Ending Treatment: Tips to a Good Goodbye

By Barbara Griswold, LMFT

Clients may end treatment for many reasons, including insurance changes, reaching treatment goals, dropping out, moving, or therapist retirement. Here’s some tips for these final sessions:

If you are ending because you are not a provider for their new health plan, have the client contact their new plan and ask if the client has out of network coverage to continue seeing you. The client might also contact their new plan about a Transition of Care Agreement (aka Single Case Agreement), which may provide coverage even if you are not in-network. For more, check out my book or contact me.
If the ending happens due to a change in your life, give clients as much notice as possible. Clients with trauma and abandonment issues may need a lot of time to process feelings.
As often as possible, tell them in person, and be ready to discuss what this means for them. Give follow-up written notice of your end date, outlining options (keep a copy in the chart).
In your final sessions, focus on wrap up — don’t open emotional new topics on exit.
Frame the ending discussion in a positive note. Tell them you would like to take a few sessions to review the work they’ve done. Tell them you feel that endings are really important, that all of us have experienced important relationships that didn’t end the way we wanted them to, and this can leave difficult feelings. Tell them you would like to end the work they are doing in the best way possible, and create together an ending where everyone has said everything they wanted to say and didn’t get a chance to say.
Go over what happened over the course of therapy. Remember together important sessions, turning points, therapy or life events, and major issues addressed.
Go back over the history of your sessions in terms of how the client built a relationship with you. What was it like for them in the first sessions? How did they learn to trust you? What risks did they take in the relationship? What relationship issues came up with you in therapy?
Share your feelings about ending, after exploring theirs. Educate your client about the grief process, and some of the ways people cope with goodbyes (like missing the last session, losing interest in final sessions, feeling detached as they emotionally pull out of the relationship early, feel irritated at the therapist), normalizing all of these,. Ask them if they notice any of these or other coping mechanisms that might be expressions of grief or coping mechanisms.
Anticipate difficulties you think that particular client might have in ending. Share with the client (ex. “it would be perfectly normal if you found yourself coming late or wanting to cancel or even forgetting our last session…”)
Educate about delayed feelings, and ask, “Next week at our usual therapy hour, what do you think you might feel? What will you wish you had said to me in our final sessions?”
Ask, “What did you like most about sessions? What was the most helpful thing I said or did?”
Ask, “what DIDN’T you get that you wish you had? What was your least favorite part of therapy? What did I do that was the least helpful? Was there anytime you felt annoyed or hurt or dissapointed, and didn’t tell me? What feedback do you have for me? What will you look for in a future therapist?”
Ask, “what did you get out of therapy? What changes did you experience? In what way have you grown?”
Give feedback on their growth in therapy. Go over your notes and memories to remember what they were like in the first sessions.Give examples of changes you’ve seen, their progress and strengths. Share with them what you appreciate and admire most about them.
Ask, “What issues do you still have to work on, and how will you work on them?” Add what you feel they could continue to work on, but frame it positively.
Ask, “what have goodbyes been like in your past?” Have them describe endings with those who have left their lives due to death, divorce, moving, conflicts, breakups, etc. Ask, “what do you need to say to make this a ‘good goodbye?'”
Ask, “what would have to happen for you to call me again?” Here is where you help clients understand your attitude toward therapy — that, as with any health professional, you find someone who can help you when you need it, and come back at times when you need support or when you’re feelings stuck. Let them know you will be there for them in the future as part of their support system (if you will), and that it doesn’t have to be an emergency.
Give a few referrals to other therapists, if you are closing your office or unable to continue treating this client.Insurance plans expect you to refer to a provider in the client’s network, when possible.
If the client is transferring to another therapist, try to do a “warm handoff,” where the client is engaged with another therapist before leaving your care, and may even be able to have a session or two with you to talk about what it is like to begin with someone else. Get a release to talk to the new therapist for continuity of care.
Document each conversation about endings and actions taken, how the client reacted, referrals given, and follow up.

If the client drops out, follow up with an email, voicemail, and letter, giving referrals, and invite them to return in the future.

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Barbara Griswold LMFT is the author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance — And Whether You Should. Check out her webinars and therapist resources at www.theinsurancemaze.com/store, or schedule a consultation at www.calendly.com/barbgris