Premature Endings in Therapy

In this blog post, I consider the impact of premature endings of therapy on psychotherapists in general, and on myself in particular.? I am focusing here on situations where a client leaves and breaks off therapy without giving the psychotherapist any preparation for the ending.

In my clinical experience, few scenarios have been as challenging as premature client termination, especially when I have not been prepared for that ending, and/or it was not foreseeable at the time. Certainly, many clients do not return after the first or a few visits, but others break off the relationship after considerable work has been done.


This may be years-long, ongoing treatment which involves complicated work around critical and aggressive transferences, and client concerns around trust. In such a case, a client may use attacking defenses to provoke reactions from the therapist, reactions that will serve to prove that the therapist cannot be trusted.

If we think of Freud’s 1912 Remembering, Repeating and Working Through, we have to work with our clients knowing that the therapeutic relationship may be part of a broken repetition of a previous relationship, rather than a more complete and healing experience that culminates in successfully working through the client’s issues.?

When there is a premature ending, the therapist is often left with the sense that the client has used the work and the premature ending to remain fixed within their problems, rather than be able to work towards a better solution.

Because the premature ending of treatment is always an ongoing occupational risk, it is helpful for the psychotherapist to have come to terms with the way in which his or her own early environmental and attachment failures and problems exist as real and deeply felt experiences that may not have been healed but had to be painfully and quietly endured. There may be cases where we have become deeply invested in long-term therapy, where we may have worked, alert as possible, to projections and different transferences.

When the work breaks off suddenly, it can wound us deeply and leave us with grief and loss, along with a profound sense of failure, disappointment and rejection. Sometimes this occurs with a client who may have been overly critical and anxious about trusting the therapist throughout the work.?This can be particularly so in treatment which has gone on for several years and in which the clinician worked hard on the client’s behalf.

The Pain of Premature Client Termination

Such a difficult client-initiated termination happened to me last year and I found the suddenness of the ending extremely hard to deal with.?I felt myself overtaken by painful grief. I went over and over the final sessions questioning myself as to what I might have done differently.?

What strikes me about these kinds of situations is the way in which, after the ending, the client remains in one’s mind, the way the transference remains alive.?For example, on coming into my consulting room after a break, I tidied the place up a bit, and could vividly recall the way my client would often criticize my room. ?

In the end, and upon reflection, I don’t think there was anything I could have done. In one way, it could be said that my client broke off with me the way her father had broken off with her. This was a client who had particularly strong and unresolved attachment issues in her very early years, had gone through the breakup of her parents’ marriage at age four, and had then lived with her mother and brother.?Her mother then remarried a very abusive man and the client witnessed as well as personally experienced violent abuse.

During our work, her capacity to trust me was the paramount cause of her recurring anxiety. Progress might have been made, but the question of trust would always hang over us, and in the end, the breaking off of the work, I think, had very much to do with the question of her not being able to trust me.

It is a difficult burden for us to carry when we are left suddenly in situations like these, when we are very invested in the work.?In fact, we may not realize how much we are invested until the work has suddenly broken off and we are left dealing with the ending alone and/or in our supervision.

I am aware of my enduring sense of attachment to my client, and that for a long time I still thought of the 6 p.m. Monday time slot as “her” session.?When I gave it to somebody new, I had the sense that they only had it on loan from her.?The pain of the difficult ending remained in my mind, thoughts, and psyche. I wondered if it remained in hers, or if by ending with me, she found the freedom to be creative in another area of her life.

Therapist Growth Through Client Transference

I say this because I was recently teaching a seminar on Freud’s 1905 case of Dora.?One of the key events of that case was that Dora broke off her treatment.?It may be that the energy Freud was left with in the abrupt termination was part of what fueled him to write the case up.?This in turn makes me think of the acrimonious split between Freud and Jung, and the creative energy that was released in each of them following the breakup of their work together.? ?

One interesting thing about the ending of Dora’s case is what she did after leaving Freud. Because she returned to see Freud, we know that she confronted Herr K about his advances towards her and received an apology from him.?For Dora, breaking off the work with Freud can be read as part of her way of escaping the abusive paternal transference. For Dora, the right to break off the treatment was crucial.

Could something similar have been provoked in my client??Could it be that in ending with me she was starting something that would lead to healthy creative expression??I like to think so. This abrupt ending may have felt premature from my side of the couch, but it might have been right for her. Nonetheless, I am still left working on the painful sense of loss, and perhaps abandonment, that her premature separation evoked in me.


Questions for Thought and Discussion

How did the author’s reflections on his case resonate with you?

How have you dealt with clients who have terminated without explanation or warning?

How would you like to use the information in this essay in your own clinical work?







 


File under: The Art of Psychotherapy, A Day in the Life of a Therapist, Musings and Reflections