Sunday, April 17, 2011

Reflections About Termination in Therapy

              
The process of terminating (the official term employed when a therapist and a client stop working together) can be a rather difficult time for both the clinician and the client because of the feelings of sadness, loss and previous endings that it may raise.

That said, termination may also be a time of positive reflection and a feeling of accomplishment as a review of the work completed together is done. In addition, some healing about prior losses and/or endings may be achieved when these emotions and past incidences are brought out into the open.

As a social work intern who is in the process of completing her second year placement, I have been in engaged for the last few weeks in the process of explaining to my clients with whom I have worked all year that my internship will be over at the end of this month.

Webtreats Grungy Festive Seamless Photoshop Patterns Part 2

For me, termination has and continues to be a time with mixed emotions. On the positive side, with some patients, as we discuss and review the work we have done together, I am being made aware of some amazing changes that have taken place and this is truly gratifying.

For example, one patient (let's call her E) with whom I had been working since September, had suffered repeated trauma in her life and had been quite depressed at the beginning of our relationship. E had essentially seen herself as a prisoner of her past but now she is in a totally different place. E sees possibilities. E has hopes and dreams now...

This has been demonstrated quite concretely by E's recent application and acceptance to an institution of higher learning! I am so excited for her and proud of her. She had shared with me the wonderful news of her acceptance during our last session.

Another illustration is with a patient (let's call him S) with whom I had also been working since September. His primary difficulties had revolved around managing his anger. Prior to our work together, he would get into physical fights with others at the slightest provocation but this has ceased.

While his environment supports his previous aggressive methods of behavior, S has truly changed his thought patterns and as a result, his feelings and behaviors. I am so proud of his accomplishments.

I am also most relieved that he has agreed to continue treatment with my supervisor after I leave. This is because I believe that he would benefit from additional therapeutic treatment as well as continued support and encouragement to maintain the newly learned behaviors.

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A third example of an ending with a client illustrating growth is one that occurred with a middle-aged woman (let's call her T) who had a history of cutting when we first met. This woman had been someone who tended to feel whatever happened to her in a very intense way.

In addition to supportive and psychodynamic counseling, I had employed cognitive behavioral and dialectical behavior techniques in my work with T. The end result was that T was ready to terminate at the same time that I had to terminate with her.

T had not resorted to cutting since we began our work together nor had she felt herself getting close to that point. She expressed feeling more in control of her emotions and therefore, of her life. T also felt fully armed with some tools and techniques of what to do should an event occur and her feelings become overwhelming so as to ground herself again. T had made great progress.

In sum, E, S and T are all examples of clients who made amazing progress over a period of seven months. This has meant that as we were discussing their treatment and reminiscing, we were expressing a sense of pride and accomplishment over a "job well done," as well as some sadness over the fact that we were no longer going to be working together.

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Talking about sadness, this has been expressed by patients in different ways. One patient (let's call her R) has been so upset about our upcoming last day that she has resorted to missing some of our appointments. In addition, she has been experiencing a regression i.e., issues that had been mastered through our work have all of a sudden popped up again as insurmountable.

E ended up terminating with me a week earlier than what was necessary because it would have been too painful for her to see me through the end. And I've had one patient who basically hasn't returned at all once she heard the news.

Yet another patient also experienced temporary regression and also felt immense rage at a family member. I was able later to help her realize that some of this anger that she felt was in fact directed at me because I was leaving. She had trusted me and felt comfortable with me; she had shared with me all her issues and now I was leaving...

On my end, I've found myself having a rough time separating as well...I will miss them. This has probably made me reach out more than what one "should" to patients who are having a rough time with this. It led me to not say right away "no" when I was asked whether I would be able to come back and visit after I completed my internship.

Thinking about parallel processing (see Parallel Processes, Boundaries and Authenticity), I suspect that part of the difficulty in my saying good-bye to my patients is a reflection of my feelings toward my supervisor. It will be very hard for me to part from her. She has been an incredible teacher.

Finally, I believe that termination may also be seen as a new beginning... The client may be "graduating" to no longer needing therapy or moving on to working with a new therapist. The clinician may be completing his/her degree, starting a new position or simply starting to work with another client.

Regardless of what the new beginning will be, I believe that both the client and therapist inevitably grow and change from the special therapeutic bond that developed between the two of them. I know that I will forever be grateful to my first clients for having allowed me to be a partner on their journey. They have taught me so much...

What are your thoughts about termination? Are there some things that you have found particularly helpful when terminating with clients?

Please feel free to share any of your thoughts, comments or advice on this topic.  I'd love to hear from you :)

You May Also Enjoy:
Are Some Therapeutic Impasses Unavoidable?
Integrating Theory with Practice
Facing the Past as You Help Others Heal
What is Eye Movement Desensitization and Reprocessing (EMDR)?
Social Worker Pay By Type of Setting, Practice Area & Region

Photo credits: webtreats
Grungy Festive Seamless Photoshop Patterns Part 2 
Grungy Green Tileable Photoshop Patterns 2 
Seamless Grungy Teal Pattern  

Reference:
Walsh, J. (2003).  Endings in clinical practice: Effective closure in diverse settings.  Chicago: Lyceum Press.

14 comments:

  1. Dorlee,

    This is one of the experiences of training that I miss a bit. The discrete endings of practica and internships provided the opportunities you described to have clear termination planning. There was a sadness and a sense of growth in that experience. However, out in private practice, things are rarely that clear. Clients have more control over when therapy ends, and sometimes the entire termination process occurs in a single session. I've been grateful that I had the extended termination training to draw on in those situations.

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  2. Thanks so much for sharing how the termination process is often so different out in private practice.

    I didn't realize that having clear termination planning is rather unique to internships and practica.

    How does that feel for you as the clinician when the termination occurs in a single session after you have had little forewarning? I imagine that must be difficult at times...

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  3. An extremely important stage of therapy that is frequently overlooked. Well Done!

    Where do you go from here Dorlee?

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  4. Thanks so much, Laurel :)

    I still have 6 more credits to complete by MSW; therefore, I will be in school over the summer and will be graduating in September.

    My plan is to also use the summer as a time to network and look for a position, as well as study for the LMSW so that I will be ready for both as soon as I graduate.

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  5. There's nothing quite like termination to activate unfinished loss issues, and what's wonderful about it is that is provides an opportunity to heal some of the losses and to say goodbye in in different way. Your post provides a wonderful illustration of all of this, Dorlee, thanks! I am particularly struck by how powerful it must have been for the patient who was able to articulate her anger at you about you leaving...I would guess this was a "first" experience for her.

    And it must feel so good to see such significant progress in your patients and to know that you've played a role in guiding them on that journey of growth. What a wonderful place for you to reflect from...it seems like just yesterday that you were interviewing for internships!

    So, as you so aptly note, part of termination is being able to acknowledge your gains and learning.

    What do you see as your most significant accomplishments in this internship? The most important thing you've learned?

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  6. It does feel good to have been able to play a helpful role in my clients' journey of growth...I'm almost amazed at how much a few of them have changed.

    I also believe that the particular strengths each of these clients brought to the table, so to speak, had a significant impact on their trajectory.

    Thanks so much for sharing your valuable input and feedback on the termination process, Nancy :)

    You ask some good questions...I will need some time to think about them... and then I will plan on addressing them in a subsequent post. Thanks for the great topic idea!

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  7. Dorlee, a great reminder to those of us who don't have the termination process embedded in our practice like it was in graduate school.

    One thing I have noticed that is very hard for interns is to express the ambivalence of being sad to be leaving their patients but also elated to be graduating. The end of the second year and graduation is such a huge deal: You made it! Summer classes aside, you have your whole professional career just about to begin. No more working for free, and it gets even more interesting as time goes on I think.

    It can be hard to hold these pleasant feelings without guilt when our patients regress in the face of loss, but I hope you do, keep it up.

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  8. Now, that you mention it...I don't think I have fully absorbed the fact that I will be graduating soon, particularly because of my need to still attend classes in the summer.

    Furthermore, I was not living mindfully because I was thinking about the important next steps I would need to take (finding work, LMSW exam) without taking even one moment to appreciate or acknowledge where I am right now!

    Thanks so much, Mike, for reminding me to take the time to enjoy the fact that I am about to graduate!

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  9. What a wonderful way to view the opposite ends of the terminating process, Dorlee! Thanks for sharing. Thanks also for sharing how folks were able to move from problems to possibilities over time. What wonderful accomplishments you and clients met over seven months.

    My favorite statement in your thoughtful article is “Finally, I believe that termination may also be seen as a new beginning...” The skills inherent in letting go really do span the admirable issues in life as well as the conflicted or dissonant areas ! When it’s time to drop things and move on, I’ve often had to work especially hard at letting go.

    Mental barriers make it harder for some people to let go, while others rewire their brains’ plasticity to adjust to the “new possibilities…” you’ve mention - and move on in refreshing ways, with far greater ease each time. Yikes - it’s sure difficult at first.

    Barriers to letting go, come from amygdalas that steam up faster in some brains to create hurt or sizzling emotional reactions, such as saddness. Speed bumps also slow down people who mentally hardwire more fix-it than drop-it patterns of behavior over time.

    It takes letting it go, to rewire a brain’s defaults in favor of leapfrogging over learned ruts into freedom to respond again to new situations in newly designed and caring ways.

    What’s been your experience about overall differences between how men and women tend to let gut-wrenching challenges go rationally or emotionally? Have there been similarities too?

    Thanks Dorlee and all, for the great discussion and inspired reflections!

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  10. I still find it really hard - well, I should qualify that, it depends where we are at the point that the 'termination' comes. Sometimes, working as I do with older adults, it is about watching and working with someone through a deteriorating dementia so I am working through the termination process while they may not have the capacity to understand wholly why I am not continuing in my work with them or I have seen them through a period of deterioration and they are leaving the service with poorer cognition processes than at the beginning. Sometimes the termination is a death, sudden or expected. While I can find it difficult to process, I have the comfort of having colleagues and supervisors to talk the process through with and it as you do, it is so important to look at the steps that have been taken and the work that has been done.

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  11. You bring such a fascinating perspective to the termination process, Ellen! I hadn't considered the rewiring of the brain, neuroplasticity...but all of what you are saying is so true...

    Brain imaging and scans have demonstrated new neural connections being created in patients' brains after successfully completing a course of psychotherapy treatment.

    You've raised some interesting questions about men and women and the potential differences in the way they may go about handling challenges...unfortunately, I can't yet speak to this based upon my experience.

    I don't feel that I've really worked with enough of both groups to make any sort of judgment in this regard...the expected bias is to anticipate women being more emotional in their approach however, my gut feeling is that the answer probably "depends."

    In terms of my experience working with patients with severe mental illnesses, some of the men have demonstrated a sensitivity and understanding for others that is much deeper than that shown by some women but the reverse also holds true.

    That said, in terms of termination, my female patients have exhibited more external displays of emotion. This is probably more a function of the fact that society has made it more acceptable for women to show emotion and be emotional than the result of men feeling any less emotion.

    Men are much more likely to have been taught from a young age to repress their feelings (particularly sad emotions).

    Thanks so much, Ellen, for having visited and shared your unique view on the termination process :)

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  12. Thanks so much, cb, for being willing to share what the process of termination is like for you.

    Having termination mean losing a patient to death and/or cognitive deterioration adds a complicated layer to this process...and it sounds like it must be very painful at times.

    I feel for you, cb...I'm also glad and relieved that you have the support of good colleagues and supervisors to help you cope with these terminations.

    Please also make sure to provide yourself with sufficient self-care... :)

    Sending you some <<>>

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  13. Great post Dorlee! I could have written the same thing since we have had similar experiences as an intern. I sometimes think that termination with clients may be one of the most important aspect of therapy. When it is done successfully, it can be tremendously gratifying for both clinician and client.

    Hopefully, after a successful termination, if therapy is needed again in the future, the client would not hesitate to call on you again.

    I still have 2 more weeks to go but will be terminating with most of my clients this coming week. I will miss them for sure but also know that they have all made great progress and most, if not all will continue on with another clinician at my agency.

    I know these forced terminations are hard for all and will not be this way again, so I am soaking up the knowledge gained from this experience and carry it forward.

    My supervisor has been excellent with talking about terminations with me as well as help me identify my own feelings with terminating and finishing the internship.

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  14. Thanks so much, Sharon, for your kind feedback and sharing your experiences about termination.

    I'm so happy for you that your supervisor has been so supportive and helpful in talking to you about your feelings around termination with your clients and your internship.

    This empathy and support, in turn, helps you to be there for your clients as they experience a difficult time...

    Wishing you the best of luck as you complete your internship and enter the job market!

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