Carsky and Yeomans Respond

Our thanks to Elizabeth Haase for her generous and thoughtful letter regarding our article “Overwhelming Patients and Overwhelmed Therapists,” which has stimulated our thinking on the issues she raises. That is, how does a therapist “switch gears,” as it were, after seeking a consultation and finding it helpful, and especially, how does a therapist end a treatment that cannot work?

To “shift gears,” engaging the patient in reviewing his or her initial presenting problems and treatment goals and progress toward them can provide the opportunity to jointly re-examine the initial explicit or implicit treatment contract. This could then lead to discussion or presentation of ways the process has strayed and the therapist's ideas about working differently, with sufficient attention to the patient's reactions. Most likely these reactions will reflect the transference scenarios that have been so difficult for the therapist, and immediately offer an opportunity for their clarification and interpretation. When the therapist is truly ready—and comfortably able—to engage in this way, we have seen many positive developments. The ability to do this successfully of course depends on the strength of the internal and external factors in both patient and therapist that have contributed to the “overwhelming” status of the therapy, and on their capacity to overcome the worst of these.

When a treatment must end, the therapist bears the additional burden of managing the feelings of loss, sadness, relief, regret, triumph and/or guilt while seeking not to act on these. There must be a shift from struggling to do one's best to move the treatment forward, to accepting the ending, mourning what will not occur, and helping the patient to engage in the best possible termination process. Ideally the therapist hopes the patient will do better with some other therapist in the future even if this therapy has to end. This is not easy when the patient is understandably feeling most distressed and impuls