The Breakup: Termination in Therapy

As a therapist in-training, I always have termination in the back of my mind.  Because I am graduating in May, I am keenly aware that come June or July, I will have to say goodbye to the clients on my caseload.  Endings are hard and therapy can be such a close and intimate relationship that the running joke likens the termination process to a "break-up."  In truth however, while some of the same feelings of abandonment and rejection may arise in anticipation of the actual separation, termination is a unique type of ending.  It is one of the only relationships I can think of in which there is a controlled goodbye; there is the opportunity for closure in the way that all the textbooks say there should be.  While an ending, it is also an occasion for growth.  Both therapist and client have to face their own fears and take a magnifying glass to the way they interact in relationships (specifically, what does their history of "terminations" look like?).

The important part though, and the piece I wanted to address through this entry is how to terminate.  We had quite a lively discussion about this in my practicum class tonight: It's almost April, when do we start talking about it?  What do we say?  Is everyone as sad as I am to be leaving?  As I consider these questions for myself, I am realizing that the termination process for children, adolescents - and to a certain extent - emergent adults is precarious.  In this age range, a primary developmental task is learning how to appropriately connect to others.  Psychoanalytic theories would say it's re-parenting, Rogers would call it a "corrective emotional experience," attachment theorists such as Mikulincer and Shaver would see it as building and internalizing a secure base - no matter what you call it, therapy is one way we learn about connecting.  To just cut this off is jarring.

I don't claim to be an expert in this, but my research, reading, trial and error, training, and discussions have helped me to come up with a few guideposts that I use:

1)  As a therapist, take care of yourself during this process.  Address the feelings that come up for you.  Get supervision, go to therapy, consult.  Yalom says that as therapists we should be affected by our clients.  I deeply agree.  However, it nevertheless remains our job to hold the space for our clients.  We cannot do this effectively if we are not "keeping our side of the street clean."

2)  Help your client to understand the process.  "Termination" is a scary word that one would not typically associate with a relationship, let alone the therapeutic process.  We as therapists are sad, but we understand the process.  It makes sense to us because we have been trained in it.  For our clients, especially the ones who have never been in counseling before, the process may be unclear.  This is where I think a lot of the abandonment, anxiety, and sadness comes up - to them, especially the younger ones, we are up and leaving them.  Termination should be an ongoing discussion between client and therapist that addresses goals, achievements, and future directions.  Obviously, per the ethics code, it isn't a one time "well, I guess you're doing well so this is it..." bomb drop in the last ten minutes.  For kids and teenagers, I usually frame this ongoing "discussion" in the form of an activity that lasts over several of the final sessions.  I have them work on creating a transitional object (a collage, a worry stone, a playlist and CD cover, etc.) and use the process of creating this object as a way to talk about ending therapy.  At the end, they get to take their project with them as a reminder of what they accomplished in counseling in the ways in which they have changed.

3)  Pick a final session date.  Don't leave your client hanging.  This kind of goes along with point number two.  In the same way that is important to keep the framework of therapy (return phone calls, same appointment time and day, always end and start on time), it is also important to be clear about the ending.  It is easier to hold the space for your client and process feelings of anxiety and grief if there is not an open ended or ambiguous "event" in the future in which you will leave them.

Now let's switch seats.
From the client perspective it is important that you:

1) Ask questions.  We as therapists should be good at explaining the process, but sometimes (as I mentioned above) we get stuck or leave important things out.

2) Be an active agent in the process.  Have an open dialogue with your therapist about what you hope to accomplish in the final sessions.  Therapy is, after all, about you.  It's our job to work with you.

3)  Wait! But I'm not ready! - If therapy is ending because your therapist is leaving or your therapist believes treatment should end, talk to your therapist about these feelings.  We recognize in situations like this, it feels like we might be just cutting and running with no good reason - or like we don't understand some aspect of what's going on for you at this time.  It is important to differentiate not wanting to end from truly not being ready.  Sometimes we therapists need a little help to clarify.

4) If you are ready for termination, but your therapist doesn't seem to be getting the hint, I will refer you to this article.  It is humorous, however the points the author makes on the second page about knowing when you're ready are solid.

Regardless of where you sit - couch or therapist chair - the takeaway is just as the song says: Breaking up is hard to do.

Bibliotherapy: I recommend...

Books and other materials are often an important aspect of treatment. I often point clients who are working through a specific issue toward one (or more) of these resources.  Below I have selected some of my favorite books which I feel may benefit my clients (and other therapists) and help promote the process of change.

Parenting/Helping children and adolescents





Death/Grief



Relationships



Eating Disorders



Workbooks




For Therapists



Miscellaneous: Existential and Positive Psychology/Memoir




Do you have any suggestions? Please comment!

Count your Blessings: The Impact of Gratitude on Wellbeing

From birth we are taught to say thank you – thank you for the things that we have, for our health, and for our family. In the exciting field of positive psychology, recent research has linked the practice of gratitude with increased immune functioning, optimism, healthy behaviors, and general wellbeing. There is however some controversy over the extent to which simply giving thanks can impact wellbeing on a long-term basis. This week I ventured into the blogosphere to examine what bloggers are saying about appreciation. My curiosity centers on the method that bloggers employ to cultivate gratitude as well as the impact that gratefulness has had on their lives. The first blog I came upon is entitled Brett Boettge’s Accountability which details Mr. Boettge’s daily actions in his pursuit of personal excellence. In his post “November…The Month of Gratitude,” he discusses the dramatic impact the practice of gratitude has had on his wellbeing. His entry focuses on the process of combating the impulse to dwell on negative life events and emotions. Leo Babauta, the author of Zenhabits, frequently offers his advice in achieving personal goals, staying organized, and being productive. His post, “8 Tremendously Important Ways that Gratitude can Change your Life,” was less of a testimonial than Mr. Boettege’s entry and instead provided a comprehensive list of ways to incorporate appreciation into one’s life.
I too have been taking this month to reflect upon the things that I am grateful for in my life. I have come to believe that simply maintaining a positive mindset, especially in the face of adversity, can work immediate wonders on one’s wellbeing. In fact, stress and negative emotions are associated with poor physical outcomes such as heart disease and poor immune function. In working with clients that are struggling with a great deal o adversity, I have become increasingly interested in the positive psychology movement and recently read a study by Robert Emmons and Michael McCullough concerning the concept of gratitude journals. Their research examines the long term effects of gratitude on health and wellbeing. In their experimental study, they found that participants who kept a daily “gratitude journal (see above left)” engaged in healthier behaviors and felt more optimistic than those who recorded daily hassles or even neutral events. I like this idea for my clients, however I fear that asking a client to keep track of what they are grateful for amidst extreme hardship can be a somewhat awkward homework assignment. Part of me says "who wants to think about rainbows and butterflies when the world seems to be one dark storm after another?" However, the other half of me thinks back to the books I read as an undergraduate and graduate student: Yalom's The Gift of Therapy, Viktor Frankl's Man's Search for Meaning, Martin Seligman's Authentic Happiness... While all of these authors use slightly different terms, the idea remains the same: assigning meaning to a struggle in some way (by being thankful for what you do have, etc.) is a survival skill that has been shown in even the most adverse of circumstances to enhance resiliency.

EQ: The Role of Feelings in Intelligence

Consider 16-year old Danny. Danny just got his driver's license and is out with his friends celebrating. He promised his mom he would be home by his ten p.m. curfew. It is now 10:30 p.m. and Danny has not called and he is not yet home. His mom is pacing the living room as anger bubbles up inside her with each tick of the clock. Finally, at around 11:45 headlights turn into the driveway. A few seconds later, the door unlocks and Danny sheepishly enters the living room to greet his mother. His mom looks at him, tells him she is glad he is safe, and that they would discuss the issue in the morning. The next day, Danny's mom informs him that he has lost his car privileges for the next month. Danny is livid. He can't believe how unfair and unreasonable his mom is being and he begins to yell. Danny's mom listens calmly and then tells him "I can see that you are angry that you can't drive for a little while and I know this is tough for you honey, but you broke your promise and this is the consequence." At the time, Danny could not comprehend that his actions caused his mother to feel angry, worried, and hurt – all he felt was his overwhelming frustration.

Self-regulation and clear limits are essential to a child's ability to navigate life experiences and learn from mistakes. This development of emotional self-control has come to be called Emotional Intelligence, or EQ. Daniel Goleman, an internationally renowned psychologist and author of Emotional Intelligence: Why it can Matter more than IQ has recognized that there is a window of opportunity for teaching children EQ. The neural circuitry that allows us to pay attention, calm ourselves, and attune to others’ feelings all takes shape in the first two decades of life. He relates that this shaping can be left to chance, or it can be taught to children and adolescents as in the example of Danny and his mom. Danny's brain is still growing, so learning to identify feelings (see left) and navigate situations in an "adult" manner with the help of his mom becomes essential. These systematic lessons strengthen Danny's budding brain capacity.

“A” for Effort: Unraveling the Myth of the Self-Esteem Movement

Eleven year-old Kate just flunked yet another math test. Over the past quarter, her cumulative grade has gradually sunk to a dismal sixty four percent. She is disheartened for a moment, but immediately forgets the bad grade and cheers up as her teacher reminds the class that there is a math pizza party at lunch. Years ago, the pizza parties used to only be for the children who earned A's in class. Today however, all students get to attend just for giving "their best effort" on homework or activities. Moreover, one popular method of teaching advocates that instructors not correct students’ spelling or grammar, arguing that kids should be “independent spellers” so they can be treated as individuals. These approaches to education originate from the advent of what has been called the self-esteem movement by San Diego State professor of psychology Dr. Jean Twenge. Since its beginning in the 1980s, there has been a marked shift in the classroom from teaching self-control and respect to reinforcing individuality, "good tries," and positive emotions, regardless of the situation. In fact, there have been lasting repercussions from this change in focus: "Self-esteem is on the rise, but it's difficult to find many clear benefits of this when viewing broader cultural changes," says Twenge. "We may think more highly of ourselves, but there's little objective evidence why we should." Her comments stem from a study that she recently published in Personality and Social Psychology Review, in which Twenge and her colleagues found that college students' self-esteem has risen steadily over the past few decades. Conversely, declining SAT scores and rising rates of teen pregnancy, crime, anxiety and suicide in the students provide evidence that academic and emotional regulation skills worsened. While it may seem like an important way to encourage children to be successful and productive, merely working to increase children’s self-esteem takes the focus away from developing more adaptive life skills such as discipline and responsibility thereby rendering them ill-equipped to enter adult life.

Twenge and her colleagues liken self-esteem to a gas gauge on a car; it is an indicator of the abilities one has in their "tank." Ideally, the gas gauge should reflect the actual amount of gas in the vehicle. However, classroom activities such as having an achievement-based pizza party that includes students who are failing or beginning each day by singing "I am special, I am special, look at me!" move the needle to indicate "full" when the child may only have a half-tank. If left unchecked, this misrepresentation can morph into narcissism in adulthood. Twenge’s findings support this trend. In an examination of 16,475 college students nationwide who completed an evaluation called the Narcissistic Personality Inventory (NPI) between 1982 and 2006, she found that more than two-thirds had an above average score by 2006. This is a thirty percent increase from 1982. The NPI is a standardized measure that asks for responses to such statements as "If I ruled the world, it would be a better place," "I think I am a special person" and "I can live my life any way I want to." This concept of narcissism is not new; in Greek myth, Narcissus (see left) saw himself as more beautiful and better than those around him. He eventually fell in love with his own reflection in a pool of water and died. Surely his inflated and inaccurate sense of self was the cause of his demise. Yet, only now has high (and inaccurate) self-esteem been scientifically implicated in the development of narcissism. There is a growing body of evidence to suggest that the problem is that the narcissist's inflated self-image lacks internal support and is fragile; like Narcissus' reflection, it dissolves with the slightest disturbance of the pool.

As a volunteer teacher in a preschool, I admit I have a hard time coming to terms with the idea that teaching children to feel good about themselves is so detrimental or that it can lead to maladaptive behavior in adulthood. Intuitively, it seems like a little unwarranted boost in confidence here and there cannot hurt. In fact, we even sing the "I’m Special Song" right before story time each morning. Research nevertheless indicates that there is no correlation between high self-esteem and meaningful relationships, achievement, or perseverance in work. In fact, Twenge and colleagues suggest that there might even be a negative correlation between unduly inflated self-worth and social interaction. University of Florida psychologist Ilan Shrira and his colleagues Joshua Foster and Keith Campbell agree. In their study that surveyed 485 undergraduates at the University of Georgia who were in romantic relationships, they found that those who scored high on the NPI expressed extremely low commitment to their partners. Shrira concludes that "narcissists tend not to value relationships unless it’s for self-serving purposes." The researchers warn that egotistical individuals can appear confident-but don’t be fooled! The defining characteristic of the narcissistic college-aged individuals that were studied was "game-playing love." They were more likely to have romantic relationships that were fraught with dishonesty, infidelity, and over-controlling and/or violent behaviors. The narcissism that is fostered in early childhood produces individuals who "aren’t playing by the same set of interpersonal ‘rules’ that most people are" notes Harvard University post-doctoral research fellow Seth Rosenthal. During his fellowship at the John F. Kennedy School of Government, he too found narcissism to be problematic in relationships. At first, in groups where there is no designated leader, members are likely to name the narcissist among them as a leader. “[Narcissists] are the people who show off the most, make the most noise, have the most ideas, or at least are most likely to keep throwing them out there,” Rosenthal says. After awhile however, group members become annoyed with the narcissist. This type of vanity leads to complications in the workplace as well. Young adults are entering the work force with a false sense of entitlement. They were taught in elementary school that everyone has a right to feel good even if they fail, cheat, or steal. Shrira adds "if all you get is positive feedback as a child and your success is not based on any sort of real accomplishment, you’re not going to be motivated...” Further, their method of interaction leads to a lack of collaboration with coworkers. Employers may be facilitators though. There is little motivation to work hard when competition is outlawed in favor of celebrating mediocrity.

The solution it seems is to intervene at the school age and teach children self-regulation and self-respect instead of just self-esteem. Building a repertoire of appropriate coping skills is an important part of maturing and it is necessary for children to be allowed to fail sometimes if they are going to learn to manage difficult situations. Additionally, there is one personality trait that is definitely linked to achievement, and that is self-control. Although the words "discipline" and "obedience" have garnered negative connotation within the education establishment, people with high levels of willpower are the most likely to succeed. In her book Generation Me: Why Today’s Young Americans Are More Confident, Assertive, Entitled–And More Miserable than Ever Before (see right), Twenge argues that “Self-control predicts all of those things researchers had hoped self-esteem would, but hasn’t.” Thus, teaching regulation is key. That is not to say children should never be praised. Positive reinforcement however should be reserved for actual achievement or improvement in ability, not just the "good effort" despite the failing grade.