“Our Time is Up”: A Relational Perspective on the Ending of a Single Psychotherapy Session
Abstract
Introduction
Literature Review
Boundary Management
Example
During my first year of psychiatric residency, a self-destructive, manipulative young woman with a history of having been a victim of sexual abuse refused to leave sessions on time. Because of my small repertoire of therapeutic skills at the time, I failed first to explore the meanings of this behavior and, instead, insisted that she leave the office when the session ended. She proceeded to end the next session on time, only to faint as she reached the office door—which only opened inward. I was then forced to commit the boundary violation of touching her to open the door!
Ned was the youngest of 11 children. As he put it, “By the time I was born, my parents were worn out. They had nothing left to give.” Ned made impressive gains in the six years he was in treatment: heightened selfreflection and self-esteem, a greater sense of personal agency, and improved interpersonal skills that translated into success at work. During his last three months in treatment, he found himself crying very near the end of several sessions, sad tears related to all the deprivation and emotional pain that he had faced and worked through to have his present life.
I rarely fail to end sessions on time, but one exception was memorable. Ed was a therapy veteran, having been a patient in a variety of therapy modalities. At the time I was treating him, he was also heavily into meditation. He came into one of our 50-minute, afternoon psychotherapy sessions that began at 4:30, and for which he paid $180/session, and ten minutes into the session he announced that he preferred to spend the rest of the session meditating. Knowing of his distrust of authority, and sensing that this was not a propitious time to challenge that stance, I went along with his wish. The next thing I knew, it was 5:22. The last time I remembered being awake was 5:00. As I said, “We have to stop now,” Ed opened his eyes, and we ended the session. The next session no mention was made by either of us about what had transpired in the previous session. As we started the next session, I said to Ed that I needed to talk with him about an administrative matter. His body stiffened as if he were about to be punished. I said, “I think I owe you some money.” He asked what I meant, and I said, “Your prerogative as a patient is to use your therapy time in a way that we both feel is productive. My job is to be here for your benefit and to be awake and attentive for the 50 minute hour. Two weeks ago I was asleep for the last 20 minutes of the session” to which Ed replied, “I KNOW.” In subsequent sessions he elaborated on why my disclosure meant so much to him: it felt like a corrective to his experience with his punitive, untrustworthy parents. We then figured out what his refund would be; I’ve never spent a more productive $72.
Unwitting Self-disclosures
Joe treated his morbid obesity as if it were as serious as a hangnail. He joked with members of the therapy group he just joined that his role was to ensure that other members felt thin. It took all Joe’s strength to extricate himself from his chair when sessions ended; the effort left him breathless. This behavior went unaddressed for several sessions; I said to the group, “To what lengths does poor Joe have to go to get someone to acknowledge the seriousness of his condition,” a comment that finally elicited expressions of concern. Slow suicide comes in many forms.
Another patient may not realize that her hostility is masquerading as a social grace. Elizabeth’s marital relationship worsened during weekends when her husband was not working. Elizabeth felt she was living in an existential hell, and yet she feared that she could not make it living on her own. She was my last patient on Friday afternoon. As she left each session, she would say, “Have a good weekend.” It became painfully obvious—at least to me—that I was going to have a much better weekend than she was. I began to feel that her parting pleasantry was not as friendly as she imagined. After some months, I brought the pleasure discrepancy between our respective weekends to her attention. At first, she denied meaning anything by that social grace but over time got in touch with its hostile component. Her acknowledgment of her anger over my having such a better (imagined) life than she did opened up a new phase in therapy. As she realized in therapy that she was not being punished for her anger and that, in fact, I seemed to welcome it, she began to stand up for herself and insist on better treatment in her marriage. This increased sense of agency began to permeate other sectors of her life.
Dorothy, a very polite woman from a nearby wealthy suburb, entered therapy with a chief complaint of depression and interpersonal problems at work. She had found fault with bosses in her last three jobs and was beginning to realize that her behavior was part of the problem. And yet, in the sessions, she came across as reasonable and relatable. I send out bills at the end of the month and expect patients to pay within a month. Dorothy began therapy in February and at the end of the last session in March she took out her checkbook as the session ended and said, “Let me write you a check.” She wrote in a slow, deliberate manner and was careful to subtract the amount of the check from her balance before handing me the check. Five minutes elapsed by the time she checked the amount of her bill, wrote the check, did the math in her check register, and handed me the check.I noticed my mixed feelings around this transaction. On the one hand, I like getting paid; on the other, I value my 10 minutes between patients. Dorothy seemed unaware of her entitlement to an extra five minutes of my time. I sensed that important meaning might reside in this possible enactment (Chused, 1991; McLaughlin, 1991). I decided to delay commenting on this behavior until I could decide if it was a one-time phenomenon or a pattern. Over the course of the next five months, it became clear that this behavior was a pattern. As we came to the last session in August, she again got out her checkbook just as the session ended. Having metabolized my counter-transference feelings to this enactment and before she was able to get her pen out I said, “We have to stop.” She said, “But I’m about to pay you” to which I replied, “Yes, I know but our time is up.” She looked at me with a combination of incredulity and muted fury and said, “Well, fuck you, I’ll pay you when I want to.” It was at this moment that therapy really began. She had a week to think about her eruption and came to the next session in an embarrassed but self-reflective mode. She realized that her anger was triggered when her boss did not appreciate all the work she had done. Not surprisingly, we found that she had a long history of feeling not appreciated. We were then able to sort out whether paying her bill was something she was “doing for me”—and thus something I should show appreciation for—or if paying her bill was simply part of our initial agreement, paying a fee for a professional service. As a result of this clarification, Dorothy felt the degree to which not being unappreciated was an emotional trigger for her. Generating meaning from this financial transaction – mentalizing (Fonagy, 1991) it – advanced the therapy.Is it possible that a gentler approach may have resulted in the same therapeutic work? I could have said something like “I notice you have a pattern of paying after the session has ended. I wonder if there is anything we can learn from exploring this behavior.” Perhaps we could have achieved the same insights but probably not with the equivalent affective valence.
Visual Challenges
Case Example
Audrey had a lifelong struggle with feelings of shame. Her father, who was an alcoholic, called her stupid and ugly, and he made derogatory comments about her body in front of his drinking buddies. Her mother provided no protection.The endings of sessions provided the opportunity to explore her shame dynamics in the transference. Upon preparing to leave a session, Audrey would pick up her coat, put it on, and turn to leave the office without looking at me. I also noted that her absence of eye contact made me feel like a “dirty old man,” an induced feeling worthy of exploration. When I thought that the timing was right, I commented on her behavior, keeping my reaction, for the time being, to myself. Her first associations were to shame about her body. Because of her father’s demeaning comments about her body, Audrey didn’t want to give another man the opportunity to disgrace her with his eyes. If she did not look at me, I magically would not see her either. If she risked looking at me, another danger presented itself: projections from her inner world, more than my actual facial expression, would determine what she experienced (Havens, 1976). Paradoxically, because she rarely looked at me, I was provided the opportunity to look at her unobserved.Repeatedly focusing on this visual dynamic at the session’s end helped us deconstruct the negative self-image that had emerged from her early experience. We were able to talk about the reality of her personhood in the present as compared to her distorted version of herself from the past. We affirmed her many good qualities: her values, her integrity, her kindness, and her reliability.It then became difficult for her to look at me for another reason: she was overcome with feelings of sadness as she recounted the many years of therapy and financial resources it had taken her to detoxify feelings from her childhood. Recently, as she is able in a more relaxed fashion to look at me as she leaves and talk about the feelings that accompany such looking, she can speak about feelings of gratitude (Gabbard, 2000) for the years we have worked so hard together.
Countertransference
Conclusion
Acknowledgments
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