How and when to End Treatment

Congruent endings are as important and valuable in the process of seeing your naturopath/homeopath as the beginnings and middle.   It is a topic that is not spoken about very much.   I have had long term patients not know how to talk to me about this and leave abruptly with a email, or a sentence in the session and leaving me disconcerted and with questions. These articles cover important aspects of any treatment process and are as applicable to the homeopathic/naturopathic process as in counselling.

When to End Treatment, Ryan Howes PhD.

Psychology Today magazine, 2017

A few months ago, a journalist sent me some questions for an article about ending therapy (because of my series on termination, I presume). I worked hard writing responses, but the article never ran, so I thought I’d post them here to bring some closure to all this hard work.

….to bring some closure to all this hard work.

Well I’ll be. That’s the function of termination as well – to give the therapeutic process a satisfying conclusion. Does that always happen? No, it doesn’t, but in an ideal world, all therapy would provide a good ending, where loose ends are tied up, take-away points are clarified, and we share a clean goodbye. Sounds nice, doesn’t it?

So why is this positive ending relatively rare? Sometimes therapists do stupid things that cause clients to leave prematurely. Sometimes clients don’t like saying goodbye so they split without notice. Many times, clients don’t even know there is such a thing as a “termination phase,” so they either ghost their therapist or fumble through the final sessions until they find a good reason to leave.

And you know what? That’s on us therapists. We should be teaching clients how to end therapy from the very moment they enter our office. Providing a good ending is one of the best things we can do as therapists. More on that below.

And so I resurrect for you the interview that never ran for your reading pleasure:

Unnamed Interviewer:  Your thoughts on what patients should consider when weighing whether it’s time to stop therapy

Ryan Howes: Clients should consider ending their time in therapy when their goals have been met or when it becomes evident that they won’t meet them with this psychotherapist. 

Ideally, therapy ends when all therapy goals have been met. If you entered therapy to treat a fear of dogs and you no longer fear dogs, your work is complete. Or you want to communicate better with your partner and you’ve learned to navigate your disagreements constructively, the goals are met. Many people have aims that are less specific, like improving self-esteem or decreasing anxiety. They may choose to leave when they’ve learned the skills necessary to do this on an ongoing basis, and the regular sessions are no longer needed to reinforce these principles. 

There’s also the idea of “internalizing” the therapist. When a client has worked with a therapist for several months or years, they’ll find themselves encountering a problem and can imagine what their therapist would say about it. We would say this incorporation of the therapist’s voice or mindset is a positive sign for the client, that they have been able to construct a portable version of the therapist who can advise them outside therapy sessions. When a positive, helpful version of the therapist has been internalized, the flesh and blood version may not be as necessary. I know, it sounds funny, but it’s true.

On the other hand, some clients realize they won’t be able to reach their goals with their current therapist. They may have a personality conflict, experience some challenges within the therapy, or they may suffer from a problem that requires a specific set of skills their therapist doesn’t have. Some therapists are highly trained to work with chemical dependency, eating disorders, or schizophrenia  for example, while others have very little training in these areas. If it becomes clear that the therapist doesn’t have the tools necessary to help the client with their issues, the therapist should make a referral to another clinician who can help.

Beyond specialty, there are also times when interpersonal issues become a barrier to the therapy. In therapy, as in all close relationships, problems with trust, communication, and empathy could render therapy an obstacle rather than a conduit to healing. If you’re seeking help with grieving a lost loved one but you don’t trust that your therapist is keeping your sessions confidential, therapy is getting in the way of your healing. In these cases, it can be helpful to discuss the problems with the therapist first, but if they can’t be resolved, leaving therapy is a viable option. 

One point to consider is whether the obstacle is central to your issues or not. If you are seeking therapy to address a history of conflict with males, and you find yourself having conflict with your male therapist, you might want to think about staying to resolve this conflict because it becomes a laboratory for your specific problem. If you have social phobia and feel awkward with your therapist, this might be just the place to work on it. But if you have a fear of heights and your interpersonal issues with the therapist are getting in the way, leaving therapy could be a good option. 

UI: Any thoughts on whether there is an optimal amount of time or number of sessions should be in therapy? What are the different variables (such as reasons for being in therapy – what would be an example of a reason that should take 8-12 sessions, what would be an example of a reason that could take months or years)?

RH: As vague as it is, it depends. 

There are people who will benefit from a single therapy session and others who have been in great therapy for 23 years and have no intention of stopping. As long as someone feels like therapy is beneficial to them and they have the practical means, they should feel free to keep going. 

A lot of this has to do with the mindset of the person seeking therapy. I’ll draw an analogy from the world of physical health, where we have two approaches – the illness model and the wellness model. In the illness model, when someone feels sick or has an injury, they go to an MD and receive treatment. When the illness clears up, they make no more appointments with the MD, and all is well. In the wellness model, a relatively healthy person decides they want to make their healthy body healthier, so they go to the gym. They work out regularly and achieve fitness goals and feel great about it. No one says: “You’re in great shape – it’s time to stop going to the gym!” That would be absurd. 

Psychotherapy is the mental health equivalent of both the illness and wellness model. People come to therapy to treat disorders like phobias, depression, anxiety, OCD, PTSD, ADHD, bipolar disorder, etc. But they also come to therapy to make a good life great by working on their relationships, finding meaning in their life, becoming a better parent, improving their communication, finding their ideal career, increasing their capacity for intimacy, enhancing their self-esteem, and so on. 

So the question about how long someone “should” be in therapy promotes a mental health stigma. It implies that people “should” be done with therapy in a predetermined amount of time and if they’re not there’s something wrong with them or the therapy. Would someone say the same thing to someone who goes to the gym? "You’ve gone to this gym for 6 years, aren’t you done yet? You’re in great shape, so stop working out.” Hell no. Let’s try to apply the same grace to mental health that we do to physical health. 

Generally speaking, people seeking relief from phobias, anxiety or depression find some relief within the first 3-6 months of therapy. People with deeper issues like trauma, relational issues, problems with core identity, sexual and intimacy problems require months to years of treatment. And if they want a safe, structured place to work on becoming the most self-aware and best version of themselves, they may want to spend much longer in treatment. 

UI: Do therapists have any responsibility to ask the patient whether he or she should stop therapy (or find another therapist)?

RH: As I said above, if a therapist finds that they are working with a client who has needs that exceed their scope of competence, the therapist is obligated to find referrals to someone who does have that skill. All ethics codes say something about therapists only working within their scope of competence.

Therapists should also be aware of whether or not therapy is giving any value to the client. This could be a therapist who recognizes that their depressed client isn’t improving despite several months of therapy, or realizing that the ADHD tools they have taught aren’t producing the desired results, or the anger management strategies seem to make matters worse. This should be a collaborative discussion with the client, where they both assess the effectiveness of the interventions and decide whether or not to stop and find outside help. 

This collaboration is very important. I remember a time early in my training when I was working with an elderly woman and I felt like our work was going nowhere. She was telling story after story and I felt like it wasn’t helping to resolve her depression at all. After several months I told her I didn’t feel I was being effective and suggested we might transfer her to someone with more experience. She nearly burst into tears and told me our sessions were the most important hour of her week, that it had helped her connect with others, and that she was heartbroken that I felt otherwise. I learned then that my experience and my client’s can be very different, and never to assume that my opinion is true for both of us. We repaired from that session, and continued several more months as her depression lifted. 

UI:  Please provide specific consumer advice tips for patients who are wondering whether they should stop or wind down from therapy, at least one robust paragraph per tip.

RH: If it’s bad therapy:

Just go. If you feel you are being exploited, if you feel unwanted romantic advances, if you feel like your boundaries are violated in any way, if you feel like therapy is going nowhere, make your next session your last. Tell your therapist you don’t feel safe and/or competently served and let them know this is your last session. If the violations are extreme or causing harm look into telling their boss or alerting the licensing board. Like physicians, therapists are ethically bound to “do no harm” in their therapy, and if you’re suffering harm there are avenues to stop the harm and find better treatment. You may feel it’s helpful for you to have a voice and tell your therapist about your complaints, or maybe not. As I’ve said many times before, it’s your time and your dime, you can have closure or choose to split with a voicemail. Whatever works best for your mental health.

If it’s good therapy:

Start early – I try to talk with my clients about when therapy will end, from the beginning. When you’re talking about the goals for therapy, talk about how and when you’ll know therapy is ready to come to a close. Maybe you’re trying to stop an annoying behavior - perhaps when you’ve been free from the behavior for a month you’ll be ready to wrap up therapy. It can seem odd to talk about the ending of therapy at the first session, but this can free both of you up to work well together and not wonder when and how you’ll end. 

Talk about it – Beyond the first session, it can be helpful to bring the topic of ending up from time to time. Let’s say you found yourself dreading therapy this week and had to drag yourself in. This can be great material to discuss and might help you develop your exit plan together. Maybe you can set a date for a final session and plan a good farewell in the meantime.

Raise your concerns – Sometimes therapy raises concerns that are speed bumps, but not necessarily reasons to end therapy. Your therapist was late for a session. You forgot an appointment. You had a disagreement. Talk about these issues and see if they are about readiness to end therapy or another problem, like resistance to diving into deeper topics. Sometimes a desire to bail is about an unwillingness to talk about really important issues more than a signal that therapy isn’t important anymore. 

Set a date – When therapy has gone well and you’ve been able to internalize the voice of your therapist, it can be helpful to set a date in the future to say your last goodbyes - some make it a month out, some make it 10% of the total amount of time in therapy. I’ve seen that doing this sometimes raises new material in therapy, issues that can be very helpful to discuss. The idea that therapy is ending can raise memories of other endings in a person’s life and give you a chance to talk about them.

Make a positive ending – The fact is, there aren’t enough good endings in life. Many relationships end in death, divorce, breakups, or a slow fade away. A good therapy ending is a lot like a graduation – it’s bittersweet. We spend some time talking about the goals achieved, lament about the problems we couldn’t resolve and had to accept, and reminisce about the time we spent together. We make an aftercare plan about what life looks like after therapy, and we end on a positive note. Unlike many relationships where there is no closure, we try to say and feel everything we can to make this as complete as possible. 

4 Reasons Not to Ghost Your Therapist

What are you really avoiding?

Posted Jan 02, 2016.  Psychology Today, Ryan Howes PhD.

  • Money’s getting tight and it just doesn’t seem worth it anymore.

  • You’ve talked through all the superficial material and all that’s left is the hard stuff.

  • You know the end is coming soon and you don’t like endings, never have.

And so ... You ghost your therapist.

Every therapist has a story or 12 about clients who seem to be connecting and doing well, but then they suddenly disappear. Poof.Phone calls and emails lead nowhere, nothing comes back. The client has ghosted.

If you’re new to the term, “ghosting” is when someone in a close relationship suddenly disappears, like an avoidant apparition. They’re there one day, everything seems to be going fine, and then they disappear——they've ghosted. You can ghost on a micro or macro scale. Let’s say you’re at a party with friends, you want to leave, but don’t want to make the rounds of goodbye hugs and “Aw, you’re leaving? One more!” so you say you’re going to the restroom but walk out the door and Uber home. That's ghosting on a micro scale.

But let’s imagine that you’re in a new relationship, and while some parts of it are working, you’re just not that into the other person. Instead of having the challenging relationship talk when you discuss your ambivalence, feel bad, and perhaps induce tears, you just stop calling. And you stop answering calls and texts. In fact, you avoid the other person completely, telling yourself that the disappearance will send the message in a more subtle way, without tears or guilt or drama of a face-to-face interaction. This is ghosting on a macro scale, breaking hearts in absentia.

Why do we ghost? We’re human: We seek pleasure and avoid pain. Goodbyes are hard for many of us, whether the harmless goodbye of leaving a party or the more substantial goodbye of exiting a relationship. All that grief, loss, guilt, and conflicted feeling are unpleasant to experience. We seek an easier route through fading away, hoping it will mitigate our pain—and maybe even the pain of the other person. By avoiding the conflict, by avoiding the other person's feelings, and maybe even our own, maybe it won’t hurt as bad. Right?

All of these ideas and behaviors show up in therapy all the time. To avoid the conflict, the feelings, the other’s opinion, clients may ghost just when the therapist least expects it.

But unlike walking away from friendships or romantic relationships, clients have one more rationalization for ghosting in therapy: “It’s not a real relationship. I pay her. I can leave whenever I want and don’t have to explain anything.”

And you know what? That's partially correct. You can leave whenever you want—that is totally your right as a consumer and a citizen (unless you’re court ordered to attend). As I’ve said many times, it’s your time and your dime. You can leave whenever you’d like. But there are 4 reasons you may not want to ghost on your therapist, reasons that may benefit you, your therapist, and society as a whole:

1. You can say anything in therapy, and that’s for your benefit.

In other areas of your life, it may be impolite to say “This isn’t working for me anymore; I’m thinking about leaving.” But in therapy, talking about the relationship is one of the central components of the work. You can say things in therapy you might feel reluctant to in other relationships, because therapy is supposed to be a safe place where all topics are fair game. Therapists are trained to hear such statements non-defensively, but even if their response is pathetic, it’s still good for you to say it. You’re just being honest, talking about how you really feel. So why not take that approach for a spin?

2. We don’t have enough good endings in life. 

Think about most endings—divorce, death, breakups, moving, fights, firing, etc. These are neither pleasant experiences nor memories. It is possible to have good endings, though. They happen all the time—graduations, for example. A journey ends with a celebration of accomplishments. Bittersweet goodbyes ensue, then brunch at the Olive Garden. That’s a decent ending. Why not model therapy’s ending on a graduation instead of a divorce?

3. What are you avoiding? 

While not everyone who wants to leave therapy is avoiding their own issues, we know that at least some are. We’re getting too close to the childhoodabuse. We’re focusing less on others in your life and more on your own contribution to your problems. We’re asking uncomfortable questions about our therapy relationship. Each of these scenarios have sent numerous people out of therapy, so they warrant mention. If you’re avoiding something you aren’t ready to talk about yet, how about talking about that? "There’s something about my childhood that I really don’t want to discuss. Can we talk about why I don't want to talk about it?” Therapists should be able to hang with that.

4. Think of the therapist’s future clients. 

Let’s say the therapist kept horrible eye contact, and this made you want to leave therapy, so you ghost. That may be a fine resolution for you, but what about all the other people this eye-avoider sees (peripherally, I suppose)? Might it be helpful, exit-interview style, to tell the therapist why it is you’re leaving, with the hope that the information may help dozens (or hundreds) of people in the future? Again, I hear you : "It’s not my job to make my therapist a better therapist.” I agree. But we do lots of things that aren’t "our job" that benefit others.

I need to add one last piece, as a therapist: It’s hard when a client ghosts, not just for the lost business or the unanswered phone calls. Those sting, but only temporarily. It’s the unanswered questions that hurt most: "Why did you leave?” “What was going on that I didn’t know about?” And the iconic, "Was it something I said?” I come to care about my clients, even after just a session or two, and a disappearance makes an impact.

Why? We spend a lot of time in our training learning to help clients feel safe and comfortable, to help them say whatever they want. Ghosting tells us that something was wrong with our rapport. Even though it seemed like the relationship was functional, something else was going on underneath. Either there was no secure connection or the client didn’t feel safe enough to talk about their insecurities. That’s a problem we’d like to correct—but without contact we’ll never know. It’s like someone telling a surgeon: “Sorry, the heart transplant failed and we lost the patient. The body is gone now, though, so we’ll never know what happened. By the way, you have three more scheduled for this afternoon.”

What happened? What went wrong? How can I improve?

These feelings are part of the cost of choosing this profession and clients shouldn’t feel that this is the main reason not to ghost. More important for you is the loss of a clean, good ending—a missed opportunity to express yourself. You lose a chance to dive into material that may be difficult, but ultimately beneficial for you.

That’s why you chose to come to therapy in the first place, isn’t it?