What are the important ingredients of a CAT goodbye letter?

Turpin, C., Adu-White, D., Barnes, P., Chalmers-Woods, R., Delisser, C., Dudley, J. and Mesbahi, M., 2011. What are the important ingredients of a CAT goodbye letter?. Reformulation, Winter, pp.30-31.


Abstract

A small scale research project was conducted by IRRAPT (Inter Regional Residential ACAT Psychotherapy Training) trainees to find out what the cohort of 20 IRRAPT trainees considered the important ingredients of a Goodbye Letter to be. IRRAPT trainees have all written at least eight Goodbye Letters, and have all received one themselves. Questionnaires were designed and circulated amongst the trainees and the results tabled in the order of frequency of listing. The research group used the results to establish a helpful list of prompts for writing a goodbye letter, which were summarised by the mnemonic FAREWELL. 

Introduction

The initial aim of the group was to establish which tools in CAT were considered most helpful. There was some interest in how the tools might have been mediated. This quickly developed into a larger project than the group was able to manage so we narrowed this down. We agreed that there is little attention paid to Goodbye Letters in the CAT literature and research, so we decided to pursue this area.

Termination is an essential part of therapy and suitably referenced in CAT literature, and this should be embodied in the Goodbye Letter. It is understood that the procedure of writing, giving, receiving and reading Goodbye Letters keeps the therapy, therapist and tools active in the patient’s mind (internalised) through the follow up period and beyond, Ryle (1990).

There are often examples of Goodbye Letters in publications, but less attention seems paid to providing guidelines on what is required in a Goodbye Letter. The suggestions that are provided in the Ryle (1990) and Ryle & Kerr (2002) books include: offer an accurate, plain and unvarnished summary; a rehearsal of the original problems and procedures and consider how far these have been resolved, identifying further work when necessary; what the patient has managed to go through and achieve, stating how the patient has been able to be open and accept help and how what has been valued can be retained; potential disappointment, sadness and anger with ending; positive achievements and reminder of developed conceptual tools; attending to uncertainties or unresolved feelings.

We decided that it would be worthwhile to develop some further guidance for writing Goodbye Letters for trainees and therapists, and established the research question of ‘What do you consider are the important ingredients of a CAT Goodbye Letter?’

Methodology

The seven researchers devised a questionnaire (Appendix 1) to be given to the current IRRAPT cohort (including the research group members themselves) asking ‘What do you consider are the important ingredients of a Goodbye Letter?’ It was felt important that the questionnaire be designed to encourage thoughtfulness and offer the opportunity to record up to ten ‘ingredients’.

A total of twenty questionnaires were sent to the trainees via email by someone external to the research group, securing anonymity.

The completed questionnaires were given an ID number and disseminated amongst the research group for initial processing.  The research group agreed on generalised statements that the various ‘ingredients’ could be assigned to, forming a list of the most commonly chosen items by our sample group.  If we agreed that a particular item wasn’t represented by the generalised statements it was recorded as a single occurrence item.

Results

Response rate: Out of the 20 questionnaires sent, 18 were returned (90%).

The number of listed ingredients per questionnaire varied from 4 to 10. (83% listed 8 or more). For a comprehensive listing of the suggestions from the questionnaires and the number of times each were mentioned see Appendix 2. The top ten ‘important ingredients’ are represented in a graph by percentage in Appendix 3.

The research group felt that some of the comments, notably ‘aims at enhancing the therapeutic alliance...’ and ‘include hooks...’ were more applicable to the Reformulation Letter. However, there are some shared aspects to both letters, e.g. the therapeutic alliance, personal use of self, and using shared language.

We established from the completed questionnaires a guidance list of ‘ingredients’ of a Goodbye Letter. They are not in order of submission, but what felt like a logical flow of writing a Goodbye Letter from beginning to end, and by no means prescriptive:

  • Give a summary of reasons for coming to therapy and established goals
  • Write what needs to be said and be concise; not a repeat of Reformulation
  • Warm, engaging and empathic
  • Written in the therapist’s voice, personal use of self
  • Use of ‘I’ and ‘We’
  • Use language that was shared: patient’s words and metaphors
  • Written with the patient’s Zone of Proximal Development in mind
  • Refer to therapeutic relationship/alliance and how this developed, including threats and ruptures
  • Acknowledge ending and possibly feelings associated with this
  • Review progress, what’s changed, what’s developed and been achieved
  • Name established exits and useful tools to draw upon
  • Reminder of tools that have been used effectively, keeping them in mind
  • Acknowledge ‘work in progress’, what happens next and challenges ahead, the pull of old patterns or possible stuckness
  • What’s not been achieved in therapy and possible disappointments
  • Express realistic hope and encouragement
  • Mention follow up
  • Thank patient for effort, commitment and openness

The research group wondered if creating a mnemonic might help keep some of the salient points in mind and propose FAREWELL.
F – Feelings on endings
A – Achievements
R – Relationship
E – Expression of hope
W – Warm and engaging
E – Exits
L – Language used
L – Life/learning after therapy

Conclusion

We felt that the list above and FAREWELL could be used to aid learning, such as on the Practitioner courses, and serve as guidance for therapists.

There is an opportunity for interested parties to take some of this work forward to other training groups such as the different Practitioner courses, and encourage ‘voices’ of other groups.

A dissertation on endings has recently been completed – we await its publication with interest.

If there are any enquiries about this small piece of work please contact a member of the research team via ACAT.

Note: Appendices 1, 2 and 3 are available from the authors, via ACAT.

References

Hamill, M, Ried, M and Reynolds, S (2008) Letter’s in Cognitive Analytic Therapy: The patient’s experience. Psychotherapy Research, 1468-4381, Volume 18, Issue 5, p.573 – 583.
Howlett, S and Guthrie, E (2001) The Use of Farewell Letters in the Context of Brief Psychodynamic Interpersonal Therapy with IBS Patients. British Journal of Psychotherapy; 18:52-67.
Ryle, A (1990) Cognitive Analytic Therapy: Active Participation in Change. Chichester: Wiley.
Ryle, A and Kerr, I (2002) Introducing Cognitive Analytic Therapy. Chichester: Wiley.

Full Reference

Turpin, C., Adu-White, D., Barnes, P., Chalmers-Woods, R., Delisser, C., Dudley, J. and Mesbahi, M., 2011. What are the important ingredients of a CAT goodbye letter?. Reformulation, Winter, pp.30-31.

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