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Tuesday, April 13, 2010

When Clients Leave Psychotherapy Prematurely

This article will focus on the topic of when clients leave psychotherapy treatment prematurely. Of course, there are times when the time is right to leave psychotherapy. One reason could be because you've met your treatment goals, discussed ending treatment with your therapist, and you both agree that it's time for you to end treatment. Another reason could be that you know that the psychotherapist that you're seeing is not the right therapist for you. It's not a good match, and you're sure that this is the reason and you're not leaving treatment for one of the reasons that I've outlined below. But ending psychotherapy treatment is a topic for another article.

Why Do Clients Leave Psychotherapy Treatment Prematurely?


When Clients Leave Psychotherapy Prematurely
Clients Leave Psychotherapy Treatment Prematurely Because They Feel Annoyed About Something Their Therapist Said:
It's not unusual for there to be ruptures in psychotherapy treatment. After all, a therapeutic relationship is like many other types of relationships between two people. There are bound to be misunderstandings at times. A client might misunderstand something that the therapist has said. A therapist, being human, might not always be perfectly attuned to a client and might say something the represents an empathic failure. But rather than leaving treatment prematurely without saying something about it to the therapist, unless what has been said is egregious, it's much more valuable for a client to talk to the therapist about it at the next session.

Some Clients Leave Therapy Prematurely Because They're Annoyed About Something Their Therapist Said
Why is it worthwhile to tell your therapist if she has said something that hurt or annoyed you? Well, for many people, growing up in families of origin where they didn't have a chance to express themselves, it's an opportunity to be heard in a way that they've never been heard before. So, it can be a very empowering experience to assert yourself in this way. Also, often, after a rupture has been worked out in psychotherapy treatment, the treatment advances further than it might have without it.

Clients Leave Psychotherapy Treatment Prematurely Because They Feel "Stuck" in the Treatment Process:
When you begin psychotherapy, you're in the initial phase of treatment. During this phase, you and your therapist are getting to know each other. If you're new to therapy, you're also learning what it means to be a psychotherapy client and how the process works.

As I've mentioned in prior articles, some clients come to therapy expecting a "quick fix." Even when they come to treatment with complicated, multi-layered problems, they expect that their problems will be resolved in a few sessions. While there are certain problems that lend themselves to brief treatment, many problems do not. So, if you're feeling "stuck" early on in treatment, it might be that you're feeling impatient with the beginning phase of treatment.

Clients Leave Psychotherapy Prematurely for Many Different Reasons
It might also be that your treatment has reached an impasse because of some obstacle in the treatment either with you or with the therapist or between the two of you. But, before you leave treatment prematurely, it's best to talk to your therapist about how you're feeling. Then, not only are you able to express your feelings, but you can also find out how your therapist assesses the treatment at that point. Maybe the two of you need to change how you're working. Maybe there needs to be adjunctive treatment for a while with a second therapist. This is often the case with trauma, where regular talk therapy isn't enough and you might need to work briefly with a second therapist who does EMDR (Eye Movement Desensitization Reprocessing) or clinical hypnosis. Whatever the reason, it's a good idea for you and your therapist to have a check-in talk with each other every once in a while to evaluate the treatment.

Clients Leave Psychotherapy Treatment Prematurely Due to Financial Reasons:
It's not surprising that many clients have to think carefully about whether they can afford to attend psychotherapy, especially because it's getting harder and harder to find psychotherapists on managed care panels, and many people are now paying for their therapy out of pocket. But rather than leaving prematurely, if you're having financial problems, it's best to let your therapist know.

Some Clients Leave Psychotherapy Prematurely for Financial Reasons
Many therapists work on a sliding scale basis and your therapist might be able to reduce your fee. Your therapist can also help you to look at your money issues. Money can be a complicated subject. Often, clients will say they can't afford to be in treatment when there are really other underlying issues. At times, it's easier to look at a concrete issue like money than to look at your fear of being in treatment. Other times, it might be a matter of looking at your priorities. Are you spending $10-20 a day on cigarettes? If you stopped smoking, not only would you have money for therapy, but you would also preserve your health. Are you spending money on other frivolous purchases as a way to momentarily boost your mood? If so, maybe that's something that you need to look at with your therapist.

Clients Leave Psychotherapy Treatment Prematurely Because They Become Fearful When Therapy Starts to Delve into Core Issues:
Compared to the other issues that I've discussed so far in this article, this is the most complicated issue. Why is it so complicated? Well, first, when clients become fearful of talking about core issues, they often don't realize that this is what's going on. It might be completely unconscious for them. They might think that they want to leave for other reasons that are really unrelated to what's really going on with them. This is often the time when clients might say that they can't afford to come to treatment any more or they don't have time any more. While these might be issues, it's always worthwhile for you and your therapist to explore if what's really operating is that you've gotten to a point in therapy where you're dealing with deeper, core issues and this is frightening you.

You might wonder how this could happen. After all, you might say, "Don't people come into psychotherapy treatment to work on these issues?" While it's true that clients start psychotherapy because they want to work on a problem and they're often motivated at the beginning of treatment, it's also true that many clients get frightened when the therapy actually starts to delve into the very issues that they came to work on. This is very common in psychotherapy.

Sometimes, clients take a "flight into health," meaning that they tell themselves and their therapists that they're feeling better now (when they're really not) and that they don't need therapy any more. This is a common reaction. When this happens, the challenge is to stick it out in therapy and to be willing to explore this with your therapist.

It might not be obvious to you that this is what's happening. But, often, if you step back and you're able to detach yourself from your fear of addressing your core issues, you and your therapist can work through this treatment impasse. Are you really feeling better or are you in denial and telling yourself this because you're too frightened to deal with core issues?

Maybe it means that the two of you need to address your fear of delving into the problem before you actually delve directly into your core issues. Maybe the two of you need to take a different tact in treatment or change treatment strategies. Whatever is needed in this situation, it's better to talk to your therapist rather than leaving treatment prematurely.

Since this is one of the most complicated issues as to why clients leave treatment prematurely, it's worthwhile to look at a composite vignette. As always this vignette does not refer to a particular client, but represents many clients who have this problem in common.

Alan:
Alan began psychotherapy because he had problems making a commitment in his relationship. He knew that this was a life long problem for him. Whenever he got close to a woman that he was seeing, he got frightened and left the relationship, even if he cared about his girlfriend very much.

A year prior to Alan starting psychotherapy, Alan began dating Paula. According to Alan, the first few months were great. But as the relationship started to get more serious and Paula wanted more of a commitment from Alan, Alan began to feel that old familiar fear again. He began giving himself all kinds of reasons why the relationship with Paula wouldn't work out in the long run. He never talked to Paula about what he was feeling, but he felt a mounting panic whenever she talked about the possibility of their moving in together.

Alan really loved Paula, and he didn't want to ruin their relationship because of his fears, so he came to therapy. During the first few months of therapy, Alan learned ways to cope with his panic so that he didn't act on it and end his relationship with Paula due to his fear. At that point, Alan actually enjoyed therapy. But when his therapist began exploring Alan's childhood issues in a highly dysfunctional family, Alan began thinking about leaving treatment.

Even though Alan knew that his life long relationship issues were related to his feeling abandoned as a child, when it came time to deal with this issue in treatment, he became frightened. At that point, he began cancelling therapy sessions or coming to his therapy sessions late so that there wasn't enough time to delve into these issues. He didn't realize that this is what he was doing. He always thought that his cancellations and latenesses were legitimate and unrelated to his feelings about what he and his therapists were talking about.

When his therapist spoke to him about his cancellations and latenesses as it related to what they were working on, Alan couldn't see the connection at first. He couldn't see that he was sabotaging his own treatment. So that, with so many cancellations and short sessions, the therapeutic work began to stall, and Alan and his therapist reached an impasse in treatment.

In order to have good treatment, clients need to come to their sessions on a regular basis. When a client misses too many sessions or comes to sessions late, the client can bring about the treatment impasse. A skilled therapist can point this out to a client, but if a client is unable or unwilling to see this, the client can end up sabotaging the treatment--often in the same way that he or she sabotages personal relationships.

While this was happening, Alan thought about leaving his therapist a voicemail message or sending an email that he thought treatment wasn't working and he was leaving. But Paula convinced him that this wasn't the way to end a therapeutic relationship and it would be better to talk to his therapist in person.

So, reluctantly, Alan came into his next session and told his therapist that he wanted to leave treatment. His therapist was able to reflect back to Alan just how anxious he had become once they began talking about his childhood. She also told him that this was not unusual.

When Alan heard this, he was able to relax a little and think back as to when he began cancelling sessions and coming in late. He realized that it coincided with talking about when his mother disappeared from the family household. His mother left when Alan was four, and Alan never saw her again. No one knew of her whereabouts. His father tried to manage as best as he could but, with five children, his father was often overwhelmed, he began drinking excessively, and Alan often felt alone.

When Alan got older, he thought of himself as being "independent" and "not needing anyone." But it was clear to his therapist that this was a pseudo independence. It was a defense against opening up his heart and getting hurt again. Alan had never recognized this before. When his therapist discussed this with him, it resonated with him, and he felt it to be true. He also knew that this was a breakthrough for him in his therapy. So, he decided to stick it out in treatment and not to run because of his fear. Whenever he felt the urge to flee from treatment, he talked about it with his therapist and each time he gained new insights into himself.

He also realized that when he felt fearful in therapy and he was tempted to leave, he was going through a parallel process in his therapy that was similar to how he felt in his relationship with Paula. In addition, he realized that his issues were complicated and treatment would not be brief.

Over time, as Alan continued to explore his childhood issues, he continued to gain new insights into why getting close to Paula was frightening for him. Rather than fleeing from his relationship with Paula or fleeing from his therapist, he learned to stay in these relationships and to manage his anxiety while he worked through his problems.

If You're Thinking About Leaving Treatment, Talk to Your Psychotherapist in Person:
Many clients feel too uncomfortable about talking to their therapists in person about leaving treatment. They will often leave a voicemail message or send an email. But when clients leave treatment in this way, they are short changing themselves and the treatment process. It's worthwhile to remember that the therapeutic relationship between a client and a therapist is still a relationship, albeit a professional relationship. You owe it to yourself and the treatment to talk to your therapist in person if you want to leave treatment or you're thinking about it.

Clients who leave voicemail messages or send emails to end treatment often regret it afterwards. Even if there are legitimate reasons to leave treatment, they've had no closure to the relationship. And it's not surprising that these same clients do similar things in their personal relationships by avoiding direct communication with people in their lives when there are unpleasant or uncomfortable things to talk about.

I hope this article has been helpful to you or someone that you know who might be thinking about leaving psychotherapy treatment prematurely. There are many other reasons why clients leave treatment prematurely, but the issues that I've discussed above tend to be the most common reasons.

I am a licensed NYC psychotherapist, hypnotherapist and EMDR therapist.  I work with individual adults and couples.

To find out more about me, visit my website:  Josephine Ferraro, LCSW - NYC Psychotherapist

To set up a consultation, call me at (212) 726-1006.

Also, see article:  Returning to Therapy

photo credit: AlicePopkorn via photopin cc

photo credit: ashley rose, via photopin cc

photo credit: Mareen Fischinger via photopin cc

photo credit: skippyjon via photopin cc

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