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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 37
| Issue : 1 | Page : 21-28 |
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A psychodynamic study on premature termination of therapy sessions
Ta-Ho Yang Ph.D
Institute of Education, National Yang Ming Chiao Tung University, Hsinchu City, Taiwan
| Date of Submission | 03-Nov-2022 |
| Date of Decision | 22-Dec-2022 |
| Date of Acceptance | 24-Dec-2022 |
| Date of Web Publication | 28-Mar-2023 |
Correspondence Address:
Ta-Ho Yang
2F, No. 15, Zi-Yun Street, Xing-Yi District, Taipei 110
Taiwan
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/TPSY.TPSY_9_23
Objectives: In this study, the author compared the psychodynamics of three patient groups before the termination of individual psychotherapy to understand how the patients differed in related themes and their dysfunction levels, conflicts and modes of conflict processing, defense immaturity level, and disintegration levels of some aspects of the psychodynamic structure. Methods: I used detailed process notes of 97 adult psychotherapy patients treated by a psychotherapist in a Taiwan psychiatric hospital. The study patients were divided into three groups: the treatment completers, premature terminators with prior information (informers), and premature terminators without prior information (non-informers), according to their completion of the treatment protocol and offering premature termination (PT) information in advance. I also used the core scheme of Operationalized Psychodynamic Diagosis-2 to evaluate the psychodynamics of the last two sessions before ending therapy. Results: Three groups of patients were not different in primary relational themes and total dysfunctional level of relations, also in conflict significance and mode of conflict processing. The completers and informers were not different in conflict types, but the completers presented themselves higher frequency of “individuation-dependency” conflict and a lower frequency of “Oedipal” and “un-notable” conflicts than noninformers. The completers showed less disintegrated “internal communication” and “external world communication” than informers and noninformers. Conclusion: Premature terminators less communicated internally and externally with the therapist than therapy completers, and non-informers depend less on dyad therapeutic relationships than informers and completers. Psychodynamics represented in preterminate therapy sessions can provide insight into predicting patients' inclination to PT with or without advance information that is difficult to detect in another way.
Keywords: discontinuation, dropout, individual therapy, prior inform
How to cite this article:
Yang TH. A psychodynamic study on premature termination of therapy sessions. Taiwan J Psychiatry 2023;37:21-8 |
| Introduction | |  |
Premature termination (PT) of psychotherapy has various negative effects on patients, therapists, institutions, research, and society at large [1],[2],[3],[4]. But studies showed that 1/4 to 2/3 of patients with PT do not inform the therapist in advance [3],[5],[6]. The question is what has happened during psychotherapy before PT? Only three quantitative studies have investigated the in-session interactional cues between patients and therapist for PT patients, consistently showing that, compared with those who have completed therapy, PT patients engage in relatively less therapeutic exploration in their last sessions [7],[8],[9], and are less likely to discuss their inclination for ending the therapy with the therapist in the final sessions [7]. In comparison with cognitive-behavioral therapy, more obstructive pauses exist in the final stage of the psychodynamic therapy, and all of which are related to insecure attachment and would affect the therapeutic alliance and the treatment outcome [10].
Premature termination from a psychodynamic perspective
If patients seldom express their dissatisfaction or intention to terminate therapy sessions, how can therapists tell their unspoken or preconscious intention? The psychodynamic theorists generally believe that the feelings about the therapeutic relationship will be revealed directly or indirectly from the evolving patient-therapist communication in the therapeutic situation, to pick up the patient's unspoken intention for the therapist to discontinue therapy is possible through analyzing the connotation of in-session interchange [11]. But few empirical studies have explored PT from a psychodynamic perspective. Since few of the empirical studies on PT explicitly acclaim adopting a psychodynamic perspective, the following findings of related empirical studies are summarized by me according to the main schools of psychoanalysis [Table 1]. | Table 1: The major findings about premature termination according to the psychoanalytic perspectives
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Classical conflict theory
No empirical studies specify exactly which conflicts or defense mechanisms are at play with PT.
Ego psychology
Some studies are found that relatively low intrapsychic function can predict non-parallel termination of therapy [12], but other studies have not found so [13]. In comparison with those who have completed therapy, PT patients have less interest in exploring transference and related psychodynamic issues in the final stage of therapy [2],[8],[9],[14]. The ego function of PT patients may be either overprotective or under-coping, making them difficult to cope with the tension and anxiety brought about by the in-depth exploration of psychodynamic therapy.
Object relations
The individual's quality of object relations is associated with refusal or PT of therapy [14],[15]. The quality of object relations also interacts with the interpretive techniques of psychodynamic therapy to influence both the treatment outcome and the likelihood of PT [2]. The interaction of low integrated personality structure and dependent personality is the best predictors of PT [16].
Relational perspectives
Interpersonal concepts have been commonly used in studies of PT, and relatively more studies suggest that PT is related to dependence or counter dependence [17],[18]. Three groups of findings are:
- In patients' experiences of therapeutic relationships, PT is more likely to happen both when the level of interpersonal stress experienced by the patients is relatively low [1],[19],[20] or when the patients have built a cooperative therapeutic relationship, experienced positive emotions, or generated positive expectations for the therapeutic relationship [2],[21].
- In the patient-therapist patterns of behavioral interaction, some studies showed that positive or negative interactions patterns can predict PT, but other studies have mixed results [22],[23],[24],[25].
- In patients' general interpersonal relationships, in comparison to therapy completers, PT patients are likely to show more retaliation/ hostility [20],[26], autonomy/self-liberation/ subjectivity [19],[26],[27], dominance [19], self-assertiveness [27],[28], but less self-blame and self-hatred [27].
Study objectives
The empirical studies usually predict PT from the beginning time of treatment, but scarce study has investigated the psychodynamic features in the final stage of treatment or right before the ending of the session [7],[8],[10]. Nor has any study integrated the various theoretical paradigms of psychodynamic to understand PT phenomenon.
With various psychodynamic perspectives, I intended to identify the in-session psychodynamic characteristics of the patient-therapist interchange, which would indicate the patient's intention to PT or discontinue the psychotherapy or if they would inform their therapist of such intention in advance. To achieve those objectives, I classified patients in therapy into three groups and compared their differences in therapy completers, PT patients with prior inform (informers), and PT patients without prior inform (noninformers).
| Methods | | |
Data source
This study is an archive study, the database consists of the process notes made between October 1999 and January 2005 by a male psychotherapist at a psychiatric hospital in Taiwan. Both during and after each therapy session, the therapist made detailed notes on the patient's verbal and nonverbal communication, as well as the therapist's own verbal communication and inner reflections. The therapist, who was in his 30s during the study period, had 6–11 years of experience in psychotherapy, and was receiving psychodynamic training and weekly supervision. During this period, 4–5 psychotherapists were serving at the hospital's adult outpatient department and took a turn to intake new patients, so each of the new patients was somehow randomly assigned. But the therapy records of the other therapists were too brief or blank to be used in this study.
The therapist conducted time-limited dynamic psychotherapy, generally following the protocols of Mann and Goldman [29] and Strupp and Binder [30], and adjusted to suit the clinical conditions of the hospital. The therapy took place once a week, and 50 min in duration. After the year 2005, due to regulation revisions of Taiwan's National Health Insurance system, the frequency of individual psychotherapy reimbursement was reduced to bi-week and therefore fewer psychotherapies were available weekly ever since. This study protocol was approved by the hospital's institutional review board (IRB protocol case number = TCHIRB-10504112-E, and date of approval = July 28, 2016, with the waiver of obtaining signed informed consent from the patients.
Population
During the aforementioned period, the therapist conducted psychotherapy with 165 adult patients. Because this study takes into account patients who were motivated to receive individual psychotherapy, excluded were the records of the following types of patients:
- Referrals for muscle relaxation or biofeedback.
- Those who refused psychotherapy.
- Those who had an initial evaluation but did not begin the main treatment course.
- Those who had to stop therapy halfway due to obvious external factors.
- Those receiving long-term therapy. The process records of the remaining patients were viewed as suitable and complete enough for inclusion in this study, constituting a total of 97 patients and 982 sessions. The sample consisted of 30 males (30.93%) and 67 females (69.07%), with an average age of 34.74 ± 11.60 years [6].
Variables
The independent variable was the way the patients ended individual psychotherapy. “Therapy completers” refers to the patients who completed the therapy protocol; that is, they attended the initial evaluation, agreed to undertake the main treatment course, appointed at least 12 sessions for the main treatment, and attended the final termination appointment. “Premature terminators” are those who did not comply with the aforementioned protocol; that is, although they began the main treatment, they did not make an appointment for at least 12 sessions; or they did, but failed to attend the final termination session. “Informers” refers to the patients who informed the therapist in advance before discontinuing the therapy. “Noninformers” refers to the patients who discontinued the therapy without prior inform, they either canceled therapy sessions or did not show up, and did not reschedule other appointment or attending remaining appointments [4]. Previous studies showed that these three groups of patients are mostly homogeneous in a broad range of demographic and clinical variables, but different in gender, age, and past treatment experiences, and the most significant differences among groups are their appointment attendance profiles [6],[31].
“Final stage of therapy” refers to the last two sessions of the therapy, because the length of time of two sessions is close to the minimum time required to carry out an Operationalized Psychodynamic Diagnosis-2 (OPD-2) assessment [32]. In addition, compared to a single session, the record of two sessions provides richer information, and the psychodynamic characteristics are less affected by the particular content of a single session.
The dependent variables were various psychodynamic features which cover different perspectives of psychoanalysis:
- The themes of relationship and their dysfunctional levels (the relational perspective).
- The types of conflict, their significance levels, and modes of processing (the classical theory and ego psychology).
- Immaturity levels of defense mechanisms (the classical theory and ego psychology).
- The disintegration levels of eight aspects of the self-object psychical structure (the self-object relations).
The OPD-2 manual provides a detailed description of operational definitions and evaluation considerations for the previous variables [32],[33],[34]. The OPD system has been in use since 1992, is widely accepted by German psychotherapists, and has been translated from German into at least six other languages. Compared with other psychodynamic assessment systems, the advantages of this diagnostic system are that it covers a wide range of psychoanalytic concepts, uses a multi-axis analysis system, has integral relationships among axes, and has high suitability with clinical treatments.
In this study, we used the core scheme of the OPD-2 psychotherapy module instead of the basic interview module [32]. Due to the restricted information of the therapy process record, we did not evaluate the experience of illness and prerequisites for the treatment axis or cyclical relationship dynamics in the relationship axis, both of which are included in the basic module. [Table 2] describes the variables briefly.
Studies conducted in the West have found the OPD-1 system to have good levels of reliability and validity in all axes [29], that the interrater reliability of the OPD-2 axes is between 0.73 and 0.79, and that its axis IV psychical structure has a high degree of criterion-related validity [35],[36],[37]. The interrater reliability of each axis for the Chinese version of the OPD-2 is between 0.48 and 0.65, and the test-retest reliability is between 0.81 and 0.93; axes II, III, and IV have an appropriate constructive validity [38].
Procedures
Two research assistants, both master's students in psychology, classified the way the patients ended therapy, with an inter-rater reliability of Kohen's kappa = 0.92 (p < 0.001), and any discrepancies in the classifications were referred to the investigator for clarification and final decision. In this way, 32 patients (32.99 %) were classified as “completers,” 36 (37.11%) as “informers,” and 29 (29.90%) as “noninformers.”
The assessment of the psychodynamic characteristics was carried out by the investigator and two members of the Taiwan Association of Psychoanalysis, all of whom have doctoral degrees and relevant research experience and attended OPD-2 training before the research. The raters repeatedly read the therapy records to form an overall impression, and then assigned relevant scores according to the OPD-2 system. The inter-rater reliability is presented in [Table 2]. For the sake of rigor, any inconsistencies in the classifications were discussed by all raters until a consensus was reached.
Statistical analysis
An χ2 analysis with Yate's correction of continuity was used to analyze the differences in the primary relationship theme, primary conflict type, and the mode of conflict processing among the three groups of patients. Multivariate analysis of variance (MANOVA) was used to analyze the differences among the three groups of patients in total dysfunctional level of relationship themes, the total significance level of conflicts, the level of defense immaturity, and the disintegration level of each aspect of psychical structure and the global level of whole psychical structure.
For study data analysis, I used International Business Machine Statistical Package for Social Science version 24.0 for Windows (IBM Corp, Armonk, New York, USA). The differences between groups were considered significant if p-value was smaller than 0.05.
| Results | | |
[Table 3] shows the categorical differences among the three patient groups in the primary relationship theme, the primary conflict type, and the mode of conflict processing. The completers presented a higher frequency of “individuation- dependency” conflicts and a lower frequency of “Oedipal” and “un-notable” conflicts than noninformers.
[Table 4] presents the descriptive data for the other psychodynamic variables. [Table 5] shows the MANOVA indicating that significant differences were found between the three patient groups, Pillai-Bartlett trace V = 0.44, F (24, 136) = 1.58, and p < 0.05, and the results of the follow-up tests. The completers showed less disintegration of “internal communication” and “external world communication” than informers and further less than noninformers. | Table 4: The descriptive data of relationship dysfunction, conflict significance, and psychical structure disintegration
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 | Table 5: The follow-up tests of multivariate analysis of variance of psychodynamic variables
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| Discussion | | |
In comparison to the non-informers, the completers were more likely to have an individuation-dependence conflict (p < 0.01), but less likely to have an oedipal conflict (p < 0.01) [Table 3]. This result is consistent with the previous relational finding that PT is related to the ambivalent relationship between dependence/counter-dependence/autonomy/self-liberation [16],[17],[18],[19],[26],[27], but seems to run counter to the object-relational finding that dropout Borderline-personality patients are more likely than completers to be fixed in one of the earlier separation–individuation subphases [15]. According to psychoanalytic developmental and object-relational theory, the individuation-dependence conflict arises earlier than the oedipal conflict, and the nature of individuation-dependence object relations is dyad and preoedipal, rather than triad and oedipal. One possible explanation for this finding is that the noninformers with higher oedipal conflict near the end of therapy might mean they do not struggle with the dyad patient-therapist conflict as much as the completers do and that they might be considering to seek help from other professionals or resources, such as psychiatric treatment, medication or social services and thus forming a triad patient-therapist-other help relationship. But due to the reserved attitude of the noninformers, they denied such feelings internally or did not discuss relevant ideas openly with therapist, but enacted to end therapy to avoid possible therapeutic conflicts. This could be further validated from the below discussion.
Besides the notable conflicts described above, in comparison to the completers, it was easier for the noninformers to be coded as having “un-notable” type of the conflict (p < 0.01) due to a lack of diagnostically precise information [Table 3]. This may be due to insufficient information contained in the process notes or lack of patient-therapist communication, possibly the result of the patients being reticent, reserved or resistance in the therapy sessions, such that the therapist had limited connection with patients and little recollecting material in mind and on paper for interpretation.
“Un-notable” conflict might indicate that the therapist or patients have obscurely sensed obstructive things in therapy but hard to make that conscious in interchange. It reflects some degree of schism between the patient and himself (internal communication), or between the patient and the therapist (external communication). The findings that three patient groups are different in internal communication (p < 0.001) and external communication (p < 0.01) [Table 5] support this result. Taken together, these results are in line with the previous findings that premature terminators engage less in therapeutic exploration in the final therapy session, and avoid discussing the idea of ending therapy [2],[7],[8],[9],[14], and that higher level of obstructive silence during therapy would affect the outcome of therapy [10]. This study further clarified that the internal barriers to communication are stronger than external ones in relating to PT, and the completers have the lowest disintegration level, the non-informers the highest disintegration, and the informers stand in between in both aspects of communication [Table 5].
Unlike non-informers who were discrepant from completers on both object-relational communication aspects and conflict types, informers show no differences from the completers in conflict types, but are more disintegrated in internal (p < 0.001) and external communication (p < 0.01) [Table 5].
To interpret the results from the OPD-2 structure, some continuum variation of dynamic characteristics exists among the three patient groups. It is possible to differentiate the therapy completers from premature terminators of either kind in conflict and object-relational axes rather than relational axes, and differentiating the informing premature terminators from non-informing premature terminators, or completers from informing premature terminators in object-relational axes. But the relational axis is less capable of differentiating three patient groups.
The initiation of therapy starts from patients' dependence on therapist, and the development of therapeutic relation is based on gradual resolution of individuation-dependency and edipal conflict, clinicians are suggested to beware of patients' upheaval of both conflict types and signs of incommunicable internal and external disruption which might lead to ultimate PT. Attention to internal un-communication are prioritized before external un-communication, and, basing on OPD-2, the former includes patient's inability to experience affects, use fantasies and bodily self and the later includes patient's inability to make contact, communicate affect and empathize with others [32].
Study limitations
- Since the data are somewhat dated, the results of this study may not fully reflect the present clinical situation. Although the process notes made during therapy are generally good at capturing both verbal and nonverbal communication, they are not a complete record of everything exchanged in sessions, so it is sometimes difficult for raters to clarify any ambiguity in the notes even after consensus discussion, making it difficult to rate some of the OPD-2 items. All of these reduce the reliability and validity of the results.
- The type of psychotherapy archives used in this study are hard to come by in Taiwan or even other countries, especially the weekly psychotherapy is becoming less common in medical settings in recent more than ten years due to the reimbursement reduction of Taiwan's national health insurance program. Nonetheless, studies carried out in some countries have confirmed the feasibility of old psychotherapy archives for empirical research even the datum were collected between 10 and 20 years ago [15],[39],[40].
- The records used in this study were all made at a particular outpatient clinic of a psychiatric hospital, so the findings may be difficult to extrapolate to other settings. Moreover, the patients were all treated by the same therapist, the limited sampling is a problem and the nature of personality or treatment modality of the therapist may restrain the applicability of the results.
Summary
This study provides psychodynamic clues for psychotherapists to be aware that certain patient is considering to prematurely termination therapy with or without prior inform, so the therapists could respond in a timely and individualized manner with patient.
As the first empirical study using the Chinese version of the OPD system, this study help clarify its cross-cultural applicability, and provide a psychodynamic insight across different perspectives on the PT phenomenon through the analysis of OPD-2 profile.
The use of clinically situated and multiple year psychotherapy process notes in study constitutes an innovative field research approach on the PT of therapy [41]. Analyzing the actual interchange nuances between patient and therapist in the final phase of therapy can be seen as a naturalistic process study with clinical and ecological validity.
| Acknowledgment | | |
The opinions expressed are author's own personal opinions. They are unnecessarily reflecting those of his hospital, current affiliation, of any school of psychodynamic theories.
| Financial Support and Sponsorship | | |
None.
| Conflicts of Interests | | |
The author declares no conflicts of interest in writing this report.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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