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 Cognitive Behavior Therapy: Basics and Beyond

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. Cognitive Behavior Therapy: Basics and Beyond

• 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? Cognitive Behavior Therapy: Basics and Beyond

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. Cognitive Behavior Therapy: Basics and Beyond

• 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 Cognitive Behavior Therapy: Basics and Beyond

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. Cognitive Behavior Therapy: Basics and Beyond