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.