Episode 233: Reframing “Goodbye” as a Transition: Guidance from Dr. Tarr

Intro by: David Puder MD

Transcription Help: Valentina D'Annuncio, Al-Baab Khan

Peer Reviewed by: Erica Vega, Joanie Burns PMHNP-BC

By listening to this episode, you can earn 0.5 Psychiatry CME Credits.

Other Places to listen: iTunes, Spotify

Introduction

This episode honors Dr. John Tarr, my late mentor, whose wisdom on ending therapy reflects what I feel now as I lose him. 

I will share a lecture he gave on ending therapy—the “graduation” or “transition” that goes on in therapy. Just like in a patient’s graduation, the therapist’s voice may stay active in their mind. Dr. Tarr and I might be geographically apart, but his presence and my memories of him endure.

I am personally, therefore, both listening to him talk about this and experiencing it to be true. In my tougher moments of life, I can attune to Dr. Tarr’s voice, advice, and kindness.

Dr. John Tarr was a psychiatrist and psychotherapist who trained under Franz Alexander. He passed away on June 12th, 2023, at the age of 94, but with the mind of a young man, while globetrotting in Scotland. After his death, I had a lovely lunch with his widow of 66 years, Beverly, who shared with me that at one point Dr. Tarr wanted to be a radio host—news to me, as he refused to come on the podcast. I believe he was subjugating his earlier life desire to be exhibitionistic to his desire to be supportive of cultivating my aspirations and professional identity.  

He was still seeing clients and mentoring residents at the time of his death. He was a citizen of the world—he was born in South Africa, attended boarding school in India, made trips to Venice for opera and connecting with glass-blowers, maintained ongoing relationships with English book-binders and worldwide orchestral musicians, made frequent visits to France, and had recently completed a trip to China.  

He was my teacher from July 2011 to June 2014. Subsequently, we co-taught psychotherapy classes together from July 2014 till May 2023, 2-5 hours per week.  

His mind was as sharp as ever when he passed. He was an obsessive, lifelong learner. He was thoughtful, encouraging, not prone to self-aggrandizement. 

Through his generativity, encouragement, and wisdom he was a later life father figure to me. 

In the clip, Dr. Tarr talks about how we internalize our mentors, loved ones, and therapists into us and can access them at a future time.  

As a new Resident at Loma Linda University, I had almost no exposure to psychotherapy when I started the Therapeutic Alliance class with Dr. Tarr.  

I remember hearing his words and thinking to myself, “What is he talking about? What? How does this work?” His language was so complex. His words were a symphony of empathic immersion into the hardships we face, reducing shame, creating a space for connection…the opening of the mind. 

It is hard to describe something with which we have no framework to understand.  

I am still understanding what it means to do deep psychotherapy, the type of psychotherapy that stirs up every kind of transference and countertransference possible.  

Back then, I was more curious, trying to understand, trying to translate his erudite pontifications  into things I could grasp.  

Several months before his passing, Dr. Tarr sent an email to me detailing that he would leave me a prized book, Meditations by Marcus Areulius.  

“This is yours on my demise.

There are colored inserts in addition to the gilding.

Bound by Sangorski and Sutcliffe, one of the most famous firms of book binders in the world.  They bound the jeweled Omar Khayam commissioned by Widener (Harvard college library is named for him) and unfortunately sunk in the Titanic.”

I wrote back:

May 9, 2023, 5:09 AM

It will be a treasure to remember you.

I gave a book to a patient. Wrote a note. It was our last visit at Loma Linda before I left for Florida. They restarted with me. Last week she told me every time she misses me she reads a bit. I am sure it will be the same for us.

I can hear Dr. Tarr’s warmth, love and kindness in my mind. He will go with me. His last words to me two days before he passed were, 

“I love and respect you.”  

I wrote him back after our conversation:

Dr. Tarr,

Thank you for sharing your words. I am sorry I was a bit speechless. My words are that I have had several fathers in my life, and you are one of them. Your mentorship has allowed me to succeed in my career. But much more, your mentorship and father-ship has given me a gift of love and support and enthusiasm that often was not there from others. I have tears in my eyes.  I know the way we see God is likely different, but I believe you have the fruit of the spirit—love being the main one. Please know that I am praying for you and will hope for your full recovery, and to see you in July. 

David Puder

The world without him feels like a bit more lonely place. But even as I say that, he still exists, inside me, inside anyone who was his patient, student, anyone who allowed his empathic wisdom to permeate their being.  

In a large part, this whole podcast is a way to carry Dr. Tarr’s spirit, erudite wisdom and prolific empathic teaching forward.  

Now, let’s listen to Dr. Tarr himself as he discusses endings—how they can become transitions, and how his voice, and the voices of our mentors, truly stay with us.

The Emotional Complexity of Goodbyes: Understanding Separation, Transition, and Psychological Impact

Dr. Tarr: 

Goodbye is one of the most visceral things that anybody can have. And it’s experienced idiosyncratically by people in a lot of different ways. There are different separation types. The ideal one is mutually agreed on. That almost never happens. It’s almost always unilateral. Even in psychoanalysis where somebody’s been coming for three or four years, three and four times a week, it’s very seldom, mutually concurred in. It’s usually triggered by one person. 

The mutually concurred in, is the easiest to handle. The one that's thrust on the patient by a rotation is the hardest. They can understand somebody dying. They can understand not going away. It's a huge feeling of abandonment, which I want to talk about. I don't like the word, as I said, “termination.” It has to do with pregnancy. I use the word “transition.” Although, sometimes I slip back into it. When it’s transitioning to another therapist or into therapy, which is a continuation of the talking therapy that goes on inside the person. 

What are the emotions that get stirred up in transitioning? Seventy-five percent of patients have extreme sadness–mourning, feelings of loss. Fifty percent have rage, anger, hostility. Fifty-four percent of patients have a recurrence of their old symptoms. And about a third of patients develop new symptoms all around the issue of parting. It's a very, very potent kind of process. 

The Deep Ties Between Goodbye, Self-Esteem, and Emotional Abandonment

Why does it become so complicated for people?

For one thing, esteem and abandonment issues almost inevitably get triggered. Do you know the Cole Porter lyric:

“Everytime we say goodbye, I die a little. Everytime we say goodbye, I die a little?” 

Non-consciously partings are portrayed as death. And finitude and death are the most potent emotions one can feel. But we experience much more that— the rest of the lyric is (it was a very popular song at one point in the age of the dinosaurs. Perhaps, before you were born):  

“Everytime we say goodbye, I die a little. Everytime we say goodbye, I wonder why a little. Why the gods above me who must be in the know think so little of me, they allow you to go.” 

What is “thinking so little of me”? That means, if they thought more of me, if I had more esteem, this parting wouldn't be happening.

So esteem, in Cole Porter's lyrics, gets portrayed in that way. It also alludes to something else that goes on non-consciously, which is that I ought to be loved forever. And that's why the god business gets triggered in there, too. The gods are involved in triggering separations, which they shouldn't be. What's the opposite of feeling “I have no esteem.” “I'm being rejected.” “I'm being abandoned,” which almost all patients feel, as a matter of fact. 

Here’s another lyric by A.A. Milne: 

“How lucky am I to have had something that makes saying goodbye so hard.” 

That's a different meaning attribution, isn't it? “I've been so lucky to have something and it was so good that it makes saying goodbye so hard.” It's a different kind of connotation. It's very hard to do that. Some patients can, as a matter of fact. Particularly if they can feel that what has gone on is permanent. And it is permanent, as a matter of fact, in many ways. Because, many patients, if in the termination— transition phase of therapy, learn about how the permanence of a voice inside them—that they can carry with them the rest of their lives—which is the dialogue that has gone on between you, that that cannot be taken away. That the insights cannot be taken away. That they can be applied to daily situations. Does any of this sound like… Have you separated from a patient or had a separation? Does any of this feel like it is fitting what I'm saying? 

The esteem component is very important because of the difference between “transitioning because it's desirable now,” and, “I count for so little that I'm being rejected now and being abandoned now.” And that's a very frequent meaning/connotation that gets detected. 

The Psychology of Transition: Renunciation, Abandonment Fears, and the Power of a Fixed Ending in Therapy

Okay, so we are relinquishing when we transition the patient—we are giving up protection and guidance. Is that one of the things that's being given up? We're also giving up a relationship and planning for that and preparing for it and processing it.

Okay. It stirs up giving up protection, but it stirs up abandonment threats, which are profound. Or, is one abandoning somebody or is one coming to the conclusion of a part effort? That effort being the enhancement of life and the transformation into better living patterns that one is hoping for- will take place in a continuing way and in an even more potent way after the therapy is stopped. I have conviction- the development can continue without the therapist when the therapist is stopped. That makes it easier for me to transition with patients. And if the patients believe that, that makes it easier for them too. It takes some convincing sometimes to do that. In part, it's a renunciation and having learned what in life has to be renounced and what cannot be avoided renouncing is one of the steps toward maturity. So, learning about renunciation techniques can be focused on in the end therapy. 

The other thing that can make it very potent toward the end is that when one knows that there's a specific date. Now there's an incubation period between telling a person that therapy will stop at a particular time and from then on to the end of therapy. That's a little bit at odds with our conviction and every writer's conviction about it, that if a resident is starting with a patient or anybody starting with a patient where there is gonna be a fixed outcome. The patient and the therapist should know that from day one in the first session: this therapy is gonna last until June, so and so. That helps keep away from the process of becoming a permanent patient. It also helps facilitate intense focus on the here and now and urgency about change because there's a fixed known. Therapy in which a fixed date is set up in advance, numerous studies have been found to be more potent than one that's open-ended.

Embracing Transition: Opportunities for Growth, Self-Reflection, and Strengthening Self-Worth in Therapy

Okay. What are some of the opportunities as transitioning to independence begins that one can do? First of all, one comes to grips with one's own feelings, how much good have I done? Could I have done more? Could the patient have done more? Dealing with the conditionality of what's been achieved so far and dealing with that explicitly with the patient. That is, what are some of the things that we wish we could have handled better? What are some of the things we wish we could have talked about? What are some of the feelings that haven't changed that you wish could be changed? And beginning with what has been accomplished and what has not been accomplished, what one is disappointed about can bring a huge amount of potency into therapy. So that the focus on in what way have I been helpful to you? In what ways have we not been helpful in our working together? What are the times when mistrust is intruded? What are the times when you felt I didn't understand what was going on? And that can be the most significant part of therapy going over the pluses and minuses of what has gone on. 

How does one attempt to cope with this? First of all, I think the most important part is to try and stabilize self-esteem and the sense of self–that this is part of life. This is not a personal idiosyncratic rejection. You're not being abandoned. This is part of living. This is the part of the way it works. Everything is finite. Nothing lives forever, unfortunately. And we are going to be dealing within the limits of what we have available with as much progress as we can. We are assuming that there's narcissistic disequilibrium in the patient, that their self-worth is inevitably affected by that. And when it is, we try and help stabilize self-esteem and self-worth. That can be even more potent than in the working through part of therapy or the introductory part of therapy.

The Enduring Impact of Therapy: Attachment, Memory, and the Transition to Independence

So a kind of reminiscing about experiences together is one component of what is very desirable. Another is a focusing on that, you know, we can be attached even though we are geographically separated. You have memories of what we've talked about. They're inside you now. You have a version of me inside you. You have feelings that are toward me. Whether we are together or not, those feelings continue. Now, if it's a kind of patient that has had an impact on me, I will say:

“This does not stop my thinking about you. When I'm reminded of…, and I'll pick up a conflict that the patient has had. When I'm reminded of a situation in which you have been rejected in the past and felt so terrible about it, and I encounter a rejecting situation, that will probably trigger in me memories of what we've been talking about. So you will be in my mind and I will be in your mind. And my voice and the things we've said together and your voice and the things that you've said to me are part of your sense of self now.” 

And that can continue short of Alzheimer's, indefinitely. And patients find that helpful, as a matter of fact. And to put it in a kind of an explicit:

“Being attached, though we are apart. Our attachment memories and our attachment representations, and your version of me and my version of you, are now part of our inner lives. And that they're there forever.”

We go a little bit away from “as we think together” and “as we've been working together” and as “you and I have been doing this,” a little more into as “you do this” and as “I do this” and change our language of “togetherness” and “we-ness” a little bit into the, “as you learn to do this” and as “I think about you” and stop using the, “we” quite as much in the collective and diminish that. 

Winding Down Therapy: The Debate on Tapering, Emotional Contagion, and Lasting Transformation

There's a debate about this because there are very few patients that you see more than once a week in psychotherapeutic circles, elsewhere where there are options. There's a huge debate about whether you wind down, I'm seeing somebody three times a week. Do I go to twice a week, and once a week, and taper off or do it abruptly? I'm not for the tapering business, I'm for working as hard as possible in the number of sessions. But there are other points of view about that. 

Can one be enthusiastic, genuinely, about some aspect of the patient's future as we're winding down the therapy? I find it possible to be enthusiastic with every patient about some aspect. I may have been disappointed in a diminished progress in one area, but if there's been progress in one area, and if I am fairly confident that that can continue, then I can be enthusiastic about encouraging the patient to have a new mastered strength. And, I think there's an emotional contagion that goes on between me and patients.

And I think that the mirror neurons pick that up and, and if I am genuinely pleased that something worthwhile is going to be permanently a part of a patient, I want them to know that. And I want them to think. 

Another question that comes up. What about the succeeding visits with the patient? Does one leave with the understanding this is over–this is forever or with certain patients you can call me. I tend to tell patients that I will be thinking about them. And after a period of time when things are settled down, I sometimes would like to be able to call them and inquire what's going on. And I almost invariably would do that about a year later and inquire on somebody, particularly if somebody's not seeing a different therapist, that complicates it a little more.

Now, in some instances, I've invited patients to come in and done a kind of postmortem on the therapy because they're feeling more secure after having stopped it. I would to venture things more, I probably told this illustration before, but one of my earliest patients was a very distressed physician, wonderful woman, volunteered around the world AIDS programs, got addicted to pain medication while a physician, went cold turkey off it, refused even when dental extractions to have any analgesics given cuz she was afraid she'd get addicted. She was bisexual. She had commitment problems. There were issues about adopting children. And it was a very long therapy. Many years after she stopped, she came in, somewhat reluctantly, and I asked her a number of things. But one of the things that really impressed me was that she said: 

“You know, Dr. Tarr, I knew that something was wrong and I knew that something had changed, but I didn't have any conviction that anything could permanently be changed in my life. And I lay there talking three or four times a week. And for the first year I was doing it mainly because you seemed so convinced that it would work and that you seemed so enthusiastic about what you were doing. And I was skeptical about that. And it took about a year before I began to feel that I was involved with that.”

Now, that was a complete surprise to me. I had no idea that she'd had that long a period of tentativeness about seeing me. It also reinforced a little bit that being together, irrespective of what the person is feeling is going on, can in some instances be rather transmuting and transforming, because she did flourish.

The Impact of Early Losses on Therapy Partings: Revisiting Trauma, Coping Strategies, and Emotional Growth

The stages of parting resemble the stages of mourning. So they can be denial, anger, depression, and bargaining. And they can be incremental- when one tries to deal with those incrementally and take them for change.

What I want to say is because breaking up with the therapist or because leaving the therapist is a parting, it's gonna be very significantly affected by the outcome of multiple past parting experiences. Particularly, if there were profound losses in early childhood. Particularly if there was an abandonment by a spouse, at some point. And what is useful about keeping that in mind is that that can get activated in the parting dealings with parting from the therapist to re-visit, or sometimes to visit for the first time some of the most significant losses from the past. So you have potency then, when in the present there's a prescribed parting taking place to open up the forced partings that a person's had to undergo in the past. And the quality of what goes on is very largely determined by how past losses have been dealt with.

The other side of that is that one can then maturate into developing new coping patterns for dealing with losses that one hasn't been able to develop from the past. So I think that there can be strong potency in loss, survival, modulation techniques in the last days of therapy. I think a lot of countertransference gets stirred up when we think about what we intended to do and hope to do with the patient. With some patients, there's a phrase that people use, “What's the escape velocity”? Some patients have been so aggravating that some therapists really want them to have a get out of there with high escape velocity. Unfortunately, that does happen. It happens to almost everybody. Although I've been very fortunate and I'm very selective about patients. I've not had the busiest practice in the world, but I've had the most gratifying. But I've only picked people that I really wanted to live with for a long period of time.

And I have at least three patients right now that I'm gonna have to have a terrible personal struggle saying goodbye to. Because I just don't want them to leave. 

David Puder: 

And, do they want to? 

Dr. Tarr: 

No, they don't want to. And I'm feeling partially- one of them I've been probably seeing for 30 years, three times a week. And another one I've been seeing almost that long. And this new guy that I have, that is so promiscuous. He is one of the most intelligent people I've ever had. And I just love getting involved in his world, which is mastery and control in some areas of life and absolute helplessness in others. Absolute helplessness. In an intellectual sense he can argue with anybody in the world. And he's the premier person in his field and his book is the standard text in the field. But when it comes to emotions and connectedness, he's lost, absolutely lost. 

Student:

What is developmentally, what do you think, would be behind that? You know, kind of one area gets strong and the other one doesn't develop?

Dr. Tarr:

There are different lines of development. Freud wrote on lines of development. There's a line of development of morality. There's a line of development of autonomy. A line of development of the superego. There's a line of intellectual mastery of the things. And he was gifted and brilliant and it worked. And he had a tyrannical grandfather he was sent to live with at a very early age. And he had a stepfather who was abusive. And he had a narcissistic mother, who was a famous politician. And he had a very complicated childhood. And he doesn't trust anyone. I'm the third or fourth therapist he's had. And what he's telling me is that he's never been involved in any relationship in which he feels as secure. And how that came about, I'm not sure. I'm not that different, much different, with him than some of the other people that have seen him in other things.

But there is an idiosyncratic chemistry with certain patients that you can't put words on- that just flows. An answer to your question, there are independent lines of development and maturation, which are not concurrent with each other and can be paralyzed in some areas and have what we used to call fixations in development. There are other people who've gone beyond that. And then they will regress and go back to the point of fixation. There's some people who've never gone beyond it. It is an actual fixation, so it's not a regression. 

Okay. So just in the last couple of minutes. Earlier losses dominate whether termination occurs at favorable or difficult times in the person's life, is a big factor. If somebody's just gotten promoted versus somebody hasn't gotten promoted, stopping therapy is gonna be a very different situation depending on that.

The reactions to termination will be significantly influenced by the level of the patient's earlier capacity to achieve mastery over the separation-individuation crisis. That's the bottom line. They're gonna be influenced by the here and now, but also some significantly from the past. Okay. What are some of the coping strategies that get used? Avoiding emotions, idealizing the therapist or the patient, a negative transference, pain and grief exaggerated. Some patients deny that it's really stopping– it's gonna be going on forever. There's self-blame: if I'd been a better patient, if I'd been more interesting, he would want to continue with me. Rage for what gets perceived as abandonment or object loss. Devaluation of the therapist–very frequent. It is easier to depart from somebody whom you're reducing in value. Devaluation of the self. Return of the symptoms, which should ensure that the relationship continues. What are the main things one tries to do?

Sustaining Esteem and Positive Coping Through Therapy Termination: A Structured Transition

Sustain esteem. Respect what's positive in the patient and that can continue in the future. Talk about the fact that there is permanence in the patient, in oneself.

“I've been altered by working with you. You've been altered by working with me. I will be thinking about you. You can think about what we said when stress arises. We can rehearse together how on your own you can handle the most significant losses.”

And I think perspective rehearsal in the final parts of transitioning are very helpful. Structuring it as graduation and as a new beginning and in a positive kind of way. Reinforcing over and over again that there's been an internalization of coping patterns, of insights, of emotional experiences. And that internalization can be positive and can be permanent. 

In some instances, when the patience will be continuing, focusing on there is an institutional transference- even though you're not seeing me, you’re coming to the same place, the same offices, same institution. Because there are institutional transferences that can help patients get through this. I use explicit words at times. “You know, my voice can stay active in you. Things I'm saying now you can remember, you can quote them to yourself. You can have a dialogue with me even though we are not talking for it.” So, I'm saying that planning for it, and preparing for it, and processing it can be rather important. 

Outro

Dr. Tarr with erudite wisdom expresses how ending treatment can bring up previous losses and meanings can get attached and potentially modulated in the process.

Therefore it is important to look at the meanings attached to the ending of treatment.  Do they feel that if the gods cared about them, this would not happen?  Do they feel “I count for so little, I am being rejected now.”  

Or rather, can we look at how parts of the goodness of treatment will go with them, empowering future connectedness with life. Can we together have the conviction that the client’s development will continue without the therapist?

Dr. Tarr may no longer be with us, but his wisdom and spirit are still a part of me, and they’re a part of anyone whose life he touched.