# 27 - 21. Termination and Relapse Prevention

# 01 - 21. Termination and Relapse Prevention

# 21. Termination and Relapse Prevention

R
esearch shows that sessions focused on relapse prevention help 
delay the onset of relapse and recurrence among depressed clients 
(de Jonge et al., 2019). The traditional objectives of CBT have been to 
facilitate a remission of clients’ disorders and to teach them skills they 
can use throughout their lifetime to reduce or prevent relapse. While 
these objectives are still critical, we now put additional emphases on 
enhancing positive mood, increasing valued action, strengthening 
resilience, and improving satisfaction and general well-being.
In this chapter, you will find answers to these questions:
How do you prepare clients for termination?
What do you do from the beginning of treatment? What do you do 
throughout and at the end of treatment?
How do you taper therapy sessions?
What does a self-­therapy session look like?
How do you prepare clients for potential setbacks or relapse?
How do clients react to ending treatment?
How should you conduct booster sessions?
EARLY TREATMENT ACTIVITIES
You begin to prepare clients for termination and relapse even in the 
initial session, telling them your goal is to teach them skills so they can 
TERMINATION AND 
RELAPSE PREVENTION

become their own therapist—­which also helps speed up treatment. As 
soon as clients begin to feel better (often within the first few weeks), 
it’s important to let them know that their recovery will probably not 
follow a straight line. You might draw them a graph (Figure 21.1) showing them the usual course of progress, with periods of improvement 
that are typically interrupted (temporarily) by plateaus, fluctuations, 
or setbacks.
Judith: Abe, I’m glad you’re feeling a little better. But I should tell 
you that you may still have ups and downs. Can I draw a graph to 
show you?
Abe: Uh-huh.
Judith: (drawing) If you’re like most people, you’ll go along feeling 
a little better and a little better; then at some point, you’ll reach 
a temporary plateau or have a setback. That may last for a little 
FIGURE 21.1.  Graph of expected progress. This graph, if skillfully drawn, can 
be made to resemble the southern border of the United States, with setbacks 
represented by “Texas” and “Florida.” While striking some clients and therapists as humorous, this illustration may help clients recall that setbacks are 
normal.
Graph of Expected Progress
Time
Improvement
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while, then you’ll feel a little better and a little better, and then you 
may have another setback, maybe shorter this next time. If you 
continue to use your skills though, you’ll start making progress 
again, until you’re over the depression. (Points to the graph.) Can 
you see that this graph looks a little like the southern border of 
the United States? So if you have a setback, it just means you’re 
visiting Texas. Pretty soon you’ll continue on to Louisiana, Mississippi, Alabama. Then you’ll go to Florida, maybe with a detour to 
Miami. But then you’ll recover and get better and get up to Maine. 
(pause) But if you didn’t know that it’s normal to visit Texas, what 
might you think?
Abe: That I’m back to square one. That I’m not going to get better.
Judith: Exactly. You’ll need to remind yourself that it’s normal to have 
ups and downs . . . You can remember this diagram where we predicted some low points.
Abe: (taking the graph) Okay.
Judith: Now, even after we’re finished therapy, you’ll have at least mild 
ups and downs. Everyone does. Of course, by then, you’ll have 
the tools you need to help yourself. Or you may want to come in 
again for a session or two. We’ll talk about this toward the end of 
treatment.
ACTIVITIES THROUGHOUT THERAPY
Certain techniques, used throughout treatment, will facilitate relapse 
prevention.
Attributing Progress to the Client
Be alert at every session for opportunities to reinforce clients for their 
progress. When they experience an improvement in mood, find out 
why they think they are feeling better. Emphasize the idea, whenever 
possible, that they themselves have brought about changes in their 
mood by making changes in their thinking and behavior. Point out 
or ask clients to state what these positive changes mean about them. 
Doing these things helps build their sense of self-­efficacy.
Judith: It sounds as if your depression is lower this week. Why do you 
think that is?
Abe: I’m not sure.
 
Termination and Relapse Prevention

Judith: Did you do anything differently this week? Did you do the 
activities we scheduled? Or did you respond to your negative 
thoughts?
Abe: Yeah. I cleaned up the apartment some, and I got out almost 
every day. And I read the therapy notes.
Judith: Is it possible you’re feeling better this week because you did 
these things?
Abe: Yes, I think so.
Judith: So what can you say about how you made progress?
Abe: I guess when I do things to help myself, I do feel better.
Judith: That’s good. And I think it also shows that even though you’re 
still depressed, you’re now able to take more control.
Abe: I guess I am.
Judith: [summarizing] So you’re feeling better, at least in part, because 
you took control. This is so important! How about if we write that 
down?
Some clients attribute all the improvement to a change in circumstance (e.g., “I’m feeling better because my daughter called me”) or 
to medication. Acknowledge the external factors, but also ask about 
changes they made that could have contributed to (or helped maintain) their improvement. When clients persist in believing that they 
don’t deserve credit, you might decide to elicit their underlying belief 
(“What does it mean to you that I’m trying to give you credit?”).
Teaching Skills
When teaching clients techniques and skills, stress that these are lifelong tools they can use in situations now and in the future. Research 
shows that using CBT skills improves outcomes in clients with recurrent depression, even in the face of stressful life events (Vittengl et al., 
2019). Encourage clients to read and organize their therapy notes so 
they can easily refer to them in the future. A good Action Plan item 
is to write a synopsis of the important points and skills they learned 
in treatment. Common techniques and skills that can be used during 
and after therapy include the following:
• Setting goals in accordance with their aspirations and 
values.
• Measuring progress toward achieving their goals.
• Using CBT techniques to overcome obstacles.
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• Monitoring positive experiences and drawing conclusions 
about what these experiences indicate about the client.
• Balancing productive, pleasurable, self-care, and social 
activities.
• Giving self-­credit.
• Cultivating positive memories.
• Reducing large goals, problems, or tasks to manageable 
components.
• Brainstorming solutions to problems.
• Identifying advantages and disadvantages (of specific 
thoughts, beliefs, or behaviors, or choices when making 
a decision).
• Using worksheets or a list of Socratic questions to 
evaluate thoughts and beliefs.
• Working on hierarchies of avoided tasks or situations.
Help clients understand how they can use these skills in other situations during and after therapy, whenever they perceive they’re having 
a reaction that seems out of proportion to the situation. For example, 
they may recognize that they’re feeling more anger, anxiety, sadness, 
or embarrassment than a situation calls for. Or perhaps they see a pattern of unhelpful behavior that they want to change.
Building Resilience and Well‑Being
There are a number of ways to help clients become more resilient 
and increase their sense of well-being. A good guide is provided by 
the American Psychological Association (www.apa.org/helpcenter/road-­
resilience). It stresses many of the interventions in this book: making 
connections, modifying catastrophic thinking, maintaining optimism about the future, accepting situations or conditions that can’t 
be changed, working toward goals, decreasing avoidance when challenges occur, identifying ways to grow as a person when encountering adversity, strengthening positive core beliefs, seeking a broader 
perspective in stressful situations, doing good self-care, and engaging 
in meditation or a spiritual practice.
Clients often lose confidence in themselves when they become 
depressed. It’s critical for them to build their resilience and increase 
their confidence so they can handle difficult times in the future without becoming depressed again. Many techniques from positive psychology, as described by Martin Seligman, PhD, in books for consumers, 
 
Termination and Relapse Prevention

and from many other authors writing for professionals (e.g., Bannink, 
2012; Chaves et al., 2019; Jeste & Palmer, 2015), promote a better sense 
of well-being.
NEAR‑TERMINATION ACTIVITIES
Tapering Treatment
If a client has a limited number of sessions with you, discuss tapering 
several weeks before termination. If there isn’t a limit, hold this discussion when clients are feeling at least somewhat better and are using 
their skills consistently and effectively. Your objective is not to solve 
all your clients’ problems or to help them reach all their goals. In fact, 
if you view yourself as responsible to do this, you risk engendering or 
reinforcing dependence—­and you deprive clients of the opportunity to 
test and strengthen their skills.
Make a collaborative decision to space sessions as an experiment. 
Initially, consider meeting every other week instead of every week. If 
that goes well for at least a couple of sessions, you might suggest scheduling the following appointment for 3 or 4 weeks in the future. You 
might have several monthly sessions before termination and several 
widely spaced booster sessions after that.
Concerns about Tapering Sessions
Although some clients readily agree to spacing sessions, others may 
become anxious. If so, ask them to verbally list (and perhaps record in 
writing) the advantages and disadvantages of trying to reduce the frequency of their visits (Figure 21.2). When clients fail to see advantages, 
first elicit disadvantages, use guided discovery to help them identify 
advantages, and then help them reframe the disadvantages. Some clients, like Maria, might have a strong reaction that you need to attend 
to.
Judith: In our last session, we talked about experimenting with spacing our therapy sessions. Did you think about going to an everyother-week schedule?
Maria: I did. It made me really anxious.
Judith: What went through your mind?
Maria: Oh, what if something happens that I can’t deal with? What if 
I start getting more depressed—­I couldn’t stand that.
Judith: Did you answer these thoughts back?
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Maria: Yeah. I read my therapy notes. I mean, it doesn’t have to be the 
absolute end of therapy. And you did say I could call you and come 
in sooner if I needed to.
Judith: That’s right. Did you imagine a specific situation that might 
come up that would be difficult?
Maria: No, not really.
Judith: Maybe it would help if we had you imagine a specific problem 
now.
Maria: Okay.
Maria imagines getting into another fight with her best friend. She 
identifies and responds to her automatic thoughts and makes a specific plan for what to do next.
Judith: Now, let’s talk about the second automatic thought you had 
about spacing our sessions—­that you’d get more depressed and 
that you wouldn’t be able to stand it.
Maria: I guess that may not be quite true. I could stand to feel bad 
again. But I wouldn’t like it.
Judith: Okay. Now let’s say you do get more depressed and it’s still a 
week and a half before our next session. What can you do?
Maria: Well, I can do what I did about a month ago when you were on 
FIGURE 21.2.  Client’s list of advantages and disadvantages of tapering therapy.
Advantages of Tapering Sessions
• Save money.
• Can use the time for something else.
• I’ll be proud of myself for solving my own problems.
• It will boost my confidence.
• Won’t have to travel to [my therapist’s] office.
Disadvantages with Reframe
• I might relapse, but if I’m going to, it’s better for it to happen while I’m still in 
therapy so I can learn how to handle it.
• I may not be able to solve problems myself, but tapering therapy gives 
me the chance to test my idea that I need [my therapist]. In the long run, 
it’s better for me to learn to solve problems myself, because I won’t be in 
therapy forever. I can always schedule an earlier session if I need to.
• I’ll miss [my therapist]. This is probably true, but I’ll be able to tolerate it and 
it will encourage me to build up a support network.
 
Termination and Relapse Prevention

vacation. Reread my therapy notes, stay active . . . Somewhere in 
my notes I have a list of things to do.
Judith: Would it be helpful to find that list this week?
Maria: Yeah.
Judith: Okay. How about for your Action Plan if you find the list and 
also do a worksheet on these two thoughts: “Something might 
happen that I couldn’t deal with” and “I couldn’t stand it if I got 
more depressed.”
Maria: Okay.
Judith: Any other thoughts about spacing our sessions?
Maria: Just that I’d miss not having you to talk to every week.
Judith: (genuinely) I’ll miss that too. (pause) Is there anyone else you 
could talk to, even a little?
Maria: Well, I could call Rebecca. And I guess I could call my brother.
Judith: Those sound like good ideas. Do you want to write them down 
to do too?
Maria: Yes.
Judith: And finally, do you remember that we said we could experiment 
with every-other-week sessions? If it’s not working well, I do want 
you to call me so we can decide together if you should come in 
sooner.
SELF‑THERAPY SESSIONS
Although many clients don’t follow through with formal self-­therapy 
sessions, it’s nevertheless useful to discuss a self-­therapy plan (see 
Figure 21.3) and to encourage its use. When clients try self-­therapy 
sessions while regular therapy sessions are still being tapered, they 
are much more likely to do self-­therapy after termination. And they 
can discover potential problems: insufficient time, misunderstandings 
about what to do, and interfering thoughts (e.g., “This is too much 
work”; “I don’t really need to do it”; “I can’t do it on my own”). In addition to helping clients respond to these cognitions, you can elicit the 
advantages of self-­therapy sessions:
• They are continuing therapy, but at their own convenience and 
without charge; they can keep their newly acquired tools fresh 
and ready to use.
• They can resolve difficulties before they become major problems.
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• They reduce the possibility of relapse.
• They can use their skills to enrich their life in a variety of contexts.
You can review Figure 21.3 with clients and tailor it to meet their 
needs. Before your final session with clients, encourage them to continue having self-­therapy sessions at least once a month, then once 
a season, and eventually, once a year. Help them devise a system so 
they’ll remember to do this.
FIGURE 21.3.  Guide to self-­therapy sessions.
Think about the past week(s):
What positive things have happened? What did these experiences mean to 
me? About me? What do I deserve credit for?
 
 
What problems came up? If they’re not resolved, what do I need to do?
 
 
Did I complete the Action Plan? What could get in the way of completing it this 
coming week?
 
 
Look forward:
How do I want to feel by this time next week? What do I need to do to make 
that happen?
 
What goals do I have for this week? What steps should I take?
 
What obstacles could get in the way? Should I consider
• Doing worksheets?
• Scheduling pleasure, mastery, self-care, or social activities?
• Reading therapy notes?
• Practicing skills such as mindfulness?
• Keeping a credit list or positive experience list?
 
Termination and Relapse Prevention

PREPARING FOR SETBACKS AFTER TERMINATION
As you near the end of clients’ regularly scheduled appointments, ask 
them what automatic thoughts they may have if they experience a setback. Sometimes clients predict they’ll think:
“I shouldn’t be feeling [down] this way”
“This means I’m not getting better”
“I’m hopeless”
“I’ll never be able to get well and stay well”
“My therapist will be disappointed”
or
“My therapist didn’t do a good job”
“CBT really didn’t work for me”
“I’m doomed to be depressed forever”
“It was only a fluke that I felt better before”
Or clients may report an image of themselves in the future, for example, feeling frightened, alone, sad, huddled in bed. Socratic questioning and imaginal techniques can help them respond to these distressing cognitions.
Recognizing the Signs of a Setback or Relapse
Toward the end of treatment, it’s helpful to discuss with clients the 
early warning signs they might experience that indicate they’re starting to become depressed again and make sure to record them in their 
therapy notes. Therapy notes should also contain important points to 
remember and instructions on what to do if their symptoms recur (see 
Figure 21.4).
Clients’ Reactions to Termination
As termination approaches, it’s important to elicit clients’ automatic 
thoughts about ending treatment. Some clients are excited and hopeful. At the other extreme, some clients are fearful or even angry. Most 
have some mixed feelings. They are pleased with their progress but 
concerned about relapse. Often, they are sorry to end their relationship with you. Make sure to acknowledge what clients are feeling and 
help them respond to distortions or unhelpful cognitions.
It’s often desirable for you to express your own genuine feelings, if 
you can honestly say that you regret the ending of the relationship but 
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feel pride in what clients have achieved—­and that you believe they’re 
ready to make it on their own. Some clients say, “I wish you could be 
my friend.” A good response, but only if you mean it, is “Wouldn’t 
that be nice? But then I couldn’t be your therapist in the future if you 
needed me. And it’s important to me to be here for you.”
BOOSTER SESSIONS
Encourage clients to schedule booster sessions after termination; a 
good schedule is after 3, 6, and 12 months. You can give clients the 
“Guide to Booster Sessions” (Figure 21.5); you can also use it to structure these sessions. Knowing in advance that you’ll ask them about 
their progress in doing self-­therapy may motivate them to do their 
Action Plans and practice their skills. And when clients know they are 
scheduled for booster sessions after termination, their anxiety about 
maintaining progress may decrease.
SUMMARY
In summary, relapse prevention is carried out throughout treatment. 
It’s important to prepare clients for an upcoming tapering of sessions 
and the ending of treatment. Particular interventions are important 
at this time, including encouraging clients to do self-­therapy sessions, 
Early warning signs—Sad mood, anxiety, rumination, spending too much 
time on the couch, desire to avoid socializing, letting apartment get messy, 
procrastinating (e.g., not paying bills), trouble sleeping, self-criticism.
What to remember—I have a choice. I can catastrophize about the setback, 
think things are hopeless, and probably feel worse. Or I can look back over 
my therapy notes, remember that setbacks are a normal part of recovery, and 
see what I can learn. Doing these things will probably make me feel better and 
make the setback less severe.
What to do—If some of these things happen, have a self-therapy session. Set 
new goals, evaluate automatic thoughts, schedule activities, do mindfulness if 
I’m ruminating, see what problems need solving, and especially—reach out for 
help—to kids and to Charlie. If this isn’t enough, call Judith so we can decide 
together whether I should return to treatment, probably briefly.
FIGURE 21.4.  Abe’s therapy notes about setbacks.
 
Termination and Relapse Prevention

identifying early warning signs of a potential setback or relapse, and 
creating a plan of what clients can do if they become more symptomatic. Problems in tapering sessions and in termination are addressed 
as any other problems, with a combination of problem solving and 
responding to dysfunctional thoughts and beliefs. Clients’ concerns or 
regrets about ending treatment need to be handled sensitively.
REFLECTION QUES TIONS
What can you do to decrease clients’ distress about termination? What can 
you do to increase the likelihood that they will continue to use their CBT 
skills after termination?
PRACTICE EXERCISE
Imagine that you’re a client who is nearing the end of treatment. Write a 
therapy note that will help you with your anxiety.
1. Schedule ahead—make definite appointments, if possible, and call to 
confirm.
2. Consider coming as a preventive measure, even if you have been 
maintaining your progress.
3. Prepare before you come. Decide what would be helpful to discuss, 
including the following:
a. What has gone well? What do these experiences imply about you? 
About how others see you? About the future?
b. How much do you believe your new core beliefs—at both an intellectual 
and emotional level? How can you keep strengthening them?
c. To what degree are you living in accordance with your values? What 
goals do you have now? What obstacles might arise? How can you 
handle them?
d. What CBT techniques have you been using? Did you have self-therapy 
sessions? Would they be useful to have in the future?
FIGURE 21.5.  Guide to Booster Sessions.
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