When it's over
Termination. The word has an ominous finality, but it’s how therapists talk about the process of ending therapy. The word’s starkness doesn’t match how carefully we think about that process, one we want to be thoughtful, mindful, and supportive. When deciding about whether it is time to end a therapeutic relationship or when working with an ending that is out of our hands, therapists consider many factors, such as how long the client has been in therapy, whether they are actively engaged in the treatment, and how effective it has been (a generally flexible measurement).
Making the decision to end therapy
For clients, however, endings often have a different meaning. Sometimes these meanings are tied to the realities of the moment. Perhaps the therapist doesn’t feel like the right fit or therapy has been triggering without any compensatory hope or comfort. Or it’s just too expensive, a common theme when many therapists don’t take insurance. Sometimes these meanings are hooked into the things that brought the client into therapy in the first place, struggles with vulnerability and what it means to be close to and trust another person, to be fully seen or continually invisible. The therapist could have gotten too deep too soon or misunderstood the client’s boundaries. The therapy may feel intolerable or the therapist may simply not be skilled. In any of these cases, particularly when communication is indirect, a client tends to skedaddle suddenly, ending therapy in a way that feels premature to the therapist—but potentially relieving to the client.
I use a relational approach, working with a child and family’s attachment and sense of connection. Therapy provides an opportunity for reparative experiences, a way of relearning and re-experiencing being in relationship in a positive, authentic, and supportive way. I also focus on understanding underlying defenses, particularly when they are not serving a child, and help kids process their aggressive impulses while building healthy ways to handle big feelings and fears. I think with parents about might be going on under the surface for their children and themselves. This behind-the-scenes work with the unseen and often unspoken does lead to change, but not necessarily in a linear or rapid fashion. It takes time and space. Sometimes that time appears to be unproductive, at least on the surface. Therapy done in this way can be expensive and feel like an uncomfortable luxury. Its focus on what lies beneath is not for everyone. And it makes the ending process particularly important.
With children, decisions about ending therapy often originate with caregivers. As a child therapist working in this relational, psychodynamic way, I hold in mind the needs, thoughts, feelings, and potential unconscious associations for parents and other significant folks in the child’s life. This requires a careful, thoughtful, and diplomatic approach, particularly in families with fraught or sparse communication. It is not always possible to do such expansive holding. Mix in other complications and the expense and ongoing time requirements of therapy and things can shift rapidly and somewhat precipitously. Endings can come suddenly with perhaps the faintest ripples of warning, low rumbles and flashes on the horizon.
The ideal ending (from a therapist’s point of view)
Under ideal circumstances, therapy ends when things are better for the client in a sustained way. This is measured through their own feelings about themselves and their relationships as well as on how they act and behave in daily life. Parental input is vital as well. With children and adolescents, the first conversation about ending may be initiated by me, the client, or the client’s parents, at which point we discuss termination more fully and make a plan that acknowledges the meaning of the relationship and affirms the positive changes the child and family have made. Sometimes I stop therapy under different circumstances, such as a mismatch of therapeutic approach or style or because the therapy has not been effective for any number of reasons. In general, I prefer to allow several sessions to end mindfully.
In reality, we often do what we can in a session or two or even after the fact. Many families have real world constraints that make the best case scenario impossible. Families don’t always have the emotional or financial means to commit to a long and unclear course of therapy. There may be other pressures unknown to the therapist and the thought of the therapeutic relationship as an important relationship and not simply a professional one may not occur to parents or clients. Ending things quickly and (apparently) painlessly can feel like the least complicated plan of action. Ending them with a text or email, removing an uncomfortable layer of direct human interaction, may feel most manageable of all.
Endings are tough
This, too, is human. Conversations about ending are hard. Providing feedback and communicating one’s concerns or worries directly is also hard. And actual endings are the most difficult of all, particularly if you have a history of painful goodbyes. When therapy is over, whether it concluded like the last chapter of a a good novel or was as unexpected as a sudden tumble down a flight of stairs, I carry a part of the relationship and a part of the loss, sometimes for families, sometimes with them.
I can’t promise quick change. I can try my best to manage expectations about how we will know it is time to end. Together we can figure it out. If that feels like too much, I will hold the ending as best I can, keeping your and your child’s needs and history in mind. But hopefully we’ll find a way to collaborate and end in a way that honors the work we’ve done and the good things that have come out of it.