Ending therapy: How to figure out when it's time

[David Baxter PhD]

How to Figure Out When Therapy Is Over
By RICHARD A. FRIEDMAN, M.D., New York Times
October 30, 2007

If you think it?s hard to end a relationship with a lover or spouse, try breaking up with your psychotherapist.

A writer friend of mine recently tried and found it surprisingly difficult. Several months after landing a book contract, she realized she was in trouble.

?I was completely paralyzed and couldn?t write,? she said, as I recall. ?I had to do something right away, so I decided to get myself into psychotherapy.?

What began with a simple case of writer?s block turned into seven years of intensive therapy.

Over all, she found the therapy very helpful. She finished a second novel and felt that her relationship with her husband was stronger. When she broached the topic of ending treatment, her therapist strongly resisted, which upset the patient. ?Why do I need therapy,? she wanted to know, ?if I?m feeling good??

Millions of Americans are in psychotherapy, and my friend?s experience brings up two related, perplexing questions. How do you know when you are healthy enough to say goodbye to your therapist? And how should a therapist handle it?

With rare exceptions, the ultimate aim of all good psychotherapists is, well, to make themselves obsolete. After all, whatever drove you to therapy in the first place ? depression, anxiety, relationship problems, you name it ? the common goal of treatment is to feel and function better independent of your therapist.

To put it bluntly, good therapy is supposed to come to an end.

But when? And how is the patient to know? Is the criterion for termination ?cure? or is it just feeling well enough to be able to call it a day and live with the inevitable limitations and problems we all have?

The term ?cure,? I think, is illusory ? even undesirable ? because there will always be problems to repair. Having no problems is an unrealistic goal. It?s more important for patients to be able to deal with their problems and to handle adversity when it inevitably arises.

Still, even when patients feel that they have accomplished something important in therapy and feel ?good enough,? it is not always easy to say goodbye to a therapist.

Not long ago, I evaluated a successful lawyer who had been in psychotherapy for nine years. He had entered therapy, he told me, because he lacked a sense of direction and had no intimate relationships. But for six or seven years, he had felt that he and his therapist were just wasting their time. Therapy had become a routine, like going to the gym.

?It?s not that anything bad has happened,? he said. ?It?s that nothing is happening.?

This was no longer psychotherapy, but an expensive form of chatting. So why did he stay with it? In part, I think, because therapy is essentially an unequal relationship. Patients tend to be dependent on their therapists. Even if the therapy is problematic or unsatisfying, that might be preferable to giving it up altogether or starting all over again with an unknown therapist.

Beyond that, patients often become stuck in therapy for the very reason that they started it. For example, a dependent patient cannot leave his therapist; a masochistic patient suffers silently in treatment with a withholding therapist; a narcissistic patient eager to be liked fears challenging his therapist, and so on.

Of course, you may ask why therapists in such cases do not call a timeout and question whether the treatment is stalled or isn?t working. I can think of several reasons.

To start with, therapists are generally an enthusiastic bunch who can always identify new issues for you to work on. Then, of course, there is an unspoken motive: therapists have an inherent financial interest in keeping their patients in treatment.

And therapists have unmet emotional needs just like everyone else, which certain patients satisfy. Therapists may find some patients so interesting, exciting or fun that they have a hard time letting go of them.

So the best way to answer the question, ?Am I done with therapy?? is to confront it head on. Periodically take stock of your progress and ask your therapist for direct feedback.

How close are you to reaching your goals? How much better do you feel? Are your relationships and work more satisfying? You can even ask close friends or your partner whether they see any change.

If you think you are better and are contemplating ending treatment but the therapist disagrees, it is time for an independent consultation. Indeed, after a consultation, my writer friend terminated her therapy and has no regrets about it.

The lawyer finally mustered the courage to tell his therapist that although he enjoyed talking with her, he really felt that the time had come to stop. To his surprise, she agreed.

If, unlike those two, you still cannot decide to stay or leave, consider an experiment. Take a break from therapy for a few months and see what life is like without it.

That way, you?ll have a chance to gauge the effects of therapy without actually being in it (and paying for it). Remember, you can always go back.

 

[Into The Light]

Terminating therapy - what, why, how

Terminating: Therapy, Part I: What, Why, How?
By Ryan Howes, Ph.D. on September 30, 2008 in In Therapy

Part I: What is Termination?

"Termination" is clinical jargon for the last phase of therapy. It has its own fancy term and deserves four posts because it's that important. In fact, for some it's the most profoundly healing, meaningful and transformative phase of therapy. But many clients split before they're able to reap the benefits of a good termination.

One hat I wear is supervisor for graduate students who rotate each academic year at a community counseling center. Most have clients who stay with them all year. In the Spring, students remind their clients that the rotation ends in the Summer and they will terminate or transfer to an incoming therapist. Most clients respond to this news with nonchalance, saying they knew this was the case and it's no big deal. But as the final session draws near, interesting material begins to emerge. My students notice their clients start talking about breakups, death and other endings. Their dreams reflect themes of abandonment and loss. Other clients suddenly "get better" or have a financial crisis and terminate via voice mail. In some cases a conflict arises and the clients leave angry. While some of this may be coincidence, the yearly repetition of these patterns seems to support the idea that termination pushes buttons on a deep, perhaps unconscious level.

We don't like to talk about termination; it brings up uncomfortable feelings for clients and therapists alike. Many of life's endings - breakups, divorce, graduation, getting fired, moving, death of a loved one, etc. - provoke feelings of sadness, anger, grief, rejection and/or abandonment. If successful therapy requires a meaningful connection between client and therapist (as my fellow bloggers and I claim), then we should expect these painful emotions when therapy ends. When we avoid termination, these thoughts and feelings may go unexplored, preventing a healthy closure. I've even heard of clients who go to therapy to grieve their previous therapy.

There are other reasons we avoid termination. Clients may fear they'll be told they aren't ready to stop, or are concerned their leaving will hurt the therapist's feelings. They worry that saying goodbye will be awkward, sappy or painful. Some avoid the sting associated with endings from their past - pain they felt before and don't care to revisit. As a result, they terminate via LMB or a voice mail message: "Hi, it's Jane. I won't be able to make it this week, I'll call you for my next appointment." And that's it, we never hear from Jane again.

Therapists may equate ending with a loss of revenue and shrinking caseload. Their business brain is afraid to mention termination out of fear they're planting a seed. Many attach their success as a therapist with their appointment book, so losing a client means they've failed. Some might avoid the topic because it's an uncomfortable conversation, and we don't want our clients to feel uncomfortable. Or maybe they're too emotionally attached to their clients and don't want to let them go. Either way, their silence colludes with their clients, resulting in a denial that termination will ever happen. By avoiding the topic their clients might not even know there is such a thing as a termination phase, and that it holds great value. In these cases, the "see ya!" voice mail is really no great surprise.

Clients (and therapists) who avoid the termination process are missing out on some of the best material therapy has to offer. For example, many issues clients raise in therapy include an element of loss. During termination, therapy becomes a laboratory for experiencing, processing and coping with those feelings first hand. What kind of model is therapy if we preach dealing with and accepting loss, but practice denial? Can we rationalize spending a year working through grieving a loved one, yet end our relationship via voicemail? Since all therapy must come to an end, shouldn't a high quality ending be part of each treatment plan?

Termination is a time to evaluate the work you've accomplished, celebrate the progress, talk about which goals weren't reached and explore any disappointments with the process. It's reminiscing, an exit interview and saying goodbye wrapped up in one. Sometimes this overview helps it all come together, as seeing the work in the rearview mirror lends perspective. Insights like "Ah, I'm glad you didn't tell me what to do," or, "That explains why I felt frustrated sometimes" are common to a good termination. Yes, sometimes this discussion opens a new can of worms, potentially resulting in more therapy. But it may be a can worth exploring.

We don't have enough good endings in life. The nature of therapy and strength of the relationship should provide clients with this one final gift: a corrective emotional experience regarding endings. Clients and therapists who avoid it are depriving themselves of the insight and healing the termination phase provides.

Coming next: Part II - The Ideal Termination

 

[Into The Light]

Re: Terminating therapy - what, why, how

Terminating Therapy, Part II: The Ideal Termination
By Ryan Howes, Ph.D. on October 10, 2008 in In Therapy
Part I of my miniseries on termination covered the value of a good ending in therapy and reasons why both therapists and clients sometimes avoid it. Here's the bottom line: we all tend to equate endings with pain and sadness, but a thorough termination provides clients with additional insight, adequate closure and a positive conclusion in a life full of negative endings.

Today I'm diving into the reasons why and when therapy should end. I resist saying there are good and bad reasons, as those terms oversimplify a complex process. Instead, I'll describe the ideal termination today and some of the many reasons for less-than-ideal terminations in Part III.

The Ideal Termination

It's ideal because both parties are able to experience all that therapy has to offer. The beginning, middle and end phases of therapy are fully addressed, giving a sense of completion. An ideal termination takes place after rapport has been built (phase 1) and the issues have been sufficiently explored and resolved (phase 2). So how will we know we're ready for termination?

Freud's Analysis Terminable and Interminable (1937c) proposes ideal circumstances for termination of treatment: "two conditions have been approximately fulfilled: first, that the patient shall no longer be suffering from his symptoms and shall have overcome his anxieties and his inhibitions; and secondly, that the analyst shall judge that so much repressed material has been made conscious, so much that was unintelligible has been explained, and so much internal resistance conquered, that there is no need to fear a repetition of the pathological processes concerned" (p. 219).

This sounds simple enough: freedom from symptoms and resolving the mechanisms that caused and perpetuated them. Jane understands why she is drawn to unavailable men and no longer feels compelled to repeat this pattern. John recognizes what triggers his anger, has developed new coping skills and has even practiced them "in the moment" with his therapist. Jean enters therapy depressed and hopeless, discovers the negative patterns holding her back and begins taking charge of her life. Simple, when I boil it down to a single sentence.

In comprehensive long-term psychotherapy, this ideal end comes after months or years of hard work. It was work finding the right therapist, establishing good rapport, collaborating on the issues and exploring any dynamics that arose in the relationship. The therapist and client, never denying that their relationship is finite, reviewed their progress all along. Having experienced significant growth in insight, resolving symptoms and accepting limitations, the client and therapist seem to reach a natural end point. Either one may bring the topic up, but it's not really a surprise. They agree to enter the termination phase, set an end date, and begin the process of closure. (More on How to Terminate coming in Part IV)

The most obvious sign of readiness to terminate is achieving the goals established at the beginning of therapy. The client has learned to be more assertive, overcome sexual dysfunction and/or resolve abuse issues from her past - whatever problem brought her into therapy. Clients also uncover and address new issues during the course of therapy, and an ideal termination includes resolution of these concerns as well.

Another sign is not so obvious. To those who haven't been in therapy, this is going to sound a little strange. Ideally, clients internalize the therapist: her words, phrases, attitudes, problem solving processes and lines of questioning. After some time in therapy clients are able to "hear" their therapist outside the session. When her supportive, positive, rational voice has been accurately internalized, it may replace the need for the actual therapist. I witness this when my clients start saying "I was starting to panic, but I thought of what we talked about last month" or "I was having a conversation with you in my head the other day." Over time, it becomes increasingly obvious that they've taken in our work together and can apply it on their own. They no longer require this time because they have a portable version in their head.

The ideal termination feels similar to a graduation. There's a bittersweet feeling for both parties. It's bitter because a productive, engaging relationship is ending. The routine of the sessions, the unique language shared and the supportive environment are drawing to a close. It's sweet because this ending marks a new era of independence while applying the skills therapy provided. Also, the ideal termination is clean. The work is reviewed, all feelings are verbalized and goodbyes are shared. There are no loose ends.

Therapists and clients alike enjoy and benefit from the ideal termination. Unfortunately, not every therapy ends this way.

Next time: Part III, The Not-Quite-Ideal Termination

 

[Into The Light]

Re: Terminating therapy - what, why, how

Terminating Therapy, Part III: The Not-Quite-Ideal Termination
By Ryan Howes, Ph.D. on October 18, 2008 in In Therapy
Part I of this series covered the merits of the termination phase. Part II described the ideal circumstances for termination. But not all therapy reaches the final chapter. Today I'll look at some of the non-ideal reasons people leave therapy.

It's your therapy, you can leave whenever and however you want. As consumers, you need to know that. The most complete therapy experience includes sticking around for all three phases: building rapport, treating/resolving the issue and termination. Not every therapy achieves this ideal; some end prematurely due to logistical, psychological or interpersonal barriers. It's considered premature because the presenting problem wasn't resolved and/or adequate termination didn't take place. Without this wrapping up, the therapy lacks closure and feels incomplete.

The reasons clients leave early are sometimes valid and sometimes a smokescreen for resistance. But since they're leaving early, without an opportunity to debrief, we can't always fully explore why. Here are some of the top reasons why clients end therapy before the work is complete:

Money: Probably the #1 cause of premature termination, lack of funding frequently ends therapy (especially this month). Therapy is a relationship, but one that requires payment for therapists' time, training, overhead and liability. A layoff, a tightened budget or a limit on insurance reimbursement can draw therapy to a sudden close.

Time: My graduate students need to move on in August, whether their client has reached her goals or not. Your new job requires you to relocate or work new hours that make continuing therapy impossible. Your semi-retired therapist is cutting down to two days per week, and you're busy those days. You get the picture. The clock and calendar have ended some great work over the years.

Impasse: Most clients feel stuck occasionally in therapy. If you've tried working together through this stuckness for several sessions and still can't move, it may be time to leave. It could be due to a psychological barrier or there could be a mismatch. For example, a client seeks treatment for sexual dysfunction and later reveals a substance abuse problem beyond the therapist's training. An ethical therapist would refer the case to someone with sufficient experience, effectively drawing their relationship to a close.

Grudge: Given the emotional nature of many therapy issues, it's not surprising that conflicts between therapist and client sometimes occur. If not adequately addressed and resolved in the therapy, some clients bail. Since therapy is where many people go to figure out relationships, this premature ending is both tragic and ironic.

Quick Fix: After three sessions, Bob says his major depression, PTSD, trichotillomania and Munchausen syndrome have all been resolved so he's stopping treatment. The therapist may voice her caution and advise Bob to stick around a while, but Bob calls the shots and he's leaving. We call this a flight into health.

Dependency: Some degree of dependence is expected in a healthy course of therapy. The client learns to trust and rely upon the therapist for the support he's been trained to offer. But if this dependence becomes debilitating for the client, where she relies on the advice and support of the therapist beyond her comfort level or his professional boundaries, and this can't be resolved in treatment, either party may choose to terminate or refer treatment elsewhere.

Boundary Violations: Let's be clear: no sex, no coercion, no intimidation, no exploitation, no breaking confidentiality, no manipulation, no shady billing, no shady touch and no shady contact outside sessions (for starters). If these or any other significant physical, emotional or ethical boundaries are violated, many clients drop therapy and pick up the phone for a second opinion, a legal consultation and/or a licensing board complaint department. They'll have a chance to process the end of this therapy, but it will probably be with a different therapist. See this article for more information.

Cut and Run: Maybe it's via voicemail or LMB. Maybe the client just doesn't show, doesn't call and is never heard from again. For these endings, we never learn why they wanted to stop, can't rectify or explain any problems within the therapy and are unable to say goodbye. As a therapist, these are the endings that sting.

Resistance: I say this to you now, empowered client, because I guarantee your therapist is considering it when you mention the above reasons for stopping. Sometimes clients create a reason to leave because therapy is too difficult and they're not sure how to talk about it.

Clients experiencing discomfort don't always mention it - sometimes they aren't even aware therapy is pushing deep buttons. Most productive therapy gets uncomfortable at times, as growth can be painful. This pain tempts clients to pull the plug on therapy prematurely. Instead of talking about the challenge of being vulnerable and intimate, the client calls saying it's time to stop for financial reasons. Or the babysitter quit so they need to postpone sessions indefinitely. Or the therapist took five hours to return a phone call, and that triggered feelings of abandonment, so we're through. Or maybe just: "I'm cancelling this week and I'll call for my next appointment." Poof.

Once in a while, a client tells me the work we're doing is too difficult and we either need to slow down and take another approach or he'll need to stop. These are great conversations. I get to learn what the client thinks and feels about the work, understand where his threshold lies, and we begin collaborating on an approach tailor made for him. His honest assessment of our work and its impact on him takes our work to a higher, more effective level. This is engaging the uncomfortable issues - the opposite of resistance.

Before you pull the plug, ask yourself some questions. Why do you want to stop? Have you reached all your goals? Is stopping about money or time, or could it be something else? Is it about feeling stuck or having a conflict with the therapist? Is it that therapy is difficult and you don't feel up to it right now? If any of those questions apply, I encourage you to take it to your next session.

Again, you can stop for any reason. Any motive you have may be valid. I just invite you to be honest with yourself and your therapist about the reason you're stopping. Many come to therapy to learn to be assertive, honest and direct, and termination is a great time to flex these new muscles.

Coming next: Part IV, How to Terminate

 

[Into The Light]

Re: Terminating therapy - what, why, how

Terminating Therapy, Part IV: How to Terminate
By Ryan Howes, Ph.D. on October 30, 2008 in In Therapy

It's time to terminate the series on psychotherapy termination. This post gives clients practical steps to ensure a good ending. (See posts I, II, III)

I enjoyed the comment from CS on Part I: "Cut & run was the route I had in mind, so I'm interested in the alternative." Why not cut and run? If I'm finished with my barber, mechanic or supermarket I'll just go somewhere else next time. I won't set up a series of appointments to process my leaving. CS isn't alone; the prevalence of cut and run is even documented in scientific journals.

In therapy, cut and run is like skipping the last chapter of a novel; the part where the loose ends are tied up, you learn what the future may hold and get a sense of closure. Therapy also may be the first time you can talk through the feelings associated with ending and wrap up a relationship on a good note. It's why good termination should be among the treatment goals, especially if the client has a history of bad endings.

If you'd like to explore the "alternative" along with CS, here are a few tips to help you terminate well (as illustrated by alternative rock):

1. Don't fear the reaper (Blue Oyster Cult, 1976)

As mentioned in Part I, the best therapy doesn't deny its finite nature. All therapy comes to an end, and unfortunately most clients and therapists don't talk about termination until it's staring them in the face. This denial sets them up for an awkward, abrupt or destructive end to their work.

Ideally, along with "what are your goals for therapy?" the therapist asks "under what conditions will we end, and what will that ending look like?" This way, client and therapist together decide why and how therapy will end. If you had that discussion in the first session, you won't have a problem terminating therapy.

Didn't have that discussion? Neither did most other clients. The good news is you can have the "why and how we'll stop" talk any time. It might catch your therapist off guard, but you'll both benefit from it. Most therapists aren't used to talking about termination unless it's happening, so they may be surprised or afraid that you're LMB'ing a sudden departure. This conversation isn't saying goodbye; it's acknowledging that someday you will part ways, and preparing you both for what it might look like. For example:

You sought help for your panic attacks. You decide together that when you've been panic free for a month (the why), you'll tell your therapist you'd like to talk termination. When you've reached that benchmark, you'll take four more sessions to wrap things up (the how).

It seems termination is one area where clients and therapists consistently fail to collaborate. One study reported that only 40% of clients felt therapy ended at the right time, with 37% believing it ended too early and 23% saying it ended too late. Even if a portion of those endings were due to external, non-ideal circumstances (ran out of money or time), a 60% failure rate seems excessive and unnecessary. All the more reason to...

2. Talk about it (Foo Fighters, 1995)

You begin to notice you're feeling better. The symptoms that brought you into therapy have diminished, you understand your issues in a way that makes sense and you're noticing practical improvements in your life. When you encounter a challenging situation, you can "hear" how the problem would be addressed in therapy. You predict your therapists' reactions to what you have to say, and you're mostly accurate. For the fourth week in a row, you notice yourself in session talking about how great things are. Then the thought comes to you: I wonder if I'm ready to stop?

A lot of clients at this point believe they need to make a bold declaration: "I've decided to leave. Goodbye." Therapy is a collaborative relationship, and this doesn't change when termination is the topic. Your thoughts about termination are interesting material you're noticing about yourself - you can talk about it like you would anything else. "I had a thought about our termination last week. I wonder what that's all about?"

It's an item for discussion. It doesn't necessarily mean you need to terminate immediately, but talking it through may give a clearer idea. It could be a fear, the beginning of an ideal termination or an indicator of a not-so-ideal reason to end. If you've trusted the collaborative working relationship this long, you might as well continue with it to the end.

3. It's better to burn out than fade away (Neil Young, 1979, Def Leppard, 1983)

Some clients want to terminate gradually by decreasing the frequency of sessions from weekly to every other to every month to every quarter. Fading away is not termination; it's mitigating the difficult feelings associated with ending. Cutting back sessions communicates: "I can handle seeing each other less often and with less intimacy, but an absolute ending is too much." Two sessions per month or less becomes "checking in" and we spend most of the time reacquainting with one another rather than diving into deeper work. The flow and continuity of therapy eventually weakens, changing the quality of the relationship. When clients tell me they'd like to cut back their sessions, I take it as a sign they're thinking about terminating and suggest we begin termination instead. This way, the corrective experience of facing and grieving an ending head-on isn't lost.

This point comes from experience. I've done the fade-away many times, and after a couple bi-weekly sessions and a monthly or two, clients typically disappear. The significance of the relationship diminishes so they simply drift away. But they're depriving themselves of the closure, the summary and the goodbye.

4. How long to sing this song? (U2, 1983)

The termination phase is the period of time between realizing you're leaving and the final goodbye. How long does it last? It depends on how long you've been in therapy, what type of therapy it's been, the nature of your issue, and ultimately - whatever you and your therapist determine. Psychoanalyst mentors in my past taught that once a patient and analyst determine readiness for termination, a termination date is set for one year later. Dr. Diamond commented that sometimes 25% of therapy is spent on termination. I've heard other psychologists who vary from 10% to a one-month minimum. Some even write their termination policy into their consent form. Again, it's an issue for collaboration. You'll come up with something between one session and one year. As long as it's enough time to say what you need to say, feel what you need to feel and wrap things up, it's long enough.

I encourage you to set an end date and stick with it (barring unforeseen obstacles, of course). Having a date in mind does interesting things. When my graduate student supervisees tell clients they're leaving in a couple months, sometimes the work moves faster. The client suddenly realizes the clock is ticking and decides to deal with their abuse or their resentment or whatever they've been avoiding. Occasionally the end date brings up sadness, regret, anger or other feelings worth exploring.

5. This is the End (The Doors, 1967)

You're now prepared to enter the termination phase. In a nutshell, here's what to expect you'll do during termination:

• Review what you've learned about yourself
• Discuss which goals (if any) you weren't able to accomplish in therapy, and what to do about them
• Develop your "aftercare" plan: everything you'll be doing post-therapy
• Reminisce about the therapeutic relationship - when you felt cared for, when she made you mad, when you shared meaningful moments, etc.
• Discuss and grieve the end of the therapeutic relationship
• Talk about the other feelings or memories this ending brings up

Sound like fun? Not all of it; some parts may be satisfying and some incredibly difficult. It's the bittersweetness I talked about in Part II. Good termination is like graduation, and people smile and cry at graduations. You're saying goodbye to someone with whom you've shared your most intimate thoughts. You've gone on a journey together. But you're equipped to fly solo and that's worth celebrating.

6. Give it away now (Red Hot Chili Peppers, 1991)

It's your last session; you've processed everything on the list above, and time is up. What happens as you walk out the door?

There is no requirement to give your therapist a parting gift or card. In fact, most therapists are anti-gift, so giving one may usher you into a whole new arena of awkwardness in your final moments. Therapists don't expect a gift and don't particularly want one, but sometimes clients want to give one anyway. If that's the case, here's a good gift for the therapist: tell her what gift you wanted to give and why. You might think it's cruel, but it actually gives the therapist what they're looking for - insight into what she means to you without the awkward gift reception. Also, you might look at why you feel compelled to give a gift. If you're looking for reciprocation, you'll probably be disappointed. As nonplussed as therapists are about receiving gifts, they're even less plussed about giving them. Why? Because therapy is supposed to be a place where words come first, physical and behavioral gestures are a distant second. If you've got your communication lines open and you're already talking about how therapy ends, discussing this point will be easy. No therapist is going to complain about a heartfelt "thank you" and a firm handshake as you walk out the door the last time.

If you've read through all four posts, you've probably got my point: termination is not a phase to avoid or rush - it's an essential element of therapy. On a pragmatic level, the termination phase provides the best customer service; giving clients the best products and tools of therapy. On the deepest level, I believe engaging in termination means connecting with grief and loss. Therapists and clients who allow themselves to explore endings are doing some of the best work therapy has to offer.

 

[Into The Light]

Re: Terminating therapy - what, why, how

3. It's better to burn out than fade away (Neil Young, 1979, Def Leppard, 1983)

Some clients want to terminate gradually by decreasing the frequency of sessions from weekly to every other to every month to every quarter. Fading away is not termination; it's mitigating the difficult feelings associated with ending. Cutting back sessions communicates: "I can handle seeing each other less often and with less intimacy, but an absolute ending is too much." Two sessions per month or less becomes "checking in" and we spend most of the time reacquainting with one another rather than diving into deeper work. The flow and continuity of therapy eventually weakens, changing the quality of the relationship. When clients tell me they'd like to cut back their sessions, I take it as a sign they're thinking about terminating and suggest we begin termination instead. This way, the corrective experience of facing and grieving an ending head-on isn't lost.

This point comes from experience. I've done the fade-away many times, and after a couple bi-weekly sessions and a monthly or two, clients typically disappear. The significance of the relationship diminishes so they simply drift away. But they're depriving themselves of the closure, the summary and the goodbye.

this is the only part in this series that i disagree with. how is making the ending so abrupt supposed to be better than spacing things out and learning to fly solo while you still have that safety net there while you get used it?

 

[Daniel E.]

Re: Terminating therapy - what, why, how

I agree with you, ITL, and I had thought of saying the same thing I assume he is talking about people who have non-chronic issues who would not benefit from maintenance therapy or coming back later.

 

[Into The Light]

Re: Terminating therapy - what, why, how

hmm, maybe that's it. i just know an abrupt ending wouldn't be very helpful to me, but i suppose it all depends on how long you've been seeing the therapist for and also what you've been seeing them for. if you see someone for 8 sessions and it resolves whatever the issue is, then yes, spacing it out wouldn't make sense. i think for longer term therapy though one might one to taper down the sessions.

 

[David Baxter PhD]

Re: Terminating therapy - what, why, how

this is the only part in this series that i disagree with. how is making the ending so abrupt supposed to be better than spacing things out and learning to fly solo while you still have that safety net there while you get used it?

I agree with you, ITL, and I had thought of saying the same thing I assume he is talking about people who have non-chronic issues who would not benefit from maintenance therapy or coming back later.

:agree: I don't think most clients are well served by an abrupt ending.

 

[Ryan Howes]

Re: Terminating therapy - what, why, how

Hi everybody. I joined just so I could respond to this!

Thanks for reading and commenting, by the way. The comments on the cut-and-pasted posts here are more critical and illuminating than those I get on my Psychology Today blog. Come visit sometime and share your wisdom.

Now, to clarify - I'll spend between 10% and 25% of the total therapy in the termination phase: tying loose ends, saying goodbye, etc. There's nothing abrupt about the process, it's usually several months of work. What I'm saying in the "burn out/fade away" paragraph is that following that lengthy process, we have a final session. One session where we actually have a process of closure, deal with the feelings of loss and say goodbye properly. All too often, when clients "fade away", there is no goodbye, no closure.

My point is, this is not a closure that is abrupt, but one that is full and complete. Clients also know if they ever want to resume regular sessions or stop in for a check-in that is fine, but the regular routine as we've known it is ending. It's this very sense of finality and closure that provides the corrective emotional experience.

Thanks for letting me have my say. Be well.

 

[ladylore]

Re: Terminating therapy - what, why, how

Thank you.

I hope this won't be the only article or discussion you will be a part of.

 

[David Baxter PhD]

Re: Terminating therapy - what, why, how

Thank you for an excellent series of articles and your comments, Ryan. I hope we'll see you back again from time to time.

 

[Into The Light]

Re: Terminating therapy - what, why, how

hi ryan, welcome and thanks so much for stopping by to clarify. your explanation makes a lot more sense, and i am glad you dropped in!

 

[GDPR]

All of this is interesting,because on Monday I asked my therapist when my therapy will be ending.Not because I'm ready to terminate,but just because I was curious.

He said I will 'just know'. He said I will either tell him I've had enough or I will feel like I have gone as far as I can. He also mentioned some goals he would like to see me achieve before ending.

I know I can't be in therapy forever. But I honestly don't see how I will know when it's time to end it.It seems to me that the therapist should be the one that decides that.

 

[David Baxter PhD]

Actually I think this is something best decided jointly by the client and the therapist.

 

[Retired]

He also mentioned some goals he would like to see me achieve before ending.

Wouldn't striving to achieve these goals be a better objective indicator of successful therapy than just "feeling" you have had enough, as long as both therapist and client agree on the goals?

 

[GDPR]

Yes,I do think so Steve. And it is a goal I would like to achieve,one that's pretty important,that we both agree on.

He seems to think that one of these days I am going to decide this trauma therapy is too hard and I will run from it and stop going at all. He doesn't want me to do that,and when he says it,it makes me want to show him he's wrong and show him that I will keep going,no matter what.

 

[GDPR]

He said I will 'just know'. He said I will either tell him I've had enough or I will feel like I have gone as far as I can.

I have been thinking about ending therapy a lot lately.Not just stop going all at once,but maybe at the beginning of the year start going every other week for awhile and then go down to once per month and then eventually stop going altogether.

I think I have had enough and also feel like I have gone as far as I can.

I think I am finished talking about my traumas.Not because I have processed all of them or anything but because I really don't think it's possible to ever make peace with some of them.And I know they will always be there,they will always affect me and the best I can do is manage my PTSD symptoms.I'm sure I will always struggle with them,but I just have to keep trying different things to help myself.I don't need to be contacting my therapist every time my symptoms are in high gear.I know what I need to do,and I am capable of managing on my own.I don't really need him as a safety net,I just like having him as one.

As much as I have hated going there the past 4 years,I also have always secretly dreaded the day when it would come to an end. I don't feel that way anymore.I don't dread it now,I feel like it will be an accomplishment when I do.

 

[Banned]

Definitely a big decision, LiT, and the termination process usually takes place over a period of time by gradually weaning down like you've described. Do you plan on discussing this with your therapist now and arranging a formal termination date and working towards this together?

 

[GDPR]

Yes,I plan on talking to him during my last session of this year,before he takes his two weeks off for Christmas.

I am not sure what he will think about it though,I have so much going on in my life at the moment that he may not think it's such a good idea.