Transitioning From Therapy To Life

 

Whitney, sixty-one, long-time patient, ends each session with “so, what should I do?” Over the years, I have come to hear that question as a signal which tells me that transitioning from therapy back to life is challenging for her, as well as for many patients. The comfort of getting honest with one’s feelings makes it hard to leave, and go into a life in which social graces demand a certain amount of deception. The relief of authenticity is palpable for some, and especially for Whitney. The question she asks, feels to me, to be “how can I feel good when I leave here?” I hear the pain of the uncertainties in her life. Her son is getting divorced. She has a health scare. Her finances are rocky. In my office, we share the anxieties, whereas with her friends and family, she maintains good cheer. Some colleagues call this transition the “insult” of psychotherapy, because telling patients they have to stop talking can feel assaultive. The notion that time is up, potentially narcissistically injures a deep unconscious which needs to feel endlessly fascinating and engaging. Whitney deals with this “insult” by hoping to take away a concrete notion, while at the same time, knowing that I am not going to answer her question directly. Sometimes I say, “you should make sure that you are taking care of yourself,” knowing that this is a very general comment, and not what she is looking for from me, but also knowing that she appreciates the reminder. Maybe I should respond “it is really hard to leave,” with the understanding that although it does not answer her question, it addresses a possible underlying motivation to her inquiry.  We know each other well enough to engage in this kind of  indirect conversation. I will try that.

“Exit Lines”

“Exit lines” as Glen Gabbard MD likes to say, or “doorknob comments” are another “royal road” to the unconscious. The comments as one leaves the therapy office are often so revealing, as this is the opportunity for the patient to get the last word, without time for challenge or deeper thought. “You got up early this morning,” one fictional patient says at the end of our 7:00 am appointment, making me think that in her mind, it was hard for her to come today. Maybe she wanted me to appreciate that she made a large effort to make this early time. Alternatively, maybe she wanted to show appreciation for me making time for her. There is always the question of bringing up the “exit line” at a future session, but by that time, the feeling in the room is gone. There is power in the “exit line” as it resembles getting the “last word” in on an argument. It is the final punch at the end of a long fight. It leaves me with wonder and curiosity. Sometimes it leaves me with difficult feelings which I am not able to discuss with the patient until the next session so I am left to stew. Universally, it helps me understand a very important  dynamic in the relationship.

See also….https://shirahvollmermd.wordpress.com/2011/07/11/the-doorknob-comment/

The Doorknob Comment

“There is one thing I want to tell you,” Vivian, sixty-two, says as we both look at the clock and know it is time to stop. I have a hunch that what comes next is the most pressing issue on Vivian’s mind. I suspect it is something like a confession; like she is about to tell me she is using too much medication, or that she has a hidden substance abuse problem. I wonder whether I should remind her that we are going to have to stop, or should I allow her a little more time to express herself. Vivian is handing me the classical doorknob comment; the comment that one says as they are about to leave the session. I could see this behavior as classic avoidance. She knows we will not be able to explore the issue in-depth on this day, but she also postponed telling me. Perhaps telling me at the last moment is a compromise; a balance between complete avoidance and meaningful exploration. In addition, maybe Vivien is pushing the boundaries. Maybe she is testing me to see if I will give her more time under these self-made critical circumstances. I am in a predictable bind. If I allow her to go over the time, then I am rewarding her avoidance. If I strictly adhere to my time limits, then I might seem rigid and uncaring.

I say, as Vivien knew I would, “I don’t mean to interrupt, but whatever you tell me, we won’t have time to talk about it very much today, and I am sorry about that since I suspect that what you are going to tell me is a challenging subject.” Vivien nods her head with understanding and proceeds to tell me that she just found out that her husband has been lying to her about giving money to his adult son, her step-son. Vivien is furious. “I can understand why you are furious, but why did you wait until the end to bring it up? I ask, thinking that Vivien struggles so much with her anger and her shame at being angry, that it is hard for her to be forthright. “No one likes being lied to,” I say, trying to help her shame, but also realizing that I did not let her answer my question, likely because I am feeling so rushed. “I wanted to mention it. Maybe it is not such a big deal.” Vivien says, with consistent defenses of  avoidance and minimization. “I think you left it to the end because it is a big deal.” I say, implying that her style is clear and self-injurious. It does not help her to minimize her pain in the way that she often does. I was surprised by the content, but not the method of delivery. The lay person might say it is “Vivien’s style” to be indirect and curvaceous in her communication. I would say that it is “Vivien’s coping mechanisms” to delay and avoid important subjects.  I suppose we are saying the same thing.