Jeff Levy, LCSW
Mental Health, Relationships, Trauma, Identity
Jeff Levy, LCSW
(originally posted on Branching Out: The Live Oak Blog, July 2014)
I recently received an email from a client thanking me for the work we have done together and telling me how much he had grown. In that same email, he shared he had decided to end therapy, at least for now. This isn’t the first time I’ve received such an email, though sometimes it’s in the form of a voicemail. I’ve had people say, in a session, often with few minutes remaining, that they’ve decided that day will be their last.
I have also had clients who want to take a break from therapy. Sometimes the break comes at the time of consolidating great gains and there is a desire to further that consolidation “in real life” before continuing in therapy. Sometimes the break is about logistical things that get in the way like a change in job, change in work schedule, or birth of a baby. But there are also those breaks that have no explicit reason attached to them. I remember the last session as being unremarkable or consistent with the work we’ve been doing, and suddenly—at least to me—there is a request for a break.
Usually, I will try to invite further conversation. I’ll offer a final session to close our work together and/or to predict anything that might create a need for therapy in the future. Sometimes I’ll explore goodness of fit, especially if I’ve been seeing someone for just a short time. While some people take advantage of a final session or an opportunity to discuss goodness of fit, there are others who don’t respond to my email, my voicemail, or even a follow-up letter inviting a final conversation.
Despite doing this work for over 30 years, whenever I receive such an email or voicemail desiring a sudden end or sudden break, I have a sinking feeling; almost a punch in the gut. For each of those kinds of messages I receive, I can logically count 30-40 other messages from on-going clients telling me how much their work with me is helping. Or cards I receive from past clients around the holidays that remind me of the work they did with me and how it is still helping. After all these years and all these people who tell me I have helped, the mysterious and unresolved endings still throw me. What did I miss?
Taking a Break in the Middle
Anthony had begun therapy with me at the urging of his wife. She had discovered a place in their bedroom closet where he had hidden a box of pornography. She was surprised by the discovery, but directly and calmly asked Anthony about it when he got home from work. Anthony apologized for hiding the pornography and then, like a floodgate opening, he confessed to anonymous sexual encounters with both men and women, spending hours on internet pornography sites while he was at work. His use of pornography was escalating and even he was afraid of the direction it was taking.
When we began therapy, Anthony talked about all the shame he felt around his pornography use and about his wife finding out. It was clearly hard for him to talk about, yet he seemed earnest in his desire to understand the reasons behind this; to find ways to stop, and to save his marriage. He committed to weekly therapy and over the next few months, he gained rapid insight about the progression of his use of pornography, how and when it transitioned to anonymous sex, and when he began using pornography at work. He began to attend Sexual Compulsives Anonymous (SCA) meetings, and engaged a sponsor to support his recovery.
Around the same time, he began to share his dissatisfaction in his relationship with his wife and his declining sexual attraction. “She’s a beautiful woman,” he insisted. “She deserves someone who can meet her needs. I’m just not sure I can do that.” And while he was exploring his relationship with his wife and going to SCA meetings, he had significantly decreased his use of pornography and anonymous sexual encounters. He came to a place where he was ready to engage in couples work.
I connected the couple with a female colleague who had extensive experience with couples, specifically around infidelity and compulsive sexual behavior. Anthony continued to see me in individual therapy and his wife was seeing someone different. Couples therapy seemed to be going well, and Anthony was investing even more in his individual work with me, linking a history of childhood sexual abuse to some of his current sexual behavior. He slowly identified himself as bisexual—something he had disclosed to no one else. He seemed to be making rapid gains with me as well as gains in couples therapy. And then he told me he wanted to stop individual therapy.
I invited Anthony to share more with me about his decision to end, especially when it seemed he was making progress in couples work and was sharing more with me. “I just think I need a break after doing all of this work. I’m exhausted,” was his reply. And when I asked a few more questions, he reluctantly shared “And if I go back to individual therapy, I think I want to see the woman we’ve been seeing for couples therapy.” “Ouch!” I remember thinking. What was I missing or what was she doing that I wasn’t?
I had a hypothesis that I shared with Anthony during our next session. “I wonder if as you have shared more with me and been more vulnerable, it feels safer to end and see someone else? Is there any chance that when you’ve felt more vulnerable with your wife you’ve also felt scared and that’s when you’ve turned to pornography or anonymous sex?” He was silent for a good amount of time. “I suppose that’s possible,” he acknowledged. “I’ll think about that a little more after we’ve ended.”
Taking a Break Before Starting
Then, there are those very short-term cases that seem like they will be longer term. Tasha called in a crisis wanting to see someone as soon as possible. Coincidentally, I happened to have one free hour the day she called and she quickly accepted the appointment time, grateful that she could be seen so quickly.
A firefighter and paramedic, Tasha had ended a two year relationship with her girlfriend after months of what she described as extreme verbal abuse. While she knew she needed to maintain her boundary of not having contact, her ex-girlfriend called or texted her several times per day, and sent daily email as well. Most recently, she contacted Tasha because her oldest teenage daughter had gotten into trouble at school and was at risk of being expelled. While they were together, Tasha had developed a close relationship with the young woman, and her ex was hoping that Tasha could help advocate for her at school and help develop alternatives to expulsion.
Tasha’s crisis revolved around her love for the young girl and wanting to help, but fearing if she did, she would be re-entering the dynamics of her relationship with her ex and undo all she had done in ending the relationship. “I need help deciding whether to get involved at all,” she shared in her preliminary phone call to me.
We met that day and rather than engaging in a traditional psychosocial assessment, we took a more crisis intervention approach to her problem. Tasha wanted help processing all her options and the consequences of each of her possible choices. After spending the hour exploring these, she felt like she had a clearer sense of how she wanted to proceed. Because of her relationship with her ex-girlfriend’s daughter, she decided to offer support to the daughter only through meeting at the school with school personnel. She would have no meetings with the young girl at her home, and would limit any contact with her ex-girlfriend to any meeting called at school.
At the end of that first session, I checked in with Tasha to see how she felt about our meeting. “This was perfect. I knew from listening to your outgoing message and seeing your face on Psychology Today that this would be a great fit, “ she affirmed. She scheduled another session the following week where we debriefed her decision and actions from the previous week and began to talk about other things she hoped to address in therapy. We acknowledged that scheduling would be a challenge based on her assignments as a firefighter, but she ended the session by saying how excited she was to meet with me more regularly.
Several days before her next session, Tasha called to cancel because she was called into work. She rescheduled for the following week. The following week she called the day of her appointment to cancel because of another work conflict. “I think I’ll have to give you a call to schedule my next appointment because I’m being called in for extra shifts,” she shared in a voicemail. I called her back but left a message on her voicemail. After she hadn’t responded in a week, I reached out again by phone and email and got no response. Several weeks later, I sent a letter inviting her to reconnect at any time, but indicating I’d be closing our work together for now.
Trying to Understand the Break
While the scenarios and dynamics are different in these two cases, we ended and I didn’t have a clear understanding of what was behind the ending. I could spend hours speculating (and in years past have done just that), without ever knowing with certainty why we ended when we did. I’ve done post-mortems with consultants with every case that ends this way. We talk about my case formulation, interventions, transferences (mine and my client’s), and other circumstantial possibilities. I sometimes feel that I have some idea what was behind the unexpected ending, but ultimately, without conversation with my client, they’re all hypotheses that I can’t test.
I think something else that makes these unanticipated endings so difficult is having no control over how the ending plays out. With no response from my clients, there is no way for me to understand what was going on, to feel a sense of closure, or to learn what I might do differently in the future that might result in a different outcome. And then I stop myself.
I have no control. None of us really has any control of how our work and our relationships with our clients evolve. Maybe there is an illusion of control when we see our clients doing or feeling better, or when we feel like our relationships with our clients have grown stronger over time. Similarly, when our clients thank us after a good session, or send an email of appreciation, or begin a session telling us how our last session was helpful, we often assume our work will have a definitive ending when our clients have achieved their goals, or have achieved one goal and we have the chance to end from a clear place of connection.
Understanding May Not Be So Important
And then I remind myself that how we end isn’t necessarily a reflection of whether the work we did was helpful. It’s possible that even with an unanticipated and unprocessed ending, something good will come from our work. Or if in the moment something helpful can’t be identified, maybe our work paved the way for future work with me, or with someone else.
Therapy is both a science and an art. As art, the same piece of work may not be perceived the same way by any two people. That doesn’t make the quality of the art less meaningful or less beautiful. It’s hard to remember these things when there isn’t that sense of immediate appreciation for the work. But often the most important and influential art isn’t understood or appreciated at the time it is created.
The end of a melody is not its goal; but nonetheless, had the melody not reached its end it would not have reached its goal either.
All AIDS Anger Apologizing Asking Questions In Sessions Authenticity Beginnings And Endings Being The Expert Boundaries Boundary Crossing Boundary Violations Breaks From Therapy Collaboration Between Therapists Coming Out Compassion Fatigue Contact Between Sessions Continuity Between Sessions Courage Crying Death Depression Disclosure Disclosure And Technology Dogs Email Emotional Support Animals Emotions Empathy Ending Psychotherapy Endings Expectations Experiments Failure Finances Forgiveness Framing Therapy Fraudulence Gifts Goals Grief Happiness Healing Rituals HIV Holding Back Homework Honesty Hope Human Animal Bond Identity Imposter Injuries Interpersonal Neurobiology Intersectionality Long Term Therapy Loss Loving Yourself Memory Metaphors In Psychotherapy Microaggressions Money Multiple Identities Neurophysiology New Information New Normal Normal Not Knowing Pain Physical Contact Positive Emotions Present Moment Priorities Privacy Questions Rage Real Relationships Resentment Resolution Rites Of Passage Rituals Rupture And Repair Sadness Safe Spaces Safety Safety Plan Safety Versus Comfort Secrecy Session Structure Short Term Therapy Silence Stigma And Mental Health Suicide Survival Strategies Themes In Psychotherapy Therapist Client Relationships Touch Trauma Trigger Warnings Values Vicarious Resilience Vicarious Trauma