![\"lillypond\"](\"http:\/\/blog.stevenreidbordmd.com\/wp-content\/uploads\/2009\/08\/lillypond.jpg\" "\\"lillypond\\"")
Two events prompt me to write about therapy endings. \u00a0In 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. \u00a0The other event, far more commonplace, was the decision of one of my own patients to stop therapy. \u00a0These events illustrate opposite ends of a continuum, as I hope to describe below.<\/p>\n
I discussed typical features of open-ended dynamic psychotherapy in my last post<\/a>. \u00a0Timelessness, 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. \u00a0Since this type of therapy has no “built-in” ending, each ending is unique.<\/p>\n In the real world psychotherapy often does not feel timeless. \u00a0External events like a job change, a move, or a change in insurance coverage may end therapy prematurely. \u00a0Therapists retire or move their practices far away. \u00a0These endings are not chosen by the patient. \u00a0Any unchosen ending can feel like a loss, or even an abandonment. \u00a0These events do come with advance warning, however, and can be discussed ahead of time. \u00a0The emotional repercussions can be contained, reviewed, and comforted in what is termed the “termination phase<\/a>” of treatment: the sessions between acknowledging that therapy is ending, and the actual last session.<\/p>\n However, sometimes there is no warning, for example when a psychiatrist or other therapist suddenly dies. \u00a0Such events are emotionally traumatic. \u00a0Patients 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. \u00a0This mini-community steps in, without advance preparation nor much knowledge of the patients affected, to make the best of a very difficult situation. \u00a0I consider this one extreme of the continuum of therapy endings, the pole where it is not the patient’s idea or wish at all.<\/p>\n 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. \u00a0This was the case with my patient who recently decided to end treatment after making much progress over the past couple of years. \u00a0Yet, in my opinion she had a long way to go. \u00a0Obviously, it is the patient’s choice to spend time and money on therapy; I can’t keep anyone in therapy if they choose otherwise. \u00a0And sometimes a patient’s unilateral choice to stop reflects progress: a newfound ability to assert oneself, or to make definitive life decisions. \u00a0Nonetheless, it isn’t an ideal outcome because it isn’t collaborative.<\/p>\n