When therapy comes to an end

How can clinicians bolster growth at the conclusion of a therapeutic relationship?

Vol. 53 No. 5
Print version: page 80

Abramson, A. (2022, July 1). When therapy comes to an end. Monitor on Psychology, 53(5). https://www.apa.org/monitor/2022/07/career-therapy-conclusion

The ending phase of treatment can have a distinctly different result from the rest of the therapeutic process, when given the appropriate time and attention. Some patients may choose to terminate prematurely, but ideally, a smooth transition following best practices can lead to optimal overall effectiveness.

In a recent study, when asked to describe a course of therapy versus the termination portion of the therapy, therapists described seeing different processes between overall treatment and the termination portion. “That creates more of a case for why this particular time in treatment is important, and why we need to focus on that time,” said Avantika Bhatia, PhD, assistant professor of psychology at Ashoka University in India and coauthor of the study.

Effective psychotherapy hinges on a number of evidence-based factors, from a patient’s motivation and a therapist’s relational skills to the pair’s therapeutic alliance. The termination phase—a patient’s transition out of therapy—is a crucial factor and can play an important role in future growth.

Although the termination phase may only constitute a short portion of overall treatment, those final sessions offer a unique opportunity for psychologists to fulfill their ethical obligation to patients. Appropriately terminating psychotherapy can preserve patients’ well-being and encourage ongoing growth even after therapy ends.

On the other hand, abandonment, or ending therapy without fully addressing patient needs or without making arrangements for other treatment, can cause unnecessary distress and even worsen patients’ symptoms (Professional Psychology: Research & Practice, Vol. 39, No. 5, 2008). “Whenever possible, there’s a need to have a termination phase of treatment, consolidating gains and preparing the client to continue independently,” said Jeffrey E. Barnett, PsyD, a professor of psychology at Loyola University Maryland. Before you and your patient part ways, understand when it’s appropriate—or necessary—to do so. Ethically, psychologists must terminate treatment if they can’t address a patient’s needs, if the patient isn’t benefiting from treatment over time, or in the event of an inappropriate multiple relationship that may impair objectivity or judgment or harm the patient. If a patient threatens or assaults the therapist, clinicians can terminate treatment immediately without a termination phase.

Even in a healthy, beneficial therapeutic relationship, many agencies (such as college campuses) or insurance plans only offer a limited number of sessions. Therapists with certain theoretical orientations may choose to end therapy when a manual ends, and therapists in training may need to end therapy when their rotations end.

Other times, therapy ends when patients plateau, which often happens after accomplishing initial treatment goals. In any of these scenarios, you and the patient may decide together that your time has come to an end. “The ultimate goal is for treatment to end because all treatment goals have been achieved and the client agrees,” said Barnett. “That’s ideal, but that doesn’t always happen.”

No matter the reason you’re terminating, ensuring a smooth transition can help your patient continue to grow after the last session. Here are expert-recommended methods for ending therapy.

Discuss termination early on. To prepare patients for termination—even if you don’t anticipate that it will happen soon—discuss how and when therapy will end as part of your informed consent agreement when you begin seeing someone. “The concept and process of termination shouldn’t come as a surprise,” said Barnett.

Along with introducing the process of ending treatment, discuss how you’ll review progress on treatment goals. Eva Feindler, PhD, professor of psychology at Long Island University, suggests collecting data about baseline symptoms before implementing your treatment strategy, then reassessing the symptoms at various points and discussing the possibility of termination based on change scores.

Avoid abrupt termination. Along with causing patients to feel abandoned, ending treatment too abruptly—whether you decide your patient has met their goals or they decide they are ready to be done themselves—misses a crucial opportunity to cement therapeutic gains. For that reason, Barnett suggests implementing a termination phase that allows ample time to discuss past gains and future goals. “Pick a date and discuss how to use that time effectively,” he said.

There’s no hard-and-fast timeline. If a patient attends weekly therapy, consider tapering frequency over time—for example, shifting to biweekly, then monthly sessions, until termination. Research suggests that psychotherapists tend to spend about 12% of the total treatment length dealing with termination issues (Tryon, G. S. [Ed.], Counseling Based on Process Research: Applying What We Know, Allyn and Bacon, 2002).

“The amount of time spent talking about termination should be relative to the amount of time the therapy has been,” said Susan Woodhouse, PhD, associate professor of counseling psychology at Lehigh University in Pennsylvania.

Know when to refer. In the event that your patient needs ongoing therapy but you can’t provide it, tell your patient as soon as possible. It may be difficult to recognize that a patient’s needs are outside your scope of expertise, but appropriate referrals are part of a psychologist’s ethical duty.

“If you see a family doctor who diagnoses you with cancer, they will refer you to an oncologist or surgeon who can appropriately treat [you],” said Jeffrey N. Younggren, PhD, professor of psychology at the University of New Mexico. “Psychologists have the same obligation for psychological interventions.”

Even if the patient’s symptoms aren’t beyond your professional scope, you may find that they are not making progress toward their goals. In that case, determine a limited number of sessions for a termination phase and work with the patient to find a better fit. “My responsibility is to do some research to find a clinician or ask the patient if they’d like assistance finding someone else, because they trust me and I know their needs,” said Barnett.

Create a professional will. It’s also important to create a plan for your patients in the event of your death or illness, especially if you work in private practice. A professional will—a document that serves as a backup plan for your patients if you’re unavailable—may include information such as how to access your patient records, your meeting schedules, and where you keep the keys to your office. It also designates a colleague your loved ones can contact in case of emergency. Typically, Barnett said, designated colleagues don’t take patients on themselves but instead meet with them to process the situation and refer to other clinicians. “It may seem morbid to think about, but it’s a way of fulfilling our ethical obligation to our clients,” said Barnett.

Consult with experts. Many theoretical orientations provide guidelines for consolidating patient gains, but focusing on your preferred theory alone may not yield the most effective treatment outcome. For example, in the cognitive behavioral therapy tradition, a therapist may be more likely to discuss behavioral goals, whereas a psychodynamic therapist might focus on the therapeutic relationship. Both aspects are important.

To avoid restricting patient growth during the termination phase, John Norcross, PhD, professor and chair of psychology at the University of Scranton in Pennsylvania, suggests modeling your practice on a pantheoretical consensus of psychologists.

In 2017, Norcross studied termination behaviors of 65 psychologists across a variety of theoretical orientations to determine best practices for ending therapy. Of 80 tasks, half received moderate to strong consensus (Psychotherapy, Vol. 54, No. 1, 2017). For example, the majority of psychologists reported seeking ways to support the patient’s progress in the future, discussing what went well in therapy, and attributing gains to the patient’s efforts.

As you consider your own termination process, consider consulting best practices across a variety of theoretical orientations or speaking with colleagues about their own processes. “There may not be a lot of research on termination, but there is robust integrative consensus on how to terminate,” Norcross said.

Leverage the patient’s response. Even if you and your patient agree it’s time to finish treatment, your patient may express disappointment, grief, or even feelings of abandonment. It can be common for termination to feel like a replay of overall treatment, said Charles Gelso, PhD, emeritus professor of psychology at the University of Maryland. For example, your patient may have progressed in their anxiety about not feeling good enough, but termination could bring those feelings up again.

“Rather than viewing your patient’s response as a regression or a sign you made the wrong decision, see it as an opportunity to consolidate gains made in therapy,” said Gelso. If your patient surfaces old feelings of abandonment, for instance, explore that feeling and remind them of the coping tools they’ve gained in your work together.

Look back on positive growth. One vital aspect of consolidating patient gains is reminding them of their success, which can instill a sense of pride and confidence for the future. “Looking back can be helpful in consolidating gains and crystallizing what the patient got from therapy so they can take it with them and remember what they accomplished,” said Woodhouse.

Along with taking time to recall examples of meeting goals, reflect on the positive components of the therapeutic relationship and how it grew or developed over time. Feindler suggests thanking the patient for working with you and giving you a meaningful experience, which can consolidate the idea that the patient mattered to you. “They walk out of the last session with a little bit of a taller stance because they know they made a difference for you, too,” she said.

Look forward to potential challenges. Use the last several sessions as an opportunity to anticipate potential challenges in the future and how patients can apply lessons they’ve learned to continue in their growth. This may involve forecasting potential issues or symptom remission and assuring the patient that they can handle these issues with their newly strengthened skills or sense of self. “Add a few reminders of the way someone has dealt with something in the past so they can be attentive to it in the future,” said Gelso.

Make a plan, too, for what the patient should do if they need support in the future. For example, you may offer the opportunity for the occasional booster session or ongoing treatment in the future. If you may not be available, tell the patient up front and provide other suggestions, whether support groups or other therapists.

Plan the goodbye. Before the final session, make a plan for how you’ll part ways. “People can be different in their individual and cultural factors in what it means to say goodbye, so it’s good to have a plan in advance,” said Woodhouse.

Ask the patient what they envision for the last session, and determine a plan you both feel comfortable with. For example, you may write a note to one another, exchange a symbolic object that reflects the patient’s work, or decide to hug or shake hands during the last session. In any case, Woodhouse says the exchange should be planned so the patient isn’t surprised.

Cope with your own emotions. You may find yourself feeling a gamut of emotions as you terminate with a patient, including a sense of pride for all your patient has accomplished, grief about the relationship ending, or even shame if you feel that you couldn’t help that person the way you wanted to. “Therapists are human and have their own experiences, so be aware of tending to and working through your experience,” said Bhatia. “If it’s affecting your therapeutic relationship, you should know what to do and how to manage that.”

To ensure your own feelings don’t impact the patient, Feindler suggests processing them with your supervisor, a colleague, or your own therapist. It may also help to reframe how you view the termination. You should feel a sense of pride in your patient, and in yourself for helping them. “If you can think about the end as a celebration or graduation, that fits more with the research on how clients actually feel about it,” said Woodhouse.