Two events prompt me to write about therapy endings. In the more abrupt and traumatic of the two, a local psychiatrist died last month in a tragic accident, leaving many patients suddenly without their doctor. The other event, far more commonplace, was the decision of one of my own patients to stop therapy. These events illustrate opposite ends of a continuum, as I hope to describe below.
I discussed typical features of open-ended dynamic psychotherapy in my last post. Timelessness, wide focus, relative freedom from protocol and direction, and promotion of transference all come into play when such a therapy eventually comes to an end. Since this type of therapy has no “built-in” ending, each ending is unique.
In the real world psychotherapy often does not feel timeless. External events like a job change, a move, or a change in insurance coverage may end therapy prematurely. Therapists retire or move their practices far away. These endings are not chosen by the patient. Any unchosen ending can feel like a loss, or even an abandonment. These events do come with advance warning, however, and can be discussed ahead of time. The emotional repercussions can be contained, reviewed, and comforted in what is termed the “termination phase” of treatment: the sessions between acknowledging that therapy is ending, and the actual last session.
However, sometimes there is no warning, for example when a psychiatrist or other therapist suddenly dies. Such events are emotionally traumatic. Patients feel the acute loss of a relationship they came to rely upon, and often there is a rocky transition to another doctor, facilitated by the colleagues, professional partners, or secretarial staff (if any) of the deceased therapist. This mini-community steps in, without advance preparation nor much knowledge of the patients affected, to make the best of a very difficult situation. I consider this one extreme of the continuum of therapy endings, the pole where it is not the patient’s idea or wish at all.
In my view, the ideal way to end psychotherapy is not the other pole of the continuum either, where the decision is entirely the patient’s. This was the case with my patient who recently decided to end treatment after making much progress over the past couple of years. Yet, in my opinion she had a long way to go. Obviously, it is the patient’s choice to spend time and money on therapy; I can’t keep anyone in therapy if they choose otherwise. And sometimes a patient’s unilateral choice to stop reflects progress: a newfound ability to assert oneself, or to make definitive life decisions. Nonetheless, it isn’t an ideal outcome because it isn’t collaborative.
Psychodynamic therapy relies, first and foremost, on a “working alliance” between patient and therapist. If the patient feels he or she must make a unilateral decision to end therapy, this alliance has been damaged somehow, or was never strong in the first place. In a therapy with relatively little protocol or explicit direction, and where transference is promoted as a therapeutic tool, the one bedrock that both parties can rely upon is their mutual aim to help the patient. Ideally, then, a time comes when the patient feels ready to stop, and the therapist feels likewise. This is the midpoint on the continuum of therapy endings, where it is neither the therapist’s abandonment of the patient, nor the patient’s defiant separation from the therapist. It is a shared understanding that the work is ending, the culmination of a shared exploration in therapy.
Yes, this does happen in real life, although not as often as anyone would hope. Yet even when it’s the patient who chooses to end therapy, and the two parties “agree to disagree,” it is still very beneficial to plan ahead and allow for a termination phase — the length being roughly proportional to the length of the therapy, from a couple of sessions to several weeks — to discuss the ending. Unexpected feelings can arise when time is short. By exploring these feelings, therapy can be therapeutic until the very end.