Have a quick way to get the signatures you need! The client PIN signature system allows a client and related contacts to digitally sign documents using a HIPAA compliant PIN number or physical signature.
Written by: Jaime Goffin, LCSW
What is termination? Besides clinical jargon we use to describe the last phase of therapy. It is a fancy term and deserves its own topic because it is so important. In fact, for some it’s the most profoundly healing, meaningful and transformative phase of therapy. But many clients split before they are able to reap the benefits of a good termination.
As final sessions start to draw near we may see clients starting to talk about breakups, death and other endings, dreams may reflect abandonment or others suddenly get better or have a financial crisis and sometimes a conflict in the therapeutic relationship may arise…. Coincidence? Likely not…there are many dynamics that start to shift for the client and therapist as we begin to anticipate termination.
For the therapist, there are several reasons we might want to avoid termination. For starters, we simply may not like to talk about termination, our business “brain” is afraid of termination- possible loss of revenue and we become attached to the client and enjoy working with them. The termination phase really is bittersweet for both parties. It’s bitter because the therapeutic relationship is ending and its sweet because the ending marks a new period of independence and application of skills.
We often don’t do a well enough job talking about termination from the very beginning. When we start to engage this conversation early on in the course of treatment it will be more comfortable for the clients to feel empowered to initiate the discussion on their own. This helps to avoid the “cut and run.” In therapy “cut and run” is like skipping the last chapter of a novel; the part where the loose ends are tied up, you learn what the future may hold and get a sense of closure. Good termination helps clients end a relationship on a good note, this is especially important if the client has a history of bad endings.
I’ve started including a discharge handbook for my clients that we discuss at the very beginning. I often get a strange look with remarks that sounds something like this, “you’re already wanting to get rid of me?” This becomes a great opportunity to talk about goals, how we will know when those goals are reached and how to start moving towards wrapping up services. In my handbook for clients here is a sample of questions that I pose for them to consider throughout the treatment phase:
- Review what you’ve learned about yourself
- Discuss which goals (if any) you weren’t able to accomplish in therapy, and what to do about them
- Develop your “aftercare” plan: everything you’ll be doing post-therapy
- Reminisce about the therapeutic relationship – when you felt cared for, what made you mad, when you shared meaningful moments, etc.
- Discuss fears around endings and grieve the end of the therapeutic relationship
Discussing termination early on will help reduce ambiguity around when and how to discuss the relationship coming to an end. Don’t be afraid to talk about it and keep it simple. Good termination means plan for it, prepare for it and process it. Since all therapy must come to an end, shouldn’t a high quality ending be part of each of treatment plan?
Managing users just got easier! Now BestNotes system administrators can create default user types specifically for staff roles.
Jamie Goffin, LCSW
About a year ago I had a realization that I had been walking through life unaware of sacred and meaningful moments in my life. There isn’t one specific “Aha!” moment that defined this but rather a build up of moments that were lost because I was distracted in thought, giving attention to something else or just simply not in “the moment.” When I was sitting with clients, my attention was wandering. I even realized that I was doing mindless listening, giving mindless hugs and even worse mindless eating. I realized that I could be “too busy” in my head to even notice it.
I became interested in mindfulness stress reduction, initially as an extra tool to help the growing number of clients that initiate services because they are “stressed.” I started this journey with Jon Kabat-Zinn’s book “Full Catastrophe Living” and his Mindfulness-Based Stress Reduction (MBSR) program; which expanded my awareness around the power of being able to quiet my thoughts, slow down and how to develop a more mindful relationship with others and myself.
The psychiatrist and Holocaust survivor Viktor Frankl said, “In between stimulus and response there is a space, in that space lies our power to choose our response, in our response lies our growth and our freedom.” Mindfulness practices help us put in that space. For instance, if we were applying this to making food choices it would be helpful to get a space between the thought; “I want that bag of cookies” and the actual behavior of eating it. We get a chance to consider what would really serve our physical and emotional health best in that moment.
Learning to cultivate and intentionally engage in the now has become a practical way for myself and millions of others to alleviate stress and pain, increase emotional freedom and even create a healthier brain. Mindfulness programs are growing not only in hospital and clinical settings but also in corporations and schools. Even Google boasts a successful mindfulness program to help its employees. Mindful leadership is on the minds of CEOs, politicians and even in sports. One of the most winning basketball coaches, Phil Jackson encouraged his players to practice mindfulness.
Mindfulness based programs are becoming one of the best researched and most talked about phenomena today. Research and brain scans are proving that how we pay attention and what we pay attention to have dramatic effects on how our brain works. In the book, “The NOW Effect” by Elisha Goldstein, he discusses that mindfulness does more than allow us to change our brain architecture, or stop our destructive behaviors, we are able to help our brain become naturally flexible in our decision making, we can regulate stress better, calm our anxious mind when it is snowballing with thoughts and have better focus on tasks with school and work. Most importantly, we can feel empathy and compassion towards others and ourselves.
As I’ve become more aware and made intentions to practice mindfulness daily I’ve learned that the practice takes only a few minutes a day, there is a wide variety of mindfulness practices available and exploring those without judgment was a bit uncomfortable at times. The practices I thought I would dislike the most actually became the cornerstones of my life by connecting with family, friends, colleagues and clients.
Many recovering substance users also have problems with process addictions that can complicate their long-term recovery from substance use. A 2010 Patient Survey which asked about compulsive behaviors such as: over-eating, excessive spending, sexual acting out, gambling, work and internet 30 days prior to admission to treatment found 45.4% of patients surveyed admitted to having struggled with one or more forms of a compulsive behavior prior to treatment. It is not uncommon for an individual to enter recovery with different addictions. Often, in treatment the focus will be to remain abstinent from the substance. When these individuals achieve recovery, their risk increases to go on to either maintain an existing compulsive behavior or engage in replacement behaviors. This addictive interactive behavior process works parallel to the chemical addiction as the brain is pleasure, reward-driven and seeks behaviors that can medicate, fuse or replace each other just like the chemical substances can.
The compulsiveness, or addictiveness, of the behavior comes from a person’s need to cope. In “Slave Master: How Pornography Drug & Changes Your Brain” author Hilton, explains how the overuse of the dopamine reward system that causes addiction when the pathways are used compulsively, decreases the amount of dopamine in the pleasure areas available for use. The reward cells become “starved” creating a craving for dopamine. In this addictive state, the person must act out in addiction to boost the dopamine to sufficient levels to feel “normal.”
So how does this relate to cross addictions? When a person engages in more than one addiction, those different addictions can interact, reinforce and intertwine with each other aside from just co-existing. For example, a very common co-addiction is tobacco and alcohol. Research shows that co-addiction pleasure pathways established co-exist. When a person removes one pleasure producing behavior the reward pathway is now not “complete” if the person continues to use tobacco. This actually increases the individual’s risk for cravings of alcohol as the pathway is constantly seeking the “other half” of the reward. Overtime, if the individual does not give up the tobacco use it can put the person at increased risk for relapse on alcohol. The brain is always trying to remain in a state of pleasure and balance. Sometimes as a way to reduce the cravings for dopamine, other addictions develop by way of the following:
- Cross Tolerance
- Withdrawal mediation
- Alternating addiction cycles
This whole process of addiction interaction reminds me of a childhood game Whac-A-Mole, whose simple objective was to hit, or whack, randomly appearing moles back into their holes using a padded rubber mallet. Sounds simple right? If anyone has played the game, you can sympathize with how fun, yet frustrating the process is. The game is now used to express a repetitious and seemingly futile task, as each time a mole appears and is successfully “whacked”, another one immediately appears elsewhere. As we work with addicts, it doesn’t really matter what the primary addiction is as our patients have such a high risk to maintain or develop another addiction. It really does seem in our work with addictions we are playing Whac-A-Mole and as we succeed in whacking one addiction; another pops back up such as gambling, sex, gaming, food or work.
So how do we win the game? We need integrated treatment approaches that actively focus on assessing and treating the spectrum of process addictions. This often becomes a barrier for treatment programs, as it requires specialized training in multiple addictions. Truly integrated treatment will specifically address the interactions between the substance use and process addictions simultaneously and have programming that matches.