Module 11;Discharge and Referral Flashcards
outline the process of finishing a counselling relationship
There are, generally speaking, two types of weaning off therapy: fixed or time-limited versus gradual weaning. A fixed or time-limited weaning e.g. ‘we have four more sessions, then we’ll finish on X date’, is often best for people anxious about money or for people who have a need for control. Conversely, more gradual weaning can be the best solution for a client with anxiety regarding loss or abandonment. It is crucial, however, to not compound a client’s original fears by using a long, drawn-out process, as this sends the message that they can’t cope without you, or may foster unhealthy dependence on you as a counsellor.
When finalising a relationship, it is good to include a review of progress, go through gains and losses, and outline any new goals. It is also good to discuss what the client and you as a counsellor gained from the therapy. Any follow-ups or referrals are also crucial to focus on.
PROCESS
1. Ensure emotional needs met outside of therapy. Therapist needs to understand goal is to help clients with specific problems and not to be helping indefinately with emotional problems. Clients need to understand their own emotional needs and how to meet them outside of therapy.
2. Draw client’s attention back to original therapy goals. (obviously should have been clearly agreed upon at beginning of therapy (eg goals may be “stopped smoking”, feeling sexually competent”, “able to cope well”…. Do ask though if there were other problems they wanted to work on before wrapping things up.
3. Make clear from the beginning that therapy is finite.
KNOW WHEN
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 consistently 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.
REPORT
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.
SUMMARISE
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.
GENERALISING 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.
PLAN FOLLOW-UP
May or may not be necessary but at least ensure client knows can come back if needed. Sometimes need to schedule a check up for a few months, sometimes leave up to client etc etc
REFERRAL
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.
Need to have signed release forms etc so can share info.
reflect on reasons why therapists and clients may not be eager to terminate the relationship.
RESISTANCE TO TERMINATION;
many reasons including;
-bond of attachment/wishing to be friends
-Feeling ineffective and wanting to hold on to do more and help more.
-Feelings of guilt, like the counsellor, hasn’t been good enough to the client.
-The counsellor lives vicariously through their client’s life experiences.
identify some common issues and solutions
- If depressed client not feeling significantly better after 5 sessions, consider referring on.
2.Three precipitating conditions can lead the counselor to initiate inappropriate premature termination:
-The counselor experiences interpersonal discomfort.
-The counselor fails to recognize and conceptualize the problem accurately.
-The counselor accurately conceptualizes the problem, but becomes overwhelmed by it.
3.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.
GEMS
- “A therapist should assist where they can, but not leave footprints in a client’s life”.
- Described as:It has been described by writers as a “loss experience”; an “index of success”; a “recapitulation of the multiple preceding goodbyes in life”; a mixture of sadness and pleasure, pride and accomplishment; and a “transformative growth experience.”
3.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
4.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
5.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.
