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Internalization takes longer than therapy

Cost/Benefit determines the end of therapy

Arbitrary endings

Conducting termination

Chapter 13: When is it Over?

What the Concepts of Catharsis and Internalization Tell Us

Having an understanding of the two change mechanisms sheds light on the issue of termination. To put it simply, catharsis is complete and permanent, where internalization is gradual and never definitive. Here is how the two relate to the end of treatment:

Catharsis: To the extent that the problem is limited to emotional processing of painful realities, the work will come to completion. As long as the patient is willing and able to allow activation of the painful feelings, then they can be processed once and for all. Both patient and therapist will suddenly and dramatically reach the sense that the work is "done."

Internalization: Most therapies, even for trauma, involve extensive work with pathological internalizations. The process of internalization is slow. Discovery is eventually mostly accomplished and the therapeutic work becomes more monotonous. As the patient becomes more familiar with what has to be done, he or she may be able to take over the job. At that point, active therapy may no longer be needed. Thus, the formal therapy can end while healing and growth continue.

Emotional Development: Continuation of emotional growth and development in therapy involves both cathartic desensitization of fears associated with new behaviors, and internalization of new attitudes and values. The process involves forward movement by increments, each accompanied by both catharsis and internalization. These increments, once they are thoroughly familiar, may at some point be continued by the patient without the therapist's help.

Resolution of Transference Plans and Internal Conflict: These classic goals of psychoanalysis also involve catharsis and internalization. As the patient becomes aware of childhood wishes, there is pain and sadness as unrealistic elements are relinquished. These emotions heal through catharsis in a process similar to mourning. On the other hand, childhood plans are also represented in the form of internalized values and ideals. These internalizations do not change easily. The willingness to let go is not enough to make them melt away. In my experience, values and ideals based on five-year-old plans have the same strength and lasting qualities as any other internalizations. They, too, may outlast the therapy. Therefore, the following principle:

 

"Therapy is Over When Costs Outweigh Further Benefits"

 

This principle leads to relatively relaxed and easy clinical approach. Following the same principle, after termination, there may be times when the patient recognizes the benefit of further sessions, and a new treatment episode may be initiated. Such an open door policy is similar to the way patients seek treatment from other medical practitioners and is a feature of many practices. In my experience, it does not create problems.

On the other hand, some therapy traditions add arbitrary elements. Traditionally psychoanalysis was expected to have a definitive end, which was believed to promote autonomy and discourage dependency. In my experience, dependency, if handled appropriately, is not a liability. A more relaxed attitude about dependency and autonomy does not seem to undermine the gains of therapy.

The brief therapy tradition also introduces an arbitrary end to therapy. This, too has significant effects, forcing a focus on target symptoms, and leaving some issues unaddressed. This may or may not lead to additional treatment episodes later.

Each model has its place and proponents. My personal preference is an open-ended model in which each session, each month, and each year is expected to maintain a positive cost/benefit ratio.

 

Conducting Termination

The principle of ending therapy when the cost outweighs the benefit makes for a simple approach to termination. It is important to note that when the idea comes into view, issues around dependency become heightened. There often is a period of work on these issues before the actual end of treatment. Therefore, it is appropriate to open the subject with adequate time to work through these issues. Beyond that, a good partnership will include occasional discussions of progress made and issues remaining. Therefore, the approaching end of formal treatment will not be a surprise to patient or therapist.