My patient terminated therapy prematurely!

And, of course I am feeling low and have been wondering what I did wrong. She was a great candidate for ISTDP, but highly resistant. She asked to reschedule a session, but I refused because I had rescheduled once a few sessions back due to extremely poor weather conditions, and I didn’t want to make this a practice. But I felt bad that she had to miss her session, so I wrote back to her offering some available slots to make up for her lost session. She became angry and said she would come as scheduled for her next appointment and hoped that I would not charge for her missed session. She also added that coming every week did not suit her. I said we would discuss it when we meet. Then the day before her next session, she terminated therapy over an sms saying that this form of therapy does not suit her and she would like to go back to her previous therapist. I offered to keep the slot open so she could come and explore her issues about therapy and about me, but she wrote back saying she would like to close the chapter. She had difficulty facing rage against her husband (who cheated on her) and her father (who controlled and berated her). She is a highly controlling individual, and I feel she was trying to control me by dismissing my cancellation policy and creating one of her own. 
Is it possible some patients don’t feel comfortable facing their rage and drop out, or do they drop out because we therapists have failed to handle their anxieties appropriately? How does one handle premature terminations?
We can help you become competent, but we can never help you become omnipotent! Sometimes patients act out rage with therapists to avoid the rage going onto family members. I doubt your back and forth about your cancellation policy was the issue. She had already cancelled a session. She had already proposed a different policy, hoping to control you. She had already opposed looking at feelings toward her husband from what you told me earlier. Thus, she had already felt rage toward you and was resisting you before your policy was even part of the picture.
This kind of patient is hard for everyone because we have trouble seeing the rage in the transference. This kind of patient rarely says she is feeling angry with you. She is not even aware of it initially. We see her anger toward you because she starts to resist closeness with you. For instance, you asked about anger toward the husband, and she resisted. Or you addressed her self attack while she remained detached, and she probably disagreed with you or argued or dismissed what you said = resistance in the T. Or she talked about people she was angry with and said she didn’t dare tell them about = I am angry with you and dare not tell you.
In other words, we fail with this kind of patient until we learn to recognize the signs of resistance toward the therapist. Once we see the resistance, we start asking for feelings toward us that make them put up a wall with us. And by keeping that consistent focus, we help them feel their rage toward us so they don’t have to act it out by quitting therapy.
Sadly, this is part of every therapist’s learning curve. All of us have a hard time picking up when the patient is feeling unconscious anger toward us as we begin our work as therapists. As a result, when we don’t see their anger in the early phase, it builds up, and then the patient acts out by dropping out of therapy. The sooner we pick up on the resistance and the underlying mixed feelings, the sooner we describe their resistance and ask about feelings toward us, the more we keep patients from acting out their rage in this way.
This is part of the learning curve for all therapists. The issue was not what you did or said. The issue was that you didn’t see the early signs of resistance, so it built up and built up until she blasted out of your office. 
Here are signs that the patient is resisting you and not just resisting feelings: looking away, pausing, going silent, going up in the head, avoiding contact, refusing to explore important issues with you, arguing with you, going helpless, going passive, describing relationships where she hides what she feels and thinks. When those actions occur, describe those actions, label them as a wall against contact, and then ask about feelings toward you that make the patient withdraw. Keep that focus exclusively until there is a breakthrough to feeling. In the meantime, her feelings toward you will rise so that she does not have to channel them into acting out.






2 responses to “My patient terminated therapy prematurely!”

  1. Miles Avatar

    “The balance of power in therapy lies with the therapist. We decide when, where and for how long is each appointment. We set the boundaries and grant exceptions. The client must work within our framework.” – The Relaxed Therapist

    Now, looking at this from the context that the therapist, not the patient, controls the schedule:
    The patient might be a highly controlling individual, or the therapist might be projecting onto her, due to feeling “controlled” by the patient.
    She might be highly resistant, or she might be resisting the perceived (or actual) controlling stance of the therapist.
    Remember the therapist 100% controls the schedule, over which the patient has 0% control.

    The fact that the therapist says she feels controlled by the patient over scheduling is to me a red flag that the reality is the therapist is the controlling one here. The patient does not control the schedule, that’s a fact. The patient can make a request of the therapist, which the therapist is entirely free to accept or deny. This is a long way from “controlling” the therapist. For the therapist to twist this around to “being controlled” is ridiculous. It’s an emotional response on the part of the therapist that has nothing to do with reality.

    Another red flag is that the therapist says the patient is trying to control her over scheduling, when she asked to reschedule *one* session, when the previous session was rescheduled for reasons beyond her control. This is the therapist controlling the patient, not the patient controlling the therapist, which makes the therapist’s assessment that the patient is “highly controlling” to be projection by the therapist, not the reality of the patient. This is probably the worst thing the therapist could do with a patient with a history of being controlled.

    So here you have a patient with a history of being controlled that is trying to assert a minimum of control of her life in what should be *her* therapy, and the therapist responds by acting out at the patient by calling her “highly controlling” and “highly resistant” and then playing control games over the schedule.

    The patient is resisting the control of the therapist, which undoubtedly is going on in the sessions themselves as well as the session scheduling. The patient is trying to assert control over her own life for a change (which is a sign of health), which the therapist is resisting instead of supporting her efforts, as well as labelling the patient with what the therapist is actually doing. The patient is in a lose-lose position with this therapist and is right to discontinue. The scheduling issue was only the last straw of an ongoing problem.

    Then the therapist treats her projections onto the patient as facts (“highly controlling” and “highly resistant”) and wonders whether she adequately handled the patient’s rage and anxieties. In other words, she is shifting the blame for the termination from her own controlling behavior to the patient’s pathologies of rage and anxiety. In other words, the therapist is shifting the blame for the failure of therapy from something entirely within her control (her own controlling behavior) to something she cannot control (the patient’s rage and anxiety), in order to excuse herself for her failure. She still feels badly about the failure, but less badly than she would feel if she faced the fact that her own behavior, which was entirely within her own control to change, caused the failure and was probably the true reason for the patient’s termination. Much easier to say the patient’s pathologies were too difficult for her stage of development as a therapist than to admit that her own behavior was the problem.

    This therapist is probably quite successful with patients that are more submissive and quickly submit to the therapist’s control without resisting it. Thus, the therapist can point to “successes” with her other patients as justification for locating the problem with this patient and not with herself.

    Jon correctly states that the cancellation policy is not the issue here. It is simply not possible for the patient to control the therapist on this issue, so if the therapist says she “feels controlled” you definitely have a problem, but it’s not the one that either Jon or the therapist states.

  2. andrew stewart Avatar
    andrew stewart

    Therapists do like to talk about themselves and how they feel don’t they? My experience of psychotherapy was feeling treated like a rat in an experiment from the beginning and have lost three years to unravelling just how unethical therapists can be about entering someone into a therapy and their intentions.

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