Dr. Skovholt: One of the great challenges of being a therapist is that we have to form attachments to many clients, and then eventually those relationships often end for various reasons, perhaps because the patient no longer needs treatment or just drops out of treatment. We don’t want to become overly attached to all our clients, because that can be draining. But on the other hand, we don’t want to distance ourselves, because the essence of healing occurs within the caring relationship.
TCPR: You talk about the “cycle of caring.” Can you describe what you mean by that?
Dr. Skovholt: In all the relationship-intense professions, there often follows, for the practitioner, a 4-phase cycle. It starts with an empathic attachment phase, where each of us begins to form a bond with the client. We see our patients, we listen to their stories, and hopefully we empathize. Once that’s established, there’s an active involvement phase. This lasts for many sessions, and it is the main work of treatment—understanding problems, helping with solutions, prescribing medications if you are a prescriber. So far it is all plowed ground for practitioners; these phases are well worn and understood.
TCPR: Yes, these are the phases that probably constitute most of our psychiatric treatment.
Dr. Skovholt: That’s right, but many practitioners don’t pay enough attention to the next 2 phases. The whole goal here is to fiercely protect our capacity to professionally attach with our patients over and over again. So there’s a felt separation phase, in which the therapeutic relationship is ending. When that happens, you have to acknowledge that an important relationship is ending, and you don’t want this to be a negative experience. You might grieve a little if you are very close to the client, and that’s appropriate, but you don’t want to feel depleted. It’s important to reaffirm your own identity as a helper, because you’ll soon be coming up to the next phase, which I call the re-creation phase. You’ve said goodbye to a client, and now you move on to your next client. If you’re very busy, this can lead to a kind of burnout in which you just can’t face beginning the process of forming another intense attachment with a troubled soul. To avoid that kind of exhaustion, you need to consciously re-energize yourself. The felt separation phase and re-creation phase can be expressed in many ways symbolically, and their time duration may vary.
TCPR: It’s true that we often just take ended relationships for granted. What you’re saying is that we should be perhaps more conscious of the fact that when a patient stops coming, that may actually affect the degree to which we are willing to re-engage with a new patient?
Dr. Skovholt: Right, and it’s just really that kind of slow erosion process that can make it challenging over time to re-engage with new patients. As an analogy, consider the simple example of dating: One day you are in a personal relationship with someone, and abruptly that person breaks up with you and essentially disappears from your life. What impact does that have the next time you try to get involved and trust somebody? So what’s the impact on the doctor of the losses, the disappearances? When a client goes away or doesn’t come back, it’s natural to think, “What happened?” “What did I do wrong?” “Did they learn anything?” And, of course, you can’t just go hunt down your former patients to answer these questions. So it’s important to have a thoughtful approach, a strategy if you will, about your investment of time and energy with each new patient.
TCPR: How would you recommend thinking about that?
Dr. Skovholt: For starters, and this is for myself, in a first meeting I would work really hard at not getting ahead of myself in terms of attachment. Because if I get too involved and the patient doesn’t return, then I might start questioning if maybe I came on too strong and scared them away, and then I’m in kind of a depleting mindset.
TCPR: Interesting. Can you give me an example?
Dr. Skovholt: Sure. Say you are doing a first session with a couple. You are trying to ascertain why they are there. One person might be threatening divorce, saying to the other, “You have to go to counseling or I’m not going to stay with you.” The other partner doesn’t want to be in the therapy at all. So you judge what you are hearing and observing, and maybe say at the beginning, “I’m thinking this is one meeting, and then when we’re done at the end we can talk a little bit and you can go home and decide whether you want to come back.”
TCPR: So my involvement is just at that initial level and no more?
Dr. Skovholt: Right; there is the ambivalence of their wanting help and not wanting it, so I am trying to create engagement and not resistance. Also, I’m focusing on not just them, but also on myself having an ending. Of course, it’s always for the sake of the patient, but it’s also for the sake of me as the practitioner. But if they do come back, then I open up a little bit more and I’m more engaged with them. So during that first meeting, you might want to decide how involved in your patient’s story, in your patient’s life, you want to be while feeling out if this is a patient who would likely benefit from seeing you.