Category Archives: Termination

Ending Therapy or Taking a Break

I am doing my practicum placement in a high school, and I plan to return there next year after a summer break. Several of my clients have said they want to see me again in the fall, so I’m wondering how to talk with them about taking a break and returning to therapy.

It is wise to think ahead about how to handle this situation. I would recommend thinking of the therapy as ending when the school year is over with the possibility of resuming when school begins in the fall. There are many factors outside of the control of you and your student clients that make the continuation of your relationship uncertain. For example, they may move, their presenting issues and symptoms may improve or worsen in a way that changes the decision about your work with them, or the school may set different priorities for which students can receive therapy. There are clinical benefits for clients to engage in a thoughtful process of termination, and they will miss those benefits if you assume continuation of therapy and it isn’t possible to do so.

I have previously published some general guidelines related to psychotherapy termination which may be helpful to reference (Psychotherapy Termination and Termination Tasks). There are some additional issues that are present when you may be resuming therapy in a few months. The first is the variation in your feelings of closeness and enjoyment with different clients. Talk with your supervisor about your countertransference feelings related to all of your student clients and your preference for seeing them next year or discontinuing permanently. It is important to examine these preferences and to discuss your plans to return to the placement next year in the same way with all of your clients. If you are more explicit with some clients than others about returning to therapy next year, you are probably expressing your countertransference, unless your statement is based on a clear clinical decision approved by your supervisor. Examining and understanding the countertransference is preferable.

A second issue is the likelihood of changes in the life of your clients over the summer, both logistically and psychologically. The client may feel differently about therapy in a few months, and issues in her life may change in a way that affects her decision. Your desire to focus on the continuation rather than termination of therapy may be a way of avoiding the potential loss of ending your therapeutic relationships and the realistic ambiguity about the coming school year. Maintaining a focus on the ending of the current therapy by reviewing the progress that has been made and acknowledging the importance of your relationship with each other provides more therapeutic benefit to your client.

Third, talk with your supervisor about recommendations you may make to your clients and their parents about ways to reinforce the gains they have made in therapy. Parents and teenagers often view summer as a time for vacation from therapy, especially when therapy has taken place at school. However, your clients may be participating in activities that provide opportunities to practice some of the coping skills they have acquired or to take on new social and emotional challenges.

I hope you find this helpful in managing psychotherapy termination when the circumstances are ambiguous. Please email me with comments, questions, or suggestions for future blog topics.

Client Responses to Therapist Leaving

Diane SuffridgeI am leaving my practicum placement at the end of the training year in six weeks and have just told all of my clients. Most of them didn’t seem to have much of a reaction to this news. What can I expect between now and when I leave?

This is a typical situation during training, when most of your placements will last a year. If you haven’t read my previous blog posts about termination, you can do so to get more information about planning for ending treatment with your clients and about structuring the ending process. In this blog, I’ll focus on the range of client responses you may experience during the next six weeks.

One common response, which sounds like how most of your clients responded when you told them you are leaving, is to avoid discussing the end of treatment and your relationship. This may be accompanied by a statement like, “I know interns always leave after a year, so I’m used to it” or may simply be apparent in shifting the topic away from your leaving. Clients may also deny having any feelings about ending treatment with you, in response to your questions or comments about the impact on them and you.

Another response you may see is that clients miss sessions more frequently or make a decision to end before you leave rather than waiting the full six weeks. This often functions partially as an avoidance but also serves to express anger and to exert control over the timing and process of ending.   A related response, especially in clients who have seen other interns before you, is to focus on the pragmatic questions about being assigned to another therapist at the beginning of the new training year.

Last, some clients may bring in descriptions of past or present interactions with others in which they felt rejected or abandoned or other situations involving loss. These clients usually do not make any conscious connection with the upcoming end of treatment and may deny the impact of your leaving if you make the connection. This may be due to avoidance of the painful feelings associated with your leaving and may also be influenced by the client’s lack of familiarity and experience with intentional endings.

Depending on your own feelings about leaving this placement, you may find yourself feeling frustrated or relieved by your clients who avoid talking directly about ending treatment. It is generally helpful to provide some education to clients about how treatment can end in an intentional way, using some of the suggestions in my previous blogs. It is also important to have some discussion of your leaving before the final session, since you can anticipate that some of your clients will not attend the final session as scheduled.

The best contribution you can make to a therapeutic ending with your clients is to talk about your feelings in your own therapy and supervision. This makes it more likely that you will be emotionally available during your remaining time with clients and that you will provide the opportunity for them to end with you in a therapeutic way.

I hope you found these examples of client responses helpful in managing your transition from this placement. Please email me with comments, questions or suggestions for future blog topics.

Unplanned Endings

worried therapistI have been working with a client for 3 months and I thought therapy was going well.  Our last session was two weeks ago and since then, she hasn’t come to sessions and hasn’t responded to my phone calls.  I’m confused about why she stopped coming in and don’t know how to find out what happened.  

This situation is one of the most distressing circumstances for therapists in field placement training and continues to be challenging for experienced therapists as well.  We develop a sense of our relationship with the client based on our shared experience, and it is disorienting when there is a sudden change in the client’s engagement in therapy.  Often this change leads to an unplanned ending of the therapy and feelings of loss for the therapist.  We usually don’t know exactly what happened and the ambiguity is unsettling.  I will outline several factors for you to review in thinking about an unexpected change in the client’s engagement, and I will also suggest things to consider in your response.

When the client stops coming to session and doesn’t respond to your efforts to reach out, it is useful to review your last contact with the client.  Maybe she disclosed some aspect of her history for the first time, engaged more deeply with her emotions, acknowledged the importance of therapy as a source of support, or made a plan to take a positive step toward growth and healing.  Any of these developments can be a source of anxiety, and the client may need to suspend or end contact to avoid feeling overwhelmed or frightened. 

It is also helpful to review the client’s history, particularly regarding early family relationships.  She may have experienced repeated abandonment and loss, abuse and exploitation, or feelings of guilt and responsibility.  Often the client becomes more worried about repetition of these early experiences, usually outside of awareness, as she engages more deeply in therapy.  It seems paradoxical, but the client may feel more frightened in therapy as she becomes more attached. 

A third area to examine is the client’s current life.  She may be living in circumstances that are disruptive and distracting.  Her attention shifts to more compelling priorities rather than her commitment to a weekly therapy session.  Examples are volatile partner relationships, financial crises, challenges in parenting, and lack of control in job duties and scheduling.  In addition, some clients find it hard to keep regular appointments when their symptoms recur or become more severe.  An increase in depression or anxiety, recurrence of a manic or psychotic episode, or a relapse on substances may lead the client to withdraw from support and help when it is most needed.  

Once you have considered the factors above, you can develop a preliminary understanding of the meaning of the client’s disengagement and a response that fits your understanding.  Your supervisor’s input will be useful in this process both clinically and administratively, since your agency may have requirements regarding frequency of contact for open cases.  Supervision is a time to reflect on your own feelings regarding this shift and potential loss.  Your response to this situation will reflect your unique pattern of managing loss and rejection as well as specific thoughts and emotions related to your relationship with this particular client.  There is a lot to learn about yourself and about the complexity of client engagement in psychotherapy when you face this type of disruption.

In most cases when the client has missed two or more sessions and hasn’t responded to phone calls, it is a good idea to make a final phone call in which you express your understanding that the client may have made a decision to end therapy and give a specified date about a week later that you will close the case if you don’t hear from her.  I also recommend sending a written letter which acknowledges the ending, after the specified time period has elapsed.  The letter can briefly summarize the issues the client discussed in therapy, describe progress that was made, and provide referrals or offer a return to you or another therapist at the agency in the future.  You and your supervisor will decide the appropriateness and specific content of communication by phone and/or letter but generally it is preferable to provide a clear ending. 

I hope you find these suggestions helpful in understanding and managing your feelings about unplanned endings.  Please email me with comments, questions or suggestions for future blog topics.

Professional Practice Decisions

therapy1I’m about to leave my counseling internship and I want to keep seeing a few of my clients.  Should I look for a private practice internship so I can continue working with these clients?

Leaving an internship is a big transition and it usually brings up many different feelings.  Transition always involves uncertainty and we sometimes deal with uncertainty by looking for something that can stay the same, to give us a feeling of security in the midst of change.  If you haven’t given thought to these issues, I encourage you to talk with your supervisor more about the upcoming change and the feelings you have about leaving your current placement.

Regarding the question of looking for a private practice internship, this is a decision to make based on your professional goals and direction rather than based on a desire to continue working with a few clients.  A private psychotherapy practice is a business that requires a significant investment of time, energy and money.  It only makes sense if it fits with your vision of what you want your professional life to be in the next several years.

I suggest asking yourself a few questions before exploring a private practice internship.  How will I feel if one or two of my clients don’t want to continue working with me after I leave the agency?  How will I feel in six months if I have no clients?  Am I avoiding some feelings of sadness or guilt about ending with these clients?  Am I worried that no one else can help them as much as I can?  Your honest answers to these questions will help you sort out your motivations and determine the right course to take.  Bringing these issues to supervision will also help you clarify what to do next.

If you do pursue a private practice internship, be sure you know the requirements of your agency in transferring clients to another setting and the requirements of your private practice supervisor in bringing clients with you into your new internship.  There are legal, ethical and licensing board issues and regulations that need to be met.  Make sure to have clear conversations with the private practice supervisor about the expectations that both of you hold about the business and clinical parts of your relationship.  Each of you may have assumptions about how you will operate, and these need to be shared to maximize your satisfaction and success.

Most importantly, use this transition as a time of personal and professional growth.  Take time to reflect on your training and supervision experiences, what you have learned and what you want to take on as your next step in training.  Think about all the clients you have seen and what you learned in working with them—about yourself as well as about clinical work.  Take time to say goodbye to your peers and supervisors as well as your clients.

Recognize what you’ll miss as well as what you’re glad to leave behind. Each phase of training contains lessons and prepares you to take on the next challenge.

Please email me with comments, questions or suggestions for future blog topics.

Termination Tasks

I have a final session scheduled with someone I’ve seen for 6 months.  What should happen in the session to make the ending go well for the client?

therapy

This blog focuses on the tasks of termination.  If you haven’t read the previous blog on Psychotherapy Termination, you’ll find that helpful before you focus on the logistics.

The main goal of termination is to create an ending that is less traumatic than the client’s prior experiences of separation and loss and that honors the client’s way of managing loss.  The tasks of ending treatment are the same regardless of whether the ending is planned or unplanned and whether it is initiated by you or by the client.  I will discuss one way to organize the ending into three tasks: reviewing the work you have done together, discussing future circumstances when therapy could be helpful, and sharing the experience of saying goodbye.  It can be helpful to share these tasks with the client in preparation for a final session, since most clients have little experience of ending a relationship with thought and acknowledgement of the emotions surrounding the loss.

The first task is to review the therapy, with you and the client sharing your thoughts about what you have worked on together and the changes that have occurred.  When you share your perspective, it is especially meaningful to the client to hear your memories about the early sessions.  An example is “When we began working together, you were really depressed and you had a hard time imagining how you could ever feel better.  Now you seem to be enjoying your job and time with your kids and you have ways to cope with sad feelings when they come up.”  If there are issues that are still problematic or have not been a focus of your work with the client, you can acknowledge those with a statement about how the client might address them on her/his own.

Second, the end of therapy is a time to provide support and education regarding returning to treatment in the future.  People often wait until symptoms are debilitating or until their lives are seriously impaired before seeking help, and a reminder about the steps that led up to the client’s presenting symptoms and condition may help her/him seek treatment more quickly.  Also, you can talk with the client about life transitions or developmental stages that may present a risk or vulnerability.  For example, a woman who was sexually abused at age 8 is likely to experience increased anxiety and reminders of her trauma if she has daughter who reaches the age of 8.  An adolescent who loses a parent will be vulnerable to episodes of depression or other grief-related symptoms when losses and transitions occur throughout adolescence and adulthood.  You can provide encouragement for future treatment by saying “If you find your symptoms returning again, I hope you’ll seek help again.  People often find it helpful to see a therapist when times are stressful or when there are life changes that may bring up some of the issues we’ve worked on here.”

The last task is to share the experience of saying goodbye.  Many clients are avoidant of emotions related to loss, and the depth and extent of this part of your conversation about ending may be limited.  However, at minimum you can make a statement like “I want you to know that I have enjoyed getting to know you and participating in the progress you have made.  I feel some sadness in saying goodbye, and I wish you well.”  This direct expression of your feelings provides the client with a different experience of ending, even if s/he doesn’t share her/his feelings.

I hope you find this structure helpful in organizing your final session.  Please email me with comments, questions or suggestions for future blog topics.

Psychotherapy Termination

therapy1I will be leaving my practicum training placement 4 months from now in the summer, and this is the first time I’ve worked with people more than 12 sessions.  Some of my clients have been coming in for more than 6 months.  How much time do clients need to end therapy?

Starting at a practical level, it is usually helpful to let clients know about your departure 4-6 weeks before the end of your work if the treatment has lasted between 4 months and a year.  Less time is generally needed if the treatment is shorter and more time if it has been longer. Anyone that begins treatment with you now should know from the beginning how long you will be able to work with them. A related question that is often unacknowledged by clinicians in training is how much time you need to end therapy with your clients.  I find that the ending process is much smoother when the clinician has spent at least a month, preferably longer, reflecting on her/his feelings about leaving clients and the placement before beginning to have conversations with clients.  Supervision, sharing with fellow clinicians and personal therapy are all places to talk about this.

All of us have personal experiences with loss and we bring those feelings and reactions to professional experiences of loss.  Even though moving to a new training placement is a move toward professional growth, you are also ending relationships that have been important in your intellectual and emotional learning.  Using self-awareness about how you approach this move will tell you a lot about the ways you are accustomed to managing grief and loss.  You may minimize the importance of this step, find fault with your current placement, become preoccupied with the welfare of your clients, focus on the logistics and required documentation, or remind yourself of the exciting opportunities ahead of you.  I encourage you instead to take time to acknowledge you are saying goodbye to people who have touched your life in unique ways.

Once you have spent some time acknowledging your own emotions about the loss of your clients, supervisor and peers, you can begin to plan your conversations with clients about ending the treatment.  The main goal of termination is to create an ending that is less traumatic than the client’s prior experiences of separation and loss and that honors the client’s way of managing loss.  Your supervisor can help you review what you know about the client’s past experiences of separation and loss and how s/he manages feelings of grief and sadness in the present.  Based on this knowledge, you will be equipped to identify what can be different in your ending with the client.  You can also develop hypotheses about how the client is likely to respond.  You can expect that some of your clients will avoid coming to the final session, and saying goodbye by telephone, email or letter may be the best possible ending for some of these clients.

I hope you have found some food for thought as you anticipate saying goodbye.  The next blog will continue on this theme with some more specific ideas about what to include in your ending process with clients.  Please email me with comments, questions or suggestions for future blog topics.