Dear Therapist,
I’m a woman in her late 20s who is struggling to “break up” with her therapist. I’ve been seeing my therapist for almost five years now, and she’s helped me through a divorce, career changes, health issues, depression, and deaths in the family. But she is no longer on my insurance, and I can’t afford to pay her out of pocket — and she’s making it very difficult for me to end things.
Before we go any further, I should let you know that I’m generally a bit of a pushover, and I am hopelessly terrified of disappointing people. From therapy, I know this stems from my difficult relationship with my troubled older sister. I’ve been working on saying no and making myself a priority, but it’s still very difficult for me.
This problem now seems to be seeping into my relationship with my therapist. I’ve told her numerous times that I cannot afford to see her (it’s been over a year of out-of-pocket sessions). Each time, she tells me to ask family members to help pay for my sessions or says that I’m having an extreme reaction (“I’m very concerned,” she told me one time), and that I have to come in again next week to talk about my behavior. I feel so guilty and insane when she talks to me like that, like I’m hurting her or being irresponsible, when I’m really just trying to be responsible and stick to a budget. I feel like she’s taking advantage of, and manipulating me.
I would like to continue therapy (as I clearly need it), but with a more affordable therapist who accepts my insurance (as I know those therapists are out there) and whom I don’t already distrust. So how do I break it off with my therapist? What’s the proper etiquette? And how can I do this forcefully enough that she won’t be able to talk me into staying?
Too Broke for Therapy
Dear Too Broke for Therapy,
Let’s imagine that you’ve been happily dating somebody and, after four good years together, he announces that though you agreed to exclusivity, there’s been a change: he wants an open relationship. You weren’t expecting this, but you consider your options: Can I see him under these circumstances? Do I want to? Your conclusion: No, this won’t work.
In the past, you may have tried to pretzel yourself into a position that prizes his needs over yours, but you’re also aware that you can be “a bit of a pushover” and are trying to change that pattern.
Do you:
a) Tell him repeatedly that this won’t work for you, accede to his pleas for you to stay despite your discomfort, become resentful, but stay with him for another year.
b) Tell him once that this won’t work for you, wish him well, grieve the loss, and go find someone else.
We’ve all been in untenable situations — a relationship, a job, an apartment with a terrible landlord or roommate — in which we convince ourselves that we “can’t leave,” only to look back years later and ask ourselves, “Who, exactly, was keeping me there?” The answer is usually “me.” We shake our heads and wonder, “What took me so long? Why didn’t I leave sooner? Why did I waste so much time with this?”
Your narrative, TBFT, is that you can’t leave, and while what your therapist has said sounds outrageous, not to mention reportable to her licensing board (let’s just say that I, too, am “very concerned”), the reality is that no matter how bizarre or unethical her behavior, you’re not being held hostage. You’re a free agent, just as you’d be with the hypothetical boyfriend who changed the terms of the relationship but tried to convince you to stay. In both cases, the real battle isn’t you against the boyfriend or you against your therapist, but you against you. There’s the “you” that really loves this therapist (and the hypothetical boyfriend) with whom you spent a meaningful four years; then there’s the “you” that can’t reconcile those strong feelings of attachment with the brew of rage, betrayal, and mistrust that emerged over the past year. But as long as this internal war wages, you remain stuck on the battlefield (because you can’t, in fact, leave yourself).
I want to help you call a truce, TBFT.
Therapists have a term for the process of ending therapy: termination. It’s a grim-sounding word for what’s ideally a warm, bittersweet, and moving experience, much like a graduation. Generally, when the therapy is coming to an end — either the patient feels ready to move on, or the therapist broaches the possibility with the patient — the work moves toward its final stage, which is saying good-bye.
In those sessions, whether they last a couple weeks or a couple months, we consolidate the changes made. What was helpful in getting to where the person is today? What wasn’t? What has she learned about herself — her strengths, her challenges, her internal scripts — and what coping strategies and healthier ways of being can she take with her? What do the therapist and patient want to say to each other by way of good-bye? Our goal from the beginning of therapy is to get our patients to leave us, much as parents hope that their children will be independent one day.
In our daily lives, many of us don’t have the experience of meaningful good-byes — if we get good-byes at all — and the termination process allows someone who has spent a significant amount of time working through very personal issues to do more than simply end it with some version of, “Well, hey, thanks — see ya!” Termination is a powerful phase in therapy, because it gives patients the experience of a positive conclusion in what might have been a lifetime of negative, unresolved, or empty endings.
A good termination experience also serves to slow down and assess whether the patient is experiencing a “flight to health,” a phenomenon in which people convince themselves that they’re suddenly “over” their issues because, unbeknownst to them, they can’t tolerate the anxiety stirred up by working through these issues. A “flight to health” might take place after a particularly emotional series of sessions, or when the therapist or patient has been away for a few weeks and in that break, unconscious defense mechanisms take hold. This “flight” is only temporary, though, because the strategies patients use to suppress their true feelings — burying themselves in their work, keeping their schedules busy, exercising excessively — aren’t effective for long. If they leave during a flight to health, more often than not, the defense eventually wears off and the anxiety emerges again.
Most commonly, though, therapist and patient both know when the work is done, or “done enough” for the time being. The patient is no longer depressed or having panic attacks, for instance, or no longer struggles so much in relationships. But even when patients decide to leave at a time that might seem premature to the therapist, having those termination sessions is still worthwhile. At least the decision will have been reflected upon so that the patient leaves having made a thoughtful and considered choice. The therapist might still share her thoughts on the decision (we’d be negligent if we didn’t offer what patients come to us for — an informed and candid perspective) but that’s different from invalidating their experience or asking them to pay for something they can’t afford.
What’s unique about your situation, too, is that you’re not saying that you want to leave therapy. This isn’t a conversation about readiness to terminate so much as the need for an in-network clinician. But no matter what the reason, patients are always free to go, and you should be able to have a positive termination experience by working through your internal struggle about both valuing the relationship with your therapist (until the insurance changed) and worrying that you’d be upsetting her by leaving. Clarifying and moving beyond this “you versus you” battle would make for a powerful and effective termination, and guiding you through this turmoil is your current therapist’s job. You shouldn’t have to go to another therapist to work out your feelings about your previous therapist.
I’m wondering what you do in the room during these interactions with your therapist. When she asks you to solicit money from relatives, what do you tell her? Do you nod and say, “Okay, I’ll ask” (the “you” who wants to please this person who has helped you through difficult times) then go home and seethe (the “you” who feels betrayed) only to come back the next week so as not to disappoint her (the first “you”)? Can the two “you”s agree that this therapist has been both things to you: life-changing and reliable and confusing and upsetting? And can you say good-bye to both versions of her in a way that’s best for you?
That’s how you’ll create a positive termination experience for this relationship, TBFT, even if you have to do it yourself. Nobody is forcing you to walk into that office each week. But if you choose to do it one last time, you can simply restate what you wrote so eloquently to me.
You say: “I’m going to continue therapy with a therapist who accepts my insurance.” You say: “This will be my last session, but I’d like our good-bye to be a positive experience, and for me that means talking about how uncomfortable I’ve felt when you’ve asked me to find a way to pay for something I’ve repeatedly told you I can’t afford.” You say: “These interactions have affected the way I view our earlier work, and what I want most from this good-bye today are your support and well wishes.” You say: “I hope you can give me that in this session, but even if you can’t, it’s still going to be my last.” Then you see what she does. And no matter what she does, when your 50 minutes are up, you walk out into the daylight, and pat yourself on the back for putting everything you’ve learned about yourself over the past five years to good use.
Years later, you’ll think back on this time and feel gratitude for the parting gift your current therapist gave you: a tremendous opportunity for growth. While I’m sure that her help with your divorce, career changes, health issues, and depression was invaluable, the most meaningful aspect of this therapy might be how emboldened you became by engineering its ending.
Lori Gottlieb is a writer and a psychotherapist in private practice. Got a question? Email therapy@nymag.com. Her column will appear here every Friday.
All letters to What Your Therapist Really Thinks become the property of New York Media LLC and will be edited for length, clarity, and grammatical correctness.
The information provided by What Your Therapist Really Thinks is for entertainment and educational purposes only, and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician, mental-health professional, or other qualified health provider with any questions you may have regarding a medical condition.
