Gayle’s pale, lined face filled my computer screen as she tossed out, “Sherry, I might have a conflict for our session time next week. I’ll let you know.”

It was the waning moments of our eighth virtual session – prime “doorknob confession” time. Since our work together had begun three months into the start of the March 2020 lockdown imposed by COVID-19, all our sessions had been conducted remotely.

Gayle’s identity was career victim.* The 67-year-old had never had a long-term romantic relationship or kept a job for more than two years. Starting with her parents, no one had ever loved or appreciated Gayle enough. When something started going well, her pattern was to quit before “things inevitably fell apart.” She alternated between paroxysms of panic and negative self-talk and hurling invectives at her 89-year-old mother and 69-year-old sister. She was a five-layer thick concrete wall mixed with equal parts defense and denial. The wall, of course, “protected” the flicker of hope I could sense buried deep inside.

Unsurprisingly, Gayle was a therapy hopper – the longest she’d stayed with a clinician was  – Ding Ding! – approximately two months. I responded to her scheduling deflection with, “We can make the appointment for a different time but I can’t help but notice this is the point in therapy when you often end treatment.”

She demurred, said it was just a time conflict, and signed off with a promise to contact me to reschedule. Two days later, Gayle sent an email saying that, for now, she was going to stop therapy. I emailed back, saying my door was always open.

When Professional Doubt Sets In

I’d entered my therapeutic relationship with Gayle feeling this result was a strong possibility. Had that assumption colored the efficacy of our work together? The therapy with Gayle began at a fragile time in my personal life – simultaneous with treatment for my early-stage breast cancer. My prognosis was excellent but I wondered if the stress of this trauma, especially combined with the secondary trauma of the ogre I call COVID-19, had made me less sharp than usual? I’d maintained a full caseload since my February 2020 diagnosis. Working had kept me sane: When laser-focused on a patient, I wasn’t mired in the muck churning round and round in my head.

Deciding to work concurrently with receiving twice-monthly chemo treatments involved careful, measured thought. For example, I opted to wear a wig close to my natural hair color and style while Zooming rather than distract the attention of my patients from their issues. I’d been relatively sanguine with how things seemed to be progressing. Until, despite my 13-plus years as an independent practitioner, Gayle’s email cast me into doubting my efficacy as a therapist.

Aware that battling cancer coupled with the stress of the pandemic put me in a fragile emotional state, I reached out to colleagues to help me properly assess why I’d just become one of the 20% of psychotherapists impacted by the unfortunate phenomenon known as “premature termination” – that is,  patients leaving the therapeutic cocoon before growing their butterfly wings.1

The Therapist’s Fixation With “Fixing”

Erin Cantor, MSW, LMSW, a New York LGBTQIA-allied clinician emailed me this remembrance: “I ‘failed’ a patient in my first year as a psychotherapist. She was a deeply depressed, middle-aged woman with borderline tendencies…. A big mistake was my inability to hold space for all that she was going through. Instead, I fell into the trap of wanting to ‘fix’ and ‘heal’ her.”

A major reason why after being in private practice for over a decade I remain susceptible to the “healing trap” is rooted in the reason I entered this profession. As a child of Holocaust survivors, I grew up listening to stories of the unspeakable horrors that my parents endured in the war. Listening and feeling helpless to erase their pain made my career choice inevitable. On some level, each new patient who walks into my office offers a fresh opportunity to rectify not being able to take away my parents’ nightmares.

Consulting with colleagues after a perceived failure to fix someone to my specifications helped me detach from this ingrained healer complex long enough to accurately assess the progression of the therapy. Buoyed by their wisdom and support I contemplated, “Were my standards and expectations for this patient more about my ego than about the patient’s capabilities? Was I too impatient to get to the destination I wanted that I didn’t offer enough room for the patient to do more of the driving?”

Analyzing why a patient leaves prematurely offers a good reminder of our roles. Our job is not to “fix” but rather to help our patients be more aware of and better able to handle their psychological stumbling blocks, to sit with an emotion rather than run from it, and to ultimately function in a healthier way.

Sometimes, a Therapy Client is Simply the Wrong Fit

Early in her career, Morgan Levy, PhD, a Florida-based psychologist who specializes in anxiety, treated teenagers with substance abuse issues.

During a phone conversation, she shared, “I’d see these teens for a while and feel I’m not helping them. They’re getting worse. Sometimes they’d stop coming but not be open to finding another therapist.” Over time, she came to realize substance abuse was “not her area” and now refers out people with addiction issues who contact her for treatment.

Of the one that got away who still occasionally takes up real estate in her head, Dr. Levy opines, “I almost wish I could speak to that teen’s family more about what was happening so they could get the intensive help their child needed.”

Talking to Dr. Levy sparked memories of a patient I’d treated for six years who made great strides with his self-esteem, depression, and grief over a close friend’s suicide which occurred in our third year of working together. But Eric* kept being hampered by his obsessive-compulsive disorder (OCD). We both agreed that a therapeutic course with specialists in this disorder might be a valuable next step for him. He enrolled in Mount Sinai’s OCD program but still checks in with me from time to time.

Our work together had been valuable but I wasn’t the best fit to help him on the next lap of his journey.

 

The Most Important Factor for Successful Work

Returning to Gayle, my self-examination helped me see that her career identification as someone who would never truly be at peace hit a countertransference nerve. Gayle was nothing like my mother and yet her permanently wounded expression brought me to the same place of impotence I’d felt when, no matter how hard I tried, I couldn’t ease my mother’s pain. This internal mirroring made it occasionally excruciating to sit with Gayle’s pain. Perhaps subconsciously, a part of me had wanted my patient to leave so I wouldn’t be faced with this weekly emotional flashback.

Whatever my failings, Gayle just wasn’t ready to do the work.

I saw her potential – compassion toward friends, talent as an artist (evidenced by her paintings hanging in the background during our virtual sessions), and fierce intelligence. But she remained married to a self-defeating pattern of blame directed at her family for “not loving her enough” coupled with self-hatred. She remained committed to maintaining her status quo – the “comfortable discomfort” of existing in a place that felt painful but also safe. No risk, no gain as the cliché goes.

I have pledged to remember this case when a similar situation may arise next so that I can avoid the same pitfalls. As Dr. Levy told me, “Failure isn’t necessarily a bad thing. It helps us realize areas where we can grow.”

*Names and identifying details have been changed.

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Last Updated: Feb 10, 2021