I lost a patient the other day. He didn’t die or anything; he just emailed to say he didn’t want to come any more. “No! Wait! Why?” I wanted to shout. “It was going so well! You told me all that horrific stuff you’ve never told anyone before. We haven’t even got going yet!” It was like being dumped by email after a few intense and moving dates. I wrote back saying that of course I understand how hard therapy can be; I know how important it is to feel a sense of autonomy, but I think we should meet to discuss his reasons for leaving or at least to say goodbye. No reply. I remember the same thing happening to someone in my first supervision group. He’d waited longer than anyone to get a patient. Week after week he’d turn up to listen to our smug session notes and week after week he’d be told that nobody suitable had come up for him yet. I heard one supervisor say: “The patients getting referred for NHS psychotherapy are much iller nowadays. Not suitable for a trainee.” Psychiatric units are closing and the open ones are full, so patients who might once have qualified as in-patients are now coming for weekly therapy. Nobody is going to let a trainee loose on them. This trainee reminded me of a student on my Psychoanalytic Theory course who couldn’t find a baby for observation. Baby observation is supposed to be good practice for becoming a therapist—picking up unspoken communication and, sometimes, creating a feeling of safety for both the mother and the baby. It’s a nightmare for male trainees because not many new mums want some silent bloke in their house staring at their child. This babyless student started accosting pregnant women in supermarkets trying to find someone. Anyway, finally the trainee got a patient. He was nervous and excited and a supervision session was spent on how he should approach the initial meeting, how to make the offer of therapy, what to wear (a tie), how much time to allow and so on. The patient stopped coming after three sessions. At the time we talked a lot about why patients leave therapy, how some people just can’t face the scrutiny and the intimacy. We nodded understandingly and made encouraging throaty noises where appropriate. Our gently maternal supervisor calmed him with her benign gaze. Privately though, we all thought it was the therapist’s fault. He was so apologetic, his tie was a bit weird, there was something off-putting about him in general. In this fantasy, no patient of mine would do anything but beg for more sessions, for more of my great insight and enormous personal charm and charisma… But I lost one. I can tell myself it’s because he didn’t really want therapy—his wife sent him (disastrous). I can tell myself his background is so disturbed that opening up was unbearable. I can tell myself he wanted to give me a taste of his own sense of abandonment. I ran away from my own analyst more than once, never because he was crap but because I was acting out my own stuff. And yet the self-doubt is consuming. I wonder how that patient is. How the trip to China went. How he feels about the way it ended. My supervisor had this to say: “Some you win. Some you lose. You can’t make someone stay in therapy.” And we moved on to the next student.

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