Tuesday, February 4, 2014

The Question of Termination

I have two patients who I see as ready to end treatment. Beverly had been conflicted about her sexuality, plagued by guilt and shame with the thought that she might be a lesbian. It has been a difficult treatment for both of us. Often I could do nothing right. At times Beverly saw me as homophobic, at other times as pushing her towards women. But we’ve come a long way. She’s now been in a solid relationship with a woman for over a year. She seems to have landed, comfortable in her body and her partner.

The other patient is Pete, a man who came into treatment extremely depressed and obsessed with homicidal fantasies about his partner. Both his depression and his fantasies have been gone for many months. Pete finds things to talk about, but mostly I think he enjoys being with me, getting my reactions,  gaining some additional insights.

I think both patients are ready to terminate. But I say nothing. That’s not unusual for me as I usually wait for patients to raise the question of termination. I don’t want them to feel rejected or discarded or cast out. At least that’s what I tell myself. But I wonder. 

I’m someone who has great difficulty with separation and I’ve certainly had more than my share of losses in the last several years. So is it my patients’ feelings I’m worried about or mine? Or do I put myself in their place and worry that they’d feel cast out, just as I might. Both my analysts were the first to suggest termination. The ending of my first analysis occurred so long ago it’s difficult for me to remember how I felt. Except that I do know I returned to treatment several times. And when my second analyst raised the question of termination, I didn’t feel rejected, but I also didn’t terminate. 

So what about my patients? Beverly made it easier for me. She began canceling sessions and just before I was going to raise it as an issue she asked, “So what do you think about my canceling so many sessions?”

“I think you want to stop,” I replied.

“Do you? Do you really think that? Do you think I’m ready? I’d be happy if you did, but is that what you really think?”

I immediately heard her anxiety and stepped back. “I think you’ve come a long way and made tremendous progress and that you’ve answered the question you came here for. But you’re the one who has to decide if you’re ready. I would never tell you to terminate if you didn’t want to.”

So we’re still in limbo. But at least the question of termination is now out there, open for discussion.

And then there’s Pete. I like him. I find him to be sharp, witty and psychologically aware, but I don’t think I want to hold onto him for me. And yet every time I tell myself I’ll bring up ending, I find myself backing off. I don’t want to do it right after my vacation. He’s not feeling well today. He’s anticipating a stressful visit with his son. These are all reasons to hold off, but are they just excuses?  What is it that I’m afraid of? 

As I type those last two sentences, two very different answers come into my mind. The first is that Pete is someone who is easily wounded by perceived slights and who responds to these hurts by both sadness and anger. It is no doubt true that I don’t want to hurt Pete. But it may also be true that I don’t want to be the brunt of his anger. After all, he did have homicidal fantasies.

My second thought involves my first analyst, who was never particularly good at maintaining boundaries, particularly with ex-patients. Seeing some of us at meetings was unavoidable. But he also invited patients to his home and encouraged interaction at social occasions. Some years after he retired, a form letter from him arrived at my home. He said that he was retired, was cutting off all contact with former patients, and did not want us to contact him. I was shocked. By this time I had very little communication with him and was amazed that he would find it necessary to send me this letter. I was also terribly hurt. Despite the fact that I had been out of treatment with him for years, his written words stung terribly.

So perhaps my reluctance to talk with Pete about termination, is about not wanting to inflict on him the rejection and hurt I felt. Perhaps. And perhaps now I will be able to raise the question of termination. And perhaps not.    

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