Termination of a Long-Term Harm Reduction Psychotherapy Group for Veterans with Substance Use Disorders

Abstract

Termination is a complex and challenging phase of treatment, and termination in group psychotherapy adds additional layers of complexity to understanding and navigating the process. This article discusses the experiences and lessons learned at a large VA addiction treatment center during termination of a long-term harm reduction psychotherapy group. Using themes identified in the literature as a conceptual framework, this study analyzes the dynamics that unfolded throughout the course of group termination. Planning, development, and implementation of termination interventions are reviewed. Client and therapist reactions are also discussed.

INTRODUCTION

Endings and farewells are inevitable and potentially difficult. As the final phase of therapy, termination is a complex and often challenging stage of the therapeutic process (Fieldsteel, 1996; Flapan & Fenchel, 1987; Schaffer & Pollack, 1984; Schermer & Klein, 1996). Accordingly, we turned to the literature for guidance on the termination of our psychotherapy group. We were surprised to find that there was a scarcity of literature on this topic, especially pertaining to our particular type of group. Our group appeared unique in several ways as compared with the ones described in the literature: (a) the group operated for eight years with an open and “rolling” enrollment; (b) when appropriate, some group members also participated in other addiction treatment services; (c) the group weathered many transitions since its inception, including changes in membership, leadership and meeting venue; and (d) active substance use was tolerated, with the exception of overt intoxication while in group. Considering the limited literature on group termination in general, and the unique group dynamics at play in our group, we believe our experience and critical observations can make a valuable contribution to this topic.

LITERATURE REVIEW

It has been noted in the literature that there is a paucity of articles on terminations (Bernard et al., 2008; Maholick & Turner, 1979; Martin & Schurtzman, 1985; Schaffer & Pollack, 1984). Furthermore, investigation of termination in group psychotherapy has remained sparse even with some increase in attention to individual treatment termination (Fieldsteel, 1996). The absence of clinical guidance in the literature is surprising, as termination is an inevitable, complex, and challenging phase of group psychotherapy that warrants thorough analysis (Flapan & Fenchel, 1987; Mangione, Forti, & Iacuzzi, 2007; Schermer & Klein, 1996). One author pointed to the complexity of the group therapy termination process itself as a possible reason for the small number of published articles (Fieldsteel, 1996). Within the small subset of papers on terminations in psychotherapy groups, only a handful of articles discussed therapist-initiated terminations in long-term therapy groups (e.g., Bernard et al., 2008; Fieldsteel, 1996 & 2005; Mangione et al., 2007; Schaffer & Pollack, 1984). Another article discussed replacement of a group therapist, which is not technically a termination (Lewis, 2016). In summary, we did not find any articles that specifically addressed our particular clinical situation, to wit, therapist-initiated termination of a long-term psychotherapy group with open enrollment. As a result, we created an integrated approach by combining insights and experiences shared by other therapists in the several relevant papers that we found.

DESCRIPTION OF GROUP

History

Our harm reduction (HR) group was held in the Addiction Treatment Center (ATC) of a large Veterans Affairs (VA) hospital. It met weekly with rolling admission beginning in 2007. The group was created to provide support and engagement for Veterans whose recovery goals did not coincide with the predominant abstinence-based treatment offerings in ATC at the time. The group was process-oriented as opposed to a structured education group and provided psychosocial support to veterans who did not otherwise qualify for abstinence-based psychotherapy groups in the clinic. Members attended the group on a drop-in basis, and some also received adjunct psychiatric care and/or individual psychotherapy. As the first mixed-goals group in the clinic, the group offered a holding space, both psychologically and administratively, for veterans whose unique recovery goals did not fit into the existing programming. For many veterans, this group was one of the first places in the clinic, or in the VA hospital more broadly, that seemed to accept them unconditionally, regardless of their abstinence status and goals in treatment. This seemed important to them, not only because have they been stigmatized by society at large, but also because the abstinence-based programming of the ATC may have also inadvertently marginalized them due to their goals in recovery.

Contract

Prospective new members of the group attended an individual orientation session with the group therapists to clarify expectations, which included the following: (a) respecting the diversity of recovery goals amongst the members of the group; (b) maintaining the confidentiality of the group; (c) refraining from attending group while under the influence of a substance; and (d) not acting out violently or threatening violence. Unlike many other groups, contact outside of group was not only not prohibited, but rather it was encouraged. The members were also informed that, should they decide to be completely abstinent and desire to be in an abstinence-based group, we were happy to talk with them further and, if warranted, to refer them to a new treatment team or group better suited to their new recovery goals. Overall, members through the years observed the above guidelines consistently, and they effectively utilized the group to gain and provide empathy and support to one other. In addition to being part of a community, members utilized the group to receive validation for their unique recovery goals, access support and guidance from fellow members on a similar journey, and participate in change talk to clarify/resolve their ambivalence. When needed, members also accessed therapists for additional support, such as referrals to inpatient detox, residential treatment, contingency management, and medication-assisted treatment.

Community

Although this was a drop-in group, certain members attended the group with regularity. For these core members, this group became for them a community of sorts. Given their long history of co-occurring substance use and mental illness, many of them have strained or broken relationships with their families and other sources of social support. Furthermore, their status both as active substance users and as disabled, low-income individuals contributed to their ongoing marginalization in society. In this group, however, they were accepted and valued by each other and by the therapists. Here they experienced a reprieve from a world that seemed cold and indifferent at best, and discriminatory and cruel at worst. In fact, the sense of alienation and isolation members experienced were frequent topics of discussion. While we strove to build universality (Yalom, 1970) through these sessions, we also gently challenged them to examine their belief systems and to try to establish meaningful relationships and social networks outside of the group. Some members made moderate progress in this area, as evidenced by developing friendships with other members of the group and providing support and companionship to each other outside of group. These successes were highlighted in the group to emphasize the possibility and importance of developing new social supports. We encouraged members to expand on that success outside of group, as most of them continued to have a difficult time building relationships with people in the community.

Evolution

As a core group of members began to maintain more consistent attendance, the group evolved from a temporary support group to a long-term process group. As the group changed, the content of discussions shifted from information gathering (e.g., obtaining housing, applying for benefits, navigating the VA system) to emotional support. The growing cohesiveness was apparent, and members gradually began talking about how important this group was to them, and how their interactions in group were often the anchor and highlight of their week. With increased cohesiveness and trust, our facilitation shifted from content to process, which we utilized to help members identify and work through difficult feelings within the group. Members came to appreciate the processing that they were able to do in this group and the resulting deepening of their relationships to one another and to the group as a whole.

Ending

The evolution of the group unfolded even as there were changes in the broader philosophy of the clinic. Over time, the ATC moved closer towards a harm reduction (HR) treatment model, with each treatment team offering HR options tailored to veterans’ unique recovery goals (which may or may not be abstinence from all substances). As a result, clinicians and the clinic’s leadership began to wonder whether this group was still serving a purpose, given the HR approaches readily available throughout the program. After some deliberation by the therapists and clinic leadership, it was agreed that the group had outlived the purpose for which it was designed, and that termination was appropriate.

At the time we decided to terminate the group, there was a core group of seven members who attended consistently over the past five years. Although this core group of members generally maintained stability, such as consistent housing and ready access to basic needs, they generally reported having minimal social outlets, noting that the group was their primary source of support. We gave this dynamic a great deal of consideration while contemplating the discontinuation of the group. For instance, members’ lack of social support was one of the key factors we considered in anticipating and responding to their needs during and after the termination process. Due to their limited social networks, they were unlikely to have meaningful opportunities to process their termination experience outside of this context. Although some members did meet socially outside of group, there was not a process component to those meetings. This required us to utilize and facilitate the remaining group sessions in very intentional ways, i.e., ensuring that termination was a topic for each session. Their lack of social supports also meant that termination of this group needed to be followed by initiation of membership in another group, so that the members could continue to receive the support they needed by building relationships in a new context. With this in mind, we focused on the transition needs of members throughout the process by: (a) checking in with them about their plans and preferences for transition; (b) meeting with them individually as needed to identify unique needs; (c) facilitating referrals to new groups; and (d) providing care coordination to connect members to their new therapists and groups. After the group ended, all members, except one who elected discharge from the clinic, transitioned to a new weekly group.

Prior to announcing the termination, the co-therapists met on several occasions to strategize about the termination process and formulate aftercare plans. The factors we considered included timing (when to announce the termination and length of time between announcement and actual termination), aftercare disposition, and potential crises that may arise in the context of termination. We also explored strategies to engage patients in processing the termination, as well as ways to develop a termination ritual. In consideration of the above, we decided to give the group a six-week period to process the termination collectively, as well as identify and implement a unique aftercare plan for each patient. As part of the termination process, a range of experiences and dynamics were observed in clients (and in ourselves), consistent with multiple themes noted in the literature.

THEMES

Since our literature review yielded no model of termination methods pertinent to our particular group, we highlighted themes among the relevant articles we reviewed to provide a framework to understand and navigate the termination process. We were guided by attentiveness and responsiveness to consistent themes that emerged from the literature on the termination phase: birth, death, and loss; regression and progression; ethics; and termination rituals (Mangione et al, 2007; Flapan & Fenchel, 1987; Shaipro & Ginzberg, 2002; Wardi, 1989; Yalom, 1970). Given the psychotherapeutic approach in which we were trained, we connected with these themes and found them to be compatible with the therapeutic lens and approach we had utilized in this group over the years. We will discuss each theme below, including findings in the literature and how these phenomena manifested in our termination process.

Birth/Death/Loss

Yalom (1970) characterized termination as a duality of birth and death—the birth of the group contains within it its death, and the death of the group sets forth the birth of a new life. The “terror of death symbolized by the breaking-up of the home/group” can be intensified as group members confront the impending loss of the group (Wardi, 1989, p. 91). This grieving process, when successfully worked through as an integral part of the termination, provides patients with the capacity to resume rewarding lives and to establish new relationships, as well as prepares them to confront other terminations in their life (Maholick & Turner, 1979; Schermer & Klein, 1996). In order to fruitfully work through this grieving process, the wide range of reactions to the intensely emotional themes of loss, death, and separation must be addressed openly in the group (Flapan & Fenchel, 1987). If this process is bypassed or compromised, Yalom and Leszcz (2005) argue, this may even “constrict” the clients’ future growth.

The core members of our group were present when termination of the group was announced. Themes of birth and death were apparent in the discussion from the beginning and continued throughout the closure process. Members reflected on the “birth” of meaningful relationships within the group context and the feelings of connectedness. Many noted the absence of meaningful relationships outside of group as part of the threat posed by termination. The majority of core members self-identify as “loners” or indicate general distrust of and detachment from others, due to past experiences as well as cultural expectations of men and members of the military. Many group members shared doubt that “birth” of new relationships, akin to the ones formed in this group, would occur again outside of this formal context. The fear appeared to intensify some members’ sense of loss and “death.” However, as the termination process proceeded, with time and attention given to these feelings, some members began to show signs of hope and resilience. This was particularly apparent with a member who simultaneously began attending a new Continuing Care group in the clinic while participating in the termination of our group. He reported that connecting with members in the new group was much less difficult than expected.

Regression/Progression

The literature on termination consistently points to themes of rejection, abandonment, loss, and anxiety emerging during this phase (Fiedsteel, 1996; Flapan & Fenchel, 1987; Mangione et al., 2007; Shapiro & Ginzberg, 2002). In the case of “forced” terminations where therapists unilaterally end treatment, those complex emotions can be even more intense and difficult (Chernus, 2015). Since terminations evoke “mini versions of the death-and-dying theme” (Schermer & Klein, 1996, p. 111), the anxiety may manifest as regression during the termination phase. Wardi (1989) noted this as a “constructive termination regression” which should not be superficially interpreted as the group regressing back to a primary dependence phase (p. 87). Rather, given the short duration of the symptoms in this context, and the limited degree of conflict, ego functioning is present in other areas. As members work to accept the death of the group and their independence after the group, they are presented with an opportunity to use the tools and insights gained during the group. “The work done in the process of terminating therapy reaffirms for the patient that they have the skills to continue growing on their own” (Fieldsteel, 1996, p.33).

After termination was announced in our group, conversations in each remaining session consistently moved in and out of the topic of termination and members’ feelings around it. As this was a difficult topic, ample space was provided for members to approach the subject at their pace. Members often drifted in and out of the topic, veering off into other, more comfortable, topics. However, they always came back to the subject at hand and continued to process the sadness and fear associated with group termination. Before long, a bimodal distribution of reactions to the group’s end became apparent: fear of the unknown versus its acceptance. Most members re-assumed their accustomed roles in the group (e.g., victim, problem-solver, caretaker, etc), whereas prior to the announcement of termination they appeared more willing to experiment with new behaviors within the group.

Themes of change and transition continued to weave through the group content. Over time, some members seemed to be more accepting of the termination; they discussed various ways they have embraced change in their lives. Members shared progress of their acceptance of this change and their transition into a life beyond this group. Members also discussed their mutual intention and desire to stay connected with one another and brainstormed ways to achieve this following termination. The initial regression eventually gave way to progression, as members shifted to a new perspective that they may have an opportunity to grow and learn in the context of this window of change. An instance of regression followed by progression was demonstrated by one member in particular.

Vignette

Kurt, an isolated disabled combat Veteran with a tendency towards externalization and avoidance, regressed to his known coping strategy by binging on alcohol and missing group for several weeks. When he returned to group, he was able to process his grief around loss of the group more readily. By the end of the termination process, he accepted the offer for transfer with optimism. This shift was made possible by the ongoing support from two fellow members, who shared the success they have had in their transition to new groups.

Ethics

Mangione et al (2007) highlighted the importance of a termination process grounded by ethical fitness and awareness, and they noted that “explicit preparation, including discussion of endings, is crucial to ending well in groups” (p. 29). Findings from their survey indicated that a significant majority of therapists agreed that termination should be jointly decided by the therapist and group, and should ideally be a discussion from the beginning. Given that patients with substance use disorders are part of a stigmatized and marginalized group, ethical considerations are even more pertinent in the context of self-determination and advocacy.

As members did not have full choice in whether this group was going to be terminated, this created an ethical dilemma for us as therapists. We resolved this ethical dilemma by maximizing choice within a context of limited options, and by using this process as an opportunity to facilitate growth and transformation. Indeed, this process is not unlike the work that is often done in this group—how to cope with situations not within our control.

Although members did not share decision-making around termination, we involved them in the process at the earliest stage possible and offered them choice and support around treatment options post-termination. Group members were informed of the decision and rationale to terminate the group six weeks prior to the expected termination date, and each of the remaining six weekly group therapy sessions was devoted to processing this termination and providing support to one other. Members were relieved to learn that they had nearly two months to process the loss and consider other treatment options. Furthermore, they felt supported and held when informed that they had access to individual sessions with the therapists outside of group for additional support, including exploration of post-termination treatment disposition.

Termination Ritual

The challenges and powerful feelings that occur during termination can be used constructively. Patients can benefit from termination rituals and extract significant meaning and therapeutic benefit from them when they are designed by the whole group (Shaipro & Ginzberg, 2002). With guidance from the therapist, the group can engage with the ritual to collectively learn from the process of ending (Bernard et al., 2008). Furthermore, authors have noted that patients seem to benefit from the genuine ways in which therapists exhibit grief and struggle in the context of termination (Martin & Schurtzman, 1985; Schermer & Klein, 1996). Termination rituals may provide the context in which this authentic grieving can take place.

Upon announcement of termination, our group members were invited to craft a termination ritual or ceremony collaboratively. However, group members were unresponsive to this offer. We revisited this topic several times in other sessions, but members remained indifferent. As we believed in the symbolic and therapeutic importance of this process, the co-therapists met several times outside of group to devise and coordinate a termination ritual. During the final group session, each member and both therapists were provided with an ATC coin (a metal coin embossed with the words “ATC Winner Circle” on one side and the Serenity Prayer on the other). Each person present took turns placing their coin on the table and then sharing what they gave to the group through the years. Next, each took turns retrieving the coin from the table and sharing what they felt they had received from the group. Members shared a common theme of both giving and receiving friendship, support, and encouragement. Members expressed gratitude toward the therapists. We became tearful while sharing. Seeing their therapists cry seemed to have an impact on the members, one of whom stated, “I didn’t know the group affected you guys like this!” The termination ritual appeared to validate the collective group experience, honor the importance of this group to involved members, and act as a bookend to the experience.

DISCUSSION

Ethics

Given the challenges of termination, especially therapist-initiated termination, it is important to keep ethics at the forefront of the process. Ideally, termination should have been discussed at the outset of the group, so clients could make an informed decision around whether they wished to participate in a group that would eventually end. This would have honored client self-determination more fully and provided more time for clients to digest the trajectory of group therapy and engage effectively with the rich, complex experiences inherent in the process. It is important to note, however, that this group has evolved over time to become something other than what had been envisioned from the outset (i.e., a temporary support group as opposed to an ongoing multi-year process group). Given the unexpected nature of this evolution, we did not foresee a need to consider termination at the outset of the group, and therefore did not include a discussion of termination as members started the group.

Although members sometimes pondered the purpose of the group and what they would do hypothetically if the group disbanded, the decision to terminate was not led by the group. We acknowledge that it was not ideal that members did not have a say in whether the group was going to end. It was an administrative decision and, although it was sound and efficient from a managerial perspective, it was sad and difficult to implement from a clinical standpoint. As therapists who walked alongside these veterans for years, we struggled with the cognitive dissonance of balancing the needs of the organization with those of the clients. We had to hold this dialectic in our hearts, recognizing that it is not always possible to give clients everything we wish to give. At the same time, within this space of limited clinical options, we strove to provide the best care possible for the members in supporting them through this transition.

Given that members did not have control over whether the group ended, we tried to maximize choice in other areas of the termination. For example, we included them in the discussion around the termination date and length of time devoted to processing the closure of the group, and we offered increased access to individual sessions to any member who needed additional support. To ensure that members can have the continued support of a group community, we encouraged and coordinated transition from this group to another Continuing Care group.

Termination Ritual

We did not give much thought to implementing a ritual until the final stages of termination. If this intervention had been part of our therapeutic “toolbox” from the outset, we would have been able to conceptualize and design a ritual that was most fitting for the unique characteristics and needs of the group, as well as facilitate the input and collaboration of group members at an earlier stage of termination. This may have resulted in a termination ritual that was more personally meaningful to the clients and increased their sense of self-determination and self-efficacy. Furthermore, it may have been helpful, in the absence of ideas from members, to offer several options for them to choose from.

Considerations for Timing

The veterans in the group required varying lengths of time for closure and transition. Those members with more psychosocial connections outside of group appeared to need only one or two sessions in order to terminate, with minimal apparent need for extended closure. It is difficult, however, to fully assess whether these members would have benefited from the full length of time designated for group closure as they may have exited the group sooner due to inability to tolerate the psychological process. For instance, members who appeared to transition easily had historically demonstrated difficulty in requesting support from the group (and were often idealized by fellow group members for their purported success), so it is unclear whether their ease of transition was merely superficial. The vignette below illustrates some of the differences in the process that we encountered.

Vignette

Tom, a single, hardworking, and sarcastic man without adequate financial means, joined the group around the same time as Eric, a married, financially secure, well-read grandfather. Both were of similar age, but life experiences contributed to different relational styles and participation in the group from start to finish. When termination was announced, these differences were highlighted. Tom was generally quiet but when he did speak it was with sarcasm, a reflection of his long-standing coping strategies. Eric responded with pensiveness and expressed a need to process deeply, despite his stated neutrality regarding continued participation in the group. Consistent with his previously established patterns, Eric attended two more groups, announced that he had reaped full benefit, and that he planned to terminate early and transition to his other group. Eric maintained his role in the group as independent and capable via his abbreviated participation in the termination process. Tom attended and engaged in all the termination groups despite his enrollment with a new treatment group, maintaining his role both as a dedicated member and one who is more comfortable with his attachment to the group.

Other members remained in the group for the duration but missed several sessions midway after some regression to old behavior, presumably triggered by transition and the prospect of loss. For example, one member coped with the impending termination by regressing to heavy drinking, but he was able to return for the final termination session. Others attended all group sessions, from the announcement of termination until the final group. Interestingly, members who overlapped the close of this group with the joining of another group had an easier time identifying specific benefits received from group and future aspirations for their new group.

Therapeutic Stagnation

Upon reflection, the experience of termination of our long-term therapy group brought to light some interesting questions pertinent to group therapy termination generally. When, for example, does the continuation of a group result in therapeutic stagnation? Ribeiro et al. (2014) noted that ambivalence in shifting from a maladaptive self-narrative to a more “innovative” and flexible one may be linked to therapeutic stagnation. By staying in the group, members may have in some ways postponed making the shift to a new self-narrative and possibly adopting new behaviors. Several members appeared to make long-awaited changes and/or gained insights which may have been previously halted by the indefinite continuation of the group.

Vignette

Chris, a single middle aged man, often resisted making changes even as he often complained about feeling stuck. He initially voiced concerns about transferring to a new group, but ultimately he was the first member to make that move. Chris fully embraced his new group and displayed a new sense of agency and confidence that had not been present before. He became a champion for the transition process, inspiring and giving hope to other members.

Members who transitioned to another group simultaneously recognized that the skills they had built, often over a course of years, were transferrable to other contexts. Group members also reflected on progress around treatment goals, some noting that their presenting problem was actually resolved long before termination. (Some members had already achieved years of abstinence, even as they continued their active participation). It is difficult to tell whether these realizations would have occurred sooner. In hindsight, this was another indication that the group may have run its course, not only administratively but also clinically. Although therapeutic stagnation was not a conscious part of our decision to end the group, it appears that it reinforces the administrative direction for termination. In the future, it would be interesting to consider ways to assess when a process group has achieved maximum therapeutic value (Ribeiro et al., 2014; Yalom, 1970).

CONCLUSION

When the members of our group initially learned of its termination, their reaction was marked by a sense of shock and abandonment. However, through the supportive six-week termination process, members came to accept the inevitability of change, as well as acknowledge the progress they had made in their own growth and recovery. Although members did not actively participate in designing a termination ritual, they appeared to benefit from the intervention that therapists developed and facilitated. In addition to providing a tangible sense of closure, the termination ritual offered a formal opportunity for members and therapists to share what they have given to and received from the group.

In terms of formulating clinical practice guidelines around group termination, it was interesting to note that there was a lack of articles in the literature around this subject, particularly in regard to long-term psychotherapy groups, and we had to craft our approach from a variety of sources. The approach provided a framework for us as therapists to identify, monitor, and address issues common to terminations. At the outset, we did not know what to expect from this integrative approach. As the termination process unfolded, and after it concluded, we came to appreciate how a thoughtful strategy, synthesized from the literature’s collective wisdom, can guide us all—therapists and members—through complex landscapes of this rich and rewarding experience.