Tuesday, October 28, 2008

Where'd Ya Go?

I'm going to tell you that I haven't found that treatment termination goes quite the way they say it should go in the textbooks. By and large, my patients haven't had a pre-defined end date where we process the meaning for months beforehand then stop, never to see each other again. Psychotherapy, I've found, ends in a more fluid and phased-out way without a whole lot of talk about the meaning of ending.

So people come in pain and distress. I usually suggest they come weekly, at least until they feel better, and we continue with that until they say they'd like to come less often, then we go to every other week, then monthly, then "call me when you want to come in." It's hard for me to figure out my schedule more than a month ahead, so there are people who call when they do and everything isn't planned out, and there are people who finish with regular therapy session who still need medications and they come in for a session every few months.

Sometimes, I realize that I just haven't heard from someone in a long time--I think more about the people I'm seeing and not so much about the people I'm not seeing, so sometimes I realize after quite a long time that I haven't seen someone (sometimes the pharmacy calls for a refill and this jogs my memory). If I realize someone's fallen off my radar, and it hasn't been so long that I'm embarrassed to call, I call. Often this prompts someone to ask for an appointment. Sometimes I hear that all is well and they're fine. Once in a while, I don't reach a real person and I never get a call back. If it's someone I only saw briefly, I don't worry about it-- people know how to find me. Patients sometimes reappear years later, some only come when they're in active distress and the rest of the time they don't want to talk. Whatever.

So every now and again, someone I've been meeting with regularly and for a long time simply disappears. They don't return calls and I have to let it go-- no one wants to be hounded or stalked by their old shrink. A couple of times, I've had the sense that the disappearance is more meaningful than "I'm done"...either they've canceled a regular weekly therapy session to fade into the sunset, or they've disappeared more benignly, but after years of treatment and no response to my "I've been thinking about you" phone calls. It's unsettling to me; I wonder how they are and I'm usually left with the nagging sense that something must have been said in the last session that was upsetting, but now can never be addressed. Oh, and I guess I can also wonder if they disappeared because of something on the blog.....


Anonymous said...

I once split on my shrink for six months because I'd had a dream he was moving back to California. When I told him about the dream, he made a joke (only realized in retrospect) about how he would be more likely to move to Florida. So I freaked (abandonment issue, I guess) and disappeared for half a year. No meds. Bad idea.

When I got sick again, I went back and explained what had happened and we discussed it. So we were fine after that.

Then he told me he had taken a job as medical director at a specialty hospital and would eventually be moving his private practice to another location -- in two years!

I guess he learned something from the first bug out, even if I didn't. Now that the move has taken place, I'm thinking of leaving again because nothing feels right at the new hospital.

I guess my point is, sometimes patients do things for what might seem like "weird" reasons.

Anonymous said...

Sometimes patients disappear for good reasons too. It might have been a very typical last session after all, and in my case that was a problem. If the therapist has a tough time hearing what the patient is saying and is wrapped up in themselves, eventually a smart patient will stop showing up. It is not worth the time and money to book another session to tell the therapist they are too self centered because they will tell you that this is transference.
Sometimes you know you have to leave. It is amazing to experience the difference with a therapist who is not self centered, at least in the session.One can reasonably conclude it was not transference after all. I am not arguing that this is what happened in your case, merely that there are so many reasons why patients disappear and that you are correct in assuming that someone who has not contacted you in a long time does not want to be chased down.
As for the blog, that is your choice but if a patient reads something there in content or in tone that does not seem to mesh with their perceptions of you, you might have to deal with that in therapy but will they bring it up? Do you care or have you drawn a line down the middle of those parts of your life and figure they will never intersect?I'm not interested in the answer but I would be if you were my shrink.

Anonymous said...

When I stopped seeing a therapist I wrote a letter explaining why, having the excuse of moving cross-country made it an easier letter to write. I did feel therapy had been beneficial but then no longer needed. The therapist responded to my letter by saying she did feel I was better equiped to deal with the ups and downs of life but if I ever needed help again not to hestiate seeking it. Reflecting on it, that was a great way to end.

Now, many years later, I've resumed my education with the ultimate goal to be a clinical therapist. It is interesting to think about the issue from the other side of the couch. Is it similar to feeling genuine concern and good wishes for a long lost friend from high school? Or more than that because of the agony and ultimate life/death issues involved with mental illness?

BTW- recently found your podcast & enjoying it very much.

JW said...
This comment has been removed by the author.
folkswitch said...

What an interesting post.
I have been thinking about this in relationship to my practice as a clinical social worker.
I take the same approach in that I generally recommend that people come weekly to begin and this often gives way to every other week as symptoms or circumstances improve. Sometimes this continues and sometimes, from there, someone doesn't schedule another appointment for one reason or another and then time passes and I realize we haven't spoken. I have taken to giving a call just to check in, say hello, acknowledge that we haven't met in awhile and to see what the person is thinking about continuing or not continuing. Often, I get a call back, in which the person says, Oh, I'm glad you called, I have been meaning to call you and I would like to come in. Other times, I don't hear anything, so I send a letter. In the letter,I note that it has been some time since we have met, that I am interested in their decision about treatment and that if I don't hear back, I will assume they have decided not to continue at this time and I will close their file with our office. I also offer that I will continue to be available if they would like a referral, information or at some point, decide they would like to return. Believe it or not, sometimes this letter results in a return call, but when it doesn't, I feel more comfortable about not having let the relationship drift away without any acknowledgement.
I agree, 'termination' rarely happens they way we learned it would in school!

Anonymous said...

If the therapist has a tough time hearing what the patient is saying and is wrapped up in themselves, eventually a smart patient will stop showing up. It is not worth the time and money to book another session to tell the therapist they are too self centered because they will tell you that this is transference.

I suspect this is happening to me.

But I also once just finally got a decent med, so I quit going because I didn't like the guy personally, for the reason above, he just didn't fucking listen, and there was a lot of "blame the patient." (I told him I was not going to be back.) Then, five years later or so I needed a med change...and called back.

It was awkward for me to make the call...and I've had a horrible time getting meds adjusted now again. But now that they seem to be working, I want to leave again, but am afraid this is offensive, especially after he put up with my shit for so long while trying to hold things together while badly medicated. I guess I'm glad you posted about this, from your end.

On the other hand, I really hate it when I hear a patient died from some other doc, or way after the fact.

Anonymous said...

While I realize you are a person, you also have to remember that this may be the one time in someone's life where they have complete control over a situation. They don't have to be considerate. They don't have to give a reason why they do not come any more, such as they would with a friend. They can burn the freakin' bridge if they want to -- and nothing serious will happen.

There will not be the repercussions that happen IRL when you want to stop being friends with someone / stop dating someone / get divorced, etc. They don't have to explain that they need space, time to think by themselves, time to breathe. In fact, they don't have to explain anything if they do not wish to. For once, they can be the one who uses instead the one who is used.

Just a thought.

Anonymous said...

They don't have to be considerate.
they can be the one who uses

There's an interesting perspective. It never occurred to me that having a psychiatric diagnosis gave one permission to be rude.

Anonymous said...

They don't have to be considerate.
they can be the one who uses

There's an interesting perspective. It never occurred to me that having a psychiatric diagnosis gave one permission to be rude.

Sounds like an angry perspective to me.

If you feel it's okay to "use" someone and disappear without telling them just to be nasty, then I suggest you could still benefit from therapy. Probably with someone else.

DrivingMissMolly said...

I quit seeing my therapist last March. I felt that I was not getting better.

After a couple of months, I realized that I was uncomfortable with something he had said to me and I couldn't go back. I also did NOT like him patting my back after sessions. Weird, I know, especially since I used to be a very warm huggy person.

Well, I went back Tuesday, and it wasn't any better. "Therapy" feels so futile....He never called in between to say anything, ask anything, etc. (7 months after going 5 years).

But, I can no longer afford to see my psychiatrist. He costs $200 a session, and I've already gone through my flexible spending $2,500 for the year. Since our plan year starts in April, I'm screwed. He is out of network. I am on a waiting list for a network shrink, but it will take MONTHS the secretary said.

I am torn up inside. I have been seeing Shrink for at least two years and he can't offer me a payment plan? He can't steer me toward some community resources?

This sounds awful, I know, but it is the truth. It all makes me want to kill myself because I am pissed off because no one cares. I also can't afford my thyroid scan (not I have hyperthyroidism) or an upped abdominal ultrasound (gall bladder). I am MAD, MAD, MAD.

I see members of my family buying new computers and planning cruises and I realize that no one really gives a sh*t.

DrivingMissMolly said...

Catherine, you wrote:

"In fact, they don't have to explain anything if they do not wish to. For once, they can be the one who uses instead the one who is used."

Brave and brilliant observation.

When you have mental illness, it is hard enough to 'go through the motions' every day with family, coworkers, boss, etc. It is exhausting. I try to be polite, but I figure that if they are going to see the scope of my illness, I need to 'let it all hang out.'

I have so much anger and I try to tightly controll it, but when I saw the psychiatrist it was like a dam burst.

It is easy to be angry with him. He isn't warm and I want him so desperately to be warm. I know if he was though, it would freak me the f*ck out.

I want to cling to his leg like a toddler; "DON'T LEAVE ME, DON'T LEAVE ME. I DON'T WANT TO GO."

It's never going to happen.

THERAPY PATIENT: You are having boundary blurring issues. Personally, I freaked when my therapist said he liked me and thought of me as a friend as well. Scared the crap out of me. I told him I liked people to stay in their "boxes."

BOUNDARIES. BOUNDARIES. BOUNDARIES. Perhaps a Shrink Rapper will expound.


Anonymous said...

Anon (I'll call you #1): I could say that your comment is rude because it is a snide putdown to my comment rather than something that generates discussion, but that would just ignite a whole flame war on somebody else's blog.

To me personally, yes, it is a "rude" behavior to not call/write somebody and tell him/her that you are not coming back. But I am not the one to whom Dinah was referring.

Anon (I'll call you #2 -- unless you are the same person?): No, it is a realistic perspective. I'd gather that most everybody has used someone else to some extent, whether it is in a big way or a small way. Even "good" people have done it at least once or twice, so don't use that excuse to let you off the hook. If you have ever once in your life thought, "Maybe if I do this for him/her, he/she will do ______ for me", then you have used someone. In life, there are some people who get used more than others, whether it is because they have some sort of homing device placed on them or something, I know not.

It's also about power and who has it. There are some people who have been in power, loved it, and misused it; there are others who have been in power, used it fairly, and gave it up because they decided that it was too easy to succomb. Then there are still others who have never been in a position of power before, and they just want a little taste of it and by golly here it is (truly, the different combinations could go on forever).

Am I that person, one that regularly uses someone and ditches them? I would like to think not. But maybe I am. Hmmm. Maybe you, someone on the internet, can help me figure it out? =P

Anonymous said...

I'm going with the assumption that I'm Anon #2...

Just realize that not everyone thinks as you do. Not everyone has that perspective on life, where everything is about power and manipulation, and having to use other people to get their way.

No, I can't help you figure that out (I know you were being sarcastic, anyway), but from the way you express yourself, it sounds like maybe you still have some things to work on in your personal life. Don't we all?

Anonymous said...

This post was all about when patients ditch but what about when the professional ditches? When the only therapy offered is very short term (like <12 sessions)? I feel like saying "where'd ya go?" to the person I was seeing for psychotherapy. Of course, this isn't private practice, but a university health system... They told me two weeks before they left for vacation that they would stop seeing me before their vacation, but that I would probably struggle with depression and an eating disorder my whole life and to join a therapy group that started in a couple months which I ended up not being eligible for because I was a grad student and the rest of the group ended up being young undergrads.

I guess it's a fact of life when you're deciding how to divvy up scarce resources, but it is a bit of a slap in the face to still be in distress, to be told I'll be in distress off and on my whole life, and then shown the door. And to have one week notice about it. And no follow up AT ALL.

Anonymous said...

Last thing and then I will retire:

Just because I recognize that it happens does not mean that I personally choose to play the game that way.

I do think this would make a good post on my own blog. Now I am curious - thanks.

Anonymous said...

Ironic. I had a friend...while I only knew him online, we were more intimate that the majority of my "real" friends...and early this year he simply disappeared. As I know he would consider what he did incredibly rude and because there was no apparent reason, 7 months later I had to accept he either died or otherwise incapacitated. Regardless, I wasn't going to speak with him again.

Then 2 weeks ago I get an email from him, saying he was embarassed by his behavior. Very little explanation of why, except "tough times."

And then there's me, who can be pretty flaky about maintaining relationships myself...too much introversion for my own good.

DrivingMissMolly said...

Tharapy Patient,

I did not mean to imply that, in your relationship with your psychiatrist, YOU were the only one with boundary issues.

I think he has them.

As human beings we have needs for affection, acceptance, etc. Mental health professionals aren't supposed to let their needs come before yours. They should be getting what they need from the people in their life that are NOT their patients.

Am I wrong? Maybe I like a lot of distance? Too much distance?

I'm concerned that he is telling you what to do. I thought this WASN'T their job. After all, like you said, you have to deal with the fallout if you quit your first-year job, not him.

You have to learn to trust yourself and make your own decisions and ferret out what YOU want YOURSELF. How are you going to do that if he tells you what to do?

Psychiatrists/Therapist are the ultimate mindfuckers. Parents are too, but at least, hopefully, most of the time they don't do it on purpose. Of course, they have the trump card. We are "sick" and came to see them so why don't we listen?

Why does he want you to be so dependent on him?

As for abuse, well, your job sounds hard, but you have a plan. Stay one year. I agree, honoring a contract is important (I taught for one hellacious year in a Title 1 school).

OK. I'm worried about you. Good luck. Your shrink sounds needy. Bring him a teddy bear, perhaps? Sorry, just kidding. Blame it on my bordeline-ness.

Take care.


Anonymous said...

I don't want to be one of those self-promoters, but I just finished a 4-part series on termination at my Psychology Today blog. I talk about all this stuff. Clients disappear all the time, but sometimes that's because they don't know any alternative. Come on over and take a look. Thanks for your blog!

Anonymous said...

I meant Oliver Sacks.

NeoNurseChic said...

Interesting post. I just had a bit of an experience with this several weeks ago. Dinah, I know I told you before about my psychiatrist moving to a new university, and the endless wait for his credentialing to come through so that I could continue to see him. I waited a loooooong time (several months), and since I have gone back, I do not have the dependent feeling I had before. I go - but I no longer get so wrapped up in the appointments and count the days before the next one.

Aside from that, things in my life have taken a very different direction. I went through 5 months of a bad situation with the nerve stimulator, and just the day after I got out of the hospital having it removed, I moved in with my boyfriend, and then my grandfather had major open heart surgery 4 days after that. I went back to work in mid-October, and all of this has been a time of transition and soul-searching.

So a few weeks ago, my psychiatrist was going away for a couple weeks. The way things are set up now, for the most part I schedule appointments with his secretary, whom I have never met face to face - and I call outside of times when I am physically present at the office to schedule the appointments. We have had to make special arrangements because I keep getting bills from the University, even though I am self-pay on a set fee. He also recently proposed raising that fee, which brought up a number of issues for me - at the end of the day, what is most important?

So he went on vacation, and I didn't call to schedule the next appt. I forgot - I really did. Simple as that. As the weekend before he was due back came, I suddenly remembered that I forgot to schedule a follow up appt and that I couldn't now as it was the weekend, and that Monday I woke up late and still hadn't called. That afternoon, I received a call from him, checking in to see how things were and to schedule the next appt. First time that's ever happened, and I've been seeing him for 4 years. Never had the opportunity to test that before because I was always so diligent in being SURE I had a follow up appt planned for when he returned.

But life happens sometimes. For me, life has been happening in big ways and as much as I know the therapy is important, somehow it fell second to just getting through each day in the first place. It was a really strange thing to get that phone call. Part of me was relieved - that he cared enough to make that call, realizing that something was not normal for me - I have never ever not had a follow up appt set in place with him - and here he was back, and I had not called, had no plans to come in. I was also relieved because it meant I didn't have to do every bit of worrying about it on my own - he gave something there. He spent a few minutes thinking or wondering about my needs, and then called me to ask what was going on. That had a profound impact, even though it was just a very brief phone call. When he called, I was hooked up to an IV, doing a vancomycin infusion at home. It was like a little bright light amidst a dark time of feeling very, very alone.

Sometimes knowing that someone cares about you, outside the bounds of financial arrangements, makes a very big difference.

Take care,
Carrie :)

NeoNurseChic said...

Oh and I further wanted to say, or rather emphasize, that I really did forget to call. I didn't put him through some test - consciously waiting to schedule the appt to see if he would call me. I just want to be clear about that. I was completely surprised when he did call - I did not expect it at all! I was pleasantly surprised, however, which is why I mention relief. At the time, I had grown accustomed to the idea that the only person looking out for me was me - that people just didn't have the time and energy to go the extra mile and see how I was doing. The fact that the call came during that time gave me a tiny bit of hope that that isn't the case. That maybe people do wonder - maybe they don't say it - but maybe they still wonder. Maybe I wasn't as alone as I thought I was. I dunno. As I said it wasn't a conscious test. I really was genuinely surprised and happy to have received the phone call. Since then, I have made sure I have a follow up appt scheduled, as I always did before. Just felt I had to say that.

Take care,
Carrie :)