Practice Guidelines for Group Psychotherapy

Termination of Group Psychotherapy

There is growing appreciation in the scientific literature for the lack of attention historically paid to the ending or termination phase of psychotherapy. A recent, comprehensive review of the salient issues associated with therapy termination identifies three key points that termination should address in group therapy.

1.     The ending phase includes a review and reinforcement of individual change which has occurred

in the therapy;

2.     The therapist guides the departing client to a resolution of the relationships with the therapist and group

members; and

3.     The individual is helped to face future life demands with the tools provided in the therapy (Joyce et al., 2007). 

The end phase of an individual’s participation in group psychotherapy is typically the capstone of the treatment.  While forming and establishing different relationships in the treatment group are crucial and working through conflict is essential, the end stage and the various aspects of the termination process can crystallize individual gains and promote the internalization of the therapy experience. Hence the ending phase is best not casually dismissed but rather embraced as a time for meaningful work.

        The ending process in a group may also stimulate a resurgence of presenting symptoms and/or previous conflicts in the group.  Moreover, the ending may stimulate unresolved conflicts related to previous losses and separation.  Termination can provide reinforcement for change and growth in the clients as they experiment with new behaviors in dealing with the ending, and have the positive experience of completing a task or phase of life. Termination is also an opportunity for the individual patient to reexamine and rework their relationship with the therapist(s) and group members.  In this process of reworking current relationships, the individual member is afforded the opportunity to practice new behaviors and develop tools for her future.

Unique aspects of termination in group psychotherapy.  In group therapy, the ending process and termination must be examined from three perspectives.  One, the time boundary of the group itself must be considered: is the group open ended or time limited?  Two, individual clients make their own decisions to become involved and depart on their own terms and in their own way.  Three, there are those situations where a therapist who functions alone or with a co-therapist must leave the therapy group.  Each of these aspects, “time boundary”, “individual client behavior”, and “therapist changes” play a role in how termination and the ending process is experienced and worked with therapeutically.

Time limited groups. Time limited groups may range from one or 1/2 day workshops of 4 to 8 hours to a set number of sessions (six, eight, twelve or more) over a predetermined number of weeks or months.  Typically, such groups are homogeneous on one or more variables: age, gender, presenting problem, experience of loss, shared life circumstance.  In the group a common theme emerges, the resulting group interaction will initiate support, energize confrontation of external and internal conflicts, and promote experimentation with new behavior in relationship to the problematic issue around which the group is organized.  Individual members will come to experience camaraderie, see similarities and differences in coping styles among the members, and bring to the group their typical expectations of leaders/experts in helping to seek solutions to personal problems.

Endings in time limited groups.  There are four levels of focus at the time of ending a time- limited group.  One, the group focuses on its own development and the sense of cohesion and group identity which emerges.  Leaving therapy after becoming part of a group which is nurturing and supportive may stimulate memories of previous groups which were more or less supportive.  Two, the group focuses on individual relationships between members which were supportive and/or conflicted.  The leader urges a process of focusing on these interactions and establishing a climate of learning from the experience.  Three, the leader engages the group and individuals to process their interactions with the leader.  The leader invites the group to process the positive and negative contributions of the leader.  In this phase, individuals in the group may rework their typical expectations of authority, leaders and experts, in seeking solutions to personal problems.  And four, the leader guides the group to review the respective symptom(s), trauma, or life event which initiated the formation of the group.  In this process, members refine or master new coping skills and anticipate how the lessons of therapy can be applied in the future.  The leader invites group members to focus upon their relations with one another and with the leader.  In this process, individuals may resolve conflicts and distorted perceptions of one another.  Group members learn the benefits of mutuality and shared problem solving.  They learn how to work with people who are similar and different from themselves.  By focusing on the ending process, the leader helps the individuals to see their own style in coping with change and endings.  The goal is to help the individuals apply the process of the group ending to future transitions and endings in their life.

        Time limited groups are frequently organized around themes and there is a limited focus on screening for dysfunctional behavior.  Only over time and during the ending process of a time-limited group will the leader(s) and individual members become aware that continued therapy and/or evaluation of personal behavior is necessary.  The leader(s) of time-limited groups should arrange for referral to adjunct professional services for those individuals who need continued professional intervention.

Open - ended groups. An open ended group is organized to be a continuously functioning therapy group meeting regularly, typically weekly.  All members are expected to attend weekly and announce absences in advance. Newcomers are asked to make a trial commitment to the group which is a prelude to making an open ended commitment of a year or more to the therapy process. The therapy group has the related goals of dealing with dysfunctional behavior and seeking personal growth through interactions within the group.   The expectation is that individual members will continue involvement with the therapy until they have reached their individual goals.  Individual therapy goals are typically established by the client in collaboration with the therapist and with the group as the therapy process evolves.  While the group is open-ended, the expectation is that individuals will leave the group and that there will be a leave taking process.  This interactional process format allows the development of relationships over time which mirrors the formation of relationships in life.  The development of cohesion, emergence and resolution of conflict, shared hopes and fears, and departures of all kinds are expected to occur.  Departures may be premature, conflicted, sad, joyous, satisfying, with each posing various challenges and opportunities to the therapist and continuing group. This kind of group therapy provides participants with the unique opportunity of mourning the loss of a therapy relationship while still in the company of others experiencing the same loss.

Premature terminations. Premature terminations may occur at different stages in the development of a group.  At the earliest point of group formation a premature termination will challenge the formation of cohesion and may prompt group members to lose faith in the treatment format and question their own commitment.  A contagion of “jumping ship” may develop.  The therapist’s role is to help the departing individual find alternate treatment formats (if so desired) and leave with dignity, while at the same time assisting the group members to assimilate the experience and to focus on their perceived role in the process of the departure.  A premature termination will frequently stimulate the group’s first experience with separation/individuation issues.  The therapist has the dual responsibilities of helping the individual client continue to make informed decisions for his or her own benefit and also helping to maintain the integrity of the treatment group.

        Premature or unanticipated terminations in the middle and ending stages of a therapy group will have different impact and meaning to the group and its individual members.    These departures are more likely to include some form of acting out by the individual client in which the personal conflicts of the client are intertwined with the current process of the group. In these instances, the therapist should be alert to the multiple meanings of these departures.  For example, an involved group member who is making progress may be challenged with a new level of intimacy or personal contact in the group and choose to leave.  The therapist’s role in these situations is to help the individual and the group examines the process to the extent possible and to learn from its own experience.  Negative emotions and reactions associated with unanticipated endings will challenge the group’s and the leader’s sense of worth and effectiveness.  The therapist must be alert to negative reactions in the group and assist the departing member in maintaining their dignity and offering referrals when appropriate.  A “premature” termination permits the group members to deal with their own feelings and perceptions of what has happened and also to compare this experience with past relationships in which people have left.

Ending therapy with personal satisfaction.  The ideal therapy ending is for the individual client to achieve symptomatic relief and a personal sense that their life is gratifying with enriching personal relationships and/or satisfaction with work.  A therapeutic ending in these instances will include taking time to say good-bye and to disengage from the relationships of the group.  The therapist provides a structure to the ending process.  There is a parallel process in the beginning and end: At the start, the individual makes an initial commitment which leads to a long term stay.  In the ending process, the individual is invited to set a deadline which permits the group to work through the departure. The reality of the ending is made clear in setting a date.   The ending may be set in weeks, months or longer depending upon the individual client and group and the tenure the member has had in the group.  The therapist’s role is to set the norms which permit the group to learn from the beginning and ending process. 

        In contrast to premature endings which frequently stimulate negative and mixed feelings, the planned departure will prompt other developmental and interpersonal issues.  In the planned ending, reenactments of positive and negative sibling relationships may emerge.  Group members may experience envy with another person’s success.  Members become more aware of mutual dependency in their relationships.  In the successful therapy ending, the therapist is seen less as an iconic figure and is experienced both as a real person and an effective therapist or professional.  Again in the ending process, the therapist will address various forms of change which may occur.  The departing member may report changes in his emotional and affective experience; changes in how he thinks and perceives people; or changes in his behavior.  It is useful for the therapist to remind the client of the problems or issues which initiated the therapy.  This process is applied to all in the therapy group since the departure of one member will stimulate comparable issues in all of the individuals. The therapist is also encouraged to focus on the relationships that the individual has formed with current and past group members.  This allows for a reworking of those relationships, particularly with those who are currently in the treatment group.   Once again, this process will be shared by all of the members.  In this regard, it is helpful to remind the group that the departure is a leave taking from the group as a whole and echoes earlier leave takings, but this time with the opportunity to make the ending as full and complete as possible, leaving as little unsaid and undone as is possible.

A Dilemma of the Open Ended Group. Therapies that are organized to deal with dysfunctional behavior and to promote personal growth are often by definition long-term ventures and the treatment process is measured in months and years.  In this treatment environment, an individual may develop a dependent attachment to the group, or her personal conflicts may lead to an avoidance of considering an end to the treatment.  In these situations, the therapist has a responsibility to help those individuals who are reluctant to address the issue of termination and the impact this plays in their life and group participation.   The therapist should attend to two aspects of this dilemma.  One, how does the individual’s history, personal conflicts, current life status, symptoms, and current functioning in the treatment group play a role in the individual avoiding the issue of termination?  Two, how does the climate and functioning of the group contribute to the individual avoiding dealing with her own separation and attachment issues?

Ending Rituals. The ending of a time limited group and the successful departure of an individual from an ongoing group frequently stimulate questions and concerns among group members about how to say good-bye.  It is helpful for the leader to offer guidance and structure to the ending process without imposing a prescribed format. Changes in the frame of therapy related to ending must be carefully considered and explored. Saying good-bye is a complex process which includes cognitive, affective and interpersonal aspects.  The major role for the therapist is to help the group learn from the experience by continuing to focus on the current ending, comparing this leave taking to previous departures in the lives of the individuals and guiding the members to address what they expect to take away from the group experience.  Gift giving, sharing of food, and physical expressions of positive regard through a hug, embrace or handshake are not uncommon.  Frequently group members ask about the protocol of gifts or bringing food.   The leader attempts to strike a balance, on the one hand normalizing the expression of positive feelings and sadness associated with ending, and at the same time offering an intellectual understanding of the process which promotes continued learning and therapeutic gains from the ending.  Promoting a warm and engaging good-bye may be an antidote to previously negative or toxic departures and provides a model for future leave takings.  

Therapist Departures. There are a variety of situations in which a therapist will leave an ongoing group.  These include training situations, groups led in institutions or agencies, a therapist closing a practice and the illness or death of a therapist.

        In training situations in which a co-leader is in a student role with a senior therapist, it is essential that the group know the co-leader’s status as well as the time commitment of the trainee.  This information sets the frame for the members and allows the individuals and group to work with their perception of the trainee, and the relationship between the co-leaders.  Additionally, the set time for the departure introduces the opportunity to deal with the therapist’s termination. Similar consideration applies to groups in institutional settings in which a group therapist’s departure may be imposed due to logistical and practical factors distinct from therapist choice.

A therapist who is closing a practice or ending a group has the responsibility to attend to the therapeutic needs of her clients.   The therapist should be prepared to process how group members expect to relate to the therapist in the future.  Possible issues may include but are not be limited to:

1. The therapist’s availability for future consultation;

2. The disposition of records;

3. The question of a social or friendship relationship post- therapy, and

4.  The therapist’s future location and whether he will be open to contact from clients

 It is useful for the therapist to have available referral sources which could meet the ongoing therapeutic needs of the clients.  Therapists should maintain an adequate record of the therapy to assist a new therapist in offering treatment.  Ideally, the therapist will announce the closing of the group or practice with sufficient notice that the clients can process their reaction to the change and have time to find realistic therapy alternatives.

Personal illness or emergency may take a therapist away from an ongoing group.  While crisis, illness and emergency by definition cannot be predicted or controlled, it is useful for a therapist to consider and make a plan for how ongoing therapy responsibilities will be maintained.  Support staff or others will need to contact clients about the unavailability of the therapist and to provide information about the anticipated return.  In extended absences, referral to colleagues and agency resources may be appropriate.  In any event, these situations stimulate a variety of responses in group members which range from an experience of traumatic loss to sadness, grief and empathic understanding of the humanity of the therapist.

Summary

1.     The ending phase or termination is best viewed as its own unique stage with its own goals and processes.

2.     The ending phase includes a review and reinforcement of change in the individual members.

3.     The leader establishes a climate and encourages processes which help group members to resolve conflicted

relationships with one another and the leader.

4.     The leader guides group members to anticipate stress and practice coping skills which have been developed in

group and will be applied in the future.

5.     In a time limited group, the leader pays particular attention to the movement of time and the dissolution of the

group as a whole.

6.     Premature terminations are disruptive to the development of cohesion and trust in the group. The leader helps

the group to process the departure as a learning experience and to aid in the process of future new entries to the

group.

7.     A successful departure from an open ended group becomes a therapeutic learning experience for all in the

group.

8.     The departure of a co-leader requires thoughtful therapeutic management.

9.     Endings in groups are frequently accompanied by rituals which aid the members in learning through the leave

taking process.

10.    Therapists who stop leading groups through illness, retirement or change in practice pattern have a

responsibility to help the members secure continued therapy and consultation.