When Are Clients Ready to Terminate?

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Abstract

Termination of psychotherapy has received less attention in the research literature than other aspects of the treatment process. This paper presents a structured framework emphasizing observable markers to indicate when termination with a client is appropriate during cognitive behavioral treatment. The 7 criteria that indicate when a client is ready for termination are: (a) decrease in symptoms as assessed by sound measures; (b) decrease in symptoms that is stable and maintained for 8 weeks; (c) decrease in functional impairment; (d) evidence that the decrease in symptoms is not a spontaneous remission, such as lower symptoms associated with the use of new skills; (e) usage of the new skills, particularly at times or on themes of former vulnerability; (f) sense of pride regarding the new skills, in contrast to initial doubt regarding whether the techniques would work; and (g) carryover of decrease in symptoms to other areas. A case report and discussion regarding the clinical application of the framework is presented.

Section snippets

Brief Review of Termination Literature

Overall, the extant literature regarding termination has primarily focused on predictors of premature termination, therapist versus client reasons for termination, treatment duration, and indicators of termination. More specifically, research has demonstrated that a number of client variables may be related to premature termination. For instance, clients with low income, low education, and minority racial status are more likely to terminate treatment prematurely (Wierzbicki & Pekarik, 1993).

A Structured Framework: Seven Criteria for Termination

Hollon and Beck (2004) describe CBT based on the theory that “thinking plays a role in the etiology and maintenance of at least some disorders, [and] these interventions seek to reduce distress and enhance adaptive coping by changing maladaptive beliefs and providing new information-processing skills” (p. 447). Thus, the proposed termination conceptualization offers methods for assessing clients’ reduction in distress and coping. Further, we believe that the termination framework is consistent

Case Presentation of How and When to Use Termination Criteria

In order to demonstrate the application of the termination framework, a case presentation illustrating how and when to use the criteria is provided. Maria is a 53-year-old, divorced Hispanic/Latina female. She did not complete college and was unemployed at the time of referral. Approximately 10 years ago, Maria divorced her husband of 20 years because of his frequent infidelity. At intake, Maria complained of chronic feelings of depression, lethargy, difficulties sleeping, appetite

How to Use the Seven Termination Criteria in Clinical Practice

The seven termination criteria are intended to serve as a framework for clinicians to use in the decision process about a client’s readiness for termination. Ideally, a client would meet all seven criteria prior to the termination of therapy. In this case, the client’s status could be viewed as analogous to a bull’s-eye in the game of darts. That is, the goal has been met clearly, fully, and precisely, and the clinician could confidently make the call that the client is ready for termination.

Client Considerations When Enacting Termination

Given that a relationship between therapeutic alliance and treatment outcome has been demonstrated in the literature (cf. Horvath & Symonds, 1991), it is important that the clients’ experiences and “attachment” to the therapist are considered in the context of termination. In light of evidence suggesting that discordant client-therapist treatment goals may be related to premature termination (e.g., Hunsley et al., 1999), collaboration on goals and expectations of treatment between the client

Directions for Future Research

Clearly, further research is necessary to provide support for and clarify the model presented herein. An obvious place for such research to begin would be studies comparing termination following the seven proposed criteria to termination as usual. We expect that clients who terminate therapy after meeting the proposed criteria would fare better than clients who did not, particularly on such measures as relapse or symptom count 1 to 2 years posttermination. Additionally, clients who terminate

Conclusion

Overall, termination is one of the most important aspects of treatment, as it dictates when a client no longer needs services. The framework described in this paper builds upon current perspectives with regard to termination. More specifically, this conceptualization provides a coherent, structured approach, utilizing specific indicators of when clients are ready for termination during CBT. A case example and discussion regarding the use of the criteria demonstrate the clinical application of

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