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Psychotherapy termination in cases marked by early parental loss

ProQuest Dissertations and Theses, 2009
Dissertation
Author: Paul M Martin
Abstract:
In the often lengthy work of dynamic psychotherapy, the process of terminating treatment may be particularly important. This "termination phase," as many therapists have come to acknowledge it, is seen as a distinct stage which is crucial to the overall success of treatment (Edelson, 1963; Firestein, 1978; Freud, 1937; Joyce, Piper, Ogrodniczuk, & Klein, 2007; Levinson, 1977; Novick, 1988; Orgel, 2000; Ruderman, 1999). Appropriate resolution of the termination phase can serve to address secondary symptoms that arise in response to anticipated termination (Levinson, 1977), consolidate gains achieved throughout treatment (Freud, 1937), and help to ensure the patient's willingness to return for further treatment if needed (Roe, Dekel, Harel, Fennig, & Fennig, 2006). Many factors potentially complicate and challenge these goals. One such hindrance that comes with the territory of terminating long-term dynamic psychotherapy is the patient's frequently observed experience of significant relational loss. Additional troublesome reactions observed during the termination phase include symptom resurgence, dependency upon the therapist, unwillingness or inability to productively discuss termination with the therapist, and anxiety upon leaving treatment. Individual relational differences among patients are presumed to influence the unfolding of psychotherapy termination and the extent to which it is difficult. Thus, it seems likely that the already mentioned relational challenges associated with termination would be magnified among patients with histories of early parental loss. While these two topics (i.e. termination and early parental loss) have been written about extensively, the intertwined implications of (1) psychotherapy termination for (2) patients with a history of early parental loss have received only minimal attention in the literature. Increased awareness of such implications will offer therapists increasing competence when terminating psychotherapy for patients with histories of early parental loss. The following research question is presented: How do the many phenomena associated in the literature with psychotherapy termination compare with termination experiences among patients dealing with early parent loss?

Table of Contents Copyright ii Signature Page iii Acknowledgments iv Abstract v List of Tables viii CHAPTER 1: INTRODUCTION 1 CHAPTER 2: LITERATURE REVIEW 4 CHAPTER 3: METHOD 35 CHAPTER 4: CASE STUDIES 37 CHAPTER 5: DISCUSSION 67 CHAPTER 6: CONCLUSIONS 78 REFERENCES 82 vii

List of Tables Table 1: Prevalence of Termination Phenomena 66 viii

CHAPTER 1: INTRODUCTION This dissertation aims to address termination of long-term, dynamically oriented psychotherapy for patients with a history of early parental loss. The specific type of psychotherapy considered in this research deserves clarification. A minimum duration of one year in therapy will be used as a framework for what is considered "long-term" psychotherapy. Further, the type of psychotherapy to be considered herein is that which uses a psychodynamic orientation to conceptualize and treat psychotherapy patients. While some authors quoted specifically reference analysis, analysis is not intended to be of primary focus. The type of therapy considered in this research is dynamically oriented psychotherapy that includes, but is not limited to, psychoanalysis. In the often lengthy work of dynamic psychotherapy, the process of terminating treatment may be particularly important. This "termination phase," as many therapists have come to acknowledge it, is seen as a distinct stage which is crucial to the overall success of treatment (Edelson, 1963; Firestein, 1978; Freud, 1937; Joyce, Piper, Ogrodniczuk, & Klein, 2007; Levinson, 1977; Novick, 1988; Orgel, 2000; Ruderman, 1999). Appropriate resolution of the termination phase can serve to address secondary symptoms that arise in response to anticipated termination (Levinson, 1977), consolidate gains achieved throughout treatment (Freud, 1937), and help to ensure the patient's willingness to return for further treatment if needed (Roe, Dekel, Harel, Fennig, & Fennig, 2006). Many factors potentially complicate and challenge these goals. One such hindrance that comes with the territory of terminating long-term dynamic psychotherapy - 1 -

is the patient's frequently observed experience of significant relational loss. Orgel (2000) says, "Considered as a vicissitude of the analytic relationship, termination contains essential elements of psychoanalytic process. Cycles of attachment, loss, mourning, and internalization mark moments in, as well as overviews of, every analysis from its beginning to well past its termination" (p. 721). Additional troublesome reactions observed during the termination phase include symptom resurgence, dependency upon the therapist, unwillingness or inability to productively discuss termination with the therapist, and anxiety upon leaving what many therapists, including Orgel, would consider, "an extraordinary day-to-day relationship" (p. 720). His position is that these reactions must be assessed and, if present, addressed in the treatment to ensure the patient moves past therapy with a sense of accomplishment and a positive attitude toward his or her psychotherapy treatment. Individual relational differences among patients are presumed to influence the unfolding of psychotherapy termination and the extent to which it is difficult. Thus, it seems likely that the already mentioned relational challenges associated with termination would be magnified among patients with histories of early parental loss. While these two topics (i.e. termination and early parental loss) have been written about extensively, the intertwined implications of (1) psychotherapy termination for (2) patients with a history of early parental loss have received only minimal attention in the literature. Increased awareness of such implications will offer therapists increasing competence when terminating psychotherapy for patients with histories of early parental loss. The following research question is presented: How do the many phenomena - 2 -

associated in the literature with psychotherapy termination compare with termination experiences among patients dealing with early parent loss? - 3-

CHAPTER 2: LITERATURE REVIEW Basic Terminology This dissertation frequently uses the terms object loss and early parental loss. Use of these terms demands definition. The definitions provided herein are generally agreed upon among psychoanalytic writers, all of whom cannot be listed here. The first term deserving definition is object loss. Rochlin (1965) provides the following definition: "Object loss in the psychoanalytic sense means the forced abandonment of a desired and valued personal relationship" (p. 1). Though typically used to describe the loss of a human relationship, object loss is also used in reference to "the loss of some abstraction...such as one's country, liberty, an ideal, and so on" (Freud, 1917, p. 3). Some writers and theorists have even applied object loss to the loss of a body part such as an amputated limb. What remains essential to the term object loss is the loss of a valued relationship to something tangible or intangible, concrete or abstract. Early parental loss will be operationally defined as the real, rather than imagined or fantasized, loss of a parent (an object loss) at a period in the biological child's life prior to adulthood. Such a loss may entail death or estrangement. Patients under consideration in this dissertation will be referred to as "early parental loss patients." It is the interest of this dissertation to explore and focus on how the loss of therapist through psychotherapy termination is impacted by reverberations of traumatic object loss of parent occurring earlier in life. That is, the common thread between these events is the object loss of an attachment figure. - 4 -

Further on the topic of early loss, a specific and agreed upon timeframe for what is considered early is not found in the literature. Researchers and theorists choose an assortment of age ranges to discuss the factor of age. Childhood tends to be the central defining variable when discussing early events. Yet, 'childhood' is another concept that has no clear definition and is only clearly defined by preceding adulthood. For the purpose of this discussion, early parental loss will be understood as interpersonal loss of a person's biological parent, mother or father, prior to adulthood. These parameters will also include parental losses that occur no earlier than age three; it is the aim of this dissertation to address loss of a parent whereby the child was able to establish a significant relationship. Early Parental Loss Desired and valued personal relationships are at the core of human experience. It can be argued that object relations, past or present, persist in their impact upon an individual throughout life. This is especially true for one's relationship with parents as his or her caregivers. The infant depends on its caretakers to survive and therein learns how to trust and be dependent on others later in life. In turn, early object relations provide a framework for how to care for others. This framework is internalized as a regulatory function, dictating how interpersonal relationships are managed and responded to. This framework also provides the individual with an understanding of self based on early relationships with caregivers (Erikson, 1959). - 5-

As the relationships in human life shape one's self-image and capacity to relate with others, so too does the loss of such relationships. Speaking of object loss, Rochlin (1965) wrote, "Grief at such a loss-whether real or fancied-usually affects one's image of oneself, sometimes pathologically" (p. 1). While relational loss has a significant impact at any stage in life, much literature suggests that early parental loss carries with it a more severe threat to well-being. John Bowlby (1963, 1980) in particular has contributed substantially to the understanding of human attachment as well as the response to loss of such attachment figures, emphasizing the loss of biological parents. Bowlby's work focuses primarily on early object loss. This work is an attempt to retrospectively understand how adults are continuously impacted by early loss in their lives. Many theorists (Bowlby, 1980; Krueger, 1983; Miller, 1971) would agree that loss experienced in childhood breeds pathological responses. These responses often persist throughout the course of one's life. Bowlby (1980) says, "...in infants and small children the outcome of experience of loss seem more frequently to take forms which lead to an adverse psychological outcome" (p. 15). In previous work, Bowlby (1963) had found that the mourning process of infancy and early childhood often "bear many of the features which are the hallmark of pathological mourning in the adult" (p. 504). Many theorists suggest that early years are a crucial time for the child to learn how to respond to loss in a healthy manner. Bowlby (1980) says, "the capacity to respond to loss in a favorable manner should.. .be attained during that very early period" (p. 31). Krueger (1983) adds, "The developmental level attained by the child at the time of loss, - 6 -

including cognitive, integrative, structural, and defensive capacities will have significant impact on the experience of the loss" (p. 583). The child, according to these notions, usually encounters loss in increasingly larger gradations, slowly learning how to master the event of loss without poor response. Small separations and/or small experiences of loss must be mourned in early life according to the capacity to do so, gradually increasing as the child matures and increases his capacity to bear the separations. In these normal bouts of mourning, the child internalizes images of others and internal psychic structure is gradually built up (Berzoff, 2003; Kalsched, 1996; Kohut, 1971). The loss of a parent to death is too large of a task to master at an early age when the capacity to mourn is not yet well-developed. One view is that a developmental arrest often ensues, primarily regarding object relationships and self-representation (Fleming, 1972). Interpersonal reverberations of such are tremendous and potentially traumatic. Bowlby (1980) commented that, in the event that a child has "no single person to whom he can relate.. .he becomes increasingly self-centered and prone to make transient and shallow relationships with all and sundry. The condition bodes ill for his development if it becomes an established pattern" (p. 14). Lingering Deficits as a Result of Early Object Loss Pathological Mourning In Mourning and Melancholia, Freud (1917) begat the object relations school of thought, saying, "and so, the shadow of the object fell on the ego" (pg. 13). Thus the - 7-

mourner is presented as suffering from a temporary loss of reality testing, holding on to the lost object intrapsychically and symbolically, letting go only bit-by-bit. The healthy mourner is eventually able to decathect the lost object and invest this energy into new relationships and activities. The pathological mourner, however, is motivated to maintain this lost relationship one way or the other, failing to decathect and resolve the process of mourning. This results in a psychic state Freud dubbed melancholia. The lost object is introjected and libido is speculated to stay within at the cost of unending devotion to the lost object. Libido is no longer invested in new objects. The strength of Bowlby's (1980) proposed model of loss, in his own words, "lies in relating the pathological responses met with in older patients to responses to loss and threats of loss that are to be observed in childhood" (p. 22). It appears that internal reverberations of loss continue throughout one's life. However, the extent to which one can resolve their mourning of a lost object determines the extent to which such a loss will adversely impact their functioning in response to future losses. Krueger (1983) says, "Simply put, adequately mastered and assimilated experiences immunize against later trauma to some degree; unmastered traumatic experiences are thinly walled off by repression, awaiting a specific triggering blow" (p. 588). Thus, early object loss and stymied mourning of such pose a particularly difficult roadblock in adjusting to future losses. Bowlby (1963, 1980) identified four pathological variants of adult mourning, highlighting the observation that those who display these responses have experienced loss of a parent during childhood: "(1) unconscious yearning, (2) unconscious reproach - 8 -

against the lost person combined with conscious and often, unremitting self reproach, (3) compulsive caring for other persons, (4) persistent disbelief that the loss is permanent (often referred to as denial)" [numbers added] (p. 15). The problem of unresolved mourning as applicable to early object loss appears to be two-fold. First, ambivalence towards the lost object motivates the child to retain introjected internalizations as a means of countering what is felt to be unjust. They need more time to directly experience the lost object whom they long for yet retain hatred for in response to feeling abandoned, yielding ambivalence (Freud, 1917). Hull, Lane, & Gibbons (1993) speak of pathological mourning in the following way: "Mourning that would have allowed resolution of the patient's guilt and ambivalence had not been completed" (p. 87). Second, the child's attachments toward others are minimized or absent altogether, fearing repeated disappointment and heartache in allowing others to be new attachment figures. Such defensive processes of detachment are "apt to stabilize and persist" if the mourning of early object losses remains unresolved (Bowlby, 1980, p. 21). Rucker (1981) addressed how synthetic capacities gone awry early in life often result in primitive defenses maintained throughout life and significant difficulty with the process of internalizing object relations and mourning. Rucker said, "Children in whom the development of synthetic capacities has gone awry may carry into childhood some of the fragmentation associated with a much earlier period of development. Primitive defenses of splitting and projection may continue to proliferate, and these children may still structure much of their internal experience around parental/object images that remain rudimentary and poorly integrated" (p. 132). - 9 -

It is important to note that much debate has occurred within the literature regarding whether or not children mourn. Some writers, most notably Wolfenstein (1966), assert that children do not have the capacity to mourn. The child, within this theoretical framework and its assumptions, is in a state of perpetual loss due to developmentally appropriate losses and acquisitions in core object representations, including self representations. It is argued that the child can not fully mourn the death of another because of their own ongoing and rapid process of self-loss pertaining to developing self representation. Mourning external losses in addition to the inevitable and ongoing mourning of self would involve too many major losses at once for the child and; therefore, can not occur. In opposition, many writers have countered this claim and asserted that children can, and do indeed, mourn (Bowlby, 1961,1963, 1980; Brice, 1982; Furman, 1974). Furman and Brice believed that children mourn according to their developmental capacity. Brice argued that the death of a loved one precedes a state of vulnerability and helplessness for children and adults alike. This difficult state within mourning is exacerbated in childhood as it is already a time in life characterized by vulnerability and helplessness. Bowlby took this stance one step further and added that childhood mourning is prototypical for all later mourning. Either way, an argument has been made in contrast to Wolfenstein's belief that children can not mourn; childhood is understood as a period of great vulnerability to interpersonal losses and, while they are able to mourn, children resultantly find death more difficult to manage than adults. - 10-

Relational Reenactment of Early Object Loss Sigmund Freud's pleasure principle suggests that, in response to punishing and perhaps harsh parents, the child seeks "other, more pleasure-providing objects" (Mitchell & Black, 1995, p. 115). That is, humans are understood to gravitate toward those who will comfort and nurture them according to the Freudian pleasure principle. Under this principle, a person with a history of early parental loss would simply seek out more fulfilling and pleasurable relationships than their early disappointing relationships. W.R.D. Fairbairn contests this assumption, claiming that children do not always seek out the most pleasurable objects. Rather, people "seek from others the kinds of contact they experienced early on" (Mitchell & Black, 1995, p. 118). Objects found early in life, according to Fairbairn, become a prototype for all future connections, regardless of how pleasurable they are. This often fosters reenactment, a reoccurring interaction between two people transferred from past interactions. Similarly, early parental loss and its future relational implications can be conceived through the lens of a form of reenactment known as the repetition compulsion. According to Mintz (1971), "trauma to the psyche are revived by the sense of time and the need for mastery through re- experience" (p. 722). This view asserts that a person will actively recreate past relational trauma, such as early parental loss, within their current relationships so as to have another opportunity to overcome the trauma and master it. This compulsion acts unconsciously, outside awareness of the person reenacting his or her own early experiences. Early parental loss is presumed to be reenacted by allowing for heightened dependency on others in hopes of their fulfilling needs for continuity and nurturance -11 -

unmet early in life. The irony of this situation is that adults who experienced early parental loss are susceptible to dependence and concurrently do not easily attach themselves to others. In a self-fulfilling prophecy of sorts, these adults often continue to find others throughout their lives to be similarly disappointing and abandoning as their earliest object relations. In summary, young children are particularly vulnerable and less prepared to cope effectively with parental loss; early parental loss is understood as a traumatic life event that carries the potential of weakening the child's psychological resiliency. The child may then fail to adequately mourn the lost object and would be apt to display pathological mourning. That is, the child may not adequately express grief for the dead and, as follows, would likely defensively block off the expression of grief because it is too painful. Reverberations of such have been well researched and are observed through childhood into adult life, highlighting deficits in interpersonal relationships and specific difficulties related to attachment (Bowlby, 1961, 1963,1980; Brice, 1982; Erikson, 1959; Furman, 1974; Krueger, 1983; Mahler, Pine, & Bergman, 1975; Rucker, 1981; Shabad, 2007). The literature reviewed herein regarding early parental loss has emphasized the loss of mother more than the loss of father. However, the literature does not present any overwhelming and/or conclusive findings that reverberations of early parental death are markedly different depending on the parental sex. Case studies and theoretical writings alike, addressing a history of early mother and/or father loss, all present similar phenomena and speculation from the writers. - 12-

When discussing "early parental loss patients," it is the concern of this dissertation to address the reverberations of early maternal and early paternal loss to death. The main focus is when the lost object was an attachment figure, whether mother or father. Similarly, this dissertation will address the termination of treatment in cases where the therapist-patient relationship is one where an attachment occurs and potentially evokes deeply rooted difficulties with attachment observed in the transference. Psychotherapy as an interpersonal relationship between therapist and patient will be seen as resonant with relational problems already addressed, particularly during the termination phase of psychotherapy. Termination Phase of Psychotherapy The lion's share of literature pertaining to termination of long-term, dynamically- oriented therapy considers the termination phase of psychotherapy to be difficult and complicated as the rule rather than the exception. What is being explored in this dissertation is whether existing literature suggests that psychotherapy termination is particularly difficult for patients with histories of early parental loss. All of the difficulties of termination presented herein are acknowledged as phenomena that usually occur for psychotherapy patients regardless of their object relational development and history. What is at issue is whether these phenomena are often exacerbated for the patient with a history of early parental loss. Wolberg (1980) differentiates patients who have endured serious loss during critical developmental stages and thus require a special period of time to work through and prepare for termination. In - 1 3 -

Wolberg's view, a history of serious object loss, particularly during critical developmental periods, increases the importance of the termination phase. Importance of Attending to Termination Phase Long-term, dynamically-oriented psychotherapy is often considered to be comprised of a beginning phase, a middle phase, a period of working through, and what is called a termination phase. These phases can be distinguished from each other with respect to the content of the work as well as typical relational qualities between therapist and patient (Levinson, 1977). The termination phase can be distinguished from the preceding phases of treatment (Joyce et al., 2007). Firestein (1978) defined the termination phase as, "the period of the work antecedent to the ending date when the issue of ending has become important in the analytic focus'"' (p. 203). Freud (1937) first attempted to convey the importance of psychotherapy termination and that which hinders its process. While innovative, Freud is frequently critiqued within the psychoanalytic literature as underestimating the continuing importance of the therapist beyond termination (Orgel, 2000; Ruderman, 1999). Nevertheless, Freud drew attention to two very important aspects of psychotherapy termination: (1) the importance of the therapeutic relationship (to be discussed later); and (2) the necessary attention given to the termination phase and its importance in the overarching success of psychotherapy. Joyce et al. (2007) summarized Freud's contribution to the topic of termination, highlighting his assertion that, "appropriate attention to termination can consolidate a successful outcome, while insufficient - 14-

consideration of the ending may serve to accentuate the limitations of the treatment" (p. 12). Recent research has demonstrated that the patient's subjective sense of success following termination depends on appropriate attention given to the termination phase. Roe et al. (2006) administered a questionnaire to 84 adult patients following termination of dynamically-oriented psychotherapy lasting a minimum of six months to gauge positive and negative feelings towards their psychotherapy experience. Seventy-nine percent of the participants (n = 66) were female. All patients terminated voluntarily. "Processing the termination" and "allowing for appropriate time to process the termination" were both shown to induce positive feelings upon termination as regards the therapeutic relationship and the whole of psychotherapeutic work. In turn, failing to process termination and allowing inadequate time to process termination induced negative feelings from research participants. It should be noted that importance given to the termination phase of therapy is often a function of theoretical orientation. Psychodynamic orientation in particular gives termination priority in therapeutic process and goals whereas more behavioral theoretical orientations do not. Indeed, Joyce et al. (2007) said, "Termination is accorded varying degrees of emphasis as a critical phase in the psychotherapy endeavor. This is, in part, a function of the therapist's theoretical orientation" (p. 4). Further, "the more the treatment is structured and oriented to skills acquisition, the less emphasis may need to be placed on termination" (p. 20). - 15-

Timing of Termination Given the importance of the termination phase in lengthy psychotherapy, its timing is crucial to the success of the entire treatment. Many factors are taken into consideration to determine whether or not entering the termination phase is appropriate in the patient's treatment at any given time. Freud (1937) considered the decision to be that of the therapist. However, contemporary therapists (Golland, 1997; Levinson, 1977; Novick, 1988; Orgel, 2000; Roe et al., 2006) are more inclined to consider the patient's cues and decisions in determining the timing of termination. Further, these therapists would argue that both the therapist and the patient mutually arrive at the decision to end therapy. Orgel (2000) wrote, "Rather than define termination as Freud did, as primarily the analyst's decision to end formal analytic work ..., I want to focus on termination as the mutual decision of two people to leave an extraordinary day-to-day relationship" (p. 720). Ruderman (1999) recommends that the therapist allow the patient to set his/her own pace in determining the appropriate timing of termination. She wrote, "For the termination experience to be truly reparative, patients must be allowed to develop in their own fashion, move at their own pace, and end when they are ready" (p. 187). She asserts that the appropriate timing unfolds "through the patient's feelings, fantasies, statements, and dreams" (p. 187). However, many writers, including Ruderman, draw attention to the pitfalls of terminating psychotherapy too late or too early. Novick (1988) discussed criteria for deciding on the beginning of the termination phase tactfully with regard to timing. Painstaking efforts are made to consider, and avoid, - 16-

both premature termination as well as overdue termination. Novick believed that, ultimately, timing of termination is important in ensuring that the therapeutic alliance is internalized so as to continue self-analysis. In his view, terminating psychotherapy too soon or too late may hinder this aim and potentially induce new symptom presentation or fail to consolidate the gains made in therapy. Terminating psychotherapy too soon and relinquishing therapeutic connection too soon may induce feelings of abandonment, especially for patients with a significant history of interpersonal losses (Novick, 1988; Ruderman, 1999). Numerous points of assessment are gauged to determine the appropriateness of terminating psychotherapy. For instance, increasing health and readiness for termination are observed, in the words of Weiss and Fleming (1980), upon patients' "growing appreciation of the difference between analyst as analyst and analyst as transference imago." Joyce et al. (2007) wrote "a change in the patient-therapist relationship reflecting a decrease in transference distortions and an increase in the quality of the real relationship" (p. 32) is an indication of readiness for terminating psychotherapy. Many writers have agreed with this view (Berent, 1983; Blum, 1983; Ruderman, 1999; Weiss & Fleming, 1975; Yalom, 1989). It is equally important to assess a patient's readiness for termination by ensuring that setting a termination date is an adaptive step towards increased psychological health and not a resistance against further analytic work. Therapists have written about an interpersonal pattern of defensive distancing and resistance often observed in patients with a history of early parental/object loss. Fleming (1975) highlights a common - 17-

Full document contains 95 pages
Abstract: In the often lengthy work of dynamic psychotherapy, the process of terminating treatment may be particularly important. This "termination phase," as many therapists have come to acknowledge it, is seen as a distinct stage which is crucial to the overall success of treatment (Edelson, 1963; Firestein, 1978; Freud, 1937; Joyce, Piper, Ogrodniczuk, & Klein, 2007; Levinson, 1977; Novick, 1988; Orgel, 2000; Ruderman, 1999). Appropriate resolution of the termination phase can serve to address secondary symptoms that arise in response to anticipated termination (Levinson, 1977), consolidate gains achieved throughout treatment (Freud, 1937), and help to ensure the patient's willingness to return for further treatment if needed (Roe, Dekel, Harel, Fennig, & Fennig, 2006). Many factors potentially complicate and challenge these goals. One such hindrance that comes with the territory of terminating long-term dynamic psychotherapy is the patient's frequently observed experience of significant relational loss. Additional troublesome reactions observed during the termination phase include symptom resurgence, dependency upon the therapist, unwillingness or inability to productively discuss termination with the therapist, and anxiety upon leaving treatment. Individual relational differences among patients are presumed to influence the unfolding of psychotherapy termination and the extent to which it is difficult. Thus, it seems likely that the already mentioned relational challenges associated with termination would be magnified among patients with histories of early parental loss. While these two topics (i.e. termination and early parental loss) have been written about extensively, the intertwined implications of (1) psychotherapy termination for (2) patients with a history of early parental loss have received only minimal attention in the literature. Increased awareness of such implications will offer therapists increasing competence when terminating psychotherapy for patients with histories of early parental loss. The following research question is presented: How do the many phenomena associated in the literature with psychotherapy termination compare with termination experiences among patients dealing with early parent loss?