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When Therapy Stalls: Why Progress Pauses and How to Respond

Why You Should Read This Article

Whether you’re a therapist, a student in training, someone currently in therapy, or simply curious about how therapy works, this article offers a rare look at what happens when treatment reaches its limit.

Psychiatrist Dr. Jason Shimiaie reflects on the moments when therapy stops moving forward and explores how clinicians can discern when to keep going, when to refer out, and when to accept stability as success. Drawing on both clinical insight and the writings of Bromberg, Kohut, and Salberg, he shows that endings in therapy can hold meaning and care rather than failure.

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How to Acknowledge Reaching a Limit in How Much You Can Help a Patient and How to Decide Whether to Refer Out or Accept Stagnation by Jason Shimiaie, M.D.

All therapists, from time to time, encounter patients who stop changing, or realize they haven’t changed much to begin with. What once felt like forward movement starts to flatten. We try new interventions, consult supervisors, read, reflect, and still the sessions sound familiar. The air in the room thickens. We interpret, we analyze transference and countertransference, we search for meaning in the stalemate. Nothing moves.

It’s rarely said aloud but some patients may not change, or at least not in the ways we hope. Accepting this can transform the work by shifting us from chasing growth to appreciating stability. Sometimes our job is not to move the patient upward but to keep them from collapsing. In other cases, the most humane act is to see that the treatment has reached its natural limit and to consider referral or termination.

This truth can be hard to face. Our professional identity is built on helping. To acknowledge limitation can stir guilt, shame, even fear of failure. Yet learning to see this acceptance as a form of caregiving, toward the patient and ourselves, is a mark of professional maturity.

Why Therapy Stalls

Defenses are not arbitrary. They are the scaffolds that once kept a fragile mind intact in the face of danger. Over time, those structures become reinforced, both psychologically and neurologically, until change feels threatening rather than liberating. Giving up defenses can feel like giving up oxygen; we play the cards we know.

Sometimes those defenses remain necessary in the patient’s current life. Asking them to relinquish these strategies may not be possible, no matter how empathic or insight-oriented we are.

Sometimes the treatment relationship itself meets the limit. If a therapist too closely resembles a traumatic figure from the past, a powerful transference can take hold. The patient may begin to act in rather than think through, repeating rather than reflecting. In such moments, the work may be constrained by what Bromberg calls “the edge of the patient’s window of self-observation.” The very process meant to expand consciousness becomes the stage on which unthinkable fear plays out.

How Stagnation Feels in the Room

When this happens, the clinician often feels it first. There’s an ache that sits in the body, a mix of frustration, inadequacy, even quiet resentment. We push harder, try to rescue, or begin to drift away internally. The work starts to feel like a mirror of our own doubts.

Many patients, though, find comfort in the familiar rhythm. They may not want change. Our constancy may be their one reliable holding environment. As Kohut reminds us, empathic attunement and mirroring can be deeply reparative, even when insight is minimal. Sometimes what we’re really doing is holding up the floor by keeping someone from falling further.

Others, however, notice the stagnation and grow restless. Their frustration may reveal a limit within the dyad, not a failure of the treatment.

Then there are those dreaded patients who respond with devaluation. They may unconsciously replay early patterns of disappointment, undermining the very person trying to help. When this becomes chronic, a kind of psychotic transference that forecloses on collaboration, we have to ask a hard question: “What are we doing by staying here?” Sometimes continuing the treatment becomes a form of collusion with the patient’s own destructiveness.

When to Accept and When to Move On

Before assuming the treatment is at its limit, it’s worth slowing down. Consult, supervise, experiment. Sometimes a small shift in stance, more transparency, less pressure, a different rhythm, can change the energy. As Bromberg reminds us, countertransference itself can become a living instrument of discovery. When shared thoughtfully, our frustration and concerns can help a patient glimpse their own impact and see what is being re-enacted between us.

If this process still doesn’t move, we must face the question of capacity (both the patient’s and ours). Some patients cannot risk dismantling their defenses without disintegrating. For them, stability is success. Others may need a new therapist or setting to move further. The task is not to fix everyone, but to discern what kind of help is still possible. Sometimes that means staying and holding. Sometimes it means letting go.

The Meaningful Termination

Ending treatment requires as much care as beginning it. Termination is not an interpretation, it’s an event. It activates the deepest layers of attachment and loss. The frame shifts from analysis to enactment; we are no longer talking about endings, we are living one. In that space, both therapist and patient confront what it means to separate without destruction, to hold love and loss in the same breath.

Jill Salberg writes in Good Enough Endings that termination is “a form of mourning that can be reparative.” A good enough ending does not mean a perfect one. It means both people can stay present in the messiness without retreating into blame or denial. Salberg invites us to tolerate imperfection, to see the end not as failure but as a vital developmental process: mourning as transformation. When a treatment concludes in this way, it becomes a new relational experience in itself, one where both parties discover that separation need not equal abandonment.

In practice, a meaningful ending involves naming what is happening, acknowledging what was achieved, and making room for what remains unfinished. It means allowing real feeling into the room without crossing the boundary of the professional frame. For the patient, this can model an ending that carries dignity instead of shame. For the therapist, it is also a time of mourning and integration, a quiet reckoning with our own attachment to the work. To end well is to affirm that even within limits, care retains meaning. Holding up the floor and saying goodbye can both be acts of love.

Learn More About Dr. Jason Shimiaie

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