Patients must decide when the work is done

When is a person ready to leave counseling? What do they need to learn or achieve or grow toward? What about someone who is in counseling for an extended period, longer than what should be needed for whatever issue they have?

— T.F., Detroit, Michigan

This is part two of my answer to this question. Readers can catch up to this discussion at www.reviewjournal.com/columns-blogs/view/anthem/there-are-three-basic-ways-person-may-employ-therapist.

T.F., this question is a great challenge to any therapist who has a sensitive, personal investment in quality patient care — what it means to add real value to people’s lives, as opposed to wasting the patients’ time. Evoking a fostering protracted, contraindicated dependencies, etc.

Let me put it to you crassly: I’m very alert to the voice inside my head that occasionally says, “Is it OK to keep taking this patient’s money?” Put another way, is it ever the therapist’s job — hell, ethical duty — to suggest, initiate or even unilaterally decide upon terminating a patient’s course of therapy? If so, under what circumstances?

In the near 30 years of my professional life, I have unilaterally terminated a patient twice. And, on both occasions, the patients in question were given fair, extended and ample warning under what circumstances I would terminate. So, in a sense, it wasn’t unilateral. It was more like giving your teenager six separate warnings that, if certain conditions weren’t met, he wouldn’t be allowed to acquire a driver’s license on his 16th birthday. And the teenager decides to test your resolve on the matter. And he doesn’t get his license.

I’m saying that never have I unilaterally terminated a patient because I decided he/she was in therapy “longer than what should be needed for whatever issue they have.”

Not that I haven’t agonized over whether I should terminate. I am never not aware of the occasional patient who seems to be lingering (or malingering) in therapy. They are faithful in attendance. On time. But the conversations seem to be less focused. Past-timing. Even interesting. But more like two friendly neighbors chatting. In some cases, after several weeks, I admit to myself the conversations never have been focused.

I interrupt a lot in session. Because I’m a focused kind of guy. Especially with anxious, emotional types. The kind who, if left uninterrupted, tend to get stuck in a ping-ponging verbal intensity. This usually works. It helps this type of patient to feel the safety of my more direct, focused questions. It helps them look deeper.

But, sometimes it doesn’t work. No amount of my interrupting, looking confused, joining with empathy or strategic detachment seems to make a difference. Occasionally I even run a one-session experiment: If I don’t utter one word during this session, will this patient even notice?

And they never do. Hmm.

So, what do I do? What do I do when, in the privacy of my own heart, it never or rarely feels like we’re digging into anything of substance? Or, if while for months we did dig in and “make hay,” now it seems like we are coasting on a plateau? Or what about the patient who always digs in to substance, yet, frankly, doesn’t seem to get better? They just keep coming in, week by week, to bemoan the same sufferings?

Surely I’m not a Professional Friend. (Don’t laugh. Patients sometimes chuckle out loud, and say with great irony, “Do I pay you to like me?”)

Every one or two years, I’ll call my supervisor to say I feel guilty about taking someone’s money. That I don’t know why they keep coming back. That I wonder if I should refer them to someone better suited, trained and equipped to help them.

And — every time — my supervisor challenges me in the same way. He says my “guilt” is my own problem. My own neurosis. My own insecurity. An especially subtle countertransference.

He reminds me that some people are so badly damaged as to warrant ongoing support merely for the support. Others pop out the other side of effective therapy, greatly healed and more whole, and then desire to use therapy because they enjoy being in therapy! The way some people enjoy going to the gym. He says when in doubt, check in. Ask. “How has/is therapy helping you? … What goals are left unmet?” Or, the real zinger: “How will you recognize when therapy is over?”

But, beyond that, it’s part of therapy to respect the patient to decide when the work is over.

Steven Kalas is a behavioral health consultant and counselor at Las Vegas Psychiatry and the author of “Human Matters: Wise and Witty Counsel on Relationships, Parenting, Grief and Doing the Right Thing” (Stephens Press). His columns also appear on Sundays in the Las Vegas Review-Journal. Contact him at 702-227-4165 or skalas@reviewjournal.com.