Written by: Maria A. Avila, LMFT, MCAP
I recently resigned from an organization where I had worked for almost 16 years. In order to allow the different groups of people I worked with digest and accept the news, it was decided that I should proceed in stages. After revealing the news to the leadership group I was part of, I addressed those colleagues that I supervised. We gathered in my office with my director present and I delivered the news. After the initial blow, the discussion was diverted into questions and concerns over other matters. The conversation was among the staff and director. The announcement of my departure quickly got me off center stage, to my relief. It was at this moment that I realized how this experience could be translated into termination issues with clients.
The work of emotional and behavioral transformation can be quite intimate between a clinician and their client. In working with those at an intensive inpatient or intensive outpatient level, the process of termination usually comes to fruition sooner rather than later. Working with clients in an outpatient setting brings about the same process but perhaps after a longer period of time. Regardless of the level of treatment, clients reach a time when they feel they are ready to depart from the work they started. How this procedure is handled can be of upmost importance in the therapeutic process. Dealing with termination of a therapeutic relationship is based on how we, as clinicians, view this issue, and especially, how comfortable we are with it. In the example of my resignation, the diversion to other issues from the end of a relationship with an organization and coworkers demonstrated my own discomfort with sadness that takes place in this process of loss.
When insurance companies dictate the length of relationships we are to have with clients, it forces the issue must faster. We have a better idea of how much time we have and certainly have the opportunity to begin the steps needed to prepare a client for the end. If one’s relationship is not controlled by insurance, then the time to build this closeness may be more fluid. Whether the client is working in an individual or group setting a certain level of trust and understanding has transpired. There are several questions that should be addressed. Do we wait for the last session before trying to access feelings around this loss? Do we assume that the client does not have these feelings as they have not come up since the day termination was known? Do we force discussion of the process because we assume that there must be something there that needs to come out? Do we assume if the client prematurely leaves right before the deadline or begins to act out that they were never that invested to begin with? How may using humor deflect from the feelings? All of these questions are aimed at addressing our own possible misconceptions of the termination process. They are also intertwined with our own feelings of saying good bye and with endings in general. Let’s look at the different scenarios.
Do we wait for the last session to address termination issues?
If you have successfully engaged a client into the treatment process and have established a bond, it is only logical that the end of this relationship will have some effect on them. Pretending that it will be business as usual is an oversimplification of what relationships are about. Think of when a client brings up important issues at the end of a session. Do they really want to deal with them? In a time when relationships are challenged, clinicians need to try and model effective interactions that contribute to positive relationships. Encouraging discussion of difficult and negative feelings, allowing this discussion to flow as well as being able to validate these feelings are cornerstone in our ability to model effective communication. When we wait for the last session to do this it cheats the client and others, especially if in a group, to have had the opportunity to explore and communicate the accompanying feelings. The pressure one may feel about having to express something at that moment does not do justice to the therapeutic process. The last session should be a time to summarize and express any other feelings or thoughts that have been expressed previously about this issue.
Strategies: Clinicians need to be able to recognize their own struggle in dealing with the end of a relationship. An awareness of this can help us to be more attuned to others’ struggles and help them access issues that may arise from termination. Giving enough notice allows for this process to unfold. Depending on how much time we have, two or more weeks may be sufficient. In the case of planned vacations or absences on the clinician’s part, the same principle can be practiced. Give them sufficient time to know you will be away. Even if the absence is temporary, we underestimate the effects it can have on some clients.
Do we assume that the client does not have any feelings as they have not come up since the day the termination date was known?
The termination process can reignite feelings similar to those clients that are grieving losses or have been abandoned or rejected. The defenses these client may have used to deal with the trauma could manifest in detachment, disengagement and other behaviors that appear indifferent. One can mistake these for an absence of feeling versus a survival technique. The clinician may think that lack of expression of feelings may be due to the client’s level of disinterest or distance in the relationship. If clinicians are not aware of their own discomfort with endings, they can easily align with the client’s distance, justifying that it was a superficial relationship to begin with.
Strategies: Bring up the topic in subsequent groups to introduce the idea that this is an important issue to be addressed. It allows others to think about what they are feeling in regards to this at different times. Confront the indifference and ask directly what they think of leaving the relationship.
Do we force discussion of the process because we assume that there must be something there that needs to come out?
The best moments in therapy are usually unplanned. Clinicians need to respect the pace of clients. Feelings cannot be rushed, no matter how much insurance companies try to rush the process along. Expecting that a client is ready to discuss feelings about termination at a specific time may be unrealistic. The clinician’s job should be to prompt the discussion, not force it.
Strategies: Create an environment that allows for clients to feel safe about what they contribute. Respecting their silence or resistance in addressing an ending creates this safety. If the client does not have anything to say in this regard, let it go.
Do we assume that if the client leaves right before their last day or begins to act out, they were never that invested to begin with?
A common pattern seen in clients towards the end of their treatment is that they may appear to deteriorate toward the end. Much to our disappointment, we may infer that they had not really learned much to begin with. We may react with annoyance, frustration and anger not seeing it as a sign of sadness due to the upcoming separation. Viewing it as such can allow the clinician to engage in a discussion of loss and sadness which could redirect the patient’s energy and coping.
Strategies: Family therapists may say that prescribing the symptom is indicated here. This can also be described as reverse psychology. It means that the clinician makes a suggestion which is the opposite of what is expected from the person. The clinician may say to the client that the occurrence of these behaviors is natural in this process of termination and predict that they will begin to engage in them. This techniques usually stops the acting out behavior from occurring.
How may humor be used to deflect?
All too often the defense of making a joke or light of intense feelings is seen in therapy as a defense against pain. Many times the client may lack insight on what they are doing and distract from the therapeutic process by making others laugh. In a group setting this may become contagious, encouraging others in this deflection.
Strategies: Increase awareness of this behavior as a way to deflect. Help the client understand their feelings more honestly and help them allow themselves to feel these feelings.
The delayed process involved in dealing with my resignation certainly helped me deal with feeling the upcoming loss and be able to talk about it with others. It allowed them the same time to be either silent or react as time went on. At the end, I can only be thankful for the opportunity that aided me in this termination. Going forward I will be more sensitive to recognizing a client’s vulnerability in this process.
About the Author
Maria A. Avila, LMFT, MCAP is a licensed marriage and family therapist and master’s level certified addiction specialist in private practice. She has over 30 years of experience working with individuals, couples and families. Along with her clinical experience she has taught at Barry University and the University of Miami and has conducted numerous workshops and presentations. Maria was the clinical supervisor of a renowned addiction treatment center in Miami and was previously in charge of the family program. She created a website especially for those struggling with this issue. You can visit this website at substanceabuseanswers.com or MariaAAvila.com.
Maria A. Avila, LMFT, MCAP