I originally wrote the post below over five years ago. It’s about a teenager I worked with for about six months at a residential treatment center. I still think about him from time to time; I hope that he was able to exit the mental health system.
A few months later, I learned that, less than 24 hours after we said good-bye, he injured himself while destroying property. He apparently threw chairs, punched walls, and tried to knock over bookcases and other pieces of furniture. There was no obvious trigger. It took four adults to subdue him. Staff commented that he had not behaved this way in over two years.
“That’s how he dealt with termination,” a staff psychiatrist murmured.
I’m still not sure if I agree with him.
I’m still not completely sure of the optimal way to proceed with termination.
Termination refers to the end of the therapeutic relationship between patient and physician (or, more specifically, psychiatrist). There are essentially three ways termination can occur:
- Patient exits the relationship (patient stops attending appointments; physician fires patient; s/he dies)
- Physician exits the relationship (s/he dies; patient fires the physician; physician disappears)
- Patient and physician mutually agree on a final appointment date and time and complete the session
Ideally—for both parties—the last option occurs. This allows “closure”. And, no, I’m not entirely sure what comprises “closure”, but the lack of “closure” is why many break-ups suck. Think about it: Break-ups are uncommonly mutually agreed upon events; usually one party decides to unilaterally bail, resulting in negative emotions all around.
In therapy, we do not want to recreate break-ups; instead, we want to model and engage in the graceful end of effective and meaningful relationships. (Psychobabble.)
Saying good-bye is difficult. The white coat-wearing medical doctor within the psychiatrist bristles at the idea of termination; there is something about our medical training that promotes the idea (“virtue”?) of emotional distance and independence from our patients. So many things about our profession (both intentionally and unintentionally) facilitate this: Doctors wear white coats. Doctors wear gloves. Doctors ask a lot of questions, but rarely answer any. Doctors aim for objectivity and evidence.
So when we psychiatrists terminate with patients, the experience is weird and we are often surprised with how difficult it can be.
It’s never too early to initiate termination, so I had informed the adolescent male three months prior to our last appointment together that our time was drawing to a close. At the time, Andrew said nothing.
It’s not that he didn’t have anything to say about it; I had learned by this time that he heard practically everything I said, even though his behavior often purposely suggested that he was ignoring me.
A month prior to last our last appointment together, I reminded him again of my departure.
“Have you seen that Geico commercial? You know, the one with the little kid imitating a monster?” he replied.
As the days passed, he spontaneously mentioned the limited time we had together, though he tossed his remark within a smokescreen:
“I can’t believe that happened; it kinda makes me sad. You and I have three sessions left; we have to make the most of them. So I think I am going to try asking her again, maybe when she’s not so depressed, but it’s hard to tell….”
And that’s the way it had been the entire time we spent together; he would share bits of himself—often only a sentence here, another one there—at random intervals. Sometimes he would acquiesce if I asked a few questions to clarify his remark; most times, he simply changed the subject. One day, I called him on it.
“You’re really good at changing the subject when I ask you questions.”
“Yeah, I know,” he nonchalantly conceded, “I don’t like it when people care about me. It makes me feel weird.”
And when I tried to ask him more about that, he promptly commented on the weather. I smiled—sadly—at him.
The last time I saw him, he greeted me warmly.
We learn in the course of our training that therapeutic termination includes reviewing the time spent together and commenting on progress and goals attained. It’s like a summary statement, an opportunity to reflect upon how the patient has changed and how the patient can continue to effectively pursue his goals.
I already anticipated that, though he would hear my monologue of the above, he would not respond. My hypothesis bore true.
I commented on our very first meeting and what he stated were his goals at that time.
“Did I tell you the joke about the buffalo?”
I continued to commend him for the significant progress he had made in several spheres.
“What did the mother buffalo say to her kid as he left for school?”
I then reiterated his strengths—he had so many: he was so good with people; his integrity was admirable; he was intelligent and thoughtful; he was fiercely independent and more than capable of taking care of himself.
I expressed my hope to him that he would continue to pursue his dreams—I was (and still am) confident that he could reach all of them.
“How about the one about the cowboys?”
I looked at him, willing him to participate in the conversation—but I knew saying good-bye was not his strong suit. His parents had abandoned him when he was young; there was no such thing as a “healthy” good-bye in his experience.
“Because they are too heavy to carry! HA!”
“Take care of yourself,” I said, patting his shoulder. “Good-bye, Andrew.”
He had already started to walk away when he answered, “All right.”
I watched his lanky figure amble down the hallway. I then quickly turned to go.