Doctorate in Clinical Psychology Thesis Research Summary
How do clients experience ending in Cognitive Analytic Therapy? A
qualitative analysis of what it means to end a time-limited therapy.
Research team
Peter Lydon, Trainee Clinical Psychologist, Lancaster University Doctorate in Clinical
Psychology
Dr. Ian Smith, Academic Supervisor, Lancaster University Doctorate in Clinical Psychology
Dr. Claire Iveson, Field Supervisor, Merseycare NHS Trust
Making the research possible
The following study was only possible, and is gratefully indebted, to the nine people who
were willing to discuss and share their experience of ending therapy (the ‘participants’).
Similarly, a number of therapists and organisations offered significant help in publicising this
study to individuals who might take part, and their help too is also hugely appreciated.
Purpose of the research
Ending therapy has been highlighted as an important but potentially complex stage of the
therapeutic process for clients. The potential for feelings of loss, disappointment and
abandonment have been discussed alongside the possibility of ending representing a time
for pride and transformation. However, very little research has been conducted which
explores the client’s perspective of ending therapy and the meanings which ending held.
This research therefore sought to ask clients directly about how they experienced and made
sense of their therapy ending. This research recruited only individuals who had received
Cognitive Analytic Therapy (CAT), a form of time-limited therapy increasingly offered by the
NHS which incorporates both psychodynamic and CBT principles.
Carrying out the research
Invitations and adverts were posted to publicise the study to a large number of potential
participants. As a result, nine individuals (2 male, 7 female; ages 26-64) came forward to be
interviewed about their experience of the end of their therapy. All participants had received
between 12-26 generally weekly sessions of CAT for a variety of difficulties, e.g. depression
and eating problems. All had had a planned ending, as opposed to having left therapy early
or abruptly. The participants came from three cities in the United Kingdom, and had been
seen by seven different CAT trained therapists across the sample. Interview transcripts
were analysed using Interpretive Phenomenological Analysis (IPA), which allows the
research team to listen to participants’ voices and also make interpretations based on their
stories and accounts. Four themes were identified, as follows:
Findings
Theme 1: “It was like an achievement, and just really frightened at the same time”: Hope
and fear in a happy ending
Many participants about the significant fear and anxiety felt at the loss of therapy and the
therapist. Participants voiced their fear about how they would deal with difficulties and
problems, even life in general, without the support and care of their therapist. Most
participants also worried that therapy’s gains, often significant, would be lost on ending,
with meanings that therapy would come to represent a failed venture.
Alongside anxiety, participants also commonly described a wish to end therapy ‘on a high’,
where the focus in the closing stages of therapy was on the progress that had been made
and reasons for hope. This gave an impression that participants had sometimes possibly not
fully disclosed how anxious they had felt to the therapist, maybe to reassure their therapist
that therapy had been successful
Example quotes
 “There was a fear that I'm losing an ally here, somebody who's on my side, who's not
going to be there any more, and I'm going to have to fight my own corner, what if I
don't win? It was frightening.”
 “because it's too short, and sweet to be ingrained in to you… I was frightened coming
away from it, thinking, 'what now? ”
 “...it's very scary, very scary…. my therapist was trying to drill in to me, 'look realise
how big this has been…you've gone from this to this... that's a massive step in such a
short time'. I don't think I got it at the time.”
Theme 2: “The first time I felt I wasn't the centre of your world”: The sweet but sorrowful
parting from a valued connection
All participants talked proudly of having formed a special, affirming, trusting and rewarding
bond with their therapist. Consequently, ending often meant a time of feeling a lot of
gratitude to their therapist for their help towards achieving change and progress, as well as
on a more personal level for making them feel genuinely cared for and valued. A number of
the people who took part in the research valued being able to communicate these warm
feelings to the therapist in a goodbye letter. In return, many also experienced great
satisfaction on receiving encouragement and recognition from their therapist in the letter
they received. However, the value of the relationships seemed to be linked to more difficult
emotions often experienced alongside the pride and satisfaction. Ending could be
experienced as a difficult and confusing process of stepping out and disentangling from the
close therapeutic bond which had grown. Linked to this, participants here talked of feeling
sadness, loss and even grief at the end of therapy, sometimes with a disappointment that
there could not be an extended or on-going relationship or connection with the therapist.
In a number of accounts, participants also discussed feelings of rejection, abandonment,
confusion or anger associated with parting from the therapist. Here, individuals described a
sense of knowing that therapy was going to end, but still on an emotional level registering
these difficult feelings. Ending seemed sometimes to symbolise a shift in people seeing
themselves no more as a valued and cared about person in the therapist’s eyes, but rather
now a soon to be former and forgotten client. These could be upsetting thoughts for
participants, and sometimes seemed to threaten to undermine the positive feelings held
towards the therapy experience. Only one participant in this research discussed having
talked about these feelings with their therapist, with this having been a very important part
of that individual being able to make sense of those feeling. For others it seemed that these
thoughts and feelings had not been shared.
Example quotes
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“You talk to someone in such depth, and expose yourself in that way, and then that
person is gone…I felt sad, and that there was an empty space I suppose where he
was no longer filling”
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“ I said to (the therapist)… I wish we'd met in a different situation, we could have
been friends then, but I suppose it was difficult, because it's 'Ok well I'm never going
to see you again'...I was sad, it hurt a little bit, but at the same time what she did was
a great thing for me.”
“you do feel a little bit rejected, I did, like not part of it anymore…, and then you
think 'Do they even care?…they're just fleeting thoughts, because obviously you're
completely aware that it was therapy, you… blur the lines.”
Theme 3 : “Therapy isn't an ending…it's the tools to give you a new beginning”: A mixture
of changed relationships with problems after ending
Ending therapy was often experienced by participants as an exciting opportunity to start to
put in to practice new self-awareness and tools to tackle often long standing problems.
Personal change and recovery was often framed by participants as on-going goal rather than
something which could be achieved or finalised by the last therapy session. Towards
change, some participants seemed to consciously and actively think about and employ
lessons from therapy on a daily basis. These changed ways of thinking or acting often
seemed on the surface fairly simple, for example avoiding becoming too busy and tired but
also with profound impact.
For others, recalling and applying what was learned from CAT seemed to be done more
consciously at times of particular difficulty or crisis. Here some participants talked about
trying to reconnect with ‘what would my therapist say to me?’ to help them cope with the
stressful circumstance. However, a number of participants talked about how difficult they
had found it to put in to practice the changes which they had begun to make in therapy.
Without the weekly sessions and the therapist’s guidance and motivation, many individuals
found it hard to keep the therapy and its lessons in mind.
In some other accounts, participants’ on-going relationships with CAT on ending seemed to
reflect more distancing from, even dismissal of the therapy. Here, individuals talked of
quickly losing, hiding away, or forgetting about the materials and ideas which had been
taken from therapy. This research wondered if feelings of abandonment or rejection on
ending had at least in part contributed to individuals themselves then turning away from
therapy after ending.
Example quotes
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you are given, the ideas… to explain how you're feeling…but therapy isn't an ending,
the letter isn't an ending, it's the tools to give you a new beginning
“it's very easy to slip back after the therapy. It's very difficult to keep that focus… to
do that by yourself… to try to keep on track, to try to move forward...very very
difficult”
“if there was somewhere I could go to practice it with other people…and to remind
me of what I'd learned, I'd be quite confident to carry on, I think it'd give me
more...ability to cope with my life”
“I've never give her (the therapist) another thought, and I did find her useful, and I
did enjoy the therapy sessions that we had together. I really felt as if I was getting
something out of them... that therapy file needs to be dug out”
Theme 4: “You're on borrowed time…so it would mean I don't waste time”: Gaining
objective but feeling objectified in the time limited ending
The time limited nature of CAT raised multiple meanings and emotions for participants. For
most, the pre-defined number of sessions represented a source of focus, motivation and
objective, seeming to spur individuals on to work to make the most of the therapy
experience. It also seemed to help individuals to remember that time in therapy was finite,
appearing to help participants to avoid a commonly perceived risk of coming to rely too
heavily on the therapist.
However, most accounts simultaneously reflected a strong sense of frustration at the lack of
individual control and choice over timing of ending. A sense of therapy feeling rushed or
pressured due to the imposed schedule was common in accounts. Some participants felt
that their potential progress in therapy was cut short due to the imposed ending coming at
a point while gains were still developing. Here, a sense of clients feeling objectified and not
treated as individuals was apparent. This sense of pressure, as if being on a conveyor belt of
clients, was often seen as related to the National Health Service (NHS) context of services.
Example quotes
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“you're given a timeline… you know you're on borrowed time effectively, so … it
would mean I don't waste time, I don't want to lie, so it does inform how you
approach it.”
“If you carried on even longer, which I felt it needed to be, there is one big
danger…using it as a kind of prop...but without getting further forward.”
“you're going to be talking about your childhood…and how it relates to now, it just
isn't the time to get that out … it's just 'push, push, push, push, push' very very
rushed”
“I really don't think there should be an ending. I think the ending should come from
the person who needs the therapy, rather than the powers that be that put the
systems in place.”
Conclusions and Implications
This research has illuminated the potential gains, pitfalls, conflicting emotions and meanings
which can be experienced in ending therapy. Implications included that conversations
facilitated by therapists can be very helpful to help individuals to acknowledge and process
possible difficult emotions related to ending therapy. While a pre-determined ending was
described as introducing motivation and focus to engagement, participants’ responses
suggested that negotiation and flexibility around how the ending was managed (e.g. spaced
sessions towards ending) offered a greater sense of collaboration and individuation need.
Endings were often discussed with reference to the process of change. Many participants
considered achieving or maintaining personal change after ending therapy to be a difficult
process, sometimes with a feeling that true change only began after therapy ended. The loss
of the focus enjoyed during therapy was often discussed as making on-going change
difficult. Groups of former CAT clients coming together to mutually support and maintain
efforts towards change was suggested as one solution to make the process of change after
ending more successful.
Again, sincere thanks to all those who took part and helped in the recruitment
process. Any correspondence can be addressed to Peter Lydon, c/o Clinical
Psychology, Furness college, Lancaster University, Lancaster, LA1 4YG or
lancslydon@yahoo.co.uk