Managing Endings A Cognitive Behavioural Approach Michael Worrell with thanks to Dr Andrew Eagle

1. Managing Endings A Cognitive Behavioural ApproachMichael Worrellwith thanks to Dr Andrew Eagle

2. Goals To consider the place of termination issues in CBT To discuss potential principles and models to support practice To explore common obstacles and problems with termination To explore the therapists experience and reactions to termination To provide space for participants to discuss experiences, dilemmas and skills in managing complex cases

3. The Service Context Focus on Acute vs Chronic Conditions Primary vs Secondary Care IAPT and Stepped Care Models Resources and Time Limits Outcomes and Performance Management How Much is Enough? Payment by Results and Clustering Private vs Public Health Setting Revolving Doors and Perverse Incentives

4. The Inherent Complexity of Termination The success of therapy The nature of the problem addressed in therapy The diagnostic status of the client The therapeutic allegiance of the therapist Length of therapy Personal characteristics of client and therapist Significant events in therapy Number of participants in therapy Logistical details Other human variables

5. Endings and the Ethical Context �Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by the continued service� �Except where precluded by the actions of client/patients or third-party payers, prior to termination psychologists provide pre-termination counselling and suggest alternative service providers as appropriate� (APA, 2002) �Counsellors do not abandon or neglect clients in counselling. Counsellors assist in making appropriate arrangements for the continuation of treatment, when necessary, during interruptions such as vacation, illness and following termination� (ACA, 2005)

6. What is Client Abandonment Termination is defined �as the ethically and clinically appropriate process by which a professional relationship is ended� �Abandonment represents the absence of that process� Ambiguity between the potential need for therapist to terminate therapy and client�s right to self-determination Abandonment worry Abandonment occurs when therapist fails �to take clinically indicated and ethically appropriate steps to terminate a profession relationship� Emphasis on appropriate process rather than clinical judgement Providers have a right to withdraw from a case provided due notice is offered Give client adequate notice or time to prepare for ending (Youngren and Gottlieb, in press)

7. Endings and the Seven Deadly Sins Sloth Pride Lust Anger Greed Envy Gluttony

8. Models of Ending Ending as Loss Ending as Crisis Ending as Cure Ending as Release/Relief Ending as Transition Ending as Development Ending as Transformation Ending as Interruption Ending as a Choice Point

9. Relationship between model and therapeutic relationship and activity

11. Types of termination Prospective termination Planned in advance; mutual discussion of treatment plan, goals and limits; often time limited Flexible termination Relatively little advance planning; response to immediate plans and contingencies; maximum client autonomy and choice Complex termination Sensitive, protracted or volatile communications about progress; difficulties negotiating termination; conflict and intense emotional reactions to termination process Oblique termination Discontinuation unilaterally enacted by client without discussion, explanation or response to follow-up; �drop-out�, premature termination Unprofessional termination Therapist fails to uphold reasonable standards of conduct; actions are exploitative; inadequate or damaging to the client (Davis, 2008)

12. The Psychotherapy Dose-Response Effect Methodological Issues - Statistical versus clinical significance - Measurement of outcomes - Use of cut-off points to differentiate functional from dysfunctional populations - Usual aim of treatment is 50% response - A dose = a session of therapy (Hansen et al, 2002)

13. The Psychotherapy Dose-Response Effect General Consensus - Correlation between number of sessions received and amount of clinical improvement - Diminishing returns over time - Different rates of improvement in different domain of functioning - Change occurs in bursts rather than even distribution - Value of session by session outcome measures - Most patients receive insufficient treatment. (Hansen et al, 2002)

14. The Psychotherapy Dose-Response Effect Between 10 and 18% of patients improve before first assessment After 2, 8 and 26 sessions of therapy, 30%, 53% and 74% of patients demonstrated improvement After a year of weekly therapy, 83% patients had improved Outcomes mostly based on clinician rating Superiority of active therapeutic interventions in accelerating recovery (Howard et al, 1986)

15. The Psychotherapy Dose-Response Effect Different symptoms improve at different rates �Acute� symptoms require 5 sessions for 50% response �Chronic� symptoms require 14 sessions �Characterological� symptoms require 104 sessions Between 13 and 18 sessions of therapy needed for symptom alleviation across various types of treatment and disorders (Kopta et al, 1994; Hansen et al, 2002)

16. Client Initiated Termination or Drop-Out Median number of sessions in studies is typically between 4 and 10 IAPT pilot sites Doncaster: Mean 3, Median 3-4 Newham: Mean 4-6, Median 2-3 25 to 50% of patients fail to return after initial session Average estimated rate of unplanned endings was calculated at between 32 and 50 % (CORE) Many patients who prematurely terminate therapy report positively on the experience Therapists tend to self-blame and anxiety for perceived poor outcomes (Garfield, 1994; Connell et al, 2006; April & Nicholas, 1997; Wilson et al, 2004)

17. How has Termination been considered in �standard� Cognitive Behavioural Therapy practice?

18. �Termination� in Standard CBT Historical and contemporary lack of empirical or conceptual research on endings and termination in CBT A traditional de-emphasis on the therapeutic relationship The difficulties of researching process variables A primary focus on observable outcome Ambivalence about engaging with analytic or humanistic topics and concepts

19. The Ends of Therapy Reflection on the End of Psychological Therapy is in essence a reflection and clarification of Therapy�s �Ends�. The place of termination in CBT is defined by the overarching goals of this orientation as well as its specific structural and process aspects.

20. Fundamental Concepts Generalization or transfer of change Maintenance of change over time �Termination issues are important only insofar as they influence generalization and maintenance of treatment effects� (Nelson and Politano, 1993) The future or end point of therapy is a focus for all interventions Issues of termination are present at all stages of therapy and in all interventions.

21. Termination and the Structural features of CBT 3 Primary Structural aspects of CBT that impact on the way termination is thought about and acted upon: Phases of Treatment Specification of Goals Time limited Contract

22. Termination and Phases of Treatment Termination is not a distinct phase or step separate from the overall context of therapy- it is present in all stages: Assessment and goal setting Intervention Phase Generalisation Phase Maintenance Phase

23. Client as Therapist A focus on the explicit goal of the client becoming their own therapist also keeps termination issues present on the agenda. The aim is to increase client self efficacy and establish expectancies and skills in coping rather than mastery or complete �cure� An agreed and negotiated �Fading� of therapist support.

24. Specification of Goals The smoothness of termination is in part dependant on the early collaboration on and specification of treatment goals. A major and frequent activity is the assessment and monitoring of goal attainment with a focus on observable behavioural change. The monitoring of progress = where are we in relation to the termination point?

25. Time Limits CBT is an explicitly time limited therapy even where the exact number of sessions may not be specified in the beginning. The failure to discuss time limits and termination in the beginning may be responsible with later occurring problems with termination Time limits as an existential given of therapy

26. Process Variables A gradual recognition that Process factors may have a significant influence on generalization and maintenance of gains. Waddington (2002): �an association between the therapy relationship and outcome has been observed more often than not, with the role of technical intervention as a possible mediator of this association greatly debated� CBT with complex cases and especially Personality Disorders has lead to an increased emphasis on relational factors and consideration of how these may effect termination.

27. Relational factors and termination Collaborative empiricism- working along side the client. Avoidance of unhelpful dependence and expectations of termination as a stage for client self mastery and independence Therapist as model: coping versus mastery Therapist as coach rather than parent A cognitive mediator for generalisation and maintenance.

28. Formulation and Termination Collaborative formulation Assists in identification of primary cognitive and behavioural processes related to problem maintenance and resolution Assists in anticipating obstacles to progress and termination.

29. The case formulation process imposes a necessary discipline on the clinician�s reasoning and actions, and generally leads to the construction of specific goals and thereby to specific outcome criteria. By contrast, the omission of a case formulation can leave the clinician, and the patient, with an amorphous blur that has no direction and can have no clean conclusion (S. Rachman, 1985)

30. Early Experiences: unstable early life; Dad had mental health problems and alcoholism � regularly assaulted Mum and me. Caned at school for failing homework assignments (no one knew I had dyslexia) I am VulnerablePeople are Dangerous If I�m strong, I�ll keep predators away If I let someone get close to me, I�ll be exploited/hurt If I ask for help, I�ll be seen as weak (and be exploited) Over-developed strategies Under-developed strategies - Self-reliance - Trust - Aggression - Empathy - Vigilance - Help-seeking behaviour - Self-protection - Relationship building skills

31. Specific Interventions and Termination Clarify and formulate key cognitions and beliefs regarding termination �I cannot function without the support of my therapist� �I am not completely better and so I and my therapist have failed�

32. Formulation and Termination Clarify and formulate key behavioural and environmental factors affecting termination Social withdrawal and impoverished or hostile relational field Lack of structure and reinforcing events and activities

33. Specific Interventions and Termination Construct termination as a �graduation� from therapy- a readiness to work independently Activity Scheduling Problem Solving Positive Data logs and continuum- an emphasis on ongoing change particularly at the level of rules for living and core beliefs Relapse prevention plans and procedures Contracting for re-entering therapy

34. Constructing a Therapy Blueprint What Have I learned in therapy? How can I take this forward- what are my next steps? What obstacles might get in the way? What plans can I make to deal with these (what resources do I have?) What might trigger a setback and how will I know? When I have a setback what steps can I take?

35. Fading and Booster Sessions Termination not seen as a final non negotiable separation Space the ending with several session at 2 or 3 week intervals and periodic booster sessions (view gaps as behavioural experiments) Assign homework to monitor progress between sessions One follow up 4-6 weeks post termination Consider telephone or email booster or reporting in sessions Utilize other people from the clients network as co therapists Review progress with an emphasise on attributions to the clients own efforts and growing skill and resources

36. Possible Anchors for Termination Criteria Time Number of sessions Calendar Date Season Task Client action completed e.g., find a job, speak in public Symptoms Clinical significant decrease or return to normal baseline Stable decrease for defined time e.g., 8 weeks Decrease in frequency and belief in maladaptive thoughts

37. Possible Anchors for Termination Criteria Functional State New skills transferred to novel situations Life satisfaction improved Resilience to stress increased and emotion regulation improved Role adjustment or acquisition as per benchmarks Adaptive behaviour maintained for defined time e.g., 6 months Adaptive cognitive regulation and shift in core belief Developmental progression e.g., milestones encountered Blend Combination of above (Davis, 2008)

38. Seven Criteria for Termination Symptom decrease Stable symptom decrease for 8 weeks Decrease in functional impairment Spontaneous remission ruled out and use of new skills tied to reduced symptoms Use of new skills even at times of former vulnerability Sense of pride about new skills Generalisation of skills to other areas (Jakobsons et al, 2007)

39. Common problems with Termination Poor Assessment of client difficulties, in particular neglect of personality difficulties and social factors Incomplete or overly loose formulation- key maintaining factors have been missed. Client continues to report new problems or lack of progress What does the formulation predict about termination issues?

40. Common Problems Poor specification of goals. Unclear behavioural or cognitive targets or unrealistic targets. Lack of a specific treatment Contract that mentions termination and plans for termination and follow up. Poor socialisation to the CBT model so the client has not taken on role of co-therapist or maintains expectancies of being cured or therapy functioning as emotional support

41. Common problems with Termination A poor balance between the relational and technical factors of therapy in either direction: Support versus challenge. Attunement versus directive change and psycho-education. Failure to effectively monitor progress and outcome at regular intervals and feed back to client Failure to keep termination on the agenda either implicitly or explicitly. Less than adequate use of feedback and summaries to client. Less than adequate requests for client feedback and failure to pick up on affect shifts in session. Client has not been socialised into co-designing homework tasks and reporting on these.

42. Obstacles to termination Safran and colleagues: The importance of alliance ruptures and their resolution. A greater emphasis on the interpersonal aspects of therapy as key agents of change. Brings into standard CBT the possibility of also addressing themes of separation and loss as an aspect of termination that can be explicitly addressed

43. Termination as Rupture Resolving Ruptures Resolution of �ultimate alliance rupture� Acceptance of reality Constructive discussion of disappointment The tension of separation and loss versus independence (Ochoa and Muran, 2008)

44. Summary Preparation for ending CBT Prepare for ending from first session Identify client expectations of progress Identify client ideas of change Use of image and metaphors Identify measures and markers of change Attributing change to the client Building self-efficacy Teaching and reinforcing tools and coping strategies Preparing for setbacks

45. Summary: Preparation for ending CBT Respond to emotional concerns Tapering sessions Booster sessions Revisiting what was learnt in therapy Written Relapse Prevention Plan Use of Blueprint for future coping

46. Ending and the Therapist�s Personality Problems with separation and loss Needs for intimacy Defence against intimacy and commitment Over-developed sense of responsibility Guilt at abandoning the patient Need for perfection and perfect outcomes Therapeutic narcissism Doubts about clinical competence Difficulty with conflict Satisfaction versus envy about achievement

47. Therapist Schemas Abandonment I should not bring up issues that will upset my client and cause them to leave Its awful if client leave therapy early Attachment avoidance- focus on superficial or skills only interventions Excessive care taking

48. Therapist Schemas The �Special Therapist� I am entitled to be successful My clients should appreciate all I do for them Clients might try and humiliate me I shouldn't feel bored by therapy or my clients Demanding Standards Clients are irresponsible and lazy Difficulty with empathy and validation I should be able to cure all my clients

49. Therapist Schemas Self Sacrifice I need to feel needed! I will do everything for you as long as you don�t leave me! I should always meet the clients needs I should make them feel better

50. Sunk Costs People are more likely to continue in a course of action the greater the prior cost has been When people see change as having a high cost relative to their resources they will continue longer in the behaviour The longer people continue with sunk costs the fewer resources they have In the short term change is more likely to result in regret than remaining inactive Absorbing sunk costs may result in social shame

51. Review To what extent have we met our and your goals today? What remains unfinished and unexplored? What will you take forward? How have you experienced this workshop and its ending?