Pixabay. And Ah Ha, apparently.
Source: Pixabay. And Ah Ha, apparently.

A few months ago, a journalist sent me some questions for an article about ending therapy (because of my series on termination, I presume). I worked hard writing responses, but the article never ran, so I thought I’d post them here to bring some closure to all this hard work.

….to bring some closure to all this hard work.

Well I’ll be. That’s the function of termination as well – to give the therapeutic process a satisfying conclusion. Does that always happen? No, it doesn’t, but in an ideal world, all therapy would provide a good ending, where loose ends are tied up, take-away points are clarified, and we share a clean goodbye. Sounds nice, doesn’t it?

So why is this positive ending relatively rare? Sometimes therapists do stupid things that cause clients to leave prematurely. Sometimes clients don’t like saying goodbye so they split without notice. Many times, clients don’t even know there is such a thing as a “termination phase,” so they either ghost their therapist or fumble through the final sessions until they find a good reason to leave.

And you know what? That’s on us therapists. We should be teaching clients how to end therapy from the very moment they enter our office. Providing a good ending is one of the best things we can do as therapists. More on that below.

And so I resurrect for you the interview that never ran for your reading pleasure:

Unnamed Interviewer:  Your thoughts on what patients should consider when weighing whether it’s time to stop therapy

Ryan Howes: Clients should consider ending their time in therapy when their goals have been met or when it becomes evident that they won’t meet them with this psychotherapist. 

Ideally, therapy ends when all therapy goals have been met. If you entered therapy to treat a fear of dogs and you no longer fear dogs, your work is complete. Or you want to communicate better with your partner and you’ve learned to navigate your disagreements constructively, the goals are met. Many people have aims that are less specific, like improving self-esteem or decreasing anxiety. They may choose to leave when they’ve learned the skills necessary to do this on an ongoing basis, and the regular sessions are no longer needed to reinforce these principles. 

There’s also the idea of “internalizing” the therapist. When a client has worked with a therapist for several months or years, they’ll find themselves encountering a problem and can imagine what their therapist would say about it. We would say this incorporation of the therapist’s voice or mindset is a positive sign for the client, that they have been able to construct a portable version of the therapist who can advise them outside therapy sessions. When a positive, helpful version of the therapist has been internalized, the flesh and blood version may not be as necessary. I know, it sounds funny, but it’s true.

On the other hand, some clients realize they won’t be able to reach their goals with their current therapist. They may have a personality conflict, experience some challenges within the therapy, or they may suffer from a problem that requires a specific set of skills their therapist doesn’t have. Some therapists are highly trained to work with chemical dependency, eating disorders, or schizophrenia, for example, while others have very little training in these areas. If it becomes clear that the therapist doesn’t have the tools necessary to help the client with their issues, the therapist should make a referral to another clinician who can help.

Beyond specialty, there are also times when interpersonal issues become a barrier to the therapy. In therapy, as in all close relationships, problems with trust, communication, and empathy could render therapy an obstacle rather than a conduit to healing. If you’re seeking help with grieving a lost loved one but you don’t trust that your therapist is keeping your sessions confidential, therapy is getting in the way of your healing. In these cases, it can be helpful to discuss the problems with the therapist first, but if they can’t be resolved, leaving therapy is a viable option. 

One point to consider is whether the obstacle is central to your issues or not. If you are seeking therapy to address a history of conflict with males, and you find yourself having conflict with your male therapist, you might want to think about staying to resolve this conflict because it becomes a laboratory for your specific problem. If you have social phobia and feel awkward with your therapist, this might be just the place to work on it. But if you have a fear of heights and your interpersonal issues with the therapist are getting in the way, leaving therapy could be a good option. 

UI: Any thoughts on whether there is an optimal amount of time or number of sessions should be in therapy? What are the different variables (such as reasons for being in therapy – what would be an example of a reason that should take 8-12 sessions, what would be an example of a reason that could take months or years)?

RH: As vague as it is, it depends. 

There are people who will benefit from a single therapy session and others who have been in great therapy for 23 years and have no intention of stopping. As long as someone feels like therapy is beneficial to them and they have the practical means, they should feel free to keep going. 

A lot of this has to do with the mindset of the person seeking therapy. I’ll draw an analogy from the world of physical health, where we have two approaches – the illness model and the wellness model. In the illness model, when someone feels sick or has an injury, they go to an MD and receive treatment. When the illness clears up, they make no more appointments with the MD, and all is well. In the wellness model, a relatively healthy person decides they want to make their healthy body healthier, so they go to the gym. They work out regularly and achieve fitness goals and feel great about it. No one says: “You’re in great shape – it’s time to stop going to the gym!” That would be absurd. 

Psychotherapy is the mental health equivalent of both the illness and wellness model. People come to therapy to treat disorders like phobias, depression, anxiety, OCD, PTSD, ADHD, bipolar disorder, etc. But they also come to therapy to make a good life great by working on their relationships, finding meaning in their life, becoming a better parent, improving their communication, finding their ideal career, increasing their capacity for intimacy, enhancing their self-esteem, and so on. 

So the question about how long someone “should” be in therapy promotes a mental health stigma. It implies that people “should” be done with therapy in a predetermined amount of time and if they’re not there’s something wrong with them or the therapy. Would someone say the same thing to someone who goes to the gym? "You’ve gone to this gym for 6 years, aren’t you done yet? You’re in great shape, so stop working out.” Hell no. Let’s try to apply the same grace to mental health that we do to physical health. 

Generally speaking, people seeking relief from phobias, anxiety or depression find some relief within the first 3-6 months of therapy. People with deeper issues like trauma, relational issues, problems with core identity, sexual and intimacy problems require months to years of treatment. And if they want a safe, structured place to work on becoming the most self-aware and best version of themselves, they may want to spend much longer in treatment. 

UI: Do therapists have any responsibility to ask the patient whether he or she should stop therapy (or find another therapist)?

RH: As I said above, if a therapist finds that they are working with a client who has needs that exceed their scope of competence, the therapist is obligated to find referrals to someone who does have that skill. All ethics codes say something about therapists only working within their scope of competence.

Therapists should also be aware of whether or not therapy is giving any value to the client. This could be a therapist who recognizes that their depressed client isn’t improving despite several months of therapy, or realizing that the ADHD tools they have taught aren’t producing the desired results, or the anger management strategies seem to make matters worse. This should be a collaborative discussion with the client, where they both assess the effectiveness of the interventions and decide whether or not to stop and find outside help. 

This collaboration is very important. I remember a time early in my training when I was working with an elderly woman and I felt like our work was going nowhere. She was telling story after story and I felt like it wasn’t helping to resolve her depression at all. After several months I told her I didn’t feel I was being effective and suggested we might transfer her to someone with more experience. She nearly burst into tears and told me our sessions were the most important hour of her week, that it had helped her connect with others, and that she was heartbroken that I felt otherwise. I learned then that my experience and my client’s can be very different, and never to assume that my opinion is true for both of us. We repaired from that session, and continued several more months as her depression lifted. 

UI:  Please provide specific consumer advice tips for patients who are wondering whether they should stop or wind down from therapy, at least one robust paragraph per tip.

RH: If it’s bad therapy:

Just go. If you feel you are being exploited, if you feel unwanted romantic advances, if you feel like your boundaries are violated in any way, if you feel like therapy is going nowhere, make your next session your last. Tell your therapist you don’t feel safe and/or competently served and let them know this is your last session. If the violations are extreme or causing harm look into telling their boss or alerting the licensing board. Like physicians, therapists are ethically bound to “do no harm” in their therapy, and if you’re suffering harm there are avenues to stop the harm and find better treatment. You may feel it’s helpful for you to have a voice and tell your therapist about your complaints, or maybe not. As I’ve said many times before, it’s your time and your dime, you can have closure or choose to split with a voicemail. Whatever works best for your mental health.

If it’s good therapy:

Start early – I try to talk with my clients about when therapy will end, from the beginning. When you’re talking about the goals for therapy, talk about how and when you’ll know therapy is ready to come to a close. Maybe you’re trying to stop an annoying behavior - perhaps when you’ve been free from the behavior for a month you’ll be ready to wrap up therapy. It can seem odd to talk about the ending of therapy at the first session, but this can free both of you up to work well together and not wonder when and how you’ll end. 

Talk about it – Beyond the first session, it can be helpful to bring the topic of ending up from time to time. Let’s say you found yourself dreading therapy this week and had to drag yourself in. This can be great material to discuss and might help you develop your exit plan together. Maybe you can set a date for a final session and plan a good farewell in the meantime.

Raise your concerns – Sometimes therapy raises concerns that are speed bumps, but not necessarily reasons to end therapy. Your therapist was late for a session. You forgot an appointment. You had a disagreement. Talk about these issues and see if they are about readiness to end therapy or another problem, like resistance to diving into deeper topics. Sometimes a desire to bail is about an unwillingness to talk about really important issues more than a signal that therapy isn’t important anymore. 

Set a date – When therapy has gone well and you’ve been able to internalize the voice of your therapist, it can be helpful to set a date in the future to say your last goodbyes - some make it a month out, some make it 10% of the total amount of time in therapy. I’ve seen that doing this sometimes raises new material in therapy, issues that can be very helpful to discuss. The idea that therapy is ending can raise memories of other endings in a person’s life and give you a chance to talk about them.

Make a positive ending – The fact is, there aren’t enough good endings in life. Many relationships end in death, divorce, breakups, or a slow fade away. A good therapy ending is a lot like a graduation – it’s bittersweet. We spend some time talking about the goals achieved, lament about the problems we couldn’t resolve and had to accept, and reminisce about the time we spent together. We make an aftercare plan about what life looks like after therapy, and we end on a positive note. Unlike many relationships where there is no closure, we try to say and feel everything we can to make this as complete as possible. 

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