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Handle the termination of treatment with care

October 27, 2014
by Maria A. Avila
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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.