Therapy Termination: The Transformation of Therapist & Patient
January 21, 2016
Termination in therapy is complex. It may often be painful, despite the fact that any decision to terminate is typically made by mutual agreement of therapist and patient – a bittersweet pain, if you will, as developmental milestones are reached and goals have been met.
The time has come to venture forward in possession of useful coping skills and increased self-awareness. Armed with greater affect tolerance and other positive, balanced ways of “being” in the world, terminating therapy is the next frontier.
In the best of circumstances, terminations can be smooth and timely. Yet there are times when ending therapy may also be complicated and more difficult to address.
Even when a termination is mutually agreed upon, ending a deeply forged alliance still remains complex. For the therapist, it requires a delicacy of affect awareness and sensitivity to subtle nuances, which speak to understandable ambivalence. Waves of affect and mental states may also present with intensity at unexpected times.
Traditionally viewed as the ultimate goal of treatment, depending on the length of the therapeutic alliance and the reasons for termination, saying goodbye can be painful. It can also be potentially exciting or welcomed, depending where on the spectrum the “goodbye” falls, whether desired or premature.
Patients terminating after a period of months, or even years, recognize that the feeling of self-efficacy is dominant. They may allude to, or even directly suggest starting a process of termination. In these circumstances, a series of reflective conversations often ensue, and often with a specific time frame in mind for which termination will complete treatment.
A mutual exploration of original goals set and goals met are often focused on the outward aspects of treatment during the termination process. This serves to highlight and validate the complex work involved in reaching positive conclusions and hopeful outcomes for the patient’s future.
Yet a crucial aspect of treatment, one that arguably supersedes traditional goals met, is that of the developmental relationship that has existed all along, interpersonally, between the therapist and patient. The subtle developing, deepening and intimate space, which has been created between two people together, over an extended period of time: one which has manifested and grown with a kind of unspoken goal, and one that speaks to the successful experience of creating and sharing of a “relational home.” A place where fears, shame, loss, sadness, joy, terror, even dread or happiness have converged, been explored and met with contextual understanding.
Termination requires the acknowledgment of a profound co-created relationship, within which the sacred space of a small room has contained the lives of two individuals. Transformed forever, they are now facing a parting of ways.
Essential to termination, if all is to go relatively smoothly in the termination process, are essential and focused conversations surrounding the relationship between therapist and patient. Platitudes such as “you know the door is always open” or “if you want to return for a check-up or a check-in, or if a crisis happens, I’m here.”
But both parties know that on this particular day, this moment was coming. And now having arrived, it is about “goodbye” endings. A goodbye which requires the fullness and reverence of a sacred process.
Taking time to explore the complexities of this dyad is one of the most important aspects of the termination process. Minimizing, or leaving an open-ended potential for return denies the significance and importance of “endings now” despite what may come. Endings in the here and now, in the furtherance of healthy integration and affect tolerance, require experiencing the present time moment in each final series of sessions.
The future is uncertain; promises of what may be around the corner are illusions. There are no guarantees, for life is uncertain. It is here in the moment of termination that the relationship requires focused attention, close attunement to all feelings, including joy and grief and perhaps unaddressed transferential guilt experienced for “leaving.”
The relationship has impacted both parties, and both have been presented a valuable opportunity, including the responsibility to address the significance of the experience that has occurred between one another in the therapeutic setting for authentic termination to conclude as an integrative experience. Termination holds a vulnerable sacred space, where hope and deep reverence for our human existence may produce deep meaning and significance of the past, the moment and potentially going forward in life for both therapist and patient, and as a result, potentially for future relationships.
Termination and relational process inquiry
Potential aspects to address between therapist and patient in the termination process might include some of the following:
- Does the patient feel the relationship between therapist and patient has changed or shifted over time while working together?
- Does the patient feel more comfortable addressing issues or feelings which previously may have been uncomfortable?
- Is the patient inclined to confront in a healthy way the aspects of conversations that do not feel accurate or true for the patient, perhaps aspects of the patient which have been misunderstood in treatment?
- When therapist indicates supporting decision to terminate, how does client feel?
- When the therapist indicates they are going to miss the patient and the time spent together in treatment, what thoughts and feelings surface?
- Does the patient recall any experiences, thoughts or feelings they might have wanted to say to therapist in previous sessions regarding the relationship – any that the patient may like to mention now and process?
Some relational lines of inquiry may speak to the developmental milestones a patient has manifested with their therapist. These conversations may facilitate an exploration of any underlying issues that may have been overlooked up to this point of treatment.
The capacity to widen, expand and express greater authenticity in the therapeutic setting during the termination process is a testament to the efficacy of treatment cautiously viewed as the emerging healthy aspects of the persons we “are becoming.”
This is the result of shared collaborative, empathic exploration, incorporated with contextual meaning and understanding.
There is no reason to assume that terminations follow a path of positive movement in every situation. Leaving therapy is a risky, courageous step. There may be feelings of fear, regret, uncertainty and trepidation. There may also be feelings of relief, happiness, healthy pride and excitement.
What is important is to explore all the affect and mental states which emerge during the process and to normalize the bitter sweetness of the termination process.
Even if circumstances change and the decision not to terminate emerges as the patient demonstrates second thoughts or fears that they are simply not ready to terminate, then this will also be additional grist for the mill, to be explored and empathically inquired of. Sometimes a patient decides just one more session is necessary, maybe two, then changes their mind and decides they may not need extra sessions.
As Elizabeth Kuhbler-Ross outlined in her paradigm of stages of loss, bargaining becomes a challenges for us all at times. This understandable movement back and forth, known in contemporary circles as the leading edge and the trailing edge, is not uncommon. Two steps forward, one step back, so to speak, may be experienced or expected during the termination phase.
Either way, termination speaks powerfully to the impact two people have in one another’s lives. This is the quintessential component of successful treatment, the unspoken goal of the relationship as being the ultimate “thing.” This is what will lead our lives in a more rich and satisfying direction, a path which can only successfully be taken when the foundation of a relational home has been established.
References available from the author
Katrina Wood, Ph.D., is director of Wilshire Valley Therapy Centers in Los Angeles and Encino, Calif. She may be reached at firstname.lastname@example.org.
Shaking hands photo available from Shutterstock
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