Help clients understand and break the txic [wounds + unawareness] cycle!

Clinical Termination Options

Final Intervention Opportunities

By Peter K. Gerlach, MSW
Member NSRC Experts Council

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The Web address of this article is http://sfhelp.org/pro/rx/terminate.htm

        Clicking links here will open a new window or an informational popup, so turn off your browser's popup blocker or accept popups from this nonprofit, ad-free site . If the windows distract you, read the article before following any links.

        This article is one of a series on effective professional counseling, coaching, and therapy with (a) low-nurturance (dysfunctional) families and with (b) typical survivors of childhood neglect and trauma. These articles for professionals are under construction.

        This series assumes you're familiar with:

        Before continuing, pause and reflect - why are you reading this article? What do you need?

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        When clients decide to stop clinical work, the termination session or process is often the final chance to make useful interventions. Some clients terminate passively by not keeping an appointment and not calling for another. Others ask the clinician's opinion about stopping, and still others decide on their own and seek closure. The last possibility is that the clinician terminates the work for various reasons.

        This article offers perspective and suggestions on the last three situations with two groups of clients: (a) those who are not recovering from psychological wounds, and (b) those who are. Premises:

  • some ways of terminating are more effective than others, and...

  • an effective  termination leaves all people concerned feeling...

    • satisfied that the work and investment were worthwhile,

    • heard and mutually respected; and if appropriate...

    • feeling open to possibly continuing the work in the future.

For perspective, compare this to how you felt terminating with any professional consultants you've used along the way...

Common Options

        This model proposes that in any solitary or social situation, each person has current surface and underlying primary needs. This suggests identifying "What do typical clients and clinicians need at termination? Consider these options...

  • The client and clinician probably need to review why they did this work together - i.e. what clinical goals were agreed on, and what resulted? One way of doing this is for the clinician to ask an open-ended question like "Recall your life when you initiated this work. What, if anything, would you say is different about your life and situation now?"

  • A mutual need is to affirm that the client's growth and healing are ongoing, not an event, and that this work was an important phase of this long-range process.

  • The clinician may need honest (vs. polite) feedback on what interventions and traits were useful to the client, and any that weren't.

  • The client may need to hear the clinician's (a) opinion on the odds of  and any limits to - further improvements for them and their family, and (b) suggestions for further work.

  • Each needs to feel clear on responsibilities related to any financial issues related to the work - e.g. insurance paperwork, treatment summaries, bills, etc.

  • The clinician may need to refer the client to another human-service program or provider for further or different work.

  • The clinician may need to summarize key suggestions made during the work, and encourage the client to remember and implement them. This summary can include specific comments on beneficial changes in the client's...

    • basic attitudes and priorities - specially improved self-respect, love, and confidence;

    • spiritual growth and faith;

    • clarifying and acting on their life purpose;

    • communication and problem-solving knowledge, skills, and effectiveness;

    • freeing any blocked grief, and/or promoting a pro-grief family;

    • managing any toxic compulsions;

    • resolving one or more stressful impasses;

    • negotiating a difficult life-transition, like adapting to a new occupation, child birth or death, retirement, divorce, disability, financial condition, or similar;  

    • reducing the effects of the [wounds + unawareness] cycle on their descendents;

    • successfully resolving one or more primary relationship and/or family problems; and...

    • any other key situational topics.

    Option - provide the client with a written summary of any of these, and include it in case documentation.

  • The client may need to thank the clinician for his or her skill, efforts, and encouragements; and/or  the clinician may need to appreciate things about the client - e.g. consistently being on time, remembering appointments and/or giving appropriate notice of cancellations, openness to trying  new things, and risking honest disclosures during the process.

  • Both need some sense of temporary or permanent closure to their relationship and common effort. If significant bonding occurred, each person may need to grieve;

  • either may need to "check in" periodically with the other by phone or email for various reasons;

  • The clinician may need to review the case progress and process with a supervisor, consultant, co-worker, or peer-review group, and identify key learnings; and...

  • Any other situational needs unique to this client and situation.

Can you think of other things a typical clinician and any clients need when they terminate?

Clients not in Wound-recovery

        My clinical experience since 1981 with over 1,000 typical Midwestern Anglo individuals, couples, and families is that a high percentage of typical divorcing-family and stepfamily clients are managed by one or more Grown Wounded Children (GWCs) in denial of their (a) childhood neglect and trauma, and (b) their personality subselves and false-self dominance, and (c) how these relate to their presenting (surface) problems.

        Whether the clinician has explicitly described these during the work or not, most client adults are not ready to commit to wound recovery during the work unless they have hit true bottom.  With GWC clients in denial, I propose that clinicians are ethically responsible to emphasize the value of eventual recovery from psychological wounds as part of any termination process - specially if living and/or unborn kids are involved. An ecological way of doing this is to give the client one or more handouts describing subselves, wounds, and personal recovery. You're welcome to copy and pass on any of the materials in this non-profit site, with this condition. 

        If you've been working with several family members - including kids - it's helpful to have everyone who participated in the work (and perhaps family members who haven't) attend a termination session. Ideally, this will include both divorcing parents and any new partners of theirs. This gives each person a chance to express their feelings about the work and any effects, hear and react to others' comments, and affirm themselves and each other for any progress. In typical low-nurturance families a focused, well-moderated family meeting like this is rare.

        If the client is a divorcing family, this is the clinician's final chance to fill the needs above and...

  • frame divorce as a family learning opportunity vs. a "failure,"

  • define a successful divorce, and encourage parents to strive for that together in the coming years; years;

  • summarize key divorce-recovery needs for adults and kids (option - provide a written checklist or summary like this).

  • recap the concept and value of a healthy family grieving policy, and...

  • recommend any appropriate support resources.

        If the client is a courting couple with one or more prior kids - in addition to filling the needs above, use termination to recap and emphasize...

  • the [wounds + unawareness] cycle that may threaten the clients and their descendents,

  • five related hazards that stress most stepfamily re/marriages, and...

  • the long-term benefits of each partner making three informed commitment choices by patiently working together on these Lessons over many months. Option - show the couple a copy of the related guidebook Stepfamily Courtship (Xlibris.com, 2002)

Option - document these suggestions and resources in a handout.

Clients in Wound-recovery

        You may have been working with (a) a divorcing-family or stepfamily in which one or more adults are committed to personal wound-recovery, or (b) with a recovering individual. Effective termination with each of these client-types differs in several respects from ending with non-recovering wounded clients.

Terminating with Recovering Families

        The key difference about these clients is that one or more of the family members has committed to reduce their psychological wounds and harmonize their personality subselves under the expert guidance of their resident true Self. Other family members may be indifferent, skeptical, curious, anxious, or supportive.

        In addition to appropriate topics above, a termination session may be the last time the client family members will hear...

  • a summary of the [wounds + unawareness] cycle and its effects, and...

  • an informed, professional opinion on...

    •  if and how the cycle is stressing their family via psychological wounds, and threatening their descendents; and...

    • the client-family's nurturance level, and what that means for marriages, kids, and future generations; and...

  • the concrete personal and family benefits, over time, of true (vs. pseudo) wound-recovery; and...

  • an invitation to help other people learn of these vital concepts and help to break the cycle in local or larger society.

Options - (a) document these suggestions and resources in one or more handouts, if you haven't done so before, and/or (b) invite the person/s in recovery to continue individually with you or another qualified clinician.

Terminating with Recovering Persons  

        Many variables determine how long a recovering adult works with a clinician and when and why the client chooses to end. Some clients will be in pseudo (trial) recovery where some subselves seek healing, and others oppose it. Some will be in preliminary (addiction) recovery, and others in full (wound) recovery. Though each case is unique, some general termination suggestions apply:

  • Summarize how and why subselves are created and cause psychological wounds, and what that usually means;

  • Summarize the key steps in, requisites for, and life-long benefits of true personal wound recovery;

  • Hilight specific inner-family changes the client has made so far, and affirm any related benefits s/he has reported;

  • If appropriate, (a) frame pseudo recovery as valuable learning experiences, not "failures;" and (b) note the value of including spiritual exploration and growth as an essential aspect of effective wound recovery and wholistic health;

  • Summarize useful recovery steps and techniques the client can adopt or continue (e.g. inner-family dialogs, council meetings, and journaling);

  • Recap the types of recovery support that are available locally and on the Web, and the value of experiencing a range of them, over time;

  • Encourage the client to keep building the reflexes of (a) sensing who is leading their subselves in any situation - their true Self (capital "S") or other reactive, well-meaning, distrustful subselves, and (b) brainstorming effective options when a false self disables (blends with) the Self;

  • Emphasize the long-term recovery and social benefits of practicing effective communication skills;  and include...

  • Any other termination options relevant to the particular client and work.

Option - document these suggestions and resources in one or more handouts, if you haven't done so before,

When the Clinician Needs to Terminate...

        Circumstances causing a clinician to end work with a client can include:

  • personal reasons, like illness or disability, retirement, moving away, new family responsibilities, clinical overload, or taking a new job; or...

  • the clinician feels s/he has nothing further to offer the client; or...

  • the clinician feels disrespected or ignored by the client too often; or...

  • the client often comes to sessions in an altered state from drugs, despite requests not to; or...

  • the clinician doesn't like or respect the client, and/or can't condone and enable the client's unethical or illegal behaviors.

        In all cases, the clinician needs to (a) have her or his Self make the decision, and to (b) honor her or his own integrity and ethical responsibility by being clear and honest with the client about the reason/s for termination. The clinician can choose whether or not to define conditions for resuming the work in the future - e.g. "If you choose to attend 12-step meetings for six months and are drug free for that time, call me." The client probably needs to own and express feeling abandoned, frustrated, disappointed, and perhaps resentful. If wounded clients repress, intellectualize, or minimize these reactions, the clinician can facilitate their feeling and expressing these appropriately.

        In some cases, this is a final chance to respectfully propose that any traits or behaviors of the client contributing to the termination (e.g. chronic interruptions, lateness, drug usage, defocusing, over-explaining, arguing, etc.) are evidence of probable false-self dominance. It may or may not be appropriate to make a referral to another clinician or program.

        If the clinician is ambivalent about terminating, consulting with a supervisor, case manager, or colleague can provide useful perspective.

Recap

        This article offers perspective and options for effective termination of clinical service to divorcing-family and stepfamily clients, and persons committed to false-self wound-recovery. Basic premises: (a) a  termination session offers the last chance for useful interventions, and (b) the clinician and each participating client has specific needs to fill for termination to be mutually effective. The article proposes a set of common clinician and client termination-needs, and suggests special needs for (a) clients who deny psychological wounds and their effects, and (b) those who admit them and are committed to some form of personal healing.  

        Pause and reflect - why did you read this article? If you got what you needed, what do you need to do next? If not, what do you need?

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Created 09-29-15