13 标志治疗旅程的终点
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 T oo 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 Client and therapist have already withdrawn from each other.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.