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‘The Sense of an Ending’ – Death and Endings in CAT

Claire Moran, 2019. ‘The Sense of an Ending’ – Death and Endings in CAT. Reformulation, Summer, pp.23-25.

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I have chosen to write about endings in CAT - why ending is difficult but necessary, how endings may be experienced, and features of a “good ending.” I have been thinking about what it is about ending that clients and therapists alike, dislike so much. It has brought me to thoughts about the finality of death, and how this may link with our fear of ending relationships of any kind, including therapy. I will consider themes of loss and death, and our propensity towards silence on the matter. Face-to-face with our own mortality, endings perhaps remind us of that which we cannot bear: “… the abortive or guillotine-like implications of termination, and the irritable connotation of interminability, suggesting instead themes of separation, death, a timeless unconscious, and the infinity of irreversible loss” (Holmes, 2010, in Good Enough Endings Ed. Salberg p. 63). Death and endings are subjects that are often avoided. In some ways, particularly within Western society, there are collusive, shared defences; we are all pretending it’s not going to happen.

I have borrowed my title from the book, The Sense of an Ending by Frank Kermode. Kermode (1966) examines literary theory, claiming that humans are profoundly uncomfortable with the idea that our lives form only a short period in the history of the world. In order to make sense of our lives, we try to find meanings and harmony in the beginning, middle, and end. Kermode coined the phrase: ‘No longer imminent, the end is immanent.’ Our ending is inherent in all we do in life. Kermode felt that humans create fictions to impose structure on unfathomable eternity, to mitigate the unfolding crisis and chaos surrounding us. The structure of CAT, with its regular sessions and agreed end point, can perhaps be seen as imposing a sense of order and pattern (such as SDR perhaps) on what is, in reality, chaotic and unpredictable.

In CAT, “Ending therapy is always emphasised with sessions counted off from the outset” (Kerr and Ryle, 2006, p 273). By talking about the ending in CAT, and holding it in mind, we can perhaps give rise to meaning in the work in the middle. Just as our awareness of death can perhaps give rise to the motivation to achieve in living. It is possible that, without the knowledge and awareness of the end, there is no ‘middle,’ therefore no drive towards change.

Qualitative research looking at the patient experience of endings, found that the pre-defined number of sessions represented a source of focus, motivation and objective, seeming to spur individuals on, to make the most of therapy. It also seemed to help individuals, to remember that time in therapy was finite, discouraging over-reliance on the therapist (Lyndon, 2013). The end, in CAT, is forever present, session by session, as in life; the knowledge of death is forever present. The sense of an ending, in life, as in therapy, is perhaps to motivate us towards achieving in the present, leaving our mark. The SDR and goodbye letters also leave a permanent mark, for client and therapist, an attempt at a ‘coherent pattern’ in the work, which in essence contains their lives.

I first began thinking about the connection with endings and death in session 14 with my client, Sarah. We had been talking about ending intermittently throughout therapy, and over the past few sessions I had noticed that every time I brought it up, she changed the subject. We started the session talking about death; she had recently lost a close relative to a long-standing illness. Sarah showed no emotion, but used powerful language, referring to her relative’s dead body left “abandoned” in the freezer, “bloated, changed beyond all recognition,” waiting for funeral arrangements to be made. My countertransference feelings were overwhelming, and my thoughts jumped to my own loved ones. I asked Sarah about her feelings, and with this she broke down – she talked of fears around death, and her mother’s health. I got the distinct feeling that we were talking about more than her relative’s death, this idea of being abandoned and “changed beyond recognition” made me wonder if that’s how she felt that therapy would be leaving her. I got the sense that she was expressing her anxiety, not only about death, but also our ending together.

I asked Sarah how she felt about ending therapy. We talked about her avoidance in going to see her relative as he died; we linked this to the avoidance of discussing endings in our relationship. This conversation led to discussion around wanting to end other things, her job, her relationship, and the fearful feelings associated with this. The rest of the session focussed around ending therapy, and Sarah’s fear that she would be unable to cope with the changes, when she was no longer attending.

Why do we have an ending in CAT? Open-ended therapy has been critiqued by Ryle, and others, for its leanings towards dependency, and perhaps lack of focus. Open-ended therapy is not practical or perhaps ethical within NHS service provision. In CAT, a ‘good ending’ is an aim in itself (Kerr and Ryle, 2006), and “Adaptive mourning involves acknowledging loss and internalising what was lost” (p. 273), an opportunity to do things differently:

“Termination of therapy can also be seen as an opportunity, albeit usually a very anxiety-provoking one, particularly for very damaged patients, to enact a new role, namely that of ending well. This involves owning and communicating painful feelings of loss and uncertainty about the future and such role enactment will be difficult but may also be highly therapeutic, especially when mourning for past losses has been incomplete.” (Ryle, p. 113)

The idea of a ‘good ending’ is rooted in an understanding that often we will see clients who have had traumatic or unpredictable endings in their lives. Much like the discussion in recent years, of the ‘good death,’ there could be therapeutic value in a ‘good ending.’ Parallels can be drawn between a ‘good ending’ and a ‘good death.’ The British Medical Journal article determines that a ‘good death’ includes:

-To know when death is coming, and to understand what can be expected.

-To have time to say goodbye, and control over other aspects of timing.

-To be able to leave when it is time to go, and not to have life prolonged pointlessly.

In CAT, we hold the ending in sight from the beginning, marking session numbers, we prepare for ending through discussion, and denote the ending with goodbye letters. The client gets to say goodbye, and express feelings around ending. There is also the parallel in trying not to ‘prolong’ therapy, about knowing when enough is enough. Everything, including life and therapy, must end eventually; this is part of living. Contrarily, there is a reasonable argument that there is no such thing as a ‘good ending,’ or a ‘good death,’ because we are dealing with unimaginable loss and grief. In that sense, we could question whether providing the client with a good and predictable ending, is actually an inaccurate reflection of life, and is this even helpful? Endings are often unpredictable, unwanted and difficult, and therefore how does imposing a false, predictable structure help anyone in therapy? Ryle’s argument is that perhaps ending in a healthy, manageable way could potentially have a poignantly meaningful place in a person’s therapy, as scaffolding for the future relationships: “what the child is able to do in collaboration today he will be able to do independently tomorrow” (Vygotsky, 1934/1998b, p. 202).

During therapy with Charlotte, her father was diagnosed with a terminal illness, and given a few months to live. Many of the reasons Charlotte had come to therapy in the first place was to deal with her relationship with her father, and the abuse she endured as a child. Charlotte used therapy as a chance to talk about her feelings towards her father, and the mixed feelings around his death – how it was hard to be angry with someone who was dying. Charlotte went from the therapy room to home, and talked to her father for the first time about the abuse. I reflected later that the time-limited nature of therapy perhaps brought into focus the paralleled time-limit of her relationship with her father. Charlotte used the space to find her voice, and to think about what she might say to her father. We were later able to reflect, in sessions towards the end, how she was dealing with multiple endings of different kinds, and how she had managed this through the therapy. In her goodbye letter, Charlotte reflected on our ending, “I am scared but I think I am ready,” and these words felt pertinent in light of her addressing the relationship with her father.

Participants in research have talked of feeling sadness, loss and even grief at the end of therapy, sometimes with disappointment that therapy could not be an extended, or that they could not keep an ongoing relationship with the therapist (Lyndon, 2013). In this sense, when therapy ends, the physical therapist is as good as dead, all that remains are memories of the relationship: therefore, perhaps a type of mourning takes place. Ryle and Kerr (2002) note that it may be tempting to be drawn into collusive responses, in order to avoid the painful feelings around ending, whilst sustaining a degree of idealisation, whilst other therapists may find it difficult to accept how important they have become to the client. With Sarah, it was difficult to accept that she may miss our sessions, as at times I wasn’t sure how helpful she had found therapy. In reading her goodbye letter, I was able to see how much she had valued the relationship.

In CAT, in an attempt to mitigate the ending, we use goodbye letters. Goodbye letters can be seen as a transitional object, a reminder of the relationship, as well as the work. From an attachment perspective, in assuaging the pain of the child leaving the securely attached other, the letter could be seen to represent the therapist. Holmes (2010) noted that the letter can be viewed as a memento that can mitigate absence, and trigger the activation of an internalised good object that effective therapy can instate. Holmes (2010) has also argued that giving very disturbed patients written communications was comparable to ‘offering a hungry crying baby a piece of paper with the word ‘milk’ written on it and expecting that to assuage the distress’ (p. 74). However, research has shown that the goodbye letter can help clients mark the ending, reflect on it, and engage in a healthier way to end a relationship, whilst still acknowledging loss and disappointment. Patients also reflected that writing them, although requiring effort and emotion, helped them order their thoughts and feelings about ending (Hamill and Reynolds, 2008).

The ending in CAT is as unavoidable as death – it is finite and, within reason, without negotiation. Perhaps we should be talking more about death? In Cognitive Analytical Therapy and Later Life (2004), Hepple and Sutton talk about CAT with older people, considering ageism in the context of our fear of death: the “need for a powerful shared psychological defence to guard against the basic existential angst in everyone” (p. 52). Ageing is constant reminder of mortality, the marking of time, a reminder of the end – something to be avoided. We could compare this to the ‘counting down’ of sessions in CAT, the constant reminder that the end will come. Thinking about CAT in later life has got me thinking about how this may affect the therapy, when you are closer to ending therapy, and also closer to death. Do we perhaps treat people differently when they come to therapy in the later stages of life, and maybe miss the opportunity to scaffold a “good ending,” which could equally pertinent at later developmental stages. Hepple and Sutton (2004) have called for theory that communicates and arises from later life, and perhaps in the same sense it would be helpful for us all to be able to talk about death more in Western society. This shared, societal collusion suggests that death is an ending that is out of most people’s Zone of Proximal Development (Vgotsky, 1978). Perhaps scaffolding a ‘good ending’ in CAT, could be viewed as a ‘ZPD version’ of managing those unfathomable feelings arising around death. Hepple and Sutton recognise that avoiding talking about death altogether helps creates other difficulties, such as underlying fear and resulting ageism in our society.

The ‘sense of an ending’ then, is perhaps to mark and address themes that are difficult to mark, yet inevitable: loss, goodbyes, and eventually death. In learning how to have a ‘good ending’ or ‘good death,’ we are perhaps allowing this to be part of therapy, a part of our lives, rather than side-lined for fear of that which we can’t control. This is tricky; there is still a cultural lean, in Western society, towards avoidance of such things, hoping it will go away. Even if we are not good with endings, we will, all of us, deal with them throughout our lives. I have also been thinking about endings in the context of the CAT community, and the death of Tony Ryle. With CAT missing from much of the NICE guidelines for mental health treatment, there is perhaps an apprehension of what lies ahead, as well as mourning for his loss – will CAT die with him? Life is a series of beginnings and endings, and integral to all of this, is the acceptance of loss along the way, something that can never truly be avoided, no matter how hard we try.

References

Bennett, D. & Parry, G. (2004). A measure of psychotherapeutic competence derived from Cognitive Analytic Therapy. Psychotherapy Research 14, 176-192.

Hamill, M., Reid, M. and Reynolds, S. (2008). Letters in cognitive analytic therapy: The patient’s experience. Psychotherapy Research, 18(5), pp 573-583.

Hepple, Jason and Sutton, Laura (2004) Cognitive Analytical Therapy and Later Life, East Sussex: Brunner-Routledge.

Holmes, Jeremy, (2010) Termination in Psychoanalytical Psychotherapy: an Attachment Perspective, European Journal of Psychoanalysis in Good Enough Endings: Breaks, Interruptions and Terminations Ed. Jill Salberg.

Kermode, Frank (1966) The Sense of an Ending: Studies in the theory of fiction, New York: Oxford University Press.

Kerr, I.B. and Ryle, A. (2006). An introduction to the psychotherapies, 4th ed. Cognitive analytic therapy. (pp 267-286). OUP

Lyndon, Peter (2013) ‘How do clients experience ending in Cognitive Analytical Therapy? A qualitative analysis of what it means to end a time-limited therapy. Doctorate in Clinical Psychology Thesis Research Summary. Lancaster University.

https://www.b-eat.co.uk/assets/000/000/148/CAT__Endings-_Thesis_summary_original.docx?1403538782 accessed January 2017.

Mann, J. (1973) Time-limited Psychotherapy Cambridge Mass: Harvard University Press.

Ryle, Anthony and Kerr, Ian B. (2002) Introduction to Cognitive Analytical Therapy: Principles and Practice, Wiley and Sons.

Sher, M., (2014) Words and Rituals: The significance of ‘smaller’ endings. Reformulation, Winter, pp.33-36.

Smith, Richard (2000) Editorial: ‘A Good Death’ BMJ 2000;320:129

http://www.bmj.com/content/320/7228/129

Vgotsky, L.S. (1978) Mind in Society, Cambridge, MA: Harvard University Press.

Vygotsky, L. S. (1998b). The problem of age (M. Hall, Trans.). In R. W. Rieber (Ed.), The collected works of L. S. Vygotsky: Vol. 5. Child psychology (pp. 187-205). New York: Plenum Press. (Original work written 1933-1934).

Yalom, Irvin D. (2008) Staring at the Sun: Overcoming the Terror of Death, San Francisco: Jossey-Bass.

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Claire Moran, 2019. ‘The Sense of an Ending’ – Death and Endings in CAT. Reformulation, Summer, pp.23-25.

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‘The Sense of an Ending’ – Death and Endings in CAT

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