Expect the unexpected: how doorknob moments provide valuable new material to help you move treatment forward.
We have all had the experience of a patient dropping a bomb—a critical disclosure that moves the treatment forward—on their way out, with a hand on the doorknob.
When the patient becomes distraught following a shocking revelation, it feels at least unkind and at worst harmful to say, “Sorry, too bad you’re bleeding, but we don’t have time to pack that wound.” What to do?
During my residency, I was taught that ending on time is therapeutic for the patient, but not why. Reviewing the literature for guidance on how to better manage this phenomenon, I found only content-driven hypotheses: the patient’s psychodynamics and pathology1; the therapeutic relationship2; the meaning of time vis-à-vis development and childhood events3; the economic value of the time and duration of session time on outcomes4; and others.5
None had sufficient power to quell the doubt that I might violate the do-no-harm mandate if I insisted we end on time.
The Power of the Deadline
Running late derails the day’s schedule (stressful for me) and inconveniences subsequent patients (stressful for them, and possibly undermining their treatments). I know a bomb will drop, but not when, how, or who will drop it. When it hits, making a judgment call about whether to run over or not has been an on-going source of professional stress. Complaining about this to other professionals in my life (an accountant, business consultant, family practice doctor, broker, lawyer, among others) I discovered—surprise—their clients drop bombs on them too.
If the phenomenon is independent of content, then it is likely that the structural element—the impending end of the session—must cause the disclosure.
No deadline, no revelation. Artists use this when producing new work.6 As Duke Ellington said, “I don’t need time. I need a deadline.”
Left-Brain Physicians, Right-Brain Patients
Conceptualizing the functional differences between patient and clinician in the treatment relationship as a metaphor for the functional differences between right and left cerebral hemispheres has surprisingly useful clinical ramifications.
At the cellular level, the brain is a vast, mind-bogglingly complex network of connectivity and plasticity that defies our wish to tag specific areas with specific functions.7 On the macro level though, findings from split brain studies of individuals whose right and left cerebral hemispheres have been surgically separated to treat intractable seizures suggest that each hemisphere, independent of the other, can do all an individual needs to live in the world (with the exception of speech, which is a function of the left side only). There is one caveat: it appears that the 2 sides differ profoundly in mode of functioning, strengths and limitations, and worldview.8
The right side’s focus is broad. Widely networked throughout both hemispheres, it uses bodily sensation (visual, auditory, touch, taste, smell) to process experience, and thinks in images. It lives concretely, moment by moment, in the present. It is comfortable with uncertainty and the unknown because it interfaces directly with the external environment (ie, new data).
The right side processes time without a break in continuity, as an ongoing narrative. It is generative and creates narrative structures to present to the outside world—stories, drawings, dances, songs—without being formally taught how to make them. Somehow, it knows what to do, and does it without conscious intent. Classic examples include the way children draw without a plan, and your hand pulls back from a hot burner before you realize it is burned.
The left side is heavily interconnected within itself, less so globally. This facilitates its primary strength—narrow focus—but it also reflects on a neural level the self-referring nature of its operations. It deals only with what it already knows (ie, the past, and the world it has made for itself). It is analytic, critical, and logical. It uses language to bring to consciousness sensory input delivered by the right side. However, that takes time. The right side has already non-verbally instructed your hand to pull away from that burner before your left side uses the words, “Hot! Pull back!”
The left catalogs time as a series of disconnected, static points and cannot follow or generate a narrative arc. It is self-conscious, bossy, resistant to change, and the source of that nasty inner voice creative people dub The Critic.
When writing an essay (or composing a piece of music, or setting up a scientific study, or bringing forth anything new) the right side creates the raw first draft, and the left then revises, edits, and polishes it. That revision process (left brain) may spark a new idea (right brain), which then needs further modification (left brain), which sparks another idea (right brain), and so on. This dance, called flow, is associated with a profound sense of wellbeing and aliveness.9 When things are going well in treatment, the same kind of back and forth occurs between patient and clinician.
Back to doorknob moments. The appointment is a narrative arc because it has a clear beginning, middle, and end. The patient’s function in the treatment relationship, like the right hemisphere’s, is to present raw material while tracking the time and figuring out how to close the narrative arc (both occur out of consciousness) as the end of the session (the deadline) approaches. One option is the cliffhanger, ie the bombshell disclosure. The clinician’s function, like the left hemisphere’s, is to analyze and think about the patient’s disclosure between sessions, and then use resulting insights to move the treatment forward. Thus, the last-minute bombshell serves both as the end of the current session, and also the beginning of the next installment in the larger creative work in progress.10
Dropping a bomb is not without danger for the patient. Revealing the raw self makes them vulnerable. Once the revelation is out in public, it can never be private again. However, although risky and anxiety provoking, disclosure is necessary to prevent stagnation. The impending end of the session—the deadline—somehow empowers the patient’s right hemisphere to disclose new data against the left’s nay-saying.
To keep revealing new material, patients need to trust us. They often break down after revealing something deeply private. Going with the hypothesis that they released the information because the session was ending, running over time sends patients 2 undesirable, nonverbal messages: 1) we are unpredictable, therefore untrustworthy, and 2) we do not trust them to pull themselves together without us.
In the first, we violate the do-no-harm rule. Lack of predictability arouses anxiety and distrust. In the second, we collude with and/or foster codependence, and again violate the do-no-harm rule. The patient’s right brain notes this (again, out of conscious awareness) and may stop dropping bombs. If a treatment is stagnating, this may be why.
I can tolerate a great deal of patient distress if ending on time guarantees a safe therapeutic environment and facilitates trust. I have found that most patients leave willingly and quickly after the disclosure—because they have done their job. Time to go. Patients use the bulk of the session time to work up to delivering the revelation (again, whether knowingly or unknowingly). They may not need, or even want, my immediate response, for various reasons, the most straightforward of which is simple fatigue. Overcoming resistance is exhausting.
Artists who regularly birth new work know newborn drafts should not be evaluated, judged, and criticized immediately after delivery.11 Such feedback by the verbal self (left brain) is almost always negative, because it rejects what is new in favor of what it already knows. After a patient drops a bomb, we too need the session to end to prevent ourselves from sharing unthought-through reactions.
Before this formulation came to me, the patient’s distress following a last-minute disclosure would influence when I ended the session. Now I end the session on time because it is the therapeutic thing to do.
I predict for patients that they will, at some point, find themselves upset by something they revealed at session’s end. When that happens, they are reassured to be reminded that it is part of the process.
Accepting this premise eliminates the need to make a judgment call under time pressure. But it is still a challenge to end the session gracefully while taking into account the patient and the situation at hand.
The Caveat. My patient “Kate,” while putting on her coat, says she has taken a month’s worth of lithium 2 hours before the session, after a fight with her boyfriend. It goes without saying, but I will say it anyway: the content of this article does not apply to a medical emergency. That requires crisis intervention. I called 911 and rescheduled my next patients in order to get Kate admitted.
The Pseudo Emergency. “Janice” is a divorced mother of 2 boys with an irresponsible ex-husband, in treatment for obsessive compulsive disorder. At the last minute, she sobs that her job is being cut. “What am I going to do? I won’t have insurance. I’ll have to stop coming in. My ex is useless. I’ll lose my house, and we’ll be homeless.” Despite adequate symptom control with medications, when there is a crisis, Janice’s default is to project into a catastrophic future.
Reframing and helping her access self-soothing and problem-solving skills is the work of the next session, so I do not go there, even though it’s killing me not to. Instead, I hand her a tissue and say, “I’m so sorry. When is your last day of work?” After she answers, I say, “We’ll figure it out, but not today. We have to close now. How about you come in for an extra session next week?”
When I feel intense emotional pressure from a patient to run over and to the rescue, I remind myself that doing so erodes trust. It has given me heart to learn that when I close as scheduled, the client often goes on to resolve the crisis between sessions. In fact, that is exactly what Janice did, which confirmed the codependent nature of the pressure and the therapeutic validity of not yielding to it.
Expect the unexpected.12 Embrace those doorknob moments for what they are: new material that you can use to move the treatment forward. Keep it safe for patients to deliver them by ending on time. When you are confident that holding the deadline is therapeutic—and it is—ending skillfully in the face of patient upset becomes a manageable challenge.
Dr Gitlin is a rural psychiatrist in private practice in upstate New York. Her first book Practice, Practice, Practice: This Psychiatrist’s Life was selected as a Finalist by the 2021 International Book Awards in the Health: Psychology and Mental Health category. Her website is danielagitlin.com.
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