[acb-hsp] Premature Terminations: A Social Construct Approach

[J.Rayl]

Premature Terminations: A Social Construct Affects
Psychotherapy's Outcome.
by M.E. Rawlings
Abstract
Premature termination is a pivotal point in psychotherapy
. When patients relate mental health professionals to medical health professionals,
the words, "I cannot help you," can be a discriminating stimulus for suicide. A patient
who hears this may feel as helpless as someone who has been diagnosed with terminal
cancer. This Analysis
of
 Variance (ANOVA) role-playing study compares the feelings experienced by patients
in open-ended and closed-ended terminations. The open-ended
psychotherapy termination
 group generated the most positive emotional reactions, with no one in the open-ended
termination
 group expressing strong suicidal tendencies. Three participants among the closed-ended
termination
 group expressed strong suicidal tendencies. The results indicate that using the
standard therapeutic
termination for a full-term psychotherapy
 relationship is a safe stance to take for any premature termination
. For ethical and legal reasons, providing an open door for future client contact
should be a standard part
of all psychotherapy
 terminations.
Key Words: halo, termination
, open-ended terminations, closed ended terminations, suicide, construct
Research into termination techniques for psychotherapy
 sorely needs developing. As late as 1999, therapists claimed that very few empirical
studies on terminations exist (Schulz, Lang, Lotz, Winfried, & Koch, 1999). Quintana
and Holahan (1992) were surprised to find how few empirical studies there were at
that time. After examining the literature on the subject
of
 therapy terminations, the researchers' concerns remain. There is still a large lack
of
 empirical data relating to terminations, especially premature terminations.
Studies with empirical data were the focus of
 this research, which examines the therapist's role when clients unexpectedly initiate
premature terminations. Some statements may seem controversial. These statements
are designed to arouse interest in research.
This paper-and-pencil, role-playing, three-group, between-subjects experiment used
therapeutic aspects
of actual psychotherapy
 cases that resulted in suicide. These aspects were carefully reconstructed into
a story that participants read in order to hold constant the important features of
psychotherapy
 for each role-playing participant. The participants had no idea that the clients
depicted in the narratives had committed suicide. Great effort was put forth to make
this role-playing experiment accurate, safe, and in harmony with the American Psychiatric
Association's ethical guidelines. The experiment is easy to replicate. It follows
a common experimental design for social psychology experiments.
Since very few empirical studies exist, some assumptions were used when writing the
story. Except for the independent variable, the assumptions were held constant for
each group in the experiment. The assumptions are as follows:
* The therapist consistently used Rogerian unconditional positive regard.
* The therapist's words about mental health were equal to a doctor's words about
physical health.
* Coping skills were learned during the client's sessions.
* The client developed too close of a relationship with the therapist.
* The client chose to terminate therapy before the therapist thought the client should.
* A social construct existed that set the mental health professional on the same
level as a medical health professional.
The moment of premature termination is a pivotal point in the life of
 a client. When the aforementioned construct becomes paired with the words, "I cannot
help you," it can be a dangerous discriminating stimulus for suicide, as the client
might feel that he or she is terminally ill. This experiment has built the pivotal
moment into the reading, and the questions following the story revolve around the
participants' reactions to this moment. This summary
of
 assumptions for the experiment is based on today's standard
psychotherapy practice.
Buddeburg (1987) found that therapists generally feel they have failed their clients
when therapy terminates prematurely. However, the clients in Buddeberg's research
indicated that they wanted to leave because they felt ready to terminate. Buddeberg's
abstract revealed that clients do not necessarily share the therapist's view
of the termination
. The client often feels positive about the act
of early termination and takes it as a sign of
 readiness to accept responsibility. April and Nicholas (1999) also found that premature
terminations were not the result
of
 failed interpersonal relationships with therapists. Clients initiated terminations
because they did not feel an urge for more counseling.
During a premature termination
, there is a risk that a therapist could communicate his or her feelings
of
 failure to a client through body language, emotions, or words. A therapist's words
can adversely change the outcome
of
 a client's therapy. If a therapist feels as though he or she has failed a client,
the client may notice the therapist's feelings
of
 failure and misinterpret them. The client may think these feelings are a result
of
 him or her being a failure or hopeless case. This is known as an internal attribution
error. Suddenly, the
termination
 the client thought was positive will become negative and will most likely result
in an unsuccessful
termination.
An unsuccessful termination, as defined for the purpose of this article, is the inability
of
 a client to leave counseling after terminating therapy, a client returning to therapy
with any therapist because
of a fear of
 living life without therapy, or a client having a serious negative halo effect resulting
from the
termination, which influences his or her life after therapy.
It is possible that when a client hears the words, "I cannot help you" from his or
her therapist, the client might suddenly feel as though he or she is experiencing
a forced
termination
. Bostic, Shadid, and Blotcky (1996) found that forced terminations resemble earlier
life losses and result in stages
of loss. In a three-group study, Khan (1995) found that the severity of
 the loss felt was proportional to whether the client had advance warning
of the forced termination
. Khan found that the most damaging element
of
 these sudden terminations was that the client interpreted them as a repeat
of previous abusive home environments.
Hopelessness raises the odds of suicide (Dahlsgaard, Beck, & Brown, 1998). This can
be a trait of
 the individual. For this experiment, it is assumed that the phrase "I cannot help
you" could tap into this trait, raising the likelihood
of suicide. This is one level of
 the independent variable. An urge to return to therapy for more help, the feeling
that some unknown thing was wrong, fury, referral to friends, and suicide were all
dependent variables.
For comparison purposes, this experiment names the negative effect upon clients as
the negative halo effect. It names the positive effect upon clients as the positive
halo effect. This is to clarify that the therapist can create a positive or negative
effect upon a client. Based on ample data from various fields that study effect,
it is assumed a positive halo effect can carry over into a person's life when he
or she experiences a more positive therapeutic
termination (another level of
 the independent variable).
Marx and Gelso (1987) studied premature terminations and found that individuals had
more positive effect at premature
termination
 than negative effect, while Ward (1984) found a significant negative effect for
premature terminations. The hypothesis is that the therapist turns the premature
termination into a successful or unsuccessful termination by the type of termination
 he or she chooses to impose: open-ended
termination (one level) or closed-ended termination
 (other two levels).
For the purpose of
 this experiment, open-ended terminations are defined as terminations in which the
therapist promises the client that he or she may return for more therapy or may contact
the therapist if he or she feels the urge to do so. Closed-ended terminations are
defined as those terminations in which the client does not receive that invitation
and cannot have further contact with the therapist.
Brogan, Prochaska, and Prochaska (1999) used the transtheoretical model to discover
techniques to lower the 40% rate
of
 outpatient therapeutic relationships that terminate prematurely. With this many
outpatient therapeutic relationships terminating prematurely, the issue
of
 how best to handle this situation is important.
Quintana (1993) estimates that 50% to 66% of
 all individuals leaving therapy return within a year. Quintana and Holahan (1992)
previously acknowledged that there has been very little research into successful
terminations (by their definition this means the ability to terminate therapy) and
unsuccessful terminations (by their definition this means the inability to terminate
therapy; it does not consider life after therapy as part
of the definition).
Maugendre (1994) found that stopping therapy abruptly made clients truly interminable.
Johnson calls this form
of termination cold-turkey termination
 and believes that such endings bring people back to therapy in what she calls revolving-door
therapy (1988). Johnson's ideas are based on experience as the head
of a large corporation, not empirical data.
This research holds constant issues in termination that could influence the outcome
of
 therapy. They are held constant by having each group read a scenario that is exactly
like the other groups' scenarios except for one sentence, the independent variable.
They involve intense, consistent use
of
 Rogerian unconditional positive regard, echoing and mirroring a client's emotions,
developing coping skills, becoming too attached to the therapist, and a diagnosis
of
 a clinically depressed client with suicidal tendencies.
The first prediction was that both groups with closed-ended terminations (Form B
and Form C) would show significantly more negative effect than the group with an
open-ended
termination
. The second prediction is that the group participants who were told the therapist
could not help them (Form C) would have significantly more negative effect than the
group having the same
termination
 using other words. The third prediction was that open-ended terminations (Form A)
would generate the most positive effect, emotional reaction. The fourth prediction
was that the participants who were told they could not be helped would be furious.
Role-playing was the design for this experiment because it could most closely resemble
the actual situations without putting anyone in an unethical position. Role-playing
gives minimally significant results regarding the strong emotions involved in
psychotherapy
 (Greenberg & Eskew, 1993). This is important for this type
of experiment because it would be too dangerous to replicate the level of
 emotion that could result in suicide. By role-playing, the experiment can safely
test the interactions
of
 these schemas in society with both open and closed terminations. Greenberg and Eskew
show that role-playing is indicative
of
 significant results (Stanton, Back, & Litwak, 1956) but cannot show the magnitude
of those results (i.e., the strength of the emotions involved with termination
). Because
of this, role-playing can provide insight into the effects of
 schemas (Spencer, 1978) that exist in the general population. It is an appropriate
model for examining the attitudes that people bring with them to therapy. It is also
a good method because it can hold certain therapy principles constant while manipulating
others for testing purposes.
Method
Participants. Fifty-nine students from Missouri State University in Springfield,
Missouri, took part in the experiment. The participants were randomly assigned to
Form A, B, or C. As each participant walked into the room, he or she took a questionnaire
from the top
of
 an ordered stack. Each participant was asked to read the story as many times as
necessary to step into the role
of
 a clinically depressed individual with suicidal tendencies and experience the therapy
scenario (Appendix A) that ends with either premature
termination
 A, B, or C. The participant then answered the five accompanying questions, which
were the same for all the groups. All participants received the opportunity for a
debriefing. All participants declined the offer, saying they did not need it.
Materials. The materials were a pencil and paper test. A reconstructed story depicted
a client entering therapy suffering from clinical depression with suicidal tendencies.
The client's mental health improved over time. Throughout the therapy process, the
therapist practiced intense, consistent unconditional positive regard, echoed and
mirrored the client's emotions and thoughts consistently (Karlsberg & Robert, 1994),
and gave practical advice for building coping skills. The client gained coping skills
and changed from one who was clinically depressed to one who decided to leave therapy
prematurely because he or she had developed too much closeness with his or her therapist.
Group A received the standard theoretical termination
 for a full-length successful therapeutic relationship with an open-ended
termination. Group B had a closed-ended termination
 in which the therapist used words other than "I cannot help you" to convey his or
her disappointment that therapy was terminating. Group C received the words, "I cannot
help you" from the therapist.
The participants answered five questions about these parting words to see what effects
the parting words have on clients. These questions were measured on a Likert scale
varying from 1 (very strongly disagree) to 9 (very strongly agree). By not focusing
on any particular therapeutic issue (other than the constants that can be manipulated
in future studies), the experiment controlled for random therapy issues.
Procedure. The participants read the instructions on the questionnaire and were asked
if they understood what it meant to role-play. They all answered yes. They were asked
to take their time and focus fully on playing the role. Careful effort was made to
refrain from indicating that the experiment checked for suicidal tendencies by sticking
to the information written. The participants all read the same scenario (Appendix
A) with different terminations according to their groups.
Participants with Form A received the following words as their therapy termination
: "Your therapist reassures you that you have made great progress, have the coping
skills you need to succeed on your own, and agrees with you that you may benefit
from leaving therapy at this time. The therapist says, 'I wish you well in your endeavors,
and you may return to see me if the need arises.'"
Participants with Form B received the following words as their therapy termination
: "The therapist is disappointed that things are not working out between the two
of
 you. You insist that you must leave, not wanting to bring up the strong bond out
of
 embarrassment for having become that attached. At the end
of
 the session, the disappointed therapist says, 'I'm sorry that therapy with me is
not meeting your needs.'"
Participants with Form C received the following words as their therapy termination
: "The therapist is disappointed that things are not working out between the two
of
 you. You insist that you must leave, not wanting to bring up the strong bond out
of
 embarrassment for having become that attached. At the end
of the session, the disappointed therapist says, "I cannot help you."
For ease of
 displaying the interesting aspects, the data in the tables were collapsed from a
9-point Likert scale to a 5-point Likert scale. This did not significantly change
the results. The results section
of this experiment refers to the non-collapsed data from the original 9-point Likert
scale.
For the tables only, the data was collapsed in this manner: Scores of 1 and 2 of
 the 9-point scale equaled 1 on the 5-point scale. Scores
of
 3 and 4 from the 9-point scale equaled 2 on the 5-point scale. Scores
of 5 from the 9-point scale equaled 3 on the 5-point scale. Scores of
 6 and 7 on the 9-point scale equaled 4 on the 5-point scale. Scores
of
 8 and 9 on the 9-point scale equaled 5 on the 5-point scale. People mentally make
these divisions when scanning the data, so putting the data in the chart in this
manner allows for easier reading. It is also interesting to compare the two scales.
The collapsed scale accounts for the fact that people tend to refrain from marking
the outer responses on Likert scales. The comparison
of
 the two scales gives some insight into the difference between these two techniques
for gathering data. The collapsed scale had no determining factor on the significance
within this study.
Results
This between-subjects single-factor design analyzed types of
 therapy terminations using a two-tailed Univariate ANOVA with a Fischer least significant
difference and an alpha level
of
 .05. All analyses are from the 9-point Likert scale. The tables present the 5-point
Likert scale.
Question #1: After a good-bye of
 this manner, I would feel like "something" is wrong with me. The ANOVA showed a
significant difference in how those with open-ended terminations and closed-ended
terminations felt about feeling something was wrong with them after they said good-bye,
F(2,56) = 4.45, 12 = .016, [R.sup.2] = .106. The LSD post hoc test showed that Group
A participants disagreed with feeling that something was wrong with them (M = 3.7000;
SD = 1.9222). Group B participants leaned toward feeling that they had something
wrong with them (M = 5.4000; SD = 2.0876). Group C participants (Table 1) leaned
toward feeling that there was something wrong with them as well (M = 5.4211; SD =
2.2439).
Question #2: After a good-bye of
 this manner, I would feel a strong urge to return to therapy. The LSD post hoc test
showed a significant difference in "urge" to return to therapy, F(2,56) = 2.856,
12 = .006, [R.sup.2] = .060, between those who received open-ended therapy terminations
and those who were told they could not be helped. Most Group A participants did not
feel the urge to return to therapy (M = 3.7500; SD = 1.9433) while many Group C participants
did feel the urge to return to therapy (M = 5.4737; SD = 2.4803). This suggests that
the participants who were told that the therapist could not help them could develop
a stronger urge to return to therapy than those with open-ended terminations (Table
2). Group B participants did not differ significantly from either Group A or Group
C (M = 4.9000; SD = 2.4473).
Question #3: After a good-bye of
 this manner, I would recommend therapy to my family and friends. The LSD post hoc
test showed insignificant difference, F(2,56) = 2.50, p = .091, [R.sup.2] = .049,
between Group A participants (M = 6.8000; SD = 2.4192) and Group B participants (M
= 5.1500; SD = 3.0483). This suggests that those with closed-ended therapy terminations
in which the therapist did not say "I cannot help you" are as likely to recommend
therapy as those with open-ended terminations (Table 3). Group C participants had
mixed feelings on the matter (M = 5.2632; SD = 2.2321). The fact that it is not significant,
however, is
of
 importance and is addressed in the conclusion.
Question #4: After a good-bye of
 this manner, I would feel furious. There was a significant difference between the
three groups regarding fury, F(2,56) = 8.031, p = .001, [R.sup.2] = .195. The LSD
post hoc test showed that Group A participants felt very strongly that they would
not be furious (M = 2.3000; SD = 1.6575). Group B participants tended to agree with
those who had open-ended terminations that they would not be furious (M = 3.2000;
SD = 1.9358). Group C participants were more likely to be furious (M = 5.0526; SD
= 2.8181). However, this does not portray everything the results show regarding fury
(Table 4). A bimodal division in the extremes arose among Group C participants. This
is important when dealing with individuals in therapy.
Question #5: After a good-bye of
 this manner, I would feel suicidal There was a significant difference between the
three groups regarding feeling suicidal after their good-byes, F(2,56) = 4.418, 12
= .017, [R.sup.2] = .105. The LSD post hoc test showed that Group A participants
felt very strongly that they would not feel suicidal (M = 1.9500; SD = 1.8202). Group
B participants were unlikely to feel suicidal (M = 3.9500; SD = 2.4165). However,
it would be dangerous to conclude that no significance existed. As a whole, Group
C participants felt they were unlikely to feel suicidal (M = 3.5263; SD = 2.451).
But, 2 participants in Group B strongly agreed that they would feel suicidal (Table
5), marking the highest levels
of
 likelihood for suicide. One individual in Group C also marked this highest level
for suicide (Table 5). Any high tendencies toward suicide in such small groups
of
 role-playing participants representing clients with paper and pencil tests are significant
and worthy
of attention.
Discussion
A discussion of
 suicide will likely arouse strong emotions. This discussion presents data with a
view to improving terminations. In the interest
of
 science, the ideas revealed in this study are addressed factually in order to search
for avenues for improvement within an already respected field.
One prediction indicates "I cannot help you" is a social construct that can influence
behavior in a negative manner when spoken in the context
of
 the therapeutic relationship. The research supported this prediction with 1 in 4
extreme responses
of
 fury for closed-ended therapy terminations in which the words "I cannot help you"
are used (Table 4, Group C). Two opposite attitudes in the level
of
 fury regarding the words "I cannot help you" appeared. To clarify the reason behind
the bimodal distribution, a detailed questionnaire regarding beliefs about the phrase
could be used in a future research project.
One prediction was that both groups with closed-ended terminations would show significantly
more negative effect than the group with open-ended terminations. The experiment
fully supported this prediction. There was a significant difference between open-ended
therapy terminations and the closed-ended therapy terminations. Altering the words
used during closed-ended terminations did not make a marked difference.
Tapering off the intensity of the use of
 Rogerian Person-Centered Therapy with a random interval schedule, especially with
mirroring and echoing
of
 feelings, is a technique that could be used for future experiments addressing the
issue
of lowering negative effect at termination
. A second idea for lowering negative effect could be educating clients early in
the therapy process on what to expect
of themselves in the process of mourning and loss during termination
. This precaution could prepare the client for the fact that mourning and regression
are temporary symptoms
of
termination
. A third idea for lowering negative effect is to develop the belief that the client
is indeed well and just needs education from the therapist on how to improve his
or her life. It is very hard for people who do not think they are well to leave the
source
of
 their health, the mental health professional. An interval schedule
of
 reinforcing the idea that the client is well throughout the therapy process could
reassure the client that he or she is indeed well and protect against hopelessness.
One assumption that could be tested is the idea that echoing and mirroring emotions
should be slowly extinguished from the therapy process to free the client from the
captivating effects that some believe exist with mirroring others' behaviors (Reibstein
& Joseph, 1988). Mirroring emotions has also been tied into developing the affectionate
bond (Karlsberg & Robert, 1994).
Sometimes ideas the client learns in therapy fit together overnight and the client
is finished with therapy. The person says good-bye without the knowledge that successful
terminations include temporary emotional pain and temporary regression in behavior
(Johnson, 1988). This lack
of
 knowledge can result in the client returning to therapy, his or her source of
 happiness, to search for a cure to the pain.
At times, the client wants to leave because intimate feelings are interfering with
the therapeutic relationship. If the therapist lets the client go (by refraining
from indicating the client needs assistance), the client will most likely feel empowered.
The opposite can also be true. If the therapist does not let the client go by indicating
that he or she still needs professional assistance, the client could be burdened
emotionally, believing he or she is somehow deficient or cannot be helped. According
to the code
of ethics of
 the American Counseling Association (1995), making the client feel a need to return
can result in malpractice.
This experiment shows that using the standard therapeutic closing for a full term
open-ended
termination
 is the best technique to handle premature therapy terminations, even when terminating
because
of too much closeness. It is a safe stance to take in any termination
 situation because it empowers the individual. The significant differences in reactions
between the closed-ended and open-ended terminations speak for the effectiveness
of
 open-ended terminations.
The second prediction was that the group of
 individuals who were told they could not be helped would have significantly more
negative effect than the group who had a closed-ended
termination
 using other words. The experiment supported this prediction on the dependent level
of fury, although it was not significant for all levels.
The experiment did not support the prediction of more negative effect for Group C
than Group B on the level of feeling that something was wrong with them. Both closed-ended
termination
 groups significantly leaned toward feeling something was wrong with them, while
the open-ended
termination
 group strongly felt that they would not feel something was wrong with them. Changing
the words "I cannot help you" to another form of closed-ended goodbye did not change
this effect in the closed-ended groups. Open-ended terminations significantly reduced
the tendency of feeling something was wrong. Feeling something is wrong may be one
reason why some people return for more counseling in closed-ended terminations, accounting
for part of the 44% to 60% who return within a year for more counseling. They appear
to be groping for an answer to an unknown question.
It is poor ethical practice for a therapist to coerce a client to return to therapy
by making the person feel an urge to come back when he or she is saying good-bye.
There appears to be an inherent danger with regard to closed-ended therapy terminations
as shown by this experiment. Once the person diagnostically needs to return to therapy
because of a feeling that something is wrong with him or her or, especially, because
of feeling suicidal, the mental health professional is required to provide more therapy--a
paradox indeed. This unethical practice can result in a long-term negative halo effect
for clients.
Open-ended terminations appear to lower this tendency. It is interesting to note
that those with standard theoretical open-ended terminations (Group A) felt very
unlikely to feel an urge to return to therapy. This is in harmony with ethical practice
(ACA, 1995). Open-ended terminations appear to generate more successful terminations
than do closed-ended terminations; appear to be cost-effective for clients in terms
of emotions, money, and future happiness; and can be implemented with little expense
to the therapist.
The therapist can promise the client that he or she will be available for contact,
for therapy in an emergency, or for contact through email, a postcard, a letter,
or an occasional phone call. The therapist can promise to notify clients if he or
she moves. This provides a safety net that allows the client to feel no urge to return
for therapy. By using the above techniques, closed-ended terminations can be turned
into open-ended terminations. Using these techniques should lower return rates for
therapy, lower fury at
termination
, lower suicidal feelings, and ensure that the client is emotionally able to leave
therapy with an enduring successful life.
Pearson (1998) gives detailed techniques for terminating therapy and indicates that
therapists who continue to make themselves available after
termination
 experience easier terminations. Many uninformed therapists object to the continuing
expense caused by people returning for therapy. Penn (1990) and Siebold (1991) found
that any fears of clients abusing this privilege are unwarranted. When clients know
that they can return in an emergency, they feel free to leave. With this safety net
to comfort them, clients rarely feel the need to return to therapy.
With so many of those who experienced open-ended terminations not having an urge
to return to therapy, why is there such a high rate of returns (Quintana, 1993) when
many therapists claim to practice open-ended therapy terminations? Is it possible
that some therapists are unethically practicing closed-ended terminations? Or could
it be due to other reasons?
Pain causes people to seek therapy in the first place, and termination
 causes pain. If the client is not ready for this reality, he or she may seek relief
and return to therapy once more. If psychologists could find techniques to lower
the pain of
termination
, then this rate of return might lower significantly. The following techniques could
be made into research projects using the
psychotherapy
 role-playing model presented in this article for cost-effective, replicable research:
tapering off the use of echoing and mirroring of emotions and intense, consistent
Rogerian Person-Centered Therapy, tapering off the use of echoing and mirroring on
a random interval scale after trust has been developed, and educating clients to
the effect that tapering off is a normal part of therapy. Siebold (1992) also believes
that therapists should prepare clients for the loss of therapy. This allows clients
to free their emotions from the therapy process, giving them time to adjust to real-world
emotional levels.
This role-playing study used suicidal clients as a constant for all three groups
and found that those participants with open-ended terminations did not have suicidal
tendencies.
Ethical practice requires that clients develop coping skills and live independently
of the mental health system whenever possible. Clients with coping skills who terminate
therapy early and receive a closed-ended
termination
 may return to therapy for a myriad of reasons. For example, a client whose family
life was doing well decided to terminate because of too much closeness. The therapist
told the client that he could not help her. The client experienced pain and confusion.
The client's spouse became angry because of the sudden emotional state for which
his spouse had no explanation. Their child ran away to friends who abused drugs.
This former client immediately returned to therapy. The family's life became tumultuous
(negative halo effect) when the family had just previously been elated (positive
halo effect). Could this good halo effect have been preserved with a little forethought
from the therapist?
Since suicidal tendencies appeared among those groups with closed-ended therapy terminations,
mental health professionals or clients who must end therapy before its natural time
need to be careful to watch for suicidal tendencies. Three participants marked the
ultimate level for feeling suicidal after closed-ended therapy terminations in Groups
B and C (Table 5). This suicidal tendency in closed-ended terminations causes great
concern in view of the fact that many people face closed-ended terminations for varying
reasons.
There is an ethical prohibition against abandoning clients (American Counseling Association,
1995). As can be seen from Kahn's study (1995), improper terminations can leave the
client with feelings of having been in an abusive relationship. The client might
suddenly feel abandoned by someone who had promised to help him or her. Many abusive
homes make family members feel abandoned. There could be a correlation here.
The third prediction was that open-ended terminations would generate the most positive
effect. The experiment fully supported the prediction. In all areas, individuals
receiving open-ended terminations had the most positive attitude toward therapy terminations.
All three groups in this experiment would recommend therapy to their families and
friends, regardless of the type of therapy
termination
 they received. There was no significant difference between the groups regarding
recommending therapy to others. This lack of significance is of note because it supports
previous studies regarding clients' evaluations of their therapy. It indicates that
underlying social influences affect the clients' attitudes instead of the actual
therapy they receive (Keijsers Schaap, & Hoogduin, 2000).
The pressure today to terminate psychotherapy
 prematurely puts clients and psychotherapists in tough situations. Therapists have
the power to turn these situations into successful terminations through good
termination
 techniques and forethought, thus reducing the urge for clients to return for more
psychotherapy and improving their chances for a successful life after therapy.
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Appendix A: The Premature Termination Story Participants Were Asked to Read
The following is the premature termination
 story that participants in this research experiment were asked to read. Participants
randomly received one of three endings: Group A ending, Group B ending, or Group
C ending.
Please be aware that the story you will read may arouse strong emotions within you.
If you experienced a similar incident, this story may reveal that you have unresolved
issues regarding your experience. You may want to seek professional guidance to resolve
your issues or speak with a school provided counselor at the counseling center to
see if you want to pursue it further.
The story given below is a real incident. What the individual did and felt is not
revealed. Your job is to play the role of this person and answer the questions from
the viewpoint of this person with this problem at this point in life. Please read
and reread this scene until you feel as if this really happened to you before you
turn the page and answer the questions provided. Feel free to look back at the story
any time you feel you have lost contact with your role while answering questions.
You are free to stop this research project at any time you like. If you stop during
this research project, it would help us if you could tell us why, but you are not
obligated to do so.
You are a severely depressed individual. You have suffered from severe depression
for a long time and finally gave up the idea of getting better. In short, you have
become hopeless--even suicidal. At the insistence of family and friends, you enter
therapy. The therapist instills hope within you that therapy will give you the coping
skills you need in order to alleviate the horrid depression. The therapist listens
with full, undivided attention to your descriptions of how you feel, and affirms
your feelings about yourself and your situation. For the first time since you suffered
the agony of this emotional state, someone understands what you are going through.
Your heart sings just a little. Maybe you will get better. The therapist continues
to affirm your feelings about yourself, your desires, and your dreams. You listen
intently to the advice of the therapist, try it, and find that it works. Your heart
sings. You now work hard to apply the counsel and make transformations to your life
that you never thought could be possible. You learn coping skills that help you deal
with life. You notice the consistency and intenseness with which the therapist works
with you during every session. You admire this attribute of consistently echoing
your thoughts to you, paying so much attention to your needs. The depression leaves.
For the first time in many years, you feel like other human beings. You laugh and
enjoy being alive. You are thankful you never committed suicide. You become deeply
grateful for what therapy has done for you. Your admiration for the therapist's efforts
intensifies. You never dreamed you could feel happy like other people and now it
has all come true for you. You have coping skills as the therapist promised you would.
You thrill at the idea. One day, you suddenly feel a strong bond much like a parent
experiences the first time the parent holds a newborn while visiting with your therapist
about some unsolved problem. Your conscience pricks you. You realize that you must
leave therapy before the bond becomes so strong that you cannot leave the safety
of this environment. You inform the therapist that you "must leave" therapy after
your next session without disclosing this personal reason for why you are leaving.
You decide to say good-bye even though you are fearful of dealing with problems on
your own because of never having been successful without therapy. You realize that
life will always have problems and you will need to face those problems on your own
someday.
Group A Ending
Your therapist reassures you that you have made great progress, have the coping skills
you need to succeed on your own, and agrees with you that you may benefit from leaving
therapy at this time. The therapist says, "I wish you well in your endeavors, and
you may return to see me if the need arises."
Group B Ending
The therapist is disappointed that things are not working out between the two of
you. You insist that you must leave, not wanting to bring up the strong bond out
of embarrassment for having become that attached. At the end of the session, the
disappointed therapist says, "I'm sorry that therapy with me is not meeting your
needs."
Group C Ending
The therapist is disappointed that things are not working out between the two of
you. You insist that you must leave, not wanting to bring up the strong bond out
of embarrassment for having become that attached. At the end of the session, the
disappointed therapist says, "I cannot help you."
Supplemental Materials
To view the complete set of downloadable forms and materials for this study, please
log on to the CE Articles section of www.americanpsychotherapy.com.
M.E. Rawlings, BS
Mary Rawlings earned her bachelor's degree in psychology from Missouri State University.
She has authored six research projects and developed an online business that offers
consultations and editing research. You can reach her via email at awesome.editing.services at netzero.net.
Earn CE Credit
Take CE questions online at www.americanpsychotherapy.com (click Online CE) or see
the questions for this article on page 47.
Table 1: Participants' Ratings of Their Agreement with the Statement
 "After a good-bye of this manner, I would feel like 'something' is
 wrong with me."
 Number of participants who selected each
 agreement level
 Strongly No Strongly
 Groups * Disagree Disagree Opinion Agree Agree
 Group A 8 5 3 4 0
 Group B 2 4 3 7 4
 Group C 2 5 1 9 2
 F(2,56) = 5.435, p = .007, [R.sup.2] = 0.133; Group A: M = 2.1500;
 SD = 1.8210; Group B: M = 3.3500; SD = 1.3089; Group C: M = 3.2110;
 SD = 1.2727
 Table 2: Participants' Ratings of Their Agreement with the Statement
 "After a good-bye of this manner, I would feel a strong urge to return
 to therapy."
 Number of participants who selected each
 agreement level
 Strongly No Strongly
 Groups * Disagree Disagree Opinion Agree Agree
 Group A 7 6 3 3 1
 Group B 5 4 2 6 3
 Group C 3 5 1 4 6
 F(2,56) = 2.509, p =.090, [R.sup.2] = 0.049; Group A: M = 2.2500;
 SD = 1.2513; Group B: M = 2.9000; SD = 1.4832; Group C: M = 3.2632;
 SD = 1.5579
 Table 3: Participants' Ratings of Their Agreement with the Statement
 "After a good-bye of this manner, I would recommend therapy to my
 family and friends."
 Number of participants who selected each
 agreement level
 Strongly No Strongly
 Groups * Disagree Disagree Opinion Agree Agree
 Group A 3 0 2 5 10
 Group B 5 2 3 4 6
 Group C 2 5 4 5 3
 F(2,56) = 2.010, p = .144, [R.sup.2] = 0.034; Group A: M = .9500;
 SD = 1.4318; Group B: M = 3.2000; SD = 1.6092; Group C: M = 3.1053;
 SD = 1.2865
 Table 4: Participants' Ratings of Their Agreement with the Statement
 "After a good-bye of this manner, I would feel furious."
 Number of participants who selected each
 agreement level
 Strongly No Strongly
 Groups * Disagree Disagree Opinion Agree Agree
 Group A 14 3 2 1 0
 Group B 8 8 1 3 0
 Group C 5 2 4 3 5
 F(2,56) = 8.559, p = .01, [R.sup.2] = 0.207; Group A: M = 1.5000;
 SD = 0.8885; Group B: M = 1.9500; SD = 1.0501; Group C: M = 3.0526;
 SD = 1.3494
 Table 5: Participants' Ratings of Their Agreement with the Statement
 "After a good-bye of this manner, I would feel suicidal."
 Number of participants who selected each
 agreement level
 Strongly No Strongly
 Groups * Disagree Disagree Opinion Agree Agree
 Group A 17 1 0 2 0
 Group B 8 3 5 2 2
 Group C 8 6 0 4 1
 F(2,56) = 3.669, p < .032, [R.sup.] = 0.084; Group A: M = 1.3500;
 SD = 0.9333; Group B: M = 2.3500; SD = 1.3870; Group C: M = 2.1579;
 SD = 1.3443
 * Group A received the standard theoretical termination with an
 open-ended termination. Group B had a closed-ended termination
 where the therapist used words other than "I cannot help you" to
 convey disappointment. Group C received the words, "I cannot help
 you" from the therapist.
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication Information:
Article Title: Premature Terminations: A Social Construct Affects Psychotherapy's
Outcome. Contributors: M.E. Rawlings - author. Journal Title: Annals of the American
Psychotherapy Association. Volume: 8. Issue: 3. Publication Year: 2005. Page Number:
9+. COPYRIGHT 2005 American Psychotherapy Association; COPYRIGHT 2006 Gale Group
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