Therapists call the end of therapy “termination.” Most therapists will be planning for termination starting in your first meeting, and they will be helping you prepare for it as well. Therapy is meant to have an end. You learn skills, apply them in your life, see changes, and then you go out on your own maintaining these changes.
Many patients have mixed feelings about termination. Some people really bond with their therapist and hate for the relationship to end. Some may feel anxious about being out of therapy and worry whether they can maintain their progress. Others may feel confused over whether they have made enough progress in therapy.
Some might need to have an unnatural end to therapy due to financial or logistical constraints. Others might feel angry or misunderstood by their therapist and not want to return.
For the purposes of this article, I will refer to the “end” of therapy as either the natural process when therapy has gone right or the process of what will happen when therapy is not going as expected.
Note: I am a cognitive-behavioral therapist; clinicians using other modalities of therapy may have different opinions on this topic.
Here are a few guidelines for termination when therapy is going well...
You Have Significant Symptom Improvement
One important thing that should be happening is measuring your symptoms. You might complete self-rating questionnaires or more formal measures conducted by your therapist. For example, the Patient Health Questionnaire (PHQ-9) is used to measure symptoms of depression. Let’s say someone started therapy with a score of 25, which is in the “severe” range. The past few times they have completed the questionnaire, their score has been around 5, which is in the mild range. That is a good sign that their symptoms have significantly and consistently improved. Of course, if they are working on more than depression, then they may not be completely done with therapy, but they would have completed their goal of improving their symptoms of depression.
You Have Significant “Functional” Improvement
When someone has a mental health condition, one or more areas of “functioning” for them is typically impaired. This means they are likely having significant difficulty either with work/school, home life, relationships, recreational activities, etc. Let’s say a teenager who started therapy was failing all their classes. Over time, they are now back to receiving As and Bs in all their courses. This is a sign of improvement in their life that may show that therapy is working for them. When there is not significant disruption in any of these areas anymore, likely someone is ready to graduate from therapy.
You Have Engaged in “Relapse Prevention”
Relapse prevention is a term from working with addiction that refers to making sure someone does not return to their previous problems. Before the end of therapy, therapists should guide relapse prevention, which helps people summarize the skills they have learned in therapy and plan for continuing to use them to maintain their progress. This would also include having an understanding of when to return to therapy. Someone should not terminate therapy without engaging in this step first.
Here are guidelines for termination when therapy is not going as expected...
You Have Identified a New Problem
Let’s say someone has been going to therapy for depression and, over time, they realize many of their difficulties stem back to the trauma they endured as a child. It’s possible that their current therapist is not skilled in trauma therapy and needs to refer them to another clinician with this skill set. In this case, we would actually call this a “transfer” rather than termination. The original therapist should be highly involved in helping find the transfer therapist and then communicate with them in order to facilitate the transfer to begin a new type of therapy.
People often feel disappointed when they cannot continue with their original therapist, but please remember that this is a positive thing! This is a sign that your therapist cares about you and wants you to have the best care, which they feel they cannot provide based on their training and skill set.
You Need a “Higher Level of Care”
Some people are experiencing symptoms that require a higher “dose” of therapy. Someone who is experiencing very severe symptoms, a very sudden change in mental status, actively planning suicide, or frequently self-harming, for example, may need more hours of therapy or a more controlled setting for therapy. These range from an acute inpatient hospitalization, residential (full-time) care, partial hospitalization, intensive outpatient (several hours per week) to joining a group in addition to individual therapy.
In the best cases, someone will transfer to the level of care needed and then return to their original therapist once they are better able to engage in “outpatient” (i.e., 1-2 sessions a week) therapy.
You Cannot Put in the Work Needed in Therapy
Cognitive-behavioral therapy involves a lot of practice of skills outside of therapy and active engagement during session. Sometimes people are just not in a place to put in so much effort and, because of this, their symptoms and functioning are not improving either at all, as much as expected, or quickly.
Sometimes the patient and therapist together decide that now is not the best time for therapy and they go on a “break.” Of course, the goal would be to return to therapy once the person is able to more actively engage in treatment. This could be either logistically (e.g., ending a busy season at work, going on summer break) or mentally (e.g., building motivation to put more effort into therapy).
Your Therapist Is Behaving Unethically
Of course, if your therapist violates their ethical code or the law, you should terminate therapy immediately and find another therapist. If your therapist works for a practice or hospital, their supervisor can assist with finding another provider and with handling the ethical violation.
I won’t try to create an exhaustive list, but examples of this would be: attempting to initiate a sexual/romantic relationship with you, releasing your mental health information without your permission and outside of the parameters of mandates to violate confidentiality, attempting to enter into a second relationship with you (e.g., becoming business partners)
Lastly, here are some thoughts on when it may not be a time to end therapy...
You Have Been Feeling Much Better for a Week
Sometimes people feel unclear on the timeline of therapy. Whether it has been a week or month, any short time of improvement may not be a guarantee someone is ready to terminate therapy. Many times, when people have been dealing with mental health conditions for a long time, they misinterpret feeling “less bad” as feeling better. Above, I outlined three areas that should be addressed before graduation from therapy. Leaving therapy too early (and without this being planned with the therapist) could leave someone vulnerable to a relapse within a short amount of time. We love when therapy is short-term but please just ask your therapist if it is time to graduate therapy before abruptly leaving!
You Had a Misunderstanding with Your Therapist
I am purposely separating this from the ethical violation guideline above. Maybe your therapist seemed to misunderstand your symptoms or goals, briefly hurt your feelings, or annoyed you when they said they couldn’t do something you suggested. These are the types of challenges that can happen in any relationship with another person. Therapists are trained to have conversations about relationship rifts. Although these can be difficult conversations, they often lead to better understanding and repair of the relationship. Many misunderstandings can be resolved through a conversation and, if not, your therapist will provide guidance as to whether working with another clinician would be better.
Your Financial Situation Has Changed
When people have a loss of income or change of insurance, they might believe they can no longer see their therapist. Often, unfortunately, they make this decision without talking with their therapist. Your therapist may be able to provide an option that alleviates your financial concern and, if not, they can certainly help find a new provider and guide the transfer of care.
You Are Moving
All therapists can work with someone virtually in the state(s) where they are licensed, and psychologists with PSYPACT authorization can work with people in select other states. Before just assuming you need to end therapy, talk with your therapist to see if your care can be continued after your move. If not, again, your therapist can assist with the transfer.
Graduating from therapy can feel unsettling, but it is a sign of a big achievement! Other moves from therapy may be disappointing, but they are almost always in the best interest of the patient. I hope these guidelines help in understanding when and why to end therapy.