Journal of Psychotherapy Integration Termination in Psychotherapy: Contributions of an Integrative Metamodel Ana Nunes da Silva, Joana Fojo Ferreira, Nuno Conceição, Catarina Vaz Velho, and António Branco Vasco Online First Publication, August 12, 2021. http://dx.doi.org/10.1037/int0000235 CITATION da Silva, A. N., Ferreira, J. F., Conceição, N., Vaz Velho, C., & Vasco, A. B. (2021, August 12). Termination in Psychotherapy: Contributions of an Integrative Metamodel. Journal of Psychotherapy Integration. Advance online publication. http://dx.doi.org/10.1037/int0000235 Journal of Psychotherapy Integration 2021 American Psychological Association ISSN: 1573-3696 https://doi.org/10.1037/int0000235 Termination in Psychotherapy: Contributions of an Integrative Metamodel Ana Nunes da Silva1, 2, Joana Fojo Ferreira1, 3, Nuno Conceição1, 2, Catarina Vaz Velho1, 4, and António Branco Vasco1, 2 1 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Paradigmatic Complementarity Lab, Lisbon, Portugal 2 Faculdade de Psicologia, Universidade de Lisboa 3 Lisbon, Portugal 4 Departamento de Psicologia da, Universidade de Évora In this article, we discuss the process of terminating psychotherapy based on an integrative perspective—the paradigmatic complementarity metamodel (PCM). One of the research fronts in PCM is the temporal sequence of phases structuring strategic objectives. The temporal sequencing of the therapeutic work in terms of phases, stages, or steps is believed to be a general principle of change among different theoretical orientations, both of an integrative and nonintegrative nature (Vasco, 2006; Vasco et al., 2018). According to the PCM, the therapeutic process unfolds as the client and therapist progress along 7 phases regarding the implementation of strategic objectives. In this article, we address termination and its implications at different phases of therapy considering the PCM. Some vignettes are used as illustrations. Keywords: termination, change process, temporal sequencing, psychotherapy integration Termination is a term typically used when referring to the ending of the psychotherapeutic relationship. It may occur as an expected and wellarticulated treatment plan that reveals the next phase of psychotherapy, or it may occur abruptly or by surprise (Barnett, 2016). The termination of a psychotherapeutic relationship can be a complex process. Clinical, practical, and ethical factors play essential roles, and therapists must have competence in termination (Davis & Younggren, 2009; Barnett, 2016). It is recognized as a significant aspect of the therapeutic process, yet it remains vastly understudied in psychotherapy literature (Bhatia & Gelso, 2017). It is difficult to think about the termination of a therapeutic process disconnected from the achievements of that specific process and the relationship established. Bhatia and Gelso (2017) showed that the working alliance and real relationship during the termination phase were positively related to termination phase evaluation and overall treatment outcome. In contrast, negative transference during the termination phase was negatively related to the Ana Nunes da Silva https://orcid.org/0000-00017125-716X https://orcid.org/0000-0003-4540Joana Fojo Ferreira 5442 https://orcid.org/0000-0001-8038-5841 Nuno Conceição https://orcid.org/0000-0002-1813Catarina Vaz Velho 5005 https://orcid.org/0000-0001António Branco Vasco 7400-2541 Funding from FCT to CICPSI UIDP/04527/2020 & UIDB/04527/2020. The authors state no conflict of interest. Ana Nunes da Silva served as lead for conceptualization, funding acquisition, writing–original draft and writing–review and editing. Joana Fojo Ferreira contributed equally to writing–original draft and served in a supporting role for writing–review and editing. Nuno Conceição contributed equally to conceptualization and served in a supporting role for writing–original draft. Catarina Vaz Velho contributed equally to conceptualization and served in a supporting role for writing–original draft. António Branco Vasco contributed equally to conceptualization and served in a supporting role for writing–review and editing. Correspondence concerning this article should be addressed to Ana Nunes da SilvaI, Faculdade de Psicologia, Universidade de Lisboa, Alameda da Universidade, 1649-013 Lisboa, Portugal. Email: AnaCatarinaNS@gmail.com 1 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 2 DA SILVA ET AL. overall treatment outcome. Also, therapists’ perceptions of client’s sensitivity to loss were positively related to both negative and positive transference during the termination phase. Westmacott et al. (2010) showed that when clients unilaterally ended therapy, therapists were only partially aware of either the extent of clients’ perceived improvements or their dissatisfaction. When termination was mutually determined, there were no differences between client and therapist ratings of termination reasons. Although working alliance and barriers to treatment participation were rated as lower in the context of unilateral termination by clients and therapists, all clients rated the early alliance and barriers to treatment highly than did therapists. From our perspective, the termination of the therapeutic process intends to help the client move adaptively throughout his or her life and says something about how the process itself unfolded. As therapists, we want our clients to leave therapy aware of their capacities and vulnerabilities and identify resources they can mobilize to deal with life’s potential challenges. In this article, we reflect on the termination of the therapeutic process using the lens of the temporal sequence of strategic objectives proposed by the PCM to assist clinical decisions regarding how to terminate. The clinical decisions are based on what the client has already achieved in terms of the general processing capacities proposed by the PCM and what the client still lacks in terms of processing capacities regarded here as hypothetical change mechanisms, reflecting the mental architecture of the client. importance of concepts like maladaptive schemes, alexithymia, and emotional dysregulation as hindering variables in the process of regulating the satisfaction of needs. The theory of intervention envisions the therapeutic process as a sequence of seven phases contemplating the promotion, on the part of the therapist, and the capacitation, on the part of the client, of phase-specific strategic objectives that will, hopefully, translate to a better ability to regulate the satisfaction of psychological needs. According to the PCM, the therapeutic process consists of four interrelated components (Vasco, 2006; Vasco et al., 2018). First, being in therapy, an aspect related to the therapeutic alliance, stresses the need for a bond and agreement between client and therapist for goals and tasks (Bordin, 1979) and a shared representation of the problem. Then the “What” of therapy regarding the contents to be considered, that is, what therapy should address, associated with specific and generic goals. Another component concerns the “How” of therapy, that is, the methods of intervention that we like to call potentially reparative therapeutic actions. Finally, the “When” of therapy concerns the utility of understanding the therapeutic process as a sequence of phases for promotion/assimilation of sequential therapeutic objectives common to all theoretical orientations. Following an integrative approach, promoting these objectives should not depend only on the theoretical orientation but also on the clients' characteristics, capabilities, and needs (for a review see, Ferreira, Basseches, et al., 2017; Vasco, 2006; Vasco et al., 2018). In this article, addressing termination, we will focus on the temporal sequencing of the therapeutic process. Paradigmatic Complementarity The Paradigmatic Complementarity Metamodel (PCM, Vasco, 2006; Vasco et al., 2018) is based on the complementary and sequential use of common factors or general principles of change and specific techniques, derived from various theories and suited to client’ characteristics and needs (Vasco, 2006). PCM considers a theory of adaptation, a theory of disorder, and a theory of intervention. The theory of adaptation stresses the pivotal importance of regulating the satisfaction of key psychological needs (14 needs organized in seven dialectical/ complementary polarities) as well as the role played by mood and emotions in signaling the level of this regulation. The theory of disorder underlines the Temporal Sequencing of Therapeutic Work in Terms of General Strategies and Strategic Goals (the “When” of Therapy) One of the research fronts in the PCM is the temporal sequence of phases structuring strategic therapeutic goals: the When of Therapy. The model describes the sequence of the therapeutic process in seven phases related to strategic objectives that are tendentially sequential. This implies a sequential phase-to-phase responsiveness of the therapist to respect the level of accomplishment of the strategic objectives of the client, concerning the strategic objectives that the therapist tries to promote in each phase. Human change processes are rarely, if ever, This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. TERMINATION IN PSYCHOTHERAPY sequential (Mahoney, 1991, 2003), but our experience has been that therapists, especially those interested in learning integration, can benefit from sequential maps to facilitate psychological growth. Thus, it provides a mapping of the therapeutic sequence, with strategic objectives, which assists in the decision-making process (at a macro level of abstraction), anchored on the being and the how of therapy (at a micro level of abstraction) of the therapy. The When of therapy, lies at an intermediate level of abstraction, between theory and technique, since the being and the how of therapy are at a more concrete level and should be understood as vehicles for the pursuit of strategic objectives of each phase, in compliance with different types of responsiveness: proactive and reactive responsiveness. Proactive responsiveness regards the selection of interventions and planning based on the client's complaints, characteristics, and needs (of a more nomothetic nature). Reactive responsiveness regards the temporal adequacy and phasing of interventions based on the level of understanding, emotional state of the client, and how the client is reacting to the therapeutic proposals (of a more ideographic character), which sometimes implies moment-to-moment interactions (Vasco et al., 2018). In other words, instead of nonintegrative models, which theoretically propose specific techniques of pursuing strategic objectives, in a “topdown” logic, the PCM argues that the decisionmaking logic should be “bottom-up,” which is based on the aforementioned responsiveness: proactive and reactive. The importance of explaining the temporal sequence of the therapeutic process has been progressively recognized to be of great therapeutic utility by several authors (e.g., Benjamin, 2003; Orlinsky et al., 2004; Shapiro, 1996). Our sequence of phases was based remotely on the intervention of Hippocrates with Perdicas II and, more recently, on our clinical experience and the general principles of therapeutic change suggested by Goldfried (1980; 2014) and common to all theoretical orientations, as well as common factors systematically identified in the literature as crucial for therapeutic success (e.g., Beitman et al., 1989; Castonguay et al., 2015; Norcross, 1986). The notion that psychotherapy proceeds in stages is a common heuristic tool that transcends theoretical orientation. The construal of change within psychotherapy as a process involving progress through a series of stages is not new, where each stage is a temporal dimension that represents 3 when particular changes occur within the client or the therapeutic process (therapist, client, interaction). This temporal sequence tries to impose some structure on the complexity of change that occurs in psychotherapy (Mahoney, 1991), conducted from a contextual-relation model perspective and seen as developmental processes. Another example with some similarities is the five-stage model of change of the transtheoretical approach (Prochaska & DiClemente, 1992), particularly suited to more short-term processes focused on more specific concrete goals. The use of this five-stage model is embraced by our metatheoretical framework in a way that does not substitute our phase model but enriches its use in assisting responsive integrative decision-making. In a proactive responsiveness level (high level of abstraction), we consider several criteria for therapeutic decision-making, attitudes, and forms of therapeutic communication to be central (for a discussion of all criteria see, Vasco et al., 2018); including the motivational stages of preparation for therapy and therapeutic change described in the transtheoretical approach. These are the stages of precontemplation, contemplation, preparation, action, and maintenance. Since not all clients come to therapy with the same level of motivation, the therapist's optimal relational attitude should vary according to the stage of change the client is in (Norcross et al., 2011; Prochaska & DiClemente, 1992). We will now briefly describe the seven phases that comprise the temporal sequencing component. According to the PCM proposal, the therapeutic process unfolds as both the client and therapist progress along several phases structured in terms of general strategies, namely: (a) trust, motivation, hope building and relationship structuring, (b) increasing awareness of self and experience, (c) new meaning making regarding self and experience, (d) regulation of responsibility, (e) implementation of repairing actions, (f) consolidation of change, and (g) relapse prevention and projection of self in the future. These strategic objectives are thought in terms of not only what the therapist is promoting, with resources offered but also in terms of what resources available were already assimilated and accommodated by the client. During the first phase of the therapeutic process, trust, motivation, hope building, and relationship structuring, the main strategic objectives are: (a) articulating concerns and problems; (b) validating distress and pain; (c) promoting trust, hope, This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 4 DA SILVA ET AL. security, and motivation; (d) bonding; (e) establishing therapeutic goals; and (f) structuring the process in terms of roles and rules. During the second phase, increasing awareness of experience and self in process–the main strategic objectives are: (a) helping differentiate problems; (b) focusing attention on each problem at a time; (c) distancing from problems; (d) differentiating between different components of the experiential cycle (feelings, sensations, thoughts, needs, action tendency, actions); (e) increasing awareness of interpersonal relationships and relational conflicts; and (f) increasing awareness of self-characteristics, rules, and internal or intrarelational conflicts. During the third phase, meaning making regarding oneself and one’s experience, the main strategic objectives are: (a) helping to connect different components of the experiential cycle; (b) clarifying the meaning of different components of the experiential cycle; (c) clarifying attributions for different components of the experiential cycle; (d) relating past, present, and future as related to learned behavior; and (e) negotiating viable explanations (proximal and distal) for problematic experiences. During the fourth phase - Regulation of responsibility toward a differentiated life the main strategic objectives are: (a) increasing awareness of needs; (b) differentiating viable from nonviable needs; (c) promoting self-efficacy and resources for change; (d) differentiating self and others responsibility regarding client’s problems; (e) promoting responsibility for feelings, thoughts, actions, and life choices; and (f) promoting compassion toward the self. During the fifth phase - Implementation of repairing actions, the main strategic objectives are: (a) promoting the rehearsal and implementation of healthier plans of action that may satisfy previously unfulfilled needs; (b) allowing emotions or other missing components; (c) exposure to previously avoided emotions, thoughts, and situations; (d) flexibilization of ways of being; and (e) relating to others in more authentic and gratifying ways. During the sixth phase - Consolidation of change, the main strategic objectives are those of: (a) dealing with intra and interpersonal blocks to the consolidation of the emergent ways of being; (b) harmonizing different parts of self and experience; (c) establishing and nurturing relationships that support the emergent ways of being; (d) caring and nurturing the new ways of being; and (e) developing an attitude of appreciation toward new ways of being, as compared to the old ones currently being grieved. During the seventh and final phase - Anticipation of the future and relapse prevention, the main strategic objectives are: (a) anticipation of future difficulties; (b) increasing awareness of resources to cope with future difficulties; (c) anticipation of future possibilities and gratifications for the new ways of being; (d) facing future difficulties as opportunities for growth and development; and (e) developing an attitude of appreciation toward the new ways of being, committed to psychological growth. These phases may overlap in part, meaning that when the therapist is essentially promoting the objectives of one phase, he is also promoting the objectives of adjacent phases. On the part of the client, phase gains tend to be acquired sequentially and cumulatively along the process (Conceição, 2005; 2010; Ferreira et al., 2011; Ferreira, Basseches, et al., 2017; Ferreira, Vasco, Basseches, Conceição, et al., 2017; Ferreira, Vasco, Basseches, Santos, et al., 2017; Vasco, 2006). Being essentially focused on general strategies, this temporal sequencing map allows a perspective taking with enough flexibility for the integration of different orientations, allowing the combination of relational, cognitive, emotional, and experiential components. The sequencing component of the PCM has been studied for the last 20 years with both transversal and longitudinal analyses and quantitative and qualitative methodologies. The results have systematically supported the sequence and the positive influence on clients’ progress during the process (Conceição, 2005; 2010; Ferreira et al., 2011; 2016; Ferreira, Basseches, et al., 2017; Ferreira, Vasco, Basseches, Santos, et al., 2017; Gonçalves & Vasco, 2001; Rodrigues, 2012; Simões, 2012; Vasco, 2006). Specifically, the studies have: (a) systematically supported a temporal sequence of strategic objectives (Conceição, 2005; 2010; Ferreira et al., 2011; 2016 Ferreira, Basseches, et al., 2017; Ferreira, Vasco, Basseches, Conceição, et al., 2017; Ferreira, Vasco, Basseches, Santos, et al., 2017), (b) showed the potential of this sequence in intervening with personality disorders in long-term processes (Conceição, 2010; Gonçalves & Vasco, 2001; Simões, 2012), (c) pointed to an increase in the estimated improvements of the client as he or she progresses along the therapeutic process (Vasco, 2006), and (d) indicated that the articulation of therapists’ work according to the client's This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. TERMINATION IN PSYCHOTHERAPY assimilation capacity may be associated with good outcomes and better alliances, at least regarding the task agreement dimension (Conceição, 2005; 2010). If the therapeutic process proceeds effectively, it should progress along a temporal dimension that respects the sequence of strategic objectives. Nevertheless, the PCM does not advocate a strict sequencing that all therapists must follow. The purpose is to provide a map of structural, phase-byphase responsiveness and a guidance tool to use throughout the therapeutic process, which alerts the therapist of the need to verify the client's processing capacities, and not rush to promote strategic objectives of more advanced phases, if the client is not yet prepared for them. The therapeutic work related to the promotion of the specific objectives of the phases may partially overlap, may vary in duration, depending on the client's characteristics and the process, and oscillating movements in promoting goals may occur. This sequential representation proves to be particularly relevant and useful for clients with problems of greater complexity and severity, benefiting from medium - or long-term processes. In these cases, to perceive linearity, it is necessary to look more at the generic processing capacities (already structurally enabled) that clients are manifesting in relation to challenging situations of therapy or everyday life and not for specific themes or contents. In this “helicopter” view, when flying over a vast territory, it is possible to distinguish patches of geography with or without vegetation, with different characteristics, without considering trees or stones in isolation. In these situations, it is equally important that the therapist discriminates against “figure” from “background,” being aware of the strategic moment-to-moment objectives that he is promoting, how he is promoting them and at what phase. In turn, regarding client training, this process appears to be more cumulative, in the sense that the acquired processing capacities seem to remain throughout the sequence of phases of the process (Vasco et al., 2018). Some studies from our group have shown qualitative evidence of this phasic sequence of therapeutic gains, with excerpts from the clients’ discourse illustrating markers of acquired processing capacities (Ferreira et al., 2011; 2016; Ferreira, Vasco, Basseches, Santos, et al., 2017; Rodrigues, 2012; Simões, 2012). Three of these studies made use of qualitative analysis of the cases that Conceição (2010) studied in quantitative terms, 5 and the other two integrated quantitative and qualitative analyses. The six studies together constitute an integration of quantitative and qualitative evidence supporting the temporal component of the PCM. Overall, the evidence accumulated upholds the claim that this temporal sequence of strategic objectives can count as a general principle of therapeutic change, being open to research inquiries conducted by other groups in the future. Termination of the Therapeutic Process: Reflections Based on the PCM A potential benefit of using PCM as an approach from which to address termination related clinical decision-making is that one of its core components, the temporal process formulation, postulates therapy as a sequence of phases regarding the promotion/assimilation of strategic objectives that are common to all theoretical orientations. It postulates phase-specific strategic goals to be promoted by the therapist, in a responsive way. This responsiveness is possible by making use of a “map” of processing capacities that the client can achieve, as a result of that phase-specific processing in order to be responsively eligible to subsequent processing goals as long as it stays in his or her zone of proximal development as defined by Vygotsky (1978). Also, this is always based on the being in therapy, that concerns the therapeutic alliance, based on Bordin’s (1979) perspective. Based on this perspective, to establish clear, and shared, goals with a client allows to assess the progress of those goals. As a result of such phase-by-phase responsiveness level added to the therapist’ repertoire, it is natural to conclude, that if change can be construed as a multidimensional construct, so can termination. This has implications for clinical decision-making and prescriptions for how to facilitate change in therapy and to when and how to stop the therapeutic process, according to what capacities have the client already achieved and those that have not. Following the PCM, we can conceptualize that termination can occur at any of the seven proposed phases, expected or not. Although termination can occur at any phase, we could anticipate it is at phase 5 that the client is already more clearly capable of implementing actual changes in his or her life, in a way that feels substantially embodied or structural, meaning the client is not only able to do it in-session, but out-session, by him or herself. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 6 DA SILVA ET AL. Previously, he or she has developed the capacity to trust the therapy and therapist, to collaborate and have a sense of being in process willing to work, psychologically (phase 1 gains), be aware of how it is to live his or her ways (within and between; phase 2 gains), understand why he or she functions the way he or she does (phase 3 gains) and realize his or her agency in the maintenance of the problem and especially to its solution (phase 4 gains). Once phase 5 gains are acquired, and the client is able to choose to live the way she wants given all circumstances, we have the final phases of the mode—6 and 7—more directly related to the termination of the process, which relates to consolidation of change, relapse prevention, and projection of self in the future. Concerning consolidation of change, the strategic objectives associated with phase 6 refer to: dealing with internal or external obstacles to the consolidation of his or her identity and growth; developing relationships/situations that support his or her choices; accepting the inevitability of a certain degree of vulnerability or conflict as a result of experiencing and expressing his or her identity; emotionally nurturing and nourishing himself/herself regarding the expression of his or her identity and growth; and generalizing the expression of his or her identity to the different domains of his or her life. Concerning relapse prevention and projection of self into the future, the strategic objectives associated with phase 7 refer to: strengthening the feeling of self-coherence and purpose in his or her life, integrating experiences from the past, present, and anticipated future into a coherent self-narrative; projecting him/herself in the future, effectively and affectively relating to self, others, and the world; anticipating resources required to cope with future scenarios beyond the termination of the therapeutic process; and realizing that he or she can cope autonomously with life’s future challenges. The development of the processing capacities associated with these last two phases is important to guarantee a smooth transition to life without therapy and the capacity to deal with life’s future challenges. This also means that, especially within this framework, the termination of the process is not, ideally, something the therapist does in a single session but something that is prepared during several sessions. Even though, throughout the process, the client is supposed to deal with life outside therapy, the amount of time a particular client needs to feel confident about his capacity to deal with his life without therapy may vary. Time and practice make permanent, and using the temporal process formulation of the PCM, equips the client several opportunities to practice this transfer. That is, in each of the five previous phases, the client has had an opportunity to bridge in-session change processes with out-session phase-specific achievements or mechanisms. This seems in line with the results of Norcross et al. (2017) that identified eight core termination behaviors, across theoretical orientations, in a successful course of treatment. Aspects such as process feelings of patient and therapist, discuss patient’s future functioning and coping, help patient use new skills beyond therapy, frame personal development as invariably unfinished, anticipate posttherapy growth and generalization, prepare explicitly for termination, reflect on patient gains and consolidation, and express pride in patient’s progress and mutual relationship, seem of core importance when ending psyhcotherapy. Notwithstanding, independent of the phase at which the process is terminated, we believe that several termination-oriented principles are of paramount importance when negotiating phase-specific terminations, namely, a) assessing what/how/why phase-specific changes or processing capacities have been transdiagnostically mastered, that is, irrespective of the themes worked upon; b) exploring, processing, and affirming experience associated with progress according to the temporal process formulation map; and c) acknowledging what issues remain to be worked on, in terms of processing capacities according to such a map. One importante aspects is related with the risk of terminationg becoming too intellectualized. Marmarosh (2017) argues that endings in therapy activate client’s and therapist’s attachments and can trigger emotion regulating strategies that can elicit client’s engagement or more defensiveness. Presented here is a brief example of working on these last two phases, approaching the termination of the therapeutic process, with a focus on consolidating the changes, by helping the client to be aware of both the challenges and how he manages to overcome them, in addition to preventing relapse by anticipating future challenges and what resources could then be mobilized. It is also helpful to allow clients to discuss feelings of loss involving termination and be aware and process our own feelings surrounding the process. TERMINATION IN PSYCHOTHERAPY This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. T: You have done tremendous work so far. How do you feel about what you have accomplished? P: It’s true. It is both fulfilling and strange. I did not think I could get to this place in my life. I mean, I wanted it, but hmm . . . I did not really picture that this is where I would get and how I would feel. And . . . I love it. T: Yeah. It’s amazing really. Looking back, do you realize how you got here? P: T: P: Yeah . . . I guess I . . . well . . . when Monica left, I got really depressed and . . . there was this huge void, it was so scary . . . And then . . . well, huuu . . . I guess the turning point was when I realized she was not coming back to me no matter how depressed I was, and then realizing that wanting her to come back to me out of pity was a strange thing too, I did not want to be that guy . . . and I guess I deserve better than that . . .. T: but also at my work, and with some friends . . . my mom definitely. That’s nice. How do you do it? How do you change your immediate response? P: Hmmm . . . I kind of monitor myself regularly. I am getting pretty good on noticing when I am reacting inappropriately, and I think . . . I instruct myself to stop it or to come out of it . . . breathe . . . and I imagine in my mind a healthier response and try to put it to action . . . if it’s possible. T: I am so glad on how you manage it . . . And I love that . . . you seem pretty aware of your vulnerabilities and instead of criticizing yourself harsh, you seem to actually nourish yourself, have some compassion. And take responsibility yes, and act, but from a much more compassionate point of departure, and that’s so beautiful to see. P: Thank you. I think that’s actually an extra gain, I am more capable of receiving compliments, I guess because I am more aware of my own qualities, do not feel so inferior, so it seems coherent and it’s easier. Yeah . . . it was important to realize how you were treating yourself, and how you were restricting yourself to a lousy deal. How is this nowadays? Well . . . I guess I still have moments where I seem to want people to pity me and come towards me. It’s like my immediate response . . . but I am more aware of it now, so at some point I manage to stand back and change the direction, or at least I have been trying to . . . And this in several areas of my life, with Sarah nowadays, 7 (. . .) T: We have been talking on taking our process to an end, and I would like to propose that you imagine yourself in the future . . . it does not have to be too far away, the near future is ok . . . and what do you feel are your developed strengths, which will make a difference on how you deal with life’s challenges . . . and 8 DA SILVA ET AL. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. P: what do you feel will still be challenges potentially hard to overcome and that may need particular care? Hmm . . . I am a bit fearful on how I would deal with a breakup with Sarah, in case it happens. I hope it doesn’t, and I don’t think it will, but I didn’t think it would happen with Monica either, so I think that’s a lesson learned . . . I want to believe I wouldn’t get so depressed, I think one of my strengths is that I am much more confident of myself, and I value myself . . . so I think that would prevent me to get too low . . . but it’s definitely something to be attentive and careful, I’m not 100% sure . . . And . . . romantic relationships will always be my main challenge, I think, cause my relationship with my mother, for example, I truly think it will be hard to come back to a pattern of submission and resentful compliance . . . I’m very pleased with my acquired assertiveness, I’ve had challenges with her which I’ve overcome with your help, and it helped me learned how it’s always better to affirm myself and impose my limits, so . . . I think I don’t even give her space to intrude my space. T: Yeah . . . Is there anything related to the therapeutic process, to our relationship, that you would like to address, approaching the end, that you would like us to take care? P: Well . . . I know you will always be there, and be a resource in case I need, which makes it easier. But mostly we have been working together for quite some time, and I know that, at least for a while, I will have your voice in my mind and I will imagine myself talking to you, and I am sure that will be tremendously helpful . . . And I do feel you do care, do not you? T: I definitely do, and I am so glad you can see it and take it with you. P: Yeah. That gives me strength. Ideally, the therapeutic process would proceed along the seven phases, but that is not always the case. Some clients end therapy prior to the achievement of important goals, and choose to terminate earlier because they are not satisfied with it, or on the other hand, are quite satisfied and feel that they had “recovered enough” (e.g., Roseborough et al., 2015); others do not contemplate the benefits of working the final phases, or do not have time or have financial restrains (e.g., Knox et al., 2011). We think it is important to be aware of these aspects and to discuss them with the clients as well as to address the risks or implications of terminating the therapeutic process prematurely, and to keep the door open to resume the therapeutic process in the future if needed. The risks may be different depending on which phase the process is terminated, the characteristics of the client (e.g., severe psychological conditions) as well as the reasons that lead to an earlier termination, as we will now discuss. In our view, a client who decides to end therapy during the first three phases of the process is probably better considered a dropout, or a premature termination, since according to our phase model, this client has neither an understanding of his contribution to his suffering and of possible solutions, nor effective changes in his life are present. Nevertheless, the dropout experience is subjective because it depends on the therapist's and client's view of the concept (Barrett et al., 2008). Frequently, dropout is defined as a unilateral termination of therapy by the client, without it being communicated to the therapist or even approved by him/her (e.g., Hatchett & Park, 2003; Knox et al., 2011). Therefore, a chance to discuss the end of the therapeutic process may not occur (Knox et al., 2011). This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. TERMINATION IN PSYCHOTHERAPY When it is possible, and the client is available to address a premature termination, we consider important to explore the reasons that lead to that decision. Considering that early termination usually implies that the client leaves therapy without achieving any goal improvement or completion requirements (Hatchett & Park, 2003); and feelings such as not being understood, not validated, and not supported by the therapist may also exist, it is important to validate these feelings for the client to keep hope in a future psychotherapeutic process. However, clients who have reported these negative feelings end up describing their therapists as unfriendly, passive, and indifferent, which causes them to feel shame and embarrassment during therapy (Roos & Werbart, 2013); which may make it difficult to discuss termination. Usually, unilateral termination is a consequence of a poor therapeutic alliance (Bordin, 1974; Tryon & Kane, 1993). We believe that phase 1 general strategies and strategic goals, the “when” of therapy, integrated with the “being” in therapy, regarding the therapeutic alliance, may guide us through this path. Being aware that not all clients come to therapy with the same amount of trust or hope regarding therapy and that this is something that as to be built, is important to be acknowledged. This allows not to rush to promote strategic objectives of more advanced phases. One other key aspect is the client feedback regarding how he is feeling about the process. Also, it is established that dealing with different types of difficulties related to the therapeutic alliance is essential to the progression of therapy (for a review see Doran, 2016). Decades of research on the relationship between psychotherapists and clients show that the quality of alliance, especially as perceived by the client, correlates positively with the outcome. It has also been demonstrated that the working alliance is an essential ingredient in promoting therapeutic change (e.g., Lambert & Simon, 2008). However, a strong alliance is not on its own enough to make therapy effective, instead a strong alliance can be the result of effective interventions: working hard in therapy together eventually brings about a good alliance; and both parts may have to work on rupture and repair (RaBu et al., 2011; Safran et al., 2011). From our clinical experience, when the client is not fully satisfied with therapy, it is possible to discuss these aspects as something that may represent an important part of the process. One of the authors had the experience of a client wanting to end therapy at phase 2. When discussing his reasons for 9 leaving, and the therapist referring the risks but also validating his perspective, he shared satisfaction since he had previously felt accused and ashamed by his previous two therapists when wanting to stop therapy. Professional experience, psychotherapist’s training, the ability to be flexible and adapt to the client's specific problem, establish a therapeutic alliance, and provide emotional support, have been identified as potential influencers of dropout, being associated with better therapeutic results and the lowest occurrence of dropouts (Blatt et al., 1996; Gülüm et al., 2016; Roos & Werbart, 2013). Most studies on termination, particularly on early termination, focus on the client's perspective, exploring both the predictors and the reasons pointed out by them for having decided to abandon psychotherapy. Being the psychotherapist's perspective and its factors less attended (Roos & Werbart, 2013). The way the psychotherapist reacts to termination has implications for his professional development and work with future clients (Piselli et al., 2011). Psychotherapists may feel hurt, rejected, abandoned or “betrayed” by their clients and disappointed with the notion of failure, reporting feelings such as frustration, sadness, guilt, anxiety and surprise. The experience of dropout may influence his view as a professional, with the possibility of the activated emotions interfering with his ability to work effectively (Piselli et al., 2011). This stresses the need for training on alliance related skills, that goes beyond the scoop of our article, as well as an had oc reflection and integration of the dropout experience. The PCM can work as a map that guide this reflective process and assist therapists understand what went wrong. Other aspects include macro versus micro changes. Some clients may be so focused on major significant changes that are not able to observe and detect the micro changes they had accomplished throughout those first phases. It is important to explore what the client still needs and underline the risks of an early termination—as for example, not having increased his awareness of interpersonal relationships and relational conflicts (phase 2 goal) – as well as help him focus on what he had achieved so far. We would suggest that most successful shortterm processes terminate when the client has already acquired phase 4 gains (regulation of responsibility), which allows him/her to proceed to his or her personal growth outside the therapeutic process, especially when we are talking about clients This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 10 DA SILVA ET AL. who are well structured and functional. When ending a process at this phase, it is important to make sure that the client understands the probable difficulties he or she will encounter when trying to implement changes in his or her life and way of functioning. Challenges can both be internal and external, as both his or her earlier maladaptive schemes and those of significant others, used to a different operating mode, will probably try harder (even if unintentionally) to keep him/her in the earlier familiar mode of functioning. Some psychoeducation on what to expect, namely some vulnerability and conflict, and reflecting on what resources he or she may mobilize are important interventions that may constitute mini phases 6 and 7 promotion (consolidation of change, relapse prevention, and projection of self in the future) in service of enabling phase 5 (implementation of repairing actions) implementation on his own. Here is a brief example of working with a client who wants to terminate therapy while being in phase 4 (regulation of responsibility). P: So, I have been feeling pretty good, I think therapy really helped, and I was considering terminating the process. I am not sure how to do it. T: Ok. Can you share your internal process of starting to feel it’s time to end? P: Well, it’s just really like . . . I think I gained a lot of awareness, I understand much better how I get stuck in my life . . . and how it’s hard to really invest in something meaningful . . . and I think now I just really need the time to put my projects going, put myself to it. I know now that it’s up to me, no one can do it for me. T: Right. I understand that . . . And I agree that you learned a lot about yourself and truly had the courage to understand your own contribution to your problems, in addition to the contribution of significant others in your life, especially your father, and those are very important gains that will definitely help you get more certain of your passion and commit to a project that makes sense to you . . . At the same time, the times that come tend to be challenging, we get excited about changing our life and when we put ourselves to it, we usually find out it’s hard, so it is helpful to try these changes accompanied, having the space to process the challenges, the difficulties, and reevaluate the direction sometimes. So, I wonder if you had this in mind, and if you reflected why you want to do this path alone. P: Yeah. I did question myself whether I was keeping old patterns and making the change harder by doing it . . . and it’s a possibility, but I feel the urge to go a bit on my own and give me a chance to do things differently on my own. Is that ok with you? T: You are the expert on yourself, and you have every right to live your life the way it makes more sense to you. I respect that, so in that sense, it’s ok with me, of course, that you choose to do what suits you best. I would just like to reinforce that . . . you will certainly feel vulnerable and in conflict along the way, that’s part of it, it’s normal. And as you will try to do this on your own, I would maybe just like to go through some challenges you may find and which resources you could mobilize to deal with them. Is it ok? P: Sure, I appreciate it, that seems important. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. TERMINATION IN PSYCHOTHERAPY T: Ok. So, what do you anticipate will be your main challenge in persecuting a project that is worth living, and keep yourself invested in it? P: Right . . . Let me see . . . Finding one project to invest will be my first challenge, there are too many of them, and that’s what always kept me from moving forward . . . And then if I start thinking of all the others, which is a tendency too, I may get shaky, question everything and start to disinvest. T: Yeah, that would be the old pattern, would not it? What resources, internal or external, do you feel you can mobilize to deal with these challenges? P: Well, this capacity to see it happening is already a resource; I did not understand the phenomenon before. Other than that . . . I know I always have you and hope I can resume therapy if needed. T: Of course, that’s always a possibility. P: Good, so that’s one . . . One thing I thought of doing, I already started writing them, is have some prompt cards at home, at my desk, keeping me focused, like “FOCUS”, “Don’t diverge”, “Keep yourself invested”. We performed a similar exercise here a while ago and it strangely helped, so . . . T: Nice. It’s a good tool. P: Yeah . . . There’s also my friend John, who usually gives good advice, and he is a T: 11 bit like you, focused and to the point, so I will keep him around and updated, he will help me regulate myself, I think . . . And I guess I will also try to find what works along the way, remember to stop and think how am I doing, where am I going, etc. Good. It seems important. Keep in mind your challenges and resources to deal with them. When terminating therapy with a client in phase 5 (Implementation of repairing actions), he has the advantage of being accompanied during the implementation of at least some changes in his life, has probably a better understanding of the challenges of implementing them, and he is probably more aware at the same time, of what it takes to make these changes happen. It is still important to help him understand the importance of consolidating his gains even outside therapy. This consolidation will not go without some periods of vulnerability and conflict, and ideally help him reflect on possible challenging scenarios and what resources can he mobilize in order to deal with them. Therefore, it is a work of psychoeducation on phase 6 objectives, pinpointing the necessity and importance of consolidating the changes he already started in his life, and a brief promotion of phase 7, trying to help him have a glance of the challenges ahead and the resources already available or necessary to develop to deal with them. Discussion Using an integrative metamodel—Paradigmatic Complementarity, which postulates the therapeutic process as unfolding throughout a temporal sequence of phases structuring strategic objectives —we can think termination as a process that can occur at different phases of the therapeutic process. Ending therapy in each of these phases has different implications in terms of the achieved processing capacities and the remaining processing vulnerabilities of the client. When terminating, it is important to consider the entire therapeutic process, the developed gains, and potential remaining vulnerabilities, and address them explicitly with the client in order to develop a process-based approach to the therapeutic work, and to potentiate his or her capacity to This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 12 DA SILVA ET AL. deal with life challenges when out of therapy. Also, potential feelings of loss surrounding the termination process, should be addressed. Termination should be seen as a multidimensional construct, where responsiveness and building a bridge between therapy and the world outside are central aspects. From an integrative perspective, the characteristics of the client and what the treatment and therapist offered are relevant to discuss termination. To have a map that guide that reflection is important. PCM offers seven points for reflecting on termination and several aspects should be considered when terminating at each of this points, namely, a) assessing what/ how/why phase-specific changes or processing capacities have been transdiagnostically mastered, that is, irrespective of the themes worked upon; b) exploring, processing, and affirming experience associated with progress according to the temporal process formulation map; and c) acknowledging what issues remain to be worked on, in terms of processing capacities according to such a map. Even if we are not able to discuss termination with a client, we could use the goals of each phase of the PCM to reflect upon the process and try to understand what went wrong in order to learn from that experience and, whenever possible, better deal with it in a knew case. The goal of our article was to reflect upon the termination process as a part of therapy and something that should be anticipated and, as something that may happen at any point of therapy. To have a map that guide this process may makes us feel more competent and aware of an ending or breaking point. The notion that psychotherapy proceeds in stages is a common heuristic tool that transcends theoretical orientation, and therapists, especially those interested in learning integration, can benefit from sequential maps to facilitate psychological growth. Ours is just one of these potential sequential maps. therapy. Also, we only briefly explored the dropout experience as a way of terminating. This is a vast literature, that justifies further and deeper exploration. As mentioned previously, we are reflecting and intervening from a position of responsiveness to the client, with a relevant focus on the therapeutic alliance. Other models may have a different approach to the client. If we take into consideration most RCTs, or specific programs, intervention may present a specific time length that may challenge what we are proposing. We are focused on goals and strategies rather than a specific timetable. Nevertheless, we presented several termination-oriented principles that are important when negotiating termination. Also, since this is a metamodel it could be used to guide reflections such as: at what phase is my client?; what will he be able to do at this point?; what does he still need to do to achieve his goals? What have been challenging these achievements? Finally, considering the theoretical nature of this reflection, it would be of value to research the impact of terminating therapy in different phases of the therapeutic process, highlighting relevant change mechanisms that were worked upon, conceptualized from a transtheoretical perspective, remaining work in progress, or work to be done before terminating. When we start intervention, we know it may at some point end, even if we do not know when or why. Our propose tries to address termination from a flexible point of view, and to equip our clients as much as possible, so that they leave therapy aware of their capacities and vulnerabilities and have improved chances of making a difference in their lives, and appreciate their sense of being in process, experiencing life from an angle of self in process. Additionally, specific training on termination may help therapist better deal with this process, whether it is an early termination or an ideal termination. Ending is always a different way of starting. Limitations This propose presents several limitations. It may not always be possible to discuss termination with clients since they may leave without discussing it. Unilateral termination is usually a consequence of a poor therapeutic alliance, which gives us clues to the training needed to better deal with that situations. The relationship is not always something that we built at the beginning, and endure, being the event of ruptures and repairs something that happens through References Barnett, J. E. (2016, October 6). Strategies for ethical termination: And for avoiding abandonment. Society for the Advancement of Psychotherapy. http:// www.societyforpsychotherapy.org/6-strategies-forethical-termination-of-psychotherapy Barrett, M. S., Chua, W. J., Crits-Christoph, P., Gibbons, M. B., & Thompson, D. (2008). Early withdrawal from mental health treatment: Implications for psychotherapy practice. 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Psychotherapy Research, 20(4), 423–435. https://doi .org/10.1080/10503301003645796 Received May 23, 2020 Revision received February 3, 2021 Accepted February 9, 2021 n