Termination issues including relapse prevention

Issues related to termination may be more critical for individuals suffering from depression than for most other disorders, because of the role that loss and abandonment plays in the onset of depression (Power, 2002). In addition, in short-term treatments such as CBT, the therapist may have had little or no opportunity to observe a client's reactions to natural breaks in therapy, such as those caused by holidays, which normally occur in longer-term treatments and provide invaluable clues about how the client deals with issues related to loss. In working with short-term therapies for depression, it is essential, therefore, that termination issues are considered early in therapy and that the therapist remains vigilant throughout. Of course, many short-term therapies have a pre-specified number of sessions, so that the client knows from the start the number of sessions involved. In other cases, however, the therapist may need to make some judgement about when the client is likely to be ready for the end of therapy. Such judgements must obviously take account of the client's own views, they may include some formal assessment of symptomatology and relevant cognitive variables, and they should also include a judgement of the extent to which the client has understood and been able to put into practice the CBT model. Casement's (1985) notion of the internalisation of a positive model of the therapist also seems like a useful proposal that can be applied to any form of therapy. For example, clues that the client has internalised a model of the therapist can be gleaned when the client reports something along the lines: "I was just about to jump over the till in the supermarket on Friday and escape in a panic, when I suddenly thought to myself, 'Oh, I wonder what my therapist would say to me now.' I then managed to calm down and continue with my shopping."

Of course, such statements are powerful indicators that the client has an internal model of both the therapist and the skills of therapy, in that the model is being applied in critical situations.

However, the real risk in short-term CBT for depression is that the therapy will merely have been palliative, and not have dealt with the high risk of relapse which runs at approximately 50% over 2 years after recovery from depression (e.g., Hammen, 1997). Therefore, one of the tasks towards the end of CBT is to develop potential relapse-prevention measures with clients, which include the identification of and working through potential high-risk situations (e.g., Segal et al., 2002). An additional focus of relapse prevention is the client's reactions to such situations. For example, if a client begins to feel miserable because of an upset at work, but then begins to worry that feeling moderately miserable means that serious long-term depression will inevitably follow, a vicious cycle downward will have begun that pulls the client further into depression (cf. Teasdale, 1988). The focus of relapse prevention should therefore be both on the likely events or situations that will lead to the client's feeling miserable, and on how the client reacts to such feelings when they occur (e.g., Segal et al., 2002). As we noted above, many individuals with emotional disorders have unrealistic beliefs about their emotional states, in that they often want to rid themselves of feelings of anxiety, depression, or sadness, and live a future filled only with the experience of happiness. Relapse prevention must therefore emphasise to clients that living happily ever after happens only in fairy tales, not in real life, and that our emotional reactions are as inherent and essential a part of us as the experience of physical pain.

Finally, on a more practical level, it is useful to include one or two "booster" sessions approximately 3-6 months after the end of therapy. These sessions allow a review of the successes and the problems that the client has faced since the end of therapy. They allow the therapist to assess how well the client has worked with the model without the support of therapy. Booster sessions also provide a tangible lifeline for the client at times when things feel difficult, and they may help the client to pull through without the need for additional professional intervention.

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