“I am co-dependent on my therapist”,  says Mr. Intherapyalot. Is this even a possibility?

Think about it this way: the patient – therapist relationship (and by therapist I am psychiatrists, psychologists, etc.) is characterized by an immense power differential. The therapist is in many respects God-like in the eyes of his patient: omniscient (appearing as if he knows everything about the patient), omnipotent (with the ability of curing deep-seated or maybe even deeper-seeded conflicts), the subject of unfiltered transference (positive for the most part) and yet available.

Who wouldn’t like to have God like figure on the line? So when those always urgent phone calls start coming in the middle of the night, when the patient starts calling repeatedly about trivial matters, when tapering the visits results in increased symptoms, and the discussion of termination is pre-emptied by sudden exacerbations, consider “therapist dependence” in your diagnostic formulation.

Of course, “dependence” on the therapist is not always bad. In fact, during the initial stages of therapy, especially for patients who come from a background of poor object relations, “dependence” might in fact be a good thing. In such instances “dependence” might indicate that the patient is finally able to trust in the context of a safe relationship.

In later stages of therapy however, especially when dependence occurs after relative independence has already been established, chance is that the patient is experiencing a maladaptive regression.

What is the solution? First, as always, prophylaxis is gold. Rather than open-ended therapy decide when the discharge date/the final session will be scheduled from the beginning. There is a lot to be said – and good data as well – supporting the fact that time-limited therapy might be more effective that open-ended therapy.  If the patient manifests dependence do not “up the ante”, in other words, do not offer heroic and out of character solutions (such as special arrangements, rescheduling for more convenient times, changing your process by “doing more as the patient is doing less”). Any such responses can become a positive reinforcement for what in essence is a maladaptive behavior.

Instead, keep doing what you have done all along and do not change the termination date. Chance is that the patient will be able to mobilize enough internal resources to hold it together through termination if you would only give him your vote of confidence that he can do so. For the minority that cannot, a return/continuation of therapy might be recommended. If so, it’s usually better if you let another therapist take over. The rationale for switching therapists follows the idea that one needs to be consistent in preventing positive reinforcements for maladaptive traits or behaviors.

Not to mention that if the patient did not improve within the parameters that you initially discussed you might not be the best therapist (at least for that one patient) and they might really benefit from no longer seeing you.