(Identifying information in the brief case discussion that follows has been changed.)
Several years ago, I was consulted by Tom, a 47-year-old man who complained of an unusual phobia, one I’d never heard of. Tom reported that he had suffered with the phobia for over 7 years. It was creating serious problems in his life, interfering with everyday functioning to an extent that most persons would find intolerable.
Tom explained that he had been in therapy with three other therapists prior to seeing me. Cumulatively, he had been in about 4 years of weekly therapy. Tom said that he was dealing with a very limited budget and he could not possibly afford more than a couple of months of weekly sessions.
As I listened to Tom during that first meeting, I suspected that the phobia served a purpose in his life: it was preventing him from doing something he needed to do, but was afraid to do. I had a specific idea about what this was, but I was far from certain and I believed that it would have been premature to offer such an interpretation, even speculatively.
Thinking privately about the possibility that the symptom was functioning to protect a larger system of personal relationships, I considered the possibility that treating the symptom directly might force the underlying issue out into the open. I also knew that if I was right about the systemic issue, we might encounter considerable resistance if the symptom moved toward resolution.
I explained to Tom that I could offer two options for how we might proceed. The first approach would be to directly pursue alleviation of the symptom in a time-limited therapy. I added that, in my experience, this might expose other difficulties. I also explained that if we went the time-limited route, I would not be able to continue with him in a longer term treatment should he feel a need to continue in therapy. There were several sound technical reasons for my position on a firm termination agreement, but I’ll save that discussion for another post. I did say that if, at the end of the therapy, he felt a need to continue in treatment, I would provide him with suitable local referrals.
The second option was an open-ended therapy with a fee adjustment. Tom declined the offer. He said he wouldn’t feel comfortable with that arrangement. Given his previous treatment experience, I suspected that Tom did not want to embark on another open-ended therapy, even if he could swing it financially. A firm short-term limit would give him a clear out if he felt things weren’t going well.
I did raise the possibility that after his previous experiences he might be reluctant to make an open-ended commitment, but Tom insisted that it was all about money. I wasn’t so sure about that, but I knew that Tom had no basis for trusting me yet. After three therapists failed to solve his problem, I knew that it was only because of desperation that he was willing to give yet another therapist a shot at the problem, albeit a very limited shot.
With Tom’s agreement, I assessed his suitability for treatment using systematic desensitization in the office, followed by real world progressive exposure to the phobic situation. Tom appeared to be a good candidate for systematic desensitization. He could handle progressive relaxation without panicking and he could easily induce anxiety by imagining the phobic situation. We agreed to 12-15 sessions maximum for the therapy.
The treatment went smoothly. From time to time, some of the underlying issues that had concerned me seemed to peek out at us, but we had an agreement to focus on symptom alleviation, so we devoted most of our time to the desensitization treatment itself. All the while, I wondered if this other issue would become a real problem in our work together.
It didn’t. After 12 sessions, Tom’s phobia had been completely resolved. Tom was very grateful; on the surface, he was as satisfied a customer as you can get. During our termination session, Tom did not manifestly share any concern about the background issue that had concerned me as we initiated the treatment. He did express some irritation that his previous therapists hadn't tried desensitization.
Afterward, I was still uneasy about the work we had done. The mention of previous therapists who failed to use the right treatment didn’t sit well with my third ear. Was that also an encoded statement about his treatment with me? Was this a case of conscious satisfaction, but unconscious, disappointed irritation? I didn't open that can of worms at the last session because we wouldn't have an opportunity to address it together if I did. In an open-ended therapy, I would have had no qualms about addressing the issue.
About a year after his treatment ended, I was surprised to receive a note from Tom. He thanked me again and said that he was doing very well. He had experienced no recurrences of the phobia and he felt a great weight had been lifted from his life.
Tom also mentioned a major change in his life, a change specifically related to the unspoken background issue that had concerned me at the outset of his treatment. He had gone back into therapy to deal with the issue. Perhaps resolution of the phobia did bring the underlying systemic issue to a head, forcing Tom to deal with the matter more directly. I don’t think Tom was consciously aware that I had been concerned about this other issue because, at the time, he didn’t seem aware of it himself.
Tom added that he remembered our original agreement—no ongoing therapy; that’s why he embarked on another therapy with someone else. Apparently his financial condition had improved, or as I had originally suspected, he didn’t want to commit to yet another open-ended therapy at the time he had consulted with me.
Actually, I had mixed feelings about the note.
Dear Dr. X: I’m doing fabulously. I’m back in therapy to address what you ignored..
I'm reading into it.
It was good to hear that Tom was progressing in his life, but I couldn’t help but wonder if the note was also a way of saying that we should have addressed this other issue. Maybe both of us felt a bit of that. Did I sell Tom short? Maybe it would have been better to have pushed the unspoken issue at the time. Maybe not. Sometimes we know unconsciously what we should do, but we’re just not ready to face it. Maybe Tom was communicating about what was lacking in the therapy with me and maybe he had mixed feelings about it as I did. Maybe he had mixed feelings about moving on to another therapist, even though we had an iron-clad agreement on the duration of the treatment. I’ve got to go back into my files and read that note again.Sorry, any of you skeptics out there, but a note to a therapist is never just a note.
Cut to about four years later. I’m watching a network morning news show and who should be a guest participating in one those 5 minute, hit-and-run interviews? It was Tom and he was with a therapist and they were talking about the problem Tom had in his life and how they resolved it in therapy. Tom mentioned that it had never been addressed in his previous therapies.
In the preface to a question, the host said something about none of Tom’s previous doctors helping. Tom interrupted to say that that wasn’t true. He said that he had one therapist who helped him over a huge hurdle. He was grateful for that, but he explained that we didn’t get into the bigger problem they were discussing on the show. I say "we" because I was pretty sure Tom was referring to his work with me. Again, I wondered if I should have handled things differently.I still have my doubts. I still wonder if I should have pressed Tom a little harder during our first couple of meetings. Maybe he would have been able to accept the interpretation if I put it out there. I felt at the time that his defenses around the issue were deeply entrenched and that Tom might have bailed immediately if he saw where I was going. And perhaps I was too worried about Tom bailing. In the end, these are judgment calls that owe a great deal to both the therapist's experience and personality. We can and should examine our own motives, anxieties and resistances as we make clinical decisions. What we should not do is pretend that our own stuff doesn't enter into our clinical choices.