Recognizing when therapy has run its course

Terminating therapy is ideal when patients have met their treatment goals and both the therapist and patient agree it is time to conclude treatment, but this scenario is not always how things play out. Patients may stop progressing with a particular practitioner, or they start struggling with an issue that is outside a therapist’s area of expertise. Other times, clinicians’ own mental or physical health challenges may start to compromise their ability to provide quality care. It’s a challenging process to navigate: Ending therapy can create sadness, anxiety, and doubt for practitioners—especially when the therapeutic relationship is strong  (Baum, N., Clinical Social Work Journal, Vol. 35, 2007opens in new window; Fragkiadaki, E. & Strauss, S. M., Psychology and Psychotherapy , Vol. 85, No. 3, 2012 opens in new window).

Psychologist Keely Kolmes, PsyD, who has a private practice based in San Francisco, experienced those feelings of sadness and loss when they knew it was time to refer a patient they had worked with for more than 2 years to another provider who had the type of expertise the patient needed. The patient had started experiencing more extreme symptoms of obsessive-compulsive disorder (OCD), and Kolmes felt out of their depth. “It was hard for both of us because we had done really good work in other areas and had an emotional bond,” said Kolmes. “But she deserved someone who was better equipped to help her specifically with OCD.”

Experienced psychologists recommend periodically stepping back to ask whether continued treatment is still the right choice for any given patient—even when ending it feels uncomfortable. “I recommend having termination built into psychotherapy goals from day one with a patient,” said Bhupin Butaney, PhD, associate program director of the department of behavioral sciences/clinical psychology at Midwestern University in Arizona and president of APA’s Division 42 (Psychologists in Independent Practice). “Clearly outline the circumstances when therapy might end and what the patient can expect.”

According to APA’s Ethical Principles of Psychologists and Code of Conduct, reasons for termination may include when a patient no longer needs the service or is not benefiting, a lack of competence to provide the necessary treatment, personal issues that prevent a psychologist from performing work-related activities, or when a therapist feels threatened or endangered by a patient.

“Part of good practice housekeeping is thinking about how your patients are progressing and whether you are being effective,” said Marnie Shanbhag, PhD, senior director of APA’s Office of Independent Practice. “Psychologists care deeply about our patients’ feelings, especially when they want to continue in treatment with us, but we also have an ethical obligation to terminate in certain situations. Doing so can actually help us be fully present for all our patients and make room for new patients as others meet their goals.” 

Even though termination conversations can be difficult, a thoughtful closure session can benefit both therapists and their patients as the duo recognizes the progress so far and future goals for the patient. By creating a consistent rhythm of evaluating a caseload, “there may also be secondary implications for self-care,” said Butaney. “Clinicians might reduce burnout, focus on working with clients that keep them stimulated, and have more opportunities to develop and refine new skills.”

One of the reasons therapists may delay termination is fear of disappointing the patient. “Our work is a form of caregiving, so it can feel like we are giving up on them if we stop working with them,” said Jen Blanchette, PsyD, a former private practice owner in Freeport, Maine, who works as a consultant for therapists. “But if a patient is no longer progressing or benefiting from therapy, then continuing may not be in the best interest of the patient.”

Blanchette, who previously specialized in eye movement desensitization and reprocessing (EMDR) therapy, experienced this when she was working with patients who could not progress beyond the second phase of EMDR, which includes learning regulation techniques to manage emotions and maintain safety. “I rarely chose to terminate,” said Blanchette. “The default is often to try to continue working with the patient even when we know it might be wise to refer out.”

There may also be more subtle signs that a patient is no longer benefiting from therapy with you. “If a therapist keeps trying to give a patient suggestions but the patient is unwilling to try things, then it might be time consider termination or referral to another provider,” said Elaine Ducharme, PhD, a psychologist in private practice in Marlborough, Connecticut. “Sometimes we feel very invested in the client, but for a variety of reasons the client may not be invested in the therapy.”

In other cases, the reason for termination is related to the practitioner’s competence. Kolmes has encountered this when interactions between partners are highly contentious in couples therapy. Kolmes was seeing a couple whose level of conflict had escalated beyond the scope of Kolmes’s training. Kolmes referred them to a therapist specializing in high-conflict couples therapy, and the couple appreciated the candor and the referral. In another case, one of the partners was actively struggling with substance use disorder, and Kolmes explained that couples work can be contraindicated with active, untreated substance use disorder. The couple paused therapy, and Kolmes coordinated care with their individual therapists. They returned when the partner with substance use disorder was in recovery and had been clean for more than 30 days.

Practitioners may also need to end therapy when their own mental or physical health is compromised when working with a patient who has problems that are too challenging for the clinician to navigate is impairing care. Blanchette considered termination when she was pregnant and working with a patient who was grieving the death of a child. “I didn’t realize how triggering to me it would be until I was in the situation,” Blanchette said. She consulted with colleagues about the situation, and they suggested she seek out personal therapy. She started seeing an EMDR therapist to help her reprocess the traumatic experience. As a result, she was able to continue working with the patient who was grieving.

The polarized political climate is also affecting the therapeutic relationship for some practitioners, which may impact a clinician’s ability to provide care. “I’m hearing a lot more stories related to political and ideological issues that are creating transference and countertransference issues,” said Kolmes. In online forums, Kolmes has seen clinicians asking themselves if they are a good fit for a patient because these issues are triggering to the therapists, which can make it difficult for them to show up for the patient’s treatment goals.

“In such cases, the clinicians should seek out consultation or supervision to ensure they are making decisions with the client’s best interest and needs in mind and to get an objective view of the circumstances,” said Butaney. Practitioners who decide to terminate should explain the rationale to the patient, why the practitioner might not be the best fit for them, and why another provider might be more effective.

Although therapists are focused on the needs of their patients, finding support from colleagues through consultation or supervision can help providers address their own emotions as they are considering termination with a patient.

Shanbhag consulted with trusted colleagues when she prepared to close her private practice after 16 years because she was starting a new role at APA. “Being in therapy is a unique relationship experience, and the bond is sacred,” she said. “The terminations were incredibly hard because it was like going to work every day and breaking up because of something happening in my life, not theirs. My colleagues normalized that it was OK for me to have complicated feelings.”

Her peers encouraged her to bring up the termination “early and often” to give patients time to prepare for the transition and revisit the topic during multiple sessions. During the conversations, Shanbhag asked patients to reflect on the answers to questions she had asked at the outset of therapy: How would we know when they had achieved what they wanted from therapy? What would be different about their lives? This gave patients an opportunity to explore if they were ready to end therapy. For patients who felt that their therapy journey was unfinished, she offered to refer them to another psychologist. Some individuals felt disappointed that they would have to tell their stories again to a new therapist. To ease the transition, she asked for permission to talk to the new therapist about the patient’s history and where they were in their work. Almost all her patients opted for this warm handoff to facilitate their care.

Regardless of the reason for ending therapy, clinicians can increase the odds of a positive experience by regularly taking time to check in with patients about progress. “I ask them how they are feeling about therapy,” said Kamieka Gabriel, PhD, owner of Gabriel Psychological Services in Atlanta and a member of APA’s Board of Professional Affairs from 2023 to 2025. “Sometimes, they feel stuck and realize it’s time to find another therapist.”

To aid the transition, therapists should tailor referrals to be clinically, financially, and geographically appropriate for the patient. Gabriel, who works with pediatric patients, celebrates the end of their therapy with cake and coloring, inviting parents or other caregivers to join and hear about the work the child has accomplished.

A thoughtful closure session is beneficial for patients and therapists. During the final meetings, Kolmes reviews the notes with the patient as they both reflect on different phases of the therapeutic journey. “I have found that people tend to really appreciate the feedback and the chance to reflect,” they said. “We can look at all the good work that has happened, and that is a rich gift for both of us.”