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Termination in psychotherapy Dr Carla Walton

Senior Clinical PsychologistCentre for Psychotherapy

Carla.Walton@hnehealth.nsw.gov.au

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Why discuss termination

Little on termination in the psychological literature (from a non psychodynamic perspective)

And yet, it’s vital for a lasting positive impact

Depending on how it’s done, it can

– either enhance the benefits of the therapy

– or diminish the effects of the therapy

It’s assumed that it’s straightforward, i.e., it will be obvious when the goals have been met and how to terminate...

– This is not always the case.

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What do we mean by termination?

Definition:

– “an ethically and clinically appropriate process by which a professional relationship is ended” (Young & Gottlieb, in press)

Contention about the term ‘termination’. Some suggest that graduation may be better, as it:

– highlights that there has been achievement

– marks the end of the formal period of education

– and the beginning of a new period of education where what has been learned can be applied and further developed

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Why terminate…?

Allows the client to own and internalise the work of therapy

Promotes independent functioning

Changes in health care delivery have led to reduced support for open ended and extended interventions

If we didn’t, we’d never get to see anyone new!

May be unethical to continue working with someone where gains are not occurring or dependence is being built

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Getting us in the space of termination

Experiential exercise:

– Picture a time when you had to say goodbye to a friend that you knew you wouldn’t see for a while

– What shows up?

– What do you want to do with that?

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When is the right time to terminate?

Depends on the philosophy of therapy and its perspective on psychopathology...

– Hence, this will differ markedly between therapies

Approximately, across all of them, rough rule of them is when the goals of therapy have been met.... But there is huge variability in this

Best point of completion is not easily defined and there are no uniform set of procedures

Perhaps no real “right” time.

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When is the right time to terminate?

And yes, despite the lack of material in the literature to guide us, we need to have some parameters for this so that we know where we’re heading and when we’ll get there.

Clinician need to share these parameters with their patients

– If the clinician has only a vague idea when therapy will end, likely that the treatment plan is non-specific about closure

– And that the therapy will end on auto-pilot

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Terminating from an ACT perspective

From an ACT perspective:

– “When valued behaviour change has been put into motion and several goals have been completed” (Hayes, Strosahl & Wilson, 1999)

The process of growth and working towards one’s values is life-long.... Hence, unrealistic to expect that we will finish that process in therapy

Clients continue to grow and make gains once therapy finishes (most ACT trials show further gains at follow-up than was found at post)

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Indicators of readiness to terminate?

The likely reason why not much is written about this – there is no formula for deciding.

Termination is an imprecise science and at the level of termination, it’s on a case by case basis.

Indicators of readiness to finish from ACT point of view:

– Openness to behaviour change.

– “on a rating of 1 to 10 of how committed are you to moving forward with your planned actions, making room for uncomfortable moments along the way?”

– Clients should give rating of 7 or higher.

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Indicators of readiness to terminate

Can the client re-orient themselves to the path of living by their values when they stray?

If they can’t, why not?

– Is it a lack of clarity around values?

– Is it a skills deficit, i.e., lack of skills to accept and defuse?

– ???

Move therapy targets to the barriers to being able to re-orient themselves to values.

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What about minimal behaviour change?

“It can be a potential trap to view the client’s behaviour change as a requirement for therapy to be considered a success” (Hayes et al)

If commitment waivers or the client returns to avoidant patterns... Therapist needs to acknowledge that no matter how carefully the stage is set for the client to choose valued actions, only they can choose.

Acknowledge with the client that whatever they choose is a legitimate choice.

Time-limited therapy may help.

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How should termination occur?

Paradoxically enough... begins in first few sessions

– When the initial direction of treatment is planned

– Informed consent is obtained

– Client is oriented to therapy participation

Termination is presented as component of the entire process of planning and treatment evaluation

May wait until after a few sessions and you have an idea of the client before discussing

Assess client’s expectations for how long they expect therapy will take

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How should termination occur?

At the end, potentially tapering off to allow the client to adjust to the removal of the social support, reduce to fortnightly then monthly.

Ensure that the client’s plan is moving forward and allows you to check in on the appropriateness of termination.

Hayes et al suggests labelling it as a ‘field experiment’.

Let them know that they know they can come back.

– Metaphor of teenager leaving home.

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Challenges with termination

Best point of completion is not easily defined and there are no uniform set of procedures…

– So nothing to guide us with the task

It’s hard for both client and therapist. Therapy involves both building a strong therapeutic relationship that can be hard for both to let go of.

For some, the therapeutic relationship may be the best relationship they have ever had

There are often minimal incentives for the client to want to finish (basically time and money)

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Challenges with termination

Termination may be forced before you or the patient or both are ready.

We often want a little more time, to do a little more work.

We need flexibility to address different client groups differently in regards to this, e.g. Dependent Personality Disorder

Wanting (a state of desire) vs needing (“for the lack of which the organism will perish”)

If desired, are there other ways this might be fulfilled?

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Challenges with termination

One of the hardest situations is where there is a strong relationship, but little progress:

– Will additional therapy produce further benefit?

– Hard for both to finish, when the goals of therapy haven’t been met

– Hard for the therapist to finish with someone when it feels like there is more work to be done.

– Some clients may be persistently resistant to termination

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

EssentialComponents

of ACT

The good old hexaflex!

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Therapist side of the double hexaflex

It is important for us to guide and to model this process:

– Clients’ values steer where therapy goes

– But our job to steer therapy

The ACT model gives us a structure to use to look at our own stuff around this.

Usefulness of using ACT on our side of the hexaflex, even if we’re using a different therapy

with the client on their side.

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Difficulty for us as therapists (Frank, 2009)

“we have come to know so personally, intimately and deeply – the person’s traumas, dreams and ideals, triumphs and defeats, strengths and vulnerabilities, joys and sorrows. This valued individual, who had the courage to place trust in us and to risk vulnerability, and who has revealed herself deeply, acting as a determined collaborative partner, is moving on. When our formal relationships with patients end, our interest in them does not” (p.148)

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Clarifying values

Values for us as therapists

– we can use this to anchor the therapy.

Experiential exercise:

– How do you want to be as a therapist?

– What will you expect of the client

– How will you know that the treatment is ready to end?

Values for clients:

– Information in the loss of the therapeutic relationship about what they care about

– How can they honour this?

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Mindfulness

Mindfulness for us as therapists:

– Are we on autopilot or are we in touch with where we are going?

Mindfulness for clients:

– Are they there with you now, doing this work or are they worrying about when they’re going to finish?

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Getting at fusion and avoidance

Experiential exercise:– Think of someone you need to finish up with or

are thinking of finishing up with

– Picture going in to the next session and telling them that this is going to occur

– Notice how they react

– Notice what shows up for you

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Acceptance

This will be the loss of a potentially cherished human relationship.

For both therapist and client, many painful feelings may show up:

Sadness Fear Disappointment

it is human to experience these at the end of a relationship

Not finishing can be a very effective way of avoiding these.

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Defusion / Self as context

Defusion for both therapist and client:

– The client is not ready to finish

– I / they will not cope

– I don’t want to lose them

– We’ve got more work to do

Notice how all of the above pushes us around.

Self as context:

– Sooo important - from this safe and permanent place, we can hold all of this.

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Keep the conversation alive in the room

Invite your client to share their reaction to the ending of therapy.

Give space for what they bring and watch for their fusion and yours.

– “remember that your mind is not your friend. Now is a time for your mind to do what all minds do, which is to create all sorts of chatter and negative thoughts about this being our last session together – thoughts like maybe your depression will come back and you’ll be overwhelmed and so on”

be willing to offer your own reactions

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Committed action

What’s here to be done?

Based on what’s been looked at today, is there something that has arisen from that that needs to be worked on?

Is your practice consistent with your values?

Have you become aware of overt or more subtle ways that you have opted out?

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Take home message

Plan it

Review it frequently

Feel it