The Breakup: Termination in Therapy

As a therapist in-training, I always have termination in the back of my mind.  Because I am graduating in May, I am keenly aware that come June or July, I will have to say goodbye to the clients on my caseload.  Endings are hard and therapy can be such a close and intimate relationship that the running joke likens the termination process to a "break-up."  In truth however, while some of the same feelings of abandonment and rejection may arise in anticipation of the actual separation, termination is a unique type of ending.  It is one of the only relationships I can think of in which there is a controlled goodbye; there is the opportunity for closure in the way that all the textbooks say there should be.  While an ending, it is also an occasion for growth.  Both therapist and client have to face their own fears and take a magnifying glass to the way they interact in relationships (specifically, what does their history of "terminations" look like?).

The important part though, and the piece I wanted to address through this entry is how to terminate.  We had quite a lively discussion about this in my practicum class tonight: It's almost April, when do we start talking about it?  What do we say?  Is everyone as sad as I am to be leaving?  As I consider these questions for myself, I am realizing that the termination process for children, adolescents - and to a certain extent - emergent adults is precarious.  In this age range, a primary developmental task is learning how to appropriately connect to others.  Psychoanalytic theories would say it's re-parenting, Rogers would call it a "corrective emotional experience," attachment theorists such as Mikulincer and Shaver would see it as building and internalizing a secure base - no matter what you call it, therapy is one way we learn about connecting.  To just cut this off is jarring.

I don't claim to be an expert in this, but my research, reading, trial and error, training, and discussions have helped me to come up with a few guideposts that I use:

1)  As a therapist, take care of yourself during this process.  Address the feelings that come up for you.  Get supervision, go to therapy, consult.  Yalom says that as therapists we should be affected by our clients.  I deeply agree.  However, it nevertheless remains our job to hold the space for our clients.  We cannot do this effectively if we are not "keeping our side of the street clean."

2)  Help your client to understand the process.  "Termination" is a scary word that one would not typically associate with a relationship, let alone the therapeutic process.  We as therapists are sad, but we understand the process.  It makes sense to us because we have been trained in it.  For our clients, especially the ones who have never been in counseling before, the process may be unclear.  This is where I think a lot of the abandonment, anxiety, and sadness comes up - to them, especially the younger ones, we are up and leaving them.  Termination should be an ongoing discussion between client and therapist that addresses goals, achievements, and future directions.  Obviously, per the ethics code, it isn't a one time "well, I guess you're doing well so this is it..." bomb drop in the last ten minutes.  For kids and teenagers, I usually frame this ongoing "discussion" in the form of an activity that lasts over several of the final sessions.  I have them work on creating a transitional object (a collage, a worry stone, a playlist and CD cover, etc.) and use the process of creating this object as a way to talk about ending therapy.  At the end, they get to take their project with them as a reminder of what they accomplished in counseling in the ways in which they have changed.

3)  Pick a final session date.  Don't leave your client hanging.  This kind of goes along with point number two.  In the same way that is important to keep the framework of therapy (return phone calls, same appointment time and day, always end and start on time), it is also important to be clear about the ending.  It is easier to hold the space for your client and process feelings of anxiety and grief if there is not an open ended or ambiguous "event" in the future in which you will leave them.

Now let's switch seats.
From the client perspective it is important that you:

1) Ask questions.  We as therapists should be good at explaining the process, but sometimes (as I mentioned above) we get stuck or leave important things out.

2) Be an active agent in the process.  Have an open dialogue with your therapist about what you hope to accomplish in the final sessions.  Therapy is, after all, about you.  It's our job to work with you.

3)  Wait! But I'm not ready! - If therapy is ending because your therapist is leaving or your therapist believes treatment should end, talk to your therapist about these feelings.  We recognize in situations like this, it feels like we might be just cutting and running with no good reason - or like we don't understand some aspect of what's going on for you at this time.  It is important to differentiate not wanting to end from truly not being ready.  Sometimes we therapists need a little help to clarify.

4) If you are ready for termination, but your therapist doesn't seem to be getting the hint, I will refer you to this article.  It is humorous, however the points the author makes on the second page about knowing when you're ready are solid.

Regardless of where you sit - couch or therapist chair - the takeaway is just as the song says: Breaking up is hard to do.