Why stopping therapy is not the same as ending psychotherapy

In psychotherapy there is a lot of focus on patients coming to therapy – the start. Prospective patients will often mull over starting psychotherapy for a long time and it is not infrequent that they have “false starts” where they perhaps research a therapist, only to abandon the process in favour of some less confronting “wellness solution”.

Endings are often less considered, especially by patients but sadly also by clinicians. And when an ending is not considered, planned for and appropriate clinically it is frankly not an ending but simply a stopping of the work.

The relationship between endings and grief

The journey of psychotherapy is about grieving, irrespective of the specific unique experience a patient has lived. Something went wrong in the developmental period of that patient that led to them experiencing a relational disturbance or trauma. Possibly many. And what is damaged in relationship can only be healed in relationship: that is the function of the psychotherapeutic relationship.

Where a patient has been unable to grieve their losses, often because they were unaware of those losses through not being able to conceptualise them in the same way a fish is unaware of the ocean it swims in – it is its whole world – their maladapted relational patterns get stuck and repeat over and over in the present. In psychoanalytic psychotherapy we think about this as the past repeating in the present driven by an unconscious way of seeing the world that is no longer valid. The only way through this is to form a relationship with the psychotherapist and to learn and experience a different way of relating which then unlocks the possibility of mourning what was lost.

Just as coming to therapy is critical to starting that journey of change, ending psychotherapy and grieving that ending is also essential. A failure to do so and thus to simply end is a repetition of something from the patient’s past – a way that they protect themselves from attachment so that they protect themselves from feelings of loss. The loss must be felt and worked through for a successful ending to happen and it is a critical piece of the work.

How do I know when to end psychotherapy?

I have practised as a depth psychotherapist for nearly 20 years, mostly offering in-person sessions from the consulting rooms in Brighton and Hove and in Lewes. Eventually in every piece of work the question of endings arises, from the patient. However, it is often not couched as an ending but as “stopping”, “taking a break” or expressed as an acting out in the shape of simply no longer attending sessions.

Most patients have no idea of how to end therapy as their experience of being in relationship to their caregivers was inconsistent and ordinary feelings not expressed openly. The thought of ending in a manner that is negotiated and acknowledged by both parties can feel confronting and anxiety provoking. This is exactly why ending psychotherapy is as important as starting as it is a time where old attachment and relational patterns can re-emerge.

Should a psychotherapist always agree to end the work if a patient wants to stop?

In my experience of the trajectory of depth therapy based on the contract agreed between the clinician and patient, an impending ending is generally felt by both parties. There is a sense that the work is nearing a natural conclusion and that the patient is able to express themselves freely within the therapeutic relationship.

The role of a psychotherapist is to think about the patient’s best interests and to protect the therapy – the work. Thinking about what is in a patient’s best interests may conflict with what a patient experiences as being in their self interest. When we are able to hold ourselves in mind we are acting from a place of best interest and it means we are able to take responsibility for our emotions and actions in the world. Conversely, when we act from a position of self interest, our focus is on the immediate, on avoiding discomfort and thus on immediate gratification.

If the therapy contract is clear and the work is progressing – the patient and clinician have a working alliance then the onus is on the clinician to think carefully about any ‘acting out’ or attacks on the therapy, including the patient wanting to prematurely end the work.

Psychotherapy is not a relationship of equals and nor should it be. The therapist holds structural and clinical power and must use it benignly. The patient, however, also has agency, choice and the right to withdraw from the work. This does not mean that every wish to stop should be treated as a clinically thought-through ending. Sometimes stopping is necessary and appropriate. Sometimes it is also a way of avoiding dependence, grief, anger, vulnerability or loss. In those instances, the task of the therapist is not to coerce the patient into staying, but to help them think about what may be being enacted through the wish to leave.

What does a good ending look like?

Good endings in psychotherapy are when the ending can be thought about and talked about well in advance of it becoming a reality. It can be “tried on for size” and moved towards and away from as necessary.

Endings, if acknowledged and worked through involve grieving and ending therapy, which is to say to bring an end to a very important relationship that may have lasted many years, involves grieving.

Grief always brings up past grief and for many patients grieving the end of the therapy may bring up further grief around their losses that previously could not be felt and expressed.

And then there is timing – how long should an ending take? The answer is the same as to the question of how long therapy should go on for: it depends. Ending will mean something different for each patient and for each piece of work. However, as a rule of thumb, I would suggest that for each year a patient has been in therapy, the ending should be worked through over a corresponding number of months.