Terminating Therapy, Part II: The Ideal Termination
What's the best reason to end therapy?
Posted Oct 10, 2008
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