Personal reflections on the therapeutic process: Learning from termination.

The process of terminating with ongoing psychotherapy patients, especially long-term patients (those generally seen for a year or more) is one that can be very meaningful and emotional for both therapist and patient. Termination has appropriately been linked with past experiences of loss and abandonment, existential fears of death and dying, as well as with opportunities for new growth and development. Under the best of circumstances the decision to terminate is agreed upon by the client and the therapist, providing them both with the opportunity to work through the process. However, more often than not termination is dictated by one party or the other, brought on by factors such as expiring insurance, a patient’s moving, or in my case stopping at training sites in order to begin my full time internship.

In my case having worked extensively at one clinic in addition to other sites, preparing to start internship meant terminating not only with the patients I had seen over the year, but also with patients whom I had been seeing for the past three years. Having never terminated with patients who I had seen for even close to this long, and certainly never having terminated with so many patients all at once, I was unsure what to expect both from my patients and myself during the termination process. Given this, perhaps it is not surprising that much like I have found throughout my clinical training, my expectations and thoughts about what terminating would be like did not match my experiences. This seemingly common – at least to the training experience – phenomenon creates in my mind an interesting gap, created not by poor expectations, but rather by the inherent difficulties of training. In other words, despite the fact that I had been taught and even experienced when completing previous externships what termination would be like (i.e. see above) it remained difficult to know how it would be when it was this different.

The hardest part of termination for me has been trying to assess the effectiveness of therapy and to evaluate how I performed as a therapist. Going through the termination process I remember voicing doubt to fellow classmates and supervisors about how I helped my patients. While many had made progress towards goals they also often remained stuck in certain places. From my perspective it was difficult to ascertain that what I did during sessions helped them achieve their goals, as opposed to it just being a product of time and their own growth.

Reflecting upon my uncertainty and ambivalence I think it is in some ways part of the tension that is a part of therapy. Both the therapist and the client have an idea of what they are working on, or what the “problem is”, but how they approach it and work at it may not be so clear. Indeed, as a student I feel that this uncertainty may even be exacerbated as there is a propensity towards trying new techniques or representing the material in ways that reflect recent readings, discussions, ideas etc. That this process of working in different therapeutic frames is likely normal if not central to the training, does not necessarily alleviate the feelings that the patient would be better off with a more established therapist, or generally that they deserve better.

Despite this, during the process of terminating one of the most consistent and perhaps surprising observations was how deep my relationship was with my patients and vice versa. While going through notes I was amazed at how much had transpired in their lives and my own over the course of my sessions with them. Not only did I feel tuned into their lives but it also felt as if I had actively participated with them. In this sense reading through notes about their stories I found myself at times thinking in terms of “we”. For example, how “we” handled a certain issue or “we” achieved certain goals. The feeling of connectedness in some ways belies the uncertainty, almost by saying that this was “you” in the relationship and that your effect was real.

This is in some sense the actualization of the gap that I described earlier. The role of the therapeutic frame and theory is meant to structure the therapeutic space providing the tools to help the patient work and make changes. However, this space does not in effect account for the human-to-human interaction that comprises all of the therapeutic interactions. Indeed, as described above, while talking with my patients about our relationship what was striking was how much they valued the relationship. That to me the frame more often than not felt ambiguous seems to have had a minimal bearing on them. What mattered more to them was that I was there, and that they knew that I would be there to listen, to share, to acknowledge, to discuss and to explore. As my patients discussed with me the aspects of myself that they valued and found effective during therapy, it was amazing how little they had to do with approach or technique. Carl Rogers knew this of course and orientated humanistic psychology around it. Cynically, I feel that in some ways the parts of me that worked the hardest for example to conceptualize them or to make certain interpretations were the least acknowledged.

What terminating has helped me to begin thinking about is how to minimize this gap. One way that comes to mind is how theory can be orientated and utilized around the actual interactions in the office. I understand this personally as a deepening and extending of my thinking about interpersonal approaches to psychotherapy that work off the therapeutic relationship. What I have come to appreciate in terminating is the need for the therapist to present himself or herself in an authentic manner so that the aspects of themselves, whether they are warmth, honesty, directness etc can be felt and understood clearly by the patient.

In many ways this feels both very obvious to me and is also somewhat of a revelation. To me it means both working as myself but doing so in ways that are clearly conveyed to my patient. Theory then becomes a way of looking at the ensuing interactions between my patients and me, providing a perspective to both elaborate upon our shared experience and create new ones. In other words, in therapy a space is created to have experiences that are real but can be explained in ways that allows for the growth of the therapist and the patient.

As a final thought it is probably not a surprise that I felt this gap while terminating with my clients. Termination is not only a time of reflection, but it is very obviously the end of the therapy. This can lead to a sense of safety where both the therapist and the client knowing that their time is ending can act more like themselves in therapy. While throughout termination I was thinking about theories about what is happening for the patient and myself, it still nonetheless felt as if my interactions with my patients were more genuine and less a matter of us participating in social role playing. Experiencing these authentic interactions, while also hearing about what my patients were taking from therapy has not only helped make terminating with them a meaningful experience but also an educational one as well.