We had been working together for roughly eight months. I work psychodynamically and frequently see clients long-term, often multiple times per week. I recommended twice-weekly sessions, and they agreed. Over time, a pattern emerged: they would commit for a couple of weeks, then discontinue due to work complications and commitments, requiring us to repeatedly reset the therapeutic frame.
I confronted the patient’s ambivalence regarding treatment, and we clarified how important work was to their sense of identity and self. The therapeutic commitment was understood as a direct impediment to experiences that helped them understand themselves as reliable and competent. They had very little exposure to those experiences outside of work, and that was part of the problem I had hoped they would come to recognize. Over the months, we discussed these issues explicitly and noted how their commitment to work was negatively affecting treatment and represented a primary treatment goal: resolving these inconsistencies.
After a two-month hiatus, they returned and requested treatment following a significantly stressful experience. After seeking supervision, I confronted them and explained that I would be happy to continue working with them, but that we needed a commitment to twice-weekly psychotherapy sessions to support their goals. Otherwise, I felt that allowing them to continue in this way – devaluing therapy and devaluing their own health – would be clinically inappropriate and would amount to colluding with self-defeating motivations.
The patient was highly agreeable to this. Sure enough, within a week, they were already canceling, minimizing sessions, and leaving early due to work complications. Today, they messaged me in the morning saying they weren’t sure whether they had a session scheduled, but that they needed to cancel because of work. I then made the decision to send an email detailing my rationale for discontinuing treatment and recommending that they see another provider.
I definitely had some negative countertransference. I felt as though my time was not valued, that I had been lied to, misled, and, in some ways, taken advantage of. I understand that part of this comes from my own experiences, but I also recognized that this may mirror how the patient experienced their upbringing with highly malevolent parents.
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The worst part is that I can see a very clear treatment trajectory, and I believe that with consistent attendance, the prognosis for this patient would have been very positive. It’s unfortunate to see so much potential go unrealized. Upon reflection, I realized that allowing the patient to come and go as they pleased without a commitment was more of a disservice than an accommodation.
I know I did the right thing clinically. It’s just really upsetting to see this. I’m not sure what I would do if they reached out now wanting to continue treatment. I might say that we would need a full commitment, but we have been down that road before. I may give them another chance, or I may not. It really depends on how I continue to reflect on the case and whether the conditions have changed, although I’m not sure how they would be different.
I’m curious whether others have been in positions like this and how they have handled situations in which a flaky client returns asking for help and promising change.
Interestingly, I feel, in a dramatic and exaggerated sense, like a battered partner – hoping that this time the client will be different and wanting to give them another chance.
Perhaps I can fix them – No. Perhaps I can use them to fix something within me.
Yeah, okay. I think I have my answer now.
