I've seen references to this article in many places in the last week or so:
60 Percent Of Psychotherapy Clients Felt Therapy Didn't End On Time
Sixty percent of private practice dynamically oriented psychotherapy clients felt that their therapy either lasted too long or ended too soon, according to recent research conducted by Prof. David Roe, Head of the Department of Community Mental Health, Faculty of Social Welfare and Health Sciences at the University of Haifa. "While there is widespread agreement that an ideal termination of psychotherapy occurs naturally, with an agreement of the timing between therapist and client, our research reveals that more often than not -- this does not happen" said Prof. Roe...
The results of the study show that only 40% of the clients felt that the therapy ended at the appropriate time, 37% felt that it ended earlier than it should have and 23% felt that the therapy went on for too long.
The sample size, 82 former patients, is adequate but not huge, so I would be reluctant to draw sweeping conclusions from it. In addition, the study was done in Israel, where it may well be that psychodynamic therapy is more widely used than it is now in the US and where external constraints, like managed care, are less a factor. In any case, it is an interesting finding.
I don't have in mind when I start work with someone how long we will work together. There are so many factors that enter in to that equation that it seems pretty impossible to know at the outset how long the journey will be. When I start with someone new, I always mention that this work is a relationship and that it is helpful if and when they feel like stopping or feel anything they are uncomfortable about to talk about it. And when I have the opportunity to, I suggest when someone starts to talk about leaving, that we talk about it together, if only for purposes of saying good bye.
Some people come a few times, get what they want or decide that the way I work is not for them, and so they leave early, sometimes before we really have much chance to begin. I invite them to discuss it with me when this happens and sometimes they do. But this kind of termination is more likely to come in a letter or a phone call than face to face. With these patients, there is often a feeling of unfinished business for me, but I do not pursue them and always respond that my door is open should they decide to return. Which in many cases they do.
There is also a significant number of patients who do their work in episodes. They will come for a while, stop for a while and then return again, sometimes repeating the cycle several times. I often have people contacting me again after several years saying they want to come back to do some more work. This is often very rich and engaging work.
Money is not a reason for ending, at least in my experience, because the fee is always negotiable. I have worked with people with whom we have adjusted the fee downward, even radically so in periods of financial difficulty. But if the patient really wants to do the work with me, we can find a way. I am able to do this, though, because I do not accept third party payment and so can negotiate the fee with each person separately.
I've thought often about the fact that there are whole books written on the first session in psychotherapy and very little on the last session. We are more comfortable writing about and talking about beginnings than we are about endings. And when the ending is in the control of the therapist and the patient, rather than an external entity, it can be hard to know when it is time to stop. Because it is a relationship. And good relationships are hard to leave. So we do our best to find our way through the issues that ending raises for us, both patients and therapists.
When someone starts talking with me about ending, I see it as a process rather than an event and suggest that we take at least a few sessions to take a look at where we are and where we have been. Sometimes both of us know that the work is not really ready to end, but that some element of discomfort has arisen which makes leaving easier to contemplate than working it through. I raise that as a question and if I have some idea of what might be going on, I gently try to bring that into our view. Sometimes, more often than not really when there is something hidden that needs discussion, that is enough to get the work flowing again and we go on. Sometimes we discover that even though the work is not completed, it is time for a break and we do a review and then say goodbye -- for now. And sometimes, because we have really done our work together, it is simply time to end because we have reached as far as we need to. And we reminisce a bit, laugh, and say goodbye.
I know when someone leaves, I may never hear from or see them again. That is part of this work. I carry them inside me, I remember them all. Sometimes I get an email or a card or a letter form someone I saw long ago. I am always delighted at this opportunity to learn how they are doing. But most people leave and go on about their lives and I neither ear from nor see them again.
It's a bit of an odd business, psychotherapy is.
