Some clients are very clear about when they want to
stop therapy even if everyone is not as direct as is little Lisa:
Lisa is 7 years and has been sexually abused. She has
been in therapy for a long time without any clear improvement of
symptoms that we don’t know very much about and eventually comes to
MS.
She improves already after the first session and on
the way to MS for the second session she turns to her foster-mother and
says: "Mom, how long do we have to continue to see Martin? Is it
till I think I’m OK, or is it till he thinks I’m OK?"
Her fostermother answers that she doesn’t know and
that they will have to ask Martin. They ask the question together and
Martin looks very seriously at Lisa and assures her that it is when she
feels that she is OK. She looks very relieved.
People stop going to therapy for different reasons.
They can be satisfied with what they have achieved or they may feel that
they can handle the rest themselves. They may also be dissatisfied with
what they got and they may have come to the conclusion that further
sessions won't make any difference.
In a goal-oriented therapy form where the number of
sessions is around 5 to 10, termination is of course very different than
in a therapy-form where the number of sessions is higher and the focus is
very different. The therapist will not become as emotionally important and
the therapy will not become as important in the client's life.
This doesn’t mean that the therapist is not an
important person to the client, but as the therapy is short and
goal-oriented and both client and therapist have an idea about the goal,
termination will be present from the start.
Mireille is 13 years old when
she goes to the police because she can no longer bear that her father is
having sex with her. The police doesn’t believe in her and nor does
her mother. She then runs away from home and quickly establishes herself
as a heroin addict. At 18 she marries and together with her husband she
explores the world and different ways to support herself and her habit
for 9 years.
She then becomes pregnant. She almost stops abusing
– though not entirely – and gives birth to a healthy girl.
A nurse starts worrying about the child who lives
with a father who is surely doing drugs and a mother who probably is,
and establishes a supportive contact with Mireille. Together with the
nurse Mireille opens up, tells about her former addiction, her decision
not to start doing drugs again and the difficulties with her husband
whom she feels resembles more and more to her father.
She gets a lot of support and finally sets an
ultimatum for her husband: "Either you stop doing drugs entirely
and contribute to supporting the family, or I will leave you." He
accepts, says "Trust me," and she starts waiting.
One year later there has been no change and the nurse
refers the couple to therapy.
Mireille is prepared to do anything to improve the
relationship. She wants to be able to enjoy sex. She never did as she
starts thinking about her dad every time she has sex. She also wants
Malte to stop doing drugs, get a decent job, and contribute to
supporting the family.
Your petty jobs is not enough to support us,"
she says, "you work to little and you have to get work at least
half-time besides the other stuff you’re doing."
He explains that it is impossible for him, that it
will be all right and that he will quit doing drugs: "Trust me."
In the eight session we ask Mireille what she got out
of therapy. She answers: "You’ve helped me do what I had to do,"
and on the following question: "On a scale from 1 to 10, how
confident are you that you can do the rest without any further help from
us?" she answers: "Seven, but I want to continue to
come."
The therapist then asks: "how high do you wish
to be on confidence before you stop coming here, and what would be
something you did that would increase your confidence in yourself?"
She answers that she would leave Malte, and that the
first step in this direction would be to start looking for a new
apartment.
When she returns after a month she has found an
apartment, signed up for a school, found a day-care center for her child
and she thinks she doesn’t need more therapy. The therapists agree on
this and they also agree with her that it will not be easy to leave
Malte, and that it will certainly be a painful process. The therapists
also agree with her that she will be able to handle it, and she is of
course welcome back IF she feels that they can be of help.
Termination is brought into therapy from its start and
is connected to the idea that the client will end therapy when he has
reached his goals. We usually ask:
"How will we know when we can finish our contact?"
or
"If you don’t tell me anything about it, how
will I know when you have reached what you want from therapy?"
Other alternatives are the future-questions mentioned
earlier:
"Imagine three years into the future and we meet
again by coincidence. I ask you how you are and you answer that all is
well and that you are satisfied with you life – how did it happen, what
did you do and how did you do it?"
"When we meet in a couple of years and all is well,
you tell me that you have been thinking of writing a book and in that
thank everyone who helped you – what do you call the book and what does
it contain?"
When you work goal-oriented and solution focused one of
your first priorities is to establish useful goals. One of the most
important criteria (the most important) for what is a useful goal is that
you and/or the client knows when it is accomplished. When you and your
clients are clear about this it will be obvious to end treatment when the
goal is reached.
Hence we therefor always examine three questions:
- Is it better or is it different?
- Is it in the direction of the goals?
- Is it enough
if it isn’t enough: What else needs to happen?
This leads on to a few simple categories of ‘ending’-situations:
- The goals are reached
- No change
- The goals are partly reached
- The clients stops coming (no-show)
When the goals have been clear and concrete and the
client and the therapist agree that the client reached his goals, it is
easy to decide jointly to terminate treatment. The flow leading up to this
decision is described in another chapter" (page *
ff.). These terminations are uncomplicated and evident to everyone and
always include the option of returning for more sessions if necessary.
Going to therapy is not exactly like going to a
solarium. There is no guarantee that therapy will make any difference.
When clients and families reach the conclusion that the therapeutic
conversations were of no help and most likely won’t be in the future
neither, it is obvious they will want to quit.
When clients bring this up with us – some don’t and
just don’t show up – we express clearly that we see the lack of
success as a result of our inability, or as an expression of us having
missed something important, and we express regret over this as clearly as
we can.
As mentioned earlier we see lack of success as an
expression of our inadequacy, while we see success as a result of the
competence of the client and family.
Relatives may want to continue in therapy even if it is
evident to you – and probably to them – that therapy doesn’t help
them change the situation nor for themselves, nor for their abusing
relative.
It’s not easy to stop seeing people who wants to
continue to come and who may feel that you are the only one who ever
understood how they felt. These endings are often very painful for
everyone involved, but may sometimes paradoxically seem to become the
starting point for change.
Ansgar is 55 and very successful in his work. For 15
years he has – accompanied by continuos guilt-feelings – contributed
financially to his sons heroin abuse in a desperate attempt to keep the
son alive. For two years he has, without success, been in therapy to try
and find other and more useful ways to help his son. During this time he
doesn’t succeed even once to bring his son to a session.
After two consultation interviews with another
therapist (HK) the team reaches the conclusion that they are of no help.
The only ideas available are such that both Ansgar and the team know
they are impossible to use. In a very difficult session the therapists
puts this to Ansgar and also say:
"For us to believe that we are of any help we
need to see your son." The issue has been raised many times before
and Ansgar has tried many times to bring him in. Everyone knows the
team's request is unreasonable and impossible. Ansgar rises staggering
and says: "If I don’t have you anymore, there is no need in
continuing..."
"We can’t do anything for your son without
seeing him," repeats the therapist, "we have tried for two
years without any success what so ever", and Ansgar leaves. A
couple of weeks later he tries on the phone to get a new appointment,
but the team maintains its standpoint.
Eight months later he calls in desperation and makes
a new appointment. In the session he recounts that it has been a
difficult time. Shortly after the session eight months earlier Ansgar
went into a relationship with a woman for the first time in 15 years.
The son had a difficult time – maybe because of this – and tried to
detox twice under great drama and turbulence. After the second he was
abstinent for four months, but has now relapsed since two weeks.
It is important that you let people measure their own
success, and that you do it very often in the therapy. Sometimes you and
the family will come to the conclusion that therapy is not helpful and it
is then wise to reflect on if you should tell them:
"I think these sessions are not helpful to you,
and it may even be so that they prevent you from doing what you need to
do."
Many clients express doubt about being in therapy. Some
express that they came because for instance their wife told them to, and
they are not at all happy about being with us. They may express clearly
that they have come just this once, and they are very clear about their
intention of not returning for any more sessions.
These clients and family members sometimes explain that
they think that one should handle this kind of problem by oneself, or they
may express that they have already come so far that they do not need any
help.
Another group of clients is those who make small, but
for them significant progress and immediately wants to terminate "and
do the rest themselves". These clients are glad to talk about the
progress they have made, but are not entirely willing to speculate over
the next step. The situation often becomes clear when the therapist uses
scaling-questions. It then becomes apparent that the client is satisfied
and doesn’t think he needs to come back.
What we think in these situations is unimportant as
long as a third part is not in danger. It’s impossible to help people
with things they don’t want help with. Any attempt in such a direction
will reduce the chances that the client returns for help with another step
at a later moment. Besides most people don’t seem to need our help to
continue a change process on their own.
It happens that clients/families stay in therapy in
order not to disappoint the therapist. As the therapist haven’t said
anything about terminating the client continues to come.
Sometimes the client continues because he has hope for
more improvement (see for instance Carolin page *).
This however happens more and more rarely as we get more skilled in
finding out how the client sees his own progress.
When we sense that the client is hesitating to return,
we often end the summary of the session with:
"...and we are not certain you need to come back.
What do you think?" The answer is often:
"Well, maybe one more time," and we then
offer an appointment a little further into the future and adding;
"...this is appointment for you to cancel if you
don’t need it".
It is very common for us to receive cancellations for
such appointments. Sometimes we feel a little bit bolder and we then say;
"...it’s an appointment for them to cancel when they have
reached the conclusion they won't need it."
It is not always though that clients express clearly
that they want to terminate therapy.
Sometimes client and families express their wish to
terminate by forgetting to come. Of course this doesn’t mean that all
clients who fail to attend wants to terminate.
We always assume that clients have good reason for not
attending. Children and relatives may have fallen sick, the client may
have been run over by a bus or anything of a million things could have
happened.
Things may also have improved so much that the client
no longer wants or needs any more treatment. It is then of course a sign
of health that we have been forgotten.
Insoo Kim Berg recounts that Oliver 30 years old,
failed to attend the fourth session. In his history were at least 15
years of poly-drug abuse and several years of homelessness. By the third
session there had been some very minimal change like for instance Oliver
having been able to postpone his morning-dose till 11 o’clock.
One month later Insoo meets him in a treatment
institution for addicts where he works as a janitor. He takes her aside
and explains he didn’t come back because he "decided to do it by
himself". One year later he is an active partner in a
self-help-program for the homeless.
This and similar – though less dramatic – cases
from our own experience has made us increasingly respectful for this way
of terminating therapy. Gradually we have become less active in
re-recruiting clients who miss their appointments.
We have written about ceremonies in the chapter
"Special techniques". Almost everything we have talked about
there is useful to mark termination and celebrate it.
A health certificate, a diploma or a party can become a memory or a
thing that may help to remember in the future what the client has
accomplished and remind him of his resources when difficulties arise. |
