How to Figure Out When Therapy Is Over

This article was published in the New York Times this week. I'm posting it here because I found it funny, insightful and interesting and hope you do too.

How to figure out when Therapy is Over
By RICHARD A. FRIEDMAN, M.D.

Published: October 30, 2007

If you think it’s hard to end a relationship with a lover or spouse, try breaking up with your psychotherapist.

A writer friend of mine recently tried and found it surprisingly difficult. Several months after landing a book contract, she realized she was in trouble.

“I was completely paralyzed and couldn’t write,” she said, as I recall. “I had to do something right away, so I decided to get myself into psychotherapy.”

What began with a simple case of writer’s block turned into seven years of intensive therapy.

Over all, she found the therapy very helpful. She finished a second novel and felt that her relationship with her husband was stronger. When she broached the topic of ending treatment, her therapist strongly resisted, which upset the patient. “Why do I need therapy,” she wanted to know, “if I’m feeling good?”

Millions of Americans are in psychotherapy, and my friend’s experience brings up two related, perplexing questions. How do you know when you are healthy enough to say goodbye to your therapist? And how should a therapist handle it?

With rare exceptions, the ultimate aim of all good psychotherapists is, well, to make themselves obsolete. After all, whatever drove you to therapy in the first place — depression, anxiety, relationship problems, you name it — the common goal of treatment is to feel and function better independent of your therapist.

To put it bluntly, good therapy is supposed to come to an end.

But when? And how is the patient to know? Is the criterion for termination “cure” or is it just feeling well enough to be able to call it a day and live with the inevitable limitations and problems we all have?

The term “cure,” I think, is illusory — even undesirable — because there will always be problems to repair. Having no problems is an unrealistic goal. It’s more important for patients to be able to deal with their problems and to handle adversity when it inevitably arises.

Still, even when patients feel that they have accomplished something important in therapy and feel “good enough,” it is not always easy to say goodbye to a therapist.

Not long ago, I evaluated a successful lawyer who had been in psychotherapy for nine years. He had entered therapy, he told me, because he lacked a sense of direction and had no intimate relationships. But for six or seven years, he had felt that he and his therapist were just wasting their time. Therapy had become a routine, like going to the gym.

“It’s not that anything bad has happened,” he said. “It’s that nothing is happening.”

This was no longer psychotherapy, but an expensive form of chatting. So why did he stay with it? In part, I think, because therapy is essentially an unequal relationship. Patients tend to be dependent on their therapists. Even if the therapy is problematic or unsatisfying, that might be preferable to giving it up altogether or starting all over again with an unknown therapist.

Beyond that, patients often become stuck in therapy for the very reason that they started it. For example, a dependent patient cannot leave his therapist; a masochistic patient suffers silently in treatment with a withholding therapist; a narcissistic patient eager to be liked fears challenging his therapist, and so on.

Of course, you may ask why therapists in such cases do not call a timeout and question whether the treatment is stalled or isn’t working. I can think of several reasons.

To start with, therapists are generally an enthusiastic bunch who can always identify new issues for you to work on. Then, of course, there is an unspoken motive: therapists have an inherent financial interest in keeping their patients in treatment.

And therapists have unmet emotional needs just like everyone else, which certain patients satisfy. Therapists may find some patients so interesting, exciting or fun that they have a hard time letting go of them.

So the best way to answer the question, “Am I done with therapy?” is to confront it head on. Periodically take stock of your progress and ask your therapist for direct feedback.

How close are you to reaching your goals? How much better do you feel? Are your relationships and work more satisfying? You can even ask close friends or your partner whether they see any change.

If you think you are better and are contemplating ending treatment but the therapist disagrees, it is time for an independent consultation. Indeed, after a consultation, my writer friend terminated her therapy and has no regrets about it.

The lawyer finally mustered the courage to tell his therapist that although he enjoyed talking with her, he really felt that the time had come to stop. To his surprise, she agreed.

If, unlike those two, you still cannot decide to stay or leave, consider an experiment. Take a break from therapy for a few months and see what life is like without it.

That way, you’ll have a chance to gauge the effects of therapy without actually being in it (and paying for it). Remember, you can always go back.

Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College