Speaker A: Welcome to the Therapist Burnout podcast, episode 35. Hey, therapist. Today I’m talking with you about transitions and terminations in therapy, and I think it’s a big issue that comes up for my therapist clients who are largely leaving therapy practices or agency work, so it’s a timely topic for them. So I’m going to talk about an EPA white paper that was on transitions and terminations, legal and ethical issues when discontinuing treatment. And so I’m kind of riffing off of this. This is also something that I talked about with Felicia, the bad therapist. So there’s an episode coming out today on her podcast. So if you want to hear just all the things about termination and ending therapy, go over to her podcast. You’ll hear me on there. She has a great podcast as well.
Speaker B: So shout out to Felicia.
Speaker A: You can get that podcast today. It’s coming out as well. I think when we think about termination or ending therapy, first of all, most therapists hate the word termination. Why do we call it that? There’s many reasons why therapy might end for a client. And so I think most of the time in grad school, we’re taught about mutual termination, not unilateral termination. And I’m going to go over both of those. And I think it’s important to think about how we frame both of these up. In grad school, we were taught about mutual termination, the beautiful process when therapy comes to a magical end, when our client has met all treatment goals and they go forth and prosperity.
Speaker B: Yes, that does happen.
Speaker A: So I’ve had some beautiful termination sessions where my client and I both wrote each other letters. And it was just beautiful. Like, there was tears, there was progress, there was all the things that we want to happen in the therapy room. And I think, just like it’s a mirror for relationships, sometimes we have, like, the satisfying goodbye with people.
Speaker B: But I think in real life, a.
Speaker A: Lot of times we don’t. For many, many reasons, we don’t have the ending that we’d want to have with people. And so I think it’s important that we talk more and more about unilateral termination and how the therapist can struggle through that process. Just more of an aside on mutual termination. So I think the best way I saw this mirrored in my training was when I was running a process group. I talk a lot about this process group experience that I had on internship. I feel like all of my career, I’m trying to get back to this process group. So I plan to go to a process group training, not because I’m doing therapy because I think it would actually be great for me to do and great to bring some of those skills to groups of therapists that I work with. So it’s my hope to just continue to uplevel my skill on that area. So I remember my senior therapist having a termination session with the group where everyone wrote what we thought about each one of the group members on little index cards. And part of me going through all of this burnout and trying to figure out what my next steps are, what I’m like as a person again, because I felt like I lost some of.
Speaker B: That when I was burned out, was.
Speaker A: Going back to the cards and reading some of the things that people wrote about me. And it was really nice. It was really lovely that that group, that therapy group still provided me with some gifts, with things that I’m taking away for myself, even today. So that group ended probably, like, 15 years ago. So I think we can’t, number one, we don’t know all of the little seeds that are going to sprout from the therapy that we provide to our clients. We may not see the progress in the moment, but they might see that progress down the road. So that’s, first of all, don’t know.
Speaker B: The impact that we have.
Speaker A: I think we’re worrying about letting the client down, about them being upset when there are a lot of endings in life that they don’t get someone to talk with, that they don’t have someone thinking about them through the ending of that relationship. So I think it’s important that we consider these wonderful mutual termination sessions that we’ve had and relationships that we’ve had in our work, because it’s our brain’s natural tendency to think about the clinical situations that didn’t work, that didn’t go well. And so bringing these up is really important. So a lot of times when my brain just wanted to tell me that, oh, you failed your private practice, like, you obviously let a lot of people down, and that was more early on in the process, I think more and more, I’m telling myself that I did some really, really good work with a lot of people. I think of a couple of clients in my mind’s eye right now, their trajectory in therapy was just beautiful. And so I think a lot of times I have to go to that place and with those clients that I still hold so near and dear to my heart, because I think we often think of the situations that didn’t go well and that we wished we would have either done better, said different things, but we’re human, so we don’t do those things. So it’s important, you know, I always tell my clients, I used to tell my clients, rather, that the brain is like Teflon. We don’t use Teflon anymore. The brain is like a nonstick pan for positive experiences. They go in, they go out, they don’t stay. So it’s really important that we have to cement those into our memory. We have to bring all those glimmers if we’re thinking of polypycle theory, into our nervous system and remember them. Mutual termination. I like to think of all the ways that I’ve ended that. I really enjoyed working with clients. So I often suggested to my clients, as a way to end therapy, that we would write cards to each other and give them and read them to each other at the last session. And some of my clients were really reluctant. I never made anyone do that, but I suggested it would be a really nice gift for them to take with them, and I would do that for them. Whether or not they would want to do that, that was okay. But I found that reading those cards to each other in session was really, really meaningful to them. And so that was a way and a tangible thing they could take with them. That’s not, like a thing, right?
Speaker C: It’s.
Speaker A: It’s a card, it’s a note, and sometimes it could just be handwritten. It doesn’t really matter. But reading those to each other kind of cemented the progress that they had in the therapy room. And just thinking, for me, like, I didn’t realize this, I was more thinking in terms of the client, but it really know was meaningful to me as well. So in the, in the mind frame of mutual termination, it’s okay that we also get something from that, too, that we’re looking at the progress that we saw in our clients and bringing that into our nervous system. Okay, so we often talk about mutual termination, but not enough about unilateral termination. So let’s dive into that. So, unilateral termination in therapy is the decision to end the therapeutic relationship, and that’s made either by the therapist or the client without a mutual agreement. Okay, so looking at our ethics code, I’m just using APA code because that’s my code. But when I looked at some of the similar ethical codes, there’s a lot of overlap. So I think we can kind of gain there’s going to be some overlap here. So therapists are ethically required to terminate therapy when it’s clear that the client is no longer benefiting from it, or when continuing may even cause harm. I think it’s important to realize when continuing may even cause harm. Oftentimes when clients stop progressing, the therapist is going to feel drained or stuck in the process. And I think if we’re mindful of how we can care for ourselves as therapists, this is one of the biggest things that we can do when we can really look often at our clinical work, and that really does take someone from outside of us. It’s hard for us to have that lens of looking at our clients and seeing them objectively because we’re invested emotionally into their progress. So it’s vital that we’re aiming to do good by preventing harm. Continuing therapy that isn’t helpful leads to burnout for therapists and stagnation for clients. So if we’re just thinking ethically what we need to do with our clients that are feeling stagnated, or we’ve tried a course of therapy that hasn’t been successful with them, then it likely is time for them to move on. However, as many seasoned therapists know, when you’ve been working with someone for years, months, we struggle to really keep that objectivity. We want to hold on to clients often because it’s easier than going through a termination process. I don’t think anyone would say that outright, but looking back on being out of therapy now for a while, especially in burnout, I can definitely see that maybe I was doing some of that and not really looking at my caseload enough. So let’s talk about the types of unilateral therapy termination. First is when a client ghosts a therapist. So they just stopped coming, right? No notice, no communication. I just recently read a Facebook post in one of the therapy groups that I’m in of a therapist who had a long term client, and the client just stopped coming. And that is really hard on us when we’ve invested in that relationship with that client, when we walked through things with them that are very difficult. Literally, there are pieces of us that we’ve given to that client, right? We’ve given our time, we’ve given our energy. Yes, it’s a professional relationship, but it’s very intimate. And the real care that we give the client is real. And so I think we’re always left to wonder when a client ghosts or just leaves, doesn’t really talk to us about why they have left the therapeutic process, why and that impact on us. So I think acknowledging the emotional toll that it takes on therapists when clients ghost, such as feelings of rejection, confusion or concern for the client’s wellbeing. I think the first things a lot of us sit with is the rejection. That’s human. When we’ve invested care into someone, we’ve invested so much into someone that we feel rejected. We feel like, what did I do wrong in this situation? And I think we don’t talk about it enough. We don’t talk about bringing those things to a peer supervision group or a consultation session. I don’t think I talked about it much with anyone else. I mean, I talked with it with my partner, who’s also a psychologist, when that happened, but not really.
Speaker B: And I think it’s those things that stack.
Speaker A: Right. We have all these situations where clients leave and they don’t have tell us what’s happening. They don’t. I think the core thing is that they’re not seeing our humanity, not giving us the benefit of that closure that we need, but we can’t ask for. So some ethical considerations to think about are that we should definitely reach out to the client and clarify the status of a therapeutic relationship and try to offer them a termination session if possible. Sometimes they don’t respond to our attempts. You should document your attempts to contact the client and provide information with alternate service providers if needed. I think that therapists generally, I hear, are doing this, I think discharging the client, letting them know, like, if I haven’t had contact with you in a month, that I need to close out your case in my system, let them know how to contact you. They obviously do know how to contact you. They are just not responding. Okay. The second type of unilateral termination is when a client dies.
Speaker B: So I’ve talked about this quite a.
Speaker A: Bit on the podcast. We talked about this in episode twelve, Secret Grief, attending to the loss of therapists.
Speaker B: So check out that episode if that’s.
Speaker A: Something you struggled with in the past. I talk about my experience of losing two clients during the pandemic. And so if that’s something that’s happened to you, I definitely recommend listening to that one. I talked about a lot of resources, including for clinicians who’ve had clients who’ve died by suicide. I didn’t have a client who died by suicide, but I think that’s another whole layer to a unilateral termination that is wrought with all kinds of emotional layers for clinicians. So certainly check that out. When a client dies, handling the personal and professional grief is important as well as liability. So certainly for a death by suicide, thinking about, you know, calling your malpractice insurance, making sure that you follow any procedures you need to follow through them to make sure that you’re kind of covered. That’s important, but then really attending to your personal and professional grief. So I certainly have talked a lot about that and working with my own therapist, also continuing to seek support through professional networks, supervision, things of that nature. Our ethical code mandates that we protect privacy and confidentiality of our clients, including after their death, unless required otherwise by law. So, you know, I continue to think of those two clients that passed away during COVID They were just wonderful gifts to me. They were, you know, long term clients, wonderful people, and I frequently think of them. And so I. I know that therapists know that we don’t realize the impact our clients have on us and how we hold them outside of the therapy room throughout our lives.
Speaker B: So I know that they.
Speaker A: That I will continue to think of my clients throughout my life. That’s just something that I will do. I will continue to hold them in some ways in my person. So if you need some resources on that, go back to episode twelve, and I talk a good bit about that, but that also takes a toll. I think a big piece of my burnout was the loss of those two clients in the pandemic. They were very dear clients to me, long term clients, and that was part of me feeling like I was able to give. I think it was more compassion fatigue versus classic burnout. Right. I just felt like I could not, I didn’t have anything left to give to my clients because I was in grief. And I really can’t, couldn’t see that until just recently that I’ve been telling myself I was grieving. And it’s really hard to feel like you can give back when you are in full blown grief. So I would just have you consider that. Is your heart really hurting? Do you need a break because of that? And that is completely valid. The last part is, what I want to talk to you about is when the therapist needs to end therapy. We don’t often think about this. So the only times other than closing my practice where I needed to end therapy were in times where I left a job. Right. So ending my internship postdoc, leaving my agency job, and all of those were for kind of socially acceptable, quote unquote, reasons, right. I was moving. I was one of those. I had a baby. All the things that seemed normal and natural that happened for transitions, for people were happening. This is less common, but there’s situations where a therapist may need to end therapy unilaterally. The first of those would be number one, lack of progress. So it becomes clear that a client is no longer benefiting from continued sessions and all appropriate therapeutic avenues have been explored. So we have thrown the therapy sync at whatever the client is bringing at us, right. And they’re just not making progress. Or, you know, maybe there’s something that is blocking them in the way we’re trying to approach the situation. Safety concerns. If a therapist feels threatened by a client or someone connected to. Connected to them, we ethically can terminate service with that client when it’s out of the scope of our competence, when the client’s needs exceed the therapist’s professional expertise or require a specialized form of therapy that the therapist is not trained in to provide. So, you know, this would be for me. I never worked with anyone, really, with eating disorders. I worked with some disordered eating. That would be a reason to refer out. There’s lots of reasons to refer out. I think the stickier places that I got in, in some of my subspecialties. So I specialized in christian psychotherapy for a while in my practice, and then I no longer specialized in christian psychotherapy in my practice. And I had some people that would come to me because they wanted that specific specialty. Yet maybe they had other concerns, such as OCD, such as substance use was actually, I have specialty in as well because I worked in drug court on my internship. But, you know, whatever, you know, OCD and eating disorders kind of like is more highlighted in my mind because that’s not an area of my specialty. So I would get into sticky situations where I’d want to refer out. Yet they wanted a quote unquote Christian therapist. They didn’t want to see a non christian therapist. So I struggled, especially in my state, because we’re a small state in the state of Maine, and growing up in the south, it’s very common to have someone who specializes in christian psychotherapy. I struggled to find referrals locally for folks who wanted that specific specialization, for example. Yet some of my clients who identified in that way, you know, had assumptions about me, had assumptions about what type of christian I was and what my belief structure was when it may not have aligned. And all of my training in spiritual interventions really taught me not to impose any belief on my client. While they may share some kind of faith structure that is similar to mine, it’s not the same. And so I think really my training in spiritual diversity taught me that we just don’t know how someone is going to present or identify. And I think that just comes with diversity in general. Whereas if I would do that with a client and say, oh, well, you’re christian, so you believe x, y and z about Christianity? No, like they’re so much diversity and variety even in that subset. So I think for me also that pressure of clients seeing me in a particular way because I knew that one part of me and then had assumptions about what that meant about me, and that came up so much in the therapy room, especially around 2020 election cycles. I know we’re about to go through another election cycle and clients like to.
Speaker B: Have assumptions about what we believe and.
Speaker A: The values we hold. Right. So I really went off on a tangent there. Okay. And another reason, another reason why we may not want, we may need to end therapy is due to our own mental health or ability to provide care to the client. So if our own mental health or ability to provide competent care is compromised, maybe that’s with some countertransference issues that are happening with that particular client, then we should refer out. However, I think a lot of times in solo practice we are silos and we aren’t regularly looking at our caseload to know that we should refer, that it’s not something that we can do. So I think, again, this is that kind of big quote, unquote. I don’t like to use the word self care because it’s so weighted now, but this is a way we can care for ourselves by trying to see that this relationship and therapy is toxic for us and we can no longer provide confident care to this individual. So the general ethical and legal responsibilities is that we’re providing sufficient notice. How long? I think a lot of therapists ask me this a lot. How long should I take to terminate with a client? And I think this gives us a little guidance. So specific issues that should be addressed and desirable length of pre determination counseling will depend on the number of factors such as overall therapy duration, clinical considerations, and treatment approach. For example, a patient who’s been in long term psychodynamic psychotherapy for chronic depression will have a longer and more involved termination phase than a patient who has been in short term treatment to cope with anxiety symptoms, for example. So I think the length of treatment, perhaps the functioning of our clients as well, will determine the type of the length of termination that we might want to have with the client. And also there’s some other plan terminations we may not consider that can happen for a number of reasons. I think when a therapist is retiring or taking a new job, or when someone’s benefits run out, for example, or they can no longer afford therapy, we will also need to make plans to terminate. I think one of the reasons we get stuck as therapists is that we worry about like we worry about clinical abandonment. So, for example, the New York rules for boards of regents state unprofessional conduct for psychologists and other any other listed health professionals that shall include abandoning or neglecting a patient or client under and in need of immediate professional care without making reasonable arrangements for continuation of care or abandoning a professional employment without reasonable notice. Furthermore. So abandonment represents a failure for the psychologist to take the clinical indicated ethical appropriate steps to terminate professional relationships. Although psychologists may become concerned when they need to unilaterally terminate therapy, legal and our state board actions against psychologists for abandonment appear to be rare. So I just want to cement that point. So even though we fear that we will abandon our clients, it really is rare as far as board complaints. Okay, so the real question is really how to handle transitions in a best way that promotes patients welfare, whether the transition is complicated or nothing.
Speaker B: So I just want to recap this episode for you. I’m doing this at a different time. I think I was on the wrong mic setting. So I’m sorry for the recording quality on that recording, but I’m not going.
Speaker A: To re record that.
Speaker B: So anyways, so just to recap what we were talking about, so why terminations can be hard for us is, I think, conceptualized Bess by Pauline boss’s ambiguous loss model. So she didn’t specifically talk about the losses of therapists per se, but she talks about this concept of ambiguous loss, and those are losses that really aren’t socially scripted. We don’t have a way to attend to the lost, attend to the grief that we have. And in her book Lost Trauma and resilience on therapeutic work with ambiguous loss, which I have referenced, I first got this book, I think, when I was writing my dissertation. So what is this book even from? Good Lord, 2006. Yeah, so I’ve had this book forever, nearly 20 years, and I continue to reference it because it just speaks a lot to losses that we don’t have, really think our losses, right. So ambiguous loss is inherently traumatic, she says, because it’s the inability to resolve the situation that causes pain, confusion, shock, distress, and often immobilization. Without closure, the trauma of this unique kind of loss becomes chronic. To understand the trauma of ambiguous loss, it’s helpful to recognize the distress of a more ordinary loss. So when she talks about that, as a society, especially in us society, we aren’t great about talking about loss in general. And let’s forget the losses that people aren’t bringing you a lasagna for. When I worked with folks with brain injury, I talked a lot about ambiguous loss because their losses are not visible. So let’s say they were in a car accident, and immediately after the car accident, they were, quote, unquote, okay. There were no visible scars or signs that they were not okay. Similarly, for like, a stroke or a brain bleed or other type of injury to the brain, and they might have symptoms that lasted years from an invisible injury. So we talked a lot about how, you know, people aren’t continuing to bring you a lasagna for two years. And I think this concept of loss and also disenfranchised grief, for me, I think these losses stack. So it’s not only for me, the loss of those two clients, which were profound when I lost them, it was also these other mini losses.
Speaker A: Right?
Speaker B: When clients ghost USDA, and we’re left to wonder and think what we did wrong, why they no longer reach out. We might even see these people. This might have happened in my real life, where I see people in my community who ghosted me as a client, and we can’t stop them and say, hey, so what happened? We’re just left to wonder. I think of kind of that parallel sometimes when I’ve worked with clients who’ve had dating distress, when they’ve had a sense of preoccupation with a loved one or a romantic partner. Modern dating apps are just awful and ripe for feelings of rejection, feelings of shame, feelings of loss, because you invest so much time into people and then they can find a new date very quickly. So anyway, there’s all these parallels with modern life right now that I think it makes people feel more replaceable and for the therapist. So if we’re just talking about us as the clinician, ghosting, these other types of unilateral terminations can really start to. Stack goes on to say, whereas finding closure is difficult with ordinary losses, it is impossible with ambiguous loss, because there’s no official recognition of there even being a real loss. Freud labeled long term preoccupation with the lost person as complicated grief or melancholia. In her model, she talks about two types of losses. So they are the physical absence with psychological presence and the physical presence with psychological absence. And that is one that I talk frequently for folks with a brain injury. So they are physically present, their loved ones can physically see them, however, theyre so psychologically different. And she also founded this model. She talks a lot in the book about 911 survivors and just a quick reflection. Over the summer, I went to the 911 museum for the first time. Oh, my goodness. I think just the wave also of collective trauma hit me when I went there. And the memories of the whole event and just seeing all the people who were at the museum with me, feeling those same emotions of the things that we have really not acknowledged, I think, as a collective people that we’re going through now with regard to terrorism, with regard to these horrific events that have happened in our communities, I’m also reminded. I’m thinking of a recent mass shooting that happened in my state of Maine. It happened just 30 minutes from me. I did an episode on it, which shortly after, and I didn’t release it. And part of me felt like it was too raw to do so. So perhaps I will talk a little bit more about that on the podcast of just how we’re responding to mass violence or mass shootings. So in her model, she talks a little bit about catastrophic and unexpected situations where there might be ambiguous loss, like 911 survivors, for example, in situations of war with missing soldiers, natural disasters with missing persons, for example. And then the more common situations. And so those would be adoption, divorce, preoccupation with work, for example, young adults leaving home. And I think thinking of you for this therapist, for clients that leave us, and that’s with mutual termination as well as unilateral termination. You know, there were some terminations where my clients were ready to go and termination was happening, but I wasn’t quite ready. And it was hard to think of my role without seeing them every week. That’s getting me emotional. Just thinking about it. Bringing, weaving in ambiguous loss at the end of this discussion of terminations would be helpful. But I just want you to think through how you likely need to attend to the loss and the grief that might be associated with the terminations that come up throughout your career. I think one thing that I did, certainly, was process that in therapy. A lot of my grief that I processed continued to do because grief continues.
Speaker A: To stay with us.
Speaker B: That person continues to stay with us. There’s a park that’s near me that one of my clients talked about and loved. And so every time I go there, I think of them. So I think of having these grief rituals and ways that we can attend to our grief, because if we’re not speaking it to someone, we’re holding it in our bodies, we’re holding it in our minds. So I would just have you think through that about how these losses have impacted you and what you can do. So a number of things. I talked often about grief and the work that I did, whether it be a traumatic loss for a client or just attending to their, their own grief of the loss of self. So I talked to a lot of my folks about grief rituals, something that has a beginning, middle, and end, like lighting a candle, attending to your grief, blowing the candle out, listening to a song, and allowing yourself to feel that feeling for the length of the song. Then when the song ends, trying to close your attending to your grief. I think a lot of times we’re scared of opening it up because there’s so much there, right. But I think having something has that beginning, middle, and end with attending to the loss of one of my clients. I would do a walk at that park that’s nearby me. So I would start the walk, think of that client, and then end the walk again. Some bilateral stimulation is happening with walking moving side to side. I’m an EMDR therapist by training, so I think through these things a lot. So I’d have you think through the strategies you can do to attend to some of the losses that happen with termination, and especially thinking about your own mental health, mental health support that you might need through this, especially if you’ve had a loss of a client. Okay. I hope this has been helpful. If you need support in managing termination loss, there’s a lot of resources. I’m going to include those for clinicians who have had a death of a client. And there’s different groups online that help support clinicians. So just reach out, I think, and build some community there. Also, thinking about personal therapy is always a recommendation that I tell you. And also thinking about for therapists, when I work with therapists, this is one of the big things we work on, because when you close the practice, thinking about all of those terminations is overwhelming. Because for many of you who have been in private practice or been at your job for a long time, the thought of ending therapy with all of those people is really overwhelming. I think therapists are scared of upsetting them, of doing harm, of them getting angry, of all of the above. And we don’t really talk about that a lot in our training. So that’s a big part of what I support therapists with when they’re ready to close, helping them walk through that termination part of it, the endings, and some of them are beautiful and wonderful, and I would say that is the majority of them, from my experience. However, there are some that are really tricky. So if you need support, reach out to me. I’d love to talk with you more about how I can support you, so I’ll put a link in the show notes with just a way to connect on a console call. And if we work together, that’s great. If not, I really treat it as like, hey, we’re just talking, so love to talk with you more. Have a good one.
Speaker C: Thank you for listening to the joy after Burnout podcast. Be the first to hear new episodes by following the podcast in your podcast player. This is an informational podcast only. Any information expressed by the host or guest is not a substitute for legal, medical, or financial advice.
