Terminating Psychotherapy with Success

We are not always so good at saying goodbyes. There’s just something a bit uncomfortable about it. While we, as mental health professionals, obtain instruction and training in the nuances of communication and relationship, carrying out a solid, healthy therapeutic adieu with our clients requires some forethought, preparation, and skill. The following is a review of considerations and tips for terminating psychotherapy with success.

Language & Conceptualization

It’s unfortunate that the ending phase in therapy is typically known as “termination.” And if we accidentally introduce this term without explanation to clients unfamiliar with it, they might think this means getting fired from therapy. Oops! It just so happens, that the language we use informs our perceptions. Instead of “terminating” therapy, we could consider reframing it as “consolidating” [1], concluding, completing, or even graduating from therapy. Ideally, a successful course of therapy would result in meaningful personal changes for a client, and at minimum, a period of developing insight, interpersonal trust, and hope for the future.

Meanwhile, concluding therapy is an opportunity for a therapist to join a client in:

• Reviewing skills learned over the course of treatment.
• Reveling in the insight gained through self-reflection.
• Valuing the positive outcomes in one’s life.
• Appreciating the therapeutic relationship.
• Identifying goals and hopes for the future.
• Celebrating one’s effort and commitment.

The language we use to refer to what we do can inform how we think about it. As a result, our language and thoughts can determine whether the conclusion of therapy is an uncomfortable blunder or an impactful therapeutic experience for client and therapist alike.

Client Factors

Clients might experience discomfort with ending therapy for a few reasons, such as concern about their therapist’s expectations for a successful therapeutic outcome – clients might believe their therapist hoped they would make more gains than they actually did. Clients may also experience self-doubt about continued personal success without therapy, and awkwardness in saying goodbye, to name a few.

For some, the conclusion of therapy may result in grief for the loss of a formative relationship, or the client may experience it as abandonment or rejection by the therapist. This loss of attachment may be a manifestation of pre-existing interpersonal problems, a possible target problem in therapy [3]. I remember, early in my graduate training, winding down with a client during a mutually pre-determined termination session to suddenly, at the last moment, being asked, “Is this because you don’t want to see me anymore?” Despite what I thought had been adequate communication about termination, something was amiss.

Many who begin therapy have not shared their personal struggles with others in any depth, or at all. You, as their therapist, may be the first to venture to the darkest, loneliest places with them. So, the end of this relationship can be quite the pill to swallow.

Therapist Factors

We often miss out on more practice closing out therapy with our clients due to early or abrupt terminations. We are all familiar with what it’s like to have a client drop out of therapy without notice or to no-show unexpectedly for the last session. These missed opportunities for consolidation of therapy and closure of the therapeutic relationship are unfortunate and unsatisfying for therapists, sometimes leaving us feeling a wee bit jilted.

Conversely, even a relatively smooth conclusion of therapy can raise personal questions about our own needs (I’m going to miss this relationship – I’m not needed anymore), insecurities (Was really I able to help this person? Did I do enough?), and expectations (I really hope ___ uses the skills we spent so much time reviewing and practicing). At times, we realize that the therapeutic relationship actually meant more to us than it apparently did to a given client based on his or her apparent indifference to the end of the relationship. Realizing this can be a bit surprising and unnerving. Without sufficient self-reflection, we might not recognize the deeper effect ending with a given client could be having on ourselves.

Mutual Factors

Not seeing eye-to-eye with our clients about the appropriate timing of termination can create friction. Perhaps you believe the client has not met his or her goals yet, or perhaps, through supervision, you have determined that you are unable to help a client achieve reported goals. Perhaps, a client might not believe you will be able to help. Alternately, a client might not have identified any particular goals at all, resulting in a potential uncharted course of therapy.

I recall having experienced this with a young female client. She decided that she did not wish to collaboratively tackle the one issue that caused her to seek out therapy. Because she did not want anything else other than to “talk,” I explained the one prerequisite of psychotherapy (i.e., a goal, need, problem, etc.). We concluded therapy with the understanding that she was welcome to schedule another appointment should something change on her end.

In any of these situations, the therapist must consider the needs of the client, ethical guidelines and principles, and the extent of one’s own competencies.

Tips & Strategies

The following are some key strategies to set up termination for success:

• Tentatively anticipate and discuss with your clients when therapy may conclude. Ask, What are the specific goals and measurable objectives? What will the markers for successful therapy be? Discuss the possibility of adding new goals along the way. Clients’ insurance coverage may also inform tentative duration of treatment.
  • I like to think that the overarching goal of therapy, even if not always attainable or even if limited to a particular problem or situation, is reaching the point when clients become their own therapists and coaches.
• Consider how termination is conceptualized through the lens of the theoretical orientation you may have been using [see 1]. This can provide a sense of coherence to the work you do with your clients.
• Discuss and prepare for the anticipated termination date with your clients as it approaches. This can include what the session(s) will entail, hopes and expectations, and wrapping up therapeutic work before the final appointment. Essentially, begin the consolidation process in advance of last session by introducing this phase in sufficient detail. Together, explore and validate your clients’ cognitive and emotional responses to termination, and as appropriate (or privately) your own [2].
• During the termination phase, promote your clients’ self-reflection and engagement by having them discuss perceived self-efficacy, review skills development and use for sake of reinforcement, and highlight improvements over time [1, 2].
• Offer the option to schedule a follow up appointment one, two, or more months out to “check in.” This is particularly useful to prevent feelings of abandonment. Ensure that your clients know they can contact you during the interim if needed.

Most importantly: The last session is an opportunity to “give a gift” to your clients. What I mean by this is that the conclusion of therapy is ripe with the opportunity to yield a very meaningful therapeutic experience. In fact, the conclusion of therapy is an integral part of the psychotherapeutic process, not merely the end of it. You can honor your clients by expressing your perspective on how they have grown or changed, the effort they put forth to implement change, what the therapeutic relationship has meant to you, and your sincere hope for the client to continue making use of the skills and lessons you have reviewed together.

References

[1] Maples, J. L. & Walker, R. L. (2014). Consolidation rather than termination: Rethinking how psychologists label and conceptualize the final phase of psychological treatment. Professional Psychology: Research and Practice, 45(2), 104-110.[2] Ward, D. E. (1984). Termination of individual counseling: Concepts and strategies. Journal of Counseling and Development, 63, 21-25.[3] Zilberstein, K. (2008). Au revoir: An attachment and loss perspective on termination. Clinical Social Work Journal, 36, 301-311.