September 1, 2005 Goodbye, Therapist. Hello, Anxiety? http://nytimes.com/2005/09/01/fashion/thursdaystyles/01THERAPY.html?pagewanted=print
By SUSAN SAULNY WHEN it came time to schedule a new round of appointments with his therapist of six months, Tom Dietzler took out his pocket calendar, affected the harried expression of a man whose life was terribly overbooked, and began chattering about obligations that he knew didn't exist.
All of a sudden his son had four basketball games instead of two, and his daughter had three soccer matches instead of one, he said, thinking back on his first awkward attempt to fire a therapist. Mr. Dietzler just couldn't think of any other way to get out of the relationship that he said was perfectly pleasant but not doing much to improve his state of mind.
"I didn't want an ugly confrontation," he said. "I just wanted to get out of there."
And he did. But a painful, prolonged situation like the one Mr. Dietzler feared actually ensnarled Joye Chizek, a marketing consultant who runs a business in Sherrard, Ill., in the Quad Cities region. Her breakup with a psychologist she had been seeing for depression landed her in another therapist's office, where it took four months to work through the previous relationship's turbulent ending.
"It was messy," she said recalling tense exchanges and tears, "the absolute worst."
Few relationships outside the realm of romance are fraught with as much potential for confusion and unhappiness at their conclusion than that of the client-therapist, a professional union built upon trust and the sharing of intimate detail.
As extreme as the cases of Mr. Dietzler and Ms. Chizek might seem, their experiences are not that rare. As an estimated 20 million Americans seek therapy each year - the result of a greater public awareness of treatable conditions like depression and a lessening of the stigma involved - one trend is clear: Unlike in decades past, many people currently experience therapy in short installments with various practitioners over time. That means more time spent on hellos and, perhaps more problematically, goodbyes.
The reasons are many. In an era of managed care, easy mobility, abundant choice and the growing popularity of brief forms of treatment, patients are more likely to bounce around. The relationships formed over the years with one specialist, Woody Allen-style, is anything but typical, and that's been the case for years. According to a federal study released three years ago, about 10 percent of people who seek psychotherapy attend more than 20 sessions, and about 33 percent meet with their therapists only once or twice.
Over time, however, a possible downside of such short stints has also become clear: today's serial-style therapy means that patients sometimes have to make multiple attempts at termination, as the textbooks call it. And, according to anecdotal evidence, the repeated process can leave them emotionally exhausted.
In interviews, patients cited personality conflicts and unprofessional behavior as the main reasons for wanting to cancel their appointments permanently.
But how? Mental health professionals are taught how to initiate and handle termination, and to be sure many routinely lead their clients through successful separations. Patients, however, have no guidebooks and are often left feeling anxious about how to broach the subject of leaving. For some, the anxiety takes on a life of its own.
"It becomes psychologically a worse problem than you came with, and that's the real evil," said Ms. Chizek, 53. "You're there to discuss whatever about your father, then you end up worrying about this other thing, getting in and out of relationships with therapists. It totally becomes its own problem."
Mr. Dietzler, 47, who works for a paper company in Appleton, Wis., and who has been with three different therapists over the last 15 years, seconded that notion. "The exits were always uncomfortable," he said.
One reason for discomfort, Mr. Dietzler and others said, was the lack of clarity about when they were done and the uncertainty about how bold a case to make for moving on.
Ms. Chizek and other patients said they were usually left to decide on their own when to walk away.
"Nobody ever says, 'You're well, get out of here,' " Ms. Chizek said, adding that she has never been to a therapist who had an exit strategy. "And it doesn't happen evangelical tent style: 'I'm healed!' " The pressure can feel intense. Mr. Dietzler said: "I was made to feel as if the loose ends that I was leaving were going to become major obstacles to my future development as a useful human being."
With few obvious physical cues like reduced swelling or a drop in temperature to help patients determine the appropriate moment for concluding treatment, sometimes they try to leave too soon, too late or not at all. To be sure, some patients manifest their inability to commit to relationships by leaving one therapist after another, experts said. Others become so dependent on their therapists that they never want to leave. The relationship risks becoming an addiction.
But experts say that therapy should be time limited. Some say that if termination has never been addressed, patients should ask their therapist how they will end the relationship and when?
"The not knowing is a very anxiety provoking thought," said Dr. Patricia Farrell, a clinical psychologist and a therapy expert for WebMD, the Internet site.
"Everyone should have an idea of what the therapy goals are, and the patient or client should know if the goals are being met and should constantly re-evaluate," Dr. Farrell said. "It shouldn't go on for 10 or 20 years."
Dr. Farrell said timidity sometimes stood between patients and their best interests. "I think that people really need to understand that you can speak up to your therapist," she said.
That's what Janine Squillari did after several weeks of feeling that her treatment had veered far off course last summer. Ms. Squillari, a writer and performer from the East Village, said of her therapist, "I felt he was attracted to me, and I didn't feel great about it."
She expressed her reservations about going forward with more appointments. She said the therapist begged her to stay after admitting an attraction, but stopped short of asking her out on a date. It took Ms. Squillari four sessions over one month to make her intentions clear.
"I said, 'I feel that this has gone past the point of being comfortable,' " Ms. Squillari said. "He said, 'Well, I'm a human being, and I have issues, too.' Then I said, 'You shouldn't be working out your issues on my time.' "
Patients often turn to Internet chat rooms and message boards like those available through WebMD to ask others how they handled termination. Ms. Chizek posts messages there, telling the story about how, after a painful separation from her first therapist - who, she later concluded, was treating her for the wrong disorder - she found a new psychologist who really helped turn her life around.
Ms. Chizek said she posted the messages because "this is not beauty tips, this is life and death, and I think it's pretty important."
Breakups are sometimes difficult for the therapist, too. And sometimes they are just as ready as patients to leave difficult relationships behind.
"I miss people probably more than they miss me," said Dr. Nancy Arndt, a clinical psychologist and marriage and family therapist in Westport, Conn. "I don't take anything personally anymore. In fact there are some people I wish would fire me. I had one couple, they just kept coming and coming. They were just exhausting."
But Dr. Arndt lets her patients set their own pace: "People feel comfortable in calling the shots, and I say that it's your time and your choice."
Kurt Bruder, a psychotherapist and a former associate professor of communication studies at Merrimack College who focused on client-counselor interaction, said that the constant coming and going of patients during his training amounted to "a parade of pain."
"The disentanglement of those relationships can feel like death," he said. "But it's only natural that clinical relationships, like others, will run their course. It's important not to get too bent out of shape when that happens."
Beth Bongar says she has found it hard to break up with several of her therapists because she has liked them so much. Guilt, pain and anxiety would plague her thoughts every time she was ready to split. So sometimes, she didn't.
"I've always had trouble telling them I want to break off," said Ms. Bongar, 51, an actress and writer from TriBeCa. "I felt like I was going to hurt them to let them go."
In one instance, Ms. Bongar said, she stuck by her therapist for a year longer than she felt she needed to, just to be nice. "I'm a perfect therapy person," she said. "They all love having me because I'm very entertaining. We have a good time during my sessions, so it's always hard for me to tell them I'm leaving."