Pod Insights Psychiatry & Psychotherapy Podcast Reframing "Goodbye" as a Transition: Guidance from Dr. Tarr About this episode How do we navigate therapy termination as a transition rather than a loss? In this episode, Dr. John Tarr explores the emotions, challenges, and growth opportunities that come with ending therapy. We discuss how termination triggers past attachment wounds, the psychological impact of separation, and how therapists can guide patients through this process. Learn how reframing 'goodbye' can lead to lasting transformation, self-reflection, and autonomy. Whether you're a therapist or someone in therapy, this episode provides deep insights into the complexities of closure, loss, and resilience in psychotherapy.
Link to blog. https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-233-therapy-termination-transition-growth
Link to YouTube video. https://youtu.be/uvtw_zsSDjw
Transcript Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.
0:14 David Puder? This episode honors Dr. John Tarr, my late mentor, whose wisdom on ending therapy reflects what I feel now as I lose him. I will share a lecture he gave on ending therapy, the graduation, transition, that goes on in therapy as someone leaves. Just like a patient's graduation, the therapist's voice stays active in their mind. Dr. Tarr and I geographically may be apart, but his presence and my memories of him endure. I am personally therefore both listening to him talk about this, but also experiencing it to be true.
0:58 David Puder? In my tougher moments of life, I can funnel Dr. Tarr's voice, advice, kindness.
1:07 David Puder? He was a psychiatrist and psychoanalyst who trained under Franz Alexander. He passed away June 12th, 2023, at the age of 94 in Scotland, while globe trotting with the mind of a young man. After his death, I had a lovely lunch with his widow of 66 years, Beverly, who shared that at one point, Dr. Tarr wanted to be a radio host, which was news to me, as he refused to come on my podcast. I believe he was subjugating his earlier life desires to be exhibitionistic for his desires to be supportive of cultivating my aspirations and professional identity.
1:52 David Puder? He was still seeing clients and mentoring residents at the time of his death. He was a citizen of the world, born in South Africa, boarding school in India, trips to Venice for opera and connecting with glass blowers. He had ongoing relationships with bookbinders in England, worldwide orchestral musicians, and frequent visits to France and a recent one to China with his wife.
2:17 David Puder? He was my teacher from July 2011 to June 2014. Subsequently, we co-taught psychotherapy classes together from July 2014 to May 2023. This was around two to five hours per week and a great highlight of my week, I might add. His mind was as sharp as ever when he passed. He was an obsessive, lifelong learner, thoughtful, encouraging, not prone to self-aggravatism. Through his generativity, encouragement, and wisdom, he was, to me, a later-life father
3:02 David Puder? figure. In this clip, he talks about how we internalize our mentors, loved ones, and therapists into us and can access them at a future time. I remember as a new resident at Loma Linda University, I had no exposure to psychotherapy. And Dr. Tar really was that early exposure in his class on therapeutic alliance. I remember hearing his words and thinking to myself, what is he talking about? What is this? What are all these words? His language is so complex. His words were a symphony of empathic immersion into the hardships we face, reducing shame, creating space for connection, and opening of the mind.
3:47 David Puder? It is hard to describe something which we have no framework to understand, and I hope over the course of listening to this podcast, you will have a framework. That was something that I wanted to pass on. I'm still trying to understand what it means to do deep psychotherapy, depth work, the type of psychotherapy that stirs up every kind of transference and counter-transference. Back then, I was more curious, trying to understand, trying to translate things into something I could grasp.
4:22 David Puder? And so I hung on his every word, wrote copious notes, and you are now the beneficiary throughout this podcast of many of those lessons. Several months before his passing, he sent me an email detailing that he would leave me a prized book, Marcus Aurelius' Meditations. He wrote, "This is yours on my demise. There are colored inserts in addition to gilding. Bound by Sengorski and Setcliffe, one of the most famous firm of binders in the world, they bound the jeweled Omen Krishman commissioned by Widener.
5:03 David Puder? Harvard College Library is named for him and unfortunately sunk in the Titanic." I wrote back, "It will be a treasure to remember you. I gave a book to a patient, wrote a note. It was our last visit before I left to Florida. They restarted with me later. Last week, she told me, every time she misses me, she reads a bit. I'm sure it will be the same for us. I can hear Dr. Tarr's warmth, love, kindness in my mind. He will go with me." His last two words, two days before he passed.
5:48 David Puder? "Where I love and respect you." I wrote back to him in an email after our conversation. "Dr. Tarr, thank you for sharing your words. I am sorry I was a bit speechless. My words are that I have had several father figures in my life, and you are one of them. Your mentorship has allowed me to succeed in my career, but more, your mentorship and fathership has given me a gift of love and support and enthusiasm that was often, was not there from others. I have tears in my eyes.
6:29 David Puder? I know the way we see God is different, but I believe you have the fruit of the Spirit love being the main one. Please know that I am praying for you and will hope for your full recovery and to see you in July."
6:48 David Puder? The world without him feels a bit more lonely. But even as I say that, he still exists inside me, inside anyone who was his patient, student, anyone who allowed his empathic wisdom to permeate their being. In a large part, this podcast is a way to carry Dr. Tarr's spirit, erudite wisdom, and prolific empathic teaching forward. Now, let's listen to Dr. Tarr himself as he discusses endings, how they become transitions, and how his voice and the voice of our mentors truly stay with us.
7:31 Speaker 01 Goodbye is one of the most visceral things that anybody can have, and it's experienced idiosyncratically by people in a lot of different ways. There are different separation types. The ideal one is mutually agreed on, that almost never happens. It's almost always unilateral. Even in psychoanalysis, where somebody's been coming for three or four years, three and four times a week, it's very seldom mutually concurred in. It's usually triggered by one person. The mutually concurred in is the easiest to handle. The one that's thrust on the patient by a rotation is the hardest. They can understand somebody dying. They can understand not going away.
8:16 Speaker 01 Huge feeling of abandonment, which I want to talk about. I don't like the word, as I said, termination. It has to do with pregnancy. I use the word transition, although sometimes I slip back into it. What is transitioning to another therapist or into therapy, which is a continuation of the talking therapy that goes on inside the person? What are the emotions that get screwed up in transitioning? Seventy-five percent of patients have extreme sadness, mourning, feelings of loss. Fifty percent have rage, anger, hostility. Fifty-four percent of patients have a recurrence of their old symptoms. And about a third of patients develop new symptoms,
8:59 Speaker 01 all around the issue of parting. It's a very, very potent kind of process.
9:08 Speaker 01 Why does it become so complicated for people?
9:15 Speaker 01 For one thing, esteem and abandonment issues almost inevitably get triggered. Do you know the Cole Porter lyric? "Every time we say goodbye, I die a little."
9:31 Speaker 01 Every time we say goodbye, I die a little. Non-consciously partings are portrayed as death. And finitude and death are the most potent emotions one can feel. But we experience much more than. The rest of the lyric is, as it was a very popular song at one point in the age of the dinosaurs, perhaps, before you were born. "Every time we say goodbye, I die a little. Every time we say goodbye, I wonder why a little. Why the gods above me, who must be in the know, think so little of me, they allow you to go." What is thinking so little of?
10:13 Speaker 01 That means if they thought more of me, if I had more esteem, this parting wouldn't be happening.
10:20 Speaker 01 So esteem, in Cole Porter's lyrics, gets portrayed in that way. It also alludes to something else that goes on unconsciously, which is that I ought to be loved forever. And that's why the god business gets triggered in there, too. The gods are involved in triggering separations which they shouldn't be.
10:44 Speaker 01 What's the opposite of feeling, "I have no esteem, I'm being rejected, I'm being abandoned", which almost all patients feel, as a matter of fact?
10:58 Speaker 01 There's another lyric by Sobieski. "How lucky am I to have had something that makes saying goodbye so hard?"
11:10 Speaker 01 That's a different meaning attribution, isn't it? I've been so lucky to have something, and it was so good that it makes saying goodbye so hard. It's a different kind of connotation. It's very hard to do that. Some patients can, as a matter of fact, particularly if they can feel that what has gone on is permanent, and it is permanent, as a matter of fact, in many ways. Because many patients, if in the termination, transition phase of therapy, learn about how the permanence of a voice inside them that they can carry with them the rest of their lives, which is the dialogue that has gone on between you,
11:55 Speaker 01 that that cannot be taken away. The insights cannot be taken away, that they can be applied to daily situations. Okay. So what are we renouncing? Does any of this sound like it's... Have you separated from a patient or had a separation? Does any of this feel like it's fitting what I'm saying? The esteem component is very important because the difference between transitioning because it's desirable now and I count for so little that I'm being rejected now and being abandoned now. And that's a very frequent meaning connotation that gets attacked.
12:40 Speaker 01 Okay, so we're relinquishing when we transition a patient. We're giving up protection and guidance. Is that one of the things that's being given up? We're also giving up a relationship and planning for that and preparing for it and processing it. Okay. It stirs up giving up protection, but it stirs up abandoned threats which are profound.
13:12 Speaker 01 ¿O alguien está abandonando alguien? ¿O alguien llega a la conclusión de un esfuerzo en parte? Ese esfuerzo siendo el mejoramiento de la vida y la transformación en patrones de vida mejores que uno espera se llevará a cabo de una manera continua y de una manera aún más potente después de que la terapia se detenga. Tengo la convicción que el desarrollo puede continuar sin el terapeuta cuando el terapeuta se detenga. Eso me hace más fácil pasar con los pacientes y si los pacientes creen eso eso también les hace más fácil.
13:54 Speaker 01 Les toma convencer a veces para hacer eso. En parte, es una renunciasión y haber aprendido lo que en la vida tiene que ser renunciado y lo que no puede ser evitado renunciar es uno de los pasos hacia la madurez. Así que aprender sobre técnicas de renuncias se puede centrar en el final de la terapia. Lo otro que puede hacerlo muy potente hacia el final es que cuando uno sabe que hay una fecha específica. Ahora, hay un período de incubación entre decirle a una persona que la terapia se detendrá en un momento particular y desde entonces hasta el final de la terapia.
14:39 Speaker 01 Eso es un poco a la par con nuestra convicción y la convicción de todos los escritores sobre ello. Que si un residente empieza con un paciente o alguien empieza con un paciente donde va a haber un resultado fijo, el residente va a estar en marcha. Los pacientes y el terapeuta deben saber eso desde el primer día en la primera sesión. Esta terapia va a durar hasta junio, entonces. Y eso ayuda a mantenerse alejado del proceso de convertirse en un paciente permanente. También ayuda a facilitar un foco intenso en el aquí y ahora y la urgencia de nuestro cambio porque hay un conocimiento fijo. Y la terapia en la que se establece un día fijo en advance
15:24 Speaker 01 y numerosas estudios han encontrado ser más potente que una que es abierta.
15:31 Speaker 01 ¿Qué son algunas de las oportunidades cuando se comienza la transición a la independencia? En primer lugar, uno se acerca a sentir con sus propios sentimientos. ¿Cuánto bien he hecho? ¿Pudería haber hecho más? ¿Pudería haber hecho más el paciente? Tratar con la condicionabilidad de lo que se ha conseguido hasta ahora. Y tratar eso expresamente con el paciente. Es decir, ¿cuáles son algunas de las cosas que deseamos que hubiéramos tratado mejor? ¿Cuáles son algunas de las cosas que deseamos que hubiéramos hablado? ¿Cuáles son algunos de los sentimientos que no han cambiado que deseamos que se cambiara? Y empezando con lo que se ha conseguido y lo que no se ha conseguido.
16:15 Speaker 01 Lo que uno se decepciona puede traer una gran cantidad de potencia en la terapia. Así que el enfoque en ¿de qué manera he sido útil a usted? ¿De qué maneras no hemos sido útiles en nuestro trabajo juntos? ¿Cuáles son los momentos en los que se ha entrado el miedo? ¿Cuáles son los momentos en los que se sintió "No entendía lo que estaba pasando"? Y eso puede ser la parte más significativa de la terapia, repartiendo los pluses y los minuses de lo que ha pasado.
16:48 Speaker 01 ¿Cómo se intenta lidiar con esto? En primer lugar, creo que la parte más importante es tratar de estabilizar el autoestima y el sentido de sí mismo. Esto es parte de la vida. Esto no es una rechaza idiosincronética personal. No se está abandonando. Esto es parte de la vida. Esto es la parte de la vida. Todo es finito. No hay nada que vive para siempre, desafortunadamente. Y vamos a estar tratando dentro de las límites de lo que tenemos disponible con el mayor progreso que podemos. Estamos asumiendo que hay un desequilibrio narcisista en el paciente. Que su valor personal es inevitablemente afectado por eso. Y cuando es así, tratamos de ayudar a estabilizar
17:32 Speaker 01 el autoestima y el valor personal. Y eso puede ser aún más potente que en la parte de trabajo a través de la terapia o en la parte introductoria de la terapia.
17:44 Speaker 01 So a kind of reminiscing about experiences together is one component of what is very desirable. Another is a focusing on that, you know, we can be attached even though we're geographically separated. You have memories of what we've talked about. They're inside you now. You have a version of me inside you. You have feelings that are toward me. Whether we are together or not, those feelings continue. Now, if it's a kind of patience that has had an impact on me, I will say, "This does not stop my thinking about you." When I'm reminded of, and I'll pick up a conflict that the patient has had,
18:29 Speaker 01 when I'm reminded of a situation in which you have been rejected in the past and felt so terrible about it, and I encounter a rejecting situation, that will probably trigger in me memories of what we've been talking about. So you will be in my mind, and I will be in your mind. And my voice and the things we said together, and your voice and the things that you said to me are part of your sense of self now. And that can continue short of Alzheimer's indefinitely. And patients find that helpful, as a matter of fact. And to put it in a kind of an explicit, being attached though we're apart, that our attachment memories and our attachment representations
19:12 Speaker 01 and your version of me and my version of you are now part of our inner lives and that they're there forever. We go a little bit away from as we think together and as we've been working together and as you and I have been doing this, a little more into as you do this and as I do this and change our language of togetherness and we-ness a little bit into the as you learn to do this and as I think about you and stop using the "we" quite as much in the collective and diminish that. There's a debate about, because you don't face this because very few patients that you see more than once a week. In psychotherapeutic circles elsewhere where there are options,
19:57 Speaker 01 there's a huge debate about whether you wind down. If I'm seeing somebody three times a week, do I go to twice a week and once a week and taper off or go in abruptly? I'm not for the tapering business. I'm for working as hard as possible in a number of sessions. But there are other points of view.
20:15 Speaker 01 About that. Can one be enthusiastic genuinely about some aspect of the patient's future as we're winding down the therapy? I find it possible, I found it possible to be enthusiastic with every patient about some aspect. I may have been disappointed in diminished progress in one area. But if there's been progress in one area, and if I'm fairly confident that that can continue, then I can be enthusiastic about encouraging the patient to have a new mastered strength. And I think there's an emotional contagion that goes on between me and patients. And I think that the minaroneurones pick that up.
20:59 Speaker 01 And if I am genuinely pleased that something worthwhile is going to be permanently a part of a patient, I want them to know that. And I want, I want them to think of it. Another question that comes up. What about the succeeding visits with the patient? Does one leave with the understanding, this is over, this is forever? With certain patients, you can call me, and certain patients. I tend to tell patients that I will be thinking about them, and I, after a period of time when things have settled down, I sometimes would like to be able to call them and inquire what's going on. And I almost invariably would do that about a year later. And inquire on somebody that's, particularly if somebody's not seeing a different therapist.
21:44 Speaker 01 That complicates it a little more. In some instances, I've invited patients to come in and done a kind of post-mortem on the therapy. Because they're feeling more secure after having stopped it. I would have ventured things more. I probably told this illustration before, but one of my earliest patients was a very distressed physician, wonderful woman.
22:09 Speaker 01 Volunteered in, around the world, AIDS programs. Got addicted to pain medication a while a physician. Went cold turkey off it, refused, even when dental extractions to have any analgesics given because he was afraid she'd get addicted. She was bisexual. She had commitment problems. There were issues about adopting children. And it was a very long therapy.
22:43 Speaker 01 Many years after she stopped, she came in somewhat reluctantly. And I asked her a number of things, but one of the things that really impressed me was that she said, "You know, Dr. Tora, I knew that something was wrong and I knew that something would change, but I didn't have any conviction that anything could permanently be changed in my life. And I lay there talking three or four times a week. And for the first year, I was doing it mainly because you seemed so convinced that it would work and that you seemed so enthusiastic about what you were doing. And I was skeptical about that. And it took about a year before I began to feel that I was involved with that.
23:28 Speaker 01 Now, that was a complete surprise to me. I had no idea that she'd had that long a period of tentativeness about seeing me. It also reinforced for me a little bit that being together irrespective of what the person is feeling is going on can in some instances be rather transmuting and transforming because she did flourish. And the stages of parting resemble the stages of mourning. So they can be denial, anger, depression, and bargaining. And they can be incremental.
24:11 Speaker 01 One can try to deal with those incrementally and take them for granted. What I want to say is because breaking up with the therapist or because leaving the therapist is a parting, it's going to be very significantly affected by the outcome of multiple past parting experiences. Particularly if there were profound losses in early childhood. Particularly if there was an abandonment by a spouse at some point. And what is useful about keeping that in mind is that that can get activated in the parting dealings with parting from the therapist
24:54 Speaker 01 to revisit, or sometimes to visit for the first time, some of the most significant losses from the past. So you have potency then, in the present, there's a prescribed parting taking place, to open up the enforced partings that a person's had to undergo in the past.
25:16 Speaker 01 And the quality of what goes on is very largely determined by how past losses have been dealt with. The other side of that is that one can then maturation into developing new coping patterns for dealing with losses that one hasn't been able to develop from the past. So I think that there can be strong potency in loss-survival modulation techniques in the last days of therapy. I think a lot of counter-transference gets stirred up when we think about what we intended to do and hope to do with the patient. With some patients,
26:00 Speaker 01 there's a phrase that people use, "What's the escape velocity?" Some patients have been so aggravating that some therapists really want them to have a get out of there with high escape velocity. Unfortunately, that does happen. It happens to almost everybody. I've not had the busiest practice in the world, but I've had the most gratifying. But I've only picked people that I really wanted to live with for a long period of time. And I have at least three patients right now that I'm gonna have to have a terrible personal struggle overcoming, saying goodbye to. Because I just don't want them to leave. And do they want to? No, they don't want to. And I'm feeling partially
26:46 Speaker 01 one of them, I've been probably seeing for 30 years, three times a week. And another one, I've been seeing almost that long. And this new guy that I have, that is so promiscuous.
27:03 Speaker 01 He's one of the most intelligent people I've ever had. And I just love getting involved in his world, which is mastery and control in some areas of life, and absolute helplessness in others. Absolute helplessness. In an intellectual sense, he can argue with anybody in the world, and he's the premier person in his field. And his book is the standard text in the field. But when it comes to emotions and connectedness, he's lost, absolutely lost. What's that? He is different.
27:42 Speaker 02 What developmentally you think would be behind that, you know, kind of that one area gets strong and the other one doesn't develop?
27:51 Speaker 01 There are different lines of development. And Freud worked on lines of development. There's a line of development of morality. There's a line of development of autonomy. There's a line of development of the superego. There's a line of intellectual mastery of the things. And he was gifted and brilliant and at work. And he had a tyrannical grandfather he was interlured with at a very early age. And he had a stepfather who was abusive. And he had a narcissistic mother who was a famous politician. And he had a very complicated childhood. And he doesn't trust anywhere. I'm the third or fourth therapist he's had. What he's telling me is that he's never been involved in any relationship in which he feels as secure.
28:36 Speaker 01 And how that came about, I'm not sure. I'm not that much different with him than some of the other people who have seen him in other things. But there is an idiosyncratic chemistry with certain patients that you can't put words on, that just flows.
29:02 Speaker 01 In answer to your question, there are independent lines of development and maturation, which are not concurrent with each other and can be paralyzed in some areas and have what we used to call fixations in development. There are other people who've gone beyond that and then they will regress and go back to the point of fixation. There are some people who've never gone beyond it. They're just an actual fixation, so it's not a regression. Okay, so just in the last couple of minutes, earlier losses dominate. Whether termination occurs at favorable or difficult times
29:47 Speaker 01 in the person's life is a big factor. If somebody's just gotten promoted versus somebody hasn't gotten promoted, stopping therapy is going to be a very different situation depending on that.
30:03 Speaker 01 The reactions to termination will be significantly influenced by the level of the patient's earlier capacity to achieve mastery over the separation-individuation crisis. And that's the bottom line. They're going to be influenced by the here and now, but also some significantly from the past. Okay. What are some of the coping strategies that get used? Avoiding emotions, idealizing the therapist or the patient. A negative transference, pain and grief exaggerated. Some patients deny that it's really stopping. It's kind of, it's going to be going on forever. There's self-blame.
30:47 Speaker 01 If I'd been a better patient, if I'd been more interested, he would want to continue with me. Rage for what gets perceived as abandonment or object loss. Devaluation of the therapist, very frequent. It's easier to part from somebody whom you're reducing in value. Devaluation of the self. Return of the symptoms, which should ensure that the relationship continue.
31:16 Speaker 01 What are the main things one tries to do? Sustain esteem,
31:24 Speaker 01 respect what's positive in the patient and that that can continue in the future. Talk about the fact that there is permanence in the patient, in oneself. I've been altered by working with you. You've been altered by working with me. I will be thinking about you. You can think about what we said when stress arises. We can rehearse together how on your own you can handle the most significant losses. And I think prospective rehearsal in the final parts of transitioning are very important. Structuring it as graduation and as a new beginning in a positive kind of way.
32:08 Speaker 01 Reinforcing over and over again that there's been an internalization of coping patterns, of insights, of emotional experiences. And that that internalization can be positive and can be permanent. In some instances, when the transference is going to be... the patients can be continuing focusing on that there's an institutional transference, even though you're not seeing me coming to the same place, the same offices, same institution, because there are institutional transferences that help patient can get through this. I use expressive words at times. You know, my voice can stay active in you. Things I'm saying now, you can remember. You can quote them to yourself. You can have a dialogue with me,
32:53 Speaker 01 even though we're not talking for it. So I'm saying that planning for it and preparing for it and processing it can be rather important.
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