Tuesday, April 9, 2013


A colleague told me that a patient of his had stopped treatment the previous day without any warning and that he felt hurt and angry. I both understood and commiserated. I also began thinking about some of the patients I’ve had over the years who quit without notice and how well I remember at least some of them, even those I saw over thirty years ago. 

There was a man I saw for several years who came in one day and said he wasn’t getting anywhere and was leaving. When he left, I started crying. Was I crying because I would miss him, because I had failed him, because I was narcissistically injured by my failure? Probably all of the above.  As I look back on that treatment today I know that he was a man who was terribly afraid of his own feelings of neediness and vulnerability and that he dealt with his fear by keeping everyone at bay.  He wasn’t going to get anywhere near me; he wasn’t going to let me in. I still remember that he told me that all he dreamed about was alternating screens of black and white. As a young clinician, although I understood the barrenness of his internal landscape, I had no idea that he was terrified of getting close. 

Another patient – perhaps even earlier in my career – was a woman who so feared closeness that she had sex only three times in her twenty year marriage. She wanted children so she thought she would try three times and take whatever she got. She had two children! When she announced one day that she was leaving, I tried to persuade her to come in through the end of the month so that we could both deal with our feelings about her leaving. Although she had no idea what feelings I was talking about, she agreed. During those final sessions she felt less anxious and uptight. Even then I knew that having a clear way out, an exit strategy, made it possible for her to be more relaxed and related. I didn’t then understand why. Today I get it. People who are afraid of their own dependency can never get too close for fear that they might be too greedy and want too much.

Probably my oddest termination occurred with a patient I saw only a few times. I was a more experienced clinician by then. I knew that this woman had difficulties with closeness and intimacy, but we were early in the treatment and I wasn’t making any grand interpretations. We had our session and she left. Under the chair I noticed a letter which I assumed she’d forgotten. When I retrieved it I saw that it was addressed to me. In it was a check and a letter that said today was our last session! I was stunned. We had spent an entire session and she gave not the slightest hint, at least not to my awareness, that she didn’t plan to continue. Seasoned clinician or not, she definitely got by me. I’d like to know why she left. I’d like to know why she chose to leave a letter as opposed to talking with me about her decision. But I’ll never know. Among the many things that remain unknowable to me forever.

So what’s the lesson here? Neither love nor caring nor empathy are, in and of themselves, enough.  And the therapist, despite all her knowledge and years of experience might still not understand what is going on with a patient.

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