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Not much is known as to why a patient in long-term psychotherapy or psychoanalysis suddenly fails to keep his appointment and terminates treatment; or why a particular patient fails to improve with a highly qualified psychotherapist, but does improve—sometimes remarkably—with one obviously inferior in training. In the same vein, do we know the specific circumstances by which we are impelled to refer a patient in the midst of a long-term psychotherapy to another psychotherapist? These and similar questions were posed by the referral of mid-stream patients to me, by my referral of such patients to others, and by the self-referral of patients who had abruptly left psychotherapists whom I greatly respected. I generically call these situations Therapeutic Departures. This paper is an attempt to define the parameters involved in such departures, and while I am not satisfied that I have reached understanding of them, the following observations may possibly be useful to psychotherapists.*
The selection and retention of the long-term patient follows the laws of similarity and dissimilarity, that is, congruence. By this I mean the similarities and dissimilarities of the unconscious structure of the two participants. It would of course be absurd to say that no patients can be given psychotherapy without such a congruence. But in the treatment of a chronic schizophrenic patient, for example, it cannot be expected that both participants could meet and handle the often bone-breaking vicissitudes without some unconscious “pull” to be together. Particularly where a choice of life or death confronts the patient (the question of suicide which regularly arises as part of such treatment), the psychotherapist must become a participant and not an observer. To be a participant means that you enter important aspects of the life of the patient, and that you allow him to enter yours.
I have noted that psychotherapists who treat schizophrenic patients are distinctive in several ways from the ge