journey to the end counseling

Termination in Therapy: The Art of Gently Letting Clients Go

It may form part of a well-formed plan, indicating the next phase in the psychotherapy process, or it may occur hastily without careful consideration (Barnett, 2016).

Either way, it can be made easier by recognizing the boundary between the working phase and the termination phase and the shift toward the process of ending therapy (Joyce et al., 2007).

This article examines how to plan for termination and what questions and activities can help ensure we meet the client’s needs.

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This Article Contains:

When is the right time to end therapy, how to smoothly end therapy: quick guide, 15 questions to ask your clients, 4 activities & exercises for your last sessions, helpful termination worksheets and assessments, 3 closing rituals for group therapy, positivepsychology.com’s relevant resources, a take-home message.

Unlike our day-to-day relationships, we expect therapy to have a clear and definite ending.

That said, for the client, it can entail a sense of loss of attachment with the therapist and who they represent (Fragkiadaki & Strauss, 2012).

If termination is abrupt, it may leave both therapist and client with unanswered questions and feelings of “anxiety, sadness, and anger” (Fragkiadaki & Strauss, 2012).

And yet, when the therapeutic relationship and outcome are seen as positive by the client, termination can be a healthy, valuable, and successful process; so much so that practitioners often report pride and a new sense of faith in the therapeutic process (Fragkiadaki & Strauss, 2012).

Therapists should assess the client’s ongoing treatment needs before initiating termination. And where possible, the final phase of the relationship should occur when goals have been reached. Still, in reality, it sometimes happens when the time available for working has ended, insurance coverage has ceased, or the client no longer wishes to continue (Felton, 2019).

According to the American Psychological Association (2017), the psychotherapy relationship should end when the client is no longer receiving benefit from the treatment or has the potential for harm. Specific factors include (Barnett & Coffman, 2015):

• The therapist does not have the skills or competencies to meet the client’s needs.
• A situation arises that could negatively affect the therapist’s judgment or objectivity, for example, when an inappropriate secondary relationship forms.
• If the client is behaving threateningly, and the therapist feels endangered.

The therapist and client should set boundaries and appropriate behavior early in the therapeutic process, and part of the planning should include provision for referral when termination is abrupt.

The Society for the Advancement of Psychotherapy suggests six strategies for the ethical termination of psychotherapy to avoid feelings of abandonment (Barnett, 2016).

The term ‘abandonment’ suggests therapy has ended before the client’s needs have been successfully addressed or the course of the treatment was inappropriate to meet them (Barnett, 2016).

Termination can be eased through early and ongoing planning, as summarized by the following six stages (modified from Barnett, 2016).

1. Agree on how the therapy will end from the outset

Clients need to know the intended duration of treatment from the start. If it is to be open ended based solely on the progress made during sessions, clients need to be aware that limitations may result from time available, client insurance, or other factors.

Only when the client has all the information can they make an informed choice and receive the maximum benefit from the treatment.

2. Agree on treatment goals and what success looks like

Ideally, when treatment ends, the therapeutic process will have met all treatment goals. But to do this, the therapist and client should agree on the intended outcome of therapy.

While changes in circumstances and insights experienced during treatment may transform goals, they should be set early to inform the “nature, focus, and scope of the treatment” and its intended duration (Barnett, 2016).

3. Prepare for therapist-led interruptions to the treatment

While not intentional, situations may occur that cause therapy to be ended by the therapist; for example:

• The client is not benefitting from the treatment.
• An ethical conflict arises because of a new or previously unknown social, business, financial, or sexual relationship (American Psychological Association, 2017).
• For reasons of safety. For example, if the therapist has been threatened or feels endangered.
• Illness, retirement, family circumstances, retirement, or even death.

While some interruptions can be anticipated, others are outside the control of the therapist. A professional will should be drawn up to identify who can access client records, perform an assessment, and arrange referral.

4. Client-led interruptions to the treatment

As with therapist-led interruptions, several factors could cause the client to end treatment, such as

• Financial changes (e.g., insurance coverage)
• Dissatisfaction with the psychotherapist or treatment direction
• Job loss or relocation

The therapist should make a reasonable attempt to help address any ongoing treatment needs, even if only to connect the client with replacement treatment resources.

Goals set out at the beginning of the treatment will most likely not have been met if either the therapist or client withdraws early.

5. Clarify what abandonment is and is not

“Abandonment occurs when the psychotherapist does not meet a client’s ongoing treatment needs appropriately” (Barnett, 2016).

Yet, it is not abandonment if the client drops out or cannot meet their obligations, or if therapy ends through mutual agreement and appropriate notice.

Both parties must understand and accept what abandonment is and isn’t to avoid inappropriate behavior and get the best out of sessions.

6. Plan for termination

In the ordinary course of events, termination should not be a surprise.

Instead, it should be planned and prepared for, working collaboratively toward the end of successful treatment.

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Ending therapy is an integral part of the overall therapeutic process. If the termination process is begun early, with clear therapeutic goals, it can be a positive experience with a long-lasting impact (Barnett, 2016).

When clear treatment plans are drawn up early and goals and objectives are agreed upon from the outset, the finish line becomes clearer.

As therapy draws to a close, it is essential to assess the client’s readiness for termination through observation and discussion, watching out for (Bhatia & Gelso, 2017; Barnett & Coffman, 2015):

• Reduced symptoms or issues concerning the problem presented
• Improvement in relationships
• More positive body language
• A better outlook regarding the future
• Improvements in functioning at work, school, or home

The client may now be better off with other forms of treatment, or based on the therapist’s knowledge and experience, therapy may no longer be required.

Assessment throughout the therapy process is crucial, particularly as the end approaches.

Client wellbeing questions

Ask clients to score themselves on the following questions to assess where they are as the end of treatment approaches (1 – never, 2 – rarely, 3 – sometimes, 4 – often, 5 – always):

• Have you felt happy?
• Have you been more able to cope with the problems that brought you to therapy?
• Have you felt good about yourself?
• Has your home life been better?
• Have you been sleeping better?
• Have you been satisfied with your relationships?
• Have you been living more healthily (diet, exercise, etc.)?
• Have you been able to focus?
• Have you been able to attend and cope at work/school?

Client’s readiness to end therapy

Questions specific to the termination phase of therapy can gauge the client’s readiness through recognizing the client’s positive feelings regarding the process ending.

Ask the client the following questions:

The following activities can all be adapted and used for telehealth sessions.

End of therapy letters

From the therapist to the client.

When therapy comes to an end, it can be helpful for the therapist to write a letter to the client to remind them of the journey they have been on and the progress made.

Consider writing a letter or email to the client to encourage closure and as a reminder of their successes.

Consider the following points when writing the letter:

• Thank the client for the opportunity to work together.
• Outline the focus of the therapy.
• Describe the problem the client presented at the outset.
• Remind the client how you approached or unpacked the problem.
• Discuss patterns of behavior, feelings, and thinking.
• Describe some changes made and coping strategies adopted by the client.
• Remind the client of the improvements you have seen in them.
• Discuss some of the changes the client has made to their life.
• Point out that you will miss the regular sessions but are available if needed.

From the client to the therapist

A client can also develop a healthy sense of closure from creating a letter for the therapist.

Children, in particular, may benefit from a structure/form. For example:

I remember when we:

It was fun when we:

Thank you for:

5-second rule

This fun activity is beneficial for children but also valuable for adults.

• Name three negative feelings
• Name three positive feelings
• Name three new coping skills for anger/stress, etc.
• Name three people you can talk to
• The client selects one instruction and has five seconds to respond (this can be performed in a group).

For online/video sessions, the client chooses a number, and the therapist reads the associated card.

What I will take with me

As a final session activity, it’s helpful to discuss the tools and skills the client will take with them following a successful series of therapy.

Ask the client to discuss each of the following, then add your thoughts regarding anything forgotten:

• Coping strategies
• Positive affirmations
• Visualization techniques
• Stress relieving tools, for example, breathing and mindfulness
• Support in the form of people, contact numbers, online resources, etc.
• Skills learned, such as handling stress and managing anger
• Reasons to be positive and hopeful
• Goals met and progress made

Afterward, it may be helpful to provide the client with a summary of what was said.

4 Activities for your telehealth sessions

With online, blended care, and virtual therapy becoming increasingly popular, it is important to ensure that termination remains collaborative.

Consider and discuss the following in the lead-up to therapy termination (Goode, Park, Parkin, Tompkins, & Swift, 2017):

• Revisit the agreed-on goals and assess progress toward their completion. An online tool like Quenza can help review each goal’s status and target areas needing increased focus.
• Return to and review the online contract.
• Summarize the lessons learned and the progress the client has made.
• Confirm the date of the final session and any resources required after termination.

The 4 must do’s of ending therapy! – Kati Morton

Use the following worksheets to assist you with the termination process.

Termination checklists

A termination checklist can be helpful as both therapist and client begin to consider the end of the therapeutic relationship (modified from Norcross, Zimmerman, Greenberg, & Swift, 2017):

Termination worksheet

Children and adults can benefit from writing what they would like to achieve in their last sessions.

Ask the individual or group to answer the following, verbally or in writing:

These forms can be completed over email or using an online tool.

Group termination questions

Ask each person to answer the following questions either in private or within the group:

• What has it been like being part of the group?
• What has been the most/least helpful aspect?
• What did you learn about yourself or how others see you?
• What were the most significant moments?
• Is there anything you regret not saying or sharing?
• How are people feeling regarding the group coming to an end?
• How are you feeling regarding the group coming to an end?

Discuss group fears

Ask each person to discuss the following prompts either in private or within the group:

• My fear is that …
• My hope is that …
• What I’d like to take away from these sessions most is …

Gift exercise

Write down something that each person in the group has given you.

Perhaps they made you laugh, gave you hope, or understood your perspective.

Below each description, describe a humorous (imaginary) gift you could give each person, such as a superpower, magic mirror to see themselves as they truly are, or a talking animal.

Read the gifts out in one of the last sessions to each person who has volunteered to receive feedback.

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Throughout our blog, you’ll find many tools you can pass on to clients to help ensure they continue in a positive direction following the termination of the therapeutic relationship.

Here are just a few that can help:

• Simple Thought Diary Worksheet This simple thought diary template can help clients systematically link experiences and situations to thoughts and emotions, serving as a useful tool to review one’s commonly adopted mindset.
• Willingness, Goals, and Action Plan This planning template helps clients identify their most valued life goals, anticipate psychological obstacles, and implement a practical plan.
• Behavior Contract This worksheet helps clients engage the support of trustworthy friends or family via a contract to encourage adaptive behaviors and habits and avoid reinforcing negative ones.
• One Hour Stress Plan This worksheet provides a 60-minute action plan for dealing with intense demands, helping clients work systematically through a list of tasks that require their most urgent attention.
• Building New Habits This worksheet succinctly explains how habits are formed and includes a space for clients to craft a plan to develop a new positive habit.

If you’re looking for more science-based ways to help others enhance their wellbeing, this signature collection contains 17 validated positive psychology tools for practitioners. Use them to help others flourish and thrive.

Ending therapy well is crucial to the overall therapeutic process.

Termination should be recognized as a valuable part of the therapeutic process, likely to bring up emotions in both the therapist and the client (Fragkiadaki & Strauss, 2012).

If managed and planned from the outset, termination that considers ethical and clinical implications will be a positive phase of treatment.

Termination should not be a surprise unless unusual circumstances prevail.

A strong “working alliance during the treatment phase” predicts overall treatment outcome (Bhatia & Gelso, 2017). It is crucial to form a solid therapeutic relationship during therapy with regular and open communication.

Clear therapeutic goals and beginning termination early can have positive, long-lasting impacts, consolidating learnings and readying the client to “move forward positively when treatment ends” (Barnett, 2016).

Agree on the goals and how the therapy will end in earlier sessions. Regularly assess whether the client is progressing toward their desired outcomes and begin planning early for the end of treatment.

The questions and worksheets within this article highlight issues that should be considered before termination while reminding the client of their work and success in reaching their goals.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

• American Psychological Association. (2017). Ethical principles of psychologists and code of conduct . Retrieved April 16, 2021, from https://www.apa.org/ethics/code
• Barnett, J. (2016, October 6). 6 strategies for ethical termination of psychotherapy: And for avoiding abandonment. Society for the Advancement of Psychotherapy. Retrieved April 16, 2021, from https://societyforpsychotherapy.org/6-strategies-for-ethical-termination-of-psychotherapy/
• Barnett, J., & Coffman, C. (2015, June). Termination and abandonment. Society for the Advancement of Psychotherapy. Retrieved April 16, 2021, from https://societyforpsychotherapy.org/termination-and-abandonment-a-proactive-approach-to-ethical-practice/
• Bhatia A., & Gelso C. J. (2017). The termination phase: Therapists’ perspective on the therapeutic relationship and outcome. Psychotherapy , 54 (1), 76–87.
• Felton, E. (2019, January 22). Termination: Ending the therapeutic relationship-avoiding abandonment.  National Association of Social Workers: California News.  Retrieved April 16, 2021, from https://naswcanews.org/termination-ending-the-therapeutic-relationship-avoiding-abandonment/
• Fragkiadaki, E., & Strauss, S. M. (2012). Termination of psychotherapy: The journey of 10 psychoanalytic and psychodynamic therapists. Psychology and Psychotherapy: Theory, Research and Practice , 85 (3), 335–350.
• Goode, J., Park, J., Parkin, S., Tompkins, K. A., & Swift, J. K. (2017). A collaborative approach to psychotherapy termination. Psychotherapy , 54 (1), 10–14.
• Joyce, A. S., Piper, W. E., Ogrodniczuk, J. S., & Klein, R. H. (2007). Termination in psychotherapy: A psychodynamic model of processes and outcomes. American Psychological Association.
• Norcross, J., Zimmerman, B., Greenberg, R., & Swift, J. (2017). Do all therapists do that when saying goodbye? Psychotherapy , 54 , 66–75.
• Terry, L. (2011, April). Semi-structured termination exercises. The Group Psychologist. Retrieved April 18, 2021, from https://www.apadivisions.org/division-49/publications/newsletter/group-psychologist/2011/04/termination-exercises
• Wachtel, P. L. (2002). Termination of therapy: An effort at integration. Journal of Psychotherapy Integration , 12 (3), 373–383.

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What our readers think.

All the information that you shared with us is very useful for us. Thank you for sharing with us.

Thank you Jeremy, this article has really helped me progress through my counselling course and is certainly a resource I will continue to use in the future. Many thanks, Alayah

I wish there were further ethical standards that make the termination phase a certain length of time. After 6.5 years my t unexpectedly terminated me. I get 3 closure sessions. He is unwilling to see me for more than that. After almost daily contact and 4 hours/week, this most definitely feels like abandonment.

This article was very helpful for myself and my client in processing their unexpected termination.

This article has helped me a great deal in handling my client.

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Web-only Feature

Ending Therapy

The therapeutic relationship during the termination phase.

Internet Editor’s Note: Dr. Avantika Bhatia and Dr. Charles Gelso recently published an article titled “The termination phase: Therapists’ perspective on the therapeutic relationship and outcome ” in Psychotherapy .

If you’re a member of the Society for the Advancement of Psychotherapy you can access the Psychotherapy article via your APA member page.

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Termination of the Therapy Relationship

As with all relationships, a therapeutic relationship has a beginning and an end. The end of a therapeutic relationship often offers an opportunity for the therapist and client to engage in the termination process, which can include looking back on the course of treatment, helping the client plan ahead and saying goodbye.

Although recognized as important, the termination of therapy has not received the empirical attention it deserves. However, results from a few studies (e.g. Quintana & Holahan, 1992; Knox, Adrians, Everson, Hess, Hill & Crook-Lyon, 2011; Marx & Gelso, 1987) do offer some support for two theoretical perspectives on therapeutic endings. The first, termination-as-loss perspective, is rooted in psychodynamic theories and describes the termination of psychotherapy as a significant loss for the client and emphasizes the importance of working through this loss in therapy (Mann, 1973; Strupp & Binder, 1985). The second, termination-as-transformation perspective (Quintana, 1993; Maples & Walker, 2014), emphasizes termination as a time for internalizing growth and transforming the therapeutic relationship by providing clients with new insights about themselves and the therapeutic relationship. Related to both these perspectives, a body of research also offers support for the importance of the therapeutic relationship during the termination phase (Knox et al., 2011; Fragkiadaki & Strauss, 2012).

Studying the Termination Phase

Intrigued by the therapeutic relationship at the end of therapy, Charles J. Gelso and I examined therapists’ perceptions of three elements of the therapeutic relationship (i.e. the working alliance , real relationship and transference ) during the termination phase in a recent study (Bhatia & Gelso, 2017). Following the widely used definition by Bordin (1979), the working alliance was conceptualized in terms of the working bond and the agreement of tasks and goals between the therapist and the client. Gelso (2011) defined the real relationship as the personal bond between the therapist and the client, characterized by the extent to which the therapist and client are genuine with each other and perceive each other realistically, and this conception of the real relationship was used in the study. Transference was conceptualized as the client’s experience of the therapist based on the client’s past experiences and involving a displacement of feelings, attitudes and behaviors rooted in earlier significant relationships onto the therapist (Gelso & Bhatia, 2012).

We used the following questions to guide our research; from the therapist’s point of view, how much time is spent in the termination phase? How do therapist perceptions of working alliance, real relationship and transference during the termination phase relate to the success of the overall treatment and the effectiveness of the termination phase? How do therapist perceptions of client sensitivity to loss associate with transference during the termination phase?

Our sample consisted of 233 licensed therapists in the U.S. of varying theoretical orientations. Therapists participating in the study identified a termination phase of treatment in their work with a client. The termination phase was defined as, “the last phase of counseling, during which the therapist and client consciously or unconsciously work toward bringing the treatment to an end” (Gelso & Woodhouse, 2002, pp. 346). Thus, at the outset, the findings and implications of the study do not address therapeutic endings that occur without warning and/or client dropouts. The major findings of the study and recommendations for clinical practice are discussed below.

Key Findings

The following key findings emerged from the results of the aforementioned study:

• Therapists reported the number of sessions included in the termination phase, as well as the total number of sessions included in treatment. Results indicated that the percentage of time spent on termination was approximately 17 percent of the total number of sessions.
• Examination of therapist ratings of termination phase evaluations and overall treatment outcome revealed that the success of the termination phase correlated with the success of overall treatment to a moderate extent (r=.30, p<.01).
• Therapist ratings of the working alliance and the real relationship during the termination phase correlated positively with termination phase evaluation and overall treatment outcome. In a regression model with the therapy relationship elements examined together, only the working alliance significantly predicted overall treatment outcome, highlighting its unique contribution to overall treatment outcome.
• Therapist ratings of transference (including both positive and negative transference) were positively associated with therapist ratings of perceived client sensitivity to loss.

Suggestions for Therapeutic Work in the Termination Phase

How can the results of the study inform therapeutic work? I offer below suggestions to consider during the termination phase. It is important to note here that these suggestions are not direct guidelines emerging from the results of the study; rather they are based on possible interpretations of the findings of this study, as well as on clinical impressions in therapeutic work. These recommendations need to be considered along with a theoretical understanding of individual cases in treatment.

Spending time on termination

As per therapist reports, the average percentage of time spent on bringing treatment to an end by talking about termination was found to be approximately 17 percent of the total number of sessions, a number similar to the 16.67 percent reported by Gelso and Woodhouse (2002) in their review of termination literature. Perhaps this number can provide a rough estimate of the time to be spent on bringing treatment to a close (although more research in this realm is certainly needed).

Effectiveness of the termination phase

From the therapist’s perspective, a successful termination phase is related to better overall treatment outcome, and yet termination phase evaluations also appear to be distinct from overall treatment outcome. This finding is in line with Joyce, Piper, Ogrodniczuk, and Klien’s (2007) suggestion that the outcomes of the termination phase differ from overall treatment outcomes. In treatment then, there appears to be value in the therapist tending to the client’s experience of the termination phase, perhaps by exploring client satisfaction with the termination phase and reflecting upon the therapeutic work being done during the termination phase, over and above overall treatment outcomes.

The working alliance during the termination phase

Therapist reports reveal that the role of the alliance is particularly important during the termination phase. In light of this finding, it seems helpful to revisit the alliance and bring it to the forefront of therapeutic work during the termination phase. For example, consolidating and discussing treatment goals, a component of the working alliance, can be an important component of the termination process (Norcross, Zimmerman, Greenberg & Swift, 2017). It may also help to discuss goals pertaining specifically to the termination phase to strengthen the alliance during the termination phase. For instance, in therapeutic work with a client expressing difficulty with ending relationships, the therapist and client may determine together to work through the end of the therapeutic relationship by providing a space for the client to mourn and express feelings about the ending.

The real relationship during the termination phase

The strength of the personal bond between the therapist and the client during the termination phase also relates to good outcomes. Thus, it would benefit therapists to pay attention to the real relationship during the termination phase. Therapists can use the following questions to reflect on the strength of the real relationship; is there a real and personal relationship between the client and I, over and above a professional relationship? Am I able to understand and express what I truly feel about my client? Does my client appear to be sharing vulnerable material with me? These are just a few examples of questions that might provide insight into the strength of the real relationship (see Gelso, 2011).

Transference during the termination phase

Given the positive relationship between perceived client sensitivity to loss and transference, it appears valuable for therapists to be particularly attuned to the transference during the termination phase in the context of the client’s previous loss experiences. How transference is dealt with in therapeutic work often depends on theoretical orientation (Gelso & Bhatia, 2012), however, it appears that clients may experience feelings towards the therapist at the end of treatment as a result of previous losses across theoretical orientations. These feelings seem to be both positive and negative, at least in the eyes of the therapist, and not necessarily related to negative outcomes. Tending to transference, both positive and negative in valence, would likely represent areas of meaningful therapeutic work during termination.

To conclude, the termination phase in therapeutic work offers a unique opportunity to reflect on the ending relationship and to process the ending in the context of previous losses. Key implications for therapists include tending to the working alliance, real relationship and transference during the termination phase and evaluating the effectiveness of the termination phase of therapeutic work.

Avantika Bhatia, Ph.D.

Cite This Article

Bhatia, A. (June, 2017). Ending therapy: The therapeutic relationship during the termination phase. [Web article]. Retrieved from https://societyforpsychotherapy.org/ending-therapy

Bhatia, A., & Gelso, C. J. (2017). The termination phase: Therapists’ perspective on the therapeutic relationship and outcome. Psychotherapy , 54 , 76-87. doi:10.1037/pst0000100

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16, 252-260. doi:10.1037/h0085885

Fragkiadaki, E., & Strauss, S. M. (2012). Termination of psychotherapy: The journey of 10 psychoanalytic and psychodynamic therapists. Psychology And Psychotherapy: Theory, Research And Practice , 85 , 335-350. doi:10.1111/j.2044-8341.2011.02035.x

Gelso, C. J. (2011). The real relationship in psychotherapy: The hidden foundation of change. Washington, DC US: American Psychological Association. doi:10.1037/12349-000

Gelso, C. J., & Bhatia, A. (2012). Crossing theoretical lines: the role and effect of transference in nonanalytic psychotherapies. Psychotherapy, 49 , 384–390. doi:10.1037/a0028802

Gelso, C.J., & Woodhouse, S.S. (2002). The termination of psychotherapy: What research tells us about the process of ending treatment. In G.S. Tryon (Ed.), Counseling based on process research: Applying what we know . Boston, MA: Allyn & Bacon.

Joyce, A. S., Piper, W. E., Ogrodniczuk, J. S., & Klien, R. H. (2007). Termination in psychotherapy: A psychodynamic model of processes and outcomes . Washington, DC, US: American Psychological Association. doi:10.1037/11545-000

Knox, S., Adrians, N., Everson, E., Hess, S., Hill, C., & Crook-Lyon, R. (2011). Clients’ perspectives on therapy termination. Psychotherapy Research , 21 , 154-167. doi:10.1080/10503307.2010.534509

Mann. J. (1973). Time-limited psychotherapy. Cambridge, MA: Harvard University Press.

Maples, J. L., & Walker, R. L. (2014). Consolidation rather than termination: Rethinking how psychologists label and conceptualize the final phase of psychological treatment. Professional Psychology: Research And Practice , 45 , 104-110. doi:10.1037/a0036250

Marx, J.A., & Gelso, C.J. (1987). Termination of individual counseling in a university counseling center. Journal of Counseling Psychology, 34 , 3-9.

Norcross, J. C., Zimmerman, B. E., Greenberg, R. P., & Swift, J. K. (2017). Do all therapists do that when saying goodbye? A study of commonalities in termination behaviors. Psychotherapy , 54 , 66-75. doi:10.1037/pst0000097

Quintana, S.M. (1993). Toward an expanded and updated conceptualization of termination: Implications for short-term, individual psychotherapy. Professional Psychology: Research and Practice, 24 , 426????432.

Quintana, S.M., & Holahan, W. (1992). Termination in short- term counseling: Comparison of successful and unsuccessful cases. Journal of Counseling Psychology, 39 , 299????305.

Strupp, H. & Binder, J. (1985). Psychotherapy in a new key: A guide to time-limited psychotherapy . New York: Basic Books.

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Appropriate time and communication spent in termination phase appears to be paramount for expectations that this will have a positive outcome for clients. Perhaps a great deal of training should be spent on this for therapists to understand just how much damage they can do — that then is on the shoulders of already hurting clients to work (and pay) to undo and heal from — if they do not care to spend adequate time or reasonably communicate with clients about potential termination of therapy.

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Psychotherapy at the End of Life

Rebecca m. saracino.

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Barry Rosenfeld

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Harvey Max Chochinov

Distinguished Professor of Psychiatry, University of Manitoba

Dr. Elisabeth Kübler-Ross is credited as one of the first clinicians to formalize recommendations for working with patients with advanced medical illnesses. In her seminal book, On Death and Dying , she identified a glaring gap in our understanding of how people cope with death, both on the part of the terminally ill patients that face death and as the clinicians who care for these patients. Now, 50 years later, a substantial and ever-growing body of research has identified “best practices” for end of life care and provides confirmation and support for many of the therapeutic practices originally recommended by Dr. Kübler-Ross. This paper reviews the empirical study of psychological well-being and distress at the end of life. Specifically, we review what has been learned from studies of patient desire for hastened death and the early debates around physician assisted suicide, as well as demonstrating how these studies, informed by existential principles, have led to the development of manualized psychotherapies for patients with advanced disease. The ultimate goal of these interventions has been to attenuate suffering and help terminally ill patients and their families maintain a sense of dignity, meaning, and peace as they approach the end of life. Two well-established, empirically supported psychotherapies for patients at the end of life, Dignity Therapy and Meaning Centered Psychotherapy are reviewed in detail.

“We are always amazed how one session can relieve a patient of a tremendous burden […] it often requires nothing more but an open question.” –Elisabeth Kübler-Ross, On Death and Dying , 1969, p. 242

Introduction

Are there particular things that you feel still need to be said to your loved ones, or things that you would want to take the time to say once again? What is a good and meaningful death? These are just two examples of the psychotherapy question prompts that comprise today’s most well-established, empirically supported psychotherapies for patients with advanced and terminal illnesses ( Breitbart et al., 2015 ; Breitbart et al., 2018 ; Chochinov et al., 2005a ; Chochinov et al., 2011 ). These therapeutic prompts were developed out of a long line of rich clinical and research knowledge that facilitated a deeper understanding of the psychological and existential needs of patients facing death.

Dr. Elisabeth Kübler-Ross is credited as one of the first clinicians to formalize recommendations for working with patients with advanced medical illness. In her seminal book, On Death and Dying , Dr. Kübler-Ross provided explicit, previously elusive guidance on how to openly broach the topic of death at the bedside. She wrote “It might be helpful if more people were to talk about death and dying as an intrinsic part of life just as they do not hesitate to mention when someone is expecting a new baby” (1969, 126). In writing specifically about psychotherapy with the terminally ill, Dr. Kübler-Ross expressed a profound clinical and human understanding of these patients: “it is evident that the terminally ill patient has very special needs which can be fulfilled if we take time to sit and listen and find out what they are. The most important communication, perhaps, is the fact that we let him know we are ready and willing to share some of his concerns” (1969, 241). Now, 50 years later, a substantial and ever-growing body of research has helped clarify best practices for end-of-life care, supporting many of the therapeutic practices originally described by Dr. Kübler-Ross. This paper reviews the empirical study of psychological wellbeing and distress at the end of life, documenting what has been learned from research on the desire for hastened death, particularly during the late 20 th century debates around physician assisted suicide. In turn, these studies, which were often informed by existential principles, have led to the development of several manualized psychotherapies for patients with advanced disease, with the goal of attenuating suffering and helping patients and their families maintain a sense of dignity, meaning, and peace at the end of life.

Shortly after Dr. Kübler-Ross began to write about her work with patients who were dying, experts in group psychotherapy began to develop systematic interventions for helping these individuals. For example, Irvin Yalom (1980) , who was heavily influence by existential philosophy, conceptualized four “ultimate concerns” of life: death, freedom, isolation, and meaninglessness. His writings and clinical insights into working with patients who were facing death formed the basis for what eventually became Supportive Expressive Group Psychotherapy (SEGT; Spiegel, Bloom, & Yalom 1981 ; Spiegel & Yalom, 1978 ; Yalom & Greaves, 1997). Although their early research was limited to women with metastatic breast cancer, SEGT was one of the first psychotherapy approaches that was specifically aimed at providing patients with advanced cancer with the type of supportive environment that could help buffer what was seen as the trauma of a terminal illness. More importantly, this early research challenged the previous thinking, that convening a group of patients with terminal illness would be an entirely demoralizing experience ( Spiegel & Glafkides, 1983 ). Over the next several decades, research in the areas of palliative care and patients’ existential needs at the end of life, as well as the role of mental health providers in these settings, expanded dramatically. In part, this course of research was fueled by the changing ethical and legal contours of physician assisted suicide.

Desire for Hastened Death

In the late twentieth century, debates regarding physician assisted death (PAD; i.e., physician assisted suicide, euthanasia) generated considerable interest from researchers who sought to understand why some patients with terminal illness might want to hasten death. The term desire for hastened death (DHD) was developed as a way of studying what was thought to be the construct underlying both requests for assisted death and thoughts of suicide more generally ( Brown et al., 1986 ; Chochinov et al., 1995 ; Rosenfeld et al., 1999 ). Initially, pain, depression, and physical symptoms were hypothesized to be the main drivers of DHD, generating considerable emphasis on improving palliative care in hopes of reducing or eliminating requests for PAD. However, the research literature that emerged in the 1990’s and early 2000’s has placed much more emphasis on psychological and existential correlates of PAD, such as depression, hopelessness, spiritual well-being and perception of oneself as a burden to others. This evolving research literature has provided an empirical basis for an ever growing number of psychotherapy interventions for patients at the end of life, most of which assume that while adequate physical symptom control is likely, addressing the psychological and spiritual needs of patients with serious or terminal illness is more challenging.

One of the seminal studies of DHD, conducted by Breitbart and colleagues (2000) evaluated the factors associated with DHD in a sample of 92 patients who had been hospitalized in a palliative care facility, all of whom had been diagnosed with terminal cancer and had a life expectancy of 6 months or less. They found that 17 percent of the study participants met diagnostic criteria for a major depressive episode, according to a clinician-administered semi-structured interview. Similarly, 17 percent of participants also endorsed a high DHD (using a self-report rating scale that had been developed by the study investigators). Perhaps not surprisingly, those with a major depressive episode were four times more likely to endorse DHD than those without MDD, but they found that hopelessness was an equally, if not more important predictor of DHD, and the presence of both depression and hopelessness had an even more powerful impact on DHD. In addition to depression and hopelessness, other risk factors for DHD that this study identified included spiritual well-being, overall quality of life, and the perception of being a burden to others. Although severity of physical symptoms and symptom distress were also significant predictors of DHD, pain and pain intensity were not. These findings aligned with and extended earlier work in which hopelessness was found to uniquely contribute to predicting suicidal ideation after controlling for depression in patients with advanced terminal cancer ( Chochinov et al., 1998 ). In subsequent analyses, McClain, Rosenfeld, and Breitbart (2003) found that spiritual wellbeing, and a sense of meaning and purpose in particular, actually buffered the effects of depression on DHD and suicidal ideation, highlighting yet another potentially important psychological/existential construct. These studies have fueled a growing interest in clinical interventions that not only target depression, but also focus more directly on hopelessness and spiritual well-being.

Simultaneous to the emerging research on hopelessness and spiritual wellbeing, Chochinov and his colleagues (2002a) began to examine the loss of dignity as a critical risk factor for DHD. In their first study focused on the importance of dignity, these authors found, in a sample of 213 patients with terminal cancer, that patients who reported feeling a loss of dignity due to advancing illness were not only more likely to report worse psychological and physical symptom distress, but were also more likely to acknowledged having lost their “will to live.” In a subsequent study focused squarely on the will to live, Chochinov et al. (2005b) found that key existential issues such as a lost sense of dignity, perceiving oneself to be a burden to others, and feelings of hopelessness were more strongly related to DHD than physical symptoms. Collectively, these studies have provided empirical support for what had long been suspected by mental health practitioners working with the terminally ill – that losing one’s hope is analogous to losing a sense of meaning and purpose, contributing to a diminished loss of the will to live in the face of terminal illness. Conversely, the preservation of dignity can help preserve an individual’s sense that they are valued and by extension, could improve a patient’s will to live at the end of life ( Chochinov et al., 2005b ). In short, the findings from these and other studies have identified a number of critical concerns for patients at the end of life and have generated a range of potential targets for psychotherapeutic interventions that might ameliorate DHD and preserve the will to live.

Dignity Model and Dignity Therapy (DT)

A primary goal of palliative care is to help patients die with dignity. This goal is traditionally achieved through symptom management, but has increasingly encompassed psychological, spiritual, and family care. Chochinov and colleagues (2002a) proposed that dignity can provide an overarching framework to guide patients, families, and health care professionals in defining the goals and preferences for end-of-life care. Influenced in part by the aforementioned DHD studies, Chochinov (2002b ; 2013 ; Sinclair et al., 2016 ) is well known as an advocate for dignity-preserving, compassionate end-of-life care. He proposed a model of dignity that was based on both clinical experience and a series of qualitative interviews with patients who were in an advanced stage of terminal cancer (see Figure 1 ). Three broad areas emerged as critical elements of dignity conservation in end-of-life care: 1) illness-related concerns, 2) a dignity-conserving repertoire, and 3) social aspects of dignity. Broadly, illness-related concerns include aspects of the illness itself such as symptom-related distress or functional impairment. Dignity-conserving repertoire includes both maintaining a dignity-conserving perspective (i.e., ways of looking at one’s situation that helps promote dignity and maintain a sense of personhood) as well as dignity-conserving practices, or techniques that can be implemented to maintain dignity. Finally, the social elements of dignity include interpersonal and relationship attributes that can either enhance or diminish one’s dignity (e.g., privacy, perceived burdensomeness, aftermath concerns). Critical to this model is the understanding that each individual possesses unique differences and personal attributes, and that acknowledging these characteristics is fundamental to dignity preservation. Chochinov also developed question prompts that were linked to various facets of the model and offer guidance to clinicians on how to achieve dignity conserving care. These prompts serve as key guideposts in Dignity Therapy (DT).

Dignity Model

Dignity Therapy (DT) was one of the first manualized psychotherapy interventions developed specifically for use in palliative care settings ( Chochinov et al., 2005a ; 2011 ). In DT, patients with a terminal illness (i.e., across a range of conditions, not only those with cancer) are invited to discuss aspects of their life they would most want recorded and remembered. Patients are told in advance that they will be asked by the therapist to speak about things that matter the most to them, including things they may want to share with their closest friends and family. These audiotaped discussions are guided by a framework of questions (see Table 1 ) that were based on the dignity model, and are provided in advance of the session, in order to give the individual time to reflect on the questions and their answers. The individual is then guided through a flexible (i.e., semi-structured) interview in which the therapist uses the question framework to facilitate the disclosure (and recording) of the person’s thoughts, feelings, and memories. Typically, this process is completed within a single session, but can be completed across several meetings, if need be. The audiotaped interviews are then transcribed and edited into a narrative in order to prepare a legacy or generativity document. In the second session, this document is presented to the patient and reviewed, allowing them the opportunity to suggest edits or make any desired changes. The final document is then given to the patient, allowing them the opportunity to share it with loved ones, if they choose to. In hopes of engendering a sense of generativity, one of the main goals of DT is to help patients feel that they will have left something of value behind. The therapeutic goal is to enhance a sense of meaning and purpose for patients, helping them to identify their lasting legacy and in so doing, contribute to preserving their dignity.

Dignity Therapy Question Protocol

An initial feasibility study of DT included adults receiving home-based palliative care services in Canada and Australia ( Chochinov et al., 2005a ). Eligibility for this study included being 18 years or older, having a terminal illness with a life expectancy of less than 6 months, English speaking, a willingness to commit to 3 to 4 contacts over 7 to 10 days, and no obvious cognitive impairment that might impede participation. Prior to participating in the pilot study, the participants completed a series of questionnaires about their physical, psychological, and existential well-being. Study participants then completed the DT process, following the procedures described above, and were then asked to complete the outcome measures again, along with a survey intended to elicit satisfaction with the DT intervention. Of the 100 patients who participated in the initial study, 91 percent reported feeling satisfied or highly satisfied with DT, and 86 percent described it as helpful or very helpful. Existential outcomes were also rated as improved, as 76 percent reported an increased sense of dignity, 68 percent reported an increased sense of purpose, and 67 percent reported increased sense of meaning. Nearly half also indicated that their will to live increased following DT. Significant treatment effects were also observed for suffering and depressed mood (i.e., significant reductions following study completion), and those participants who reported greater despair and distress at baseline appeared to demonstrate the greatest benefits from DT. A subsequent randomized controlled trial (RCT) of DT compared to supportive client-centered care or standard care (n = 441) also found promising trends that supported DT ( Chochinov et al., 2011 ). Specifically, participants reported that DT increased their sense of dignity and quality of life, and felt it had been or would be of benefit to their family (compared to the other study arms).

Following the initial reports about DT, numerous research studies have been implemented and evaluated around the world. A 2017 systematic review of DT included 28 articles that had been published between 2011 and 2016 ( Martínez et al., 2017 ). Overall, the quality of the studies was rated as high, with five RCTs of DT. In the two RCTs that included patients with high baseline levels of distress, one (Juliao et al., 2015) demonstrated statistically significant decreases in patients’ anxiety and depression scores over time, while the other ( Rudilla et al., 2016 ) demonstrated significant decreases in anxiety but not depression. As with the initial DT feasibility study, uncontrolled replication studies have also demonstrated significant improvement for patients across psychological and existential outcomes ( Martínez et al., 2017 ). Despite the overwhelming positive evaluation of DT provided by patients and families across DT studies, future RCTs are still needed to determine whether DT is more (or less) appropriate and beneficial for identifiable subgroups of terminally ill patients (e.g., those experiencing high levels of distress), and to more systematically evaluate the mechanism of change observed in pre-post intervention outcome measures.

Meaning Centered Psychotherapy (MCP)

Unlike Dignity Therapy’s focus on generativity and legacy, Breitbart and his colleagues (2000 , 2002, MANUALS) developed a more traditional psychotherapy approach to helping patients cope with the challenges of terminal illness. Inspired primarily by the works of Viktor Frankl (1955 ; 1959 ; 1969 ), and his emphasis on the importance of meaning in human existence, Meaning Centered Group Psychotherapy (MCGP) was initially conceived of as a group-based intervention for individuals with advanced cancer. MCGP draws heavily from Frankl’s concepts, by identifying the sources of meaning as a resource to help patients develop or sustain a sense of meaning and purpose, even while in the midst of suffering. In addition, MCGP incorporates a number of fundamental existential concepts and concerns related to the search, connection, and creation of meaning ( Park & Folkman, 1997 ). In short, enhanced meaning is conceptualized as the catalyst for improved psychosocial outcomes, such as improved quality of life, reduced psychological distress, and a decreased sense of despair (see Figure 2 ). Hence, meaning is viewed as both an intermediary outcome, as well as a mediator of changes in these important psychosocial outcomes ( Rosenfeld et al., 2018 ).

Meaning Centered Psychotherapy Conceptual Model

Although originally developed as a group-based intervention, Meaning Centered Psychotherapy was subsequently adapted to permit delivery in an individualized format (Breitbart et al. 2012; 2018 ). This adaptation is particularly important for those individuals with very advanced disease, where physical limitation and/or treatment needs may limit the ability to attend regularly scheduled group sessions. The structure of the Individual Meaning Centered Psychotherapy (IMCP) is similar except in the group version, with the exception of the initial sessions dedicated to learning about patients’ cancer stories (only one such session is needed for IMCP, rather than two for MCGP). Thus, IMCP is a seven-session, manualized intervention that focuses on specific themes related to meaning and the experience of having advanced cancer. Both versions of Meaning Centered Psychotherapy have three overarching goals: 1) to promote a supportive environment for patients to explore personal issues and feelings surrounding their illness on a therapeutic basis; 2) to facilitate a greater understanding of possible sources of meaning both before and after a diagnosis of cancer; and 3) to aid patients in their discovery and maintenance of a sense of meaning in life even as the illness progresses. In short, MCGP and IMCP were designed to help patients optimize coping through an enhanced sense of meaning and purpose. Moreover, the intervention is intended to help broaden the scope of possible sources of meaning through a combination of: 1) educating patients in the philosophy of meaning on which the intervention is based, 2) in-session exercises and between-session homework that each participant is asked to complete, and 3) open-ended discussions, which typically include the therapist’s interpretive insights and comments. Table 2 presents a list of session topics, including an outline of the sources of meaning (i.e., historical, attitudinal, creative, and experiential).

Topics of Individual Meaning-Centered Psychotherapy (IMCP) Weekly Sessions

To date, four RCTs conducted by Breitbart and colleagues (2010, 2012, 2015 , 2018 ) have examined the efficacy of MCP in patients with advanced cancer in the outpatient, ambulatory care setting. The first pilot study of MCGP provided strong support for the efficacy of this intervention, not only improving spiritual well-being and a sense of meaning, but also in decreasing anxiety, hopelessness, physical symptom distress, and DHD (Breitbart et al., 2010). In that study, 90 patients were randomly assigned to receive either 8 eight sessions of MCGP or Supportive Group Psychotherapy (SGP). Results of this study demonstrated significantly greater benefits from MCGP compared to SGP, with the strongest effects for enhanced spiritual well-being and sense of meaning. Importantly, treatment effects for MCGP appeared even stronger two months after treatment ended, suggesting that benefits may not only persist but even grow after treatment is completed. On the other hand, participants who received SGP did not demonstrate any such improvements in spiritual well-being, quality of life, or psychological distress at either post-treatment or the follow-up assessment. This study provided initial support for the benefits of MCGP as a novel intervention for improving spiritual well-being and sense of meaning, and fueled interest in this intervention as a potentially efficacious treatment for end-of-life despair. A second pilot RCT tested the individualized format of Meaning Centered Psychotherapy, IMCP, in 120 patients with advanced cancer (Breitbart et al., 2012). In that study, IMCP again demonstrated significant treatment effects in improving spiritual well-being, sense or meaning, and overall quality of life, while also reducing hopelessness, DHD, depression, and physical symptom distress. Two subsequent RCTs, one investigating MCGP ( Breitbart et al., 2015 ) and a second examining IMCP ( Breitbart et al., 2018 ), have replicated and extended the results of the initial pilot study findings in substantially larger samples (N = 253 and N=325, respectively). These studies, totaling nearly 800 patients in randomized clinical trials, have provided strong support for the effectiveness of Meaning Centered Psychotherapy in improving spiritual well-being and reducing psychological distress.

Although the emerging research on Meaning Centered Psychotherapy has supported its effectiveness, and has consistently demonstrated that supportive psychotherapy, while frequently used in medical settings is largely ineffective, the extent to which the observed results are due to changes in one’s sense of meaning require further evidence. Recently, Rosenfeld and colleagues (2018) provided such evidence in their examination of the mechanism of change in MCGP. Using data from drawn from two RCTs of MCGP (Breitbart et al., 2010, 2015 ), they used structural equation modeling to evaluate the mediation effects of treatment type on key psychosocial outcomes (e.g., quality of life, depression, hopelessness, and DHD). Specifically, they demonstrated that post-treatment changes in psychosocial outcomes were mediated by changes in the patient’s sense of meaning and peace. These analyses are some of the first to empirically evaluate the hypothesized mechanism of change in these types of existential psychotherapies for patients with advanced medical illnesses, and provides empirical support for the theoretical foundation underlying this psychotherapy approach.

Like Dignity Therapy, enthusiasm for Meaning Centered Psychotherapy has fueled multiple adaptations of this treatment approach, in order to target unique clinical populations and settings. These adaptations have included cancer survivors, bereaved family members, and caregivers ( Applebaum, Kulikowski, & Breitbart, 2015 ; Lichtenthal et al., 2019 ; van der Spek et al., 2017 ). In addition, several “cultural” adaptations of MCGP have been developed and/or pilot tested in samples ranging from Latin and Chinese immigrants in the United States to individuals from Israel, Spain, the Netherlands (e.g., Costas-Muñiz et al., 2017; Gi,l Fraguell & Limonero, 2017; Goldzweig, et al., 2017; Leng et al, 2018). Further, given the unique needs of palliative care patients, many of whom cannot realistically complete a 7-session intervention (e.g., due to deteriorating cognitive and physical functioning), Rosenfeld and colleagues developed a 3-session version of IMCP that was intended to be delivered at the bedside for patients in the final weeks of life ( Rosenfeld et al., 2017 ). Their small feasibility study demonstrated promise for this abbreviated version of IMCP, but more systematic research is needed to determine whether this intervention can be effectively delivered in a highly condensed format. In addition, while virtually all research examining Dignity Therapy and Meaning Centered Psychotherapy have focused on oncology settings, the potential for the core principles of these interventions to help patients with other advanced diseases is clear. Thus, future research should focus on examining the utility of these interventions for patients with a range of other advanced and terminal illnesses.

Other Interventions for Adults with Terminal Illness

Although Dignity Therapy and Meaning Centered Psychotherapy have garnered the most attention in the fields of palliative care and psycho-oncology, several other researchers and clinicians have developed interventions for this vulnerable population. For example, Ando and colleagues ( Ando et al., 2008 , 2010 ) proposed a treatment approach, called Short-Term Life Review (STLR), that has structural similarities to Dignity Therapy. Like Dignity Therapy, STLR also consists of an initial interview focusing on important memories, relationships, and messages for younger generations. This interview is used to create an album that is reviewed with the patient in a second session. The difference between these two approaches (DT and STLR) lies primarily in the substance of the interview. However, unlike DT, there has been little research to support the STLR approach, with a single published RCT examining its utility. This study ( Ando et al., 2010 ) demonstrated that patients with terminal cancer who received STLR showed greater increases in spiritual wellbeing, sense of hope, and preparedness for death compared to patients who received two sessions of general support.

Another brief, structured intervention for patients with advanced and/or terminal cancer is Managing Cancer and Living Meaningfully (CALM; Hales, Lo & Rodin, 2015 ; Nissim et al., 2012 ). Drawing on some of the same underlying principles as MCGP (e.g., the importance of spiritual well-being and a sense of meaning), CALM also focuses on identifying and navigating changes in self and relations with close others, symptom management and communication with health care providers, and advance care planning. The intervention is delivered in three to six sessions over a three-month period, therefore providing less emphasis on spiritual well-being and related existential issues (because the intervention content also encompasses a range of other important foci). However, preliminary research has supported the effectiveness of this intervention, beginning with Lo and colleagues’ (2014) pilot study of 50 Canadian palliative care patients. In that study, those who completed CALM reported significantly fewer symptoms of depression and death anxiety, and significantly better overall quality of life, compared to those who did not complete the intervention. More recently, Rodin and colleagues (2018) described the first large-scale RCT of CALM in their study of 305 individuals receiving outpatient cancer care. Patients randomized to CALM demonstrated significantly greater improvements in depressive symptoms and overall quality of life for patients randomized to CALM compared to those receiving usual care, but no difference in changes in anxiety, spiritual well-being, or death anxiety. Although encouraging, these interventions require further study before firm conclusions can be drawn about their effectiveness and relative efficacy compared to more well-established interventions such as Dignity Therapy and MCGP.

The aforementioned interventions, as well as others that are not described in this review, were synthesized in a recent meta-analysis that summarized 24 RCTs that addressed interventions that primarily focus on existential issues in adults with cancer ( Bauereiß et al., 2018 ). This review identified the strongest effects for these treatments on measures of existential wellbeing, quality of life, and hope/hopelessness. However, only the treatment effects for hope were sustained at six months, though significant effects on self-efficacy also emerged at the 6-month time point. Surprisingly, treatment effect sizes for spiritual well-being, depression, and anxiety, were small. Notably, the analyses did not identify any moderator effects for cancer stage or type, suggesting that despite the heterogeneity of the cancer experience, existential distress may be an appropriate treatment target across the cancer continuum. Finally, Bauereiß et al., (2018) highlighted several future directions for research addressing interventions at the end of life, such as striving towards greater standardization of outcome metrics and ways of lowering the resource intensity of the interventions (e.g., telehealth adaptations).

Future Directions

The history reviewed here only scratches the surface of the palliative and end of life care literature, which continues to grow. For psychotherapeutic interventions in particular, it is critically important that researchers determining how to optimize training and dissemination efforts of evidence-based psychotherapies (e.g., Dignity Therapy, Meaning Centered Psychotherapy, CALM). As the world population continues to diversify, efforts to adapt these treatments to various cultures are critical to developing culturally responsive interventions. Similarly, as the world population ages, heterogeneity in chronic and terminal illnesses is also likely to increase, so determining the relative efficacy of these psychotherapies for different patient groups (beyond cancer) should be prioritized. As first recommended by Kubler-Ross, communications that include open, honest discussions of illness and prognosis between clinicians, patients, and families, continues to be critical, particularly as they facilitate informed treatment decisions and enhance end of life care. Finally, the growing adoption of physician assisted death (PAD) in more and more jurisdictions requires mental health providers be prepared to discuss PAD with their patients and the potential existential questions that may accompany its consideration. Clinicians must also be competent to deliver psychotherapeutic interventions, targeting various sources of existential distress, to patients who are coping with a terminal illness.

Conclusions

This review provides a window into the progression of psychotherapy research with patients at the end of life that began in the aftermath of Dr. Elisabeth Kubler-Ross’s seminal book. While the content, structure, and empirical foundation underlying end of life psychotherapies have evolved considerably in the 50 years since that book’s publication, her recommendations for providing a nonjudgmental space for open discussion of fears and concerns around death and dying remains a cornerstone of these interventions. Whether through Dignity Therapy, Meaning Centered Psychotherapy, or other interventions that draw on existential principles, patients who are navigating the demands of an uncertain future both require and deserve state of the art interventions. The goal of attenuating suffering and helping patients and their families to maintain a sense of meaning, dignity and peace is central to this work.

Acknowledgements

This work was supported by the National Institutes of Health under Grants T32CA009461, and P30CA008748.

Declaration of Interest Statement

The authors have no conflicts of interest to disclose.

Contributor Information

Rebecca M. Saracino, Assistant Attending Psychologist, Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center.

Barry Rosenfeld, Professor and Chair, Department of Psychology, Adjunct Professor, School of Law, Fordham University, Bronx NY 10458, Past-President, International Association of Forensic Mental Health Services.

William Breitbart, Chairman, Jimmie C. Holland Chair in Psychiatric Oncology, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center.

Harvey Max Chochinov, Distinguished Professor of Psychiatry, University of Manitoba.

Expectations For Your Therapy Journey: What Does Progress Look Like?

Whether you’re considering participating in therapy or have just begun the counseling process, you may be wondering what to expect. Everyone’s journey with therapy can look different, and it may take varying amounts of time to start making progress and positive changes in your life. While therapy can be a lengthy procedure, the process is not all stress and hardship. It may be helpful to understand the phases of therapy you may progress through as you delve deeper into self-knowledge and self-healing. Keep reading to learn more about the therapeutic process and what you may be able to expect along the way.

Initiating the journey

Since therapy is a personal journey, it’s possible that your experience could be nonlinear or complex. When participating in therapy, it can be important to trust the process while maintaining open and honest communication with your therapist regarding your feelings about your treatment plan. The two of you may find a way to collaborate on creating a positive therapy journey together.

When you begin therapy, you and your therapist will often focus on building a stronger relationship. You may not feel comfortable starting the healing process right away, as your therapist is a stranger to you, and you might need some time before you are okay with being fully open and vulnerable with them. You may start by talking about your thoughts, feelings, and relationships in your life while your therapist listens and validates your experiences. This validation can help to create a sense of safety between the two of you, which then may lead you to have deeper, more closely held emotions that could lead to greater therapeutic insight.

At this phase in the journey, counseling may slightly reduce the mental health symptoms you have been experiencing. This shift is likely due to the benefits of simply talking to someone else about what you have been going through. However, it is important to note that the real gains are likely still yet to be made, and it can be crucial to stick with and trust the therapeutic process at this phase. 

In other cases, counseling may cause slightly worsening symptoms at the start of the process, as opening up to someone may reveal deep and intense emotions. This doesn’t mean therapy isn’t working to treat the symptoms of the mental illness; rather, you may just need more time to see its full effect.

Self-reflection

Once you and your therapist have developed a connection , you can start to approach a central question of your counseling journey: what challenges are you hoping to address? You may have started sessions with an idea of what you would like to work on, such as tackling relationship troubles, improving emotional hardships, building greater self-esteem, or deepening your relationship with yourself. Even if you already have a sense of what you’re hoping to gain from therapy, working through the process may help illuminate potential underlying concerns that are contributing to the challenges you are experiencing in your life.

On the other hand, you may have no tangible feeling of what you want from therapy. Maybe you started your journey because you don’t feel like you’re the best version of yourself that you could be, but you don’t know what that version looks like. Maybe you have a general sense of stagnation or frustration in your life, and are unsure how to address it. It is perfectly okay and understandable not to know what you hope to get out of therapy – that too can be part of the journey. Your therapist can help you identify your idea of progress in personal development and how you can start moving in that direction. 

Goals for your experience

This phase can be the most exciting component of the journey. By this point, it’s likely that you and your therapist have built a  strong therapeutic relationship and have identified a concern you want to work on – now you can develop a plan to address that concern and engage in personal growth.

You and your therapist can work as a team to create this plan. You may start by discussing your value systems and making sure you develop a plan that is authentic to you and supportive of your specific needs while you are tackling your goals. These goals may include finding a resolution to an ongoing conflict or challenge in your life or reducing symptoms of a mental health condition. It could also mean learning how to shift behavioral patterns, such as feeling empowered enough to stand up for yourself, integrating mindfulness into your daily life, prioritizing your own well-being, or something else. Having clearly stated goals can help you identify the progress you are making on your individual journey. 

Exploration can be the most difficult stage of this process. As you and your therapist embark on your treatment plan, you may uncover forgotten memories, emotional challenges, and hidden thoughts and feelings. You might begin to realize that certain belief systems are not serving you any longer and start to reassess your understanding of other people, including close relationships in your life. As you re-examine your past experiences, you might even learn that you have survived trauma. Exploring different parts of your mind and consciousness that you have previously been disconnected from can be complicated and potentially messy.

If you are experiencing trauma, support is available. Please see our Get Help Now page for more resources.

This phase of your therapy journey may be emotionally distressing, but it may be helpful to know that it is all part of making important self-progress. Your therapist can be there to support you every step of the way.  For those seeking a more transformative healing experience, a unique approach called Brandon Bays' Journey therapy may help individuals heal from the very core of their being.

Integrating counseling lessons into your everyday life

After all, your mental health can have effects on other aspects of your life, including your physical health. If you find yourself experiencing new or worsening physical symptoms alongside mental health challenges, you may need to seek medical advice from a licensed healthcare provider.

Identifying an endpoint

In some cases, though, your journey may feel as though it has reached an endpoint. Perhaps you feel as though you have maximized the potential benefits and self-growth from the work you are doing with a particular therapist. In these instances, you may be comfortable stepping away from therapy. Maybe you show up to therapy with nothing to talk about, or your provider has suggested that you may be in a place to continue your healing independently. 

Regardless of how or if your journey concludes, therapy can continue to be a helpful support system and a resource to lean on. Navigating life can be complicated, and future challenges could cause a resurgence of unhealthy thought or behavior patterns. A therapist can be a beneficial resource for working through challenging times, no matter what stage of life you’re in.

Other options for support

If you’re considering therapy but aren’t sure where to begin, online therapy could help you start the process with ease. It’s likely that you’ll want to find a therapist that matches your specific needs, preferences, and situation. With online therapy platforms such as BetterHelp , you can fill out a form stating the areas you’re struggling in and what qualities you’d like in a provider. 

Online counseling

BetterHelp provides a comprehensive database of counselors with proven expertise and experience in helping their clients improve their lives and understand themselves more deeply. Upon matching with one of these providers, you can speak with them from the comfort of your home and start to determine whether they’re the right fit for you. You can switch therapists as needed and participate in sessions for as long as you’d like. Having control over your therapy journey may allow you to have a more positive experience. 

Research has indicated that there may be no substantial difference in efficacy between online therapy and therapy received in a traditional in-person setting. In one study, clients who completed their therapy journeys online saw a significant reduction in symptoms of a range of different mental health conditions, including post-traumatic stress disorder, anxiety, eating disorders, depression, bipolar disorder, mood disorders, phobias, and more. Cognitive behavioral therapy, or CBT, was the chosen approach that contributed to these outcomes and worked by providing participants with the tools they needed to change their thoughts and alter their behaviors.  

• How To Find A Therapist: Embarking On Your Therapy Journey Medically reviewed by Paige Henry , LMSW, J.D.
• Honesty And Open Communication: What To Expect In Couples Therapy After Infidelity Medically reviewed by Julie Dodson , MA
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Transform your life with therapy. Explore the therapy process, find the right therapist, and unlock the benefits of personal growth and mental well-being. Discover how therapy can enhance relationships, overcome challenges, and promote self-discovery.

Understanding the therapy process can seem overwhelming and daunting, especially if it's your first time. However, navigating your therapy journey doesn't have to be a process shrouded in mystery. This comprehensive guide will provide valuable insights on what to expect from the beginning to the end of therapy; by reading on, you'll understand the different stages of therapy, indicators of progress, and how to maximize your therapeutic journey.

Table of Contents:

Understanding the need for therapy, choosing the right therapist, exploring different types of therapy, navigating the course of therapy, assessing your progress in therapy, dealing with challenges and plateaus in therapy, enhancing your therapy experience outside the sessions, recognizing when to conclude therapy, life after therapy, frequently asked questions.

Recognizing that you may need therapy is the first step towards improvement. This may include persistent sadness, difficulties managing daily activities, experiencing significant trauma, or being overwhelmed by various life stressors. It's important to tune into your feelings, physical symptoms, and thought patterns. Research has consistently shown that therapy, particularly cognitive-behavioural therapy (CBT) , is effective in treating depression. CBT helps individuals identify and change negative thought patterns and behaviours that contribute to their depression. It focuses on developing coping strategies, setting realistic goals, and improving problem-solving skills.

The success of therapy largely depends on picking the right therapist. The types of therapists and their specialities can range from psychologists and counsellors to psychiatrists, all offering different therapeutic services. In the selection process, consider their licensing and credentials, areas of expertise, therapy styles and approaches, and session fees. Finding the right therapist is a subjective process; what works for one person may not necessarily work for you. A good example illustrating the impact - In a survey by the American Psychological Association , 80% of patients who felt a good relational connection with their therapists reported significant improvement in their condition.

Preparing for Your First Therapy Session

The first therapy session typically involves a comprehensive assessment of your mental and emotional health. The therapist will ask questions about your symptoms, personal history, and goals for seeking therapy. Preparatory steps could include noting down important points you would like to discuss or your questions, allowing you to get as much from the session as possible. Subsequent sessions will typically follow a structure based on the therapy type and your specific needs.

Depending on your specific needs, you may benefit from various types of therapy. Common therapeutic approaches include Cognitive Behavioral Therapy (CBT), which is effective for anxiety and depression, and Psychodynamic therapy , which helps individuals understand their unconscious processes. Understanding the basics of these different methodologies is important to communicate effectively with your therapist about your preferred approach.

A typical therapy session lasts 45-60 minutes, in which you talk about your feelings, thoughts, and behaviours. Openness and honesty form the bedrock of successful therapy sessions, as it allows the therapist to gain a detailed understanding of your experiences and challenges. Remember, this is your safe space, and everything you share is confidential. Objectively tracking your feelings and experiences throughout the process can later serve as a useful tool for evaluating progress and areas for improvement.

Tracking your progress in therapy is crucial to see how far you've come. Remember that individual progress varies greatly - for some individuals, change might be noticeable quickly, while for others, it might take time. Key indicators you're progressing can include experiencing less intense emotional distress or finding it easier to cope with stressful situations. Regularly discussing your progress and adjustments with your therapist is also critical.

Therapy isn't always a linear progression. Sometimes you feel like you aren’t making progress or even regressing, and that's completely normal. It's important to communicate this with your therapist, who can help navigate these periods of stagnation. Remember, therapy is just as much about building mental resilience as it is about solving specific issues.

Your work in therapy extends beyond the therapist’s office. Engaging in “home assignments”, such as journaling your experiences or practising stress management strategies, can enhance your therapy experiences. Building a strong support system of friends, family, or support groups can enhance the therapeutic process.

Understanding when it's time to end your therapy is equally important. Generally, you and your therapist collaboratively decide this, often when your therapy goals have been reached or if you’ve developed sufficient skills to manage your emotions independently. The process of ending therapy is important and should be handled thoughtfully. It's common to have a few final sessions discussing the termination and consolidating the gains made.

Skills and strategies learned during therapy, such as effective communication, emotional regulation, and stress management, can serve you long after therapy concludes. But remember, it's okay if you need to return to therapy; life presents new challenges, and therapy can again be an effective tool to handle these situations.

Therapy is a powerful tool for navigating mental health challenges and improving our emotional well-being. Understanding its process helps us be better prepared, preparing us for success. We can make the most of our therapy journey by recognizing the need for therapy, choosing the right therapist, knowing what to expect, effectively dealing with challenges, and learning when to conclude.

Is therapy expensive?

Therapy costs can vary greatly depending on the type of professional you see, length and frequency of sessions, geographical location, and other factors. However, many therapists offer sliding scale fees; some insurances cover mental health services.

How long does therapy typically last?

Therapy duration is highly individual and depends on various factors, including the nature of your concerns and their severity, the type of therapy, and the goals you’ve set with your therapist.

Does going to therapy mean I'm weak or a failure?

Absolutely not. Seeking help when you need it is a sign of strength and self-awareness. Therapy offers a supportive environment to explore your feelings and challenges, promoting personal growth.

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Ending Therapy: How Do You Know When the Work Is Finished?

How do you know when to end therapy? Is it after a certain number of sessions? After a few months or years? Or is it just when you no longer feel like you need it? 

At times, the therapeutic relationship can feel complicated. The work can feel so vulnerable and intimate. And yet, it’s a professional relationship- you enter it intending to leave. You start the process, knowing that it eventually ends.

But ending therapy isn’t always straightforward. How do you know when it’s time to consider cutting back or stopping your sessions? What milestones should you consider? Let’s get into what you need to know. 

What Is Termination?

Termination refers to the process associated with ending therapy. Therapy does not go on forever without a plan. Many therapists consider termination as more of an active collaboration, rather than as a single decision. Successful termination offers a profound opportunity for closure, growth, and reflection.

When you choose a therapist , you choose to share a part of yourself with someone else. You decide to prioritize your needs and focus on growth. 

In some ways, termination begins at the very beginning of therapy. That’s because you and your therapist will establish your treatment goals and discuss the nature of your work together. 

In other words, you should know what you’re trying to achieve. As you move towards completing those goals, the subject of termination may emerge more frequently.

What Are the Signs That You’re Ready for Ending Therapy?

Every therapist is different, and every client’s progress looks different as a result. It’s unhelpful to assume that everyone reaches the same goalposts associated with termination.

With that in mind, here are some common signs that you may be ready:

• You are regularly using the tools and coping strategies you learned in sessions.
• You don’t feel like you have much to talk about anymore.
• You have better insight into your patterns.
• You have built up a strong support system , and feel comfortable sharing your emotions with other people.

If you’re having thoughts about ending therapy, it’s a good idea to discuss them with your therapist. They may also bring up the concept of termination first. If this happens, it isn’t because they want to get rid of you! It’s because they recognize your progress and want to prepare you for your next steps!

Other Factors That Can Result In Ending Therapy 

Sometimes, you need to end treatment due to unforeseen circumstances like:

• Financial constraints
• Scheduling concerns
• Geographical relocations
• Clashing interests with your therapist
• Needing a higher level or more specialized kind of care

If any of these factors apply to you, you can also talk about that in session. Many therapists are flexible and can accommodate different needs. 

Remember that they want to help you succeed. If they can’t continue working with you, they will collaborate to determine the best strategies for moving forward in your care.

What If New Issues Emerge?

Let’s say you enter therapy because you’re struggling with grief after a loved one died. But throughout your therapeutic work, you start exploring the childhood trauma that you never spoke about before. You start realizing you aren’t as happy in your marriage as you would like to be.

Even if you start coping better with the grief, does that mean you’re now ready to end therapy? 

Not necessarily! It’s important to know that therapy goals can be fluid. As new material arises, your therapist will work with you to discuss how to integrate it into your treatment. You are human, and some issues can be layered, complex, and covert. 

Subsequently, therapists maintain an open-door policy for past clients. That means that you can return to treatment if you need support or something new happens. Once a therapist is your therapist, they will always consider you a client. 

What If You’re Scared of Ending Therapy? 

This is a common fear, although some clients may feel ashamed or embarrassed over it. It’s normal to feel attached to your therapist, and it can feel frightening to imagine what your life might look like without them. After all, they have hopefully been an unconditional source of empathy and compassion for you.  

In thinking about termination, you may worry about relapsing into old behaviors . Or, you might feel concerned that nobody else can support you in the same ways. 

Try to talk about these thoughts and feelings with your therapist. Termination can be a slow and gradual process- many clients transition into having fewer sessions over time, rather than stopping abruptly. 

Final Thoughts 

Ending therapy can feel scary, but it’s a natural part of the relationship. Moreover, finishing means that you have grown and made headway towards living a happier and healthier life. 

At Willow Counseling, we are here to support you on your journey towards self-exploration. Contact us today to schedule a free consultation. 

Willow Counseling, LLC – Nashville, TN

Willow Counseling, PLLC exists to provide quality trauma-informed mental health counseling to the Nashville community, recognizing the interconnectedness of our emotional, spiritual and physical selves. We work together to alleviate symptoms, learn better coping skills, relieve burdens, remove the pain of trauma, and so much more. However, our greatest desire is for you to know what it means to feel purpose and joy again and to recognize the strength and worth you have to offer the world.

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Table of Contents

The Beginning, Middle and End of a Counselling Session – A Complete Guide

As a BetterHelp affiliate, we may receive compensation from BetterHelp if you purchase products or services through the links provided.

The Optimistminds editorial team is made up of psychologists, psychiatrists and mental health professionals. Each article is written by a team member with exposure to and experience in the subject matter.  The article then gets reviewed by a more senior editorial member. This is someone with extensive knowledge of the subject matter and highly cited published material.

Coming to a point in life where you finally realize that you need help from a professional, to deal with your emotional baggage is a big step in life. This kind of self-realization takes time. Deciding that you need help is never a sign of weakness.

Many fear that they may appear weak if they go for therapy but what they don’t realize is that it takes a lot of courage to actually ask for help. It only makes you stronger. 

A lot of preparations go in for a counselor before, during and after every session. Each session is customised according to the client’s issue. The counselor then creates a plan of action to overcome the client’s problems. 

The three stages of counselling – the beginning, the middle and the end 

The beginning.

In the beginning of counselling, the therapist first tries to build a rapport with the client.  It is essential to create a safe space for the client. This is the initial disclosure phase where the counselor starts getting to know about the client.

It is always best to start the session with introductions to make the client feel more comfortable. It is natural for the client to feel nervous and anxious at the first session so it is crucial for the counselor to slowly ease the client into the therapeutic process. 

Building a relationship with the client is the most important step at this stage. The more comfortable the client feels, the more likely he/she is to open up to the counselor. The counselor needs to be patient and actively listen to the client.

It is also important for the therapist to observe the client’s body language. That helps determine whether the client feels comfortable or closed-off. The client slowly starts to open up about their issues that they need help dealing with. 

The client needs to feel that the counselor is genuinely interested in listening to their problem and they should feel the counselor exhibiting empathy towards them. Once they feel heard, they are more willing to dig deeper into their emotions.

It is not only important to listen to the client, but it’s also important to listen and react to what the client is trying to say. The counselor must encourage the client as much as possible and give them unconditional positive regard. 

Although this stage is more about getting the client to open up and express their thoughts and emotions, the therapist must also establish boundaries so as to avoid transference and countertransference during the counseling process. 

In therapy, the middle stage would be where the counselor does the history intake of the client. This is the in-depth exploration phase where the therapist examines the depth of the issue faced by the client. In this stage, the counselor also explores the client’s life and personality.

The history intake consists of the client’s basic personal data, as well as their emergency contact details. The counselor examines, in detail, about the client’s personal life – their childhood, their upbringing, interpersonal relationships, family background, etc. 

The counselor also tries to determine the onset and duration of the problem faced by the client. In this stage, the counselor further asks the client about his/her goals and expectations from therapy. 

Making a note of the client’s presenting problem plays a key role in his/her further diagnosis. It is important for the counselor to cross check with the client, by paraphrasing or summarizing, whether they have actually understood what the client is trying to say.

Making wrong assumptions and misunderstandings between the therapist and client can hamper the therapeutic relationship. If the rapport is hindered then the counselor will need to take a few steps back and rework their way back to the relationship building stage. 

It is necessary for the counselor to determine where the presenting problem posed by the client has manifested from. The therapist needs to observe the client carefully and catch any verbal or non-verbal cues exhibited by them. 

Non-verbal cues can be difficult to pick up on but some clients communicate more with their body language than their words. The therapist also needs to listen to any changes in the client’s tone. That can say a lot about how the client is actually feeling.

In this last stage, the therapist sets goals that are acceptable to the client in order to start treatment. This is the commitment to action phase where the therapist and the client work towards achieving their goals.

The client is always focused on the problem, whereas, the therapist’s main focus is the client and how to create a healthy enough therapeutic process for them to get through their issues and be able to achieve their goals. 

Setting goals gives direction to the process. Otherwise, there comes a point where the therapist and client may feel that they are stuck and unable to make progress. Achieving goals one by one helps the process to make progress.  

There are two types of goals that need to be set – short term goals and long term goals. Short term goals should be simple and easily achievable but long term goals need to be more concrete and give purpose to the client’s life.

If the client already has long term goals in mind but is finding it difficult to work towards them, it’s best to break them down into smaller goals. If you provide a step by step format to your client, then they can easily move forward with their goals. 

By the end of the session, the counselor must summarize everything that the client said during the session in a structured manner. It is important to gain clarity so as to understand the client correctly. It is also important to reflect the client’s feelings. 

Summarization at the end of the session also helps the client remember what was discussed and how to go about it for the next session. The best way to end a counseling session is to assign homework to the client so that they can work on improving themselves outside of therapy. 

Before ending the session, the therapist should check in with the client to see whether they are feeling too overwhelmed by the process.

In conclusion, the beginning, middle and end of a counselling session has three phases – the initial disclosure phase, the in-depth exploration phase, and the commitment to action phase. 

We explored each phase in detail.

Frequently Asked Questions (FAQs): Beginning, Middle and End of a Counselling Session

What are the 3 stages of a counselling session.

The 3 stages of a counselling session are:

• The beginning stage, also known as initial disclosure stage
• The middle stage, also known as the in-depth exploration stage
• The end stage, also known as the commitment to action stage

What is the middle stage of Counselling?

The middle stage of counselling is when the counselor enables the client to gain perspective about their problems. The middle stage involves exploring the client’s personal and work life, family history, medical history and the onset of the problem. 

What are the 5 stages to a counseling session?

The following are the 5 stages to a counseling session:

• Stage 1: Initial disclosure.
• Stage 2: In-depth exploration.
• Stage 3: Commitment to action.
• Stage 4: Counseling intervention.
• Stage 5: Evaluation, termination, or referral (if needed)

How do you end a counseling session?

Around 10-15 minutes before ending the session, the therapist needs to summarize the session for the client and check with the client whether they missed anything. After summarizing, the counselor should reflect the client’s feelings so they feel heard and understood. 

The therapist should then ask the client whether there was anything more they would want to discuss about. Before the client leaves, the therapist should assign homework from the client to do. This encourages them to work on themselves before their next appointment. 

https://www.ukessays.com/essays/psychology/stages-and-skills-in-a-counselling-session.php

https://allassignmentsupport.com/blog/3-stages-of-counseling-process/

http://www.dspmuranchi.ac.in/pdf/Blog/stages%20of%20counselling.pdf

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Welcome. My name is C hristina Toney, LPC . I am a licensed therapist who has been working with children and families for over 20 years. I work from a holistic and trauma-informed approach. My specializations include ADHD, Autism Spectrum, and trauma. I focus on attachment, boundaries, self-understanding, and self-compassion to support growth and healing.  

​ Currently, I offer telehealth counseling for adolescents and adults. In addition, I am certified by the Oregon Board of Licensed Professional Counselors and T herapists to provide private supervision for licensure and ongoing practice.

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Through telehealth counseling, convenience is offered without compromising quality. I am dedicated to helping you find clarity, resilience, and healing. No matter what you're facing, you don't have to go through it alone. Take the first step towards a brighter tomorrow by scheduling a session today. Welcome to a journey of self-discovery and growth.

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When I Get to the End of the Way

Poetry that comforts the heart and stirs the soul by beautifully communicating biblical truth is a blessing to God’s people. Yesterday, the following poem ministered to my heart, and I hope it is a blessing and encouragement to you as well. It was originally posted by Tim Challies and is reposted here with permission.

Introducing the poem, Tim writes: “The poet looks forward to the end of her journey through life–to the end of her way. In one collection I’ve seen it attributed to H. Cole, in another to simply B. P. C., and in another Margaret Baker Culp.”

My life is a wearisome journey, I’m sick with the dust and the heat, The rays of the sun beat upon me, The briars are wounding my feet. But the city to which I am journeying, Will more than my trials repay, All the toils of the road will seem nothing, When I get to the end of the way. There are so many hills to climb upward, I often am longing for rest, But He who appoints me my pathway, Knows just what is needful and best. I know in his word he has promised, That my strength shall be as my day, And the toils of the road will seem nothing, When I get to the end of the way. He loves me too well to forsake me, Or give me one trial too much, All his people have been dearly purchased, And Satan can never claim such. By and by I shall see him and praise him, In the city of unending day, And the toils of the road will seem nothing, When I get to the end of the way. When the last feeble step has been taken, And the gates of the city appear, When the beautiful songs of the angels, Float out on my listening ear. When all that now seems so mysterious, Shall be plain and as clear as the day, Then the toils of the road will seem nothing, As I get to the end of the way. Though now I am footsore and weary, I shall rest when I’m safely at home, I know I’ll receive a glad welcome, For the Savior himself has said Come. So when I am weary in body, And sinking in spirit I say, All the toils of the road will seem nothing, When I get to the end of the way.

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By God’s grace, I’m a husband, dad, grandpa, and pastor at Cornerstone Community Church in Mayfield Hts, OH. I love Christ because He first loved me.

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How to Gracefully End a Therapy Session On Time

by Reina Remigio, PhD | Sep 25, 2017 | Professional Resources , Student & Intern Resources

Ending a session on time and doing so gracefully can be tricky. There are a plethora of ideas out there of how to end a session on time, such as setting a timer or providing a nonverbal cue, and many of those suggestions may be effective in ending a session on time.

However, very few, if any, address implementation of those techniques fluidly and in a manner that is natural and least disruptive to the client’s process. Why does this matter?

One reason the way in which a therapist ends a session matters is because it could help in facilitating a sense of support for the client, augmenting the support already given during the meat of the therapy session. It could contribute to the client’s sense of feeling valued which in turn contributes to the therapeutic alliance.

The therapeutic alliance has been correlated with improved treatment outcomes across individuals with varying mental health issues [1] and has been found to be a better predictor of treatment outcome than the type of intervention [2].

Ending the session smoothly could be analogous to landing an airplane. The pilot needs to see the passengers through to the end of the flight, which may have been turbulent or smooth, and instill a sense of safety and trust from boarding to the moment the last passenger has deplaned.

Similarly, ending a session gracefully may nonverbally communicate to the client that you can and are going to be there to support his growth whether the emergent therapeutic material is pleasant or unpleasant, thereby building trust and openness – part of the framework for growth.

What follows are some suggestions that may be helpful in facilitating graceful endings to sessions and in contributing to the strengthening of the therapeutic relationship, providing the opportunity for growth and healing.

Please note that these suggestions are oriented toward non-crisis situations and are suggestions based on mine and my colleagues’ professional and personal experiences, having had our own therapy and having worked in diverse settings and with populations ranging from young children to the geriatric population. Please consider if these are appropriate for you and your client, and seek consultation.

1. Consider the ending as therapeutic.

Conceptualizing the end of the session as a therapeutic interaction that could contribute to your client’s growth may encourage and inspire you to end the session in a timely and thoughtful manner.

For instance, the way in which you end a session could demonstrate healthy boundaries and time-management skills, model compassionate and effective communication skills, or even possibly provide a corrective experience for the client.

Communicating with the client that ending the session on time is a step toward one of the client’s treatment plan goals or an interaction you see worth working on may invite the client to also be thoughtful about ending the session (or at least have a little bit of understanding if you have to interrupt him or her). This could reduce awkwardness and the potential for hurt feelings, and in a way gives you some permission to interrupt the client at the end of the session.

For example, when I worked in a forensic setting, one goal that many clients worked on was respecting boundaries. Ending the session on time was modeling for the client respecting boundaries, which in this case were each other’s time, the following client’s time, or the client’s next appointment’s time. Because I had discussed with the client the importance and purpose of being able to end the session on time, the client was understanding of whenever I interrupted him to end the session.

2. Orient and collaborate.

Orient the client to the general logistics of the therapy session and invite collaboration during the initial meeting or at the start of any meeting periodically throughout as needed. As you review confidentiality with the client, familiarize the client with the general course of the session.

For example, I have informed clients that I prefer to set a timer so that I can fully focus on them without being distracted by monitoring time. The alarm will sound to indicate there are a certain number of minutes remaining and I will summarize the highlights of the session and discuss assignments or things to practice during the week.

Please be mindful of the type of alarm sound – loud obnoxious beeping is usually not preferred. You can also adjust the timing of the alarm and the alarm sound for each client. You may find that two minutes works effectively for some clients and five minutes works well for others.

I have also asked clients if they would prefer a hand gesture or some other notification to signal that there are a certain number of minutes remaining and it is time to wrap up the session.

Figure out a game plan with each client so you both know what to expect. This helps to set the end of the session up for success and reduces anxiety from both ends.

3. Reflect and summarize.

Another way to end a session gracefully is to reflect and summarize. Reflect the important message in the client’s last statement, tie that back into the overall theme(s) of the session or relevant takeaways, and then translate that into a practical action step or question to ponder for the week.

This technique has the potential for nicely wrapping up the whole session into a neat package. However, it also has fumbling potential. For one, you may have to interrupt the client as he or she is speaking in order to reflect and summarize, which could feel as though you are telling her when her last statement is as opposed to the client naturally stopping on her own. Attunement, authenticity, and finesse facilitate this type of ending, which also requires good communication.

4. Use verbal and nonverbal communication.

Colleagues of mine have shared that they utilize nonverbal cues to help communicate to the client that the session is over. These cues could include closing their notebook or placing the cap back on their pen.

Some therapists begin to stand or gradually shift their seat if they are in a swiveling chair. Another therapist stated that she energetically begins to withdraw from the conversation by reflecting less profoundly and providing less complex responses.

An example of this might be guiding the conversation back to small talk as what may have taken place at the very beginning of the session or redirecting the client to the assignment and next session-oriented messages (e.g., “That is a great example of what to write in your journal” or “That is exactly the kind of thought to document in your daily log we just discussed. I’m looking forward to what new insights this assignment could evoke for you”).

Good old direct communication is always an option, especially if the client is not responsive to ending the session as agreed upon or as communicated in less direct ways (e.g., “I have another appointment now. Let’s talk about this next session”).

5. Be flexible.

There will be times when the session is just not going to end on time and you may have to go over a few minutes. Once in a while, this may be necessary to provide sufficient support to the client, but note that I said “once in a while.”

If the session is going over time regularly, that is unlikely to be therapeutic and may actually be unhelpful to the relationship and to the client’s growth (e.g., enabling ignorance of boundaries). It may be helpful to introspect and process underlying factors within yourself that may be contributing to this with your supervisor, therapist, or colleagues, and in select cases, may be something to discuss with the client.

Also consider that some clients may respond better to one style or technique of ending a session versus another (e.g., direct communication versus nonverbal cues) or perhaps a combination of two or more.

You might have a client who prefers a routine or ritual (non-obsessive-compulsive) ending that consists of a timer, summary, and then sitting in meditative silence for a minute. You could find that you have been ending sessions one way and then the client wants to modify that after a few months. You may also find that there are clients with no preference.

The point is to be flexible and consider what works best and most effectively not only for the client but also for you as the clinician. Consider what is authentic and natural for you . For example, if meditation makes you cringe, it may be ill-advised to end the session in this manner even if it is your client’s favorite past-time.

6. Practice and try, try again.

Play with different methods, phrases, words, and even role play. Get comfortable with it. Notice your own experience.

Perhaps you notice that you feel uncomfortable or do not like the way the word “end” feels (or the memories it evokes), which could translate into the session. It is absolutely okay to try something else that is natural to you, such as “pause for now,” “session coming to a close,” or “transition out of the session,” or whatever other words or phrases feel most authentic and accurate for what you would like to convey.

It is also okay to check in with the client if you think it is necessary for the client’s benefit (not solely to allay your own discomfort, which would be better addressed by consulting with a supervisor, therapist, or colleagues).

Gracefully ending a session can be done with a little thoughtfulness, authenticity, and attunement .

The method of ending the session on time likely accomplishes the goal (like looking at the time and telling the client it is the end of the session) but the graceful part is facilitated by mindfulness. The way a clinician can bring herself/himself into connection in therapy contributes significantly to the client’s positive response to the clinician’s therapeutic efforts [3].

There is, after all, a human being, and likely one who feels a little (or a lot) vulnerable, sitting across from you, not an appointment.

I invite and encourage you to play mindfully with the aforementioned suggestions aloud to yourself, with a colleague, or with a client, as appropriate. Notice your experience, get explicit feedback from colleagues, or notice your client’s response, and make modifications accordingly to what is natural for you and what is effective in conveying your support to the client and ending on time.

What are some other methods you have tried or have considered for ending a session gracefully on time?

• Recent Posts

• Improving Clinical Supervision Through Collaboration - January 29, 2018
• How to Gracefully End a Therapy Session On Time - September 25, 2017

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Rant and Rave: Reader on a journey to end overuse of the word ‘journey’

RANT to the rampant overuse of the word “journey.” Please stop. Life is a journey. A three-month trip through Europe is a journey. A trip to the grocery store or making an online purchase is not. PLEASE STOP!

RAVE to the kind woman who stopped me at the airport to let me know my backpack zipper was wide open. She even zipped it shut for me. Thank you!

RANT to the allowance of dogs in farmers markets. What is the health department thinking? Food, small children, tripping factor. All need to be addressed. I witnessed a large dog snapping at a beautiful service dog. Who can help enforce a no-dog policy?  

RAVE to the eagles of Seward Park. When the wind pushes clouds across the sky, their family swoops and soars in play over the cedar tops, reminding us that Seattle remains a place of magic.

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The opinions expressed in reader comments are those of the author only and do not reflect the opinions of The Seattle Times.

When and How to End Therapy

Knowing how to end therapy if we choose will help us stay in charge..

Posted June 2, 2021 | Reviewed by Chloe Williams

• What Is Therapy?
• Find counselling near me
• Talking about an ending early on in therapy can prepare people for the inevitable.
• Some situations that can bring about an ending include reaching a point when one is happy, or changes in one's circumstances.
• Talking with a therapist about wanting to end treatment can help resolve any outstanding issues.

One of the least-often discussed subjects at the beginning of therapy is when or how we can finish our treatment. Unless we are receiving time-limited therapy—six to eight sessions of solution-focused therapy, for example—it is unlikely we will know exactly when the end of therapy will be.

However, therapy must come to an end at some point. Having built a therapeutic relationship with our therapist, it can be tough to get used to a life without them or the regular space for supportive interactions. Being without this can leave a big empty space in our life, especially if our therapy has been ongoing for some time.

The meetings with our therapist form a relationship that, while professional, may have gone deeper than our closest friendships. As with any other relationship we come to depend on, the ending is bound to have some effect on us. For this reason, and in most cases, it is important to make the completion of therapy graduated.

Our therapist might suggest a set number of sessions—for example, three to six—that are booked further and further apart. This enables us to work through any outstanding conversations and gradually let go of the comfort of therapy. The final sessions will then work as a check-in, a reminder of the tools and skills we have learned, and a look back to the beginning to see how far we have come.

When and How to Talk About Ending Therapy

Although it may seem an odd time to talk about endings, ideally this conversation should start at the beginning of therapy. This can help us to manage our expectations and so make the ending emotionally easier to cope with.

While many of us might ask how long therapy will take, this question is usually to plan time and finances. Asking how endings are managed will give us a clearer idea of what we can expect, helping us to prepare for when this moment arrives. Preparing for an emotional event cannot begin too soon.

Of course, the opportunity to have this conversation might not have been available at the beginning of therapy. If we are now wanting or needing to finish therapy, we might not know how.

The answer to this is always to talk with our therapist. They will have managed many endings and are likely to have a preferred way of completing therapy that has worked for their clients in the past.

Situations That Can Bring About an Ending

It is a common misunderstanding that therapists should be the ones to decide when therapy is to end. The fact is that we, the clients, have just as much control over this as our therapists. While a premature or abrupt ending can result in the undoing of some of the good work we have done, there are situations when an ending is preferable or necessary. When managed with care, we will get a sense of having some control of this ending and it can then be a celebration of all we have achieved.

A natural ending. When we have worked through the issues we brought to therapy and are managing life to our satisfaction, it is time to move on. Telling our therapist that we have reached a point we are happy with and that we would like to finish therapy is perfectly acceptable. They may suggest a graduated end and we can negotiate this according to what we feel we need.

Therapy is becoming too intense, or the pace isn’t right . Sometimes therapy can seem too powerful, or we might feel encouraged to look deeper than we feel comfortable with. Therapy can be a little overwhelming and we might not be ready or prepared for the depth of the conversation just yet. We need to talk with our therapist about our experiences; they may not know how we feel. However, if we really do not want to carry on with therapy, we have the right to tell our therapist that we need a break.

The therapeutic relationship is not a good fit. The fit with our therapist is important. If after a few sessions we experience a lack of trust and connection, or feel that therapy isn’t working for us, it is time to talk about it.

Having spoken with our therapist, and still finding that they don’t “get” us or that we are not gaining from therapy, then it’s time to find another therapist. Therapists are people, too, and sometimes the fit isn’t right with the first professional we see.

Circumstances prevent us from carrying on. There are all sorts of reasons why therapy might need to stop: loss of income, a long-term illness, or a tragic death (fresh grief can be too raw to work with in therapy immediately), or perhaps we entered therapy too soon after a trauma , or maybe we have to move away.

Whatever the reasons, we must talk with our therapist; the chances are that they will be able to work around us if we really do want to carry on with therapy.

A break in therapy. It isn’t unusual for clients to take a break for a couple of months or more before returning. We can work out a time scale with our therapist and establish a support structure should life throw us a curveball while we've stepped away.

Unethical therapeutic behaviour. If we experience our therapist as unethical, we would ideally talk with them about their behaviour. However, having this conversation isn’t always possible. If we, for example, feel intimidated or that the therapist’s behaviour has been inappropriate, it might be best not to have this conversation with them.

Ultimately, in these situations, we need to make sure that we are safe, and if having another session puts us in emotional, psychological, or physical danger, we must remove ourselves from therapy. (Learn more here .)

The end of therapy is not the end of the therapeutic effect. Therapy will have given us tools, insights, and skills that will help us carry on developing. After the last session, we leave therapy with hope for our future and a sense of achievement knowing that if we should need, we can return to therapy and reconnect with the journey.

LinkedIn image: YAKOBCHUK VIACHESLAV/Shutterstock

Karin Blak is a psychosexual and relationship therapist, trainer, and writer. She is the author of The Essential Companion to Talking Therapy .

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Popular non-WWE star isn't giving up on a dream match with John Cena

W WE legend John Cena has revealed that his journey as a wrestler is nearing its end. Meanwhile, TNA Wrestling star Joe Hendry believes that a dream match against The Franchise Player is not beyond impossible.

During a recent appearance on the Gabby AF podcast, Hendry mentioned that he missed a Friday Night SmackDown show when he was 15, but luckily his friend was there to save the day. The 36-year-old star's buddy scored VIP tickets and even hooked The Prestigious One up with a phone call from The Leader of Cenation .

Since then, the TNA star has set his sights on crossing paths with Cena and having a one-on-one match against him. During an interview with Alistair McGeorge of Metro.co.uk , Hendry shared that he's not ruling out a collision with the former WWE World Champion.

"Are you going to tell me that it's impossible for me to face John Cena? You can't tell me it's impossible, because there would have been people that told me that last week was impossible," he said. [H/T: Metro.co.uk]

WWE Hall of Famer claims John Cena's 17th World Title depends on one thing

The Undertaker shared his two cents on the possibility of Cena winning the World Championship for the 17th time. Currently, The Franchise Player is tied with Ric Flair , who has 16 World Championships to his name.

Speaking on his Six Feet Under podcast, The Deadman explained that John Cena becoming a 17-time World Champion depends on whether he has time before hanging his boots .

"I think it probably depends on him [John Cena], whether you know he has the time; he obviously deserves it, but I think it basically just depends on him... I mean, he's put a lot into it, and I think whatever he wants to do," Taker said.

Both Cena and The Undertaker made a shocking appearance at WrestleMania 40 to help Cody Rhodes beat Roman Reigns for the Undisputed WWE Universal Championship. It remains to be seen if fans get to witness the two legends once again together in the company.

Screen Rant

Dark matter ending: does daniela end up with the original jason showrunner responds.

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I Finally Understand Inception's Ending After Watching Apple TV+'s New Sci-Fi Show

Why dark matter's ending makes one major change to jason's book fate explained by joel edgerton, dark matter season 2 potential addressed by joel edgerton & blake crouch: "there's almost too many possibilities".

Warning: MAJOR SPOILERS ahead for the Dark Matter season 1 finale!

• Showrunner Blake Crouch confirms the original Jason ends up with Daniela in the Dark Matter season finale.
• While there is some ambiguity in the finale about which Jason is which, it was always intended for the story to follow the same version of him the whole time.
• The ending is made stronger by the original Jason reuniting with Daniela and Charlie, as it offers a satisfying conclusion instead of leaving it up in the air.

Dark Matter showrunner and author Blake Crouch has revealed whether Daniela ends up with the original Jason at the end of the series. At the end of Dark Matter , Jason ends up taking his family through the Box. The trio relocate to another world after various versions of himself come back in search of his family. However, while it's clear one version of the original Jason ended up being with his family, it's never made apparent if this is the same one that viewers followed throughout the rest of the show.

Speaking with Screen Rant , though, Crouch offered a definitive answer, confirming the Jason who ends up with Daniela during Dark Matter 's ending is the same one focused on throughout the show. While the showrunner admits there's room for a different interpretation about which version is the original, the intention was never to trick audiences or leave anything unanswered. Check out what Crouch had to say below:

The intention really isn't to get to the end of the show and be like, are we watching our heroes the whole time? In my mind, yeah, we are. There's enough other big questions raised. I'm not trying to mess with the audience along those lines. Technically, yes, between [episodes] five and six, we could have switched to a different Jason [and] Amanda. For all we know, the Jason we were following from [episodes] one through five was actually the Jason that tells him to be careful and make sure you take care of her [at the end]. It's a valid interpretation. I'm sure there will be many of those crazy, crazy theories that come out after the show finishes airing. The ambiguity came out just because we really had the time to tell the story of this family coming back together in the last episode, and, in a lot of ways, in a book, you don't have to address some things that you have to address [on TV]. When you see things on a screen, and especially with what Daniella went through, and how that would actually cast a real shadow on the family's reunion, that was kind of a big thing that we found in making the show that wasn't there in the novel.

Why The Original Jason Being With Daniela Makes The Ending Better

His journey was worth every step.

Although the ending of the sci-fi series has plenty that is left up for interpretation, especially the stories of other Dark Matter characters , Crouch makes it a point to confirm which Jason wound up with Daniela . His explanation makes sense, as the one seen in episodes 8 and 9 hinted at having the same memories as the one followed throughout the rest of the show. While there's wiggle room for interpretation that he's just a similar version of the main character, the showrunner is direct about how the ending was intended to be viewed.

By having the original Jason end up with Daniela, the series provides a satisfying conclusion to the story , without any loose ends for the Dessen family. Had it been a different version of him than the one followed throughout the show, it wouldn't have been as impactful to see the trio reunited. But, because the one followed from the very start ends up with his family, it makes for a well-rounded story with a happier ending than if it was left up to interpretation.

It also means that, if Dark Matter season 2 were to happen in the future, it wouldn't require the Dessen family because of the definitive, happy ending they got in season 1. This concludes their story with a note of finality, meaning whatever could happen in the future likely won't see them coming back into the picture. Thanks to Crouch's elaboration on the season finale, it's given a much more definitive, happy ending for Jason and Daniela, making it the perfect conclusion to the show.

Dark Matter could continue thanks to other character stories, like Amanda and Ryan, not being entirely resolved.

Dark Matter (2024)

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Based on his novel of the same name, Dark Matter is a sci-fi drama-thriller television series created for Apple TV+ by Blake Crouch. The series follows a physicist who is kidnapped and thrown into an alternate reality where he witnesses one potential path his life could have taken. However, he learns that the lives of his family are in jeopardy by an alternate version of himself.

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Jennifer Connelly "Absolutely Believes" THIS Was the Actual Ending of 'Dark Matter' Season 1 [Exclusive]

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The Big Picture

• Collider's Steve Weintraub interviews Jennifer Connelly about her role in Apple TV+s series Dark Matter .
• Connelly plays Daniela Vargas Dessen in the adaptation of author and showrunner Blake Crouch's sci-fi novel, opposite Joel Edgerton, Alice Braga, and more.
• During this interview, Connelly discusses the ending, her character's journey, working with Crouch, and a possible Season 2.

[Editor's Note: The following contains spoilers for Dark Matter Season 1] In just under three months, that's a wrap on Season 1 of the new Apple TV+ series, Dark Matter . Now that all nine episodes are available to stream, it's time to unpack what we've just seen and start looking at Season 2. In this interview with Oscar-winner Jennifer Connelly ( A Beautiful Mind ), who costars opposite Joel Edgerton 's ( The Gift ) many alternate personas as Daniela Vargas Dessen, we find out who she really believes stepped out of that box the final time.

Dark Matter , based on the novel by author and showrunner Blake Crouch , is a sci-fi series that's all about the choices we make — or could have made. In the show, Edgerton's Jason Dessen is forced into an alternate world that sets him on a journey to track down his original life, one in which he always wondered if he'd made the "right" choices. Through desperate trials and errors that involve Alice Braga ( Queen of the South ), Jimmi Simpson ( Westworld ), Dayo Okeniyi ( See ), and Oakes Fegley ( The Fabelmans ) in the mix, Jason does finally manage to step through a door that reunites him with his original family — or so we're led to believe.

What does Connelly think? Collider's Steve Weintraub discusses the possibilities that the Season 1 finale offers up, and the actress shares her own thoughts on which Jason really returned. They discuss what might await the family beyond the box, what potential Season 2 could hold, and why working with Crouch was vital on set. Connelly also talks about Daniela's journey and whether she, herself, would ever enter the box.

You can watch the conversation in the video above or read the full transcript below.

Dark Matter (2024)

A man is abducted into an alternate version of his life. Amid the mind-bending landscape of lives he could've lived, he embarks on a harrowing journey to get back to his true family and save them from a most terrifying foe: himself.

COLLIDER: I’ve got to start with the most important thing. Did you know that they have made a Labyrinth pinball machine, and have you played it?

JENNIFER CONNELLY: I did not know. No, I haven't, but that sounds awesome.

David Bowie's all over it, but you really need to check it out just on principle.

CONNELLY: I'd love to. I'll look it up.

If you actually were presented with the box in real life, and you could go in and travel to who knows where and most likely return home, but you don't know, would you actually go in? You could experience wonder and amazement, or who the hell knows?

CONNELLY: Would I be going in by myself, or could I bring my entire family and my Golden Retriever, Wallace?

I think the box is big enough to do all this.

CONNELLY: There's no way I'm leaving any of those people or creatures, so if we can all go and everyone's on board, it's still a maybe. It's still a maybe. It's a hard maybe .

I think that's actually very honest. It would be a maybe for me, as well.

CONNELLY: Yeah, it's a hard maybe. I don't know. Especially the way that it works in our story and how easy it is to influence the outcome of where you wind up. That’s five of us, plus Wallace, to think about frame of mind. She's a pretty fearful doggy. I'm not sure.

Daniela's 'Dark Matter' Journey

This had to be a very cool show to film just because of the layers upon layers of what's going on in each scene. What is it like as an actor — and I'm sure for Joel it was very challenging — for you to figure out different versions?

CONNELLY: For me, it was really fun. I like the different chapters of it. Most of my time in the show I'm playing one iteration of my character, which we called, very creatively, Daniela 1. She has an interesting — I thought it was interesting — journey, where she's presented with this version of her husband who's kind of a new and improved version of her husband, and it's kind of great, but then it just starts to feel different. Then she goes through this sleuthing chapter trying to figure out what's really going on, and then it becomes more and more disturbing. I enjoyed that journey for her. Then also what happens when he comes back and she's confronted with that. I thought that was a really interesting thing to have to try and imagine someone reckoning with and reconciling.

In terms of playing the different versions of the character, for me, it was really fun. It was not the same kind of endeavor as it was for Joel, who had to do scenes with different versions of himself, and it was much more to wrangle in that way. For me, they were really separated by time, by episode, and were quite distinct from one another. So it was just sort of fun, honestly, for me, that process.

What are you actually most looking forward to audiences seeing because there are a lot of layers to this show?

CONNELLY: I think it has a lot going on in a really fun way. I think it was a smart way to use the idea of a multiverse in this show. I feel like I haven't seen this use of that idea before. While I've seen other multiverse stories, I haven't seen it used in this way where it's like these characters, who are kind of working through, frankly, a marriage, like a 20-year marriage. They've come to this place in their lives where they're taking inventory of how they've lived, the choices that they've made, the regrets that they have, and the things that they've gone through, and it's playing out in this multiverse story . But they're not going to these far-off places. They're going to different versions of their own lives and different versions of the city that they live in, and meeting different versions of themselves that are sometimes even just slightly, slightly off. I thought that was a really fun ride in the book, and I thought it was a fun ride when I read the scripts, as well.

Jennifer Connelly "Absolutely Believes" This Was the Ending of 'Dark Matter' Season 1

What do you think about the very end of the series? You can look at it where Jason makes it back to his family, but you can also look at it that it's an alt version of Jason and an alt version of his family that are just slightly different, but no one will ever know.

CONNELLY: I felt like it was our original version of Jason and our original version of Daniela who came back together. I absolutely believe that.

That’s what Blake wants the audience to feel.

CONNELLY: I absolutely believe that. I absolutely believe that, but I don't think that they know that initially when they first are reunited. I think he knows that, but I don't think that she knows that. Once she realizes that there are other versions of all of us somewhere, I don't think she believes that or trusts that. But I think in that time that they spend together, I believe that she found him again and knew that it was him again and chose him again.

Sure. You can also make the argument, and this is me just playing devil's advocate, that one of the 100 standing there is actually the Jason. It could just be a five-minute difference. You never know.

CONNELLY: That's true.

It’s crazy. That's what's great about it is that you can play those mind games.

Yeah, who knows? At the very end of the show, you guys are reunited; you walk through a doorway and go into a new world. Did Blake or anyone tell you what that world was, or is it sort of like everyone's imagination?

CONNELLY: I don't think we know what it is yet because we were just sort of stepping through the portal. We didn't talk about it because literally all we do is kind of take one step. So, we'll have to see.

I'm just curious, as an actor, were you like, “Blake, where did we end up?”

CONNELLY: No, weirdly. I didn't. I didn't have that conversation with him. For better or worse, whatever that says about me. No, we didn't have that conversation.

One of my favorite shots, it’s Episode 8 or 9, and you are in the locker and you were looking at the alt money, the John F. Kennedy bills, the $2,000 bills. I love that because it's little subtle sci-fi. Did you end up borrowing any of those bills?

CONNELLY: [Laughs] I didn't. I should have. They were really great. But no, I didn't.

Author Blake Crouch Kept 'Dark Matter' From Becoming "Disjointed"

What do you think would surprise people to learn about the making of the show that maybe was unique to this, or is every show basically the same with slight variances?

CONNELLY: I don't know. I don't have enough experience making shows. I've really made two, so I don't have enough experience to say what's unique and what's a common thread. One thing that's different, obviously, is the amount of time that you spend making them, so those relationships with the people that you're working with become really important because it's not two months or six weeks, even, that sometimes you have on a film. We started filming in September and I think we finished in, like, April. It's really a significant portion of time that you're spending with them, so those relationships become really meaningful.

And in this case, it was a really happy experience making the show. Everyone was lovely. Blake is great to work with. He was on set every day, and he was really our onset leader and point person. It was so great to have the person who had written the book there as our showrunner and writer, whom we could ask questions of. Obviously, he holds that material, so it was really wonderful to have him there. It felt like in him, we had a real throughline. I know sometimes shows can become more disjointed as different directors come in, but with Blake, we had that stability and it was really tethered in that way to that origin story and his viewpoint. So, I really enjoyed that about the show.

All nine episodes of Dark Matter Season 1 are available to stream on Apple TV+.

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Steph Curry opens up about journey from Davidson to NBA in documentary 'Underrated'

The new Stephen Curry documentary “Underrated” opens with Basketball Hall of Famer Reggie Miller reading pre-draft scouting reports on Curry from 2009.

“Far below NBA standard in regard to explosiveness and athleticism.” ... “At 6-2, he’s extremely small for the NBA shooting guard position.” ... “Do not rely on him to run your team.” ... “Can overshoot and rush into shots. Doesn’t like when defenses are too physical with him.” ... “Not a great finisher around the basket due to his size and physical attributes.”

The documentary then segues into a Golden State Warriors game against the New York Knicks on Dec. 14, 2021, the game in which Curry broke the NBA’s all-time record for made 3-pointers in a career. The scene ends with a celebration of family and friends at a New York restaurant.

Even though he was the No. 7 pick in the 2009 draft, no one expected Curry to become one of the greatest players in NBA history and the face of a Warriors dynasty. No one anticipated Curry turning into the best long-distance shooter in league history and altering the way basketball is played with his 3-point shooting.

Even Curry had his doubts at one time.

“I could not have ever imagined that this would be a reality,” Curry says in "Underrated," set for release in select theaters and Apple TV+ on Friday.

In the film, he says he asks himself “How did I get here?” unintentionally referencing the Talking Heads’ song “Once in a Lifetime.”

“My mind goes to those places and I think about everything,” said Curry, who has proven himself a once in a lifetime player. Much of the film focuses on Curry’s college recruitment, his years at Davidson and surprising development into a lottery pick.

I sat down with Curry and Davidson coach Bob McKillop on a video conference call to discuss “Underrated.”

The Steph Curry-Davidson experience

Q: What was it like reliving those Davidson moments?

Bob McKillop: “No surprise. Joy! Wow, don't they know that's Steph Curry?”

Steph Curry: “It's a great moment of reflection because Coach has still been a part of my life since I left. And in the last, what, 15 years since I left school to then go back to before I even stepped foot on campus and all that led up to the decision to go Davidson and the belief that Coach had in me from day one. Just the community that was built around our team and the program that he – was it 34 years Coach you spent building, pouring your life into? So all that stuff is just special to kind of put into the framework of this documentary.”

McKillop’s everlasting faith in Curry

Curry had 13 turnovers in his first game as a freshman at Davidson in 2006-07. Curry wondered if McKillop would bench him for the second game. He didn't, and Curry had 32 points, nine rebounds and four assists in that next game against Michigan.

Q: Why didn’t you bench him?

McKillop: "In the summer of prior to his (high school) senior year, he was in a tournament in Las Vegas, and it was in an auxiliary gym. In the main gym were all the high-profile prospects and high-profile coaches were watching. Whereas in this back auxiliary gym, there were very few coaches. Stephen turned the ball over, missed shots, got beat defensively. Never once did he lament a mistake. Never once did he criticize an opponent. Never once did he question an official. He went to the bench, and he cheered his teammates on. He looked in his coach's eyes directly during every timeout. He transcended time. He transcended experience. He did not let anything interrupt him. He was in a starting lineup on opening day because we believed that he transcended time and transcended mistakes.  … He got us to believe in him.”

Q: Steph, I know this is a huge hypothetical, but you brought it up. Do you think your trajectory is different if he makes a decision to do something different with your playing time and minutes?

Curry: “I 100% do believe my trajectory would be a little different had he not acknowledged or been aware and believed in the patterns that he saw in me, to have confidence that I would find a way to push through some of those learning curves and those tough times based on how I approached everything.”

Finding ways to get the best from Steph Curry

McKillop understood how to motivate Curry from his first practice through his last game at Davidson. He often put Curry on the spot in front of his teammates.

Q: How did you embrace the way he challenged you?

Curry: “I absolutely loved it. One thing is, he knew I worked and I wasn't afraid of many environments or moments or challenges. … He was putting me to the test early to see how I would respond to the adversity that was eventually going to hit me at some point at that level. I embraced it all through all the ups and the downs. And it all comes back to, again, just the way that you apply yourself to anything and the work that you put in, that you earned that confidence to push through those lessons that you’ve got learn. He was going to make sure I was exposed to as many of them throughout those three years.”

Q: Bob, how did you know how to challenge him in ways that wouldn't turn him in another direction?

McKillop: “Stephen checked the boxes beyond talent and one of the boxes that he checked was coachability. He wanted to get better, he wanted to be coached, he wanted to be taught toughness.”

One memorable season for Curry, McKillop and Davidson

In 2007-08, Davidson finished 29-7 after a 4-6 start. They won 19 consecutive regular-season games, three consecutive Southern Conference tournament games and extended it to 25 straight with three wins in the NCAA Tournament coinciding with Curry's rise to one of the best college players in the country. In the regional final against Kansas with a spot in the Final Four on the line, Davidson had a chance to win but missed a 3-pointer at the buzzer. McKillop said in the documentary it was “as if you never wanted the ride to end.”

In some sense, the ride has continued. Curry, McKillop and Davidson are forever connected in what has turned out to be a remarkable story.

Curry: “I'm aware Davidson is a badge of honor everywhere I go in terms of representing the program that coach created. I always say that Coach was the best, not just coaching the basketball player and the athlete, but coaching the person and the life skills that he provided for you to have on and off the court. So I carry all of that with me everywhere I go, and that's part of the Davidson pride. … And you never want to forget where you came from. So there's always a great reminder of that.”

McKillop: “Because of the way he lives his life, I'm convinced he's one of the greatest leaders in the history of our country and the history of our world with the impact he's had on people. Look at the way the game has changed, and the game has changed dramatically. … For him to be able to have that kind of impact on this game that's been around for a hundred years is a rather extraordinary statement about this very average-size human being, and he is able to give people an example. And that's why so many kids embrace him because they can see themselves being Stephen Curry.”

Curry reflects on career: No one does it alone

Near the end of "Underrated," Curry contemplates the career he has had, and understands that as much work as he has put in to become the player and person he is, he doesn't get from there to here without help.

Curry: "If you walked into a gym and saw me 20 years ago, there’s no way you’d think any of this is possible. And that feeling of being overlooked or underrated will always be part of the drive that keeps me going. But also I’ve just been blessed to have so many people in my life that took the time to get the sense of who I really was. I’ll remember that forever.”