It’s a long standing joke that a therapist’s primary goal is to work themselves out of a job. Many therapeutic models support the notion that most presenting problems can be worked through therapeutically and once the client perpetually reports low levels of symptoms then the termination process can begin. Session frequency declines, the last session is planned, and the therapist and client part ways for an indeterminate amount of time. This is not to say that clients cannot reach out in the future if needed, but the verbalized hope is that the client will be able to adequately manage stress that arises by using coping skills learned in session. However, like most of us are aware, stress ebbs and flows and problems can arise in a different form that feel novel and scary. Interestingly, I find that mental health is one of the only fields under the umbrella of medical care that does not incorporate yearly or bi-yearly check-ins.
Could you imagine going to your primary care Doctor for a physical and having them tell you, “It seems like you’re doing well right now so there’s no need for you to schedule any future check ups!” or for your dentist to say, “As long as you continue to brush and floss twice a day you’re golden.” We have come to understand and accept that checking in with a professional on a yearly basis helps to address current concerns, prevent symptom flare up, and identify problematic symptoms early on so treatment can be initiated before it intensifies. We do this in all other forms of our medical care except for arguably the most important organs we need to care for-our brains.
So why isn’t this already standard practice? I have a few ideas.
In the realm of therapy, when a person has met their agreed upon goals and consistently reports that they are mentally, emotionally, and physically well they enter into the maintenance phase. Maintenance is typically scheduled as monthly appointments to ensure that a person is coping with stress in adaptive ways and has an avenue for additional support if needed. Because the client is still on their clinician’s caseload, they can increase frequency more easily than if they are considered an inactive client. Most clinicians set expectations about how many weeks can elapse between sessions during the maintenance phase due to liability purposes. If a client’s status is active then the clinician is taking on a certain amount of responsibility for their care and degree of wellness. The therapeutic relationship is an agreement that the clinician has the education and experience needed to treat the concerns reported by the client and that the client is willing to commit a portion of their time and energy into deep reflection and behavioral change. If too much time elapses between appointments, it becomes more challenging to ensure that the client’s mental health is stabilized. All of this is to say that check ins every several months or yearly leads to confusion about whether a client is considered active or inactive. Due to the amount of responsibility that comes with caring for an active client, clinicians want to have a clear understanding of who they are actively treating.
Another possible hindrance to ongoing therapy sessions is the concern about formation of dependence on the therapist. A deep attachment forms within the context of therapy due to the intimate nature of content shared within session. It’s natural to feel nurtured by a therapist and hesitant to say goodbye, even when both parties agree that the bulk of the therapeutic work has been completed. Much like a parent aims to launch their adult child with skills to manage their obligations, a therapist hopes to launch their client with the skillset necessary to navigate life’s stressors. Problems can develop when a client leans solely on their therapist for support rather than differentiating their support network. Seeing clients on an ongoing basis needs to be assessed to ensure that the relationship hasn’t shifted into the zone of friendship or codependency where the relationship is used as a vessel to sooth each party’s relational wounds. Therapists also recognize that there are tremendous benefits to helping a client end relationships in a way that is emotionally safe, prepared for, and determined to be mutually beneficial. Closing treatment provides for closure, allows the client to explore what arises when relationships end, and upholds the boundaries of the relationship.
It's clear that the therapeutic relationship differs in many ways from the relationship one might have with their doctor or dentist which tends to be more symptom focused and solution based. However, health concerns fluctuate over time and I can’t help but wonder if we are limiting client access to a much needed part of their routine medical care. I believe mental health as a field should normalize check ups that allow boundaries to be maintained while providing an opportunity for clients to state their concerns, work through recent challenges, and refresh their coping skills to renew their sense of confidence and self efficacy that led them to therapy termination in the first place.