Blocks to Termination
Blocks to Termination
Counseling can be such an intimate and valued personal experience for both the counselor and client that the thought of ending the relationship may be most unappealing. From the counselor’s perspective, helping a client who grows, overcomes obstacles, and accomplishes goals is an immensely rewarding experience. In addition, counselor–client relationships often assume a personal as well as a professional dimension. Counselors begin to like clients and appreciate their humanity and idiosyncratic qualities. Thus, there can be some personal investment in maintaining the relationship. Clients often experience counselors in ways they wish could have happened in their family relationships. In this context, termination often means saying goodbye to a very valued person.
However, Quintana (1993) challenges the termination-as-crisis concept, suggesting that it lacks empirical support. In other words, counselors who assume that termination will be a highly charged and difficult transition for their clients may be overestimating their role in their clients’ lives and might even be guilty of creating a crisis where one would not otherwise occur. Quintana instead advocates an alternative definition of termination-as-development that views termination as a transformation that encourages growth and development in the client “that is applicable across gender, ethnicity, and race” (p. 429).
Client Resistance to Termination
Much has been written in both the theoretical and experimental literature about the termination experience and its effect on clients. The theoretical notions of its impact appear to be in conflict with the empirical evidence. For example, according to psychoanalytic thinking, “the most desirable state of affairs is for the patient to slowly wean himself away, for him to eventually accept his limitations and be willing to relinquish the desires which cannot be realized” (Lorand, 1982, p. 225). In his review of the theoretical views of termination, Quintana (1993, p. 427) describes how “clients are expected to react to termination with a plethora of neurotic affective, cognitive, interpersonal, and defensive reactions related to grief reactions [and] clients’ reactions are . . . intense enough to overwhelm positive gains made earlier in therapy.” However, Quintana describes the research on termination’s effect on client reactions:
The frequency and intensity of clients’ reactions to termination do not reflect inherent crisis over loss. Results [of research by Marx & Gelso, 1987; Quintana & Holahan, 1992] suggest that only a small minority of clients experience a psychological crisis over the end of therapy, and the crisis seems to focus on the disappointing level of client outcome rather than specifically on loss. (1993, p. 427)
Whatever may be the more likely reaction, it is appropriate for the counselor to evaluate the client’s degree of concern with the prospect of termination and respond therapeutically.
Counselor Resistance to Termination
It may be surprising that counselors often resist terminating with clients even though the client has reached a logical hiatus in the counseling process. Yet most counselor resistance is understandable. The counselor forms real human attachments to clients. In fact, it might be argued that counselor investment in the person of the client is a prerequisite to successful counseling. When this is part of the relationship, letting go has an emotional impact. Goodyear (1981) identifies conditions that can lead to the counselor’s experience of loss when termination occurs. In addition to those having to do with a positive working relationship, Goodyear also includes instances when the counselor may feel guilty or anxious that counseling was not more effective, instances when termination may signify the end of a unique learning experience for the counselor, and instances when termination may trigger unresolved farewells in the counselor’s personal life.
The counselor trainee may have a supervisor who can point to any apparent resistance, but what does the professional counselor do? Most experienced counselors know, at some level of consciousness, when the relationship with a client has grown quite important. This is a cue to the counselor that peer consultation or supervision would be both appropriate and desirable. The more human counselors tend to be, the more susceptible they are to personal intrusions in their professional practice. Having a colleague who can provide a level of objectivity through discussion and peer supervision is a valuable asset.
Case Illustration of Termination
The Case of Alex
Alex is a 34-year-old stockbroker who has been unemployed for 14 months as a result of his firm’s downsizing. He has tried to see this dilemma as an opportunity to move his career in new directions; however, he has decided to seek counseling at this time for two reasons. Although he had extensive outplacement counseling, he really doesn’t know in what direction he would like to go with a new career and, in fact, has growing uncertainties about his potential. Added to this uncertainty, during the past few months Alex has grown increasingly bitter about being let go and how the outplacement was handled by his supervisor, whom he considered a close friend. The case was seen in a private psychotherapy group practice.
First Session
The first session began with the counselor orienting Alex to the conditions he could expect, including confidentiality, the necessity for the sessions to be recorded, and the fact that the counselor belonged to a consortium of mental health professionals who met periodically to provide and receive peer supervision. In addition, the counselor indicated that he practiced “short-term” psychotherapy, which meant that clients contract for 10 sessions. If, at the end of that time, the client had any remaining issues, the contract could be extended for an additional brief period of counseling.
Counselor:
Alex, one of the things we will be doing at each session is a review of your progress and how it is reflecting your goals. Because you have already had extensive career assessment, I would like your permission to request those results and they will become part of our weekly focus. So how would you like to begin this ten-week exploration?
Alex:
If you don’t mind my saying so, I don’t see how you can solve all my problems in ten weeks.
Counselor:
You may be right, but of course, it won’t be me doing it. It will be the two of us doing it.
Alex:
Still, I don’t see how it can be done. I’ve been sweating this out for more than a year already.
Counselor:
Yes, and hopefully we can find some new and more efficient ways to look at your issues. But the first thing we need to address is which concern we should consider first: your future or your anger.
Alex:
Well, it’s my future that brings me here.
Counselor:
Yes, but do you think your anger and your loss of confidence are having any effect on your ability to make sound decisions about your future?
Fourth Session
As the fourth session was about to end, the topic of termination was initiated by Alex.
Alex:
This was a really tiring session today.
Counselor:
Yes, we covered a lot of ground. I do think you are making some good progress.
Alex:
Yeah, I do feel better about things, but that worries me, too.
Counselor:
What is it about a good feeling that makes you worry?
Alex:
Oh, it’s not the good feeling. I’m just aware that things have been moving awfully fast and we only have six more sessions. I’m not sure I trust this idea of only ten sessions and boom, you’re fixed.
Counselor:
I don’t think I said, “Boom, you’re fixed,” when we started. And we can renegotiate for a couple more sessions when the time comes. But let’s not jump to conclusions too quickly. Most of the time, when clients are feeling good about their progress for several weeks, the feeling can be trusted. I’m glad you raised the issue, because we are almost halfway through our ten-week contract. We don’t have to do anything about that except to be aware that we will be terminating one of these days.
The counselor took this opportunity to extend Alex’s awareness of the termination process. In effect, this discussion became the starting point for the termination process. The seed of awareness was planted, and the client took that awareness with him at the end of the session. Three sessions later, the awareness had grown and matured.
Seventh Session
Nearing the end of this session, which had been a difficult but significant session, the counselor introduced the termination topic again with Alex.
Counselor:
Well, you’ve worked hard today, Alex. How are you feeling about your progress?
Alex:
To tell you the truth, I’m exhausted. But I feel pretty good about how things are going. I’m glad I’ve gotten over that anger I was feeling toward Jim. That was really getting in the way.
Counselor:
About a month ago, you mentioned that one of your fears was feeling too optimistic about your improvement. Do you still feel that way?
Alex:
When was that?
Counselor:
Oh, I was reviewing the recording of our fourth session and heard you say that you didn’t trust that you could get your situation under control in only ten sessions.
Alex:
Well, I still wonder about that. But I do feel like I’m a lot clearer on things now than I was then. I don’t feel as shaky.
Counselor:
What about terminating soon. Do you feel shaky about that?
Alex:
[Laughing] Well, you still owe me three sessions. I’m not ready to terminate today. But, unless the bottom falls out, I don’t think I will need another 10 sessions.
Counselor:
[Chuckling] No, if you had another ten sessions, you’d probably begin to lose the ground you have gained.
Alex:
What do you mean? Do people lose ground if they stay in counseling too long?
Counselor:
I think so. There’s a time to leave your parents; a time to leave your training; a time to leave a job; and, in our case, a time to leave counseling. If we don’t make that break when it’s time, then you could grow dependent on the process and that would be self-defeating.
In this dialog, the counselor is able to present the therapeutic effects of appropriate termination so that it is seen as a normal, developmental process, like growing up. That does not remove all of the client’s fears, but it does place termination in a context that is anything but catastrophic. Quintana (1993) suggests that counselors can greatly facilitate the termination process by framing it as outgrowing rather than losing a valued relationship. At the same time, Quintana emphasizes that counselors “should be careful not to imply that clients have outgrown their needs for therapy definitely . . . [because] future therapy should remain an option for clients as a way to support or catalyze their continued development” (p. 430).
Ninth Session
The counselor begins this session by introducing the topic of termination.
Counselor:
Well, Alex, this is our next-to-last session. How shall we use it?
Alex:
We could call it a tie and go into extra innings.
Counselor:
You’re right, we could say that your weaknesses are still equal to your strengths.
Alex:
Well, I don’t believe that and you don’t either, I don’t think.
Counselor:
No, I don’t think that at all. In fact, I think your strengths are real and many of your weaknesses were imagined.
Alex:
Yeah, I’m feeling that. But it’s good to hear you say it, too. Maybe that’s how I’d like to spend today.
Counselor:
What do you mean? Talking about your strengths?
Alex:
Yeah. I think I know what I want to do with my life. The graduate school idea seems right and I did have an interview at the university this week.
The counselor intentionally introduced termination at the beginning of the ninth session to allow Alex time to process his feelings about the imminent ending of the relationship. Alex might have dwelt on the insecurity of ending a meaningful relationship, he could have negotiated an extension at this time, or he could try to cement the gains he has realized through discussion and review. In this case, Alex chose the last alternative.
Tenth and Final Session
Alex began this session with the acknowledgment that it was the final session.
Alex:
Well, this is it.
Counselor:
Meaning?
Alex:
This is the last time I’ll be seeing you, I think.
Counselor:
I think so, too.
Alex:
It’s been good. When we started, I really wasn’t so sure this was going to work. But things are starting to pull together. Oh, by the way, Jim and I went out for a drink last Friday night. It was good to see him again. And I’m filling out application forms for an MBA [masters of business administration] program.
Counselor:
That sounds good. Did Jim call you, or did you call him?
Alex:
I called him. And it’s neat. I think he’s going to be able to help me with some contacts.
[Later in the session]
Counselor:
Before we finish today, I want you to know that I would like to hear from you in six months or so. Just a quick call telling me how things have been going would be fine. Would you do that?
Alex:
Sure. What if I need a booster shot between now and then?
Counselor:
If that happens, you can call and set up an appointment.
In this final session, the counselor provided a bridge to aid the transition by asking Alex to get back in touch in 6 months with an informal progress report. This is as much for Alex’s benefit as it is for the counselor, because it says, “I’m not just dropping you from my appointment book and my consciousness. You will remain my client in absentia.” In addition, the counselor has provided a termination structure that allows Alex to make contact for future needs, should they arise. This would seem to be assumed, but clients often do not take this privilege for granted or are reluctant about such a move. In fact, an invitation to clients to return seems to result in greater levels of client satisfaction and lower levels of distress.
Evaluation of Counseling
Thus far in this chapter, we have discussed ways to assist clients at the end of your counseling relationship with them. There is another important opportunity, we might even say duty, at the end of counseling, and that is to do what you can to evaluate your counseling so you have the data you need to know that you have offered the best counseling possible. Unfortunately, evaluation of counseling has not received the same attention in professional research as other topics. Still, there are some methods worth your consideration.
Evidence-Based Practice
Although not evaluation per se, one way to have increased confidence in your work is to remain a student of the professional literature. The term evidence based has become quite popular, and it means only that some treatments have been studied for their success with certain clinical populations. Although there are critics of some of the emphasis on evidence-based practice (EBP) in certain settings, counselors should still be aware of the research in their field, especially if they work with one particular clinical population. In short, one way to evaluate your work is to evaluate your professional knowledge on an ongoing basis. Training programs give the counseling trainee adequate generic knowledge to begin practice; this knowledge is not adequate, however, for the length of a career. EBP is one place to begin to keep yourself current with which intervention combinations have been found to be successful for particular diagnoses or for particular populations.
Although the EBP literature is a good place to begin, it is not sufficient. Membership in your professional organization(s) connects you to an ongoing literature for your practice. Counseling is a rich profession with a broad array of resources for practice. Counselors who have a desire to excel need not go it alone.
Exit Interviews
An exit interview is a relatively easy way to gain some feedback about the counseling we have provided our clients. As part of a last session, counselors simply devote a bit of time discussing process goals rather than outcome goals. Statements like, “We’ve been working together over the last few months, and our sessions weren’t all alike. Can you recall anything I did that was particularly helpful?” Perhaps even better is for the counselor to list interventions and ask for feedback. “During our work together, I gave you some homework to do regarding your thoughts and feelings between sessions. I also did that empty-chair exercise and followed that with work regarding the thoughts you were having that didn’t add up once we took a look at them. As you think back, is there anything that you found particularly helpful as far as reaching your goals?”
Of course, especially if counseling has been relatively successful, the danger is that clients will want to please their counselor at the exit interview and will say that everything was wonderful; therefore, the counselor must frame the request as doing the counselor a favor. “Although I hope that my approach with my clients is productive overall, I’m under no delusion that everything I do is equally helpful. I know that you think our work together was good. I wonder if you could identify what you think was the least helpful thing we did and tell me a little about why that was the case. I would be grateful for that input.
”There are two other ways to conduct exit interviews. One is to arrange for another person to conduct it. Again, it is important for it to be framed as a desire for improved service, and not to evaluate the counselor as a professional Finally, a written form could be given to the client with a request for feedback. In order for this to be helpful, the counselor must customize the form for each client so that questions asked relate to particular interventions used with the client. Forms that are too generic do not produce the kind of feedback that is helpful for a counselor’s clinical development.
Client Satisfaction Surveys
A rather common feedback tool used by counseling centers is the client satisfaction survey. Although this is unlikely to give specific feedback about interventions, it does provide information about overall tenor of counseling and its helpfulness to the client. Typically, such forms are a list of statements and the clients check from “Strongly agree” to “Strongly disagree.” The items most often included are the general atmosphere of the counseling office, the interest in the client communicated by the counselor, respect for the client, confidence in the counselor, helpfulness of counseling, and whether the client would refer others to the counseling center.
For those who do not presently use client satisfaction surveys, models used by a variety of counseling centers are easy to access online.
Referral Input
When appropriate and possible, feedback from persons who provided the original referral for counseling can be valuable. Although school counselors often receive informal feedback for their efforts, more formal feedback can be invaluable when counseling positions need to be defended. Forms that stipulate the reasons for a referral and a subsequent form to assess the helpfulness of counseling are included as Appendix B-9 and B-10. These forms were created for use with school counseling interns but have utility for any school counseling professional. We argue that similar forms could be used for any “in-house” or “within-system” referrals.
