[acb-hsp] The Goal is to Say Goodbye and . . . Article

[J.Rayl]

The Goal Is to Say "goodbye" and Have the Treatment Effects Generalize and Maintain:
a Cognitive-behavioral View
of
Termination
by W. M. Nelson III , P. M. Politano
As might be expected, the behavioral therapy literature has paid scant attention
to the issue
of treatment termination. Over 1,400 articles from Behavior Modification (1981-1991),
Journal
of Behavior Therapy and Experimental Psychiatry (1975-1991), Annual Review of
 Behavior Therapy (1975-1984), and Behavior Therapy (1975-1991) were reviewed looking
for the word "
termination" in either the title or abstract. Of
 the eight articles found using the word "
termination
," three focused on treatment effects at follow-up (Heins, Lloyd, & Hallahan, 1986;
Khanna, Desai, & Channabasavanna, 1987; Kozak & Miller, 1985), one dealt with the
methods used by clients to withdraw from treatment (Caveil, Frentz, & Kelley, 1986),
two dealt with
termination of
 symptoms using different treatment techniques (Neimeyer & Feixas, 1990; Teri & Lewinsohn,
1986), and one focused on
termination of
 smoking using behavioral techniques (Glasgow & Lichtenstein, 1987).
Only one article focused on the process of termination of treatment. The primary
focus of
 this article, however, was on the mechanics
of termination such as the exit interview, delineation
of progress, reinforcement of treatment gains, and anticipation of
 potential future problems (Wisocki, 1987). Neither the Wisocki article nor any
of
 the others examined the conceptual underpinnings
of termination from a cognitive-behavioral perspective. This absence of
 articles directly addressing the process
of termination
 from a cognitive-behavioral perspective is, in part, historical and dates back to
the minimization
of
 the client-therapist relationship by early behaviorists (Eysenck, 1960, 1982). This
absence also reflects in part the difficulty
of
 subjecting more process-oriented variables to empirical scrutiny, the more pervasive
behavioral focus on verification
of
 outcome effectiveness (Eysenck, 1960; Kazdin, 1979), and the greater focus on objective
measurement
of
 observable behavior as opposed to the inference
of subjective states (Kazdin, 1979).
However, with the advent of
 less "traditional" behavioral treatment methodologies, particularly cognitive-behavioral
approaches (e.g., cognitive therapy, Beck, 1976, Beck & Emery, 1985; rational emotive
therapy, Ellis, 1970, 1974; selfinstructional training, Michenbaum, 1977; problem-solving
training, D'Zurina & Goldfried, 1971, Goldfried & Davidson, 1976), client-therapist
relationship variables dealing with the interplay
of
 cognitive-behavioral, cognitive-affective, and cognitive-affective-behavioral dimensions
began to receive more attention (De Voge & Beck, 1978; Garfield, 1983; Klien, Dittman,
Parloff, & Gill, 1969; Lazarus, 1982; Politano, 1992; Wilson, 1982; Zajonc, 1984).
Despite this increased attention, there still seems to be considerable ambivalence
about finding common ground with more dynamic or humanistic orientations at methodological,
philosophical., conceptual, or implementational levels (Eysenck, 1982; Franks, Kendall,
1982). This ambivalence is demonstrated by scholarly articles that address the need
for changes and new directions in behavioral therapies but which do not mention,
or focus on, relationship issues (such as
termination) as part of
 that change (Berstein, 1982; Jacobson, Follette, & Ravenstort, 1984). This ambivalence
has likely contributed to a less-than-energetic investigation into the more subjective
aspects
of
 the client-therapist relationship within the behavioral therapies.
Given that termination is an important aspect of
 the total treatment process and the client-therapist relationship, this paper will
attempt to examine those conceptual underpinnings
of
termination
 that are particular to cognitivebehavioral treatments. This will be done by examining
those concepts that underlie cognitive-behavioral treatments in general with an extrapolation
of the impact of those concepts to termination followed by a discussion of
 the identified concepts relative to clinical considerations.
COGNITIVE-BEHAVIORAL CONCEPTS IMPACTING ON TERMINATION
In looking at general concepts of cognitive-behavioral treatments, and how those
impact on
termination
 issues and processes, it may be heuristically helpful to approach the task by grouping
the concepts into those that have structural implications (e.g., phases
of
 treatment) and those thathave process implications (e.g., client therapist relationship).
Integral to this structural/process grouping are two fundamental concepts that underpin
and drive cognitive behavioral interventions: generalization (transfer) and maintenance
(durability)
of
 treatment effects. Generalization and maintenance are so central to the core
of
 cognitive-behavioral treatments that it could be suggested that relationship and
termination
 issues are important only in so far as they influence generalization and maintenance
of
 treatment effects. Since generalization and maintenance primarily address issues
related to aftertreatment progress, all other concepts which are hinged to these
two concepts necessarily must also have an after-treatment focus which, by its very
nature, always keeps the end point
of
 treatment (
termination) as a central focal element in cognitive-behavioral strategies.
STRUCTURAL IMPLICATIONS FOR TERMINATION
There are three primary structural aspects of
 cognitive behavioral treatments that go hand-in-hand with, and impact directly on,
termination. They are: the phases of
 treatment, specification
of treatment goals, and the time-limited nature of treatment.
Termination
 from a cognitive-behavioral orientation cannot be viewed in isolation from the rest
of
 treatment nor seen as a distinct therapeutic "stage" as in the more dynamic or humanistic
approaches. Rather,
termination, as a focal point, is evident at each phase of
 cognitive-behavioral treatment. For example, the initial assessment and goal-setting
phase
of
 cognitive-behavioral treatment establishes the desired end behaviors (emphasis on
"end"). This phase is then followed by an intervention phase concerned with the induction
of
 change in behavior directed at achieving already defined goal (end) behavior(s).
This is followed by a generalization phase in which change is expanded within the
client's environment with increasing emphasis on independent functioning. The fourth
phase is concerned with the maintenance
of
 changes over time with decreasing support from the therapist (Kazdin & Wilson, 1978).
Given generalization and maintenance as the desired endpoint, all preceding stages
involve a careful anticipation and planning
of
 that endpoint (
termination) such that an optimal level of
 generalization and maintenance occurs. The crucial focus
of preceding phases of
 treatment is to assure that the treatment effects transfer to the client's natural
environment and endure over time. This requires incorporating
termination
 as an aspect
of
 treatment early in the process so as to foster the idea in the client that transferring
and maintaining gains within the natural environment can and will eventually occur
without indefinite external support in the form
of the therapist.
Given that termination
 has been defined as an endpoint early in therapy, the smooth transition to increasingly
less therapeutic support will be, in part, dependent on how well the client has been
prepared for this by the structuring
of treatment goals in the early phases of
 therapy. Of foremost consideration is the importance of
 setting specific, clearly defined treatment goals that are anchored in observable
behavior (Kazdin, 1979; Masters, Burish, Hollon, & Rimm, 1987). Therapy, then, involves
the frequent examination and ongoing analysis
of whether or not the goals of therapy are being achieved.
Closely tied to the phases of treatment and goal setting is the time-limited nature
of
 cognitive-behavioral therapy. To the extent that long-term involvement of
 a client with a therapist can override a more task or problem-oriented focus, then
to that extent such difficulties are more likely to be minimized in the short-term,
time limited, goal-oriented approach
of the cognitive-behavioral strategies.
What actually constitutes "time-limited" or "short-term" therapy is somewhat arbitrary;
however, most cognitive-behaviorally-oriented therapist consider between 15 and 25
sessions as being within this framework. The exact number
of
 sessions may not be stated at the beginning; however, achievable goals may be stated
early on in such a way that they clearly become the markers for eventual
termination.
At an applied level there may be some value to setting the stage for termination
 early in the process by emphasizing to clients that they will not stay in treatment
indefinitely and that therapy will be focused on teaching them to handle their problems
more realistically and on achieving specified goals. Failure to suggest, explicitly
or implicitly, some time limit can have considerable disadvantages. For example,
without a clear endpoint, unnecessary dependencies may develop, potentially increasing
the difficulty
of introducing the subject of
termination. Thus it is important to "set the stage" for termination
 by emphasizing to clients that they will not stay in treatment indefinitely and
that therapy will be focused on teaching them how to handle their problems not only
more realistically but also independently.
Thus, the interrelationship of
 the three structural components is as follows: clearly defined behavioral goals
formulated at the outset define the point
of termination of
 treatment as clients move toward those goal behaviors across the phases
of
 treatment with an anticipation that they will achieve those goals within a limited
(if not clearly stated) amount of
 tune. As should be clear, each structural element serves to focus the attention
of
 treatment on the desired endpoint, i.e., independent functioning (through generalization
and maintenance). In essence, structurally and conceptually, the beginning goal
of
 therapy is to achieve the end
of therapy as it was defined at the beginning (allowing, of
 course, for some modifications to goals along the way).
PROCESS IMPLICATIONS FOR TERMINATION
As suggested earlier, the client-therapist relationship as an influencing factor
in treatment is not incompatible with cognitive behavioral perspectives despite some
degree
of
 ambivalence associated with more process-oriented factors. Historically, a critical
drawback to both traditional and cognitive-behavioral therapies has been the absence
of
 long-term follow-up studies to determine whether behavioral gains have generalized
and have been maintained (Keeley, Shemberg, & Carboneil, 1976). More specifically,
there has been a dearth
of
 research as to what factors contribute to, or mitigate, generalization and maintenance.
Within this context, it becomes important to examine how the client-therapist relation
ship influences such factors as cooperation, truthful feedback from the client, therapist-as-model,
etc., and how this then influences the client's perceptions
of self efficacy, benefits of therapy, etc., all of
 which can, interactively, impact on generalization and maintenance of therapeutic
gains.
Although most of
 these factors, with few exceptions, have not been examined within either the traditional
behavior modification or cognitive-behavioral therapy frameworks, as early as 1969,
Klien, Dittman, Parloff, and Gill suggested that the therapeutic relationship may
be central to the outcome
of
 behavioral treatments. This perception has been restated by others suggesting that
the relationship may be not only central, but perhaps crucial, to outcome andmaintenance
of
 gain (Alexander, Barton, Schiano, & Parsons, 1976; Bandura, 1989; Bornstein & Rychtarik,
1983; Crisp, 1966; Emmelkamp & van Der Hout, 1983; Ford, 1978; Garfield, 1983; Kazdin
& Krouse, 1983; Kelly, 1990; Mathews, et al., 1976).
Despite the lack of
 research on client-therapist relationship variables, cognitivebehavioral strategies
nevertheless present a clear conception
of that relationship with implications for
termination
. For example, cognitive-behavioral therapists generally perceive the relationship
between the client and therapist as an active, collaborative relationship ("collaborative
empiricism" as Beck, et al., 1979, defined it). This perception, in addition to the
structure described above, impacts on
termination
. The shift in emphasis away from a conceptualization that emphasizes transference
and countertransference issues and possible dependency exerts pressure on the client-therapist
relationship in the direction
of
 eventual independence
of the client from the therapist. The ultimate goal of
 the cognitive-behavioral therapist is to work him/herself out
of
 a job by teaching the client the skills needed to solve his/her own problems in
the future. Just as a carpenter may come into your home and remodel your kitchen,
according to your wishes, and then leave, the cognitivebehavioral therapist helps
the client to revamp his/her maladaptive cognitive process and aberrant affect in
more adaptive directions and then also leaves. The expectation from the beginning
is that you will not have a lifelong relationship with the carpenter; likewise with
the cognitive-behavioral therapist.
This idea of the gradual withdrawal of the therapist over the course of
 therapy is important and is best explained as a "fading" process wherein a prompt
is used to initiate a behavior, then gradually withdrawn. Generally, the need to
use a prompt, e.g., therapy, to elicit a target behavior diminishes as the behavior
begins to be maintained by reinforcement When targeted behaviors occur with enough
frequency so that they can be adequately reinforced by naturally-occurring consequences,
the need for therapy and the therapist is systematically withdrawn. This gradual
fading-out process, as the client assumes more control and responsibility for his/her
progress and develops the cognitive set
of
 personal mastery and a growing confidence that he/she can deal with problems enhances
generalization and maintenance
of the behavioral changes made over the course of
 treatment and reduces the abruptness
of termination.
When looking at the collaborative nature of
 the client-therapist relationship, it should be remembered that the client, ideally,
is incorporated into helping define problem behaviors and goals, target those behaviors
he/she wants to focus on, develop strategies to achieve the goals, and test, analyze
and monitor changes in his/ her behavior relative to the goals. Thus, there is an
ongoing joint examination and analysis
of
 whether the defined goals are being achieved which keeps the endpoint
of
 treatment constantly in view for both the client and therapist.
Paralleling the collaborative nature of the client-therapist relationship is the
effort by the therapist to guide clients toward becoming their own "personal scientist"
(Mahoney, 1974; Mahoney & Arnkott, 1978) or own "therapist" wherein they begin to
understand how their cognitive processes are related to problematic overt behavior
and begin to recognize that their cognitive perceptions represent hypotheses about
their environment that should be tested rather than just accepted as truth (Beck,
Rush, Shaw, & Emery, 1979). Thus, the implicit assumption is that clients will learn
more effective ways to deal with their problems, actually begin to put these into
practice leading directly to
termination
. As can be seen, the emphasis is on self-reliance, growth and development, and eventual
independence within the concept that "it is easier to act your way into a new way
of behaving than to think your way into a new way of acting."
Of prime importance in setting the stage for eventual termination
 is the attitude of the therapist By viewing the therapy as short-term, and communicating
this to the client, the therapist acts to counter unnecessary dependency and forestall
beliefs that the client may have that they will be miraculously "cured."
This cognitive set by the therapist wherein there is the expectation that clients
will learn to handle their own problems is likely an important cognitive mediator
that influences generalization and maintenance of treatment effects. Bandura (1977b,
1986,1989) has argued that clients' self-efficacy (the extent to which they have
acquired the expectancy that they can now master/deal effectively with their difficulties)
is the primary factor that mediates outcome and the maintenance and durability of
self-aiding behaviors. The cognitive set of the therapist is suggested to have direct
bearing on the client's attitude with concomitant impact on outcome.
TREATMENT IMPLICATIONS RELATIVE TO TERMINATION
With generalization and maintenance as primary therapeutic objectives, many techniques
used in the latter stages of cognitive behavioral treatments aim at responding to
termination
 issues and transcending the end of therapy. Many of these techniques lend themselves
to maximizing client confidence and independence while, at the same time, decreasing
therapist involvement, thereby keeping the endpoint of treatment in the forefront
of consideration.
The degree to which termination
 issues become important will depend on several factors, not the least of which is
the "climate" under which treatment is terminated. Most frequently the suggestion
for
termination
 is made by the therapist, usually with the expectation that the client will agree.
However, the client can also initiate
termination
 for various reasons, most common of which is the feeling that his/her problem(s)
has/have been resolved. If this is the case, the therapist is likely to agree to
termination
, especially if the therapy focus has been on the attainment of clearly defined and
specific goals.
There are other ways in which therapy termination can occur. Some termination
 processes revolve around naturally-occurring events, such as the client changing
jobs and moving from the area, financial problems of the client that preclude continuation
of private therapy, etc. Other factors may be related to client dissatisfaction with
the treatment process or to pressure from external sources (family, etc.) who see
the therapy as a threat, financial drain, unacceptable time commitment, etc. (e.g.,
second-order effects, Graziano & Fink, 1973).
Ideally termination
 is a joint decision between therapist and client. Even so, clients' reactions might
range from infrequent staunch objections that they are "not ready" to expressions
of some nervousness over the idea of "just stopping." The cognitive behavioral therapist
should listen to such objections to terminate by the client as the basis for understanding
the client's potentially troublesome beliefs about discontinuing. Typical statements
by the client might include:
1) "I won't be able to remember things we talked about after therapy ends."
2) "I've got a 'new problem' that I really need to work on (the implication being
that therapy is viewed as an activity in and of itself rather than as a means to
develop independent problem-solving behaviors).
These reactions provide opportunities for the cognitive behavioral therapist to help
the client test out his/her anticipatory thoughts about
termination
 and ascertain whether these are irrational or dysfunctional. Thus, answers to the
aforementioned statement by clients might be:
1) "These are not objective facts; they are your beliefs/hypotheses about what will
happen upon
termination, so let's look at how realistic they are."
2 "How confident do you feel in the tools that you have to work with now that therapy
is drawing to a close?"
3) "It is good to be challenged/tested by new problems because you'll have a chance
to practice the skills we've been talking about in therapy. What do you think you
can do about this problem?"
4) "It sounds like you feel you have to be so perfectly competent and prepared that
if you make a mistake it will be catastrophic. What do you think will happen it you
make a mistake in dealing with (specific situation)?"
Regardless of the behavioral expression, it is safe to assume that most clients will
feel at least some uncertainty about the accomplishments of therapy and whether or
not they will be able to maintain these changes once therapy is ended. Therapists
can diminish significant
termination
 problems by emphasizing the educational nature of cognitive-behavioral treatment
(Beck, et al., 1979). Either implicitly or explicitly therapy should be approached
from the beginning as being a "training period" where clients will learn to develop
more adaptive ways of handling their own problems. The assumption is thatmany of
the client's problems will remain unsolved at the end of treatment but he/she will
have the appropriate 'tools" to approach and solve problems on their own, knowing
that the therapist is available for "booster" sessions if necessary. Bandura (1977
a, b; 1986) has suggested that this process where clients assume the cognitive set
("self-efficacy") that they will be able to perform the newly learned more adaptive
behaviors is the most important mechanism in mediating and maintaining therapeutic
changes. Pertaining more specifically to treatment
termination
, a client's self-efficacy can be ascertained by asking them:
1) "Do you think you can continue to... (carry out the target behaviors) when we
are not seeing each other as frequently (fading out therapy sessions) or not seeing
each other anymore (
termination)?"
2) "How confident are you about your ability to carry on with less support from the
therapy sessions (ranked on a scale of 10 or as an expression of the percent of confidence)?"
Thus, the cognitive-behavioral therapist can attempt to prepare or immunize clients
against serious relapses following
termination
 of treatment by establishing, as a therapeutic objective, not only the development
of client skills to deal with moderate reversals before they become full-blown relapses,
but also through the development of a self-efficacious set that they are confident
that they can continue to more effectively deal with their problems during and after
the
termination process.
Throughout treatment the therapist works with the client to expect fluctuations in
his/her adaptive behavior and feelings and works with him/her in learning how to
cope with such exacerbations in problematic behavior. Clients may even be encouraged
to try to have a "setback" so they can practice newly learned adaptive behaviors,
whether they be cognitive and/or behavioral in nature. This prepares them for challenges
and struggles that will inevitably be encountered in everyday life once therapy has
ended and helps them prepare for the possibility that things may worsen after treatment
has ended.
It is also useful to schedule follow-up, or "booster," sessions several months after
a more formal
termination
 of sessions to see how the client is doing, or to leave the door open for "booster"
sessions on an as-needed basis when an intensification of problems occurs. The focus
of booster sessions should be to enhance the client's notion of self-efficacy and
to keep him/her focused on his/her continued efforts to deal with his/her specific
problems and to reinforce such efforts. It also allows client's to report to someone
who is invested in their improvement and can help them reassess their coping efforts
as needed. The message to clients in the booster sessions is to "keep your confidence
(self-efficacy) up" and continue to "try out your newly learned skills and behaviors."
It is crucial that clients see these sessions as "booster" sessions only, and not
the reinitiation of a more formal or traditional treatment process. By extending
the time period between sessions or by scheduling "booster" sessions, the therapist
is gradually "fading" him/herself out of the picture and encouraging clients to test
their newly developed skills by themselves. This "fading" process may also involve
assisting the client to attend appropriate support groups within the natural environment
The following types of activities seem to hold promise for "fading" the therapeutic
relationship, enhancing generalization, and minimizing relapses:
1) spacing the ending therapy sessions to 2 or 3 weeks apart or using periodic "booster"
sessions
2) assigning homework to self-monitor progress between these sessions (if not already
utilized during the actual therapy itself) to ensure that clients review and reflect,
hopefully, upon their new successes and develop a growing sense of mastery
3) scheduling one follow-up session after approximately 4 weeks or intermittently
for several months to evaluate the maintenance of treatment effects
4) reporting efforts over the telephone or through the mail at regular intervals
of time, perhaps once every 2 weeks for 12 weeks posttreatment
5) having more than one person involved in treatment and changing the settings in
which treatment occurs so that the client does not simply associate the therapeutic
change with a single person or setting
6) employing self-control procedures so that the primary agent of change is the client
who, obviously, will always be present to exert the control (adapted, in part, from
Speigler, 1983).
In addition to such termination
 techniques, one must consider the characteristics of the client and how those characteristics
will interface with
termination
 issues and strategies. For example, Beck, Freeman, and Associates (1990), in working
with different types of personality disorders, have found that frequent booster sessions
are more likely with schizoid personality disordered individuals because of their
tendency to fall back into isolated life styles after formal treatment is over. Avoidant
disordered clients, on the other hand, will likely require strong support from the
therapist for them to space out sessions and test out troublesome beliefs that "if
people really knew me, they would reject me." Another issue with such individuals
may be a perceived desire to terminate coupled with an unrealistic fear of hurting
the therapist's feelings by bringing up such a topic. For dependent personality disordered
clients, the threat of
termination
 can be particularly severe due to characteristic maladaptive beliefs that "it's
impossible to maintain treatment gains without my therapist's support." For these
individuals, the process of scheduling sessions less frequently can be used as a
behavioral "experiment" to test and evaluate such beliefs. A suggestion of future
booster sessions for dependent individuals may also facilitate the
termination
 process since the therapeutic "door" is left open for them to recontact the therapist
it they feel a need. Borderline personality disordered clients' strong anticipation
of rejection and accompanying intense emotional reactions suggest that
termination
 issues be directly dealt with for a much longer period of time (typically for at
least three months). Tapering of treatment gradually by moving from weekly to bi-weekly
and then monthly sessions is likely to be most helpful. Frequent reiteration that
termination
 will be a joint decision is also reassuring for such clients.
Kendall, et al. (1992) suggest that in working with children, termination
 can be facilitated by giving them a final reward or some special type of recognition
(e.g., a diploma, party, etc.) for participation in the therapeutic program as well
as giving them a great deal of encouragement about their progress and accomplishments
over the course of treatment It is also important for the therapist to discuss with
the child's parents how to support the child and the changes he/she has made. Parents
should be aware of coping strategies learned by the child so they can encourage their
child to utilize these coping strategies. In addition, refraining anxiety into anticipation
of "new challenges" can be beneficial for children.
SUMMARY
A client's reaction to termination
 might range from infrequent staunch objections that they are "not ready" to expressions
of some nervousness over the idea of "j ust stopping" to an expressed readiness to
be on their own and try their new skills. When self-doubts are expressed, it is important
for the therapist to view them as an opportunity for the client to evaluate treatment
generalization and enhance maintenance of therapeutic gain rather than as a prelude
to increased dependency. Thus, responses to self-doubts might center around objectification
of the facts, rationality of the conclusions, confidence of the client to apply new
skills, opportunities to practice new skills with new challenges, decatastrophizing,
etc., all aimed at fostering the continued movement of the client toward
termination
 and independent functioning. The real test of readiness, near the endpoint in therapy,
is the evaluation (hopefully, conjointly by therapist and client) as to whether or
not the client is actually behaving differently. It seems likely that anxiety associated
with
termination
 will increase relative to the extent that clients have little to no "visible" indications
of any changes in themselves. It is at this point that the conjoint review of actual
behavioral changes and the examination of generalization can be beneficial, particularly
if such a review focuses on a longitudinal examination of where the client was when
he/she came into therapy and where they are now.
>From a cognitive-behavioral point of view, it must be emphasized that, most importantly,
therapeutic effort should be in the direction of teaching new skills, then transferring
those skills to the client's environment such that maximum generalization and maintenance
occur. When the end goal of a therapeutic process is to end the process, and when
this goal is explicit from the start, then
termination
 takes on another dimension such that it is seen as being the beginning rather than
the end.
-1-
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication Information:
Article Title: The Goal Is to Say "goodbye" and Have the Treatment Effects Generalize
and Maintain: a Cognitive-behavioral View of Termination. Contributors: W. M. Nelson
III - author, P. M. Politano - author. Journal Title: Journal of Cognitive Psychotherapy.
Volume: 7. Issue: 4. Publication Year: 1993. Page Number: 251+. © 1993 Springer Publishing
Company. Provided by ProQuest LLC. All Rights Reserved.
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Jessie Rayl
EM: thedogmom63 at frontier.com
PH:304.671.9780
www.facebook.com/eaglewings10

"But they that wait upon the LORD shall renew their strength; they shall
mount up with wings as eagles. They shall run, and not be weary"--Isaiah 40.31
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