My goal as a therapist: to make myself obsolete

Traditional psychodynamic therapy is often caricatured as endless, with a complacent therapist silently growing cobwebs, listening to a patient who never plans to leave.  This isn't completely unfounded: there are therapeutic advantages to losing track of time, "swimming in the material," and letting one's therapeutic focus be broad.  The patient's chief complaint, i.e., the ostensible reason for coming, often gives way to more troubling underlying conflicts and concerns that might never appear in more directed or time-limited work.  Highly defended material may be uncovered and worked through in the fullness of time.

All the same, and as many critics have pointed out, this is a cozy arrangement.  If the therapist is happy to have a paid hour, and the patient is gratified to pay for the undivided attention of a caring doctor, nothing need change.  Ever.  Many patients fear becoming emotionally dependent on their therapists, i.e., finding it too comfortable to stop.  And some therapists, being human, are not above maintaining a pleasant status quo.

Psychoanalysts and analytic psychotherapists anticipate this concern, and hold that a patient's dependency, like everything else, can be explored, understood, and overcome.  However, in highly non-directive therapy, i.e., with a mostly silent therapist, this can take a long time and be painful for the patient in the meantime.

My approach to dynamic work is more interactive.  While I believe transference and countertransference are highly useful tools, and that both manifest and latent content are important, I also strive to help paients in the here and now, whenever doing so doesn't interfere with long-term gains.

In this light, I often tell patients that I aim to make myself obsolete in their lives.  Saying this can quell dependency fears, but it's open-ended enough that I'm not promising how long (or briefly) we'll work together, nor that I guarantee they won't feel dependent along the way.  I can't promise these, because I don't know.  But I can give my word that I won't allow myself to get so comfortable with our arrangement that I forget why we're meeting at all.  It's a comforting statement that has the advantage of being true.  It feels good to have a patient not need me anymore, a little like the bittersweet feeling when a child goes off to college.  And in a way, hearing myself say so out loud helps me remember it.

The trade-off, a psychoanalyst might point out, is that I short-circuit any fantasies patients might harbor that I seek to trap them, that I want them to feel dependent.  Patients might gain more insight about themselves if I let such fantasies germinate, and then collaboratively explore them.  It's an important point to keep in mind, but on balance I usually feel this modest bit of support helps the therapeutic alliance much more than it forestalls exploration.

A successful psychotherapy is when a patient leaves with the satisfaction that she "got what she came for," and no longer needs, or even wants, to see a therapist.  And a successful psychotherapy practice is one where patients come (in need) and go (improved), the therapist becoming obsolete one patient at a time.

Is your therapist biased by money?

Earlier this year, blog commenter TK wrote: "Isn’t this the greatest countertransference, in this age of fee-for-service psychotherapy as opposed to psychotherapist-on-salary: How do I work around my own economic motivation in deciding whether to continue with a patient or terminate?

"In other words, how does one reconcile the consistent economic incentive to keep a client coming back to your office, particularly when one is being paid by the therapy hour instead of by salary? After all, there’s always something to work on, to improve, to understand better…

"In other, other words — and this is only partially tongue-in-cheek….Is there truth to the adage that you don’t ever want to see any psychotherapist who has openings in their practice?" 

In a similar vein, a reader named Cynthia more recently posed a challenge:

What would you think about a patient asking a therapist at the outset of therapy to report to her at the start of each session how many client/patient hours you have scheduled for that week? That would give her real insight into what’s going on in the therapist’s practice, and would help determine how important it is for the therapist for her to keep coming back. Would you personally be willing to provide that kind of information?

To me, this seems far more important to know than any therapist personal life information that would arouse normal patient curiosity.

I replied to Cynthia's comment, noting that such disclosure might appear to be a useful consumer tool not only for therapy clients, but also for anyone hiring an electrician or plumber, a lawyer, a music teacher, or a medical doctor.  For each of these, financial incentive may be a factor in determining how "important" it is for the customer, client, or patient to return.  However, none of these service providers offer this information, and presumably all would consider the question intrusive and overly suspicious.

Of course, even having this concrete information may lead to different conclusions.  An underemployed service provider may be relatively unskilled, and/or more desperate for income.  As TK offers: "you don’t ever want to see any psychotherapist who has openings in their practice."  On the other hand, overly busy providers may not be available at all, may be hard to schedule, or may not give you their full attention.  Nor is busy-ness always a sign of quality.  Some providers market themselves better, or offer faddish services that are popular at the moment.  All of this applies equally well to hiring a house painter or a psychotherapist.

Seeing a therapist is different than hiring a plumber or painter, though.  Popularity (e.g., high ratings on Yelp, or on one of the dedicated rating sites for doctors or therapists) is no guarantee of a good personal connection with you as an individual.  Rapport with a therapist is more idiosyncratic and subtle than that, a matter of chemistry.  Also, since therapy quality is more subjective than the quality of a plumbing or paint job, the impressions of others may not be as reliable.

However, even if we agree that a busy therapist is apt to be a good therapist, TK and Cynthia share a somewhat different concern.  They worry that therapist economic incentive may lead to unnecessarily prolonged therapy.  "Isn't this the greatest countertransference...?"

In a sense, yes, the wish to be paid for providing psychotherapy is the greatest countertransference.  There are important ancillary gratifications of the work — the satisfaction of helping troubled people, the intellectual challenge — but being a therapist is, first and foremost, a livelihood.  A therapist who lacks the money to buy food, or who faces eviction or mortgage foreclosure, is not in a position to "bracket" his or her own needs and put the patient's first.  I confess that when I first opened a private office in 1995, retaining my first few patients mattered more to me than it should have.  While I don't believe I harmed anyone, or kept anyone in treatment longer than needed, the economics loomed large in my mind.

However, this situation passed quickly.  I cannot speak for all therapists or all psychiatrists, but on the whole we make a decent living whether our practices are full or not.  Patients come and patients go; the economics surrounding any one patient is not a major consideration.  As in many features of the therapy relationship, the dynamics feel weightier to the patient than to the therapist.  This makes good sense, as the patient only has one therapist, but the therapist has a number of patients.  (And transference magnifies these issues for the patient more than countertransference does for the therapist.)  Thus, a vacation of either party usually matters more to the patient.  Fees and money issues usually matter more to the patient, and so forth.

As I read the comments of TK and Cynthia, I recognize a core of realistic concern that the therapist may be biased by economic incentive.  But barring specific evidence of desperation or money grubbing on the part of the therapist, I can't help but think of this as a concern magnified by transference.  Economic incentive is the default situation when hiring anyone for anything.  Do you worry that your car mechanic, tax preparer, or personal trainer is just stringing you along for the money?  We all need to keep our eyes open, but there's a point at which one's natural suspicion can give way to trust and a sense of security.  Healthy relationships reside in the sweet spot between gullibility on the one hand, and paranoia on the other.  If suspicion persists, whether in therapy or elsewhere, there is a problem.  Maybe the other person gives subtle signs of untrustworthiness.  Maybe one's own "trust meter" (transference) is a bit askew.  Figuring this out is itself the stuff of dynamic therapy; it can shed light on one's relationships inside and outside the therapy office.

Ending therapy

Two events prompt me to write about therapy endings.  In the more abrupt and traumatic of the two, a local psychiatrist died last month in a tragic accident, leaving many patients suddenly without their doctor.  The other event, far more commonplace, was the decision of one of my own patients to stop therapy.  These events illustrate opposite ends of a continuum, as I hope to describe below. I discussed typical features of open-ended dynamic psychotherapy in my last post.  Timelessness, wide focus, relative freedom from protocol and direction, and promotion of transference all come into play when such a therapy eventually comes to an end.  Since this type of therapy has no "built-in" ending, each ending is unique.

In the real world psychotherapy often does not feel timeless.  External events like a job change, a move, or a change in insurance coverage may end therapy prematurely.  Therapists retire or move their practices far away.  These endings are not chosen by the patient.  Any unchosen ending can feel like a loss, or even an abandonment.  These events do come with advance warning, however, and can be discussed ahead of time.  The emotional repercussions can be contained, reviewed, and comforted in what is termed the "termination phase" of treatment: the sessions between acknowledging that therapy is ending, and the actual last session.

However, sometimes there is no warning, for example when a psychiatrist or other therapist suddenly dies.  Such events are emotionally traumatic.  Patients feel the acute loss of a relationship they came to rely upon, and often there is a rocky transition to another doctor, facilitated by the colleagues, professional partners, or secretarial staff (if any) of the deceased therapist.  This mini-community steps in, without advance preparation nor much knowledge of the patients affected, to make the best of a very difficult situation.  I consider this one extreme of the continuum of therapy endings, the pole where it is not the patient's idea or wish at all.

In my view, the ideal way to end psychotherapy is not the other pole of the continuum either, where the decision is entirely the patient's.  This was the case with my patient who recently decided to end treatment after making much progress over the past couple of years.  Yet, in my opinion she had a long way to go.  Obviously, it is the patient's choice to spend time and money on therapy; I can't keep anyone in therapy if they choose otherwise.  And sometimes a patient's unilateral choice to stop reflects progress: a newfound ability to assert oneself, or to make definitive life decisions.  Nonetheless, it isn't an ideal outcome because it isn't collaborative.

Psychodynamic therapy relies, first and foremost, on a "working alliance" between patient and therapist.  If the patient feels he or she must make a unilateral decision to end therapy, this alliance has been damaged somehow, or was never strong in the first place.  In a therapy with relatively little protocol or explicit direction, and where transference is promoted as a therapeutic tool, the one bedrock that both parties can rely upon is their mutual aim to help the patient.  Ideally, then, a time comes when the patient feels ready to stop, and the therapist feels likewise.  This is the midpoint on the continuum of therapy endings, where it is neither the therapist's abandonment of the patient, nor the patient's defiant separation from the therapist.  It is a shared understanding that the work is ending, the culmination of a shared exploration in therapy.

Yes, this does happen in real life, although not as often as anyone would hope.  Yet even when it's the patient who chooses to end therapy, and the two parties "agree to disagree," it is still very beneficial to plan ahead and allow for a termination phase — the length being roughly proportional to the length of the therapy, from a couple of sessions to several weeks — to discuss the ending.  Unexpected feelings can arise when time is short.  By exploring these feelings, therapy can be therapeutic until the very end.