When Is It Time to End Treatment?
And if you’ve reached that point, how should you go about it?
When you have a child in treatment for emotional or behavioral problems, it can be hard to know when it’s time to stop. What role should parents, the therapist and the child have in reaching that decision? And how can you ensure that the ending will be a positive experience for the child?
In general, our experts say, it’s time to wind down therapy when your treatment goals have been met. That could mean, say, getting the child back in school, reducing symptoms of anxiety or depression, or seeing fewer tantrums. On the other hand, if treatment isn’t working — if the child hasn’t made progress — it may be time to change course and consider a different approach. (See Ending Therapy When It’s Not Working. And for tips on how to take children off medication safely, see How to Take Kids Off Medication.)
Set goals early and have regular check-ins
A good ending for therapy is set up from the beginning. The key is establishing clear, measurable goals at the outset of treatment, and having check-ins along the way to discuss how much progress has been made. When the therapist and the family have been working towards specific goals, and marking progress along the way, it should be clear when an endpoint is near.
“You start by asking, ‘What’s the point of all of this? What are we working towards?’ ” says Heather Bernstein, PsyD, a clinical psychologist at the Child Mind Institute. “And then along the way, you’re constantly assessing, ‘How much closer are we getting to those goals?’ ”
The scheduled check-ins should be an opportunity for everyone to be transparent about what’s working and what’s not. The child can report how they’re feeling, and parents and teachers can add observations about the behaviors they’re seeing. And as you’re getting close to reaching your goals, you have a forum ready for conversations about ending treatment.
Part of the purpose of these check-ins is for the child to see how the work they’re doing in therapy is paying off. “For kids it feels good when they’re getting feedback that they’re doing a really good job and that they’re making an improvement,” notes Dr. Bernstein. “And I think being able to link a reduction in symptoms to the work that they’ve done is important at the end of treatment, too.”
Goals should be realistic
One thing to keep in mind about ending treatment is that the goal shouldn’t be perfection. No child is always compliant with adults or is never anxious. “You don’t want to set a goal that your child listens to you 100% of the time,” notes Stephanie Lee, PsyD, head of the ADHD and Behavior Disorders Center at the Child Mind Institute. “In fact, the research suggests that five-year-old kids only follow their parents’ directions 75% of the time on the first command. You don’t want to set a goal that’s above and beyond what we would consider typical.”
Sometimes it’s hard for families to decide how much progress towards a goal is enough, points out Rachel Busman, PsyD, head of the Anxiety Disorders Center at the Child Mind Institute. “Let’s say you have a child with separation anxiety, and they had been having trouble sleeping on their own or being away from parents. But now they’re sleeping on their own, though every once in a while they have some anxiety. And they’re going on play dates — sometimes they say they don’t want to go, but they generally go.” Even though the anxiety isn’t completely gone, it doesn’t interfere much in the child’s daily life, so it may be appropriate to end treatment.
Dr. Busman suggests one way to think about it: “When parents are unsure, sometimes I’ll say, ‘If your child hadn’t been in therapy, and you looked at how she’s doing today, would you think she needs to go to therapy?’ And if we’re near the end, probably the answer would be, “No, I think we’re actually doing pretty well. We’re getting through tough moments. We’re using good skills.’ ”
But don’t quit at the first sign of progress
Sometimes families may be ready to end therapy before the therapist thinks it’s a good idea. Often, that’s because the family sees the child making progress, but the therapist feels that more work is necessary to maintain that progress.
Many treatments for kids teach techniques in a specific sequence that has been tested on many children and found to be effective. Stopping in the middle of this “evidence-based” treatment, when children have learned some skills and made some progress but haven’t completed the course, can lead to early return of symptoms. Then, parents might want to start therapy again. “It can lead to the children feeling like they didn’t get a chance to round out with their therapist and that therapy is more of a punitive process,” says Dr. Lee.
Following through with therapy and wrapping it up more deliberately enables the child, and the family, to solidify their successes and to talk about how they’re going to continue those successes.
If you’re starting to wonder whether treatment is still needed, that’s a good time to talk to the clinician about where you are in the process, Dr. Busman notes. Be candid about what you’re thinking and collaborate with the clinician: “What are our goals, what are we still working on, when do you think we’ll be done?”
It may help to taper off treatment
Sometimes when a family isn’t sure whether they’re ready to end therapy, a clinician will propose decreasing frequency. ‘”Instead of stopping therapy cold turkey,” says Dr Lee, “we fade the frequency — the dosage, if you will — of therapy.”
Going from weekly to every other week, or once a month, gives everyone a chance to see how the child does with less support while still setting aside time to reinforce skills they’ve learned.
“When you do that, you don’t expect the kid to come in saying, ‘It was great. I’m completely fine,’ ” explains Dr. Busman. “Actually, what’s great to hear is, ‘I had a really hard time last Tuesday, but I did this, this, and this, and I got through it.’ And that’s a good indication to the therapist the child is using the skills. It’s your chance to say, ‘Amazing! Wow! You were your own therapist.’ ”
Discussions near the end of treatment should highlight the skills that kids have learned and are using successfully, our experts say. And it’s important to rehearse for them how they will apply those skills when they’re in difficult or stressful moments going forward.
But skills parents have learned are important, too, notes Dr. Lee. Especially with young children, maintaining progress will depend in part on the parents’ ability to support kids effectively as the therapist’s role fades.
Parents (and kids) may be worried
In some cases, the therapist feels that a child is ready to end treatment, but parents are reluctant. Dr. Busman says it’s helpful for parents and therapists to discuss what parents are worried about. How will they handle challenges that might occur? How can parents use the skills they have learned during treatment? How will therapists be available for follow-up support or refresher sessions?
Children, too, may be concerned about ending treatment. “Sometimes kids are like, ‘Oh, I don’t want to end. I really like our time.’ Or, ‘You helped me, I’m nervous,’ ” notes Dr. Busman. Addressing what kids are worried about is an important part of the last few sessions.
It’s also helpful to have a conversation about the boundaries of communication after treatment ends. “Some therapists will say, ‘I’d love to hear good news, or hear how things are going,’ ” notes Dr. Bernstein. “Some will want contact only to schedule a future appointment. But that totally depends on the therapist.” Whatever the plan is, knowing what to expect can make the transition easier for kids.
Make a plan for coping after treatment
Our experts stress that before treatment ends, the therapist, the child and the parents should work together on a plan for handling problems that arise or an increase in symptoms. “We talk a lot about relapse prevention,” says Dr. Busman. “ ‘Okay, what would you do if this symptom popped up? What would you do if you started to feel worse about this particular thing?’ ”
The plan could include skills the child could use to handle uncomfortable emotions or stressful situations. It could include an agreement that if the child experiences an increase in anxiety or depression, they will let their parents know. And there would be benchmarks for events that would prompt them to go back into treatment. Children who have anxiety or OCD often come back for occasional “booster” sessions to get support and brush up their skills.
“If they had a history of suicidal ideation or self-harm, there would be a safety or crisis plan,” adds Dr. Bernstein.
Our experts stress that the child should be involved in identifying the red flags that might indicate that they might need support again. Carolyn Moriarty, LCSW, a clinical social worker at the Child Mind Institute, notes, “Therapy doesn’t always take problems away. It just gives you skills to cope with them. And part of coping with a problem is being able to identify it when it’s happening. And so I think that a big part of ending treatment is not just that the parents can recognize when it’s time to go back, but the child can say, ‘I don’t feel right. This is suddenly really hard again.’ ”
For some children, it’s important to make sure adults outside the family are aware of the plan after treatment, to act as back-up, adds Moriarty, who treats kids in a trauma-related program in schools. “Some students have learned enough that they can utilize the coping skills and the parent can make sure that they’re supporting those skills at home. For other students, they need another person to check in with. Sometimes it’s a teacher or a school psychologist. Sometimes it’s a mentor or an afterschool program.”
The important thing, Moriarty adds, is that “ending treatment is not just, ‘And we’re done!’ There’s always a plan for following the end of treatment. And the more people who are in on that plan, the more success you’re going to have.”