Ending Therapy When It’s Not Working
If your child isn’t making progress, how do you transition to another treatment approach?
Ideally, when a child is in therapy, it’s time to end it when your treatment goals are met. The crippling anxiety has receded. The child is back in school and doing play dates. The outbursts and temper tantrums are much less frequent. Whatever the troubling symptoms were, they have abated. (For tips on ending treatment when goals have been met, see When Is It Time to End Treatment? And for information on how to take children off medication safely, see How to Take Kids Off Medication.)
But therapy isn’t always successful. And if your child isn’t making progress with their current therapist, you may need to need to try something different. How do you end a relationship with a therapist without it feeling like a bad break-up? What’s your role, and the therapist’s role, in transitioning to something new?
Assess progress regularly
The best way to make the ending of treatment less difficult, our experts say, is to be candid with your therapist from the beginning of treatment. At the outset, it’s important to agree on the goals you hope to achieve with therapy. And as you go along, there should be regular check-ins to discuss how much progress your child is making. They should be built into the process — say, every month — and not just something that happens when there is a crisis.
For check-ins to be effective, parents need to be honest about doubts and concerns they are feeling. Where’s the area that we need to see more improvements? Where is this process not working out? “If the parent is unable, for instance, to implement the behavior plan that the therapist has created and thinks is so perfect, then it’s not going to do any good,” explains Carolyn Moriarty, LCSW, a clinical social worker at the Child Mind Institute. “The parent can say, ‘Okay, I think this is a great idea. I just can’t do it. I can’t reinforce. I’m not consistent enough. It’s not working.’ ”
That kind of information may not be good news but it’s critical for the therapist to hear. Often, when a family decides to end treatment, the therapist is surprised to hear concerns and issues they had not been aware of, and those things would have been very helpful for them to hear earlier, to understand the child, and the family, better.
“It’s always helpful for the therapist to have more information,” adds Heather Bernstein, PsyD, a clinical psychologist at the Child Mind Institute. And it’s good not to put off sharing it. “If the family is thinking of pulling a child out of therapy, and has been feeling that way for a while, then kids feel that too. Certainly, if parents are doubting the treatment, it’s hard for that to not trickle down and affect the child’s engagement.”
Start the conversation
If you have doubts or frustrations, speaking up about them can lead to fruitful discussions, whether they end in a decision to stop treatment, or a better understanding of why it would be good to continue.
“You’re not going to see progress every single time your child has a therapy appointment,” says Stephanie Lee, PsyD, head of the ADHD and Behavior Disorders Center at the Child Mind Institute. “But I think if the trend is not moving in the right direction, it’s definitely worth a revisit of your goals, or revisit of the frequency and dosage of treatment, the style of treatment, to make sure that you really are getting your child’s needs met.”
“Sometimes a parent is thinking, ‘I don’t know what my kid’s getting out of this,’ or, ‘I don’t know if I, as a parent, am learning a lot. Are we done?’ ” says Rachel Busman, PsyD, the director of the Anxiety Disorders Center at the Child Mind Institute. “When that happens, you should definitely talk to your clinician.”
Sometimes parents avoid discussing the possibility of changing or ending treatment because they don’t want to hurt their therapist’s feelings. But therapists need to be able to hear uncomfortable information and be open to the possibility that a child may need some kind of care that they can’t offer.
“A big part of therapy is being able to name the uncomfortable thing that is happening,” observes Moriarty. “And so as therapists we need to be open — and I think most of us are — to the idea that we cannot be all things to all people. And that there may be a better fit of a different therapist for your child or for your family. And that’s completely okay.”
One thing that can help parents feel more comfortable about bringing up their concerns is to talk about quantifiable results, notes Dr. Lee. “I think trying to use objective data to make your points can be really powerful and help parents to feel a little bit less like it’s a personal thing. It’s not, ‘I don’t like your style,’ but more, ‘I’m not seeing the results I’m looking for in terms of the number of tantrums per week. It’s still at a really high rate.’ ”
Or you might bring in objective reports from school. For instance, “I think that we maybe need to shift gears, because we’re still having a lot of interruptions when the teacher is trying to do this at school.”
When the clinician thinks treatment isn’t working
Sometimes it is the clinician who feels that treatment isn’t working, and the family needs to go to a different approach. It can be a difficult conversation, Dr. Bernstein notes, but it’s the clinician’s responsibility to recommend treatment that they feel is going to be the most beneficial.
This can be difficult for the therapist, she notes. “The child might feel comfortable with you and you might have a really good relationship, but if you can’t provide them with the treatment they need, and they’re not doing the things that you are recommending — just coming to see you — it’s not good patient care to just keep them in a cycle.”
Another reason a clinician might feel the current treatment shouldn’t be continued is when the clinician and parents have different expectations for how therapy should work. If, for example, the child’s behavior is an issue, the parents might want the child to have individual therapy, but the clinician might feel they need to work with the parents, notes Dr. Busman. “There may be things going on that aren’t going to change without significant parent involvement. Sometimes the clinician has to say, ‘I’m not going to be able to help you unless you can be part of this work.’ ”
Discuss follow-up care
When therapy ends, it’s the role of the therapist to help guide the family towards alternative treatment, our experts say. In some cases the child might need a higher level of care — like in-patient treatment — or a more specialized or intensive form of treatment, and the therapist can make that recommendation, and steer the family towards a way to find it.
“It’s not the therapist’s job to find the other person and make sure that the family is totally tucked in with a perfect therapist,” notes Dr. Bernstein, “but to help them along the way.”
For instance, if a child has mood symptoms and isn’t making progress with CBT, the therapist might recommend a DBT program instead, though it might be something they’re not qualified to do. “Then the next step is on the family to follow through with that treatment recommendation, ” adds Dr. Bernstein.
Our experts emphasize that parents should not be discouraged or give up if their first attempt at care for a child isn’t successful. “Your first stop might not be the right fit and you may need to keep going,” says Dr. Lee. “Model for your kids that you’re persistent in seeking help. That if you don’t get help from the first person you go to, you go to someone else or you find someone that does have the expertise that you need. Therapy is a process. Just like any other medical service, it may take a little while to find the right avenue.”