Academic journal article American Journal of Psychotherapy

Our Time Is Up: Forced Terminations during Psychotherapy Training

Academic journal article American Journal of Psychotherapy

Our Time Is Up: Forced Terminations during Psychotherapy Training

Article excerpt

Psychiatry residents often must terminate psychotherapy before patients complete their treatment goals, introducing a stressful event into the therapist-patient relationship. Determining what, how, and when to announce the impending termination, anticipating patient responses, managing resident reactions and countertransference, and planning the forced termination to the patient's benefit require careful consideration. The literature on forced terminations is reviewed, two cases illustrate common issues encountered, and nine guidelines are described.

As health care limitations on psychotherapy proliferate, psychotherapists are increasingly forced to terminate therapy before patients have achieved their treatment goals. Simultaneously, the future role of psychiatrists as psychotherapists is becoming more uncertain, as reimbursement patterns continue to favor pharmacologic treatments by psychiatrists. These external factors, as well as limitations imposed by shorter training rotations, relocation after completion of training, and changes in emphasis of psychiatry residency programs, have culminated in psychiatry residents now rarely completing therapy cases with planned terminations.l Instead, forced termination, that is, therapist-initiated termination of therapy because of extratherapeutic parameters, most frequently now occurs, introducing a potent, often stressful event into the immediate therapist-patient relationship.2

While forced termination has become increasingly common, this topic has not been addressed as it pertains to psychiatry residents; rather, issues in forced terminations have been described as they affect experienced psychotherapists. Unlike psychiatry residents, these psychotherapists have usually treated many cases, providing them with a more stable self-image as therapists and greater confidence and familiarity with options for successfully navigating their patients through this experience. As a result, psychiatry residents, while at greatest likelihood of completing their psychotherapy cases with forced terminations, have been the least provided with guidelines for handling this situation. Not surprisingly, only 16% of residents report satisfaction with their therapy terminations, and they report that less than 20% of their patients are ready for termination when it occurs.3

Simply, forced termination involves different and significant dynamics, requiring some deviations from traditional termination practices. This discussion reviews reactions of patients and residents to forced termination, addresses the pragmatic issues confronting the resident, provides clinical vignettes illustrating peculiarities of forced terminations, and lists guidelines to assist the departing resident. While forced-termination issues have been described primarily in long-term psychotherapies such as psychoanalysis, the principles derived are applicable to any psychotherapy where intense relationships develop.


Patient Reactions

To patients, forced termination suggests they will lose their therapists, rekindling the helplessness they experienced from arbitrary, unexpected, and "selfish" behavior of earlier parental figures.4 Patients' affective responses usually resemble earlier reactions to similar experiences; they may feel unworthy, believe the therapist does not really care, feel guilty for transference expressions, or complain "nothing ever works out." They commonly respond to the announcement with denial, displacement, acting out, vengeful self-defeating behavior, searches for substitute transference objects, deprecation of the therapy, increases in symptoms, efforts to immediately terminate without exploring their reactions, attempts to induce guilt in the therapist, or urges to "get everything out" to quickly finish treatment or to hold onto the therapists

Patients may also experience forced termination similar to the "stages" of denial, anger, bargaining, depression, and acceptance described by Kubler-Ross. …

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