Into The Light
MVP
End times: Coming to the end of psychotherapy
Sleight of Mind
2008.06.03
Will it never end? Perhaps not. There's a follow-up to this post, which you may wish to read: Leaving therapy - so what? (2009.01.15)
Everything ends eventually, including psychotherapy. A grace-full, well managed ending is ideal, but, in reality, ending psychotherapy - leaving a psychotherapy relationship - is a problem for some individuals. Mental health professionals would do well to acknowledge this more often, and respond with some specific suggestions for our clients, before they start wondering whether it?s time to stop, and then how to do it.
PSYCHOTHERAPY AS AN INTIMATE RELATIONSHIP
Intimacy takes many forms. Most intimacy in life is familial. Some occurs in the context of friendship. And some occurs in psychotherapy. In all cases, it is true that intimates know things about each other not generally known by other people in their life.
Intimacy is not always between peers. We may know significant details of the life of our First Family (President, etc.). It?s unlikely that they know anything of us, as individuals. Mothers know more about their children than the children know of them. Psychotherapy relationships are similarly unequal, for in them therapists know more about their clients than clients about therapists.
INTIMACY AND VULNERABILITY
Intimate knowledge creates vulnerability. Where intimate knowledge is asymmetrical, vulnerability is also. Whoever is known most about is usually the vulnerable one, for multiple reasons. In psychotherapy, this vulnerable one is the client.
The specific vulnerability I want to address here has to do with the likelihood that leaving a psychotherapy relationship will be a distressing time for a client. I want to consider the possibility of reducing this distress.
WHY LEAVING PSYCHOTHERAPY CAN BE DIFFICULT FOR YOU
There are so many reasons why this may be so. Here a some of the reasons most immediately obvious to me:
I want to take up here each of challenges I listed above, and possibly a few others that come up as I work things through.
You may never have done it before. First-time therapy clients have a lot of ?firsts? to work through in therapy. Leaving is certainly one of them. If this is not your first therapy relationship you?re more likely to have some knowledge of the challenge of leaving, even if you don?t yet quite know how to do it well. If this is your first time leaving therapy, you really ought to talk about it with your therapist. They, after all, are not first-timers, relative to this issue, and just might be able to help you. If you find it a difficult topic to bring up, then the difficulty you?re experiencing needs to be the first thing you talk about. That difficulty may well be a legitimate ?therapy issue?.
Your therapist may not talk with you about leaving before you begin to feel like the time is close. If we therapists don?t take up this problem and make sense of it, what chance do you have if doing it at all well? We?re interested in getting you into therapy, and keeping you there until we can get some real work done. And then what? We seem to have little to say about this.
When I brought up this topic to my very capable faculty adviser during my internship in graduate school, his reaction was that this concern was not for us to address. ?The client determines when therapy ends?, he said. OK - there?s a very good idea in that sentence, but the problem remains. (And I suspect that if I?d asked the question better I?d have gotten a better answer!)
We have many ideas to offer you. How to leave therapy well seems not to be among them. I?ve never heard this issue seriously discussed in a professional context. We seem not to think about it. We should, because it?s too often a source of distress for our clients. As a client, you cannot fix this problem, but you can realize that part of the problem for you is that too often you?re on your own with the problem. You shouldn?t be, I think, but you usually are. There is a remedy for this, however, and it?s under your control.
You will probably not feel finished, when the issue of leaving comes up. It is rare for a person to have addressed all their problems when they leave therapy. There really isn?t a need to have done this. It?s better to take up focused issues, make progress (any progress at all is better than staying stuck), leave, and then return later if this seems called for. It is realistic to see life as a series of ongoing challenges - and to accept that you?re not going to run out of problems. Do you really think psychotherapy is going to fix this? I wish!
You may not be the one who brings the issue up. If you have to deal with ?managed care?, or have a seriously limited budget, you know that external factors and people can have a real say about when therapy ends. Or?your therapist may be moving, or retiring, or going on vacation. Your situation then is one of feeling unfinished but having to leave anyway (see the paragraph above, concerning this). This can be difficult, but it can also be talked about, and learned from. See that this is how it gets handled in your case.
You may have real conflict about leaving - feeling like you want to leave AND you want to stay. This is very common, for many reasons. The best thing to do is to take up the matter of the conflict(s) you feel with your therapist (do you notice a theme in my remarks, here?). Such conflicts arise from the fact that our mind virtually always holds multiple points of view about critical issues. These conflicts are part of being human, so talk about it. It?ll help, and it?ll often work to actually resolve the conflict.
You may be aware that your therapist is more engaged in working with your problems than you are, and you don?t have any idea what to do about this. In a sense, this shouldn?t happen, but it often does, anyway. First of all, it?s probably generally true that your therapist experiences a degree of fascination with your problems - dealing with them is his/her chosen profession, after all. You, on the other hand feel something other than fascination, and in this there is an essential imbalance.
Nevertheless, the rule is that the client leads. We may invite you to go certain places, but when you indicate disinterest, that settles it. It?s YOUR opinion that counts. I hope your therapist doesn?t forget this, but if they do, you still shouldn?t. If your therapist appears to need to engage with your problems, they have matters to take up with their therapist. This kind of problem is actually common in psychotherapy. Freud talked about it, and we?ve been talking about it since then. What you should know is that it?s OUR problem, not yours.
Therapists are people, and they do have problems, at times, but that should not be your concern. In psychotherapy, you?re expected to be self-centered, and you should maintain this focus right on through the time of your leaving. Your therapist can take care of themselves. They have access to excellent resources for doing this.
You don?t want to hurt your therapist?s feelings. I see this issue come up most often with young women, who are often deeply in contact with their maternal side. Such instincts are one of the glories of humanity, but really don?t belong in the psychotherapy relationship. Your therapist does have feelings, and you likely will be missed. Your therapist also has experience with this problem, and can take care of themselves.
It?s good for you to notice that your therapist values you. You do have value, and we all need to know this. However, children leave home, clients leave therapy, and we all leave life, at some point. It?s the Way of Things. If this is a persisting problem for you, you owe it to yourself to bring this problem to therapy. Doing so is an excellent idea.
You may have no idea how to justify your leaving. Many people in therapy have a history of being disrespected, and thus have some trouble respecting themselves. They often feel defensive or in need of justification. Try to understand that this is a developmental problem which you don?t have to have, and really should not tolerate. If you DO have this problem, take it into your therapy as a topic.
The best reason to leave therapy is a very simple one: you want to. I teach assertion, and I?ll say it plainly: Your feelings are your best justification for anything. (You do well to see that your feelings are based on correct perceptions of course.) If you find this difficult, then you?ve just identified and area in which you need some work, and definitely some practice. Assertion skills definitely have to be practiced. I look for opportunities to practice mine. You should too.
Other people in your life who matter to you may want you to stay in therapy. Who? Parents, spouses, children, friends, employers?did I leave anyone out? While sometimes therapy may be mandated by a judge, in all other cases, it?s your call. People can have any opinion they want. It?s a free country. And you need to keep your own counsel. Participation is your decision. When someone else has feelings about your leaving therapy, take it up with them. Understand that THEY are having a problem. Talk with them to see what?s at the root of the problem (it?ll usually be some fear which isn?t well enough identified). This will help your relationship with them, and may even give you some useful information.
SOME THINGS I WANT YOU TO KNOW ABOUT LEAVING THERAPY
You may not be the only one distressed by the idea of your leaving. We often come to truly like and enjoy our clients. I know that in mine I virtually always see the essential problems of all of us as human beings. I usually develop a strong sense of compassion, and come to care significantly about each individual I work with. How can I look casually upon the prospect of coming to the end of our meetings? I don?t know how to do this, and I?m not sure I want to learn. So, that your distress is likely shared is a very good reason for taking up leaving as a topic, with your therapist. You both should talk about it with each other. Very often the problem is one of dealing with loss - and that?s a problem that challenges all of us, in various ways.
Some therapists are as puzzled by the ?leaving? problem as you may be. Not all therapists grasp that clients will leave with some of the problems they brought into therapy. I can recall our being confronted with the necessary ?unfinished client? problem, by one of our teachers in graduate school. I was already familiar with it, but some of my fellow students had not thought of it, and found it troubling. If your therapist has not grasped this reality, and the fact that it?s not necessarily a problem, you still can. You must, in fact, because everyone leaves unfinished. We?re all a work-in-progress. You think this is a problem? Wait until you face dying, unfinished! (You?ve been warned - so now you have some time to prepare for that one?)
Loss is one of the great themes of everyone?s life - you do well not to turn away from it. Some people, when the time comes, simply run from therapy. It?s the only way they can handle it, but it?s not a good response. Losing your therapist is but one of many losses you will have in your life. USE the experience to address the issue of loss and what it means to you and how you handle it. It?s an excellent chance to add to the benefit you get from your therapy.
Your therapy is about you and what?s good for you. This may seem obvious, yet concern for others and a desire to take care of others, sometimes in inappropriate ways, is common, especially in psychotherapy clients. Your therapist, if she/he has a lick of sense, has done psychotherapy work themselves, and has taken up the issue of loss in the course of that work. He/she comes to their work prepared to handle the eventual loss of clients. You don?t need to be worried or concerned about them. Your attention belongs on you.
You can come back. Surprise! This doesn?t occur to many people. You can think of leaving as an experiment. Do it and see how it goes for you. You can return, if you find that you?re not ready. I?ve had a number of clients return, virtually always for only a short period of additional work. Some have come back 2-3 times. One came back four, and the fourth time was the one where she really got down to work. I was thrilled, and I think she was as well. You can simply take things as they come, just like you have to do with the rest of your life.
SOME GOOD WAYS TO TALK ABOUT LEAVING THERAPY
I want to offer here some little ?mini-scripts? which may help you deal with leaving.
(To your therapist) - ?I?ve been thinking that I?m about finished with therapy. What do you think about that??
(To anyone at all) - ?I?m feeling about ready to leave therapy. It?s been a challenge/good experience/disappointment/real puzzle to me/a life changing experience (pick one or more). I?m ready for a rest.?
(To yourself) - ?I feel about ready to stop. I want to respect that. I can come back if I want to, or go elsewhere, later. I will always have many options.?
(To your spouse) - ?I?m graduating soon from therapy. I hope you?ve been keeping up, because your life is about to get really interesting!?
(To your therapist) - ?Thanks for the challenges, for the patience, for information, for the compassions and caring. I?m not who I was when I came here. I know I?ll keep growing after I leave, and what?s happened here will help to make that good growth. I?m grateful. I hope you think of me from time to time. I know I?ll think of you. Maybe I?ll send you a postcard.? (I always like to hear these sorts of statements. Expressing gratitude is something I very much value. I will often express a lot of it back - I do admire the courage and humanity of my clients. I always am inspired by it. Rarely, I think, do they realize how much they enrich my life. I want them to have some small sense of that. And I always respond positively to the idea of that ?postcard?.)
CONCLUSION
I wrote this originally in one sitting, while thinking particularly of one client of mine (who reported finding it useful), but always had in mind a more general problem, involving many more individuals. What I have written seems incomplete, and unfinished, and I hope to revisit the topic and revise it further, but for now it?s time to go. This, too, is a work in progress.
Sleight of Mind
2008.06.03
Will it never end? Perhaps not. There's a follow-up to this post, which you may wish to read: Leaving therapy - so what? (2009.01.15)
Everything ends eventually, including psychotherapy. A grace-full, well managed ending is ideal, but, in reality, ending psychotherapy - leaving a psychotherapy relationship - is a problem for some individuals. Mental health professionals would do well to acknowledge this more often, and respond with some specific suggestions for our clients, before they start wondering whether it?s time to stop, and then how to do it.
PSYCHOTHERAPY AS AN INTIMATE RELATIONSHIP
Intimacy takes many forms. Most intimacy in life is familial. Some occurs in the context of friendship. And some occurs in psychotherapy. In all cases, it is true that intimates know things about each other not generally known by other people in their life.
Intimacy is not always between peers. We may know significant details of the life of our First Family (President, etc.). It?s unlikely that they know anything of us, as individuals. Mothers know more about their children than the children know of them. Psychotherapy relationships are similarly unequal, for in them therapists know more about their clients than clients about therapists.
INTIMACY AND VULNERABILITY
Intimate knowledge creates vulnerability. Where intimate knowledge is asymmetrical, vulnerability is also. Whoever is known most about is usually the vulnerable one, for multiple reasons. In psychotherapy, this vulnerable one is the client.
The specific vulnerability I want to address here has to do with the likelihood that leaving a psychotherapy relationship will be a distressing time for a client. I want to consider the possibility of reducing this distress.
WHY LEAVING PSYCHOTHERAPY CAN BE DIFFICULT FOR YOU
There are so many reasons why this may be so. Here a some of the reasons most immediately obvious to me:
- You may never have done it before.
- When the issue of leaving occurs to you, you may not feel finished with therapy.
- Your therapist may not talked with you yet about leaving, at the time you begin thinking about it.
- You may have real conflict about leaving.
- You may not be the one who brings the issue up.
- You may be aware that your therapist is more engaged in working with your problems than you are, and you don?t have any idea what to do about this.
- You don?t want to hurt your therapist?s feelings.
- You may have no idea how to justify your leaving.
- Other people in your life who matter to you may want you to stay in therapy.
I want to take up here each of challenges I listed above, and possibly a few others that come up as I work things through.
You may never have done it before. First-time therapy clients have a lot of ?firsts? to work through in therapy. Leaving is certainly one of them. If this is not your first therapy relationship you?re more likely to have some knowledge of the challenge of leaving, even if you don?t yet quite know how to do it well. If this is your first time leaving therapy, you really ought to talk about it with your therapist. They, after all, are not first-timers, relative to this issue, and just might be able to help you. If you find it a difficult topic to bring up, then the difficulty you?re experiencing needs to be the first thing you talk about. That difficulty may well be a legitimate ?therapy issue?.
Your therapist may not talk with you about leaving before you begin to feel like the time is close. If we therapists don?t take up this problem and make sense of it, what chance do you have if doing it at all well? We?re interested in getting you into therapy, and keeping you there until we can get some real work done. And then what? We seem to have little to say about this.
When I brought up this topic to my very capable faculty adviser during my internship in graduate school, his reaction was that this concern was not for us to address. ?The client determines when therapy ends?, he said. OK - there?s a very good idea in that sentence, but the problem remains. (And I suspect that if I?d asked the question better I?d have gotten a better answer!)
We have many ideas to offer you. How to leave therapy well seems not to be among them. I?ve never heard this issue seriously discussed in a professional context. We seem not to think about it. We should, because it?s too often a source of distress for our clients. As a client, you cannot fix this problem, but you can realize that part of the problem for you is that too often you?re on your own with the problem. You shouldn?t be, I think, but you usually are. There is a remedy for this, however, and it?s under your control.
You will probably not feel finished, when the issue of leaving comes up. It is rare for a person to have addressed all their problems when they leave therapy. There really isn?t a need to have done this. It?s better to take up focused issues, make progress (any progress at all is better than staying stuck), leave, and then return later if this seems called for. It is realistic to see life as a series of ongoing challenges - and to accept that you?re not going to run out of problems. Do you really think psychotherapy is going to fix this? I wish!
You may not be the one who brings the issue up. If you have to deal with ?managed care?, or have a seriously limited budget, you know that external factors and people can have a real say about when therapy ends. Or?your therapist may be moving, or retiring, or going on vacation. Your situation then is one of feeling unfinished but having to leave anyway (see the paragraph above, concerning this). This can be difficult, but it can also be talked about, and learned from. See that this is how it gets handled in your case.
You may have real conflict about leaving - feeling like you want to leave AND you want to stay. This is very common, for many reasons. The best thing to do is to take up the matter of the conflict(s) you feel with your therapist (do you notice a theme in my remarks, here?). Such conflicts arise from the fact that our mind virtually always holds multiple points of view about critical issues. These conflicts are part of being human, so talk about it. It?ll help, and it?ll often work to actually resolve the conflict.
You may be aware that your therapist is more engaged in working with your problems than you are, and you don?t have any idea what to do about this. In a sense, this shouldn?t happen, but it often does, anyway. First of all, it?s probably generally true that your therapist experiences a degree of fascination with your problems - dealing with them is his/her chosen profession, after all. You, on the other hand feel something other than fascination, and in this there is an essential imbalance.
Nevertheless, the rule is that the client leads. We may invite you to go certain places, but when you indicate disinterest, that settles it. It?s YOUR opinion that counts. I hope your therapist doesn?t forget this, but if they do, you still shouldn?t. If your therapist appears to need to engage with your problems, they have matters to take up with their therapist. This kind of problem is actually common in psychotherapy. Freud talked about it, and we?ve been talking about it since then. What you should know is that it?s OUR problem, not yours.
Therapists are people, and they do have problems, at times, but that should not be your concern. In psychotherapy, you?re expected to be self-centered, and you should maintain this focus right on through the time of your leaving. Your therapist can take care of themselves. They have access to excellent resources for doing this.
You don?t want to hurt your therapist?s feelings. I see this issue come up most often with young women, who are often deeply in contact with their maternal side. Such instincts are one of the glories of humanity, but really don?t belong in the psychotherapy relationship. Your therapist does have feelings, and you likely will be missed. Your therapist also has experience with this problem, and can take care of themselves.
It?s good for you to notice that your therapist values you. You do have value, and we all need to know this. However, children leave home, clients leave therapy, and we all leave life, at some point. It?s the Way of Things. If this is a persisting problem for you, you owe it to yourself to bring this problem to therapy. Doing so is an excellent idea.
You may have no idea how to justify your leaving. Many people in therapy have a history of being disrespected, and thus have some trouble respecting themselves. They often feel defensive or in need of justification. Try to understand that this is a developmental problem which you don?t have to have, and really should not tolerate. If you DO have this problem, take it into your therapy as a topic.
The best reason to leave therapy is a very simple one: you want to. I teach assertion, and I?ll say it plainly: Your feelings are your best justification for anything. (You do well to see that your feelings are based on correct perceptions of course.) If you find this difficult, then you?ve just identified and area in which you need some work, and definitely some practice. Assertion skills definitely have to be practiced. I look for opportunities to practice mine. You should too.
Other people in your life who matter to you may want you to stay in therapy. Who? Parents, spouses, children, friends, employers?did I leave anyone out? While sometimes therapy may be mandated by a judge, in all other cases, it?s your call. People can have any opinion they want. It?s a free country. And you need to keep your own counsel. Participation is your decision. When someone else has feelings about your leaving therapy, take it up with them. Understand that THEY are having a problem. Talk with them to see what?s at the root of the problem (it?ll usually be some fear which isn?t well enough identified). This will help your relationship with them, and may even give you some useful information.
SOME THINGS I WANT YOU TO KNOW ABOUT LEAVING THERAPY
You may not be the only one distressed by the idea of your leaving. We often come to truly like and enjoy our clients. I know that in mine I virtually always see the essential problems of all of us as human beings. I usually develop a strong sense of compassion, and come to care significantly about each individual I work with. How can I look casually upon the prospect of coming to the end of our meetings? I don?t know how to do this, and I?m not sure I want to learn. So, that your distress is likely shared is a very good reason for taking up leaving as a topic, with your therapist. You both should talk about it with each other. Very often the problem is one of dealing with loss - and that?s a problem that challenges all of us, in various ways.
Some therapists are as puzzled by the ?leaving? problem as you may be. Not all therapists grasp that clients will leave with some of the problems they brought into therapy. I can recall our being confronted with the necessary ?unfinished client? problem, by one of our teachers in graduate school. I was already familiar with it, but some of my fellow students had not thought of it, and found it troubling. If your therapist has not grasped this reality, and the fact that it?s not necessarily a problem, you still can. You must, in fact, because everyone leaves unfinished. We?re all a work-in-progress. You think this is a problem? Wait until you face dying, unfinished! (You?ve been warned - so now you have some time to prepare for that one?)
Loss is one of the great themes of everyone?s life - you do well not to turn away from it. Some people, when the time comes, simply run from therapy. It?s the only way they can handle it, but it?s not a good response. Losing your therapist is but one of many losses you will have in your life. USE the experience to address the issue of loss and what it means to you and how you handle it. It?s an excellent chance to add to the benefit you get from your therapy.
Your therapy is about you and what?s good for you. This may seem obvious, yet concern for others and a desire to take care of others, sometimes in inappropriate ways, is common, especially in psychotherapy clients. Your therapist, if she/he has a lick of sense, has done psychotherapy work themselves, and has taken up the issue of loss in the course of that work. He/she comes to their work prepared to handle the eventual loss of clients. You don?t need to be worried or concerned about them. Your attention belongs on you.
You can come back. Surprise! This doesn?t occur to many people. You can think of leaving as an experiment. Do it and see how it goes for you. You can return, if you find that you?re not ready. I?ve had a number of clients return, virtually always for only a short period of additional work. Some have come back 2-3 times. One came back four, and the fourth time was the one where she really got down to work. I was thrilled, and I think she was as well. You can simply take things as they come, just like you have to do with the rest of your life.
SOME GOOD WAYS TO TALK ABOUT LEAVING THERAPY
I want to offer here some little ?mini-scripts? which may help you deal with leaving.
(To your therapist) - ?I?ve been thinking that I?m about finished with therapy. What do you think about that??
(To anyone at all) - ?I?m feeling about ready to leave therapy. It?s been a challenge/good experience/disappointment/real puzzle to me/a life changing experience (pick one or more). I?m ready for a rest.?
(To yourself) - ?I feel about ready to stop. I want to respect that. I can come back if I want to, or go elsewhere, later. I will always have many options.?
(To your spouse) - ?I?m graduating soon from therapy. I hope you?ve been keeping up, because your life is about to get really interesting!?
(To your therapist) - ?Thanks for the challenges, for the patience, for information, for the compassions and caring. I?m not who I was when I came here. I know I?ll keep growing after I leave, and what?s happened here will help to make that good growth. I?m grateful. I hope you think of me from time to time. I know I?ll think of you. Maybe I?ll send you a postcard.? (I always like to hear these sorts of statements. Expressing gratitude is something I very much value. I will often express a lot of it back - I do admire the courage and humanity of my clients. I always am inspired by it. Rarely, I think, do they realize how much they enrich my life. I want them to have some small sense of that. And I always respond positively to the idea of that ?postcard?.)
CONCLUSION
I wrote this originally in one sitting, while thinking particularly of one client of mine (who reported finding it useful), but always had in mind a more general problem, involving many more individuals. What I have written seems incomplete, and unfinished, and I hope to revisit the topic and revise it further, but for now it?s time to go. This, too, is a work in progress.
