Should a doctor or friend help the patient to stop the therapy that does not develop well?

Sometimes, over the course (or ‘in the process’ according to the professional vernacular) of psychotherapy, the patient’s complaints increase significantly. This leads to doubts even in patients who have been warned of such a possibility in advance, for example during the preparatory interview, the qualification for therapy or in the so-called therapy contract.

Doubts about psychotherapy

These doubts, as we know from those patients who have decided to talk to us and from those who have sought re-therapy after discontinuing their previous treatment, are related to concerns about the sense of the therapist’s approach, the optimal nature of his or her interventions, the ‘suitability’ of the patient for psychotherapy or a particular type of therapy.

Why should you suspend your reflex to save the sufferer?

The reflex to avoid unpleasantness and pain and to spare them to those closest to you makes a lot of sense. However, it can lead to the interruption of psychotherapy, equally inopportune as the interruption of chemotherapy or antibiotic therapy crucial for the patient’s health and life. The discontinuation of psychotherapy is sometimes compared to leaving the operating table during surgery without even a makeshift dressing of the surgical wound. Of course, the consequences of interrupting psychotherapy are fortunately not so life-threatening, but they do put the patient’s health and therapy continuation potential in danger. Here again, the surgical or obstetrical metaphor sometimes comes into play - it is not good to perform a series of procedures causing further adhesions in the abdominal layers, it is not good to open the abdomen without any need, too often or too extensively.

You should not be in two therapies at the same time

Another related example should be briefly mentioned here - there are patients who try to use two therapies at the same time - which can even lead to the combination of adverse effects (when the therapists treating one patient do not collaborate).

Another problem is the patient’s own approach to therapy. Sometimes patients misunderstand psychotherapy as something ‘to buy’ and expect that the therapist should only work on topics controlled by the patient and support the existing mechanisms.

The right to a second opinion. Supervision

Unlike in other fields of medicine, in psychotherapy the patient does not have such an easy access to the second opinion concerning the recommended treatment. Consulting other therapists before or during the course of treatment is sensible and it is guaranteed by the rights of the patient. It is an equivalent of the consultation that any doctor can and should resort to in the event of difficulties. In such a situation, the therapist may take advantage of supervision.

What should the patient and his relatives or a consulting physician of any specialization do then? Well, the same thing that the psychotherapist who has a patient who plans to discontinue or has discontinued another therapy - recommend that the patient return to the current therapist providing the ‘discontinued’ therapy, preferably explaining the reasons for such a recommendation.

Attempts to restore collaboration

A careful explanation of the circumstances described above to the patient combined with accommodating his or her emotions and presenting the likely benefits should be sufficient to convince the patient to continue. This, of course, means that the author of the recommendation will not offer a new therapy to such a patient. His or her ‘lost benefits’ (not only financial) are an additional argument proving his or her impartiality and good will in acting on behalf of ‘someone else’s patient’. Discussing a crisis in therapy is always beneficial and it is ground-breaking especially if sudden break-ups without any attempts of repair are an important aspect of that particular patient’s pattern of functioning.

When to intervene to protect the patient

In principle, the only situations where the idea of abandoning therapy should be supported are the ones when the patient is abused by the therapist (sexually or financially) in the form of an obvious malpractice, a failure to follow the rules set out by the ethical codes of psychotherapists, or simply a crime. Fortunately, such phenomena are rare.

When to support the continuation of the therapeutic relationship

Much more common situations are misunderstandings and communication difficulties related to tension, or, to put it in terms of the psychodynamic therapy theory concepts, the transference-countertransference phenomena (i.e. the patient’s unconscious reactions to the therapy and the therapist, which are related to the patient’s previous close relationships, and the therapist’s reactions related to such reactions of the patient) or the patient’s symptoms that make it difficult for him or her to remain in a long-term relationship and build cooperation. Another area for discussion at such moments may be the patient’s expectations. The reasons for attempting to discontinue therapy can and should be ‘repaired’ by discussing them with the previous therapist (and preferably before therapy ends), even if it initially seems impossible, pointless and painful. Moreover, psychotherapy which has been discussed and summed up is easier to end, if the patient or the therapist decide so.

Reference literature

1. Richard F. Summers, Jacques P. Barber. Psychodynamic Therapy. A Guide to Evidence-Based Practice. Guilford Press, 2009. ISBN 9781606234433
2. Jerzy Aleksandrowicz. Psychoterapia. Poradnik dla pacjentów. Wydawnictwo Uniwersytetu Jagiellońskiego. Kraków, 2004. ISBN 978-83-233-1890-3
3. Jerzy Sobański, Katarzyna Klasa, Krzysztof Rutkowski, Edyta Dembińska, Łukasz Müldner-Nieckowski. Profil objawów pacjentów, którzy przerwali psychoterapię kompleksową w dziennym oddziale nerwic. Badanie retrospektywne. „Psychiatria i Psychoterapia” 2013; 9, 4: 14-30.

About the author

Jerzy A. Sobański, MD-PhD – psychiatrist and psychotherapist, assistant professor at the Faculty of Psychotherapy of the Jagiellonian University Medical College. For two decades he has been teaching psychotherapy to students of medical and postgraduate programmes. He has authored publications on the psychopathology of anxiety disorders and the effectiveness of psychotherapy. He is deputy chief-of staff of the bimonthly ‘Psychiatria Polska’ and secretary of the Edititorial and Publishing Committee of the Polish Psychiatric Association. He earned his doctoral degree in medical sciences from the Medical Faculty of the Jagiellonian University Medical College.