He had told me that he intended to schedule an appointment to see me in about two months. Over six months had passed and I hadn’t heard from him. I hoped that he was doing well.
“I got your letter,” he said in his voice message. “Thank you so much for sending it. I would like to see you before you graduate. There are still a few things going on that I’d like to talk about.”
I called him back and after we had scheduled an appointment, he casually remarked, “So you’re departing after graduation?”
“Yes,” I answered.
“So you’re departing in June,” he clarified.
“Yes,” I replied, “I am leaving Seattle.”
“Okay—not a wise move, but—″
I laughed. We both knew he was poking fun at me.
“Termination” is the term used to describe the process of ending a therapeutic relationship. Termination represents a loss. Some therapists suggest that termination represents death: “With your departure, you are dying to him. Soon, you will be dead.”
Termination sounds like a single, discrete event. It is rather a process, an unfolding sequence. In psychotherapy, the general guideline is to begin to discuss termination at least three months prior to the expected end of the relationship.
“If you don’t talk about it, your departure can manifest itself as abandonment,” supervisors consistently counsel. “Plus, most people often have strong reactions to loss. Discussing termination allows people to learn a lot about themselves and to learn that the ending of a relationship doesn’t have to be bad.”
How many of us have experienced the loss of a loved one to an unexpected death? or been dumped with no warning? or suddenly realized that a friend is no longer one?
Where’s the “closure”?
Ideally, termination should enable, not disable. Termination allows people to review what they have learned about themselves and the world in which they live. They can then look to the future and focus on how to achieve other goals in their lives, whether that involves a therapist or not. (Remember, life happens outside of the office, not inside.)
That being said, termination is not necessarily easy. Loss can kinda suck.
Psychotherapy relationships are unlike any other relationships I have ever experienced. (This may sound hand-wavey and new-agey; I trust that you’ll cope somehow.) These people are not my friends, nor are they family members. These relationships are asymmetrical, as I know more about them than they do about me. The relationships are artificial; some have argued that psychotherapy relationships are merely paid friendships. Regardless, there is a contractual aspect to these interactions.
And yet, I find that I care about these people. I worry about them when they are not doing well and I delight in their successes. I hope that, through learning about themselves, they will reach their goals, whatever they may be.
It’s cool to watch people change. Often, they do that in spite of what we do, not because of what we do.
If termination represents the process of one loss, mass termination represents the process of many losses.
The process of terminating with my entire panel of patients kinda sucks. Let me rephrase that in less judgmental terms: I do not enjoy the process of terminating with my entire panel of patients.
Furthermore, in an effort to create extra buffer space in my psyche, I use the clinical term “termination” to describe my departure from my training program. I am in the process of terminating with all of my supervisors, many faculty members, nursing staff, case managers, and clerical staff.
I’m also terminating with my colleagues, those people within my training cohort.
Then there are all of my friends.
And the people I have danced with on a regular basis for the past two-plus years.
And the beautiful city of Seattle.
Would it be easier for me to terminate with my entire panel of patients if I was not terminating from my life in Seattle? I do not believe that the two could be mutually exclusive. This is such an artificial termination.
Is death the only “natural” termination?
I’ve been thinking about termination (in gross terms, not merely in the clinical sense) since I learned of my pending relocation to New York. I’ve considered writing a series on termination, much like my relationship series. I anticipate, though, that writing about termination will be more challenging.
(Somewhere, a psychoanalyst is writhing in agony because I’ve written this entry. God forbid I actually reveal that I’m not a blank slate, that I actually care about people, about what I do.)
31 Mar 2008 | 4 comments.
Salmon Sandwiches.
She really wanted a salmon sandwich.
Her mind was already conjuring up the image of a tender slab of soft, flaky salmon glistening between crisp leaves of green lettuce. Little blobs of white sauce oozed out from under the thick, chewy slices of bread and the flash of a red tomato slice highlighted the asymmetry of the sandwich.
She was salivating.
Cognizant that Seattle is well-known for its salmon, she confidently walked into a McDonald’s in the downtown district to satiate her craving. Without viewing the menu overhead, she stepped up to the counter.
“How can I help you?” the cashier asked.
“I’d like a salmon sandwich, please,” she said, smiling.
The cashier looked blankly at her. “Do you mean a filet o’ fish?”
“No, no,” she said. “I want a salmon sandwich.”
“We don’t serve salmon sandwiches here, ma’am,” the cashier explained, perplexed. This is McDonald’s.
A bit miffed that the cashier addressed her as “ma’am” (I’m not old enough to be a “ma’am”!), she commented, “But this is Seattle… and Seattle is known for its salmon. You do sell sandwiches here, right? You’ve got other kinds of sandwiches here—why not a salmon sandwich?”
The cashier pointed up at the menu overhead and, with annoyance, commented, “We do sell sandwiches here, but no salmon sandwiches. There are other sandwiches you can order.”
She looked at the cashier in disbelief. “I can’t get a salmon sandwich here? In Seattle? Wow. Okay.”
Saddened, she left the building.
Her craving for a salmon sandwich returned several hours later. She returned to the same McDonald’s, figuring that the cashier she had spoken to earlier had already left for the day. Her hunch was correct. She again approached the counter.
“What can I get for you?” the cashier asked.
“Can I get a salmon sandwich?” she asked.
The cashier cocked an eyebrow at her. “A salmon sandwich?”
“Yes,” she answered.
“We don’t sell salmon sandwiches here,” the cashier said. “We’ve got burgers and a filet o’ fish, but no salmon sandwiches.”
“But this is Seattle,” the woman protested, “and Seattle is known for its salmon. And McDonald’s sells sandwiches. Surely you must sell salmon sandwiches.”
“No, we don’t,” the cashier said. “This is McDonald’s. We sell burgers, fries, and the occasional salad. No salmon sandwiches.”
Irritated, the woman sighed, turned around, and left the building.
Undeterred, she visited other McDonald’s in Seattle. And at each restaurant, she was denied a salmon sandwich. It mattered not how she ordered one—she cajoled cashiers; she demanded to speak to supervisors; she offered to pay extra money—they all informed her that they simply did not sell salmon sandwiches.
“But this is Seattle!” she exclaimed. “This is what Seattle is known for! People come to Seattle to eat salmon! How on Earth is it possible that McDonald’s, which has served over a billion sandwiches, could not have a salmon sandwich in Seattle? This is totally absurd!”
They all sighed impatiently at her.
“No salmon sandwiches” was the refrain.
Devastated, she trod back outside.
She couldn’t walk any faster; Pike Place Market was crammed with people and many of them were ogling the beautiful bouquets of flowers for sale. People lazily pushed past each other just to move. The fishmongers wagged their gloved hands at passersby; buskers sang their hearts out with hopes that coins would collect in their open guitar cases; farmers stacked gigantic heads of garlic in neat geometric shapes underneath hot incandescent bulbs.
Her eyes were downcast, as were her spirits. Here she was, in Seattle, and she could not secure a salmon sandwich.
The crowd eventually pushed her past the Market Grill. Her eyes spied people sitting at the simple countertop. She smelled cooking fish.
Mmm….
She convinced herself that she was hallucinating. Her desire for a salmon sandwich was surely overwhelming her. She had done the best that she could to find one—she went to a common sandwich shop in Seattle and her efforts were clearly useless.
The crowd shuffled to a halt again. She sighed, frustrated.
“This is the best salmon sandwich I have ever had,” she overheard. She snapped her head to the left and saw the speaker. He was wiping his mouth with his left hand and holding a sandwich in his right.
And there it was: A tender slab of soft, flaky salmon glistening between crisp leaves of green lettuce. Little blobs of white sauce oozed out from under the thick, chewy slices of bread and the flash of a red tomato slice highlighted the asymmetry of the sandwich.
Salivating, her eyes darted up to the menu board hanging over the grill. She smiled broadly.
Pushing her way through the crowd, she made haste towards the simple counter and, leaning forward, breathlessly asked the cashier, “Can I get a salmon sandwich, please?”
“Sure,” the cashier replied. “Do you want your salmon blackened?”
Sometimes, we want things from people that they simply cannot provide… or hope for outcomes that are simply unrealistic. Hopefully, we eventually learn that we would do better to look elsewhere—a place or person that can actually fulfill our request—to increase the likelihood that we will get what we want.
28 Mar 2008 | 5 comments.
The Former Professor.
“Hi, this is Maria returning a page,” I said.
“Hi. One of your former professors is here,” she said.
“Really?” I said, perplexed. Former professor?
“Hang on,” she said before I could ask for the identity of this former professor. I’ve had a lot of former professors. And most former professors don’t wander into the business office to page me. “I’m going to hand the phone to him.”
I waited, listening to the shuffling noises as the phone passed from hand to hand.
“Maria. Edward Mentor here,” the male voice said formally.
“Dr. Mentor!” I blurted enthusiastically. I smiled brightly, though he could not see it. “How are you?”
Dr. Mentor is the fellow who was arguably the greatest influence in my decision to pursue a career in psychiatry. He was my attending physician during my psychiatry clerkship as a third-year medical student. At that time, I was certain that my future was in internal medicine. I had yet to go through my internal medicine rotation, though I was already anticipating a career as an oncologist or an infectious disease physician. I had the good fortune of working with Dr. Mentor on the consult-liaison psychiatry service. Though admittedly a bit odd (bow ties, suspenders, formal greetings, the absence of contractions in his speech, the regular use of words like “grand” and “erudite”, and brevity that suggested aloofness), Dr. Mentor was a fantastic teacher, effective with patients, clearly intelligent, and inspiring. He noted my curiosity and tolerated the many questions I had for him about psychiatry. He ultimately became my mentor and, though he put forth great effort to persuade me to enter psychiatry, he helped me to assess what I liked in medicine and identify my strengths.
“I am well; how are you?” Dr. Mentor replied. He still sounded as serious as ever.
“I’m great! It’s so nice to hear from you. What brings you to Seattle?” I asked. Dr. Mentor and I met in California.
He provided a terse explanation for his visit, then suggested that we meet up to chat following his business.
“Of course,” I replied. I hadn’t seen him in four years. It was only a few months ago that I had written several personal statements for my consult-liaison fellowship applications about his role in my decision to enter psychiatry. Those who interviewed me asked about him and I effusively spoke of my experiences working with him. And, unexpectedly, now he was in Seattle.
He looked older and he wasn’t dressed as I remember him (i.e. in a crisp, pastel dress shirt, conservatively-patterned necktie, suspenders, pleated slacks, with glasses perched on his aquiline nose—and, really, “aquiline” is accurate). An umbrella was slung across his shoulder.
“Hello!” I said, smiling brightly. We both approached each other and that awkward moment of “do we hug each other?” presented itself. Neither one of us embraced the opportunity. We instead looked at each other, grinning.
He suggested a stroll outside. Our footfalls naturally fell into a synchronized cadence. He asked me about my future plans (”New York? What a grand opportunity!”), my ideas for the future (”I don’t know what I’ll do after fellowship; it makes me anxious to think about it, so I avoid it.”), and my opinions about my training (”I’ve enjoyed it.”). I asked him about his work (”I am engaged in more academic duties now.”), his reflections about his current position (”Yes, I do believe that I am doing what I had anticipated, though I do not perform as many clinical duties.”), and my colleagues who are still in California (”Yes, I see her occasionally. She seems to be doing well.”).
He naturally fell into his role as a mentor again. “I anticipate that you will enjoy your time in New York immensely,” he opined. “You will do well. You may find that people on the East Coast are more brusque in their interactions with each other, though do not interpret that behavior as rudeness. It is merely more competitive there and people tend to communicate in a more direct fashion.”
I smiled. He had spent much of his life in New England and spoke from experience.
“You will grow accustomed to that quickly, though you may find such behaviors noteworthy during your first month there.”
We did not complete a loop around the medical center. Our conversation never delved deeper than academic topics. He did not rebuff the gratitude that I expressed to him, though that interaction was like the embrace that never happened: The sentiment was present, though he did not not explicitly acknowledge it.
“Do stay in touch,” he said before we parted ways. “Send me a note after you are settled in New York. I look forward to hearing about your experiences there.”
“I will. Thank you,” I said. He leaned stiffly forward and waved good-bye.
“Good-bye, Dr. Mentor,” I said, waving. He smiled. Even his smiles are serious.
It was windy in Seattle today, a brisk wind that agitated the hem of my coat, sending it flying around my legs. I pushed my hands further into my pockets.
I remembered that I am connected, that I would not be who I am today without the influence of Dr. Mentor, that I continue to pass along the lessons I have learned from him and others onto colleagues and medical students. Though the links of knowledge and wisdom are invisible, they make tangible the interdependence and relationships that we so often overlook.
26 Mar 2008 | 1 comment.
Three Events That Trainees Don’t Ever Want to Experience, But Might.
1. She had just started her clinical rotations; she hadn’t had even three months of experience in interviewing patients.
Her eyes skimmed over the sheet of paper in her lap and she proceeded to elicit social history.
“Are you currently in a relationship?” she asked.
His eyes widened and an expression of surprise mixed with disgust crossed his face.
“You know, it’s totally unprofessional for you to ask me out on a date,” he sniffed.
2. It was their third therapy session.
The videocamera unobtrusively occupied the corner of the room. She had asked his permission to tape their sessions so that she could learn how to improve her technique and become a skilled therapist.
Perhaps she was having an “off” day; perhaps he was feeling more irritable than usual.
Before the session ended, he squarely faced the camera and shouted, “Do you see how much she’s messing up?”
3. He knew that she had a diagnosis of some sort of psychosis, though she was now doing much better.
They met on a regular basis and though they did not exactly connect with each other, there was a congenial understanding of their clinical relationship.
At the end of one meeting, he asked her, “Is there anything else I can do for you today?”
She blurted, “Bend me over the table and [expletive] me hard.”
25 Mar 2008 | 5 comments.
Photograph.
My paternal grandfather was apparently skilled in the art of face reading. According to this practice, particular facial features are associated with personality traits or certain fortunes. As a youth, my father learned some of the patterns and has retained some of this knowledge as the years have passed.
“I don’t really believe these things,” he usually says. He makes the same remark when discussing Asian astrological animals. “But it’s interesting.”
My paternal grandfather, shortly after my birth, apparently noticed the size and contour of my forehead and opined that my future was bright. “Spacious foreheads,” my father said, “suggest high capacity for intelligence.”
My father no longer looks at my face to predict my future, though he routinely examines my face to assess my spirits. Upon seeing me, either in person or in a photograph, he will share his evaluation of my state of mind and health within fifteen minutes. The evaluation isn’t exactly a reflection of my physical state. I may be physically exhausted, but at ease. My father will immediately pick up on the ease, despite the bags under my eyes, my constant yawning, or my relative reticence.
He’s pretty good.
This assessment is practically part of his usual greeting now.
I recently sent him a photograph. Both subjects are smiling broadly at the camera. The eyes, not the mouths, are what suggest joy in the image.
“You know that photograph you sent me?” my dad said on the phone. “You look good; you look well. You look very happy. It’s obvious that your spirits are high.”
My dad couldn’t see me smile.
“If he’s the reason why you look so happy, then that is good. Ultimately, that is what matters the most: He has to treat you well. You two have to get along. That’s really the only thing that matters. It looks like you two are off to a good start.”
My father is the man who loves me the most in this world. In his explicit assessment was implicit approval.
23 Mar 2008 | 4 comments.