Friday, November 30, 2007

Therapeutic Relationships: How (and When) to Say Goodbye?

What do clinical boundaries really mean? Where does a therapeutic relationship end and a friendship begin? When we interact on deep and profound levels with clients/patients over long periods of time---sometimes for years---what does it mean to say goodbye? Is it possible to satisfactorily take one's leave of a long-term therapeutic relationship and feel OK saying "Have a nice life!" as the door slams on your way out

Having just emerged from a psychotherapy appointment wherein I was discussing just these issues, my mind and heart are simply brimming with thoughts and feelings about just such scenarios.

Leaving a job is (almost always) a process of letting go, of relinquishing the past in the interest of a newly forged potential future. When one leaves a workplace, there are the inevitable goodbyes to colleagues, "subordinates", "superiors", and others with whom one shared a relatively large portion of one's waking life. This is no small matter, and such a leave-taking is more often than not fraught with uncertainty, nostalgia, and a tinge of regret. It is an accepted and normal phenomenon that, when one gives notice and begins to prepare to leave a workplace, that workplace will suddenly seem more friendly, more amenable, and more comfortable. It's almost as if the Universe begins immediately to test one's resolve to leave just as one submits one's resignation. How maddening!

For myself, being on a leave of absence has allowed me more than sufficient time to process my decision to leave, and I have already begun the process of considering my patients and colleagues and what those goodbyes will entail. In a recent post, I began to delineate those challenges. As for colleagues, maintaining contact is simple. Phone calls, emails, dinner or lunch invitations, the occasional party or professional gathering---those relationships can be maintained like any acquaintance or friendship. Inevitably, time and lack of frequent proximity will preclude frequent contact, with many of those professional but collegial relationships falling by the wayside over time, some more quickly than others.

Now, when it comes to patients, that is another arena entirely, and a great deal of forethought must be given to a decision to offer to maintain contact following the end of a therapeutic relationship. Of my 80 patients, there are probably thirty with whom I feel a deep affinity and positive mutual regard, so much so that ending those relationships will be emotionally difficult. Amidst that group of thirty there are probably ten people to who I feel an even deeper connection, and saying permanently goodbye would be painful. Narrowing the field further still, there are most likely two or three people with whom I feel an intimate, almost familial bond, and these are the therapeutic relationships which I could foresee morphing into friendships, albeit friendships with strict parameters and severely limited scope.

Considering such an outcome, one must ask certain questions:

-Does the client want continued connection?
-Is the offer of a continuing friendship/connection in the patient's best interest?
-Are you pursuing this friendship out of guilt or true desire for such?
-How will the new boundaries of such a relationship be established?
-How would said individual contact you?
-Will expectations of frequency of contact be considered?
-Why not just say goodbye?

There are dozens of questions to consider, many of which perhaps you, esteemed Reader, could raise (and please do!). This is a conversation worth having!

Those of us in Human Services and the so-called "helping professions" constantly face the issues of boundaries, transference, counter-transference, and projection. When facing the end of a therapeutic alliance, all bets are off and the game becomes simultaneously murkier and much simpler. The path of least resistance? Say "goodbye, nice to know you, have a good life, and thanks for being you". The path of potential complication (but also of richness and authenticity)? "Let's stay in touch and see what our new relationship/friendship is capable of within certain parameters". In all likelihood, most connections made in this way will, like tangential friendships, fizzle out over time. People move, phone numbers change, lives develop through unanticipated twists and turns, address books are lost, and the frequency of contact gradually subsides. Still, the effort was made, and true authenticity was honored.

As Jerome Groopman, M.D. writes so eloquently in his outstanding book, The Anatomy of Hope (and please simply subsitute the word "nurse" for "doctor" as you read):

"There are some patients whom a doctor grows to love. It is a unique type of love, distinct from any other type of love the doctor has experienced before. It moves outside the bounds of the usual doctor-patient relationship; feelings and thoughts are no longer strictly professional and are shared among true friends."

If this area is simultaneously murky and simple, I am certainly still in the murk. And, as I do in many areas of life when I am faced with difficult choices, I remember that age-old adage that I have quoted here on Digital Doorway before: "Don't just do something, sit there." Thus I will sit with these feelings, with this sense of impending and inevitable change, and perhaps, if I am quiet enough, the answer will make itself known.

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