Dear Inadequate Graduate,
I’ve been working with a patient in what was supposed to be short-term therapy but was extended repeatedly due to various and unforeseen circumstances. It’s time, however, to revisit termination and I’m feeling very guilty about abandoning her. Well actually, my emotions are mixed – I know that my patient feels I’m giving up on her, but I see it differently. I made it known that our work together would be time-limited from the beginning and I honestly don’t know if I have anything more to give to her. I am emotionally exhausted and psychologically at a loss for how to further the treatment, and I think transferring her to someone more specialized and who can provide long-term care is necessary and warranted. The end is in sight, which I’m glad about, but I’m also worried that she won’t follow up with the next provider and am simultaneously flooded with self-doubt and relief at the prospect of ending our work together. I feel that transferring her care really is best, but any advice you have would be appreciated.
Dear Compassion Fatigued,
The dynamics around this case sound complex (they usually are) and that you are experiencing a flurry of emotions that are common in working in our field. Termination can be a difficult time for both patient and therapist, even when the separation is mutually agreed upon and treatment ends on a good note. This patient sounds quite attached to you and although the therapeutic relationship is shown to be a significant predictor in patient’s experience, there are limits to what we can offer even in the best of circumstances. It’s unclear why the treatment was extended or whether she might have benefited from being transferred to someone who could provide long-term care from the start (which are important things to consider going forward as you gain experience and knowledge) but maintaining firm boundaries while exploring and validating her feelings about the transfer are important. I’ve had patients who became very attached after only a few sessions, and many people (both patients and providers) struggle with feelings of abandonment or guilt even when the work together has been brief.
That said, if your clinic is not formatted to work with patients long-term, it is also important to refer them to a place that could better meet this need so a similar pattern doesn’t ensue. You can never be sure a patient will follow up with a referral, but patient’s also need to take responsibility for their care and provided you did the best you could with the transfer process, make sure the referral is as clear and smooth for the patient to cut down on confusion or miscommunication. I’d encourage you try and replace your guilt with curiosity about your internal state, and speak with a trusted supervisor or professor where you can further express and understand the dynamics surrounding this case as it is to your, and your future patients’ benefit, to understand why the treatment was extended and what you might learn from this experience. Developing both technique and intuition takes time so try to be kind to yourself in the process, perhaps this kindness with reinvigorate some of the compassion you feel has faded, and remember that regardless of what you do or do not have to give,
You. Are. Enough.
The Inadequate Graduate