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Dr. Hirsch identifies a rarely discussed but ubiquitous phenomenon that he calls “coasting,” which involves complacently resting, with a significant degree of awareness, in a relational pattern that is in the therapist's best interest but may not be in the patient's. Dr. Hirsch admonishes us to question the many practical and theoretical justifications, however elaborate and elegant they may be, that we use to obfuscate and maintain this potential for exploitation.
The book is organized according to interrelated contributing factors Dr. Hirsch delineates. These include the preferred relational patterns that fit the therapist's personality as well as situational factors ranging from the time of day to the number of patients seen to the therapist's life circumstance to, most importantly, money. His review of the literature is extremely thorough, and it highlights how little is written about this concept. On each topic, Dr. Hirsch is careful to distinguish coasting from other clinical concepts that might appear to be closely related. For example, when discussing daydreaming, it is important not to confuse a countertransferentially relevant reverie with a consciously preferred state of withdrawal. Dr. Hirsch points out more broadly that what often passes as unconscious enactment is in fact a justification of (at least partially) conscious coasting. I will return to this crucial issue of awareness below.