Good psychotherapy eventually ends

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 patients 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.

Steven Reidbord is a psychiatrist who blogs at Reidbord’s Reflections.

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  • DoubtfulGuest

    Nice post. Dr. Reidbord. I like your approach with this issue. You make a lot of sense.

    I hope your countertransference post (that you linked here) will appear on its own sometime. I enjoyed your analysis of that issue and the way you don’t heap all responsibility on the patient. I’ve experienced what appeared to be blatant countertransference with more than one medical doctor. One example came across as a sibling-like reaction on the physician’s part, that had both positive and negative elements to it with a very bad ending. I don’t think it could have been completely in response to my emotions or behavior because I don’t have any brothers or sisters as a reference point.

    As far as I can see, most docs continue the “tradition” of 100% blaming the patient for anything like that that ever happens. There can be grave consequences for patients: undeserved termination/abandonment, misdiagnosis, deception. So I’d like to see more self-reflection on doctors’ parts, and I really appreciate your writing on the topic. Like you say, any harm comes not from the emotions themselves, but through allowing them to drive our behavior without understanding why.