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Dos and Don’ts Facing Termination

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Nof, A. & Zilcha-Mano, S. (2017,  May). Dos and don'ts facing termination. [Web article]. Retrieved from: http://www.societyforpsychotherapy.org/dos-donts-facing-termination

Ella Fitzgerald articulated memorably the personal meaning of ending relationships in her song “Every time I say goodbye, I die a little.”  Termination is a naturally occurring process, and one may wonder whether there is a need for discussing it in the literature. Psychotherapy, and the process of termination that is part of it, is built on this dialectical tension between a natural processes and a special, intentional-therapeutic one. This tension helps work through aspects that went wrong in the original, less sensitive environment, and that can be handled better when the therapist is prepared for it.

This article is based on the authors’ paper, “Supportive-expressive interventions in working through treatment termination” (Nof, Leibovich, and Zilcha-Mano, 2107). We translated the main ideas of the original article into “do and don’t” points, to help therapists handle the termination phase of therapy. The guidelines are based on our accumulated experience derived from the clinical studies at our supportive-expressive (SE) psychotherapy laboratory. SE is a time-limited, manualized, dynamic treatment. It includes supportive and insight-oriented elements, designed to work on the patients’ Core Conflictual Relationship Theme (Luborsky et al., 1998).

SE is a short-term psychotherapy, in which the end date is known from the beginning. Our guidelines can be easily adapted to CBT or an open-ended psychotherapy. After agreeing with the patient that the goals have been achieved, the decision of ending may be translated into a mutual agreement on an ending date. Such declaration launches the start of the termination phase, which we discuss here.

Termination Dos

The clock-like reminder: Initiate the termination processes

As part of the clock-like reminder technique, the therapist issues reminders of the end date of the treatment at fixed time points in the course of the treatment, inviting the patient to conduct a dialog about it. In the first three sessions, the therapist should state the termination date, adding that the patient will be reminded several times in subsequent sessions. The next opportunity to use the clock-like reminder is during the last five sessions, as the countdown to the end begins: “We have five more session to the end.” The purpose of the repetition is to keep in mind the short time left, and use it to enhance goal achieving and to work through the termination themes.

Handling the patient’s explicit frustration in a supportive manner

Some patients react to the clock-like reminder with an explicit response about termination (e.g., “It’s frustrating that we have such a short time”). We propose handling the patient’s explicit response in a supportive manner. The therapist should first validate the emotional tone and the short time left. Next, the therapist should emphasize the joint effort needed to produce a change, using the pronoun “we” (“we are together in this meaningful and sometimes painful separation and we will talk and think about how we do that”). Lastly, it is important to explore the personal meaning of termination (“I wonder if you could tell me some more about your feelings about it”).

Alone again? Evoking the separation conflict

According to the SE perspective, every patient has a particular wish he or she tries to fulfill with other people. When the wish continually fails to be fulfilled, distress and possible depression may arise. Often the wish cannot be fulfilled because of the patient`s subjective anticipation of a negative response from the others (e.g., rejection). Therefore, the patient develops a pattern of self-response that may be maladaptive and cyclic in the long term (e.g., detachment). In SE therapy, we work on changing and expanding the patient’s self-response repertoire and opening new ways to fulfill the wish.

When termination is approaching, however, some patients regress to their original pre-treatment self-responses. Termination is a complex process to handle because of its ambivalent, conflictual nature. The termination triggers a temporary regression because the separation from the therapist resonates with past separation conflicts (Mann, 1973; Bauer & Kobos, 1987). Therefore, self-doubts about autonomy increase, with possible expressions of separation anxiety. The therapist might be experienced as abandoning the patient. In response, some patients temporarily regress to the old, pre-treatment pattern of defenses and of ways to relate to others, to protect themselves from the disappointing other, and it is the therapist’s job to help them end the therapy successfully.

Because the end of treatment may activate unconscious emotional themes of bereavement and separation (Joyce et al., 2007), the therapist should listen and look for such unconscious projections or representations. Based on Mahler’s separation-individuation model (Mahler & Pine, 1975), and on clinical experience, we suggest looking for projected representations of leaving or coming back, separation anxiety or longing for care, or for symbolic representation of overdoing things in an omnipotent excitement. After identifying the symbolic content of termination, the therapist can choose to interpret the underlining theme. We recommend using the VIP steps, introduced next.

VIP:  Providing an empathic insight about termination

When facing the symbolic cues of termination and separation, the therapist should consider three techniques in sequence. We refer to these three steps of insight-oriented intervention as validating, interpreting, and personal meaning exploration (VIP). The therapist should begin by validating and relating empathically to the content of the story. It is crucial to stay with the explicit story, lest the interpretation is experienced as a negation, resulting in resistance. For example, “As you mentioned, taking the train to another city can be difficult. Finding yourself suddenly in a new place, new smells and sights.”

The second step is the interpretation, and it should be introduced in the form of a proposal, but without confronting the patient. We recommend doing so by selectively connecting a section of the patient’s narrative with a specific termination element, as opposed to making a complete comparison between the symbol and underlying content, which may be too difficult for the patient to accept. For example, “When you spoke about the mixed emotions of going to new places by train, it reminded me of the mixed emotions of terminating here. I wonder how you feel about the end of therapy” (interpretation and personal meaning exploration).

“The moon is both dark and bright:” Combining into a whole

Clinically, it is convenient to think of termination regression as an articulation of a certain narrative with particular features. The regressed response of the patient is often a one-sided narrative (e.g., “I feel strong now and don’t need anyone near me anymore”), which is neither coherent nor integrative. The one-sided narrative refers either to the old pre-treatment pattern or to the new one, but not to the synthesis of the two.

The therapist’s goal is to rephrase the one-sided narrative into a coherent one, using a technique we called the “combing into a whole,” which combines disparate elements into a whole and contains both sides of the narrative. First, the response should be supportive in a way that affirms its one-sided quality (e.g., “It’s wonderful to feel that strong”). The next step is to formulate an abstraction metaphor summarizing the one-sided tone (e.g., “It’s like finding a treasure that gives you strength”). The purpose of the abstraction is to create a space from which to observe the one-sided experience. After being stated, the abstraction metaphor serves as a bridge to an interpretation based on the technique of combining into a whole. The therapist can offer a suggestion or use an exploratory question, aiming to capture both the old and the new narrative (e.g. “I recall that in the previous session you were quite sad about ending here. I wonder how you feel today, knowing that there are times you feel sad and now you feel strong and ready to finish our therapy…”)

“Gently on the gas pedal:” Maintaining a regulated atmosphere at termination

It is the therapist’s role to recognize emotionally overloaded dynamics and to help the patient regulate them. One way of handling the peak moment at the very end is to first validate the emotional tone, and next to empathically share with the patient the dilemma of whether or not to open new themes, because of lack of time (e.g., “You mentioned your separation from your beloved aunt, and it’s very sad to hear about it. I wish we could talk more about it. It’s not easy for either of us not to be able to deal with it, but the time is not on our side”). Another way of regulating the dynamics is to use structured open questions, such as “what is the best way for you to end here?” or “How will your weeks look without our meetings?” This type of reappraisal has been shown to activate a regulation process, in which the prefrontal cortex down-regulates the emotional experience of the limbic system (Golding et al., 2008; Gross, 2002).

Offering a goodbye letter. Lemma et al. (2013) suggested giving the patient a goodbye letter that contains the central understandings of the therapy, a description of the process, and thoughts about the work that can be done in the future.

Using summarizing questions. Marx and Gelso (1987) described termination as consisting of three objectives: looking back, saying goodbye, and looking ahead. We suggest building on these objectives and asking the patient the following three questions with regard to the change in the Core Conflict Relationship There (CCRT):  What do you take away from therapy? What have you learned about being in relationships? How do you feel about finishing?

The don’ts of termination

Don’t offer new interpretations that haven’t been discussed before

Holding back and containing new insights helps regulate the atmosphere.  The therapist should continue in a supportive mode and help the patient feel understood. Patients should feel that their ideas and emotional reactions are normal and contained. It is important to empower the patient’s ego and validate adjustment coping efforts.

Don’t take the lead when the patient needs to lead

During the SE treatment, therapists are generally encouraged to take an active stance in working through the patient’s CCRT (Leibovich & Zilcha-Mano, 2016). In the last session, however, and mainly at its very end, we recommend following the patient’s lead, and not being as active as before. This means that the therapist should adapt to the tempo and the unique emotional expression of the patient (e.g., happiness in celebrating the success should meet with a similar rhythm and emotional tone from the therapist, whereas hesitation about the future should be met with validation of it).

Don’t overlook your countertransference reaction

Termination events can evoke an intense countertransference reaction (e.g., in response to the patient giving a present or as a reaction of the therapist to his own history of separation). We recommend using the three Ws (wait, watch, and wonder) as a guideline, which we adopted from parent-child psychotherapy (Muir, 1992). The three Ws can help therapists reflect on the event and on their possible therapeutic reaction, and wonder internally, or as part of a dialog, about what has happened. The three Ws can help mentalize the meaning of patient’s signals and needs in the termination phase, so that the separation can be meaningful, emotional, and at the same time contained and understood.

Don’t judge or educate the patient about his defensive way of separating

The very last interpersonal exchanges can vary along a wide spectrum of behaviors and emotional tones. The variations stem from the versatile cultural norms, a tendency for emotional reactivity, interpersonal distance attributes, and personality tendencies. Some dyads choose to shake hands, others to hug, say goodbye, make a light comment (“See you around…”), or say nothing.

We recommend that the therapist respect the defenses of the patient as adaptive mechanism, and act in a receptive unconditional attitude. The criticism that might emerge from countertransference disappointment (e.g., the patient is not sad enough and that means it was not meaningful enough for her), should be contained and not articulated at this ending point. Therapists may mistakenly try to educate patients on how separation should feel and look like (e.g., “I know that it is common to feel sad and sorry for ending therapy. I wonder how you feel”). This unconscious paternalistic intervention leaves no space for truly opening a dialog about the diverse feelings, thoughts, and reactions that may come at termination. We therefore recommend following a flexible, non-judgmental approach, staying within ethical limits, and behaving according to one’s natural tendency of saying goodbye.

Now it’s really time to say goodbye

As we were writing these guidelines, we did not want the reader to get the wrong impression that termination will be easier if all our guidelines are followed to the letter.  Generally, we believe in flexibility and accommodation. We recommend that therapists choose the ideas that best fit their unique way of handling therapy termination.

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References

Bauer, G. P., & Kobos, J. C. (1987). Brief therapy. Northvale, NJ: Aronson.

Goldin, P. R., McRae, K., Ramel, W., & Gross, J. J. (2008). The neural bases of emotion regulation: reappraisal and suppression of negative emotion. Biological psychiatry63(6), 577-586.‏

Gross, J. J. (2002). Emotion regulation: Affective, cognitive, and social consequences. Psychophysiology39(3), 281-291.‏

Joyce, A. S., Piper, W. E., Ogrodniczuk, J. S., & Klien, R. H. (2007).Termination in psychotherapy: A psychodynamic model of processes and outcomes. American Psychological Association.‏

Leibovich, L., & Zilcha-Mano, S. (2016, July 18). Integration and Clinical Demonstration of Active Ingredients of Short-Term Psychodynamic Therapy for Depression. Journal of Psychotherapy Integration. Advance online publication.

Lemma, A., Target, M., & Fonagy, P. (2013). Dynamic Interpersonal Therapy (DIT): Developing a new psychodynamic intervention for the treatment of depression. Psychoanalytic Inquiry33(6), 552-566.‏

Luborsky, L., & Crits-Christoph, P. (1998). Understanding transference: The Core Conflictual Relationship Theme method. American Psychological Association.‏

Mahler M., & Pine F. (1975). The Psychological Birth of the Human Infant: Symbiosis and Individuation. New York: Basic Books, Inc., Publishers,

Mann, J. (1973). Time-limited psychotherapy. Oxford, England: Harvard U. Press.

Marx, J. A., & Gelso, C. J. (1987). Termination of individual counseling in a university counseling center. Journal of Counseling Psychology, 34(1), 3-9.

Muir, E. (1992). Watching, waiting, and wondering: Applying psychoanalytic principals to mother–infant intervention. Infant Mental Health Journal, 13, 319– 328.

Nof, A., Leibovich, L., & Zilcha-Mano, S. (2017). Supportive–expressive interventions in working through treatment termination. Psychotherapy54(1), 29.‏

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