Handle the termination of treatment with care

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 to 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 colleagues whom 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, with the conversation involving 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 inform the termination issues that arise with clients.

The work of emotional and behavioral transformation can be quite intimate between a clinician and a client. In working with individuals at an inpatient or intensive outpatient level, the process of termination of a therapeutic relationship 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 will reach a stage where they feel ready to depart from the work they started. How this procedure is handled can be of utmost importance in the therapeutic process.

Dealing with termination of a therapeutic relationship will be influenced by 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 co-workers demonstrated my own discomfort with the sadness that takes place in this process of loss.

When insurance companies dictate the length of the relationships we are to have with clients, it forces the issue much faster. We have a better idea of how much time we have, and we 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 been built. 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, if 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 that if the client prematurely leaves right before the deadline or begins to act out, he/she never was that invested to begin with? How might using humor deflect from the feelings?

All of these questions are aimed at addressing our own possible misconceptions about the termination process. They also are intertwined with our own feelings about saying goodbye and about endings in general.

Optimal timing

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 the client. Pretending that it will be business as usual oversimplifies what relationships are about. Think of the scenario when a client brings up important issues at the end of a session. Does he/she really want to deal with them?

In a time when relationships are challenged, clinicians must try to model effective interactions. Encouraging discussion of difficult and negative feelings, allowing this discussion to flow, and being able to validate these feelings are a cornerstone of 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, from having 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 any other feelings or thoughts that have been expressed previously about this issue.

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 to 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 clients sufficient time to know you will be away. Even if the absence is temporary, we underestimate the effects it can have on some clients.

Understanding feelings

The termination process can reignite feelings similar to those for clients who are grieving over a loss or have been abandoned or rejected. The defenses these clients may have used to deal with the trauma could manifest as detachment, disengagement and other behaviors that appear indifferent. One can mistake these for an absence of feeling, as opposed to a survival technique.

The clinician might think that lack of expression of feelings results from a client's lack of interest or from distance in the relationship. If clinicians are not aware of their own discomfort with endings, they can easily align with the client's distance, reasoning that it was a superficial relationship from the beginning.

This topic should be brought up in groups as an important issue to be addressed. It allows others to think about what they are feeling in regard to this at different times. Confront the indifference and ask directly what the person thinks of leaving the relationship.

Should you force the discussion?

The best moments in therapy are usually unplanned. Clinicians need to respect clients' pace. Feelings cannot be rushed, no matter how much insurance companies try to speed 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 promote the discussion, not force it.

Create an environment that allows 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, let it go.

Leaving prematurely or acting out

A common pattern seen in clients toward the end of their treatment involves their appearing to deteriorate. We may conclude, much to our disappointment, that they had not really learned much at all. We may react with annoyance, frustration and anger, not seeing it as a sign of sadness due to the impending separation. Viewing it as the latter can allow the clinician to engage in a discussion of loss and sadness, which could redirect the patient's energy and coping.

Family therapists may say that prescribing the symptom is indicated here. This also can be described as reverse psychology. It means that the clinician makes a suggestion opposite to what is expected from the person. The clinician may say to the client that these behaviors are natural in the process of termination, and may predict that the client will begin to engage in them. This technique usually stops the acting-out behavior from occurring.

Using humor to deflect

All too often, the act of making light of intense feelings is seen in therapy as a defense against pain. Clients may lack insight on what they are doing, and may distract from the therapeutic process by making others laugh. In a group setting this behavior may become contagious.

Increase awareness of this behavior as a way to deflect. Help clients understand their feelings more honestly, and help them to allow themselves to feel these feelings.

Conclusion

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 the others the same time either to be silent or to react as time went on. I can only be thankful for the opportunity that assisted me in this termination. Going forward, I will be more sensitive to recognizing clients' vulnerability in their own termination process.

Maria A. Avila, LMFT, CAP, has a private practice in Miami and also serves as a Family Therapist at Lucida Treatment Center in Lantana, Fla. She was Supervisor of the Family Program and Clinical Supervisor for South Miami Hospital's Addiction Treatment and Recovery Center for more than 15 years. She also is Adjunct Professor at the University of Miami, where she teaches courses in substance abuse to graduate students.