Magazine article Clinical Psychiatry News

Fink! Still at Large: When Patients Quit Therapy. (Opinion)

Magazine article Clinical Psychiatry News

Fink! Still at Large: When Patients Quit Therapy. (Opinion)

Article excerpt

Tony Soprano, the main character in the popular HBO series "The Sopranos," recently told Dr. Melfi that he did not want to continue treatment. Dr. Melfi, knowing that this would not be best for her patient, encouraged him to keep his next appointment. But Tony refused.

For Discussion: This case, though fictional, raises an important issue for psychiatrists. What do you do when a patient who clearly needs to continue treatment opts not to do so? What is the most effective way to handle such situations?

Stop Acting, Start Thinking

If my patient says he wants to leave, I try to understand why Usually it's something that is bubbling up that the patient is becoming aware of that makes him nervous and scared. It's up to the psychiatrist to interpret why the patient feels this way and to show the patient why he needs to stay.

In the end, you can only lead a horse to water. The issues or feelings a patient brings up may lead to transference, such as angry or sexual feelings, which he doesn't understand is about someone or something else, not him. I have to assure him that such feelings exist for a reason and that therapy is a safe place for feelings to come out. The point is to get the patient to start thinking and talking about those feelings.

It's often helpful to enumerate the issues that led the patient to come to therapy in the first place and ask whether they have been resolved. Without doing this, patients can convince themselves that they are better when they really are not.

Gail Saltz, M.D.

New York

Transference Recognition

The way to handle the situation of a patient who wants to leave treatment depends on the stage of treatment, the goals of the treatment, the kind of treatment, and the nature of the patient's problems.

Many patients clearly are in need of treatment but are so frightened of the possibility of either psychotherapy or psychoactive medications that they will simply come for one or two meetings because a relative or a good friend insisted.

The psychiatrist's goal should be to identify this fear as soon as possible and to try to address it. I do think that even if such a situation is handled perfectly very often the patient will go through a series of potential therapists or psychiatrists.

In an ongoing psychodynamic psychotherapy (with or without medication), as in the case of Tony Soprano, the major reason for a precipitous exodus is related to some transference/countertransference issue that either has not been recognized by the therapist or has been recognized by the therapist and not interpreted. In that sense, Tony's leaving was such an example.

Tony was complaining to Dr. Melfi because she was not helping him. Rather than addressing Tony's anger at her and trying to help him master his disappointment with her (as a representative of other disappointments in his life--transference) she points out what would be called "reality." This does not work in a therapy.

I would surmise that she was frightened of his anger. After all, this is a violent man. Many therapists would not work with such an explosive personality so it is difficult to generalize with this example. But in a usual kind of psychotherapy patient, a discussion and exploration of anger at a therapist is crucial.

Leon Hoffman, M.D.

New York

Tactful Interpretation Required

In my experience as a supervisor, I have found that patients leaving treatment prematurely is one of the most commonly mishandled situations in psychotherapy Patients decide to stop treatment for a variety of reasons, including some good ones. Some psychiatrists get into trouble by imposing their own ideals on the patent, not respecting the patient's wish for independence, and then trying too hard to persuade the patient to stay We have to be honest with ourselves when we conclude that the patient needs to continue treatment. …

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