Humanities Homework Help

From the required readings, create one question to ask your classmates and post in the discussion.

Students should then respond to two classmates questions. 

Transcript from lecture;

Learning termination as a skill also means being very sensitive and attuned to cultural and developmental issues that arise in the termination process. So I first want to think about developmentally what we have to keep in mind. And when I say developmentally, I mean thinking about the age of your client, where they are currently in their stage of life and life development, what’s going on with them at this particular time, and how the termination itself maybe coincides with various specific developmental phase in their life.

We also think about developmentally differences in understanding ideas about saying goodbye, ending relationships, especially with children and adolescents. So in this conversation regarding the developmental considerations, I want to talk about it in part in terms of working with children and adolescents, but I think also with adults– and thinking about, again, what’s happening currently in their life. So that has us really reflect on the importance of the timing of the termination.

One thing that happens, especially as students, is that the termination often occurs in concert with the school cycle. You are placed in an internship or you have a practicum, so at the end of your school year is when the termination occurs. And this is also when kids are in school and ending school and going on summer vacation. So we have to be very considerate and mindful of that. It’s not just ending of the therapeutic relationship, but they’re changing schools, or they’re going to be going into the high school next year or into middle school next year.

So there’s lots of things that are happening at the same time. So when you are planning out a termination– and especially if it’s a termination that isn’t determined on the progress made in therapy, but more so just by what’s happening in the system in which the therapy is being provided– we want to think clinically about how that impacts what’s going on in this relationship. So timing might be, again, because of the school cycle, where you are in your training, it might be because of what’s going on in the world.

We also want to think about the child’s understanding of time. So when you’re planning termination, you want to give notice. And you want to give sufficient notice so that they can really comprehend what that means.

When you are only five years old, six months of your life is– I can’t do math that well. But you know, it’s a big chunk of your life. So it’s a different meaning for someone who, say, is 36. Same thing with even one week, or two weeks, or one month. So kids can be a different understanding and planning of the time that’s going to be involved.

What often helps is titrating down some of that termination. So we can think about, right now, we’re meeting every week. Maybe now we’re going to go to every other week. And then we’re going to go to once a month. And when we do that two times, that might be the last time we meet, and we’ll be ready to say goodbye to each other. So you give a lot of advanced notice and warning and planning of the termination process.

One way to facilitate all of this to be mindful of the timing– not just in terms of the child’s life and what’s going on in their life, or timing developmentally in terms of their understanding of time– but one way to help facilitate that is through the use of different activities and processes. Working with kids gives us lots of opportunities to be creative. And I think in preparing for termination is definitely one of those opportunities.

You can create a calendar for your client and help them each week as they are getting ready to end to cross off the dates. You can help them create kind of a box of all the tools, like a tool box of all the things they’ve learned with you. And as you are reviewing their progress and helping them refresh your memory of all the things that they’ve learned with you, you can put that in their toolbox to take with them.

You can maybe even think of something that represents your time together. Maybe there was a particular activity or toy that you guys always played with that you want to have them take with them as a transitional object or something to remind them of the pleasant time they had together. There’s a lot of different activities that you can do as part of this termination process to facilitate that that’s developmentally respectful of, again, a child or adolescent’s understanding of what this means. But it also helps make the termination process understandable and reasonable.

As I said before, there’s one goal that we have in termination– is to help people have a healthy way of saying goodbye. I think this is especially true for kids who don’t quite understand why. Why are we saying goodbye? What’s going on?

So use of appropriate clinical termination activities can help them understand that, oh yeah, it’s because I have this toolbox now. I’m going to take this toolbox with me, and I’m going to have it with me as I get ready over the summer for the next school year. And we can even think about that for ourselves as well.

So those are some of the developmental considerations. It’s just kind of a rough overview, but it hopefully is getting you to think about what it means to terminate with a child and an adolescent versus with an adult and how that may vary.

In addition to thinking about developmentally, we also need to consider any cultural differences that may arise in the termination process and how that could impact our relationship with our clients. There’s some research literature to suggest that cultural barriers that come up in the therapy process maybe actually are linked to premature termination, meaning that maybe there’s some ruptures or disruptions in the therapeutic process that are related to clients maybe ending on their own before achieving goals.

And so we want to be mindful, not just kind of how to terminate in a way that’s culture congruent, but think about are there any cultural issues that are present or apparent in our relationship with our client that might actually move a client to leave without properly terminating. So that would be the first thing I would want us to think about in terms of cultural considerations in determination. Why we want to attend to culture early on is to prevent a premature early termination.

Where culture also becomes important and relevant in our termination process is in the different rituals and routines that we have for saying goodbye. Again, this is a relationship like any other. And many times, when people are maybe moving away, or I guess at the end of a relationship, or even if it was a romantic relationship, there are things that we do.

We give going away gifts, we exchange addresses, phone numbers. They’re different rituals or routines. And sometimes, those are embedded in cultural norms and expectations. Many cultural groups like to give gifts at the end of relationships to say thank you. They like to celebrate this with food.

And sometimes, our ethics suggest that we should not accept gifts or sharing food with our clients, so we actually have to think really carefully about what the meaning of this is for our clients. And again, if our ultimate goal is to say goodbye in a healthy way, how can we accomplish that in a manner that is respectful not just of the client’s culture, but this relationship that you have been in. Fortunately, we can use supervision to get guidance around these issues.

And there is no one set answer, because everything is so individual and unique. I think what I want you to think about right now, though, is what are those rituals or routines even that you have for saying goodbye? How would you bring that into the relationship with a client? Is it clinically and ethically appropriate? Is it culturally congruent for this client? Is it representative of the work that you’ve done together?

We want to build in something, right? We want to have respect for the relationship and not just end it without acknowledging the end. But we also want to do it in a way that’s respectful and kind to each other.

Termination is one of those processes of therapeutic relationships that I think brings about a lot of concern, anxiety on part of both the client and the therapist. So we really have to be thinking about not only when it is appropriate to terminate but in what way we do terminate that is consistent with our ethical and legal mandates? So we’re going to spend some time right now thinking through, what are some of the ethical and legal issues that come up in termination?

So here’s just a list of probably the ones that we encounter the most. Again, in this portion of our conversation, not necessarily to kind of give you the right or wrong answer or thing to do, but just to kind of bring to your attention the kinds of issues that may surface when you are beginning the termination process with a client.

The first, and I think the one that we often are left with the least amount of information and most amount of concern, is a premature termination. And what I mean by premature is either on the part of the client or the therapist. Sometimes, for reasons unknown to us, clients may just kind of drop out, not show up, and stop making their appointments, stop returning our phone calls. And that can be concerning because we don’t know what happened and how well they’re doing. That is something that may happen in the course of your work as a psychotherapist. Sometimes it’s because we, as a clinician, we’re working in an agency and we get a promotion into administration and we’re no longer seeing clients. And so although there’s still more work to be done with this client and for this client, in our new role and capacity, we have to transfer the case to someone else.

So sometimes, again, the termination comes about on the part of the client, sometimes on the part of the therapist. I think what we can do to make sure that we are the most clinically, ethically, and legally appropriate is ensure that we provide any resources or referrals to the client so that if they leave, then we can send a letter or reach out and say, OK, seems like right now is not a good time for therapy. And if problems arise in the future, this is how you know to contact me. What we want to do is just give our best reasonable effort to make sure that there is a bridge for them in terms of any help or access to services.

Same thing as if we were the person who, for one reason or another, had to end the therapeutic relationship before the client met their therapeutic goals. We want to make sure that we facilitate that process and that transition as best as possible under the circumstances– so helping to identify a new therapist, helping to actually maybe make the first connection with that therapist, providing as much information as we can to kind of ease that transition. It will happen, but we just have to make sure that we try to put reasonable efforts forth to do it in a way clinically sound way that is very ethical and respectful to the client.

Sometimes those premature termination come about based on our clinical judgment, not again from the client or even the therapist, but sometimes third-party payers such as insurance companies. If working with an insurance company, you have to get authorization for services. And sometimes they will be very specific and clear in how many sessions you’re allowed. And if an insurance company will not reauthorize, then you may be in a position of trying to decide what to do next.

So again, I bring this up more as information so that you have a sense of why premature termination might occur and what you would do in the situation. Similar to what I said before, you would just kind of put forth your best reasonable effort to make sure the client has information of where to go, resources and supports, how to contact you if they need to, and help guide them in this transition.

As we’re thinking about the sort of premature termination and different situations that arise, the two main things that we want to make sure we keep in mind always is the welfare of the client and clinician. What is in the best interests of the client and the clinician? How do we keep every party involved safe? How do we make sure that people have access to information and resources, that there’s any risk of danger minimized, et cetera.

And sometimes, again, we think about this often with the client, but we have to think about this for ourself too. If you are feeling unsafe and at risk, you as a clinician have the right to kind of think about your own safety and think about, maybe this isn’t the best relationship and maybe I can help provide referrals for you to someone else. We don’t often think about that for ourselves. So I do want to, as you are beginning to consider termination and the skills that are involved, kind of highlight that as something that we do want to keep in mind, just as much as we keep in mind the welfare of the client.

Most notably is our ethical responsibility to our clients. We’ve taken them into our care. So when we’ve initiated a therapeutic relationship, we have taken on sort of the professional responsibility of working with this person, keeping their best interests in mind, and making sure that we do no harm to them. So our ethical responsibility is definitely at play in termination when this relationship probably is going to be ending and we won’t be able to kind of see them and monitor what’s going on.

So one thing to do to make sure that we are upholding our ethical responsibility to the standard that we can is to try to terminate when it is clear that the client is no longer benefiting from therapy or might even be harmed for it. Again, above all else, do no harm. So we want to make sure that all the work that we’re doing is helpful and advantageous to the client.

To the extent possible, we want to provide preterm counseling. And so again, what this means in pretermination counseling is that we review the progress and the gains that have been made in the therapy, that we talked with the client about, if they are going to be any potential conflicts or a relapse in the future, how they’re going to handle it. We help them think about any future challenges that may arise and how they’re going to do that outside the therapy room. And we also make sure they know how to find us, what to do, how to return if they need help. And we also can give them other referrals and say, I think that we’ve done all the work that we can together and you’ve shown some progress, but maybe a different kind of therapist can help move you even further. So this pretermination counseling kind of helps prepare them for what it might look like and what it might feel like once the termination has occurred.

During the actual termination process itself, we also want to minimize the risk of harm to clients. I think I’ve said it before, but this is a relationship, and that can be hard to think about ending. And so we want to make sure that we end this relationship in a way that is respectful, that is kind and healthy, and that we don’t do it in a way that kind of has them reverting back to old patterns and engaging in harmful behaviors.

So a way to do this is just, again, by providing that pretermination counseling, assessing and ensuring that the timing of the termination is appropriate, make sure the client has resources and referrals, and making it safe for them to talk about that they are sad for this to be ending, maybe even angry at you for this to end. That’s what the whole goal of therapy has been, for them to have a safe place to talk about and manage emotions that they experience, even when those emotions are coming at you because the relationship is about to end.

We also want to continue to kind of promote trust and respect in this relationship. Again, I think one of the most trusting or respectful things that you can do as a clinician is tell a client, I think you’re ready. I think you’re ready to move on. I think that we’ve done a lot of good work together and I trust you to be able to do this on your own.

So we can do that as part of the termination process, but we have to do that in a manner that is professional and really reflects our professional ethics and standards. So we have to individually accept responsibility for making sure that we’re professional in this termination.

We’re going to miss our clients too. And it might be very tempting when they say, can I email you? Can we now be Facebook friends? It might be kind of tempting, but we have to maintain our ethical standards and codes even after this relationship has ended.

So hopefully this gives you an idea of some of the clinical, ethical, legal concerns that may arise, hopefully hasn’t been too scary to think about them. But definitely we’ll spend much more time talking about them and you will get good supervision and discussions about how to terminate with your clients in a way that’s clinically appropriate and still maintains our ethical and legal mandates in the profession. 

Question 1- In the lectures regarding termination, it was discussed a couple of times about sometimes looking at termination as a celebration or even an empowerment to the client. As we know, the process will not always be seen as a “positive” from the client’s point of view.

What happens when the clinician sees the ending as a step in a more positive direction while the client has not intention of ending the sessions? Or, in what ways would you explain to the client that you believe they are ready to terminate? 

Question 2
So, when writing a plan for both vignettes I did some research. There seemed to be a plethora of treatment plan forms and examples, but when it came to termination it seemed to be a vacant hole of nothingness.

My question: What do YOU include in a termination session and if a client seeks your advice is it your job to blindly support or do you give your honest advice?