Negotiating ending: A qualitative study of the process of ending psychotherapy

Objectives: When psychotherapy is open-ended, the question of termination is a matter for negotiation. A model based on both content and the process of ending may explain how ‘good enough’ psychotherapies can be brought to ‘good enough’ endings.

Design: Twelve processes of ending were explored through a combination of audio recordings made during therapy sessions and post-therapy interviews with clients and therapists. Therapies had been tailored to the needs of the clients and were based on a broad spectrum of theoretical affiliations.

Methods: A procedure for systematic text condensation was used on a case-by-case basis. Issues surrounding the initiation and negotiation of ending were pointed out in each case and were then compared across cases.

Results: The initiation of ending and exchanges concerned with when and how to end therapy unfolded as a concerted process because both parties seemed to be aware that the theme of ending contained a potential challenge to the alliance. Dual affect regulation, implicit communication and a future-oriented perspective were important features. Structural elements such as schedule changes and temporary breaks served several psychological functions. Therapies seemed to reach ‘good enough’ endings when the client and therapist joined in their efforts to resolve basic ambivalences embedded in the decision to terminate contact with the affirmation of a continuing emotional bond.     

Learning from within: Therapists' actions in daily clinical practice

The integration of theories and techniques is part of family therapists' daily practice, raising the need to understand which resources are used in this professional's clinical actions. Our aim is to reflect on the use of theoretical and technical resources by family therapists in their daily practice. We developed an inquiry process inspired by collaborative action research and social constructionism. Couple and family therapy sessions were conducted by two family therapists, and we developed subsequent dialogs with them focused on describing theoretical and technical inspirations for their actions. Next, we named four categories of actions in this process: exploratory actions, actions for the construction of relational visions, actions for the construction of communication, and actions for family orientation. The therapists-participants referred to many theoretical and technical resources that inspired their practice. For them, the choice of using one or another resource was based on the demands of the interactive moment, which involves their relational and embodied responses to what was experienced in the sessions. We argue that epistemological coherence is not something that guides the therapist's practice a priori, but something that can be achieved by talking about and reflecting on their actions. This article can contribute to clinical practice and training in family therapy by presenting an interesting reflexive process that can be useful to enhance practice in couple and family therapy (FAPESP, Process n. 2015/21316–1).     

The Relationship Between Dropout and Outcome in Naturalistic Cognitive Behavior Therapy

Dropout from psychotherapy is frequent and limits the benefits patients can receive from treatment. The study of factors associated with dropout has the potential to yield strategies to reduce it. This study analyzed data from a large sample of adults (N = 1,092) receiving naturalistic cognitive behavioral therapy (CBT) to test the hypotheses that dropouts, as compared to completers, had (1) higher symptom severity at treatment termination, (2) a slower rate of symptom change during treatment, and (3) a higher odds that the therapist rated treatment as ending for reasons related to poor outcome. Results showed that although dropouts ended treatment with higher symptom severity than completers, dropouts and completers did not differ in their rate of symptom change during treatment, suggesting that dropouts had higher symptom severity at termination because they received fewer sessions of treatment, not because their symptoms changed at a slower rate. Dropout was also associated with a higher odds of having a therapist-rated termination reason indicating a poor outcome, suggesting that dropout is more likely if patients are dissatisfied with some aspect of the therapy outcome or process. These findings suggest that strategies for monitoring and enhancing patient satisfaction with the process and outcome of treatment may help patients stay in treatment longer and end treatment with fewer symptoms than if they had dropped out.     

Termination,Terminable and Interminable: Commentary on Paper by Jody Messler Davies

The termination process begins while the analytic couple is preparing together to end treatment. Mourning the loss and binding the edges of the analytic relationship proceed within each participant after they no longer meet. Many of our common termination practices, however, undermine the patient's leave taking and endanger the positive internal object relationship that we hope our patient will carry into the future. Traditional teachings about how to practice termination, based on one-person psychology and classical principles of anonymity, abstinence, and neutrality, must change to reflect newer ideas about how analysis works. I propose that we think of termination as both a death and a graduation. I suggest ways in which the analyst might engage with the patient in mourning together. I stress the critical importance of follow-up sessions in which unanticipated negative reactions to the termination might be examined before the analytic tapestry has a chance to unravel.     

The Nature of the Co-Therapy Relationship

Termination is a complex phase in the total therapeutic process. Criteria for termination of long-term analytic group therapy encompass both intrapsychic and behavioral changes. One of the useful ways of conceptualizing the termination phase is in terms of the issues of separation-individuation. Three different kinds of termination that can occur and the techniques for working with each are described. Multiple transferences are worked with in the long-term analytic group and both real and transferential losses acknowledged. The ability to leave group therapy with a stronger, better defined sense of self is one of the goals of therapy.     

The concept of termination and the evolution of psychoanalytic thought

Termination is a post-Freud contribution to the psychoanalytic process, which is never complete. The concept is illuminated in its analytic history and development. A formal well-defined terminal phase led to a tripartite psychoanalytic process which derived from and contributed to advances in psychoanalytic theory and knowledge. The terminal phase is a valuable addition and conclusion, but may be invested with irrational expectation and analytic myth. Various features and formulations of the terminal phase are explored, and the limitations of termination are noted.     

Coming to an end: A case study of an ambiguous process of ending psychotherapy

Aim: When the duration of therapy is not preset and the outcome is a matter for negotiation, the decision to end psychotherapy will be an experiential concern for the two participants. This case study draws attention to how ambiguities may be settled in a process where ending is initiated by the therapist and resisted by the client. Method and analysis: The actual case was strategically selected as exceptional owing to a combination of circumstances. The client and the therapist had developed a ‘good enough’ alliance (WAI) and reached a ‘good enough’ outcome (OQ‐45), and still the client felt she was far from finished. A close inspection of interactional data in sessions together with both clients' and therapists' reflections in post‐therapy interviews elicited information about both substantial content and structural aspects of this complicated process of ending. Findings and discussion: The discrepancy between therapist and client was not addressed, but rather postponed and revisited again later. Structural elements like preparations for a break for vacations and reducing the frequency of sessions were used to test experiential qualities, such as how the client managed life without therapy. Carefully preserving a ‘good enough’ emotional bond through the negotiations seemed important to both parties. Significantly, the client's autonomy was interpreted as the final proof of improvement and the client came to a point where she could affirm that she had got better only by accepting that treatment was coming to an end.     

Brief encounters and available places to land

In this paper the author addresses the process of ending in brief therapy. While recognizing the importance of attending to the symbolic meaning of the ending itself and the need to interpret this as it manifests in the transference, he points out the limitations of such an approach. He highlights the significance of the environment of interpersonal relationships and family systems and the wider communities in which the client lives. He suggests that the therapist needs to assess the extent to which these can provide an environment that facilitates the client's development and working through as the therapy ends. The therapist needs to establish whether the patient will have an available place to land, and one that provides sufficient security and safety for the client's onward journeying and exploration without the therapist. The author's conceptualization of 'landing at the end of brief therapy' links together Malan's triangles of insight with Sullivan's concept of the ordinary solution and selective inattention and Gustafson's concept of dilemmas to add depth to the therapeutic effectiveness with which the practitioner can approach brief therapy in general, and the ending in particular. The article concludes with a case example that illustrates these themes.     

Leaving whom? Motherless families: problems of termination for the female family therapist

The issue of planned termination is seldom addressed by family therapists. Given the goals and assumptions of most family work the concept may indeed be irrelevant, but there are circumstances where it is necessary not only to understand the principles of planned termination, but the factors in client, family and therapist which can make it difficult to terminate at all. This may be the case where a female therapist has been working with a family where father is the single parent (motherless family): the family may experience itself as incomplete and attempt to draw the therapist into the family to fill the gap left by mother and marital partner, and pari passu the therapist may assume that the family cannot well cope without her. Some strategies for resolving the problems of termination which may arise from such assumptions are described.     

A comparison of attachment outcomes in enactment-based versus therapist-centered therapy process modalities in couple therapy

Attachment issues are viewed by many therapists as lying at the heart of couple distress. It is critical to empirically validate therapy processes that facilitate couples in responding to each other's attachment needs. This study examined enactments as a therapy process and change mechanism to promote secure attachment in couple therapy. Sixteen couples were randomly assigned to 1 of 2 experimental groups--1 group received 3 therapist-centered sessions followed by 3 enactment-based sessions, and a second group received 3 enactment-based sessions followed by 3 therapist-centered sessions. To measure between-session and within-session change, each spouse completed presession and postsession measures of attachment security each week. Results showed that couples who received enactment-based sessions first reported greater increases in attachment security than those receiving therapist-centered sessions first. These same couples continued to show improvement after switching to the therapist-centered sessions. Conversely, couples who received therapist-centered sessions first did not increase attachment after switching to enactment-based sessions. For wives, enactment-based sessions produced the greatest improvement in attachment, yet both therapy process modalities led to some improvement. Conversely, for husbands, attachment improved only when they received enactment-based sessions first. Enactment-based sessions may therefore be more important for husbands than wives. Overall, with some qualification it appears that enactment-based therapy process may improve attachment more than a therapist-centered process. These observed trends and findings are generally consistent with previous research supporting use of enactments in couple therapy.     

Termination as a therapeutic intervention when treating children who have experienced multiple losses

Children who have endured traumatizing events often have a history of prior disruptions and losses which also have been experienced as traumatic. Termination of therapy with these children, therefore, provides a unique opportunity for the clinician to provide the traumatized child and his or her caregiver with a new experience of loss; one that is controlled, predictable, and paced. Through this experience, the child and caregiver can develop a new model for loss, one that permits for losses that are a natural part of healthy growth and change. This article outlines one approach to utilizing termination as an integral component of the therapeutic process with infants, toddlers, and preschoolers and their caregivers. Using a psychodynamic model and working dyadically with the child and the caregiver, termination is approached as a primary intervention, pivotal to the successful treatment of this vulnerable population.     

Treating Parents and Children Together

SUMMARY

In this paper I look at two traditions of psychotherapy with children: family therapy {here considered in its common paradigm of systems theory and not in its diversity of approaches) and individual psychodynamically oriented child therapy. The author examines how, in these two modalities of treatment, the real world of the parent-child relationship, which remains mostly a world of women and children, tends to be left out in practice. Many family therapists “exclude” children from their sessions and concentrate on the marital relationship while child therapists “exclude” parents from the core of the therapeutic process. The issues for therapists and the consequences for adults and children in families in this com-partmentalization of services are examined within a feminist framework. The development which is advocated is for therapists to expose themselves fully to the world of the parent-child relationship as a fust step in reexamining their stereotypical views of motherhood and fatherhood which trap women in conflicted and potentially exploitative situations and do not consider that children actively construct their own relationships.     

Poetic closure, psychoanalytic termination, and death

Our pull to grasp narrative structures--including beginnings and especially endings--applies not only to the intentional craft of fictions, but to life as lived, as it is in psychoanalytic termination. Remarkable parallels, for instance, exist between thematic closure in poems and the conscious and unconscious signals of closure that develop in pretermination and accelerate in termination proper. A case illustrates this point: the slow crescendo of cues begins months before the first "pretermination dream." It is the patient's emerging awareness of greater health and freer functioning that likely gives rise to these phenomena, yet this awareness is often warded off because of the grave task of ending that it implies. Literature and psychoanalysis share concerns with how an ending is borne. Fictive closure and apocalyptic narratives allude to or imply finality (i.e., death), and lesser "endings" in daily life may not escape the specter of that linkage. But Kermode asserts that "ending" confers significance on an entire narrative and may thereby console us. Coltart links the realities of mortality and psychoanalytic termination, yet falls short of consolation. Clues to the role of beginnings (in final matters) and how they may help emerge from considering Basho's last days and poems. Nonetheless, the power of narrative has its limits in helping us bear the burden of a real ending, as of an analysis. Joining present to future, as through normal hope, or joining present to past through normal nostalgia, works toward a "bearing of the burden"--but only within the context of health achieved through the analysis.     

In-session gaming as a tool in treating adolescent problematic gaming

For some adolescent gamers, playing online games may become problematic, impairing functioning in personal, family, and other life domains. Parental and family factors are known to influence the odds that adolescents may develop problematic gaming (PG), negative parenting and conflictual family dynamics increasing the risk, whereas positive parenting and developmentally supportive family dynamics protecting against PG. This suggests that a treatment for adolescent PG should not only address the gaming behaviors and personal characteristics of the youth, but also the parental and family domains. An established research-supported treatment meeting these requirements is multidimensional family therapy (MDFT), which we adapted for use as adolescent PG treatment. We report here on one adaptation, applying in-session gaming. In-session demonstration of the “problem behavior” is feasible and informative in PG. In the opening stage of therapy, we use in-session gaming to establish an alliance between the therapist and the youth. By inviting them to play games, the therapist demonstrates that they are taken seriously, thus boosting treatment motivation. Later in treatment, gaming is introduced in family sessions, offering useful opportunities to intervene in family members' perspectives and interactional patterns revealed in vivo as the youth plays the game. These sessions can trigger strong emotions and reactions from the parents and youth and give rise to maladaptive transactions between the family members, thus offering ways to facilitate new discussions and experiences of each other. The insights gained from the game demonstration sessions aid the therapeutic process, more so than mere discussion about gaming.     

Treating family relational trauma: a recursive process using a decision dialogue

This article describes a therapeutic process that combines individual and family sessions to maximize therapeutic opportunities to bring forward, understand, validate, and empower children's experience as equal participants in family therapy. The aim is to strengthen relational bonds within the family. Drawing from earlier work with families where incest had occurred, the authors present a recursive process that utilizes a "decision dialogue" to link individual and family sessions. Clinical examples are provided.     

'We are the stuff that dreams are made on': the use of dreams in systemic therapy

This paper considers the place that dream material has occupied in therapy, and particularly family therapy. A rationale will be given for the inclusion of this source of information by systemic therapists. The use of dreams in systemic therapy with individuals, couples and families is described. Dreams are divided into five main categories: those that precipitate therapy, provide hypotheses, as memories, relationship dreams, and those that reflect the process of change. Each category is described and illustrated with relevant clinical material. The paper concludes with a method for working with dreams that is congruent with a systemic perspective applicable to individual, conjoint or family therapy sessions.     

Drawing a family map: an experiential tool for engaging children in family therapy

Inclusion of children in the treatment process is a central aspect of the discipline of family therapy. Young children's verbal skill and level of abstraction may not be suited to ‘talking therapy’, but they have an intuitive grasp of family life which is invaluable, and their views and needs should be considered when effecting change in the family system. A method is offered to engage young children, adolescents and adults of divergent verbal skills into a shared process. It requires no special set‐up or tools, only paper and markers. Distance and proximity are represented in a simple map of the family, adding symbols for affection and conflict. A spatial representation of the family system is created, and may be referred to in the course of the therapy.     

When Are Clients Ready to Terminate?

Termination of psychotherapy has received less attention in the research literature than other aspects of the treatment process. This paper presents a structured framework emphasizing observable markers to indicate when termination with a client is appropriate during cognitive behavioral treatment. The 7 criteria that indicate when a client is ready for termination are: (a) decrease in symptoms as assessed by sound measures; (b) decrease in symptoms that is stable and maintained for 8 weeks; (c) decrease in functional impairment; (d) evidence that the decrease in symptoms is not a spontaneous remission, such as lower symptoms associated with the use of new skills; (e) usage of the new skills, particularly at times or on themes of former vulnerability; (f) sense of pride regarding the new skills, in contrast to initial doubt regarding whether the techniques would work; and (g) carryover of decrease in symptoms to other areas. A case report and discussion regarding the clinical application of the framework is presented.     

Dilemmas in kinship care: negotiating entitlements in therapy

This paper considers how ideological dilemmas that arise in therapy can be analysed usefully for therapeutic practice. The focus is on the particular situation of kinship care families where family or friends are caring for children without birth parents being present. In the process of family members negotiating the entitlement to care and to be cared for, multiple possibilities about family constructions and authorities throw up many dilemmas for therapists and families. Based on the author's research study with kinship care families, a method for linking discourse theory and therapeutic practice through the use of discourse analysis and positioning theory is explored, with reference to the hierarchical method of the Co‐ordinated Management of Meaning model. The paper contends that a consideration of ideological dilemmas in conversation is a core part of any therapeutic encounter, which needs to be recognized and considered in order that those involved in therapy may reflect on several possible futures and so open up the space for future decision‐making.     

Predicting premature termination within a randomized controlled trial for binge-eating patients

Understanding the dropout rates of efficacious forms of psychotherapy for patients with binge eating disorder (BED) is an unsolved problem within this increasing population. Up until now the role of psychotherapy process characteristics as predictors of premature termination has not been investigated in the BED literature. Within a randomized controlled trial (N=78) we investigated the degree to which early psychological process characteristics, such as components of the therapeutic relationship and the experiences of mastery and motivational clarification, predicted premature termination of treatment. We statistically controlled for the influences of covariates such as rapid response of treatment, treatment group, body mass index, Axis II disorder, and patients' preexisting generalized self-efficacy at baseline. Patients' postsession reports from Sessions 1 to 5 indicated that low self-esteem in-session experiences was a stable predictor of premature termination. Its predictive value persisted after controlling for the above-mentioned covariates. Exploratory analyses further revealed low self-esteem experiences, low global alliance, and low mastery and clarification experiences as predictors in those patients who explicitly specified discontentment with therapy as reason for premature termination. These results indicate that patients' self-esteem experiences may not be an epiphenomenon of their specific psychopathology but may represent general mechanisms on which remaining or withdrawing from psychotherapeutic treatment depends. Early psychotherapy process characteristics should therefore be considered in training and evaluation of psychotherapists carrying through BED treatments.