Terminations: The Importance of a Good Ending for Therapy

The nature of counseling is time-limited.

In an ideal world, the counselor and client would have a planned termination session and multiple previous discussions to process the ending of the therapeutic process and relationship. 

Sometimes this is not the case. Therapy stops for a variety of reasons.

There will be times when a termination is perceived as a positive growth experience and others may not end as smoothly. 

To increase the odds of a good ending, termination must be discussed throughout the counseling process, starting at the first session.

Treatment Plans

At the first session, you and the client formulate goals for treatment. During this discussion, both of you form what needs to happen to consider a goal to be complete. This means each goal will have a clear and specific behavioral target. 

Whenever a goal is achieved, this benchmark is a time to discuss the ongoing effectiveness of therapy. For some clients, this is an indication for termination of services. For other clients, with deeper concerns or persistent symptoms, additional goals may be added to continue their therapeutic treatment.

Assessing Readiness for Ending Therapy

Some clients may look forward to ending therapy. These clients will ask how many sessions they have left or when they will know they are ready to complete therapy. Other clients may not have the words to express a readiness, but will show it through their behaviors, such as canceling or not showing up for appointments. 

Lastly, other clients who are resistant to leaving therapy, avoiding the discussion altogether or denying their progress. These clients may do better with a reduction of services, such as meeting bi-weekly or monthly, rather than weekly. After a period of time, again revisit the discussion of termination of treatment and goals. 

There will be some clients who do well to continue long-term counseling treatment. At a monthly interval of sessions, symptoms can be noted, along with medication compliance.

The counselor’s judgment is important in assessing client readiness. It is the counselor’s job to note a significant and lasting reduction in symptoms or an increase in functioning. If necessary, they must be prepared to advise that these symptoms may be better managed through support groups or other services.

The Difficulty of Saying Goodbye

Whether the termination of services is planned or not, it is difficult to say goodbye. As a society, we often avoid endings due to the painful feelings that arise in the letting go process. For some clients, this may be their first experience with having a healthy end to a relationship. When the therapeutic process has been successful, it is not unusual for counselors to experience a mix of pride and sadness that an end has come to your time together.  

Termination is a loss and can bring up feelings of grief, loss, or abandonment issues. Allow clients to express all of their feelings, validate this experience and remind them of their coping skills. Everything they have learned up until this point can help them navigate this process. 

Sahin & Barber (2017) state: 

Psychodynamic theorists view termination as a loss for the patient and the therapist. Termination is often considered a crisis that triggers past experiences of object loss, be it by death, divorce, separation, or abandonment. Termination as loss emphasizes experiences of sadness, depression, and grief. There are also positive aspects of this experience, as it provides an opportunity for transformation.

Tips for The Last Therapy Session

It is the counselor’s role to steer the conversation to the achievements clients have made and aftercare plans. For clients who have addictions, recommending they continue groups such as Alcoholics Anonymous or Narcotics Anonymous would be appropriate. 

Other clients may want to attend mental health support groups. All clients who are prescribed medications are recommended to continue medication management services. You can also discuss with the client what signs would indicate the client needs more help or a possible return to treatment.

The Giving of Gifts

A part of the termination process may involve exchanging a card or a small inexpensive gift. Some counselors view accepting a gift from a client as an ethical violation. As a counselor, you need to assess the ethical implications and decide what is in your client’s best interest.

Some clients and counselors exchange small gifts or tokens to represent the work they have done together. This could be in the form of a greeting card, poem, or small inexpensive keepsake. It is best to present gifts during the beginning or middle of the session to have adequate time for discussion. You and the client can explore the meaning of the gift and say your goodbyes.

According to Brown & Trangsrud (2008), who examined the ethical decision-making of 40 licensed psychologists to accept or decline gifts from clients: 

Results indicated that psychologists were more likely to accept gifts from clients when the gift was inexpensive, informed by cultural context, and presented with gratitude for good work at the end of psychotherapy treatment. Psychologists were more likely to decline gifts that were expensive, were presented during treatment rather than at the end of treatment, and had sentimental or coercive value. Two psychologists indicated they would not accept client gifts because they perceived gift acceptance to be a violation of their code of ethics. 

In the American Counseling Association (2014), code of ethics, A.10. Fees and Business Practices, it details A.10.f. Receiving Gifts:

Counselors understand the challenges of accepting gifts from clients and recognize that in some cultures, small gifts are a token of respect and gratitude. When determining whether to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, the client’s motivation for giving the gift, and the counselor’s motivation for wanting to accept or decline the gift.

When Ending Therapy Doesn’t Go as Planned

Goodbyes are not easy. At times, therapy ends because the client avoids termination and the feelings that come with it. For some clients, their endings may be limited by insurance constraints, while others may prematurely end therapy for various reasons unknown to the counselor. Some of these may be financial, transportation issues, a rupture in the therapeutic relationship, or completion of therapeutic goals.

Clients could become non-compliant due to the nature of their mental illness. They may not be taking their medications, engaging actively in addictive behaviors, or experiencing a relapse in their recovery. For these reasons, it is wise to reach out to your client by phone. Some clients feel safer ending therapy by phone rather than in person. 

If you cannot reach the client in person or by phone, a letter may be sent to the client to indicate the end of services. Once again, you can invite the client to reach out by phone, if they desire.

Some clients drop out of therapy and the counselor does not know why. When a client does not show up for scheduled appointments and is not answering phone messages, it is good practice for the counselor to reach out with a final letter. In this letter, the counselor can state when the last appointment the client was seen for therapy and any missed appointment dates. Invite the client to reach out by phone to reschedule. 

It is also important to give a deadline with a date for when the case will be closed if you do not hear from the client. You can always welcome your client back in the future if they reach out. For safety considerations, cases should not remain open-ended without any client contact.  

There are times it is the counselor who ends treatment. Counselors ethically end treatment when they lack the competence or skills to work with an individual, when a client is no longer benefiting from treatment, when a counselor is in harm by the client, or when counseling fees have not been paid. 

Sometimes, relationship differences can be too great to build a rapport and working alliance. Another instance of termination can occur when long-term clients have not made any progress therapeutically or their symptoms have worsened. Counselors also end treatment when they leave their profession or job. In all instances, counselors must supply clients with appropriate referrals.

Some terminations are due to a severe illness or death of the client or of the counselor. If your client has died, seek supervision from your supervisor and peers. Due to confidentiality, you cannot discuss these feelings or your experiences of grieving your client with your family or friends. You may need your own therapy to process such a loss. For more information on this topic, you might like to read the article, How to Grieve a Client’s Death Ethically. 

With each ending, the counselor can learn something about themselves, their clients, and their lives. Relationships within the therapy room and outside are often messy. As long as the counselor makes attempts to reach out, reengage, or reassign a client, proper termination will be considered complete. 

As a final note, these are the ethical codes from the American Counseling Association (2014) in regards to A.11. Termination and Referral:

A.11.a. Competence Within Termination and Referral

If counselors lack the competence to be of professional assistance to clients, they avoid entering or continuing counseling relationships. Counselors are knowledgeable about culturally and clinically appropriate referral resources and suggest these alternatives. If clients decline the suggested referrals, counselors discontinue the relationship.

A.11.b. Values Within Termination and Referral

Counselors refrain from referring prospective and current clients based solely on the counselor’s personally held values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.

A.11.c. Appropriate Termination

Counselors terminate a counseling relationship when it becomes reasonably apparent that the client no longer needs assistance, is not likely to benefit, or is being harmed by continued counseling. Counselors may terminate counseling when in jeopardy of harm by the client or by another person with whom the client has a relationship, or when clients do not pay fees as agreed upon. Counselors provide pre-termination counseling and recommend other service providers when necessary.

A.11.d. Appropriate Transfer of Services

When counselors transfer or refer clients to other practitioners, they ensure that appropriate clinical and administrative processes are completed and open communication is maintained with both clients and practitioners.

Lisa Hutchison, LMHC

Lisa Hutchison, LMHC

Writer & Contributing Expert

Lisa Hutchison, LMHC, is a licensed mental health counselor for the Commonwealth of Massachusetts. She works for professionals who want to treat and prevent compassion fatigue. With over 18 years of psychotherapy experience, she helps her clients assert themselves, set boundaries, and increase their coping skills. Her specialty is decreasing stress, anxiety, and depression while increasing realistic methods of self-care for those who help others. Ms. Hutchison’s psychological advice has been featured in Reader’s Digest and the Huffington Post. Her articles have been published in numerous magazines, including Grief Digest and Today’s Caregiver.

Lisa is the bestselling author of I Fill My Cup: A Journal for Compassionate Helpers and a faculty member writer for NetCE. Her latest continuing education unit publication is “Setting Ethical Limits for Caring and Competent Professionals.” She has taught creative writing in colleges and presented on boundaries for the compassionate helper; the use of expressive art to heal grief, anxiety, and depression; inspirational and motivational topics; and creative writing techniques.