Evaluating and terminating treatment, domain 4

Jake, who has had two psychiatric hospitalizations for suicide attempts in the past year, is moving across town and asks to switch to video sessions. The therapist is licensed where he will live. What is MOST important in deciding whether telehealth is appropriate?

1. Whether his home internet connection is fast and reliable
   A reliable connection is a practical requirement, but it does not tell the therapist whether remote care is clinically safe for him.
2. Whether his insurer reimburses video sessions
   Reimbursement is a business question; it does not decide whether video care is clinically appropriate.
3. Whether he prefers video to in-person sessions
   His preference matters for engagement, but it cannot outweigh whether a high-risk client can be kept safe at a distance.
4. Whether his risk can be managed safely at a distance
   With two recent suicide attempts, the deciding question is clinical: whether his risk can be assessed and managed by video, with a local emergency plan (AAMFT 6.1a).

As therapy ends, a client asks whether an AI mental-health chatbot could replace the booster sessions in her relapse-prevention plan. What is the MOST appropriate response?

1. Endorse the chatbot in place of the boosters
   Round-the-clock availability is not clinical oversight; endorsing the chatbot as a replacement drops the human follow-up her plan relies on.
2. Forbid its use after therapy has ended
   Forbidding the app after therapy ends oversteps her autonomy; the issue is substitution for care, not use.
3. Let the app decide when she needs to return
   Letting the app decide when she returns hands a clinical decision to software, which AAMFT 6.2 rules out.
4. Discuss its limits and keep a human follow-up
   An app can support maintenance, but the therapist discusses its limits and privacy issues and keeps a human booster or return plan, because technology does not replace clinical judgment (AAMFT 6.2).

A single mother misses about half of the office sessions for her family because she has no car and cannot arrange childcare. When she attends, she is engaged. What is the BEST response?

1. Refer her to a parenting class nearer home
   A parenting class nearer home replaces family therapy with a different service and does not address the missed sessions.
2. Reduce sessions to monthly until she can come
   Cutting to monthly sessions dilutes treatment and leaves the barriers unsolved.
3. Consider home-based or telehealth sessions
   No car and no childcare are practical barriers, so the therapist re-evaluates how services are delivered; home-based or video sessions keep an engaged family in care.
4. Enforce the attendance policy and discharge
   Discharging under the attendance policy treats a practical barrier as lack of motivation and drops a family that engages when it can attend.

After five sessions, parents working on their son's defiance call to say they want to stop therapy, although their goals have not been met. What should the therapist do FIRST?

1. Explore what is behind their request
   A request to stop early may reflect an alliance rupture, practical barriers or real improvement, and each calls for a different response, so the first step is to learn their reasons.
2. Schedule a final session to review progress
   Scheduling a final review session accepts the ending before the therapist understands why they want to stop.
3. Urge them to continue until goals are met
   Urging them to continue disregards their right to decide (AAMFT 1.7) and skips finding out what is wrong.
4. Mail them referrals to other services
   Mailing referrals jumps to closure without the conversation that might resolve the problem.

In couple therapy after one partner's affair, which development MOST strongly suggests the couple is ready to end treatment?

1. The affair no longer comes up in sessions
   Silence about the affair may be avoidance rather than resolution.
2. They can discuss the affair without escalating
   Being able to take up the affair and its triggers together without falling into the old destructive cycle shows the couple has repair skills that will outlast therapy.
3. The betrayed partner says she has forgiven him
   A statement of forgiveness can come early and be fragile; it does not show the couple can handle the affair when it resurfaces.
4. The involved partner has apologized fully
   A full apology is an important early step in affair recovery, not evidence that the couple can manage on its own.

A Korean American family entered therapy after their 17-year-old stopped speaking to her grandparents. The therapist plans to measure progress by the teen's assertiveness at home. What should the therapist do FIRST?

1. Agree with the family on what success means
   Culturally responsive evaluation starts from criteria the whole family shares, which here may center on restored respect and contact across generations rather than the teen's assertiveness.
2. Keep assertiveness as the main measure
   Keeping assertiveness as the yardstick imposes an individualistic value the family may not share and could count more conflict as progress.
3. Let the grandparents set the goals for everyone
   Letting one subsystem set everyone's goals ignores the teen and the parents, whose views also define success.
4. Use a standardized measure normed on U.S. teens
   A measure normed on U.S. teens may not fit this family's values, and it still skips agreeing with them on what success means.

Midway through therapy for a couple's parenting conflicts, the husband's mother moves in and begins disciplining the children. What should the therapist do NEXT?

1. Reassess and consider including the grandmother
   A grandmother who moves in and disciplines the children changes the household's structure and hierarchy, so the therapist reassesses and considers including her.
2. Advise the couple to ask her to move out
   Advising her to move out imposes a decision about living arrangements that belongs to the family.
3. Keep the original plan and goals unchanged
   Keeping the original plan ignores a major change in the system the plan was built for.
4. Refer the grandmother for individual therapy
   Referring the grandmother to individual therapy treats her as the problem and keeps her out of the system being treated.

A family completes psychoeducation for their 24-year-old son's schizophrenia. Which change at home would MOST reduce his risk of relapse?

1. Lower expressed emotion in family interactions
   High expressed emotion (criticism, hostility, emotional overinvolvement) reliably predicts relapse in schizophrenia, and lowering it is the main goal of family psychoeducation.
2. Parents taking over all of his daily decisions
   Parents taking over all decisions is emotional overinvolvement, one component of high expressed emotion.
3. More frequent confrontation about his symptoms
   Frequent confrontation about symptoms raises criticism, another component of high expressed emotion.
4. Insight into the double bind that caused his illness
   The double-bind theory of schizophrenia's cause has been discredited; seeking insight into it promotes blame, not lower relapse.

Midway through couple therapy, a husband's depression deepens: he has stopped working and sleeps most of the day, though he denies suicidal thoughts. What should the therapist do NEXT?

1. Suggest an antidepressant for him to request
   Recommending a specific medication is outside the MFT's scope (AAMFT 3.10); the prescriber decides after an evaluation.
2. Switch to individual therapy with him alone
   Switching to individual therapy alone drops the relational context that is part of his depression and recovery.
3. Suspend couple therapy until his mood improves
   Suspending couple therapy removes support at a vulnerable time.
4. Refer for psychiatric evaluation and continue
   Worsening vegetative symptoms call for a psychiatric evaluation, while the couple work, which can itself help depression, continues in coordination.

In one of the final sessions, a therapist asks a couple, “What might tempt you back into the old pattern, and what would you do if it happened?” The PRIMARY purpose is to:

1. test whether they are ready to terminate.
   The question builds a coping plan for after therapy; it is not mainly a test of readiness to end.
2. prepare them to handle a future setback.
   Predicting a setback and rehearsing the response is relapse prevention: it normalizes slips and prepares the couple to catch early signs and use their skills.
3. suggest that relapse is likely to happen.
   Planning for a possible slip does not predict that relapse is likely; it prepares them in case it happens.
4. uncover conflicts they have not yet raised.
   Opening new conflicts in a final session is not the aim; the question works with the pattern already treated.

Each week, a couple brings the therapist a new dispute and asks, "Who's right?" From a Bowen perspective, the therapist should recognize that:

1. the couple is showing readiness for termination.
   Bringing a new dispute every week shows dependence on the therapist, not readiness to end.
2. the couple needs a fair ruling in order to move on.
   Ruling on who is right would put the therapist inside the triangle and keep the couple dependent on outside verdicts.
3. the couple is triangling her in to manage anxiety.
   Bowen theory holds that an anxious couple pulls in a third person to stabilize itself; a weekly request for a verdict is an invitation into a triangle.
4. the partners lack basic communication skills.
   A skills-deficit reading misses the emotional process: the couple uses the therapist to manage anxiety, not for lack of technique.

In the consolidation stage (steps 8-9) of emotionally focused couple therapy, the therapist MOST likely helps the couple:

1. re-engage the more withdrawn partner.
   Re-engaging the withdrawn partner is stage two, restructuring the bond.
2. use their new bond to solve old problems.
   In EFT's third stage, consolidation, the couple uses its newly secure bond to find new solutions to longstanding practical problems.
3. learn structured rules for communicating.
   Structured communication rules are a behavioral couple therapy tool, not a step of EFT.
4. identify the negative interaction cycle.
   Identifying the negative interaction cycle is stage one, de-escalation.

A family rates therapy highly but falls back into old blaming patterns whenever a new stressor hits. How should this affect plans to end therapy?

1. Refer the identified child for individual work
   Referring the identified child moves the problem back into one member, while the blaming pattern belongs to the family.
2. End and schedule a check-in the following week
   A check-in a week after ending does not consolidate change; the work needed is before termination.
3. End now on the strength of their high ratings
   High satisfaction is not evidence of durable change; the family still falls back into blaming under stress.
4. Continue until the gains hold up in hard times
   Gains that collapse under stress are not yet consolidated, so therapy continues until the new patterns hold when stressors hit.

Two sessions after a family agreed to end therapy, the parents report that their 9-year-old's bedtime fears have briefly returned. What is the BEST response?

1. Cancel termination and resume weekly sessions
   Canceling termination and returning to weekly sessions can teach the family that problems are the way to keep the therapist.
2. Proceed without mentioning the setback at all
   Ignoring the setback misses a chance to rehearse relapse prevention and may leave the parents feeling unheard.
3. Normalize it and review what helped before
   A brief return of old symptoms around an ending is common; the therapist normalizes it, reviews what helped and keeps the plan unless the setback persists.
4. Reassess the child for a new anxiety disorder
   Reassessing for a new disorder overreacts to a brief, familiar symptom that returned around the ending.

A couple who ended therapy two years ago calls to resume after a new crisis. What should the therapist do FIRST?

1. Book weekly sessions without an intake
   Booking weekly sessions without an intake skips assessment of new risks such as violence or substance use.
2. Refer them to a new therapist
   Referring them to someone new is unnecessary: a closed file does not bar a return to care, and the couple chose to come back to this therapist.
3. Reassess them and renew informed consent
   After two years, circumstances, risks and goals have changed, so the therapist reassesses and renews informed consent before resuming (AAMFT 1.2, 'as often as necessary').
4. Resume the old plan where it left off
   The old plan was built for problems from two years ago and may no longer fit the new crisis.

A therapist and family define individualized goals, each with five levels from 'much less than expected' to 'much more than expected', and rate them at each review. This evaluation method is:

1. Outcome Rating Scale
   The Outcome Rating Scale is a fixed four-item well-being measure given each session. Its items are the same for every client, not built around individual goals.
2. Goal Attainment Scaling
   Goal Attainment Scaling sets a five-level scale for each individual goal, from much less to much more than expected (−2 to +2), and rates where the family stands at each review.
3. A solution-focused scaling question
   A solution-focused scaling question asks for a single 0–10 rating in the moment. It has no predefined outcome levels for each goal.
4. Circumplex Model assessment
   The Circumplex Model and its FACES measures assess family cohesion and flexibility, not progress on goals the family set.