Psychotherapy research has made significant strides over many decades in identifying treatment ingredients that bode well for a successful outcome (Greenberg, 2016; Lambert, 2013; Norcross, 2011). Yet, relatively little empirical evidence or transtheoretical consensus has been produced about the closing moves in effective terminations. Instead, attention has more frequently been turned to the problem of premature termination or “dropout” from psychotherapy. The evidence, based on tens of thousands of patients and hundreds of published studies, shows that about 20% of patients leave psychotherapy treatment early with unsuccessful results (Swift & Greenberg, 2012, 2015). However, relatively little information is provided about the treatment ending for the vast majority of patients who achieved their treatment goals.
We became intrigued by the twin questions of what happens at the end of successful psychotherapy and whether there is commonality among expert clinicians on therapist termination behaviors. The details of our quest, methodology, and results can be found in our recent article in Psychotherapy (Norcross, Barrett, Greenberg, & Swift, 2017). Here, we highlight the major findings and clinical practices.
Our results derive from the answers of 65 psychotherapy experts to our 80-item Termination Tasks Survey. The experts represented 6 theoretical orientations: psychoanalytic/psychodynamic, experiential/humanistic, cognitive-behavioral, interpersonal, multicultural, and integrative/eclectic.
These seasoned therapists showed substantial agreement in termination tasks. This might come as a surprise given the diversity of orientations, but the result is quite consistent with research showing that experienced therapists tend to move toward practices that are more similar to each other than they are to inexperienced clinicians from the same orientation (e.g., Fiedler, 1950a, 1950b; Goldfried, Raue, & Castonguay, 1998; Wogan & Norcross, 1985).
Despite differences in theory and style, expert therapists have developed common ways of ending a successful course of individual therapy. In short, experience seems to foster greater flexibility and an integrative approach based on what works in practice.
Outline of Expert Advice
The expert therapists endorsed 8 dimensions of important tasks when terminating psychotherapy.
Prepare Explicitly for Termination: This task entails following the ethics codes regarding therapist responsibilities during termination. There is also discussion of what went well in therapy, consideration of what the ending will be like, and a reminder of when the therapy will actually conclude.
Process Feelings of Patient and Therapist: This task involves exploring with the patient feelings about the treatment relationship, including the sense of loss about ending the sessions as well as both positive and negative reactions to the therapy and the relationship.
Discuss Patient’s Future Functioning and Coping: Processing the risks for relapse, thinking about the future, and opening the door to possible return to therapy if needed. On the positive side, it entails discussing the patient’s development in therapy of new skills, capacities and tools for dealing with future stressors.
Help Patient to Use New Skills Beyond Therapy: Discussing plans for continuing to practice in the “real world” new behaviors and understandings acquired in therapy. Also emphasized is the hopeful message that the patient will continue to learn to master new problems as they apply what they learned.
Frame Personal Development as Unfinished: Normalizing the idea that problems are a natural part of life and the expectation that more will be learned by the patient up ahead. It may also result in discussing resources that may be helpful with unresolved future problems.
Anticipate Post-Therapy Growth and Generalization: Pointing out that the treatment achievements are likely to carryover to symptom reduction and better functioning in other areas of life. Also suggested is the possibility of scheduling some treatment breaks before termination in order to experience life without therapy and note any potential problems. In addition, clients are helped to see that they have played a significant role in achieving their gains.
Reflect on Patient Gains: Emphasizing positive gains made, assessing improvements, helping the client to understand the changes, and actually saying goodbye.
Express Pride in Patient’s Progress and Mutual Relationship: Attributing gains to client’s effort, taking pride in the new skills achieved, acknowledging satisfaction in working together, and expressing some of the therapist’s feelings about ending the therapeutic relationship.
These termination tasks in many ways replicate and revisit important aspects of establishing a therapeutic relationship at the outset of treatment. There is no substitute for a therapist who is able to listen empathically and provide a warm, accepting interpersonal atmosphere for the encounters that will follow. Indeed, empirically supported strategies for reducing the likelihood of premature termination encompass: strengthening hope, enhancing motivation, fostering the therapeutic alliance, and assessing and discussing treatment progress with clients (Swift & Greenberg, 2015). Our findings regarding termination behaviors suggest these aspects provide a boost to the process from beginning to end.
Our results point to pantheoretical activities that therapists can apply and trainers can teach. Perhaps a termination checklist of sorts could be created, predicated on the strong consensus tasks to guide therapists. Training in this area may prove particularly important given that students typically do not receive many opportunities to practice successful, planned terminations with their clients – due to higher rates of client premature termination with trainees (Swift & Greenberg, 2012) and the need to transfer cases as students move from one training site to another (Williams & Winter, 2009). A central challenge in training entails helping students feel comfortable in speaking openly with patients about the journey they have taken together.