Saying Good-bye

“Well,” Arlene begins, “We have three sessions left including today.”

“How do you feel about that?” I ask.

“Good. I’m happy. I never thought I’d be able to say that. When I started with you three years ago I was totally miserable. I’m sure part of it is being on medication, but you’ve been so helpful to me.”

I’ve been seeing 65 year old Arlene in therapy for three years. And she’s right. She’s made excellent progress. She’s no longer depressed, can speak up for herself with her husband, and is more accepting of her grown children’s need for their own lives.

She continues. “Even last night, Larry took the remote and started flipping channels when I was right in the middle of watching ‘Madame Secretary.’ For a second I sat there and said nothing, but I could feel myself shutting down and I knew – because of you – that’s the first step to my becoming depressed. So I told him that wasn’t considerate of him and that I wanted to finish watching my program. I could see he wanted to give me an argument, but he didn’t and he did put my show back on.”

“And how did you feel about that?”

“Good.”

“Only good? Didn’t it feel like a victory, like you wanted to jump up and shout for joy?”

“I wouldn’t go that far. But I did give myself a kind of pat on the back.”

“Good for you!”

Silence.

“I don’t know what else to talk about. I’m happy.”

“I glad you’re happy but can I ask you again how you feel about ending?”

“Like I said, good. I feel that I’ve accomplished a lot and that we’ve talked about my big issues - my fear of my father and my dependency on my mother - and that we’ve been mostly rehashing for months and that I don’t need to be here anymore.”

“I agree with you, Arlene, that you don’t need to be here, but I still wonder, we’ve had a long relationship. Do you feel any sadness about leaving?”

“No. I don’t feel I need to be here.”

I’m taken aback by Arlene’s response. I know that she has been quite attached to me during the time we’ve worked together. I also know that I almost always feel some sadness at the ending of a treatment. How is it possible she’d feel no sadness? I persevere.

“I agree you don’t need to be here. And you can feel a terrific sense of accomplishment and satisfaction about being ready to leave. But you can still feel sad about saying good-bye. I do. That doesn’t mean you shouldn’t leave. Let me ask you this, will you miss me?”

“No. I hope I’m not hurting your feelings, but I don’t think I’ll miss you and I don’t feel sad. I feel too happy to be depressed. Maybe the medicine keeps me from feeling sad.”

“I wonder if you’re saying you’re afraid to feel sad for fear of becoming depressed again.”

“I just don’t feel sad.”

Increasing confident that Arlene is defending against her sadness I ask, “What does make you sad?”

“Nothing.”

“I know that’s not true, Arlene. You were certainly sad when your granddaughter went into the hospital or when your friend Miriam died.”

“That’s different. That was about death. I was scared for Haley and Miriam’s death was a big loss.”

“You look a little sad now, thinking about Miriam’s death.”

She nods.

Silence.

“Maybe we shouldn’t terminate,” she says suddenly.”

“You know, Arlene, it is all right to feel sad and still terminate.”

“There’s no reason we have to end.”

“I think what you’re saying, Arlene, is that you don’t want to feel sad. If you’re going to say good-bye you have to keep yourself from feeling sad and if you start to feel sad you have to keep yourself from leaving.”

Arlene shakes her head. “If I feel sad maybe it just means I’m not ready to leave.”

“I wonder, Arlene, if you’re feeling with me as you did with your mother. In order to be your own person you felt you had to cut off your feelings about her, to feel nothing, or separating from her would have been too painful. And that’s what you’re doing with me as well.”
 
“Well, if I’m still doing that maybe I’m not ready to terminate.”

“Or maybe in our two remaining sessions we need to deal with your allowing yourself to feel sad and still say good-bye.”

Good-bye

“I’ve decided this is going to be our last session,” Beth begins. “It’s the end of the year, so it’s a good time to wrap things up.”

I’m beyond startled. I’ve seen 32 year old Beth in twice weekly therapy for over three years. She hadn’t said anything about wanting to terminate and I hadn’t picked up any clues in her material. Besides, we have a relationship and a relationship requires time to say good-bye. Termination is the part of therapy I like the least, feeling the pain of losing the connection with a person I have come to know intimately over an extended period of time. But I do know that all relationships end and that the process of leave-taking, although often painful, can be both rewarding and growth producing.

Beth has certainly made progress in her treatment. She no longer experiences sudden panic attacks nor feels overwhelmed by life’s small difficulties. However relationships continue to be a problem for her, as she vacillates between excessive clinginess and total indifference, a repetition of her experience with her mother. I’m now experiencing the indifference side of the equation and I don’t like it at all. I feel discounted, dismissed and discarded. 

“Are you dismissing me, Beth, just as you felt dismissed by your mother?” I ask.

Beth rolls her eyes, crosses her arms and jiggles her leg. “Do you have to interpret everything?” she says, clearly exasperated. “It’s time, time for me to go. I’ve been here long enough. Besides, like I said, it’s the end of the year.”

Trying to keep my annoyance in check, I ask, “Have you been thinking about this for a while because if you have, I wonder why you hadn’t mentioned it?”

“No, not really. I just decided.”

“’Just’ meaning …?”

“I don’t know,” she says, tossing her head. “Sometime during the week.”

‘The week’ I think to myself. That’s right, because of the holidays I only saw Beth once last week and am scheduled to see her only once this week as well. She also spent Christmas with her family which is guaranteed to bring up issues. I decide to explore the family question first.

“Did something come up with your family at Christmas?” I ask.

“No,” she says casually, indifference oozing from every pore. “It was the usual zoo. My mother totally frazzled and expecting me to know what she wants me to do by reading her mind and not asking me a single thing about my own life. So what else is new? It was fine,” she adds, shrugging again, “Just one day in the year.”

So Beth felt dismissed by her mother and, in turn, is now dismissing me. But she also felt dismissed by me, because I treated Christmas like, “just one day,” rather than appreciating that she might have feelings about us not meeting. Beth needs to feel important without feeling intruded upon, not always an easy tightrope to walk. And she doesn’t like to be reminded of her need to rely on me, which makes the tightrope even more slippery.

“Several things occur to me,” I begin.

“I’m sure,” she says snidely, interrupting me.

“But maybe we should look at why you’re taking jabs as me today,” I say, putting aside what I planned to say.

She shrugs.

“So let’s say you’re angry with me.”

“Why would I be angry with you?”

“Well, I know you knew we weren’t going to meet on Christmas or New Year’s, but I think I took that too much for granted without giving you the opportunity to talk about how you felt.”

“You think I can’t live without you for a day?”

“I didn’t say you couldn’t live without me, I said you might have feelings about us not meeting. And you might have felt dismissed by my not giving you the opportunity to talk about those feelings.”

“You sure you just don’t want to lose a patient?” she asks, with less of an edge to her tone.

“I don’t want to lose you, Beth. And whenever you do decide you want to end, I want us both to have the time to deal with saying good-bye.”

“OK. I’ll stay.”

I look at Beth quizzically. “Had you really planned to terminate today or did you want me to show you that I cared enough to talk you into staying?”

She purses her lips and taps them with her finger, looking almost child-like. “I had decided to terminate. But I guess down deep I wanted you to change my mind.”

“I’m glad you could see that, Beth. And I don’t think either one of us is ready to say good-bye.”  

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.