End Game

Higher levels of care (i.e., any form of treatment other than outpatient therapy) are meant to be brief - they offer intensive intervention to stabilize acute distress, and get clients to the point where they can continue with standard outpatient treatment. Sometimes a client is so impaired that they do not stabilize quickly, even at the highest levels of care, resulting in long-term hospitalization. Most, however, show some improvement within a few days to a few weeks of treatment.

Because of the nature of higher levels of care, clinicians have to be thinking about discharge from the very beginning of treatment. Given that treatment is meant to stabilize acute symptoms, rather than restore someone to full functioning, what are reasonable treatment goals? What will tell us that the client is ready for discharge to a lower level of care? When should we conclude that the client has gotten as much as they can from this level of care, and lengthening their stay will not be therapeutic?

The answers to these questions are rarely clear. Client self-determination is a factor - what are their goals? Do they want to stay? When do they think they should discharge? It's not the only factor, though: sometimes clients want to discharge when they're still in crisis, and sometimes clients want to stay when they've already stabilized. Another litmus test is needed. Sometimes it's clear - the client is no longer suicidal or self-injuring; psychotic symptoms have resolved; weight is restored; target behaviors have been in remission for a period of time.

There are other times, however, when it is much less clear. Often, there is only partial remission of symptoms and behaviors, so the question becomes: how much improvement is necessary to warrant discharge? There are a few rules of thumb:

• Safety is paramount - if the client poses a threat to self or others at a lower level of care, they obviously aren't ready for discharge. Safety is also a consideration from the perspective of self-care, for psychosis, as well as indirect forms of self-harm, such as eating disorders.
• A decline in functioning may indicate that a higher level of care is necessary, while a plateau can be a sign that the client has gotten all they can from the current treatment and is ready for discharge. That said, some regression is possible prior to a planned discharge, and plateaus may not last.
• Disengagement may indicate a higher level of care (when there are safety issues) or discharge (when there are not safety issues) 

Especially the latter two considerations are very ambiguous to define in practice, and require judgment calls. When discharge is considered for clients whose symptoms have not fully resolved, it's important to ensure that there is some vehicle for continued care (e.g., outpatient providers who will continue to work with the client), as well as sources of support (family, friends) who can monitor the client's safety and help him/her decide if a return to a higher level of care is necessary in the future.

How do you decide when to discharge or terminate with a client? What factors go into that decision?

Another Take on Termination

A few months ago, as I was leaving a job, I wrote about the termination process in individual therapy. Now, as I prepare to transition from the program where I've been filling in to my permanent program (set to open in a few weeks!), I'm reflecting on how termination seems different at a different level of care.

The therapeutic relationship is (obviously) different in individual therapy than it is in a setting where treatment is provided by a multidisciplinary team in groups on a milieu (as it is in all higher levels of care). Specifically, the relationship is more intimate and therefore more intense in individual therapy, making termination feel more like a loss. In contrast, relationships are more diffuse in a group setting, so termination is less significant (at least termination between client and clinician; I think clients feel more sadness about terminating with "the program," because the whole is more than the sum of its parts).

At the last partial program where I worked, staff held mini "graduation" ceremonies for clients as they left the program - diplomas and all. At the program where I work now, staff help clients lead their own ritual of saying goodbye with each of their peers sharing something positive about who they are and/or how they've changed/grown. While we introduce the process, this ritual happens without staff present. In both programs, clients have tended to feel more sad at saying goodbye to peers, and anxious about leaving the safety the program symbolizes, than anything they may feel terminating with staff.

Perhaps as a result, my own feelings about terminating from the program are almost opposite to the feelings I had leaving my last job (which involved all individual therapy). At my last job, I was sad to say goodbye to clients, but didn't have a lot of feelings about leaving colleagues or the clinic. This time, I don't have a lot of feelings about leaving clients, but am sad to leave the team.

My theory is that my feelings about terminating with clients are countertransferential (reflective of the client's degree of attachment to me), while feelings toward colleagues perhaps reflect the degree to which the team, versus individual clinicians, is the central therapeutic relationship. Of course, my feelings could simply reflect the amount of time I've spent with a client, and how collegial my relationships with colleagues are.

How do you feel about termination? Have you noticed different feelings in different settings? If so, what do you make of it?

On Their Own Terms (Or, It Takes Two to Terminate)

A few days ago, in my post on Good Goodbyes, I wrote about my ideal termination process from a clinical perspective. However, as I sit here waiting for my clients to come in for scheduled termination sessions (after notifying them last week that this would be our last session together), I am reminded that what I consider a "good" goodbye clinically may NOT be what my clients want. And while they may not have much say over whether or not I leave, they do have some say in how they take their leave from me: it takes two to terminate.

Some clients will come in for a final visit. They may studiously avoid speaking of endings, and instead try to divert conversation onto other, less sensitive subjects. However, some will talk about goodbyes, this one and others, and express their feelings about it. They may be able to review the work they've done, and the progress they've made. They may express anxiety about whomever the next provider will be - sometimes I get the sense that it is change rather than endings or goodbyes that causes the most discomfort during termination. They may try to drag the session out as long as it will go, to delay the inevitable. But, eventually the end comes, and we bid each other farewell - some over their shoulders as they rush out the door, others with a handshake or hug or wave.

I like the closure of saying goodbye. But, a lot of people really HATE goodbyes. Confronting their feelings about the loss, sitting with those feelings, isn't something that they want to do. So, when it comes to a planned termination, clients who hate goodbyes may just not come. They prefer to say goodbye on their own terms, by not saying it at all. Avoidance at its finest. I find this kind of non-goodbye deeply dissatisfying because it lacks closure...but I understand the impulse, because I'd just as soon not make a fuss of saying goodbye to my colleagues.

Another possible response to planned termination is regression - the client may revert to symptoms or behaviors they experienced earlier in treatment. When this happens, it can leave you feeling discouraged about the work...but it helps to know that it's normal, and time limited: the progress is still there, and will reemerge after this ending has passed.

It's been suggested to me that therapists can predict and plan for how each client is likely to respond to termination by seeing how they respond to other separations during treatment, such as the therapist's vacations or sick leave. However, not enough of my clients have been with me through this kind of break, so I can't tell whether a pattern would appear. Are there other things you've learned or noticed about how clients handle termination on their own terms?

Good Goodbyes

In my last post, I wrote about leaving a job, and the resulting terminations with clients, as a kind of "break up:" awkward, emotional, and often one-sided. Now, after a week of breaking up (with one client or colleague after another), I've decided to write about how I'd like to be able to terminate - what I think makes for a "good" goodbye.

The biggest challenge in my current situation is that it is rushed. Because my new job is at a new program, with a specified opening day, my start-date wasn't flexible, and I could only give two weeks notice. While that is plenty of time in some kind of work, it's not much time at all in outpatient therapy. If I see somebody once a week, that means I can meet with them twice during this time. If I see them every other week...or if they miss an appointment...or if there's a holiday (e.g., Veteran's Day)...that's only one visit to tell them I'm leaving, process the goodbyes,  and plan for what comes next. There have been other situations where terminations have also been rushed - when someone lost their health insurance, or abruptly decided to move. But, ideally, I'd like to have a month, or 4 visits, to make the most of the termination process.

Goodbyes can be emotionally-fraught for many of us. They represent loss, and may bring up unresolved feelings of abandonment, rejection, helplessness and hopelessness. Without time to process these responses, termination can mean a setback. With time to process these responses, termination offers an opportunity for resolution and mastery of old feelings from past losses. That requires sharing the news of an upcoming goodbye; leaving time for feelings and associations to bubble up (sometimes time elapsing during the session, but sometimes requiring the week between sessions, or longer); exploring these reactions, where they come from, and what they mean to the client; and finding ways to make this goodbye different. If it's rushed, old "stuff" may not be adequately processed, or worse, may not even surface until after the client leaves for the last time.

Of course, ideally, the client will be transitioning to a new therapist, who can work with them on any leftover issues raised by termination. However, that brings us to a second task requiring time - identifying any work the client has left to do in therapy, eliciting their preferences (are they willing to continue now, or do they want a break? do they want a male or female therapist, or someone who has a particular skill, like EMDR? do they have preferences for time of day, day of the week, or location?), and making a referral. If the client has difficulty with trust (perhaps due to past trauma, or paranoia), or is particularly attached to you, these barriers have to be worked through before the referral process can proceed.

However, before talking about the work left to do, I like to take stock of the work already accomplished - what progress the client has made during our time together. I think it is so important to honor and recognize this progress. Naming it and encouraging the client to take pride in it help to consolidate gains, increasing the likelihood that they will maintain the progress, and feel more optimistic about the possibility of further change.

So, that's my definition of a "good" goodbye: it's planned, it helps to resolve old issues related to loss, it solidifies gains and suggests next steps forward. How do you think about termination? What do you think makes the "goodbye" therapeutic?

Breaking Up is Hard to Do!

A lesson learned early in life - breaking up is hard. It hurts to be broken-up with...but it also hurts to be the one doing the breaking. It's still a loss, even if it's your choice, and you think it will be better for you overall. It's also hard to know you're hurting, and/or letting down someone you've cared about.

Leaving a job is a lot like breaking up - whether you quit, or get fired, one party in the employment relationship is choosing to end it. Feelings stirred up may include sadness, anger, disappointment, rejection, abandonment...maybe even feeling betrayed by the "infidelity" when someone went looking for another employer/employee without letting the other party know their intent.

I'm reflecting on this because I resigned this week. After accepting a full-time job (I'll be at a new eating disorder partial hospitalization program opening in December), I had to tell one job I'm leaving completely, and tell the other I'm cutting way back on my hours and clients. It was nerve-wracking for me, and awkward, and I continue to feel like I'm letting people down.

And then there are the clients. Leaving a job as a therapist (usually) means ending relationships with each of your clients. This is the part of my job transition that is hardest for me. I'm painfully aware that I'm terminating not because it's clinically indicated, but because I'm choosing to leave. I do this work because I want to help people, but now I'm doing something that hurts. Of course, they will all still be able to get treatment...but one relationship doesn't replace or erase a previous one. It's still a loss.

It's a loss for me, too. These are people I've come to know and care about, and for whom I've worked hard. What's harder than the loss, though, is accepting their expressions of hurt, disappointment, betrayal, and abandonment. All while still finding a way to say a meaningful goodbye that solidifies the progress they've made and lays a foundation for the work they have left to do.

Yes, breaking up is hard to do!

I'm spending the next ten days or so making referrals, summarizing treatment, and speaking and writing my goodbyes. I'd love to hear how others thing about, and go about, this challenging part of therapeutic work.