Jennifer A. Hardy and Susan S. Woodhouse
The Pennsylvania State University
Termination is generally viewed by psychotherapists as a complex stage of psychotherapy (Gelso & Woodhouse, 2002). Research confirms that during this phase, the process and progress of psychotherapy are typically reviewed, goals are developed for the future, and the dyad says goodbye (Marx & Gelso, 1987). For some clients and psychotherapists, psychotherapy termination is also theorized to trigger a reexperiencing of past losses and unresolved grief (see Joyce, Piper, & Ogrodniczuk, 2007, for a review).
Treatment length in the studies reviewed here ranged from relatively short-term psychotherapy of 10-15 sessions at university counseling centers or clinics (Marx & Gelso, 1987; Quintana & Holahan, 1992) to long-term relationships averaging from 72 sessions (Boyer & Hoffman, 1993) to 28 months (Roe, Dekel, Harel, & Fennig, 2006) in private practice settings. Clearly we know less about termination in longer term psychotherapy, although two of the studies concerned relatively longer-term psychotherapy. Given the strong attachment that can form over the course of long-term psychotherapy, it is possible that termination may be more complicated and difficult when compared to short-term psychotherapy. More research, however, will be needed to explore that possibility.
Traditionally, termination as been conceptualized using a “termination as loss model” (Quintana, 1993, p. 426). Quintana divided the “termination as loss” model into two components: termination as crisis and termination as development. The first suggests that clients and psychotherapists experience termination as a difficult process in which symptom relapse is probable. Little empirical support has been found for this perspective (for a review, see Gelso & Woodhouse, 2002). The second component proposes that termination serves as a catalyst for growth, crystallizing the process of psychotherapy and one’s personal growth. Research has provided support for this conceptualization of termination (see Gelso & Woodhouse, 2002, for a review), as will be seen below.
What does the research tell us about the affective experience of termination? First, the research suggests that most clients (69%) appreciate the opportunity to discuss their reactions with their psychotherapist (Marx & Gelso, 1987). When surveyed about their reactions to termination, clients most commonly identified a variety of feelings including: pride, health, a sense of accomplishment, independence, cooperative, calmness, alive, agreeable, friendly, good, healthy, thoughtful, and satisfied (Fortune, 1987; Fortune, Pearlingi, & Rochelle, 1992; Marx & Gelso, 1987; Quintana & Holahan, 1992). It is important for psychotherapists to be aware that these positive feelings are those most commonly identified, as psychotherapists may tend to expect clients to feel more negative emotional reactions to termination. The most highly rated psychotherapist reaction was pride, both in terms of their client’s growth and their therapeutic skill (Fortune; Fortune et al.).
The importance clients placed on discussing their reactions to ending has been significantly related to client loss history as well as loss as a theme in psychotherapy (Marx & Gelso, 1987). It appears as though clients with loss as a predominant theme may experience termination both as a crisis and, when given appropriate clinical attention, an opportunity for development. In other words, psychotherapists can aid these clients in more fully experiencing and processing their reactions to ending so that these clients have a corrective termination experience.
In terms of deciding when to mutually terminate, Roe et al. (2006) found that clients reported initiating these discussions about two-thirds of the time. The most common reasons given for termination were accomplishment of goals, situational/external factors, and dissatisfaction with psychotherapy (Roe et al.). Interestingly, a discrepancy was found between clients’ and psychotherapists’ views, with almost twice as many clients attributing termination to successful achievement of goals (38.6% vs. 26%; Hunsley, Aubry, Verstervelt, & Vito, 1999). It may be that psychotherapists tend to underestimate how much clients feel that they have gained from psychotherapy. Also, it has been suggested that clients who cite “lack of interest” as a reason for termination are likely dissatisfied with psychotherapy because lack of interest has been significantly related to feeling that psychotherapy was going nowhere or making things worse as well as having little confidence in the psychotherapist (Hunsley et al., 1999). It seems as though clients may have a difficult time expressing dissatisfaction with psychotherapy and consequently, psychotherapists may not be aware of dissatisfaction as a factor in termination. It may be helpful to actively explore reasons for termination, actively asking about some of the reasons that clients frequently cite such as accomplishment of goals, situational/external factors, and dissatisfaction with psychotherapy (Roe et al).
Compared to client reactions, much more empirical research has been conducted regarding psychotherapist reactions to and behaviors during termination. First, psychotherapists were more likely to view termination as significant to the therapeutic process in successful cases than in cases considered unsuccessful (Quintana & Holahan, 1992). With these clients, psychotherapists were also more likely to express their own reactions to termination, self-disclose, and relate to their client in an egalitarian manner (Quintana & Holahan). In general, during the final session, 69.9% of psychotherapists invite their clients to return if needed (Quintana & Holahan, 1992). No differences have been identified in the empirical literature regarding theoretical orientation, except that non-analytically oriented psychotherapist were more likely to invite their clients to return than analytic psychotherapists (see Gelso & Woodhouse, 2002, for a review). In terms of the theoretical proposition that termination elicits past grief, psychotherapist grief reactions have been found to be positively related to psychotherapist feelings of anxiety and depression during termination (Boyer & Hoffman, 1993). As a result, psychotherapists may want to be aware of their own feelings related to grief and loss as they impact the process of termination.
Finally, Zuckerman and Mitchell (2004) examined the impact of training on pre-doctoral psychology interns perspectives on forced termination (due to the end of a rotation). About half of their sample described themselves as less than adequately prepared for termination, and the most commonly identified emotions regarding termination were sadness, guilt, and relief (Zuckerman & Mitchell). This finding suggests that trainees may benefit from extra attention to termination issues and supervision that is focused on preparation for and the process of termination. Special attention in supervision to issues of termination when the client has not yet reached desired goals (e.g., at the end of a trainee’s rotation) may be beneficial for trainees.
Termination appears to be viewed as a positive transition by most clients, supporting the termination as development model suggested by Quintana (1993). For most clients, rather than eliciting unresolved losses, the research suggests that the final stage of psychotherapy is characterized by a sense of accomplishment, pride, calmness, and health for both psychotherapist and client. Clients reported that these feelings were due in large part to the open discussions they had with their psychotherapist about their reactions to termination and their feelings about the therapeutic relationship (Marx & Gelso, 1987).
Termination research has generally focused on identifying the behaviors that occur in session, attempting to predict unilateral termination, and understanding psychotherapist reactions to termination (Gelso & Woodhouse, 2002). Little is known about the effect of other factors on termination such as theoretical orientation and termination from long-term psychotherapy as opposed to shorter-term psychotherapy. The bulk of the studies thus far have focused on termination in shorter-term psychotherapy and only two studies have specifically examined termination in longer-term work. It is possible that the attachment formed in longer-term psychotherapy may make termination in longer-term therapy more complex than in shorter-term therapy. Thus far, the research on longer-term psychotherapy has shown that clients display positive reactions to termination when they are satisfied with their progress (Roe et al., 2006) but that psychotherapists feel more anxious during termination from long-term psychotherapy when either the psychotherapist or the client has a loss history (Boyer & Hoffman, 1993). Clearly additional research is needed regarding the process of termination. Given the influence of constructs such as working alliance, attachment style, empathy, and transference/countertransference in the general psychotherapy research, it would be interesting for future research to examine how the process of termination changes as each of these constructs varies.
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