I had been seeing Martin for therapy for two years. Initially presenting for couples counseling with his wife, Gina, Martin requested to continue working with me individually after Gina dropped out of therapy. Martin seemed to love using therapy as a place to ruminate about his various existential concerns.
Unfortunately, a frustrated Gina contacted me some months after I had begun working individually with Martin. She simply had to tell me that Martin’s behavior was testing the outer limits of her tolerance and that she didn’t know how long she could hold on to her marriage.
I had challenged Martin’s underfunctioning behavior in his marriage several times, both in couples therapy and later in individual therapy. Martin consistently resisted my attempts to structure therapy and promote behavioral change. He finally told me that he actually had no interest in improving his relationship with Gina and that if this was the direction therapy would take, he would leave.
When asked what he would like to achieve in therapy, he asked without irony if we could use the time to read and discuss the book I’m Okay, You’re Okay.
Who decides when therapy is no longer productive? Is it entirely up to the client? Or is the therapist responsible to propose termination if therapy seems to be going nowhere?
According to the APA Ethics Code, Standard 10.10(a), “Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service.” This standard raises more questions than it answers.
When is it “reasonably clear” that therapy should end? Plateaus are commonplace in therapy, as is slow progress.
Additionally, even if we don’t perceive progress in therapy, our support may be preventing the client from deteriorating. Withdrawing that support could have unwanted consequences. Further, to whom should it be “reasonably clear” that termination is in order? What if the need to terminate is clearer to the therapist than to the client, or more likely, vice versa?
Unfortunately, as therapists we can sometimes fail to recognize when it’s time to terminate therapy. It may be difficult to accept our limitations when our therapy is not working for a client. And when we find it rewarding to work with a receptive client, we may feel reluctant to end that relationship. Finally, we may feel inappropriately attracted to the client or to the steady income that the client provides.
Then there are clients like Martin, who are eager to continue therapy in a vein that seems unproductive to the therapist. Some clients may believe they are addressing their difficulties simply by attending therapy sessions, even if they are not making behavioral changes.
The decision to terminate a no-longer-productive therapy is difficult, but a number of practices can help us act ethically.
Psychologists should review progress and goals regularly, both in their own reflections on the therapy and in dialogue with the client. If therapy has reached a plateau or an impasse, the therapist should consider revising goals and procedures together with the client.
Through regularly reviewing goals and progress and soliciting client feedback, the therapist creates an atmosphere where clients feel they can safely acknowledge dissatisfaction with the therapy or express a desire to terminate. Should the client and therapist agree to continue therapy, that decision to continue treatment should be clearly justified, perhaps with adjusted goals.
Finally, as with many therapy dilemmas, supervision and peer consultation can be helpful.
With Martin, supervision actually highlighted the difficulty of this dilemma and the many possible perspectives on it. When I shared Martin’s wish and expressed my ethical concerns, my supervisor’s reaction was milder than I expected. Since the book Martin wanted to read technically was a therapy book, it didn’t seem inappropriate to her to use the therapy this way.
In response to my discomfort, though, we agreed that I would explain to Martin that our therapy had continued long enough and we would be terminating in three months. I hoped this deadline would motivate Martin to consider a more targeted approach, but that wasn’t the case. We spent three final months discussing I’m Okay, You’re Okay, and terminated psychotherapy.
While I felt responsible to live up to my own ethical standards, ultimately it was Martin’s therapy.
Khaya N. Eisenberg, Psy.D., provides psychotherapy to a broad population of children, adolescents, and adults at Bartky Healthcare, LLC, in Livingston, N.J. She is a member of the New Jersey Psychological Association’s ethics committee and acknowledges the committee’s helpful input into this article. Her email address is: firstname.lastname@example.org.