13 标志治疗旅程的终点

第十三章 结束治疗

开始的艺术固然伟大，但结束的艺术更为伟大。 —亨利·沃兹沃斯·朗费罗

治疗往往逐渐减少、慢慢消失或突然中断。在会谈频率减少后，来访可能不会回复最后的信息。或者，来访会去旅行或冒险，跨越一个重大生活事件的门槛，并模糊地承诺在秋天重新开始会谈，但随后这并没有发生。又或者，有一个更正式的终止会谈，但过程略显尴尬且缺乏高潮。来访和治疗师已经彼此疏远。

然而，结束——包括应对结束和对结束的恐惧——是关系中的重要部分。它们也可能直接或间接地与临床问题相关。例如，一些有被遗弃历史或不可靠照顾者的来访会在开始依附治疗师时开始害怕治疗的结束。有些来访会因为这种恐惧而避免与你亲近，或者在结束临近时退缩或功能失调。即使其他来访表面上处理得很好，他们也可能会带着对治疗关系的不确定离开：他真的在乎吗？他怎么看我？他很高兴继续和其他人工作吗？当然，这并不总是问题，但在FAP中，我们希望从功能的角度来看待结束，并问这个问题：这个结束对这个人意味着什么——它如何起作用？

此外，结束治疗对治疗师来说也可能很困难，特别是如果建立了牢固的关系，可能会引发各种T1。例如，你可能会在预期来访离开时变得不那么响应。虽然治疗结束的方式主要应服务于来访，但治疗师也有重要的需求，因此FAP对待结束的态度旨在鼓励CRB2和T2。

治疗结束引发的问题

对于许多来访来说，治疗的结束会唤起以前过渡和失去的情感和记忆。对于这些来访，你可以利用治疗的终止来进一步建立应对失去和结束的技能。当然，当应对失去是治疗的主要目标时，这些问题将在治疗早期得到解决。（对于那些以失去为核心问题的来访，可以在治疗初期就探讨未来治疗关系的终止。例如，“失去是你日常生活中如此核心的部分。随着我们开始治疗关系，关于有一天我们的工作也将结束这一点，你有什么感受？”）

现实世界中的关系往往不会很好地结束。有时它们以愤怒或冲突告终，有时人们只是逐渐疏远而没有说再见。如果这些是来访对结束的主要体验，那么努力实现一个刻意且有意义的治疗终止可能是有价值的，在这个过程中，来访明确识别并体验她可以采取的CRB2，使治疗的结束令人满意且难忘；然后这一技能可以推广到未来的告别中。在这种情况下，尽管可能痛苦，但结束的重要部分是表达所有重要和建设性的东西——感激、遗憾、愿望。目标往往是带着这样的感觉结束：我已经把我心中想说的话都告诉她了。我对这段关系的意义毫无保留。

对于其他来访来说，结束治疗最重要的方面是从与治疗师的相互依赖转变为相对独立。每周治疗会议的缺失——尤其是长期治疗的情况下——可能是支持或稳定性的巨大损失。考虑治疗的目标是否得到了充分解决，以及来访是否建立了足够的支持。评估来访是否表达了关于终止治疗的需求并寻求其他形式的支持是很重要的。

以下是一些在治疗结束时可能出现的常见CRB，其中任何一种也可能出现在治疗师身上：

• 避免谈论治疗的结束
• 在预期结束时与治疗师保持距离，通常是为了避免终止的痛苦
• 由于对终止的恐惧而变得更加焦虑或要求更多
• 经历或制造更多问题以便治疗可以继续
• 过度关注结束
• 匆忙结束以尽快完成
• 未能充分计划终止，如考虑来访是否有足够的支持
• 过度准备或在结束治疗时过于谨慎

因为结束会影响之后的一切，糟糕的结束可能会玷污所有的进步。良好的结束有助于确保你们一起做的工作具有持久的影响。

结束治疗的信件

令人惊讶的是，许多疗程结束后没有任何具体的记录表明学到了什么。治疗随着时间的推移而被遗忘。为了明确标记结束并创建持久的记录，我们建议写一封结束治疗的信给来访。这有助于使终止过程明确、开放，并专注于最重要的CRB2，同时产生一份具体、持久的记录，记录治疗中最重要的教训。如果你愿意或认为有益，也可以邀请来访根据他们的需要为自己、为你或双方写类似的信件。例如，涉及向他人沟通的CRB2的来访可能会发现写一封信给治疗师是有意义的，而涉及自我关怀、自我同情或自我导向的CRB2的来访则可能从给自己写信中受益。

结束治疗时的信件

因为希望来访能够长期保存治疗师的信，所以在撰写时要格外小心。除了表达你想现在说的内容外，还要考虑在未来的一年、五年或二十年里，哪些提醒可能会对来访有益。这封信可以包含以下任何或所有适当的部分。我们倾向于在每封信中包括大多数这些部分：

• 来访在治疗中的目标和进展
• 来访的独特品质及你欣赏她的地方
• 与来访互动中特别突出的事情，对你个人的影响，以及你喜欢的部分
• 你从与来访的合作中学到了什么，你会记住他什么，以及这段经历如何改变了你
• 你希望来访从与你的合作中带走什么，对她来说重要的是记住什么
• 你对共同工作的任何遗憾
• 你对来访的希望和祝愿
• 你会怀念来访哪些方面
• 关于未来需要注意的任何建议，如何防止复发

写信和分享信件的过程可以帮助治疗师和来访整理告别过程，这样做也可能加深治疗体验。一旦你写好了信，在会谈中大声读给来访听。如果来访也写了信，她也可以大声朗读。这可能是一个极其感人的互动。读完信后，交换信件，并建议来访将你的信保存起来，以便在未来几周、几个月乃至几年内参考。

以下是一封示例信件： 亲爱的[来访]，

我记得你曾带着一些恐惧和羞愧对我说，你“太强烈”了。从那以后，我就开始留意这种强烈性。我内心的一部分在等待你变得愤怒、固执己见或要求苛刻。但大部分时间我知道这些都不会发生。因为在你身上我看到的不是刺耳或失控的强烈性，而是强烈的情感、承诺、正直、可信度，以及一种基本的倾向——与他人和世界建立联系。

我还看到了——你也感受到了——伴随这些品质的是大量的恐惧和自我怀疑。然而，即使在这里，在会谈中，面对你对自己最困难的想法时，你仍然有清晰观察和同情的冲动。

我认为我们最终清楚地看到，你对自己强烈的看法来自特定的时间和地点。或许我们可以称这些时间和地点为“当你处于最脆弱状态而你的家庭成员处于最局限状态时你们之间的互动”。从这个理解中不需要产生对任何人的同情丧失。实际上，这种认识可能会让你感到更多的同情。

基于这一理解，可以说我们共同工作的一切都是为了让你摆脱那个你是强烈的的故事，帮助你看清某些互动是如何把你从最好的自己拉出来的，然后通过“我是-你是”的方式、风险日志以及“像欣赏日落而不是数学题一样欣赏自己”来回归自我。

你所做的最有力的事情——也是你做自己的最好例子——是通过会话桥接问题和电子邮件交流，向我要求更多的存在感、专注和指导。这件事之所以酷是因为：尽管你非常害怕，但同时你也在要求这些事情时非常真实地连接到自己。尽管你因认为自己太强烈且男人不会关心也不会回应你的故事而感到害怕，你还是听从了自己的声音，因此你与我建立了真实的联系。你的强烈性引导你走向我，而不是远离我。

最重要的是，我希望你从我们的工作中获得这样的体验：你的强烈性可以引导你接近他人并吸引他们，而不仅仅是推开你自己或他们。我也希望你能认识到，你远不止强烈性。你的强烈性包含了敏感、同情、慷慨、灵活等特质。让你的强烈性成为你的存在和对自己的承诺。我们总是会有需要改进的地方。但当我们拥有温和的工具——如细砂纸和软布——以及重手和大锤时，我们就更有能力完成这项工作。

一切都会过去，终将结束。随着我们在这次治疗中的时间即将结束，你让我记住了最重要的不是我们无休止地拖长或经历许多相同的时刻。更加珍贵和持久的是我们对他人的贡献和联系的质量与完整性。你为这项工作带来了不可思议的质量和完整性。

正因为如此，我们在过去几个月的合作对我来说将真正难忘。

充满敬意和关怀， [治疗师的名字]

结束治疗时的问题

我们开发了一组问题，可以帮助处理治疗的结束。反思并回答这些问题可以帮助来访巩固他们的成果，也有助于有意义地说再见。如果你邀请来访给你写一封告别信，你也可以建议他们在信中包含对这些问题的回答：

• 一般而言，结束带给你什么样的想法和感受？
• 对于与我结束这段治疗关系，你有什么样的想法和感受？
• 你学到了什么？这次治疗对你有什么帮助？
• 你现在意识到关于自己的哪些事情是你之前没有意识到的？
• 你最突出的勇敢行为是什么？
• 你爱的能力如何改变，或者你的人际关系如何变化？
• 你学到的最重要的技能有哪些，你希望继续在生活中实施？
• 你喜欢和感激自己的哪些方面？你在生活中感激什么？
• 你与我的互动中最突出的是什么？
• 你喜欢和感激我哪些方面？你会永远记住我什么？
• 你对治疗有什么遗憾，或者你希望有什么不同？
• 哪些情境、想法或行为使你容易感到[此处填写来访的主要问题]，你可以如何应对以减少这些感觉的严重程度？
• 你可以做些什么来维持治疗的成果，并继续改善你的生活？
• 在你说再见时，你觉得最难启齿的是什么？

总结

• 关系的结束对许多来访的历史来说是重要的篇章。
• 治疗的结束提供了机会，以治疗的方式处理来访所激发的感受，并确保结束尽可能集中和具有治疗意义。
• 结束治疗的信件是一种有用的工具，可以使结束过程明确和开放。

知识点阐述

1. 治疗结束的重要性

   • 定义：治疗的结束不仅是治疗过程的一个阶段，也是关系中的一个重要部分，它可能涉及到情感处理、依恋问题以及对未来的规划。
   • 重要性：良好的结束可以帮助来访巩固治疗成果，并为未来的人际关系提供积极的模式。不良的结束可能会导致负面情绪和未解决的问题。
   • 具体实践：
     • 提前规划：尽早讨论结束的可能性和方式，让来访有心理准备。
     • 处理情感：帮助来访处理因结束而产生的各种情感，如悲伤、失落、焦虑等。
     • 总结经验：回顾治疗过程中的重要经验和学习，确保来访能够将这些经验应用到未来。

2. 结束治疗引发的常见问题

   • 定义：治疗结束时，来访可能会表现出多种行为和情感反应，这些反应可能反映了他们在其他关系中的经历和模式。
   • 重要性：识别和处理这些反应可以帮助来访更好地应对结束，并为未来的人际关系做好准备。
   • 具体实践：
     • 识别模式：注意来访在结束治疗时的行为模式，如回避、疏远、焦虑等。
     • 提供支持：给予来访情感支持，并帮助他们找到应对策略。
     • 强化技能：利用结束治疗的机会，进一步加强来访应对结束和丧失的技能。

3. 治疗师的角色

   • 定义：治疗师在结束治疗时也需要处理自己的情感和需求，这可能会影响到与来访的互动。
   • 重要性：治疗师需要保持专业性，同时也要关注自己的情感状态，以确保治疗的顺利结束。
   • 具体实践：
     • 自我反思：定期进行自我反思，了解自己在结束治疗时的感受和需求。
     • 寻求支持：与其他专业人士讨论自己的感受，获取支持和建议。
     • 保持专业：即使感到不舍或焦虑，也要保持专业的态度，确保来访的利益优先。

4. 结束治疗的信件

   • 定义：结束治疗的信件是一种书面记录，概括了治疗过程中的重要经验和学习，为来访提供了持久的参考。
   • 重要性：信件可以帮助来访巩固治疗成果，并为未来提供指导。同时，它也为治疗师提供了反馈和总结的机会。
   • 具体实践：
     • 撰写信件：根据来访的具体情况，撰写一封包含重要经验和学习的信件。
     • 邀请来访参与：鼓励来访也写一封类似的信件，无论是给自己还是给治疗师。
     • 分享和讨论：在最后一次会谈中，分享和讨论信件的内容，确保来访理解并认同其中的信息。

通过这些具体的练习和方法，治疗师可以有效地帮助来访处理治疗结束带来的各种情感和挑战，确保治疗的结束是一个积极且有意义的过程。这样不仅有助于巩固治疗成果，还能为来访的未来人际关系提供积极的示范。此外，通过结束治疗的信件，治疗师和来访都可以获得宝贵的反馈和总结，为未来的个人成长和发展奠定基础。

知识点阐述

1. 结束治疗时的信件

   • 定义：结束治疗时的信件是由治疗师撰写的，旨在总结治疗过程、表达对来访的赞赏和支持，并提供未来生活的建议。
   • 重要性：这封信不仅是治疗的一个正式结尾，也是来访未来生活中的一个宝贵资源。它可以帮助来访巩固治疗成果，提醒他们曾经的成就和成长，并提供持续的支持。
   • 具体实践：
     • 内容选择：根据来访的具体情况，选择合适的信件内容，包括来访的目标、进步、独特品质、治疗中的互动、治疗师的感悟、对来访的期望等。
     • 情感表达：在信中真诚地表达对来访的情感，包括感激、希望和祝福。
     • 未来建议：提供具体的建议，帮助来访在未来避免复发，并继续成长。

2. 结束治疗时的问题

   • 定义：结束治疗时的问题是一系列反思性问题，旨在帮助来访回顾治疗过程，巩固学习成果，并为未来的挑战做好准备。
   • 重要性：这些问题可以帮助来访深入思考治疗的意义，识别自己的成长点，并为未来设定新的目标。
   • 具体实践：
     • 问题设计：设计一系列问题，涵盖来访对结束治疗的感受、学到的东西、自我认知的变化、勇气的行为、人际关系的变化等。
     • 引导反思：鼓励来访认真思考这些问题，并在会谈中讨论他们的答案。
     • 整合到信件中：如果来访写告别信，建议他们在信中融入对这些问题的回答，以增强信件的深度和意义。

3. 结束治疗的重要性

   • 定义：治疗的结束是治疗过程中的一个重要阶段，涉及情感处理、总结经验、巩固成果和展望未来。
   • 重要性：良好的结束不仅可以帮助来访更好地过渡到新生活，还可以为治疗师提供反馈和成长的机会。
   • 具体实践：
     • 提前规划：尽早讨论治疗结束的可能性和方式，让来访有心理准备。
     • 情感处理：帮助来访处理因结束而产生的各种情感，如悲伤、失落、焦虑等。
     • 总结经验：回顾治疗过程中的重要经验和学习，确保来访能够将这些经验应用到未来。
     • 展望未来：讨论来访的未来计划和目标，提供支持和建议，帮助他们顺利过渡。

通过这些具体的练习和方法，治疗师可以有效地帮助来访处理治疗结束带来的各种情感和挑战，确保治疗的结束是一个积极且有意义的过程。这样不仅有助于巩固治疗成果，还能为来访的未来人际关系和个人发展提供积极的示范。此外，通过结束治疗的信件和问题，治疗师和来访都可以获得宝贵的反馈和总结，为未来的个人成长和发展奠定基础。

C H A P T E R 13 Marking the End of Therapy Great is the art of beginning, but greater is the art of ending. —­Henry Wadsworth Longfellow Too often, therapy tapers off, trickles out, or cuts off. After a decrease in the frequency of ses- sions, the client doesn’t respond to a final message. Or, the client goes on a trip or adventure, crossing the threshold of a major life event, with the vague promise of picking up sessions again in the fall, and then that doesn’t happen. Or, there is a more deliberate termination session, but it is slightly awkward and anticlimactic. Client and therapist have already withdrawn from each other. Yet endings—­including coping with endings and fear of endings—­are important parts of rela- tionships. They may also be related to clinical issues, either directly or indirectly. For example, some clients with a history of abandonment or unreliable caregivers will begin to fear the ending of therapy when they begin to attach to the therapist. Some clients will avoid getting close to you because of this, or they will withdraw or decompensate as the ending draws nearer. Even though other clients may ostensibly handle the ending well, they may walk away with lingering uncertainty about the therapeutic relationship: Did he really care? What did he think of me? Was he happy to move on to work with other people? This is not always a problem, of course, but as with everything else in FAP, we want to look at endings functionally and ask this: What does the ending mean—­ how does it function—­for this person? Further, ending therapy may also be difficult for therapists, especially if a strong relationship has been formed, and it might evoke various T1s as a result. For instance, you might become less responsive to a client as you anticipate her departure. While the manner in which therapy ends should primarily serve the client, the therapist may have important needs as well, and therefore the FAP stance toward endings is designed to encourage both CRB2 and T2. ISSUES EVOKED BY THE END OF THERAPY For many clients, the end of therapy brings up feelings and memories of previous transitions and losses. With these clients, you can use the termination of therapy to further build skills for coping with loss and endings. Of course, when coping with loss is a central therapy target, it will be addressed much earlier in treatment. (For some clients for whom loss is central, the imagined future termination of the therapy relationship might be explored from very early in treatment. For example, “Loss is such a core part of your daily life. As we begin our therapy relationship, what comes up for you about the fact that one day our work together will also end?”) Relationships in the outside world frequently don’t end well. Sometimes they end with anger or conflict, and sometimes people just gradually slip apart without ever saying good-­bye. If these have been a client’s primary experience with endings, it may be valuable to strive for a deliberate, mean- ingful termination of therapy in which the client clearly identifies and experiences the CRB2s she might engage in to make the ending of therapy satisfying and memorable; this skill can then be generalized to future good-­byes with others. In cases like this, as painful as it might be, the impor- tant part of an ending is to express everything that is important and constructive to express—­ appreciations, regrets, wishes. The goal is often to end with the sense that I told her everything it was in my heart to say. I held nothing back about what this relationship meant to me. For other clients, the most important aspect of ending therapy is addressing the transition from interdependence with the therapist to relative independence. The absence of a weekly therapy meeting—­especially when the therapy has been long-­standing—­can be a tremendous loss of support or stability. Consider whether the goals of therapy have been adequately addressed and whether the client has set up adequate support. It may be important to assess whether the client is expressing his needs in regard to terminating therapy and seeking other forms of support. Here are some other common CRBs that may show up around ending therapy, any of which may also show up for therapists: Avoiding talking about the end of therapy Distancing from the therapist in anticipation of the ending, usually to avoid the pain of termination Becoming more anxious or demanding in response to fear of termination Experiencing or creating more problems so therapy can continue Being overly preoccupied with the ending Rushing through the ending to get it over with Failing to adequately plan for termination, such as considering whether the client has enough support Overpreparing or otherwise being overly cautious about ending therapy Because endings affect everything that follows, ending poorly can tarnish all of the progress that was made. Ending well helps to ensure that the work you did together has sustained impact. END-­OF-­THERAPY LETTER TO CLIENT It’s amazing that many courses of therapy end without any concrete record of what was learned. The therapy is later lost in time. To mark endings explicitly and create a lasting record, we recom- mend writing an end-­of-­therapy letter to clients. It helps to make the process of termination explicit, open, and focused on the most important CRB2s, while also producing a concrete, durable record of the most important lessons of the therapy. If you wish or think it would be beneficial, you can also invite clients to write a similar letter for themselves, for you, or both, according to their needs. For instance, clients whose CRB2s involve communicating to others might find it meaningful to write a letter to the therapist, and clients whose CRB2s involve self-­care, self-­compassion, or self-­ direction might benefit from writing a letter to themselves. Because the intent is for the client to keep the therapist’s letter for a long time, take care with what you write. In addition to addressing what you want to say now, also consider what reminders the client may benefit from in one, five, or twenty years. The letter may include any or all of the following components, as appropriate. We tend to include most of them in every letter: The client’s goals and progress in therapy The client’s unique and special qualities and what you appreciate about her Interactions you had with the client that stand out, what impacted you personally, what you enjoyed What you’ll take away from your work with the client, what you’ll remember about him, how you’re different as a result of having worked with him What you want the client to take away from her work with you, what’s important for her to remember Any regrets you have about your work together Your hopes and wishes for the client What you’ll miss about the client Any parting advice about what to watch out for in the future, how to prevent relapse The process of writing and sharing the letters can help organize the process of saying good-­bye for both therapist and client, and doing so may also deepen the experience of therapy. Once you’ve written the letter, read it out loud to the client in session. If the client has written a letter, she can read it out loud as well. This can be an extremely evocative interaction. After reading the letters, exchange them, and recommend to the client that she keep your letter to refer to in the weeks, months, and years to come. Here’s a sample letter: Dear [Client], I remember when you said to me, with some fear and shame, that you are “too intense.” I started looking for this intensity after that. Part of me was waiting for you to get angry or superopinionated or demanding. But mostly I knew none of that would happen. Because instead of grating or out-­of-­control intensity, what I kept seeing in you was strong feeling, commitment, integrity, trustworthiness, and a fundamental orientation toward connecting with others and with your world. What I also saw—­and you felt—­alongside those qualities was a lot of fear and self-­doubt. However, even here, in session, with your most difficult thoughts about yourself, you had the impulse of clear seeing and compassion. And what I think we came to see clearly is how your view of yourself as intense comes from particular places and times. Maybe we could call these places and times “interactions between you and your family when they were at their most limited and you were at your most vulnerable.” There doesn’t need to be any loss of compassion for anyone arising from this understanding. Actually, you could feel even more compassion from this recognition. From that understanding, you could say everything we worked on together was about getting you free of that story that you’re intense, helping you to see how some interactions pulled you out of you as your best you, and then returning you to you through “I-­am-­you-­are”; risk logs; and “appreciating yourself as a sunset, not a math problem.” The most powerful thing you did—­and the best example of you being you—­was asking me for more presence and focus and direction in our work via the session bridging questions and in our e-­mail exchanges. Here is what is so cool about that: you were very afraid and yet simultaneously also very yourself and connected to yourself when you asked these things of me. Despite your fear borne from the story that you’re too intense and that men won’t care and won’t respond to you, you listened to your own voice, and because of that you forged a real connection with me. Your intensity led you toward me, not away. Above all, I hope you move forward from our work with the experience that your intensity can lead you toward others and draw people in, not just push you or them away. I also hope you recognize that there is a whole lot more to you than intensity. Your intensity contains sensitivity, compassion, generosity, flexibility, and so on. Let your intensity become your presence and your commitment to yourself. There will always be rough edges for us to work on in ourselves. But we are more capable of doing that work when we have gentle tools—­like fine sandpaper and soft cloths—­as well as heavy hands and sledgehammers. All things pass and come to an end. And as our time together in this therapy comes to a close, you’re helping me remember that what matters most is not that we drag things on and on or experience lots of the same moments together. What is far more precious and persistent is the quality and integrity of our contribution and connection to others. You brought an incredible quality and integrity to this work. For these reasons, our work together these last months will be truly memorable for me. With great admiration and care, [Therapist’s name] END-­OF-­THERAPY QUESTIONS FOR CLIENTS We’ve developed a set of questions that can assist with processing the end of therapy. Reflecting on and responding to these questions can help clients consolidate their gains and also facilitates saying a meaningful good-­bye. If you invite clients to write a good-­bye letter to you, you might also recommend that they incorporate their responses to these questions into that letter: What thoughts and feelings do endings in general bring up for you? What thoughts and feelings are you having about the end of this therapy relationship with me? What have you learned? What’s been helpful for you in this therapy? What are you aware of about yourself that you weren’t aware of before? What courageous actions on your part stand out to you the most? How has your ability to be loving changed, or how have your relationships changed? What are the most important skills you’ve learned that you want to keep implementing in your life? What do you like and appreciate about yourself? What are you grateful for in your life? What stands out to you most about your interactions with me? What do you like and appreciate about me? What will you always remember about me? What regrets do you have about the therapy or what do you wish had gone differently? What situations, thoughts, or behaviors make you vulnerable to feeling [state the client’s presenting problems here], and how can you deal with them to decrease the severity of these feelings? What are some things you can do to maintain your gains from therapy and continue to improve your life? What do you feel most vulnerable about saying to me as you say good-­bye? SUMMARY • The endings of relationships are significant episodes in the history of many clients. • The ending of therapy offers an opportunity to work therapeutically with what is evoked in the client and to ensure that the ending is as focused and therapeutic as possible. • The end-­of-­therapy letter is a useful tool for making the ending process explicit and open.