Terminating Therapy, Part IV: How to Terminate
How to end therapy
Posted Oct 30, 2008
I enjoyed the comment from CS on Part I: "Cut & run was the route I had in mind, so I'm interested in the alternative." Why not cut and run? If I'm finished with my barber, mechanic or supermarket I'll just go somewhere else next time. I won't set up a series of appointments to process my leaving. CS isn't alone; the prevalence of cut and run is even documented in scientific journals.
In therapy, cut and run is like skipping the last chapter of a novel; the part where the loose ends are tied up, you learn what the future may hold and get a sense of closure. Therapy also may be the first time you can talk through the feelings associated with ending and wrap up a relationship on a good note. It's why good termination should be among the treatment goals, especially if the client has a history of bad endings.
If you'd like to explore the "alternative" along with CS, here are a few tips to help you terminate well (as illustrated by alternative rock):
As mentioned in Part I, the best therapy doesn't deny its finite nature. All therapy comes to an end, and unfortunately most clients and therapists don't talk about termination until it's staring them in the face. This denial sets them up for an awkward, abrupt or destructive end to their work.
Ideally, along with "what are your goals for therapy?" the therapist asks "under what conditions will we end, and what will that ending look like?" This way, client and therapist together decide why and how therapy will end. If you had that discussion in the first session, you won't have a problem terminating therapy.
Didn't have that discussion? Neither did most other clients. The good news is you can have the "why and how we'll stop" talk any time. It might catch your therapist off guard, but you'll both benefit from it. Most therapists aren't used to talking about termination unless it's happening, so they may be surprised or afraid that you're LMB'ing a sudden departure. This conversation isn't saying goodbye; it's acknowledging that someday you will part ways, and preparing you both for what it might look like. For example:
You sought help for your panic attacks. You decide together that when you've been panic free for a month (the why), you'll tell your therapist you'd like to talk termination. When you've reached that benchmark, you'll take four more sessions to wrap things up (the how).
It seems termination is one area where clients and therapists consistently fail to collaborate. One study reported that only 40% of clients felt therapy ended at the right time, with 37% believing it ended too early and 23% saying it ended too late. Even if a portion of those endings were due to external, non-ideal circumstances (ran out of money or time), a 60% failure rate seems excessive and unnecessary. All the more reason to...
2. Talk about it (Foo Fighters, 1995)
You begin to notice you're feeling better. The symptoms that brought you into therapy have diminished, you understand your issues in a way that makes sense and you're noticing practical improvements in your life. When you encounter a challenging situation, you can "hear" how the problem would be addressed in therapy. You predict your therapists' reactions to what you have to say, and you're mostly accurate. For the fourth week in a row, you notice yourself in session talking about how great things are. Then the thought comes to you: I wonder if I'm ready to stop?
A lot of clients at this point believe they need to make a bold declaration: "I've decided to leave. Goodbye." Therapy is a collaborative relationship, and this doesn't change when termination is the topic. Your thoughts about termination are interesting material you're noticing about yourself - you can talk about it like you would anything else. "I had a thought about our termination last week. I wonder what that's all about?"
It's an item for discussion. It doesn't necessarily mean you need to terminate immediately, but talking it through may give a clearer idea. It could be a fear, the beginning of an ideal termination or an indicator of a not-so-ideal reason to end. If you've trusted the collaborative working relationship this long, you might as well continue with it to the end.
Some clients want to terminate gradually by decreasing the frequency of sessions from weekly to every other to every month to every quarter. Fading away is not termination; it's mitigating the difficult feelings associated with ending. Cutting back sessions communicates: "I can handle seeing each other less often and with less intimacy, but an absolute ending is too much." Two sessions per month or less becomes "checking in" and we spend most of the time reacquainting with one another rather than diving into deeper work. The flow and continuity of therapy eventually weakens, changing the quality of the relationship. When clients tell me they'd like to cut back their sessions, I take it as a sign they're thinking about terminating and suggest we begin termination instead. This way, the corrective experience of facing and grieving an ending head-on isn't lost.
This point comes from experience. I've done the fade-away many times, and after a couple bi-weekly sessions and a monthly or two, clients typically disappear. The significance of the relationship diminishes so they simply drift away. But they're depriving themselves of the closure, the summary and the goodbye.
4. How long to sing this song? (U2, 1983)
The termination phase is the period of time between realizing you're leaving and the final goodbye. How long does it last? It depends on how long you've been in therapy, what type of therapy it's been, the nature of your issue, and ultimately - whatever you and your therapist determine. Psychoanalyst mentors in my past taught that once a patient and analyst determine readiness for termination, a termination date is set for one year later. Dr. Diamond commented that sometimes 25% of therapy is spent on termination. I've heard other psychologists who vary from 10% to a one-month minimum. Some even write their termination policy into their consent form. Again, it's an issue for collaboration. You'll come up with something between one session and one year. As long as it's enough time to say what you need to say, feel what you need to feel and wrap things up, it's long enough.
I encourage you to set an end date and stick with it (barring unforeseen obstacles, of course). Having a date in mind does interesting things. When my graduate student supervisees tell clients they're leaving in a couple months, sometimes the work moves faster. The client suddenly realizes the clock is ticking and decides to deal with their abuse or their resentment or whatever they've been avoiding. Occasionally the end date brings up sadness, regret, anger or other feelings worth exploring.
5. This is the End (The Doors, 1967)
You're now prepared to enter the termination phase. In a nutshell, here's what to expect you'll do during termination:
- Review what you've learned about yourself
- Discuss which goals (if any) you weren't able to accomplish in therapy, and what to do about them
- Develop your "aftercare" plan: everything you'll be doing post-therapy
- Reminisce about the therapeutic relationship - when you felt cared for, when she made you mad, when you shared meaningful moments, etc.
- Discuss and grieve the end of the therapeutic relationship
- Talk about the other feelings or memories this ending brings up
Sound like fun? Not all of it; some parts may be satisfying and some incredibly difficult. It's the bittersweetness I talked about in Part II. Good termination is like graduation, and people smile and cry at graduations. You're saying goodbye to someone with whom you've shared your most intimate thoughts. You've gone on a journey together. But you're equipped to fly solo and that's worth celebrating.
6. Give it away now (Red Hot Chili Peppers, 1991)
It's your last session; you've processed everything on the list above, and time is up. What happens as you walk out the door?
There is no requirement to give your therapist a parting gift or card. In fact, most therapists are anti-gift, so giving one may usher you into a whole new arena of awkwardness in your final moments. Therapists don't expect a gift and don't particularly want one, but sometimes clients want to give one anyway. If that's the case, here's a good gift for the therapist: tell her what gift you wanted to give and why. You might think it's cruel, but it actually gives the therapist what they're looking for - insight into what she means to you without the awkward gift reception. Also, you might look at why you feel compelled to give a gift. If you're looking for reciprocation, you'll probably be disappointed. As nonplussed as therapists are about receiving gifts, they're even less plussed about giving them. Why? Because therapy is supposed to be a place where words come first, physical and behavioral gestures are a distant second. If you've got your communication lines open and you're already talking about how therapy ends, discussing this point will be easy. No therapist is going to complain about a heartfelt "thank you" and a firm handshake as you walk out the door the last time.
If you've read through all four posts, you've probably got my point: termination is not a phase to avoid or rush - it's an essential element of therapy. On a pragmatic level, the termination phase provides the best customer service; giving clients the best products and tools of therapy. On the deepest level, I believe engaging in termination means connecting with grief and loss. Therapists and clients who allow themselves to explore endings are doing some of the best work therapy has to offer.
*** 2104 Update: Guess what? There's a Part V: Therapist Termination