Social Work News Headlines

Updated on: Fri, 26 May 2017 14:00:39 EST

An introduction to the special issue on psychotherapy termination.
This introduction to the special issue on psychotherapy termination begins by noting the almost complete lack of research and clinical discussion on this topic in the literature. It is with a desire to effect some sort of change to this current state of affairs that Psychotherapy invited manuscripts for this special issue. Specifically, the editors sought contributions on both the clinical practice and research aspects of the psychotherapy termination process from a variety of different theoretical orientations, perspectives, and methodologies. This special issue will include two sections, clinical practice and research, each serving to help better define the nature and extent of this important, but often ignored aspect of psychotherapy. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Fostering engagement during termination: Applying attachment theory and research.
Therapists often struggle to determine the most important things to focus on during termination. Reviewing the treatment, identifying plans for the future, summarizing positive gains, and saying goodbye receive the most attention. Despite our best intentions, termination can end up becoming intellectualized. Attachment theory and recent developments in neuroscience offer us a road map for facilitating endings that address client’s underlying relational needs, direct us to foster engagement, and help us facilitate new relational experience that can be transformative for clients. We argue that endings in therapy activate client’s and therapist’s attachments and these endings trigger emotion regulating strategies that can elicit client’s engagement or more defensiveness. The current paper will highlight through de-identified case examples how clients automatically respond termination and how therapists can foster rich relational experiences in the here-and-now that clients can take with them. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

A collaborative approach to psychotherapy termination.
Collaboration has been recognized as an important relationship variable in psychotherapy that is linked to client treatment outcomes. Although many therapists seek to build a collaborative working relationship with their clients when making treatment decisions, collaboration is also an important technique that can be used to help clients plan for a successful termination. Collaborative termination strategies can first be used in the initial session in order to address clients’ termination expectations. Strategies can also be used throughout treatment to help clients focus on their treatment goals. Last, collaborative termination strategies should be used in the final session to help clients take ownership of their gains and to equalize the therapeutic relationship. In this article, we provide specific recommendations for collaborating with clients in preparing for psychotherapy termination. Case examples demonstrating these strategies are also provided. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Termination in cognitive–behavioral therapy with children, adolescents, and parents.
The process of terminating cognitive–behavioral therapy (CBT) with families has been largely neglected in the literature, with the limited research focused on premature termination. This article describes the natural termination process in CBT with children, adolescents, and their parents. Based on existing theories, we describe a cognitive–behavioral model for: (a) initiating and engaging in discussion of termination, (b) processing the termination of treatment and the therapeutic relationship, (c) key aspects of the termination process in the final session, and (d) the very end of the final session (saying goodbye). For each of the 4 components, we review relevant theories, provide clinical exchanges to demonstrate techniques, and provide related research support. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Saying good goodbyes to your clients: A functional analytic psychotherapy (FAP) perspective.
Functional analytic psychotherapy (FAP) promotes client growth by shaping clients’ daily life problems that also show up in session with their therapists. FAP therapists create evocative contexts within therapy that afford clients the opportunity to practice, refine, and be reinforced for new, more adaptive behaviors which then can be generalized into their outside lives. In FAP, the termination process will vary from client to client depending on the nature of the client’s problems and targets. For many clients, the process can be a rich, multifaceted, final opportunity to evoke, reinforce, and promote generalization of clients’ in-session improvements, particularly improvements related to vulnerable self-expression in the service of intimate and close relationships. By making explicit agreements at the outset of therapy to participate in an intentional termination process, and by later providing an evocative structure for ending therapy with vulnerable emotional expression, clients have the opportunity to develop more adaptive behaviors in the context of relationship endings which can be a painful part of the human experience. Equipped with the skills of open-hearted communication developed from an authentic relationship with their therapist, clients can leave therapy on a trajectory of further growth in interpersonal connection and living more boldly. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Supportive–expressive interventions in working through treatment termination.
Supportive–expressive (SE) psychodynamic treatment has been receiving much empirical support. It is based on conceptualizing and working through the patients’ Core Conflictual Relationship Theme, which includes their main wish (W) in the context of an interpersonal relationship, an actual or anticipated subjective response from the other (RO) in relation to the W, and the subsequent emotional and behavioral response from the self (RS) to the RO. Studies suggest that the RO and RS components show the greatest change as a result of effective SE treatment. Clinical experience, however, suggests that in the last phase of treatment, when termination is anticipated, at least some patients regress to their original RS. This process is part of a separation conflict, which includes unconsciously renouncing their RS gains. In the present article we make recommendations regarding the timing and manner of initiating the termination discussion (the “clock-like reminder” and the “symbolic listening to termination cues”), integrating both supportive and expressive techniques. The article contains practice-based guidelines on how to work through the potential RS regression. We pay specific attention to what to do and not to do in the very last session and use examples from the pilot phase of a randomized controlled trial to demonstrate each recommended technique. Lastly, we suggest paths for future research to examine the proposed framework for working through termination. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Terminating supervision.
The focus of this paper is on the termination of clinical supervision. Although clinical supervision is considered the backbone of most mental health training programs, it gets relatively little theoretical or empirical attention. The termination of supervision has received even less attention. In this paper, we describe an approach to terminating supervision in our treatment team, which integrates intensive assessment with a relational perspective in a clinical science training program (Levendosky & Hopwood, 2016). We describe our established conceptual framework, review empirical evidence, and provide verbatim examples from final supervision meetings on our team to elaborate the importance of conceptualizing individual differences across trainees and parallels between supervision and psychotherapy dynamics. We conclude by emphasizing the need for research on supervision in general and supervision termination in particular. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: A meta-analysis of head-to-head comparisons.
The purpose of this meta-analysis was to examine rates of treatment refusal and premature termination for pharmacotherapy alone, psychotherapy alone, pharmacotherapy plus psychotherapy, and psychotherapy plus pill placebo treatments. A systematic review of the literature resulted in 186 comparative trials that included a report of treatment refusal and/or premature termination for at least 2 of the 4 treatment conditions. The data from these studies were pooled using a random-effects analysis. Odds Ratio effect sizes were then calculated to compare the rates between treatment conditions, once across all studies and then again for specific client disorder categories. An average treatment refusal rate of 8.2% was found across studies. Clients who were assigned to pharmacotherapy were 1.76 times more likely to refuse treatment compared with clients who were assigned psychotherapy. Differences in refusal rates for pharmacotherapy and psychotherapy were particularly evident for depressive disorders, panic disorder, and social anxiety disorder. On average, 21.9% of clients prematurely terminated their treatment. Across studies, clients who were assigned to pharmacotherapy were 1.20 times more likely to drop out compared with clients who were assigned to psychotherapy. Pharmacotherapy clients with anorexia/bulimia and depressive disorders dropped out at higher rates compared with psychotherapy clients with these disorders. Treatment refusal and dropout are significant problems in both psychotherapy and pharmacotherapy and providers of these treatments should seek to employ strategies to reduce their occurrence. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Therapist effects and the impacts of therapy nonattendance.
Although dropout from psychotherapy has received substantial attention, the impacts of nonattendance on client outcome across a course of psychotherapy have not been well researched. All in-person psychotherapy treatments require clients to actually attend sessions to generate positive symptomatic results, and missed sessions have at least a time and financial cost. Furthermore, it is plausible that therapist differences exist for client attendance rates. The present study examined impacts of nonattendance, particularly early in a course of treatment, comparing the effects of canceled and no-showed appointments on overall symptom reduction and rate of change while accounting for therapist effects. Using multilevel hierarchical regression, the impact of nonattendance on symptom reduction and rate of change was modeled on 5,253 clients (67.2% female, 72.3% white) across 83 therapists gathered from a practice research network. Results suggested that no-shows, but not cancellations, had negative impacts on the magnitude and rate of symptom change, with larger effects when occurring before the third session. Therapist effects on attendance also were identified; therapists varied greatly on nonattendance percentages of their clients after the third attended session. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Do all therapists do that when saying goodbye? A study of commonalities in termination behaviors.
This study aimed to identify core termination behaviors of psychotherapists across theoretical orientations in a successful course of treatment. Sixty-five experts from diverse theoretical traditions reported the frequency with which they used 80 tasks in a planned, mutually agreed termination of individual psychotherapy. Fifty-one items reached a positive consensus, 27 items did not obtain consensus, and 2 items were consensually employed infrequently. Termination behaviors/tasks achieving the strongest consensus concerned supporting the client’s progress, promoting client growth posttermination, following the ethics code, consolidating gains made, and highlighting patient’s recognition of competence. Only a few differences in self-reported use of termination behaviors were found across theoretical orientations, indicating some uniqueness but largely commonality in practice. Principal components analyses of all tasks identified 8 robust factors: process feelings of patient and therapist, discuss patient’s future functioning and coping, help patient use new skills beyond therapy, frame personal development as invariably unfinished, anticipate posttherapy growth and generalization, prepare explicitly for termination, reflect on patient gains and consolidation, and express pride in patient’s progress and mutual relationship. These findings integrate multiple models of termination and provide a pantheoretical consensus that can inform practice, training, and research. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

The termination phase: Therapists’ perspective on the therapeutic relationship and outcome.
The termination phase of treatment is recognized as a significant aspect of the therapy process and yet remains vastly understudied in psychotherapy literature. In the present study, therapists’ perspectives were used to examine how 3 elements of the therapy relationship (working alliance, real relationship, and transference) during the termination phase relate to perceived client sensitivity to loss, termination phase evaluation, and overall treatment outcome. Self-report data were gathered from 233 therapists, recruited from 2 Divisions of the American Psychological Association. Therapists completed measures for their work with a client with whom they could identify a termination phase of treatment. Results revealed that the working alliance and real relationship during the termination phase related positively to termination phase evaluation and overall treatment outcome, whereas negative transference during the termination phase related negatively to overall treatment outcome. Therapists’ perceptions of client sensitivity to loss related positively to both negative and positive transference during the termination phase. Post hoc analyses revealed only the working alliance during the termination phase uniquely predicted overall treatment outcome in a model with the 3 therapy relationship elements examined together. On the other hand, all 3 therapy relationship variables during the termination phase uniquely predicted termination phase evaluation, when examined together. Limitations and implications of these findings are discussed, and recommendations for future study are suggested. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Client–therapist agreement in the termination process and its association with therapeutic relationship.
There is no consensus among different therapeutic approaches on the process of termination when therapy does not have a prefixed duration. Moreover, both clinicians and researchers are still exploring decision making in the termination of treatment. The present study assessed former client’s perspective of therapy termination in a nonprobabilistic sample from Buenos Aires, Argentina. Seventy-three semistructured interviews, lasting ∼60 min each, were conducted with participants that had finished a therapeutic treatment or dropped out. They were asked about several aspects of therapy, including their experience of termination, specifically who decided to terminate, if there was agreement on termination or not, and their thoughts on the termination process. All interviews were transcribed and analyzed using an adaptation of Consensual Qualitative Research (CQR). Quantitative analyses were also conducted to examine associations between variables. Two main factors emerged from the analysis: client/therapist initiative on termination; and level of agreement between client and therapist regarding termination. Whereas nearly all (95%) of therapist-initiated termination cases agreed on termination, client-initiated termination cases could be sorted in agreed (49%) and disagreed (51%) terminations. Both therapist-initiated terminations and agreed upon terminations presented more categories of positive termination motives, better therapeutic bond, and higher overall satisfaction with treatment. Implications for research and clinical practice are discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Therapists-in-training experiences of working with transfer clients: One relationship terminates and another begins.
Data from interviews with 12 graduate-level trainees about their experiences of working with clients who had been transferred to them from another therapist were analyzed using consensual qualitative research. Trainees reported a range of helpful and hindering aspects about the transfer experience related to the client (e.g., client had experienced a prior termination and transfer, client had severe character pathology), the prior therapist (e.g., prior therapist prepared client for transfer, prior therapists did not process their termination with client), themselves (e.g., participant was open to addressing grief, participant was fearful of rejection), supervision (e.g., the supervisor provided important feedback on dealing with loss, the supervisor failed to address the unique nature of transferring), training (e.g., there was not adequate readings on termination and transfer, there was no readings on transfers), and clinic practices (e.g., meeting with the prior therapist and current therapist facilitated process, having clients end treatment with debt hindered the development of the new relationship). Participants also provided recommendations for improving the transfer process. Implications of these findings for clinical practice, training, and research are addressed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

The impact of psychotherapist training and experience on posttermination contact.
This study sought to enhance our understanding of posttermination contact, with a particular focus on the role of training and experience in shaping attitudes and behaviors with respect to the posttermination period. We collected anonymous online survey data related to attitudes, policies, and experience of posttermination contact from 144 licensed clinicians. Our sample was composed of an experienced group of clinicians, with 20.7 years in practice on average. Clinicians had a range of clinical orientations and ∼25% of respondents were from outside of the United States. Over 90% of the participants (130) endorsed having had some form of posttermination contact, and 25% (36) reported initiating posttermination contact with a past patient. Only 62 participants (43.4%) reported receiving graduate training related to posttermination contact, and those with graduate training were more likely to have an established posttermination policy that they reviewed with patients. In addition, recent graduates were more likely to report having had training on this topic than older graduates. In terms of attitudes, therapists were more likely to anticipate positive rather than negative consequences of posttermination contact for both patients and themselves, and the longer a therapist had been in practice the less likely they were to anticipate negative consequences of posttermination contact. Additionally, a clinician’s contact with their own therapist made them more likely to anticipate positive consequences for both themselves and their patients. Given the ubiquity of posttermination contact, the posttermination period should be given more attention in training programs and research. (PsycINFO Database Record (c) 2017 APA, all rights reserved)