Time to Retire "Termination"

Why it matters what we call the end of therapy.

Posted Feb 29, 2020

Deborah Cabaniss
Source: Deborah Cabaniss

On a lovely day in March, Angela sits in her therapist’s office. She’d first called for an appointment two years ago, during her divorce. She breathes a sigh of relief. Noticing the first flowers of spring outside the window, she realizes how much more alive she feels now. Her therapist sees the sigh and asks about it. Turning towards her therapist, Angela says: I just feel so much better. I’m so grateful and so glad I called you. It was hard to do, but I don’t think I’m overdoing it by saying that therapy saved my life.

The therapist sits back in her chair and thinks, Yes, Angela has done such good work. She’s allowed herself to think about how much she has to offer others and has learned about the way that early life experiences led her to pursue hurtful relationships. And, over time, she’s been able to feel cared for by me, and to understand why it was so hard to acknowledge.

The therapist takes a little breath herself and says, I’m so glad to hear that. You have come such a long way. You know, I’ve been thinking that it may be time for us to talk about termination.

"Termination"? Really? Do we still have to use that word?

Maybe it’s just because of Hollywood action movies, but to me the word termination rings of finality and destruction. The word derives from the Latin terminare, which means to limit, or end, so the usage is not incorrect. But today, termination signifies being fired from a job, inducing abortion, and being shot with a machine gun. It’s not quite being canceled, but it’s close.

And there’s more. In the early history of psychoanalysis, the idea was that analysts should essentially paint themselves out of the room. When you were done, you were done forever. The fantasy of the early analysts, particularly during the heyday of ego psychology, was that analysis could eliminate a person’s conflicts completely. To them, the presence of residual difficulties was considered a failure of the analysis. And the relationship with the analyst was not thought to be a “real” relationship that would carry on in any meaningful way after the analysis was over. So, the work needed a true limit – a termination.

Today we know better. About 15 years ago, I participated in a study at the Columbia University Center for Psychoanalytic Training and Research about what has historically been called “post-termination contact” (1). In our sample, 65% of patients had contact with their analysts after “terminating” analysis; 40% of those patients returned to see their analysts in person, 55% of whom had some extended treatment. They continued to grow as people and to have new experiences and challenges. They remained connected to their analysts and sought their help with future issues. They had not been terminated.

I think about this issue – and this word – every spring as I work with psychiatry residents learning to become psychotherapists. Since the academic year goes from July to July, spring has typically been the time to discuss “termination.” Somehow, despite the fact that we now know so much more about the relationship between patients and their therapists, about time-limited treatments, and about the episodic use of psychotherapy, the use of the word persists. I still hear young therapists asking about termination and using the term with their patients. It must be because of us – their supervisors. It’s hard to let go of the words we were initially trained to use. For example, when my colleagues and I initially wrote a clinical manual of psychodynamic psychotherapy, we used the word termination, but in our second edition, we changed it to ending. Because that’s what it is. It took a little doing, but I gradually weaned myself off the word termination. Now I think about the ending phase, teach residents about when to think about ending, and talk about ending with my patients. It’s a better word and closer to what I want it to mean.

So, let’s retire "termination." It suggests a finality that is no longer clinically real or appropriate. It’s anachronistic and doesn’t serve patients or therapists. Not to mention that it’s the kind of jargon that potentially distances patients from us just when they often need real warmth. I sometimes wonder if that’s why it was used – to push people away. But that’s not what we want to do. Today we want to appropriately and responsibly end treatment while leaving the door open for more if that makes sense. If you’ve had an infection for which you’ve had to see your primary care doctor a few times, when you’re better, she doesn’t say, “Time for termination!” Rather, she says, “Be well, call me when you need me.” We should do the same.

Back to Angela and her therapist, Take 2: I’m so glad to hear that. You have come such a long way. You know, I’ve been thinking that it may be time for us talk about ending our work together, at least for now.

Maybe Angela will return, and maybe she won’t. But let’s make it because of the way her life will go rather than because she thinks that if she returns her initial therapy failed. And on that note, I will end.

References

Roose, S.P. Yang, S. Caligor, E. Cabaniss, D.L. Luber, B. Donovan, J. Rosen, P. Forand, N.R. (2004). Posttermination Contact: A Survey Of Prevalence, Characteristics, And Analyst Attitudes. J. Amer. Psychoanal. Assn., 52(2):455-457.