November Quandary: I have a client who I think is making good progress in therapy, but it seems like she has one foot out the door. She’s skipping sessions, growing impatient, and seems less willing to engage. Every week I feel like she’s going to tell me it’s her last session. What can I do to address what feels like an impending premature ending?
1) A Corrective Emotional Experience
One of the most important—and too often overlooked—skills we therapists need is the ability to assess tricky relational hesitancies that present in the first few sessions.
Twenty-eight-year-old Ruthie came to see after a breakup, reporting feelings of isolation and loneliness. Her parents divorced when she was 10, so she lived with her mother and visited her father on holidays and summer vacations. Her early life was full of disruptions and traumas, which prevented her from fully connecting with others. In detailed descriptions of relationships, work colleagues, dating partners, family, and friends, her sense of feeling rejected was palpable.
When Ruthie began to display concerns about various aspects of my practice and of me, I knew the pattern was going to lead to an early exit. When she attempted to reschedule yet a third time, I decided to address it with her. “You’ve been through so many difficult and painful changes and losses that have left you feeling let down by others,” I said. “That must be very painful for you, and I’m wondering if it keeps you from feeling as though you can join in with others. I really want you to let me know when you start to feel that way with me so we can discuss these feelings together. If you ever feel I’m not attentive or helping you in any way, because I am human and do make mistakes, please let me know. If we can discuss this together, I promise I will do my very best to hear your needs.”
I had hoped that this early intervention would be a corrective emotional experience for Ruthie that would set the stage for success in her personal relationships. Ruthie was able to stay in therapy consistently and began to share her concerns, criticisms, and fears regarding my role as her paid therapist (paid to care, she said), various office issues such as not having bottled water available, and my scheduled vacation absences. I reassured her that although I was her paid therapist, I am also a human being who genuinely cares for her and has a sincere passion for helping her with challenges, and that I’d be there for her until she felt less symptomatic and more hopeful about her future. I listened openly to her concerns without defensiveness in order to model a new skillset of self-acceptance, self-awareness, and an understanding that we humans are all full of both positive and negative traits. By detecting early clues in her thematic life patterns, I was able to address them directly with her for a successful therapeutic experience.
Sally James, MA, LPC-S, NCC
2) Parts Work
I love this Quandary because it reminds me of why I’m an IFS therapist!
In Internal Family Systems, the therapeutic relationship is collaborative, not hierarchical. I am not the expert; I am a guide, partnering with the client to better access her inner wisdom. If I had a part concerned about an impending, premature ending, I would speak for it in a gentle, Self-led way. Perhaps I would say something like, “As we’re talking, I’m noticing a part of me that is waiting—almost expecting—you to say you’re ending therapy today. How are you feeling about what I’m saying?” Here, I am modeling how to speak for parts, rather than from them. I wonder what’s stopping this therapist from being this direct. I’m struck by his anxiety about an unexpected ending. What’s he afraid might happen?
If I felt like the client had one foot out the door, I might say something like, “I could be way off-base here, but I’m feeling as though you have one foot out the door. What do you think?” If that resonated with the client, I would normalize any ambivalence she was feeling, reassuring her that many clients have one foot out the door! What does she know about that foot that’s out the door? I might ask. Does that feel okay to her? How is it for her talking about it with me?
When it comes to endings, therapists have to do some self-exploration, too. What would you believe about yourself if a client ended therapy prematurely? Would you think you’re a bad therapist? What does “prematurely” mean, anyway?
I believe our inner work is multilayered, and that we do it in stages or chunks—sometimes years apart. I don’t know when a client’s system has had “enough” therapy. I trust the client to make that decision, and, in most cases, I can support it.
Tish Miller, LCSW
Germantown, MD
3) Premature Ending? No Such Thing.
There are two things this therapist can do. The first is to check for any concerns, which often contain baseless assumptions. We have to see if those concerns are reasonable, and then follow up by forming a stronger relationship with the client so those concerns and assumptions can be assessed within the therapeutic relationship.
I think it’s important to first address the therapist’s concern that the client will end therapy prematurely. The assumption is that there are premature endings, but I believe there are no premature endings in therapy, only endings. We are therapists, not adjudicators of our client’s motivations. Once our worrisome concerns enter the picture, it can color our perception of our client’s thoughts and motivations with our own fears and assumptions. We need to evaluate our concerns and check the assumptions that inform them with our clients so we don’t hold them in obeyance, potentially degrading the therapy. Concerns that therapy may end prematurely can be a valuable part of therapy. The assumption of what is premature and timely for a client is just that: an assumption. If a therapist talks to their client about these concerns, they’ll see the client more clearly, without the distortion of their own assumptions affecting the relationship.
It’s disingenuous not to talk to clients about missed sessions and how they engage in therapy. For example, a client may choose to leave therapy right when things are heating up. We may assume the client is avoiding difficult issues, and missing sessions frequently may lend further credence to that assumption. Have we considered, however, that the client may have taken in as much as possible for the time being and is leaving therapy not due to avoidance, but as a means of digesting what they’ve discovered? Maybe they’re feeling ambivalent about what’s emerging in therapy. Maybe they’re overwhelmed. Maybe they’re slowly integrating the material and have ambivalence about what’s being uncovered. The list of possibilities is endless.
Consider that in five years, this client returns to therapy, this time with another therapist, and uses the stopping point from five years ago as the starting point for a new cycle of growth and discovery. What looked like a premature ending five years ago now becomes a starting point for a new cycle of exploration.
Larry Laveman, LCSW
Solana Beach, California
4) Check Yourself
The first thing that strikes me when I read this Quandary is how similar it feels to the classic pursuer-avoider dynamic in couples therapy. In this case, the therapist sounding like the pursuer. So I wonder what is going on for the therapist here, as there seems to be some interesting countertransference that could help him or her become more self-aware. There’s probably some insecurity about their value as a clinician if, despite progress, they feel as the client might be leaving. At the same time, I would encourage this therapist to recognize that they may have some anxiety about being abandoned or rejected. After all, when we build the therapeutic alliance, we assume there’s a personal factor involved, a chemistry between client and therapist that involves the client liking the therapist in some way or another. So if the client wants to leave despite “not being ready,” what’s coming up for the therapist here?
At the same time, what’s going on gives interesting information about the client. Perhaps she’s hoping the therapist will pursue her in order to prove that she’s important to him. Perhaps she’s engaging in a “flight to health” in order to avoid having to deal with difficult emotions. The only way to know is to ask the client, approaching the situation with curiosity about what’s going on for her rather than seeking confirmation that she still likes you. Part of this discussion should definitely include a review of goals, whether they still seem valid, and a collaborative assessment of whether or not they’ve been met. Maybe there’s something big the client knows she has to talk about and so she’s avoiding that. The therapist should also directly address whether there’s anything in the relationship that the client feels uncomfortable about. By being open and calm in asking the question, this therapist can create an open atmosphere in which it feels safe to talk about it. The important thing is for the therapist to do their own work so that they can approach these questions with an open heart.
Carey McIntosh, LMFT
Riverside, CA
5) Good Byes
When I start to intuit that a client may be thinking of exiting, I’ll ask myself if I’m feeling stagnant, uninterested, or just plain overtired. And if there’s something I need to do to re-energize myself to show up at my best, I address that first.
Then, I’ll use the ORS (Outcome Rating Scale) developed by Scott Miller, and the SRS (Session Rating Scale), which I’ve already introduced when the client and I first started working together. After that, I’ll compare the results to the earlier measurements to get a sense of progress versus plateau. If there seems to be a plateau or backward movement, I’ll invite reflection on that.
I might say, “Sometimes when there’s a plateau, it can indicate that there’s a hurdle ahead, along with some fear about exploring it. Other times, it could indicate that I’ve missed something and need to go back and reassess. Other times, clients may feel a simmering discontent toward their therapist that needs to be addressed, which can feel scary and uncomfortable. In other instances, it can indicate we’re coming to a period of integration or getting ready to end our work together. Do you have a sense of what may be contributing to this trend based on the numbers?”
The other option is to look back at the original intake form and see what brought the client in, and to review progress on their goals. Often, clients forget how much progress they’ve made and feel discouraged because they feel their gains haven’t been celebrated. Reviewing progress can incentivize the client to keep going, or help them recognize that they got what they came for. Then, we can begin prepping for completion of care or carve out time to do an integration.
Of course, if this awareness brings up fear in you (“What if they leave?”) then it’s helpful to notice if you’re holding on to them beyond therapy’s usefulness.
When first meeting with clients, I’ll mention how it’s helpful to decide when to end therapy. I’ll tell them, “My aim is to have you ‘fire me’ at some point in the future. It’ll say we’ve completed what you came here to do, and that’s a good thing.”
I’ll also mention how a conscious, planned ending can result in good feelings because we can review and celebrate their work. Some people have difficulty saying goodbye, and so I’ll also mention that this is an opportunity to practice that. I remind them I’m one of the safest people with whom they can practice their communication skills, and that my job is to collaborate and support them in getting their needs met.
Lisa Love, MSN, RN PMH CNS, BC
Portland, ME
6) Tough Love
First, your client needs a kick in the butt so she can start taking therapy more seriously and start treating the therapist and the therapy process with more respect. However, you should never kick someone in the butt until you first pat her on the back. If she’s already heading toward the door, you’re likely to shove her out completely with a negative confrontation.
So, you start with the positives, and I mean real positives—don’t make stuff up. You tell the client whatever you like about her that is particularly germane to therapy. You applaud her efforts. You praise her progress.
Next, you tell her how you’re frustrated by her skipping sessions. Make sure you say that you’re frustrated as her therapist—this isn’t personal. You tell her you’re not so much frustrated at her as much as you are for her.
You tell her that from your vantage point she seems to be less invested in therapy than you need her to be, and you ask her to share her honest feedback about what she’s gotten out of therapy so far. What does she get out of coming? What difference, if any, have these sessions made in her life?
Emphasize that you have a healthy therapist ego (and if not, get one) and you’re only wanting to know where the two of you stand. You’re not asking to be told you’re doing a good job. You’re asking her for her honest reflections of therapy so far.
You tell her that today is the day that you both decide where to go from here. What changes, if any, need to be made? What do you want her to accomplish?
It’s also worth mentioning: If she’s skipping sessions, you’d better have a well-defined cancelation policy that covers skipping sessions, and you’d better be holding her to it.
Jim Guinee, PhD
Conway, AR
Photo © iStock/retrorocket
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