Thursday, July 21, 2016

Evaluation and Termination

Chapter Twelve
Evaluation and Termination
            Every session could be the last session, so every session encompasses some elements of evaluation and termination.  Right from the first session I remind clients that based on my professional philosophy and practice model therapy has a beginning, middle, and an end.  The evaluation process is not just part of every session but the essential intervention of therapy itself.  What is working?  What is not working?  What have you tried?  What would you like to try? How can I help?  In addition to following a specific treatment plan that includes exploring trauma, practicing coping skills, and increasing emotional management, I often start each session with, “What would you like to work on today?” or “What would make this session worthwhile?”  The idea that we are always measuring progress in a time-limited process brings energy, motivation, and urgency to therapy, just as assignments, tests, grades, and a semester end bring focus to a class or course.
            Each of the following questions has a purpose as an intervention in and of itself.  What have we accomplished?  In the daily struggle of life and the routine of weekly sessions, clients sometimes do not see how much has changed since they started.  I return to the initial assessment paperwork, the client’s description of their concerns, and the scores they gave specific symptoms.  It is often surprising and gratifying for the client to hear, “Your child’s tantrums have decreased from daily to rare.  How did that happen?”  What is left to do?  Having resolved their most critical and persistent concerns, clients will often turn to higher functioning desires or, having experienced success in smaller ways are now ready to tackle more serious problems.  How might that be accomplished?  If clients have learned new skills, like communication, they may feel more competent to try resolving issues on their own or in another format, like group therapy.  If the client has seen little or no improvement in their situation, the answer may be to change the treatment plan, change the therapist, or try again at a later date.
            The process of therapy is often more important than the content.  The understanding, knowledge, and skills clients learn in session are applicable to many life challenges.  The purpose of therapy is at least two fold, to address current concerns and teach skills to apply to future issues.  The skills I try to teach and model are empathic and reflective listening, keeping boundaries and setting limits, and problem solving that respects individuals and relationships.  What has worked?  The question is meant to prompt the client to identify the specific skills and interventions, to consolidate the gains from the therapeutic process.  What has not worked?  This question is just as important as clients assemble a toolbox of life skills.  The two questions posed together illustrate the very practice of problem-solving; identifying issues, listing possibilities, evaluating options, making choices, trying solutions, measuring progress.
            Evaluating the therapist is not just about rating their work or collecting success stories.  What worked with the therapist?  This question invites the client to give the therapist feedback.  Giving feedback is another communication skill clients may use in the future.  What did not work with the therapist?  The client gets the chance to provide perhaps negative feedback in a positive way, yet another skill applicable to life in general.  More specifically, these questions put the client in the empowering position of being the customer of a service.  They ask the client to consider the nature of that service and what works for them.  In a parallel process, the client learns how to solve their problems and how to shop for services to help them in the future.  The questions allow the therapist to adjust the treatment plan and interventions if the client keeps them engaged or to make a referral if the client decides to hire another service provider.
            Having participated in the therapeutic process the client may have uneven progress in the future and experience setbacks both simple and serious.  What are anticipated challenges?  This question helps clients expect, normalize, and prepare for such challenges.  In the case of mental illness, substance abuse, and trauma, there are stressors, triggers, and relapses.  For couples and parents, families enter different life cycles and children grow into subsequent developmental stages.  Issues like adoption and learning disabilities are life-long.  When to return or seek help?  Clients often seek therapy when they are in crisis or when everything else they have tried to solve their problems has not seemed to work.  This question helps clients specify what circumstances would warrant returning to therapy to avoid a crisis.  A person with mental illness may want to return if they have had a major loss like a death in the family.  A person who relapses on drugs or alcohol may need a quick intervention.  A couple may return before they decide to adopt or have another child.  An adoption family may want to return as the child becomes an adolescent.  I specifically encourage parents and children to return when things are going well to celebrate success normalizing therapy as a support to well-functioning families.
            Because the client-therapist relationship continues in perpetuity after services have ended, it is important to restate the legal and ethical requirements at least during the last session.  I nearly repeat everything I said during the first session with parents and the first session with children.  “I will always have the responsibility to protect your confidentiality because we will always have only this professional relationship.  That means I will still not acknowledge you in public or do other kinds of business with you.  For example, I will not be attending your family weddings and you will not be attending my funeral.”  My responsibility for protecting the client’s privilege and privacy does not end with the termination of services.  I keep files and records for 10 years after the end of services or until the child turns 28 years old.  If I have not heard from the client for 30 days I send a discharge letter offering further services or a referral to another therapist informing them that I will be closing their file to officially end my responsibility for their care.
            Because my practice philosophy is based on the social work value and ethical principle of the importance of human relationships, I try to spend some time in each session and particularly in the closing session to honor my relationship with the client.  The client, whether individual, couple, or family, has taken a chance to share very personal information, to open themselves to examination, and to try news ways of interacting.  They have made themselves vulnerable in an intimate relationship that is by its nature unequal, the therapist has more power and does not reveal themselves in the same way that clients do.  It makes the therapist more responsible.  That is why it requires a license and continuing education, consultation, supervision, and audit, and is subject to complaint, investigation, administrative sanction, and legal action.  At the very least I express my appreciation of the relationship acknowledging what we have done together.  Further, especially with children and families, marking endings is an important therapeutic intervention.  For clients, especially children, who have experienced abrupt changes as a result of their trauma; removal from biological family, moves from one foster home to another, little or no contact with important family members, closure is necessary.  For this, ritual is important.  This can include recalling shared memories; the fun, human, personal, silly moments, blowing bubbles, drawing pictures, playing games in therapy.  Returning routinely to a book, game, or toy in session may seem repetitive as if we are making no progress and should be focusing on something new.  However, these rituals are as important to the therapeutic process as they are to family life.  Of course, I encourage clients and families to return to therapy if crises, changes, or new challenges arise, but I also encourage clients, especially traumatized and adoptive clients, to return when things are going well.  This is also a therapeutic intervention to consolidate and celebrate gains and to reset the role of the therapist from rescue to support.  Especially with children, even adolescents and adults, I like to end the final “see you later” session by reading Dr. Seuss’s Oh The Places You Will Go! (1990), which has a realistic message predicting a positive future.  Reading it models and reinforces the nurturing and positive relationship.
Sticking Points
Particularly with families, and especially adopted families, when healing seems to stall four issues are most likely to be at the route.  Adult trauma: parents have not dealt with their own childhood experiences and they are being triggered in ways that keep them from being warm, nurturing, and consistent with their children.  This often requires putting the family work aside to address the parents’ issues either in consultation or with outside therapy.  Adult relationships: parents have deep unaddressed difficulties in their relationship, differences in their ideas about parenting, and inability or unwillingness to communicate about them.  This requires stopping conjoint parent-child work to avoid further damage to focus on these issues.  Adoption attitudes: due to unresolved infertility issues that make adoption seem shameful, parents are unable to appreciate, communicate, and facilitate relationships with biological family to benefit their children and family.  Theoretical differences: the client, despite adequate psychoeducation, cannot accept and does not agree with a relationship-based non-behavioral orientation.


No comments: