Posttherapy Contact

Post-termination contact can include a range of interactions: letters, phone calls, e-mails, face-to-face meetings and social meetings. Whether we have any such contact is most probably influenced by our own analytic experiences with our therapists. Indeed a recent study of analysts by Schachter & Brauer (2001) confirmed this: those analysts who made themselves available to their patients after termination had maintained strong feelings of attachment to their own analysts. In this study, the analysts who reported frequently, consciously thinking about their own analysts were also contacted more frequently by their patients, suggesting an effect of the therapist on post-termination rather than the contact being a function of the patient.

What kind of contact, if any, we should have with our patients once therapy has finished is a controversial topic. In one sense there is no rational justification for not having any kind of contact at all with the patient after the end of therapy. But if we do have contact, we need to think carefully about why we may be setting this up as it may reflect difficulties - on both sides - with letting go. The post-therapy period is rife with opportunities for acting out on both parts, as Kubie suggests:

Even an entirely innocent informality creates an opportunity for the analyst to turn to the patient with his own needs. ... Unconsciously he [the analyst] feels, 'I have been the giver. Now it's my turn to be given'... I have seen more than one magnificent analytic job destroyed by the premature invasion of an intrinsically innocent and platonic social relationship into the post analytic period (1968: 345).

How we manage post-therapy contact is a very individual matter for each of us to consider. In my own work, in the last session, if the patient expresses a wish to write to me to let me have news of his life, I warmly indicate my pleasure at receiving some news. In my experience, a minority of patients do not ask if this is possible, fearing a rejection. Typically, these are patients who have been quite deprived or neglected and who have little hope that the object will be interested in them. This is why it is my practice to convey explicitly to these patients my interest in hearing news if they so wish to let me know how they get on.

Most patients want to leave the door open as they approach the end. Some request a follow-up and want to arrange it in the last session, whilst others find that they make contact eventually even though they might not have anticipated a need to do so when the therapy ended. If a patient asks for a pre-arranged follow-up, I am inclined to explore this quite extensively before agreeing to it since it usually denotes considerable anxiety about ending that is best worked through rather than assuaged by the false reassurance of a follow-up meeting. With more disturbed patients, however, follow-ups can be very valuable as they allow the patient to feel there is a safety net if things do not work out and indeed they might not. In these situations, I would more readily agree to seeing the patient a few months down the line to review progress.

During follow-ups, I strive to maintain a professional but more interactive manner. For example, if I have not seen the patient for some time and the patient comments on change in the room or in my appearance, I would acknowledge that things are different and that perhaps that might feel disorienting, but I would not approach such a comment or question with silence or an interpretation as would be my normal inclination if such a comment were made in the context of an ongoing therapy. This is because I am not wishing to encourage any kind of regression; rather, unless the patient has decompensated, the aim of the follow-up is to reinforce the patient's adult, reality-oriented self. Nevertheless, I would keep my answers brief and quickly shift the focus back onto the patient.

The follow-up meetings take place face-to-face. I generally let the patient take the lead and tell me whatever it is that he wishes me to know. I ask questions more liberally than I would do if it were an ongoing therapy. I do not interpret the patient's material, unless it becomes apparent that the patient is contemplating returning into therapy or if they are evidently anxious about something. My basic stance is one of interest in the developments in the patient's life since ending therapy: it is a broadly supportive stance rather than exploratory.

Even if no arrangements were made at the end of therapy to meet the patient, we may yet meet him by chance. Again, how this is managed varies. If I meet a patient outside the confines of the consulting room, whether during or after the end of therapy, I greet him discretely but warmly. If the therapy has ended and the patient clearly wants to approach me and exchange a few words, I will happily engage with this. It can feel very rejecting to the patient if we barely acknowledge him in a public place.

Other kinds of contact post-termination of therapy pose potentially significant problems, though they may be very tempting for both patient and therapist. The question of whether one should have any kind of social contact with a patient after the end of therapy is a challenging one. As with many aspects of the therapeutic frame, how and whether we have contact with patients can never be reduced to some simple guidelines. Being prescriptive in these matters seldom helps since each case deserves special consideration. Those of us who go on to train as therapists will most probably encounter our training therapists in professional and possibly even social situations. The transition from being a patient to becoming a colleague is likely to arouse a lot of intense feelings. Likewise for the patient who is not a therapist but who establishes a more social contact with his ex-therapist.6 Although consciously this may feel very gratifying, at another level there is often a price to pay. The moment a more friendly, social rapport is established, it becomes impossible to rewind to the patient-therapist relationship. The boundaries of these two relationships are different: you can't exchange pleasantries over tea and then discuss your sexual fantasies.

Some therapists suggest that the patient who cannot manage the transition from therapy to social contact has not worked through his transference. To my mind, this represents a serious error ofjudgement. If the transference, as we generally understand it, is ubiquitous to the extent that all our relationships are filtered through varying degrees of projection, then the transference can never be fully worked through. Of course, by the end of the therapy we hope that the patient will have re-owned enough of his projections to allow him to relate to us more realistically. But being able to relate to us more realistically does not necessarily mean that the patient should feel comfortable having a social relationship with us. Indeed the patient's difficulty, as it were, to shift to a more social relationship may reflect his "realistic" appreciation that the analytic relationship does not end once therapy is over and that to pretend otherwise is a denial of the reality of that relationship as it lives on inside the patient. The goal of therapy is not to help the patient to reach a position where he can manage to feel relaxed about meeting his therapist socially; rather, it is to help the patient tolerate the limitations of this relationship without resorting to denigration or idealisation.

Once therapy is finished, no matter how much the transference has been worked through, we remain for our patients someone who has privileged knowledge about them. Being interested in our patients once therapy is over and meeting them for follow-ups can be a helpful way of allowing them to maintain a live connection with us. However, if we undertake to be therapists, even when we experience a particular resonance with some of our patients, we need to maintain the boundaries necessary to

6I am not referring here to anything other than social contact. Sexual contact with a former patient is, in my opinion, invariably damaging, no matter how many years have lapsed since the end of the therapy.

Table 8.1 Preparing for ending

• Make contracts clear and specific at the outset.

• In brief therapy, work with the ending from the start - keep referring to it in each session as a reminder from the middle phase onwards and explore the patient's reactions to this, systematically.

• In longer-term therapy, ensure that you have sufficient time to prepare for the ending (one year or several months rather than weeks depending on the overall length of the therapy).

• Think about whether there are particular features of the patient's background and experiences that might make him especially sensitive to endings and how these earlier experiences will colour his experience of the ending.

• Try to put into words the unspoken feelings/phantasies stimulated by the ending.

• Encourage the patient to express affect related to ending. Normalise the experience of anger, sadness and loss if the patient is struggling to express his feelings.

allow them to come back into therapy with us should they need to. The job of being a therapist requires that we renounce some of our wishes so as to remain available to the patient well after the therapeutic contract has ended.

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