New Perspectives on Termination
Studies indicate that the average course of therapy lasts only five sessions and that as many as 60 percent of clients drop out of therapy before their goals are met. These numbers suggest a lot of treatment failures and the need for practitioners to reevaluate their basic assumptions about anticipating drop-outs and tracking clients’ session-by-session satisfaction with the therapy process. That’s especially important early in therapy. Outcome research by Michael Lambert and others finds that clients who don’t experience progress in the first few sessions are the likeliest to drop out and the least likely to ever make progress.
So why don’t more therapists identify therapy that isn’t working and take steps to address it? The cynical view attributes their reluctance to potential income loss. But the reluctance to admit that therapy isn’t on track, especially in the early stages, may reflect the very quality that accounts for effectiveness: the therapist’s refusal to give up hope for successful treatment. There may be some ego involved, too—clinicians who buy into the notion of therapist as a Master Fixer may find it difficult to admit when therapy isn’t gaining traction.
Finding out from clients early on how they feel therapy is going can alert overly sanguine therapists that something is amiss and help them understand more about what specifically isn’t working for the client and why. Out of that collaborative discussion, decisions can come more organically about how to alter therapy or, when appropriate, make a referral. Directly soliciting feedback and discussing it may require a different mindset for many therapists, however. Studies have shown that therapists often assume clients are primarily responsible for treatment failures, and therapists operating from a blaming mindset are less likely to handle a dissatisfied client’s negative feedback well.
According to University of Minnesota professor William Doherty, the ways in which such defensive therapists react may unconsciously push clients toward terminating. They may lapse into a type of consumer-speak: “If this isn’t working for you, you certainly have the right to find someone else.” They may suddenly spring the termination option as the “best” decision for the client before adequately exploring what went awry with therapy, how both therapist and client may have contributed, and whether therapy can be repaired. Or they may slip into a passive voice—“mistakes were made”—that smothers the therapeutic relationship with too much professionalism, killing any meaningful connection.
If the discussion makes it clear that a particular therapist–client match isn’t likely to work, then termination should be conducted with nondefensive clarity, as is the case with other parts of therapy. Therapists can handle uncomfortable discussions about therapy more directly, Doherty says, by thinking of themselves not as the experts at solving every problem that comes their way, but as the experts at therapy: they can’t fix everything, but they can know when they’re not the right therapist for a particular client.
The Age of Digital Therapy
We have no way of knowing how many therapists have at least occasionally used e-mail or video-based platforms, such as Skype, to conduct psychotherapy, but the numbers are growing quickly. As electronic communication has become integral to everyone’s lives, many clients have begun to expect that their therapists will connect with them occasionally via computer. Some have predicted that therapists who restrict themselves to the in-person therapy session may eventually become marginalized and irrelevant.
“Increasingly, our clients are demanding electronic therapy,” says psychologist DeeAnna Nagel, cofounder of the Online Therapy Institute. Medicare and Medicaid already pay for telehealth under certain circumstances, and according to psychologist Marlene Maheu from San Diego, California, founder of the TeleMental Health Institute, 12 states have mandated that insurance companies pay for telehealth. She cautions that therapists currently can expect considerable difficulty collecting insurance payments for such services, but there’s a clear trend. The main question about electronic therapy may soon become not whether today’s therapist should do it, but whether tomorrow’s therapist can afford not to.
It’s become so easy to bring psychotherapy into the Internet Age that a lot of therapists who previously considered sending an e-mail a major accomplishment now have websites and Facebook pages and regularly communicate electronically with clients. However, that’s a long way from providing effective telemental health services. Both Nagel and Maheu recommend that therapists first try it on clients with whom they’ve already done in-person therapy. In fact, Maheu won’t take on a client for telehealth until she’s done an in-person intake. Although numerous studies show that video-based therapy can be as effective as in-person therapy, data indicates that when it comes to intakes, in-person is much more reliable.
Converting an already existing in-person therapy relationship to telehealth therapy leaves less room for subsequent misinterpretations. In e-mail and other text exchanges, says Nagel, therapists can’t see the visual feedback cues from clients that tell whether their feedback has been accurately received. She cautions that when sending messages, therapists should make sure to look at what they’ve written from their clients’ viewpoints as well as their own. “Check and recheck what you write before you send,” she says. It’s important to pay as much attention to the tone as to the content, and check frequently with clients to ensure they’ve understood what you said in the way you meant it. Video brings different complex considerations into the therapy mix, such as eye contact, background, and gestures. For example, if a therapist breaks eye contact while she’s thinking, in-person clients may experience her as thoughtful, while clients watching over a webcam may feel she’s disengaged.
Nagel warns that therapists may have a tendency to lose awareness of the therapy process itself once they go electronic. “It’s not so much about how we use the technology, but how we transfer our skills,” she says. Because e-mail is asynchronous, therapists may lapse into an advice-giving instead of a reflective mode. In synchronous, text-based modes like Instant Messaging chat, there’s a tendency to fall into more of a friend role. Plus, all forms of electronic therapy can have powerfully disinhibiting effects, she cautions. Therapists should remember that, just as in in-person therapy, sometimes it’s important to stop clients from disclosing too much too soon. Clinicians need to maintain the tone they’d use when working in person.