How does a therapist end it gracefully or without damage to the client, especially terminating someone with abandonment issues?

Recent themes on PC have me thinking. When a therapist feels they can no longer see a client , because of their professional limitations and/or the client / therapist relationship isn't conducive to the client's healing anymore, How does the therapist end it?

I look back when I was doing psychotherapy with a psychiatrist and was ceremoniously dumped by her (dumped previously by a bimbo psychologist while in high school) ~30 years ago, I believe no matter what was she said that day would have made any difference for me to respond in a calm rational way after I left her office. I set on a course of continued self- destruct for thirty more years.

Thirty years later, a more recent therapist went on to repair the damage as she continued to reassure me it wasn't MY fault, the fault was theirs. Well, I now believe it wasn't the fault of one of the therapist for leaving terminating me. She was using due diligence, ~ 4 hour plus train ride, before cell phones could turn me around if an emergency came up on her end (I do wish it had ended over a few sessions). Yet, I also believe I would still have acted-out after leaving her office no matter what. Maybe, a few termination sessions may have helped shorten the time frame, ~30 years of self-destruct (I walked out on my Ph.D program).

Those intense feelings that were unnamed and were so bent on destroying me were gonna happen no matter what. There was nothing the therapist could have done 'at that moment' to have lessened the impact. I think I overdosed within a few hours.

Fast forward. I have a great setup now with a therapist on standby — my ex therapist and I embarked on a friendship — who will see me if things come up. I only hope she doesn't retire in the next decade if need arises. But, I also know how to be a savvy shopper when negotiating in the "lands of therapists."

So, how do therapist go about making it pretty or can they?

[NowhereUSA]

I think that as soon as a therapist realizes they're dealing with someone who's struggling with abandonment issues, they need to work on that and help teach coping mechanisms. Most of what I've seen on PC seems like people who's abandonment issues weren't really dealt with. The T worked to make them feel safe and then never taught them effectively how to deal with change or loss.

Change and loss are difficult for everyone, even those who are mentally healthy. If someone has abandonment issues, I think long, extended terminations might be the best way to do it, to help the person process reality. Sometimes I get the impression that therapists aren't very forthright with their clients.

Idk. I guess it's hard for me to picture. I'd want my T to admit to me ASAP that he thinks his skill set isn't the right one for my illness. From there, I'd like him to keep seeing me as *he* helps me transition to a new therapist, ideally within a month. A letter from him acknowledging my progress and time with him would be nice... and then maybe a check in after I've been with the new therapist for about three months. And then from there... it could be nothing.

That being said, it's all contingent on having prepared a person to realize that loss is part of life and that it doesn't always mean you're being abandoned. And if a therapist hasn't worked on that, they're setting themselves up honestly. I don't know why abandonment issues aren't treated more primarily. I mean, people leaving is a thing in life and I'd say dealing with that is an invaluable coping skill.

[ThisWayOut]

Termination with abandonment issues or attachment issues can be tricky. I've had lots of trouble with termination in the past, even when I knew the therapy was time-limited (most of mine has been). I think T's are in a tough spot with that kind of stuff. I definitely agree that there needs to be over-lap with other services and a transition if possible. My most recent termination was maybe the best one. My T didn't leave because the fit no longer worked, but the end was still really difficult at first. She did give me a sense of control though. She had the flexibility to stick around at the organization for several weeks after giving up most of her other clients. We tapered sessions, and eventually, I was able to recognize that I was hurting more than being helped by the arraangement. I went in one day and told her I needed her to not push me on stuff, and that I needed to say something with enough time to talk about it, but I wasn't ready to say it the moment I walked in... She was taken by surprise (we really only had about 2 or 3 session left), but said that she was glad it was my decision... It was forced, but still easier than any of the other terminations...

I don't think there's a way to make termination "pretty" or "easy" if it's not a mutual decision (or the client's decision).

[NowhereUSA]

I don't think there's not a way to make it "not hurt" - it's going to hurt and part of working with a client is getting them to accept that pain and to deal with it.

I think sometimes we want it to "not hurt" and that's just not going to happen.

It starts from the beginning, with:

• not making promises to never leave
• not fostering dependency by encouraging between session contact to process emotions
• making it clear that the type of therapy they practice does not focus on the therapeutic relationship (and if it does, then they do have an obligation to stick it out)
• apologizing
• admitting to not being skilled enough
• not blaming the client

And, if it's clear that to the therapist that she/he isn't skilled enough, to find a good referral and continue to see the client for check ins (like an MD would do).

Also, I think it's a systemic failure, not a condition of clients with abandonment issues. There's just a tremendous amount of incompetency in this field.

[NowhereUSA]

Originally Posted by licketysplit

It starts from the beginning, with:

• not making promises to never leave
• not fostering dependency by encouraging between session contact to process emotions
• making it clear that the type of therapy they practice does not focus on the therapeutic relationship (and if it does, then they do have an obligation to stick it out)
• apologizing
• admitting to not being skilled enough
• not blaming the client

And, if it's clear that to the therapist that she/he isn't skilled enough, to find a good referral and continue to see the client for check ins (like an MD would do).

I agree with all but the "not fostering dependency" one. I think the therapeutic relationship can be helpful practice and to some extent we depend on people. I depend on my husband, for example. I need him and he depends on me, he needs me. We've built a family and we all need each other to survive in the way we want to - as a unit. People who are overly dependent need to learn how to have balance and those, like me, who try to do everything like a one woman superhero, need to learn it's okay to relax in the uncertainty that dependency and needing can bring. It's okay to depend on people even if they might fail.

That being said, I think my T has a healthy way of our connection - I can email as much as I want and there's no expectation he's going to reply. Sometimes he does and that's great, it's helpful, and it doesn't happen often. For me, this has been helpful in terms of me working through some very negative self-judgments I have and my inability to express certain things.

The key is that it be done thoughtfully. I don't think Ts always do that. Nor do I think they set up realistic expectations with regards to their time or what they can do.

Originally Posted by licketysplit

It starts from the beginning, with:

• not making promises to never leave
• not fostering dependency by encouraging between session contact to process emotions
• making it clear that the type of therapy they practice does not focus on the therapeutic relationship (and if it does, then they do have an obligation to stick it out)
• apologizing
• admitting to not being skilled enough
• not blaming the client

And, if it's clear that to the therapist that she/he isn't skilled enough, to find a good referral and continue to see the client for check ins (like an MD would do).

I hear you loud and clear. BUT, my exthera did tall of the above., except she never blamed me for anything. When she was stuck she went back and reread all of Bowlby's volumes of work, sought out a colleagues to help her help me get through.

We went round a lot in the beginning and the middle of therapy, "never leave me,"and my proof to her was what was happening too many people here on PC, so her promise did not mean squat! "Nothing I can do if I die..." She was speaking to the adult, 'the cognitive' part of me, and I got it. That did not stop her from having to actually tell the distressed part of me over 100 times, "I'm not going to leave you."
Still on my bedroom wall is the paper she gave me that said, "I Am Not Going AnyWhere, No Matter What! I Am HERE

I got real lucky!

Originally Posted by NowhereUSA

That being said, it's all contingent on having prepared a person to realize that loss is part of life and that it doesn't always mean you're being abandoned. And if a therapist hasn't worked on that, they're setting themselves up honestly. I don't know why abandonment issues aren't treated more primarily. I mean, people leaving is a thing in life and I'd say dealing with that is an invaluable coping skill.

I think some people do realize this, but the abandonment feelings are feelings from the past. They are like PTSD flashbacks. So while the rational part of your brain knows that you are not being abandoned, the emotional part of the brain overrides the rational part of the mind, especially for those who by their nature, feel things more intensely. There's been several times where I took a break or 'quit' therapy with this therapist and every time I spiraled into massive feelings of abandonment even though I was the one in control and initiating the separation. The separation itself triggers the emotional re-experiencing of an abandonment regardless. When therapists handle this poorly, i can imagine how much it would intensify these feelings.

Coping skills can certainly help, but long-term psychodynamic therapy seems to be, imo, the only thing that fixes the core of the problem, changing how a person relates to oneself and others (personality) in attachment relationships.

And there's the problem--there aren't enough therapists competent in this area. I can't see that it's abandonment issues that need addressed, but ego strength, intra-psych structure, internalized object relations, etc...all things that take years to transform by someone with appropriate training who has gone through years of their own therapy as to avoid the enmeshment and inabilitly to handle countertransference that I frequently see occurring by poorly trained therapists on here who end up calling it quits.

Also, I think it's a systemic failure, not a condition of clients with abandonment issues. There's just a tremendous amount of incompetency in this field.

I do think it comes down to this ^ in more cases than not. This population makes up a considerable proportion of outpatient and inpatient mental health care utilization in comparison with the low prevlance in the mental health population, and the profession needs to do more to address this, help these clients. There are so many Ts who don't even take insurance, and often the most experienced ones with full client panels can cherry pick the 'most desirable' clients, leaving those with these issues in the hands of the less trained, the less experienced, the less dedicated, the less everything. This population really gets shortchanged through no fault of their own. No one asked to have abandonment issues or BPD/CPTSD, and I think clients do they best they can to deal with these issues.

I am lucky to have someone well-versed in treating clients with my issues, but I still cannot afford to get the treatment I need even though he reduced his fee considerably to accommodate me.

So while it might be true in some cases where no matter what the therapist says or does the client may feel abandonded, the professionals, who control the training, ethics, and professional standards, are the ones who I think need to do more, not the clients.

[NowhereUSA]

Originally Posted by mian síoraí

I think some people do realize this, but the abandonment feelings are feelings from the past. They are like PTSD flashbacks. So while the rational part of your brain knows that you are not being abandoned, the emotional part of the brain overrides the rational part of the mind, especially for those who by their nature, feel things more intensely. There's been several times where I took a break or 'quit' therapy with this therapist and every time I spiraled into massive feelings of abandonment even though I was the one in control and initiating the separation. The separation itself triggers the emotional re-experiencing of an abandonment regardless. When therapists handle this poorly, i can imagine how much it would intensify these feelings.

Coping skills can certainly help, but long-term psychodynamic therapy seems to be, imo, the only thing that fixes the core of the problem, changing how a person relates to oneself and others (personality) in attachment relationships.

And there's the problem--there aren't enough therapists competent in this area. I can't see that it's abandonment issues that need addressed, but ego strength, intra-psych structure, internalized object relations, etc...all things that take years to transform by someone with appropriate training who has gone through years of their own therapy as to avoid the enmeshment and inabilitly to handle countertransference that I frequently see occurring by poorly trained therapists on here who end up calling it quits.

I agree that it's from the past which is why I think therapists should be helping clients deal with it. I personally can't stand psychodynamic therapy so I can't speak to its efficacy. There are clearly people here who like it and benefit from it.

I do know that abandonment issues are a trait in BPD and DBT is effective in dealing with the various intense emotions. When I say "skills" I should clarify I mean like DBT skills - learning to experience an emotion, check facts, and essentially interact with the emotion in a way that is in line with one's values. It's been proven you can re-train the brain and that's essentially the core of what DBT does.

I get not everyone's a fan and it probably isn't going to be for everyone, and at the same time, I think it can be one more tool in the toolbox that Ts use.

I agree about the incompetence in the field, both the previous therapist that abandoned me were incompetent (the first one lost her license). My exthera feels there is so much incompetency in the field, especially when dealing with attachment issues.

Yes, we are the clients. What is the 'MORE' that the professional/ethics boards, therapists can do? I can't see a linear solution to this. But, we as clients can have this dialogue on PC and hopefully they will hear us. I hope the future therapist in training that are among us will help make what ever changes are necessary.

There would need to be a major sea change, but I don't see that ever happening at the corporate (read: insurance and government) level. It would have to come from a grassroots swell and demand for accountability and regulations around a cottage industry that lets pretty much anyone hang a shingle and set up shop.

Individuals need to know what they can and should expect, but the problem is that when someone needs therapy and is vulnerable, s/he is easy prey to incompetence and bungling.

I agree with you that there are multiple issues. Are there even incentives within and outside the profession to address this?

It reminds me of the current debate over the shortage of primary care physicians.

Except in this case, I don't see much attention being devoted to this issue; maybe one reason is that it affects a small percentage of the overall population. But the fact that this small percentage of the population comprises a considerable % of mental health service utilization, it seems like the priority should be bumped up or at the very least, formally examined in ways that can make an impact.

Originally Posted by therapyworked4me

I agree about the incompetence in the field, both the previous therapist that abandoned me were incompetent (the first one lost her license). My exthera feels there is so much incompetency in the field, especially when dealing with attachment issues.

Yes, we are the clients. What is the 'MORE' that the professional/ethics boards, therapists can do? I can't see a linear solution to this. But, we as clients can have this dialogue on PC and hopefully they will hear us. I hope the future therapist in training that are among us will help make what ever changes are necessary.

...shortage of primary care physicians

Except it's from the other end--do we have an abundance of generalists, but a shortage of specialists?

I can't imagine this happening with people with other health conditions. People get referred to specialists all the time by primary care professionals, but what if you had a disease that required specialty care, (not a rare, little known disease), and you could not find a competent specialist? Or you were given a list of them, and none took insurance? Sometimes people have to travel to get to specialists, like if you have a rare disease or live in rural areas.

So how does one find a trauma specialists? Some here on PC seem to be informed about such things, what to look for, etc., but what about everyone else? I've read about how so many of us had go through trial and error to find a competent therapist; some had to experience considerable emotional damage along the way. That is really sad.

It would have to come from a grassroots swell and demand for accountability and regulations around a cottage industry that lets pretty much anyone hang a shingle and set up shop.

Maybe Licketysplit has the right idea here. We could start an advocacy group here on PC.

i have no idea. but im interested to see everyone else's perspectives.

There is nothing that a therapist can do. I see it as the job of the client. As a client you need to remind yourself daily...this T is not my friend not my spouse not my mom not my dad,etc over and over again. they can be friendly, be a good listener, empathize etc. but they are a paid professional and the moment you let your heart forget that is trouble!

They can not save you...you have to do that for yourself...and yes lots of people need a T to get there but they are only there to walk along...and a different T can do that too.

Originally Posted by Readytostop

There is nothing that a therapist can do. I see it as the job of the client. As a client you need to remind yourself daily...this T is not my friend not my spouse not my mom not my dad,etc over and over again. they can be friendly, be a good listener, empathize etc. but they are a paid professional and the moment you let your heart forget that is trouble!

They can not save you...you have to do that for yourself...and yes lots of people need a T to get there but they are only there to walk along...and a different T can do that too.

I agree. I think the problem is if people were able to do that they wouldn't need the therapist in the first place. It kind of goes around in a vicious cycle.

[missbella]

Originally Posted by licketysplit

Also, I think it's a systemic failure, not a condition of clients with abandonment issues. There's just a tremendous amount of incompetency in this field.

I agree. Therapy can be constructed to trigger one's most helpless, childish state--with the therapist posing as the inscrutable authority as the client as troubled, defective invalid. I've seen strong, competent women get weak-kneed, regressed and mesmerized when talking about their therapists.

I personally didn't feel the therapy relationship had much parallel to relationships outside it. My response were unique in my experience. Nor I believe my susceptibility calls for some grand diagnosis or indication of an issue. My therapists played a manipulative game, and I had a a human reaction to it.

[bounceback]

I have been in therapy awhile and I have nothing against them but I think they got to be a bit masochistic to do their jobs. The setup in therapy is what causes the pain. They have you act like they are nonjudgmental, that they are there to listen, that they care about you, etc but in reality life is not like this. The power differential I think has a lot to do with it. I am going to be leaving my therapist of six years in October. While it is hard for me and devastating and painful, I doubt she feels any of this. She will go about her life seeing other clients and I get to grieve the loss of her.

I don't know, I am trying to understand all this. Maybe none of it makes any sense.

[bounceback]

I wish I knew how not to get attached.

Originally Posted by bounceback

I wish I knew how not to get attached.

Your response made me chuckle, and I agree with you. But, I'm not sure I could have gotten this far without it. It was a hell of a lot more painful than my previous therapies.

[stopdog]

I see a huge problem in that therapists themselves are not clear about what their job is or how they should be going about it. If they were more honest, they would tell every client how much of a crap shoot it all is, that they have no idea if they will be useful or not, that time or other things may be just as effective, and that they are winging it most of the time. But too many of them like to be thought of as gods, or the good safe knowing thing and the power is sedutive when a client gives it to them. I don't worry about maligning them, I think they need a bit more maligning to put them in perspective for themselves and clients. I also don't think it matters if they are trying to help or not. I don't think most really care but if they do, so what? The road to hell is paved with good intentions.

I am not too concerned about the poor "maligned" therapists. Usually nothing happens to them even if they do something horribly wrong. The client is the one who has to live with the damage and trauma, not the therapist. So no sympathy for them from me. That would be a waste of my time.

Sincerely trying to help and screwing things up horribly is unacceptable. I get sick of people putting them on pedestals and blaming the clients for the therapist's failures. It's loathsome. It's not good enough in therapy to just have good intentions.

I agree with stopdog too. It is all pretty much a crap shoot. If you start researching things like how much time they spend on studying how to help someone who is suicidal you feel kind of sick. It's crazy. To go by "feelings" and their gut and whatever seems so dangerous to me.

No feeling sorry for them from me. I feel sorry for the poor people they destroy and harm.

[Lauliza]

Originally Posted by NowhereUSA

I agree that it's from the past which is why I think therapists should be helping clients deal with it. I personally can't stand psychodynamic therapy so I can't speak to its efficacy. There are clearly people here who like it and benefit from it.

I do know that abandonment issues are a trait in BPD and DBT is effective in dealing with the various intense emotions. When I say "skills" I should clarify I mean like DBT skills - learning to experience an emotion, check facts, and essentially interact with the emotion in a way that is in line with one's values. It's been proven you can re-train the brain and that's essentially the core of what DBT does.

I get not everyone's a fan and it probably isn't going to be for everyone, and at the same time, I think it can be one more tool in the toolbox that Ts use.

I agree with this point - that when clients have abandonment issues the therapist needs to be versed in the therapy that has shown to be most useful- DBT. It is not for everyone I know, so you have to go with what feels best as a client. But it is the one approach that was designed with these very issues in mind, by a person who struggles with these issues. So it's purpose is to help build the client build skills, not to create a false sense of security in someone and make promises that any rational person knows they cannot keep. Saying "I am here for you" is appropriate. Saying "I will always be here for you" is just a non truth and a competent T should know better. Like stop dog said, it's always going to be a crap shoot, and therapists should disclose this up front. Good intentions are never an excuse for poor judgement and unrealistic promises. From what I've read, most clients who have been abandoned had therapists that acted out of "good intentions" but were not competent enough to handle the consequences of such intentions. It seems a but arrogant to me when Ts believe they can deliver on or manipulate someone with promises.