There is not much written about termination in the ISTDP literature (with the exception of Patricia’s 1996 book). With students I usually offer my own “integration” of different sources. I describe typical criteria for termination: the review of patients’ presenting complaints, their understanding of the therapy process, the importance of helping them “own” their changes and prepare for the future, planning follow-up interviews, and facing all feelings that come up in the termination process. In practice, however, I find that the termination and follow-up process “looks and feels” quite different from patient to patient depending on their capacity at the start of therapy, the length of the treatment, complexity of the problems, etc.
Could you post something about the termination process in general and discuss issues specific to ISTDP?” Thanks to Peter for offering this question!
Peter has offered an excellent summary of the issues raised during termination. Traditionally, it was thought that termination would not arouse many feelings because the therapy was brief and the transference had not been allowed to develop as a defense. In fact, however, ISTDP is not always brief, and a therapy that changes a patient’s life will trigger many feelings that will arise during the termination.
In brief therapies with low to moderate resistant patients, there are not many complex feelings that arise toward the therapist during termination except for gratitude for a helpful result.
However, once we are working with highly resistant patients where the work has been deep, lasting forty sessions or more, or with fragile patients whose restructuring could take 50-150 sessions, or severely fragile patients who need more time, many deep feelings will be aroused during the termination process. All the issues Peter described will arise and must be dealt with. In addition, any time we are working with a patient who has overcome superego difficulties, we should be on the watch for any return of symptoms as a defense against loss and complex feelings toward the therapist. This is the same issue that arises in other therapies as well. The longer the therapy, the longer the termination that may be necessary to work through those complex feelings and work through the feelings of loss of the therapy which connect to all the past losses in the patient’s life.
Of course this looks different from one patient to another. Not every patient has the same self-reflective capacity, verbal skills, cultural expression of affect, or genetic endowment. Thus, their ability to describe the process will vary in sophistication and depth. Their ability to bear and express feelings openly will vary according to their capacity and cultural background. That’s why it’s important to respect the strengths and capacities of the patient, accepting this variety of response during termination. Otherwise, our perfectionistic ideals may fail to give credit to the accomplishments the patient has made, even if he or she doesn’t look like some ideal image.
Progress is progress. And the therapist’s ideals can be a defense not only against termination but against recognizing the real limits of life. Our perfectionism at termination shows how we accept neither the patient nor ourselves. How can we ask for perfection in our patients when we cannot deliver it ourselves? It’s also important to remember outcome research findings. Patients in psychodynamic therapies continue to improve after therapy. Our task is not to “cure” a patient, i.e., purify them of their pathology. Rather, our task is to get them back on a progressive direction which they can follow the rest of their lives.
If we look at ourselves, many of us have had a variety of therapies and gained (hopefully) from each one. Yet each day we are learning something new about ourselves. Every day we are growing a little bit. Never perfect, but every day a little bit better.
Thus, when thinking of termination of a therapy, we must face the limits of what we can do in the time we have. And we must accept those limits rather than browbeat a patient to live up to some ideal. In saying our goodbyes, we must accept the limits of the patient and of ourselves, trusting the patient to grow and develop once he or she has left our “home”. Thus, termination, in a certain sense, is an expression of our faith in our patients, in others, and in life itself. “You can grow without me.”
And in letting go of one patient after another, we face death. A patient early in my career asked me, “So I’m supposed to get close to you so then we can say goodbye!!?” It’s not that we are “supposed” to do that. That is just how life works. We get close and either we die or our friends die. Love and death are inextricably tied together. Sometimes the pain of so many losses can lead therapists to detach from the pain of these losses after deep involvements. That is our struggle: to bear our feelings during terminations, our mixed feelings, our limits, our own impending deaths.