In Therapy

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Terminating Therapy, Part V: Therapist Termination

When your therapist says farewell

...or the beginning of something better?
I wrote a four part series on termination in 2008 and it still attracts regular comments. Apparently, not everyone has a pleasant experience ending therapy.

If a therapist suddenly wants to terminate with a client, the client's first question is probably “why?” Actually, it might look a bit more like: “WHY?!? Why me, why now? Is this termination about you or me? Is it a reflection of your incompetence, my unworthiness, or something completely benign? And can I trust that you’re telling me the truth about that reason?" Being on the receiving end of an unexpected termination is among the most powerless feelings a person can experience. I hope to shed a little light onto the topic here.

To review: Part I covered the importance of the final phase of therapy, where loose ends are tied up and the client gains a positive experience of closure to a relationship. Part II  introduced the “ideal” termination where issues are resolved and the client and therapist take time to wrap up and experience the bittersweet “graduation” from therapy. I discussed the “not-so-ideal” termination in Part III, listing several factors that bring therapy to a close before all the work is complete. And Part IV I talked about what actually happens in termination, what topics are discussed, etc. Many people discover the most meaningful nuggets during the termination phase, or at least reinforce all they’ve learned. They get to have one experience of a good, clean relationship ending in life; an experience not many have had.

I posted the series to generally favorable reviews and moved on to other topics. Then the stories started trickling in. Stories of abrupt endings, mixed messages, even abandonment. Since there isn’t much written on the topic, the termination series pops up early in a Google search. I imagine it is found by people who have some personal experience with the subject, at least enough to Google the term. But they're painful experiences, judging from the stories they tell. For example:

“My recent experiences with terminated therapy were very hurtful and unexpected. I ... have no intention of using [therapy] again as a means of coping with my issues.”

“It does seem like a great deal of this guy’s advice is to make the therapist feel better. I get to leave and I do not have to justify it to you or anyone else.”

“What hurts is you all want us to go ... just like everyone else in our lives have wanted us to just go away.”

“This must be added to the list of reasons why people quit therapy abruptly: because the therapist is an incompetent moron.”

Holy smokes.

If these comments are a sample of a greater population of clients hurt or confused by termination, this deserves (at least) another post about the professional ethics, the personal factors, and the relational dynamics that are often behind a therapist initiated termination.

Why would therapists terminate therapy? 

Client Care: First, let’s take a look at the ethics of termination. Every major mental health professional organization has a code of ethics, and they all have something to say about termination (you can find each statement here). Virtually every code mentions that the therapist should practice within their scope of competence, and if issues arise that are beyond their abilities, they should help the client find another therapist. Most codes share this phrase: “therapists terminate therapy when it becomes reasonably apparent that the client no longer needs assistance, is not likely to benefit, or is being harmed by continued counseling.” There are other statements that cover specific issues like the therapist being at risk for harm or what should be done when the therapist has personal issues that may impact therapy. The common thread is, if therapy isn’t helping as much as it should, and it doesn’t look like it will improve with that therapist, the licensing boards request that therapists refer the client to someone else. This judgment call falls on the shoulders of the therapist and their supervisors or colleagues with whom they consult. If you have an eating disorder and your therapist has no training in the treatment of eating disorders, they’ll refer you to someone with the skills to help you. At least they should.

Personal Factors: I’ve known therapists who had issues arise in their own life that make them unable to practice with competence (permanently or temporarily) or unable to work with a particular group of clients. Let’s say the therapist loses a loved one, and treating grief in their clients becomes very difficult. Or the therapist is going through a divorce and fears they may lose objectivity in couples counseling. Or a suicide hit close to home and they feel overwhelmed by the despair in their suicidal clients. Due to issues that arise in the therapist’s life that have nothing to do with you, it may be in your best interest to work with another therapist. This one stings for many clients, especially if the therapist doesn’t disclose what happened in their life that brought them to this conclusion. And even when you know the whole story, it still doesn’t seem fair - you came to work on your stuff, and now someone else’s stuff is getting in the way. I hope there’s a place to discuss this disappointment in the final sessions, or in the first sessions with your next therapist.

Interpersonal Dynamics: Here’s the sticky one. Sometimes the therapist has adequate training, they aren't having any personal crises, but they believe the relational issues are an obstacle to successful treatment, so they terminate. What dynamics could cause this? Maybe they perceive  dramatically different communication styles or values systems that couldn’t be overcome (despite supervision or consultation). Maybe the therapist has strong transference feelings (called "countertransference” when it goes this direction) that clouds their judgment. Perhaps their feelings for you are so strong (positive, negative, or both) that it threatens their professionalism and could prevent you from reaching your goals. This is rare, but it does happen. In this situation, it's actually the most ethical therapists who will terminate and refer before they cross a boundary or provide subpar treatment. Again, communicating about this is important, but not everyone does it, and sometimes these very issues are the obstacle to clear communication. See what I mean? Sticky. 

Ideally, a therapist initiated termination is ultimately in the best interest of the client. So why all the hurt and anger in the comments sections? There are as many reasons as commenters, but I think we could summarize by saying endings can be painful - for everyone on the planet, including therapists and their clients. Rejection, loss, fears of abandonment; these are the issues people come to therapy to heal, not to re-experience. And while I believe in the value of psychotherapy and the concept of healthy termination, I can’t act as an apologist for all therapists. It's clear that not all therapists were taught how to provide a good termination, and even if they were, not all practice it. Therapists have their own blind spots, and some are blind where endings are concerned. I also recognize that for many clients, a difficult termination seems like an inevitability for them; yet another painful ending in a life of bad endings.

As I said at the beginning, the main question clients have is “why?” I recommend clients in this situation seek an answer to this question by asking clear, direct questions, as many as it takes. And I think therapists need to do an excellent job of communicating the reasons. If it has nothing to do with the client, or everything to do with the dynamics, I think clients should know this, have an opportunity to talk about it, and learn how to avoid the problem next time. If there is a next time.

—————

There are no sticky terminations over at my website and facebook. Be sure to leave me some comments and questions about termination so I'll never be able to terminate this series. 

Ryan Howes, Ph.D., is a clinical psychologist, writer, musician and professor at Fuller Graduate School of Psychology in Pasadena, California.

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