[imapatient]

I’ve been thinking deeply about the general types of reasons for termination—by T in unilateral fashion. In general, not specific to my situation. 4 categories of reasons to explain T’s thought process about why they want to or must unilaterally terminate.

1. Formal. For some formal reasons outside of therapy itself it has to end. T dies, leaves, patient moves....etc. Technical conflicts of interest fit here, too.

2. Benign. Serious-enough violations of boundaries, trust, breaking the therapeutic bond, etc. These are Doing Bad, not Being Bad reasons. No more progress seen as possible with that T, etc. That isn’t a “Bad” reason.

3. Personal feelings. T develops dislike, hatred, anger, contempt, disgust, resentment, etc. Significant enough (to impair) negative feelings personally regarding the patient. These are Being Bad reasons re: the patient.

4. Clinical. These are of the "worst case scenario" in mental terms of being rejected: T has figured out that patient is so severely mentally disturbed that she is horrified and rejects, abandons, runs away. Sees the "real self" of patient and comes to new clinical understanding of patient as previously not--psychotic, so seriously screwed up as to be beyond repair.

Type 1 reasons are the easiest to handle.

Type 2 Benign reasons a bit harder to handle, they're not about "Being Bad." They aren’t comments on the patient as person, rather just as patient. For most of this category the reasons for violations are Doing Bad in some given circumstances.

Reason 3 is a negative personal vibe from T, hostile, anger, contempt? As a Being Bad reason it's hard to take—assuming one believes the T is right to feel what she does.

Reason 4 haunts the mind. The universal fear of being rejected once T sees real self as being so severely mentally disturbed as to reject patient in horror, disgust, terror, etc. To the point possibly that T fears patient now understood as so significantly sick in the head.

To Be Bad in that way is far worse than at a level of feelings by T.

What do others think about these types and/or other types?

[pegasus]

I disagree completely with number 4

A good T would not see another human being as being so mentally disturbed that they would run away in horror. I find this laughable! A good T loves to work with a challenge! The more complicated the better! T's do not view people as being 'sick in the head' Not unless you happen to be a paedophile?

[sittingatwatersedge]

my $0.02,

I think that (3) is pretty unlikely - these are countertransference reactions aren't they? which Ts are trained to pick up on and work with, not avoid and flee from. Remembering that Ts are very often in counseling themselves, or consulting with other Ts, and that outside opinion would work to resolve these feelings.

as for (4), I can't accept this. This conjures up a picture of going to an oncologist and hearing him say, whoa - you have CANCER! I am outta here!!
for mental health, the various professionals in this field handle different types of cases. A "life coach" may help you to get a better job, but if you are PTSD you need a different kind of counselor.

I haven't been on PC for long, but it seems that I am not the only one who sometimes struggles with occasional fears of being deeply sick... but even if it should be so, from what I am reading here, Ts have tremendous resources at their disposal & are good what they do.

[pegasus]

Originally Posted by sittingatwatersedge

my $0.02,


as for (4), I can't accept this. This conjures up a picture of going to an oncologist and hearing him say, whoa - you have CANCER! I am outta here!!

Exactly!

[ErinBear]

Actually, I've experienced both #3 and #4, although not exactly in the way you describe.

About 15 years ago, I saw a counselor for five years who ended the working relationship with no warning. He said a lot of terrible things in the final session, with many terrible insults to me, that I was bad and all sorts of things. He pretty much threw me out of the office. It was very unethical, with no referral or anything. But I've recovered from that now, thankfully, and later met a really great counselor with whom I had a truly wonderful working relationship.

In regards to #4, I have had counselors tell me that they couldn't work with me because (in short) they weren't equipped to work with the problems and needs that I have with depression, especially since I've been hospitalized in the past with it in the past few years. It wasn't that they were bad counselors, or I am a bad person. This has actually happened quite a few times in recent years, to the point that I've stopped looking for counselors now. I've been to a wide variety of therapists and clinics. I think there probably is somebody out there who would see me and could be a good fit, but given the financial realities of my life I've come to realize I can't see some of the therapists that might be willing to work with me. I think if a counselor admits that a problem is bigger than they are prepared to deal with, hard as it is, it is probably healthy. They need to look out for the client first of all. If they can't provide what is really needed for the client, then it is truly important that they find the needed help elsewhere for the client. The counselor also needs to take care of themselves as well, so that they will be healthy and they can keep serving their other clients without burning out. So even though it is very difficult, it is actually logical for a counselor to refer a client elsewhere if the case is beyond their ability to provide appropriate care, in my opinion, for whatever reason.

Take care,
ErinBear

[ErinBear]

PS I meant to add that i later learned that the counselor in the first story was going through a divorce, I later learned, and I'm 99.9% certain that's why I was sent away so abruptly from his practice that day. I have a hunch he was really angry and took it out on me.

[Bleah]

Originally Posted by ErinBear

Actually, I've experienced both #3 and #4, although not exactly in the way you describe.

About 15 years ago, I saw a counselor for five years who ended the working relationship with no warning. He said a lot of terrible things in the final session, with many terrible insults to me, that I was bad and all sorts of things. He pretty much threw me out of the office. It was very unethical, with no referral or anything. But I've recovered from that now, thankfully, and later met a really great counselor with whom I had a truly wonderful working relationship.

Take care,
ErinBear

Wowww, Erin, that sounds really painful! I'm sorry, and I'm glad you recovered from it.

[imapatient]

"I think that (3) is pretty unlikely - these are countertransference reactions aren't they? which Ts are trained to pick up on and work with, not avoid and flee from. Remembering that Ts are very often in counseling themselves, or consulting with other Ts, and that outside opinion would work to resolve these feelings."

I qualified the comment as to be significant enough to impair the T. That's not something that can be disagreed with; if impaired > must terminate. It's tautological. If a T feels strongly that they're to the point of being impaired/not objective, they are required (ethically) to terminate. I'm not talking about garden variety dislike, etc. that can be effectively dealt with by addressing countertransference. Obviously one can envision that there is a "point of no return" in some circumstances with a T where they are impaired beyond being able to be effective. Ideally that would never happen, but it can and does. Countertransference is not always perfectly successfully dealt with. You say unlikely, so do I, but that doesn't mean impossible.

"as for (4), I can't accept this. This conjures up a picture of going to an oncologist and hearing him say, whoa - you have CANCER! I am outta here!!"

I'm projecting on all of these and above all on #4. The one caveat that I didn't emphasize enough was the fear factor. A T can conclude that someone is too disturbed to the pint of fearing the patient. It can manifest itself in a stated threat to the T by the patient. Delusions, in particular as relates to the T. As well, if their attitude is to the point of impairing objectivity they're required to terminate. If an oncologist sees a case of cancer that is so disturbing? Other than being beyond their competence, I can’t see that happening. Why? The psychological issue addresses sickness that can and/or does affect other people, as the psychologist herself. Cancer has no effect on the behavior of the patient in the way that they might behave immorally or mistreat others, including possibly the M.D. herself. Apples and oranges.

So I guess the point of 3 & 4 is that if whatever the circumstances are are something that the T can't get past in their attitude and feelings, they must terminate. Ideally that would never happen, but T's are human. In the extreme it would be a Type 4. Theortically.

I am projecting from my situation with #4 as my greatest fear of what happened, with #3 as the 2nd greatest fear.

I’m taking as a given in my analysis that the situations are to the point of impairing the T. If you want to say and take as a given that ideally that would never happen, then of course 3&4 are irrelevant.

I'm saying that T's are human and that Types 3 and 4 are possible, not likely or very common or anything like that. But possible in the real, not ideal, world.

#4 was my great fear in starting therapy. I was REALLY scared in particular that once T realized how dissociative I am, he would refer me to someone else. And once we got through that, I was terrified that all of my bad "coping mechanisms" would be reason for a referral.

I've talked to him about it - how he had NO idea what he was getting into when I came in for that first appointment and was like "I'm a little stressed" or whatever I told him I really think I must be one of his "sickest" patients in some ways. He said this way he is never bored. Ha! That's an understatement

[sittingatwatersedge]

Originally Posted by imapatient

If an oncologist sees a case of cancer that is so disturbing? Other than being beyond their competence, I can’t see that happening. Why? The psychological issue addresses sickness that can and/or does affect other people, as the psychologist herself. Cancer has no effect on the behavior of the patient in the way that they might behave immorally or mistreat others, including possibly the M.D. herself. Apples and oranges.

not apples and oranges at all. "Beyond their competence" you are closer to it - "mental health professional" is pretty creaky but it says what it means - people come to these MHPs because there is somehting to be looked at. If the person's condition is serious, or even very serious, it doesn't strike fear into an MHP any more than a serious cancer would to an oncologist - it is precisely what he is trained for, precisely what he has chosen to work with all his life.

about this >> Cancer has no effect on the behavior of the patient in the way that they might behave immorally or mistreat others, including possibly the M.D. herself.
certainly it can. it's not unknown that some, receiving that diagnosis, go out on a what-the-**** spree, or even take their own lives. I had a surgeon once who said he had lost more than one patient that way.

but bottom line... why spend time wondering whether one is "horrible" enough to frighten one's T away? Until / unless that happens (and I am still betting that it rarely happens), precioius time is better used in other ways.

therapists are like confessors - it's hard to shock them. Doesn't make the telling any easier, but for sure you don't often hear a "clunk" on the other side of the screen as he hits the floor.

[imapatient]

"In regards to #4, I have had counselors tell me that they couldn't work with me because (in short) they weren't equipped to work with the problems and needs that I have with depression, especially since I've been hospitalized in the past with it in the past few years. It wasn't that they were bad counselors, or I am a bad person. This has actually happened quite a few times in recent years, to the point that I've stopped looking for counselors now. I've been to a wide variety of therapists and clinics. I think there probably is somebody out there who would see me and could be a good fit, but given the financial realities of my life I've come to realize I can't see some of the therapists that might be willing to work with me. I think if a counselor admits that a problem is bigger than they are prepared to deal with, hard as it is, it is probably healthy. They need to look out for the client first of all. If they can't provide what is really needed for the client, then it is truly important that they find the needed help elsewhere for the client. The counselor also needs to take care of themselves as well, so that they will be healthy and they can keep serving their other clients without burning out. So even though it is very difficult, it is actually logical for a counselor to refer a client elsewhere if the case is beyond their ability to provide appropriate care, in my opinion, for whatever reason."

What you're talking about isn't a #4. #4's are about the patient as Being Bad. IF a T isn't qualified to treat a certain type of problem, then you're not bad, she's not bad, she's not skilled in the way needed. I didn't address this type, but it would be a Type 1 Formal Issue. They can't treat you for the formal reason of not being competent in the way needed. It's about your illness as illness, not illness as who you are.

[deliquesce]

the way my pdoc puts it - it's philosophically bankrupt to divide the world of people into black/white good/bad. surely we are better than that.

also - who cares what a T thinks? they aren't moral adjudicators. my T has told me he once had a client who disturbed him a lot - the way he thought, what he acted upon etc, all made T think "here is someone who's morals i just cannot come to grips with". he referred that client on to another therapist who was better able to deal with that client.

so, even if a T were to classify you as "bad" (and if you were to accept that label) then you'd need to recognise that there are other Ts who would not classify you as "bad". it's all arbitrary.

Originally Posted by imapatient

2. Benign. Serious-enough violations of boundaries, trust, breaking the therapeutic bond, etc. These are Doing Bad, not Being Bad reasons. No more progress seen as possible with that T, etc. That isn’t a “Bad” reason.

4. Clinical. These are of the "worst case scenario" in mental terms of being rejected: T has figured out that patient is so severely mentally disturbed that she is horrified and rejects, abandons, runs away. Sees the "real self" of patient and comes to new clinical understanding of patient as previously not--psychotic, so seriously screwed up as to be beyond repair.

i think maybe you are confusing 2 and 4. i wouldn't necessarily consider a boundary violation as benign. of course it would depend on what you were referring to. i don't think your category 4 really exists as therapists are trained to help people with serious problems and to be empathetic. you're not bad, no more than anyone else at least. you're just human. and you are not your illness. it is only a part of who you are.

take care

[ErinBear]

Sounds like my experience that I was definining as #3 was more like your definition of #4 then.

Take care,
ErinBear

[pachyderm]

Originally Posted by reflection

i don't think your category 4 really exists as therapists are trained to help people with serious problems and to be empathetic.

"Therapists are trained to help people, therefore therapists know how to help people" is logically inconsistent. In my experience it is also sometimes false. I think it is more likely false the more the patient needs help.

"Training" is not equal to "learning".

Sorry to stick in this discordant note, but I really have a hard time when it appears that my difficulties in getting help seem to be made to appear to be solely due to my inadequacies. If they are, then I am sunk.

sorry pachy, i probably wasn't very clear in what i was trying to say.

Originally Posted by pachyderm

"Therapists are trained to help people, therefore therapists know how to help people" is logically inconsistent. In my experience it is also sometimes false.

that's cool but i didn't say what you quoted. more importantly, i don't think this. i was speaking generally and trying to communicate to imp that in his situation, that he shared on another thread, i highly doubt his therapist terminated him due to finding him a horrid person. maybe there are some therapists who would act like that? i sure hope not.

Sorry to stick in this discordant note, but I really have a hard time when it appears that my difficulties in getting help seem to be made to appear to be solely due to my inadequacies. If they are, then I am sunk.

nooo, i wasn't implying that any problems in therapy are all the patient's doing. not at all! sorry for the miscommunication.

[chaotic13]

So where would ...as therapy progresses the T learns that you have a specific condition that would be better treated by someone else go? # 4?

If so, I DO fear this. I always seem to worry that when my T accepted me as a patient, she didn't really know what she was getting herself into. I often wonder if she knew everything she knows now...would she have referred me.

I think there are a lot of times when a T might be objective and conclude that the BEST possible care for his/her patient is under someone else's care. It may be a difficult transition, and just like any other treatment there may be unforeseen complications, but the decision to discontinue was made with good intentions.

I don't know... if my T said, "Chaotic, I don't think I am the best person to help you with this issue." or "Chaotic, some things have come up in providing your care that make it difficult for me to remain objective and do my job the way it should be done. Therefore, I think it is in your best interest to discontinue with me." I think I would freak out, but I would respect her doing what she thinks is appropriate. You can't fault a professional for recognizing their own limitations and doing what professionals are supposed to do-- insure that the patient receives the best quality care.

Originally Posted by chaotic13

I always seem to worry that when my T accepted me as a patient, she didn't really know what she was getting herself into. I often wonder if she knew everything she knows now...would she have referred me.

Yep. This was a HUGE HUGE fear for me. I was SURE I was going to get referred as he learned more about me.

But, Chaotic, I think we have both been with our Ts long enough to assume they will stick it out with us for the long haul

[sunrise]

Originally Posted by chaotic13

I always seem to worry that when my T accepted me as a patient, she didn't really know what she was getting herself into.

I don't really worry about this but sometimes I am curious about the moment when T knew who I was. When did he realize? Did he know he right away? The first session? By the fifth?

I don't know... if my T said, "Chaotic, I don't think I am the best person to help you with this issue."

My T has said this to me twice and referred me out, but it didn't mean terminating with him. PHEW!!! It just meant seeing someone else for a particular issue that was outside of his scope of practice in one case and presented a situation where he would have gotten involved in yet another role with me (he said we had enough already!). So it worked out OK and didn't feel like rejection and I got to continue seeing him. If he ever said "we've gone as far as we can, it's time for you to see someone else," I would freak big time. I have this rather protective philosophy that it should be up to the client to decide that. Kind of self serving, but yeah, I'm sticking to that.

[chaotic13]

Earthmama said:
But, Chaotic, I think we have both been with our Ts long enough to assume they will stick it out with us for the long haul

Intellectually, I know you are right. My T has NEVER acted overly surprised, seemed out of her area of expertise, or tired/frustrated with me. Even when I present something I think is totally wacky she is just like...we can deal with that. Trust me I am very alert to any sign of these reactions... if she had any of these she hid them very well.

Unfortunately, knowing and feeling that I'm not going to get the boot any session are two different things. I'm this way with other stuff too. Like I know reenacting some crazy dance video New Years doesn't make me a sleazy *****, but I still felt like one.

sunrise said:
If he ever said "we've gone as far as we can, it's time for you to see someone else," I would freak big time. I have this rather protective philosophy that it should be up to the client to decide that.

I kind of agree with this. In the type of patient care I provide, there have been times when a condition is uncovered or develops that I am not well trained to deal with. I feel it is my job to inform that patient of this and provide them with information on other treatments or caregivers who would be better able to provide the care they need. In some cases the patients have chosen to remain under my care. As long as I was still operating with my state practice act and I felt I could quickly upgraded my skills to accommodate them this was acceptable. However, the patient was not the sole decision maker. There are certain conditions that legally I can treat, but that I do not for various reason. The nice thing about my profession is that it is a lot easier to separate the condition from the person, so they don't feel like you are rejecting them. This is not so easy in psychotherapy.

Maybe in psychotherapy there are situations where the client is not privy to all the the information that is factored into the situation. For example, maybe a T DOES develop counter-transference, attempts to deal with it but, isn't able to remain objective. The patient should be informed that the therapeutic relationship has been compromised (not by anything that they specific did) and that it needs to be discontinued. I don't think the patient needs to know exactly what the counter-transference is about. I get that these situations can be very challenging especially for someone....Like me...who no matter what they did or said...would ultimately feel rejected. Bottomline...if they can't work with you they way they are supposed to then the relationship has to end.

These are just my opinions of course....worth .000001 cent.

[deliquesce]

what kind of health care do you do, chaotic? if you don't mind me asking, of course .

my T used to say to me, that maybe i should talk to someone else about certain problems. i never followed it up with him, though. couldn't bear to face looking at the rejection head on. anyway, those certain issues never got dealt with.

[imapatient]

Originally Posted by chaotic13

Maybe in psychotherapy there are situations where the client is not privy to all the the information that is factored into the situation. For example, maybe a T DOES develop counter-transference, attempts to deal with it but, isn't able to remain objective. The patient should be informed that the therapeutic relationship has been compromised (not by anything that they specific did) and that it needs to be discontinued. I don't think the patient needs to know exactly what the counter-transference is about. I get that these situations can be very challenging especially for someone....Like me...who no matter what they did or said...would ultimately feel rejected. Bottomline...if they can't work with you they way they are supposed to then the relationship has to end.

I don't think the patient needs to know what the c-transference is exactly, but there should be some sort of explanation--in my mind--so that the patient isn't left to wonder if it's about them per se, not about T per se. This is the conundrum I'm in: is it because of something with me or with her. Or is it a simple thing as being unable to treat the problems of whatever type, or progress has stalled and T can't see a future in working together. Those are impersonal things to me. The troubling ones are the ones that are "personal" to me-the worst case scenarios of what I think many people fear--being seen as "being bad."

[imapatient]

*******TRIGGER WARNING*******



"not apples and oranges at all. "Beyond their competence" you are closer to it - "mental health professional" is pretty creaky but it says what it means - people come to these MHPs because there is somehting to be looked at. If the person's condition is serious, or even very serious, it doesn't strike fear into an MHP any more than a serious cancer would to an oncologist - it is precisely what he is trained for, precisely what he has chosen to work with all his life."

Yes, in some respects it CAN be apples and oranges, not that it (always) is.

Ex: A female T who's a rape victim is treating a male patient and in the course of therapy she learns that he's a rapist. That might make her not want to or be unable to treat him. She might think he's "bad." Maybe he's made some very veiled threats--or said things that weren't threats per se but unsettling to her personally upon reflection after finding out he's a rapist.

Maybe particular ways about how he carried it out--rather than just being a rapist in general—trigger her to think “he's bad" that in other cases wouldn’t trigger her (a given T in some scenarios).

The T who's a victim of child abuse of a certain kind who treats child abuser of that certain kind--they might adopt a "you're horrible" attitude and terminate. Doesn't mean they tell the patient they're terminating because of whatever reason leads them to develop a very negative opinion of the patient, but it can be present. If a male rapist finds that there's a pattern of (some) female T's to terminate after they find out about how horrific his crimes were, he might reasonably assume (including whatever other elements to the course of treatment and post-confession) that he's regarded as "bad."

The personal stake of the T can be very diff. than of an oncologist. If the F T rape victim is trying to treat a male rapist to deal with his issues that make him a rapist that is a different ball-game from an oncologist trying to treat him for lung cancer.

>>>Cancer has no effect on the behavior of the patient in the way that they might behave immorally or mistreat others, including possibly the M.D. herself<<< certainly it can. it's not unknown that some, receiving that diagnosis, go out on a what-the-**** spree, or even take their own lives. I had a surgeon once who said he had lost more than one patient that way."

You're not addressing what I was referring to. What that patient does--spending spree--has nothing to do with the oncologist. Contra the F T who develops a fear of her male rapist patient because of a fear that he might rape her. That's what I'm talking about. The oncologist doesn't fear that the patient is going to actively try to give him lung cancer.

"but bottom line... why spend time wondering whether one is "horrible" enough to frighten one's T away? Until / unless that happens (and I am still betting that it rarely happens), precioius time is better used in other ways. therapists are like confessors - it's hard to shock them. Doesn't make the telling any easier, but for sure you don't often hear a "clunk" on the other side of the screen as he hits the floor."

Because one likely doesn't know it's happening if it is. Maybe the vicious male rapist should start wondering why F T's seem to terminate him after learning of his horrific crimes. Maybe he should pick up that he's better off with male T's or F T's who aren't rape victims--as if there were a way to learn that ahead of time. But maybe earlier in T rather than later and the greater investment in therapy with a given T. We wonder because we wonder, as evidenced by the many who've replied here and wonder/worry about it. As infrequent as it is in reality, if it's a fear, one has to deal with those feelings. I'm trying to deal with those feelings, as inaccurate as they might be, or accurate. It is possible, a worst-case scenario, but people worry in general—not just with T’s—that they’ll be rejected by others if only they knew the real “them.” It’s a barrier to intimacy. It’s what something, among other things, that in reality that can prevent people from opening up about themselves with other people. The examples here are kind of extremes, but that doesn’t mean that other sceanrios can’t produce the same effect. That’s the fear.

You end up agreeing with me on the main point I make: That it's possible for these sorts of dynamics to be part of a therapy relationship--possible, not definitely, not likely--but possible, in your words "I am still betting that it rarely happens.....you don't often hear a "clunk" on the other side of the screen as he hits the floor."

“Rarely” and "don't often" don't mean never or impossible.

[deliquesce]

imapatient.

what horrific crime did you commit that would make a T think you were a 'bad' person? IMO, setting up the website is not 'horrific'. not all Ts would terminate with you if they found that out.

also, i have been raped and also abused as a kid, but i do not view rapists or abusers as "bad" people. it is possible you could find a T with the same views as myself. whose opinion would you trust then? the female T who terminated or the female T (with the same life experience) who did not terminate?

[imapatient]

[quote=deliquesce;913583]imapatient.

what horrific crime did you commit that would make a T think you were a 'bad' person? IMO, setting up the website is not 'horrific'. not all Ts would terminate with you if they found that out.
[quote]

Well, I'm not sure, but here's something that makes me wonder if there was a Type 4 thing going on.

At termination, she said I should see male therapists. In 2 phone conversations she repeated it. In her letter telling me of termination --she had told me in a session, writing it is a requirement here--she said it; in correspondence with my pdoc she said it. I didn't really get an explanation from her why--there was so much going on and so little contact time that it was lost in the shuffle to me trying to get termination explanation. The explanation she gave my pdoc was that she recommended it due to the highly sexual nature of my transference. She repeated at all points that those she consulted with recommended it, too, including she said, her lawyers.

I worry that it's a Type 4, in that she's determined that I'm so screwed up with women that can't function/be trusted to function/have a relationship with a F T where she'll comfortable with me. If she feels that way about me and female T's, what does that say about my relationships with women in general?

That's my fear, that I'm horribly damaged regarding women that blah blah blah. That’s the worst case scenario fear, and the lack of getting real explanation of why she thinks that makes me fear the worst. If she does somehow think I'm so screwed up with women blah blah blah, that's a type 4 to me.

Aside from the website, there was on-going discussion of sexual transference issues through-out—having been sexually abused by my mother, in the ways it was, it was exponential than for most therapy relationships. The ex-GF/stalker found and gave to T who gave to my T posts I made to a Yahoo group I made asking mental health professionals about the attraction: How much is real attraction vs. transference, the strength of it, and advice about how to deal with. Maybe the strength of it, my obsession spooked her.

True or not, I’d be better off having been given an explanation about the male therapist recommendation. The T I’m talking to now is addressing it with me, and I hope that he can talk with her to clear some things up.

But it’s a real Type 4 fear of mine. If it was Type 4 to her, I doubt she'd come out and say, "Well, because you're so severely screwed up regarding women and/or female therapists...."