Termination

The concluding phase of IPT, over the last several sessions, involves reviewing and consolidating gains, reflecting on how the central focus has been resolved, contingency planning, and emotionally processing the end of the therapeutic relationship. I tried to prepare her for the upcoming termination phase towards the end of Session 13:

therapist: We have three more sessions. Over the next few weeks, I’d like us together to reflect on this experience of therapy, on your sense of what’s changed and what you are taking away from this process. As well, if there are areas that remain a concern, we can discuss them along with feelings, frustrations, or disappointments in therapy or in other relationships. Sometimes feelings can emerge, such as sadness about this coming to an end, or worries about how you will be after this ends. It will be important and helpful for us to be able to discuss these feelings and to do some contingency planning in the event that the depression returns.

Barbara: Well, I feel a whole lot better, closer to my husband, and kind of pleased with how well our daughter is doing as a result of our hard work; and I’m not feeling depressed any more. Say, did I mention that I’ve joined a book club with some of my old friends? And I’ve started working part-time as a production assistant for my friend. It has way more flexibility than my old job. therapist: That’s terrific news! I’m pleased to hear how much better you are feeling and doing.

Barbara was aware that her weekly scores on the BDI-II had gone from 19 at the start of our treatment to 6, indicating remission: she no longer met DSM-IV criteria for major depressive disorder. I was looking forward to entering the termination phase, to reflect on how she had resolved her role transition. However, Barbara telephoned several days before our second-to-last session and left a message expressing appreciation and satisfaction for the care she had received. She stated that she didn’t feel the need to attend the final two sessions and had called to cancel. I had thought we had a good therapeutic alliance, and given that her symptoms of depression had remitted, I felt confident that the therapeutic focus had been relevant and helpful. I was also aware that endings can be evocative and can open up therapeutic opportunities. I was surprised that her tendency to avoidance had arisen again at this point. I telephoned her back and requested that she attend at least one final session so that we could wrap up, consolidate her gains, exchange feedback, and say goodbye to one another. I was also prepared to explore her wish not to meet for our final sessions. She agreed and returned for her next scheduled session.

I began, as always, by requesting she fill in the BDI-II, to which she stated that she’d rather not. In the session, I tried to make sense of her wish for early termination and her protest against doing the symptom self-report. Although my request to track symptoms could certainly be viewed as benign and therapeutic, I told her it was not necessary to complete the questionnaire and gently inquired about it. I wanted to explore her affective experience of ending therapy, including negative affects. She flushed with emotion at my asking.

therapist: Barbara, you seem flushed with emotion. Can you tell me what you’re in touch with right now?

Barbara: (tearfully) I’m not sure. I thought you were going to be mad at me and insist that I fill it out.

therapist: (passing the Kleenex). Ah, okay. Can you tell me more? I’d like to better understand what’s going on, as this is clearly touching a nerve for you.

Barbara: Well, I know this might sound foolish, but I kind of feel like a kid or something—like when my mom would only agree to let me hang out with my friends if I agreed to babysit my brother.

therapist: So, something about feeling anger and a reaction to care being contingent on you doing something in return?

barbara: Yeah. I never really thought about it, but I guess I felt obligated to fill out this form in order to get therapy, and I hate feeling like I have to. I never spoke up, but it feels good letting you know. (Appearing calmer) I really appreciate your not insisting on it for today’s session. It’s a huge relief actually. I know it sounds like a small thing, but it kind of feels big. And I guess I feel worried about ending, worried that I’ll feel worse once this stops. therapist: I’m glad you could tell me how you feel. I wonder if this is another example of your being able to communicate your emotions and expectations—in this case your wish that care not be contingent on your filling out a form. Like we’ve talked about, what has been true in the past (that care was contingent, with minimal reciprocity of giving and getting in relationships), is not necessarily so in the present and future.

Barbara and I went on to complete the last two sessions. In the ending sessions, we used a wide-angle lens to examine the course of acute treatment. Rather than examining the week-to-week interactions and life events in a close-up, detailed manner, we focused our attention more broadly. In exploring her feelings about concluding IPT, Barbara expressed some sadness about our treatment ending, saying she would miss our meetings. She worried that this indicated a return of depression. We carefully examined how this sadness differed from her depressed mood: it was neither pervasive, nor functionally impairing, nor accompanied by neurovegetative symptoms. Rather, I reflected that this was an expected emotional reaction of mild sadness to the end of our therapeutic process and separation in a relationship we had both come to value. We went on to review the numerous positive changes she had made, which included resolving her daughter Karen’s school situation, rekindling emotional and physical closeness with her husband, being more active socially, and being more assertive with her mother, as she had come to feel more competent.

In contingency planning, Barbara understood that if clinical depression returned, my door would be open for reassessment, booster sessions, maintenance treatment, or another course of IPT if indicated. She expressed some worry about whether she would worsen once therapy ended. Throughout treatment I had made efforts to point out that her improvements resulted from the changes she had made and the work she was doing in therapy. She had achieved the goals of treatment.

 
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