Words and Rituals: The significance of 'smaller' endings

Sher, M., 2014. Words and Rituals: The significance of 'smaller' endings. Reformulation, Winter, pp.33-36.


Introduction  

It has been a depleting session. A significant disclosure…a fair number of enactments. We ran over a bit…I skip past our usual session ending rituals and pleasantries and stand at the door signalling to my client that it is time to leave. I do not give any further thought to how the session ended. A few weeks later, I think how could I have missed this? My own experience of therapy and session endings brought all this to the forefront of my mind. A similar experience as the one with my client, only this time properly FELT, as I was in the client chair. So how is this relevant and how would CAT view this? One of the fundamental aspects of CAT is for the planned and healthy ending of therapy. But what about session endings?             

Endings in CAT  
 
There are significant benefits that come from CAT being structured and time-limited – those which make it unique in the psychotherapy arena. The structure and focus on ‘healthy’ endings provides clients with a situation in which they are comforted and focused by knowing what is expected. Planning for the ending involves setting dates for ending, considering the client’s response to ending, and planning for how things will be managed (Quintana et al, 1992). The process of writing, sharing and reading Goodbye Letters helps internalise and continue the work done once therapy has ended (Turpin et al, 2011; Ryle, 1990). The follow-up is seen as a ‘safety-net’ in some sense, and endings can, and generally are, accepted. In addition, much has been written on how the process of termination is experienced, which may reflect on a client’s perception of the therapy afterwards, as well as impact on gains made during treatment (Quintana et al, 1992).

For some, the structure of CAT may be experienced as “rigid” and ‘”frustrating”, and so endings may be approached with “dread”, “fear” and “anger” (Rayner et al, 2011). As a result, it is important to recognise that clients may react with intense emotions as the end nears (Quintana et al, 1992). In the same way, some disappointments or anger may emerge as a session ends, which if unacknowledged, may build up barriers in future sessions. This also highlights for CAT practitioners the importance of paying attention to why and when this is likely to be experienced by their clients, and respond to it. 

From my experience, problems with session endings are more likely to be evident following particularly emotive sessions or those where significant disclosures are made, followed by some anxiety or shame about what was being shared. This is because as therapy ends, prior experience of “betrayal and loss” may emerge (Fozooni, 2010). In CAT, the discussions on endings and the Goodbye Letter provide vehicles for exploring the end of therapy, but are not overtly considered as playing a role in the end of a single session.  

Approaches informing therapy endings

A handful of psychoanalytically informed approaches have paid some attention to the end of sessions. For instance, in the child play therapy literature, the process of packing away the toys at the end of a session is a symbolic way of containing what has been expressed in the session, and also prepares the child for the session end and ‘detachment’ from the therapist (Axline, 1969). In addition, showing the client they have been “kept in mind” between sessions can be demonstrated by remembering what was covered or discussed before (Salzberger, 1983). 

Gutheil and Simon’s (1995) paper exploring the transition zone “between the chair and the door” is unique in that it acknowledges the importance of the ‘process’ of a session ending and the client leaving. Whilst the paper largely explores this within the context of boundary violations, they recognise that at the end of a session there is a potential increase in the level of transference that may contribute to “behaviours” not evident within the session itself (Gutheil & Simon, 1995). In addition, the roles of attachment theory in understanding how clients may experience endings, as well as the trauma literature, are likely to be relevant (Bourque, 2008). This is because both the client’s and therapist’s attachment experiences in their lives will impact on how they “navigate” the “emotional and physical spatial process” of their therapy sessions (Bourque, 2008).

Gutheil and Simon (1995) also acknowledged how the end of each session is in many ways the “psychological precursor” to the end of therapy, and that any separation (or other concerns) would also be evident here, and not only at the end of treatment. Bourque (2008) makes reference to the intense “connection” that can develop in face-to-face therapy (Bourque, 2008), and that when the client stands and leaves the therapy room they are seen as taking the bond with them. Bourque (2008) also articulated how the client might not be as “attuned” as the therapist to the fact that the session was coming to an end, and thus cannot consciously prepare themselves. This would suggest the necessity to have some period of ‘de-acceleration’ and containment at the end of a session.  Bearing this in mind, there is a clear place for the consideration of ruptures and how they fit in with the words and rituals of endings.

Procedural enactments - the process of change

Endings are permanent features of life, such as leaving a job, ends of relationships, death of a close one (Salzberger, 1983). But what of the smaller endings – such as the end of a difficult day at work, a fight with a partner, shouting at your child just before sending them to bed? All these can leave a person feeling insecure as it deviates from what is familiar (Salzberger, 1983). If something ends in a way that is perceived as negative, it can leave clients not only with the sense that the therapist is now “absent”, but also “bad”. Like a toy or comforter for a child, the client may need some form of “substitute” to get them through until the attachment figure returns (Salzberger, 1983). This concept, of finding a means to ‘comfort’ in the ‘transition zone’ from session to session ending, can be drawn on when trying to address the ‘loss’ experienced by the ‘mini-ending’. The way that session endings ‘play out’ could be considered ‘mini-endings’ that may get ‘enacted’ in the actual ‘big’ ending. 

The significance of losses can generally be linked to earlier life experiences, and can go some way to help our understanding of the conflicting emotions evoked – especially those involving helplessness, confusion and fear (Salzberger, 1983). These can then turn into negative feelings toward the “responsible” individual and can serve to undo some of what had previously been gained (Salzberger, 1983). In Rayner et al’s (2011) study exploring the process of change in CAT, they found that clients often reported that the process of exploring difficulties and often painful life experiences was central to them understanding the patterns they wanted to change. If this is the case, a central feature of therapy will be dedicating significant amounts of time, often intense, in exploring these painful experiences, which will bring up a number of issues, potentially leaving open a ‘raw nerve’. 

It then seems that the process of exploring what was previously suppressed, ignored or denied, brings with it some secondary benefits to paying close attention to session endings. In the same way, Safran’s rupture and repair model (Safran et al, 2011), stipulates that the therapist highlights what has just happened in the session, facilitates a process of self-expression, then “validates” the “self-assertion”, thus providing the client with the healthy context in which to explore the rupture and “achieve a state of individuation in the context of relatedness” (Bennett et al, 2006). This may be particularly helpful to consider in the context of bringing the session to a close. Use of the SDR, as recommended in CAT, can support these explorations, and fulfils its role as the key tool. Thus it is important to consider what reciprocal role procedures for a particular client may be enacted, especially in relation to ending the session. The greater the release and exploration of difficult experiences, the more likely the client will experience the end of the session as difficult, and be vigilant to shifts in the therapists ‘usual’ behaviours.

Reflections on the reality of therapy - use of words and rituals

According to Young (2003), influenced by Winnicott (1956), “There are many elements of the analytic frame. It is a room – a physical setting. It is a set of conventions about how one behaves. It is a state of mind – a mental space. It is all of these at once and something more…the essence of the safety of the space is that the patient can project things into the therapist which are contained by the therapist, detoxified and given back in due course in a form which can be used as food for thought”. 

This brings me back to the reflections that opened this article. At the end of each of our sessions we had found ourselves ‘containing’ and ‘closing’ with something of a ritual involving checking the calendar and booking the next session in, even when they were already booked in advance. So what was the impact on the client of me appearing to ‘dismiss’ the significance of what he had shared and experienced in our session on a day that the session ended differently - a session where he had actively explored some very painful memories, and how they impacted on him now? He may have felt judged or dismissed by me and he may have seen my quick departure as a sign that I was desperate to get away from him. My later reflections were nothing like that, but highlighted that I suddenly became aware of over-running, and wanted to bring the boundary back in quickly. In doing this though, without acknowledging the deviation, or simply even verbalising, “oh my gosh, we have run over”, I did dismiss him – at least that is how it feels. However, it is important to acknowledge that therapists are human too and thus “fallible” and cannot always be “constantly present”, as I have learnt from my own personal therapy. For some, that one hour a week is the only time they truly feel heard, understood and concerned for - and ‘losing’ that can be hard. 

Things like setting appointments or paying fees are generally viewed as “exploration-free” zones that fall into “clinical administration” (Gutheil & Simon, 1995). As such, the client and therapist can, at times overlook the value or meanings in how these interactions are undertaken. The ritual of checking our diaries at the end of a session with one of my clients, and then deviating from this one day, shows how I had initially failed to recognise the meaning in this task. It is well known in psychodynamic writings the importance of maintaining consistent and reliable boundaries and therapeutic style, in order to contain the process, and that deviations can be problematic and even harmful (Jacobs, 2012). 

Bringing the end together - the final word and ritual

The therapy room can feel like a haven and somewhere clients want to be, almost as soon as the session ends. The process of “coming together and being apart” develops importance with it being more or less relevant depending on the level of attachment needs the therapy meets (Jacobs, 2012). By looking at this more closely, I came to realise that in many ways I am engaged in a number of ‘rituals’ and verbal interactions with my clients as I bring a session to an end. For instance, I would comment that we had a few minutes left, would review what we talked about and ‘check-in’ with how they were feeling. I would then enquire what they were doing following the session or double check the date of the next session, even if it was a regular slot. I also recognised the significance of the rituals developed within my personal therapy that helped contain some of the significant experiences I explored in that room, and how a deviation at the end of one session, from what we “normally said” and did at the end, raised a lot of discomfort in me.

All endings are important. Our role as therapists is to try to model ‘good enough’ endings. With high dropout rates in psychotherapy (Hunsley et al, 1999), it is important to do our best to reflect carefully on how we navigate through endings and consider how our approaches may be experienced by our clients. As such, this topic highlights the importance of those working in psychotherapy, and in this case CAT, to pay attention to factors likely to contribute to dissatisfaction or difficulties, and potentially termination. Having a better understanding of the significance of session endings may also contribute to the research on dropouts and ruptures.

So how should we reflect on this with our clients? In my case, a deviation from the session ending ‘ritual’ in my own therapy prompted me to consider session endings with those I provide therapy for. Thus, the first step is simply about being aware that they are significant. We also need to know how to recognise what a specific client needs and when. As acknowledged by Bennett et al (2006), in order to resolve enactments effectively, the therapist needs to be able to identify them when they happen. The Assessor Response File may help initially as well as supervision. Even if we do not notice what has happened in session or the process of the session ending, completion of this will support the growth of our ‘internal supervisors’ and thus hopefully enable us to address the session ending at the start of the next session. By considering how you, the therapist, feel at the end of a session, may provide some insight into how the client feels.

Since my zone of proximal development  (ZPD) (Vygotsky, 1978) expanded as a therapist in relation to appreciating the ‘process’ of session endings, I have definitely changed the way in which I contain the end of a session. This has involved developing a ‘ritual’ with each individual client. I have also introduced discussions in the first few sessions about how session endings may be experienced. Since this change, I have noticed some improvements in how enactments are prepared for, experienced and worked through with my clients, especially those with significantly challenging personality traits. At the same time, I cannot ignore why the significance of endings has struck such a cord with me. Yes – I did go back to my SDR. I think I have some understanding. Part of working this through has been writing this down.

References
Axline, V.M. (1969). Play Therapy. Ballantine Books: New York. 
Bennett, D., Parry, G. & Ryle, A. (2006). Resolving threats to the therapeutic alliance in cognitive analytic therapy of borderline personality disorder: A task analysis. Psychology and Psychotherapy: Theory, Research and Practice 79, 395-418
Bourque, G.B. (2008). Leave taking and relationship endings in Rosen Method Bodywork sessions. Rosen Method International Journal 1(1), 15-23
Fozooni, B. (2010). Cognitive Analytic Therapy: A Sympathetic Critique. Psychotherapy and Politics International 8(2), 128-145
Gutheil, T. G. & Simon, R. I. (1995). Between the Chair and the Door: Boundary Issues in the Therapeutic “Transition Zone”. Harvard Review of Psychiatry, 2(6), 336-340
Hunsley, J., Aubry, T.D., Verstervelt, C.M. & Vito, D. (1999). Comparing therapist and client perspectives on reasons for psychotherapy termination. Psychotherapy 36, 380-388
Jacobs, M. (2012). The Presenting Past: The core of psychodynamic counselling and therapy. 4th edition. Open University Press: Berkshire.
Quintana, S.M. & Holahan, W. (1992). Termination in Short-Term Counselling: Comparison of Successful and Unsuccessful Cases. Journal of Counselling Psychology 39(3), 299-305.
Rayner, K., Thompson, A.R., & Walsh, S. (2011). Clients’ experience of the process of change in cognitive analytic therapy. Psychology and Psychotherapy: Theory, Research and Practice 84, 299-313
Ryle, A. (1990). Cognitive Analytic Therapy: Active Participation in Change. Chichester: Wiley.
Safran, J.D., Muran, J.C. & Eubanks-Carter, C. (2011). Repairing Alliance Ruptures. Psychotherapy 48(1), 80-87
Salzberger-Wittenberg, I., Henry, G. & Osborne, E. (1983). Different kinds of endings. In: The emotional experience of learning and teaching. Routledge: London.
Turpin, C, Adu-White, D., Barnes, P., Chalmers-Wood, R., Delisser, C., Dudley, J. & Mesbahi, M. (2011). What are the important ingredients of a CAT goodbye letter? Reformulation, Winter, 30-31.
Vygotsky, L.S. (1978). Mind and society: The development of higher psychological processes. (p86). Cambridge, MA: Harvard University Press.
Young, R.M. (2003). Containment: The technical and the tacit in successful psychotherapy. 
Downloaded from: http://human-nature.com/rmyoung/papers/pap145h.html
Marilyn A  Sher is a Consultant Forensic and Clinical Psychologist
marilyn.sher@yahoo.co.uk

Full Reference

Sher, M., 2014. Words and Rituals: The significance of 'smaller' endings. Reformulation, Winter, pp.33-36.

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