Tuesday, May 29, 2012

The Bright Side of Termination

Recently, a friend of mine left a therapy job and thus had to terminate with all her clients.  This reminded me of the last time I endured that and I dug up something I wrote at the time and decided to share it here.

After three and a half years of practicing psychotherapy with the chronically, severely mentally ill, I accepted a position at a military medical center in order to work with a more diverse population.  My first thought was of how this would help advance my career ... then reality hit!

In the mental health field, we describe those clients who have schizophrenia, bipolar I disorder, or the kind of long-term, disabling depression that causes clients to commit suicide as chronically, severely mentally ill.  Today I became aware of the challenges that lay ahead, primarily that of working with possibly higher-functioning clients than those I had been seeing.  But the PRESENT challenge was that my current clients must be "terminated," ending my relationship with each of them.  I was faced with the daunting process of ending not one, but thirty-odd relationships of varying intensities and durations.

Termination is a fact of life in therapy.  All clients terminate and it is, in fact, an important part of the therapeutic process.  One doesn't simply say, "Okay.  You're cured.  Have a nice life."  Instead, termination is a process, one that can take several weeks or even months, depending on the length of the therapy and the attachment the client has formed to the therapist.  Therapists who have the luxury of staying in one job long-term do terminate with all their clients, but they usually do so one at a time.  When a therapist leaves a job, however, he or she suddenly has to end all these relationships at once and the impact can be devastating, and not just for the clients.

A good start on my first day!  I went to the Day Program where our residential clients spend their days, and announced to them all, en masse, that I would be leaving.  (If one tells them individually, one is only able to tell one or two directly; the others will all have heard the news minutes after that first session ends.)  About 10-12 of the clients lined up to hug me and tell me how much they would miss me.  In this group was a woman who wasn't my client, but with whom I had often joked, and there was another woman who had recently joined the program and whom I didn't even know.  These clients are used to loss and they have all had a variety of therapists, so they handled the news well, even through their tears.

By late afternoon, I was feeling as though this wasn't going to be the horror show my therapist friends had painted.  Then Lucy* came in.  Lucy has been suicidal the entire three and a half years we've been working together.  She's never actually attempted suicide, though she's threatened, and I've never actually hospitalized her, though I've threatened.  Her official diagnosis is major depression, recurrent.  In reality, she has traces of a variety of "ills", including PTSD, anxiety, an eating disorder, and traits of four separate personality disorders,  She is a survivor of incest and physical and emotional abuse.  Lucy has trusted very few people in her life, but, slowly, she has come to trust me.  When I mentioned that she must "feel as though" I were abandoning her, she said, "No.  You are abandoning me."  Her sadness took, as I expected it to, the form of extreme anger.  She threatened to set my house on fire.  She wished aloud that I would be physically harmed in my new job so that I would have to return to her.  This was indeed the horror story that I'd heard it was.

And yet, over the next three or four weeks, my clients learned a great deal about themselves, their resiliency and their strength, and they taught me a great deal, too.  One of the tenants of therapy is that the clients never entirely lose a therapist.  They should be able to "feel" the therapist's presence and "hear" what the therapist would say in a given situation, long after the therapy ends.  What I had not realized was that I would carry my clients with me in much the same manner.

The next time I'm feeling as though I'm incapable of making a difference for a client, I'm going  to remember Martin.  Martin has had severe schizophrenia for decades and the medicines don't help him much.  He isn't delusional, that I've ever been able to ascertain, but he spends all his time with his "voices", which makes it impossible for him to focus on reality for more than a few seconds at a time.  When we began working together, at the end o every session, he would walk out of the room, closing the door, and turning out the light.  He wasn't able to retain my image once he was no longer facing me; he "forgot" that there was anyone left in the room.  After several months, he stopped turning out the light.  A victory!  When I told him I was leaving, he looked at me and whispered, "Shame."  Not only did he leave the light on, following our final session he shook my hand and told me he'd miss me.

No matter where I go, I don't think I'll shake the image of Sally, who had her first psychotic break when she was in college.  She is understandably angry at this illness that has stolen, or, at best, delayed many of her dreams, and she tends to take this anger out on those around her.  She challenged me at every turn.  Because she was a residential client, I had the ability to go find her and bring her to her sessions.  But that doesn't mean she came willingly.  She'd often refuse to come to my office; other times she'd spend her entire session facing the wall with a blanket pulled over her head; there were times when she'd spew out vulgarities aimed at me in a barrage of hostility.  Although I actually liked her in many ways, and cared a great deal for her, she also made me feel victimized and helpless more often than not.  I had no idea what to do with her.  I'd like to pretend that all my interventions were well-planned and that they were all designed with maximum therapeutic aid in mind.  They weren't.  I flew by the seat of my pants with her and sometimes, my interventions were as much to help me cope with my anger and frustration at her (my counter-transference) as they were to help her.  When I told her I was leaving, I thought there was the strong possibility that she would cheer.  Instead, she missed her next session.  When I ran into her a few days later, in the program's day-room, she confronted me and told me that she was angry with me for leaving.  This, from a client who is a master of passive-aggressiveness and downright meanness, but who had never, to my knowledge, appropriately confronted anyone with her anger before!  She came to her next session, sobbed the entire time, and talked, in heartbreaking detail, about all the myriad of things she'd gotten out of therapy.  In retrospect, I can see where my training "kicked in",  causing me to do things that actually were helpful for her, but I still feel like I was groping in the dark every step of the way.  The only thing I can take away from this is the belief that a strong degree of caring will be intuited by even the sickest client ... even when the counter-transference is negative.

By the end of my tenure at this program, I was emotionally exhausted and felt like I had nothing left to give to anyone.  So when Lucy came in, my last patient on my last day, I dreaded the session.  She was composed, however.  She told me that she planned to take my recommendation of another therapist since she trusted me to choose wisely for her.  She explained that she was still angry at me, but she understood my need to move on and she wished me well.  When we hugged good-bye, I knew I would miss her for a long time to come.

I've learned that my clients are almost always stronger than I know.  That they have reserves of compassion and empathy that we often don't provide them room to demonstrate; that all the insight and interpretations in the world won't help unless the therapeutic relationship is strong; that these relationships are two-ways streets and the clients usually give as much as they get.

I'm hoping that I stay at this next job for a long, long time, so that I don't have to endure another mass termination anytime soon, but I know that, when it happens, I'll continue to learn from my clients.  And I'll continue to miss them.

*All client names and details of their diagnosis/treatment have been changed.