Termination of the Therapy Relationship
As with all relationships, a therapeutic relationship has a beginning and an end. The end of a therapeutic relationship often offers an opportunity for the therapist and client to engage in the termination process, which can include looking back on the course of treatment, helping the client plan ahead and saying goodbye.
Although recognized as important, the termination of therapy has not received the empirical attention it deserves. However, results from a few studies (e.g. Quintana & Holahan, 1992; Knox, Adrians, Everson, Hess, Hill & Crook-Lyon, 2011; Marx & Gelso, 1987) do offer some support for two theoretical perspectives on therapeutic endings. The first, termination-as-loss perspective, is rooted in psychodynamic theories and describes the termination of psychotherapy as a significant loss for the client and emphasizes the importance of working through this loss in therapy (Mann, 1973; Strupp & Binder, 1985). The second, termination-as-transformation perspective (Quintana, 1993; Maples & Walker, 2014), emphasizes termination as a time for internalizing growth and transforming the therapeutic relationship by providing clients with new insights about themselves and the therapeutic relationship. Related to both these perspectives, a body of research also offers support for the importance of the therapeutic relationship during the termination phase (Knox et al., 2011; Fragkiadaki & Strauss, 2012).
Studying the Termination Phase
Intrigued by the therapeutic relationship at the end of therapy, Charles J. Gelso and I examined therapists’ perceptions of three elements of the therapeutic relationship (i.e. the working alliance, real relationship and transference) during the termination phase in a recent study (Bhatia & Gelso, 2017). Following the widely used definition by Bordin (1979), the working alliance was conceptualized in terms of the working bond and the agreement of tasks and goals between the therapist and the client. Gelso (2011) defined the real relationship as the personal bond between the therapist and the client, characterized by the extent to which the therapist and client are genuine with each other and perceive each other realistically, and this conception of the real relationship was used in the study. Transference was conceptualized as the client’s experience of the therapist based on the client’s past experiences and involving a displacement of feelings, attitudes and behaviors rooted in earlier significant relationships onto the therapist (Gelso & Bhatia, 2012).
We used the following questions to guide our research; from the therapist’s point of view, how much time is spent in the termination phase? How do therapist perceptions of working alliance, real relationship and transference during the termination phase relate to the success of the overall treatment and the effectiveness of the termination phase? How do therapist perceptions of client sensitivity to loss associate with transference during the termination phase?
Our sample consisted of 233 licensed therapists in the U.S. of varying theoretical orientations. Therapists participating in the study identified a termination phase of treatment in their work with a client. The termination phase was defined as, “the last phase of counseling, during which the therapist and client consciously or unconsciously work toward bringing the treatment to an end” (Gelso & Woodhouse, 2002, pp. 346). Thus, at the outset, the findings and implications of the study do not address therapeutic endings that occur without warning and/or client dropouts. The major findings of the study and recommendations for clinical practice are discussed below.
The following key findings emerged from the results of the aforementioned study:
- Therapists reported the number of sessions included in the termination phase, as well as the total number of sessions included in treatment. Results indicated that the percentage of time spent on termination was approximately 17 percent of the total number of sessions.
- Examination of therapist ratings of termination phase evaluations and overall treatment outcome revealed that the success of the termination phase correlated with the success of overall treatment to a moderate extent (r=.30, p<.01).
- Therapist ratings of the working alliance and the real relationship during the termination phase correlated positively with termination phase evaluation and overall treatment outcome. In a regression model with the therapy relationship elements examined together, only the working alliance significantly predicted overall treatment outcome, highlighting its unique contribution to overall treatment outcome.
- Therapist ratings of transference (including both positive and negative transference) were positively associated with therapist ratings of perceived client sensitivity to loss.
Suggestions for Therapeutic Work in the Termination Phase
How can the results of the study inform therapeutic work? I offer below suggestions to consider during the termination phase. It is important to note here that these suggestions are not direct guidelines emerging from the results of the study; rather they are based on possible interpretations of the findings of this study, as well as on clinical impressions in therapeutic work. These recommendations need to be considered along with a theoretical understanding of individual cases in treatment.
Spending time on termination.
As per therapist reports, the average percentage of time spent on bringing treatment to an end by talking about termination was found to be approximately 17 percent of the total number of sessions, a number similar to the 16.67 percent reported by Gelso and Woodhouse (2002) in their review of termination literature. Perhaps this number can provide a rough estimate of the time to be spent on bringing treatment to a close (although more research in this realm is certainly needed).
Effectiveness of the termination phase.
From the therapist’s perspective, a successful termination phase is related to better overall treatment outcome, and yet termination phase evaluations also appear to be distinct from overall treatment outcome. This finding is in line with Joyce, Piper, Ogrodniczuk, and Klien’s (2007) suggestion that the outcomes of the termination phase differ from overall treatment outcomes. In treatment then, there appears to be value in the therapist tending to the client’s experience of the termination phase, perhaps by exploring client satisfaction with the termination phase and reflecting upon the therapeutic work being done during the termination phase, over and above overall treatment outcomes.
The working alliance during the termination phase.
Therapist reports reveal that the role of the alliance is particularly important during the termination phase. In light of this finding, it seems helpful to revisit the alliance and bring it to the forefront of therapeutic work during the termination phase. For example, consolidating and discussing treatment goals, a component of the working alliance, can be an important component of the termination process (Norcross, Zimmerman, Greenberg & Swift, 2017). It may also help to discuss goals pertaining specifically to the termination phase to strengthen the alliance during the termination phase. For instance, in therapeutic work with a client expressing difficulty with ending relationships, the therapist and client may determine together to work through the end of the therapeutic relationship by providing a space for the client to mourn and express feelings about the ending.
The real relationship during the termination phase.
The strength of the personal bond between the therapist and the client during the termination phase also relates to good outcomes. Thus, it would benefit therapists to pay attention to the real relationship during the termination phase. Therapists can use the following questions to reflect on the strength of the real relationship; is there a real and personal relationship between the client and I, over and above a professional relationship? Am I able to understand and express what I truly feel about my client? Does my client appear to be sharing vulnerable material with me? These are just a few examples of questions that might provide insight into the strength of the real relationship (see Gelso, 2011).
Transference during the termination phase.
Given the positive relationship between perceived client sensitivity to loss and transference, it appears valuable for therapists to be particularly attuned to the transference during the termination phase in the context of the client’s previous loss experiences. How transference is dealt with in therapeutic work often depends on theoretical orientation (Gelso & Bhatia, 2012), however, it appears that clients may experience feelings towards the therapist at the end of treatment as a result of previous losses across theoretical orientations. These feelings seem to be both positive and negative, at least in the eyes of the therapist, and not necessarily related to negative outcomes. Tending to transference, both positive and negative in valence, would likely represent areas of meaningful therapeutic work during termination.
To conclude, the termination phase in therapeutic work offers a unique opportunity to reflect on the ending relationship and to process the ending in the context of previous losses. Key implications for therapists include tending to the working alliance, real relationship and transference during the termination phase and evaluating the effectiveness of the termination phase of therapeutic work.
Correspondence concerning this article should be addressed to Dr. Avantika Bhatia