Preparing for the End of Therapy

Halfway through our session, Abigail—who’s been attending weekly individual sessions with me for nearly three months—says the thing I’ve always hoped I’d never hear as a therapist.

“I don’t feel like I’ve accomplished anything with you.” She sighs, then shrugs.

Abigail can be wickedly funny. She’s smart and insightful. Despite her aversion to experiencing her own emotions, she responds to our work in ways that suggest she’s sensitive to emotional undercurrents. In my view, we’re a good fit, as far as client–therapist relationships go. True, she’s become a little more reluctant to take my guidance, lately, and she’s started hinting that coaching appeals to her more than psychotherapy. When her wife gave her an IOU coupon as a birthday gift and I asked her how she felt toward her, she said, “Ah, I see what you’re doing; you’re trying to get me to express anger.”

“Not necessarily,” I gently corrected her.

“But you think I’m angry,” she persisted.

“Are you?” I asked. “You’ve mentioned anger twice.”

“Okay,” she snapped, “so how is being angry at my wife going to help improve our relationship? At this point, I’d like you to tell me how to fix things.”

Despite our increasingly challenging dynamic, I’m convinced Abigail’s pushback is a natural part of the process, and that it’s cropping up precisely because we’re getting somewhere meaningful—and that we’ll soon move past these obstacles.

In today’s session, I repeat the words I’ve just heard to myself: I don’t feel like I’ve accomplished anything with you. Then I nod, once, twice, three times, like a bobble head on a dashboard. My easygoing façade hides the confusion and emotional upheaval I’m sensing within. Her statement has blindsided me. I’m angry, sad, ashamed, and hurt.

“Are you having any feelings toward me right now?” I ask with a slight tremor in my voice. “I mean, when you say you don’t think you’ve accomplished anything in our sessions?”

Abigail pulls her beaded bracelet across her wrist, then meets my gaze.

“There’s disappointment,” she begins. “I know you’re not a miracle worker, but I’m not sure this type of therapy is right for me. It’s been a while, and nothing has changed.”

“It sounds like you have some doubts about my ability to help you,” I say. “Maybe—.”

“I’m not demeaning your competence,” Abigail interrupts, and I flinch, recognizing the comment for what it is: a spontaneous negation, which I like to think of as the modern cousin of Freudian slips. She is demeaning my competence. In other words, when people offer you random information you haven’t requested in the form of a denial, there’s a good chance that what they’re denying is in fact true for them, whether or not they’re consciously aware of it.

“Do you see any parallels between what’s happening here with me and what ends up happening with your wife?” I ask. “You’ve said she’s not living up to her role as your partner, and now it seems I’m not living up to your expectations as your therapist.”

“Interesting.” The muscles around Abigail’s mouth relax, but I’m not sure it’s in a good way. She looks tired. “I guess I do have high expectations of her, and maybe of you, too. So it’s possible I just have unrealistic expectations of everyone.”

By the end of our 50 minutes, Abigail and I have agreed to begin our next session exploring her ambivalence about continuing therapy. But when the next session rolls around, we end up talking about an incident that upset her at work. We meet for three more sessions, and each time, even when it’s my intention to circle back to the issue of our work and the possibility of ending it, some new concern takes us in a different direction.

Then, one week, Abigail leaves me a voicemail saying she’s sick. A month passes. She never reschedules. I reach out by phone. She doesn’t respond. I email her, letting her know a final session might help with closure. Crickets. I send a similar message via text. More crickets. After a while, I put on my invisible therapist cone of shame and give up.

Our work has both ended and not ended. It’s petered out.

Part Twilight Zone, Part Bermuda Triangle

I wish I could say the end of Abigail’s therapy was a fluke, but the truth is, therapy endings have always challenged me. From my conversations with colleagues and friends, I get the sense I’m not alone. Whether it’s me working toward ending therapy with a client, or a client ending therapy with me, terminations aren’t easy or predictable, at least not in private practice, unlike in schools, hospitals, and mental health clinics, where a limited number of sessions is usually built into the treatment frame. Terminations run the gamut. They sting, implode, and, as with phantom limbs, leave gaping holes of unprocessed feelings in their wake. They’re inauthentic, abrupt, sloppy, and painful in a death-by-a-thousand-cuts sort of way. They’re heartbreaking.

They’re also healing, potent, satisfying, intimate, vulnerable, loving, and gratifying. I’ve experienced—and facilitated—intentional, thoughtful endings with clients that have felt liberating, magical, and complete, functioning as deeply corrective emotional experiences. But these “good” endings—for me, at least—seem to be more the exception than the rule.

I’ve worked with many clients over the years who share my mixed feelings about ending therapy. Some have dreaded termination so much that they’ve called to apologize profusely as they told me they couldn’t make it to our final session. They’ve been ill; a distant, long-lost relative was visiting; a paycheck didn’t hit their bank account on time, and they couldn’t afford to come; their car wouldn’t start; their refrigerator failed and a repairman was on his way to rescue a stockpile of frozen dinners; they were parked in wall-to-wall highway traffic; the train or metro wasn’t running; their boss called them in for an emergency meeting; or—occasionally—they simply got distracted and forgot we were scheduled to meet.

I’ve also had clients who didn’t bother with an excuse: they just didn’t show.

Beginnings—at least as far as I’ve been able to gather in my 17-plus years of working as a therapist—aren’t generally seen as all that difficult by anyone with a year or two of clinical experience under their belts. As with the start of any relationship, beginning therapy is exciting. There’s hope and curiosity. Everyone’s on the same page. Let’s do this! Endings, in contrast, are tricky, elusive, and mysterious. What’s happening here? Something has shifted. Is this over? Are we ending with the understanding that you, the client, can come back to see me, the therapist, in the future? How long will termination take? What if you begin a session saying you want to end? Can that same session be our last? Do we have to wait until the next one? Are terminations better if they span several sessions? How many? Should the process be indefinite, something we do, week after week, till it feels fully over?

Part Twilight Zone, part Bermuda Triangle, anything can happen when therapist and client venture into the powerful electromagnetic field of termination. Navigational tools fail, compasses go berserk, whirlpools suck you down into the dark depths of a lifetime of every other emotionally painful ending you’ve ever been through, either vividly recalled or unconsciously sensed. Because the ins and outs of termination aren’t always clear to both participants in the therapist–client dyad, no one is immune to the strangeness. Regardless of your expertise or advanced degree, the end could derail you at any time. It could enrage, confuse, trigger, and embarrass you. It could even—and this may well be the most tragic fate of all—elude you indefinitely.

“I still remember when I tried to end therapy with my first therapist,” a colleague told me recently. “It was kind of traumatic. I let my him know I was ready to switch to a different therapist, but he didn’t think that was the right course of action. He claimed we were the ones with ‘the relationship.’ It was like that Seinfeld episode where George Costanza tells his girlfriend he wants to break up with her and she just smiles and says, ‘No.’ Constanza says, ‘What do you mean, no?’ ‘It’s like launching missiles from a submarine,’ his girlfriend explains. ‘Both of us have to turn our keys.’ That’s exactly how it felt. My therapist wouldn’t turn his key. After him, I was reluctant to go back to therapy. I told every new therapist I met for an initial consultation, ‘I need to know it’s okay to end this.’”

Thanks for Everything

Why is termination so hard? What do modern-day therapists say about this issue? I typed “ending therapy” into the search bar on my computer and a string of hyperlinked articles geared toward therapists appeared on my screen with names like “When to End Therapy” and “The Art of Letting Clients Go.” They hit on similar points: talk about ending from the get-go, process accomplishments throughout, and when it’s time to wrap up, review successes, missed opportunities, and future possibilities. A surprising number of links led to error messages and expired pages. Others seemed fishy, offering PDF worksheets in exchange for my email address.

When I searched “ending therapy” on Amazon, a small book called Writing Happy Endings promised to help therapists give clients narrative therapy homework to improve their mood. One book on ending pain—which I realized could relate either directly or tangentially to my search topic—appeared next, midway down the page. Below that, a 300-page hardcover book called Terminating Therapy looked promising. Despite being published 15 years ago, you could still buy it for $66.95—expensive for a book, but maybe not for an antique. Folks who sounded like retired university professors praised its clinical wisdom in five-star reviews, but it was a terse, clunky, 2½-star review that piqued my interest.

I am in the position of having to terminate therapy, an Amazon user who’d earnestly dubbed themselves “Book Lover” had written. I have been seeing the same therapist for 16 years. I am having a problem with this.

Would Book Lover have had a problem ending therapy if they’d written their Amazon review today? Although I hadn’t done a social media poll on the subject, I was pretty sure most people in 2023 wouldn’t see the same therapist for 16 years straight. And what exactly was the problem Book Lover was referring to? Was it the problem of wanting to end therapy and not knowing how? Was it the problem of realizing, “Sixteen years have passed, and for some reason, I’m still in therapy with the same therapist”?

It seemed odd that my search for timely, engaging resources on something as important as ending therapy had led to vintage books, how-to articles, dead ends, and marketing funnels. Maybe termination had become one of those quaint, awkward-in-retrospect mental health trends—like neurasthenia—that no one bothered with anymore, particularly when there were so many other shiny new mental health objects to pay attention to.

Or maybe no one needed to end therapy these days because it was always in a state of perpetual beginning—just a tap, click, or swipe away. Subscribe to Spotify and allow notifications and 24/7 therapy apps, chatbot therapists, therapy-by-proxy podcasts, and preprogrammed anger management reminders will appear on your screen, preempting your common triggers, responding to your texts, or helping you heal attachment wounds vicariously as you listen to famous therapists work with volunteer clients while simultaneously washing dishes or speed walking around the neighborhood with a headset on. Parked at a stoplight or waiting for a checkout station in a grocery store aisle, you can even send your real therapist a quick email: I won’t be coming to our next session, and I’m going to take a break from therapy. Thanks for everything. A selection of smiley faces, heart emojis, and clasped hands are available on your touchscreen to soften the blow.

Ending Group Therapy

Twenty years ago, when the members of a therapy group I belonged to settled into their chairs, one of my fellow group members—my future husband, though I didn’t know this at the time—announced he was withdrawing from the group in order to date me.

“This is my last session,” he said.

Our attraction had grown over a period of two years through meaningful, sidelong glances, smiles, questions, answers, and private conversations in the waiting area before any of the other group members arrived, but things had reached a climax a week earlier, when, after leaving the group, he and I had ended up on the same train together, headed downtown.

“We need to process this,” our therapist said. “You broke the group rules about outside contact with other group members.”

“We’re family in here!” someone interjected. “I mean, would you fuck your own sister?”

“Give him a break,” one of the male group members hissed in a show of locker-room solidarity. “They’re not biologically related.”

“I’ve been doing this for eight years.” My future husband’s voice emerged through clenched teeth. He was squeezing an empty plastic water bottle and the crackling made my skin crawl. He’d locked his unblinking gaze on the group therapist.

“So does this seem relational to you?” she asked. “Leaving like this?”

“How am I supposed to leave?” He thrust the water bottle into the air. “I mean, do you want me to stay another eight years until you give me permission to go? Because I’m not doing that. Seriously, this feels like a cult!”

“I can hear how angry you are,” the group therapist said sternly. “What I’m wondering is if there’s a better, more conscious way to do this.”

“Sorry I broke the rules,” my future husband looked deflated. “But I’m ready to go live my life.”

That night, group ended for him. But it didn’t end for me.

Every Wednesday, I went back and settled into the same chair, in the same circle of people. I didn’t want to be there, but I stayed anyway. Maybe I was doing penance. Week after week I sat in a room with people I didn’t want to be with, spending money on something I no longer felt I was benefiting from. You’re a coward, I told myself. Be assertive. Speak up. But whenever I tried, it didn’t go well. “I’m not sure why I’m here,” I’d say. “Yeah, the two of you are dating, so who cares about the rest of us?” one of the other group members said. “Basically, you’re a homewrecker.” It was hard to see those kinds of exchanges as therapeutic, but maybe I was missing something. I wondered if the low-grade anger I’d always felt toward my family of origin was getting transferred onto the surrogate family of this group.

Our therapist added a new member, but my future husband’s absence remained palpable. Whether we talked about it or not, the group dynamic felt wonky.

“Why are you all so hung up on this dude who left?” the new guy asked.

It took me six months to develop the courage to go against what I thought were my therapist’s and the other group members’ wishes by ending. The truth was, I’d come to know and care about everyone in the group over the course of our time together, and I knew I’d miss them. As I entered the small room where we’d met regularly for so many years, I smiled weakly, nodded, and sat in my chair. My sympathetic nervous system was on hyperdrive; I could feel my necklace popping at my throat from the blood coursing through my extremities.

“I’m leaving,” I blurted out. “Tonight’s my last session.”

The new group member thanked me for speaking up. Someone else said that even though I’d been a part of what hurt them when my fellow rule-breaker left abruptly, my willingness to stay had given them an opportunity to process their reactions to unpredictable loss. I expressed gratitude for what I’d learned and shared some regrets.

When our time was up, everyone gathered their coats and I stole away through the waiting area, down the hall, and across the ornate, art deco lobby. Then, incredibly, I walked out of the building’s front door. I was free. It felt good. Except that now there was nothing left to escape from. It was just me, my future husband, and all the issues we still hadn’t faced.

Talking About Sex Won’t Make You Pregnant

In 2020, when COVID hit and everyone went into lockdown, a peer-supervision group that used to meet once a month in my dining room disbanded. By the time I consider restarting it, some of the therapists have moved away, others have gotten busy with new projects, and one—Dianne Modell—has decided it’s time for her to wind down professionally and spend more time painting as she recovers from knee-replacement surgery. She lives nearby, so I pay her a visit a few weeks after we’ve both gotten our vaccines.

We sit across from each other on her living-room couch, eating grapes, as the conversation turns from her decision to end her private practice to endings in general. She begins telling me about Salvador Minuchin, Jay Haley, Marianne Walters, and Cloé Madanes teaching her about ending therapy in the early 90s.

“They’d watch from behind a one-way mirror as I terminated with a couple or family. When someone said, ‘We don’t know what we’ll do without you,’ and I responded, ‘Well, if you need my help, just give me a call,’ the intercom phone would ring. I’d pick up, and one of the supervisors would say, ‘Reflect what they’re saying. Ask them what that brings up for them.’”

Modell’s husband greets us cheerfully on his way to the kitchen. He’s a retired lawyer who spends most of his free time giving guided tours of local cemeteries, doing legacy workshops for seniors and retirees, and volunteering at hospice-care centers. He’s passionate, Modell tells me, about the ultimate therapy ender: dying.

“My friends and I call him Mr. Death,” she whispers with a mischievous smile when he’s out of earshot, though this is clearly done more for dramatic effect than because it’s a secret. “Lately, his favorite thing to say to people when he first meets them is, ‘Talking about sex won’t make you pregnant, and talking about death won’t make you die.’ I feel the same way when it comes to talking with clients about ending therapy.”

Modell says she’s always started the process of ending therapy as soon as she can, sometimes at the very beginning.

“Years ago, I had a client—a freshman in college—who came to see me with erectile disfunction. We knew his treatment would last 10 months, the length of the school year. At month five, we began termination. Half of our work was about ending our work—half!

“Termination connect­ed to all his struggles: his parents’ divorce, leaving home, fear of failure, anxiety about his future. We talked about the ways I’d let him down and disappointed him as a therapist, because we always let people down and disappoint them, you know. It’s inevitable. Could he express that and trust me to hear him? Knowing he’d lose me connected him to all the losses he’d had in his life. It connected to his sense of aloneness, to the lack of male role modeling in his childhood, to the pressures his parents had put on him to be perfect at school. There’s so much work that gets done when we face the end of therapy.”

When I ask New York–based psychologist Yuko Hanakawa about termination, she says, “Ending therapy is so powerful.” She’s sitting on a wooden stool in front of a white curtain that fills her entire Zoom screen. “If you think about attachment theory research, it was done by people who created states of separation between mothers and children. These states of separation were artificial endings. That’s how they assessed attachment styles. How we do separations—and endings—is at the core of who we are in relationships.” The white curtain in the background ripples as though moved by a sudden breeze. In the absence of a Ouija board, I muse, maybe Mary Ainsworth’s spirit has found another way of signaling her agreement.

“When we go through an ending in therapy with our clients—or they with us—we’re separating,” Hanakawa continues. “Our own and our clients’ attachment styles emerge in these situations. Whether you’re the therapist or the client, you can’t bypass that. I mean, you can. People do. But ideally, you experience endings and separations as fully as possible.”

Hanakawa shares the story of a client who, in one of their sessions, said, “Maybe I have narcissistic tendencies.” Hanakawa echoed the client’s words, “So you’re wondering whether you have narcissistic traits or tendencies.” She’d done this as a form of active listening, but the woman misunderstood her. She insisted Hanakawa had introduced the word narcissistic into their discussion. “Is that how you see me?” her client had lamented. “Is that how you’ve always seen me, as narcissistic?” Though Hanakawa apologized for having inadvertently hurt her and explained that she didn’t see her that way, the client had remained shut down.

Two sessions later, she’d walked into Hanakawa’s office and announced, seemingly out of the blue, “I want to quit.” Although the client’s decision caught Hanakawa off guard, she said what surprised her most was that they proceeded to have their best session ever.

“We did our deepest work. She was a stoic person, but not that day. She cried a lot. She shared positive memories of our treatment. She said, ‘You help me feel so safe in this relationship—safe enough to end our therapy.’ This was a woman who tended to stay in relationships not because she wanted to but because she was afraid of disappointing people. She’d grown up with a hypercritical mother. Her ability to voice her desire to end therapy felt like a huge accomplishment. Ironically, it also meant we didn’t have any more sessions left to explore the impact and meaning of her choice to end when she did.”

Renee Doe, an international psychologist in private practice, tells me about her earliest experience terminating a caseload of 30 middle-schoolers and high schoolers dealing with immigration and acculturation traumas as part of her first supervised internship.

“I genuinely loved these kids,” she says. “I’d seen Black and Brown kids pathologized and misunderstood a lot, misdiagnosed in ways that didn’t take their traumas into account, so I did everything I could to help them feel safe with me. A few of them used to come by my office between classes. I’d get a knock on my door, and they’d say, ‘Can you walk me through a lovingkindness meditation before lunch?’

“When the school year was coming to a close, my supervisor encouraged me to get creative. I did activities with each kid long before our last session, reviewing their gains, giving them mementoes symbolizing our work, helping them grieve. For some of them, I’d been one of the few points of stability in their lives.”

What strikes me about Doe’s story is that she’d taken the time to do her own termination. She’d done this in private. At home, she’d journaled about challenges her kids had faced. She’d recalled their struggles and what had shifted in their lives. Then, she’d finished with a blessing for each kid and read it out loud, like an incantation.

“Blessing them was how I made peace with the fact that I probably wouldn’t ever see them again,” she tells me.

Did It Have to End?

I’m on a Zoom call with my former group therapist. Not long after my final Wednesday in group therapy, I’d emailed her about a billing issue. That was when she’d let me know that the group had only met twice more after I left—then, it had ended for good. When I returned to graduate school, got my counseling degree, and started seeing clients of my own, I’d reached out to her again, and we’d become colleagues. Today, she’s agreed to talk to me about endings.

“Did you have any regrets about the way our group ended 20 years ago?” I ask.

“Sure,” she says. “What’s haunted me most, though, is the question, Did it have to end?” She grows quiet. “I loved that group. I was proud of everyone in it.”

In his book The Theory and Practice of Group Psychotherapy, Irvin Yalom writes of therapists’ experience terminating, “We are not impervious to feelings of loss and bereavement. We have grown close to the members, and we will miss them as they miss us. To us as well as to the client, termination is a jolting reminder of the built-in cruelty of the psychotherapeutic process.” I wonder if my former group therapist might still benefit from doing her own private termination with each of us, the members of that long-ago therapy group, just as Doe did with the adolescents and teenagers on her first caseload.

“The purpose of that group was to help people understand how they showed up in relationships,” she explains. “Looking back, I think I was too rigid about the rules. I wish I’d been more flexible. I wish I’d said, ‘Hey, let’s look at what we’ve been about till now, and how that’s changing, and what we might become.’ My shortcoming was I didn’t explore that possibility.”

Bittersweet

Not all terminations are as confounding as the end of therapy was with my client Abigail, or as emotionally fraught as the end of my group. But all therapy does end. Are we keeping the end in mind when we start treatment with a new client, particularly if the end isn’t built into the treatment frame, as often happens in private practice? Do we brace ourselves against therapy endings or welcome them—not only as inevitable sources of discomfort, but as opportunities for vulnerability, intimacy, and healing? When the end of therapy takes us off guard, do we berate ourselves for not having gotten ahead of it by seeing it coming, or by being a better or more intuitive therapist and avoiding it altogether? Do we believe that for therapy endings to be successful, they need to be structured and predictable?

Talking about sex won’t make you pregnant. Similarly, avoiding talking about ending therapy won’t stop therapy from ending. On the contrary, it may—like avoiding talking about death—keep you in your comfort zone as you sidestep a painful reality. There’s a time and place for comfort, but when our therapy offices turn into comfort zones, our work stalls.

“There’s so much ending in my life these days,” Modell sighs as we pluck our last grapes from their stems. “Just this morning I told a woman I was no longer taking new clients. ‘I guess I caught you at the wrong end of your career,’ the woman said. There it was again—that word! End, end, end. It’s everywhere. But there’s nothing wrong with it. There’s nothing wrong with ending.” As I rise from the couch, she follows, a little unsteady on her new knee.

“Like right now,” she laughs, giving me a long hug. “We’re ending our visit, aren’t we? Endings are opportunities to give more, while we still can—and to correct our mistakes. They’re bittersweet.”

Illustration Source: James Endicott