Sometimes
a client precipitously leaves therapy with no explanation. They may
ghost the therapist, or it may be done with elegant finesse such as
suspending therapy for a foreign trip of indeterminate duration from
which they seem never to return. Either way an anticipated
confrontation involved in going through the exercise of closure is
avoided. Such subterfuge is a Pyrrhic transferential victory because
the client is taking baggage away from the ruptured relationship,
however delicately they engineer their disappearance. The reasons
behind such ruptures are wide-ranging, including unstated
transference, embarrassment, unstated plateauing in the ability to
further confront phobic material, feeling unsafe or insufficiently
supported, and so on. These are actually opportunities to advance the
therapy if the therapist is quick to recognize what is happening, but
in a busy practice, such situations are easily overlooked before the
critical moment has passed.
There are clients who leave therapy for less overtly avoidant reasons. Sometimes a client gradually drift away, appointments become less and less frequent, and then the client stops booking, or even fails to show up and doesn’t respond to enquires. Perhaps the therapist closes the file and thinks nothing more of it. “Perhaps their benefits ran out or they weren’t ready for more therapy.” Imagining reasons when there are no explanations is tempting, but the truth may be very different from what we imagine. It is better to tolerate the ambiguity of not knowing than to engage in projection and judgement based on circumstantial evidence.
Simpler territory is the situation where the therapy has achieved its goals, but sessions continue with no mention by either the therapist or the client that the objectives of the therapy need redefinition. Continuing therapy with no explicit reason creates what is sometimes called false alliance—a collusion of motives that do not advance the client’s mental health. Two situations frequently arise:
- It is useful to make a distinction between tactical problems and strategic problems. A tactical problem might be recent job loss, recent bereavement, illness or relationship failure. Strategic problems include recurrent job loss, recurrent relationship failure or developmental trauma. If therapy has supported client through a tactical problem which was the stated reason for coming to therapy, and the client continues to want to come to therapy, there needs to be a clarification and redefinition of the reason for continuing the therapy.
- While they would actually prefer to quit, the client continues for fear of offending therapist (transference issue) or has insufficient confidence in their capacities to cope without the regular visits with the therapist. Eventually, the sessions feel sufficiently pointless the client quits, and what could have been a good ending is turned into one that leaves a negative feeling that could prevent the client from seeking to resume their therapy at some later date when they may then need it.
What the client may need in both of these situations is
encouragement and support to undertake deeper work.
In all of these ambiguous circumstances, it is best to follow up with
the client rather than to make assumptions. Better still is to
prevent such inconclusive endings. Having clients complete the
Miller-Brown brief questionnaires [Scott
D. Miller & Duncan, 2000, Outcome Rating Scale (ORS) / Session Rating
Scale (SRS)] to bookend each session has the potential to catch
misalliances early before other defences of the client are activated.
Implicit in the use of the ORS and SRS is the reaffirmation of the
consent from the client to receive treatment. If the therapist is
not inclined to use questionnaires, explicitly returning to the
matter of ongoing informed consent* is another approach.
As part of the intake process, a psychotherapist solicits from the
client their objectives for therapy, preferably in writing. A
comprehensive history taking, including previous therapy and its
outcome, would include goals for the current therapy. Ethically, if
the therapy proceeds to address the stated objectives, even if the
therapist is aware of other or deeper issues, the client cannot claim
to be ill served. Unfortunately, clients sometimes are unhappy with
their therapy when their stated reasons for seeking help are at
variance with their willingness to follow through. They may have
bitten off more than they can chew and are embarrassed to say so. If
the therapist doggedly pursues the original objective for therapy,
irritation, resistance and dropping out of therapy may result.
There are instances where the client claims to have a particular
problem, leaves therapy because their resistance is aroused by the
therapy, and then seeks counsel elsewhere for something less
triggering. They may not see that their problem is that they set the goal of therapy to be jumping to the top of the mountain. Instead they find another practitioner who will address more
superficial issues, and then the client claims that the original
therapy was misdirected or mishandled. “You should have known that
all I needed was Treatment X.”. The client may not be aware
that the vulnerability required to do the deep work they asked of the
first therapist may be at odds with their control issues or other
psychological defences. For example, a client reports marital
breakdown because of a history of childhood sexual abuse by close
relatives, leaves therapy with no notice or explanation because the
developmental trauma work is too challenging, and then claims better
results and takes up umbrage against the original therapist when a
subsequent therapist treats only the symptoms of the
developmental trauma such as anxiety, addiction or eating disorders.
Neither therapist is wrong because both are treating what they were
asked to treat, but the client may complain against the first therapist even though they did as they were asked.
In this example, it may seem that a potential malpractice issue is
arising—not from improper actions of the therapist who acted on the
client’s requests and offered what was requested, but that turned
out to be too much for the client, or another therapist who offered
them a less challenging treatment—but from the changing perceptions
and emotional comfort of the client.
The mistake that the therapist may make is to fail to restate and
reconfirm frequently the objectives of the therapy.
While it may seem pedantic to periodically repeat back to a client
their reason for seeking help, there may be practical and legal
reasons for doing so. This revolves around the principle of ongoing
informed consent*. Unfortunately,
there may be few indicators that the therapist’s understanding of
the objectives of the therapy and the client’s emergent
desires for the therapy are diverging, especially if the client is
inclined toward pleasing others and is therefore hesitant to
interrupt the therapist’s approach to treatment.
In summary, it is never a bad
time for the therapist to clarify what is going on with the client,
and there is never a good time to make assumptions about the shifting
dynamics in the therapeutic relationship. It is better for everything
to be on the table all the time, which for many clients may be unique
experience missing from problematic relationships in their lives.
*Ongoing Informed Consent
Informed consent
in the context of a professional service means that nature, purpose
and risks of a therapeutic procedure are explained to and understood
by the client receiving the service. Having a client sign a document
alone may not stand up legally as there is no determination of the
client’s understanding unless there is a verbal verification and
preferably a discussion with the client.
Regulatory organizations require that mental
health practitioners maintain ongoing
informed consent from their
clients for the treatment they are receiving. It does not mean
signing a legal document every time the therapist seeks to reaffirm doing something that
has been done before. It does mean asking, are
you still OK with (treatment X),
or are you up for doing
a little more work on problem Y today. For
various reasons, the answer may be
No,
perhaps because the client it too tired today, too anxious, has other
present needs or other more urgent matters to discuss. Leading
by following
is the principle here. While some clients may welcome the therapist
leading the therapy and that may accord with the therapist’s
personality, it sidesteps ongoing informed consent and may be
colluding with client’s issues such as, passivity, pleasing,
reticence, unassertiveness, taking personal responsibility or making
decisions.
Another take on ongoing informed consent
is that it is not so much about consenting as it Is about checking
in on refusing. The client may
agree in principle about certain activities in therapy, but they may
not want them on a particular day. There may be things that the
client has done in previous sessions that they do not wish to do
today, and checking in may be more about the timeliness of the
intervention then it’s overall acceptability. The only way for the
therapist to be sure is to ask.
Some may argue that the therapist can
sometimes proceed on the basis of implicit consent because of the
inter-subjectivity -- essential to any effective psychotherapy --
exists with the client. Has the therapist failed to obtain consent
if they proceed on the basis of an intuition based on the therapist
knowing the client well enough to sense of what is OK and what is not
on a particular day, and doesn’t say anything about this awareness?
The lack of explicitness may fail legal metrics, but consent may be
there implicitly. The problem is that there is no objective
attestation, even though there is attunement
between
the therapist and the client.
Parallels exist in medical situations where a nod of the head, or the
blink of an eye may have to substitute for a signature or an
affirmative verbalization or refusal.
