Tag Archives: Ending Therapy

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.