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This is a working paper about a particular kind of therapeutic rupture: a patient abruptly terminates an impaired treatment.1 By impaired I mean the treatment is below the standards of care in the profession—the analyst's judgment is impaired, the analyst is impaired by drugs or alcohol, and/or the analyst uses techniques that are damaging. In this kind of rupture the patient initiates the termination, and the patient's reports about the treatment are proven to be accurate. In many cases, the patient has filed a complaint to an ethics or licensing board, and the analyst has been censured.
I will begin with a composite case example of a patient and a therapy gone wrong. I will describe the rupture and my interventions as a consultant in the immediate aftermath of the abrupt ending. In my discussion I will offer a formulation about what happened in the therapy. Why did the patient remain so long in an impaired treatment and why did the patient suddenly leave? I will conclude with a description of my interventions as an impasse consultant commenting about the roles and function of a consultant. I want to emphasize that even though this type of ruptured termination creates a special set of circumstances for the impasse consultant, all abrupt terminations have several elements in common. For example, most of the challenges faced by the patients outlined by Dr. Elkind in her paper2 apply to the patients in this kind of rupture.
I would like to preface my presentation with a hope about your listening attitude. First, it will be tempting for you to hear what this analyst did, and think: “I would never do that. It is outrageous.” While this may be true, please remember that none of us is exempt from making errors. Let's have compassion for the mistakes we all make. Second, the content of this case