A review of events and changes during therapy and identification of warning signs

During the ending stage, reviewing the course of treatment (using, for example, the metaphor of the photo album as described by Wittenberg, 1999):

enables reflection on the experience [of therapy] and offers a third position. When the work is ongoing the experience is from inside.

But when the work is ended the experience is from the outside. [Ryz & Wilson, 1999, p. 399]

A kind of speeded-up reworking of all the major themes of therapy often occurs in the last stage, although how much of this will be a conscious verbal exchange will vary greatly. This may give rise to a flare-up of the original problems. The therapist will need to assess whether this is a communication about the difficulty of ending, or whether it needs to be addressed by realistic measures. Consultation with the parent worker and other colleagues will be important in coming to a conclusion about this. While the therapist's role will involve the interpretation of the young person's experience of ending, specifically in terms of the kind of person the therapist is felt to be in that context, the parent worker may, for example, need to alert the network that the young person may require extra vigilance and attention for a time.

Eliciting feelings about ending treatment and working through reactions to ending

The termination of an analysis stirs up painful feelings and revives early anxieties in the patient.

Quagliata, 1999, p. 411

In this stage, the fact of the approaching ending becomes the central focus, though not, of course, to the exclusion of important issues in the young person's life. In addition to the aims previously discussed, the therapist will strive to help the young person to be fully aware both of the changes that have been achieved during the course of the therapy and of his or her frustration and feelings of disappointment at what it has not been possible to achieve. This may take the form of reproaches against the therapist for not extending the treatment, for leaving the young person with unresolved problems, for being uncaring, and so on. The therapist can often feel extremely guilty, which is complicated by the fact that the therapist's own wish may be to continue treatment and that he or she may feel unfairly blamed for something that is not his or her choice. Additional complications can come about if the parents express similar feelings towards the parent worker, leaving both workers with the fear of having been useless.

It is important to address such feelings as fully as possible and for the therapist not to confine herself to pointing out the progress that has been made in the attempt to part on a good note or to defend herself from the pain of these accusations. The therapist should beware of avoiding hostility in this way. Some young people will also avoid expressing negative feelings or hostility for fear that expressing any disappointment or resentment will leave them with a sense of the good aspects of the therapy being irreparably spoilt. In this case, it is essential for the therapist not to give in to the temptation to go along with this. It can be particularly hard not to do so in cases that have gone well and where the therapist feels that precious gains may be lost. As mentioned previously, however, having a good outcome at follow-up may be associated with the therapist confronting hostility during the ending stage of the treatment (Long & Trowell, 2001). On the other hand, the therapist's conviction of good progress made by the young person may represent a projection into the therapist either of more hopeful feelings of the young person's or of a stronger part of him/herself (or "ego strength"); careful attention to this process can enable the young person to own his or her hopefulness and recognize new-found strength or resilience.

One useful way of approaching this can be to explore the possibility that young people's complaints may be justified. In view of their difficulties and the many issues they could profitably address, it is reasonable for them to feel that they should have had more help, and for them to harbour feelings of disappointment, resentment, and even hatred. When these negative feelings are taken seriously, patients are generally able to recognize that they also feel lasting appreciation of the therapeutic opportunity; thus, loving and hating feelings may become better balanced.

Confronting the negative feelings strengthens the young person's sense of inner security, which is based on hope that his or her good feelings outweigh his or her aggression, and that both can be recognized and accepted. As Wittenberg (1999) puts it:

the [therapist] is seen to survive attacks and continues to care, and is seen to be attentive and loving in spite of the patient's disappointments, accusations of abandonment, betrayal and disloyalty; the analyst goes on being concerned and understanding even if the patient temporarily turns away in anger; is able to bear and share the grief at losing what is valued. [p. 355]

This very difficult work is therefore essential to the patient's later capacity to draw on the internalized experience of the therapy:

The work of learning to let go of having an analysis can . . . be of great value as a preparation for later experiences of loss and relinquishment. [Wittenberg, 1999, p. 355]

Some young people put the therapist in the position of being the one who is left behind - the one who would like to continue working with a patient who, on the contrary, is looking forward to a new life in which the therapist has no part to play. This can be acted out by non-attendance of the final sessions. This may sometimes be understood as age-appropriate in part, but it can also contain an element of role-reversal and revenge for the pain of dependence. Whichever form it takes, the work of the last stage places considerable emotional burdens on the therapist and parent worker, and support from team meetings and from supervision is essential.

In one sense, the ending stage may be considered to start whenever thoughts of ending are raised and discussed as a realistic possibility by the therapist or the young person. Some patients are so anxious about having to stop before they are ready that they cannot get started at all until their fears about premature loss of the therapist have been analysed.

Issues of separation and loss are likely to have been central for young people with moderate to severe depression, given the links between depression, mourning, separation, and loss. The ending stage provides the opportunity to work on this in the here-and-now, as this is a planned ending. Reflecting on the process of the treatment will be helpful, as will reviewing what has been worked on and achieved. The stage of ending is likely to encourage thoughts about the future, of what may come next, and also encourage the patient to think about what kind of person he or she might develop into.

As mentioned above, towards the end of STPP, the therapist may expect some reappearance of themes that have been worked on earlier in therapy, allowing a final working through and consolidation of internal changes. Certain feelings and behaviour are therefore common. These may include some of the following:

» return of symptoms, especially depressive symptoms, and pleas of helplessness (Wittenberg, 1999) - one needs to assess whether this is an attempt to hold on to dependency, a reworking of earlier stages of treatment as part of integration/working through, or a real setback;

» denial of dependency and dismissal of the need for the therapist; » reactivation of "that part of their personality, which tries, through a phantasy of omnipotent possession, expressed through pathological projective identification, to obscure the reality of separateness and loss" (Quagliata, 1999, p. 412);

» enactments of rage about dependencies or unconscious enactments of feelings of rejection, including "acting out" and risk-taking behaviour;

» fear of the work done being lost;

» jealousy or envy of the fantasized new baby/patient (Wittenberg, 1999, p. 352);

» re-working of the young person's fundamental object-relationships in the context of facing loss.

Anna: the ending stages

The ending stages of Anna's therapy coincided with her public exams. Outwardly, Anna seemed quite unconcerned by the pressure of her exams. The structure of her studies was based around incremental assessment of course work, with which she had progressed steadily, much as she had engaged with her psychotherapy. Her course work results to date indicated that she would exceed the grades she needed to go to college. There was also another break in treatment for two weeks, over the Easter period. Soon after this, Anna had her sixteenth birthday. Anna talked about how neglectful her stepfather had been in marking her birthday. She was open about how hurt she felt. In another session, she described a state of acute anxiety at school, which she labelled as a “panic attack”. She was able to get help from her teachers, yet described this experience as evidence of everything going back to the beginning. This felt like a powerful accusation of failure and of protest in the transference, which left Anna's therapist concerned that the ending was premature and somehow precipitous (despite having acknowledged the time limit sensitively throughout), rendering it inadequate and ineffective. (This also understandably generated anxiety in Anna's mother; see “Anna's parents: the ending stages of parent work” in chapter 5.)

Anna explained that she had to sleep with her mother because she felt so frightened of everything going wrong. Over the course of treatment, she had described how she often retreated to her mother's bed at night, which would result in her stepfather having to sleep in Anna's bed or on the sofa. A sense of looming disaster was tangible, and when this was named, Anna responded by saying that she had images in her mind of her mother dying and this made her question who she would then have to turn to. Anna's therapist talked about the sense of endings being sudden, painful, and shocking, like the experience of her aunt and the family friend dying. She also suggested that Anna might feel very angry about this, that too much was being expected of her too soon. The therapist expected Anna to block these interpretations by communicating something about how she could manage. Anna was thoughtful, however, and there was an emotional quality to her acknowledgement of the pain and seriousness of her circumstances that did not feel persecutory. Anna could allow her therapist to be alongside her. Indeed, her reliable and emotionally engaged attendance during this final stage was remarkable, with a passionate and open communication of conflicted states of mind that could be borne and processed. The sadness felt poignant and shared.

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