Reference no: EM133373401

I have put together this presentation knowing that you are all ending the-- getting close to the end of your first-year internship at Fordham. The idea of endings and finishing up work with clients in both the literature-- the literature is not always given a lot of attention. And it's a very, very important topic. And it's also something thaT I'm sure many of you are grappling with, certain issues related to ending your internship.

So I'd like to spend some time today talking about the goals of termination, what we're trying to accomplish, what typically goes on in terms of feelings, and so forth. And I think it's really-- it's an important area to think about as you're ending your internships-- and for us to spend some time together about it.

One of the things I want to start by saying is that I've taught this class for many years, or a version of this class for many years, probably 13, 14 years. And one of the things I see year after year is that students in their first-year internship are often very surprised by how much they have meant to their clients, what that relationship has meant to both them as the social worker, social work student, but also to the clients, constantly surprised because you're learning and you're floundering and you are not sure that you've been effective. But the relationship has often been very meaningful to the clients. So it's important that we utilize this time to really review where you are with the client, for the client to have a chance to review the process with you, and for you to come together and talk about next steps. So I'm glad to spend this time with you and focus on this topic.

So the ending of the internship or the ending of-- oh, say you're at a job-- termination-- I'll call it termination-- is a transition for both the client and for you. It's the end of your work together and the beginning of your work separate, or the work without the social worker. Just like the intake process, the termination process should have a focus, a purpose, and help formulate the next steps.

And the focus-- you're focusing on both what you achieve, the tasks achieved, as well as the relationship ending. So those are the two keys you're-- things you're looking at. What are the tasks that we've achieved, what we have accomplished? And also, you've had this relationship. We've built a relationship-- so working-- focusing on the fact that the relationship is ending.

When transitions are insignificantly marked and integrated, they may continue to be sources of pain, stress, and dysfunction. So we just really-- it's easy to-- like I said before, I've seen this in so many years, where students don't feel like they've had that big of an impact, or what difference does it make? But you really need to take this seriously and give your clients and yourself an opportunity to process the ending because there's a lot-- often a lot going on there. And we don't want to do any damage. We really want to make this a healing experience for the client, and also for ourselves.

So generally associated with loss, termination also elicits positive feelings, like pride, relief that the work is over, a sense of accomplishment. So there's a lot of mixed feelings that come up in termination.

So some of the skills that we're using during this time-- are we reviewing the process and how things have gone in the work together, doing a final evaluation of the work, sharing our feelings and saying goodbye and having the client share their feelings and have an opportunity to say goodbye, and then recording the closing summary? Skills also include discussing that the relationship is coming to an end and pointing this out early enough to discuss, asking for a mutual exchange of feelings related to endings, maintaining a safe and supportive space, asking for honest evaluation of the work together and the experience, reaching for thoughts and feelings, or what is often called in the text as a demand for work-- don't let the client gloss over the ending-- and exploration skills, exploring skills.

So just to go up to that first point for a second, you'll talk with your supervisor about-- it's important to talk to your supervisor and to just let clients know that-- when you're leaving, how much longer you'll be in the agency. It's very common for students to have told the client early in the year, but then the client either forgets or denies that you're leaving. So these are all very important things to do-- talking about our feelings, as I mentioned, maintaining a safe and supportive space, being open to honest evaluation, and providing opportunity for thoughts and feelings and reaching for those because they are likely there, but unless we reach for them, often, clients are not comfortable sharing them, and also exploring what the client-- what's going on for the client.

Identifying indirect and nonverbal cues-- so we might see some acting out behavior, particularly in children, or people coming late to sessions or people missing sessions, like what-- noticing things that maybe are non-indirect or nonverbal cues that the clients are giving you if you see-- notice some change in behavior, evaluating the work perhaps. So there's some tools that you could use to evaluate your work. One of them, I think is great-- is to use an eco-map and map where the client was at the beginning of your work or map it over time and then see how things have changed for the client as you work together and see how their social systems have improved or their relationships have improved.

You also need to do closing or transferring. Let the client help. So this is one of the things that I think is very useful. And I read it somewhere. I don't know who to give the credit to. But closing and transferring-- so let the client help you write the transfer summary.

So let's say the client's going to stay in the organization and work with a new social worker there. Give something concrete to the next social worker so that they can know about the work that you've done together. I think it's very helpful to let the client help you write that transfer note about where you've-- what you've done, where you're going, some of the things that have worked well for you, anything you could share about how you've worked together, to make that transition as easy as possible. Identify major learning that's occurred in the work together-- and then identifying areas for future work.

So the types of termination or endings could be transferal or referral, termination, or client discontinuation. So a transferal would be probably within an organization where you transfer. You're leaving as an intern. And somebody else is going to work with that client. A referral might be the client worked with you for a while or was not appropriate for your agency. And so you refer them to another organization or another service for help.

Termination is when the client has completed the work with you. And it's that type of ending. And then client discontinuation is another way of terminating. The client doesn't return for further work with you.

So understanding and responding to termination reactions-- so in this process, it's usually mixed-- a lot of mixed feelings for both you and the client, but usually positive feelings and, like I said-- can be quite complex. So that's why exploring these and not just taking things on face value is really, really important. And I know that it takes some risk to talk about these things and to be-- make yourself a-- vulnerable to what the client's experience was. But I really want you to do that because that's how you're going to grow. And that's how you're going to learn from the client. And often, you're surprised that things are much better than you thought they would be.

So how are reactions to the work together depends on many, many things. So it depends on what did you achieve and the success of your achievements. It depends on the intensity of the attachment and the relationship-- how are people going to respond depends on what kind of termination it is-- on the cultural orientation of the client-- that could have an impact on the termination process, what it looks like, and how people respond emotionally-- and clients' previous experience with separation from significant others. I think that's always really interesting.

What endings mean for them? And as I always say in every slide, what is ending-- what is our experience with endings? And how are we with endings, because that's going to impact then how we navigate this with a client? And the client's previous experience with separation should inform our work with them. But it also is an opportunity to have a new kind of experience, a positive experience, with ending for clients who may never have had that experience before.

So common reactions we might see in clients, and we are-- one would be anger, especially if the client-- clinician leaves suddenly or with short notice. And so we need to be very thoughtful in social work. A lot of times in jobs, you'd leave a two-week notice. Well, typically, in my experience, in social work, you would leave, if you were leaving a job, four to six weeks, especially if you were doing clinical work, to make sure that you had time to finish up with clients and adequately help them on to the next phase.

You don't want to leave in a week or two and just-- because the relationships and the transfer is too important. So you don't want to leave too suddenly. And you want to give people plenty of time to know that you are leaving and that you're-- what the process is going to look like.

You want to encourage expression of emotions and respond empathically while keeping a professional distance so that you can be of assistance to the client. So whatever the clients is going through, you want to have enough distance so that you're not getting wrapped up in it and that you can-- and you can actually facilitate the client expressing and working through those feelings.

A second feeling we might see, and is common with the termination process, is denial-- so clients saying they weren't aware that the work was ending or just dropping out of treatment all of a sudden or dropping out of working with you or-- those are some things that you might see. So one of the things I want you to keep in mind is that I don't want you to assume that the client is taking termination in stride. They might really-- this might be a very painful process for them. And so they may be doing these things to try to minimize their pain.

So it's very common-- I see it all the time with students-- where two months before the ending of their internship, clients will say, well, you never told us when you were leaving. And absolutely, they told them two or three times. But the person's in denial that this relationship is ending.

So we need to reach out to clients. We need to see what's going on with them. Don't assume that you did a bad job or they don't care. You need to find out what's going on. And you need to be the one to reach out.

Avoidance-- so this could be that the client rejects you before you reject them. So that's-- they don't connect-- stay connected with you, or they may fail to attend sessions. So again, we need to reach out to clients, show them that we care, and are understanding of their reactions.

So if somebody is avoiding you, but they've been working with you for a year, don't just say, oh, I guess my work with them didn't matter, or whatever. It's likely that they're having an emotional reaction that needs to be attended to. And you, as the professional, are in the role to reach out to them and explore that with them.

Another common reaction is reporting recurrence of old problems. So somebody might revert to some self-destructive behaviors that they had worked through with you and/or had minimized or gotten rid of, or you might see other kinds of aggressive behavior. So those are things that you want to acknowledge and talk with the client about. But it may be an effort to stay engaged with you and not move forward. So that's something to be aware of.

Another thing would be an introduction of new problems. This is not uncommon, either, and even in-- like I said, in internships. So you want to try to keep the relationship-- so the introduction of new problems is often an effort to try to keep the relationship going. So the person might share information previously not told. Sometimes, our texts calls it a doorknob confession, where they share something right at the end as a way to stay connected with you.

And this very much could have to do with the ending of the relationship rather than the stated problem that they are-- want to discuss with you. And so, together, you may want to renegotiate and continue to work together, or you may be able to really unpack that and say, you know what? This ending is really difficult. We've done a lot of good work together. I'm leaving the agency, or I was only here as a year for an intern.

Let's talk about how you can maintain your progress. And if you need to continue services with somebody else, let's make that happen in a fruitful way for you. So sometimes, that-- there are things that need to be worked on. And sometimes, it's just that the person is apprehensive about the relationship ending.

So over the years, I've really noticed some common issues that students have with ending their internship and the termination process. So I wanted to talk about this for a few minutes with you. So one of the biggest issues I see with students is that they attempt to prolong contact and feel very confused about whether they should stay in touch with clients that they worked with at their internship.

So some of these-- some of the issues with this are there's an-- ethical considerations. So you have dual relationship. You're trying to have a friendship. But you also had a professional relationship.

A second is you may undermine the client's confidence in their ability to function without you. So by staying in their life, you're sending the message, or they could be interpreted as a message, that you're still needed and that the client isn't really able to go off on their own now. And it can undermine the client's confidence and can keep the client from investing in other relationships. So that's something to pay attention to, if it's too much of a dependent relationship with you. Our goal is to be useful to the clients so that they can go back out in the world and have a more meaningful life, including relationships.

And if stay-- attempting to prolong contact, we should have a clear-- should have a very clear therapeutic purpose. So there might be a reason to have booster sessions, meet with a client occasionally, or wean off the sessions and start seeing each other every other week instead of every week. So that could be-- you have to really think about, is this therapeutically appropriate for the client? And if so, maybe it's something you want to do. But if it's just to maintain the relationship, then it's really important to address the issues of endings instead of letting something go on and on that's not really therapeutically meaningful.

So things to consider about prolonged contact-- you will get busy. And what can you really maintain with a client? So you're going to start your new internship. You've got all sorts of things going on in your life. So you may have a emotional commitment to this client. But what are you really going to be able to maintain?

A second is, is it more an issue that you are having trouble saying goodbye than what is in the best interests of the client? So that's something to look at. What's going on with me? And is this in the best interests of the client?

Third, what if a crisis emerges and the client comes to you, but you are no longer at the agency and not the best person to help? So let me say I put that in because I've heard that a couple of times from students, where they've given out their cellphone number. And a high school student calls them in a crisis. And they're in no position to help the student. They're not connected to the school. They're not an intern there anymore.

And it's a really dangerous situation for the child. So you really do not want to do that. And I've seen students get themselves in those positions. And it's not right for the clients. It's not really what you want to do.

Number four, ethical issues of having a dual relationship-- again, you had a specific role with this client as a social worker. So what is your role going to be now-- and how that can be very confusing for the client?

Another issue-- if you want to change the relationship, the client may feel rejected. So these are all things I've seen in my years of teaching that happen when students try to prolong contact. And prolonging contact is one of the issues that really emerges for our students because they care deeply about the clients. And they know some of the challenges the person is dealing with. And they want to be there.

So the intentions are good. But it's really something that needs to be teased out because often, even though the intentions are good, the outcomes are not in the best interests of the client. So if you want to change the relationship, the client feels rejected.

Another is, six, missed opportunity for a healthy goodbye. So this is an opportunity to really have a healthy ending with the client, but that's a missed opportunity if that doesn't happen.

Seven, difficulty with transferring the case-- so this is an important one, too. The client comes to you, doesn't fully connect with the next worker. So the client is coming to you. I had a student who got-- finished her internship. And then she was working at the agency in the summer. But the client had already been transferred to somebody else. And it was very important that the social worker who was going to intern there in the summer, but was no longer working with this client, be very clear about what her role was because she didn't want to model what was happening with the new worker. And that's very, very important.

You need to be clear about what you will do if you're going to have some contact with the clients. Perhaps you're going to come to the next holiday party or you be an-- open to a note or update from the client. But you don't want to overextend what you're going to be able to do because you're-- that might very much change for you and be a big disappointment for the client.

Number nine, may want to terminate slowly, have fewer sessions, or boosters sessions-- so again, something that you might want to do is to have a slower termination. Leave enough time, depending on the relationship and the work you've done with the client, to ensure that the transition works well for the client.

Part of termination-- there is-- are the maintenance strategies. So what does that mean? The ability to take skills learned and apply to them real life. So one of the goals is that whatever has happened in the work with you-- that they can now continue and expand on their ability to take what they've learned and use it in their lives.

May begin to limit number of sessions-- client relies more and more on external resources for support and transition/weaning period. You might want to titrate that a little bit and give, depending on the circumstances-- but help wean the client or help your client move off of working so dependently with you and more utilizing some of their natural resources or other resources in the community.

And we want to express confidence in the client's ability to cope-- also, let the client know that you and others are available, if needed-- so again, really having confidence in the client that they have developed skills, developed resources, developed internal resources, external resources, connections, skills that will help them. But if they need help, let them know that the agency or that you, if you're staying at the agency, or other organizations are there to support them as well. And point out what resources, like I said, they have developed in the community that they can reach out to.

Another thing to consider in ending your internship or work or termination is the idea of using rituals. So these are often used as an ending-- during the ending process. So they help to mark the event as special. They provide a connection between the fast and future-- so symbolic continuation, help-- may help to focus the experience and feelings, discussion of feelings. And it's an avenue of communication.

So just like with the second bullet point, and I'll talk about this again in another slide-- but something like provides a connection between the past and future and symbolic continuity-- so something like-- I keep thinking of a picture. If there's a picture of you and the client, and that's appropriate, that gives them something that's a symbolic representation of your relationship and that they can take into the future.

So some other rituals might be a comment or graduation ceremonies if you're running a program or working in a program. So people comment on growth of the members, offer good wishes. There's an opportunity for family to come and to really celebrate the accomplishments from the-- of completing the program-- maybe giving people certificates would be an ending ritual, creating some kind of collage to represent where the client was, where they are, where they're moving to, et cetera, or some-- a collage representing your work together.

Writing a card-- so it can be appropriate to write a card for a client expressing what you've noticed in terms of their growth and wishing them well. Memory books are nice. Those are often nice for anybody. But really, young children like those a lot-- and/or a small gift to symbolize your work together.

So you want-- one of the things you want to do is ask the client how they would like to mark the final session or sessions and offer options, if needed-- so want to hear from them, what would you like to do? What would be meaningful for you? Sometimes, it's as simple as, I'd really like to go outside and have a cup of-- have a drink out, have a glass of water, have a soda outside with you, or I'd like to take a walk with you, or I'd like to sit by-- on that bench outside, or it could be something very simple. But it's good to ask the client.

Also, it's a-- really, an opportunity for modeling of celebrating and acknowledging accomplishments. So celebrations, achievements communicate support. It's an opportunity to really acknowledge what the person has accomplished, but also celebrating or acknowledging their accomplishments. It's very common that clients may not have had that experience, may not have really gotten acknowledged for them.

And then I just-- I think this last bullet point is important because it's about being conscious of this client. So you always want to think about, if you're going to give a card to a client or do some-- have a ceremony, what might that mean for this client. So if there's a-- you might have a client-- if you give a card to them, they might read into that and think that that means all sorts of things about what you want in the future with them.

So you have to be very thoughtful about what does it mean to give a card to a client. So for the majority of your clients, giving a card might be totally appropriate. But with a client who tends to misconstrue or has some kind of attachment to you that you want to make-- be very clear about what's happening in terms of the termination, that might not make sense.

Same with something like a graduation-- so if you have people who are finishing up and you really want to make it a celebration, but you know that several members of your group have no family, have no friends, and are not going to have anybody come to the celebration, you might want to think about doing something else because your goal is to make this something that is uplifting for them and where they feel really good about themselves. And that might complicate things if they didn't have anybody who would be interested in attending. And it might make them feel sad rather than feel good about what they've done.

So about the ending process, we want to make sure that we're doing some kind of evaluation. We want to review the gains achieved and not achieved. We want clients' experience of working together and hear about that-- also, their experience with the agency and getting services. We want to-- evaluation also can lead to clients discussing their feelings. And it's just really crucial.

So I just want to stress on this for a second or say a couple of words about this-- that I know for-- personally, and I also know as a-- working with a lot of students that it can be hard to ask for feedback from clients. It's a little scary. You're not sure about the work that you've done.

But this is a crucial part of your learning. And I'd say more often than not, students are surprised by what they hear, how important they've been to the client, what they did that was effective. So I want you to get in there and understand what did you do that was effective.

This is such a great opportunity for you to learn-- and also, what didn't work so well. To be open to that, even though it might be a little bit painful-- that's forever going to be useful information for you as you move through your social work career. So I really encourage you to get feedback from the clients you work with.

And it should be structured, like I said before, like the intake process. So we want to gather information. We want to explore. And we want to examine the relationship and the termination process-- so want to get information about what was it like working with the agency, with the services. You really want to understand in depth. So you can have a-- an evaluation form. But I highly recommend that you spend 10, 15 minutes with the client discussing that.

And, as a previous slide said, sometimes, by doing that evaluation, you-- then the client will talk about their feelings. So it's not-- sometimes, it's not so easy to talk about feelings. But if you do an evaluation and they start to say what was good or not so good, what worked, what didn't, then they can start talking about how it felt to-- the range of feelings they had in working with you, and also the ranges of feelings they have about leaving, ending.

So here are some suggested questions. Why did you like best about our work together? What did you find most helpful? What did you like least about our work together? What was least helpful? What will you miss about our work together? And what do you look forward to when we stop meeting?

And those are rich questions that will give a lot of room for conversation, hopefully, and for you to get-- for the client-- so this is helpful for a couple of reasons-- one, because you get feedback from the client. But the client also gets to verbalize and hear themselves say what they got from the work, what didn't work so well and why, what they need or will miss, and what they-- where they're at in terms of moving forward. So them articulating this is also very beneficial to them at this stage of the game.

We want to think a little bit about goal attainment-- so what was achieved. So we want to examine the progress towards specific goals and use behavioral terms, if possible, how-- what was accomplished and be as defined as possible, discuss feelings about achievements and lack of achievements. We want to make room for that and identify strengths related to goals achieved-- so what strengths either emerged through this or did they develop through this process.

Eco-maps, as I mentioned earlier, can be very helpful because it helps to look at what-- how the client is in relationship to their social context, how-- what relationships have maybe been developed, what negative relationships have maybe been minimized. So it connects with various systems in the environment. And you can compare it to earlier eco-maps. That can be very helpful.

And it's a communication vehicle-- so workers leaving the map for the next person who's going to work with them. So that's another reason that if you're-- if the client's going to work with somebody else, it's very helpful for them to have this eco-maps that they can refer to and then have a conversation with a client using-- and that should really be useful in terms of facilitating the new relationship that they're developing.

A couple slides about your reactions to ending-- so this is an emotional experience for both you and the client. And it's, just like we said before-- it's common to have a wide range of feelings. So you might feel some guilt about leaving the agency and the work and the clients. Maybe you feel like you're letting clients down. Maybe you feel like you didn't do enough.

You might feel a sense of avoidance, just like the client might. So you might be delaying termination because of your own feelings, or feelings may evoke-- they might invoke in the client. So you might be showing some avoidant behavior. You might feel a sense of relief after working with challenging clients.

You might also have a desire to prolong services. So in some instances, they're-- for financial or emotionally fulfilling relationship for the social worker-- so this does happen. So it's really important that you think about, if you're thinking about prolonging services, is this in the interest of the client? Why am I doing this? Is it because it's difficult to end? Is it because I'm gaining something from this? And those are all questions that you have to be very thoughtful about and ethical-- use ethical thinking in making a determination of how to move forward.

So we need to be aware of what termination with clients brings up for us so that we can avoid letting this get in the way of what is in the best interest of the client. So it's really important, just like every other slide, I think, I've done, to say-- to look at what are my feelings about endings. How do I feel about this ending? How have I felt about other endings? Have I had difficult endings in my life that make this ending challenging for me and make it so that I'm protecting myself rather than being of best service to this client and always keeping our role as-- providing a service to the client is what we're there for. So our own work on ourself and our own self-awareness really needs to be part of this process so that we can be as available and use this time as productively as possible in the service of our clients.

 

DISCUSSION 2

So I'd like to take a little time and talk to you about termination and what that looks like when we're working with families. Because of the intensity of the work that goes on with families, as well as the ongoing relationships that family members have with one another despite their circumstances, as well as the intense attachments that family members have and the histories, termination looks a little bit different with families than it might with individuals. And so I just want to spend a little time with you highlighting some of those differences.

So if the family has achieved its goals and identified specific problems that have been resolved, then it's time to begin thinking about and initiating the termination phase of our work. Just like in other areas of practice, we want to work collaboratively with our clients. And so let's talk a little bit about shared decision making. Once the decision to end therapy is reached by both the family and the therapist, shared decision making should occur on the following-- deciding when the therapy should end, if any type of follow-up is needed, and what the family should do if problems occur again.

So when we think about termination with families, one of the things to be aware of is that it can be really a difficult phase, one, because the families come with a lot of challenges frequently. They usually don't seek services unless they're forced to or they are really in need of help. And so a lot of good relationships and work has been done, and so termination can feel scary for the family in terms of moving on without the social worker. And it just can be a bit of a painful process, both for the social worker and for the clients.

However, the loss is often modified by the reality that the family is likely to remain intact and that family members can turn to one another for support. The loss may be moderated by the attachment shared by family members and review of shared accomplishment. So you want to review what's been accomplished. And also, even if, let's say, you're working with the family and there's a divorce, those relationships are-- hopefully, the work has helped family members to learn how to communicate and work together, resolve issues together and that those relationships, whatever it's going to look like, will be intact and hopefully healthier now that you're completing the work together.

Termination within families may also entail a high degree of relationship intensity, which I mentioned. And it will be different than termination with an individual because the family member's attachments to each other, right? So you're ending a lot of relationships with the individual members as well as the family as a whole. And the attachments among the family members will continue. So there's a lot of dynamics going on when you're ending work with a family.

Some of the tasks of termination with families. You want to review the process of work together, the therapy with the family. Review what has been gained and lost by the family throughout the process. Acknowledge the changes that have occurred, and clarify any misunderstandings not addressed during the work together.

You also want to facilitate the individual's communication with others and solidify members' attachment with one another's. So a lot of work has been done, and things are shifting and changing. And you want to reinforce and solidify the attachments and the gains that have been made.

Attachment between individual clients and the social worker is diffused through the family system. So there's a lot of work that's happened. The therapist has been integral to the family system as the work has gone on. And now the family will move on without the social worker.

You also want to review the reasons for the intervention that the therapist used, so review what you did and why you did it. And review what the family should do if future problems arise, how they can handle things on their own and reinforce some of the things they learned, and also when it might be valuable to reach out for additional help and to remind them that that's OK.

You also want to make it clear that the door is always open at this agency or in others, that, as I said, that help is always available. Express your continued interest in them and your hope for them and your belief in their ability to move on.

ANSWER THESE QUESTIONS BASED ON THE TWO DISCUSSION

1. How is the material covered in these lectures relevant to you and the anticipated ending of your work with your clients and your internship?
2. Specifically, what do you imagine with be challenging for you?
3. What feelings can you imagine will come up for you?
4. What will you do (what resources will you use) to managing your anticipated reactions?