In Therapy

A user's guide to psychotherapy

The Last Minute Bomb in Therapy

The Last Minute Bomb in therapy
Jane and I are having a good, productive session. We seem to have a solid connection, interpretations are flowing, neurons are firing and the unconscious is becoming conscious. I notice the clock is at 48 minutes past the hour, so I begin to summarize our work and shift in my seat, preparing to close the session. Jane, noticing my body language, appears struck by a revelation. "Oh," she says, "I almost forgot ..." The payload doors open and something like this falls out:

... I've decided to break up with John.
... I quit my job today.
... I was really mad at you last week.
... I think I have a tumor.
... my mother died last night.
... I'm feeling like hurting myself.
... this is my last session.

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My jaw drops. I'm the latest casualty of the Last Minute Bomb (LMB). This all-too-common phenomenon occurs when clients divulge a full-session-worthy topic in their last 30 seconds. Experienced therapists have seen dozens of LMBs, but experience doesn't make them any easier. They're frustrating for client and therapist alike because they typically result in rushed or postponed management of the issue.

This being a user's guide for therapy, I'll first discuss a few factors that contribute to clients dropping LMBs then talk about my response. So why would a client drop an LMB?

Time Management - Sometimes clients have several items to cover and do a quick internal survey right before the session. They might have two minor issues and one major issue to discuss and decide to get the smaller ones out of the way before tackling the big one. But then the minor issues take up the majority of the time and they have no choice but to drop an LMB. It's best to just start with the major issue. If you're concerned that the minor issues won't get any air time, sharing your outline with the therapist at the beginning of the session is a good compromise. It might look something like this: "I've got a couple small family things to talk about and one big health concern. I'd like to talk about the health issue and come back to the family stuff if we still have time." This way you're letting your therapist know your outline, and if the smaller issues are pressing, you'll revisit them.

The Passive Approach - Some client/therapist relationships get into a pattern of the therapist asking questions to draw out the client. As I stated once before, this may be helpful as a last resort if you're feeling stuck in therapy, but if you truly have a critical issue this approach may fail. The therapist could poke around all session with questions about your family and friends while you need to discuss getting fired. Don't be afraid to set the agenda for the session. The best therapies are collaborative - you tell your therapist what you want/need to talk about, and she helps you learn about yourself in the process. Waiting for your therapist to finally ask the right question is a waste of your valuable time.

Reluctance - Most LMBs include material that is uncomfortable to talk about. It's human nature to seek pleasure and avoid pain, so I'm not surprised that some people bring up difficult material at the last possible moment. Let's see, 50 minutes of feeling bad talking about my divorce, or 30 seconds? The problem is, by dropping an LMB you prevent yourself from reaping the full benefit of therapy. You end up avoiding the treatment as well as the pain. In order to grow in self understanding, we need to learn to tolerate the discomfort of vulnerability, intimacy and strong emotion.

Testing - Whether conscious or unconscious, it seems some LMBs are a test of the therapist's boundaries. Clients pay for their time, and each minute beyond that eats into the therapist's time. Some clients may want to know if they or their dilemma are important enough for the therapist to give their personal time to attend to it. This "are you willing to break the rules for me?" test is a dangerous slippery slope. If you wonder how your therapist feels about you, ask. You'll learn and grow a lot more by putting this question into words rather than acting it out.

Slipped My Mind - Sometimes, the issue really doesn't occur to you until the last minute. You're as perplexed as the therapist as to why you didn't think of it sooner. Now you've got two concerns to tackle: your repression of the topic and the topic itself. Has this happened before? It's not uncommon for people to repress highly emotionally charged material, but it's definitely worth exploring with your therapist. You may want to ask for an extra session to allow time to cover both these areas if you'd rather not wait a week.

Back to my response to LMBs. I've got two choices: end the session as planned, adhering to the agreed-upon boundary of time, or scrap the rules and discuss the new material, certainly losing the 10-minute cushion between sessions and possibly eating into the next client's time.

Of course, my response depends on the severity of the issue. If someone's wellbeing is in jeopardy (meaning there is a threat of harm to her or someone else) I'll certainly take the time to discuss the issue. But apart from that, I'll need to end the session out of respect for her time, my time and the pre-established boundary. I'll offer an additional session later in the week, time permitting, but today's session must end. While it might seem harsh, the jolt of ending abruptly today may help us prevent LMBs in future sessions.

Ryan Howes, Ph.D., is a clinical psychologist, writer, musician and professor at Fuller Graduate School of Psychology in Pasadena, California.

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