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Category: Arts & Education Subjects: English literature Deadline: 12 Hours Budget: $100 - $150 Pages: 2-3 Pages (Short Assignment)

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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 …