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Therapy

What Comes Out at the End of Therapy, and Why It Matters

"Doorknob comments" define the boundary, when they come up.

Key points

  • "Doorknob comments" are things ripe with unexplored significance people say at the end of a therapy session.
  • There is usually no time left to address their significance, unless there is an emergency or other reason to extend the time.
  • Doorknob comments become less common over the course of one's therapy, as the capacity to communicate and collaborate deepens.
  • Working through doorknob comments, their impact, and the meaning they convey contributes to personal growth.

Co-authored with Fara White

There’s a phenomenon called "doorknob comments” by therapists. Recently, podcast cohost Fara White and I, on the Doorknob Comments podcast, explored this phenomenon—here are some of the highlights. Hand on doorknob, session ending, something major comes out… then, see you next time? What to do?

What is a "Doorknob Comment"?

Doorknob comments (2013) are defined as:

“...instances in which a patient produces important material while leaving the session—in some cases literally with one hand on the doorknob. If and when it is appropriate to extend the session length in order to process these comments immediately or to defer this conversation until the next session is an important clinical question.”

Most doorknob comments are non-urgent and unconscious revealing important things in a potentially anxiety-provoking way. Of course, that’s part of what it means to be a therapist. They challenge the frame and boundaries of the session, coming right at the end when "we have to stop for today."

Here are 8 common examples of what doorknob comments are about, with illustrations:

  1. The therapy: “I am not sure if this is the right therapy for me. I scheduled an appointment with a new therapist.” “By the way, I’ll be away on business for the next three weeks. See you in May." “FYI, I decided to stop therapy. Today was our last meeting. Thanks so much for all you’ve done.”
  2. Personal development: “I don’t know why I didn’t say anything earlier, but I realized after we spoke last time that I need to overhaul my life. I’m going to start by selling all of my belongings and move to Costa Rica. Do you think I should?”
  3. Work: “By the way, I got fired yesterday. I wasn’t sure if I wanted to talk about it.” “I decided to quit my job and go back to school, like you suggested." [therapist doesn't think they suggested it]
  4. Basic psychological concerns: “I'm seriously depressed, again. Sorry, I should have brought it up earlier.” "I think I might be narcissistic. Am I?"
  5. Substance and alcohol use: “I’m not sure if this is important to mention, but I guess I should tell you I’ve been drinking a lot more. It feels like I'm losing control.”
  6. Safety: “You know, I’ve started feeling suicidal again last week. I didn’t want you to worry but I guess I should say something.”
  7. Family relationships: “Hope you have a great holiday. I’m going to be spending Thanksgiving with my family whom I haven’t seen in twenty years.” Or “I just found out I have a half-sibling. Have a good week!”
  8. Your therapist: “So where are you going on vacation? What are you up to for the summer?”1 “Hey, I saw you last week at a nightclub. Nice moves, doc.” "So, what were you looking for at Duane Reade the other day?”

Here are 6 common underlying dynamics underlying doorknob comments:

  1. Not enough time: It may be that there isn’t enough time in the session or in the therapy itself—if doorknob comments happen regularly, meeting more often may be the proper remedy. Sometimes the stress around ending the session brings up feelings of abandonment or rejection that provoke a reaction in the form of the doorknob comment.
  2. Early days: It may be that the therapeutic relationship is still young, making it harder to bring up emotionally charged issues. If there are trust issues in the therapeutic relationship, the patient may be reluctant to bring something up.
  3. Avoidance: It may be that the patient has social anxiety or embarrassment, leading to difficulty speaking about things openly earlier on.
  4. Defensiveness: The patient may have “defenses," characteristic ways of relating to others or managing themselves, which leave many things off until the eleventh hour.
  5. Checking: Bringing things up at the end of the session, again generally unconsciously, allows patients to see how the therapist responds to "being put on the spot," testing the frame of treatment and the safety of the relationship. Testing boundaries is a healthy developmental activity and is welcomed, even when unsettling. Routine difficulty stopping on time suggests the need for careful inquiry.2
  6. Countertransference3: Along the same lines, the therapist may not be creating a comfortable environment, leading the other person to hold back because of concern they will not be heard as they need to be. Or the therapist may be influencing the patient in other ways so that they don't bring up important topics, for example by showing discomfort around money issues.

A key realization is that doorknob comments are almost without exception psychologically and/or emotionally driven by one or both participants in the therapeutic process.

Doorknob Comments in the Therapeutic Process

The therapist has to make a snap judgment about what to do. Do they need to extend the meeting? Can they, if they have another meeting? If there is a psychiatric emergency, what needs to happen? If it’s important, but it can wait, what will the implications be for the next appointment? If it can’t wait, is there even time to talk about scheduling to meet sooner?

People in therapy become with time and practice more aware of important ideas lingering beyond the edge of awareness. When they happen over and over, doorknob comments, if managed well, help us learn to notice and express concerns with better timing born out of self-reflective awareness of social context and personal needs. Finding the right words at the right time is an amazing communication skill.

Therapists learn with experience to tune in and say something, rather than waiting to see if they come up “organically” without inquiring. This means that doorknob comments become both less common and more significant when they do come up. Over time, significant experiences like doorknob comments become woven into the texture and history of each therapeutic relationship, often recalled fondly, with amusement sometimes, or sometimes more somberly.

As part of the therapeutic process of developing the capacity for close attachments, acceptance of change, and the development of shared narratives—things which may have been absent or limited during childhood—doorknob comments are important "grist for the mill" (another common expression therapists use which you may not have heard about, meaning "raw material").

Click here to listen to the Doorknob Comments Podcast

LinkedIn image: Prostock-studio/Shutterstock

References

1. There is anxiety around these issues of separation but it may feel scary to ask in the session, since it would mean processing those feelings together.

2. Countertransference is about what the therapist brings into the therapy and what they do with their reactions.

3. If it is always hard to stop on time, there are usually a few possible reasons. One, the therapist may have difficulty ending. Another is that the patient may have feelings about stopping which are not being addressed, something they ought to talk about. In some cases, it speaks to feelings in the therapeutic relationship and may represent a therapeutic problem. Rarely, patients refuse to leave on purpose, though. Typically difficulty around the frame of treatment speaks to unconscious issues.

Margaret Arnd-Caddigan (2013) Don't Let the Doorknob Hit You: A Relational-Intersubjective Exploration of Leaving and Remaining within the Therapeutic Frame, Psychoanalytic Social Work, 20:2, 134-149, DOI: 10.1080/15228878.2013.791868

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