Article Review

ORIGINAL PAPER

Au Revoir: An Attachment and Loss Perspective on Termination

Karen Zilberstein

Published online: 23 May 2008

� Springer Science+Business Media, LLC 2008

Abstract Traditional views of psychotherapy hold that

termination allows both for a consolidation of therapeutic

work and an opportunity to work through issues of sepa-

ration and loss. Such a view suggests not only that those

issues will resolve in treatment, but also that endings are

inevitable, permanent, and that the feelings invoked can

and should be mastered and worked through. Recent

research on termination, attachment, loss and grieving

suggests a different conception. Consideration of that

research can better ground therapists in more nuanced

techniques for ending treatment in both child and adult

psychotherapy.

Keywords Psychotherapy � Termination � Attachment � Loss � Coping

Introduction

Traditional views of psychotherapy, especially those

influenced by psychoanalysis, hold that the termination

phase allows both for a consolidation of therapeutic work

and an opportunity for therapist and client to work through

issues of separation and loss including mourning of those

losses (Cangelosi 1997; Frank 1999; Levinson 1977;

Novick 1997; Timberlake and Cutler 2001). In child ther-

apy, this premise is based on the view that therapy comes

to a natural end when the child’s developmental course

becomes normative and the child’s parents are able to

function in ways that support optimal functioning (Sandler

et al. 1980). In adult therapy, criteria are similar, but

slightly different. Both remediation of symptoms and

ability to function independently, that is to resume a

developmental course of separation and individuation, are

seen as goals. Such a conception constitutes a tall working

order. Few therapies do, in fact, end in such graceful

conclusions (Golland 1997). This is in part because such a

view of termination suggests, by its very definition, not

only that those psychological issues will resolve in treat-

ment, but also that endings are inevitable, permanent, and

that the feelings invoked by ending and loss can and should

be mastered and worked through.

Recent research on termination, attachment, loss and

grieving suggests a different conception. It is the thesis of

this paper that an understanding of that research can better

ground therapists in more nuanced techniques for ending

treatment for both children and adults. Termination con-

siderations should be made not just on the basis of

symptom resolution and developmental progress, but also

according to the client’s relationship or attachment to the

therapist, the other types of attachments in the client’s life

and the client’s history of previous losses. The topic will

also be explored through two case vignettes.

Termination as a Phase

Particularly in psychoanalytic orientations, termination is

an important piece of work that pervades the entire treat-

ment (Frank 1999; Novick and Novick 2006). That theory

holds that the resolution of loss and separation issues that

emerge at this time leads to a greater sense of autonomy

and individuation and are seen as critical to a completed

therapy (Bembry and Ericson 1999; Frank 1999; Levinson

1977). Such autonomy remains a crucial goal in adult work

K. Zilberstein (&)

The Children’s Clinic, 17 Brewster Ct, Northampton,

MA 01060, USA

e-mail: [email protected]

123

Clin Soc Work J (2008) 36:301–311

DOI 10.1007/s10615-008-0159-z

as the client internalizes the therapist’s self-reflective atti-

tude thus enabling independent functioning (Novick and

Novick 2006). It is generally believed that the avoidance of

mourning and defense against loss greatly interferes with

the client’s ability to separate and internalize the therapist

and the self-analytic function that is so necessary for

autonomy (Golland 1997; Novick and Novick 2006; Sug-

arman 2006). Certainly there are dangers to avoiding

losses, but it is not clear whether such a magnified focus

upon loss, both through an emphasis on the finality of

termination and through the weight placed on grief issues

during termination is really warranted.

Returning to therapy post-termination was initially seen

as a sign that the psychotherapeutic work was incomplete.

This stance has since been questioned. As Wachtel (2002)

states, ‘‘the very ‘reality’ that termination is something

final that the patient must come to terms with is an artifact’’

(p. 375). Clients return to therapy and former therapists for

a variety of reasons, including new issues that arise

developmentally (Malin 1990). As such, an understanding

that termination does not necessarily entail a final ending

and loss has recently taken root. Many now note that the

therapeutic relationship often endures post-termination. In

one study, a full two-thirds of analytic clients contacted

their therapist within 3 years of termination (Craige 2002).

Noting that feelings about the therapy and therapist con-

tinue after formal therapy ends, the term ‘‘post-

termination’’, somewhat of an oxymoron, has emerged to

connote this stage (Craige 2002). It suggests that leaving

therapy is not an easy task and that termination does not

truly entail the finality it signifies.

Truly mourning the therapist is a large and painful task,

one that eludes even those in long-term analysis (Craige

2002). And those clients with histories of previous and

painful losses often have the most difficult time with this

undertaking (Golland 1997; Hill 2005; Levinson 1977).

Even clients without substantial loss issues often respond to

termination, whether it is planned, forced or premature

with a number of reactions and emotions. Notable amongst

these are loss, regression, acting out and avoidance (Lev-

inson 1977: Siebold 2007). Whether or not these reactions

are inevitable is unclear. Both Craige (2002) and Roe et al.

(2006) have found that termination is more likely to be

experienced as a loss or rejection when clients feel they

cannot return. This produces more symptoms in the client,

including feelings of anger, rage, anxiety, mourning and

abandonment.

Termination boundaries in child work have always been

less rigid. There is a long-standing recognition that chil-

dren, because their development is incomplete, may need

to return to therapy at a later date and that tapering sessions

toward the end or allowing for check-ins after termination

is permitted (Cangelosi 1997; Chazan 1997; Sandler et al.

1980). However, an emphasis on separation, loss and

mourning the therapeutic relationship continue to be seen

as goals (Bembry and Ericson 1999; Cangelosi 1997;

Timberlake and Cutler 2001). Whether such working

through could or should be a goal of treatment remains an

open question (Tyson 1996). Children grow within

attachment relationships, not by leaving them, thus con-

traindicating a model that stresses detachment (Shapiro

1995). In addition, individuals with prior experiences of

attachment difficulties and extreme losses may or may not

have the capacity to work through those issues. These

clients often have significant difficulties with emotional

and behavioral regulation (Schore 1997; Zilberstein and

Messer, in press). Successful therapies for these clients

may increase those skills, but not necessarily make them

impervious to stresses and losses. In fact, they often remain

quite vulnerable to those issues. Regressions can be vivid,

dangerous and extremely dysregulating rather than func-

tioning as experiences that help with working through. For

them, and for others with attachment vulnerabilities, the

task of ending therapy may need to be formulated

differently.

While many clients do experience significant feelings of

loss upon termination, other feelings including pride,

accomplishment and self-respect are also prevalent (Baum

2005; Hill 2005; Wachtel 2002). Highlighting those feelings

for clients can prove helpful. When the accomplishments

and ongoing connection to the therapist are acknowledged,

the termination experience is eased (Baum 2005; Hill 2005;

Wachtel 2002). This makes sense given what we know about

attachment, loss and mourning.

Research on Attachment

Attachments are now recognized as an essential and

important aspect of development. Attachments stem from

the biological need of an infant to procure protection and

nurturance in order to survive. They can be characterized

as secure, insecure—with subtypes of ambivalent/preoc-

cupied and avoidant/dismissing—or disorganized

according to the type of physical and psychological avail-

ability and security the relationship provides. The more

secure the primary relationship, that is, the more physically

and emotionally available the attachment figure, the more it

provides a ‘‘secure base’’ from which the child safely and

calmly explores both his internal and external world.

Insecure attachments stem from experiences with caregiv-

ers who are emotionally unavailable or only intermittently

responsive, causing the child to either avoid attachment

experiences or continuously seek them out (Ainsworth

et al. 1978). Disorganized attachment derives from repe-

ated experiences of the caregiver being frightened or

302 Clin Soc Work J (2008) 36:301–311

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frightening, so that the child gains no organized ability to

cope with attachment needs and feelings (Main and Solo-

mon 1990). The initial attachment to a caregiver then

serves as a developmental springboard for the individual.

Many skills, in particular affect regulation and social

cueing, emerge from the attachment relationship, which are

then transferred to other experiences and bonds (Schore

1997; Simpson and Rholes 1998). When distressed, an

individual returns to the attachment figure for soothing and

refueling, which allows for moderation and regulation of

emotions.

Attachments remain operative throughout life, although

both primary and secondary attachment figures may change

over time. Teachers, spouses and therapists may all become

primary or secondary attachment figures for an individual,

if they serve the function of providing emotional nurtur-

ance and felt security. An individual may possess multiple

attachment figures, which does not degrade the security of

attachment to other figures. In fact, one positive relation-

ship helps foster others (Hopkins 2000). In this regard, it is

not necessary to give up or mourn an attachment figure in

order to make a new attachment (Klass et al. 1996). Clients

do not need to separate from therapists in order to invest in

other meaningful relationships.

In many ways, the therapist does act as an attachment

figure or at least a secondary attachment figure for the

client (Farber et al. 1995; Hill 2005; D’Elia 2001; Parish

and Eagle 2001; Sterlin 2006). Treatment activates the

attachment system in that it replicates many of the char-

acteristics of the early parent–child bond. It creates a

‘‘secure base’’ through boundaries, attunement, reflective

functioning and emotional communication that allows for

exploration of various issues. The more analytic the work,

the more those early relationships and attachments are

represented, understood and resolved in the transference.

The therapeutic relationship thus remains key to thera-

peutic success. The quality of the therapeutic relationship

appears to be one of the major indicators of change,

whereas problems within that relationship constitute the

primary reason treatment ends prematurely (Garcia and

Weisz 2002). It is precisely because the therapeutic rela-

tionship is so important that ending is so difficult (Levinson

1977; Siebold 2007).

Attachment relationships, once established, become

internalized as working models (Bowlby 1980). In therapy,

these working models effect how the client attaches to,

works with and leaves the therapist. They also determine

how the client attends to, organizes and interprets infor-

mation, particularly material related to threat and/or the

attachment figure (Edelstein 2006; Rowe and Carnelley

2003; Shilkret 2005; Simpson and Rholes 1998; Vermigli

and Toni 2004). While research does not currently exist on

how clients with different attachment styles approach

termination, there is some evidence that attachment styles

influence how they leave relationships in general and

handle issues of loss.

Secure individuals have the most flexible approach to

emotional material, including issues of loss. They have

access to their affective reactions and are able to think

about and act upon those responses in an organized man-

ner. This does not mean that they do not feel distress.

Bereaved adolescents with strong attachments feel great

distress for many years (Klass et al. 1996), but they possess

better skills for coping with such reactions. Secure adults

facing the break up of a romantic relationship, the loss of a

job, the death of a loved one and deceit in relationships

experience less distress and better ability to cope than

others because they employ adaptive behaviors, can talk

directly about the issues and deal better with conflict

(Hobody et al. 2007; Jang et al. 2002; Kachadourian et al.

2004; Sbarra 2006). Those qualities also allow them to

move on (Sbarra 2006; Stroebe et al. 2005). Secure clients

would thus approach termination with an understanding of

both the gains and losses inherent in this phase, an ability

to regulate and organize their responses, and the capacity to

move on and cope with their level of distress.

Ambivalent or preoccupied individuals tend to fear

rejection and react with heightened emotionality to events,

particularly ones they perceive as distressing. This

increased emotionality occurs, in part, because cognitive

understandings that would help them evaluate threats and

situations are not well integrated. Ambivalent clients may

delay termination because they cannot disengage emo-

tionally from the therapist (Holmes 1997). Studies on how

they cope with other losses indicate that these individuals

show the greatest distress and depression and the greatest

difficulty moving on as they tend to ruminate on the loss

rather than focus on adaptive solutions (Sbarra 2006;

Stroebe et al. 2005; Wayment and Vierthaler 2002). Often

rather than address problems directly, they talk around the

issue (Jang et al. 2002), thus seeking much support but

little resolution (Hobody et al. 2007). Upon termination,

these clients may thus become clingy, extremely upset, and

preoccupied by rejection and loss, thus having trouble

engaging in other relationships. Therapeutic tasks with

these individuals include helping them understand the

positive gains and achievements that the ending signifies

and to aid in the establishment of internal coping skills and

environmental supports.

Avoidant or dismissing clients tend to limit closeness

and evade emotional material. They approach attachment

information cognitively, thus avoiding emotional process-

ing and memory for significant relational events. Avoidant

clients are likely to terminate too early (Holmes 1997;

Shilkret 2005) and to deny the impact of termination by

dismissiveness toward the therapy and therapist. When

Clin Soc Work J (2008) 36:301–311 303

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responding to losses of other relationships or jobs, they

tend to avoid grieving, dismiss attachment needs and rely

more on themselves than others (Davis et al. 2003; Field

et al. 2005; Stroebe et al. 2005). While those tactics are

partially successful in decreasing grief and depression,

these individuals experience their grief through greater

somatization (Wayment and Vierthaler 2002). It is thus

clear that defensive exclusion of emotional material

impacts their ability to cope. Therapeutic tasks with this

population involve helping them understand the impor-

tance of the therapeutic relationship, maintaining that

connection and learning to tolerate and feel empathy for

their feelings and those of others. Ongoing relationships

and connections can be promoted through the use of

memories, recollections and photos (Field et al. 2005). For

these clients, self-disclosure of the therapist’s own reac-

tions to ending may provide helpful modeling.

Early experiences of loss or insufficient attachment

complicate the process of mourning and good-byes (Stro-

ebe 2002). In fact ‘‘unresolved loss or trauma’’, a hallmark

of disorganized attachment, tends to signify great diffi-

culties in maintaining relationships and regulating

emotions. These clients tend to have complicated and

troubled grief reactions to losses (Stroebe et al. 2005).

Individuals who enter treatment with a disorganized style

may need much help structuring both the cognitive and

emotional aspects of endings. Despite therapeutic gains,

these clients are likely once again to feel overwhelmed and

dysregulated during termination. For these clients, in par-

ticular, an emphasis on the continuing relationship and

availability of the therapist is important. Concrete advice

on coping and learning to reflect on therapeutic gains that

can be organizing and supportive during emotional

moments is crucial.

It is a goal of therapy to change pre-existing insecure or

disorganized working models and eventually create a new

representation of the therapist as a secure attachment figure

(Brisch 2002; Cangelosi 1997). That working model

remains operative, even after treatment ends (Farber et al.

1995). Clients draw upon those images and memories of

the therapist and therapy to solve problems and gain

security and comfort after termination (Farber et al. 1995;

Novick and Novick 2006; Parish and Eagle 2001). A

positive ending that helps clients feel valued and helped

rather than abandoned or dismissive of the relationship

enables those new working models to better endure.

Research on Loss

Making or breaking an attachment (Bowlby 1980) tends to

stimulate the most intense emotions in an individual. The

unavailability of an attachment figure kindles attachment

behavior, causing the individual to seek out proximity and

connection to that person. It is thus not surprising that

termination brings on such strong reactions and feelings. In

so far as termination involves ending an attachment rela-

tionship, it functions to activate the attachment system and

drives the individual to crave and seek out the attachment

figure. This occurs also in bereavement. How individuals

cope with grief and mourning can thus guide us in under-

standing how they may also approach termination.

A debate currently exists about what constitutes grief

and mourning, particularly adaptive mourning (Shapiro

1995; Stroebe 2002). Early theories focused on the need to

mourn a loss and move on, an idea echoed in the psycho-

analytic view of termination involving separation, loss and

autonomy. More recent studies, however, indicate that

rather than separation, adaptive grief work often entails

ongoing connection, even when the connection is to a

deceased individual (Klass et al. 1996; Shapiro 1995).

Bereaved individuals often continue to maintain and

cherish their relationship with the deceased, which may

include speaking with that individual or other ritualized

behavior (Klass et al. 1996). This is less a marker of

pathology and incomplete mourning than a testimony to the

strength and importance of the relationship. Grief does not

‘‘resolve’’ and rarely does it neatly conclude, allowing an

individual to let go and move on. What is more the hall-

mark of secure individuals is that they can form a coherent

representation of their loss and also balance grief with

ongoing coping with daily events (Stroebe 2002).

Even young children can cope with loss when appropriate

conditions exist (Bowlby 1980; Silverman 2000). Those

conditions include an available attachment figure providing

a reasonably secure relationship, accurate information, the

ability to discuss the topic and ask questions and the

opportunity to participate in grieving or rituals of grieving.

Some control over the process also appears helpful (Sandler

et al. 1980; Siebold 2004). Preliminary research indicates

that certain approaches to loss can be counterproductive.

Symptoms in children who were separated from their parents

due to abuse and neglect increased when helpers tried either

to distract them from the issues or to place a strong focus on

the expression of feeling (Schneider and Phares 2005).

Neither denial nor exaggeration of the impact of loss proves

healthy. Instead, it is important to ascertain the true nature of

the loss and help the child cope. According to Schneider and

Phares (2005) this entails a shift from promoting ‘‘healthy

grieving’’ to normalizing the situation, answering children’s

questions and insuring that resources for support, problem

solving and self-esteem are available. This supports Stro-

ebe’s (2002) view that emphasizes a balance between coping

and mourning.

As many note, termination is not the only time in ther-

apy that affords opportunities to work on loss.

304 Clin Soc Work J (2008) 36:301–311

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Consideration of the client’s reactions to separations both

within the therapeutic environment and without is an

important task (Brisch 2002). These include reactions to

beginnings and endings, in general, including therapy

sessions, vacations, school and other activities. Although

these can and should certainly be worked on prior to ter-

mination, it remains unclear whether such issues can truly

be resolved or whether resolution of separations really

prepares clients for more permanent endings. More likely,

vulnerability as regards to separation and loss issues will

remain for those clients who experienced early and severe

experiences of disrupted attachments or loss, which will be

lessened, but not completely eroded, by new attachments

(Brisch 2002; Stroebe 2002; Zilberstein and Messer, in

press). In fact, those early loss and attachment issues are

likely to be once again triggered when termination

approaches.

One loss often begets another. In children who have lost

a parent, many losses occur simultaneously (Klass et al.

1996). Beyond the obvious and severe loss of the parent

and relationship, such children also tend to experience

many other changes in their lives. This may include

changes in routine, the increased or decreased availability

of other attachment figures, new homes or schools and, at

times, decreased financial resources. So, too, in therapy, the

end of treatment and therapeutic relationship may not

constitute the only loss. Clients become invested in the

soothing quality of the therapy room; children become

partial to certain toys and games. Various interactions and

rituals involving events such as beginning and ending of

sessions may also feel significant. Receptionists or others

met frequently in the waiting room may be missed.

Understanding the full ramifications of the changes that

occur for the client is important in fashioning interventions.

Because of these issues, many now advocate a different

approach to ending. Whenever possible, endings should be

planned, tapered and focus not simply on loss but on

accomplishments as well (Baum 2005; Siebold 2004;

Wachtel 2002). Clients should also feel free to contact the

therapist at a later date (Craige 2002; Hill 2005; Roe et al.

2006). Characterizing the end of therapy as a transition,

rather than a loss (although that transition may entail some

losses) could be more fruitful (Baum 2005). Focusing on

positive coping is also important (Roe et al. 2006; Stroebe

2002; Wachtel 2002). Lastly, rather than emphasizing

issues of loss, issues of ongoing connection become para-

mount. Such connection may involve real actions such as

letters, email, telephone contact or visits (Siebold 2004) or

more internalized memories and representations. A client’s

return to treatment or wish to remain in contact with the

therapist should not be seen as an incomplete or failed

treatment, but an important indicator of the attachment to

the therapist (Brisch 2002; Malin 1990; Siebold 2004). As

Inge Bretherton writes in the afterward to Brisch (2002),

‘‘In attachment theory, separation refers to physical sepa-

ration only, and is not the royal road to autonomy and self-

reliance’’ (p. 254). If attachments truly remain important

throughout life, the developmental goal becomes interde-

pendency rather than autonomy. And the therapeutic goal

becomes object permanence rather than termination, with

the ‘‘object’’ in this case being a relational object. This

orientation is particularly important for those with histories

of loss and trauma who have had few opportunities to

experience secure, ongoing attachments.

These issues will be demonstrated through case

vignettes.

Case Vignette: A Child with Disorganized Attachment

Raoul, an 8-year-old Latino boy, had been in weekly

therapy for 3 years. For the first 4 years of his life, he lived

with his birth mother and uncle in conditions of poverty

and squalor. The Department of Social Services was

involved for much of that period, monitoring the home

environment and helping mother define parenting tasks.

Despite these early interventions, problems persisted. Ra-

oul spent most of his time eating and watching TV, leading

to early problems with obesity by the time he entered

preschool. His behavior over time became increasingly

difficult to manage as he refused to obey his mother’s

limits. His preschool program complained that Raoul

lacked the ability to control his behavior and seldom fol-

lowed through on rules or activities. Social skills were

largely lacking. At age 4, Raoul exhibited sexualized

behaviors at preschool and when questioned about them,

offered that his uncle often sucked his penis. Mother’s

denial of this allegation and refusal to have her brother,

whom she depended upon for childcare and financial help,

leave the home, led to Raoul’s removal.

Raoul’s behavior in foster care became even more

extreme. He hoarded food, talked incessantly about sex and

disturbed children with his graphic chatter and aggressive

behavior. He also claimed to miss his mother terribly, and

weekly visitation did little to lessen his grief or longing for

her. He appeared to worry about his mother and her well-

being, insisting that he had certain obligations to his family.

Mostly due to his difficult behavior, Raoul lived in three

different foster homes in the space of 6 months before

coming to his current specialized placement. Though his

behaviors continued, his foster mother was able to tolerate

and contain them, while she sought treatment for him.

Raoul’s presentation during the first session was that of

a confused and disorganized youngster who craved rela-

tionships, but also feared them. Upon introduction to the

therapy room, he attempted to hug and kiss the therapist

Clin Soc Work J (2008) 36:301–311 305

123

and then immediately cowered in the corner. His play was

flat and lacked richness or depth. He demonstrated in his

play a pre-occupation with bad guys and safety, but little

ability to grapple with themes. Over and over again, he

established a scenario involving one bad guy surrounded by

numerous good guys who immediately trounced and

destroyed the evil character before that character even

moved. Even more strikingly, he refused to allow the

therapist to play with him. Attempts to comment on the

play, join or even provide sound effects were dismissed as

annoying and intrusive.

With much work, over a period of months, the therapist

was gradually allowed to enter his play and help him with

themes of relationship and safety. He worked on the sexual

abuse he experienced as well as on his relationships to his

two moms (birth mother and foster mother). Throughout

this period, visits with his birth mother continued on a bi-

weekly basis. Reports from the Department of Social Ser-

vices indicated that mother continued to show difficulty

structuring interactions in those visits and either played

little with Raoul or tried to engage him in activities that

were developmentally too old and frustrating for him.

Often, after visits, his foster mother reported that Raoul

vomited and showed difficulty regulating his appetite. In

contrast, Raoul began to feel increasingly safe and con-

tained in his foster home. Collateral work with the foster

mother helped her to manage his behaviors at home and to

become an attachment figure for him. That attachment,

combined with his work in therapy, drove tremendous

gains. Raoul slimmed down, calmed down and began to

engage in appropriate school and social activities. How-

ever, he also began to experience loyalty issues about

whom he could love and whether loving his foster mother

meant abandoning his birth mother. Over time, he resolved

this issue by determining that he loved both, but preferred

to live with his foster mother. He commented that he had

‘‘two moms—one that I live with and one that I visit.’’

After 2.5 years, Raoul began to resist coming to therapy.

He claimed that it was boring or that he would rather go

swimming or that he wished he could play with a friend.

Raoul’s reasons and behavior were developmentally

appropriate and both his foster mother and therapist agreed

that despite ongoing vulnerability due to his early history,

Raoul was ready to end this phase of therapy. As such, the

next time Raoul complained that he had better things to do

than come, the therapist agreed with him and broached the

subject of ending. Raoul’s reaction was strong. He pro-

tested greatly that he did not want to end and became angry

and anxious. His foster mother reported that he vomited

soon after the session, had nightmares and that his agitation

was so great that he scared a younger child.

It was clear that although Raoul did not want to come to

therapy, he did not want to end, either. Ending entailed

confronting a number of losses for which he was not ready.

Those involved the therapeutic relationship, which had

become a secure base for him, as well as the parts of his

history and self that had been held, developed and under-

stood within the therapeutic environment. Given that so

much of the therapeutic work had centered on forging and

maintaining psychological connections with the therapist

and also with figures such as his birth mother from whom

he was physically separate, a firm and forced ending

appeared inappropriate. In addition, given Raoul’s early

history, he continued at risk for later problems or for the

need to readdress issues at later developmental stages.

Termination needed to be a less permanent process and one

more centered on the continuing availability of the

therapist.

At the next session, Raoul was told that he had really

reacted to the idea of saying good-bye. The therapist

understood why. He had said a lot of really difficult good-

byes in his life and had worked hard to stay connected to

those people even when he did not see them a lot. So, even

though he did not want to come each week that did not

mean he and the therapist could not stay in touch. The

therapist offered that they schedule a few more meetings,

spaced apart by a few weeks so he could see what it was

like to come less. If it felt OK, no more meetings would be

scheduled, but he was free to call or make an appointment

whenever he wanted to be in touch. Raoul accepted this

arrangement and his anxiety and regressive symptoms

quickly abated. The last few meetings were not spent

processing losses, but focused on what had been accom-

plished, what would be remembered and how the

connection would endure. Raoul and the therapist made a

photo album with a narrative that reflected the work.

Together they decided on the activities, games, toys and

other individuals (i.e., receptionist) that were important to

Raoul and which he wanted to remember. It was also

particularly important for him to hear specifically how the

therapist would remember him. Raoul’s foster mother did

call and bring him occasionally over the next few years,

although he never returned to active treatment.

Case Discussion

This case involves a young Latino child with many expe-

riences of loss and poor attachments that influences both

his ability to form new attachments and his reactions to

leaving them. At the start of treatment, he presents as a

fearful and aggrieved child with a disorganized attachment

style that is reflected both in his poor affect regulation and

his contradictory approach to relationships. He both kisses

and cowers from the therapist and then has much trouble

using her as a secure base with whom to share and explore

306 Clin Soc Work J (2008) 36:301–311

123

his feelings and experiences. His increasingly difficult

behavior in his various foster homes can be viewed both as

a result of the disorganization and abuse in his mother’s

home and of his grief reaction at leaving a loved and

familiar parental figure, even if that person did not con-

stitute a secure attachment figure. In Latino culture, high

value is placed on family relationships and obligations and

it is clear that worries about his mother and his responsi-

bility for her drove some of that confusion and grief (Walsh

and McGoldrick 1991; Zebracki and Stancin 2007). Thus,

for Raoul, therapeutic tasks involved not just resolving

early trauma, but establishing secure attachments, learning

developmental skills not previously mastered and finding a

way to remain connected to his birth mother.

Other cultural issues also influenced Raoul’s presenta-

tion. Raoul’s somatization of symptoms that included

vomiting and difficulties with appetite could reflect Latino

cultural tendencies to somaticize strong emotions (Ze-

bracki and Stancin 2007). Latino values of respect, in

which respect for and from authorities such as therapists is

crucial, and fatalism, in which some events are accepted as

unavoidable and uncontrollable, are also apparent (Walsh

and McGoldrick 1991; Zebracki and Stancin 2007). Raoul

needed to make a relationship with the therapist slowly,

over a period of months, and the therapist needed to show

respect for his pace and feelings by not becoming overly

intrusive. Raoul’s ability to accept his new home and foster

mother, and to work through the loyalty conflicts and guilt

provoked by that situation, may have been aided by cul-

tural values of accepting one’s fate.

Although, over time, many of those issues seemingly

resolved, termination brings a violent regression and

renewed disorganization and somatization. Despite sub-

stantial therapeutic gains and stable and supportive

relationships in his life, he feels completely overwhelmed

by the impending loss of another attachment figure. For

him, the loss of an attachment figure resonates with both

the fear and disorganization of his early life and the grief

that he experienced upon removal from his mother. In

therapy, those issues were resolved, in part, through help-

ing him stay connected to his mother and forming new and

stable attachments. Those factors take precedence again at

termination. Thus the therapist chooses not to address these

issues by working through issues of loss and grief. While a

traditional view of termination would hold that this con-

stitutes an avoidance of the topic, thus prohibiting the child

from working through loss issues, a different stance is

offered here. Given this boy’s tendency toward disorgani-

zation, termination is handled in a more structured way. He

is allowed more control over the process, including deter-

mining when and if he wants to see the therapist again

(Sandler et al. 1980; Siebold 2004) Activities that are

symbolic and ritualistic in nature are employed, which

allows him to organize and hold on to the important aspects

of the therapy and therapist, without overwhelming him

with negative affect or fears. Although the reality of the

separation is acknowledged, the therapist remains a secure

base that allows the child to leave and explore the outside

world, but also continues to be psychologically and phys-

ically available as an object to whom he can return.

Case Vignette: Adult with Dismissing Attachment

Leslie, a 34-year-old, Irish American woman entered

weekly individual treatment due to marital difficulties. On

the verge of separating from her husband due to continuous

conflicts, Leslie was alternately angry, resentful and

blaming of the lack of support she felt in her marriage. She

felt lonely and isolated and catalogued at length how this

was due to her husband’s enormous insensitivity and faults.

Leslie appeared to have little insight into her own contri-

butions to the conflicts or to the deeper feelings and needs

they aroused.

Leslie’s childhood was dominated by the highly con-

flicted relationship and then divorce of her parents when

she was 6 years old. Leslie recalled continuous bickering at

home and domestic disputes that were verbally and emo-

tionally abusive. As she remembered, her parents appeared

preoccupied with their own conflicts and needs and paid

little attention to her reactions or feelings. She could not

recollect her mother or father checking in with her after a

particularly violent fight to see how she was doing. Leslie

coped by shutting herself in her room and reading or

watching TV so that she could drown out the sounds of

arguing. At an early age, she took care of many of her own

needs: fixing snacks for herself or arranging to get to her

own activities as her parents seemed unavailable. Little

improved after the divorce. Leslie lived primarily with her

mother but spent weekends with her father. She recalls that

the arguments between her parents continued on the phone

and during drop-offs and that her mother became so

stressed by financial and other pressures that she was often

emotionally absorbed by her own affairs.

Despite this home life, Leslie did well in school and

obtained a college degree. In fact, school felt like a refuge

and intellectual ideas invigorated her. She had few friends

as she felt disappointed by most people, whom she claimed

did not understand her. When asked by the therapist for

positive memories of interactions with her parents, Leslie

had difficulty coming up with examples, although she did

finally mention that they went on a few fun vacations.

Leslie entered therapy feeling distrustful of the therapist.

She presented herself as self-sufficient and tended to rely on

her intellect to analyze situations, to explain what was wrong

and to devise solutions. These included many diatribes about

Clin Soc Work J (2008) 36:301–311 307

123

her husband needing to learn to support her and listen to her

and do more of the household chores. Suggestions or

empathy offered by the therapist were often dismissed as

inaccurate or unhelpful. Over time, the therapist gently

questioned this rejecting response and suggested that per-

haps the same dynamics occurred with her husband. Leslie at

first argued with this stance and then broke down into tears.

Fears that the therapist would find her needs overwhelming

or would criticize them arose. As these were discussed,

Leslie relaxed and became more emotionally involved and

accessible in therapy. The therapist pointed out that rela-

tionships and others were important and that she did want and

need them, which was one reason she felt so angry when

others misunderstood her. She also focused Leslie on the

importance of stating her needs clearly to others, like her

husband, with whom she wanted to be close so that they

could better understand her. Despite Leslie’s increased

interest in relationships and in therapy during this time, she

continued to deny any reactions to the therapist’s vacations

or other breaks in treatment, stating defensively at those

times that she did just fine on her own.

As the therapist and therapeutic environment became

more important to Leslie, her ambivalence further

emerged. Leslie would periodically take breaks from

therapy, canceling her sessions for as much as weeks at a

time. She would then fear that the therapist would be angry

and critical with her. During those times, the therapist

would contact her by letter or phone stating that she

wondered how she was doing and offering to meet with her

when she was ready to return. Leslie later stated that those

contacts were extremely important in helping her realize

that the therapist could think about her and hold her

interests in mind even in her absence.

Over time, as Leslie learned to recognize her own needs

and feelings and to gain support from others, her marriage

and outside relationships also improved. She announced

after 3 years of therapy that she was doing very well, had a

secure marriage and felt she no longer needed to come. In

typical fashion, this announcement was accompanied by

numerous rational reasons as to why it was time to end,

with little focus on the emotional impact of saying good-

bye to an important relational figure.

In fact, Leslie had made solid progress and was doing

well in numerous ways. Ending treatment appeared war-

ranted, although the therapist worried about Leslie again

denying important feelings, which would inhibit her ability

to understand and cope with those emotional reactions and

draw upon those lessons after therapy ended. Thus, during

this period of termination, therapy became focused in a few

ways. The gains Leslie made were reviewed with some

emphasis on how understanding her feelings and recog-

nizing the importance of relationships were crucial to her

improved marriage and functioning. Leslie was asked to

think about her various reactions to ending, including

issues of loss and how she could handle those feelings. The

therapist also disclosed some of her own feelings, as well,

which included pride in Leslie’s accomplishments and her

ongoing concern and curiosity about Leslie’s well being.

The therapist focused Leslie on thinking about how she

would handle marital and other issues once therapy ended.

They discussed how she could call upon what she learned

in therapy, including the therapist’s care and concern, to

guide and sustain her during difficult moments. The ther-

apist also predicted that there might be future hard times in

which further therapy could be beneficial. She explained

that such situations are common and not a sign of failure or

shame. Leslie was told that she was welcome to contact the

therapist at those times to continue the work or simply to

check-in briefly. Leslie did return to therapy a number of

times for periods of up to a few months.

Case Discussion

This case involves a young Irish American woman with an

avoidant attachment style who is dismissive of relation-

ships and poorly connected to her own emotions.

Therapeutic tasks with this woman include helping her

value and engage more deeply in relationships and gain

emotional understanding. She needs to accept others as

attachment figures and then become such a figure, herself,

to her husband. Before she can do this, Leslie needs to

learn about her own importance to others (something not

communicated to her by her dueling and preoccupied

parents). Only then, can she acknowledge the importance

of others to her. To some extent, Leslie’s presentation

resonates with cultural traits. In Irish families, pain and

grief are often not widely expressed or shared, with a focus,

instead, on life returning to normal after difficulties occur

(Walsh and McGoldrick 1991). In this respect, Leslie’s

difficulties with such expression may also emanate from

her cultural upbringing.

Challenging and altering those beliefs and traits in

therapy occurs in a number of ways. The therapist main-

tains a stance of concern and interest during sessions, and

also when Leslie is dismissing of the therapist or taking

breaks from therapy. Through her absences, Leslie tests

whether the therapist can be a secure base for her from

whom she can both leave and return and whom she can use

for emotional security. When the therapist shows interest in

what Leslie is feeling, and reflects those feelings back to

Leslie, it allows her to both focus on and integrate those

feelings. This, in turn, allows Leslie to learn how rela-

tionships can provide emotional sustenance.

At the time of termination, Leslie again reverts to a

dismissing stance in which she denies the importance of the

308 Clin Soc Work J (2008) 36:301–311

123

therapeutic relationship and her feelings about it. For her,

the impending loss of the therapist stimulates the same

response as did the emotional unavailability of her mother.

She becomes self-sufficient and intellectual rather than

acknowledging sadness, loss or neediness. Such a stance

will likely interfere with her ability to cope with the

complex feelings around termination and will also not

allow her to draw upon the relationship and the lessons

learned within it at a later date. Thus, unlike her mother,

the therapist does not ignore Leslie’s reactions, but rather

provides empathy and structured coping, skills Leslie has

not previously practiced. She once again focuses Leslie on

the importance of the relationship, her feelings about

ending and the skills she has learned. She also actively

engages Leslie in thinking how to use those skills in the

absence of the therapist. To fully integrate them, she needs

them focused on and reflected back to her by the therapist.

In addition, given Leslie’s tendency to dismiss relation-

ships, it is doubtful that she would return to therapy in

times of need without the therapist stating her ongoing

availability.

Conclusion and Further Directions

This paper considers how an understanding of attachment

and loss can contribute to our theories and techniques of

termination. As attachments remain important throughout

life, an emphasis on connection and interdependence rather

than separation and autonomy become important goals that

change how termination is handled (Brisch 2002; Klass

et al. 1996; Simpson and Rholes 1998). The importance of

the therapeutic relationship becomes focal as well as the

way in which it can endure after therapy ends. This sug-

gests that termination does not entail finality as returning to

the therapist for further work or contact post-termination is

not discouraged (Craige 2002; Malin 1990; Roe et al.

2006). It also has the impact of lessening some of the more

difficult reactions clients have to termination including

rage, anxiety, mourning and abandonment. Although loss

and grief may still be components of termination that bear

exploring, they should not be overemphasized to the

exclusion of other important components.

Research shows that loss and its concomitant reactions

are just one piece of the termination puzzle. Feelings of

pride and accomplishment are also important and incor-

porating them into ending eases the termination experience

(Baum 2005; Roe et al. 2006; Wachtel 2002) To the extent

that termination does constitute a loss, research emphasizes

that individuals cope with loss in certain adaptive ways.

This includes balancing grief with coping and maintaining

emotional connections to important individuals (Klass

et al. 1996; Shapiro 1995; Stroebe 2002; Walsh and

McGoldrick 1991). Helping clients with this task, espe-

cially the more vulnerable clients who have experienced

earlier, devastating losses, is important.

An attachment perspective also helps the therapist

conceptualize the type of relationship and termination a

client can tolerate and use (Holmes 1997; Shilkret 2005;

Simpson and Rholes 1998). Although many other factors

besides attachment determine how a client responds to

termination, including other aspects of that client’s history,

difficulties and cultural concerns, a consideration of

attachment styles can help therapists structure some aspects

of ending therapy. Ambivalent clients need help with

cognitive coping skills and initiating and maintaining

relationships outside of the attachment system. Those skills

help them to disengage from therapy more effectively.

Avoidant clients require assistance in valuing emotions and

relationships, and termination should include an explora-

tion of those skills as well as encouraging clients to

maintain an emotional connection to the therapy that will

help them draw upon those lessons once therapy has ended.

Disorganized clients may become so overwhelmed by

issues of loss that they may need significant help in

structuring the ending and coping with their cognitive and

emotional responses. For those very vulnerable clients, in

particular, the possibility of ongoing connection should be

offered.

Some termination issues are similar for children and

adults, but differences also exist. While attachments remain

important for everyone, and both children and adults may

react to losing them, they do so in different ways. Children,

who are still rapidly developing, do so within attachment

relationships. Children who have strong parental supports

and attachments can cope better with termination and

losses because they have both the support to help them

cope and a strong attachment figure on whom to rely. But

for those children without such attachments, the loss of an

attachment figure can be developmentally devastating.

Those children, who may be terminating because of a

change of placement or other circumstances, require care-

ful handling of losses and efforts to connect them to other

supports. For adults, as well, those with strong attachments

and supports can cope better with loss and termination.

But, in general, adults are capable of more autonomous

functioning than children and can exercise skills that

enable them to understand and cope with loss differently.

Though emotionally reliant on attachment figures, they are

less physically dependent upon them and better able to fend

for themselves. They also have more control over when and

if they return to therapy than do children. As such, they

may need less concrete help and structuring during the

termination phase. In addition, children’s cognitive

understandings of their internal and external worlds differ

from those of adults. Children’s cognitive abilities continue

Clin Soc Work J (2008) 36:301–311 309

123

to grow and change as they mature, thus allowing them to

view and remember their internal states, relationships and

environments in different ways at different ages. For

children to be able to grasp, remember and revisit the gains

of therapy as they age, it is helpful for them to hold on to

more concrete reminders such as pictures or narratives,

which they can later review from a more advanced devel-

opmental level. Adults, who, for the most part, remain at a

constant cognitive level, may not need such concrete

reminders and keepsakes.

There are numerous other important aspects to termi-

nation, many of which are already discussed extensively in

the literature, which could be integrated into an attachment

and loss formulation. Those include an evaluation of cri-

teria for termination, timing of termination, differences

between planned, premature and forced terminations and

the countertransference reactions of the therapist. For

instance, countertransference reactions tend to depend both

on the pull of the client’s attachment style and the

attachment status of the therapist (Shilkret 2005; Simpson

and Rholes 1998). Criteria for termination and length of the

termination phase may also be influenced by attachment

style. In addition, there remain many techniques through

which individuals cope with bereavement, which could be

incorporated into the termination phase. Amongst these are

various cultural rituals that focus on loss and connection

that could particularly help clients from those backgrounds.

Rituals have special salience because they can simulta-

neously mark an event and express the multiple meanings

inherent in it (Walsh and McGoldrick 1991). For instance,

public funerals can acknowledge the painful reality of a

loss and also connect individuals with memories of the

deceased and a living supportive community. For many of

our clients, who struggle with both the tremendous gains

and losses they experience at the end of therapy, finding a

language that integrates the accomplishments and feelings

of this stage can be difficult. But understanding how their

experiences with attachment and loss impact them can help

clinicians structure endings in ways that allows them to

remain connected to their feelings, successes and important

relationships and provides important grounding for the

future.

Acknowledgment Special thanks go to Eileen Messer for helpful

insights and comments on this manuscript.

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Author Biography

Karen Zilberstein MSW, LICSW is a psychotherapist at The

Children’s Clinic, Cutchins Programs for Children and Families,

Northampton, MA, USA and an adjunct faculty member at Smith

College School for Social Work.

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>> >> setdistillerparams << /HWResolution [2400 2400] /PageSize [5952.756 8418.897] >> setpagedevice