Tag Archives: Ending Therapy

Unplanned Termination by Therapist

diane suffridge therapistI have been working at an agency job for a year and have been seeing a number of clients for six months or more.  I’m looking for another job, and I’m wondering how much notice I should give at my current job in order to allow enough time for termination with my clients.  

The topic of termination is covered in Chapter 13 of my book, including planned and unplanned endings that are initiated by the client or the therapist.  The situation you describe is one in which you will be initiating the termination process with clients who may or may not have completed their treatment.  It is a good idea to think ahead to the impact your job change will have on your clients so you can do as much advance planning as possible.

I recommend thinking about three tasks to be addressed: reviewing the treatment progress and relationship, anticipating future needs for treatment, and saying goodbye.  These tasks are discussed in more detail in a previous blog.  Another blog discusses the importance of processing your feelings about ending with your clients, preferably before you begin the termination process with them.

Usually it is ideal to allow 4-6 weeks for a termination process with clients you have seen for six months or more and 2-4 weeks for shorter term clients.  If you work in an outpatient setting, always assume that some of your clients will miss one or more sessions during the ending process, making it advisable to have a longer rather than shorter time to end.  When making a job change, however, you may not be able to give your clients more than 2 or 3 weeks notice, depending on the circumstances of your job search and any break you plan between leaving one job and beginning another.  I’ll discuss here how you can handle the three termination tasks mentioned above in this compressed period of time.

The first issue to keep in mind if you are ending treatment of six months or more with 2-3 weeks notice is that the ending will inevitably feel somewhat incomplete.  Since you are initiating the ending, you may feel a degree of guilt which could lead you to minimize the discomfort of the ending for both you and the client.  It will serve both of you to acknowledge that you would like to have more time to say goodbye.  In addition, you will be ending with all of your clients at the same time, which will bring up a lot of emotions for you, while you are also saying goodbye to colleagues and supervisors.  Anticipate the emotional work this will require of you and use your support system to help with your own need for processing the endings of these relationships.

A second issue to consider is that some of your clients will miss their final scheduled session, so begin the termination discussion at the time you let them know you are leaving, even if you plan to meet another one or two times.  Since the clients won’t be expecting this news, you’ll need to give them time to take it in before talking about it.  I recommend beginning the session by telling them that you’re leaving, with a simple statement like “I’d like to start our session today by letting you know that I’ve taken another job and will be leaving here on (date).  I’d like to take some time to talk today about ending our time together, though we’ll also be able to do that in our next (1 or 2) session(s) as well.”  Then wait for the client to respond, and if she/he moves quickly into another issue about her/his life, look for another opportunity later in the session to come back to the termination process.

When the termination process is brief, it is often helpful to give the client a written note with some of your thoughts about the treatment as a supplement to your discussions in person.  Many clients lack the experience of talking directly about the ending of a relationship, and this often leads to avoidance and denial of feelings of loss.  You may not have an opportunity to share everything you would like to say to the client in a session, so writing a note ahead of time gives you a chance to express yourself more fully.  It may also be easier for the client to take in your thoughts at a later time.  If the client misses the session in which you plan to give her/him the written note, you can consider sending it by mail.

One of the three tasks I recommend addressing during termination is the client’s future needs for treatment.  When you are leaving your job, the client’s continued treatment will be dependent on another clinician’s availability at your agency so you will discuss this issue differently based on those circumstances.  The other two tasks—reviewing the treatment and saying goodbye—are solely about your relationship and aren’t dependent on the agency arrangements for the client to continue or end.  Although there may be a lot to say, it is possible to accomplish these two tasks in a relatively short period of time if you prepare for these sessions by thinking about each client individually and what you can say about the nature of your work together and how you feel about ending.  It is often meaningful for the client to hear how you have been affected by the work.

These recommendations will help you in managing an unplanned ending with clients with thoughtfulness.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

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.

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.