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A Call for “Negotiation” in the Termination Process

Dr. Julieta Olivera and colleagues recently published an article titled “Client–Therapist Agreement in the Termination Process and Its Association with Therapeutic Relationship” in Psychotherapy.

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Psychotherapy termination is that moment in which therapists and clients say goodbye (or “call me if you need me”). As part of the first author’s doctoral dissertation, we conducted a research study in which we asked former clients about their treatment. Surprisingly, when clients were asked about their treatment, many started the recount by addressing its ending and described it either as a friendly termination or a conflictive one. From our own experience as clinicians, we assume that practitioners would seek to avoid those conflictive ending, making efforts towards “friendly terminations”. Anyway, our work highlighted some concerns as regarding how therapists usually deal with termination and the outcomes of their strategies. What follows are our main conclusions about the topic and some suggestions for clinical research and practice.

The Gap Between Prescriptions and “Actual Practice”

Theoretical orientations have established some general guidelines and recommendations on how to pursue good terminations (see for example Goode, Park, Parking, Tompkins & Swift, 2017; Nof, Leibovich & Zilcha-Mano, 2017), even while the effects of friendly vs. conflictive terminations remained unknown based on lack of empirical research on  the field (Hilsenroth, 2017).  The scarce literature on the subject suggests that therapists would benefit from talking about the termination process during treatment, even at the beginning of it, presenting to the client their expectations about treatment’s end (Barnett & Coffman, 2015). However, research shows that especially in open ended therapy, clients experience that the termination was not adequately addressed and discussed. An interesting study on the subject showed that positive terminations were usually discussed in advance with the therapist. While, negative terminations tend to be produced by abrupt and unilateral endings due to a therapeutic rupture (Knox, Adrians, Everson, Hess, Hill, Crook-Lyon, 2011). Additionally, in our study, many clients felt that after long therapeutic processes and having accomplished changes, they could not mention termination to their therapists. Many of them, even felt that this issue was undermining the therapeutic relationship and the overall treatment (Olivera, Challú, Gómez Penedo & Roussos, 2017).

When talking to therapists about the topic they seem not to pay much attention to the termination process, norshow an explicit interest in figuring out how to improve it in their own practice (Bhatia & Gelso, 2017). Why is this so? We hypothesize two possible explanations. First, therapists might pay less attention to termination because they spend more cognitive resources on dealing with other components of the treatment that they might consider more important. Second, it might be that the final phases of treatment have a residual (i.e. less important) position in clinical training programs, more circumscribed to initial and mid phases of therapy. We argue that instead of being excluding hypotheses, these eventual explanations are strongly interdependent.

In terms of the value therapists give to the termination phase of treatment, although a lot has been discussed and studied about preventing drop-out (one of those “conflictive terminations” we mentioned earlier)(Hunsley, Aubry, Verstervelt & Vito, 1999; Ogrodniczuk, Joyce & Piper, 2009; Westmacott, Hunsley, Best, Rumstein-McKean & Schindler, 2010).  Our own research showed that clients do not perceive therapists’ efforts on working towards a good termination (Olivera et al., 2017). Most of the therapeutic approaches present specific guidelines on how to begin the treatment and help the client to get engaged in the therapy process. Furthermore, they strongly focus their manuals in fundamental change mechanisms of the treatment, such as what interventions should be used given the patient and how they need to be applied. Besides, most of them present the therapeutic alliance as an essential aspect of therapy, and seek to establish strategies to overcome difficulties in the relationship during treatment. However, the magnitude attributed to the final phase of treatment seems to be minor in most of the therapeutic frameworks. Most theoretical approaches have protocols for therapists about what to do on the final stage of therapy in terms of relapse prevention, but not many of them point out when and how to address the termination process with clients.

In addition, as previously suggested, training programs (in line with theoretical approaches priorities) do not give much time and attention to discuss the termination phase either. In our personal experience in training programs, we have had full courses focused on the beginning of treatments while we did not even have a complete lesson on how to deal with termination.

So, Why is the Termination Process Important?

As we see it, termination is not only the end of therapy but also a time to find new meanings to the treatment. As it has been well established in the researched literature, it is not only the finish line but also a process that can affect the outcome, the perceived relationship, the whole treatment sense of satisfaction, and even the maintenance of positive outcome on the long-term (Hunsley, 1999; Olivera et al., 2017).

There are therapists, mainly in open ended treatments, who decide not to present the client what they should expect about the termination. They argue that clients should assess their personal process and present the termination themselves. This is a tricky maneuver that should be carefully revised.  Many psychotherapy treatments have strong therapeutic relationships, and this is a good thing because it is usually related to a positive outcome. However, previous research has established that good therapeutic relationships are associated with compliant characteristics of the client (Muran, segal, Samstag & Crawford, 1994).  So, in those treatments where a good therapeutic relationship comes along with compliant or submissive characteristics of the clients, they could be unable to establish boundaries to their therapists and communicate that they are thinking about terminating the treatment. In other words, a client may have a good relationship with the therapist but might be afraid that if she/he presents the idea of terminating the treatment, the therapist would feel resented, affecting that relationship. In those cases, if we mislead compliance with collaboration we might not be enhancing the client's autonomy, but reinforcing the client´s submissiveness. Eventually, this would not only be iatrogenic, but it would also maintain the patient in a non-helpful process or would result in an abrupt (and non-friendly) unilateral termination of the treatment.

Classically, the early responses usually observed in successful treatments have been related to an initial remoralization process in the client, due to the fact of starting a treatment (Frank & Frank, 1961).  Clients usually start treatment with a burden related to all the failed attempts to overcome their situation. Therefore, beginning a new treatment, in which they believe in and with a therapist they trust, produces a shock of hope that helps to initially reduce the burden related to the thought that they would not be able to improve their situation. On the other hand, problematic or conflicted terminations can reach the opposite reaction by producing a demoralization effect that might undo part of the therapeutic gains achieved. For example, a client that started treatment with hope, good motivation and an early outcome, could become frustrated and experience low levels of self-efficacy if a disruptive event, such as a conflictive termination, arises. Thus, that first moment of connection and communion with the therapist, and the therapeutic achievements during the process, could be blurred after a conflictive termination and the client would feel worse than if he had had a friendly termination.

How to Foster Positive “Friendly” Termination Processes?

In psychotherapy research, collaboration between patient and therapist (i.e. in terms of agreement on therapeutic goals and tasks) has been historically pointed out as fundamental process for clinical success (Horvath et al., 1991). However, as mentioned above, some authors consider that the plain “agreement” between the participants might not be sufficient, because it could mask compliance attitudes of the patient towards the therapist (Safran & Muran, 2006). A patient fearing to hurt therapist's feelings could show on the surface an explicit collaboration and agreement with therapeutic tasks and goals, while presenting some underlying concerns about how therapy is being conducted or about what they are trying to reach with it. Then, rather than seeking to have a collaborative attitude from the patient towards the therapist, it has been stated that the most important relational thing is to negotiate and deal with eventual (implicit or explicit) disagreements or problems between the participants (Safran & Muran, 2006).

We considered that this same ideals could (and ought to) be transferred to the termination process. Therapists might benefit from installing an active debate and negotiation with their patients about how and when therapy should finish, instead of just trying to get patients´ collaboration (i.e. adapting and adjusting to therapist's ideas about it). Our research as well as other current literature on the subject is clear on the role the termination has on the overall treatment. So, we propose that therapists get engaged in explicit conversation with their clients on the termination since the beginning of treatment.

Negotiation implies dialogue and consensus between therapist and client, and it is a process based on a joint effort between them. Nevertheless, it is the therapist (from its professional position) who should bring it into the table, since the beginning of the therapy. During treatment initiation, the therapist would need to listen to the client’s previous experiences, current expectations, and ideas about termination, while emphasizing that they would be further discussed along the treatment. During the process, the therapist should periodically monitor client’s ideas about termination, while also explicitly asking the client to express their doubts about the treatment’s ending. We consider that these strategies will not only prevent those drop-outs in which the clients mentioned that they did not feel comfortable to present their therapists their wishes of finishing the treatment (Olivera et al., 2017), but would also make the termination process smoother. Instead of possibly being an uncomfortable talk at the end phase of treatment, termination could be something progressively co-constructed between patient and therapist during the complete psychotherapeutic process.

Termination Research Vacancy

Although we stated that negotiation is a key point in the termination process, the fact that there is, in Mark Hilsenroth’s words, “an almost complete lack of research and clinical discussion on the topic” (Hilsenroth, 2017, p1) makes it difficult for therapists to reach more specific evidence-based conclusions.

This piece could have also been called “a call for research on termination” as our first impression when reviewing the literature on the subject was that there are still few research approaches on types of therapy termination. We would have liked to find experimental research on the impact that termination processes (e.g. with or without explicit negotiation devices) have on various treatment variables, such as outcome, satisfaction, long-term outcome, and retrospective alliance. Other interesting experimental research could be to compare treatments where the termination is set since the beginning with treatments in comparison to therapists who wait for the goals to be fulfilled before addressing the theme.

Also there is a gap in the literature on how treatment terminations really are performed, given that most research is conducted with therapists’ and clients' recall of the termination processes (Norcross, Zimmerman, Greenberg & Swift, 2017; Olivera et al., 2013; Westmacott et al., 2010)

We started this piece talking about how great “good goodbyes” are. Well, it seems that a good goodbye implies a mutual goodbye, where both therapists and clients have something to say. It also seems that we need more and more specific investigations to further aid clinicians on the subject.

Cite This Article

Olivera, J., Gomez Penedo, J. M., & Roussos, A. (2018, January). A call for “negotiation” in the termination process. [Web article]. Retrieved from http://societyforpsychotherapy.org/a-call-for-negotiation-in-the-termination-process

References

Barnett, J. E., & Coffman, C. (2015, June). Termination and abandonment: A proactive approach to ethical practice. [Web Article]. Retrieved from: www.societyforpsychotherapy.org/termination-and-abandonment-a-proactive-approach-to-ethical-practice

Bhatia, A., & Gelso, C. J. (2017). The termination phase: Therapists’ perspective on the therapeutic relationship and outcome. Psychotherapy, 54(1), 76-87.

Frank, J. D. & Frank, J. B. (1961). Persuasion and healing: A comparative study of psychotherapy. Baltimore: The Johns Hopkins University Press.

Goode, J., Park, J., Parkin, S., Tompkins, K. A., & Swift, J. K. (2017). A collaborative approach to psychotherapy termination. Psychotherapy, 54(1), 10-14.

Hilsenroth, M.J. (2017). An introduction to the special issue on psychotherapy termination. Psychotherapy, 54, 1-3.

Horvath, A. O. & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139–149. http://doi.org/10.1037//0022-0167.38.2.139

Hunsley, J., Aubry, T. D., Verstervelt, C. M., & Vito, D. (1999). Comparing therapist and client perspectives on reasons for psychotherapy termination. Psychotherapy, 36(4), 380-388.

Knox, S., Adrians, N., Everson, E., Hess, S., Hill, C., & Crook-Lyon, R. (2011). Patient’s perspectives on therapy termination. Psychotherapy Research, 21(2), 154- 167. doi: 10.1080/10503307.2010.534509

Muran, J. C., Segal, Z. V, Samstag, L. W., & Crawford, C. E. (1994). Patient pretreatment interpersonal problems and therapeutic alliance in short-term cognitive therapy. Journal of Consulting and Clinical Psychology, 62, 185–190.

Nof, A., Leibovich, L., & Zilcha-Mano, S. (2017). Supportive-expressive interventions in working through treatment termination. Psychotherapy, 54, 29-36.

Norcross, J. C., Zimmerman, B. E., Greenberg, R. P., & Swift, J. K. (2017). Do all therapists do that when saying goodbye? A study of commonalities in termination behaviors. Psychotherapy, 54(1), 66-75.

Ogrodniczuk, J.S., Joyce, A.S., & Piper, W. E. (2009). Strategies for Reducing Patient-Initiated Premature Termination of Psychotherapy. Harvard Review of Psychiatry, 13(2), 57-70.

Olivera, J., Braun, M., Gómez Penedo, M., & Roussos, A. (2013). A Qualitative Investigation of Former Clients’ Perception of Change, Reasons for consultation, Therapeutic Relationship, and Termination. Psychotherapy, 50(4), 505-516.

Olivera, J., Challú, L., Gómez Penedo, J.M., & Roussos, A. (2017). Client-therapist agreement in the termination process and its association with the therapeutic relationship. Journal of Psychotherapy, 54(1), 88-101.

Safran, J. D., & Muran, J. C. (2006). Has the concept of the therapeutic alliance outlived its usefulness? Psychotherapy: Theory, Research, Practice, Training, 43(3), 286–291. http://doi.org/10.1037/0033-3204.43.3.286

Weil, M., Katz, M. & Hilsenroth, M. J. (2017). Patient and therapist perspectives during the psychotherapy termination process: The role of participation and exploration. Psychodynamic Psychiatry: 45, 23-43.

Westmacott, R., Hunsley, J., Best, M., Rumstein-McKean, O., & Schindler, D. (2010). Client and therapist views of contextual factors related to termination from psychotherapy: A comparison between unilateral and mutual terminators. Psychotherapy Research, 20(4), 423-435.

1 Comment

  1. Ryan Howes

    1. I’ve devoted a lot of time to writing and speaking on this topic, and couldn’t agree more: therapy programs neglect teaching future clinicians about the benefits of a good termination, which in turn means they don’t teach clients about it, and both parties exit therapy unsatisfied. I would contest that therapists erroneously believe that talking about termination will result in an early termination, but I have seen the opposite to be true: clients disappear because they don’t have the language to talk about endings, so they avoid the encounter altogether.
    2. A simple edit would make this article much more accessible. I hope the website editors can devote a little time to editing this public-facing content.
    3. I’ll take this discussion a step further to the existential and say that a good termination is more than good customer service, it’s helping clients have one good ending in a lifetime of destructive endings. Most relational endings (think death, divorce, breakups, fading away, etc) are traumatic at worst and unsatisfying at best, and therapy has the unique opportunity to give clients the closure and sense of completion they rarely find, or even seek, in other relationships. Having a good ending in therapy can help them seek it out in breakups or other losses, which can prevent years of rumination and turmoil.
    4. In my own practice, after covering the goals for treatment in an intake session, I’ll ask “when do you believe you’ll be ready to end therapy, and what would you imagine that would look like?” Not that we’ll have concrete answers to these questions from the beginning, but it allows for this to be a conversation throughout the treatment, giving permission to the client to talk about our inevitable end. Try this, and you’ll find ghosting and terminations via voicemail to sharply decline.
    5. Bravo to the authors for tackling this topic, and I agree that much more research should be done. We can’t devote so much energy to building a practice while denying each treatment’s inevitable end.

    Reply

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