Some phrases never grow old, never become routine. “I love you” is one.” So is “I don’t want you anymore.” It is not that we’ve never heard the words before, but that they are so powerful and fraught with significance (or so hard to say or mean so much) either to the one who utters them or the one to whom they are delivered. In therapy the dread-laden expression is different: “I can’t do more. I need to refer you. Treatment has been long. The lack of progress means we must stop.”

Yes, perhaps it is said differently or becomes evident not through language, but impatience or facial expression or indifference. Where once enthusiasm and intensity bloomed, now the counselor seems to be enduring you, too conscious of the time, growing weary of your moments together. Two of my readers, Claire and Rosie, asked me to write about what permits a therapist not to take this dreaded path, the one leading to his desire to dump you — hoping you “never again darken my door” even if he doesn’t say the precise words I just used. Thanks to them I will try. I speak for myself, but know many therapists who would agree with much of what they will find below.

• I like people. I like stories. I like individuals, not groups. I try to provoke meaningful conversations even with friends, not small talk. The time I spent with my patients was the perfect environment for me to look into a person’s history, history being a favorite subject from my early school years on.
• I learned to notice small signs of progress. Sometimes we advance in microscopic steps. We reach a plateau on the mountain climb of treatment and then must catch our breath or wait for the storm to pass. The old Chinese saying tells us, “A journey of a thousand miles begins with a single step.” Therapists measure their work in moving toward a goal, not reaching it in quick time.

• The work is gratifying. Where else do people come to you, rather than requiring your travel? Watching others grow — helping them grow — generates good feeling on both sides. You receive thanks.
• The work is an honor. New counselors find the responsibility almost overwhelming: another person places his well-being in your hands. A wiser, more experienced, older doc should know (or remind himself) of the implicit tribute his patients give him by their consultation and expectation of his help.
• I received payment for my effort. It was easier to be patient with patients in the knowledge some of my compensation came in a material way. That said, in a handful of cases, long-term clients were thousands of dollars in debt to me before the sessions ended and they achieved the life they wanted. Yes, they did then pay me, usually over time. Healers must not be so self-sacrificing that they become resentful of those they treat.
• The patient’s life was not mine or that of my spouse or children. While clients sometimes wish to be closer to their doctor, the therapeutic distance created by him makes it possible to put treatment still-points in perspective. I am less calm and understanding with my wife and adult children than with those who sought my professional skills. I cared about the people I treated, but (usually) not to the point of a disruption of my equanimity. Thus, I tended to be patient with a lack of movement, thinking of such episodes as a rather commonplace experience not usually requiring a desperate and immediate remedy.
• I was responsible for making therapy fresh. A therapist’s job is to bring his intense focus to every session. He must also reflect periodically on whether he has missed something important. I reevaluated my patient and my approach, made course corrections as needed. A therapist who is often bored or unable to change perspective and look anew at the client is in the wrong profession. I kept it interesting both for myself and for those who put their trust in me. A patient is not your entertainer. The counselor should be emotionally and intellectually engaged on his own
• Of course, if you aren’t putting in the effort, you might wear the therapist down. If you are simply paying for a friend, buying his time because you have affection for him (or using him to replace a missing social life) then he should recognize this and talk to you about it. So long as you rededicate yourself to “the work” of therapy, no ouster need be expected.

• Progress isn’t linear. I once asked my money manager, a professional analyst of financial markets, what he expected in the near term from the stock market. He answered, “It will fluctuate.” What he said was funny, but his comment acknowledged that no one predicts economic busts or booms, much as many people claim to. Therapy doesn’t move in a straight line of ascent from start to finish, anymore more than the stock market goes straight up or down in perpetuity. There are bursts of change, but more often, periods of little movement. I didn’t expect patients to be elite prodigies of self-analysis and courage, sprinting to psychotherapy’s finish line, so I wasn’t desolated if treatment took its time.
• The therapist discovers value in challenges. If therapy were always smooth sailing, counselors would become bored with it.  They would learn nothing new because no greater progress could be made by doing so. Since I lacked a magic wand, I had to continue to consult colleagues, read books, and attend classes. Those who posed therapeutic dilemmas generated some of my growth as a counselor and a person. Why would I wish to cast aside people who were, in effect, helping me to do better?
• Elite athletes are useful models for clinicians. Baseball players grind out a 162-game schedule from April through September, longer if they reach the playoffs. Successful athletes learn to put today’s failure behind them, lest they worry themselves into being unable to perform well tomorrow. I was better than many in my capacity to go home and think about other things, relate to my loved ones, and set the therapist hat on a closet hook. To do otherwise would have burned me out. I was not available 24/7, nor did I guarantee rapid responses to email or phone messages. I made sure I didn’t get used up. A doctor who takes good care of himself is less likely to get tired of you.
• Buddhists provide yet another excellent example for therapists. You know the frustration of a long static line: a line where there is but one indolent checker or ticketing agent taking care of all those in the queue. You have places to go, people to see. Yet your reaction to just this type of setting — one seemingly out of your control — might determine whether you lead a satisfying life: 1) You can be frustrated and make yourself miserable. 2) You might jump to the line’s front and complain, which will not usually make the line shorter or the ticket agent more efficient. 3) You can reframe the experience. A Buddhist would say, in fact, you should be grateful for the line and the plodding employee because they are giving you the opportunity to learn patience. A lengthy term of treatment where every inch of progress is dearly won offers the same opportunity.
• My job was a gift. I performed work that was not always “work.” A summer job during my school years in the 100-degree heat of a metal-stamping factory taught me how soul-killing “work” can be. I later came to make a good living in clean, climate-controlled surroundings as a psychologist. My patients helped me become more patient, more thoughtful, more loving — more grateful. I was my own boss and I took meaning from the relationships and the privilege, the stories and the intimacy. I used my brain, one of my favorite body parts! Living this professional life and remaining (mostly) grateful defused many frustrations.

The task of a therapist is not to say, “You’re fired,” but to find a way through or around, under or over; whether running, crawling, pushing, pulling, cajoling, asking questions, waiting, reconfiguring, staying silent, or getting his own help. Much as some of our patients worry about being put into a dumpster, we are working to get them out of one.

Rest easy.

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The top photo is called Doraemon by istolethetv from Hong Kong, China. The second is named I’ll Miss You Dad by Cecilio M. Ricardo, Jr., USAP. The final image is a highway Sign at the Truth or Consequences, New Mexico Exit taken as part of an August 24, 2009 road trip by CGP Grey.