With the undoubted exception of CBT and IPT, most of the literature on termination derives from long-term work, particularly psychodynamic, which like systemic work is relationship based. But unlike, psychoanalysis, a systemic therapist takes a facilitative role (much like an IPT therapist), so endings more likely to be mostly experienced by what has been gained, rather than by the loss of the therapist or uncertainty about a future without them.
Even so, favourable change at this time of a family’s life would have been less likely without the therapist’s involvement in change, so their appreciation of what meeting together had been achieved likely to be tempered by some sad or uncertain feelings about parting, and occasionally with considerable anxiety. The Chinese symbol for transformation, a metaphor used by Alison Burgess and Bill Ness, Family and Systemic Psychotherapists, reflects the interconnection of uncertainty and opportunity.
We live our lives, forever taking leave. —Rainer Maria Rilke
To a considerable extent this is true for all psychotherapy, not only as each session ends but, in the approach we advocate, by the formal review of progress that occurs over the course of working together, looking backward to how things began as well as looking forwards. Nevertheless, however much the final meeting has been anticipated, it often evokes new or mixed feelings in the family: accomplishment at the achievements gained but also loss of someone who has got close to the family as they were helped to overcome difficult obstacles.
So, leaving the family – success or crisis? And for whom? However much change would have become an ongoing theme, termination often reminds family members of past experience of closeness and attachment or the past lack of them at crucial times of their lives (a prominent issue for interpersonal therapy too).
Furthermore, since the therapeutic use of self in systemic work is important, termination of the encounter necessarily faces the therapist too with a challenge in human-relations terms. There is comparatively little on the literature on termination about the loss therapists may feel. Kahil Gibran’s reminder, on parents’ responsibility for children and the loss that lies ahead, seems appropriate: family members “are the sons and daughters of Life’s longing for itself, they come through you but not from you”, the reminder that therapy is “the bow from which living arrows are sent forth” not only perhaps a fact but a consoling reflection.
Depth, duration, meaning, and outcome of the therapeutic relationship: these are aspects of therapy that are likely to profoundly influence how the termination of it is experienced, above all ‘meaning’ as well as whether the problems for which they came had been fully resolved. There is no simple linear effect: the two-examples we used of brief contact (at the end of the previous chapter) were families with very troubled (and by no means resolved) pasts, yet most change had been achieved quite quickly. An atmosphere of a ‘job well done’ had characterised the last session of each, although for their therapists separation was quite heartfelt, aware of the uncertain future each family was facing. By a process of introjective and projective identification – feeling perhaps like a family member when the remainder of the family is getting ready to leave home and live elsewhere.
The meaning of the therapeutic contact and the achievement of the agreed therapy goals represent the two key aspects of termination that require reflective practice – the personal and the pragmatic:
- pragmatic: how far the formulation had proved useful, whether the problems that had precipitated referral had been resolved, where the ‘right first time’ approach had been vindicated by subsequent treatment-effectiveness. This may have required the introduction of additional inputs, the systemic approach acting like a boat that took on a mixed cargo (purposely chosen, securely held, and coherent with the family’s understanding of the formulation), the ‘minimum sufficient’ inputs to enable problem-resolution.
- personal: because as already described, to be effective even brief therapeutic work must involve a real meeting with one-another. Even a single helpful encounter may never be forgotten, so it is always important to acknowledge how and what has occurred. Where long-term work has been necessary, and the therapeutic relationship has gradually provided an ‘earned secure’ base for the family, termination of this attachment invariably evokes intense feelings.
Systemic family therapists aim to nurture attachments within families as much as possible, rather than positioning themselves at the centre of a psychoanalytic field. That said, in his 1995 book Re-writing Family Scripts, John Byng-Hall reminds family therapists that for families with insecure attachment patterns we, and the therapeutic space we provide, have often become a temporary secure base to facilitate change (similar to the ‘earned secure’ base described in the trauma literature).
Being mindful of this position can assist therapists to avoid unnecessarily lengthy intervention that foster dependence rather than fostering independence strengths and family resilience. Regardless of the duration of involvement with a family, therapists must be sensitive about the timing and the meaning of leaving the family and shape their therapeutic approach accordingly. Endings may occur in very different ways and over different periods of time.
What is most important for managing our exit from the lives of families? How should our exits be most productively timed, and who should decide that it is time to leave the family? There should certainly be no surprises when leaving the family. Taking a collaborative stance means sharing responsibility with a family for deciding when to end therapy.
Working sometimes under intense contract pressures in health and social services, therapist require a significant commitment to the ethics of family therapy: to consolidate the achievements made during the period of involvement, not leaving the family with an experience of abandonment and breach of a delicately co-constructed trust.
Sharing responsibility for leaving the family calls for ongoing attention to review and change. As in the case-example of Mandy and David (below), setting the context for becoming only temporarily (albeit deeply) involved with the family from the first therapeutic encounter. This will involve consideration of
- how an end point would be defined and how it would be recognised
- what the costs and benefits might be of ending intervention at given points
- historical attachment patterns to avoid replicating experience of broken attachments.
Some core tasks to attend to: leaving the family is a reflective process as well as an event in time. So working towards an ending involves attention to a developing coherent narrative of the therapeutic journey shared with a family
- recognising the start point
- the content of shared understanding of a problem and of alternate narratives within a family as they developed
- noting significant waypoints that marked the change process
- acknowledging setbacks and how these were overcome
- taking account of wider contextual factors that influenced the family
- giving attention to resources that helped the family with change
- considering the change in beliefs and family patterns that have occurred during therapeutic intervention
- sharing the experience of working with the family from a therapist’s position.
In addition to looking back as we work towards leaving the family, we also will be opening up a co-constructed vista for a preferred future using the family’s own resources that do not involve therapy. This draws on individual and collective imaginations as a powerful, creative tool to reinforce capacity and self-reliance within a family
- examining the detail of what a preferred future will look and feel like
- exploring hope
- considering which resources a family will draw on to assist with their preferred future
- encouraging self-monitoring of progress to reduce the need for external or statutory monitoring
- identifying someone outside of the family that might assist with this monitoring of progress
- consolidating self-monitoring skills by checking how close or far away progress is at any given point to the course of a family’s preferred future
- normalising setbacks as part of lived family experience
- revisiting how previous setbacks were resolved successfully
- deconstructing where and when setbacks are most likely to occur and who would notice what that would galvanise the family resources and move them toward early resolution?
- rehearsing how a family might respond, i.e. who might do what and how might this be agreed?
- checking how a family might know they are back on course for their preferred future after an inevitable setback
- acknowledging any traumatic experience that has been voiced but not been resolved within therapy and what approach, if required, a family might take to attend to this in the future
- detailing how a family might decide that further intervention might be needed
- considering how a family might be re-referred to therapy should setbacks become overwhelming
Evaluating the Therapeutic Journey
Taking time with a family to evaluate the therapeutic journey can serve a dual purpose: to highlight what was most useful for a family (brought to mind as an internal resource when the therapeutic journey has ended); and to assist our own developmental journey, to know directly from families what was useful and what did not go so well.
Evaluation tools like SCORE can be extremely useful in opening up a dialogue of where changes have been achieved and what was most useful along the way. In addition, as an established evaluation tool within systemic family therapy, SCORE can be used toward developing research and evidence-based practice, vital for the expansion of systemic family therapy as a profession within health and social services.
We conclude with the case-example of David and Mandy, a 12-year-old young man and his mum who feature in several chapters throughout this book/website. The ending process was perhaps one of the most significant episodes of their contact in consolidating the changes they made.
Conversations about ending the treatment contact had in fact started on their very first meeting with the therapist: how will we know when you don’t need to meet with me anymore?
From this point, with hoped for outcomes established from the beginning, the notion of leaving the family on their journey was set. Reviewing progress of change and setbacks week-to-week and session-to-session helped gauge in a transparent manner how close or far away David and Mandy were from ending therapy.
Mandy was more concerned than her son about the implications of ending therapy. David was the most pleased. Mandy had made significant steps during contact with the therapist to recognise where her best efforts to comfort and support David when he had been feeling anxious had actually reinforced his fears.
She had also reflected on her own history and could now predict scenarios in different contexts where unresolved emotional experience was being activated. These memories that activated a reactive, emotionally driven response had hindered her from taking rational steps to consider what response might help David the most. This had also freed the mother-son relationship from expectations that belonged to historical relationships and historical disappointments.
David, through engaging in systemic family therapy, had begun to change his view of himself. He left the problem-saturated view of himself behind and developed a different, alternate and resilience-focused view that opened up opportunities for change. His changing perspective of himself as a young man with talents and competencies was reinforced by Mandy’s similarly changing view of him.
When he felt anxious, Mandy was able to remind David of his capacity to confront and then overcome his anxiety and stay steady in this view while he did so, congratulating him on his success. David, instead of feeling defeated at the first obstacle, was able to take in Mandy’s expectation of competence, which added to his confidence to keep trying. This change had been noticed in school as well as at home. The family had rehearsed this step several times during the course of therapy, not always succeeding but eventually finding a way through the challenges that worked for them.
Nevertheless, Mandy remained concerned that without regular meetings with the therapist, the old problems would return. The therapist, mindful of Mandy’s early attachment history, proposed a follow-up session in several months’ time. This served the purpose of alleviating activation of fears of abandonment for Mandy but still communicated a belief in the competence achieved by the family.
Mandy, three months later, contacted the therapist’s department to cancel that final appointment. She reported that David was doing well and had an important school trip that day. The therapist wondered whether saying goodbye had also been too painful for Mandy but equally had been pleased to hear that leaving the family to chart their own course had been a success.