Learning Objectives

This is an intermediate-level course. After completing it, mental health professionals will be able to:

• Describe a structured approach to processing clients’ unilateral termination decisions.
• Identify ways to prevent premature unilateral termination.
• Formulate a plan to restore personal well-being from an experience of premature unilateral termination.

This course is adapted from the article Schaeffer, J.A., Ph.D. and Kaiser, E.M. (2013) A Structured Approach to Processing Clients’ Unilateral Termination Decisions. American Journal of Psychotherapy, 67(2), 165-184. American Psychiatric Association Publishing. These adaptations are done with permission of the publisher.

This course is based on the most accurate information available to the author at the time of writing. However, new information may emerge that supersedes some information in this course. Theories and research related to minorities, in particular, are shedding new light on why premature unilateral termination occurs more frequently than is desirable because of important cultural values and expectations.

This course may provoke disturbing feelings in readers due to the sensitive nature of therapists’ experiences of premature unilateral termination. Guilt, remorse, shame, resentment, and discouragement may be among these disturbing feelings. If they endure and/or become pronounced, readers may need to seek supervision, consultation, or personal therapy in order to deal with their distress.

Outline

• Introduction
  • Definition and Theories
  • The Problem
  • The Solution
• Step One: Honoring an Initial Reaction
• Step Two: Appraising Probable Causes
  • General Purpose of Cognitive Appraisal
  • Reviewing Research and Theory
• Step Three: Determining Probable Reasons and Taking Responsibility
• Step Four: Engaging in Mourning and Other Reparative Tasks
  • Mourning
  • Other Reparative Tasks
• Step Five: Evaluating Well-Being and Sense of Self-Efficacy
• Step Six: Taking a Broader Perspective
• Conclusions: Implications, Applications, and Limitations
• References

Introduction

Definition and Theories

It is important to note that there is no standardized definition for premature termination (Self, Oates, Pinnock-Hamilton, & Leach, 2005). It is defined as ending therapy prior to expiration of the treatment contract (Philips, Webart, Wennberg & Schubert, 2007). It is also defined as clients’ failure to keep their last appointment (Pekarik, 1985) or clients’ decision to terminate therapy contrary to the therapist’s advice (Ogrodniczuk, et al., 2005). More recently, it is defined as clients’ discontinuing “an intervention prematurely, before recovering from the problems that led [them] to seek treatment and/or before completing the intervention’s specified protocol.” It implies that clients dropped out “before finishing the therapeutic endeavor, before experiencing a substantial reduction in symptoms, and before returning to a nonclinical level of functioning” (Swift & Greenberg, 2014, p. 193).

It is also important to note that theories about why clients terminate prematurely vary according to treatment context and theoretical orientation about treatment objectives, expectations concerning the length of therapy, and criteria for success (Ogrodniczuk, et al., 2005).

The Problem

In any case, early termination is clearly an occupational problem (Schoenherr, et al., 2019) that brings significant distress to mental health professionals. They know that even their highly effective treatments “will be of little use if … clients fail to complete [them]” (Swift & Greenberg, 2014, p. 200).

Premature termination is especially distressful if it is the result of a decision made unilaterally by clients. Their therapists know about it only after the fact. They have had no input into the decision. They are left unsure of their clients’ welfare, their own professional competence and reputation, and the financial impact on their practice. Regardless of whether in private practice or on the staff of a hospital or agency, they are quite aware of early termination being a costly problem (Xiao, et al., 2017).

Thus, therapists worry that they contributed to – or even caused – the termination. Because unilateral decisions preclude feedback from clients, therapists have significant unanswered questions that lead to loss of self-efficacy (Joyce, et al., 2007; Lambert, 2004; Ogrodniczuk, et al., 2005; Roe, 2007; Sledge, Moras, Hartley, & Levine, 1990; Van Denburg & Van Denburg, 1992). They may have not had the skills to deal with their clients’ pain and thus did not help – perhaps even harmed – them. Especially if they believe their clients rejected them in spite of their skills, therapists can suffer from painful loss of self-esteem.

Perhaps it would not be so bad if unilateral premature termination were an uncommon occurrence. But research over several decades reveals that close to half of clients in the United States terminate psychotherapy before finishing their work, sometimes without discussing the matter with their therapist. The most effective therapists see 70% of their clients through to the completion of their work. The rest do so in far fewer cases, with an average national premature termination rate somewhere between 20% and 47% (Beutler, Harwood, Alimohamed, & Malik, 2002; Joyce, Piper, Ogrodniczuk, & Klein, 2007; Lambert & Ogles, 2004; Roe, 2007; Swift & Greenberg, 2014; Swift, J., et al., 2017); Wierzbicki & Pekarik, 1992).

These statistics have changed little in the past few decades (Baekeland & Lundwall, 1975; Beutler, et al., 2002; Garfield, 1986; Lambert & Ogles, 2004). They have held across various theoretical orientations (Swift & Greenberg, 2014), settings, levels of education (Joyce, et al., 2007; Roe, 2007), and even years of experience (Schwartz & Flowers, 2010).

The Solution

Thus, therapists need to process their experience of clients’ terminating without seeking their input (Pekarik, 1985). They need a structured approach that is different from one designed for mutually determined terminations.

This course proposes such an approach. It is based on an analysis of mental representations: how therapists experience themselves and their clients (Jacobson, 1954). Regardless of theoretical orientation, these representations impact therapist-client relationships and play a part in unilateral termination decisions (Blatt, Auerbach, & Levy, 1997).

This proposed approach is comprised of six steps to be undertaken seriatim. A step not completed in one attempt is to be revisited.

The steps are pan-theoretical in that they interweave the affective, somatosensory, cognitive, and behavioral work necessary for therapists to meet both their personal needs and their professional responsibilities.

Finally, in this proposed approach, the term unilateral termination is used rather than premature unilateral termination since the former both captures the construct of premature termination and avoids problems related to diverse theoretical definitions of premature (Westmacott, Hunsley, Best, Rumstein-McKean, & Schindler, 2010).

Step One: Honoring an Initial Reaction

First, therapists honor their initial reaction to a unilateral termination: one derived from natural assessments made routinely and automatically by their perceptual system (Kahneman, 2003). Occurring within 150 milliseconds, these natural assessments are the quick and efficient “work” of a specialized neural circuitry (Kahneman, 2003) rather than activity mediated by conscious awareness (Huron, 2006).

One frequently occurring natural assessment therapists tend to make is that what happened is either “good” or “bad” (Kahneman, 2003). Another is that it is surprising (Kahneman & Miller, 1986), unexpected, or out of place.

In performing this first step, therapists refrain from trying to understand or justify their cognitive-affective-somatosensory reaction. Rather, they purposefully honor their idiosyncratic response to an unanticipated event, expressing whatever they are experiencing. If, for instance, if it is surprise conflated with relief, they take time to enjoy their relief. If, as is more common, it is surprise conflated with sadness, therapists embrace their sense of loss.

Therapists can process their initial distress by exercising (Crone & Guy, 2008) or massaging their muscles, particularly those of the cheeks and mouth (Porges, 2003). They can journal (Tokolahi, 2010). They can allow both dominant and non-dominant hands to draw, crayon, or paint (Bradshaw, 1990). They can sculpt, letting their emotions take shape in whatever way they wish (Hughes, 2009). They can reach out, as confidentiality permits, to a trusted colleague or take refuge in a safe sanctuary.

Of course, therapists can combine various forms of self-care. The important point is that they avoid – initially – the difficult analytic work they usually want to begin immediately, for their ultimate goal is to benefit from a structured approach that is designed to transform the experience of a painful ending into one of a new beginning.

Step Two: Appraising Probable Causes

General Purpose of Cognitive Appraisal

Lest therapists base future professional plans solely on their initial perceptions, a conscious, cognitive appraisal must soon follow (Kahneman, 2003), for if their initial unconscious assessment is that what happened is “bad” and they have failed, that assessment may prevail unless it is qualified or contradicted.

Indeed, even in cases of contrasting input, unconscious assessment reactions tend to function as powerful suppressors of alternative interpretations (Kahneman, 2003). Internally generated images created by the brain combine with the original external stimuli to create neural “maps” (Kandel, 2006; Siegel, 2001) that subsequently function as enduring mediators. Provided nothing is done to interrupt the process, neurons consistently firing in the same patterns govern and facilitate future responses to similar external stimuli (Siegel, 2001). Fast and powerful the first time a therapist experiences a unilateral termination, a natural assessment becomes even faster, more potent, and more impervious in subsequent cases.

Because cognitive appraisal is a key mediator in transactional models of stress (Lazarus & Launier, 1978), it is wise to have it as a second step in the event of unilateral termination. Otherwise, a situation perceived as a threat might result in avoidance rather than becoming an opportunity to engage in problem-solving and emotion-focused coping. Only by approaching the issue of what has most likely caused a particular termination will therapists experience a beneficial feeling of control over a distressful situation and an awareness of a challenge rather than a threat (Folkman & Lazarus, 1985). As a result, therapists will be much more likely to choose a more cognitive, less emotional, more effective corrective strategy (Wong & Reker, 1985) for dealing with similar situations in the future.

Reviewing Research and Theory

Therapists generally need to begin a cognitive appraisal by reviewing research regarding common causes of termination and trans-theoretical explanations for unsuccessful therapy, keeping in mind the cognitive appraisal factors outlined by Lazarus and Launier (1978). In performing this review, therapists need to hold several hypotheses in mind, for in most cases, several reasons will carry explanatory power.

Therapists are oftentimes not as objective as they would like to believe they are, due to self-serving tendencies. For one thing, they tend to attribute causality to clients and/or environmental factors when evaluating their own termination cases, but not the termination cases of other therapists (Murdock, Edwards, & Murdock, 2010). For another, they tend to overestimate clients’ improvement, and underestimate – if they even notice – their deterioration (Norcross & Lambert, 2019). Thus, reviewing research and theory paves the way for therapists to shift the weight away from their own explanations for reasons clients terminate to empirical data and sound theory.

Termination reasons can be put into three broad categories developed by Pekarik (1992), and a fourth based on other research findings.

Category One: Improvement

Some clients terminate because they believe they have reached their goals (Hunsley, Aubry, Verstervelt, & Vito, 1999; Roe, Dekel, Harel, & Fennig, 2006). They have benefited from therapy; they’ve solved the problem(s) and lessened the pain that brought them to treatment. They are ready and able to end their therapeutic commitment (Kramer, 1986; Roe, 2007).

Indeed, many clients do not personally experience what therapists define as “terminating too soon” or terminating inappropriately (Ellington, 1990; Hunsley, et al., 1999). Sometimes, because they regard goals that therapists cherish – such as “acceptance of self” – as never fully attainable, they believe partial attainment is good enough (Roe, 2007). At other times, clients regard their experience of having diminished their pain, usually by solving their presenting problem(s), as an empowering “truth.” They are cognizant of additional work they need to do, but prefer not to do it at the present time. They judge that they will do the needed work better in the future if they “bask in the sun” of their present accomplishments (Todd, Deanne, & Bragdon, 2003). At still other times, clients believe that, having achieved their goals, they are able to deal with other barriers to their well-being without additional therapy (Arnow, Blasey, Manber, Constantino, Markowitz, & Klein, 2007; Roe, 2007; Wierzbicki & Pekarik, 1992).

After reviewing Category One reasons for terminating, therapists might be justified in moving on to confirmation work and mourning. Their cognitive appraisal would be that they were not at fault. It is usually wiser, however, for therapists to continue their review, for research also suggests human decision-making is usually multi-based. As many as eight or more motivations influence human decisions to take action, and most of them are unconscious.

Category Two: Dissatisfaction with Treatment

About one-third of all clients terminate because they experience their therapists as unhelpful (Hunsley, et al., 1999; Pekarik & Finney-Owen, 1987). In some cases, they regard their therapists as deficient or unskilled and consequently have no faith in them (Roe, 2007).

Some clients find their therapists unskilled in managing their own reactions from earlier or extra-therapeutic experiences that are indistinguishable from those presently occurring in therapy (Levinson, McMurray, Podell, & Weiner, 1978; Mohr, 1995; Nagliero, 1996; Van Wagoner, Gelso, Hayes, & Diemer, 1991). In some instances, they appear to be angry, which makes clients fear aggression in the therapeutic setting (Frayn, 1992). Certain clients even perceive their therapists as malevolent persecutors whom they must leave in order to protect themselves (Dewald, 1971).

Other clients experience their therapists as being caught in sustained, heightened anxiety (Berry, 1970; Gamsky & Farwell, 1966) or in pervasive depression that keeps them self-focused in spite of their desire to help. Still others experience their therapists as giving subtle but unnerving indications that they are sexually aroused and might be unable to contain that arousal (Frayn, 1992).

In brief, some clients find their therapists incapable of offering adequate empathy (Robbins & Jolkovski, 1987) and/or providing the help they need.

Ironically, other clients terminate because they find their therapists deficient in detecting and managing their own emotional involvement in the therapeutic interaction. Some experience their therapists as overtly polite but covertly repelled by what they share, such as their dreams (Harris, 2021). Others experience their therapists as overly or purely empathic: having an excessive need to nurture or an inordinate need for approval from clients (Bandura, Lipsher, & Miller, 1960; Mills & Abeles, 1965; Robbins & Jolkovski, 1987). Thus, such therapists refrain from using confrontations and interpretations that challenge their clients’ worldviews and mediate and/or moderate change. This becomes problematic, of course, because on an unconscious level, most clients know that for them to get better, they must engage in a demanding change process (Bollas, 1987).

For other clients, when another person, such as their therapist, finally meets their needs, they find it extremely difficult to maintain the relationship (Arnow, et al., 2007; Kohut, 1977). Therapists attempting to treat them may not be overly empathic from an objective standpoint, but they are too empathic for these particular clients. Thus, their anxiety becomes intolerable as they experience their therapist as unable to extricate themselves from affective empathy (Arnow, et al., 2007; Greenson & Wexler, 1969; Newman, 1994; Reich, 1960).

Other clients terminate because they find their therapist lacking expertise in dealing with them: individuals with traits that are so stable or chronic that they find their challenges in living virtually insurmountable. They may be so masochistic, for example, that they can scarcely engage with anyone, especially healthy individuals, on a long-term basis (Levinson, et al., 1978). Or they have become so pervasively angry and/or sadistic that they have irresistible desires to rebel, manipulate, control, or devalue those with whom they come in contact (Freud, 1937/1968; Novick, 1982), including a therapist (Winnicott, 1975). Other clients are so envious that they cannot tolerate the thought that their therapist has other relationships, as evidenced by fellow clients in the waiting room (Frayn, 1992).

Yet others are so chronically impulsive that they cannot handle any form of separation from a therapist who has, for example, gone on vacation. It causes too much anxiety (Masterson, 1981). This “separation” may even be simply an internal experience resultant from a therapist’s relatively low number of empathic responses during the working phase of therapy (Newman, 1994; Frayn, 1992; Levinson, et al., 1978). Chronically impulsive, as well as intensely fearful of rejection, these clients leave therapy rather than being left by their therapist. They reject before being rejected (Mahler, Pine, & Bergman, 1975).

Insurmountable philosophical and coping style differences that directly affect some clients’ therapeutic relationship may also motivate them to drop out of therapy. Some terminate because their therapist seems unable to reconcile striking differences between them with regard to theories of change and well-being (Philips, et al, 2007; Safran, Crocker, McMain, & Murray, 1990).

For example, clients uncomfortable with introversion, withdrawal, social restraint, self-attribution, self-blame, self-criticism, and inhibition can find it too taxing to work with an insight-oriented and interpersonally focused therapist who keeps to a steady, theoretically determined course (Beutler, et al., 2002). Similarly, clients uncomfortable with expression and excitation, impulsivity, gregariousness, or expressiveness – often combined with a propensity to blame others and rely on external attributions of cause – can find it too difficult to work with a therapist who uses behavioral and skill-focused interventions (Beutler, et al., 2002).

Still other clients determine that their therapist is not able to meet their high need for approval (Strickland & Crowne, 1963). They quickly experience negativity if their therapist evaluates them, even unconsciously, as immature and approval-seeking (Strickland & Crowne, 1963). They become desperate to protect their vulnerable self-image. Fearing that continuing in therapy will erode their self-image even more, they terminate.

Similarly, chronically dependent clients may terminate for fear that their nondirective therapist cannot or will not meet their dependency needs (Heilbrun, 1970). In contrast, dependent clients who finally embrace their need for independence may terminate from a therapist they experience as too consistently directive (Roe, 2007; Smith, 1971). In either case, these clients lie at the distancing end of the approaching-distancing continuum (Philips, et al., 2007) and see ending therapy as a way to get the distance they need.

A caveat is in order in therapists’ review of Category Two: Therapists should not automatically conclude that either they or their clients are at fault (Shedler, 2021). Clients might be worse off if they recovered from disorders which have become adaptive in the light of continuing distress. Those caught in an abusive relationship, for example, can hardly benefit from asserting their independence if they do not have access to money. Their dependency offers a temporary solution at the time. Rather, therapists need to assess their expertise in working with clearly challenging clients. High levels of expertise raise the question of whether therapists are able and/or willing to use their expertise. Low levels of expertise, by contrast, make therapists think about either acquiring sufficient expertise or referring certain clients to others in the future.

Category Three: Environmental Obstacles

Many clients terminate because of external reasons beyond their control, such as too little money, pressing concerns about other matters (Xiao, et al. 2017), incapacitating medical problems, family responsibilities, and/or having to relocate (Roe, 2007). They regret having to end therapy but believe they have no choice.

Revealing these environmental obstacles to their therapists, of course, is significantly different from simply not keeping the last appointment or not responding to phone calls or evaluations. Therapists who are not informed can only review their work, hoping to discover data that shed light on what eventually happened.

Category Four: Other Reasons

About 10% of clients who enter therapy find the emotional pain they begin to suffer sufficient motivation for leaving therapy (Hynan, 1990). They determine that they have already suffered too much either before therapy or during trauma work. Some simply want to put pain behind them while others want to avoid new painful discoveries and fear such discoveries in therapy (Dickes & Strauss, 1979).

Vignette:

The therapist had worked with young men during her year-long residency. She had also taught them for four years in a rural, racially biased setting where she had frequently met with other teachers to discuss how to handle the racial micro-aggressions they commonly noticed. In addition, she took a course in Islamic traditions, customs, and values.

Thus, she felt confident that she would do well with the young male client from a Muslim country who asked to work with her.

When he came, one of the first things she said was that she had deep respect for Islam and Mohammed. Her client immediately said that he had no use for Islam. None whatsoever. His facial expression registered both disgust and dismay that someone would presume he did.

His therapist immediately apologized and went on to ask about how things were going at school, which he had said was the major cause of his distress. Saying nothing but revealing empathy non-verbally, she tried hard to become a person he could begin to trust.

At the end of the session, when asked when he could return, the client agreed to the following week. However, he failed to keep the appointment and never called to say why.

As this vignette suggests, it is most likely that the level of the client’s distress due to the complex trauma he was experiencing was too high for him to participate meaningfully in therapy.

Other clients believe they can safely terminate because they have other resource persons. Now involved in new, meaningful relationships (Roe, 2007), they can achieve their goals in collaboration with other professionals or simply supportive persons. Thus they prefer to put their time and energy into their non-therapeutic relationships.

Other clients terminate simply because they do not have the ability to relate to a therapist or make use of therapeutic interventions in spite of their objective suitability (Henry & Strupp, 1994). Some are not ready to change; some will never be (Todd, et al., 2003). They are in a permanent contemplative or pre-contemplative state that prevents them from moving into action

Still others have such powerful, disorganizing resistance to change that they cannot form a therapeutic alliance (Frayn, 1992). In this category would be those addicted to extremely re-enforcing drugs and/or those with long-term reliance on alcohol – to mention but two addictions common in U.S. culture (Anderson, et al., 2019; Xiao, et al., 2017). The inability to form a therapeutic alliance is highly unlikely to change because a therapist tries to influence these clients, especially one who is not an addiction recovery specialist. In fact, the inability only worsens. The clients are caught in an approach-avoidance conflict in which the fundamental dilemma they face is giving up their addiction/defensive self-image or defying the one who implies their “truth” is not valid. “The outcome of such an approach-avoidance conflict [will inevitably be their] leaving the field” (Strickland & Crowne, 1963, p. 100). If they do not leave physically, they are likely to leave psychologically, making anything more than minimal goal attainment improbable.

Vignette:

The wife had used drugs and alcohol since she was a teen-ager. Since her marriage 5-12 years ago, she had increased the amount of alcohol she used to reduce her distress.

In their therapy sessions, her husband complained about how much she changed when she drank and how problematic that was not only for him but for their young children. When hearing this, she argued that she had changed so many other things for her family’s sake it was unfair to ask her to stop drinking. She added that most of the time she did not drink enough to deserve having to give up alcohol.

In marital therapy sessions, the therapist worked hard to remain as unbiased and neutral as possible, coaching both husband and wife when they needed help to explore more thoroughly the family dynamics that explained a good deal of the emotional pain both the wife and husband were suffering

But the issue could not be resolved. Finally, the couple decided on their own to stop coming to sessions. They did not discuss their decision with their therapist, which left him in the dark as to exactly why they terminated. Upon reflecting carefully, however, the therapist began to see that he had failed to take seriously the wife’s being in a pre-contemplative stage of change.

Step Three: Determining Probable Reasons and Taking Responsibility

Having reviewed empirical data and theory in the light of a specific client’s termination, therapists are faced with choosing from various contenders the most likely explanation(s) for what happened. They should aim for high probability rather than certainty, however, overly long analytic work will preclude timely movement to any remaining steps they need to take.

During the third step, in order to minimize confirmation bias (Baron, 2000) and heuristics (Kahneman, 2003), it is important that therapists distance themselves from what they have deduced thus far. They need to increase their objectivity by searching for evidence that disconfirms – rather than confirms – their favored hypotheses. Such evidence includes statistical information regarding percentages of terminating clients who fall into four categories: heretofore unexamined verbal and nonverbal “messages” from clients; analysis of their own countertransference, especially that which was operant toward the end of treatment (Schaeffer, 2007); and the viewpoint of an unbiased colleague.

In intentionally distancing from their hypotheses, therapists perform what is perhaps their most crucial task: applying research-supported theory and statistics to an individual case while giving subjective, affective, intuitive, and contextual forces the attention they deserve.

Therapists taking Step Three also need to keep in mind that mental health practitioners often disagree with clients about whether they have actually attained their goals. In fact, most therapists do not corroborate satisfactory goal achievement by clients whose decision to terminate is unilateral (Hunsley, et al., 1999). They tend to regard therapeutic work in its totality. They easily identify parts of the work clients have not completed.

Similarly, therapists question reduction in distress as a sufficient condition for termination. Some clients delude themselves into evaluating their original distress at a lower level than what they claimed originally in an effort to bolster their self-esteem or create a positive illusion about themselves. These clients are not actually conducting an honest assessment (Safer & Keuler, 2001). Rather, they are using their decision to terminate as further proof of their self-efficacy when in fact it is further proof of their basic problem: falsely inflating capabilities by using some growth as a sign of sufficient growth (Safer & Keuler, 2001).

Most therapists also doubt clients’ capability to choose termination unilaterally. Those whose life patterns indicate pervasive dependence, in particular, would hardly be able to make sound decisions independently without considerable work (Heilbrun, 1970; Kupers, 1988). Therapists should also bear in mind that clients’ decisions to terminate therapy may be based on flawed or limited perceptions of their therapy and their therapist.

Some clients may not even know why they terminated (Hunsley, et al., 1999). Their memories are fallible, and unconscious factors affect ratings of their experiences (von Benedek, 1992). They may well have based their decision to terminate not on what was going on at the time but on earlier, contemplative thoughts or even pre-contemplative thought fragments (Derisley & Reynolds, 2000; McConnaughy, Prochaska, Velicer, & Di Clemente, 1984; Miller & Rollnick, 1991). They may have based their decision not so much on a conscious evaluation process but on their therapists’ unconscious communications of their own discouragement, insecurity regarding their skills, or temporary limitations such as fatigue (Schaeffer, 2007).

Once therapists have reached reasonable certitude regarding a given termination, they are wise to set aside their most compelling explanation and entertain a contrasting one. They do so by affirming one for a number of hours or days, then the alternate for an equal amount of time, all the while paying careful attention to their somatic reactions. Bodily reactions will ordinarily support the accuracy of attributions, with pain or discomfort designating what is inaccurate, and calm and bodily well-being what is accurate (Oschmann & Oschmann, 1995).

Next, therapists determine whether they should assume responsibility for the explanation that resulted from their analysis. They consider whether their personal limitations, such as lack of expertise and/or self-awareness, poor judgment, or burnout, significantly affected their work. They weigh the characteristics of the client who terminated and the likelihood of effective treatment of the disorder or problem with which the client presented. They give consideration to realistic expectations for actually helping certain kinds of clients.

Step Four: Engaging in Mourning and Other Reparative Tasks

Once therapists have determined a probable reason or reasons for a termination and their possible contribution to it, they should set aside their cognitive work and engage in the affective task of mourning. For according to bereavement theory, mourning is a pre-requisite for skill-building and other reparative work. Alternately, in cases in which therapists need not assume responsibility for a termination, mourning can become the essence of the reparative plan (Weiss, 2001).

Mourning

Whether or not therapists are suffering from ethical guilt in the sense of having done harm, they need to deal with the acute and episodic psychological pain of being separated from an emotionally significant other to whom they were attached by virtue of the therapeutic process (Bowlby, 1988; Weiss, 2001).

Although therapists can usually abbreviate their mourning in cases in which they have judged a termination justifiable, they still need to systematically reorganize, restructure, and rebuild the assumptive world that has been jolted – if not broken down – by the termination (Stroebe, Hansson, Stroebe, & Schut, 2001). They have lost a client. They have experienced loss of, or at least damage to, their professional self-image.

In cases in which they have contributed to the termination, they also need to mourn the erosion of their sense of self-efficacy. They need to process the additional pain of realizing that they might have been unskilled, unperceptive, and/or wanting in empathy and respect, if not objectively, at least in the eyes of their client.

Some therapists may benefit most from performing the more traditional tasks of mourning: accepting the reality of their loss, working through their grief, adjusting to an environment in which the client is missing, and moving on with life (Worden, 1991). Others may benefit from focusing on meaning-making that more recent research finds is the heart of mourning; meaning-reconstruction that can even include continued symbolic bonds with the client who terminated (Weiss, 2001). For in spite of clients’ decisions to leave therapy, therapists who invested time and energy in their work have the right not to erase the record of what was accomplished. Highlighting the many interventions they used to help their clients is no less valid and beneficial than focusing on those that caused the termination. In fact, self-efficacy may not be restored without the former (Bandura, et al., 1960).

In any case, it is appropriate for therapists to engage in an individualized mourning process, which simplifies and/or abbreviates their mourning as they honor their unique personalities as well as their responsibilities to their remaining clients and to life in general. Therapists who have contributed significantly to a given termination may begin their mourning as a separate step, but not complete it before performing reparative tasks called for by their mistakes. In fact, adjusting to a changed environment and moving on with life both depend largely on a future determined by the completion of those tasks and the appreciation of life-enhancing growth that results from integrating the lessons of loss (Weiss, 2001).

Other Reparative Tasks

Having mourned, therapists are in a position to allocate time and energy to other suitable reparative tasks. In some cases, they may engage in self-purification and professional realism: replacing self-serving and ego-inflated attitudes with those that are selfless and altruistic. For example, therapists who continued to treat clients they should have referred to another practitioner might seriously question their humility, honesty, and motives for not referring to other professionals. Specialists in personality disorders, for example, may have been able to help clients with seemingly intractable traits.

Vignette:

The therapist was a newly graduated psychologist who believed his expertise was sufficient to help his new client: a 30-year-old woman who was not only very physically attractive but also humorous, entertaining, and seemingly very sincere in wanting to find out why men stopped dating her after a short period of “fabulous” beginnings of being together.

Her therapist began to realize that his client kept telling story after story about the men she dated in spite of his asking her to stay with what she was feeling and explore the depth of what might be painful for her. Her stories were just too unique to bring to an end once she got into them. He wanted to hear more, wanted to learn from them how to approach her abandonment issues.

Things seemed to be going well. The client kept all her appointments and assured her therapist that she really enjoyed her sessions. “This is what I’ve always wanted in a relationship,” she said, before adding “Of course, I know we are not dating. You are someone I’m coming to for help.”

After some thirty sessions, however, she cancelled her appointment and gave as a reason that she was too busy at work and was now dating a marvelous gentleman who met all her needs. When contacted by her therapist to return for what might be a termination session, she refused, saying she was doing very, very well.

Upon careful reflection, the therapist realized that he did not have the specialized skills necessary for working with someone with a Histrionic Personality Disorder. He had made the mistake of seeing his client way too long without making any real progress. He should have referred her to a specialist.

In the case of clients who suffered what felt like insurmountable traumas, therapists may need to examine carefully their own emotional involvement in the therapeutic interaction. Perhaps they were unable to let clients determine the pace and nature of their trauma work because they, as therapists, brought to sessions their own unprocessed trauma anxiety. Perhaps they accepted too many clients whose traumas bore too close a resemblance to their own. Perhaps they even unconsciously decided to reverse abuser-victim roles in an attempt to deal with their own painful memories of victimhood. In pushing their clients forward with trauma work, they may have hoped to replace a feeling of powerlessness with power over their clients. Reparative work in this case would then take the form of therapists entering into their own therapy and/or consulting with colleagues.

In the case of clients with coping styles and philosophies strikingly different from their own, therapists might need to examine their inflexibility. Therapists might also need to become more familiar with theories of change and with methods of discussing those theories. As Philips and others (2007) have admonished, “The interplay between [client] and therapist concerning their theories about how the [client] could be cured [must be] a crucial part of the therapeutic collaboration,” (243).

In cases in which clients determined that therapy was going nowhere and the therapist was unskilled, therapists might consider whether their skill levels were commensurate with their clients’ problems and personality patterns. If they did not actually practice outside the areas of their expertise, they might have failed to tailor their interventions to particular clients’ needs. They might not have given clients the opportunity to rate progress toward goal achievement and the helpfulness of their therapists at least two times within the first five or six sessions, as Duncan and Miller (2000) highly recommend.

Vignette:

The client was so intelligent and personable. She seemed to be making progress in her therapy sessions although she took very long breaks from them. Her therapist knew she was working in a most demanding profession that called for significant overtime work. Her therapist heard her client allude to needing more help from professionals more experienced in her field of human services, but always presumed she was referring to third parties. Thus, she never asked about whether she was one of those professionals.

After about three years of periodic work, the client simply stopped scheduling sessions. She did not discuss termination with her therapist but told the administrator of the agency that she needed someone who could resonate with the kind of work she was doing.

Upon hearing this, the therapist realized that she had not dealt well with the transference and countertransference phenomena present in her work with this particular client. She had not been objective regarding her client’s transference messages nor her own countertransference “messages” to herself.

In the case of clients who experienced their therapists’ negative emotional involvement in the therapeutic interaction, therapists’ reparative work might be learning to identify and manage – indeed benefit from – awareness of their emotional involvement (Schaeffer, 2007). In cases where clients experienced troubling positive emotional involvement by the therapist, therapists’ reparative work might be to learn to skillfully introduce other interventions, such as confrontations, in order to make the therapeutic setting a place for clients to balance dependence with interdependence and independence.

Another recommendation is to ask clients at the beginning of therapy “how they will manage obstacles that they may encounter as they strive to complete treatment,” (Avishai, et al., 2018, p. 1059) and then help them develop a plan to do so.

Similarly, therapists should ask clients for feedback regarding how effective the interventions they are using are and, based on that information, adjusting their coping styles or approaches (Schwartz & Flowers, 2010).

Other recommendations are to maintain the therapeutic alliance no matter how tempting it is to forge ahead with work (Schwartz & Flowers, 2010) and to bring up termination issues at the beginning of therapy (Duncan & Miller, 2000).

Finally, regardless of the specific reasons for unilateral termination decisions, reparative work might call for therapists allocating time, money, and energy to adopting strategies for reducing the number of unilateral terminations in the future. Ogrodniczuk and colleagues (2005) suggest providing prospective clients with information about what therapy can and cannot do for them, how long it will take to address the issues they bring, and difficulties they might have during the course of therapy. They also recommend screening prospective clients: selecting only those suitable for the kind of therapy they provide; making therapy more time-limited; offering a short-term treatment contract that can be renewed; negotiating an agreement on the nature of the client’s problems and the manner in which they should be addressed; and contacting clients to remind them of their appointment times.

Step Five: Evaluating Well-Being and Sense of Self-Efficacy

Upon completing reparative tasks, therapists are in a position to evaluate their current well-being and sense of self-efficacy. In some cases, a series of unilateral terminations – or one unilateral termination that has required extensive reparative work – has taken a heavy toll. Therapists might still be suffering from significant distress, perhaps even heretofore unacknowledged burnout. In other cases, therapists may need to conduct another cognitive appraisal, re-discern their contributions to a treatment failure, and perform additional reparative tasks. In still other instances, therapists may simply have to accept the limitations of their efforts and thereby free up energy for partnering with other clients and taking better care of themselves (Shedler, 2021).

Some therapists may have to acknowledge their own psychological impediments to successfully completing an appraisal and/or reparative task and thus their need for personal therapy. One such impediment might be constant self-reproach that leads to an excessive sense of personal responsibility (Shapiro, 2006), causing the therapist to engage in self-punishment for having done or not done something.

Another impediment might be the experiencing of shame that involves an excessive and critical focus on the self rather than on the offensive behavior (Tangney, 1991). When experiencing this, therapists may define themselves not as professionals who have made errors in judgment, but as innate professional failures. Thus, no reparative act or series of acts can repair the damage they have done and forgiveness of the self is hampered (Tangney, 1991). Therapists in these instances should consider doing their own therapeutic work or seeking consultation.

In yet other cases, therapists may simply have to accept the limitations of their efforts to make reparation for their mistakes, such as their inability to quickly perfect a new skill or possess the wisdom of a highly experienced clinician. In doing so, they may need to engage in additional mourning, followed by taking a broader perspective.

Step Six: Taking a Broader Perspective

Finally, it is beneficial for therapists to end their processing of an experience of unilateral termination by pondering the broader perspective of Carl Jung (1931). Jung believed well-being to be based on a balance between what would be ideal and what is realistic due to human imperfections and limitations and the constraints of the environments within which human beings exist. Thus, even though therapists sincerely desire to partner with those who begin therapy, they cannot be successful with every client. In some cases, their best efforts will result not in a positive outcome but in painful humiliation and a weakened sense of self-efficacy. At the same time, therapists can prize the outcome of their reparative work: professional and personal growth that has placed them in a better position to prevent similar terminations in the future.

Therapists have also placed themselves in a position to make a contribution to the profession (Jung, 1931). By sharing what they have learned, they can enlarge professional understanding of what will never be fully understood – the mystery of human beings working with other human beings to bring about change – not through miraculous cures but through hard-won victories over egocentricity and reluctance to change what has worked for them, at least at some level. Therapists can also model for their clients how to benefit from unconscious displacement of one’s feelings onto others even as they are occurring.

Therapists can also take comfort in the fact that in some cases, by making a unilateral decision to terminate, clients have taken responsibility for themselves. They have released in themselves “all those helpful forces which have always enabled humanity to rescue itself from all danger and to endure the longest night” (Jung, 1931, pp. 70-71).

Vignette:

The client realized she had struggled since childhood to be at peace with her own judgments and plans. Her mother, though well-intentioned, had raised her to believe that if what she did failed to receive parental approval, it had to be wrong.

Thus, when she decided to take a job in another city, after careful consideration of her needs and skills, she simply moved. She did not inform her therapist. He had been exceedingly helpful. She had grown significantly in perceiving herself as a capable adult whose carefully thought-out decisions were the right choice for her, with or without the approval of parental figures. Thus, she did not communicate her plans with a therapist to whom she had assigned a father-figure role and enacted her relationship with him during the course of therapy. Up until the end, that is, when she assumed the parental-figure role herself. It felt right. It was something she needed to do. So she did it.

Later, though she second-guessed herself regarding the appropriateness of what she had done – terminated therapy unilaterally – she still believed it was necessary for her own growth and development. She still felt transformed; an adult and not a child.

In parallel fashion, therapists can take comfort that their mourning and other reparative work have facilitated their own personal and professional transformation. They have used termination distress as an opportunity to broaden their expertise and refine their skills. They have chosen self-evaluation over others’ evaluation and reduced their dependence on external proof of their professional performance. Their transformation has entailed sacrifices of their ego to that of their client; of having control over a situation; and of being regarded as always powerful, influential, and efficacious (Jung, 1931). Through these sacrifices, they have enabled at least some of their terminating clients to have an experience of being capable, self-determining persons.

Finally, by undertaking reparative work, therapists may have brought into focus a damaging self-image: one of being extraordinarily influential over others, much like gods or goddesses (Goldbrunner, 1965). Now, what they need to continue nurturing in themselves is a self-image that is more realistic and therefore more wholesome for both themselves and for their future clients.

Conclusion: Implications, Applications, and Limitations

Unilaterally determined termination, though often painful and humiliating, offers therapists an opportunity for personal and professional growth in ways not usually prompted by mutually determined termination. Therapists deal more effectively with their termination distress when they use a structured approach to allocate time for expression of their initial affective-somatosensory reaction, cognitive appraisal work, mourning, and other reparative tasks. They thereby preserve time and energy for making attitudinal and practical changes that increase their ability to help clients complete their work.

Perhaps even more important, therapists cast what has been painful and humiliating in a positive light: an opportunity to bring about professional and personal growth and contribute to our understanding of why unilateral terminations are so common and what might prevent those that can be prevented.

A challenge that now arises is to subject this structured approach to empirical study. Other challenges are theoretical. To name but one issue, the constituents of the categories into which terminations fall has not by any means been exhausted. There are other bases on which clients make decisions to terminate, as well as other mistakes therapists make. The theory on which this structured approach is based must undergo further conceptual analysis and must integrate new research findings.

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