End times: Coming to the end of psychotherapy

Successfully moving through the end of therapy

by Tom Cloyd, MS, MA – Counselor / Psychotherapist – Bellingham, Washington (360) 920-1226 – email: tc (AT) tomcloyd.com (please read about content licensing)

SUMMARY

Everything ends eventually, including psychotherapy³. A grace-full, well managed ending is ideal, but, in reality, ending psychotherapy – leaving a psychotherapy relationship – is a problem for some individuals. Mental health professionals would do well to acknowledge this more often, and respond with some specific suggestions for our clients, before they start wondering whether it’s time to stop, and then how to do it.

Psychotherapy as an intimate relationship

Intimacy takes many forms. Most intimacy in life is familial. Some occurs in the context of friendship. And some occurs in psychotherapy. In all cases, it is true that intimates know things about each other not generally known by other people in their life.

Intimacy is not always between peers. We may know significant details of the life of our First Family (President, etc.). It’s unlikely that they know anything of us, as individuals. Mothers know more about their children than the children know of them. Psychotherapy relationships are similarly unequal, for in them therapists know more about their clients than clients know about therapists.

Intimacy, experience, and vulnerability

Intimate knowledge creates vulnerability, for knowledge is usually power. Where intimate knowledge is asymmetrical, power and vulnerability are also. Whoever is known most about is usually the vulnerable one, for multiple reasons. In psychotherapy, this vulnerable one is the client.

There is at least one other clear knowledge imbalance characteristic of psychotherapy relationships: knowledge of the experience of ending such relationships. Here again therapists are at an advantage, which makes clients the more vulnerable of the two.

The specific aspect of this vulnerability I want to address here has to do with the likelihood that leaving a psychotherapy relationship will be a distressing time for a client. I want to look first at some reasons for this distress, and then at some ways one can reduce this distress.

Why leaving psychotherapy can be difficult for you

There are so many reasons why this may be so, among which are:

• You may never have done it before.
• Your therapist may not talked with you yet about leaving, at the time you begin thinking about it.
• When the issue of leaving occurs to you, you may not feel finished with therapy.
• You may not be the one who brings the issue up.
• You may have real conflict about leaving.
• You may be aware that your therapist is more engaged in working with your problems than you are.
• You don’t want to hurt your therapist’s feelings.
• You may have no idea how to justify your leaving.
• Important people in your life may want you to stay in therapy.

Thinking clearly about each of the challenges

Each of these challanges can be responded to. While the consequences of your engaging well with each challenge may not be ideal, they don’t have to be. They just have to be good enough that you can get on with you rlife comfortably. That outcome is probably within reach, for most people.

You may never have done it before. SOLUTION: Talk about it, so you can draw upon the ideas and experience of others..

First-time therapy clients have a lot of “firsts” to work through in therapy. Leaving is certainly one of them. If this is not your first therapy relationship you’re more likely to have some knowledge of the challenge of leaving, even if you don’t yet quite know how to do it well.

If this is your first time leaving therapy, you really ought to talk about it with your therapist. They, after all, are not first-timers, relative to this issue, and just might be able to help you. If you find it a difficult topic to bring up, then the difficulty you’re experiencing needs to be the first thing you talk about. That difficulty may well be a legitimate “therapy issue”. If you’re not having such difficulty, talk about it anyway – it’s likely to be a good discussion.

Your therapist may not talked with you yet about leaving, at the time you begin thinking about it. SOLUTION: Initiate the discussion.

She or he may never talk to you about the matter, and that would be unfortunat, for if we therapists don’t take up this problem and make sense of it, what chance do you have of doing it at all well – by yourself? We’re interested in getting you into therapy, and keeping you there until we can get some real work done. And then what? Too often, professionals seem to have little to say about this, which is not helpful.

When I brought up this topic to my very capable faculty adviser during my internship in graduate school, his reaction was that this concern was not for us to address. “The client determines when therapy ends”, he said. OK – there’s a very good idea in that sentence, but the problem remains. I didn’t think his answer was adequate at the time I heard it, and I still don’t. (And I suspect that if I’d asked the question better I’d have gotten a better answer!)

We have many good ideas to offer you, but how to leave therapy well seems not to be among them. I’ve never heard this issue seriously discussed in a professional context. We seem not to think about it. We should, because it’s too often a source of distress for our clients. As a client, you cannot fix this problem, but you can realize that part of the problem for you is that too often you’re on your own with the problem. You shouldn’t be, I think, but you usually are.

What can you do about this? Simply bring up the matter with your therapist. You can initiate this important discussion.

When the issue of leaving occurs to you, you may not feel finished with therapy. SOLUTION: Accept the reality of unfinished work.

It is rare for a person to have addressed all their problems when they leave therapy. It is actually often better to take up focused issues, make progress (any progress at all is better than staying stuck), leave, and then return later to work on other problems if this seems called for. It is realistic to see life as a series of ongoing challenges – and to accept that you’re not going to run out of problems. Do you really think psychotherapy is going to fix this? (I wish!)

You may not be the one who brings the issue up. SOLUTION: Seek out allies in dealing with this challenge.

If you have to deal with “managed care”, or have a seriously limited budget, you know that external factors and people can have a real say about when therapy ends. Or…your therapist may be moving, or retiring, or going on vacation. Your situation then is one of feeling unfinished but having to leave anyway (see the paragraph above, concerning this). This can be difficult, but it can also be talked about, and learned from. See that this is how it gets handled in your case. You can, in fact, consult a number of different people about this problem – your managed care case manager, your close friends, and, of course, your therapist.

You may have real conflict about leaving. SOLUTION: Make constructive use of this conflict, in your therapy.

You may well feel like you want to leave AND you want to stay. This is common, for many reasons. The best thing to do is to take up the matter of the conflict(s) you feel with your therapist (do you notice a theme in my remarks, here?). Such conflicts arise from the fact that our mind virtually always holds multiple points of view about critical issues. These conflicts are part of being human, so talk about it. It’ll help, and it’ll often work to resolve or significantly reduce the conflict.

You may be aware that your therapist is more engaged in working with your problems than you are. SOLUTION: Stay focused on your issues.

Ideally, this problem shouldn’t happen, but it often does, anyway. First of all, it’s probably generally true that your therapist experiences a degree of fascination with your problems – dealing with them is his/her chosen profession, after all. You, on the other hand likely feel something other than fascination, and in this there is an essential imbalance.

Nevertheless, the rule is that “the client must lead”. We may invite you to go certain places, but when you indicate disinterest, that settles it. It’s YOUR opinion that counts. I hope your therapist doesn’t forget this, but if they do, you still shouldn’t. If your therapist appears to need to engage with your problems, they have matters to take up with their therapist. (Yes, therapists not uncommonly have therapists – why would we want to exclude ourselves from the benefits of psychotherapy?)

This kind of problem is actually common in psychotherapy. Freud talked about it, and we’ve been talking about it since then. What you should know is that it’s OUR problem, not yours.

Therapists are people, and as such they have problems, at times, but that should not be your concern. In psychotherapy, you’re expected to be self-centered, and you should maintain this focus right on through the time of your leaving. Your therapist can take care of themselves. They have access to excellent resources for doing this.

You don’t want to hurt your therapist’s feelings. SOLUTION: As before, yrust that your therapist will take care of themselves.

I see this issue come up most often with young women, who are often deeply in contact with their maternal side. Such instincts are one of the glories of humanity, but really don’t belong in the psychotherapy relationship. Your therapist does have feelings, and you likely will be missed, after you leave. Your therapist has experience with this problem, and surely has worked out their own ways of working with it productively.

It’s good for you to notice that your therapist values you. You do have value, and we all need to know this. However, children leave home, clients leave therapy, and we all leave life, at some point. It’s the Way of Things. If this is a persisting problem for you, you owe it to yourself to bring this problem to therapy. Doing so is an excellent idea.

Finally, you may be having problems concerning your therapist’s feelings about your leaving because you’re a bit co-dependant. Co-dependents by definition are overly focused on other people, especially people important to them. This, of course, is a “therapy problem”, and should be addressed as such.

You may have no idea how to justify your leaving. SOLUTION: Aceept that no justification is called for.

Many people in therapy have a history of being disrespected, and thus have some trouble respecting themselves. They often feel defensive or in need of justification. Try to understand that this is a developmental problem which you don’t have to have, and really should not tolerate. If you DO have this problem, take it up in your therapy.

The best reason to leave therapy is a very simple one: you want to. I teach assertion, and I’ll say it plainly: Your feelings are your best justification for anything. (You do well to see that your feelings are based on correct perceptions of course.) If you find this sort of justification difficult, then you’ve just identified an area in which you need some work, and definitely some practice. Assertion skills definitely have to be practiced. I look for opportunities to practice mine. You should too.

The core of assertion is simply the declaration of your desires. You do not need to justify what you’re saying, since all desires are what they are: facts. About your desires, you are the authority. Three year olds often seem to know this instinctively. In this, they are often good models for us! Stand by your desires. Don’t justify. (You can, however, carefully think about your desires, and will often benefit from doing so. Self-analysis is simply seeking understanding. It has NO necessary relationship to justification, and you are not obliged to share your self-analysis with anyone unless you want to.)

Important people in your life may want you to stay in therapy. SOLUTION: You make the decision, period.

Who might these people be? Parents, spouses, children, friends, employers…did I leave anyone out? While sometimes therapy may be mandated by a judge, in all other cases, it’s your call. Other people can have any opinion they want. It’s a free country. And… you need to keep your own counsel. Engaging in psychotherapy, or not, is your decision.

If someone else has feelings about your leaving therapy, one option you have is take up the matter with them. Understand that THEY are having a problem – you’re not the focus of this discussion. They are. Talk with them to see what’s at the root of the problem (it’ll usually be some fear which isn’t well enough identified). This will help your relationship with them, and may even give you some useful information.

Some things I want you to know about leaving therapy

You may not be the only one distressed by the idea of your leaving.

We often come to truly like and enjoy our clients. I know that in mine I virtually always see the essential problems all human beings have. I usually develop a strong sense of compassion for, and come to care significantly about, each individual I work with. How can I look casually upon the prospect of coming to the end of our meetings? I don’t know how to do this, and I’m not sure I want to learn.

So, that your distress is likely shared is a very good reason for taking up leaving as a topic, with your therapist. Very often the problem is one of dealing with loss – and that’s a problem that challenges all of us, in various ways. It’s also one of the grandest and most productive problems people ever bring to therapy.

Some therapists are as puzzled by the “leaving” problem as you may be.

Not all therapists grasp that clients will leave with some of the problems they brought into therapy. I can recall our being confronted with the unavoidable “unfinished client” problem by one of our teachers in graduate school. I was already familiar with it, but some of my fellow students had not seen it, and found it troubling.

If your therapist has not grasped this particular fact about therapy in the real world, and the fact that it’s not necessarily a problem, you still can. You must, in fact, because everyone leaves unfinished. We’re all a work-in-progress. You think this is a problem? Wait until you face dying, unfinished! (You’ve been warned – so now you have some time to prepare for that one…)

Loss is one of the great themes of everyone’s life – you do well not to turn away from it.

Some people, when the time comes, simply run from therapy. It’s the only way they can handle it, but it’s probably not the most productive response. Losing your therapist is but one of many losses you will have in your life. USE the experience to address the issue of loss and what it means to you and how you handle it. It’s an excellent chance to add to the benefit you get from your therapy.

Your therapy is about you and what’s good for you. Stay focused on this.

This may seem obvious, yet concern for others and a desire to take care of others, sometimes in inappropriate ways, is common, especially in psychotherapy clients. Your therapist, if she/he has a lick of sense, has done psychotherapy work themselves, and has taken up the issue of loss in the course of that work. He/she comes to their work prepared to handle the eventual loss of clients. You don’t need to be worried or concerned about them. Your attention belongs on you.

You can come back.

Surprise! This doesn’t occur to many people. You can think of leaving as an experiment. Do it and see how it goes for you. You can return, if you find that you’re not ready. I’ve had a number of clients return, virtually always for only a short period of additional work. Some have come back 2-3 times. One came back four, and the fourth time was the one where she really got down to work. I was thrilled, and I think she was as well, since at that time we really cleaned house, so to speak.

In leaving therapy, you can, and should, simply take things as they come, just like you have to do with the rest of your life. “Go with the flow.” It works for the wind, and for rivers. It’ll likely work for you.

Some good ways to talk about leaving therapy

I have found that often what people need is words. They don’t know how to say what they’re thinking and feeling, and having good words for these matters can be extremely helpful. So, I want to offer here some little “mini-scripts” which may help you deal with leaving psychotherapy.

(To your therapist) – “I’ve been thinking that I’m about finished with therapy. What do you think about that?”

(To anyone at all) – “I’m feeling about ready to leave therapy. It’s been a challenge / good experience / disappointment / real puzzle to me / a life changing experience (pick one or more). I’m ready for a rest.”

(To yourself) – “I feel about ready to stop. I want to respect that. I can come back if I want to, or go elsewhere, later. I will always have many options.”

(To your spouse) – “I’m graduating soon from therapy. I hope you’ve been keeping up, because your life is about to get more interesting!”

(To your therapist) – “Thanks for the challenges, for the patience, for information, for the compassion and caring. I’m not who I was when I came here. I know I’ll keep growing after I leave, and what’s happened here will help to make that good growth. I’m grateful. I hope you think of me from time to time. I know I’ll think of you. Maybe I’ll send you a postcard.”

Concerning the last mini-script: I always like to hear these sorts of statements. Gratitude expressions are something I much value – as both a receiver and a giver. I try to give a lot to my clients, and I know that I receive a lot. I do admire the courage and humanity of my clients. I always am inspired by it. Rarely, I think, do they realize how much they enrich my life. I want them to have a some small sense of that, verbally. And I always respond positively to the idea of that “postcard”, in whatever form it may take..

In considering speaking out on your own behalf, remember that you may need simply to repeat yourself – in other words, to be a bit assertive. Don’t be shocked if this need arises; just be ready for it. Simple repetition is the heart of assertion.

Circumstances under which you should be cautious about leaving therapy

Some people should think twice, or more, about leaving therapy. One category of individuals for whom this is true is anyone with a recent history of self-harm or harm to others, or anyone who knows they are headed toward a time of grave stress in their lives. For these individuals, psychotherapy can well function as a safety net, one which is often much needed.

In addition, people with certain classes of problems typically have real difficulty with stable relationships – including stable therapy relationships. They characteristically can only tolerate a limited amount of stability, progress, and positive feedback, before some part of them wants to be protective by making a quick escape.

This tendency toward premature or ill-advised leaving is not unusual for individuals with Borderline Personality Disorder, Dissociative Identity Disorder, or Complex PTSD¹ . It can also be a problem for people with other diagnoses, including those with strong Co-dependency² tendenies. If you know you fall in, or near, one of these diagnostic categories, be cautious in your thinking about leaving psychotherapy. Your desire to leave is likely to be motivated by a looking-back at a former time in your life, a time when sustained contact with anyone was simply not a safe proposition. Responding to the present in terms of the past, in this way, may simply not be reasonable.

All that said, you may still decide to leave. That’s fine – it’s your decision. My desire is that it be a decision, and not an impulsive, ill-considered action. I realise that this is easy to advise, and may be difficult for you to implement, and I’m sorry if that is the case for you. On the bright side, consider that working through difficulties is often how we get stronger, and getting stronger is a good thing. Just do the work!

Conclusion

I wrote this statement originally in one sitting (and have revised it since then). I was thinking particularly of one client of mine, who later reported finding it useful, but I always had in mind a more general problem, involving many more individuals. A number of people have now read this piece, and have responded to it positively.

While this is not, and cannot be, the final statement on the issue, I think there will be found here some solid starting points for constructive thinking about the topic. Leaving therapy can be its high point for many people, curiously enough. You do well to invest time and effort in seeing that this is so for you.

Notes

¹ This is not yet a formal diagnosis, but is likely to be in the next revision of the diagnostic category set we all use in psychotherapy – the Diagnostic and Statistical Manual of the American Psychiatric Association, comonly referred to as the DSM-IV, since it’s in its 4th edition.

² (See note one¹, above.) Co-dependency is probably less likely to be a formal diagnosis, in the next revision of the DSM. Some say it’s already included, a “V-code” – see “V61.9 Relational Problem related to a Mental Disorder or General Medical Condition”, in the DSM. The problem with this view is that is far from clear that the authors of the DSM-IV had co-dependency in mind when they framed this auxillary diagnostic category. The reality of co-dependency remains, however.

³ This document originally appeared as the August 1, 2007 entry in my blog Sleight of Mind. This present version is a substantial, but not major, revision of that original version.

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psychotherapy, psychotherapists, clients, termination, leaving, challenge, problems, intimacy, vulnerability, assertion, co-dependence, communication, risk (about tags)