Please see attached.
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).
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.
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.
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.
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.
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.
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.
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.
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.
Although satisfaction surveys are too broad to offer help with increasing intervention expertise, they are not without value. For example, the surveys can be used to determine if persons who are more culturally different from the counselor respond as favorably as those who are more similar to them. A counselor can also use the surveys to see if using a distinct intervention changes clients’ overall satisfaction with his or her work. In other words, even the most generic feedback is more useful than no feedback, and sometimes it can identify patterns that are useful for counselor development.
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.
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The Termination Stage
Termination is not so much an ending as it is a transition from one set of
conditions to another. Pate (1982) caught the spirit of this perspective,
saying,
When counseling is viewed as a process in which an essentially competent
person is helped by another to solve problems of living, solving the problem leads
to termination, not as a trauma, but as another step forward in client growth. (p.
188)
At some level, both the counselor and client know from the beginning of
the counseling relationship that it will eventually end. However, the
knowledge that counseling ultimately will end provides no guidelines for
making the decision. This raises the question, “What are the determinants
for when counseling should terminate?” The answer to this question is
based on both theoretical orientations and counselor–client interactions.
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Determinants of Termination
Counselors begin counseling with some idea of appropriate parameters for
termination. Counselors with a phenomenological theoretical orientation
and in private practice may view the process as highly tailored to each
client—that is, especially if insurance is not limiting the length of
counseling unduly, counseling goals can be short term or longer term,
depending on the readiness of the client to address major psychological
barriers to their well-being.
Other counselors are constrained by third-party payors or workplace
expectations that counseling will be relatively short in its duration. At the
very least, counselors in these situations must be prepared to defend
continuing with a particular client based on progress toward specified
goals.
Finally, some counselors work from a brief therapy orientation by choice
and are focused on symptom removal as the primary function of their
counseling. They tend to believe that short-term counseling, even if clients
return to counseling on occasion, is more realistic and allows clients more
immediate opportunity to apply new skills in their naturalistic world.
In each of these examples, the question of when termination should occur
is answered by the counselor’s theoretical stance or workplace constraints.
There are, however, other variables that play a role in determining
termination, including client input and the counselor’s judgment.
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Determinants of Termination: Client and
Counselor Input
In practical terms, counseling ends when the client, the counselor, or the
process indicates that termination is appropriate. Teyber and McClure
(2011) offer what is probably the most pragmatic answer to the question
of when counseling should end:
Therapists know that clients are ready to terminate when they have converging
reports of client change from three different sources: (1) when clients report that
they consistently feel better, can respond in more adaptive ways to old conflict
situations, and find themselves capable of new responses that were not available
to them before; (2) when clients can consi stently respond to the therapist in new,
more direct, egalitarian, and reality-based ways that do not enact their old
interpersonal coping styles or maladaptive relational patterns; and (3) when
clients’ significant others give them feedback that they are different or make
comments such as, “You never used to do that before.” (p. 441)
Such a convergence is not only pragmatic, but is also optimal. We might
argue that termination is not usually quite so clear-cut.
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When Clients Initiate Temination
Clients may elect to terminate for a number of reasons. They may believe
that their goals have been accomplished. They may believe that the
relationship (or the counselor) is not being helpful, or may even be harmful.
They may lack the financial means to continue, or the third-party coverage
for counseling has ended. They may move to a new community or, if they
are students, finish the school year. Whatever the client’s reason for
terminating, it should be emphasized that the counselor’s legal and ethical
responsibilities do not end with the client’s decision. Ethical standards are
quite clear on this, including the requirement that pre-termination
counseling is offered when other services are recommended following
counseling (American Counseling Association [ACA], 2014, Code of
Ethics, Section A.11).
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When the Counselor Terminates
Often, the counselor is the first person to introduce the notion that
counseling is approaching termination. This decision may be based on the
client’s progress toward identified counseling goals, or the counselor may
determine that his or her expertise does not match the client’s needs.
When counseling has been predicated on a behavioral or other form of
contract, progress toward the goals or conditions of the contract present a
clear picture of when counseling should end. Although clients may be in the
best position to experience counseling-based change, they are not always
in the objective position necessary to recognize change. Thus, the
counselor may need to say to the client, “Do you realize that you have
accomplished everything you set out to accomplish?” Ordinarily, the
counselor can see this event approaching several sessions before it
occurs. It is appropriate to introduce the notion of termination at that time,
thereby allowing the client an opportunity to adjust to the transition. A fairly
simple observation, such as, “I think we probably have about three or
perhaps four more sessions and we’ll have finished our work,” is enough to
say. It provides an early warning, opens the door for discussion of progress
and goal assessment, and focuses the client’s attention on what life may
be like after counseling.
Occasionally, as a case unfolds, the counselor may become aware that the
demands of the client’s problem call for skills or qualities the counselor
does not possess. For example, after a few sessions, a client may reveal
that she is manifesting symptoms of an eating disorder. If the counselor is
unacquainted with the treatment procedures for such a condition, the client
should be referred to a professional who is recognized as competent with
this problem. Another, and often preferred, alternative to termination is for
the counselor to receive additional supervision specific to the client’s
diagnosis.
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One reason that is not acceptable for termination is when clients pose a
value dilemma for the counselor. The ACA Code of Ethics is quite clear that
in such cases, it is expected that counselors will seek additional training
and supervision so that their values do not hamper their client’s progress
toward their goals. To do otherwise is discriminatory in nature and an
ethical violation (ACA, 2014, Code of Ethics, A.11.b)
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Premature Termination
Among the more demoralizing occurrences for inexperienced and
seasoned counselors alike is premature termination. Very often,
termination occurs almost before a working alliance can be formed. This
can be a function of many different conditions. One important reason is
client readiness. Smith, Subich, and Kalodner (1995) report that clients
who are in a “precontemplation stage” or a stage with low potential for
change are far more likely to terminate after only one session than those
who initiate counseling at a contemplation stage. Other reasons for early or
premature termination may be related to matching of gender, ethnic, or
other cultural factors (Kim, Lee, Chu, & Cho, 1989; Lin, 1994; Tata & Leong,
1994).
Sometimes counselors suggest that counseling terminate before an
appropriate point has been reached. Because many clients rely heavily on
the counselor to be the best judge of such matters, clients may go along
with the counselor’s recommendation, and the relationship may end
prematurely. It has already been suggested that there are some legitimate
reasons why the counselor may decide to terminate counseling and refer
the client to another professional. Aside from these situations, three
precipitating conditions can lead the counselor to initiate inappropriate
premature termination:
1. The counselor experiences interpersonal discomfort.
2. The counselor fails to recognize and conceptualize the problem
accurately.
3. The counselor accurately conceptualizes the problem, but becomes
overwhelmed by it.
Personal discomfort may result from the counselor’s fear of intimacy or
inexperience with intense counseling relationships. With good supervision,
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this situation remedies itself through continued counseling exposure and
awareness. If the counselor’s conceptual skills are weak or if the
counselor’s approach to all problems is to minimize the situation, then the
result may be premature termination because of a failure to understand the
client. This situation obviously calls for a careful reassessment of the
counselor’s decision to become a mental health professional and whether
additional training and supervision can remedy the situation. The third
reason for premature termination is that the counselor accurately
conceptualizes the client’s problem, but becomes overwhelmed by its
complexity. When this happens, it is most likely that the counselor is not
receiving adequate supervision. The assumption of the mental health
professions is that supervision is endemic to becoming competent
(Bernard & Goodyear, 2014). Too often, supervision is ended when
counselors reach a minimal level of competence; therefore, they do not
continue to advance in their ability over time. The outcome affects all
stages of the counseling process when more challenging clients appear,
including that of termination.
The special case of the counselor-in-training or the counselor who relocates
should be acknowledged. In most cases, counselor trainees provide
services in a practicum or internship setting that conforms to university
semester or quarter schedules. When counselor trainees know that their
practicum will end at a certain date and the client will either be terminated
or referred to another counselor, ethical practice dictates that the client be
informed in the first session that a terminal date already exists. This allows
the client a choice to enter into what might be brief counseling or potential
longer-term counseling with the condition of referral, or to seek another
counselor who does not impose this terminal limitation on the counseling
relationship.
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The Termination Report
Whether counseling is brief or long term, a summary report of the process
is appropriate, desirable, and often mandated for several reasons.
Assuming that the client may have a need for future counseling, the
termination report provides an accurate summation of the client’s
responsiveness to counseling and to specific types of interventions. Should
the client request the counselor to provide information to other
professionals (e.g., social worker, psychiatrist) or the legal system, the
report provides a base for the preparation of that information.
The counseling case can usually be summarized in two or three typewritten
pages and should include the counselor’s name and address, date that
counseling began and concluded, number of sessions, presenting
problem(s), diagnosis (if one was made), types of counseling interventions
used and their effectiveness, client reaction to the counseling relationship
over time, client reaction to termination, and the counselor’s assessment of
the client’s success with counseling. The termination report is a
confidential document and should not be released without the client’s
written permission (see Appendix B , Forms B-5 and B-8).
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Termination as a Process
The termination process involves several steps. The first is a careful
assessment by the counselor and client of the progress that has been
made and the extent to which goals have been achieved. Depending on the
results of this assessment, the counselor takes one of two directions:
termination or referral. Assuming termination is the appropriate choice, the
counselor and client may proceed to discuss in depth the gains that have
been made; how those gains might be affected by future situations; making
plans for follow-up; and, finally, saying goodbye. Typically, the termination
process is characterized by cognitive discussions interspersed with
acknowledgment of emotional aspects of the relationship. When
termination is appropriate and is done properly, the process has a
constructive and positive quality.
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Assessing Progress
Quintana (1993) views the role of assessment during termination as
[a] particularly critical opportunity for clients and therapists to update or transform
their relationship to incorporate clients’ growth. For this transformation to occur,
clients need to acknowledge the steps they have taken toward more mature
functioning. Perhaps most important to clients is for therapists to acknowledge
and validate their sense of accomplishment. (p. 430)
This notion of transformation from the helping relationship to a more
autonomous and normal lifestyle is related to the maintenance after
counseling of those therapeutic gains that have been made. If the
counseling agreement was based on specific goals identified by the client,
or if some form of counseling contract was established early in the
process, then the assessment of change may take a rather formal
character. Each goal that had been set becomes a topic to discuss,
changes related to that goal are identified, perhaps environmental
consequences that grow out of those changes are enumerated, and so
forth. In this approach, there is a sense of structure as the counselor and
client review the outcomes. When counseling has involved couples or
families, the assessment becomes even more complex because each
member’s change is considered, as well as systemic changes in patterns
of interaction.
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Summarizing Progress
It may seem redundant to suggest that the assessment of progress should
be followed by some sort of summary of that progress by the counselor.
The rationale for providing a summary is twofold. First, hearing one’s
progress from another person or perspective is quite different from hearing
oneself describe progress. Most clients benefit from the counselor’s
statement, even though it is not new information. As one client described it,
“I knew I had made some gains, but it sure helps to hear you say it, too.”
Clients’ efforts to internalize the counseling relationship are also enhanced
when the counselor validates their accomplishments and encourages them
to take credit for all of the steps they have taken toward their goals.
The second reason for a summary is that the counselor can inject some
cautions if some counseling gains need to be reinforced or monitored by
the client. This is related to future client efforts to preserve or generalize
the progress that has been achieved.
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Generalizing Change
Having identified the changes that have occurred directly or indirectly
through counseling, the counselor and client should turn to how those new
behaviors, attitudes, or relationships can be generalized to the client’s
world. This step in the process calls on the client to extend beyond the
immediate gains to potential future gains. The counselor might introduce
this with such questions as, “In what other situations could you anticipate
using these social skills you have acquired?” or “If your husband should
develop some new style of troublesome behavior next month, how do you
think you might handle it?” The basic goal of the generalizing step is to test
the client’s willingness and ability to adapt learned skills or new attitudes to
situations other than those that provoked the original problem.
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Planning for Follow-Up
Follow-up in counseling refers to the nature and amount of professional
contact that occurs between the counselor and client after termination has
occurred. Some counseling approaches place greater emphasis on follow-
up than others. For example, some therapists take the position that an
individual or the family therapist is like a family physician. Over the years,
the people they serve will encounter new crises and problems and will
reenter counseling as these situations demand. This approach
acknowledges that some persons enter adulthood with complicated
histories that make functional living more challenging for them. Thus,
counseling is viewed as a service that can extend, intermittently, over a
sizable portion of the client’s lifetime. Other approaches, most notably
those that emphasize self-actualization, view counseling as a
developmental experience, the object of which is to facilitate the client’s
growth and capability of dealing with new problems more effectively. In
this context, future returns to counseling are not expected, although they are
certainly not discouraged.
Follow-up also has an ethical aspect. Even when the counselor and client
agree that sufficient progress has been made to warrant termination, it is
appropriate for the counselor to (a) make his or her future services
available and (b) explain to the client how future contact can be made. In
so doing, the counselor has established a link between the client’s present
state and future needs. This link can also be an effective intervention for
those clients who believe termination is appropriate but experience anxiety
at the prospect. For such clients, it may help if the counselor suggests a 3-
or 6-month “checkup.” Depending on the client’s response to the
suggestion, the counselor can even schedule an appointment or suggest
that the client call to make an appointment if needed. This is an effective
bridging intervention because it gives the client a sense of security and
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relationship continuation, even when counseling has terminated. The
counselor might also suggest to the client that should the future
appointment not seem necessary, a phone call to cancel the appointment
would be appreciated. Our experience has been that clients are responsible
about either keeping the appointment or canceling it. Even when they call to
cancel, the telephone contact provides some follow-up information on how
the client is coping.
If counseling outcomes include post-counseling activities that the client
has decided to pursue, the counselor might want to follow up on the
success of these goals. For example, if a client decides to make a career
change that involves future job interviewing, the counselor might ask the
client to keep him or her informed of progress, either through written or
telephone contact.
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In the Absence of Termination
We have already mentioned the frustration of premature termination. There
are other settings where termination is not a viable construct. The most
obvious of these is the school counseling context, where counseling is
interwoven into the overall developmental goals of students. School
counselors are either assigned “grades” or cohorts of students whom they
follow throughout the students’ progress in their school building. For these
counselors, promotion to the next grade level or graduation are more
normative constructs than termination.
There are exceptions, of course, and these include the student who moves
from the area, or the student who has been referred to a mental health
professional outside of school, thus terminating within-school counseling.
In such instances, we believe that the content of this chapter is relevant.
A danger for counselors when termination is not normative is to default on
the good practice of assessing progress in counseling. When a particular
problem has been tackled in counseling, the counselor should be careful to
process the progress that has been made with the client in as concrete a
manner as possible. It should never be assumed that the client understands
both progress and generalizability in a way similar to the counselor.
Furthermore, longer time frames, such as the summer break, must be
planned for in a way that includes many of the conversations that occur
during a termination process. In short, all counselors should operate with
an internal framework that identifies their work as beginning, middle, and
ending, even if the ending is not a permanent one.
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The Referral Process
Referrals are of two types: (a) a referral may be additive—that is, the
counselor may refer the client for services that he or she cannot provide but
with no intention of terminating the client; and (b) a referral may be
necessitated when the counselor is unable to continue working with a
particular client for a number of reasons.
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Additive Referrals
There are many reasons for an additive referral. The client may benefit from
career counseling or need input from a nutritionist or consult with a
psychiatrist regarding medication. Most mental health agencies, for
example, have a psychiatrist on their team who consults with clients on a
regular basis, while a primary therapist continues to offer counseling. This
example brings us to an important matter of coordination and client
releases. Although there might be exceptions, in most cases, it is important
for counselors to be able to consult with any other professional who is
offering services to their clients. Therefore, counselors should have a
release of information form readily available for clients to sign as part of
an additive referral.
If a release of information has been signed, it can be highly productive for
the counselor to contact the second professional to offer a reason for the
referral and to establish a professional relationship (if one does not already
exist). The counselor can also determine whether the second professional
is open to having the client sign releases in their practice as well, thus
creating a cycle of information sharing between professionals for the
benefit of the client. Although this kind of sharing is the normal routine
within organizations (agencies, hospital, schools), it takes more effort to
accomplish across organizations.
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Referrals That Include Termination
Client referral is a special form of termination. Referral occurs when the
counselor is unable to continue working with a particular client for a variety
of reasons. For example, as the counselor is continuing the case
assessment, it may become apparent that the client’s problems are beyond
the counselor’s capabilities, and referral to a counselor who has the
necessary expertise is warranted (ACA Code of Ethics, 2014, Section
A.11.a). Another fairly common reason to refer is that the counselor is
taking an extended leave of absence from employment, moving to another
position with another organization, or relocating beyond commuting
distance from a current place of employment. Ideally, a referral involves a
number of steps: (a) identifying the need to refer, (b) evaluating potential
referral sources, (c) coordinating the transfer, and (d) preparing the client
for the referral.
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The Need to Refer
The most frequent reason for referral is that the client needs some
specialized form of counseling. This does not mean that the client is
exhibiting serious symptoms, although that can be the case for referral. It is
more likely that the client needs a specific form of counseling that the
counselor does not offer (e.g., career counseling, gerontological
counseling, a specialist in post-traumatic stress disorder). Because clients
rarely are informed consumers of the various forms that counseling can
take, counselors should be keenly attuned to specialized needs and their
own ability to provide quality services.
Clients may also need or prefer special conditions for counseling related to
gender, ethnicity, religion, or sexual orientation, to name just a few potential
cultural factors. Such specific needs might be apparent early in counseling
or might be more evident later in the relationship. Whenever they do
emerge, it is the counselor’s responsibility to respond to them.
Clients may resist the first suggestions that a referral is appropriate. After
all, having risked themselves by sharing their concerns or vulnerabilities,
they probably prefer not to have to go through the same process with yet
another person. If the counselor provides explanations that are complete,
answer the client’s questions clearly and thoroughly, and support the
client’s ambivalence, this resistance will most likely ease.
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Evaluating Potential Sources
It is important that counselors be familiar with potential referral sources in
the community. Some communities publish a mental health services
directory that lists public agencies and practitioners, services provided,
fees, and how referral can be accomplished. Another obvious source is the
Internet. By doing a search for the terms mental health counselor, marriage
and family therapist, psychologist, or psychiatrist for your city or county, you
can obtain a list of licensed professionals and their areas of practice. Such
lists or directories may provide little more than names and possible
affiliations. For example, a listing under “Marriage, Family, Child, and
Individual” counselors might read:
Psychotherapy/Counseling
Ralph T. Marcus, Ph.D.
Center for Psychotherapy
Marriage Enrichment
Divorce Bereavement
Family Mediation
Conveniently located in the Meridian Center
Call for appointment: 555–5555
Just what can be learned from this listing? Dr. Marcus offers psychotherapy
for marriages that may require enrichment, surviving divorce, and resolving
family conflict issues. What is not known is (a) the kind of training Dr.
Marcus received, (b) whether his doctorate was earned in psychology or a
related mental health field or whether he is licensed as a mental health
practitioner in his state, (c) his therapeutic orientation (e.g., individual vs.
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family, theoretical base), or (d) his skill level or success rate with different
types of problems. The best way to find answers to such questions is
through exposure to different sources. Lacking that, the counselor could
call Dr. Marcus and ask him such questions. After obtaining this
information, the counselor should ask Dr. Marcus if he is accepting
referrals and what referral procedures he prefers to follow. Over time,
counselors can build up their own listings of referral sources based on
direct experience. Such listings are by far the best resource when the need
to refer a client arises.
Making referrals has legal ramifications. Because one can never know with
certainty that a referral to a specific mental health provider will prove to be
a positive experience for the client, it is probably best to provide the client
with choices of referral sources. In that way, the client has the opportunity
to choose a professional whose personal characteristics and professional
qualities are closest to the client’s perceived needs. If the referring
counselor provides only one potential referral professional to the client and
that proves to be a problematic experience, the referring counselor cannot
be said to have met his or her responsibility fully.
Coordinating the Transfer
Whenever a client is referred to another professional, the counselor hopes
that the referral will occur successfully and without undue strain on the
client. If the client is highly anxious or if the counselor thinks the client
might not accept the referral, special attention should be devoted to the
client’s concerns. In addition, successful referrals require that the counselor
make contact with the receiving professional and provide information that
facilitates the referral process.
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Preparing the Client
Preparing the client for referral involves both details of the referral and the
client’s anxieties about any aspect of working with a new professional. It
helps if the counselor has discussed the case with the receiving
professional and can assure the client that painful details may not have to
be repeated. It also helps if the counselor can tell the client some details
about the potential new professional(s), including personal characteristics,
professional competency, and the person’s receptiveness to the referral.
Referral details may include helping the client identify what he or she
should be looking for in a new counselor or in a professional with the
required expertise.
Communication With the Receiving Professional
Before any referral recommendation is made, you should establish whether
potential receiving professionals are willing or able to accept the referral.
Once an acceptable receiving professional has been identified, the transfer
of information about the case must be addressed. Usually, a receiving
counselor requires a written case summary. The termination report
described earlier provides sufficient information to meet this requirement.
Before sending any written material, however, you must obtain signed
consent from the client to share this information. Most counseling centers
and educational settings use a standard consent form. Private practitioners
should develop a referral form that gives the counselor power to transfer
written information with the signed consent of the client to other specified
professionals, agencies, or authorities.
Compassion Fatigue
Post substantive responses which includes your initial post and 2 replies to classmates Each of the three required posts MUST be 175 words.
Compassion fatigue is an occupational hazard among professionals who spend a great deal of time doing crisis intervention.
Respond to the following in a minimum of 175 words:
· What should professionals do to take care of themselves while engaged in crisis intervention?
· What do you think motivates professionals to continue in this stressful form of counseling?
O.B.
What motivates workers to stay in a stressful field is a great question, and the answer to that has been my guide and what I think is others that causes us not to give up. I have always found my life’s work in caring for the less fortunate or those in need, and I sort of glean from the fruit of knowing I am making a difference in the world.
What I think the motivation for others who stay in a stressful business is they sort have become numb, are not confident they can do better in another line of work, or do the bare minimum within their work just enough to get by due to job security. I think it is also important to know that culturally some individuals may have been raised with role models that worked hard and stayed in stressful lines of work because that was just a way of life. I recall my dad at one point asking me why I always chose “hard jobs”. I guess I didn’t realize it, but my mother who was the primary caregiver always maintained high stress jobs, so It was like second nature to me.
According to the Australian Institute of Professional Counsellors (AIPC, 2009) Reflective counselors that are able to remain in such stressful jobs practice constant mindfulness pf their stress levels by 1) Evaluating their own performance, 2) Develop self-awareness, 3) Monitor potential for burnout, and 4) Ensure they have adequate self-care.
Australian Institute of Community Services (2019). Reflective Practice, Supervision & Self-Care. Retrieved from https://www.counsellingconnection.com/wp-content/uploads/2009/10/report-4-reflective-practice-supervision-self-care
D.N
Define the roles of termination and referral in the counseling relationship.
What are the common mistakes and misperceptions of beginning counselors? How may you avoid or recognize these occurrences?
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