What makes A Good Ending in Therapy?
Relationships are hard work and when they end people can feel devastated. A secure therapeutic ‘alliance’ often helps clients find a more constructive way to say “goodbye”. But to do this, counsellors must focus on the end of therapy as a phase rather than a single event, as this is crucial “…to it feeling like a good and a productive experience” for both client and therapist.
It’s in this vein that Margot Weil at Adelphi University and her colleagues set out to explore both client and therapist perspectives “during the termination phase”. Using standardised psychotherapy measures, these researchers discovered that genuine collaboration frequently occurs at this stage, even though significant issues and conflict resurface. Above all else, it is a time for “goodbyes” and dealing with feelings of loss and anger.
When Weil’s team interviewed 30 participants who had recently or was currently receiving short-term psychodynamic psychotherapy (STPP) at a university-based community clinic, and videoed the experience, they found significant improvement in their sample. Specifically, they discovered that ending sessions were distinctly more useful if they actively participated in them.
Using short-term psychodynamic psychotherapy (STPP) offered a way for client and therapist to collaboratively identify patterns in actions, thoughts, feelings, experiences and relationships, and to delve into past experiences and explore dreams causing discomfort. Therapists’ willingness to explore key issues in the client’s relationships during a ‘termination phase’ session coincided with their realisation that the termination phase/session could be productive.
Intriguingly, Weil and her colleagues provide an example of an ending session in which a 26-year-old woman contemplates saying “goodbye” to her therapist, in a dialogue focusing on the relationship between them:
- Patient: Hopefully you remember me. You know…
- Therapist: You think I wouldn’t?
- Patient: Yeah, well, OK, well, I don’t know if you’re the type of person to bring your work home with you…OK, I know some professions you kind of end up bringing your work home, but…
- Therapist: Well, let me ask you a question, is it going to be easy for you to forget about our work together?
- Patient: No, no it’s not.
- Therapist: I think I share that feeling.
Correspondingly, client perspectives on what makes a productive hour significantly relate to their level of participation. Therapist exploration might not always be seen as “good”, and yet it can be productive, providing clients with a sense of accomplishment and a clear idea of their own resilience. Mysteriously, therapists’ rating of their own exploration in no way relates to clients’ experience of the session as “good” or “bad”, suggesting very different ideas about what therapist exploration looks like in practice.
What we do know is that the therapist is tasked with the responsibility of addressing any negative feelings and ruptures during this ‘termination phase’:
- Therapist: …I think it’s important for us to talk about ending, but I don’t want you
to feel that I am coercing you in any way…
- Patient: No, no, no, no. Not at all. (Laughs) I don’t mean to laugh. Not at all. Just
when I think about this that’s what I think.
- Therapist: So you’re feeling stuck…does that include here?
- Patient: Sometimes it does…It can. Every week I think oh no I have this.
- Therapist: What do you imagine it’s going to be like to end our relationship here?
- Patient: Sad, really sad. You have been my role model for the past year and really helped me. You didn’t enable me…didn’t force me to do anything. It’s moving me to tears…I appreciate our time.
Only clients and therapists who had experienced the termination process of successful therapy were included from “a relatively mild-to-moderate pathology outpatient sample” in this small-scale study. It also unclear if STPP can be used with inpatient populations or different therapy approaches. What we are certain about is that therapists need “to tease out the complex interactions around termination between the patient and therapist”.
Weil, M.P., Katz, M., & Hilsenroth, M.J. ((2017). Patient and therapist perspectives during the psychotherapy termination process: The role of participation and exploration. Psychodynamic Psychiatry, 45(1), 23-4. doi:10.1521/pdps.2017.45.1.23