For many doctoral-level training programs, psychology trainees are limited to one year or less of therapeutic work with clients per clinical practicum rotation. This can be difficult for both students and clients alike, as transferring clients is not always clinically indicated and can seem abrupt and unnatural. It is estimated that 80% of student-clinicians must forcibly terminate with their patients, with more than 50% of these trainees reporting being inadequately prepared to terminate therapy (Zuckerman & Mitchell, 2004). Likewise, the duration of clinical rotations often requires clients to cope with the loss of a therapist each year. Due to many training sites using a sliding pay scale, individuals of lower socioeconomic status are disproportionately affected by the one-year training model (Aubry, Hunsley, Josephson, & Vito, 2000; Thompson, Graham, Brockberg, Chin, & Jones, 2017). Consequently, clients who fall within a lower socioeconomic status often become entrenched in the cycle of building intimacy and trust with a therapist and then “losing them” at the end of the training year.
As practicing professionals, it is important for psychology trainees to take socioeconomic status and premature termination considerations seriously when discussing and planning initiating therapy under a one-year therapy training model. As issues of attachment are at the forefront for therapists working with clients who have experienced complex trauma (Gold, 2000), discussing termination early and often is advised in our trauma clinic. Still, given the nuances within the complex trauma survivor population, planning and predicting a client’s response to termination can be difficult. Clients may experience unexpected feelings of anger, anxiety, abandonment, shame and a sense of loss when approaching termination (Penn, 1990). Additionally, many clinics have a brief gap between training year rotations, resulting in clients having a therapy hiatus prior to receiving their new therapist assignment (Kirchen, 2015). This gap in provider care can cause anxiety for both the clients and the therapists. Below we discuss potential difficulties that may emerge when terminating with individuals with a history of complex trauma.
Clients with Attachment Concerns
When working with clients with attachment-related concerns, there is no “foolproof plan” for an effective termination. Student therapists may ask themselves, “Should I distance myself from my client prior to the termination date?” or, “Am I harming a client with attachment difficulties by allowing the therapeutic relationship to grow, knowing we only have a year together?” Other students have reported fearing that clients with a borderline personality disorder will feel “seduced and abandoned” as a byproduct of the one-year training model (Gould, 1978). From my experience, the establishment of a trusting relationship with a predetermined end is not harmful for our clients.
If we view the therapeutic relationship as a corrective experience, we can frame termination to our clients as a healthy way to mutually end a relationship. That being said, there are few other life circumstances in which positive relationships are mutually, permanently terminated, such as the death of a loved one. Because forced termination can mimic death, feelings similar to death anxiety (e.g., fear of loss and increased longing for intimacy and emotional security) may develop (Firestone, 1993). To prepare properly for the “death” of the therapy relationship, termination should resemble an in-vivo funeral, extending the duration of the therapeutic relationship. Some dynamically oriented therapists suggest treating termination like “death” by allowing the therapist and client to mourn together while the therapy relationship is still “alive” (Vance, 2013), leaving nothing kind unsaid. Termination is an opportunity to demonstrate to our clients that a healthy relationship can be ended while maintaining respect for the relationship and the individuals involved. As a junior therapist, I frequently found myself thinking “Does my client hold anger towards me regarding termination?” It is important to trust that our clients with attachment concerns internalize the good object within us and do not view termination as betrayal (Seligson, 1977). One of my clients stated, “I cried for three days. I felt the panic that I initially felt prior to [starting] treatment and was afraid it had permanently returned. And then, after a few days, I noticed that I actually felt fine. I felt like I was going to be okay, and it was honestly surprising. I felt like I was going to miss you, but I was going to be fine without you.”
Premature Termination from Therapy
It is normal for clients in long-term treatment at student clinics to feel frustrated with losing their therapist at the end of every academic year. One client stated she would prefer to pay out-of-pocket to keep her therapist longer than a year, whereas another proposed he would like to take a “vacation” from therapy until he relapsed into self-harm behaviors. How can we assure our clients that they will establish good rapport with their new therapist? In all honesty, we cannot. However, we can provide them with the tools to assert their needs and desires.
Toward the end of my trauma-focused practicum rotation, I asked my clients what they would do if they did not like their new therapist. All but one responded they would either abruptly discontinue therapy or contact the clinical director. No client considered telling the therapist what they did not like or would want done differently. In fact, a 2015 aggregate study reported that 22%-46.2% of the time, clients terminate early due to being dissatisfied with the therapist or treatment (Swift & Greenberg, 2015). Termination is an opportunity to initiate a dialogue about the benefits of being assertive with others and the pitfalls of chronic passivity and social avoidance. To enhance client’s confidence in asserting their needs and desires in the context of therapy, it may be helpful to provide opportunities for your client to be direct with you during treatment. For example, you might ask, “We’ve been meeting together for several months. I am certain to have made many mistakes. How could I have been more effective?” This question allows your client to practice assertiveness skills with you to increase their interpersonal effectiveness skills moving forward, including with their next therapist, if necessary. Moreover, there is an undeniable power dynamic between client and therapist, which can make abruptly leaving therapy or contacting the clinical director the easier option, rather than making a request of the new student therapist. Therefore, it often falls on the transferring therapist to increase the client’s sense of competence in asserting their needs.
Termination With Clients Who Are New to Therapy
In the “real world” of therapy, termination is not something that a client typically thinks about when they sit down to meet their therapist for the first time. However, in the world of psychology trainees and practicum rotations, termination is at the forefront for trainees. It has been my experience as a psychology trainee that clients who are new to a training clinic and therapy in general often feel surprised when they are informed that the therapeutic relationship will last one year. I have received many comments and questions (e.g., “is it even worth it?”, “Why would I want to get close to you only to have you leave in a few months?”). In full transparency, at times, I have asked myself a related question: “Why is it worth it?” And although my answer to this question often changes, I have found myself coming back to the same thought “Why not take a chance and see if something valuable can come from this experience?”
In the case of Donald*, he had never been in therapy prior to our meeting and was hesitant to begin treatment given the shortened time frame. Despite frequently reminding Donald of our impending termination and explaining the concept of termination, it appeared as though he did not realize how he would be emotionally affected by the experience. As we entered the termination phase of treatment, it became clear how difficult ending our therapeutic relationship would be for us both, and I felt it was important for him to hear that. For Donald, expressing his emotions proved to be challenging and I observed him often steer the focus of our sessions away from discussions of termination. This behavior is not uncommon when discussing termination with individuals with a history of complex trauma because feelings of abandonment, grief, fear and loss of security may be provoked (Courtois, 2004). As a result, I took this opportunity to model for Donald the way in which relationships can be ended effectively (Joyce, Piper, Ogrodniczuk, and Klein, 2007; Vasquez, Bingham, & Barnett, 2008). Over the course of the final phase of treatment, I expressed to Donald my care and admiration for him, what I had learned during our work together, as well as gratitude for his commitment to living a life that he found fulfilling. I reminisced on the lighter moments of therapy and of the jokes we shared, as well as some of the deeper more honest and raw discussions we had. As I shared with Donald, he too began to slowly reflect upon our therapeutic relationship and on treatment in general. He described feelings of safety and security to explore his past and discover who he is presently, and how he learned without explicitly being taught, that he is worthy of respect.
When Termination Represents More Than Just an End of a Relationship
Whereas termination with novice clients may be more of a teaching and modeling experience, termination due to the end of a training year may highlight progress that has not been made and remaining treatment goals. For many clients who have gone through the revolving door of student therapists when engaging in long-term therapy at a psychology training site, they have developed expectations for the end of the training year. Often their engagement in therapy is maintained by the possibilities of a new relationship with a new therapist, learning new skills and coping strategies, and potentially processing their past and current experiences differently. However, I was quickly reminded that this is not always the case. In fact, one individual whom I had been seeing weekly opened my eyes to the complexities of termination in ways I had not previously learned or experienced. For Mary* termination represented the years of therapy she had received and what she identified as “a lack of progress” and notable growth during that time. Mary disclosed, it was not simply our relationship coming to an end that was difficult to acknowledge, rather it was the fact that she continues to view herself as unchanged and as experiencing the same problems that brought her to therapy years prior. As a psychology trainee, this was difficult to hear, as it threatened my confidence as a therapist and caused me to question the work accomplished and the collaborative relationship we built. I even started to question Mary’s growth in our year together. After extensive supervision and self-reflection, I understood that in Mary’s eyes, growth was measured by vast changes and extreme shifts. It was important to her that she no longer feel consumed by the pain of her past. However, she was not yet ready or able to consistently employ new, adaptive skills, contributing to her feelings that she had not improved. And while our treatment together did not end in epiphanies or miracle moments, I learned from Mary that termination can represent so much more than just an end.
Tips for Termination
As a result of some of the abovementioned difficulties when discussing and initiating termination with individuals with a history of complex trauma, experts in the field have identified several important considerations. The following ideas may be helpful for students in training clinics who are encountering forced termination for the first time:
- It is common for clients to feel anger, anxiety, a sense of mourning, feelings of abandonment, or shame upon forced termination (Penn, 1990).
- Discuss termination in the beginning of treatment, in anticipation of termination, and when termination occurs (Barnett & Coffman, 2015; American Psychological Association, 2002).
- Frame the therapeutic relationship as a corrective and modelling experience for clients to apply outside of the therapy room (Joyce, et al., 2007; Vasquez, et al., 2008).
- Termination does not mean the relationship was lacking. As psychology trainees we can show our clients how to end relationships while maintaining love, care and respect for the individual (Vasquez, et al., 2008).
- Understand that forming a trusting relationship with a predetermined ending is challenging for individuals, specifically those with complex trauma and attachment concerns (Kirchen, 2015).
- Not all clients know and understand how to “terminate.” It is up to the therapist to model for the client how to effectively end the therapeutic relationship (Vasquez, et al., 2008).
- Review progress and growth
- Comment on the therapeutic alliance established
- Discuss how the client can take with them what they have learned in treatment
- Discuss areas of growth and focus for future treatment
- Keep in mind that termination can represent many different things to clients. Be curious and inquire as to how they are experiencing the relationship coming to an end (Penn, 1990).
- Termination does not only affect the client; it can also affect the therapist (Vance, 2014), so seeking supervision is advised. Be kind to yourself!
*denotes that the name of the client has been changed to maintain confidentiality.
About the Authors
Olivia Carelli, MS, is currently a student at Nova Southeastern University completing her PsyD in clinical psychology. Her current research interests involve examining perceptual and sensory deficits and differences experienced by individuals with depersonalization/derealization disorder. She is currently in her third practicum rotation at Florida Atlantic University’s Counseling and Psychological Services Center. Ms. Carelli is also the database coordinator for the Sidran Institute for Traumatic Stress Education and Advocacy, where she oversees the referral of individuals across the U.S. to trauma-informed mental health professionals.
Tiana Skawinski, LMSW, MS, is a former social worker and is currently a student at Nova Southeastern University completing her PsyD in clinical psychology. Her research interests include complex trauma, specifically examining the potential effects of child sexual abuse on identity, sexuality, sexual health and functioning in women. She is currently completing an elective practicum rotation and is the program coordinator for the Trauma Resolution and Integration Program (TRIP) at Nova Southeastern University’s Psychological Services Center. Tiana is passionate about trauma-informed care and working with survivors of trauma.
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