ENDING WELL: a reflective approach through creative writing can help us process the impact of client endings appears in the July / August 2023 edition of THERAPY TODAY
Endings are difficult, a client, Tara,* remarked at the end of the session, after a series of six, which I felt had gone well. Like many others, she asked if she could come back at a later date but for now, life was busy, and she had achieved relief from her anxiety which had been the reason for coming.
It set me thinking about my approach to endings. My practice focuses on creative and therapeutic writing, so I planned a supervision workshop for practitioners to explore how writing can help both client and practitioner to round off this process, whatever the quality of the ending.
Those who attended represented various disciplines within the helping professions – counselling and psychotherapy as well as alternative/body therapies, academia and community settings. All of their endings varied. I was prompted to think there is no one approach, but there is the perennial question of how a practitioner ends a series of sessions.
The art therapist working with children in a community setting invoked an apt metaphor with ‘the door’, saying that her door was never closed. This was reflected by an alternative therapist who said she would never introduce an ending because someone might return for treatment at a later date, even years later. The bereavement counsellor, however, who runs groups that last for six sessions, prepared participants for the ending right at the beginning of the course. One practitioner recently had led a week-long retreat, which ended with a closing circle but then observed group members swapping contact details. This prompted discussion about what was a ‘real end’, and the responsibilities about endings as a practitioner.
Polly,* a coach and facilitator in educational settings, contributed her experience of short-lived residential groups, where invariably there was a compulsion to stay together. She used the phrase ‘a manifesto of endings’ and contacted me afterwards to share her thoughts: ‘Our collective reflections during the workshop led me into a deeper understanding of my own practice around endings. Thinking together about endings felt like the missing piece of a jigsaw that I didn’t realise existed. I know I cannot meet all the needs of all the participants and their own endings, in the form that they may need to take them. I am responsible for the navigation and resources for a course. But I am not responsible for the individual endings my clients and participants choose to take.’
Beginnings
Right at the beginning when I have an exploratory session with a prospective client, before either of us have committed to regular sessions, I bring up the subject of mutually assessing the work as we go along, and highlight that when it is time to end, we will lead up to it before a final session. In this way, we start with the ending in mind.
The initial reason for consulting me is usually a writing project, or exploration of someone’s inner life through creative writing. Ending sessions include ‘appreciation’ and ‘the unsaid’. There is space for us both to state our appreciation of the sessions, and we may also say what we appreciate about each other. I will ask if there is anything that has been unsaid, and if I have something unsaid that is relevant, I may voice that too.
Tara, my client who had ended after six sessions, said she felt I was critical of a personal decision she was making about family matters. It was clearly difficult for her to say this and gave me the opportunity to say what had flashed through my mind at the time. Her decision mirrored a scenario in my own life. Whatever had flashed through my mind was related to my circumstances, not hers, but Tara had picked it up and interpreted it as criticism. When she heard my story, she felt relief, and I was pleased to clear this up for her. I’m pretty certain she would never have mentioned this had I not specifically asked whether there was anything she hadn’t said and allowed for that space to say something.
This kind of self-disclosure in some therapeutic modalities would not be acceptable, but in my own practice I feel able to voice aspects of my life if it meets the purpose of serving the client and is not gratuitous information. I am aware of but not overtly working with transference, so it is not always appropriate for me to explore this area of connection with a client, although I definitely would do so in supervision.
Going forward
TS Eliot reminds us in the Four Quartets that to make an end is to make a beginning.* An important part of an ending session for me is to allow space to consider how the client’s writing or plans will progress after our work is finished. The client will often ask me if they may return in the future.
In The Brain has a Mind of its Own, Jeremy Holmes speaks of the ‘borrowed brain’ of the therapist who is able to hold the hand of the client (metaphorically). The client, through therapeutic interventions, will learn to act more freely in his or her world, rather than dysfunctionally, driven by previously learned negative behaviours and narratives.* Successful interactions between client and practitioner often reframe transference and countertransference, manifested in how a series of sessions comes to an end, and how the client views going forward with their life.
Often there is no such thing as a real ending, as Tim,* a psychotherapeutic counsellor, says: ‘Clients disappear after various failed or cancelled appointments, often after only a few sessions. They may give genuine (but perhaps not saying everything) reasons.’ Better endings are more achievable with long-term work Tim describes the ending of several years of work with his client Jack* as ‘textbook’: ‘We had several sessions in which there was discussion about whether we might end or not, what it might mean for him, issues we had covered over the time we had been meeting, the person he had been when we started therapy and how he was now, how he saw his future. There was an acknowledgment of ambivalence – some fear, some excitement – with thoughts expressed of, “Maybe I can do this ending, I never thought I would be able to.” As we fully confronted the reality of it, he said, “I think I need to have a real ending here, and integrate what I have learned and become as a person, without having our sessions as a continuous backdrop.” There was a sense of loss on both sides, but an acknowledgment of the sense of stability Jack had gained, enabling us to part ways. A heartfelt message of thanks arrived shortly afterwards.’
A poor ending
This reminds me of an ending with Katie.* She sent me an email cancelling her next session, saying she intended to discontinue our arrangement, after what I felt was a very good session, the fifth. Perhaps the session was too good from my perspective – had she revealed vulnerable feelings that felt fine in the session but afterwards were unsettling? Instead of confronting her inner life in the next session or even telling me she didn’t want to continue she postponed the next session, then sent an email about how life had become busier, thanking me for the sessions, and giving her decision not to continue.
I felt unsettled that we had not had a proper ending. When I discussed the situation in peer supervision, a colleague suggested I respond to Katie in a way that gave her something open-ended to think about. In all probability, Katie wasn’t ready for her defences to be challenged by the sessions. So I wrote an appropriate email responding to her reasons for stopping, referring to our last powerful session and her decision to stop at this point rather than be willing to continue or tell me personally.
But I still had feelings of being ‘up in the air’, and I minded. I wondered if I should speak to the practitioner who referred her to me and how appropriate that might be — it turned out that the other practitioner was glad for that discussion, which took place when we met in person. My disquiet about the client was confirmed and allowed me to let go of an incomplete ending.
My responsibility only goes as far as it is possible to go in the space we create – between me and another person. I am not in the business of control, but I do have to look at how I might like to control how I work. I deal with my own unresolved issues in my journal and in supervision. As Marie Adams reminds us in The Myth of the Untroubled Therapist, therapeutic practitioners are also human beings with a back story of family history and early childhood experiences. *
Two case studies follow – in the first a client describes the impact of what felt like an unnecessary ending, and in the second a therapist explores how she processed her feelings after an unsatisfactory ending. Both examples were sent to me as a result of conversations with others as part of my research for this article.
Sarah*
After a year with a psychodynamic therapist Sarah was left with a sense of betrayal of trust and a feeling of being ‘banished’ and ‘unlovable’ – a re-enactment of her original infant attachment trauma – after the ending of the therapy.
Sarah was born with a congenital hip disorder, which remained undiagnosed until she started to walk. When she was 15 months old she was taken into hospital for three months for treatment. This was a time when there were limited visiting hours for parents and no real understanding of the attachment needs of an infant. Sarah spent the following 18 months in a plaster cast from the waist down, which was changed into different positions to facilitate corrective growth of the hip muscle.
This experience left her suffering from insecure attachment all her life, with the attendant abandonment issues and the impact on intimate relationships. She has undertaken a number of therapies to help her resolve this although some difficulties have persisted.
More recently, she sought therapy to explore her long-term relationship, which she increasingly realised didn’t meet either of their needs. The in-person sessions with Ann,* a psychodynamic therapist, were very helpful in revisiting her attachment difficulties, and she felt satisfied with the understanding she gained. She initiated the end of the relationship with her partner, albeit with sadness and loss. She would have liked to continue the therapy while processing her feelings but, unfortunately, Ann told her that she was moving some distance away. The sessions were planned to end with three months’ notice.
The final six sessions were focused on the ending of therapy, and Sarah considered it a good piece of therapeutic work. It emerged, however, right at the end of the final session that Ann’s move had fallen through and was not going to happen for the foreseeable future. There was no time to discuss this, and Sarah left without expressing any of the turmoil that she was experiencing.
After some reflection and discussion with a friend, Sarah decided it was important to communicate her thoughts and reflections to Ann so that she did not revert to her previous pattern of letting things go without expressing any feelings, out of fear of rejection and shame. It was important for Sarah to be able to hold on to the good aspects of the therapy, while acknowledging the pain that Ann’s final disclosure of information caused.
Sarah wrote an email to Ann letting her know the impact that the circumstances surrounding the ending had had on her. Ann replied acknowledging she could have handled the ending better. Taking this adult stance of writing the email to express herself empowered Sarah to regain her sense of agency.
Phoebe*
Phoebe is an integrative child psychotherapist working with primary-age schoolchildren, and on one day towards the end of the school year she faced the planned ending of 14 months of work with three children.Her formal reports do not usually require a reflective stance, but she has found that reflective writing helps her to process and understand the painful and empty feelings of the farewells with her clients, which echo a parallel personal journey through chapters of relational loss over her lifetime.
‘I went into school holding each client in mind, gathering my feelings for the final session with little gifts and cake,’ she recounts. ‘I was filled with a sense of pride and happiness at how far I had come with Tommy,* who initially presented with chaotic and dysregulated symptoms. There was a great sadness that I wasn’t going to meet him regularly again. Liam,* who had been referred as a split-off and angry child, was channelling his intellect and exuberance into a sense of self-integration and was very chatty as he ate his cake. But the third child, Ben,* who was a poor school attender, was unwell and absent. My heart sank and I stared at the cake and present laid out on the table – I became still like these objects, waiting for no one to arrive.
‘At home later that day, seemingly having minimised the possible impact of these endings, I noticed myself getting triggered and annoyed by unusual things. This was a sign for me to take notice of my internal state. A deep grey and green well of emptiness sat inside me. I wanted to coil inwards like a shell and go to sleep there for a long time so that I didn’t have to feel how painful it was to shut the door.
‘Part of me also wanted to dance and sing in a ritual of letting go. I needed space, movement and music, and I needed those around me to hold and understand what I had taken on and what I had let go. The attachment relationships with the children were a testament to the linking of two beings coming into a bond and slowly integrating through push and pull, rupture and repair, mirroring, co-regulation, empathy and play. Even though the experience of endings is often mixed, part of me will go with these children and part of them will stay with me. Our relationships will be stored in a chest of memories.’
After embodying her feelings, Phoebe used the metaphor of sewing: ‘These reflections helped me to sew up the process, particularly with Ben who had missed his final session as if the thread of writing closed up a seam.’
Closing the seams
In reflecting on this issue of good and imperfect endings, I have come to the conclusion we may have less control over the ending of a series of sessions than we realise. As a practitioner I may suggest a good way to end, but unless there is a mutual wish between me and the client, it may not happen as I would like.
Like most practitioners I always strive for a good ending, where the completed work feels satisfying and fulfilling both for myself and for the client. But, as Jeremy Holmes writes, a ‘perfect’ ending may be both impossible and undesirable – there will always be themes and issues left unexplored in any given therapy. As a writer I find the invaluable support of reflective writing adds to the process of ending, as Phoebe found in making sure the ‘seams were closed’, and as Sarah did in expressing her feelings after a disappointing ending. If a good ending hasn’t been achieved, along with exploring it in supervision, journalling about the experience can help us to process what has happened and see what can be learned and done differently next time.
*Clients’ permission to use their material has been obtained, but client names and identifiable details have been changed.
REFERENCES
1. Eliot TS. Four Quartets. London: Faber and Faber; 1944.
2. Holmes J. The brain has a mind of its own: attachment, neurobiology, and the new science of psychotherapy. London: Confer Books; 2020.
3. Adams M. The myth of the untroubled therapist: private life, professional practice (2nd ed). Abingdon: Routledge; 2023.
4. Holmes J. Termination in psychoanalytic psychotherapy: an attachment perspective. European Journal of Psychoanalysis 2014; 1(1). bit.ly/3N7Ifh2
© This article was first published in Therapy Today, the journal of the British Association for Counselling and Psychotherapy (BACP)