I wrote the following article after experiencing difficulties with the ending of Cognitive Analytic Therapy (CAT). The ending led to intense sadness and I searched online for articles from people who had gone through a similar experience. There seemed to be very little written by therapy clients who had struggled with the ending of therapy. So I wrote about my own experience in the hope that it would help me to process it and help others in similar situations.
I also wonder if it would be helpful for trainee therapists to read. It might be hard for a trainee to appreciate quite how vulnerable clients can be when they’re in therapy and form an attachment to a therapist. I don’t think the sad side of my experience could have been prevented but I was certainly helped through it by virtue of my therapist having clear boundaries, strong ethical practice and confidence in her decision making.
My start in life was a disrupted one; born to a single mother in the late ‘60s it was decided I would be adopted. I’m not sure who made that decision – my mother, who was unable to tell her parents of her pregnancy so told them she was moving 300 miles away for a nurse training course? My father, who visited us after my birth and asked my mother ‘what are you going to do with her?’ Or the Mother & Baby Home who had already helped my mother navigate her first pregnancy and give away that baby for adoption? This decision, undoubtedly made with the best of intentions, had long term implications for my life.
I was a worrier as a child, fearing danger and seeing catastrophe round every corner. Finding it hard to articulate these feelings, I buried them and sought reassurance through holding people close. Separation from my adoptive mother was hard; I was insecure and clingy. As a teenager and young adult I struggled when I wasn’t with friends. Leaving home for university only 50 miles away was a stressful time and there were many tearful phone calls home.
Trying to be safe and sure
Irrational fears of losing loved ones affected me as an adult; I’d feel panicky if I couldn’t account for people I loved. Numerous nights I’ve lain in bed, planning my husband’s funeral through distraught tears. I could make myself ill with the thought of him dead in a gutter just because he was out and hadn’t responded to a text. I’ve done the same with my two children. For me, scout camps and sleepovers do not offer welcome relief from parenting. Instead they are fraught with intrusive fears (something I would rarely admit to others).
In my late 40’s these specific fears grew and anxiety extended to other areas of life; after a near choking incident I became fearful of swallowing food. This fear led to compulsive, panicky attempts to swallow when I was driving, socializing, in the cinema or theatre, in a work meeting, even lying in bed trying to sleep.
I tried several approaches to reduce the anxiety – a course of hypnotherapy, eye movement desensitization and reprocessing (EMDR) and Havening (a sensory therapy using touch to reduce unpleasant feelings). I had an app on my phone, the ‘Breathing Zone’ which slowed my breathing. I’d downloaded specific music and spoken poetry to help me with spikes in anxiety. But the anxiety was leaking out, impacting on my relationships and reducing my confidence at work. I had a real sense that my world was shrinking as I focused on avoiding triggers.
After an assessment with a clinical psychologist I started a course of CAT; a 16 session therapy designed to look at patterns of behaviour that contribute to problem symptoms (like anxiety) to work out more helpful ways of behaving. I liked the idea that CAT was a time limited therapy and wouldn’t be a long term drain on my time or finances.
The CAT was an intense experience with weekly one hour sessions and lots of thinking in between. Reflecting on childhood experiences led me to make sense of how these had shaped me and were still affecting me. Experiences which I had buried came out and my therapist helped me understand their impact, their link to my current problems and alternative ways of behaving. We developed a map of my patterns which was complex, but made complete sense to me.
Opening up further
I developed trust in her which allowed me to go beyond the anxiety symptom and explain to her something that I hadn’t told anyone about before. This was something I certainly hadn’t expected to raise in therapy – the way in which I developed obsessions with women. These were a constant for me; a private fantasy life which operated in my head in which I developed imaginary relationships with women.
It could be a woman I’d met at work or socially. A mild attraction could quickly turn into an obsession, with daydreaming time taken up in this fantasy life. They were comforting fantasies, always close and affirming, often sexual in nature. They would last weeks or months before fading away gradually or before being replaced with a new woman I’d come across. I hadn’t analysed this at all prior to therapy. I buried it along with other uncomfortable aspects of my emotional life, sort of imagining this was something everyone had going on in their minds.
By midway through therapy I had a much clearer picture of myself. I understood the role of these fantasies and also the less benign side of keeping so much of me hidden from people I was close to in real life. I started to tell close friends and family that I was bisexual. Rather than something that needed hiding, I found it just became an acceptable part of me.
Starting to make changes
My anxiety reduced in observable ways; I no longer avoided eating chunky food and wasn’t anxious seeing others doing so. If I had a fearful thought when eating, I’d take a small breather, reflect on the source of the fear and return to eating with a calm acceptance of this fear as an understandable part of me. I began to do the same when driving. Work became easier as I was no longer limited to sitting in the seat nearest the door.
I could now drink during meetings, films or the theatre without an overwhelming fear of swallowing. The compulsive, panicky swallowing faded once I’d stopped trying to make it go away. I began to ‘channel’ my therapist, hearing her voice in my head, visualizing her in front of me; other times I spoke to myself, becoming my own wiser, kinder self.
I was learning to turn the anxiety round in minutes either through mentally getting curious about it or by physically writing it down in my therapy journal.
But then something unexpected happened.
Known but still a surprise
We began dealing with the ending of therapy. Closure of therapy was mentioned by my therapist from the start but I paid it no heed, not expecting it to be significant. It wasn’t until we focused on it directly in the last few sessions that I properly recognised that therapy was going to end. I became anxious, tearful and the icy cold feeling in my legs and neck returned. Going round in my head were thoughts about how ‘risky’ it was to end my therapy. There was no way of knowing if I could cope; maybe the anxiety would return and be disabling again? I felt upset with my therapist for limiting my therapy to these 16 sessions. I started feeling small, lost and unimportant in her life.
The final session of therapy is a complete blur. I can’t remember what we talked about; I remember leaving and afterwards not knowing how I managed to lift myself up from the chair and walk out. We didn’t shake hands or hug, we just both stood up and said goodbye as we had each week before.
Feeling the loss keenly
In the days that followed I felt intensely sad and my therapist kept appearing in my thoughts. One night I dreamt about us being at a conference where she ignored me and walked off with several other women. An upset feeling spiraled into a feeling of being excluded from her life. I was sad not to know who her friends were, where she liked to hang out when she wasn’t working, what she liked to eat or drink.
Sometimes I’d be comforted by a fantasy of us being together, just the two of us sharing a pot of tea in front of a roaring fire or going for long walks together. Other times I’d be hit by the realization that we were never going to be part of each other’s lives. I’d feel intense sadness with a childlike lack of understanding as to why I couldn’t be part of her life. It was a small, lost feeling.
Intrusive thoughts of my therapist were distracting in the weeks after therapy closed. I’d think about the structure of her clinic day and imagined her filling ‘my slot’ with a more interesting client. Small things came back to me with an increased significance. The day we both wore the same teal coloured nail varnish felt like an invisible thread of connection between us. Sometimes I’d reflect on very personal things I’d shared with her and I’d feel exposed; embarrassed that I’d been so open, almost as though her kind understanding was now lost to me.
Making sense together and apart
It took a bit of work in follow up sessions to face what was actually going on for me. I’d developed an obsession with my therapist; I loved her. The point in the follow up session where this was acknowledged was an enormous moment of both disclosure and fear for me. I can’t remember exactly what was said, just a feeling of terror and vulnerability. Her manner stuck in my mind more than her words; she was calm and reassuring. The strong sense I had of my therapist was that in her kindness she was taking care of me.
Encouraged by my therapist, I told a few close people how I felt about her and each person reacted calmly with understanding. Writing about it was invaluable. Stepping back and reflecting on why I’d developed strong feelings for her enabled me to make sense of it; I began to think about it with less terror and more compassion.
Going through all this self-reflection led to further processing of painful memories of my birth and adoptive mothers, neither of whom were emotionally available to me. I faced up to the real experience of being rejected by my birth mother after our reunion. This was a ‘soft rejection’ which manifested in subtle ways, such as her keeping me a secret from her husband and daughter. She would sometimes, but more often not, send a birthday or Christmas card. And there was her obvious discomfort at my suggestion of meeting up.
My adoptive mother had also been emotionally distant throughout my childhood. Her focus was on developing my independence by pushing me out into the world, when what I most wanted was to be held close. Feeling excluded from my therapist’s life triggered sad days grieving for the lost relationship with my birth mother and the unmet needs I had as a child.
Staying with the loss and finding more of myself
During sad moments, my therapy notes were like a comfort blanket to me. I took them on holiday with me for reassurance two weeks after therapy closed. On one occasion what interrupted me being upset was a hazy memory of my therapist saying you couldn’t be both distressed and curious at the same time as they used different neural pathways in the brain. By trying to recall whether she had actually said that or not and whether it might be true, I’d distanced myself from the emotional reaction. I could see it for what it was; just a ‘to be expected’ feeling.
Over time, by facing up to it and analyzing my reasons for feeling this way towards my therapist, I felt less like an unhinged stalker and more compassionate towards myself. I recognized not only the impact that being separated from my birth mother had had. I also realised how my strategy of burying my needs and not being authentic with those close to me, meant I’d limited the emotional support available to me.
The unique relationship with a therapist, who validated and helped me make sense of my experiences and emotions, was a hugely significant catalyst for me. The emotional processing after therapy closure was helpful but it was hard, often sad work. Letting others in to my private emotional world came tentatively. However on each occasion this led to relief and an immediate, visceral deepening of the relationship.
In time, intrusive thoughts about my therapist stopped hijacking my concentration. I was able to feel the sadness without getting overwhelmed. Thoughts of her existed more in the background and in amongst an enormous amount of positive regard for the therapeutic work we’d done together.
Leaning in and holding firm
The follow-up sessions after therapy had closed were spread out over several months. At any point during these follow-ups I would have gone back into therapy. I felt I still needed it and I voiced that to my therapist in each session. Her response was the same every time – that she didn’t feel I needed therapy; that I was managing well. I’d travel to each follow-up session with a clear rationale worked out of my need for therapy, an optimism that she’d agree and I’d be back having weekly sessions. Then I’d leave each session with a strange conflict of emotions – on the one hand sadness & disappointment that I wasn’t back in regular therapy; on the other a liberating sense of freedom. Looking back I realise how vulnerable I was. In the hands of a therapist without strong ethical practice I could have easily been exploited.
Trusting myself and feeling ready
After five follow up sessions it was time to finally end the therapy. I realized that I wasn’t quite sure what the purpose of going was and that I felt ‘ready’ to finish. The missing-her feeling after the final follow-up was mild and manageable. I was aware of how different it was to my feelings after the previous four follow up sessions when the sadness felt much heavier.
Reaching a place of ‘manageable anxiety’ has been life changing. It’s not gone completely and in all likelihood never will. But through practicing the strategies I’ve learnt and writing in my journal, I can work my way through to understanding and compassion. I am learning to sit with difficult emotions, without trying to escape, by self-soothing, reflection and acceptance. I feel much more known to myself now, more deeply known by others and still loved.