by Columbia University Irving Medical Center

Credit: Unsplash/CC0 Public Domain

Therapy can be a critical tool for taking care of your mental health. Finding the right therapist can take time, but patients can go to therapy for years and still see benefits, which raises the question: When is the right time to stop therapy?

Erin K. Engle, PsyD, is an assistant professor of medical psychology at the Vagelos College of Physicians and Surgeons, where she serves as clinical director of Columbia Psychiatry Specialty Services, provides individual and group therapy, and teaches and supervises clinical psychology interns and postdoctoral fellows within the Department of Psychiatry. Here's what she has to say about how to navigate the ending of psychotherapy.

What are the signs that it's time to end psychotherapy?

Generally speaking, there are three scenarios where patients look to end psychotherapy: 1) when a patient finds their treatment is ineffective; 2) when there are "red flags" to suggest that the therapist is not or is no longer a good fit; and 3) when a patient has made desired progress toward their goals and feels they are ready to end treatment.

In the first scenario, it can be important for a patient to check in with themselves about insufficient progress toward their goals. How do they feel after a number of consecutive weeks with their therapist? If a patient consistently leaves therapy sessions feeling stuck, it may be time to consider ending therapy. A reputable (and ethical) therapist will want to hear their patient's concerns and try to remedy them. If that doesn't work, they should help the patient find a new therapist.

In the second scenario, the case of "red flags," a patient might feel judged, shamed, unheard, or emotionally unsafe. It is critical for a patient to raise these concerns directly with their therapist. If a patient intuitively feels that "something's off" in a persistent manner, it's best that they trust their instincts and search for a therapist who can provide a better fit for therapeutic work.

The third scenario, where a patient has made significant progress in therapy, allows the therapeutic relationship to play out in a couple of ways. Sometimes, there is a sense of reaching a plateau and stagnating. Having achieved their goals, a patient may have much less to say to their therapist and very little content to address in session. In this circumstance, a patient may indeed be ready to end treatment.

In many cases, patients who have made substantial progress toward their goals decide to continue therapy at a reduced frequency. These so-called maintenance visits can still be very productive, as they help to maintain and extend progress made during the working phase of therapy. A good therapist can remain a helpful resource and help a patient choose a suitable course of action.

When considering ending therapy, what questions should a patient ask themselves?

There are several important questions a patient can ask themselves to self-assess their progress in therapy. Here are a few suggestions:

• Have I met the goals that brought me to therapy? What have I achieved in therapy, or what specifically has changed in accordance with my goals?

• What key changes can I identify in myself, my life, and my relationships that suggest I've grown through therapy?

• Why am I thinking or feeling that this might be a good time to end therapy? Is my assessment based on feelings in the moment, or a more continuous and overarching feeling of readiness and progress towards my goals?

• What support might I need to continue my positive change, growth, and development after I end therapy?

What questions should a patient ask their therapist?

Let me break these down into early-stage and later-stage questions. Near the beginning of therapy, a patient might ask, "How long will my therapy last?"; "How do you define progress in therapy?"; "How will we measure my progress in treatment?"

Later in the therapeutic relationship, when a patient is feeling ready to end therapy, they might wish to ask their therapist these:

• From your professional perspective, what progress have you observed in me that indicates that I could be ready to end treatment

• What do you feel I've gained through therapy? How have I changed, or what progress have I made since we started treatment?

• What do you think of reducing the frequency of our meetings?

• What would you recommend I do to leverage the gains I've made in treatment thus far, should we decide to end treatment?

• What are the benefits of discontinuing therapy?

The benefit of discontinuing therapy may be that the patient has an opportunity to practice or rehearse new skills, coping resources, or a perspective gained in therapy more independently, which may enhance confidence or trust in oneself. As it often takes time for new perspectives, skills, or coping resources to generalize, this independent practice (outside of continuous therapy) may help a patient to navigate new situations and gain mastery and a sense of self-efficacy while doing so.

However, as effective therapy provision also ties back to a safe and trusting relationship built between therapist and patient, these kinds of gains or even troubleshooting can also be addressed in maintenance sessions with their therapist. This is often a critical moment, where a therapist can play in important role in preparing their patient for more independence.

Are there any possible pitfalls to ending therapy? Could the impulse to end therapy mask something else?

The biggest possible pitfall occurs when the ending has not been appropriately discussed or agreed upon by therapist and patient. It is best if there are no surprises around the termination process. Therapists have an important professional obligation here to ensure alignment with their patient's goals, and this should be discussed and known by both parties. If termination is not agreed on, a patient may be unprepared, or even harmed by a premature ending.

Sometimes an impulse to end therapy reflects a patient's fear of exploring a sensitive issue. One way to avoid this pitfall is to implement a termination phase, with an appropriate end date, during which the patient and the therapist together determine if the desire to end therapy is, in fact, avoidant behavior. I think the biggest misstep for a patient and therapist around termination is to not address it at all.

If one decides to end therapy, what are a patient's options? Is there a best way to do it?

When considering ending therapy, I would suggest that a patient be direct with their therapist. This is important not only for the therapist to understand more about the patient's perspective, but also supports the patient being empowered in their treatment. And while endings in therapy can be celebratory, they also can provoke a feeling of ambivalence, a sense of uncertainty, or a fear of change.

That's why this conversation requires open and compassionate communication that can help prepare the patient for a termination phase, and ultimately, a treatment end date. And while the termination phase aims to reduce the frequency of meetings, it affords an opportunity to acknowlege gains, such as positive growth in relationships. It's also an opportunity to talk about how the patient can address continuing challenges outside of psychotherapy.

Is 'termination' for everyone?

For some patients, there is a benefit to staying connected to a therapist for ongoing treatment or maintenance sessions, even when the main symptoms for initiating treatment have resolved. Ongoing therapy may be helpful to those with chronic mental health issues, though this also may reflect a degree of personal preference. Much like going to the gym or maintaining a healthy diet, ongoing therapy for some serves as an important avenue to general well-being.

Also, some patients come to therapy with broad, humanistic goals. These might include self-discovery, self-improvement, identity exploration, deepening of relationships, or tapping new emotions. For these patients, progress is not so much about benchmarks. The most important thing for them is that therapy serves to enhance the quality of their life.

Provided by Columbia University Irving Medical Center