Prout, T. A., & Wadkins, M. J. (2014). Endings. In Essential interviewing and counselling skills: An integrated approach to practice (pp. 283-299). Springer Publishing Company.
There is no real ending. It’s just the place where you stop the story.McNelly, Herbert, and Herbert (1969)
Psychotherapy has both a beginning and an end. Counseling interventions are truly successful when they are no longer necessary. The purpose of therapy is to help clients make sufficient gains in treatment so that they can move on and utilize what they have learned and internalized. This end point in the therapeutic relationship has long been referred to as termination (Freud 1937/1953). The word seems to have some negative implication, bringing to mind being terminated from employment or having a terminal illness. Although the end of psychotherapy is in fact the conclusion of a relationship, the end of something, it is also the beginning of a new phase in the client’s life. This next chapter is one in which the client begins to cope independently in ways he or she had not been able to previously (Goldfried, 2002). The termination phase of treatment requires a shift in focus as client and therapist begin the process of saying goodbye. Although termination may be represented as a date on the calendar, it is also a transition point between the process of therapy and a new phase of life without therapy.
Different orientations of therapy place varying emphases on the termination phase of treatment (Joyce, Piper, Ogrodniczuk, & Klein, 2007b). In some treatment approaches, termination is actually the central focus (Mann, 1973; Mann & Goldman, 1982). Mann (1873) recommends a “relentless” focus on termination as a way to address separation and ending, which are inevitable in all relationships and in life itself. Others have suggested that the entirety of the work of therapy is a prologue to termination (Hoyt, 1979). Cognitive behavioral approaches view termination as a time of consolidation and preparation for the next phase of independent application, whereas psychodynamic practitioners also incorporate an emphasis on mourning the loss of therapy. Regardless of therapeutic orientation, all agree that it is important that clients demonstrate the ability to continue the work initiated in psychotherapy on their own. Some therapists will discuss how to manage anticipated future problems and others may help the client make contingency plans for returning to treatment if needed. Termination of therapy gives clients an opportunity to say goodbye in a controlled way, with both parties taking the process seriously. This type of ending is different from many other endings clients may have experienced that were sudden, unexpected, or unreciprocated.
There are different types of termination. Ideally, the decision to terminate will be made mutually, based on the progress the client has made. Termination is sometimes initiated by the client for any number of reasons – including dissatisfaction with the treatment, relocation, or financial pressures. Therapists may also initiate termination because of the end of training, changes in health status, or even death. When termination is unilateral – that is, initiated by only one member of the dyad – many issues may arise. This chapter will begin to explore the many aspects of termination that beginning clinicians should consider before therapy even begins.
There are many things to consider when thinking about termination. There are different reasons for ending therapy and, thus, various types of termination. The end of therapy may be initiated by client or therapist (or both), or it may be brought about by institutional forces or external forces, like finances. Most people – therapists and clients alike – experience a complex array of emotions when it comes to saying goodbye to an important person in their life. Early losses and concerns about being left or leaving others can often affect the process of termination. The ending phase of therapy can be emotionally and cognitively intense. There is a summing up process that involves consolidating and integrating the gains of the therapy. The inherent challenges of termination – which involve embracing independence and leaving a relationship that has been helping – are a test of the therapy itself, a way to evaluate the stability of the achievements made (Levy, 1986).
The question of when a treatment should end is a complicated one. In the first major work ever written about termination, Freud (1937/1954, p. 219) wrote about the requirements that should be fulfilled in order to proceed with termination:
Two conditions have been approximately fulfilled: first, that the patient shall no longer be suffering from his symptoms and shall have overcome his anxieties and his inhibitions; and secondly, that the [therapist] shall judge that so much repressed material has been made conscious, so much that was unintelligible has been explained, and so much internal resistance conquered, that there is no need to fear a repetition of the pathological processes concerned.
As you begin working with clients, you will become aware that it is deceptively simple to say that therapy ends once the goals of treatment have been achieved, or that the unintelligible has been explained. Therapists of different theoretical orientations may quantify or measure progress in psychotherapy in a variety of ways; however, most agree that termination is ideally a mutually agreed upon decision (between client and therapist) that emerges naturally once the client has achieved relief from distress and mastery of new insight and skills to manage future distress (Jakobsons, Brown, Gordon, & Joiner, 2007; Joyce, Piper, Ogrodniczuk, & Klein, 2007a). There are many things to consider when considering termination. In terms of the appropriate time for termination, clinicians should begin by considering whether the treatment goals have been met and whether the client appears to have achieved some degree of mastery over his or her problems.
Goals Have Been Met – Relief from Distress
The goals of therapy are most often to decrease symptoms or subjective distress. With the exception of therapy that addresses one very specific problem (such as a specific phobia), clients are not expected to reach the farthest extent of their goals. If that were the case, we might be binding clients to lifelong psychotherapy. Rather, counseling professionals help clients to make substantial progress on specific treatment goals. Goal-setting in psychotherapy is a critical aspect of measuring progress and outcome. Clients may sometimes have very specific goals that are relatively straightforward to assess, such as “I want to be able to function at work with less anxiety.” Other goals may be more nuanced; clients may want to experience closer and more long lasting intimate relationships, or achieve greater independence from their parents. Attainment of goals may be measured in several ways. Many therapists rely on clients’ subjective reports coupled with their own clinical assessment. Clients may report fewer depressive symptoms, exhibit a broader range of affect, and demonstrate increased functioning at work and in social relationships. All of these data points suggest that a goal of decreasing depressive symptoms may have been attained.
Alternatively, some clinicians administer self-report measures such as the Beck Depression Inventory (Beck et al., 1996) weekly or by session. This can afford both client and clinician a clear assessment of goal attainment. There are some problems with this type of concrete measurement. First, there is no clear definition of what constitutes a clinically significant reduction of symptoms (Jakobsons et al., 2007). This problem is also inherent in more subjective assessments of symptom reduction. If the goal for the client is to make substantial progress in his or her stated goals, the definition of the “substantial progress” is open to interpretation. Second, for clients with comorbid disorders, assessment of multiple domains may be complicated. Finally, there is evidence that as many as 50% of individuals who appear to be asymptomatic on objective symptom measures may not consider themselves to be in remission (Zimmerman et al., 2012). For some clients there appears to be a discrepancy between their scores on self-report measures and their subjective self-assessment of their well-being.
Another aspect of goal attainment is to assess whether additional progress can be made. For many clients, there are periods of life during which therapy may be indicated. A client who comes to therapy to address the death of a parent may make sufficient progress to indicate termination. The client and therapist may decide together that no additional progress can be made. Although the client may return to treatment some years later if another issue arises, for the time being, no additional progress can be made on the goal of overcoming grief. This is also an appropriate juncture to consider termination.
Sustained Remission and Mastery
Symptom reduction is the hallmark of a successful treatment, but the remission of symptoms must be sustained, not simply spontaneous and temporary. For termination to be considered, it must seem likely that symptoms will not reappear in the absence of the therapy. In other words, clients should be able to maintain the gains made during treatment. The goal of psychotherapy is not to create dependence upon the therapist, but rather to foster independence. Some researchers (Bohus et al., 2004) have utilized periodic assessment of symptoms for disorders over the course of several months to assess the sustainability of recovery. This is especially important with clients who experience symptoms, such as those seen in patients with borderline personality disorder, which tend to have great variability across time. Some psychotherapy researchers have recommended that symptom decrease should be maintained for 8 weeks or more (Jakobsons et al., 2007; Keller et al., 1987).
Clients typically learn new skills and coping mechanisms during therapy; they also develop greater insight into the genesis of their distress and acquire an ability to prevent future relapses. Independent implementation of these new skills over time, particularly during times of increased vulnerability, is an important criterion to consider when evaluating readiness for termination. It is often helpful to see carryover of symptom reduction into other areas of the client’s life. For example, a client treated for work-related anxiety may report an increased sense of ease in social situations.
During the process of assessment and diagnosis, clinicians typically evaluate functional impairment. This refers to the degree to which the client is prevented from operating at full capacity at work or school and in interpersonal relationships. When prolonged symptom remission is coupled with a return to an optimal level of social and vocational functioning, this is referred to as recovery (Zanarini, Frankenburg, Reich, & Fitzmaurice, 2010). For some clients with chronic psychiatric problems, the first goal of treatment is not recovery but symptom remission. This conceptualization of healing acknowledges that for some individuals with particular problems, symptoms may return. This is especially true for individuals with substance abuse problems (Walitzer & Dearing, 2006), bipolar disorder (Scott, Colom, & Vieta, 2007), psychotic disorders (Alvarez-Jimenez et al., 2012), and personality disorders (Zanarini et al., 2010). Assessing recovery involves evaluating whether the client has demonstrated improved social and emotional functioning. These aspects of recovery, however, are not required for all types of termination. For example, termination happens within a hospital setting when clinicians deem a client ready for discharge. Although this client has achieved enough symptom relief to recommend a less restrictive level of care, it is not expected that he or she will have returned to a pre-morbid level of social functioning.
Mastery involves resolving many of the problems that gave rise to the symptoms. This includes, but is not limited to, insight and cognitive understanding of the problem. It also suggests an ability to function at a higher capacity if the precipitating problem were to arise again. For psychodynamic clinicians, mastery may include the resolution of certain interpersonal styles that become apparent through the therapeutic relationship. For example, if a client is prone to suspicion and mistrust in relationships and this leads to anxiety and interpersonal dysfunction, termination should be predicted partly on successful resolution of this style of relating. In this case, the transference relationship may be the mechanism that leads to change. As the client has increased opportunity to test his or her hypotheses about other people’s motives and intentions, he or she may be able to internalize certain aspects of the therapy and the therapeutic process. Therapist and client can utilize the therapeutic relationship to prepare the client for maintaining a healthier way of interacting with others. Termination is typically recommended when clients report a sense of pride regarding the new skills they have acquired, as opposed to doubt about whether they will be able to function. This type of confidence is often indicative of symptom remission and a significant degree of mastery.
The termination phase of therapy is distinct from the initial assessment phase and the working phase. It has a tendency to simulate issues associated with separation and loss and is likely to provoke such feelings in both therapist and client. The salience of the termination phase varies widely with respect to theoretical orientation, duration of treatment, and the quality of the therapeutic relationship. Termination of open-ended psychotherapy is likely to focus more substantially on the loss of the therapeutic relationship and expression of grief over this loss may be encouraged. Within a short-term or problem-focused treatment, termination may emphasize the client’s resources and ability to function independently. Therapists who recognize the importance of the therapeutic alliance are also more likely to explore all of the feelings – positive and negative – associated with termination.
In most termination processes it is useful to discuss some, if not all, of the following topics with the client:
- Changes in symptoms, problems, and areas of conflict
- Extent of resolution of precipitating stressors or life events
- Improvements in ability to cope with daily hassles and major stressors
- Changes in the ability to tolerate a broader range of affect (e.g. feelings of sadness and worry)
- Increased awareness, appreciation, and acceptance of self and others
- Progress that has been made in daily functioning
- Improvements in quality of life, particularly those because of changes in internal capacities to cope
- Capacity to observe oneself and analyze situations (e.g. metacognitive and meta-emotive abilities)
Most therapists approach these topics in a relatively unstructured way. As termination approaches, it can be useful to notice the client’s enhanced abilities and skills in self-observation. For example, as a client tells the therapist about a recent event at work, it is therapeutic to use comments such as,
It’s important to notice what happened this time. You experienced a problem that was similar to the ones you faced when we began working together. What is different now is that you were able to think through this challenge without feeling particularly anxious and you resolved it with great skill. Now when you come in to talk about it, there is actually very little to discuss because you’ve taken care of the problem so effectively.
These types of observations reinforce the client’s confidence in his or her own abilities and help the client see concrete evidence that termination is appropriate.
Termination can occur in any number of ways. The ideal termination situation is one in which the client and therapist mutually agree upon the decision to end treatment and collaborate to develop a process for termination. The intensity and duration of the therapy typically dictate the length of the termination phase. For example, a client receiving six sessions of therapy for a specific phobia will likely require minimal planning for termination.
It may be introduced at the end of the fifth session with treatment concluding by the end of the sixth session. At the other end of the spectrum, in a 2-year therapy focused on childhood neglect and long-term sexual abuse, the termination phase of treatment may cover several weeks or months and require extensive preparation. The fact that different clients require different levels of closure may also dictate the length and intensity of the termination phase. Therapists must be sensitive to clients’ idiosyncratic reactions to saying goodbye as well as the complex countertransference reactions that may arise.
Clients may come to session with fewer problems to report. There may also be evidence of internalization for the therapist, for example, “I remembered what we talked about last week and it really helped me when I started to argue with my boss.” These types of statements may mark the beginning of the termination phase. For some clients, it will be difficult to suggest that termination be considered. In one study of clients’ feelings during psychotherapy termination, a participant stated that one of the most positive aspects of termination was the “capacity to end a routine and announce without concern my wish to end and the capacity to cope with the therapist’s response” (Roe, Dekel, Harel, Fennig, & Fennig, 2006, p. 75). This comment highlights the importance of the therapeutic relationship, the client’s implicit concern about hurting the therapist by leaving, and ultimately the ability to pursue his own goals separate and apart from the therapist.
When therapy ends, the interpersonal connection between the therapist and client does not cease to exist. The gains that have been made in therapy should be sustained, and aspects of the therapy (and even the therapist) should have been largely internalized by the patient. Edelson (1963) has said, “what has been happening keeps going on inside the patient” (p. 14). Growth and change continue beyond the bounds of formal treatment. In an ideal scenario, the termination phase should focus on the gains the client has made, the current strengths, and areas in which he or she is likely to continue growing independently. This is all part of the consolidation process that allows the client to continue in a process of growth and interpersonal development even after the therapy has ended.
With some clients, particularly children and adolescents, it can be helpful to create a concrete reminder or summary of the work that has been done. Therapist and client consider creating a memory book that describes, visually and in words, how the therapy began, major highlights, and hopes for the future (Elbow, 1987). Another option is to create an award certificate for a child that describes her achievements in therapy (e.g. “This award recognizes Juliet for facing her fears and overcoming them”). This type of ritual is an effective way of providing children with closure and a tangible reminder of this meaningful relationship. Some day-treatment programs or other institutionalized services provide graduation ceremonies or goodbye parties when someone moves on. These types of formal celebrations can also be helpful markers along a person’s journey toward mental health.
Even in mutually agreed upon terminations, there is a certain degree of affective turmoil that is expected. Therapists may anticipate clients’ reactions to impending termination based on the clients’ responses to other separations (e.g., therapist vacations) during the course of therapy and other types of losses the client has experienced (e.g., death of loved one, divorce, children leaving for college). Some clients experience a temporary increase in symptoms as the termination date approaches. This may be a type of resistance to termination, a way to demonstrate the client’s need for the therapist. Sometimes it is difficult to discern whether these types of re-emerging symptoms indicate the need for continued psychotherapy or whether they are an expected reaction to the impending loss of the therapist. This can be discussed with the client and an exploration of the meaning of these symptoms may be useful. The experience of sadness or anxiety is a normal part of living. As Greenberg (2002b) has written, “getting depressed, being unsure, or arguing again are all part of a process of living and never go away completely” (p. 359). Difficulty arises when clients become stuck in these old patterns and are unable to effectively manage them. It may be useful to emphasize the client’s strengths and to assure them that, should they need further help at a later date, the therapist will be available.
In an ideal termination situation, clients often experience a feeling of pride, a sense of accomplishment, and hope for the independence they are moving toward. Therapists also tend to experience similar emotions toward clients who have successfully utilized the therapy and are ready to conclude. Although saying goodbye is difficult, the therapeutic termination has many benefits and rewards. Mutual termination after a successful therapy is an inherently positive step forward. The ending is constructive and serves to consolidate the gains the client has made. Often both therapist and client have the opportunity to make statements about what the therapy has meant (Long, Pendleton, & Winter, 1988).
Time-Limited or Spaced Termination
The termination phase of therapy can be implemented in a variety of ways. In a time-limited termination, sessions continue at their usual frequency and then stop abruptly at a pre-determined date. For example, once a termination date is set, the client will be seen in his usual once-weekly manner until the date arrives and then the therapist and client will part ways. In spaced termination, sometimes referred to as “fading out,” the time between sessions is gradually extended and termination is approached in measured steps. A client in weekly treatment might be seen biweekly for a period of time, then monthly for several months, before treatment finally ends. Spaced termination does not always involve setting a final termination date ahead of time. Client and therapist can take a “wait and see” approach and determine when to conclude treatment spontaneously, based on the client’s sense of well-being and subjective readiness for termination.
Traditionally, treatments on the more expressive end of psychotherapy continuum tend to favor time-limited termination; supportive treatments, on the other hand, are more likely to utilize a spaced termination approach. This is not always the case, and termination plans in any treatment should be developed in accordance with the individual client’s needs. Termination plans must be amenable to change. If a client begins bringing up new and unresolved issues, it may be wise to consider extending the timeframe for termination. It is important for the therapist to remain flexible and willing to meet the needs of the client. Later in this chapter, we explore the multiple meanings of symptoms that reappear as termination approaches.
Beyond this ideal framework for termination – a mutually agreed upon and purposeful ending to a successful therapy – there are many other scenarios that can unfold. Premature termination refers to any early ending to the therapy that takes place before it would have ideally ended. It is estimated that between 30% and 60% of clients end therapy prematurely and unilaterally (Reis & Brown, 1999). Client-initiated premature termination is when the client decides to end therapy contrary to either the therapist’s current recommendation or the originally agreed upon duration of treatment (Ogrodniczuk, Joyrce, & Piper, 2005). Premature termination is associated with certain demographic variables. In one meta-analysis of 125 studies of premature termination, increased risk for dropping out of therapy was associated with being non-white, having a lower level of education, and lower socioeconomic status (Wierzbicki & Pekarik, 1993).
Not all premature terminations represent treatment failures. Some clients who discontinue psychotherapy may feel sufficiently helped. Other types of premature terminations may occur because of certain life circumstances such as financial pressures or relocation. These more positive types of premature terminations appear to be the exception rather than the rule. Clients who discontinue psychotherapy early understandably report less therapeutic progress and more psychological distress (Pekarik, 1992). They also have a tendency to overutilize mental health services (Carpenter, Del Gaudio, & Morrow, 1979), by contacting mental health providers at twice the rate of those who complete therapy.
In addition to the effects of premature termination may have on clients, it can also impact the therapist. Being left, as it were, can naturally bring up feelings of abandonment and anger. The therapist’s own self-esteem may be affected if his or her identity is closely linked with her ability to help others. Treatment failures may have an even greater impact on therapists who strive to demonstrate genuine warmth and empathy with their clients (Piselli, Halgin, & MacEwan, 2011). Premature terminations also have an economic impact on therapists in private practice. For trainees, having a client leave therapy early may cause concern about how their performance will be evaluated by supervisors and colleagues. Counseling professionals should closely monitor the feelings they have in the aftermath of premature termination. Painful reactions such as hurt, rejection, and loss may arise and can potentially affect the therapist’s work with other clients.
Given that premature termination appears to be a common problem for therapists, it is important to consider ways to reduce the frequency of therapy dropout. Research has shown that there are three major categories of reasons for leaving therapy prematurely (Pekarik, 1983). These include the aforementioned problem improvement, environmental obstacles, as well as dissatisfaction with treatment. Frequently, clients who choose to terminate prematurely do so without notice. They may tell the therapist, “I will not be coming back next week,” or they may simply fail to show up or call, essentially disappearing.
Encouraging Treatment Completion
Ogrodniczuk and colleagues (2005) identified nine strategies for reducing premature termination. They include: (a) pre-therapy preparation, (b) client selection, (c) time-limited treatment, (d) treatment negotiation, (e) case management, (f) appointment reminders, (g) motivation enhancement, (h) facilitation of the therapeutic alliance, and (i) facilitation of affect expression. These strategies are particularly useful in that they balance their focus on both client and therapist factors that may lead to premature termination.
Pre-therapy preparation is one of the most frequently discussed strategies for preventing client-initiated premature termination of psychotherapy. This type of preparation involves teaching the patient about how treatment unfolds, the rationale for treatment, expectations for client and therapist, and identifying the types of difficulties one may face during therapy. The purpose of this type of therapy preparation is to increase psychological mindedness among clients and to reduce incongruence between client and therapist expectations of therapy.
Selection of clients is an important component of beginning psychotherapy. Not all potential clients are suited to all types of therapy. It is important to find a match between the client’s capacities and the demands of a specific type of counseling intervention. Some clients are particularly motivated for cognitive behavioral or psychodynamic treatment, whereas others may benefit from supportive psychotherapy or social skills training.
In some cases, time-limited treatment or clear consensus between client and therapist about the goals and parameters of therapy – treatment negotiation – are useful tools in facilitating treatment completion. Having a definite time limit for treatment and collaborating with the client to develop a plan of action can be helpful in this regard. Time-limited treatment offers an explicit and pre-determined ending that can be a helpful boundary for some clients. Additionally, some studies have shown that some clients who terminate prematurely do so because they could not come to a common understanding with the therapist about the nature of the client’s problems and the methods that should be used to address the issue (Epperson, Bushway, & Warman, 1983; Tracey, 1988).
Particularly for clients from disadvantaged backgrounds or those facing multiple challenges of daily living, case management can be an essential adjunctive treatment. Case managers do not serve as additional therapists; instead they serve as coaches and assistants to help clients maintain basic standards of living. Case management can help clients find housing, maintain health insurance coverage, and pursue employment and educational opportunities, as well as provide social support. Maintaining or improving these important aspects of daily living can improve overall mental health. Having fewer daily stressors also allows clients to come to therapy with greater emotional resources and fortitude. Appointment reminders are also a low-cost form of case management. Although eschewed by many practicing clinicians because they tend to deemphasize client responsibility for the treatment, appointment reminders can be helpful for client populations facing multiple stressors. They are often in day treatment programs for individuals with chronic mental illness and hospital-based outpatient clinics.
Directly out of the motivational interviewing playbook (see Chapter 10; Miller & Rollnick, 2002), motivation enhancement is another tool that can facilitate treatment completion. This strategy involves creating incentives for change, eliciting self-motivational statements about treatment, acknowledging the client’s efforts, and reframing problems so they seem less formidable. This type of strategy is particularly relevant for clients who are ambivalent about treatment or exhibit problems (like substance abuse) that are often associated with resistance to change.
The last two strategies for addressing early termination include facilitation of the therapeutic alliance and the expression of affect. As you learned in Chapter 7, therapeutic alliance is one of the essential ingredients of successful therapy. All the components of the alliance – warmth, empathy, genuineness – are factors that will help facilitate communication between therapist and client. Within the context of a strong therapeutic alliance, clients will also have room to express doubts and questions about therapy. A good working relationship between client and therapist will also create space for clients to express a broad range of affect. Exploration of negative affect can help clients resolve emotional problems and will often lead to more frequent expressions of positive affect. Clients who have difficulty expressing their true emotions in therapy are also more likely to terminate prematurely (Oei & Kazmierczak, 1997).
As you can see, there are many ways to foster an environment that leads to treatment completion. Not surprisingly, many of the strategies described here are things you have learned about – addressing client expectations (see Chapter 5), enhancing motivation (see Chapter 10), building a strong therapeutic alliance (see Chapter 7) and encouraging expression of a broad range of emotions (see Chapter 11). Keep in mind that throughout your career as a counseling professional, clients will leave treatment unexpectedly and sometimes even without notice. It is important to recognize that clients pursue and complete treatment when there is a good working relationship, but also when they are willing and able to engage in the work of psychotherapy.
Therapists, particularly those in training, are frequently forced to terminate therapeutic relationships with clients who have not achieved their treatment goals and, if given the choice, would prefer to continue in treatment. This is referred to as therapist-initiated premature termination or forced termination. This most common reason for this type of premature termination is the end of the therapist’s clinical rotation, signaling that he or she must leave the clinic or hospital. Less frequently, therapists may be forced to terminate care with clients prematurely because of institutional pressures. The agency may be moving to a time-limited treatment model or the service may be closed entirely because of economic realities. Once beyond their training years, therapists may initiate termination before the treatment is complete because of relocation, health reasons such as chronic illness or pregnancy, or retirement.
Whatever the reason for this type of termination, there is a common thread: the therapist is leaving the client. This is an inherently stressful event for both members of the therapeutic dyad. Clients may understandably have negative reactions to therapist-initiated termination. Being forced to accept the departure of a therapist is a loss of control and can trigger feelings of abandonment that may be reminiscent of earlier losses. Some clients may see it as a defection (Siebold, 2007), a kind of switching sides. Clients may give indirect expressions of their disappointment and anger. These can include missed appointments, arriving late, and nonpayment. More direct expressions of frustration are also likely to come. Clients may say things that are difficult for empathic, caring professionals to hear, such as “How can you leave me right after my mother died?” or “If you really cared about me, you would stay.”
Therapists are also likely to feel a range of negative emotions surrounding initiating termination. Leaving a job, for any reason, highlights the natural limitations of the therapist. The relationship between therapist and client is limited in time and scope. But when the therapist is the one to discontinue the relationship, she becomes the source of the client’s hurt. Therapist-initiated termination often sends a message that is opposite to what the entire therapy has been designed to communicate. Therapists may fear they are communicating to the client, “You are not my first priority,” “I have needs and obligations that are more important than your need for me to stay,” and, “You have been vulnerable with me and now I will abandon you.” As helping professionals whose entire professional identity centers on being a supportive presence, leaving will understandably bring up a complex array of feelings.
Trainees forced to initiate termination because of the end of a clinical placement may feel anxious, depressed, angry, or sad during termination (Baum, 2006; Zuckerman & Mitchell, 2004). Clinicians in training may worry about how much they are harming their clients and feel guilty about leaving (Baum, 2006; Gould, 1978).
Guidelines for Therapist-Initiated Premature Termination
Given the difficulties associated with ending any relationship, particularly a therapeutic one with a strong working alliance, there are several guidelines new therapists should consider as they prepare to say goodbye. It is critical that the therapist allow ample time for the termination phase to unfold (Bostic, Shadid, & Blotcky, 1996). This is especially true for clients who have more substantial difficulties, such as psychosis or personality disorders, as they are likely to have greater difficulty with forced termination (Zuckerman & Mitchell, 2004). You may notice yourself behaving differently with each client, delaying telling certain clients about your upcoming departure. Fair and Bressler (1992) found that trainees had greater difficulty properly attending to termination issues with their more challenging clients.
The length of time required for termination also varies widely, depending on how long and intense the treatment phase has been. It is also highly recommended that students inform clients at the beginning of treatment that they will be leaving at the end of their training (Gould, 1978; Mason, Beckerman, & Auerbach, 2002). Natural breaks in the therapy, such as vacations, can also be used as previews for what termination may feel like (Sanville, 1982). This affords both client and therapist the opportunity to discuss the end of treatment multiple times and in advance. The movie What About Bob? (Williams & Ziskin, 1991) is a wonderful comic portrayal of the effect of a therapist’s vacation can have on a client. In the film, Bob follows his new psychiatrist on a family vacation and is relentless in his pursuit of him. Although this type of scenario is (hopefully) unlikely to happen, the characters in the film demonstrates a caricature of the feelings and issues that may come up around temporary terminations.
The therapist who is leaving should also clearly present the reason for the termination. Pumpian-Mindlin (1958) recommended that departing therapists take responsibility for the termination. Although it may be tempting to explain the termination as a result of external institutional forces, this will likely add to the client’s sense of loss of control. It suggests that neither party in the dyad has a sense of agency, that they are both simply victims of a system rather than actors creating a situation. If termination is not planned from the beginning (as in the case of a training placement), therapists should announce their decision to leave as soon as possible. It is often useful to let clients know where you are going and why. This should be done with discretion – each client population has different needs and abilities to tolerate this type of self-disclosure.
Clients may react specifically to this type of information. An underachieving adolescent client was informed that his therapist was leaving the clinic to pursue an academic job at a local university. He responded, “Maybe I’ll actually stop ditching school. I want to come to that college and learn from you.” In another situation, a therapist indicated she would be leaving her private practice in order to spend more time with her family. A client with significant personality disorder symptoms retorted, “Seems kind of selfish to me, but I guess you have to do what you have to do.” Another client, with tears in his eyes saying goodbye to his therapist because her training placement had come to an end, told the smiling therapist to “stop crying.” It is impossible to prepare for this wide range of reactions departing therapists may get from their clients, but it is helpful to recognize that anything can happen.
Many of the guidelines for reducing client-initiated premature termination carry over to guidelines for managing therapist-initiated termination. It is important to facilitate the expression of the client’s feelings about the forced termination. Clients are likely to experience feelings of sadness, frustration, anger, and loss in response to the imminent loss of the therapist (Gelman, Fernandez, Hausman, Miller, & Weiner, 2007). These spontaneous and authentic reactions are an important part of the therapeutic process. Therapists should strive to tolerate these reactions and attempt to process them thoughtfully with clients. This can be challenging when the therapist is facing his or her own feelings about leaving. The therapist must table her own feelings and emotions – to be processed in supervision and individual therapy – and do her best to respond empathically to the client’s sense of loss.
Supervision during training is essential and seeking additional assistance around the difficulties associated with forced termination is highly recommended. Given the added responsibility and feelings of guilt that may arise when therapists initiate termination, counselors should seek out supervision specifically focused on managing termination and its related anxieties. Therapists should discuss within themselves the affective factors that may affect the forced termination as well as practical matters of how to talk with clients about termination.
When initiated by the therapist, forced termination often leaves clients with a sense that they have no control over what is happening to them. It is incumbent upon the therapist to encourage clients to make their own decisions when it comes to setting a termination date and considering whether and how to be transferred to another therapist. Transferred clients tend to have much poorer outcomes in psychotherapy, dropping out nearly twice the rate of non-transferred clients (Wapner, Klein, Friedlander, & Andrasik, 1986; Tantam & Klerman, 1979). Termination plans should be individualized to the unique needs of each client, and departing therapists should work to facilitate the transfer-referral process.
Self-care is also an important component of successful terminations. Supervision is one avenue for discussing the intense feelings you may experience as you approach this difficult task. Individual therapy, peer supervision, and informal conversations with other trainees and colleagues are also useful ways of finding support. It is also important to maintain your energy level by getting adequate rest, exercise, and maintaining good nutrition.
Other Types of Therapist-Initiated Termination
Counseling professionals may also recommend termination to clients if they believe the client is not making sufficient progress (in which case a referral may be indicated), they feel ill-equipped to treat the client, or if a dual relationship emerges. These are unusual situations that arise infrequently but are important to acknowledge. If a client seems to be stuck and is not improving, it may be because of any number of factors. Clients may be in need of medication in conjunction with therapy, there may be a poor therapist-client match, or the client may be resistant to the interventions being offered. It is important for the therapist to seek consultation and supervision on the case and to explore the lack of progress with the client.
When a therapist recognizes she is not the appropriate clinician to treat the client, she has an ethical duty to consult and refer the client to another professional (Knapp & VandeCreek, 2012). For example, consider a client who comes to treatment for help with sexual performance issues. During the course of treatment, an underlying depressive disorder becomes evident, and the therapist requests a psychopharmacology consultation. The client begins taking medication and focusing on the depressive symptoms in therapy, but the symptoms worsen. The therapist, whose specialty is in sex therapy, pursues supervision on the case and recognizes that she is not the appropriate person to treat this combination of symptoms. In this case, the therapist has an ethical obligation to initiate termination and facilitate a smooth transition to another clinician who can better assist the client.
A conflict of interest or dual relationship may become evident to the therapist during the course of treatment. For example, a therapist may realize after several months that his client has ongoing business dealings with the therapist’s spouse. Because the therapist and his spouse do not share the same last name, this conflict was not evident at the beginning of the therapeutic relationship. In most cases, it will likely be appropriate to refer this client to another clinician with whom the client has no overlapping relationships. In both of these situations, the therapist should speak as openly as possible with the client about his assessment of the situation and the recommendation for a referral. Many of the other principles of therapist-initiated termination apply in these types of cases, especially in a discussion of the incompleteness of the therapeutic work.
Untimely Termination
Garcia-Lawson, Lane, and Koetting (2000) found that 90% of therapists who died had no plan in place to safeguard their clients’ interests, records, and future treatments. Some authors have recommended that therapists create a professional will and identify several colleagues who can serve as emergency responders in the event of a critical incident such as a catastrophic accident or death (Firestein, 1994; Steiner, 2002, 2011). A professional will should identify other professionals who will notify clients and colleagues in the event of your death or major injury. Your emergency response team and your lawyer should have a copy of your license, liability insurance policy, professional contacts who should be notified if your ability to practice becomes compromised, and contact information for all clients. They should also have access to contact information of former clients who may attempt to contact you for medical records, future appointments, or to simply inquire if they learn of your death or injury. Although it may be existentially difficult to consider your own death or serious injury, it is important component of being a competent, thoughtful, and helping professional.
