50 Ways To Leave Your Therapist: Termination and why it's important
post by squidious · 2017-11-05T01:00:01.646Z · LW · GW · 4 commentsContents
4 comments
I've heard a number of people talk negatively about professionals they feel stuck with. "I feel like my dentist is judging me for not flossing enough", "I don't feel like I can be honest with my doctor", "I wish my hair stylist didn't ask so many questions". We feel stuck with these people because, despite the lack of a personality fit, they may be really good at their job, perhaps better than anyone else we've turned to. We are hesitant to look for someone else, and risk it with someone who may not do a good job.
When it comes the therapeutic work, the alliance between client and therapist is widely considered to be the most important part -- more than theory or technique. So although we may feel compelled to continue, a therapist we cannot deeply trust isn't going to be as helpful as one we do -- in some cases, the wrong therapist can actually prevent us from moving forward.
A good therapist may be attuned to this. Some therapists will ask a client about how they feel therapy is going, and occasionally, a therapist may even refer a client to someone else if they feel they cannot do a good job. Most times, though, it is on the client to decide how well therapy is working for them. This means that if therapy isn't working, they have to decide what to do about that.
The most common way for a therapeutic relationship to end is that the client disappears. Sometimes, they call to cancel the appointment and never reschedule. Other times, they stop showing up altogether. Either way, the client and therapist never get to go through a true termination phase (the final phase of the therapeutic process).
The termination phase is arguably where the most work gets done. Clients who have trouble with endings (attachment issues, grief and loss, separation anxiety) may grow the most here, and having a planned, positive termination can be crucial for the client's growth. We don't often get a chance to experience positive ends to relationships, and this is one of the few ways we do. If termination is planned in advance, therapist and client can work together to find something special to do together for the last session. Sometimes that's a special activity, other times it's just a discussion on the client's growth over the course of therapy and things to keep in mind going forward. Some therapists like to use a transitional object -- a gift of sorts, to remind the client of their time together.
The ideal termination comes from therapist and client agreeing that the client doesn't need to come in anymore, but this rarely happens. More common planned endings are due to one or more parties moving, lack of funds or insurance, or only having a limited number of sessions covered. If the client intends on continuing therapy after termination, the last session can include referral information, so the therapist can refer them to someone new. Ideally, also, the client and therapist can give each other feedback. This is particularly important if termination is due to a bad fit. If your therapist is doing something that doesn't work, feedback is the only way they'll improve. And while not all therapists will offer last session client feedback, most therapists will do so if asked. This kind of feedback from a therapist can be particularly helpful in looking at interpersonal problems -- if your therapist finds you to be defensive, closed off, or needy, it's quite likely that other people in your life feel the same way.
Another ideal for therapy is that termination is addressed from the beginning. Many therapists will bring it up in the first session, saying something like "If you feel concerned about how therapy is going, please talk with me about it. I can always refer you to someone else if I am not a good fit." A good therapist knows that finding the best care for the client comes first, and will be willing to refer the client to someone else, even if it means losing the client. Similarly, it is important to be honest with your therapist about how therapy is going. The therapeutic relationship is like any other in that it is better to bring up problems as they come up than hide them in order to be polite. If your therapist says something that makes you uncomfortable, bring it up in session! If a particular technique didn't work, say so. Your therapist is likely to ask follow up questions, but this is only to have a better understanding of what does and doesn't work for you, as well as to better their own therapeutic skills.
If you've already been open with your therapist about what does and doesn't work, deciding to split shouldn't be a surprise to either of you. Depending on where you are in therapy, your therapist may ask for one or two last sessions, which will be devoted to wrapping things up. As I mentioned, these sessions would be devoted to review and looking forward; examining how therapy has been and deciding what is right going forward. Any information on what did and didn't work in therapy can be used for your therapist to refer you to someone new. If behavioral techniques didn't work but focusing did, your therapist can find someone who does more focusing-related work, for example.
What if the split isn't amicable? It can be tempting to ghost on a therapist you don't like, but it's important not to just stop showing up. This is both because of payment and paperwork reasons. Most therapists have a 24 hour cancellation policy that means you have to pay for a session if you don't show up, and depending on how scheduling works, ghosting may result in you owing your therapist a lot of money. Even if you cancel the appointments, your therapist cannot close the case without one party informing the other of a termination. Depending on the policy, your case may remain open for a month or more. Even just a voicemail or email stating intent to terminate therapy can be enough. If you really don't like your therapist, you don't have to have a final session -- and in fact, if your therapeutic relationship is that bad, you might be better off not having one.
Any kind of work that isn't individual gets complicated, because it's often a case-by-case basis. Different groups have different rules; some are open groups where you can come and go as you like, and others are closed groups, where you pay upfront for the duration of the group time (like a class). Unless the group explicitly allows you to leave whenever you want (such as an open group like AA), it's best to talk to the group leader about leaving, since a sudden disappearance can really affect group dynamics. In couples or family work, the decision to stop seeing a therapist should probably be made together. Sometimes a couple may find that one person likes the therapist more than the other, and so that person starts individual work with the therapist instead. When this happens, it's important to note that once someone begins individual work with a therapist, that same therapist cannot shift into doing couples or family work; the history of individual work with one person makes the therapeutic relationship unbalanced.
With kids, things get complicated based on custody and age. If there is shared custody, both parents need to agree to have the kid in therapy, and either parent can choose to terminate at any time (even if the other parent disagrees). In California, a kid can consent to therapy on their own starting age 12. However, their parents may still be able to pull them out of therapy at any time. With kids, having a proper termination can be especially crucial, since it gives the kid more control over their relationship with their therapist. Think of this as similar to a kid's school environment: changing school over the summer is easier than in the middle of the year, partly because most classes have some sort of ending ritual for the last day of school, thus wrapping things up neatly in a way that doesn't happen at the end of an average school day.
Endings are difficult, and how we react to them says a lot about us. Some of us want to disappear without a trace, while others may want to hold on like our life depends on it. Therapy gives us a chance to have happy endings, and while the reason to end therapy might be sad, there is often no reason why we can't wrap things up neatly in a narratively satisfying way. Termination is a skill, one most therapists are fairly adept at. After all, our jobs depend on it.
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comment by G Gordon Worley III (g-gordon-worley-iii) · 2017-11-05T22:01:08.494Z · LW(p) · GW(p)
I guess the obvious problem is that a person going to therapy may not feel sufficiently secure to be comfortable formally detaching. How are such cases noticed and approached?
Replies from: squidious↑ comment by squidious · 2017-11-06T20:35:54.587Z · LW(p) · GW(p)
In cases like this, it helps if the end condition is discussed early on in therapy. If this worry comes up, it becomes important to find out where this insecurity comes from. Many therapists will have an open door policy -- if we decide your goals have been met and we terminate, you can at any time come back and decide to start therapy with me again. If termination is due to the therapist leaving, they can refer the client to someone new. In some cases (though this is easier in a clinic) the gap can be bridged by having a session dedicated to the old therapist introducing the client to the new therapist, and helping create that bond before detaching from the client.
comment by FireItself · 2017-11-05T21:15:21.904Z · LW(p) · GW(p)
Can you give more details on termination when the patient and therapist feel there is no longer need for therapy? How does one recognize that situation? What is the end goal of therapy? Do you need to be fully healed, or is it when the therapist can no longer teach you any new skills?
Replies from: squidious↑ comment by squidious · 2017-11-06T20:30:47.675Z · LW(p) · GW(p)
Usually, therapist and client talk about goals early on in therapy. This depends a lot on what the therapist's expertise is and what the client sees as being the major problem. A client could come in with PTSD and say their major goal is to not have flashbacks anymore, or with social anxiety and have the goal of being able to approach new people without having a panic attack. It may not necessarily mean the end of therapy (could continue with new goals or see someone new or just stop, depending on what the client wants).