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.
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