the therapist. That allows her anger to go outward in a healthy way rather than inward, causing her depression.

Keep asking about the feelings toward you. After several times, the patient’s weepiness should stop. After several more times, her depression will probably lessen. After several more times, she will begin to tense up as anxiety moves out of the smooth muscles into the striated muscles. And after several more times, she may be able to tell you that she is irritated with you. And that word, “irritated”, will be big progress for this patient. By that point, she can put her feeling into words without becoming depressed or weepy, and without criticizing herself.

Therapists who do this for the first time get worried when the patient cannot say the word “anger.” Since the patient has been avoiding her anger for years, there is no reason she should be able to describe that feeling in two minutes. Your gentle persistence sends her the unconscious message that it is ok to be angry with you. You must pass the test many times until she takes the risk to say the word that was always too dangerous as a child.

Rather than worry about whether she says the word “anger”, notice the drop in weepiness. Notice the drop in depression. Notice how her body begins to tense up instead of being slumped. Notice her first sigh. Notice how she becomes energized. All of those unconscious signs tell you that you are helping her overcome her depression. And those signals tell you to keep asking about the feelings toward you. After all, if your question is making her healthier, why not continue? After five minutes or more, she will tell you what she feels. In the meantime, she will already have become less depressed and anxious.

I hate to cry? What a beautiful picture of how she identified with her father’s reproach as a way to protect him from her anger toward him. She was angry when he reproached her. To ward off her anger toward him she identified with him. Rather than be angry at the reproaching father, she became the reproaching father to herself. When angry with you, she fears your reproach, so she reproaches herself. Thus, when she reproaches herself in session, always ask about the feeling toward you. After all, this time she doesn’t have to protect you from her feelings by hurting herself instead. That’s the message you send when you ask, “What feelings are coming up here toward me?”