SCHEN ET AL. TRANSFERRING PSYCHOTHERAPY PATIENTS
Transfer of Care of Psychotherapy Patients: Implications for Psychiatry Training Cathy R. Schen, Laurie Raymond, and Malkah Notman Abstract: Transfers of care occur routinely in medical training, but the transfer of psychotherapy patients has received relatively little attention. This article discusses important issues concerning these transfers, using case examples and findings from a survey of the experience of psychiatry residents transitioning psychotherapy patients. Residents have difficulty telling patients they are leaving and often delay doing so. Because feelings of closeness and attachment can develop in long-term therapeutic relationships, residents describe feeling guilty, uncertain, anxious, sad, and occasionally relieved as they prepare their patients for transfer. Outgoing residents can feel anxious when recognizing and addressing their patients’ and their own positive feelings. Incoming residents experience discomfort at being compared to the previous therapist and often encounter the patient’s negative feelings at the transfer and the loss of the previous therapy. Teaching about the two poles of transfer of care is recommended to better understand and respond to this transition for both patient and therapist. This should include addressing the stresses involved and recommendations for management.
In this article, we explore residents’ experiences transferring psychotherapy patients. We examine the psychodynamic implications of the transfer of care, considering both saying goodbye and starting anew. We present findings from a questionnaire developed for psychiatry Cathy R. Schen, M.D., Assistant Clinical Professor, Harvard Medical School; Faculty, Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA. Laurie Raymond, M.D., Assistant Clinical Professor, Harvard Medical School; Faculty, Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA. Malkah Notman, M.D., Clinical Professor of Psychiatry, Harvard Medical School; Faculty, Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA. We gratefully acknowledge the contributions of the psychiatry residents who participated in the survey and the faculty writing group at the Cambridge Health Alliance. We thank Carol Nadelson and Janna Malamud Smith for reading an earlier draft of this article. Psychodynamic Psychiatry, 41(4) 575–596, 2013 © 2013 The American Academy of Psychoanalysis and Dynamic Psychiatry
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residents terminating with and accepting transferred psychotherapy patients. Four case examples illustrate some of the central themes of psychotherapy transfers. Transfers of patients from one physician to another occur routinely in medicine as residents advance in training. Research on interhospital and end-of-shift transfers (termed handoffs or handovers in the medical literature) has increased in response to the restriction of resident on-call hours and the establishment of patient safety goals (Reisenberg, Leitzsch, Massucci, Jaeger, Rosenfeld, et al., 2009). Relatively few studies, however, address outpatient psychiatry patient transfers (Mischoulon, Rosenbaum, & Messner, 2000; Young & Eisendrath, 2011; Young, Pringle, & Wachter, 2011; Young & Wachter, 2009), and none, to our knowledge, address outpatient psychotherapy patient transfers. Psychiatry residents often learn about termination in the context of changing rotations or ending residency. These terminations are not based primarily on the patient’s readiness to terminate but because of the service or educational needs of the resident. Residents often learn about starting therapy and building an alliance with patients who are accepting them as a new therapist. The central challenge patients face during transfer consists of dealing with loss, with the special aspect that it is initiated by the therapist and not in the patient’s control. This contributes to the patient’s feelings of rejection and abandonment, and may enlist the patient’s unconscious attempts to assert control and regain self-esteem in order to defend against feelings of helplessness, insecurity, loss of power, or despair. In addition to the dynamic of loss, there is the patient’s positive developmental growth toward independence, readiness for change, and consolidation of progress made and goals achieved. Depending on the length and expectations of treatment, the depth of the therapeutic relationship, and the patient’s character structure and history of attachments, patients respond to and manage the transfer with a wide range of emotional responses. Residents as well as patients experience strong feelings when terminating therapy. They must come to terms with putting their own institutional needs above those of the patient. Unless adequately prepared, they can feel guilty for inflicting an “iatrogenic” condition on the patient. They can identify with the patient’s feelings of rejection or abandonment. Termination also stimulates feelings of loss for the resident and can bring up the resident’s past losses. Residents can also feel relieved that they “have to” terminate with a patient who is difficult or challenging. This guilt can be magnified when the resident can select one or two patients with whom she will continue.
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Residents routinely begin therapy with patients who are transferred. While not all patients who terminate with a departing resident need further psychotherapy, many do. When beginning with a new therapist, patients face the loss of the old therapist. Many patients compare the new therapist to the old one. This is one aspect of working through the loss and reorienting to a new relationship. On the positive side, a new therapist can provide a patient with the opportunity to outline progress, provide a new perspective, and help identify repeated patterns of dysfunction as they reoccur in the new relationship. Residents accepting transfer patients have common countertransference reactions to new patients that can involve competitively comparing themselves to the old therapist. Sibling issues, or the question of who is the better parent, can arise for residents in these situations. Residents must separate their own competitive feelings from the comparisons made by their new patient. When patients seem eager to move on and express appreciation of the perspective of the new therapist compared to the old, the accepting resident can both take this at face value and also consider this as flattery that might indicate the patient’s unconscious defense of avoiding grief at the loss by devaluing the former therapist. Residents working to establish an alliance with transferred patients often spend the initial phase of treatment working through the loss of the previous therapist. Literature Review Examining the literature from a historical perspective, we note that there are a significant number of articles that deal with the psychotherapy transfer in an anecdotal way. These papers identify important psychodynamic issues surrounding the transfer that support our findings from the residents’ narratives in our survey. The literature contains papers that examine resident or therapist mandated termination (“forced termination”) only, and also papers that address both phases of the psychotherapy transfer—termination and starting anew. Reider (1953), in one of the earliest papers on forced termination, coined the term “institutional transference” to describe the patient’s presumed shift in attachment from the person of the therapist to the institution involved after multiple transfers of care. Pumpian-Mindlin (1958) underscored the importance of the therapist being aware of her countertransference reaction in order to effectively treat the patient. This author was one of the first psychiatrists to consider forced terminations in psychiatry training. He described the resident who deflects
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the patient’s negative feelings by blaming outside sources, acting on her unconscious guilt about leaving, potentially compounding the patient’s feeling of helplessness and suppressing a more open discussion with the patient. Dewald (1966) posited that the client who has been terminated prematurely is dealing with a loss equivalent to the death of a loved object. Dewald looked primarily at patients in his psychotherapy practice and their reactions to his announcement of a move to a distant city. While some patients had a positive outcome, in which the termination helped patients work through previous reactions to loss, other patients had negative reactions or were neutral in their response to the author’s departure. Dewald noted that patients in supportive therapy tended to respond with more sadness, regret, and well wishes toward the therapist, whereas patients in insight-oriented psychotherapy showed more negative reactions based on re-experiencing and working through initial reactions to separations in childhood. Patients felt betrayed and denied the loss, or bargained to follow the therapist to the new city. They displaced anger and rejection onto relationships with family members, withdrew from the therapy relationship, and tried to “get a lot of work done” in order to finish therapy. Dewald also discussed terminations in psychiatry training and common resident reactions. He described residents who avoided dealing with termination and the separation reactions of their patients, who delayed telling patients when they were leaving, and who minimized patients’ reactions. Residents might quickly arrange transfer and not work through the patient’s experience of loss sufficiently. Dewald argued that a rapid transfer might impede the working through of termination issues with the outgoing therapist and displace them onto the next therapy, delaying the establishment of the new therapeutic relationship. Identifying the psychotherapy transfer as a transfer consisting of both forced termination and transfer to a new therapist dates back to Keith, who defined “transfer syndrome” as a cluster of symptoms resulting from an inadequately understood loss experienced by the therapist and the patient during administratively required transfers (Keith, 1966; Muller, 1986; O’Reilly, 1987). Keith identified common patient defenses at termination, such as “I will leave you, before you can leave me,” when patients miss the final sessions and thus avoid negative or ambivalent feelings. The author identified defenses of the transferring therapist, such as denial or self-denigration, for instance, “I cannot believe I am important to the patient,” or “how can I be important to the patient since I am just a clumsy beginner,” that can lead the resident to transfer the patient abruptly or focus on procedures rather than feel-
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ings. A resident’s discouragement with a patient’s progress and conscious wish for a “fresh case” may represent a defense against facing the patient’s hostility and bereavement over recurrent therapist loss. Muller noted that the accepting therapist often is concerned about how he or she compares to the past therapist (Muller, 1986). O’Reilly (1987) observed that transfer patients often direct their anger at the incoming rather than outgoing therapist, comparing her unfavorably to the prior therapist. O’Reilly interpreted this anger as the patient’s defense against establishing an alliance and losing yet another therapeutic relationship. If this is the case, O’Reilly recommended scheduling extra sessions, demonstrating the new doctor’s interest in the patient in order to work against the patient’s fear that he or she is “just another case” to the doctor. Later work focusing on forced terminations identified the power struggle that can occur between client and therapist in which patients assert control by missing or cancelling final sessions (Zahourek & Crawford, 1978). Mikkelson and Gutheil (1979) viewed the patient as going through Kubler-Ross’s stages of grief and recommended actively interpreting this to patients in order to assist in their accessing unconscious reactions to loss. Glick (1987), like Pumpian-Mindlin cited above, cautioned residents working with patients with chronic mental illness from trying to turn the patient’s rage and helplessness onto the institution and away from themselves, such as, “it’s not my fault, it’s the clinic policy forced on both of us.” Bostic, Shadid, and Blotcky (1996) undertook an extensive review of the psychoanalytic literature on forced termination and provide illustrative case examples. These authors recommended that residents invite patients to discuss their feelings about termination. They advised residents to be honest when patients make observations about signs of the therapist’s own emotional reactions. The authors noted that, “concluding remarks by the resident can leave a lasting imprint on patients,” and encouraged residents to carefully prepare for the final sessions with patients. The authors instructed residents to offer their patients some facts about their leave-taking in order to create transparency and remove unnecessary mystery. Rather than interfering with transference reactions, the authors suggested that grounding the circumstances of termination in reality allows the patient to work through reactions based on unconscious defenses or past experiences. In general, much of the transfer literature supports telling the patient of the therapist’s eventual departure in the beginning of treatment and giving notice three to six months in advance of departure (Bostic, Shadid, & Blotcky, 1996; Gabbard, 2004; Gabbard, 2009; O’Reilly, 1987; Summers & Barber, 2010; Wittenberg, 1999). Educating the patient about
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the therapist’s tenure and collaborating on treatment goals actively engages the patient in the treatment frame and helps reduce the patient’s feelings of anger and helplessness at termination. Patients who have been repeatedly transferred require periodic reassessment in order to avoid becoming chronic transfer patients and acquiring a kind of second-class status. Summers and Barber (2010) described the repeatedly transferred patient as one who is less likely to demonstrate a fresh reaction to yet another transfer. They argued that these patients, rather than developing an institutional transference, have adapted by detaching from the loss of multiple individuals. Their lack of response can make residents feel inadequate if supervisors haven’t taught them about this kind of patient response but expect the resident to present material showing deeper exploration of the patient’s feelings. Two papers addressed the parallels between the resident’s loss of colleagues, faculty, and patients upon graduation and the loss that takes place at the same time for their patients (Rice, Alonso, & Rutan, 1985; Wittenberg, 1999). These authors observed that when programs fail to acknowledge and make room for residents’ emotions when leaving training programs, a negative model of saying goodbye is created. They recommended that faculty and trainees create the space to acknowledge the intensity and range of feelings that arise at graduation and suggested that by doing so, residents are better able to facilitate a similar process for their patients who are ending treatment. Finally, residents moving on in training may change their roles from combined psychotherapy and medication management to psychopharmacology alone. In these situations, the reaction to the loss of the psychotherapy relationship may be unnoticed by the resident involved who may feel that the continuity of the relationship overrides the patient’s loss of the psychotherapy part of it (Mintz, 2005). The Resident Survey To gain information about the resident’s experience transferring psychotherapy patients, the authors created an online questionnaire with free response questions (see Appendix). In constructing the questionnaire, the authors drew from their experience teaching psychotherapy, supervising psychiatry residents, and from their review of the literature. Institutional Review Board approval for the survey was obtained (CHA-IRB-0453/06/10). Completing the questionnaire was voluntary
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and unpaid. The questionnaire was sent to all residents at the authors’ institution from June to August, which is when most transfers occur. Since the patient transfer involves a natural overlap of saying goodbye to one therapist and starting with another, the questionnaire was constructed in two sections. Section One asked about terminating patients. Section Two asked about patients transferred from a previous therapist and beginning with a new therapist. The questions covered the following issues: the resident’s preparation for the transfer, discussion of the patient’s feelings and attention to the issue of loss, how the transfer impacted the therapy, what created the most anxiety for the resident, and what would have been helpful to know in advance. Information about the patient’s age, diagnosis, and Global Assessment of Functioning Score (GAF) was obtained. The authors reviewed the responses independently and discussed and compared findings. RESULTS Twenty-three of 25 residents participated. Those residents not completing both sections stated that when they gave no response or “N/A” to one section, they had not yet terminated and transferred a patient, or had not yet accepted a transfer patient. Although the small size of our survey makes it not possible to draw inferences between patient diagnosis and response to transfer, we found it noteworthy that patients had a full range of Axis I and II diagnoses. The GAF (Global Assessment of Function) ranged from a low of 31 to a high of 70, with the majority of patients falling in the 50s–60s. This information indicates that residents treat a wide range of psychotherapy patients, and therefore need teaching and supervision about issues arising across the diagnostic spectrum.
Section I: Saying Goodbye: It’s Hard to Tell Your Patient that You’re Leaving The main reason residents terminated with and transferred their patients was the end of a training year and advancement in training. Residents gave poignant descriptions of how hard it was to tell the patient of their impending departure:
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“It was very hard. He and I have worked together for over 1.5 years.” “Very difficult to do in retrospect.” “Very difficult to do.”
Only one resident told the patient at the beginning of treatment when she would be leaving. Most delayed telling the patient, reporting that they gave the patient notice from one to several months in advance or just weeks before stopping. Residents were aware that they could keep some psychotherapy patients, but not all, when advancing from PGY3 to PGY4. This aspect of choice appeared to compound guilt feelings and may be an additional reason why residents found it difficult to announce their departure date. Several residents voluntarily described this dilemma. For one resident, “The patient was a great ‘learning case’ for another resident. I felt that my training needs would be best served by continuing with other pts (over and above this particular individual).”
For another resident, “At the end of the academic year, I could only take a limited number of patients with me, and deemed this patient did not offer as much educational potential as others.”
The one resident who said it was not hard to tell the patient was also the only resident in our survey who framed the transfer as benefiting the patient. This resident recommended a different therapy modality acknowledging that terminating was a relief, “largely because I felt stuck in the therapy.” Working Through the Loss Residents consulted supervisors and their own therapists when transferring patients. They discussed the transfer with their patients, and in some cases were able to provide information to the patient about the new therapist. All the residents said they talked with the patient about the patient’s feelings about the transfer at termination. Residents described themselves as having a range of positive and negative feelings. The intensity and range of residents’ emotions was one of the most impressive findings of our survey.
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Residents’ feelings included: “sadness,” “feelings of loss,” “a feeling of abandoning the patient,” “concern that the patient would decompensate,” “not knowing,” “guilty/awful,” “very torn about what to be working on,” “bad,” “feeling that I hadn’t helped the patient, feeling like you could have done more,” “feels that a great deal of work gets done during termination,” “For me, it’s that he’s (the patient) come a long way and I’ve enjoyed our relationship and I will be sad to end it,” “high esteem, respect.”
While most residents addressed the issue of loss directly with patients, many felt uncertain how best to do this: “I tried to bring it up (patient’s feelings about ending treatment), but I’m not sure how well he was able to take hold of the conversation.” “I wish I had known better how to bring up the feelings of loss/abandonment that were likely getting triggered. It felt like (on my end, at least) one of the elephants in the room, but that I’d be hammering him on the head with my ‘abandonment’ or ‘dumping’ of him if I insisted on talking about it.”
While we anticipated that residents would be anxious facing their patients’ angry feelings (Markowitz & Milrod, 2011), we learned that residents also felt anxious hearing patients express positive feelings. Residents found it hard to bear their own positive feelings of caring and attachment as well, and unsure what they could, within professional boundaries, say to their patients: “I found myself uncomfortable when they (the patient) told me they like working with me and realized it was primarily my own discomfort with my own personal sadness around ending so many relationships with people I really like and am proud of.” “I still struggle with how (and indeed IF at all) to verbalize the basic notion of ‘caring for’ and ‘caring about’ patients unconditionally.”
Arranging for a Person-to-Person Handoff The survey indicates that residents are more anxious and guilty when they don’t know who will be assigned to their patients and cannot deliver a person-to-person handoff.
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“Not knowing exactly who was going to pick this patient up—whether he would be going to one of the new PGY3’s (in which case I could at least picture what treatment might be like, and have a good conversation with them about the transfer, or an incoming psychology or social work intern that I didn’t know. I felt bad particularly not being able to give a name (and any kind of endorsement) to my patient.”
Section Two Most patients were transferred because outgoing residents had advanced in training or graduated. A few were transferred because of the abrupt departure of the therapist for personal or employment reasons or for a change in treatment. We had the impression that incoming residents rather than terminating residents were more likely to tell patients in the beginning of treatment approximately how long they would be available, sometimes in the first meeting or first phone contact (especially because some patients asked directly), and sometimes with reminders during the treatment. Three residents had not told their patient of their eventual departure at the time of the questionnaire. One of these explained that since she would be working with the patient for at least two years, she would tell the patient later, within the first year. All residents but one reviewed the medical chart; half were able to speak directly with the previous therapist; all but one said that the main way they began treatment with the new transfer patient was to talk with the patient about his or her previous therapy, therapist, and address the patient’s feelings about starting over. We found subtle differences in the resident’s focus with the patient about the transfer: Some residents talked with the patient about his or her feelings about the former therapist, while others talked with the patient about what the patient thought worked and didn’t work in the previous therapy. Some residents discussed the patient’s concerns about the transition in general, and others talked with the patient about his or her anxiety starting with a new provider and setting goals. We think that the differences may indicate, on the one hand, a resident’s sensitivity to the capacity of the patient to address feelings of loss (or even the lack of such feelings for the less-attached patient), or could represent the resident’s own style as a therapist and willingness to engage with patients at a deeper level.
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Addressing Comparison Incoming residents expressed the most anxiety about being compared to former therapists or comparing themselves to the former therapist: “Would I be as good as the therapist before?” “I was worried I wasn’t going to measure up to the former therapist in all sorts of ways.” “Thinking about the other therapist and how we were similar or different, thinking that he (the patient) wouldn’t connect with me or have the same positive transference to me that he had with the previous therapist.”
Residents in our survey observed pressure from the patient to continue as if there had been no break in the treatment. One resident said she learned the importance of realizing, “that you cannot be the former therapist.” Two residents compared themselves favorably to the former therapist in cases where patients’ former therapists had left abruptly for personal reasons. These residents felt anxious to repair the rupture of the former treatment relationship and described having the wish to be the perfect therapist: “Trying not to repeat the same things as the last person.” “I have a lot of countertransference feelings around this case—guilt/responsibility about how badly her last therapy ended and wanting to somehow ‘make it up to her,’ a desire to be infinitely patient and good to show that I’m not like her last therapist.”
Dealing with the Patient’s Negative Feelings Incoming residents, even before meeting with the transferred patient, were anxious about being a recipient of the patient’s negative feelings. In fact, the survey indicated that more incoming than outgoing residents did encounter more of their patients’ anger and frustration due to the transition: “His anger at the hospital system and my concern that he would take it out on me.” “I was worried about annoying the patient by retaking a history.”
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“I was concerned that she would be frustrated with having to repeat aspects of her history.” “I was most concerned about the patient’s negative transference toward me for not being like their prior therapist.” “She (the patient) told me she didn’t want to talk about the past (things that have been covered in the former therapy sessions). She said her former therapist had reassured her that we’ll only talk about what she wanted to talk about.”
Overall, residents seemed able to receive these negative feelings without becoming defensive or judgmental. They empathized with their patients who were starting with a new therapist and seemed able to address this difficulty directly. Sometimes they viewed the conversation as having a positive effect: “It’s hard for patients to start over every year trying to be understood by another person.” “It’s okay to talk about feelings of loss from the other therapist and how those dynamics can be helpful in the therapy moving forward.”
Transfer of Care Protocol Half of the incoming residents talked with the previous therapist for a person-to-person handoff. One resident commented that, in retrospect, it would have helped to ask more questions of the outgoing resident about the patient being transferred. While one resident reported that the transfer was handled well, several residents commented that the system of transfer could be improved: “I would like to have a clearer idea of how patients are transferred and by whom. My impression now is that patients should be assigned by the coordinator instead of by residents themselves. I think that the process is unnecessarily confusing.” “It definitely taught me how much the quality of a termination affects the next therapy.”
Clinical Vignettes The following four clinical vignettes illustrate key psychodynamic processes with transferred psychotherapy patients.
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Case One At the end of a two-year psychotherapy treatment with an adolescent boy, Dr. C, a psychiatry resident, observed that his patient was missing school, running away from home and getting into fights—a regression to old behaviors from early in treatment. Dr. C was well aware that the boy had major disruptions in early attachment and that these behaviors expressed the boy’s feelings about losing his therapist. Dr. C recommended that the patient meet twice instead of once a week. In a session subsequently, the boy resisted all attempts at engagement and started playing with a doll and hanging it by a rope. Dr. C responded with the following interpretation: “We can either spend twice a week with you taunting me with a hanging doll or we can talk about what it means to have someone care about you who is going to leave, to hold caring and anger at the same time.” The interpretation seemed to make a difference. The boy stopped acting out. Dr. C rallied outside supports—school services, family support, court officials and the department of mental health resources. In the last weeks of the psychotherapy, the boy asked Dr. C a personal question: “Are you gay?” Dr. C chose to reply, “I will answer your question, but first I’d like to know what it means for you.” The patient answered, “If I knew that you were gay, then it would give me hope for myself, my life, my future.” Dr. C chose to disclose his sexual orientation to the patient for dynamic reasons. He told the patient, “Yes, I am gay.” This case illustrates some of the common dynamics therapists encounter when transferring psychotherapy patients, such as their patients’ unconscious feelings of loss and anger expressed by acting out and a return of old symptoms. Dr. C increased the frequency of sessions, thus demonstrating his concern and caring in the face of his leave-taking and mitigating his patient’s feelings of abandonment. The therapist directly confronted the patient’s aggression in the session with a transference interpretation, naming both the patient’s anger and the unacknowledged positive feelings. Significantly, as we saw from our survey of psychiatry residents, Dr. C also indirectly stated his own positive feelings for the patient. It is noteworthy that Dr. C did not say, “I care about you.” Rather, he said, “to have someone care about you who is going to leave.” This use of the third person avoided making inappropriate claims of intimacy and kept professional boundaries, while giving the patient the freedom to not respond in the moment. It also suggested, by invoking the universal human condition around loving and losing, that the patient had, and would have in the future, other
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people who cared about him, but who would come and go in his life: parents, teachers, mentors, friends.
Case Two A second year resident met twice weekly with a 47-year-old woman diagnosed with schizophrenia and hospitalized for many years. The patient was a “resident case,” routinely transferred as residents rotated through the hospital ward. In one of their last meetings before Dr. T was due to leave for assignment at another hospital, the patient protested her impending transfer to a new doctor. “What do you think I am,” she exclaimed, “a human football? You are the 49th doctor that I’ve had and I can’t stand it any longer. I’m not going to let you go.” Dr. T was surprised by the forcefulness and lucidity of the patient’s request. After consultation with her supervisor and hospital staff, Dr. T arranged to continue meeting with the patient. The resident drove from her new location to the patient’s hospital each week to meet with the patient. Several months later, the patient transitioned to the open unit on the hospital grounds and then to supportive housing in the community. Initially, the patient said she didn’t feel safe meeting in Dr. T’s office and requested that they meet in a more public place nearby. After several weeks, the patient said she was ready to move to the more private space of an office. There, two and a half years into treatment, the patient confided that she had assaulted her mother over 20 years ago, causing severe injury, and that she feared she would be dangerous to her therapist. Guilt over the past, anger at her mother, and ongoing fears of her own hostility endangering others were worked through. After Dr. T graduated from training, she continued to meet with the patient for another year. Due to a job change, Dr. T announced her departure six months away. The patient, established in a halfway house, and with four years of a continuous relationship, accepted transfer to another psychiatrist. In this example, the chronic mentally ill patient is designated a resident learning case because she requires ongoing care and because low expectations are set around progress or improvement. While these patients benefit from the fresh interest and enthusiasm of the new resident, they can suffer from the frequent change of doctors, with its inherent difficulty in establishing trust and a sense of safety in order to support recovery and risk exploring painful areas. While in this example the patient’s protest at termination could be viewed as denial, it instead
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led to a reassessment of the patient’s care. In many ways, it is the extraordinary patient who can convincingly advocate for him- or herself and establish a strong enough connection that persuades a doctor, or a hospital system, to find a more permanent arrangement.
Case Three A graduating resident asked to transfer her patient to Dr. E, a PGY2 resident. Dr. E agreed and got the “sign-off” which included the longstanding arrangement of meeting the patient exclusively on the first floor of the clinic. The residents and attending psychiatrists had their own offices on the second floor of the clinic. General use offices and reception were on the first floor. Every week, Dr. E scrambled for one of the offices on the first floor, increasingly irritated at the inconvenience. Finally, Dr. E told the patient that they had to figure out how they could meet in her own office upstairs. The patient then confided that she was terrified of running into a psychiatrist who she’d encountered two years ago when hospitalized with a psychotic depression. She remembered how the psychiatrist had stood in the doorway of her room and said, “Can’t get any rest anywhere, hmm?” This statement had confirmed the patient’s worst fears—that she carried the devil inside her. Dr. E asked to talk with the psychiatrist, who had a spacious office on the second floor, about the incident. The attending asked to meet with the patient in order to apologize to her for his comment that been unintentionally hurtful. The patient agreed, met with the attending psychiatrist, and accepted his apology. By uncovering the reason behind the patient’s avoidant behavior and creating an opportunity for the patient to confront the object of her fears, Dr. E helped the patient work through internal feelings of guilt and badness that had been managed for years through projection and avoidance. As in this case, accepting a transfer patient can involve a hand-selection process from one resident to another. Flattered to be chosen by the senior resident, a junior resident can feel anxious to “be as good as” the former resident, especially when there has been a positive transference. The former resident in this case, in keeping to the first floor office visits, had unknowingly colluded with the patient’s defensive operation. Dr. E found it difficult to challenge the status quo. Only after an alliance was established, and assisted by the inconvenience of scheduling appointments, was Dr. E able to revise the treatment parameters and encourage the patient to change her behavior and address the underlying conflict.
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Case Four A PGY2 resident started working with a patient transferred from a recent graduate. Two months into the treatment, the patient revealed to his new therapist a very shameful past experience. He told the therapist that he never felt able to tell his previous therapist because that therapist was too handsome, too charming, too jocular. The new resident had early on taken a different tack, not engaging in the joking banter and being a little more distant and serious. The new resident felt flattered and pleased by the patient’s comment. He also, sheepishly, admitted that he guessed the patient was saying he wasn’t quite as good looking. Sometimes, patients can benefit from a transfer when they find a better match with the new therapist. This could be the situation in the case above. Another positive advantage of transfer occurs when patients use the loss and new beginning to experience fresh emotion that enables them to break through their resistance. At the same time, the example could represent more complex feelings in the patient that warrant further exploration. For example, could the patient’s flattery be an attempt to gratify the therapist and defend against feelings of shame and insecurity? Could they also harbor a subtle critical transference that defends against feelings of rejection, of being passed on to a “less handsome” therapist? Discussion The findings from our survey and case examples describe residents’ shared experiences transferring psychotherapy patients, supported by our review of the literature. Limitations of our survey include its small size, the inability to compare repeat transfers with first time transfers or make correlations based on a patient’s diagnosis and level of function. Our findings are meaningful because of the high proportion of residents who responded and because of the heartfelt responses by individual residents. These show the impact on the resident of the transfer and reveal patterns in their experience. Departing residents have difficulty telling patients they are leaving, feel guilty, are anxious about hearing the patient’s positive feelings, and are uncomfortable with their own sad or positive feeling for the patient. Incoming residents are anxious about encountering the patient’s negative feelings, compare themselves to previous therapists, and consistently address the loss of the former therapy as part of starting anew with their patients.
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Even with individual supervision and psychotherapy training, residents often feel unsure and anxious when managing the psychotherapy transfer. Many residents approached the treatment at the beginning as if it were open-ended. New residents may focus on building an alliance in order to fully engage the patient and may not consider their own departure one to two years in the future. Our concern is that residents use the ambiguity of their departure as a way to avoid talking about their eventual termination. Residents may believe that they will find ways to continue with new patients, regardless of the obstacles. More incoming residents who started with transfer patients told their patients at the beginning of treatment that they would be leaving in a year or two, than outgoing residents who were leaving patients. One explanation for the difference is that incoming residents completed the survey at the same time they began with patients, and the survey may have prompted them to inform patients. This suggests that it is possible to teach residents to educate their patients about the probable length of treatment and set appropriate expectations in ways that are still sensitive to the resident’s efforts to build an alliance. It is easier for residents to talk about their training status and the length of time they will be available to patients when the patients have those same concerns if they have just said goodbye to their former therapist. These patients are aware of the system and may inquire directly about the resident’s training status and the length of time they will have to work together. Not feeling guilty about abandoning patients also facilitates the conversation about tenure early in treatment, rather than one or two years later. Residents terminating with patients were more uncertain and anxious about how to help the patient work through the loss than residents who are helping patients start again. Those who are graduating and ending treatments were anxious about their own sadness and unsure how to communicate their caring in a professional manner. Guilt feelings were more common among these residents. Residents may feel guiltier if they consciously acknowledge how important they are for the patient they are leaving. In addition, the patient’s positive feelings may stir up concerns about erotic transference or countertransference feelings for the resident. Competitive issues are stirred by the close juxtaposition of one doctor to another, a situation which occurs during transfer of care. Psychiatrists doing outpatient psychotherapy often do not have the opportunity to measure themselves against others and compare their own personal style with that of their colleagues, since much of the professional work takes place in the relatively private space of an office. The hierarchical system of physicians, where the lines between medical student, junior and senior resident, and junior to senior faculty are clearly defined, can
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inhibit incoming junior residents from directly asking questions of, or challenging the treatment directives of, their more senior outgoing colleagues. These factors contribute to residents feeling uneasy with the inevitable comparisons involved in transferring patients, and make it difficult to accept and explore their patient’s views. Furthermore, patients who refer to the former therapist in the comparison can have the unconscious intention of denying the loss and possibly pressuring the new therapist to be the same as the old one. Patients may feel inhibited expressing negative feelings about the therapist who is both the object of their attachment as well as the person they are losing—and more ready to solely acknowledge positive feelings and review positive gains with the outgoing therapist (this was suggested by Keith in his paper, and Yalom [Yalom & Leszcz, 2005] in his work on groups). Patients may feel safer expressing negative feelings about the loss with the new therapist, since this does not represent a direct attack on the therapist with whom they are now working.
Recommendations It is important to include issues of transfer of care of patients in the residency curriculum. Teaching should include an understanding of the issues raised when transferring patients and recommendations for treatment. Residents beginning psychotherapy with patients should be encouraged to tell patients at the beginning of treatment of the approximate duration of their availability, with another announcement three to six months before the date of termination. It is useful to set realistic treatment goals that recognize that there will always be problems left unfinished. Outgoing residents need to recognize that some patients may contain their negative feelings until they are starting with the new therapist because of their need to preserve the current treatment relationship as well as to acknowledge positive feelings and attachment. Residents also should be prepared to hear their patients express positive feelings, to learn ways of communicating caring and to be accepting of their own positive and sad feelings. Because many outgoing residents are graduating from training, having administrative support and time set aside for residents to acknowledge and discuss their own emotional experiences around this loss is important and would be helpful to facilitate a parallel process in the residents’ treatment of patients who are terminating. Incoming residents can be prepared to anticipate being compared by their patient to the former therapist either positively or negatively.
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When patients are devaluing, residents can learn to tolerate the patient’s negative affect by understanding this as an expression of the patient’s loss and need to work through the prior termination. Teaching about setting appropriate limits regarding the patient’s expression of hostility or acting out behaviors is also important. Residents’ feelings of guilt about abandoning patients are mitigated when residents meet what they feel is the highest standard of transfer of care. In our program, this means selecting the new therapist in advance of termination, talking with that person, and establishing continuity of treatment. This level of transfer is impossible in many situations. Guidelines from research on the medical handoff and psychopharmacology transfer emphasize the importance of physicians meeting faceto-face to talk about the patient being transferred. Identifying high-risk and acute patients who can be seen more quickly is also recommended (Horwitz, Moin, Krumholz, Wang, & Bradley, 2008; Young, Pringle, & Wachter, 2011). These guidelines provide a working model to continue our efforts to integrate patient care. Our impression is that implementing a more systematic transfer will alleviate some of the uncertainty and confusion of residents, thereby improving patient care.
Appendix: Questionnaire Part I: Termination and Transfer of Psychotherapy Patients 1. What was the reason you terminated with and transferred your patient? 2. How long before stopping did you tell your patient about your departure and plans about transferring? How hard was this to do? 3. What was the main way you prepared your patient for termination and transfer? 4. What was the main way you prepared yourself for terminating with and transferring your patient? 5. Did you and your patient talk about your patient’s feelings about ending treatment with you? 6. Was the issue of loss addressed explicitly by either you or your patient during termination? 7. What was the main way termination and impending transfer of care impacted the psychotherapy? 8. What caused you the most anxiety about the termination and transfer? 9. In retrospect, is there something you learned during this process of transfer of care that you would like to have known in advance? 10. Please indicate the patient’s age, Axis I and II diagnosis, and global assessment of functioning score.
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Part II: Accepting a transferred Psychotherapy Patient What was the reason your patient was transferred to you? What was the main way you helped your patient adjust to starting psychotherapy with you after leaving a former psychotherapist? What was the main way you prepared yourself for starting psychotherapy with your transfer patient? Did you and your patient talk about the patient’s feelings about starting with you and/or stopping treatment with the former psychotherapist? Was the issue of loss addressed explicitly either by you or your patient in the psychotherapy? Did you tell your patient when you might be leaving? If yes, at what point in the psychotherapy? What is the main way the transfer impacted the psychotherapy with your new patient? What caused you the most anxiety in doing psychotherapy with your newly transferred psychotherapy patient? In retrospect, is there something you learned from this process of transfer of care that you would like to have known in advance? Please indicate the patent’s age, Axis I and II diagnosis, and global assessment of functioning score.
REFERENCES Bostic, J., Shadid, L., & Blotcky, M. (1996). Our time is up: Forced terminations during psychotherapy training. American Journal of Psychotherapy, 50(3), 347-359. Dewald, P. A. (1966). Reactions to forced termination of therapy. Psychiatric Quarterly, 39, 102-126. Gabbard, G. O. (2004). Long-term psychodynamic psychotherapy: A basic text. Washington, DC: American Psychiatric Publishing. Gabbard, G. O. (2009). What is a “good enough” termination? Journal of the American Psychoanalytic Association, 57(3), 575-594. Glick, R. (1987). Forced terminations. Journal of the American Academy of Psychoanalysis, 15(4), 449-463. Horwitz, L. I., Moin, T., Krumholz, H. M., Wang, L., & Bradley, E. H. (2008). Consequences of inadequate sign-out for patient care. Archives of Internal Medicine, 168(16), 1755-1760. Keith, C. M. (1966). Multiple transfers of psychotherapy patients. Archives of General Psychiatry, 14, 185-189. Markowitz, J., & Milrod, B. (2011). The importance of responding to negative affect in psychotherapies. American Journal of Psychiatry, 168, 124-128. Mikkelson, E., & Gutheil, T. (1979). Stages of forced termination: Uses of the death metaphor. Psychiatric Quarterly, 51, 15-27. Mintz, D. L. (2005). Teaching the prescriber’s role: The psychology of psychopharmacology. Academic Psychiatry, 29(2), 187-194.
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Mischoulon, D., Rosenbaum, J. F., & Messner, E. (2000). Transfer to a new psychopharmacologist: Its effect on patients. Academic Psychiatry, 24, 156-163. Muller, R. (1986). The trainee and the transfer case. American Journal of Psychotherapy, XL(2), 265-276. O’Reilly, R. (1987). The transfer syndrome. Canadian Journal of Psychiatry, 32, 674-678. Pumpian-Mindlin, E. (1958). Comments on techniques of termination and transfer in a clinic setting. American Journal of Psychotherapy, 12, 455-464. Reider, N. (1953). A type of transference to institutions. Bulletin of the Menninger Clinic, 17, 58-63. Rice, C. A., Alonso, A., & Rutan, S. J. (1985). The fights of spring: Separation, individuation, and grief in training centers. Psychotherapy, 22(1), 97-100. Riesenberg, L. A., Leitzsch, J., Massucci, J. L., Jaeger, J., Rosenfeld, J. C., Patow, C., et al. (2009). Residents’ and attending physicians’ handoffs: A systematic review of the literature. Academic Medicine, 84(12), 1775-1787. Summers, R. F., & Barber, J. P. (2010). Psychodynamic therapy: A guide to evidence-based practice. New York: Guilford. Wittenberg, I. (1999). Ending therapy. Journal of Child Psychotherapy, 25, 339-356. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books. Young, J. Q., & Eisendrath, S. J. (2011). Enhancing patient safety and resident education during the academic year-end transfers of outpatients: Lessons from the suicide of a psychiatric patient. Academic Psychiatry, 35, 54-57. Young, J. Q., Pringle, Z., & Wachter, R. (2011). Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer. The Joint Commission Journal on Quality and Patient Safety, 37(7), 300-307. Young, J. Q., & Wachter, R. M. (2009). Academic year-end transfers of outpatients from outgoing to incoming residents: An unaddressed patient safety issue. JAMA: The Journal of the American Medical Association, 302(12), 1327-1329. doi: 10.1001/jama.2009.1399 Zahourek R., & Crawford, C. (1978). Forced termination of psychotherapy. Perspectives in Psychiatric Care, 16(4), 193-199.
Cathy R. Schen, M.D. Assistant Clinical Professor, Harvard Medical School Faculty, Department of Psychiatry Cambridge Health Alliance 1493 Cambridge St. Cambridge, MA 01239 [email protected]
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Transfer of Care of Psychotherapy Patients: Implications for Psychiatry Training Cathy R. Schen, Laurie Raymond, and Malkah Notman Abstract: Transfers of care occur routinely in medical training, but the transfer of psychotherapy patients has received relatively little attention. This article discusses important issues concerning these transfers, using case examples and findings from a survey of the experience of psychiatry residents transitioning psychotherapy patients. Residents have difficulty telling patients they are leaving and often delay doing so. Because feelings of closeness and attachment can develop in long-term therapeutic relationships, residents describe feeling guilty, uncertain, anxious, sad, and occasionally relieved as they prepare their patients for transfer. Outgoing residents can feel anxious when recognizing and addressing their patients’ and their own positive feelings. Incoming residents experience discomfort at being compared to the previous therapist and often encounter the patient’s negative feelings at the transfer and the loss of the previous therapy. Teaching about the two poles of transfer of care is recommended to better understand and respond to this transition for both patient and therapist. This should include addressing the stresses involved and recommendations for management.
In this article, we explore residents’ experiences transferring psychotherapy patients. We examine the psychodynamic implications of the transfer of care, considering both saying goodbye and starting anew. We present findings from a questionnaire developed for psychiatry Cathy R. Schen, M.D., Assistant Clinical Professor, Harvard Medical School; Faculty, Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA. Laurie Raymond, M.D., Assistant Clinical Professor, Harvard Medical School; Faculty, Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA. Malkah Notman, M.D., Clinical Professor of Psychiatry, Harvard Medical School; Faculty, Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA. We gratefully acknowledge the contributions of the psychiatry residents who participated in the survey and the faculty writing group at the Cambridge Health Alliance. We thank Carol Nadelson and Janna Malamud Smith for reading an earlier draft of this article. Psychodynamic Psychiatry, 41(4) 575–596, 2013 © 2013 The American Academy of Psychoanalysis and Dynamic Psychiatry
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residents terminating with and accepting transferred psychotherapy patients. Four case examples illustrate some of the central themes of psychotherapy transfers. Transfers of patients from one physician to another occur routinely in medicine as residents advance in training. Research on interhospital and end-of-shift transfers (termed handoffs or handovers in the medical literature) has increased in response to the restriction of resident on-call hours and the establishment of patient safety goals (Reisenberg, Leitzsch, Massucci, Jaeger, Rosenfeld, et al., 2009). Relatively few studies, however, address outpatient psychiatry patient transfers (Mischoulon, Rosenbaum, & Messner, 2000; Young & Eisendrath, 2011; Young, Pringle, & Wachter, 2011; Young & Wachter, 2009), and none, to our knowledge, address outpatient psychotherapy patient transfers. Psychiatry residents often learn about termination in the context of changing rotations or ending residency. These terminations are not based primarily on the patient’s readiness to terminate but because of the service or educational needs of the resident. Residents often learn about starting therapy and building an alliance with patients who are accepting them as a new therapist. The central challenge patients face during transfer consists of dealing with loss, with the special aspect that it is initiated by the therapist and not in the patient’s control. This contributes to the patient’s feelings of rejection and abandonment, and may enlist the patient’s unconscious attempts to assert control and regain self-esteem in order to defend against feelings of helplessness, insecurity, loss of power, or despair. In addition to the dynamic of loss, there is the patient’s positive developmental growth toward independence, readiness for change, and consolidation of progress made and goals achieved. Depending on the length and expectations of treatment, the depth of the therapeutic relationship, and the patient’s character structure and history of attachments, patients respond to and manage the transfer with a wide range of emotional responses. Residents as well as patients experience strong feelings when terminating therapy. They must come to terms with putting their own institutional needs above those of the patient. Unless adequately prepared, they can feel guilty for inflicting an “iatrogenic” condition on the patient. They can identify with the patient’s feelings of rejection or abandonment. Termination also stimulates feelings of loss for the resident and can bring up the resident’s past losses. Residents can also feel relieved that they “have to” terminate with a patient who is difficult or challenging. This guilt can be magnified when the resident can select one or two patients with whom she will continue.
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Residents routinely begin therapy with patients who are transferred. While not all patients who terminate with a departing resident need further psychotherapy, many do. When beginning with a new therapist, patients face the loss of the old therapist. Many patients compare the new therapist to the old one. This is one aspect of working through the loss and reorienting to a new relationship. On the positive side, a new therapist can provide a patient with the opportunity to outline progress, provide a new perspective, and help identify repeated patterns of dysfunction as they reoccur in the new relationship. Residents accepting transfer patients have common countertransference reactions to new patients that can involve competitively comparing themselves to the old therapist. Sibling issues, or the question of who is the better parent, can arise for residents in these situations. Residents must separate their own competitive feelings from the comparisons made by their new patient. When patients seem eager to move on and express appreciation of the perspective of the new therapist compared to the old, the accepting resident can both take this at face value and also consider this as flattery that might indicate the patient’s unconscious defense of avoiding grief at the loss by devaluing the former therapist. Residents working to establish an alliance with transferred patients often spend the initial phase of treatment working through the loss of the previous therapist. Literature Review Examining the literature from a historical perspective, we note that there are a significant number of articles that deal with the psychotherapy transfer in an anecdotal way. These papers identify important psychodynamic issues surrounding the transfer that support our findings from the residents’ narratives in our survey. The literature contains papers that examine resident or therapist mandated termination (“forced termination”) only, and also papers that address both phases of the psychotherapy transfer—termination and starting anew. Reider (1953), in one of the earliest papers on forced termination, coined the term “institutional transference” to describe the patient’s presumed shift in attachment from the person of the therapist to the institution involved after multiple transfers of care. Pumpian-Mindlin (1958) underscored the importance of the therapist being aware of her countertransference reaction in order to effectively treat the patient. This author was one of the first psychiatrists to consider forced terminations in psychiatry training. He described the resident who deflects
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the patient’s negative feelings by blaming outside sources, acting on her unconscious guilt about leaving, potentially compounding the patient’s feeling of helplessness and suppressing a more open discussion with the patient. Dewald (1966) posited that the client who has been terminated prematurely is dealing with a loss equivalent to the death of a loved object. Dewald looked primarily at patients in his psychotherapy practice and their reactions to his announcement of a move to a distant city. While some patients had a positive outcome, in which the termination helped patients work through previous reactions to loss, other patients had negative reactions or were neutral in their response to the author’s departure. Dewald noted that patients in supportive therapy tended to respond with more sadness, regret, and well wishes toward the therapist, whereas patients in insight-oriented psychotherapy showed more negative reactions based on re-experiencing and working through initial reactions to separations in childhood. Patients felt betrayed and denied the loss, or bargained to follow the therapist to the new city. They displaced anger and rejection onto relationships with family members, withdrew from the therapy relationship, and tried to “get a lot of work done” in order to finish therapy. Dewald also discussed terminations in psychiatry training and common resident reactions. He described residents who avoided dealing with termination and the separation reactions of their patients, who delayed telling patients when they were leaving, and who minimized patients’ reactions. Residents might quickly arrange transfer and not work through the patient’s experience of loss sufficiently. Dewald argued that a rapid transfer might impede the working through of termination issues with the outgoing therapist and displace them onto the next therapy, delaying the establishment of the new therapeutic relationship. Identifying the psychotherapy transfer as a transfer consisting of both forced termination and transfer to a new therapist dates back to Keith, who defined “transfer syndrome” as a cluster of symptoms resulting from an inadequately understood loss experienced by the therapist and the patient during administratively required transfers (Keith, 1966; Muller, 1986; O’Reilly, 1987). Keith identified common patient defenses at termination, such as “I will leave you, before you can leave me,” when patients miss the final sessions and thus avoid negative or ambivalent feelings. The author identified defenses of the transferring therapist, such as denial or self-denigration, for instance, “I cannot believe I am important to the patient,” or “how can I be important to the patient since I am just a clumsy beginner,” that can lead the resident to transfer the patient abruptly or focus on procedures rather than feel-
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ings. A resident’s discouragement with a patient’s progress and conscious wish for a “fresh case” may represent a defense against facing the patient’s hostility and bereavement over recurrent therapist loss. Muller noted that the accepting therapist often is concerned about how he or she compares to the past therapist (Muller, 1986). O’Reilly (1987) observed that transfer patients often direct their anger at the incoming rather than outgoing therapist, comparing her unfavorably to the prior therapist. O’Reilly interpreted this anger as the patient’s defense against establishing an alliance and losing yet another therapeutic relationship. If this is the case, O’Reilly recommended scheduling extra sessions, demonstrating the new doctor’s interest in the patient in order to work against the patient’s fear that he or she is “just another case” to the doctor. Later work focusing on forced terminations identified the power struggle that can occur between client and therapist in which patients assert control by missing or cancelling final sessions (Zahourek & Crawford, 1978). Mikkelson and Gutheil (1979) viewed the patient as going through Kubler-Ross’s stages of grief and recommended actively interpreting this to patients in order to assist in their accessing unconscious reactions to loss. Glick (1987), like Pumpian-Mindlin cited above, cautioned residents working with patients with chronic mental illness from trying to turn the patient’s rage and helplessness onto the institution and away from themselves, such as, “it’s not my fault, it’s the clinic policy forced on both of us.” Bostic, Shadid, and Blotcky (1996) undertook an extensive review of the psychoanalytic literature on forced termination and provide illustrative case examples. These authors recommended that residents invite patients to discuss their feelings about termination. They advised residents to be honest when patients make observations about signs of the therapist’s own emotional reactions. The authors noted that, “concluding remarks by the resident can leave a lasting imprint on patients,” and encouraged residents to carefully prepare for the final sessions with patients. The authors instructed residents to offer their patients some facts about their leave-taking in order to create transparency and remove unnecessary mystery. Rather than interfering with transference reactions, the authors suggested that grounding the circumstances of termination in reality allows the patient to work through reactions based on unconscious defenses or past experiences. In general, much of the transfer literature supports telling the patient of the therapist’s eventual departure in the beginning of treatment and giving notice three to six months in advance of departure (Bostic, Shadid, & Blotcky, 1996; Gabbard, 2004; Gabbard, 2009; O’Reilly, 1987; Summers & Barber, 2010; Wittenberg, 1999). Educating the patient about
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the therapist’s tenure and collaborating on treatment goals actively engages the patient in the treatment frame and helps reduce the patient’s feelings of anger and helplessness at termination. Patients who have been repeatedly transferred require periodic reassessment in order to avoid becoming chronic transfer patients and acquiring a kind of second-class status. Summers and Barber (2010) described the repeatedly transferred patient as one who is less likely to demonstrate a fresh reaction to yet another transfer. They argued that these patients, rather than developing an institutional transference, have adapted by detaching from the loss of multiple individuals. Their lack of response can make residents feel inadequate if supervisors haven’t taught them about this kind of patient response but expect the resident to present material showing deeper exploration of the patient’s feelings. Two papers addressed the parallels between the resident’s loss of colleagues, faculty, and patients upon graduation and the loss that takes place at the same time for their patients (Rice, Alonso, & Rutan, 1985; Wittenberg, 1999). These authors observed that when programs fail to acknowledge and make room for residents’ emotions when leaving training programs, a negative model of saying goodbye is created. They recommended that faculty and trainees create the space to acknowledge the intensity and range of feelings that arise at graduation and suggested that by doing so, residents are better able to facilitate a similar process for their patients who are ending treatment. Finally, residents moving on in training may change their roles from combined psychotherapy and medication management to psychopharmacology alone. In these situations, the reaction to the loss of the psychotherapy relationship may be unnoticed by the resident involved who may feel that the continuity of the relationship overrides the patient’s loss of the psychotherapy part of it (Mintz, 2005). The Resident Survey To gain information about the resident’s experience transferring psychotherapy patients, the authors created an online questionnaire with free response questions (see Appendix). In constructing the questionnaire, the authors drew from their experience teaching psychotherapy, supervising psychiatry residents, and from their review of the literature. Institutional Review Board approval for the survey was obtained (CHA-IRB-0453/06/10). Completing the questionnaire was voluntary
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and unpaid. The questionnaire was sent to all residents at the authors’ institution from June to August, which is when most transfers occur. Since the patient transfer involves a natural overlap of saying goodbye to one therapist and starting with another, the questionnaire was constructed in two sections. Section One asked about terminating patients. Section Two asked about patients transferred from a previous therapist and beginning with a new therapist. The questions covered the following issues: the resident’s preparation for the transfer, discussion of the patient’s feelings and attention to the issue of loss, how the transfer impacted the therapy, what created the most anxiety for the resident, and what would have been helpful to know in advance. Information about the patient’s age, diagnosis, and Global Assessment of Functioning Score (GAF) was obtained. The authors reviewed the responses independently and discussed and compared findings. RESULTS Twenty-three of 25 residents participated. Those residents not completing both sections stated that when they gave no response or “N/A” to one section, they had not yet terminated and transferred a patient, or had not yet accepted a transfer patient. Although the small size of our survey makes it not possible to draw inferences between patient diagnosis and response to transfer, we found it noteworthy that patients had a full range of Axis I and II diagnoses. The GAF (Global Assessment of Function) ranged from a low of 31 to a high of 70, with the majority of patients falling in the 50s–60s. This information indicates that residents treat a wide range of psychotherapy patients, and therefore need teaching and supervision about issues arising across the diagnostic spectrum.
Section I: Saying Goodbye: It’s Hard to Tell Your Patient that You’re Leaving The main reason residents terminated with and transferred their patients was the end of a training year and advancement in training. Residents gave poignant descriptions of how hard it was to tell the patient of their impending departure:
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“It was very hard. He and I have worked together for over 1.5 years.” “Very difficult to do in retrospect.” “Very difficult to do.”
Only one resident told the patient at the beginning of treatment when she would be leaving. Most delayed telling the patient, reporting that they gave the patient notice from one to several months in advance or just weeks before stopping. Residents were aware that they could keep some psychotherapy patients, but not all, when advancing from PGY3 to PGY4. This aspect of choice appeared to compound guilt feelings and may be an additional reason why residents found it difficult to announce their departure date. Several residents voluntarily described this dilemma. For one resident, “The patient was a great ‘learning case’ for another resident. I felt that my training needs would be best served by continuing with other pts (over and above this particular individual).”
For another resident, “At the end of the academic year, I could only take a limited number of patients with me, and deemed this patient did not offer as much educational potential as others.”
The one resident who said it was not hard to tell the patient was also the only resident in our survey who framed the transfer as benefiting the patient. This resident recommended a different therapy modality acknowledging that terminating was a relief, “largely because I felt stuck in the therapy.” Working Through the Loss Residents consulted supervisors and their own therapists when transferring patients. They discussed the transfer with their patients, and in some cases were able to provide information to the patient about the new therapist. All the residents said they talked with the patient about the patient’s feelings about the transfer at termination. Residents described themselves as having a range of positive and negative feelings. The intensity and range of residents’ emotions was one of the most impressive findings of our survey.
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Residents’ feelings included: “sadness,” “feelings of loss,” “a feeling of abandoning the patient,” “concern that the patient would decompensate,” “not knowing,” “guilty/awful,” “very torn about what to be working on,” “bad,” “feeling that I hadn’t helped the patient, feeling like you could have done more,” “feels that a great deal of work gets done during termination,” “For me, it’s that he’s (the patient) come a long way and I’ve enjoyed our relationship and I will be sad to end it,” “high esteem, respect.”
While most residents addressed the issue of loss directly with patients, many felt uncertain how best to do this: “I tried to bring it up (patient’s feelings about ending treatment), but I’m not sure how well he was able to take hold of the conversation.” “I wish I had known better how to bring up the feelings of loss/abandonment that were likely getting triggered. It felt like (on my end, at least) one of the elephants in the room, but that I’d be hammering him on the head with my ‘abandonment’ or ‘dumping’ of him if I insisted on talking about it.”
While we anticipated that residents would be anxious facing their patients’ angry feelings (Markowitz & Milrod, 2011), we learned that residents also felt anxious hearing patients express positive feelings. Residents found it hard to bear their own positive feelings of caring and attachment as well, and unsure what they could, within professional boundaries, say to their patients: “I found myself uncomfortable when they (the patient) told me they like working with me and realized it was primarily my own discomfort with my own personal sadness around ending so many relationships with people I really like and am proud of.” “I still struggle with how (and indeed IF at all) to verbalize the basic notion of ‘caring for’ and ‘caring about’ patients unconditionally.”
Arranging for a Person-to-Person Handoff The survey indicates that residents are more anxious and guilty when they don’t know who will be assigned to their patients and cannot deliver a person-to-person handoff.
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“Not knowing exactly who was going to pick this patient up—whether he would be going to one of the new PGY3’s (in which case I could at least picture what treatment might be like, and have a good conversation with them about the transfer, or an incoming psychology or social work intern that I didn’t know. I felt bad particularly not being able to give a name (and any kind of endorsement) to my patient.”
Section Two Most patients were transferred because outgoing residents had advanced in training or graduated. A few were transferred because of the abrupt departure of the therapist for personal or employment reasons or for a change in treatment. We had the impression that incoming residents rather than terminating residents were more likely to tell patients in the beginning of treatment approximately how long they would be available, sometimes in the first meeting or first phone contact (especially because some patients asked directly), and sometimes with reminders during the treatment. Three residents had not told their patient of their eventual departure at the time of the questionnaire. One of these explained that since she would be working with the patient for at least two years, she would tell the patient later, within the first year. All residents but one reviewed the medical chart; half were able to speak directly with the previous therapist; all but one said that the main way they began treatment with the new transfer patient was to talk with the patient about his or her previous therapy, therapist, and address the patient’s feelings about starting over. We found subtle differences in the resident’s focus with the patient about the transfer: Some residents talked with the patient about his or her feelings about the former therapist, while others talked with the patient about what the patient thought worked and didn’t work in the previous therapy. Some residents discussed the patient’s concerns about the transition in general, and others talked with the patient about his or her anxiety starting with a new provider and setting goals. We think that the differences may indicate, on the one hand, a resident’s sensitivity to the capacity of the patient to address feelings of loss (or even the lack of such feelings for the less-attached patient), or could represent the resident’s own style as a therapist and willingness to engage with patients at a deeper level.
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Addressing Comparison Incoming residents expressed the most anxiety about being compared to former therapists or comparing themselves to the former therapist: “Would I be as good as the therapist before?” “I was worried I wasn’t going to measure up to the former therapist in all sorts of ways.” “Thinking about the other therapist and how we were similar or different, thinking that he (the patient) wouldn’t connect with me or have the same positive transference to me that he had with the previous therapist.”
Residents in our survey observed pressure from the patient to continue as if there had been no break in the treatment. One resident said she learned the importance of realizing, “that you cannot be the former therapist.” Two residents compared themselves favorably to the former therapist in cases where patients’ former therapists had left abruptly for personal reasons. These residents felt anxious to repair the rupture of the former treatment relationship and described having the wish to be the perfect therapist: “Trying not to repeat the same things as the last person.” “I have a lot of countertransference feelings around this case—guilt/responsibility about how badly her last therapy ended and wanting to somehow ‘make it up to her,’ a desire to be infinitely patient and good to show that I’m not like her last therapist.”
Dealing with the Patient’s Negative Feelings Incoming residents, even before meeting with the transferred patient, were anxious about being a recipient of the patient’s negative feelings. In fact, the survey indicated that more incoming than outgoing residents did encounter more of their patients’ anger and frustration due to the transition: “His anger at the hospital system and my concern that he would take it out on me.” “I was worried about annoying the patient by retaking a history.”
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“I was concerned that she would be frustrated with having to repeat aspects of her history.” “I was most concerned about the patient’s negative transference toward me for not being like their prior therapist.” “She (the patient) told me she didn’t want to talk about the past (things that have been covered in the former therapy sessions). She said her former therapist had reassured her that we’ll only talk about what she wanted to talk about.”
Overall, residents seemed able to receive these negative feelings without becoming defensive or judgmental. They empathized with their patients who were starting with a new therapist and seemed able to address this difficulty directly. Sometimes they viewed the conversation as having a positive effect: “It’s hard for patients to start over every year trying to be understood by another person.” “It’s okay to talk about feelings of loss from the other therapist and how those dynamics can be helpful in the therapy moving forward.”
Transfer of Care Protocol Half of the incoming residents talked with the previous therapist for a person-to-person handoff. One resident commented that, in retrospect, it would have helped to ask more questions of the outgoing resident about the patient being transferred. While one resident reported that the transfer was handled well, several residents commented that the system of transfer could be improved: “I would like to have a clearer idea of how patients are transferred and by whom. My impression now is that patients should be assigned by the coordinator instead of by residents themselves. I think that the process is unnecessarily confusing.” “It definitely taught me how much the quality of a termination affects the next therapy.”
Clinical Vignettes The following four clinical vignettes illustrate key psychodynamic processes with transferred psychotherapy patients.
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Case One At the end of a two-year psychotherapy treatment with an adolescent boy, Dr. C, a psychiatry resident, observed that his patient was missing school, running away from home and getting into fights—a regression to old behaviors from early in treatment. Dr. C was well aware that the boy had major disruptions in early attachment and that these behaviors expressed the boy’s feelings about losing his therapist. Dr. C recommended that the patient meet twice instead of once a week. In a session subsequently, the boy resisted all attempts at engagement and started playing with a doll and hanging it by a rope. Dr. C responded with the following interpretation: “We can either spend twice a week with you taunting me with a hanging doll or we can talk about what it means to have someone care about you who is going to leave, to hold caring and anger at the same time.” The interpretation seemed to make a difference. The boy stopped acting out. Dr. C rallied outside supports—school services, family support, court officials and the department of mental health resources. In the last weeks of the psychotherapy, the boy asked Dr. C a personal question: “Are you gay?” Dr. C chose to reply, “I will answer your question, but first I’d like to know what it means for you.” The patient answered, “If I knew that you were gay, then it would give me hope for myself, my life, my future.” Dr. C chose to disclose his sexual orientation to the patient for dynamic reasons. He told the patient, “Yes, I am gay.” This case illustrates some of the common dynamics therapists encounter when transferring psychotherapy patients, such as their patients’ unconscious feelings of loss and anger expressed by acting out and a return of old symptoms. Dr. C increased the frequency of sessions, thus demonstrating his concern and caring in the face of his leave-taking and mitigating his patient’s feelings of abandonment. The therapist directly confronted the patient’s aggression in the session with a transference interpretation, naming both the patient’s anger and the unacknowledged positive feelings. Significantly, as we saw from our survey of psychiatry residents, Dr. C also indirectly stated his own positive feelings for the patient. It is noteworthy that Dr. C did not say, “I care about you.” Rather, he said, “to have someone care about you who is going to leave.” This use of the third person avoided making inappropriate claims of intimacy and kept professional boundaries, while giving the patient the freedom to not respond in the moment. It also suggested, by invoking the universal human condition around loving and losing, that the patient had, and would have in the future, other
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people who cared about him, but who would come and go in his life: parents, teachers, mentors, friends.
Case Two A second year resident met twice weekly with a 47-year-old woman diagnosed with schizophrenia and hospitalized for many years. The patient was a “resident case,” routinely transferred as residents rotated through the hospital ward. In one of their last meetings before Dr. T was due to leave for assignment at another hospital, the patient protested her impending transfer to a new doctor. “What do you think I am,” she exclaimed, “a human football? You are the 49th doctor that I’ve had and I can’t stand it any longer. I’m not going to let you go.” Dr. T was surprised by the forcefulness and lucidity of the patient’s request. After consultation with her supervisor and hospital staff, Dr. T arranged to continue meeting with the patient. The resident drove from her new location to the patient’s hospital each week to meet with the patient. Several months later, the patient transitioned to the open unit on the hospital grounds and then to supportive housing in the community. Initially, the patient said she didn’t feel safe meeting in Dr. T’s office and requested that they meet in a more public place nearby. After several weeks, the patient said she was ready to move to the more private space of an office. There, two and a half years into treatment, the patient confided that she had assaulted her mother over 20 years ago, causing severe injury, and that she feared she would be dangerous to her therapist. Guilt over the past, anger at her mother, and ongoing fears of her own hostility endangering others were worked through. After Dr. T graduated from training, she continued to meet with the patient for another year. Due to a job change, Dr. T announced her departure six months away. The patient, established in a halfway house, and with four years of a continuous relationship, accepted transfer to another psychiatrist. In this example, the chronic mentally ill patient is designated a resident learning case because she requires ongoing care and because low expectations are set around progress or improvement. While these patients benefit from the fresh interest and enthusiasm of the new resident, they can suffer from the frequent change of doctors, with its inherent difficulty in establishing trust and a sense of safety in order to support recovery and risk exploring painful areas. While in this example the patient’s protest at termination could be viewed as denial, it instead
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led to a reassessment of the patient’s care. In many ways, it is the extraordinary patient who can convincingly advocate for him- or herself and establish a strong enough connection that persuades a doctor, or a hospital system, to find a more permanent arrangement.
Case Three A graduating resident asked to transfer her patient to Dr. E, a PGY2 resident. Dr. E agreed and got the “sign-off” which included the longstanding arrangement of meeting the patient exclusively on the first floor of the clinic. The residents and attending psychiatrists had their own offices on the second floor of the clinic. General use offices and reception were on the first floor. Every week, Dr. E scrambled for one of the offices on the first floor, increasingly irritated at the inconvenience. Finally, Dr. E told the patient that they had to figure out how they could meet in her own office upstairs. The patient then confided that she was terrified of running into a psychiatrist who she’d encountered two years ago when hospitalized with a psychotic depression. She remembered how the psychiatrist had stood in the doorway of her room and said, “Can’t get any rest anywhere, hmm?” This statement had confirmed the patient’s worst fears—that she carried the devil inside her. Dr. E asked to talk with the psychiatrist, who had a spacious office on the second floor, about the incident. The attending asked to meet with the patient in order to apologize to her for his comment that been unintentionally hurtful. The patient agreed, met with the attending psychiatrist, and accepted his apology. By uncovering the reason behind the patient’s avoidant behavior and creating an opportunity for the patient to confront the object of her fears, Dr. E helped the patient work through internal feelings of guilt and badness that had been managed for years through projection and avoidance. As in this case, accepting a transfer patient can involve a hand-selection process from one resident to another. Flattered to be chosen by the senior resident, a junior resident can feel anxious to “be as good as” the former resident, especially when there has been a positive transference. The former resident in this case, in keeping to the first floor office visits, had unknowingly colluded with the patient’s defensive operation. Dr. E found it difficult to challenge the status quo. Only after an alliance was established, and assisted by the inconvenience of scheduling appointments, was Dr. E able to revise the treatment parameters and encourage the patient to change her behavior and address the underlying conflict.
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Case Four A PGY2 resident started working with a patient transferred from a recent graduate. Two months into the treatment, the patient revealed to his new therapist a very shameful past experience. He told the therapist that he never felt able to tell his previous therapist because that therapist was too handsome, too charming, too jocular. The new resident had early on taken a different tack, not engaging in the joking banter and being a little more distant and serious. The new resident felt flattered and pleased by the patient’s comment. He also, sheepishly, admitted that he guessed the patient was saying he wasn’t quite as good looking. Sometimes, patients can benefit from a transfer when they find a better match with the new therapist. This could be the situation in the case above. Another positive advantage of transfer occurs when patients use the loss and new beginning to experience fresh emotion that enables them to break through their resistance. At the same time, the example could represent more complex feelings in the patient that warrant further exploration. For example, could the patient’s flattery be an attempt to gratify the therapist and defend against feelings of shame and insecurity? Could they also harbor a subtle critical transference that defends against feelings of rejection, of being passed on to a “less handsome” therapist? Discussion The findings from our survey and case examples describe residents’ shared experiences transferring psychotherapy patients, supported by our review of the literature. Limitations of our survey include its small size, the inability to compare repeat transfers with first time transfers or make correlations based on a patient’s diagnosis and level of function. Our findings are meaningful because of the high proportion of residents who responded and because of the heartfelt responses by individual residents. These show the impact on the resident of the transfer and reveal patterns in their experience. Departing residents have difficulty telling patients they are leaving, feel guilty, are anxious about hearing the patient’s positive feelings, and are uncomfortable with their own sad or positive feeling for the patient. Incoming residents are anxious about encountering the patient’s negative feelings, compare themselves to previous therapists, and consistently address the loss of the former therapy as part of starting anew with their patients.
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Even with individual supervision and psychotherapy training, residents often feel unsure and anxious when managing the psychotherapy transfer. Many residents approached the treatment at the beginning as if it were open-ended. New residents may focus on building an alliance in order to fully engage the patient and may not consider their own departure one to two years in the future. Our concern is that residents use the ambiguity of their departure as a way to avoid talking about their eventual termination. Residents may believe that they will find ways to continue with new patients, regardless of the obstacles. More incoming residents who started with transfer patients told their patients at the beginning of treatment that they would be leaving in a year or two, than outgoing residents who were leaving patients. One explanation for the difference is that incoming residents completed the survey at the same time they began with patients, and the survey may have prompted them to inform patients. This suggests that it is possible to teach residents to educate their patients about the probable length of treatment and set appropriate expectations in ways that are still sensitive to the resident’s efforts to build an alliance. It is easier for residents to talk about their training status and the length of time they will be available to patients when the patients have those same concerns if they have just said goodbye to their former therapist. These patients are aware of the system and may inquire directly about the resident’s training status and the length of time they will have to work together. Not feeling guilty about abandoning patients also facilitates the conversation about tenure early in treatment, rather than one or two years later. Residents terminating with patients were more uncertain and anxious about how to help the patient work through the loss than residents who are helping patients start again. Those who are graduating and ending treatments were anxious about their own sadness and unsure how to communicate their caring in a professional manner. Guilt feelings were more common among these residents. Residents may feel guiltier if they consciously acknowledge how important they are for the patient they are leaving. In addition, the patient’s positive feelings may stir up concerns about erotic transference or countertransference feelings for the resident. Competitive issues are stirred by the close juxtaposition of one doctor to another, a situation which occurs during transfer of care. Psychiatrists doing outpatient psychotherapy often do not have the opportunity to measure themselves against others and compare their own personal style with that of their colleagues, since much of the professional work takes place in the relatively private space of an office. The hierarchical system of physicians, where the lines between medical student, junior and senior resident, and junior to senior faculty are clearly defined, can
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inhibit incoming junior residents from directly asking questions of, or challenging the treatment directives of, their more senior outgoing colleagues. These factors contribute to residents feeling uneasy with the inevitable comparisons involved in transferring patients, and make it difficult to accept and explore their patient’s views. Furthermore, patients who refer to the former therapist in the comparison can have the unconscious intention of denying the loss and possibly pressuring the new therapist to be the same as the old one. Patients may feel inhibited expressing negative feelings about the therapist who is both the object of their attachment as well as the person they are losing—and more ready to solely acknowledge positive feelings and review positive gains with the outgoing therapist (this was suggested by Keith in his paper, and Yalom [Yalom & Leszcz, 2005] in his work on groups). Patients may feel safer expressing negative feelings about the loss with the new therapist, since this does not represent a direct attack on the therapist with whom they are now working.
Recommendations It is important to include issues of transfer of care of patients in the residency curriculum. Teaching should include an understanding of the issues raised when transferring patients and recommendations for treatment. Residents beginning psychotherapy with patients should be encouraged to tell patients at the beginning of treatment of the approximate duration of their availability, with another announcement three to six months before the date of termination. It is useful to set realistic treatment goals that recognize that there will always be problems left unfinished. Outgoing residents need to recognize that some patients may contain their negative feelings until they are starting with the new therapist because of their need to preserve the current treatment relationship as well as to acknowledge positive feelings and attachment. Residents also should be prepared to hear their patients express positive feelings, to learn ways of communicating caring and to be accepting of their own positive and sad feelings. Because many outgoing residents are graduating from training, having administrative support and time set aside for residents to acknowledge and discuss their own emotional experiences around this loss is important and would be helpful to facilitate a parallel process in the residents’ treatment of patients who are terminating. Incoming residents can be prepared to anticipate being compared by their patient to the former therapist either positively or negatively.
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When patients are devaluing, residents can learn to tolerate the patient’s negative affect by understanding this as an expression of the patient’s loss and need to work through the prior termination. Teaching about setting appropriate limits regarding the patient’s expression of hostility or acting out behaviors is also important. Residents’ feelings of guilt about abandoning patients are mitigated when residents meet what they feel is the highest standard of transfer of care. In our program, this means selecting the new therapist in advance of termination, talking with that person, and establishing continuity of treatment. This level of transfer is impossible in many situations. Guidelines from research on the medical handoff and psychopharmacology transfer emphasize the importance of physicians meeting faceto-face to talk about the patient being transferred. Identifying high-risk and acute patients who can be seen more quickly is also recommended (Horwitz, Moin, Krumholz, Wang, & Bradley, 2008; Young, Pringle, & Wachter, 2011). These guidelines provide a working model to continue our efforts to integrate patient care. Our impression is that implementing a more systematic transfer will alleviate some of the uncertainty and confusion of residents, thereby improving patient care.
Appendix: Questionnaire Part I: Termination and Transfer of Psychotherapy Patients 1. What was the reason you terminated with and transferred your patient? 2. How long before stopping did you tell your patient about your departure and plans about transferring? How hard was this to do? 3. What was the main way you prepared your patient for termination and transfer? 4. What was the main way you prepared yourself for terminating with and transferring your patient? 5. Did you and your patient talk about your patient’s feelings about ending treatment with you? 6. Was the issue of loss addressed explicitly by either you or your patient during termination? 7. What was the main way termination and impending transfer of care impacted the psychotherapy? 8. What caused you the most anxiety about the termination and transfer? 9. In retrospect, is there something you learned during this process of transfer of care that you would like to have known in advance? 10. Please indicate the patient’s age, Axis I and II diagnosis, and global assessment of functioning score.
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Part II: Accepting a transferred Psychotherapy Patient What was the reason your patient was transferred to you? What was the main way you helped your patient adjust to starting psychotherapy with you after leaving a former psychotherapist? What was the main way you prepared yourself for starting psychotherapy with your transfer patient? Did you and your patient talk about the patient’s feelings about starting with you and/or stopping treatment with the former psychotherapist? Was the issue of loss addressed explicitly either by you or your patient in the psychotherapy? Did you tell your patient when you might be leaving? If yes, at what point in the psychotherapy? What is the main way the transfer impacted the psychotherapy with your new patient? What caused you the most anxiety in doing psychotherapy with your newly transferred psychotherapy patient? In retrospect, is there something you learned from this process of transfer of care that you would like to have known in advance? Please indicate the patent’s age, Axis I and II diagnosis, and global assessment of functioning score.
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Cathy R. Schen, M.D. Assistant Clinical Professor, Harvard Medical School Faculty, Department of Psychiatry Cambridge Health Alliance 1493 Cambridge St. Cambridge, MA 01239 [email protected]
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