Terminating Therapy, Part 3: The Not-Quite-Ideal Termination

Ending therapy on a sour note

Posted Oct 18, 2008

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