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
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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,
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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,
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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
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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.
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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
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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.
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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).
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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
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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.
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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
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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. Psychotherapy: Theory, Research,
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
Practice, Training, 45(2), 247–267. https://doi.org/10
.1037/0033-3204.45.2.247
Beitman, B. D., Goldfried, M. R., & Norcross, J. C.
(1989). The movement toward integrating the psychotherapies: An overview. The American Journal
of Psychiatry, 146(2), 138–147. https://doi.org/10
.1176/ajp.146.2.138
Benjamin, L. S. (2003). Interpersonal reconstructive
therapy. Guilford Press.
Bhatia, A., & Gelso, C. J. (2017). The termination
phase: Therapists’ perspective on the therapeutic
relationship and outcome. Psychotherapy: Theory,
Research, & Practice, 54(1), 76–87. https://doi
.org/10.1037/pst0000100
Blatt, S. J., Sanislow, C. A., III Zuroff, D. C., &
Pilkonis, P. A. (1996). Characteristics of effective
therapists: Further analyses of data from the
National Institute of Mental Health Treatment of
Depression Collaborative Research Program.
Journal of Consulting and Clinical Psychology,
64(6), 1276–1284. https://doi.org/10.1037/0022006x.64.6.1276
Bordin, E. S. (1974). Research strategies in psychotherapy. Wiley.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, & Practice, 16(3),
252–260. https://doi.org/10.1037/h0085885
Castonguay, L. G., Eubanks, C. F., Goldfried, M. R.,
Muran, J. C., & Lutz, W. (2015). Research on psychotherapy integration: Building on the past, looking to the future. Psychotherapy Research, 25(3),
365–382. https://doi.org/10.1080/10503307.2015
.1014010
Conceição, N. M. (2005). Articulação entre promoção e assimilação de objectivos estratégicos: Marcadores para a sequencialização temporal do
processo psicoterapêutico [Articulation of promotion and assimilation of strategic objectives:
Markers for the temporal sequencing of the psychotherapeutic process], [Unpublished master’s
thesis]. Faculty of Psychology, University of Lisbon, Portugal.
Conceição, N. M. (2010). If you want to get ahead,
get a sequence of general strategies: Integrative
decision making in real-world psychotherapy
[Unpublished doctoral dissertation]. Faculty of
Psychology, University of Lisbon, Portugal.
Davis, D. D., & Younggren, J. N. (2009). Ethical
competence in psychotherapy termination. Professional Psychology, Research and Practice, 40(6),
572–578. https://doi.org/10.1037/a0017699
Doran, J. M. (2016). The working alliance: Where
have we been, where are we going? Psychotherapy
Research, 26(2), 146–163. https://doi.org/10.1080/
10503307.2014.954153
Ferreira, J. F., Basseches, M., & Vasco, A. B.
(2017). Guidelines for Reflective Practice in
13
Psychotherapy: A Reflection on the Benefits of
Combining Moment-by-Moment and Phase-byPhase Mapping in Clinical Decision Making. Journal of Psychotherapy Integration, 27(1), 35–46.
https://doi.org/10.1037/int0000047
Ferreira, J. F., Conceição, N., & Vasco, A. B. (2011).
Movimentação e diferenciação narrativa ao longo
do processo terapêutico: Um estudo de caso longitudinal à luz do modelo de complementaridade
paradigmática [Narrative movement and differetiation along the therapeutic process: A longitudinal
case study in light of the paradigmatic complementarity model. Psicologia, 25(1), 173–201.
Ferreira, J. F., Vasco, A. B., Basseches, M.,
Conceição, N., Vaz-Velho, C., & Goldman, R.
(2017). Tracking and understanding phase progression in Lisa’s case. Clinical Psychology &
Psychotherapy, 24(6), 1355–1369. https://doi
.org/10.1002/cpp.2111
Ferreira, J. F., Vasco, A. B., Basseches, M., Santos, A.,
& Ferreira, J. M. (2016). Exploring phase progression throughout the therapeutic process: The case of
Eva. Clinical Psychology & Psychotherapy, 23(5),
407–424. https://doi.org/10.1002/cpp.1970
Ferreira, J. F., Vasco, A. B., Basseches, M., Santos,
A., & Ferreira, J. M. (2017). Analysing phase progression in Susan’s case. Clinical Psychology &
Psychotherapy, 24(6), 1343–1354. https://doi.org/
10.1002/cpp.2110
Goldfried, M. (2014). On the assumptions underlying
therapy change principles. Journal of Psychotherapy Integration, 24(4), 275–279. https://doi.org/10
.1037/a0038281
Goldfried, M. R. (1980). Toward the delineation of
therapeutic change principles. American Psychologist, 35(11), 991–999. https://doi.org/10.1037/0003
-066X.35.11.991
Gonçalves, I., & Vasco, A. B. (2001). Estudo de caso
de uma perturbação “borderline da personalidade”
à luz do modelo de “complementaridade paradigmática” [Case study of a “borderline personality”
disorder in light of the “paradigmatic complementarity model”]. Psicologia (Conselho Federal de
Psicologia), 15(2), 227–266.
_ Soygüt, G., & Safran, J. D. (2016). A comGülüm, IV.,
parison of pre-dropout and temporary rupture sessions
in psychotherapy. Psychotherapy Research, 28(5),
1–23.
Hatchett, G. T., & Park, H. L. (2003). Comparison of
four operational definitions of premature termination. Psychotherapy: Theory, Research, & Practice, 40(3), 226–231. https://doi.org/10.1037/00333204.40.3.226
Knox, S., Adrians, N., Everson, E., Hess, S.,
Hill, C., & Crook-Lyon, R. (2011). Clients’
perspectives on therapy termination. Psychotherapy Research, 21(2), 154–167. https://doi
.org/10.1080/10503307.2010.534509
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.
14
DA SILVA ET AL.
Lambert, M. J., & Simon, W. (2008). The therapeutic
relationship: Central and essential in psychotherapy outcome. In S. F. Hick & T. Bien (Eds.),
Mindfulness and the therapeutic relationship (pp.
19–33). Guilford Press.
Mahoney, M. J. (1991). Human change processes.
Basic Books.
Mahoney, M. J. (2003). Constructive psychotherapy:
A practical guide. Guilford Press.
Marmarosh, C. L. (2017). Fostering engagement
during termination: Applying attachment theory
and research Psychotherapy: Theory, Research
& Practice, 54(1), 4–9. https://doi.org/10.1037/
pst0000087
Norcross, J. C. (1986). Eclectic psychotherapy: An
introduction and overview. In J. C. Norcross (Ed.),
Handbook of eclectic psychotherapy (pp. 3–24).
Brunner/Mazel.
Norcross, J. C., Krebs, P. M., & Prochaska, J. O.
(2011). Stages of change. In J. C. Norcross (Ed.),
Psychotherapy relationships that work: EvidenceBased responsivness (2nd ed., pp. 279–300).
Oxford University Press.
Norcross, J. C., Zimmerman, B. E., Greenberg, R. P.,
& Swift, J. K. (2017). Do all therapists do that
when saying goodbye? A study of commonalities
in termination behaviors. Psychotherapy: Theory,
Research, & Practice, 54(1), 66–75. https://doi
.org/10.1037/pst0000097
Orlinsky, D. E., Ronnestad, M. H., & Willutzki, U.
(2004). Fifty years of psychotherapy process-outcome research. Continuity and change. In M. J.
Lambert (Ed.), Bergin and Garfield’s Handbook
of psychotherapy and behavior change (5th ed.,
pp. 307–390). Wiley.
Piselli, A., Halgin, R. P., & MacEwan, G. H. (2011).
What went wrong? Therapists’ reflections on their
role in premature termination. Psychotherapy
Research, 21(4), 400–415. https://doi.org/10.1080/
10503307.2011.573819
Prochaska, J. O., & DiClemente, C. (1992). The
transtheoretical approach. In J. C. Norcross &
M. R. Goldfried (Eds.), Handbook of psychotherapy integration. Basic Books.
RaBu, M., Halvorsen, M. S., & Haavind, H. (2011).
Early relationship struggles: A case study of alliance formation and Reparation. Counselling &
Psychotherapy Research, 11(1), 23–33. https://doi
.org/10.1080/14733145.2011.546073
Rodrigues, P. (2012). Observação clínica e verificação
empírica: Um estudo de caso sobre a sequenciação
de processos de mudança do paciente [Clinical observation and empirical verification: A case study on
the sequencing of change processes in the patient]
[Unpublished master’s thesis]. Faculty of Psychology, University of Lisbon, Portugal.
Roos, J., & Werbart, A. (2013). Therapist and relationship factors influencing dropout from individual psychotherapy: A literature review. Psychotherapy
Research, 23(4), 394–418. https://doi.org/10.1080/
10503307.2013.775528
Roseborough, D. J., McLeod, J. T., & Wright, F. I.
(2015). Attrition in psychotherapy: A survival analysis. Research on Social Work Practice, 26(7), 1–13.
Safran, J. D., Muran, J. C., & Eubanks-Carter, C.
(2011). Repairing alliance ruptures. Psychotherapy: Theory, Research, & Practice, 48(1), 80–87.
https://doi.org/10.1037/a0022140
Shapiro, D. A. (1996). Models of change in psychotherapy. Current Opinion in Psychiatry, 9(3),
177–181.
Simões, A. (2012). Identificação de marcadores de
capacidade estrutural de processamento em processos psicoterapêuticos de médio/longo curso:
Uma análise qualitativa consensual [Identification
of markers of structural capacity in medium and
long term therapeutic processes: A consensual
qualitative analysis], [Unpublished master’s thesis]. Faculty of Psychology, University of Lisbon,
Portugal.
Tryon, G. S., & Kane, A. S. (1993). Relationship of
working alliance to mutual and unilateral termination. Journal of Counseling Psychology, 40(1),
33–36. https://doi.org/10.1037/0022-0167.40.1.33
Vasco, A. B. (2006). Entre nuvens e relógios:
Sequência temporal de objectivos estratégicos e
integração em psicoterapia [Between clouds and
watches: Temporal sequence of strategic objectives and integration in psychotherapy. Revista
Portuguesa de Psicologia, 39, 9–31.
Vasco, A. B., Conceição, N., Silva, A. N., Ferreira, J. F.,
& Vaz-Velho, C. (2018). O (Meta)Modelo de Complementaridade Paradigmática (MCP) [The Paradigmatic Complementarity (Meta)model]. In Isabel Leal
(Ed.), Psicoterapias (pp. 339–361). Pactor.
Vygotsky, L. S. (1978). Mind in Society: The Development of Higher Psychological Processes. Harvard University Press.
Westmacott, R., Hunsley, J., Best, M., RumsteinMcKean, O., & Schindler, D. (2010). Client and
therapist views of contextual factors related to termination from psychotherapy: A comparison
between unilateral and mutual terminators. 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
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