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