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.     

We have travelled a long distance and sorted out the mess in the drawers: Metaphors for moving towards the end in psychotherapy

Aim: To explore the process of ending in psychotherapy, in particular how clients and therapists draw on their notions of client improvements and prepare for the upcoming end. Data: The data comes from an intensive process‐outcome study at the University of Oslo, Norway. The study includes audio‐recording from all sessions and separate post‐therapy interviews with clients and therapists. Twelve psychotherapy dyads were selected because they had reached a ‘good enough’ ending. Therapy duration ranged from 7–43 months. The number of sessions ranged from 10–67. Method and analysis: A hermeneutical‐phenomenological approach analysed and combined the observational and reflexive data. The analysis was carried out using a method for systematic text condensation and through reflexive dialogues with the material and between the researchers. Findings and discussion: The language of improvement towards the end of treatment seemed packed with metaphors conveying growth in both affective and relational management. Metaphors based on travel (how they have moved); cleaning (how they have cleaned up and sorted out things); sensing (how the clients have grown stronger, got their heads above water and see things differently); and the clients’ feeling of having received something (gifts or tools) are widely used. Such metaphors are created in the interaction with a mutual sensitivity to their capacity to confirm and regulate affect towards the end. In this sense, the metaphors celebrate accomplishments in a way that exceeds therapy, and the client can keep them to use afterwards.     

Therapists facing masks: A qualitative study of the nature of relationships between masks and relational depth

Background

Central to this research was exploring characteristics facilitating and disinhibiting meetings at relational depth to explore underlying driving factors of change. The overall aim was to explore relationships between masks and relational depth. Viewing masks as a characteristic sought to understand further the socio-cultural impacts of masks on client/patient care and decision-making to meet at depth. This research demonstrates immediate social and international context due to COVID-19.

Methods

A phenomenological methodology was utilised. The primary research vehicle was an examination of primary data from semi-structured interviews. Four therapists who had used masks within sessions (where both therapist and clients wore masks) provided data on meetings at relational depth.

Findings

Interpretative phenomenological analysis revealed four themes: ‘epicentre of aetiology’, ‘loss’, ‘masked-disinhibition’ and ‘disconnection paradox: depth through disconnection’. Findings suggest masks are a characteristic that can facilitate and inhibit meetings at depth—acknowledging common factors, including how therapists related to masks as an extended part of the client, and mutuality within disconnection to masks, not one another, was significant.

Conclusions

Findings suggest the exigent presence of masks could facilitate or inhibit meetings at depth, regulated by what masks represented to therapists/clients at moments of contact. Yet, when both therapist and client appeared mutually disconnected (to masks, not each other), they found moments of relational depth within the disconnection. Masks are suggested as a characteristic that can influence meetings at depth. Opportunities for depth seemed reliant on individual capabilities to offer depth, emphasising therapists' experiential awareness of their interoceptive process.     

The manifestation of transference during early psychotherapy sessions: Exploring an alternate data source for therapist narratives in transference research

Introduction: Previous transference studies have compared in‐session client narratives about significant others to in‐session client narratives about the therapist, limiting data to the information that clients are willing to share with the therapist. Method: The first three sessions of 30 therapies with high‐functioning individuals were examined using the Core Conflictual Relationship Theme (CCRT) method. Client narratives about others were drawn from the psychotherapy sessions and client narratives about the therapist were drawn from a Participant Critical Event (PCE) interview conducted after the third session of therapy. Results: Factor analyses of the CCRT components indicated several relational patterns: a complementary pattern of relating characterised by a devaluation of the therapist and idealisation of others; a concordant relational transfer where clients feel bad with both the therapist and others; and as clients experience control issues with significant others, they wish to adopt a submissive stance toward the therapist. The results suggest that the source of therapist narratives may influence the results of transference research.     

Coming to terms: Client subjective experience of ending psychotherapy

How do clients consider their own contribution and that of their therapist in the last phase of therapy when they are moving toward the end? Thirty-seven clients who had received therapy from highly experienced clinicians were interviewed. Since the time for ending had not been decided at the onset, clients in both short- and long-term therapies were included. Thematic case-by-case analyses were carried out. Clients actively engaged in looking back and looking ahead, as means of reflecting on their capability to handle issues on their own. The majority of clients were satisfied with what they perceived as a reciprocal engagement that enabled them to come to terms with emotionally charged issues in life and in therapy. For some clients unresolved issues remained: wondering whether a therapist with another approach could have helped more; feeling pushed away by the therapist; having to take the lead in ending therapy; the fear of being an “unworthy” client; or wanting to end without the therapist’s approval. Coming to terms with the ending of therapy was highly personally meaningful and loaded with affective tensions, in ways that were not always shared with their therapist.     

Is how it is said important? The association between quality of therapist interventions and client processing

This study examined the association between the quality of therapist interventions and client in‐session processing using the York Therapist Process Measure (YTPM; Toukmanian and Armstrong, 1998). The instrument's three dimensions — attunement, tentativeness and meaning exploration — were tested separately for their impact on clients' manner of processing and depth of experiencing. For each of the 20 mild‐moderately depressed clients, treated in short‐term experiential therapy, a high and a low client‐process segment was isolated from a session that was judged by an experienced therapist to manifest the greatest amount of “good therapy moments”. Therapist interventions within these segments were then rated on the YTPM. Results revealed significant differences in the quality of therapist interventions between high and low segments. Attunement and tentativeness were associated significantly with greater complexity in manner of processing, and meaning exploration with greater depth in experiencing. The implications of these findings for psychotherapy research and practice are discussed.     

Mindful Parenting: a group approach to enhancing reflective capacity in parents and infants

In this paper, the process of ending therapy is likened to the ordinary developmental task of ‘letting go’ that parents have to undertake, to help their child to grow up. ‘Letting go’ is contrasted with the process of ‘holding’ the child in mind that is so central to the therapeutic and parental task Following thoughts about some of the external issues that play a part in the decision to end a child's treatment, this developmental perspective of psychoanalytic psychotherapy is discussed through a clinical illustration of the ending of a 5-year-old boy's treatment. Different strands of the therapeutic relationship as highlighted during the ending phase of therapy are distinguished and attention is drawn to the role of the ‘new relationship’ between therapist and child and how this differs from the transference relationship. Countertransference issues in their broadest form are also considered.     

Therapist empathy,homework compliance,and outcome in cognitive behavioral therapy for generalized anxiety disorder: partitioning within- and between-therapist effects

Although client-perceived therapist empathy relates to positive therapy outcomes, including in cognitive behavioral therapy (CBT), little is known about how empathy exerts its ameliorative effect. One possible way is by promoting clients’ subsequent homework compliance, a variable that also predicts positive outcomes in CBT. The present study sought to investigate simultaneously, in the context of 43 therapist–client dyads receiving 15 sessions of CBT for generalized anxiety disorder, (1) the association of early client-perceived therapist empathy (averaged over sessions 1, 3, 5) with mid-treatment client homework compliance (averaged over sessions 6, 8, 10); (2) the association of mid-treatment homework compliance on client posttreatment worry severity; and (3) the indirect effect of early perceived therapist empathy on posttreatment worry through mid-treatment homework compliance. Given that clients were nested within therapists, we examined both within- and between-therapist differences in clients’ ratings of therapist empathy and homework compliance, and tested both of these indices as predictors of the relevant dependent variables in a multilevel model. At the within-therapist level (i.e., differences between clients within a given therapist’s caseload), greater early empathy was associated with greater mid-treatment homework compliance. At the between-therapist level (i.e., differences between therapists across all of their cases), greater between-therapist homework compliance was related to lower posttreatment worry. Finally, homework compliance was not found to mediate the relationship between empathy and posttreatment outcome. The results underscore the importance of parsing client and therapist effects, and are discussed with regard to their training and research implications.     

What student psychotherapists want from an experiential group

A study of four thirty-week experiential groups, involving two group conductors and forty-one other group members showed that 90 per cent of students' expectations of change were exceeded, indicating increase in interpersonal learning and, over a longer period, emotional change. the culture of the groups was consistently positive and expressive. There was some evidence that conductors had a similar style which corresponded to that predicted by the group analytic method, and that both showed behaviours which were indicators of ‘good quality' therapy. There were substantial correlations between a positive culture and better than expectation outcome at the end of term one, and good psychodynamic practice by the conductors and outcome at the end of the course.     

Memory-enhancing characteristics of client-recalled important events in cognitive and experiential therapy: Integrating cognitive experimental and therapeutic psychology

In an attempt to encourage further integrative theorizing and experimental work across cognitive and therapeutic psychology, characteristics of therapeutic events that might contribute to their ‘memorableness’ were examined. Scales that rate five ‘information processing’ characteristics of therapeutic events were employed to score such characteristics of 55 client-identified important and 55 matched control events taken from actual therapeutic sessions of both cognitive and experiential psychotherapies. Results indicated that scales scoring the ‘depth’, ‘elaborateness’, and ‘conclusion-orientation’ of therapeutic dialogue during the events examined tended to discriminate reliably and as predicted between client-identified important and control events, particularly when ratings of therapist talking turns were examined. Limited support also was found for a second prediction based on Paivio's (1986) dual coding theory of memory concerning different patterns of results for cognitive versus experiential therapeutic events. Suggestions are offered for further research on human memory for specific events in therapeutic and other areas of applied psychology.     

Therapy Outcomes: Client Perception and Similarity with Therapist View

This study examined clients' perceptions of therapy outcome and how those perceptions related to therapist views. Additionally, the effects of client and therapist gender and ethnicity, and the match on these variables (e.g., female therapist-female client) were examined. Results showed that clients generally improved from both the client and therapist perceptions, although therapists' views were influenced by client ethnicity. There was no difference between gender or ethnicity matches on perception of outcome. Further examination showed that gender and ethnicity interacted to influence both client and therapist perceptions of outcome. The authors discuss the research and practice implications of these findings.     

Therapist orientation,supervisor match,and therapeutic interventions: Implications for session quality in a psychotherapy training PRN

Background: Theoretical orientation is a multifaceted construct that is integral to the process of psychotherapy and psychotherapy training. While some research has been conducted on personal identification with particular schools of psychotherapy, techniques used in psychotherapy sessions, and match between trainees and supervisors in training, there is insufficient information regarding how these may interact with one another. Aim: This study, conducted in a practice research network of trainee therapists, was designed to test whether these variables may be related to one another in predicting session quality. Method: The sample comprised 328 sessions from 26 clients and 11 therapists, with the clients completing session quality measures and therapists completing measures of technique immediately post‐session. Results: Using multilevel linear modelling, the data showed varied results. For behavioural therapy and person‐centred therapy, techniques and orientation were unrelated to session quality in the sample. However, process‐experiential, psychodynamic, and cognitive therapy techniques were all involved in interactions with therapist and/or supervisor orientations. Conclusions: These results suggest that the impact of specific psychotherapy techniques sometimes depends on the orientation of the therapist and/or supervisor. For instance, sessions high in cognitive therapy techniques were only associated with positive outcome when both the therapist and supervisor were highly cognitively oriented. Though preliminary, these results suggest that orientation may be an important variable to consider in training and supervision, especially in the context of other variables.     

An Integration of Feminism into Experiential Psychotherapy

Abstract

Feminist therapy altered how marriage and family therapists conceptualized their clients’ realities and psychopathology. Upon an extensive search of the literature, there is a sparse amount of literature regarding the integration of feminist therapy with experiential therapy. The authors discuss feminist and experiential therapy models, propose a model of feminist-experiential therapy, and highlight the need and fit of these theories. A discussion on giving space to silenced voices, establishing an egalitarian relationship, expanding the definition of deviance, and exploring the importance of language will be done to aid the experiential therapist in their work and expand their client’s experience.     

Emotion in an alliance rupture and resolution sequence: A theory‐building case study

Aims: Alliance rupture and resolution processes are occasions for the client to have his or her core interpersonal patterns activated in the here and now of the therapy and to negotiate them with the therapist. So far, no studies have been conducted on emotional processing, from a sequential perspective using distinct emotion categories, in alliance rupture and resolution therapy sessions. This is the objective of this theory‐building case study. Method: This client underwent a 34‐session long, psychodynamic psychotherapy within the context of an open trial. An alliance rupture‐resolution sequence of two subsequent sessions, along with a third control session, was selected from this case and these sessions were rated using the Classification of Affective‐Meaning States (CAMS), an observer‐rated method to classify distinct emotions, according to current emotion‐focused models. Results: The results indicate that the rupture session was associated, above all, with core maladaptive fear, evoked in the actual here and now of the therapeutic relationship, whereas the resolution session was associated with the expression and experience of adaptive hurt as regards biographical issues of the client. Discussion: These results are discussed with regard to the alliance rupture and resolution model and the exploration of integrating client's emotional processing in the model.     

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.     

Inside out,or outside in: meeting with couples

The complex difficulties often faced by couples require a range of models for effective help. Relational intensity is heightened in therapy by the ease with which the therapist can be triangled into the couple's relationship and by the influence of the emotional triggers from their respective internal worlds. This article draws on systemic and psychodynamic models and a transgenerational perspective for gendered stories. Different time frameworks link interpersonal and intrapersonal themes. In this sense, the therapist works ‘inside out’ and ‘outside in’. A framework of behaviours, emotions, feelings, meanings and beliefs is proposed to help link these perspectives. ‘Invisible contracts’ and the sense of there often being an unconscious ‘pact to disappoint’ are described. Clear models are not enough, for it is the intimate encounter between client and therapist that is the bedrock of therapeutic change and growth. There is no short cut to this sense of intimacy in the unique encounter between therapist and each new couple. Brief examples from practice describe how the issues discussed may be addressed in couples work.     

Interviewing a Therapist in the Presence of a Couple: A Description of the Therapeutic Process

A therapy research team interviewed a therapist in the presence of a couple. Following each of six consecutive sessions with a couple, an interviewer posed questions to the therapist and couple. While one question was standard to each interview, other questions were generated by team members who tracked the entire process via live observation. These questions were directed first at the therapist, then at the couple, and then focused on therapeutic process and outcome. Findings of this process for the therapy system included decreasing the hierarchy within the client/therapist relationship; increasing the client ownership and energy in the therapy process; discovering the presence of parallel processes between the systems; and informing the direction of future therapy sessions. Practical, clinical implications are discussed for a variety of therapy settings.     

When is it time to stop? When good enough becomes bad enough

This article draws on Winnicott’s concept of the good enough mother to discuss how to know whether a therapeutic situation is good enough to continue or bad enough to end. This dilemma is explored in terms of clinical syndromes, such as anorexia and pathological gambling, but focuses mainly on analyst-initiated endings, which are termed the ‘Casablanca dilemma’, based on an amplification of the ending of the film Casablanca. The author goes on to discuss such one-sided endings, drawing on interviews with 40 analysts and therapists about their clinical experience. A typology of bad enough endings is presented. The psychological differences between a good enough analysis as opposed to a bad enough one are explored through the ideas of Winnicott and Neumann.