Berk, Michael

Conus, Philippe

Hasty, Melissa K.

Macneil, Craig A.

RERO DOC Digital Library

Termination of therapy: what can clinicians do to maximise gains?The progress a patient makes duringtherapy should be enriched andheightened by a positive treatmentending. When termination issues areignored or mishandled, the whole oftherapy is jeopardized.—Kramer (1990, p. xv)Although there has been a significantemphasis in the clinical literature ontherapeutic engagement and process, therehas been surprisingly little focus on howto conclude therapy in a way thatmaximises gains.Preparing for termination of therapycan be extremely important when workingwith most clinical populations. Theclinician may have played a significantrole, often at a time when a patient ismost distressed, and it is likely that therecould be some sadness or concern inrelation to this potential loss of support.Indeed, Ryle and Kerr (1) noted that ‘. . .as termination is approached, the absenceof anxiety and disappointment wouldsuggest that the reality of the end is notyet felt by the patient . . .’ (p. 113).Although a sense of loss may beexperienced by most clinical populationswhen concluding therapy, additional caremay need to be taken with patients whohave experienced difficult attachmenthistories, particularly when this hasincluded significant loss or abandonment.Sensitive management is also requiredwhen difficulties remain at the conclusionof therapy and the patient does not feel‘cured’, and particularly when the sense ofhope that may have been present at thecommencement of therapy is replaced bysadness or anger. Termination withindividuals who have experienced thesedifficulties is arguably the most importantpart of therapy, and if managed well, cangive the patient a sense that endings neednot be traumatic or inevitably involve aprofound sense of loss. Mathews (2) notedthat ‘Despite its attendant complications,therapist-initiated terminations, like otherendings, provide potentially importantgrist for the growth mill’ (p. 34).Having said this, it is important that theclinician does not assume the patient’sresponse to the termination of therapy. Itcan be surprising when some patients forwhom therapy appears to have beenextremely important do not seem overlyconcerned by termination, whereas othersappear significantly more affected than theclinician may have anticipated. AsKramer (3) succinctly noted ‘To eachpatient, termination means somethingdifferent . . .’ (p. 63). Perhaps the easiestsolution to this potential difficulty is forthe clinician to simply ask whatconcluding therapy means to each patientand to provide time for discussion aboutthis.Types of ‘Termination’Service considerations and the clinician’stheoretical model are likely to dictate atleast partially how and when therapyterminates. However, given that patientsare likely to have different needs,Kramer (3) suggested that the clinicianmay want to consider different types ofendings. These can include reducing thefrequency of sessions, taking ‘breaks’when the person is asymptomatic orhaving an ‘open door’ policy once therapyhas officially ended. It is likely that for anumber of people—even following aseemingly successful conclusion oftherapy—some concern will remainregarding the possibility of recurrence orexacerbation of the presenting difficulties.Therefore, it is not uncommon to receivephone calls or occasional visits frompeople who have officially finishedtherapy. It appears important that theclinician remains available, wheneverpossible, in these situations, even if themain focus is on encouraging the person’sengagement with another service. Formany individuals who are sensitised toabandonment and who manage theambivalence of intimacy by avoidance,drop-out may be their way of anticipatingand taking control of termination.Therapist challengesIt should be noted that part of thedifficulty in concluding therapy comes notonly from concern experienced by thepatient, but also from concernsexperienced by the therapist. Davis (4)summarised some potential difficulties thattherapists can experience regardingtermination including: ‘. . . the avoidanceof uncomfortable affect,under-assertiveness . . ., lack of clarityabout possible reasons or criteria fortermination, discomfort with interpersonalchange, or a fear of precipitating someharm by discontinuing treatment too soon’(p. 78). Patients will have beliefs relatingto gains that have been made, what mayneed further work, and loss of theclinician. However, clinicians are alsolikely to evaluate how the patient hasprogressed, reflect on the intervention heor she has provided and also consider theimpact that finishing with the patient hason him/herself. As Kottler (5) noted offinishing therapy, ‘The clinician may feelguilt, failure, disappointment, sadness,pride, apprehension, hope, jealousy andrelief—all at once. And there is theconstant cycle of growing immensely fond43https:/www.cambridge.org/core/terms. https://doi.org/10.1111/j.1601-5215.2009.00443.xDownloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 14:01:50, subject to the Cambridge Core terms of use, available atof people and then turning them loose’(p. 94). It is therefore important for theclinician to have time to acknowledge hisor her own thoughts and feelingsregarding the end of therapy with eachpatient. Although workplace demands maymean that there are constantly peoplewaiting to be seen, it is important that theclinician takes time to reflect ontermination and if possible, not haveanother appointment immediately after afinal session with a patient.Timing of terminationOne of the challenges of termination canbe identifying when it should occur, withFreud (6) having noted, ‘Is there such athing as a natural end to an analysis?’(p. 219). From a psychodynamicpsychotherapy viewpoint, Kramer (3)defined key termination criteria astherapist’s intuition, symptom relief,improved intrapsychic functioning,resolution of transference and interpretingdreams relating to termination. However,Kramer also concluded, ‘. . . criteria fortermination vary greatly. Even within thesame school of thought, there aredifferences in opinion. I propose that thewhole idea of criteria may be irrelevantand possibly damaging to therapy itself. Itis likely that all abstract and theoreticaldiscussions of termination criteria are oflittle value and perhaps actually contributeto practitioners’ and patients’ confusionsabout the process of ending treatment’(p. 59). Regarding more brief therapy,Henry et al. (7) stated ‘The purpose oftime-limited therapy is not to cure patientsof all their problems; rather it is to helpindividuals develop skills to manage andovercome further problems andchallenges’ (p. 54). Similarly, MiltonErickson offered the somewhat reassuringstatement ‘Therapy is often a matter oftipping the first domino’ (8) (p. 41).Again, however, we recognise thattherapeutic model, financial considerationsand the setting in which the clinicianpractices may have considerable influence.It is also notable that with the bestplanning and intentions, therapy may alsoend when the patient makes the decisionunilaterally by failing to turn up.Planning for terminationIt is necessary to begin planning fortermination of therapy at thecommencement of therapy. When firstdiscussing the process of therapy with anindividual, a framework for the expectedtimeline of the therapy needs to beintroduced with a clear expectation of howthe therapy will terminate. There is hugevariability in this process, from theopen-ended model of analytic therapies tothe highly structured nature of certainmanaged care approaches toreimbursement, that for example onlyallow six sessions for a particularindication. The process needs to bestructured to manage expectations, to setgoals and to provide a framework fordealing with crisis, non-response orrecurrence.The goodbye letterNarrative and cognitive analytic therapiesdescribe the use of therapeutic letters atthe conclusion of therapy (1,9). Theseletters are used to document issues thathave arisen during the course of therapyand to summarise and reflect. They canalso describe the shared formulationreached during therapy, progress made,and how this could be maintained orstrengthened. Importantly, the narrativetherapy literature also uses letters to allowtherapists to reflect on, and whereappropriate, disclose their own experienceof therapy with the patient. This caninclude describing challenges that theyhave experienced, what he or she hasenjoyed about work with that particularpatient and what the clinician has learntfrom the experience him/herself (10).Discussion about such a letter can alsobe an opportunity for the therapist toreceive feedback about key messages thepatient has retained, what the patient hasnot found particularly helpful, and whatwas most valuable about the therapy.Discussion at this point can also be a finalopportunity to correct anymisunderstandings, examine any areas thetherapist has neglected to include and alsoallow the therapist to model that sadness,disappointment and anxiety, in addition tohope and optimism, may be appropriate.Summary and guidelinesAs mentioned earlier, how termination isundertaken likely to be, at least in part,dictated by the service in which theclinician practices and by his or hertherapeutic model. However, the followingrecommendations may be useful regardlessof therapeutic orientation. Specifically:• Termination should be on the agendaearly in therapy. This can be challeng-ing, particularly when a patient initiallypresents as hopeless or distressed, or forwhom there are already concerns aboutengagement. The cognitive analytic ther-apy literature (1) advises discussingtermination in the first session, sug-gesting that this allows for planning ofthe end of therapy by both clinician andpatient, and encourages the full utilisa-tion of all sessions. Similarly, Davis (4)advised ‘Communications about termi-nation at the beginning and throughouttherapy are essential to effective man-agement of this important task’ (p. 47).• Taking time to set appropriate goals earlycan prevent aimless sessions that mayparadoxically be more difficult to end.Time can also be spent ensuring thatgoals are realistic within the time periodthat the clinician is able to offer.• Regular reviews can focus therapy andallow for ongoing discussion regardingtermination.• Although it can be tempting for the clini-cian to minimise the importance of termi-nation of therapy to the patient to reduceany anxiety, it is important that sufficienttime is given to allow both the clinicianand patient to express concerns and opti-mism regarding the future post-therapy.• Although core beliefs, schema, recipro-cal roles or transference can be actedout throughout the course of therapy,the termination phase can lead to anacute presentation of key concepts suchas abandonment, rejection, perceivedfailure, entitlement and perfectionism,both on the part of the patient and theclinician. However, this can provide anextremely valuable final opportunity forthe clinician to work in the ‘here andnow’ with issues that could continue toaffect the patient, and also impact on theclinician’s own practice.• Termination can offer the clinician andpatient time for a valuable ‘all cards onthe table’ exercise, where both can voicewhat they think could have gone better,and what they have been happy with.Encouraging honest feedback can be oneof the most valuable opportunities for aclinician to request advice from patientswho could potentially improve his or herclinical skills.• Narrative therapy encourages the clin-ician to reflect on what he or she hasgained from contact with the patient dur-ing the sessions. This can be particularly44https:/www.cambridge.org/core/terms. https://doi.org/10.1111/j.1601-5215.2009.00443.xDownloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 14:01:50, subject to the Cambridge Core terms of use, available atimportant for patients who may minimisetheir own contributions to therapy andplace excessive credit for success on thetherapist.• Although use of letters summarisingtherapy can be challenging to completein a busy practice, these can be veryvaluable and both reinforce gains madeand serve as a reminder to clients of keyconcepts long after therapy as finished.• Rather than providing generic positivefeedback, or overly optimistic platitudesabout future success for the patient, it canbe important for clinicians to be preciseabout what they believe has improvedduring the course of therapy, while alsoasking the patient to specify their ownexperience of change.• The clinician should ensure that he orshe takes the time to hear realistic con-cerns expressed by the patient regardingtermination.• Relapse prevention work should be revis-ited towards the end of therapy to ensurethat key strategies have been retained bythe patient.ConclusionsIn conclusion, the termination of therapycan be challenging for both patient andclinician. As noted in the opening quote,termination can be a significant event,offering dangers relating to underminingprevious work done, while also presentingopportunities for consolidating gainsmade. However, if sufficient time is taken,if managed sensitively and if used toconsolidate and strengthen gains made,termination can be one of the mostpowerful phases of therapy.Craig A. Macneil1, Melissa K.Hasty1, Philippe Conus1,2,Michael Berk1,3,41Early Psychosis Prevention and Intervention Centre(EPPIC) and ORYGEN Research Centre, 35 Poplar Road,Parkville, Melbourne, Victoria 3052, Australia;2Treatment and Early Intervention in Psychosis Program(TIPP), De´partement de Psychiatrie CHUV, Universite´ deLausanne, Clinique de Cery, 1008 Prilly, Switzerland;3Department of Clinical and BiomedicalSciences—Barwon Health, University of Melbourne,Geelong, Australia; and4Mental Health Research Institute, Melbourne, AustraliaDr Craig A. Macneil,ORYGEN Youth Health,Melbourne, Australia.Tel: +61 3 9342 2800;Fax: +61 3 9387 3003;E-mail: craig.macneil@mh.org.auActa Neuropsychiatrica 2010: 22: 43–45© 2010 John Wiley & Sons A/SDOI: 10.1111/j.1601-5215.2009.00443.xReferences1. Ryle A, Kerr I. Introducing cognitiveanalytic therapy: principles and practice.West Sussex: John Wiley & Sons, Ltd.,2002.2. Mathews B. Terminating therapy:implications for the private practitioner.Psychother Priv Pract 1989;7:29–39.3. Kramer SA. Positive endings inpsychotherapy: bringing meaningful closureto therapeutic relationships. San Francisco,CA: Jossey-Bass Publishers, 1990.4. Davis DD. Terminating therapy. Aprofessionals guide to ending on a positivenote. Hoboken, NJ: John Wiley & Sons,Inc., 2008.5. Kottler JA. On being a therapist, 3rd edn.San Francisco, CA: Jossey-Bass Publishers,2003.6. Hillman J. The myth of analysis: threeessays in archetypal psychology. IL:Northwestern University Press, 1998.7. Henry L, Edwards J, Jackson H,Hulbert C, McGorry, P. CognitivelyOriented Psychotherapy for First-EpisodePsychosis (COPE). Victoria: EPPIC, 2002.8. O’Connell B. Solution-focused therapy.London: Sage Publications, 2005.9. Freedman J, Combs G. Narrative therapy:the social construction of preferred realities.New York: Norton, 1996.10. O’Keefe P, Berk M. Writing letters topatients. Acta Neuropsychiatr 2009; 21:314–316.45https:/www.cambridge.org/core/terms. https://doi.org/10.1111/j.1601-5215.2009.00443.xDownloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 14:01:50, subject to the Cambridge Core terms of use, available at

Termination of therapy: what can clinicians do to maximise gains?

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