When to Terminate

In contrast to the literature on the therapeutic alliance and other phases of the psychotherapeutic relationship, there is little literature and almost no empirical evidence about the best way for therapists to deal with termination. However, it is thought that failure to work with termination issues may result in patients being unable to achieve their therapeutic goals (Levenson, 1995). Competency in the last phase of psychotherapy reflects the therapist’s ability to assess the patient’s readiness for termination and to manage termination issues within the context of the approach used in the treatment. Termination is an essential phase of the therapeutic relationship, and there should be a plan in place by the therapist to process relevant issues that arise as the end to the relationship nears.

Hopefully, the goals that have been set at the outset of therapy have been successfully met. Unfortunately, this often is not the case. Patients frequently drop out of treatment without a plan for termination. Barnett (1998) classifies reasons for why patients leave treatment other than mutual agreement and successful goal achievement. These include the following:

Another reason for termination that can be added to this list: when a student must leave at the end of a designated period at a training site. This is a more “manageable” termination in that both student therapist and patient know at the outset that there is a specific period for therapy, and the end date is known well in advance.

Binder (2004) reviews the few studies that have been conducted on termination and the duration of therapy and comes to these tentative conclusions: Limiting the duration of therapy may influence the rate of change; acute symptoms exhibit more rapid change than characterologic problems; and more time in therapy leads to more change. However, there are no longitudinal studies proving that longer-term psychotherapy results in better outcomes than shorter-term psychotherapies.

Termination optimally occurs when coping and functioning have improved, symptoms are reduced, and the goals of treatment are met. Achievement of goals depends on the collaborative goals set with the patient at the outset of treatment and on the type of approach or model used. For example, supportive psychodynamic psychotherapy criteria for termination would include the strengthening of the ego, reversal of regression, and symptom improvement. In contrast, more expressive psychoanalytic psychotherapy criteria for termination would involve the resolution of the transference neurosis, an acceptance of the futility of perfectionist strivings and childhood fantasies, a reduction in the intensity of core conflicts, and the development of a self-analytic capacity (Wolitzky, 2003).

Self-analytic capacity means that the person has learned to be reflective and to become his/her own therapist. The advanced practice psychiatric nurse (APPN) can usually detect that this has been achieved by what the patient says and does. For example, the person may say, “I thought about what you would say when I was in that situation” or “I had a whole conversation in my head with you before I talked to him.” These kinds of statements reflect the patient’s internalization of the therapist’s reflective function. Sometimes, nothing is said, but the person’s functioning has greatly improved, and it is obvious to the therapist from what the person says about how s/he has handled various situations that a newfound ability to self-reflect or self-soothe is operating.

For cognitive-behavioral psychotherapy, termination begins in the first session, and the expected duration is usually discussed at that time, when issues and goals for treatment are clarified. The therapist usually sets a specific number of sessions, sets a predetermined date to end, or informs the patient that the treatment will not go longer than a few weeks or months without specifying an exact date (Binder, 2004). The idea is for the therapist and patient to keep a problem focus and momentum moving forward. Reinecke and Freeman (2003) recommend setting parameters for treatment at the outset because studies have found no correlation between duration of therapy and effectiveness. Improvement after 12 to 15 sessions has been found to be minimal so it is the first 3 to 4 months when most of the positive changes occur. It is a generally accepted practice in cognitive-behavioral therapy (CBT) to remind the person from time to time throughout the treatment about when termination will occur so the person has an opportunity to discuss how s/he feels about ending and can prepare for it (Safran & Muran, 2000).

The goals of treatment in CBT involve changes in maladaptive thinking and behaviors toward more positive adaptive thinking and behavior and more effective coping skills. The last session is used to review the goals and skills the person has developed and to discuss how to prevent a relapse. Cognitive and behavioral factors that are unique for the person, that brought them into treatment and that were ameliorated, such as perfectionism, negative thinking, or a lack of assertiveness, are highlighted with new strategies that were learned. Usually, termination for CBT is gradual, with the person coming to sessions every other week, then every month, then every 3 months, and then every 6 months so that modifications or changes can be addressed to ensure success.

In interpersonal psychotherapy (IPT), major goals of treatment relate to resolution of interpersonal problems in the “here and now.” To that end, alternative strategies for interpersonal relationships are identified, new relational patterns are practiced, and old ways of relating are grieved. Once the patient is successfully implementing the new ways of being, goals of therapy are met. Termination begins as early as the middle phase of treatment and is embedded in the work of that phase, working with the sadness about the loss of the relationship with the therapist and addressing issues of relapse prevention. As with CBT, there is a finite number of sessions delineated (16), and this provides incentive for the person to do the work within a circumscribed parameters of the treatment. The therapy does not really end at the last session in that the work continues with the person working independently. Chapter 7 discusses termination strategies for successful outcome.

How to Terminate

Historically, psychodynamic psychotherapists thought that termination represented a crisis that needed to be worked through because earlier losses or separations are revived and inevitable. For example, if a patient suffered abandonment issues, this would be enacted and exacerbated in the transference just before termination. Termination has been likened to the rapprochement crisis as delineated by Mahler (1975). The patient’s core conflict centers on the need to be autonomous and self-reliant, while at the same time, the patient wishes to be dependent. These opposing forces are always in the background of the therapeutic process, and they must be understood for successful termination to occur (Quintar, 2001).

Binder (2004) believes that separation anxiety about termination has largely changed because psychotherapy is briefer and therapy is viewed more from a primary care perspective. Patients feel they can move in and out of psychotherapy and use it as a resource, much as they would any other form of health care. An intermittent psychotherapy model has evolved that treats termination as an interruption of services rather than an end point. Proponents of this model posit that complications inherent in termination, such as exacerbation of symptoms and transference issues, are avoided if termination is reframed as an interruption of services (Cummings, 2001). In intermittent psychotherapy, the word termination is not used; rather, therapy is said to be interrupted. It may be resumed in several months or several decades, depending on the patient. The person is encouraged to write the therapist about how she or he is doing after interrupting treatment, and the therapist responds to all communications warmly. If the person is doing well, the therapist responds by offering positive comments on the person’s problem solving skills. If the person is having difficulties, the therapist asks the patient if it is time to come in for a session. Foundational to this process are the therapeutic contract, homework, and resiliency. In this model, the patient is required to complete assigned homework as part of the therapeutic contract, and failure to do so results in sending the person home or even termination of treatment. Although seemingly a severe punishment for such a transgression, the author points out that if enforced, there is rarely the forfeiture of a second session.

From a psychodynamic viewpoint, all requests from the patient to terminate should be explored. Often, the patient’s desire to end treatment is thought to reflect resistance. Gabbard (2004) states that underlying motives should always be explored with these questions in mind: Is the patient anxious and afraid and running from something? Angry at the therapist? Enacting a flight into health? Discouraged about the therapy? Feeling judged by the therapist? If the goals of treatment have not been met, it is likely that anxiety is underlying the wish to terminate. The person may not be aware of any underlying reason other than the stated “I am fine now.” For example, one patient who had been in treatment for depression and had difficulty in sustaining long-term relationships came only for several sessions and then unexpectedly announced that this would be her last session because she was feeling much better. The therapist was quite surprised because during the previous session, the patient had talked about how sad she had felt as a little girl about her mother’s absence in her life due to her alcoholism. This issue of loss seemed to permeate all relationships and situations, and the therapist had been moved by the previous session. The therapist gently explored whether the patient felt that her goals of being able to sustain a long-term relationship and trust someone were already met. As the session unfolded, the therapist wondered aloud whether her desire to leave now was based on some of the sad feelings she had expressed during the last session. Tearfully, the patient realized that she was fleeing as she was beginning to feel vulnerable in therapy. After this was expressed, she was able to stay and continue to work in ongoing psychotherapy.

Premature termination is a term that encompasses any other reason that the patient may terminate before the goals of treatment are met. These reasons are numerous and include the person’s financial situation changing, a move to another city, inability to tolerate emotions or success, therapist error, and devaluation of therapy (Hollender & Ford, 2000). The inability to tolerate intense emotions speaks to the importance of the therapist assisting the person in affect management strategies and titrating the amount of arousal during treatment. Patients may be well served to flee treatment if their defenses are fragile and they are not assisted with controlling overwhelming states of anxiety, rage, depression, and guilt. Chapter 10 discusses stabilization and affect management strategies.

For patients who are unable to tolerate success, treatment may be terminated by the patient as soon as the person begins to improve, leaving a perplexed therapist wondering what happened. These individuals can be triaged through their history of self-defeating behavior in times of happiness and success. The therapist can point out to the patient that this may happen in therapy too and stress the importance of discussing ending treatment when the patient wants to leave treatment. Underlying this may be much guilt and masochism because the person may unconsciously feel that s/he does not deserve to be happy or successful. Dynamic interpretations about this issue can be helpful throughout the treatment, and the vigilant therapist keeps this in mind as the person improves.

Perhaps the devaluing patient is the most difficult to work with because the person insists that the therapy was not worth the time and did not help, and the therapist most likely feels demoralized. Often, these individuals do not keep their last appointment. Of course, they may be accurate in their assessment, but it is important for the therapist to keep in mind that these feelings may be anxiety driven and that unconsciously the person may need to minimize the loss by not acknowledging the importance of the relationship. Underlying the devaluation may be deep feelings of inadequacy and worthlessness, with the person perceiving the therapist as critical and uncaring. Maintaining an empathic, exploring stance without defensiveness in the face of a barrage of devaluation is extremely difficult. Sometimes, the best that can be hoped for in such situations is providing the patient a new type of relationship experience through the therapist’s benign presence. The overall goal then is that the person will be more likely to seek help at some point in the future.

If the APPN knows that the person has a history of anger, it may be helpful to include the family in treatment especially initially (Stevenson, 2000). The therapist can then prepare the patient and family member for the likelihood of anger at the therapist and premature treatment at the beginning of treatment. In this way, Stevenson (2000) posits that the anger will seem like a “normal” part of the therapy and a healthy triangulation with the family, therapist, and patient will be established at the outset. These patients are often referred by others and may be less than willing participants in therapy. Stevenson (2000) also suggests reframing anger as a problem for the patient’s physical health to normalize anger and motivate the person for treatment.

For patients who are aggressive, termination can be seen as the ultimate rupture in the therapeutic alliance. Relational psychodynamic theorists posit that these patients are counterdependent and that termination provides a rich opportunity to rework conflicts of dependency versus autonomy. Safran and Muran (2000) say that when patients are aggressive and counterdependent in therapy, the therapist’s work involves ultimately working toward exploration of the dependency that is being defended against. In contrast, when patients are more dependent and deferential, the therapist’s job is to help the person access the angry feelings that are being defended against. This gives the person the opportunity to learn that the therapist can survive his or her aggression. The therapist empathizes with and validates feelings of anger that emerge during termination, which may include feelings of disappointment and resentment about not getting what the person wanted from therapy.

Gabbard (2004) points out that termination involves mourning by both the therapist and the patient. This is thought to be especially true for those who have been significantly traumatized in that the loss of termination is related to the loss components of the traumatic event (Horowitz, 2003). The person has emerged from the trauma having lost a sense of personal invulnerability. The loss of the therapeutic relationship and acceptance of the idea provides a context for mourning other past major losses. The person realizes that ultimately no one can take care of him/her and love them unconditionally. The therapist also mourns the loss of the relationship with the patient. The therapist must reconcile the limitations of what the therapy has accomplished. Novice APPNs sometimes have unrealistic expectations about what therapy can accomplish. Both parties may harbor unconscious fantasies about being healed and healing, and they need to come to terms about the limitations of what one person can do for another.

However, if the goals of therapy have been met, the patient typically does not have much to say about termination when asked, other than expressing appreciation and some sadness about terminating. No matter which psychotherapy approach the therapist is using, after a termination date has been set, whether 1 month, 6 weeks, or several months in the future, the patient’s feelings about termination should be explored intermittently in the time left. Even if the patient initiates termination, the therapist’s agreement to terminate may be experienced as a rejection and abandonment (Gurman & Messer, 2003).

Toward the end of treatment, the patient may have an exacerbation of symptoms that brought the person into therapy in the first place or a decrease in functioning. For this reason, it may be important for the therapist to inform the patient that this commonly occurs beforehand. The APPN should be aware and watchful for recidivism so that the person can be encouraged to express their feelings of sadness, abandonment, and loss rather than acting them out. Important work can be accomplished during termination, particularly for patients with significant issues revolving around loss and dependency. These painful feelings are associated with earlier memories of loss or abandonment, and related neural networks are often triggered by the current loss of a relationship. This is important to point out to the patient, and the therapist needs to explore the issue with sensitivity so the treatment does not end on a bad note with the person feeling battered by repeated interpretations that further entrench the patient’s position that there is no connection. Leaving therapy feeling misunderstood can feel better to the patient than the pain of separation and loss, but this is not the ideal way to terminate. A useful analogy is the nearly universal experience of most adolescents in the senior year of high school, who turn their parents into ogres and become so obnoxious that all parties concerned are glad when they finally leave home. This helps to assuage sadness about leaving but is a less than ideal way to terminate a therapeutic relationship.

In addition to understanding the patient’s unconscious issues related to termination, the therapist needs to be aware of his or her own issues. It is a good time for the therapist to reflect on whether their goals are congruent with what the patient wants. The therapist’s goals may be too ambitious for the person and wanting the person to function at a higher level may not be appropriate at this time for this person. The APPN may be busy rescuing the person who does not share the same values or aspirations. The therapist may have her own abandonment issues and may feel comfortable and rewarded from working with the patient and find termination difficult. These issues affect the therapist and the patient. For the therapist, unresolved personal conflicts may predispose the therapist to use the therapeutic relationship to satisfy his/her own social and emotional needs. Patients who have been difficult to work with may engender a sense of relief when they terminate, in which case, the therapist may neglect to adequately explore their wish to stop. It is important for the APPN to self-reflect and to examine his/her own feelings about the patient’s termination to ensure that the patient’s best interests are in the foreground of the therapeutic process.

There are various models for whether to taper sessions or schedule follow-up sessions, depending on the therapist’s orientation, the goals, and the needs of the patient. Most psychoanalytic psychotherapies do not taper off sessions, but some contemporary relational, psychodynamically oriented therapists do feel that it is useful for patients to see how they manage on their own (Curtis & Hirsch, 2003). Other therapists schedule an appointment for a month or two after the last session as a follow-up session. A review of the treatment and how the person has changed may be conducted in the last session. Scheduled periodic phone calls may also be helpful for the therapist to monitor how the person is able to handle stresses outside of therapy. Some patients find regular ongoing support after therapy crucial in keeping on an even keel, and checking in periodically helps the person to maintain functioning at a high level. This may be especially important for the patient who has suffered severe or complex trauma. Kluft (1999) suggests that for these patients, follow-up sessions may need to be held every few months indefinitely (1999).

It is prudent to ask the patient what would be good for him/her if you suspect that ongoing support is needed. However, it is important not to convey to the person that you expect that s/he will have problems in the future. One patient who had been severely depressed and came intensively over a period of 2 years achieved much higher functioning than he ever dreamed possible and continued to schedule appointments over the next several years every few months to “touch base.” The focus of these sessions reflected his eagerness to share with the therapist his successes, and the therapist shared his pleasure, but she also further explored how he did not believe that these changes belonged to him and were long-lasting. As his confidence grew in his newfound ability to deal with his life, he was able to increasingly lengthen the time between sessions. Some patients may never wean themselves completely from therapy. Gabbard (2004) calls these individuals “therapeutic lifers” and suggests that consultation be sought to be sure about whether this arrangement is beneficial for the patient.

An important point about termination is that the door should always be left open for the patient to return, and if the experience was a positive one, the person will be able to use therapy as a resource and feel comfortable about seeking help in the future. However, if the patient is being transferred to another therapist, it may not be appropriate to “leave the door open” for the person to return to you because this can cultivate splitting. In these situations, when the person is being transferred to another colleague, particularly if it is in a clinic setting, it may be helpful to introduce the patient to the new therapist or have the new therapist come to a few sessions before termination to ensure a smooth transition (Gabbard, 2004).

Reviewing the patient’s file before termination to identify issues and important themes highlighted during treatment is helpful so the APPN can organize his or her own thinking about the progress that has been made during the therapy process. In addition to the APPNs reflections, it is important to ask the patient what was and was not helpful in the treatment. Reflecting and reminiscing with the patient and outlining the ways that the person is functioning better is important in the sessions leading up to the last session or at the very least in the last session. This discussion should emphasize that these accomplishments are a consequence of changing maladaptive thinking patterns, of insight gained, of finding better ways of handling situations, or of an increased ability to manage emotions. In examining the changes that have occurred, the therapist can reinforce education about how to maintain the gains made during times of stress and explore patient expectations about accessing resources in the future. Hopefully, educating the person has been part of the therapy all along, but reinforcing again is essential during termination.