Ending therapy

lillypondTwo 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.

90 comments to Ending therapy

  • Lottie

    Hello,
    I just wanted to ask a question.
    Basically, I have seen my therapist for over 2 years. My therapist admitted her diagnosis of BPD with ‘Narcissistic overlay’ – quite why she told me this, I am not sure – but it seems the narcissist has come out to play during a very unplanned ending.
    We had a misunderstanding about a missed session (I had given her verbal notice – she claimed she remembered me saying something, but didn’t remember what it was). This led to me having to agree to pay that season – and skipping a week as I couldn’t afford to pay for both. I then had to miss a week for a deadline – but was happy to cover the cost as its my fault – and assumed we would be meeting at my usual time slot this week, as she replied with ‘ok’ and didn’t contact me further.
    I then had an email the day before my session, telling me that she had given my slot to someone on the waiting list, so it is no longer available – and “still wants to support” me, so has graciously offered me other times which I can’t – and don’t want to do.
    She is claiming that because I can’t give her 4 weeks of sure dates (I am waiting to hear back from a job, which she was aware of – and told me we would ‘play it by ear’), she had to offer my time elsewhere – even though this was never explained before the event, and contradicted her last conversation.
    I feel that she is being manipulative – phrases such as ‘I feel that these 4 weeks are an important part of our work’ and ‘I care for you greatly, and this is all your choice’ etc keep cropping up. I outlined clearly why I felt that the boundaries have been unclear, but she has refused to acknowledge that – only coming back with ‘this is your choice, and I still care for you’ etc.
    I feel that I have been reasonable throughout – but this feels a little like an ‘Im going to hurt you first’ game, which I am very familiar with due to NCP family. She had previously even admitted that Narcissists attract certain times of people – and I feel we have sunk into those roles.
    I am aware there is no repair, I have lost all trust in her as a safe and open space – but I feel very hurt, and scared of further help, as even in this situation, I have been easily manipulated.
    Is this unreasonable of me to have expected more warning and clearer boundaries if she was making this decision?

  • Angela

    After 12 years of weekly appointments my psychiatrist abandons me. I was having a bad month of August. Prior to August my antidepressant had stopped working. I then lost my job at the beginning of August is which my mental health began to decline some more. On top of that I am going through Per-Menopause so my hormones were all over. At the end of August I was admitted to the hospital where my psychiatrist faxed a letter terminating my care. My physical and mental health declined a lot more and it is the worse it ever has been because of being abandoned by someone I trusted for 12 years.

  • TK

    Dr. Reidbord, I followed your blog closely for a while some time back. Then I read this column in the NYT today and thought of you and your blog. Here, the moment the analyst broke the frame and asked a question that was wholly for the benefit of the therapist (it was the last minute of a termination session, or what was going to be a termination session,and the analyst says straight out that she asked the question for her own benefit…the work shifted.

    http://opinionator.blogs.nytimes.com/2015/11/03/a-last-minute-breakthrough/?action=click&pgtype=Homepage&module=opinion-c-col-left-region&region=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region

    • Hi TK, glad to have you back. That was one of the better “Couch” columns in my opinion. The way I read it, Dr. Diman was taken aback by the sudden decision to end treatment, and intuitively aimed, in the few remaining minutes, to explore her patient’s dissatisfaction. At literally the last minute:

      “Let me ask you this,” I said, “just for my own clarification and edification: Was there ever a time when you asked me for help, for suggestion and advice, and I ignored it? Or refused it?”

      She says it was for her own clarification and edification, but these things are complicated. As it happened, it clearly wasn’t wholly for her own benefit: the patient gained insight and changed her mind about stopping. (I’d also quibble that she didn’t “break the frame” by asking.) Even if she had no therapeutic intent, she asked to gain a better understanding of her work with that particular patient, not to garner feedback about working with patients in general. (She wasn’t soliciting her patient’s opinion about whether she’d be a better therapist by giving more suggestions and advice.) What’s so good about this article is how it illustrates engaging in a transference-countertransference enactment, i.e., getting caught up in the patient’s typical relationship pattern, and then using it for therapeutic insight. For first part happens all the time; the latter only when the therapist is skillful and attentive.

  • Elizabeth

    Hello. I’ve written to you once or twice before on different issues and found your advice helpful as I navigate my way through my own course of therapy. How does one really know when therapy is over (apart from instances of blatant violation)? In my case, I am actually in both couples and individual therapy (different providers), which is quite astounding given an upbringing that cemented a need for independence and secrecy across all disciplines of life. By all rights, I am an otherwise well-functioning member of society (sounds funny to say that after admitting to seeing two therapists). Recently, I have wondered if my individual efforts may be working at cross purposes to my couples work. My hesitancy, however, is if my latest question instead represents a justification to stop individual therapy at a point whereby it has become somewhat uncomfortable (in terms of my being able to disclose and deal with the repercussions of my own feelings). As it stands now, I did attend what I stated was a final session recently (although had been asking to do that for a majority of the time in therapy). I was very upset emotionally when I left – mostly because of the recognition of losing one of the few resources I allow as a listener of my concerns, but also because of the cross-road of sorts that I realized I had to act upon within my personal life as well as the strife that would occur as a result. I gather I still have options – one being an attempt to engage my spouse in more conversation and another accepting the assistance offered by my therapist (who feels timing is not optimal for me given my initial distraught response and return to some less-than-optimal familiar ways of thinking). I am guessing that actually talking, whether it be with a therapist or my spouse, might be a recommended approach? I make many decisions during a typical day (at work and at home) and yet this one seems to loom over me with much weight and trepidation.

    • Elizabeth,

      You’ve been “asking to quit” for a majority of the time in therapy? Maybe you were right to finally do so. On the other hand, “actually talking,” whether with a therapist or spouse, sounds like a good idea too. I can’t really advise you over the internet. Have your individual and couples therapists talked with each other directly? That’s sometimes very helpful, particularly over the question of working at cross purposes. Fleeing from therapy because it is uncomfortable is very common — and not always a bad idea. Only you can decide whether the discomfort is/was constructive and worthwhile.

      None of this is about whether your therapy is over (in the sense of finished); you clearly have more to work on. It’s your decision whether to continue with your therapist, find a new one, or handle it yourself. Take care.

  • Elizabeth

    Hello again – last wrote in January (found the post) at which time I was debating staying/going from therapy. In some ways, I remain in the same place, although for somewhat different reasons. To belatedly answer one of your questions to me – I have not granted permission for my therapists to speak. Our couples therapist is great but feel that issues may have been raised in session (shared by me with my individual therapist) that I was not quite ready to address with my spouse (regarding my uncertainty about the future of our relationship). Probably less of an issue now, though have not revisited signing such a release of information. However, following a rough session together, our couples therapist did ask me if I am working on some of the [personal] points raised with the other [therapist] directly. I was reluctant to comment at the time in front of my spouse following a very emotionally charged exchange, whereupon the therapist asked if I thought my other therapist was adequately skilled (the two do know each other). That comment was raised at least one other time, such that I began to question the other’s abilities myself. Again, I am a healthcare provider myself, though not in psychiatry, and have only these experiences of my own upon which to draw (I do talk with some of the psychiatrists and psychologists to which I’ve referred some patients – but not the same when discussions are about others). I can say that I most definitely feel supported by my therapist (couples one as well) but do not know if the progress would be different with a different provider. I have discussed this somewhat with my therapist although life events have a way of interrupting my conclusions (such as an unexpected ambulation-limiting procedure). Perhaps the most viable question to you now would be whether a goal of therapy could simply be accepting of the support of an external party for someone who so values her own control and independence and yet seems to want that elusive connection to others (sadly, three of my closest friends have relocated to locations distant from my own within the past year) OR might accepting such support possibly serve a new starting point for more directed discourse (e.g., why I continue to want to flee situations in which I perceive too much closeness/dependency)? Thanks.

    • Hi again. Yes, it’s sometimes a mark of progress in therapy when a person who values control and independence opens up to allow someone else, e.g., the therapist, to support her. It also may lead to a useful exploration of the importance of control and/or the fear of dependency. I”m afraid I can’t offer you anything more specific; these are matters to explore in your own therapy.

  • Susie

    thank you for this post. I know it was written a long time ago but I am in the midst of a very difficult ending with my therapist of 6 years. I have been searching for something that tells me how we ‘should’ end in the absence of him being able to explain this to me. I am distraught and it is a very difficult time. But the simplicity of your post helps me understand that each ending is different and far from being that our difficult ending is as a result of me being a difficult client the fact is we just do not have a strong enough working alliance, and indeed probably a damaged one. I can blame myself for this but the reality is that he is the therapist. So thank you for making me feel slightly better at a very tough time in my life.

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