university of calgary making room to practice: a …
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UNIVERSITY OF CALGARY
MAKING ROOM TO PRACTICE: A GROUNDED THEORY OF COUNSELLORS’
EXPERIENCES OF UNPLANNED ENDINGS
by
Eva Janine Helpard
A THESIS
SUBMITTED TO THE FACULTY OF GRADUATE STUDIES
IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY
FACULTY OF SOCIAL WORK
CALGARY, ALBERTA
December, 2010
© Eva Janine Helpard, 2010
978-0-494-81787-2
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ii
UNIVERSITY OF CALGARY
FACULTY OF GRADUATE STUDIES
The undersigned certify that they have read, and recommend to the Faculty of Graduate
Studies for acceptance, a thesis entitled "Making Room to Practice: A Grounded Theory
of Counsellors’ Experiences of Unplanned Endings" submitted by Eva Janine Helpard in
partial fulfilment of the requirements of the degree of Doctor of Philosophy.
Supervisor, Dr. Leslie M. Tutty, Faculty of Social Work
Dr. Dan Wulff, Faculty of Social Work
Dr. Carole-Lynne Le Navenec, Faculty of Nursing
Dr. Nancy Arthur, Faculty of Education
External Examiner, Dr. Mary Russell, Faculty of Social Work, University of British Columbia
Date
iii
Abstract
This study explores how clinical counsellors working in the field of mental health
experience unplanned endings. Although recognized as an important, if not critical phase
in the counselling process, endings have traditionally been overlooked and neglected in
the clinical research. Further, despite indications that unplanned endings may constitute
almost half of counsellors’ clinical experiences of endings; very little research has sought
to gain counsellors’ input or understanding.
Ten expert clinicians with an average of over 20 years of counselling experience
were interviewed in order to gain insight into their experiences of unplanned endings,
including how they conceptualize these experiences in practice. Utilizing grounded
theory methods, a conceptual framework centred on the core concept “Making Room”
emerged. “Making Room” not only captures the diversity of counsellors’ understanding
and reactions to unplanned endings, it also offers a process for counsellors to reflect,
learn and grow from these experiences. Re-conceptualizing unplanned endings in clinical
practice to include the opportunity for closure and as expressions of client self-
determination is suggested.
iv
Acknowledgements
I am grateful to a number of important individuals who have supported me
throughout my academic journey. Specifically I owe the largest dept of thanks and
gratitude to my supervisor, Dr. Leslie Tutty. Her wisdom, care and faith in my ability to
succeed have sustained me in my academic pursuits for almost two decades. To me, she
represents the best of social work practice, research and education and I feel incredibly
fortunate to have her as my supervisor. I would also like to thank my core committee
members Dr. Dan Wulff and Dr. Carole-Lynne Le Navenec who provided support,
encouragement and expertise to guide me through the process from inception to finished
product.
I would also like to acknowledge a number of professors within the Faculty who
have challenged and inspired me during the past five years: Catherine Worthington,
Sally St. George, Anne Marie McLaughlin and Pam Miller.
I am extremely grateful to my colleagues on this journey: Carla Alexander, Cathy
Pearl and Lesley Taylor who provided camaraderie, laughter, and encouragement, as well
as offered critical insights and understanding.
Finally, I would like to thank the expert counsellors who participated in this
study. My time with them was perhaps the most rewarding part of this experience as they
helped me to learn and grow while reminding me of all that is good in clinical social
work practice.
v
Dedication
To my daughter Janine whose presence in my life has taught me more than I ever
imagined. Her question: “Why would anyone ever choose to go to school?” challenged
me to find purpose and reminded me why learning and growing are essential in life.
To my husband Richard who never questioned my ability to succeed. His love
and support was felt every day with encouragement, patience and endless cups of coffee.
To my sister and soul mate Julie, who inspires me with her gentle and persistent
love to be the person she knows me to be.
vi
Table of Contents
Approval Page..................................................................................................................... iiAbstract .............................................................................................................................. iiiTable of Contents............................................................................................................... viList of Tables ..................................................................................................................... ix
CHAPTER ONE: INTRODUCTION..................................................................................1Genesis of the Project ......................................................................................................3
CHAPTER TWO: A CONCEPTUAL EXAMINATION OF ENDINGS IN CLINICAL PRACTICE..............................................................................................8
Historical Perspective: The Psychoanalytic Influence on Endings .................................8Termination as Loss .................................................................................................11Mourning ..................................................................................................................13
Research on Termination ...............................................................................................15Reactions to Termination .........................................................................................15Avoiding Termination (Nihilistic Flight) .................................................................16Dependency ..............................................................................................................17The Finality of Termination .....................................................................................19
A Generalist Social Work Practice Perspective on Endings..........................................21Termination and Social Work Practice.....................................................................22Termination as Transformation and Growth ............................................................25Termination as a Transition......................................................................................26Termination as an Interruption .................................................................................28Termination as a Rite of Passage..............................................................................30
Moving Forward ............................................................................................................33The Impact of Unplanned Endings ................................................................................34Defining Unplanned Endings.........................................................................................34Impact on Organizations................................................................................................36Impact on Clients ...........................................................................................................39Impact on Clinicians ......................................................................................................42Revisiting Unplanned Endings in Current Practice .......................................................44Positioning the Research Question ................................................................................45
CHAPTER THREE: STUDY DESIGN AND METHODOLOGY..................................48Locating the Research....................................................................................................48Grounded Theory...........................................................................................................50Philosophical Underpinnings of Grounded Theory .......................................................51Grounded Theory Processes ..........................................................................................53Reflexivity .....................................................................................................................54Gathering Data...............................................................................................................57
Selecting Participants ...............................................................................................57Recruitment Strategies..............................................................................................58
Theoretical Sampling.....................................................................................................59Interviewing ...................................................................................................................60
vii
Analysis .........................................................................................................................62Coding ......................................................................................................................64
Initial/Open Coding ...........................................................................................64Focused/Selective Coding..................................................................................66
Memo-Writing..........................................................................................................67Saturation..................................................................................................................69
Writing ...........................................................................................................................70Trustworthiness/Rigor ...................................................................................................71Ethical Considerations ...................................................................................................73Conclusion .....................................................................................................................75
CHAPTER FOUR: COUNSELLORS’ UNDERSTANDINGS OF PLANNED AND UNPLANNED ENDINGS........................................................................................76
The Research Participants..............................................................................................76Making Room in Clinical Practice.................................................................................77Describing Planned and Unplanned Endings.................................................................81
Beliefs about Endings...............................................................................................83Practical and Functional Purposes of Endings .........................................................90
Fulfilling Agency Mandates and Contracts .......................................................90Endings as Evaluations of Progress and Goal Achievement .............................92Achieving Closure .............................................................................................93Client Self-determination...................................................................................94
Situational Contexts..................................................................................................95Client Circumstances .........................................................................................96Client and Counsellor Match .............................................................................96Counsellor’s Abilities ........................................................................................97Agency and Counsellor Circumstances .............................................................98
Relational Accounts..................................................................................................99
CHAPTER FIVE: RESPONDING TO UNPLANNED ENDINGS IN PRACTICE ......105Reacting to Unplanned Endings ..................................................................................105Managing Unplanned Endings.....................................................................................110
Detaching................................................................................................................110Sensing ...................................................................................................................111Becoming More Transparent ..................................................................................113Evaluating Progress ................................................................................................115Integrating Rituals ..................................................................................................117Keeping the Door Open..........................................................................................118
Pulling the Pieces Together .........................................................................................120Reflecting, Learning and Growing ..............................................................................120Challenges to Making Room .......................................................................................124
Avoiding Endings...................................................................................................124Unclear Boundaries ................................................................................................126Blaming the Client..................................................................................................128Managing Worry ....................................................................................................129Feelings of Shame and Self-doubt..........................................................................130Lack of Support or Supervision..............................................................................130
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The Inevitability of Unplanned Endings......................................................................132
CHAPTER SIX: DISCUSSION ......................................................................................135Reflections on the Research.........................................................................................136Returning to the Literature...........................................................................................140Closure .........................................................................................................................142Unplanned Endings and Social Work Values, Principles and Practice .......................148Summary......................................................................................................................152Strengths and Limitations of the Study........................................................................153Recommendations and Implications for Further Research..........................................156Conclusion ...................................................................................................................158
REFERENCES ................................................................................................................160
APPENDIX A: INTERVIEW GUIDE ............................................................................171
APPENDIX B: PARTICIPANT RECRUITMENT ........................................................172
APPENDIX C: CONSENT TO PARTICIPATE IN RESEARCH .................................173
APPENDIX D: RESEARCH PARTICIPANTS’ DEMOGRAPHICS............................176
APPENDIX E: ETHICS APPROVAL ............................................................................177
ix
List of Tables
Table 1 “Making Room” Categories and Sub-Categories ................................................ 82
Table 2 “Making Room” Sub-Processes......................................................................... 122
x
List of Figures and Illustrations
Figure 1: Making Room.................................................................................................... 78
Figure 2: Gestalt Principle: Incomplete Circle (adapted from: Skaalid, B., 2010)......... 143
1
CHAPTER ONE: INTRODUCTION
Canadian social work practice exists in a diverse and increasingly complex world.
As front-line professionals, social workers are challenged to provide services for those
faced with a broad range of social issues. Over time, social work clinical counselling has
evolved to meet these challenges. Recognizing that people struggle with mental health
concerns in virtually all public and private service settings, social workers have sought to
advance clinical research, education and training to develop expertise in counselling
theory and practice (Austrian, 2005; Payne, 2005; Turner, 2002a). Often collaborating
with a variety of mental health professionals, social work counsellors have also sought to
advance the understanding and practice of the counselling process (Brothers, 2002;
Walsh, 2003).
Although social work’s research and education emphasis has historically focused
on the engagement, assessment and intervention phases, most counsellors would agree
that ending the counselling relationship is also an important, if not critical, phase in the
counselling process. ‘Endings’ have historically been referred to as ‘termination’ and are
described in the literature as a process or stage in counselling that occurs under the
guidance of the counsellor with the intent to formally end the therapeutic relationship
(Fortune, 1987; Pearson, 1998; Walsh, 2003). Ideally, clients and counsellors navigate
through a process of ending that allow clients the opportunity to integrate learning and
change; providing a means for closure to the therapeutic relationship (Pearson, 1998;
Walsh, 2003).
Closure is an important concept in the ending process, described by Walsh (2003)
to reflect the mutual understanding and agreement between clients and counsellors that
2
the end of the relationship is happening. Walsh clarifies that achieving closure does not
necessarily imply satisfaction or success in counselling. Instead, closure involves an
open acknowledgment of the time and work involved during the counselling relationship.
As well, closure provides the opportunity for both client and counsellor to reflect on their
feelings and their relationship.
However, recent authors suggest that, in the majority of counsellors’ casework
experience, this preferred ending process does not occur (Connell, Grant, & Mullin,
2006; Ogrodniczuk, Joyce, & Piper, 2005). In fact, across a variety of clinical contexts,
an estimated 50% of counselling relationship endings do not achieve closure and are
considered by counsellors to be ‘unplanned’ (Connell et al., 2006; Mirabito, 2006;
Ogrodniczuk et al., 2005).
Lackstrom and Macdonald (2002) describe unplanned endings of counselling
relationships as, “situations when a client unexpectedly and apparently prematurely
withdraws from counselling or simply drops out” (p. 204). Studies show that the reasons
for unplanned endings vary widely however many authors conclude that the majority of
clients drop out of counselling when they feel they have achieved their goals (Baekeland
& Lundwall, 1975; Hunsley, Aubry, Verstervelt, & Vito, 1999; Pekarik, 1992). Other
common reasons include external circumstances of clients such as family pressure,
relocation, and limited financial resources (April & Nicolas, 1997; Pekarik, 1992; Pekarik
& Finney-Owen, 1987; Todd, Deane, & Bragdon, 2003). Least common is
dissatisfaction with the counsellor and differences in treatment expectations (Pekarik,
1992; Pekarik & Finney-Owen, 1987). Forced terminations also result in unplanned
3
endings. These include counsellor circumstances such as job or role transfers, illness,
leaves of absence, and temporary student placements (Baum, 2007; Pearson, 1998).
Unplanned endings pose significant concerns to administrators, clients and
counsellors (Connell et al., 2006; Ogrodniczuk et al., 2005; Tryon & Kane, 1993). For
the most part, they are perceived as providing considerable barriers to program efficacy
(Connell et al., 2006; Ogrodniczuk et al., 2005) and although challenged by recent
research (Wilson & Sperlinger, 2004); they also raise concerns of potential treatment
failure (Ogrodniczuk et al., 2005; Tryon & Kane, 1993; Walsh & Harrigan, 2003).
Genesis of the Project
As a practicing clinical social worker and educator in mental health for over two
decades, I am one of many social workers committed to improving counselling practice
for the benefit of the people I serve. My experience includes years of working with
individuals and their families who struggle with acute and chronic mental health issues.
Clinical social work has always been my focus and passion which started with a strong
foundation in humanism and systemic approaches. As I reflect back on how much I have
grown and changed over the years, I’ve come to appreciate the efforts in research to
advance and create practice theory to reflect and address complicated issues experienced
in clinical social work practice. I have seen how practice theory has evolved to become
more pragmatic and relevant to the clients I serve.
I had the opportunity to be at the forefront of working with youth and their
families in an addictions treatment program and later with individuals and their families
who struggled with eating disorders. My overall philosophy and subsequent practice
theory shifted significantly to incorporate a focus on strengths, motivation, solution
4
focused and narrative perspectives. I witnessed first hand how research in clinical social
work practice helped to advance these perspectives and move clinical counselling into the
21st century.
For the past ten years I have also been teaching social work students and
supervising counsellors from various disciplines in clinical practice. I have learned a
great deal about the need for practical and useful practice theory from the experiences of
my students. Keeping up to date with current research and literature on clinical social
work counselling practice has highlighted the importance of counsellors to engage in
clinical research for practice to remain relevant to clients in their diverse circumstances.
My commitment to improving counselling practice extended into my research and
studies as a PhD student. Beginning on a long hike in the Canadian Rockies, I sought
input from five social work colleagues to find a topic worthy to devote years of study. I
wanted this topic to address clinical practice in social work and this hike offered the ideal
opportunity to seek input from these social work counsellors. I asked for their
perspectives on clinical practice and I invited them to share challenging clinical issues
from their diverse counselling practices.
My colleagues revealed numerous social issues that are faced by Canadians every
day. They conveyed heartfelt stories of their clients’ lives; narratives of individuals who
experienced mental illnesses, addictions, family violence, grief and suicide. My
colleagues also spoke of numerous challenges in their efforts to assist.
Although many of these challenges clearly required much needed attention and
research, the topic I chose emerged when three of the counsellors ended their stories with,
“I wonder what happened to that person?” “I never saw that person again,” and “I
5
didn’t have a chance to say goodbye.” Drawing upon my own clinical experiences, I
wondered if not knowing what happened to one’s clients was common. I also questioned
the importance of having the opportunity to say goodbye to their clients. These questions
made me pause. It became clear during this discussion that, although they shared diverse
experiences, my fellow counsellors were significantly impacted by endings and in
particular, unplanned endings. I decided then that my topic would focus on the process
of endings in counselling and in particular, understanding counsellors’ experiences of
unplanned endings in clinical practice.
In this dissertation I first situate the topic of endings in clinical social work
practice with a review of the literature (Chapter Two). Beginning with historical and
theoretical conceptualizations, the purpose of this review is to orientate the reader to the
evolution of endings from its roots in psychoanalytic thinking to today’s more recent
interpretations. This leads to a summary of the implications for clinical social work
practice while advancing it into more recent conceptualizations of endings. The review
provides an opportunity to stand back and reflect on the broader issues that have
influenced the practice of counselling and, in particular, the practice of ending
counselling.
The exploration of the literature then focuses on research specifically related to
unplanned endings. Beginning with challenges to define unplanned endings, it explores
current research on the impact of unplanned endings on organizations, clients and
counsellors. The literature review concludes with the premise that research into
counsellors’ experiences and understanding of unplanned endings has been sparse and
inconclusive.
6
Chapter Three provides a summary of grounded theory methodology and
addresses why this is considered an appropriate research method for this study. This
discussion explores some of the debates and controversies surrounding the method. It
also includes an overview of the philosophical underpinnings of grounded theory that
have evolved to include constructivist and relativist perspectives. These are then
considered in the context of the original research questions with an argument for the ways
in which unplanned endings are processes that are appropriate for research inquiry using
grounded theory methodology.
In Chapters Four and Five, I present the analysis of the themes that emerged from
this study. Chapter Four is the first part of the analysis that begins with a general
overview of the participants’ backgrounds. I then offer a theoretical model that is centred
on the core concept: ‘Making Room’. This model provides deeper understanding of
counsellors’ experiences of unplanned endings. Accounting for the similarities and
diversity of counsellors’ experiences, ‘Making Room’ is a higher concept illustrating an
important social process involved with endings in current clinical practice.
The next section of this chapter provides an overview of counsellors’
understandings of planned and unplanned endings including their beliefs about endings,
the practical and functional purpose of endings, the situational context of endings and the
relational account of endings.
Chapter Five continues the analysis by presenting how counsellors respond to
unplanned endings in practice. This includes how counsellors emotionally react to
unplanned endings and how they manage them in practice. This chapter captures how
unplanned endings impact clinical practice.
7
Following this is an exploration of the central sub-processes, ‘reflecting, learning
and growing.’ These processes tie the results together, explaining how this emergent
theory can be conceptualized in practice. The sub-processes that challenge or impede
‘making room’ are also described. The chapter concludes with a discussion of the
inevitability of unplanned endings.
Chapter Six presents the findings of this research as it contributes, compares and
contrasts to the current professional literature on unplanned endings. This chapter brings
the research into focus by extending the core concept of ‘Making Room’ to current
concepts in the literature of closure and client self-determination. Reflected in both this
study and the literature, the discussion highlights the extent that counsellors are adapting
to the needs of society and the people they serve by reconceptualising unplanned endings
in practice. The final chapter also presents the strengths and limitations of the current
study as well as recommendations for future research.
8
CHAPTER TWO: A CONCEPTUAL EXAMINATION OF ENDINGS IN
CLINICAL PRACTICE
This chapter provides a comprehensive review of the literature on endings in
clinical practice. Beginning with the current discourse on the topic, I explore the range of
historical and theoretical conceptualizations of what is commonly referred to as
termination that have challenged social workers and counsellors from all disciplines.
This includes the origins of termination within the paradigm of psychoanalytic practice
that involves an expansive look at how termination has been conceptualized as loss.
Current research that challenges some of the critical underlying assumptions
inherent in the termination as loss model is also presented. Implications for clinical
social work practice is outlined including how practice models in social work have
integrated termination as loss perspective while advancing it further into four more recent
conceptualizations. This section allows the opportunity to reflect on the broader issues
that have impacted the practice of counselling and, in particular, the practice of ending
counselling.
This review of the literature then focuses more specifically on the topic of
unplanned endings. I provide a critical review of the current research addressing the
impact of unplanned endings on clients, clinicians and organizations. The research
literature is both wide-ranging and diverse, as the complexities of defining this important
issue are revealed.
Historical Perspective: The Psychoanalytic Influence on Endings
The process of ending the counselling relationship has traditionally been referred
to as termination (Murphy & Dillon, 2003). This term was originally conceived by
9
psychoanalytic theorists, and conceptualized as a critical process involving significant
feelings of loss, anxiety, ambivalence, guilt, and sadness for both client and therapist
(Fortune, Pearlingi, & Rochelle, 1992; Novick, 1997; Quintana, 1993). Commonly
thought of as intentional, the process of termination is ideally managed by the counsellor
when the majority of the treatment goals have been achieved (Vasquez, Bingham, &
Barnett, 2008). The intent of termination, from this perspective, is to assist clients to
summarize and integrate change while helping them to resolve feelings of loss. The
process culminates in the final event of ending and saying goodbye. This
conceptualization has dominated the literature on ending counselling relationships.
(Epston & White, 1995; Marx & Gelso, 1987).
Deeply rooted in psychoanalytic theory, it is interesting that Freud himself had
very little to do with the eventual conceptualization of the ending process (Bergmann,
1997; Blum, 1987; Frank, 1999). Intending psychotherapy to be an ‘open-ended,
timeless analytic process’ (Blum, 1987, p. 275), Freud focused primarily on the opening
and middle phases of counselling; not on the process of termination or ending (Frank,
1999). Referring to his long-held belief that analysis and, in particular, self-analysis was
a life-long process, Freud neglected to conceptualize the ending of therapy. This left a
legacy of significant discourse in the field of psychotherapy (Bergmann, 1997; Blum,
1987).
It was not until the end of his life that Freud made reference to termination. In
Analysis Terminable and Interminable (1937) he questioned the concept of a natural end
to analysis. “Is there such a thing as a natural end to an analysis --- is there any
10
possibility at all of bringing an analysis to such an end?” (as cited in Frank, 1999, p.
120).
According to Blum (1987), Freud’s paper only provided vague guidelines that
hinted at what ending analysis involved. Freud wrote that ending treatment indicated that
the analyst believed the patient would not relapse and, ultimately, that no further change
could be expected if analysis continued. This guideline left many believing that, “a
complete analysis or finished analysis could never be met” (Blum, 1987, p. 282).
Consequently, establishing an end-point to treatment was ultimately left to the discretion
of the individual psychoanalyst (Frank, 1999).
With no criterion for termination of psychoanalysis established, many therapists
relied on their intuition. This was reflected in a 1940 survey involving members of the
British Psychoanalytical Society. As noted by Bergmann (1997) and Frank (1999), the
majority of these analysts admitted that they used intuition rather than theory to guide
their decisions to end treatment. These psychotherapists likely believed that Freud had
intended for them to use their intuition. Interestingly, the literature on termination
continues to recognize the importance of intuition or ‘clinical judgement’ to determine
client readiness to end counselling (Bergmann, 1997; Ward, 1984).
Because there was no paradigm for termination in psychoanalysis, Bergmann
(1997) argued that, “the termination moment is still a matter of art rather than science”
(p. 172). He added that premature or unproductively prolonged counselling cannot be
avoided when the optimal time for termination remains an exercise in guessing.
However, Blum (1987) has suggested that psychoanalysts need much more than intuition
to guide the practice of termination:
11
After a long period during which analysis was practiced without a characteristic
terminal phase and with more or less intuitive, pragmatic considerations for
ending, the concept of termination was rapidly assimilated into the psychoanalytic
process, practice and education. It was almost as if there were a need for closure
in a well defined analytic process. (p. 284)
Thus began an important transition in the practice of ending psychoanalysis. The
focus shifted from the idea that analysis is ‘forever’ or ‘time-unlimited’ to consideration
of a conscious ending to the therapeutic relationship. However, this process needed to be
conceptualized and, as such, the process of ending evolved to incorporate psychoanalytic
principles. The process of termination became synonymous with a process of loss.
Termination as Loss
Blum (1987) suggested that Freud’s death and the inevitable termination from
him forced analysts to finally acknowledge and confront their need for a defined process
of termination. Termination processes quickly became synonymous with the crisis of
loss (Novick, 1997; Pearson, 1998; Pinkerton & Rockwell, 1990). It was initially
referred to as the ‘terminal’ phase of counselling which brought to mind the concept of
death and the inevitability of loss.
According to Novick (1997), psychoanalysts had great difficulty conceiving of
termination because of this focus. Apparently, psychoanalysts had also been expected to
commit to their own life-long journey in therapy. Leowald (as cited in Novick, 1997)
questioned: “As with death, how can one conceive of the termination of analysis when
one is in analysis?” (p. 146). Thus, despite the emphasis to integrate a ‘terminal’ phase
12
shortly after Freud’s death, termination issues were reportedly ignored and denied by
psychotherapists for decades.
During the 1950’s, the concept of termination once again resurfaced as an
important phase needed in therapy during an international symposium (Blum, 1987;
Novick, 1997). First published in the International Journal of Psycho-Analysis, this
symposium resulted in renewed interest and enthusiasm from psychoanalysts to learn
more about termination. Textbooks, such as Wolberg (1967), The Technique of
Psychotherapy were subsequently published, addressing termination as an important
phase in psychotherapy. Wolberg described the process of termination to be based on
novel ideas of setting and achieving goals.
With this focus, termination evolved in psychoanalytic practice to become central
to treatment (Frank, 1999; Novick, 1997; Zilberstein, 2008). Mann’s (1973) time-limited
psychotherapy made the termination phase central to therapy by setting the date of the
final session at the very beginning of treatment (Malan, 1976; Pinkerton & Rockwell,
1990; Quintana & Holahan, 1992). Considered to be an early form of brief therapy,
termination was seen as absolute with no room to negotiate further sessions. In this way,
clients were forced to face the inevitable loss and work through these issues from the
very start of therapy (Malan, 1976).
According to Zilberstein (2008), early developments of termination centred solely
on the resolution of loss and separation. The primary treatment goals focused on the
development of autonomy and individuation. The reasons for this were that termination
was thought to evoke painful memories and feelings of earlier losses or separations.
Therefore, psychoanalysis emphasized working through unresolved or delayed grief
13
reactions (Malan, 1976; Mann, 1973) by addressing intense feelings of sadness, guilt,
anger and fear (Pinkerton & Rockwell, 1990). The overall goal of therapy was helping
the client (referred to as the patient) become more apt to tolerate separation and loss.
In summary, psychoanalysis evolved from an open-ended, time-unlimited process
with minimal recognition of termination to a more concrete, rigid and time-limited
process that centered practice on the very concept of ending. However, despite this
dichotomy, the processes involved in termination remained focused on central themes of
loss and dependency.
Mourning
Although first conceived and evolved within a psychoanalytic perspective,
conceptualizing termination as a loss has resonated through many models of
psychotherapy practice. This focus also impacted how social workers practiced endings,
emphasizing the need to attend to issues often considered as associated with grief. This
section describes how psychotherapy in general was influenced by the emphasis on
mourning during the termination or ending of the counselling relationship.
Traditional views of psychotherapy identified the process of termination as a grief
reaction (Fortune, 1987; Fortune et al., 1992; Ward, 1984). Guided by principles outlined
in Kubler-Ross’s (1969) work on death and dying, the termination phase addressed
denial, anger, bargaining, depression and finally acceptance of the impending loss of the
clinical relationship (as cited in Fortune et al., 1992). Crisis was thought to occur in
reaction to severe and debilitating anxiety that was caused by the impending loss
(Quintana, 1993).
14
According to Fortune et al. (1992), clients were expected to suffer significantly
while anticipating and working through the loss of the relationship. Similar to what was
expected if they had lost loved ones through death; clients were thought to avoid
termination by regressing, developing new symptoms, or by ending therapy prematurely
(Fortune et al., 1992).
Similarly, counsellors were also suggested to experience intense and complex
reactions to termination (Pearson, 1998) such as counter-transference (Bergmann, 1997;
Novick, 1997), avoidance (Ward, 1984), grief, sadness, anger and a re-awakening of the
counsellor’s previous losses (Boyer & Hoffman, 1993; Fortune, 1987). Guided by the
metaphor of termination as grief and loss; both clients and counsellors faced the
inevitable task of mourning (Fortune, 1987; Pearson, 1998).
According to Novick (1997), mourning the psychoanalytic relationship involved
not only the loss of the person, but also fantasies that served both the patient and the
therapist in psychoanalysis. In this way, the termination phase became devoted to
helping the client and therapist work through transference and counter-transference issues
that originated in earlier, unresolved losses (Fortune, 1987).
When termination issues were not managed well, the crisis of termination was
anticipated to intensify, and was thought to result in narcissistic injury, anger and,
potentially, rage (Fortune, 1987; Novick, 1997). Bergmann (1997) added that mourning
might also turn into depression or hostility toward the analyst after termination.
In summary, traditional views of psychotherapy held that failure to mourn or
address the impending loss in counselling was thought to result in pain, anxiety, sadness
and potentially a re-awakening of past loss for both clients and counsellors (Boyer &
15
Hoffman, 1993; Fortune, 1987; Novick, 1997). These views assumed that clients were
not only vulnerable to intense reactions to termination, but also that they were dependent
on the therapist to such an extent that they would avoid termination by fleeing therapy
early and risk losing gains that were made during their time in counselling.
Research on Termination
The current research on termination highlights the discourse that resulted from
perceiving termination as a loss. Many assumptions underlie this conceptualization,
posing a number of challenges to counsellors in current clinical practice. One of the
primary challenges is making sense of research that contradicts these assumptions.
(Fortune, 1987; Fortune et al., 1992; Marx & Gelso, 1987). This section explores four of
the more common assumptions that termination as loss implies, highlighting research that
calls these assumptions into question: 1) reactions to termination; 2) avoiding
termination; 3) client dependency and; 4) the finality of termination.
Reactions to Termination
One of the key assumptions challenged by current research is with respect to
client and counsellor reactions to termination. As described above, perceiving
termination as a loss reflects the assumption that clients and counsellors experience
intense negative responses to termination. According to Marx and Gelso (1987), this has
never been clearly supported by research. They conducted one of the first studies of
client reactions to termination, asking 72 former clients at a university counselling centre
about their experiences. The majority of the clients reported positive reactions to ending
counselling. More than half the participants described their feelings during termination
as calm, alive, good, healthy and satisfied.
16
Fortune (1987) and Fortune et al. (1992) concur with Marx and Gelso. Fortune’s
research exploring counsellor and client reactions to termination conclude that both
typically experienced strong positive affect during the process including pride,
accomplishment and independence (Fortune, 1987; Fortune et al., 1992) as well as a
sense of maturity, achievement, confidence and relief (Fortune et al., 1992). In
particular, counsellors reported feeling pride, joy, gratitude and a sense of freedom or
relief during termination (Baum, 2007; Fortune, 1987). These studies suggest that
negative reactions to termination are overstated in the literature, while positive reactions
are not emphasized enough (Fortune, 1987; Pearson, 1998).
Several authors have questioned why positive client and counsellor reactions to
termination are rarely highlighted in the literature, hypothesizing that positive reactions to
termination do not align well with the grief/loss model that continues to dominate the
literature (Fortune et al., 1992; Marx & Gelso, 1987; Quintana, 1993). Marx and Gelso
(1987) and Quintana (1993) suggest that this emphasis creates significant barriers to
understanding the termination process and counsellors’ apparent inability to
conceptualize termination beyond that which is heavily influenced by psychodynamic
principles.
Avoiding Termination (Nihilistic Flight)
Research on client and counsellor reactions to termination address another
underlying assumption of termination as loss: That clients attempt to avoid termination
by fleeing therapy (Fortune et al., 1992). The psychoanalytic term for this is “Nihilistic
Flight” and it is seen as resulting from client dependency on the therapist. Flight from
therapy or what is often regarded as unplanned endings, is interpreted as clients’ effort to
17
postpone the inevitable loss (Fortune, 1987). Clients and counsellors are believed to be
vulnerable to denying the inevitable ending of therapy resulting in early or premature
termination (Siebold, 1991).
However, recent research on client dropouts or unplanned endings shows that
clients unilaterally end therapy for many reasons (Ogrodniczuk et al., 2005). Avoidance
of termination has not been shown to be a consistent or significant factor (Ogrodniczuk et
al., 2005; Pekarik, 1992; Todd et al., 2003).
Instead, researchers suggest that clients often drop out of treatment when they
believe that they have accomplished their goals, there are external reasons that interfere
with continuing treatment and, of course, when they are dissatisfied with the services
provided (Ogrodniczuk et al., 2005; Pekarik, 1992; Todd et al., 2003). Additionally,
Connell et al. (2006) cite a number of studies indicating that early termination may also
reflect success. Opposing notions of avoiding loss or therapeutic failure, these studies
suggest that unplanned, unilateral termination by the client often occur when clients
believe that their problems have been sufficiently addressed (Connell et al., 2006).
Dependency
Another important assumption that underlies termination as loss is the belief that
clients become dependent on the counsellor (Epston & White, 1995). Psychoanalytic
perspectives have emphasized the role of therapists as the ‘experts’. As part of the
therapeutic process, termination is ‘managed’ by the counsellor; leaving clients with little
or no control (see Ward, 1984; Malan, 1976; Mann, 1973). Epston and White (1995)
believe that this “reinforces the dependency of the person seeking assistance on the
‘expert knowledge’ of the therapist…(which then) fails to legitimize the person’s own
18
role in freeing him/herself from the problem-saturated identity that brought the person to
therapy in the first place” (p. 277).
The assumption of dependency is challenged by current research. Pollak,
Mordecai, and Gumpert (1992) investigated the reasons for clients discontinuing long-
term therapy and found that many did so in attempts to avoid dependency. Fearing
dependency on the counsellor led a number of these clients to prematurely and
unilaterally end counselling. Malan (1976) stated:
…it must be emphasized that dealing with termination should not be overvalued
and elevated into a fundamental principle. There are patients who never become
dependent; they get what they want from therapy and feel ready to terminate and
go their own way. (as cited in Pinkerton & Rockwell, 1990, p. 364)
Along with the assumption of dependency is the assumption of counsellor
responsibility. Termination as loss implies that termination is managed exclusively by
the counsellor. From a psychoanalytic perspective dire consequences may occur if this
process is not managed well (Novick, 1997).
Recent studies that explored counsellors’ reactions to termination have discussed
this sense of responsibility (Boyer & Hoffman, 1993; Tweed & Salter, 2000). Tweed and
Salter (2000) reported that therapists who viewed themselves as “super-therapists” or
“all-knowing experts” often perceived client non-attendance as reflecting failure. When
the end of counselling was not within the counsellors’ control, feelings of guilt and self-
blame were evident (Baum, 2007; Fortune et al., 1992). Supporting this, Resnick and
Dziegielewski (1996) found that unplanned or forced termination resulted in an overall
decrease in job satisfaction for social workers.
19
The psychotherapy literature continues to reinforce that poorly managed
terminations have the potential to destroy positive client outcomes and may prevent
clients from seeking further help when necessary (Novick, 1997; Quintana, 1993; Tweed
& Salter, 2000; Ward, 1984). Researchers suggest that counsellors have accepted
responsibility for termination to the extent that unplanned endings result in significant
emotional and potentially long-term consequences to them (Ogrodniczuk et al., 2005;
Resnick & Dziegielewski, 1996). In a comprehensive review of the literature on
premature termination, Ogrodniczuk et al. (2005) stated: “Painful reactions to losing a
patient through premature termination, such as hurt, rejection, or anger, may interfere
with other aspects of the therapist’s professional or personal life” (p. 58).
In summary, conceptualizing termination as a loss includes the assumption of
dependency in the therapeutic relationship. This has not been supported by research on
unplanned endings in current clinical practice. This assumption does, however, lead to
counsellors feeling responsible for unplanned endings, resulting in what studies have
shown as significant consequences for the clinicians.
The Finality of Termination
One last challenge to an underlying assumption of termination as loss is the
finality of termination. Contrary to the idea that termination is a final ending to the
clinical relationship, Quintana and Holahan (1992) summarized a number of studies
indicating that most counsellors do not view the ending of counselling as final. Instead,
their research shows that the majority of counsellors invite clients to return to therapy or
‘keep the door open’.
20
From a psychoanalytic perspective the practice of keeping the door open for
clients to return counselling has the potential to diffuse crisis at termination (Quintana,
1993). Quintana (1993) argues that current research shows high rates of satisfaction
when clients experienced low rates of distress. Therefore, it is believed that diffusing
negative reactions by “keeping the door open” may result in overall client satisfaction
with treatment.
Additionally research shows that counsellors devote relatively little time to
addressing termination with their clients. Believing that most clients will return to
counselling at some point in the future, many counsellors choose to limit conversation
about endings (Pinkerton & Rockwell, 1990). As well, Pinkerton and Rockwell (1990)
found that discussions about termination only occurred ‘in passing’ in a significant
number of the cases. True to a psychoanalytic interpretation, these authors suggest that
this may be due to patients’ and therapists’ efforts to avoid or deny the impending loss.
However, other authors (Cameron, 2007; Sanville, 1982) argue instead that this reflects
therapists’ beliefs that endings are not necessarily final and that most counsellors are
reluctant to impose this agenda on their clients.
In summary, the research reflects the idea that counsellors seldom consider
endings as certain or final. However, the concept of termination as loss implies certainty
and finality by suggesting that one needs to grieve or mourn. Research has shown that in
reality, clinicians devote relatively little time in counselling to addressing issues of
termination and this may be due to consideration of how working through a process of
loss and grief with clients may potentially prevent them from returning to therapy.
Alternatively, counsellors are choosing to ‘keep the door open’ by not formally ending
21
the clinical relationship allowing clients the opportunity to return to counselling if they
feel the need.
It is clear that current researchers have successfully challenged several of the
underlying assumptions inherent in a psychoanalytically-conceived ‘termination as a
loss’ model. Proponents of the current practice models of psychotherapy upon which
clinical social work practice draw, continue to challenge these assumptions.
A Generalist Social Work Practice Perspective on Endings
This section of the literature review explores the views inherent in generalist
social work practice of the ending phase of counselling and how practice has been
influenced by the interpretation of termination as loss. More recently, social work
clinicians and authors have advanced this to include four alternative ways to
conceptualize termination: termination as a transformation/growth; termination as a
transition; termination as an interruption, and finally, termination as a rite of passage.
Social work practice has always been considered diverse and flexible. Turner
(2002b) emphasizes that, although there are exceptions, practitioners usually develop
their own styles of counselling based on a variety of methodological and theoretical
principles that fit with the unique populations and circumstances of their work. Further,
he believes that social workers are expected to be ‘multi-skilled’ and ‘multi-theoretically’
informed.
With few exceptions, writers have also considered clinical social work practice to
be somewhat pragmatic. Integrating various theoretical and methodological frameworks,
social work counselling education has focused on developing an adaptable, skilled and
knowledgeable generalist practice (Sheafor & Horejsi, 2006; Turner, 2002b). Generalist
22
social work practice draws from more than 30 theoretical perspectives or practice theories
that include everything from psychodynamic, cognitive behavioural, person-centred and
family therapies to task centred, solution-focused, problem-focused and narrative
therapies.
Practice theory may, or may not, conceptualize and suggest processes of
termination or how to end therapeutic relationships. Regardless of the approach used
however, the termination or ending phase is seen as a critical to a generalist social work
practice model (Sheafor & Horejsi, 2006; Shebib, 2007; Turner, 2002b). It is described
as one of the most important ‘phases’ of a counselling process that some consider vital to
ensuring that clients maintain their gains (Lackstrom & Macdonald, 2002; Sheafor &
Horejsi, 2006; Shebib, 2007; Shulman, 1992). The following describes the literature on
generalist social work practice and specifically how it has understood termination
including a discussion of updated conceptualizations of endings that more accurately
reflect current social work practice.
Termination and Social Work Practice
Clinical social work practice has not been immune to the influence of the
psychoanalytic conceptualization of termination as a loss. Indeed, many notable social
work authors, including Shulman (1992), emphasize the ending phase of counselling as
one of working through grief and facilitating mourning. In fact, Shulman referred to
Kubler-Ross’ phases of dying and individuals’ reactions to separation as illustrating the
ending process of the helping relationship. He described the dynamics of endings as
similar to a process of resolving grief by addressing denial, anger, and mourning.
23
However, Shulman (1992) also moved beyond the emphasis of loss and discussed
the importance of transitions and ‘new beginnings’. Recognizing that endings offer the
“greatest potential for powerful and important work” he believes that the process of
termination is an opportunity to reflect on new insights and strengths that may assist
clients in the future (p. 174).
Similarly, Lackstrom and Macdonald (2002) describe the process of termination
as one of attending to feelings while generalizing and maintaining gains. They view
termination as a time of balancing the recognition of accomplishments with attending to
feelings of distress that may accompany the ending of the relationship. Similar to
Shulman (1992), they recognize client strengths as potential coping strategies. Thus,
clients are encouraged to evaluate and maintain new insights, skills and abilities in the
context of their own lives during the ending phase.
Whether or not to consider the end of therapy as “final” is contentious in social
work writings. Although Lackstrom and Macdonald (2002) acknowledge the potential
for clients to wish to return to counselling, it was not seen as preferable. This is because
of the potential to create dependency on the social work counsellor. Alternatively,
Murphy and Dillon (2003) describe returning to counselling as “making perfect sense”
because they view the nature of people’s lives as fluid and dynamic. Therefore, they
consider the need for counselling to be accessible according to the life circumstances of
each client. They understand the process of termination as “finishing work for now” (p.
274).
A number of authors, including Shebib (2007), Shulman (1992), and Lackstrom
and Macdonald (2002) describe the process of termination as starting at the very
24
beginning of counselling, when contracts, goals and the parameters of the working
relationship are established. They believe that this respects the client’s needs by keeping
the focus of termination on progress and achieving clinical goals. From this perspective,
counsellors negotiate the ending with clients and make the ending transparent through
continually evaluating the work conducted together. From this view, termination is
considered a time for evaluation.
Similarly, Sheafor and Horejsi (2006) emphasize evaluation as the primary
function of the termination phase. In the United States, they perceive social work as
shifting to become more ‘service driven’ and as such, accountable, describing assessing
the impact and effectiveness of workers’ interventions as imperative in an environment
focused on accountability and managed care. Essentially, the function of termination is
seen as an opportunity to establish outcomes through measuring client change.
In summary, a number of current social work authors purport that termination and
the process of ending counselling have evolved to include much more than the resolution
of loss and grief. Although most social work authors emphasize the need to attend to any
important feelings expressed during the ending phase of counselling, they do not limit
termination to resolving these emotions. Instead, interpretations of termination appear to
have broadened to allow for a variety of client and societal influences, as well as the
theoretical priorities of the therapist. As noted by Pedder (1988):
The concept of termination is reviewed and reconsidered. It is suggested that the
expression itself is a curiously inappropriate term with its negative and finite
connotations that fail to convey the positive hopes for a new beginning that
normally surround the end of a satisfactory analysis. (p. 495)
25
In line with this, four recent alternative conceptualizations of termination are
presented: Termination as transformation/growth; termination as transition; termination
as interruption and; termination as a rite of passage. These ideas appear to reflect that
the current practice of ending counselling is much broader than termination as loss.
Termination as Transformation and Growth
First proposed by Quintana (1993), termination as transformation and growth
reflects, “the view that termination is a critical transition that promotes the
transformations in the therapist-client relationship and in how clients view themselves,
their therapists, and their therapies” (p. 429). Rather than mourning the loss of therapy,
clients are seen as outgrowing it (Pearson, 1998). Termination is considered a new
beginning or an opportunity for continued growth (Fortune et al., 1992; Pearson, 1998;
Quintana, 1993).
Quintana (1993) believes that this interpretation allows clients the opportunity to
reflect on their contributions to the therapeutic process by taking credit for the progress
and changes made during counselling. Clients are helped to internalize aspects of therapy
and, in particular, their own role in it, which is considered helpful to the outcome. In this
way, clients essentially graduate from therapy.
While recognizing that clients may feel sad, this perspective does not over-
emphasize the importance of the therapeutic relationship in clients’ lives: “If therapy has
been constructive and if the clients have internalized important aspects of therapy, they
are likely to have outgrown much of their need for the formal structure of therapy at this
time in their ongoing development” (Quintana, 1993, p. 430).
26
However, this perspective also recognizes that some clients underestimate their
resources and supportive networks, which could lead to dependency on the therapist or on
therapy. In these instances the focus of termination is suggested to address a process of
‘de-idealization’ where counsellors increase self-disclosure and minimize interpretation
in the final sessions of therapy (Quintana, 1993). This is thought to create a more
egalitarian relationship.
Many notable social work authors appear to have integrated similar ideas on the
ending phase of counselling (Heinonen & Spearman, 2006; Miley, O’Melia, & DuBois,
2009; Murphy & Dillon, 2003; Shebib, 2007). Emphasizing that termination is an
evaluative process; they encourage clients to recognize their achievements and gains
from counselling. Meanwhile, counsellors promote opportunities for clients to utilize
these gains in their lives. Although not identified as such, this interpretation also shares
some common similarities with termination as a transition.
Termination as a Transition
Clinical counselling and social work textbooks often refer to processes of endings
as ‘transitions’ (Gitterman & Germain, 2008; Murphy & Dillon, 2003; Shebib, 2007).
Similar to the concept of termination as transformation, Murphy and Dillon (2003)
describe termination as a transitioning process during which clients integrate learning and
use this knowledge as an inner resource for the future.
However, the concept also recognizes the impact on clients who present with
serious and complex problems and who have few resources in their lives. Here,
termination represents “a transitioning process by which clients moving to other systems
of support and problem solving (family, mutual aid groups) often take the work and the
27
relationship away with them as sustaining inner resources” (Murphy & Dillon, 2003, p.
274).
With some variation and differing emphases, the following processes of
termination as a transition are described: 1) acknowledging and managing feelings; 2)
reviewing accomplishments, goals and processes in counselling; 3) planning for the
future and; 4) evaluating treatment and counselling (Gitterman & Germain, 2008;
Murphy & Dillon, 2003; Sheafor & Horejsi, 2006; Shebib, 2007).
As well, and as mentioned previously, a number of social work authors suggest
that the process of ending be made explicit from the very start of counselling. Setting an
end-date and establishing clear goals are seen as an important part of the transitioning
process (Murphy & Dillon, 2003; Shebib, 2007).
Shulman (1992) referred to the practice of termination as including both attending
to loss and transitioning. While he emphasized mourning and loss as the primary
affective response to termination, Shulman highlighted the importance of reviewing
accomplishments, consolidating learning, integrating change and planning for the future.
In summary, termination as a transition appears to be the preferred interpretation
of the ending phase for a number of contemporary clinical social work authors
(Gitterman & Germain, 2008; Lackstrom & Macdonald, 2002; Shebib, 2007; Shulman,
1992). While acknowledging and respecting the range of clients’ feelings when
counselling ends, these authors emphasize the need to also attend to processes that allow
clients to move forward with confidence (Gitterman & Germain, 2008; Shebib, 2007).
Termination conceptualized as a transition “enables us to better account for the positive
self-feelings that may arise when treatment ends” (Baum, 2007, p. 104).
28
Termination as an Interruption
Another more recent and perhaps controversial conceptualization of termination
recognizes the changing nature of people and society. Termination as an interruption is a
conceptualization of ending counselling that responds to demands for more efficient and
cost-effective services. Quintana (1993) suggests that many clients and counsellors
understand termination to be more of an interruption of counselling than a permanent
ending or death of a relationship. Citing numerous authors, Quintana (1993) summarized
studies that suggest that as many as 70% of therapists invite clients to return to therapy.
Of those, 50 to 66% of their clients returned within the year.
Believing that many clients return to counselling, Murphy and Dillon (2003)
describe termination as finishing the work ‘for now’ as opposed to ‘forever.’ As such,
there is little emphasis on the process of termination because it is not seen as a critical
phase that needs to be processed. Instead, they consider endings as more of an event that
involves evaluating clients’ work, being given the option to return, and simply saying
goodbye.
Adopting this conceptualization of termination has implications for treatment.
Jean Sanville (1982) describes therapy as providing opportunities for experiencing
togetherness and parting. He noted that keeping an open-door policy allows clients to
work through issues of separation (partings) in their own ways. Moving away from the
prescriptive ‘medical model’ approach, Sanville argues that clients are in the best
position to judge how termination occurs and how much counselling they need.
Alternatively, recent advances in single-session psychotherapy appear to
conceptualize termination as an interruption but do so in support of the influences of the
29
medical model standards and expectations (Bloom, 2001; Cameron, 2007). As a
response to increasing health care costs, single-session therapy meets bureaucratic
expectations for treatment to become shorter, more efficient and less invasive (Bloom,
2001).
According to Miller (2008) single-session psychotherapy also emerged in
response to clients’ expectations for more convenience and shorter wait times. He
reviewed studies dating back to the 1950’s indicating that single-session formats were not
only common, they were created collaboratively and, as such, reportedly found to be
quite effective. In Miller’s recent (2008) study of client satisfaction of a walk-in single-
session counselling agency, over 80% of clients reported overall high satisfaction, “with
the greatest strengths of the service reported being immediate accessibility and the caring
attitude of the therapist” (p. 78).
Cameron (2007) views single-session therapy as a pragmatic approach to
providing counselling services in today’s environment. It is based on a foundation of
client self-determination, assuming that clients are capable of recognizing their needs and
therefore, should decide for themselves when therapy is necessary (Cameron, 2007). In
this model, termination does not reflect that all problems have been solved, but
acknowledges the beginning of work that is subsequently entrusted to the clients to
manage (Bloom, 2001).
However, the intermittent nature of single session counselling does not allow for
attention to focus on the ending of the counselling relationship. This stands in contrast to
a generalist social work practice that has always recognized and valued relationship as a
foundation for clinical practice. Coady (2002) clearly articulated that within, “clinical
30
social work practice, the helping relationship has long been considered the cornerstone of
effective helping” (p. 116). Shebib (2007) believes that the relationship is the
“foundation for change.” Indeed, many authors, including Shebib, adhere to Carl Roger’s
Client-centred approach, with the primary emphasis on relationship as core to effective
helping.
Criticisms of single session approaches to counselling also extend to those with
renewed interest in Relationship-based practice. According to Ruch (2005), relationship-
based practice challenges “the prevailing trends which emphasize reductionist
understandings of human behaviour and narrowly conceived bureaucratic responses to
complex problems” (p. 111). These views respond to trends in current practice, including
single-session models that adopt what may be seen as a ‘fast food’ approach to
counselling.
In summary, termination conceptualized as an interruption emerged from a
number of divergent influences that include the core social work value of respect for
client self-determination. It also arose in response to societal and bureaucratic trends for
more efficient, less costly and more convenient counselling services. The latter may be
seen as directly opposing another core value inherent in clinical social work practice,
which is the relationship. As such, termination conceptualized as an interruption may
provide a clinical environment that diminishes the value of the clinical relationship.
Termination as a Rite of Passage
A final interpretation of termination that is currently gaining support is the
conceptualization of termination as a rite of passage. Adopted by many social work
counsellors who practice from a narrative or post-modern perspective, this
31
conceptualization values the ending phase of counselling as an opportunity to help clients
form a preferred identity.
Narrative therapists, social workers and authors, Epston and White (1995), refer
to termination as a ‘rite of passage,’ meaning that they emphasize the importance of
“legitimizing the person’s own role on freeing him/herself from the problem-saturated
identity that brought the person to therapy in the first place” (p. 277). The ending phase
is concerned with “joining of the person with others in a familiar social world and
encourages the recruitment of others in the celebration and acknowledgment of the
person’s arrival at a preferred destination or status in life” (Epston & White, p. 277).
According to these authors, ideally, the person’s identity transitions from ‘patienthood’ to
‘personhood’.
Epston and White (1995) suggest that traditional psychotherapy that
conceptualizes termination as a loss reinforces dependency on the therapist, who is
considered the expert in client’s lives. Alternatively, conceptualizing termination as a rite
of passage allows the person to elevate their status to one that is equal to the therapist. It
involves practices that encourage documenting ways that persons have resisted dominant
stories, while eliciting ‘solution knowledges’ and ‘alternative knowledges’ about their
lives and relationships. “These knowledges then become more available for persons to
redeploy when necessary and for others to consult as aids to their own self-development”
(Epston & White, 1995, p. 278). Appearing similar to processes involved in termination
as a transition, Epston and White refer to it as a process of reincorporation.
Described by Epston and White (1995) and White and Epston (1990), practices of
reincorporation may include any of the following: 1) Celebrations that involve awards
32
and prizes and are often attended by significant persons in the person’s life; 2) News
releases, which are written notices highlighting information about the person’s arrival at
a new status that is sent to significant persons in the person’s life and, possibly, to other
agencies or support people; 3) Personal declarations and letters of reference, and; 4)
Formal consultation which includes inviting persons who have completed counselling to
consult with people currently seeking assistance. Utilizing these practices during the
ending phase is thought to allow people to use their solution knowledge, helping them
move towards alternative or preferred knowledge about their lives and relationships.
Termination as a rite of passage incorporates innovative and creative practices
during the ending phase of counselling. These practices allow the individual seeking help
to end therapy by becoming a consultant to themselves and to others. This
conceptualization respects the counselling relationship in that it elevates the status of the
person seeking help from patient to person in their own right. The therapist remains one
of many consultants in the person’s life who can be re-deployed when necessary (Epston
& White, 1995).
In several respects, this conceptualization incorporates many characteristics
valued in termination as a transformation/growth, transition and interruption. While
supporting the development of a preferred identity (transformation and growth), it
formally recognizes a persons transition to join with others in a familiar social world
(transition) while allowing the door for future contact with consultants, including the
counsellor, to remain open (interruption).
However, conceptualizing termination as a rite of passage also challenges a
number of concerns identified with respect to the termination as loss perspective. In
33
particular, it does not elevate the status of the counsellor to that of expert who may take
full responsibility for treatment and outcome. Instead, it allows the practice of
termination to more accurately reflect the values, theoretical perspectives and philosophy
of the clinician practicing in a post-modern era.
Moving Forward
Throughout the history of counselling practice, the ending phase has consistently
taken a back seat in research and education. Freud’s reluctance to address termination
appears to have persisted throughout the 20th century. A number of authors have
acknowledged the significant lack of research focused on therapeutic endings, especially
in comparison to the effort and research that has helped to improve practice in other
phases of counselling. This is evidenced by the relatively few pages devoted to endings
in the majority of current textbooks for counselling practice (Coady & Lehmann, 2008;
Heinonen & Spearman, 2006; Miley et al., 2009; Sheafor & Horejsi, 2006; Shebib,
2007).
However, Lackstrom and Macdonald (2002) emphasize the importance of the
ending phase of counselling with a bold statement: “The keystone of social work practice
is termination” (p. 204). They believe that the, “foundation set during assessment and
built upon during the working stage can be seriously challenged, if not lost, during
termination” (p. 204).
Thus far in this chapter, I have detailed the progression of the practice of
termination through history and more currently within a generalist social work
framework. It is clear that the ending phase of treatment is now moving beyond the
influences of psychodynamic thinking. New and exciting alternative conceptualizations
34
of ending counselling have begun to emerge in the literature that reflects changes in
society’s expectations of counselling in general, and social work practice theory in
particular. It is clear that ongoing interest and research is needed to ensure congruence
between counsellors’ understanding and practice of these emerging conceptualizations of
endings.
The Impact of Unplanned Endings
Moving beyond conceptual understandings of endings, the literature that
specifically addresses the impact of unplanned endings on clients, clinicians and
organizations is now explored. To begin, it is important to discuss the challenges
involved in defining unplanned endings and, as a result, the implications for current
research. Due to the complexities of defining this important concept, the research
literature is both wide-ranging and diverse. The discussion then focuses on research that
illustrates how clients, clinicians and organizations experience unplanned endings, and
how these systems relate to each other.
Defining Unplanned Endings
Researchers agree that defining unplanned endings is challenging. The
inconsistency of definitions has complicated reviews that seek to discover common
features and generalize results (Hunsley et al., 1999; Mennicke, Lent, & Burgoyne, 1988;
Wierzbicki & Pekarik, 1993). Some researchers define unplanned endings as the
unilateral decision of the client to end treatment (Connell et al., 2006; Ogrodniczuk et al.,
2005); while others define unplanned endings according to more specific criteria such as
failure to attend a certain number of scheduled appointments (Weirzbicki & Pekarik,
1993; Tryon & Kane, 1993). Alternatively, Baum (2007) and Pearson (1998) define
35
unplanned endings as examples of forced termination involving the counsellor and the
organizational factors that initiate it.
In one of the earliest and most comprehensive reviews of the literature on
unplanned endings, Baekeland and Lundwall (1975) defined unplanned endings as client
‘drop-outs’ and as occurring in one of the following situations: 1) the client refused to
return; 2) the client failed to return; and 3) the client was expelled from treatment.
Pekarik (1992), another well-known researcher on unplanned endings, offers two criteria:
1) failure to attend the last scheduled visit; and 2) the therapist’s judgement that treatment
was terminated unilaterally by the client against the therapist’s advice. Although similar,
these examples demonstrate the subjectivity involved in operationally defining unplanned
endings.
Additionally, significant and subtle differences in how unplanned endings are
conceptualized and operationalized for research include how and when it is determined
that clients end treatment (Baekeland & Lundwall, 1975; Pekarik, 1992; Wilson &
Sperlinger, 2004). Some researchers have determined that clients end counselling when
they fail to attend one session, a number of sessions, or after a certain amount of time
(Connell et al., 2006; Wilson & Sperlinger, 2004). Connell et al. (2006) also highlighted
that the number of sessions clients attended before an unplanned ending occurred
determined wide variations in prevalence rates.
In their review of the research on unplanned endings, Ogrodniczuk et al. (2005)
offered yet another subjective factor in defining unplanned endings that involved
clinicians’ opinions. “Premature termination typically, but not always, occurs early in
therapy before the patient has experienced significant improvement” (p. 57). Whether a
36
client has improved usually involves the subjective and sole opinion of the clinician and
is often based on whether or not the clinicians determined that treatment goals were
achieved.
The extent of subjectivity and variability in defining unplanned endings has far-
reaching implications. As will be shown, because of this, there is little consensus in the
research about how unplanned endings impact organizations, clients and clinicians.
Impact on Organizations
According to the current literature, organizations and mental health agencies are
particularly impacted by unplanned endings (April & Nicholas, 1997; Connell et al.,
2006; Ogrodniczuk et al., 2005; Pekarik, 1992; Tweed & Salter, 2000; Wierzbicki &
Pekarik, 1993). However, a number of authors and researchers make these claims based
on anecdotal interpretations of prevalence rates (April & Nicholas, 1997; Connell et al.,
2006; Pekarik, 1992; Tweed & Salter, 2000; Wierzbicki & Pekarik, 1993). High rates of
unplanned endings are thought to raise concerns about both the efficacy and cost-
effectiveness of treatment.
Reflecting the sentiments of a number of researchers, Wierzbicki and Pekarik
(1993) suggest that unplanned endings are a “significant obstacle to the delivery of
effective mental health services” (p. 190). Further, unplanned endings are commonly
viewed as a “breakdown of the counselling process and representing a drain on valuable
and limited resources such as time and money” (April & Nicholas, 1997, p. 379).
As indicated, however, these accounts are primarily anecdotal. Apart from
prevalence rates that widely vary according to how unplanned endings are defined, April
and Nicholas (1997) found no research exploring the direct impact of unplanned endings
37
on organizations and mental health agencies. The impact on organizations has typically
been interpreted in the literature to mean financial costs only and this was based primarily
on conjecture.
For example, Connell et al. (2006), citing both April and Nicholas (1997) and
Lucock et al. (2003), suggested that unplanned endings result in increased attrition or no-
shows, which create costs to organizations. As well, Keen et al. (as cited in Tweed &
Salter, 2000) concluded that unplanned endings “may be seen by the organization as an
inefficient use of professionals’ time, producing extra administration tasks and
exacerbating waiting lists” (p. 467). However, these conclusions were based solely on
the authors’ anecdotal interpretations and not on research exploring these factors.
Therefore, apart from the apparent costs to mental health services, little is known
about the impact of unplanned endings on organizations. At the same time, it is clear that
consistently high prevalence rates of unplanned endings have caught the attention of
those who endorse evidence-based practice and the use of outcome studies to evaluate
practice (Lucock et al., 2003).
Ruckdeschel and Balassone (1994) raised concerns about the criteria used for
establishing evidence for accountability in social work practice. Rates of unplanned
endings may be used to establish agency and counsellor efficacy. As noted by Hunsley et
al. (1999) recent outcome studies suggest that client drop-out rates should be used as at
least one indicator of a therapist’s performance.
According to Balassone, the controversy exists not because of general agreement
about the need for accountability and evidence, but rather because of differences in what
defines and constitutes evidence (Ruckdeschel & Balassone, 1994). Therefore, an
38
important question addressed in this exploration of the literature is whether the
prevalence of unplanned endings should be used by administrators as evidence on which
to judge the efficacy of programs and clinicians’ performances.
The concern with this is firstly that research on the reasons for unplanned endings
does not support the commonly-held belief that they represent treatment failure (Connell
et al., 2006; Marx & Gelso, 1987; Pekarik, 1992; Pollak et al., 1992). A number of
factors that are discussed in the next part of this chapter have been shown to influence
clients’ decisions to end treatment.
Secondly, as already noted, there is significant disagreement regarding the various
definitions and conceptualizations of unplanned endings. Prevalence rates vary from
11% to 85% depending on the criteria used to define the concept (Connell et al., 2006).
Finally, the merit of using unplanned ending data to assess clinical efficacy and
establish administrative goals is questionable. Research exploring the impact of
unplanned endings on clinicians has shown that shame, self-doubt, and decreased morale
are the result of beliefs that unplanned endings reflect treatment failure (Hill, Nutt-
Williams, Heaton, Rhodes, & Thompson, 1996; Mirabito, 2006; Tryon & Kane, 1993;
Tweed & Salter, 2000; Wierzbicki & Pekarik, 1993; Wilson & Sperlinger, 2004).
Because evidence of treatment failure is not conclusive and some studies directly
opposed it, using prevalence of unplanned endings to hold clinicians accountable for their
services is questioned.
While Ruckdeschel and Balassone (1994) believe that all clinicians have a
responsibility for accountability to “themselves (in making practice decisions),
administrators and boards that oversee service programs, clients, other social workers,
39
other professionals, policy-makers, and service-funders” (p. 15), there remains
considerable debate about how, or if research on unplanned endings should be used to
meet organizational expectations for accountability. The following discussion about
clients’ experiences of unplanned endings sheds more light on this controversy.
Impact on Clients
Ogrodniczuk et al. (2005) reflected widely-held views that clients who terminate
unilaterally and prematurely, “reported less therapeutic progress and more psychological
distress” (p. 58). These authors add that, when making unilateral decisions to terminate,
patients often experience, “a sense of dissatisfaction or failure, which can result in a
worsening of problems” (p. 58). Baum (2007), April and Nicholas (1997), Tryon and
Kane (1993) and Walsh and Harrigan (2003) concur, indicating that how termination
occurred and how the practitioner managed the ending of therapy affects treatment
outcome. In general, according to these authors, unplanned endings are generally
regarded as negative therapeutic outcomes.
However, Pekarik (1992) has pointed out that few studies directly asked clients
about their experiences of unplanned endings. He believes that this may be due to the
challenge of contacting and recruiting clients who unilaterally end counselling. Along
with his research, four additional studies sought clients’ views and input directly (April &
Nicholas, 1997; Hunsley et al., 1999; Todd et al., 2003; Wilson & Sperlinger, 2004).
These studies focused on the client reasons for what they refer to as ‘dropping out’ or
prematurely ending counselling. Except for April and Nicholas (1997), they also
compared clients’ reasons to those given by their counsellors.
40
Significantly, these studies found contradictory evidence to the widespread belief
that unplanned endings are the result of poor client outcome. Indeed, according to
Pekarik (1992), they found that client dropouts were not a “homogenous group of
dissatisfied or unimproved clients” (p. 96). Instead, they found three major reasons that
clients ended counselling: 1) the problem was improved; 2) practical or environmental
problems impeded access to continued treatment; or 3) dissatisfaction with the therapist
or treatment. In all five studies, environmental circumstances and believing the problem
improved were the two most common reasons cited for discontinuing treatment.
In the study conducted by Hunsley et al. (1999), almost 50% of clients reported
that they had left treatment early because they had accomplished their goals. Pekarik’s
(1992) study found roughly equivalent proportions among three groups of ‘improved’,
‘environmental’ or ‘dissatisfied’ clients. Wilson and Sperlinger’s (2004) qualitative
study concluded that clients who dropped out were likely to reflect that they were
“shopping around,” looking for counselling that was congruent to their expectations. Due
to the wide range of circumstances that lead to unplanned endings, these authors could
not draw any definitive conclusions about the impact of these experiences, however, they
clearly advocated that unplanned endings did not necessarily reflect poor treatment
outcome. Similarly, April and Nicolas’ (1997) survey of 20 ‘premature’ terminators
concluded:
Premature termination was not the result of negative experience of counselling by
the client; nor was premature termination the manifestation of a failed
interpersonal relationship between the client and the counsellor; clients who
41
terminated prematurely are likely to seek counselling again at a later stage in their
lives…. (p. 379)
It is interesting that most of the studies that attempted to understand the impact of
unplanned endings on clients accessed only therapists (Baum, 2007; Boyer & Hoffman,
1993; Hill et al., 1996; Mirabito, 2006; Pekarik & Finney-Owen, 1987; Tweed & Salter,
2000). The conclusions of these studies varied widely, reflecting what Hill et al. (1996)
admits are therapists’ biased views and differing perspectives.
Research exploring therapists’ perspectives resulted in a range of client reasons
for unplanned endings: Motivation or readiness to change (Ogrodniczuk et al., 2005;
Wilson & Sperlinger, 2004); developmental and emotional factors (Mirabito, 2006);
avoidance of painful feelings (Wilson & Sperlinger, 2004); client perceived poor
therapeutic alliance (Tryon & Kane, 1990); and therapeutic impasses (Hill et al., 1996).
In summary, few studies have captured how clients experience unplanned
endings. The researchers that contacted clients directly concur that most clients leave
treatment unexpectedly because of environmental reasons including their ability to
continue paying for counselling, pressure from others such as family or insurance
companies and moving or relocation. Additional to environmental reasons, there was
strong consensus in the research that the majority of clients who left unexpectedly
indicated that they believed their goals for treatment had been met.
Finally, although not a majority, clients also reported that they left counselling
because they were shopping around, not happy with their current counsellor or not happy
with the goals and expectations of counselling (Hunsley et al., 1999; Pekarik, 1992; Todd
42
et al., 2003). Therefore, client views and experiences of unplanned endings varied
widely based on their reasons for leaving counselling.
Impact on Clinicians
This section addresses the research that explored clinicians’ diverse experiences
and clinical interpretations of unplanned endings. Although relatively few studies have
explored the impact of unplanned endings on clinicians, researchers concur that
clinicians’ experiences of unplanned endings are primarily negative and harmful to
practice (Baum, 2007; Boyer & Hoffman, 1993; Connell et al., 2006; Tryon & Kane;
1993; Tweed & Salter, 2000; Wierzbicki & Pekarik, 1993). The reactions most
commonly acknowledged include feelings of failure and demoralization (Connell et al.,
2006; Ogrodniczuk et al., 2005; Pekarik, 1992; Resnick & Dziegielewski, 1996; Tweed
& Salter, 2000).
These studies suggest that many clinicians experienced unplanned endings as
personal rejections that they interpreted as revealing professional weaknesses and failings
(Hill et al, 1996; Ogrodniczuk et al., 2005; Tweed & Salter, 2000). Consequently, the
clinicians reported experiencing painful emotional reactions such as sadness, hurt,
rejection, anger and grief. Such reactions contributed to narcissistic injury that interfered
with clinicians’ ability to help others (Fortune, 1987; Hill et al., 1996; Ogrodniczuk et al.,
2005; Tweed & Salter, 2000).
Resnick and Dziegielewski (1996) supported these findings, suggesting that
unplanned endings may also lead to demoralization and possible burnout. This survey of
144 social workers in short-term medical treatment centres found a strong relationship
between burnout and the absence or lack of therapeutic termination.
43
Similarly, Tweed and Salter’s (2000) qualitative research on psychologists’
reactions to unplanned endings concluded that the clinicians experienced anxiety and
self-blame. However, this study also found that the reason for the anxiety and self-blame
was a strong sense of responsibility for their clients resulting from the adoption of an “all
knowing” expert identity (Tweed & Salter, 2000). Similarly, counsellor reactions of
anxiety and depression were found in Boyer and Hoffman’s 1993 study; however, they
interpreted these reactions as due to the counsellor’s histories of loss.
Conversely, Mirabito’s (2006) recent qualitative study that addressed clinician’s
perceptions of termination with adolescents found differences to what the previously
presented literature suggests. Due to high turnover rates with adolescents in a mental
health setting, the clinicians spent little time planning for or thinking about termination.
They did not perceive unplanned endings as reflections of their abilities or as treatment
failures; many believed that their clients would return to counselling (Mirabito, 2006).
This research suggests that both client and clinic factors impacted how clinicians
experienced unplanned endings.
In summary, the majority of the published research confirms that unplanned
endings have significant and harmful effects on clinicians. Fortune et al. (1992), a well-
known author on termination, conducted surveys exploring the impact of termination on
social workers. Although she found that the clinician’s experiences of termination were
generally positive, she also acknowledged that experiences varied widely when
termination was unplanned, unexpected or was not in the social worker’s control.
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Revisiting Unplanned Endings in Current Practice
Research on the impact of unplanned endings on organizations, clients and
clinicians reflect a great deal of uncertainty and contradiction. Two generally accepted
beliefs could contribute to this uncertainty: 1) clients who leave counselling early are a
homogeneous group of unsatisfied clients; and 2) unplanned endings reflect treatment
failure. Although the research results concur that unplanned endings constitute a
significantly high percentage of clinical caseloads, there is little understanding of the
reasons for its occurrence.
A number of authors have attempted to find common factors that predict or
contribute to unplanned endings. Several addressed client factors (Baekeland &
Lundwall, 1975; Hunsley et al., 1993; Pollak et al., 1992; Wierzbicki & Pekarik, 1993),
however, the majority focused on clinician and counselling factors (Baum, 2007; Boyer
& Hoffman, 1993; Hill et al., 1996; Marx & Gelso, 1987; Pekarik, 1992; Pekarik &
Finney-Owen, 1987; Tryon & Kane, 1993; Tweed & Salter, 2000; Wilson & Sperlinger,
2004).
With the exception of Resnick and Dziegielewski (1996), few studies have
addressed organizational factors that contribute to unplanned endings although some
qualitative studies mentioned this as important for further investigation (Mirabito, 2006;
Resnick & Dziegielewski, 1996). As Connell et al. (2006) summarized, “No simple
demographic characteristics of the client or therapist have been found to consistently
predict client termination apart from (client) socioeconomic variables” (p. 61).
Furthermore, research on the variables related to unplanned endings is often
“inconclusive, conflicting and fraught with its share of methodological problems”
45
(Mennicke et al., 1988, p. 458). This has resulted in debates that challenge
organizations’, clients’, and clinicians’ understanding and interpretations of unplanned
endings.
Nevertheless, this discourse has also led to authors presenting new ideas and
suggestions about the ending phase in mental health practice (Miller, 2008; Pearson,
1998; Pinkerton & Rockwell, 1990; Quintana, 1993). These authors recommend that the
task of defining unplanned endings be revisited because this has the potential to create
new opportunities for mental health clinicians and organizations to provide services that
meet clients’ needs and expectations while minimizing the harmful consequences
clinicians currently experience from significantly high numbers of unplanned endings.
Research that addresses the impact of unplanned endings has given rise to new
ideas and strategies in mental health practice. It has also led to revisiting current
definitions of endings. A number of contemporary authors are considering fresh
approaches to endings and this review, although not exhaustive, highlighted some
examples.
Positioning the Research Question
The existing research on unplanned endings has primarily focused on identifying
the reasons for unplanned endings and, understandably, on the impact of unplanned
endings on clients and agencies. However, a paucity of research has explored the impact
of unplanned endings on counsellors (Baum, 2007; Boyer & Hoffman, 1993; Fortune,
1987; Ogrodniczuk et al., 2005). The few studies conducted to date suggest that
counsellors’ experiences of unplanned endings are, for the most part, negative and
harmful to practice.
46
Recently, research have emphasized that how endings occur reflects the strength
and quality of the counselling relationship (Baum, 2007; Pearson, 1998; Gelman et al.,
2007; Tryon & Kane, 1993). This research suggests that unplanned endings are the result
of poor working alliances between the counsellor and client (Tryon & Kane, 1993). The
focus of many of these studies has emphasized counsellor characteristics and deficits that
contribute to feelings of failure and self-blame. This emphasis reinforces perceptions that
counsellors are somehow to blame for unplanned endings.
While recognizing that unplanned endings of counselling relationships are shared
phenomena across many clinical contexts, the purpose of the current study is to explore
counsellors’ experiences of unplanned endings as well as the impact this has on current
clinical practice. It is hoped that this exploration will not only clarify long-held beliefs
and assumptions about this common experience, it will also contribute to social workers’
understanding of how counsellors with significant experience in the field conceptualize,
interpret and process unplanned endings in clinical practice.
It has been my experience that this topic is rarely addressed openly in clinical
practice or in social work education. Perhaps this is due to existing underlying
assumptions about the causes of unplanned endings, such as counsellor deficits or
inexperience. As such, it is anticipated that the research may also facilitate dialogue and
transparency in clinical practice for the benefit of students and counsellors alike.
This research involves a qualitative examination of ten expert counsellors’
experiences of unplanned endings and how these endings impact them and their practice.
The criteria for participants included they have a minimum of five years of counselling
experience with a graduate degree in a related field. The purpose of this research was to
47
answer the following major question, “How do counsellors experience unplanned
endings?” More specifically, the research meant to uncover: a) how counsellors
understand unplanned endings; b) how counsellors are impacted by unplanned endings;
and c) how unplanned endings affect counsellors’ clinical practice.
How counsellors experience unplanned endings involves inquiry into what they
know, how they react, and the impact of these experiences in practice. Few researchers
have directly asked counsellors how they understand and experience this common
phenomenon as this study intends to do. The results will add to our limited
understanding of unplanned endings and point to new directions in clinical research and
practice.
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CHAPTER THREE: STUDY DESIGN AND METHODOLOGY
As previously highlighted, across a variety of clinical contexts, an estimated
almost 50% of clinical relationship endings are unplanned (Connell, et al., 2006;
Mirabito, 2006; Ogrodniczuk et al., 2005). The sheer prevalence of unplanned endings in
practice reflects an important deficiency in our practice knowledge and theory. Research
with respect to how counsellors experience unplanned endings and how these experiences
impact practice is imperative if we are to improve the practice of ending counselling, and
consequently, the counselling services offered to clients.
This chapter explores grounded theory methodology as a form of qualitative
inquiry that is appropriate and useful for this dissertation topic. I begin by locating the
research in the context of qualitative inquiry. Grounded theory is then defined and
described with important constructs that make this form of qualitative research unique.
These include the purpose of data, constant comparison and theoretical sampling. This
chapter addresses the philosophical underpinnings of grounded theory and how a
constructivist perspective is accommodated by and influences grounded theory methods.
Providing an argument that supports utilizing grounded theory methods leads to the
central focus of this chapter, grounded theory process. The processes of reflexivity,
participant recruitment, data gathering and interviewing, analysis, and finally,
establishing trustworthiness are explained.
Locating the Research
According to Denzin and Lincoln (2005), qualitative research is a practice that
endeavours to make the world more visible. They believe that qualitative research is an
effort to understand the world by “attempting to make sense of, or interpret, phenomena
49
in terms of the meanings people bring to them” (p. 3). Seeking answers to questions
about how experiences are created and given meaning, “Qualitative researchers stress the
socially constructed nature of reality, the intimate relationship between the researcher and
what is studied, and the situational constraints that shape inquiry” (p. 10).
To this end, researchers use a variety of methods and practices that involve
creating a “complex, holistic picture” of an area of inquiry (Creswell, 1998). They
interview and record detailed accounts of informants’ experiences, and incorporate a
variety of empirical materials to describe and capture meanings in individuals’ lives
(Denzin & Lincoln, 2005). Aiming to uncover multiple dimensions of complex issues or
problems; qualitative research is exploratory, requiring study of individuals in their
natural setting (Creswell, 1998).
Exploring counsellors’ experiences of unplanned endings requires qualitative
methods. This approach captures what unplanned endings mean to participants and how
these experiences shape their practice. Unplanned endings are complex processes that
require in-depth exploration of the people who experience them regularly.
Qualitative inquiry can take many forms and reflect a variety of epistemological
and ontological perspectives. The particular methodology chosen is often guided by the
nature of the inquiry, the questions one hopes to address, and the researchers’
philosophical perspectives. Grounded theory is one form of qualitative inquiry that is
flexible, accommodating a variety of epistemological and ontological influences
(Charmaz, 2006; Corbin & Strauss, 2008). Its aim is to uncover social processes and
develop theory to capture these processes. Currently, theories on processes of endings
are considered to be outdated as they do not address processes of unplanned endings.
50
Therefore, grounded theory is an appropriate qualitative methodology for the purpose of
this research.
Grounded Theory
Grounded theory is a research method that provides guidance and structure to the
process of collecting and analyzing qualitative data (Charmaz, 2006). It was originally
developed by Glaser and Strauss and described in their 1967 publication “The Discovery
of Grounded Theory”. Considered an effort to legitimize the practice of generating
theory as a science, grounded theory is an inductive process for discovering theory that is
grounded in the data itself (Glaser & Strauss, 1967).
Glaser and Strauss (1967) developed grounded theory methods to uncover social
processes and construct substantive or formal theory. They described substantive theory
as “middle range”; falling between a minor working hypothesis and an all-inclusive grand
theory. Substantive theory is developed for one particular area of inquiry usually
focusing on one clearly defined substantive area. Examples include patient care,
education or delinquency. Alternatively, formal theory is considered to be more
conceptual (Glaser & Strauss, 1967). Examples include deviancy, stigma or processes of
power. Discussed further in the next part of this chapter, this research lies within the
substantive area of clinical endings and includes an exploration of the perceptions and
experiences of mental health counsellors when faced with unplanned endings.
Grounded theory methods begin with close involvement and interaction with the
data (Bryant & Charmaz, 2007). Barney Glaser (2002) believes all is data and that data
is used “for conceptualization to be what it is – theory” (p. 1). According to Charmaz
(2006), data form the foundation of theory that emerges from an iterative process of
51
moving back and forth between data and emerging analysis. This is more commonly
referred to as a process of constant comparison.
Constant comparison is defined as a rigorous process that underlies grounded
theory method (Charmaz, 2006; Glaser & Strauss, 1967). This process guides how data
is used to make connections that bridge important constructs together. The data is
studied, compared to each other, interpreted and written in a process that allows tentative
analytic categories to emerge (Charmaz, 2006).
Levels of abstraction build as additional data is gathered. This involves another
fundamental process to grounded theory referred to as theoretical sampling. This crucial
process involves seeking new data in order to check and refine the emerging analytic
categories (Charmaz, 2006). Theoretical sampling assists in accounting for variations of
the data, allowing for theory to be developed inductively (Glaser & Strauss, 1967).
Developing new theory, whether substantive or formal, is the primary goal of grounded
theory (Glaser & Strauss, 1967).
Philosophical Underpinnings of Grounded Theory
Glaser and Strauss (1967) first conceived grounded theory from an objectivist,
post-positivist perspective. At that time, traditional grounded theorists believed that
reality existed but that it could only be imperfectly understood (Mills, Bonner, & Francis,
2006). The methods and philosophical underpinnings of grounded theory have since
evolved to reflect a variety of ontological and epistemological positions. One of the more
recent has been constructivist grounded theory (Bryant & Charmaz, 2007; Charmaz,
2003, 2004, 2006).
52
From a constructivist perspective, knowledge is viewed as ‘constructed’, which
means that knowledge does not reflect an external truth or reality. Constructivism is
based on relativism, which involves an appreciation for multiple truths and realities.
Charmaz (2003, 2004, 2006) traces constructivist grounded theory back to its roots in
pragmatism. According to Charmaz (2006), pragmatism informs symbolic interactionism
that “assumes society, reality and self are constructed through interaction” (p. 7).
Language and communication are interpretive and underlie the meanings people
create. However, Charmaz states that a constructivist approach “goes one step further by
making everyone’s vantage points and their implications explicit” (Charmaz, 2006, p.
184). Therefore, it is argued that adopting this approach means recognizing and
incorporating the influences of traditional thinking behind the methods of grounded
theory while advancing them further into a more reflexive stance (Charmaz, 2003, 2006).
A constructivist approach to grounded theory captures and conceptualizes the
methods and in particular, the interview, in a manner that is congruent with my
epistemological beliefs and practice experience. This approach is ontologically relativist
and epistemologically subjectivist highlighting the importance of reflexivity, reciprocity
and transparency (Charmaz, 2006; Mills et al., 2006). By recognizing that meaning is co-
created, constructivist grounded theory reflects how meaning becomes data that
eventually forms the foundation of the emerging theory.
Challenging the traditional objective/observer role researchers adopt with
participants in other forms of qualitative research, Mills et al. (2006) describe how a
constructivist approach promotes equality, mutuality and transparency in the research
53
relationship. The researchers’ subjective interpretations along with their influence on
participants are made clear or transparent throughout the research process.
Grounded theory methods require interpretation (Charmaz, 2006; Clarke, 2005;
Corbin & Strauss, 2008; Glaser & Strauss, 1967; Strauss & Corbin, 1998). However,
epistemology and ontological perspectives will influence the degree of interpretation and
how this interpretation is accounted for in the research. Piantanida, Tananis and Grubs
(2004) suggest using grounded theory methods in ways that are flexible and appropriate
for a variety of research interests. They warned against the pull to “find and follow the
one ‘pristine’ method of grounded theory” (p. 329). A number of grounded theory
researchers have integrated traditional methods of analysis within more current
epistemological and ontological frameworks (see Charmaz, 2006; Clarke, 2005).
This research was designed with consideration of methods that were best suited to
address the purpose of this research, while supporting my philosophical and
epistemological perspectives. Glaser and Strauss (1967), Corbin and Strauss (2008),
Strauss and Corbin (1998), and particularly Charmaz (2003, 2004, 2006) contributed to
my understanding of grounded theory methods, and influenced my thinking about how to
conduct this dissertation research.
Grounded Theory Processes
According to Charmaz (2006), grounded theory is a method that provides tools
for analyzing processes. She describes how grounded theory creates an analysis of an
action and process that answers the questions: “What is happening here?” and “What are
the basic social and psychological processes involved?” Corbin and Strauss (2008)
define process as “an ongoing action/interaction/emotion taken in response to situations,
54
or problems, often with the purpose of reaching a goal or handling a problem” (p. 96). In
short, a process refers to how people act or react in response to something. A process
occurs over time and incorporates sequential activities that express purpose and
continuity (Corbin & Strauss, 2008).
Counselling relationships that end in unplanned ways imply processes. Grounded
theory methods allow the researcher to explore and understand these processes, which,
according to Glaser and Strauss (1967), will eventually lead to the development of
theory. Thus, the purpose of this research is to develop substantive theory about how
unplanned endings are experienced by counsellors.
Provided with the context within which this research is now situated, more
specific grounded theory processes will be explored in this section. This begins with an
important discussion about reflexivity. Describing what it means to take a reflexive
stance informs how this research was conducted. This is followed with descriptions of
more specific grounded theory processes including how data is gathered, analyzed,
written, and evaluated for trustworthiness and rigor.
Reflexivity
Accepting a constructivist position that reality is co-constructed and
acknowledging that interpreting data is, itself, a construction to which I am inextricably
linked, I must account for and differentiate my own interests, positions and assumptions
in this research. This process is referred to as reflexivity.
Myerhoff and Ruby (as cited in Ahern, 1999) defined reflexivity as, “the capacity
of any system of signification to turn back upon itself, to make itself its own object by
referring to itself” (p. 408). This means acknowledging my feelings, beliefs, values and
55
experiences that not only led to this topic but also influenced the interviews, analysis and
interpretations. The goal of reflexivity involves both the acceptance of my subjectivity
and the honest evaluation of how this may influence the research.
Summarized by Charmaz (2006), a reflexive stance “informs how the researcher
conducts his or her research, relates to the research participants, and represents them in
written reports” (p. 189). It allows the reader access to a process of scrutiny while
aspiring towards transparency and honest reflection at each stage of the research process.
For example, my personal and professional experiences as a social work
counsellor and educator led to my initial interest in unplanned endings. Experiencing
unplanned endings on numerous occasions helped me to connect with this topic
intimately. Colleagues, fellow students, advisors, and teachers have since provided
insight, clarity, and their own interpretations about my topic. This led to an initial review
of the literature that helped to refine this topic and solidify the research questions. It also
provided support and a rationale to undertake this study. Much of this work influenced
my interpretations and focus of the study.
Engaging in a process of reflexivity, from the original conception to the analysis
and writing, allowed the opportunity to incorporate prior work into the research, and to
describe how these actions influenced my interpretations and shaped my thinking about
unplanned endings. I used journaling to trace the evolution of my thinking including how
this influenced the research through many transitions and turning points. I used
journaling and memo-writing to facilitate transparency throughout the research process.
In the end, it is believed that my efforts towards reflexivity enhanced the rigor and
trustworthiness of the research (Hall & Callery, 2001).
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Another practical method used to incorporate reflexivity prior to data collection
involves conducting practice interviews and the more innovative ‘self interview’. In an
email exchange, Chenail and Onwuegbuzie described their preliminary ideas about the
value and utility of engaging in these practices for novice qualitative research
interviewers such as me (personal communication, R. Chenail & A. Onwuegbuzie,
October 15, 2008). The goal of conducting practice and self-interviews is to improve and
amplify the researchers’ awareness of their experiences, thoughts, feelings and
perceptions.
Onwuegbuzie suggested that the investigator participate in a number of practice
interviews throughout the research process. He encouraged novice researchers and
students to experience what it may feel like to be interviewed before conducting their
own. Subsequent analyses of tape recordings heighten reflexivity as potential sources of
bias are exposed. This bias includes:
The researcher’s interview background/experience; perceptions of the
participant(s); perceptions of non-verbal communication; interpretations of
interview findings/interpretations; perceptions of how the study might have
impacted the researcher; perceptions of how the researcher may have impacted
the participant(s); awareness of ethical or political issues that might have arisen
before, during, or after the interview(s) and; identification of unexpected issues or
dilemmas that emerged during the interview(s). (personal communication, R.
Chenail & A. Onwuegbuzie, October 15, 2008)
Chenail also described a pre-pilot self-interview he referred to as ‘interviewing
the investigator’. With the use of a recorder, the interviewer analyzes questions and the
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overall structure of the interview by asking her/himself questions and attempting to
answer them. In this way, assumptions and bias are exposed prior to subjecting research
participants to the questions.
The value of engaging in these activities prior to and during the research process
not only led to enhanced reflexivity, it also enhanced the interview process. Practice and
reflection on potential questions, wording, and structure, allowed this researcher clearer
interpretations of the participants’ experiences while making the most use of their time.
It also avoided using participants in a pilot study, which would have negated their
involvement in the main study (personal communication, R. Chenail & A. Onwuegbuzie,
October 15, 2008).
Overall, I remained committed to the practice of integrating various methods to
improve reflexivity throughout this research process. This included journaling, reflexive
memo-writing, practice pilot interviews with a colleague and a supervisor, and self-
interviews.
Gathering Data
Within this context of reflexivity, I now explore the processes involved in
gathering data. This includes the selection of participants, recruitment and interviewing
process.
Selecting Participants
In this research, I am concerned with understanding how counsellors working in
mental health settings experience unplanned endings and how that impacts their clinical
practice. Mental health counsellors with extensive knowledge and practice experience
were considered to be the best resource to explore this topic. Therefore, I sought
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participants with a minimum of a Masters degree plus five years of clinical supervision or
practice from the disciplines of social work, psychology, nursing, psychiatry or family
therapy.
Counselling practice in mental health is broad and encompasses a variety of
clinical services. It is generally understood that experienced counsellors are employed in
many of these clinical environments. I chose to interview counsellors who previously or
currently work in mental health settings including the Calgary Health Region, Alberta
Mental Health, Mount Royal University, Family Psychology Centre and private practice
agencies.
Recruitment Strategies
The research participants were recruited using purposive sampling. A notice was
created inviting experienced mental health counsellors to participate or to nominate
others they considered to be expert clinicians. These notices were sent to colleagues and
managers of counselling agencies. Referred to as ‘snowball’ sampling, “the researcher
makes initial contact with a small group of people who are relevant to the research topic
and then uses them to establish contact with others” (Bryman & Teevan, 2005, p. 227).
A letter of invitation was sent to nominated individuals asking for their
participation in the research. After completing their interviews, I inquired whether they
could recommend anyone else who met the criteria and might be interested in
participating. This method of sampling was very effective and was particularly relevant
to the purpose of theoretical sampling in grounded theory.
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Theoretical Sampling
Theoretical sampling is a method of collecting data that responds to the data
(Corbin & Strauss, 2008). What this means is that it involves seeking out data
deliberately and purposefully to help fill out and strengthen emerging categories.
According to Glaser and Strauss (1967), theoretical sampling reflects a process of how to
collect data that will eventually develop emerging theory: “This process of data
collection is controlled by the emerging theory, whether substantive or formal” (p. 45).
Sampling and finding new data occurs as a response to what has already been collected,
coded and analyzed, in an effort to further develop theory. According to Charmaz
(2006): “You conduct theoretical sampling by sampling to develop the properties of your
category(ies) until no new properties emerge” (p. 96).
Theoretical sampling is directive and predictive. It guides the researcher to
avenues for further exploration while aiming to fill out properties of major categories
(Charmaz, 2006). Taking many forms, theoretical sampling includes seeking new
participants, re-interviewing initial participants, studying documents or cases, observing
events, or finding comparison groups.
Charmaz (2006) believes that what you look for and how you go about doing it
depends on your reasons for doing it. “Through theoretical sampling you can elaborate
the meaning of your categories, discover variation within them, and define gaps among
categories” (p. 108). In this research, theoretical sampling helped to raise the conceptual
level of the emerging categories and extended the analysis to emerging theory
development. As the interviews and data analyses progressed, more detailed questions
were asked of participants to help clarify, understand, and expand on emerging themes
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and categories. Described next, the interviewing process evolved over time to address
the purposes of theoretical sampling.
Interviewing
Interviewing is the most common form of data collection in qualitative research
and because of my experience as a counsellor; I found it to be the most rewarding part of
conducting this research. Kvale (1996) wrote that the research interview “attempts to
understand the world from the subjects’ points of view, to unfold the meaning of peoples’
experiences, to uncover their lived world prior to scientific explanations” (p. 1).
Participants are asked to share personal and often intimate aspects of their
experiences that help researchers uncover meaning and heighten understanding. They
may find this experience to be risky; however, Corbin and Morse (2003) believe that it
can also be a positive and rewarding experience. My preference was to conduct
relatively unstructured interviews in keeping with constructivist principles that allow data
to emerge through a transparent co-creation of meaning. This involved my willingness to
openly share my interpretations of what the participants were saying during the
interviews.
Corbin and Morse (2003) described the nature of unstructured, interactive
interviews. Different from semi-structured or structured interviews, unstructured
interviews allow the participants considerable control over the direction and process of
the interview. The purpose of these interviews is to provide guidance without directing
or anticipating outcomes.
With underlying principles similar to a constructivist approach to interviewing,
unstructured interviews focus on the telling of the participants’ stories. It recognizes
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reciprocity in the process of the interview while the central focus remains on the
participants and their narratives.
Charmaz (2006) described the intensive interview as “open-ended yet directed,
shaped yet emergent and paced yet unrestricted” (p. 28). Intensive interviews allow for
in-depth exploration of a topic with a person who has the relevant experiences and
insights. The underlying processes of reciprocity and bracketing help to fulfill this goal.
In a constructivist grounded theory interview, the researcher endeavours to create
a sense of reciprocity (Mills et al., 2006). Reciprocity leads to co-creation of reality,
grounded in both the interviewers’ and participants’ experiences (Mills et al., 2006). This
means that the influence of the researcher on the process of interviewing, the participant
and the resulting meaning or data that emerges from that interview is acknowledged
(Charmaz, 2006). The implication of this is how researchers account for themselves in
the research interview (Ahern, 1999; Gearing, 2004; Sword, 1999).
Accounting for my influence in the interviews involved exploring the context of
the conversations from which the participants’ expressed their insights and thoughts. I
accounted for myself in terms of recognizing how the mutual construction of meaning
emerged and effort was made during the interview to clarify and expand my
interpretations as they occurred.
Gearing (2004) believes that researchers can utilize what is referred to as reflexive
bracketing to “become consciously self-aware of their influence on the phenomenon
under investigation” (p. 1449). Bracketing refers to a process that helps to contain the
influence of assumptions and suppositions during the research interview (Ahern, 1999;
Gearing, 2004). Challenged by some as impossible, I conceptualized this process in a
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similar manner to how I might in a therapeutic interview: It involves consciously
recognizing my bias, assumptions and history and then ‘containing’ those during the
conversation by sharing them consciously and appropriately with the participants. For
example, I might say “It sounds like you don’t like the term ‘unplanned’ and I’ve
struggled with that term myself. Could you tell me more about your thoughts on how we
are using this term and what it means to you?” In this way, I am transparently grappling
with how we are using the term ‘unplanned’ during the interview and my effort shifts to
uncovering and co-creating new understanding and meaning in the conversation.
Although unstructured, three main questions initially helped to provide guidance
in the research interviews: “How do you understand unplanned endings?” “How do you
feel about unplanned endings?” and “How do unplanned endings impact your work?”
These questions served to begin initial conversations about unplanned endings;
subsequent questions (see Appendix A) deepened and broadened the conversations from
which new understanding and insight about unplanned endings were found.
The interviews were scheduled at the convenience of the participants,
accommodating their preferences to meet in their homes, at their work and other
locations. The interviews lasted an average of 1½ hours. I requested follow-up
interviews for an additional hour, which were conducted with five of the ten original
participants. In total, fifteen interviews were used in the research analysis.
Analysis
Traditional grounded theory methods suggest that when interviews begin, the
process of analysis also begins. The analysis of the current research began after the third
interview was completed and transcribed.
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This section describes the process of analysis, beginning with a description of
initial/open coding and focused/selective coding, and followed by a discussion on
grounded theory processes involved in memo-writing, theoretical sampling and
saturation. These methods provided guidance and formed the basis to analyzing data in
this grounded theory research.
Corbin and Strauss (2008) see analysis as an act or process that gives meaning to
data. This process begins with ‘delineating the context’ and involves recognizing and
appreciating the conditions under which the research occur, including how something is
said, done or felt. Corbin and Strauss (2008) believe that ‘context’ helps to ground the
concepts while “minimize(ing) the chances of distorting meaning and/or misrepresenting
intent” (p. 57).
In this study, I address context in the form of reflexivity, by including a
description of participants, their work environments and my general impressions of the
how participants presented during the interview. Journaling and memo-writing assisted
to reflect what I saw, how I was impacted by the participants, and my overall general
impressions of the interview. These reflections were expressed in my interpretations of
the data as I pulled the pieces together to create a sense of meaning.
Sword (1999) suggests that consciously reflecting on the influence of self creates
awareness of how the research is shaped and “provides a context within which audiences
can more fully understand the researcher’s interpretation of text data” (p. 270). Within
this broad understanding of context, formal analysis, or coding, began.
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Coding
As originally suggested by Glaser and Strauss (1967), the formal analysis of the
data begins early in the research process. Qualitative coding is the first analytic step.
Corbin and Strauss (2008) referred to coding as taking raw data and raising it to a
conceptual level. It involves ‘thinking outside the box’ and, “it means putting aside
preconceived notions about what the researcher expects to find in the research, and letting
the data and interpretation of it guide analysis” (p. 160).
Charmaz (2006) also believes coding to be much more than paraphrasing. It
involves “moving beyond concrete statements in the data to making analytic
interpretations” (p. 43). The process of coding involves steps that assist in linking data to
the development of theory, which then explains the data. These steps involve two main
phases: initial or open coding, and focused or selective coding.
Initial/Open Coding
Referred to as open coding by Corbin and Strauss (2008) and initial coding by
Charmaz (2006), the first step in analysing the data involves a brainstorming approach
that “open up the data to all potentials and possibilities contained within them” (Corbin &
Strauss, 2008, p. 160). This is done by scrutinizing the data line by line.
Charmaz (2006) recommends that the researcher quickly look at each line of data
and spontaneously apply words of action to denote what is occurring. Line-by-line
coding allows the researcher to take a close look at what the participants are saying and
with what they struggle. The purpose of these initial codes is to describe the participant’s
meaning or action. Staying close to the data, remaining open-minded, and keeping the
codes simple and precise are the first steps suggested by Charmaz.
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Line-by-line coding also helps to keep the focus of the analysis on emerging
processes. Emerging processes become defined when initial codes reflect action.
Charmaz (2006) recommends asking questions of the data that help focus on processes
rather than descriptions: Attempting to make analytic sense of the material, careful initial
line-by-line coding helps to keep the focus of the research on the processes, addressing
what is happening while making relationships between “implicit processes and structures
visible” (Charmaz, 2006, p. 54).
Charmaz also recognized the merits of analysing data line by line to help contain
bias. This is because the detailed account of the data provides a sense of distance from
the researchers’ preconceptions and assumptions so that experiences of counsellors can
be seen in a fresh new light.
I conducted line-by-line coding as the first step in this analysis, which helped to
stimulate new ideas and directed the research to new avenues to explore. I initially kept
the process structured and routine as I interpreted each word and line of data to reflect an
action. These action words were typed beside the text in a different color so I could refer
back to them in my analysis.
As the research and analyses progressed, additional information and details were
sought from the subsequent interviews helping to expand and fill out the initial codes.
Using what Glaser and Strauss (1967) referred to as ‘constant comparative methods’,
data was compared with other data to find similarities and differences. Data was
compared from different interviews and also the same interview at different times.
Summarized by Hallberg (2006), the constant comparative method includes every
part of the data: “emerging codes, categories, properties, and dimensions as well as
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different parts of the data…constantly compared with other parts of the data to explore
variations, similarities and differences in data” (p. 143).
Allowing for emergent themes to unfold naturally and creatively, the guidelines in
the process of constant comparison are intended to be flexible, as opposed to following
rigid rules (Glaser & Strauss, 1967; Hallberg, 2006; Strauss & Corbin, 1998). Tentative
categories that made sense of data emerged through this process of comparison. Thus,
began the journey into further abstract understanding of events and meanings through
focused or selective coding.
Focused/Selective Coding
The next important step in analyzing the data is referred to as focused or selective
coding. Selective coding further refines and synthesizes the data. Rather than pursuing
every category or concept that emerges from the data, analysts must use judgment and
select only a few important variables (Corbin & Strauss, 2008).
Charmaz (2006) referred to this process as focused, describing it as pulling
together and interpreting larger amounts of data. Prevalence, usefulness and
appropriateness of the initial codes lead to new categories as they are compared to each
other and then as they are compared to newly introduced data. In summary, focused
coding condenses the data.
This process is iterative, meaning that I needed to go back and forth with the data
and actively engage in a process of emergence and the unexpected (Charmaz, 2006).
Charmaz encourages researchers to embrace a sense of adventure and playfulness with
the data. She believes that coding should be flexible; moving from the concrete to
possible analytic theory.
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The initial codes that reflected action were grouped together in segments of the
interviews and then analyzed in terms of ‘what are they telling me?’ I then wrote a
summary or memo of my interpretation at each break in the data and titled these.
Sometimes the titles were similar to each other which made comparison of the codes
easier to address.
Diagrams also helped me to visually see the links in the codes and categories
during the initial stage of analysis and coding. With visual representation, I was able to
track how data formed the properties that emerged into codes. They also visually
represented comparison of data with data and with codes, to further advance more
abstract analysis. As mentioned, memos served an important function in this process and
are thus described next.
Memo-Writing
Writing memos is considered imperative in the analytic process according to
Charmaz (2006) and Corbin and Strauss (2008). These authors believe that writing is
fundamental to the process of raising data to codes, codes to categories and categories to
theory. Memos provide a record of the researcher’s thinking that make the process of
analysis transparent (Charmaz, 2006; Corbin & Strauss, 2008). They also reflect gaps in
thinking that lead the researcher to explore concepts further.
According to Charmaz (2006), writing memos help to make ideas more abstract.
“Memos catch your thoughts, capture the comparisons and connections you make, and
crystallize questions and directions for you to pursue…(it) makes the work concrete and
manageable – and exciting” (p. 72).
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Charmaz (2006) and Corbin and Strauss (2008) emphasize the need to write
memos early and continue throughout the research process. The writing process is
considered fundamental to engaging with the data: “It is not the form of memos that is
important, but the actual doing of them…. (It) forces the analyst to think about the data
(Corbin & Strauss, 2008, p. 118).
As a novice grounded theory researcher, I relied on different types of memos
throughout the analysis. Initially they helped to group the initial codes together and
interpret their meaning. Then they helped to reflect what I saw when I compared the data
to each other and to other memos. My interpretations in the memos also asked questions
of the data that allowed me to think about how I might explore that concept further. I
was careful not to assume that any of my initial interpretations were true until I had the
opportunity to question them openly with participants through theoretical sampling.
Thinking creatively and in pictures, the process of ‘clustering’ described by
Charmaz (2006) and using visual ‘diagrams’ according to Corbin and Strauss (2008) also
assisted in the process of writing memos while furthering my analytic thoughts and ideas.
In summary, writing memos helped me to define the codes and categories; make
comparisons between data, codes, and categories; bring new ideas and data into the
research; support my decisions and definitions with empirical evidence; ask questions of
the data and my interpretations of the data, and finally; identify gaps in the data, and in
the process of my analysis (Charmaz, 2006).
I began the analysis after the first three interviews were transcribed. Initial line-
by-line coding and analysis that included a number of tentative memos led to preliminary
categories. The preliminary categories were then questioned further in subsequent
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interviews to fill out the properties of the categories, which led to furthering analytic
definitions. Through theoretical sampling, I not only uncovered new avenues to explore,
but also expanded on existing categories to demonstrate the links between them. To do
this, I had to keep focused on the processes that were being uncovered and avoid my
tendency to get caught up in description and details.
Additional information was also used in the analysis. Journals, data from the
literature, case notes and consultation with supervisors were all used to help fill out
properties of categories and raise the conceptual level of the data. It was interesting to
me that every time I felt stuck in terms of what was emerging; I realized that I needed to
go further in my interpretations. Getting caught up in details and descriptions often led to
a dead-end in the analysis. When this happened, I consulted with my supervisors,
reflected openly with colleagues and supportive people in my life and I took time away
from the data. I also met with five of the participants a second time to ask for their input
about the emerging categories. Their insights kept the research focused yet allowed for
further analytical insights. However, deciding when to stop collecting data was a
challenge. This is referred to as reaching saturation.
Saturation
A contentious issue in grounded theory is when to stop or how to determine that
saturation is achieved. Charmaz (2006) believes that “categories are saturated when
gathering fresh data no longer sparks new theoretical insights, nor reveals new properties
of these core theoretical categories” (p. 113). However, many researchers may not be
able to discern when this happens. Instead, they look for repetition as a sign that no new
properties are emerging. Glaser (1978) warned against the tendency to look for
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repetition. However, he provided little understanding of what else a novice researcher
might see that would reflect saturation has occurred.
Alternatively, Corbin and Strauss (2008) accept that total saturation is unlikely to
be achieved. They believe that saturation occurs and sampling is sufficient when “major
categories show depth and variation in terms of their development” (p. 149). They
suggest that this becomes evident when the researcher stays focused on data that has
relevance to the analysis. Knowing that saturation has occurred is much more difficult if
the researcher gets distracted by new information that has little bearing on the concepts.
In this study, I used theoretical sampling to fill out properties of the categories
until new data no longer sparked new theoretical insights. I used my intuition and trusted
that I exhausted ‘sufficient’ data to support the emerging categories while ensuring that
those categories showed depth and variation. The process of constant comparison helped
to uncover the similarities as well as the differences in the categories and once these were
exhausted I was ready to pull the saturated categories together to reconstruct theory of
counsellors’ experiences of unplanned endings. I had to continually ask myself over a
period of weeks how these categories fit together and also what is happening between
them to be able to construct new theoretical insights and meaning. Considerations of
writing the grounded theory research are now presented.
Writing
Writing is not only an important feature to grounded theory research, it is also
considered to be a crucial part of the analysis (Charmaz, 2006; Corbin & Strauss, 2008).
The process of writing allowed me to continually extend to the analysis by providing
opportunity to clarify and enrich the emerging concepts.
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Charmaz (2003, 2006) believes that the process of writing is ambiguous and
challenging, however, it is a process that must be pursued and trusted: “Learning to trust
in the writing process, if not in ourselves, is like learning to trust in the grounded theory
analytic process: our writing, like our analyses, is emergent” (Charmaz, 2006, p. 155).
The writing process involves reflection and evaluation. This includes describing
how the memos relate to each other and the process involved in making these
connections. Recommended by both Charmaz (2006) and Corbin and Strauss (2008), it
requires extensive studying, sorting, writing and re-writing as the concepts and ideas take
form.
Importantly, the goal of writing is to satisfy the participants who read it that the
story is understood. There is an effort to pull the reader in so they can sense and situate
the feelings conveyed by the author. As Charmaz (2003) states: “Through sharing the
worlds of our subjects, we come to conjure an image of their constructions and of our
own” (p. 281).
Trustworthiness/Rigor
Evaluating the trustworthiness, rigor or, as Corbin and Strauss (2008) refer to the
‘quality’ of the research, differs among grounded theory researchers. From a
constructivist perspective evaluative criteria are a construction itself, and therefore, open
to debate (Corbin & Strauss, 2008). Nevertheless, foundational authors in grounded
theory including Glaser (1978), Glaser and Strauss (1967), Corbin and Strauss (2008),
and Charmaz (2006) agree that some criteria must be used to judge and evaluate the
trustworthiness of the research.
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Glaser (1978) suggests four criteria from which to assess trustworthiness: fit,
work, relevance and modifiability. However, Charmaz (2006) believes that these criteria,
although relevant, are limited to how theory is constructed. She suggests going further to
address credibility, originality, resonance and usefulness. In my efforts to abide by
constructivist methods to grounded theory, the following summarizes the criteria I used
to form the basis from which to judge the trustworthiness of this research.
First, evaluating the credibility of the research involved conveying that I had
achieved intimate familiarity with the topic. It is also important to ensure there is
sufficient data to merit the claims made; providing evidence to make certain the reader is
able to independently assess and agree with these claims.
In terms of this research, emergent categories covered a wide range of empirical
observations from a variety of counsellors with diverse experiences. The participants are
cited within the text to support the interpretations throughout the analysis. The links
between the categories and resulting analysis are supported by the data and
interpretations of the data.
Second, in terms of originality, the focus on the ending of counselling
relationships is not new but it has taken a back seat in education and research in the
recent decades. Counselling processes are continually adapting to meet the changing
demands of individuals and society. I hoped to offer new insights into how unplanned
endings are experienced by counsellors and how this affects their practice. I used the
literature to explain the social and theoretical significance of this research, describing
how this grounded theory research has the potential to advance the understanding of
endings in current clinical practice.
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Third, how this study resonates with counsellors and academics in the field
depends on whether the categories “portray the fullness of the studied experience”
(Charmaz, 2006, p. 182). Revealing what the experiences of unplanned endings meant to
the participants was important in this process. It was also important to ensure that this
research made sense and offered deeper insights to the counsellors. This involved
sharing the development of the theory with the participants, my supervisors, and also
interested friends and colleagues. As well, support, guidance and critiques from
respected clinical researchers throughout the research process helped to ensure that the
emerging results resonated with them.
Finally, this research is expected to offer counsellors understandings and
interpretations that has potential to help in their clinical practice. This is referred to as
usefulness. While recognizing that this study is exploratory, substantive theory has
emerged to suggest a process for how the experience of unplanned endings impacts
clinical practice. It is not only hoped that this information is useful to practice but also
that conversing openly about unplanned endings will de-stigmatize the experience and
renew interest in research and education.
In summary, it is anticipated that the results of this research meet the proposed
criteria for trustworthiness and rigor in grounded theory research. Attending to these
important criteria throughout the research process provides a strong foundation from
which to present the following results.
Ethical Considerations
There were a number of ethical considerations taken into account in this research.
First, recruitment of the participants was completely voluntary. I did not directly
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approach any of the counsellors. Initial recruitment involved distributing a poster to past
colleagues through the mail and email, outlining the purpose and rationale for conducting
this research (see Appendix B). Volunteers contacted me directly by phone or email at
which time questions about the research were addressed. The counsellors were informed
that no specific client information would be solicited or used in this research. Those who
met criteria and agreed to participate were also informed that the interviews would be
tape-recorded.
Second, prior to conducting the interviews, I met with the counsellors at their
convenience at which time they were asked for their written consent to participate in the
research (see Appendix C). They were given a consent form outlining the parameters of
confidentiality that includes how the recordings will be used, stored and disposed of. The
participants were also assured of their right to withdraw from the research at any time,
without repercussions.
Finally, it was recognized that this research addresses a potentially sensitive topic
in clinical practice. Through journaling and pre-interviews I became aware of the
potential for participants to worry that disclosure about their experiences of unplanned
endings may be interpreted as clinical weakness or failure. With this in mind, I was
transparent with the participants about my own experiences of unplanned endings,
assuring them that this experience is common in clinical practice. Although the majority
of the counsellors were enthusiastic about taking about their experiences, I remained
attuned to any issues that may have caused discomfort; often asking if they were okay to
continue discussing the issue at hand. My primary concern was that these participants
felt comfortable with the level of disclosure during the interviews. At the conclusion of
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the interviews, I asked all the participants for feedback about the research interview. One
of the participants requested the opportunity to preview the results chapter to ensure
accurate interpretation of some of her comments which was accommodated. Apart from
this, there were no other concerns expressed.
This research was reviewed and approved by the Conjoint Ethics Review Board
(see Appendix E) ensuring that this research meets ethical standards set forth by the
University of Calgary.
Conclusion
There are many advantages to using grounded theory methods in qualitative
analysis. This chapter demonstrates that grounded theory methods are indeed flexible
and can be used to advance understanding of the processes involved in counsellors’
experiences of unplanned endings. Its methods are also adaptive, accommodating
epistemological perspectives in constructivism.
This research lies within the substantive area of clinical endings and includes an
exploration of how mental health counsellors experience unplanned endings in clinical
practice. Using grounded theory methods within a constructivist framework allows for
the advancement of knowledge while proposing substantive theory on this important
clinical issue.
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CHAPTER FOUR: COUNSELLORS’ UNDERSTANDINGS OF PLANNED AND
UNPLANNED ENDINGS
The results of this study are divided into two parts. This chapter is the first part of
the analysis that begins with a general overview of the participants’ backgrounds. I then
offer a theoretical model that is centred on the core concept: ‘Making Room’. This
model is presented in a diagram and explained using the metaphor of a train station to
understand the general processes involved.
The next section of this chapter provides an overview of ‘Describing Planned and
Unplanned Endings’ which is the first of three major categories: ‘Describing Planned and
Unplanned Endings’, ‘Reacting to Unplanned Endings’ and ‘Managing Unplanned
Endings’ leading to the core concept. Describing planned and unplanned endings
includes the following sub-categories: Beliefs, practical and functional purposes of
endings, situational context of endings, and relational account. The core concept ‘making
room’ and how the participants of this study described, understood, and conceptualized
endings, provides a starting point to the overall analysis that explains how the counsellors
experience unplanned endings in clinical practice.
The Research Participants
Although grounded theory focuses on processes and not the individual
characteristics of the participants, a general description of the counsellors sets the context
of the results. Ten experienced counsellors, who represented a large cross-section of
mental health practice, participated in this research. The sample consisted of seven
women and three men with ages ranging from 33 to 64 years. Six were registered social
workers and four were registered psychologists. Their educational qualifications
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included five PhDs, two PhD candidates, one MSW and two master’s degrees in
psychology.
With the exception of two, all worked either part- or full-time in mental health
counselling settings. Of the two who were not currently employed, one was teaching
social work full-time and the other was on maternity leave. Their years of clinical
practice ranged from seven years to 40 years with an average 20.9 years of practice.
The counsellors practiced in diverse settings, focusing on a variety of clinical
issues. Five worked in private practice, one in adolescent addictions, one in paediatric
palliative care, one in youth justice and one in an employee assistance program. Each of
the counsellors had extensive experience working with individuals, families and groups.
In order to clearly and accurately reflect the participants’ experiences, many quotes from
the actual interviews are included. Some of the participants chose to use pseudonyms.
Making Room in Clinical Practice
The results of the current study evolved into a theoretical model describing how
counsellors experienced unplanned endings in clinical practice. The model, presented in
Figure 1, is represented as a triangle with arrows depicting forces both moving away
from the centre and moving towards the centre. The central or core variable of the theory
emerged as ‘making room’.
The concept of ‘making room’ best captured what the participants described to be
their experiences of unplanned endings. It is a cognitive, emotional and practical process.
Simply stated, the counsellors cognitively, emotionally and practically ‘make room’ or
provide space to practice. The cognitive process reflects the participants’ descriptions
and definitions of planned and unplanned endings; how they understand and
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conceptualize planned and unplanned endings in practice. The emotional process is the
counsellors’ emotional reactions to unplanned endings. The practical process is their
response to unplanned endings or what they do in their practice to manage them. In each
of the categories, the participants expressed diverse thoughts, feelings and reactions.
Figure 1: Making Room
Depicted inside the triangle, reflecting, learning and growing are the sub-
processes that explain how the counsellors make room. These link the categories
(Describing, Reacting and Managing) to the core variable (Making Room). They also
represent direction: a ‘pushing out.’ In other words, reflecting, learning and growing
facilitate making room in the participants’ clinical practices. These processes provide the
necessary space to work as a clinical counsellor.
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There are also sub-processes that impede making room, which are represented by
the arrows that push inward. Labelled as ‘challenges,’ they include: Avoiding endings,
blaming the client, worry, unclear boundaries, feelings of shame and self-doubt, and lack
of support and supervision.
In summary, the core category ‘making room’ includes various sub-processes that
work to facilitate or impede the process. Reflecting, learning and growing are the sub-
processes that create space allowing for new people to enter into clinicians’ practices. In
this way, ‘making room’ is thought to be a greater social process that helps to explain
how counsellors engage in their clinical work.
The following depiction uses the metaphor of a train to help clarify and visually
represent the abstract concepts involved in ‘making room’. The core concept ‘making
room’ can be visually depicted as people getting on and off a train in a train station.
People represent the clients, while the train-car represents the counsellor’s practice. The
counsellor is represented as the conductor on the train. The space between people on the
train-car represents the counsellors’ capacity to practically, emotionally and cognitively
work with clients. Of course, some train cars are larger than others, and therefore, hold
more passengers. As well, some train passengers take up more space than others. These
individuals or clients require more practical, emotional and cognitive space in a
counsellor’s practice.
Endings, whether planned or unplanned, are imagined as people getting off the
train. Sometimes, they exit the train at an unscheduled stop without any warning, as
reflected in unplanned endings. Perhaps they stay on the train until they reach their
destination, as in planned endings. Finally, individuals may choose not to depart from
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the train until the conductor facilitates their exit, sometimes representing forced endings.
In these instances, the conductors also symbolize the business of counselling, such as
agency mandates, funding, costs for services, and counselling contracts.
When people leave the train, it may be permanent or temporary. Sometimes
people exit and never come back. At other times, they are invited to return to continue
their journey or perhaps, to reach a new destination. All of these reflect the often-
tentative nature of endings in clinical social work practice.
The process of ‘making room’ can be seen as people leaving the train, which then
creates space for new people to come aboard. However, passengers often leave some of
their belongings behind. Baggage, coats and umbrellas that are left behind continue to
take up space on the train and reflect the emotional, cognitive and practical ‘challenges’
to making room. At times the original owner may get back on the train to retrieve their
belongings; however, it is often the case that these items are removed with the support of
others. The sub-processes (reflecting, learning and growing) and their properties (follow-
up calls, supervision, mentorship and support) that facilitate making room represent the
processes involved to create space on the train.
As space on the train is limited, it is important for counsellors to find ways to
‘make room’ for new clients to come aboard. Space is created when counsellors take
time to reflect, learn and grow. However, these do not occur for every passenger nor do
they necessarily happen in sequence. Reflection, learning and growing facilitate ‘making
room’ but are not necessary in every case. They explain how the counsellors often react
to unplanned endings, and how these experiences provide the opportunity to achieve
closure, improve their practices and continue their work.
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Continuing with the metaphor of the train also assists in understanding why some
unplanned endings do not take up additional emotional, practical or cognitive space. For
example, some passengers take up very little space on the train. They stand by the door
and exit quickly. Counsellors, who had limited contact or opportunity to develop
emotional connections with clients, expressed minimal reactions to unplanned endings.
As well, in some cases when clients were considered to have little investment to change
or the counsellor did not believe that they could be helpful, unplanned endings were often
a welcome relief. In these situations, unplanned endings facilitate making room for new
clients who may be more invested to work with the counsellor. In other words, when
clients exit the train at an unscheduled stop it is not always considered negative or
emotionally taxing to the counsellor. In many instances, unplanned endings provide the
practical space necessary for new passengers to come aboard.
Depicted in this way, planned and unplanned endings are not distinguishable from
the overall process of ‘making room’. Both serve an important function that the
counsellors address in their practice: their capacity to cognitively, emotionally and
practically counsel individuals. Beginning with the cognitive aspect, the following
presents a detailed description of the category ‘describing planned and unplanned
endings’ (see table 1).
Describing Planned and Unplanned Endings
Conversations with the participants about endings in clinical practice required
shared understanding and context. Most of our conversations began with the counsellors
clarifying their views of the concepts of planned and unplanned endings. Throughout the
interviews, they further interpreted, described and contextualized these concepts.
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Table 1 “Making Room” Categories and Sub-Categories
Categories Sub-Categories
Describing Planned and Unplanned Endings
Beliefs about Endings
Practical and Functional Purposes of Endingso Fulfilling agency mandateso Evaluation of progresso Achieving closureo Client self-determination
Situational Context of Endingso Client circumstanceso Client/counsellor matcho Counsellor’s abilitieso Agency/counsellor circumstances
Relational Accounts
Reacting to Unplanned Endings Range of Emotions
Managing Unplanned Endings DetachingSensingTransparencyEvaluating ProgressIntegrating RitualsKeeping the Door Open
Four sub-categories of the ways in which the counsellors described endings
emerged through the analysis: 1) Beliefs or what meaning the counsellors bring to the
conceptualization of planned and unplanned endings in clinical practice, 2) Practical and
Functional Purpose or the purposes that planned and unplanned endings serve in clinical
practice, 3) Situational Context or the counsellors’ understanding of different situations
that lead to planned and unplanned endings in clinical practice, and 4) Relational Account
or the counsellors’ consideration of the extent to which they emotionally connect with
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their clients both personally and professionally. Describing endings within these contexts
allowed the counsellors to distinguish between planned and unplanned endings and
helped them to elaborate their understanding of endings in clinical practice.
Beliefs about Endings
The counsellors’ beliefs about endings emerged through both my own and the
participants’ efforts to deconstruct concepts that are otherwise commonly considered to
be the ‘truth.’ Delving deeply into the meaning and context of planned and unplanned
endings led to rich conversations about the counsellors’ beliefs and overall philosophies.
In order to discuss their experiences of unplanned endings, the counsellors first
shared their insights and beliefs about endings in general. Specifically, they described
and interpreted the words “ending,” “termination,” “planned” and “unplanned.”
Emily asked, “Do endings exist?” The counsellors grappled with the existential
meaning of endings in clinical practice. They raised questions about the meaning of
endings to both themselves and their clients. They also provided their unique
perspectives and beliefs about the relevance and importance of endings in clinical
practice. Emily reflected:
I don’t know if I believe in the word ‘endings’ even. I’ve always had issue with
the language around that and teaching it. How do you describe what endings
are? Endings could happen any time. Endings could be your first session. For
various reasons, people might not be come back. You could have an ending at
any time, planned or unplanned.
Sue viewed endings in clinical practice as tentative and uncertain. Further, she
questioned whether most endings actually occur at the end of the counselling process.
She used the term ‘transmutation’ to describe endings, “They mutate into something
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new.” She believes that, instead of one significant ending, there may be many ‘ending
points.’ Endings occur when something significant shifts, changes or becomes known.
She considers these events to be ending points because everything that comes afterwards
simply reinforces that event. Sometimes the ‘ending points’ happen early in counselling
and, because of this, are perceived to be as significant as the final ending.
I don’t look to the final ending as being any more important than the other
punctuations along the way. The biggest punctuation might have come in the first
session and now we’re just consolidating. We started ending then because they
‘got it.’ Now, we’re just reinforcing it. I’m just making sure that …it really fits,
but they got it way earlier. To me that was the beginning of the end. So the
ending doesn’t have to come at the end.
Similarly, John believes that counselling involves a series of small endings
throughout. When one aspect of the work is completed, the focus then shifts to another.
John believes that it is at these junctures that the decision to continue or end the clinical
relationship is made.
The majority of the participants questioned the certainty and finality of endings in
practice. They believe that endings are often temporary and, as such, they consider the
term to be inappropriate and uninformative. John said, “Endings are not certain”. What
he means is that they are not absolute, because most counsellors anticipate that their
clients will return at some point in the future. Several clinicians used alternative concepts
to describe endings such as ‘leaving the door open,’ ‘tune-ups,’ ‘pauses’ or
‘interruptions’:
Endings are for now and they can be forever… but definitely, leaving the door
open, that you’re open for the engagement. You understand that things are okay
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now; that they don’t have to stay okay. If I’m the person that can be helpful in the
future, I’m open and ready to be. That’s generally my ending anyways. (John)
One of Emily’s clients conceptualized coming back to counselling as ‘tune-ups’:
Do you ever truly have an ending, when you could be saying hello to that person
in the aisle at Safeway? One couple used to call it their ‘tune-ups.’ They just
liked to come in for tune-ups and you were the only game in town. It may not be
an issue of why they came to see you in the first place. You see them in different
situations, context, but still within your role as social worker.
Sandy indicated that many of her clients prefer to leave the door open when
ending their counselling sessions:
They’ll say, “I don’t feel the need (to continue counselling) but I have your
number so if I need to start a new file or commence counselling again, I’ll call.”
Some of them really liked the idea of a follow-up session…they liked knowing that
it’s available to them if they need it.
Several participants explained that they prefer to ‘redefine’ their relationships
with clients at the end of counselling instead of outright ending them. Meaghen
commented, “Instead of ending the relationship I would talk about how is this
relationship different now.” Although all of the counsellors accept that some endings in
clinical practice are final, the meaning often attributed to ‘endings’ does not apply to
those situations when endings reflect a transition or change.
Additionally, all of the participants recognized that the ways in which endings in
clinical practice are viewed have changed over time, reflecting more of a consumer’s
perspective to counselling. In society today, counselling is commonly considered to be a
service that is purchased by clients, which they see as having a direct impact on
counselling and, in part, how endings occur in practice. Teeya summarized it this way:
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“It’s a new sort of consumer-driven model, ‘I’ll take what I want and then I won’t come
back’ or ‘I’ll come back if I need to.’ It’s the open-ended nature of it.”
Tara also addressed differences between the counsellors’ expectations of endings
and the reality of endings in current practice:
I think we idealize endings as therapists where we say that you’re finished and
this is the last session. I don’t know if that comes out of the psychoanalytic
tradition where people might have come for a long, long time. Oftentimes we only
see people once, twice or three times.
Furthermore, a number of the participants wondered about the importance of
endings to their clients, recognizing that counselling practice exists in a society where,
for the most part, people are busy and want their problems to be resolved quickly. Teeya
shared her thoughts:
I know (endings are) important to me for the closure piece. What I don’t know is
how important it is to them (clients). My hypothesis on this is they all get busy
and the wheel isn’t squeaking anymore. It’s like they’ve got many more things to
do.
As such, the majority of the counsellors recognized that their definition and
understanding of endings may be different from their clients. For example, Emily
acknowledged that many of her clients continue to work on issues long after her
involvement with them as their counsellor, “What does ending mean to a person who is in
the middle of a crisis?” She recognized that, although she had ended her work with the
client, they continued the work and, therefore, they may not define it as having ‘ended.’
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“Do endings exist?” “Do endings matter?” “What are endings?” These were a
few of the philosophical questions that the counsellors raised about endings in current
clinical practice.
The participants also addressed the meaning of ‘unplanned’ endings. They raised
a number of beliefs that highlighted different ways to define and conceptualize unplanned
endings. The following are some of the most common beliefs that the counsellors
identified.
To begin, a particular challenge that the counsellors faced in defining and
describing unplanned endings was determining the point at which counselling had begun.
Emily referred to many clients who were searching for help but had not yet made a
commitment to counselling. Some clients did not come back for a second or third
session. She commented, “In that first session, you haven’t begun yet so how can you
end? You know they haven’t made the decision that, ‘Yeah let’s work on this together.’”
Determining that counselling had begun was imperative for counsellors to identify
unplanned endings. As such, a number of the counsellors discussed the need to initiate
an open conversation with clients to signal the beginning of a clinical relationship.
Several counsellors described having some form of this conversation and most
considered it to be a common practice. The conversation attends to both the client and
counsellor’s commitment to counselling and the work that will be addressed. Its purpose
is to make the decision to work together overt by setting goals, discussing time-lines and
clarifying roles within the clinical relationship. Without having some form of this
discussion, the counsellors could not, with certainty, determine that an unplanned ending
had occurred.
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The counsellors also debated the meaning of the word “unplanned.” Three
clinicians asked, “Unplanned, according to whom?” believing that if an ending occurred,
someone had made the decision, or had planned to end. Unplanned endings were,
therefore, dependant on the individual’s perspective. The counsellor might view it as
unplanned while the client may have planned to end. Knowing that the client, counsellor
or agency could be the catalyst to end the clinical relationship was important to the
participants as it raised questions about the meaning of ‘unplanned endings’ in general.
However, the majority of the counsellors in this research assumed that the term
‘unplanned endings’ referred to the client’s unilateral decision to end counselling,
“People just don’t show up anymore. They make an appointment and then they don’t
show up.” The clients essentially ‘planned’ the end and, in these instances, the
counsellors recognized that the term ‘unplanned ending’ was from their own perspective.
The participants also recognized that unplanned endings are not limited to ‘no
shows’ or ‘drop outs.’ Death and suicide were also discussed by several counsellors.
However, apart from recognizing that these forms of unplanned endings occur, they were
considered beyond the scope of the current research and were not explored thoroughly.
Unplanned endings can also result from circumstances outside of the client’s
influence such as agency mandates, cuts in funding for programs, counsellor attrition and
various other circumstances that the client has no control over. These are described in
more detail under the sub-category “Situational Context.” In short, answering the
question, “unplanned, according to whom?” was important for several participants to
adequately describe their clinical experiences of unplanned endings.
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By addressing the meaning of the words ‘unplanned’ and ‘endings’, the
participants explored this topic more thoroughly. Broadly, there was consensus among
the participants in this research that unplanned endings are common and that they are
inevitable. The counsellors accepted that unplanned endings ‘happen,’ recognizing that
clients may, at any time, decide not to return to counselling. They considered unplanned
endings to be ‘part of the job’. Sue summarized it this way:
That’s an ending that is sort of ‘up in the air.’ Its like, ‘Huh, I wonder where they
went?’, or ‘I wonder if they’ll call me again?’ After being in practice for quite
some time, I don’t worry about it because sometimes they do come back and they
call me in a year, and I’m like, ‘Okay, so it was an ending.’ But it may not have
been an ending; it might have been just a ‘pause’ and it ended for a brief period
of time and then it might pick up later but it might not. It doesn't matter, because
it’s not for me to pre-determine what they do with what I give them.
In summary, the counsellors’ beliefs about planned and unplanned endings
provided context and an avenue to understand their experiences. For the most part, the
participants did not consider their beliefs to be either right or wrong. They did not
present them with certainty or as facts. Instead, they often discussed their beliefs with
tentativeness and in the context of rhetorical questions.
In some instances, the term ‘ending’ was unhelpful to the counsellors because it
does not fully or adequately describe their experiences of the often tentative nature of
endings in clinical practice. The term ‘ending’ reflects a temporal concept that is
recognized as certain and final. However, most clinicians in this study preferred to view
endings with more flexibility in practice. Although some endings are certain and final,
many are seen as transitions, interruptions or pauses in treatment. The counsellors
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highlighted these distinctions when describing their beliefs about endings in clinical
practice.
The counsellors also attributed various meanings to unplanned endings but the
overall belief is that they are inevitable, there are many reasons for them and they may
reflect current societal or North American trends towards consumerism.
Practical and Functional Purposes of Endings
The participants also described planned and unplanned endings more concretely,
recognizing how these serve practical and functional purposes in their clinical practices.
Compared to the conversations regarding their beliefs about endings, here the participants
provided clear examples of actual endings and the purposes that they serve.
Most described planned endings as fulfilling agency mandates and policies, as
validating practice approaches and theoretical perspectives, and as marking the
completion of contracts and fulfillment of goals. Another purpose was achieving closure.
The clinicians also described unplanned endings as serving the functional purpose of
client self-determination. In general, endings were seen as practical and functional, and
most endings, whether planned or unplanned, were viewed as serving a purpose for the
client, counsellor or agency.
Fulfilling Agency Mandates and Contracts
Fulfilling agency mandates and completing contracts are common examples of
how planned endings serve practical and clinically functional purposes. The counsellors
working in private practice and employee assistance programs receive contracts from
large government, non-profit or for-profit organizations to counsel individuals or
families. These contracts usually include agreements to offer a specific number of
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counselling sessions. The contracts come from Children’s Services, the courts or, in the
case of employee assistance programs, corporations or large organizations:
You have people who come for a very specific thing like an assessment and the
assessment by definition has a start and finish to it. You have a planned ending
because the assessment is done and the report is written. Your time is done and
that’s that. That’s more like fulfilling a contract or an agreement that you are
there for a purpose and you’ve done your purpose. (Peter)
Several participants also mentioned that their agency mandates define practice
endings. Mandates provide the parameters of counselling and may well pre-determine
the ending. The research respondents who worked in probation, crisis intervention,
addiction treatment and mental health programs perceived such mandates as important.
The number of allowable sessions or length of treatment ranged from a few months to a
few years but the organizational mandates clearly outlined the parameters about
beginning and ending counselling.
The type of clients (voluntary versus involuntary), program policies and
counselling contracts also determine the parameters of counselling interventions and
often establish the length of time that the counsellors work with clients. Endings are
therefore pre-determined and acknowledged from the outset. Peter described mandated
endings in this way:
They’ve got very clearly in their mind that the mandated therapy is X. So, they’re
going to commit to X and nothing beyond it. It’s very clear to them that there’s
this time-limited involvement that’s a necessity and as soon as it’s done, it’s done.
… X sessions are required, X sessions are done, ‘hasta la vista’.
Denise provided additional examples of pre-determined endings from her clinical
practice as a group and youth probation counsellor:
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The endings (with groups) are quite structured because it would be an 8-week
group. It’s voluntary. They do the group (and) they finish. You know that the
ending is there, so that’s quite straightforward. Probation is a little trickier,
because it’s mandated clients, for one. They are typically 12 to 18 year olds and
depending on what kind of order they’re on from the court; they might know when
the end of their order is. So we both know how long our relationship is going to
last.
In private practice, insurance companies dictate the terms of counselling, which
pre-determines the ending. Sue shared an example of a conversation she might have with
her clients about this: “So it’s a package that I can give you and we can always negotiate
that afterwards, but right now, that’s what I can offer you”. In this example, Sue makes
it clear to her clients that the ending occurs after a fixed number of sessions. Once again,
endings serve a practical purpose. In this case, they reflect the limits of the client’s
insurance.
Endings as Evaluations of Progress and Goal Achievement
The counsellors also described endings as serving the functional purpose of
evaluation, in which the process of ending clinical work involves an evaluation of both
the clients’ progress and the counsellors’ effectiveness. In an effort to improve her
services and skills, Teeya discussed the importance of endings to evaluate efficacy:
I want to know whether or not the services I deliver are effective. I would love to
know when the final appointment is. Secondly, I would like to use that
appointment to evaluate how far we’ve come in terms of, ‘Have we reached the
goals?’
According to a number of the clinicians, planned endings occur when the client
and counsellor agree that they have reached their goals or rated themselves as having
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achieved what they came for. Unplanned endings occur when the clients decide on their
own that they have achieved their goals, without seeking or gaining agreement from the
therapist. However, in both planned and unplanned endings, the practical and functional
purposes of endings often reflect the achievement of the clinical goals.
Achieving Closure
A number of the clinicians believe that achieving closure is an important purpose
of endings in their practices. It is the process of working through an ending with a client
that is believed to provide closure. Meaghen described her process for this:
When I think about my practice at the children’s hospice, I think my endings were
much more conscious. They (endings) were part of what we talked about as a
team. Part of it was we wanted to model conscious goodbyes. That’s what we
used to talk about. We never know when the last time we might see somebody is…
and I was always, in the back of my mind, aware that this might be the last time
that I work with this child. There was a ritual to the end of every session that
closed the session and in some ways closed it for me too. We would have a candle
that we would light at the beginning and at the end we would blow out the candle
and do an affirmation. So, (we would say) ‘something that I enjoyed about you
today.’ That was just how I was mentored into it, really. That’s the philosophy of
the hospice and I think that that was such a gift because it also applied in my
private practice. I just built that (ritual) into every session.
Rituals serve an important function; to achieve closure by celebrating moving on.
Tara commented that the ending rituals in her practice facilitated her and her clients’
ability to feel a sense of closure to the clinical relationship by celebrating the ending:
“That was one neat thing that they did for the kids… to have some special kind of good
bye, talk about their progress, and have some celebration around that.”
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Client Self-determination
Unplanned endings were also seen as serving an important practical and
functional purpose. A number of the participants described unplanned endings as a
function of their clients’ self-determination, believing that clients may end counselling
when they have either met their goals or they no longer believe counselling will be
helpful to them. In both instances, endings may be due to differences between what the
client wants or expects and what the counsellor expects:
Frequently, counsellors have good plans for the clients but the clients don’t have
good plans for themselves. A lot of counsellors haven’t been able to let the client
determine what it was that needed to change. They have already decided what it
was that needed to change. (John)
Recognizing the uncertainty of unplanned endings, Tara described her
experiences this way:
It really varies. Sometimes you have clients that come regularly for a long time
and they seem to be doing well and then, when I think they’re doing well, they just
stop phoning for appointments. I’ve had clients where you do the follow-up call
and you don’t hear back from them... or you do a follow up call and you find out
that they put the things that you suggested into practice or perhaps even consulted
another professional. They may have needed the services of a psychiatrist and
they got that help or they got the meds that they needed and they’ve moved on to
other treatment.
In these examples, unplanned endings reflect clients’ determination of whether
they want or need to continue in counselling. John had similar ideas:
The assumption can be made that they (clients) have had enough of this particular
counselling relationship. It doesn’t have to be negative; it is just that they move
on with their life and that’s what it is.
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In summary, the counsellors described planned and unplanned endings as serving
practical and functional purposes of the client, the counsellor and the agency. The
purposes of ending clinical relationships vary from fulfilling contractual needs to
evaluating services and meeting client goals. Endings are also seen as a means to achieve
closure for both counsellors and clients.
Unplanned endings are considered to serve an important function for the client:
that of client self-determination. A number of the participants believe that clients choose
to end counselling when there are differences in goals and expectations, when clients
receive what they come for, or when they no longer want to work on issues. Unplanned
endings were not defined by the participants as good or bad, right or wrong. Instead, they
were thought to reflect what the client determined was best for them.
Along with the participants’ beliefs, the practical and functional purposes of
endings emerged as a sub-category that described how the counsellors understood
planned and unplanned endings in their clinical practice. Extending this further are the
situational contexts that ‘cause’ or ‘create’ unplanned endings.
Situational Contexts
The participants defined and described endings according to the circumstances
that created them. In this sub-category, the situations and circumstances of the client,
counsellor and agency lead to ending the clinical work with the client. The numerous and
varied situations described by the participants assisted to discern ‘what happened’ or
what they believed caused the clinical work to end. The situational contexts of
unplanned endings related to client circumstances, the client and counsellor match, the
counsellor’s abilities, and the agency and counsellor circumstances.
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Client Circumstances
A number of the counsellors directly related endings and, particularly, unplanned
endings to both the external circumstances of the client as well as their internal
circumstances such as their histories, personalities, or motivation. Emily reflected,
“Sometimes there are things that are outside any of our control, whether somebody has
to go back to work, whether it costs too much to park, or whether they (clients) are so
overwhelmed.”
In a number of instances, the counsellors made assumptions about possible
external circumstances in their clients’ lives that lead to unplanned endings. Financial
constraints, transportation issues, returning to work and moving were a few of the
examples that several participants, such as Tara provided, “The endings actually might be
because schools are ending or the family is moving.”
As already noted, they also attribute endings to clients’ history, personality and
motivation. Sandy shared that, from her experience, clients leave counselling early when
they are not ready to address issues or make changes:
They do what they feel they need to do at the time and what they are ready to do.
I think that if they don’t return or there’s an unplanned ending it could be due to
a number of factors. In a lot of cases, just from what they’ve told me, they’re not
ready to continue. I’ve heard clients say, ‘I’m not ready to touch that issue with
my dad, I just can’t do it.’ (Sandy)
Client and Counsellor Match
Another situation that often leads to endings was the therapeutic ‘match’, ‘fit’, or
‘connection’ between the counsellor and client. A number of the clinicians addressed this
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as a lack of rapport or chemistry, or an incongruent philosophy about change and
responsibility for change.
There’s another form of planned ending that doesn’t happen very often but it does
happen, where you don’t like the client and the client doesn’t like you and there’s
just no chemistry. It’s sort of like, ‘We do not like working with each other and
let’s help you find somebody different to work with.’ (Peter)
I am a strong believer that the therapeutic match is the critical element of
therapy. If it's not working then, my goodness, we’ve got lots of qualified people
in this city. We can help you find someone else. (Tom)
A number of the participants recognized the importance of the therapeutic match
for the client. They supported their clients’ attempts to shop around to find counsellors
with whom they feel they can work. Most of the counsellors did not see this as a
personal issue. Instead, they perceived their clients as acting like responsible consumers
of therapy. The majority of the participants concur that it is appropriate and healthy for
clients to end sessions when they do not feel comfortable with the counsellor. In a
number of instances, the counsellors helped their clients to make these decisions before
beginning their clinical work.
Counsellor’s Abilities
A similar circumstance that leads to unplanned endings was raised by both Peter
and Sandy. They purport that counsellors are often expected to take on a variety of client
issues for which they may not be prepared. Sandy openly acknowledged that some
unplanned endings may have been due to her limited experience:
With some cases, I’ve had clients I’d prefer not to see if I had a choice because I
don’t have the expertise. So the unplanned ending is more unfortunate because I
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think they could’ve been better served by seeing someone with more expertise in
that area.
The experienced counsellors interviewed for this research appeared to know their
limitations. They were willing to admit that they were not experts with respect to every
issue they were presented. In these instances, they recognized that they were not the best
person to assist the client with their issue. Peter summarized it this way:
You’re in a situation where, “They come for A and you end up with B.” That’s a
situation where, from a clinicians’ perspective, what I should be doing is saying
to the client, “I'm probably not the person you should be seeing.” I should be
initiating the ending because they would be better served with a different
clinician.
Agency and Counsellor Circumstances
Finally, most of the counsellors identified agency and counsellor circumstances
that lead to endings including circumstances such as funding cuts, transfers, or policy
decisions. John spoke about common policy decisions that limit treatment based on
client age. He had ended some of his clinical relationships only because the client turned
18 years of age. Meaghen also described policy in a children’s palliative care program
that limited counselling for parents to two years after their child had passed away.
As well, agencies and treatment programs are often in a state of transition that
may be largely determined by funding. Emily poignantly described her painful
experience of being laid off when funding was suddenly cut to the program where she
worked:
I had a nightmare experience when I was laid off. Most of my endings were done
on the phone, frantically making sure people had resources; calling in favours
from other practitioners. That was tough to deal with, because ethically it went
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against everything I was. I also thought it wasn't dealt with how I would have
dealt with it so I could live with myself professionally and personally. Some
(clients) felt abandoned. I was in the middle of a group. It was absolutely
horrific and it bothered me. I was mad because my professional identity and who
and what I was, was compromised. I did the best I could.
The counsellors frequently mentioned unplanned endings that resulted from the
situational contexts of the client, agency, and counsellor as beyond the counsellors’
control and influence. These unique situations and circumstances caused the end of the
counselling relationship and, in some instances, prevented the client and counsellor from
having the opportunity to say goodbye.
Relational Accounts
The participants’ descriptions of planned and unplanned endings were not limited
to their beliefs, the purpose, or the situations that caused them. As Teeya highlighted, all
of the participants extended their understanding and descriptions of planned and
unplanned endings to also account for the relationship:
(Endings) give you a chance to say goodbye to the people and say, “Call me in a
year if you need to.” It kind of allows you to wrap things up. With my personality
type, I’m a closure person…it’s the goodbye, good luck, nice to have worked with
you... the relationship part.
How the research respondents accounted for their relationships with clients is
essential information to fully understand their personal and professional experiences of
endings. The counsellors acknowledged ‘being human’ and spoke of the degree to which
they emotionally connected to clients. For many, these conversations highlighted how
they managed personal and professional boundaries. It also led to new insights into some
of the challenges faced by the counsellors when counselling ended.
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The clinicians directly related their experiences of planned and unplanned endings
to their feelings about their clients. This was not limited to whether they liked or disliked
the client; instead, endings were defined according to how they perceived the
relationship. Sue expressed it as follows:
It’s not just a therapeutic relationship; there’s an element of, ‘I know this person.’
There’s a sense of caring, of course, especially with clients you’ve been with
several times. I don’t think we can really be good at what we do unless we care.
We don’t really think we are there to be friends … I’m not talking about that, I’m
talking about caring about them as a human being.
Tom also discussed the importance of relationships in counselling and recognized
how this may be changing for new counsellors:
It is a relationship that we enter into and we bring all of our own junk. I’m sure
that you’ve encountered this old style of teaching. If you’re from an analytic
background, you tried to be in analysis yourself. We’ve gone so far away from
that. As I was saying about my teaching, there’s this sub-group of students who
just want techniques, the book, and that’s a real shame.
A number of the respondents grappled with the personal and professional roles of
counselling. They understood that a large part of what they do in therapy, including how
they end their relationships with clients, reflect who they are as individuals. Addressing
her experience of unplanned endings, Denise commented, “You can’t separate your
personal life from work.” She believes that counsellors’ personal lives ‘mesh’ with their
professional lives. She also believes it is impossible to separate the two. Sue highlighted
the challenges that most counsellors face in addressing this issue:
I’m not just there as a therapeutic agent. I’m there as a person. If I didn’t bring
so much of myself to it, I probably wouldn’t care. But it goes back to, ‘I can't
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split those two things apart.’ I’m very clear about my responsibility and not
being involved in relationships with people. We’re not talking about dual
relationships.
Most of the participants shared examples of how they personally connected to
clients in counselling. Many understood that the nature and strength of the clinical
relationship was crucial to the process of ending, and the ways in which they experienced
the endings. Reflecting on her private practice, Tara mentioned that some clients came to
therapy primarily because they wanted to feel connected to people, not necessarily
because they wanted to work on goals or to make change. She commonly saw this in her
practice and it required her to find the balance of caring and being professional.
Tara recognized that there were consequences to being completely professional.
She thought it resulted in weak or impersonal relationships with clients. However, she
also believes that it is important to maintain professional boundaries:
The whole lack of connection is what makes our jobs so difficult because we want
to have good boundaries with our clients. The more I do this, the more I realize
how important that (connection) is. It’s always changing, like what that needs to
look like. I remember working at a (hospital). It was more likely for people to
want to be your friend because it was a totally different context. Most people who
work there are volunteers and you’re working through trauma with people. At
first that really freaked me out and then I realized that it was okay. But learning
how to navigate the (relationship) and have an appropriate ending when they may
want to continue because they feel a bond with you (was hard).
Maintaining boundaries was a challenge for many participants when they ended
counselling. Meaghen became pregnant while working in a palliative care program for
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children and shared her struggle to end a clinical relationship with a parent whose child
had died:
There are relationships that in some ways transcend the professional
relationship…like the mom that I feel I maybe let down. She was so excited for
me when I got pregnant, so happy for me. That relationship had a personal feel
to it as well as a professional feel. Maybe that’s why I avoided that ending,
because goodbyes are hard. Goodbyes in our personal life are hard. So I
understand why I did it (avoided saying goodbye). I see that it was an avoidance
tactic and I think it was partly my own self-preservation around not wanting to
say goodbye to them…wanting to believe that I could keep in touch. At the time,
that did feel feasible. I think it is changing for me and in my practice. I’ll have to
spend some time thinking about the fact that, if I am going to share pieces of
myself with people, then the ending probably does look a little bit different than if
I have these rigid boundaries.
In one way or another, all of the participants accounted for their relationships with
clients when they discussed planned and unplanned endings. However, this also included
accounting for relationships that were not close; describing some clinical relationships as
ambivalent or distant. Some feared or disliked certain clients. In some instances the
client triggered feelings in the counsellors that made it difficult to work with them.
Sandy shared an example of a colleague’s ambivalent relationship and how it ultimately
impacted the ending:
Some clients are just not a fit and some clients are so scary. I’ve had counsellors
come to me and say, “I’m so scared, I’m just so scared; I’m spending all my time
just calming down and breathing,” and they’re totally frightened of the client.
(They ask me), “How can I connect with this client when I’m looking at the door
and I’m thinking that I’ve got to get out of here?” You really push towards
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endings. That’s a reality too. I think we push towards endings with clients that
create discomfort and stress for us.
Tom summarized what all the participants said at one time or another, “To be
really frank about it, there are times I’m glad people discontinue.” Many of the
participants admitted these feelings when they accounted for the diverse relationships in
their work. They recognized their limitations and knew that they may not be the right
counsellor for every client. Peter commented: “But as well, there is the knowledge that
you will not be perfect in every case and probably you will be imperfect in most cases.
So some level of imperfection in your work is also the norm.”
Similarly, Meaghen added, “Sometimes we have to be honest about our limits and
our ability to help the people we work with. We are human, our lives are changing and
so is the nature of our work. We recognize that our lives are a big part of what we do.”
Lastly, in terms of how counsellors accounted for ‘relationship’ during the ending
phase, many participants shared that they reflected on their feelings about their clients
when counselling was coming to an end:
Maybe it’s at the end that we allow ourselves to reflect on it or to acknowledge it
in some way. A lot of my final sessions with clients tend to be very emotional
compared to what happened before. Maybe that’s because there was more
reciprocity at the ending; because I’d give more. (Sue)
When it has become personal, it is doubly hard to say goodbye; and then you may
have to do some sort of ritual around that. We certainly do that in our group
therapies. After 12 weeks we would go through our ritual and we would be very
emotionally connected to that particular event of testimony. There is a certain
amount of testimony about the voyage that that particular person has made and
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the position that they are in now, and that can be very emotionally engaging.
That particular emotional engagement can be satisfying. (John)
Despite challenges to maintain personal and professional boundaries with clients,
when it came to ending the clinical relationship, the counsellors acknowledged that
endings are personal.
They do become more personal, especially where I’ve supported a family whose
child has died. Here I am pregnant and they want to know about this child that
I’m bringing into the world. It doesn’t feel right to say to them, “Now that I’m
not your counsellor anymore, I can’t share that part of my life with you.” To me,
a part of their healing is seeing that they can re-invest in other relationships and
be happy for other people that are having a baby. (Meaghen)
In summary, it appeared important for the respondents to account for their
relationships with clients when defining and describing their experiences of planned and
unplanned endings. Accounting for the nature of the clinical relationship added yet
another layer to how they understood and experienced endings in clinical practice. It
tapped into their feelings and personalities and it opened up conversations about the
nature of clinical counselling and their personal investment in the work. It raised issues
of boundaries that required they distinguish between the personal and the professional
aspects to the counselling relationships. In short, planned and unplanned endings were
described as a time to reflect on the clinical relationship.
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CHAPTER FIVE: RESPONDING TO UNPLANNED ENDINGS IN PRACTICE
This chapter continues to present the results of the analysis with a description of
the categories ‘reacting to unplanned endings’ and ‘managing unplanned endings.’
These categories capture how the participants responded to unplanned endings. The
diverse range of emotions that the participants expressed also helped to understand how
they responded and made changes in their practice.
Following this is an exploration of the central sub-processes, ‘reflecting, learning
and growing.’ These link the categories to the core concept, ‘making room’, explaining
how this emergent theory can be conceptualized in practice. The sub-processes that
challenge or impede ‘making room’ are also described. The chapter concludes with a
discussion on the inevitability of unplanned endings and how this realization helps
counsellors to ‘make room’ to continue their work.
Reacting to Unplanned Endings
The participants’ overall descriptions and definitions of planned and unplanned
endings helped to understand the diversity of feelings they expressed when experiencing
unplanned endings. The counsellors’ emotional reactions to unplanned endings depended
on how they understood planned and unplanned endings and in particular, how they
accounted for the relationship. In other words, the counsellors’ reactions depended on
the nature of the clinical relationship, the practical and functional purpose of the ending,
the situational context of the ending and their overall beliefs about endings.
The clinicians mentioned a range of emotional reactions to unplanned endings,
varying from worry and concern to apathy. They described feeling sad, or a sense of loss
and sorrow in some of their experiences; guilt, frustration and disappointment in others.
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In contrast, still others felt happiness, satisfaction and relief. Denise, Sue and John
explained the wide range of emotional reactions.
(It) depends on my relationship with the client. Quite honestly there are some
clients that I kind of go, ‘Whew, I don’t have to actually deal with this anymore.’
Other clients, I’ve felt quite close to (and) I’ve thought we’ve had a really good
relationship and I’ve done things that normally I wouldn’t in terms of, in their
mind, they’re done with me but I still need to phone them and have a conversation
with them and say goodbye or good luck. (Denise)
It depends on how well I know them, how long I’ve met with them. Isn’t that
interesting, I wouldn’t have thought about that before. But if I’ve seen someone
for a number of sessions and something goes sideways, that’s going to bother me
a lot more. (Sue)
Probably the unplanned ending is just, ‘You get on with your life.’ There is not a
lot of feeling with it. The planned ending can have some; it isn’t sadness, but
some fairly mild sense of loss. If you have made a real connection with that
person then there is a real like of that person in a personal way. Sometimes it is a
relief, because certain clients are either making little progress or it is continuous
crisis (and has) become a little bit of a burden to the counsellor. In order to end
that particular relationship, there is a certain amount of a relief. (John)
Many considerations affected the participants’ emotional reactions to unplanned
endings. Reflected above was consideration for how they accounted for the relationship.
Other feelings expressed included concern, frustration, worry, and a strong desire to help
when they perceived a risk or danger to the client’s well-being. Denise expressed worry
when one of her young clients disappeared:
If a young person takes off and they’re gone, those are usually the really high-risk
kids, so you worry about them. That’s just awful when you bond with your clients
and develop a relationship and, when they’re gone, you worry about them.
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They’re all young and vulnerable and high-risk. They might be prostituting, they
might be using drugs or abusing alcohol, they might be in gangs, and they might
be at risk to re-offend. They might be perpetrators, so you worry about their
safety and the safety of other people. I’ve had a boyfriend/girlfriend take off
together, and my goodness, you’re worrying about what’s going to happen to the
two of them!
In other instances, counsellors reported different reactions. When the participants
believed that the client made a choice to end counselling because they were stronger and
more independent, many reported feeling rewarded:
I have to deal with it. A guy just last week called and said, “I don’t need my
Tuesday appointment because I’m doing much better.” Great! That feels so good
to know that because, “Great, cancel the appointment, save some money.” So
that to me is very rewarding. (Teeya)
However, sometimes counsellors questioned the strength of the relationship and
their role in its ending. Tom shared his emotional reactions to unplanned endings in his
clinical practice:
Initially, I’m pretty hard on myself. The primary emotion is disappointment.
Maybe a bit of guilt, I suppose or a sense of wrong-doing that I should have done
something different or I’ve missed something or I was distracted. I guess the
being hard on myself is (because) part of our jobs is to assess the client’s
situation and figure out a few options about how to address what we used to call
resistance. How do you address that? A good teacher isn’t one who just helps
good students, right? A good teacher is somebody who’s able to work through
the barriers. I think it’s the same in therapy.
Tom did not blame his clients when they failed to return for counselling. Instead,
he evaluated his own competence, believing that he could learn something from this to
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improve his work. In this way, Tom expected that he should minimize the occurrence of
unplanned endings in his practice.
Meaghen expressed sadness when she believed that she had let a client down by
not keeping in touch with a family. Feeling close to this family, she was reluctant to
formally end the relationship, resulting in an unplanned ending. This left her with mixed
emotions:
One family comes to mind. I was quite close with the mom and the sibling of this
child who died and, for about 3 years, provided support off and on. I don’t think I
handled that goodbye quite the way that I should have and in the end, there’s a
possibility that I disappointed the family because I didn’t keep in touch.
Sometimes the counsellors reported feeling disappointment when clients did not
return. John struggled to describe his emotional reactions:
I may still have a reaction a certain…I wish I had a word that wasn’t “sadness”
because it is kind of a disappointment that the person wasn’t able to go in the
direction that I perceived would be a better or a happier space for them.
Sandy expressed different emotional reactions to unplanned endings. Working in
an Employee Assistance Program with high caseloads resulted in Sandy and her
colleagues experiencing frequent unplanned endings. Over time, the counsellors adapted.
Sandy shared that she does not take time to dwell on clients who do not return. Agency
policy required that she follow-up with clients who do not return, and, once she did this,
she was not bothered:
Some clients disappear and I actually don’t have a lot of time to think about it,
because we have so many new clients. So it’s not something that really bothers
me. There is a certain amount of relief sometimes because there are enough
people knocking on the doors.
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Nevertheless, most of the clinicians were concerned for their clients, especially
when they knew that the decision to end counselling was not the client's. When
unplanned endings occur as a result of the counsellor or agency policy, some counsellors
feel frustration, anger and concern for their clients. When Emily was faced with an
untimely departure, she experienced considerable frustration:
Well, if you’re leaving them, another loss, and right? Even if you had to leave
because you had to move on or funding was cut to half-time, you do that. But to
be told, “End of week, you’re done,” and I’ve got clients I won’t be able to see. I
had appointments for two weeks later that I had to cancel.
It was clear that Emily was frustrated because she felt a strong sense of responsibility to
the people with whom she worked. She was also upset because she had no choice in
ending these relationships.
In general, the majority of the participants described unplanned endings as feeling
nebulous. They felt unfinished, and they often wondered where they stood. These
endings left many counsellors, such as Sue, with unanswered questions:
Were they lying to me or did they forget or were they blowing me off or did they
just not feel the need? It is perfectly fine if they didn't feel the need. Maybe their
intention was to check their schedule but it never really came up again. So that’s
okay, it’s their life… not for me to say.
Ultimately, the practitioners experienced a wide range of emotional responses to
unplanned endings depending on the circumstances of the endings, the nature of their
relationships and the work environments. There were little consensus among the
participants. However diverse their emotional reactions to unplanned endings, it opened
the door to understanding how they managed these experiences in practice.
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Managing Unplanned Endings
The emotional impact of the counsellors’ experiences of unplanned endings
seemed to precipitate change in their practices over time. Therefore, the final category
that emerged in the data was the participants’ management of unplanned endings in
practice. ‘Managing’ refers to how the participants responded to unplanned endings. It is
what they did, oftentimes in response to their emotional reactions.
Most of the participants recognized that not only their understanding but their
practice of endings has evolved over time. Numerous experiences of unplanned endings
appear to have precipitated changes to their practice and reflect the counsellors’ efforts to
both minimize the occurrence and the impact of unplanned endings. Six themes emerged
as the most common changes in the counsellors’ practice: 1) detaching, 2) sensing, 3)
becoming more transparent, 4) evaluating progress regularly, 5) integrating rituals, and 6)
keeping the door open.
Detaching
A number of the participants described managing unplanned endings as involving
a process of detachment, meaning that they chose not to take responsibility for their
clients’ decisions to end counselling. Instead, they detached from taking responsibility
and, in doing so, managed the impact of unplanned endings.
Being detached means that I am not taking responsibility for your change or your
lack of change. That’s detachment. In other words, your change as a client is not
my accomplishment. I may have created an environment in which you could make
a different choice that you are now happier with and, therefore, that change suits
you. But whether you do or do not change is not my responsibility. Over time as
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a counsellor I was able to understand that better and be less concerned about
whether or not you did or did not make change (John).
For some, detaching is a process of ‘letting go,’ as described by Teeya:
I just have to let them go. If I look through my book, sometimes I can’t even
remember who that person is and what they were there for. Whereas the ones
that I’ve ended with; I definitely know who they are. Otherwise, it’s just kind of,
‘easy come, easy go’.
‘Detaching’ and ‘letting go’ were processes that a number of the counsellors
offered as strategies to manage the impact of unplanned endings. Detaching did not
reflect that they did not care; instead, they recognized and accepted their limitations to
control their clients’ decisions to make change and to end counselling. In this way,
detaching may be seen as one way that the counsellors respected their clients’ right to
self-determination.
Sensing
Detaching often occurs after the unplanned ending occurs. However, many of the
counsellors also manage unplanned endings by preventing them; finding ways to predict
and address them before they occur. Attempting to minimize the occurrence of
unplanned endings, the counsellors described tuning into their senses.
How do counsellors know when their clinical relationships are ending? As
already noted, the research participants accept that sometimes endings are out of their
control and unpredictable. But when they took the time to reflect on the out-of-control or
unpredictable endings, several sensed that the ending was coming. Intuiting that the
clinical relationship may be ending is an important part of managing unplanned endings
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in practice. Emily recalled, “You just sometimes get that sense that you’re not going to
see this person again.”
According to Emily, sensing is a feeling, “It’s that whole ‘spidey’ senses thing
that defies articulation…” Some counsellors referred to it as a ‘gut feeling’. With time
and practice, the counsellors paid attention to those feelings and noticed signs and signals
that pointed to the ending of their clinical sessions; noting patterns of behaviours, subtle
comments, overlooked opportunities to book another appointment and apathy: “You can
see on their faces, you can see in their responses.”
Sensing involves recognizing clients’ intentions. When clients appear satisfied
that they have accomplished what they want, they often give clues that they are ready to
end. As well, several counsellors sensed when clients were not satisfied or happy with
the counselling. They also recognized signs of their clients’ ambivalence to change,
taking note of the verbal and non-verbal clues that indicated their clients were not ready
to address certain issues. The clinicians recognized that they could often sense when
clients wanted to end despite the clients’ reluctance to speak openly about it. Sue
described it this way:
I often sense that it’s happening and I sense it in either of two ways. Either I feel
like, ‘Oooh, the person isn’t feeling that they’re getting what they want” or,
“They’ve got what they want.” Either can be a sense that they may or may not
come back. I may be offering something to them with my approach, methodology,
who I am, that they don’t want to buy right now. That it’s not quite what they
want.
Tom and Denise paid attention to signs of dissatisfaction in their clients. They
noticed when some clients started to disengage and recognized that counselling was
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“winding down”. They sensed “It’s time to take a break” and began the process of
ending before an unplanned ending occurred:
We process it just as you process any issue in therapy. You say, “It feels like
we’re starting to wind down,” or, “You guys have made some great progress.”
You identify it and process it. When I feel that a couple or a person is starting to
disengage I try to approach that as well. (Tom)
I think that you’re always trying to do some assessment as you go through, as you
work with them. You’re kind of checking in, in terms of how things are and how
they’re feeling. (Denise)
Sue uses her senses to open up conversations with clients about ending their work
together:
I think that you both just know that we’ve done what we need to do and sometimes
we talk about that. We say, “This feels like this is what you came for. This is
what I’m thinking where you are. Are we here?” Being here doesn’t necessarily
mean that we don’t set new goals but we’ve done what they came in for initially.
In summary, Sue, Tom and Denise made efforts to minimize the occurrence of
unplanned endings by sensing potential endings, signalling the need for conversations
with clients to evaluate and assess their work together. In this way, sensing facilitated
transparency in the clinical relationship, having the potential to transform a potential
unplanned ending into their preference for a planned ending.
Becoming More Transparent
The term transparency is used here to mean talking openly with clients about
issues with respect to the counselling processes. Counsellors become more transparent
when they openly discuss their clients’ expectations of counselling early on in the
therapeutic relationship. Transparency is also discussing signs of change or lack of
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change with clients. Using a variety of formal and informal strategies, the counsellors
determine progress and their client’s motivation as ways to manage or minimize the
occurrence of unplanned endings. Sandy described transparency as recognizing and
discussing clients’ progress:
There’s self-report. They say, ‘I’m feeling a lot better or I’m doing better’ and
then we talk about that. ‘What changed? What is helping you?’ We always ask a
scaling question like, “From zero to 10, how are you functioning now?” For me,
it’s gratifying to hear that they’ve made progress and that some of those
uncomfortable symptoms that they were feeling, the uncomfortable emotions were
being alleviated and they’re feeling happier, more positive. They’re doing some
things differently.
Peter recognized that clients may also be transparent about ending the counselling
relationship:
It’s when the client has reached a point of being able to say that they are ready to
move on without you. That may not necessarily be as a result of them having
achieved the outcome but they may have achieved the confidence to be able to
personally continue to work on the issues but they don't need the therapist. In
some fashion, the good endings tend to be overt. They’re talked about.
Several counsellors mentioned transparently sharing their concerns when they
sensed that a client was planning to run away or when they recognized apathy in a client.
Denise described transparency in her practice with adolescents:
You check-in; you make it overt and say, “I wonder if you’re feeling this way or
you’ve been thinking about leaving?” Some kids will say, “I’m running away. “
They’ll tell me and then you try to deal with the situation as best you can. I’m
pretty honest with my kids in terms of, “If you choose this behaviour, I will react
this way.” I don't tend to hide things. I try to be as honest and upfront as
possible. I’m not sure how you could do this job any other way, actually.
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Tara believes that transparency leads to better endings than those that are not
discussed. Allowing her clients the opportunity to have input and guide the ending
process openly is considered ideal. Along with Peter and Denise, she recognized the
benefits of talking openly about endings with her clients:
Especially lately, I’ve been wondering if I could keep the termination
conversation open more often. In some context, I do; but talking about
termination more often could maybe lead to a better ending and how they’d like to
terminate. Sometimes I’m really caught up in what’s going on now and thinking
we have more time. So yeah, I think that could help.
Recognizing and using their senses, and becoming more transparent were
identified by many participants as efforts to minimize the occurrence of unplanned
endings and therefore manage them in practice. Evaluating progress was another way
that the counsellors described managing unplanned endings.
Evaluating Progress
Believing that unplanned endings are inevitable and are part of the counselling
process, some clinicians regularly evaluate progress with their clients, helping both the
client and counsellor to find closure at the end of each session. In this way, the process
of evaluation may be considered an attempt to prevent the apparent consequences of an
unplanned ending by incorporating an ending within each session. Not only does this
strategy assist the clients and counsellors to recognize endings earlier, it also allows the
counsellors new insights into what their clients need from counselling. Overall, the
majority of the clinicians believe that regularly evaluating progress is the basis for good
counselling practice.
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Some counsellors treat each session as though it might be their last, prompting
them to end sessions by identifying strengths, summarizing work and sharing resources.
As well, a few counsellors regularly ask clients for feedback and to reflect on what they
have gained from the session. They often build these strategies into practice, resulting in
finding closure when formal endings are not always possible. As Emily commented:
I never make an assumption that I’m going to see that person again. Every time I
see them may be our last, so that’s going to have an impact on how I counsel. I
always end the session by identifying the person’s strengths or summarize what
they’ve worked on. I don’t wait to share different resources. I always treat each
session like I may not see that person again and it isn’t “Good-bye,” but that they
have something that they can take.
Tara’s practice changed after she came to the belief that many of her clients
would not return for a second session:
When I did some work at a private college I knew that with most of these students,
I might be lucky if I saw them again. I started in my regular practice to get as
much information as I could and give as much information as I could and
hopefully have enough contact information to give feedback and not assume I
could get those things later. I’m just making sure that I’d be able to reconnect
with that person; that seemed to help.
Several of the participants also identified regular evaluations and client feedback
as part of their agency’s expectations. These ongoing reviews provide clients with the
opportunity to evaluate their own progress and to discuss this with their counsellors.
Posing questions that help clients establish their current concerns, what they hope for,
and what they are prepared to invest to reach their goals may help to offset a potential
unplanned ending.
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A few of the participants use formal evaluations to open up conversations and
establish goals before clients become frustrated or apathetic, which may lead to
unplanned endings. These evaluations or client feedback forms highlight and recognize
success and change. The practice of evaluation also allows the client the opportunity to
talk about what may be preventing them from making progress while giving the
counsellor the information necessary to meet their client’s needs and expectations. The
counsellors recognize that unplanned endings are inevitable. However, with regular
evaluation they can feel more confident that their interventions are congruent to their
client’s expectations. Knowing this also helps the counsellors to reach closure more
easily when unplanned endings occur. The concept of closure will be discussed in more
depth in the next chapter.
Integrating Rituals
Some participants build the evaluation of client progress into their counselling
practice, which may ultimately become a ritual. Rituals are established patterns or
actions that are integrated regularly in counselling sessions. Several counsellors
identified rituals as an important strategy to manage unplanned endings.
A few counsellors integrated rituals at the end of each session to signal the end of
the work completed. Examples include giving and receiving affirmations, identifying
change and commitment to future steps. Meaghen described a ritual that her team in
palliative care integrated in their sessions. This ritual symbolized ‘saying hello’ by
lighting a candle and ‘saying goodbye’ by blowing it out at the end.
A number of the counsellors described various rituals as their way to end
counselling sessions, move to a new phase of work, or outright end the counselling
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relationship. The ritual provides the time and space to evaluate progress, recognize
success, and move on to the next phase.
Keeping the Door Open
Sometimes, however, the next phase of counselling is not apparent or clearly
established. For many counsellors, understanding the uncertainty in clients’ lives lead
them to ‘keeping the door open,’ another way that counsellors responded to unplanned
endings.
A number of the counsellors prefer that their clients know that they are free to end
counselling if that is their choice. However, they also want clients to know that they can
return or phone if or when they need help in future. Feeling assured that clients know
that the door is open to return to counselling is another way that counsellors minimize the
impact of unplanned endings. These counsellors overtly provide clients with the choice
to come or not to come to counselling:
Knowing the work they have yet to do and being able to continue it, that
awareness that it’s not over and that their time with me was just a small part of
their life. Knowing when and if they need to seek help in the future… that’s
important. (Emily)
I try to say (to clients), “Here’s my phone number. It’s a cell phone, you can
leave me a message, and I appreciate updates.” Some people use it and some
won’t. But that leaves it more open for them to return. (Tara).
To me, it’s like the open-door policy: My door is open and if people want to walk
through it they can, and if they want to walk past it and go into somebody else’s
door, that’s okay, or if they don’t want to go in any door, that’s okay too. (Sue)
The counsellors prefer that clients come to counselling when they are invested,
not because they feel obligated to the counsellor or to anyone else. When they had
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communicated to clients that the door to return to counselling was open, they often felt
better about unplanned endings because they knew that their clients had made an
informed choice. A number of the clinicians did not expect clients to account for their
absences; instead, they viewed unplanned endings as an acknowledgment of their clients’
right to choose.
In summary, the counsellors identified a number of strategies to manage
unplanned endings, most of which emerged when I asked the participants how they
responded to unplanned endings. The counsellors incorporated strategies to minimize the
occurrence and the impact of unplanned endings. For the most part, the counsellors
reflected that these were not always consciously thought-out decisions to manage
unplanned endings. Strategies, like sensing, emerged when the counsellors reflected on
how they made change in their practice over time. Their years of clinical experience
became evident when they considered changes in their practice and more specifically,
‘what they did’ when unplanned endings occurred.
The majority of the clinicians recognized that managing endings did not always
comprise conscious decisions, rather appears to evolve over time as an adaptation to
changes in clients’ needs and expectations. The participants of this study adapted their
practice in response to the inevitability of unplanned endings. At times this was thought
to result in minimizing the occurrence of unplanned endings, transforming the potentially
unplanned ending to a planned ending, or ensuring the opportunity for closure when an
unplanned ending occurred.
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Pulling the Pieces Together
As noted previously, the core category of ‘making room’ captured counsellors’
overall experiences of unplanned endings. ‘Describing’, ‘Reacting’ and ‘Managing’
captured what the counsellors knew, felt, and did when they experienced unplanned
endings. Together they helped to understand the breadth and diversity of the counsellors’
experiences of planned and unplanned endings.
However, apart from describing the participants’ knowledge, feelings and actions,
‘making room’ also encompasses three sub-processes, reflecting, learning and growing,
each of which capture how counsellors make room. Represented in table 2, these link the
categories to the core category, which creates new understanding of ‘what happens’ when
counsellors experience unplanned endings.
Reflecting, learning and growing are themes that wove in and out of the
interviews with the participants. They reflected on the clinical cases that ended
unplanned. They learned about unplanned endings from their interactions with clients,
supportive colleagues and supervisors. They grew as counsellors and changed their
approaches over time. Reflecting, learning and growing facilitated ‘making room’ so that
they could continue their work after a client’s unplanned ending.
Reflecting, Learning and Growing
The end of a clinical relationship, whether planned or unplanned, provides
counsellors with the opportunity to ask important questions about their practice. In this
way, endings provide a catalyst for growth. These events occur regularly in practice and
may be used to reflect on what happened, how they feel and what they know.
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When the participants looked back on their experiences of unplanned endings,
many remembered feeling embarrassment and guilt. Several clinicians blamed
themselves and doubted their counselling skills. Tom remembered that unplanned
endings felt “hard on the ego and hard on the heart.” He questioned whether the client
liked him and wondered if he had “messed up,” “missed something,” or “done something
wrong.”
However uncomfortable these feelings were at the time, unplanned endings often
provoked healthy self-reflection leading to new insights and growth. According to Tara,
reflecting is similar to watching “As though you are videotaping yourself.” She noted
that replaying what happened allows her to:
Really consider how I practice and I think that’s really positive. Sometimes I’m
able to take a step back and wonder if I had done something a little differently, we
might have had a different outcome. Maybe it’ll lead me to… try harder.
Reflection may also lead counsellors to seek supervision, peer consultation, or
personal support. Objective input from others allow the participants to “step back” and
“look at it from all different levels.” Tom remembered the importance of supervision
when he experienced unplanned endings. More experienced counsellors taught him new
strategies and techniques that improved his practice with endings:
Great supervisors can help you to see the bigger picture and understand clients’
expectations. They can also help you become more open to the notion that you
will make mistakes and have therapeutic failures. You can learn through feeling
bad and use your experiences to grow and help others.
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Reflection, supervision, and talking to colleagues all helped the counsellors to
examine the situation critically. Denise also relied on her colleagues and supervisors
when she experienced unplanned endings:
You talk to your co-workers because you’re not in a unique situation. The people
I work with, we had gone through a lot of the same situations. So it was really
great to hear their experiences and gain some knowledge. I was fortunate as I
had a great supervisor who was also extremely supportive and helped me through
some tough situations, giving me encouragement.
Table 2 “Making Room” Sub-Processes
Facilitative Sub-Processes ReflectingLearningGrowing
Impeding Sub-Processes Avoiding EndingsUnclear BoundariesWorryBlaming the ClientShame and Self -DoubtLack of Support/Supervision
A number of the counsellors recognized that experiencing unplanned endings
helped them to learn and grow as therapists. When faced with difficult challenges, they
often considered what they might have done differently. Taking time to reflect on
unplanned endings helped Sue to learn and grow as a therapist:
I had all kinds of ideas of how I could help this person and they didn’t call me
back. I did need to go through a process of thinking about that and figuring out
what I would do differently if that person walked in the door again. It’s when we
bump into problems that we have to dig deep and figure out what is going on.
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These experienced counsellors understand that attending to unplanned endings is
inevitable in practice, “this is your job.” They accept responsibility for their part in what
happened, admitting: “Yeah, I did really mess up.” As such, they acknowledge their
strengths and limitations. Peter and Tara mentioned their strategies:
Reflecting, meditating, and consulting. I participate in a supervision group and
sometimes we’ll chat about cases and challenges and an unplanned ending might
be part of that discussion. Sometimes it is being able to look at your own case
management and say, “How might I improve in that area?” (It’s) being open to
the idea that there may be areas that you can improve upon. (Peter)
I think overall I learn. Whether I’m right or wrong about why they terminated, it
does help me to be better if I take myself out of the equation in the ego sense and
consider what might have been therapeutic for the client. (Tara)
These counsellors used these often-challenging experiences to become better
counsellors and to learn more about themselves as individuals. Sue expressed it this way:
What sense can I make of what I know about them, about me, about our work
together, that would help to explain why they’re not coming back? It doesn’t
matter what it is. Whatever it is, if I come to understand it, I’m good.
Sue believes that reflection helps her to make sense of what she knows, which is essential
to learn and grow as a counsellor.
Unplanned endings provide space to learn and grow by prompting counsellors to
pause and reflect. They may become topics to address with supervisors and colleagues.
In general, unplanned endings are often considered as opportunities for counsellors to
improve their practice for the benefit of future clients.
These participants were motivated to learn what they could from their experiences
of unplanned endings. Seen as a ‘wake-up call,’ unplanned endings gave the counsellors
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the opportunity to pause and reflect on ‘what happened.’ Without having all the
information about the reasons for the endings, many of the counsellors needed to make
sense of it and find closure. Essentially, unplanned endings, however uncomfortable at
the time, facilitated ‘making room’ by reflecting, learning and growing, so that the
participants could potentially move on and become better counsellors.
Challenges to Making Room
The participants shared several common impediments or sub-processes that made
reflecting, learning and growing difficult. Represented in Figure 1 as the arrows that
push inward, the following dynamics hamper the process of ‘making room’: Avoiding
endings, unclear boundaries, managing worry, blaming the client, feelings of shame and
self-doubt, and lack of support and supervision.
Avoiding Endings
A number of the counsellors acknowledged that, on occasion, they avoid talking
about endings during counselling. While they identified many reasons for this, several
participants attributed avoiding endings to high turnover rates. These counsellors worked
in areas such as addiction counselling or with youth where clients were likely to come
and go.
Many people with substance abuse problems will drop out of treatment even
though they think that you're a good person to talk to. Maybe it's the nature of the
problem of addictions that we feel it is out of their control in some way or for
some of them anyway. (Tom)
We have some clients who disappear and I find I actually don’t have a lot of time
to think about it because we have so many new clients. We go though so many
clients. (Sandy)
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Endings may also be seen as emotional and uncomfortable, especially for those
who work in bereavement or in those instances when long-term relationships have been
established:
The organization I worked for was really clear on boundaries. So I felt that
prevented me from doing a proper goodbye in some ways. Because I felt I wanted
to avoid it because it was hard. It's hard to say goodbye to a mom whose baby
not very many people knew, that maybe I held the baby and I remember the baby.
It's really hard to say to her, “This is goodbye now.” (Meaghen)
Openly addressing endings in counselling can be challenging in such
circumstances, especially for new clinicians. All of the experienced counsellors in this
research learned to appreciate the importance of endings and talk openly about them with
clients early in the counselling process. However when they were novice counsellors,
most remembered avoiding endings because they did not know how to deal with the
difficult feelings involved.
Further, several counsellors pointed out that ‘endings’ do not receive the attention
they deserve in professional education, leaving students with little information about how
to handle endings in clinical settings:
When we’re involved in education we don’t give people enough opportunities to
integrate personal and professional responses to endings. We don’t allow people
to look at what’s triggered for them with endings. Some people avoid endings. I
would say some professionals do. They deal with it poorly because they avoid
them or don’t know how to deal with them or stuff’s triggered for them for
whatever reason. Every once in a while you have one class and maybe a quarter
of it is focused on endings and what you should do during the termination
process… I don’t know if we avoid it or we don’t think it’s important or both.
(Emily)
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The participants who were also teachers and supervisors recognized that very
little time is given to students to learn and understand endings in clinical practice. The
counsellors considered that this oversight in counselling education may feed into
believing that the process of ending is unimportant. Novice counsellors may not be
prepared to deal with endings and will avoid them if they don’t discuss them, learn from
them, or share these experiences. Emily shared her thoughts about this:
Counsellors need the opportunity to reflect and debrief when their counselling
relationship ends. All counsellors experience challenging clients and they need
the opportunity to learn from this. Challenges in clinical work may lead to
counsellors’ feeling vulnerable and questioning their sense of self; judging
whether or not they have done a good job. It is only through sharing, gaining
support and supervision from others that counsellors can decide if they did
everything they could.
Unclear Boundaries
All of the research participants addressed the importance of boundaries when
discussing the impact of unplanned endings. They recognized that, although they may
struggle with a client’s decision to end counselling, they need clear boundaries around
what they can and cannot control. Clear boundaries help counsellors accept clients’
decisions to end counselling; especially when they do not agree with these. Tom shared
an example of this struggle in his practice:
There are times when I’ll have somebody who’s got an addiction and drops out of
treatment because they don’t like the pressure that is inherent in the process of
them quitting. There are times that I feel like I want to chase them down and get
them back in here. You feel like, “Man, you don’t really understand what you’re
losing.” But you also know that by chasing somebody down and trying to bring
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them in, you’re perhaps perpetuating the problem. There are those kinds of
struggles.
The counsellors believe that having clear boundaries does not mean that they do
not care about their clients. Instead, they understand that clear boundaries allow them to
have the necessary space to reflect on what they can and cannot control. When they
perceived they were taking too much responsibility for their clients’ decisions, they
struggled emotionally to continue in their work:
(As a novice counsellor) I would take it (unplanned endings) much more
personally. It was much harder on my ego and also my heart just in terms of,
“Oh, this isn’t working and I’m not making a difference in peoples’ lives.” The
other thing is that I have probably changed my sense of what’s healthy in terms of
the emotional boundaries with clients. I think that I’ve pulled back some and I’m
much more comfortable with the idea that while I’m hopefully making a
difference, I’m not the reason (for clients making change). (Tom)
Establishing boundaries was also a challenge when the counsellors liked their
clients and enjoyed working with them, as Emily recalled:
There are always those people (with whom) you work fabulously and they make
you feel like you’re such a wonderful social worker. You don’t want it to end.
Everybody’s got their favourite clients where, “Oh my god, I don’t want to stop
working with you and if I knew you in any other way in my life we’d be good
friends.”
Similarly, Sue believes that some clients may get attached to their counsellors and
be reluctant to end counselling:
They don’t want to end the relationship. They might want to end the therapy but
they don't want to end the relationship part or they think they should keep coming
for some reason. They feel obligated.
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Denise summarized the importance of boundaries in terms of ending relationships
with clients:
You need to have clear boundaries. You’re in this job and there’s a professional
relationship, so there are expectations about those lines that you do and don’t
cross.
Establishing clear boundaries may be crucial to ‘making room’ in clinical
practice. Without good boundaries, counsellors may interpret a client’s decision to end
counselling as being personal and, consequently, may have trouble letting go and moving
on in their practice.
Blaming the Client
Blaming the client was another obstacle identified by Sue that impedes learning
and growing as a therapist. She and several other participants recognized that blaming
clients when they do not return prevents counsellors from addressing clinical issues and
subsequent changes to their practice.
That’s my approach to life. I don’t blame the other guy because what am I going
to learn from that? All I’m going to do is dump responsibility on them and go
away feeling a little better. My self-esteem might feel a little better in that
moment but I’ve denied myself and I’ve probably done an injustice, by doing that.
(Sue)
As previously stated by Sue, when counsellors blame clients for unplanned
endings they may be doing themselves and their clients an injustice: They deny
themselves the opportunity to learn and grow.
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Managing Worry
Another challenge to ‘making room’ is managing the worry that counsellors
experience when some clients choose not to return. Worrying about clients challenges
some counsellors and ‘takes up space’, limiting their capacity to work with others.
Denise and Tara described several instances when they were concerned for their clients
who disappeared:
Some of the hardest endings for me are when kids disappear. And they literally
disappear. They run away and you haven’t a clue where they are. Those are
really, really difficult for me…If a young person takes off, and those are usually
the really high risk kids, you worry about them. That’s just awful when you bond
with your clients and you develop a relationship, and then they're gone. Of
course you worry about them. (Denise)
I think concern is the primary thing that I feel. Sometimes it's a bit of frustration
too. I think it’s more because I would like to help and I know that (leaving) could
put this person at risk, from a health or well-being perspective. So that's not a
good feeling. It’s just because we're ethically bound to help people and ensure
that they safeguard their health. (Tara)
Concern and worry would likely be considered appropriate under these
circumstances. However, continued worry and concern that is not addressed is likely to
take a toll on counsellors, leaving them vulnerable to burning out and posing a major
obstacle to ‘making room’. A number of the participants recognized the emotional
demands of their work and emphasized the importance of support and debriefing with
others in order to address troubling feelings such as worry and concern.
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Feelings of Shame and Self-doubt
Similar to managing worry, many of the participants recognized the importance of
overcoming feelings of shame and self-doubt. They understand that unplanned endings
may lead counsellors to question their competence in this very challenging field. Tom
summarized his initial feelings about unplanned endings, ones shared by other
participants:
I think that there’s an element of, what’s the word - shame I guess would be the
right one. Embarrassment maybe. Feeling of inadequacy.
Despite knowing that unplanned endings are common in practice, these
experienced counsellors were often surprised and dismayed when they occurred:
I’m thinking of one person in particular where that happened (unplanned ending).
It did bother me and I did think about it and I wondered what I had potentially
done or said that might have given that person the impression that I wasn't going
to be helpful to them. (Sue)
However, each of the counsellors appeared to use these experiences to reflect,
learn and grow. They attended to their initial sense of failure and self-doubt by
evaluating their practice and making changes when necessary:
It did feel like failure to begin with. I have to say, I did feel a sense of letting them
down. It made me evaluate what went on in the group that upset him and that
prompted his mom to pull him out of the group. Could we have handled it
differently? It made us really examine and change our assessment and our intake
process into the groups. (Meaghen)
Lack of Support or Supervision
Lack of support and supervision is a final challenge to ‘making room’ that all the
participants identified as crucial to learning and growing as a therapist. Unplanned
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endings are considered to be very challenging clinical situations that require ongoing
support, consultation and supervision. Yet, Emily recognized that in many instances,
counsellors lack support or the opportunity to debrief:
We’re not prepared for it (unplanned endings). I don’t think we talk about it. I
don’t think we support each other in it. There’s just an assumption that we will
manage it because we have to…We have so little time to talk to each other about
what’s so difficult about our jobs and that’s (unplanned endings) just one thing.
It’s not just that we don’t talk about it; we don’t look after each other, we don’t
check in on each other to see how we’re doing. You go from bedside to bedside,
or client to client without having the time to reflect…It’s the debriefing that
doesn’t happen or it’s difficult to make that happen. When our relationships with
clients end and it’s done we don’t debrief it much with each other. (Emily)
Sandy’s experience was similar: “It’s very different being in EAP when you’re
the only counsellor. It’s a lot more stressful. It’s more isolating. You just don’t get the
opportunities to debrief.”
A number of the counsellors expressed gratitude for the support and guidance
they have received throughout their careers. When experiencing unplanned endings, they
regard this support as especially important:
For me it’s always been really helpful to have the support of my colleagues and to
have somebody that can really empathise with what you’re going through; for
somebody to help validate how you're feeling. Having people there that you can
do that with is really important. (Denise)
I had a wonderful mentor who taught me these kinds of things. Like when
somebody decides not to come back there may be a reason and there’s also client
self- determination right? She really helped with that, but not everybody has that
kind of mentorship. And, especially if they don’t have anybody to talk to, that can
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contribute to becoming (burned out). It contributes to questioning themselves and
not trusting that instinct, that practice wisdom. (Emily)
I was just so blessed with great therapists who were supervisors and by working
within teams. I was truly blessed…Colleagues are so important. We phone each
other up and say, “Got any ideas on this one?” or, “This Thursday we’re going
for coffee.” I’m sure that one or both of us at some point will say, “Can I pick
your brain for a minute?” I think that’s really all you want. (Tom)
That’s what I find is so important. We have to be there for each other and
mentor, because it can really create a horrendous situation for people if they
haven’t got that. Like harm to the worker. We should be looking after ourselves
the way we do clients as far as I’m concerned. (Emily)
The Inevitability of Unplanned Endings
Recognizing that unplanned endings are inevitable was important for a number of
the participants to learn and grow as counsellors. Although unplanned endings may
provide opportunities for reflection to improve practice; it is also important to recognize
the areas that are beyond the counsellors’ ability to control or influence.
Part of it is to take some time to reflect on your cases. Take a look and see if
there’s something about what you’re doing or how you’re doing it, but also
understand that unplanned endings are inevitable. They’re going to happen and
take care of you if they are happening. Read some books and take a break.
(Tara)
When faced with challenging clinical situations such as unplanned endings, self-
care was seen as crucial. This meant understanding the limits of counsellors’ influence
and being kind to oneself. Knowing that clients are making choices is an important part
of self-care because it allows counsellors to recognize when it is not a reflection of their
limitations. Peter and Emily expressed the following:
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There are some issues that are clearly beyond your control. One of them is the
choice that some people make about… coming back to counselling or not coming
back to counselling. They are the consumers and they have the ability, the right
and the capacity to be able to say, “I’m done, I’m not going to do this.” (Peter)
You look at the number on a case load too. I don’t mean this in a bad way, but
I’ve got 50 people on my caseload. Not everybody comes and says good bye,
thank you, you were wonderful. You know? The trouble with this job is we don’t
know the ending, right? (Emily)
When clients choose to end counselling without a final conversation about why
they are making this choice, it can pose significant challenges to ‘making room.’
Without client feedback, counsellors are left with questions that cannot be answered;
learning and growing is difficult because counsellors must rely on their intuition and
assumptions. These experienced counsellors overcame these challenges by reflecting,
learning and growing whenever possible. They also learned to recognize their limitations
and accept the inevitability of unplanned endings.
With experience, mentorship and support, many of the counsellors attended to
incidents of unplanned endings from a more reflective and positive perspective. When
facing unanswered questions, they chose to learn what they could instead of ‘beating
themselves up’. They also recognized client’s right to self-determination and re-framed
incidents of unplanned endings from one of ‘failure’ to one of ‘client growth.’
In conclusion, planned and unplanned endings are necessary for counsellors to
make room for new people to come aboard. ‘Making room’ does not only refer to the
physical presence of clients in counsellors’ lives it also refers to the emotional and
cognitive toll. These clinicians identified a number of situations and circumstances that
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facilitate and impede making room. In general, though, most of the study respondents
benefited from their experiences of unplanned endings, using these to reflect, learn and
grow as counsellors.
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CHAPTER SIX: DISCUSSION
This study explored the processes that occur when counsellors experience
unplanned endings. While a number of authors suggest that this phenomenon is common
in clinical practice, little is known about the impact on counsellors and their practice
(Baum, 2007; Connell et al., 2006; Ogrodniczuk et al., 2005). Instead, for many reasons,
research in this area is fraught with conflicting and often detrimental accounts of how to
interpret and understand unplanned clinical endings (Connell et al., 2006; Mennicke et
al., 1988; Mirabito, 2006; Ogrodniczuk et al., 2005).
Nevertheless, a number of clinicians and the current study participants recognize
that counsellors adapt to the realities of these experiences (Miller, 2008; Pearson, 1998;
Pinkerton & Rockwell, 1990; Quintana, 1993), conceptualizing unplanned endings in
ways that support their values, self efficacy and practice. They incorporate strategies,
both personally and professionally; accepting the inevitability of unplanned endings as
part of their practice.
In this chapter, I revisit the current research findings, beginning with reflections
on the research process, which provides a more personal and transparent account of the
researcher, the participants, the interview process and the analysis. The conceptual
model entitled ‘Making Room’ is then re-examined in the context of what is known in the
literature, extending my interpretations of counsellors’ experiences of unplanned endings
to include the concept of closure. I also address how counsellors’ experiences of
unplanned endings are influenced by the core social work value of client self-
determination. This allows for consideration of possible ways to update and re-
conceptualize unplanned endings in clinical social work practice. The limitations and
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strengths of this study are highlighted before several implications for further research and
clinical practice are presented.
Reflections on the Research
From a long hike in the Canadian Rockies to completing this research emerged a
personal and professional process that I found very valuable. I hoped to learn from other
counsellors, exploring a topic that was meaningful and relevant to current social work
practice. Reflecting on this, I now realize that what initially brought me to this topic was
a strong desire to increase communication among experienced clinicians with the hope of
learning and growing from their experiences.
Conducting qualitative research allowed me entrance into other counsellors’
clinical experiences and the opportunity to use skills that I developed over years of
counselling practice. I was transparent and shared my experiences which made the
research interviews intimate, interesting and enjoyable. Although I had previously
known several of the participants in a professional capacity, some were counsellors
whom I had only recently met. In both circumstances, I believe that I connected to the
participants in meaningful ways that allowed for rich and deep conversations about
endings in clinical practice.
In many instances, the research interviews uncovered a variety of interesting
topics that delved deeply into issues relevant to current clinical practice. In my opinion,
this depth could only be achieved through collaborative and openly transparent
conversations about clinical practice. Although the participant’s understandings and
experiences of unplanned endings were always the focus of this research, the interview
process aimed towards equality and mutuality.
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Several participants questioned why counsellors devote so little time exploring
their clinical experiences. Most shared the perspective that although unplanned endings
are common in clinical practice they are rarely examined openly in professional settings.
A number of the participants expressed gratitude for the opportunity to talk about
unplanned endings in their practices.
From a constructivist perspective, it was clear to me that knowledge and new
insights about endings in clinical practice were co-created during the interviews. I was
genuinely curious about other clinicians’ experiences of unplanned endings which led to
questions that, in many instances, had never been considered or expressed. Many “ah ha”
moments occurred during the interviews as the participants and I explored the meaning
behind what they were describing. As well as sharing experiences and knowledge,
together we created new understanding about this common clinical experience.
Nevertheless, being new to the field of qualitative research, I worried about the
extent of my subjective influence on the research and how I would account for this. I
believe in relativism, with a strong leaning towards constructivism. This means that, in
my mind, reality does not exist, waiting to be discovered. Instead, it is created or
constructed in the context of continually changing circumstances and relationships. As
such, I adopted a reflexive stance and incorporated strategies that I hoped would create
transparency and accountability within the research. I believe it is important to
acknowledge the influence and impact of my ideas, background, assumptions, position,
and behaviours.
With the use of journaling and consultation with colleagues and supervisors, I
developed a reflexive approach to this research. I reflected on my ideas, questions and
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general impressions after each interview. From these reflections, I examined my own
personal and sometimes unconscious actions and reactions to the interviews, which
helped to look beyond the words of the transcripts into the meaning that the participants
were conveying.
The journaling and pre-interviews increased my sensitivity to the challenge for
participants to talk openly about a subject that is often considered taboo. Some of the
counsellors described unplanned endings as shameful when they introduced the
possibility that they may be judged to be incompetent. Journaling on this and then
reflecting about the participants’ worry provided me with insight into the importance of
establishing trust in the research interviews. Looking back, it appears that the very
process of conversing openly and transparently about unplanned endings alleviated the
participants’ concerns about being perceived as incompetent.
In addition to reflecting on the research interviews and processes, journaling and
consulting with supervisors and colleagues also informed the research analysis.
Consistent with theoretical sampling methods, the analysis was ongoing and concurrent
with the data collection or, in this case, the research interviews. The journal was used to
keep track of what I was thinking and how I was feeling throughout the analysis. When I
felt stuck or uncertain, I went back to my journal to re-capture those insights and
interpretations that excited me; helping to keep the analysis progressing forward.
Initially, I found the process of analysis interesting, as new ideas and concepts
emerged. I studied the transcripts line by line and beside each, wrote an action word to
describe what was happening. At each natural break in the transcript, I reflected on the
words and wrote memos to summarize my interpretations of what was happening. I titled
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each memo to capture the main premise and colour-coded and numbered them so that I
could easily refer back to the original transcripts. Cutting and tacking the memos to a
large wall, I moved them around, finding different ways to fit them together. The ones
that did not fit were grouped as well and kept on the wall for further reflection.
The initial open-coding, although interesting, was structured and routine. I felt
comfort in the knowledge that I was following grounded theory methodology and I
trusted that this initial work would lead to more depth in the analysis.
After the initial codes were grouped together, I continued to reflect and write
additional memos, which were longer and took time to develop into concepts. However,
as the concepts became more abstract and I struggled to find connections between them, I
became uncertain and self-doubting. Journaling, memo writing, consulting with others
and theoretical sampling assured me that the ideas and concepts made sense and that my
interpretations remained closely tied to the data. When I had difficulties, I went back to
my journals, the memos and the original transcripts. I continued to journal my thoughts
and feelings; sometimes reflecting on these for days.
As the interviews progressed, I shared some of my ideas, questions and reflections
with the participants who added their own understandings and interpretations. Together,
we created broader and deeper meaning for many of the concepts. Crucial to this stage of
the analysis was finding comfort with not knowing where the data was leading. I stayed
open to what emerged and to what the participants were sharing.
The core concept “Making Room” was one of the initial codes that did not fit with
the other categories. Five participants discussed ‘moving on’ and two referred to
‘making room’ when describing how they continued to practice after experiencing
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unplanned endings. Raising this code to a category and then to the core concept,
connected the other categories together. By asking what was happening between the
categories, I identified the codes reflecting, learning and growing as sub-processes.
These sub-processes helped to uncover how ‘making room’ happens.
As previously discussed, Charmaz (2006) and Corbin and Strauss (2008) believe
that the research analysis extends well into the writing. I continued the analysis as I
wrote the first drafts of the dissertation. Concepts and processes became clearer as I went
back to the original transcripts to include excerpts from the participants. “Making Room”
came alive as the participant’s voices were expressed in the writing.
At this point in the research process, I returned to the literature. Although classic
grounded theorists Glaser and Strauss (1967) advocate delaying any review of the
literature until after completing the analysis, the requirements of my studies led me to
become familiar with the literature on this topic prior to the onset of the research. The
worry is that pre-existing knowledge or theories may interfere with the researcher’s
ability to allow for new ideas and concepts to emerge. However, I took a critical stance
towards the existing knowledge and theory on unplanned endings and I ensured that it
earned its way into the research through the processes of constant comparison. The
following section revisits the literature on unplanned endings to clarify and extend the
concepts and categories that emerged.
Returning to the Literature
Consistent with the participants’ accounts, the literature and research on
unplanned endings is diverse and often inconclusive. The nature and impact of
unplanned endings in practice is difficult to capture, which may be due, in part, to the
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challenges in defining this concept (Wierzbicki & Pekarik, 1993). Evident in this study
were the diverse ways that the counsellors interpreted and conceptualized endings, their
beliefs about planned and unplanned endings, the practical and functional purposes of
endings, the situational context of endings and how the counsellors’ accounted for the
relationship.
Studies in this area have primarily focused on the situational context of unplanned
endings (Hunsley et al., 1999; Pollak et al., 1992; Todd et al., 2003; Tryon & Kane, 1993;
Wierzbicki & Pekarik, 1993). These researchers sought to understand the ‘causes’ or
predictors of unplanned endings, focusing on solving the ‘problem’ of unplanned endings
(Mennicke et al., 1988; Ogrodniczuk et al., 2005; Pekarik, 1992; Pekarik & Finney-
Owen, 1987). With the exception of Baum’s (2007) study that recognized the importance
of relationship in counsellors’ reactions to unplanned endings, researchers have not
considered the full range of interpretations to include what the counsellors in the current
study identified.
As well, the vast majority of research that addresses the impact of unplanned
endings on counsellors emphasizes the negative effects, neglecting the full range of
emotions experienced by the participants in this study (Boyer & Hoffman, 1993; Hill et
al., 1996; Tweed & Salter, 2000; Wilson & Sperlinger, 2004). This emphasis has been
noted by recent researchers who, similar to this study, have found counsellors to
experience a diverse range of feelings associated with unplanned endings (Baum, 2007;
Fortune, 1987; Fortune et al., 1992; Mirabito, 2006). This oversight in the research may
be due to authors’ attempts to justify further study in this area or allegiance to outdated
conceptualizations of “endings as loss”. Unfortunately, the effects of this may actually
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impede progress in understanding and re-conceptualizing unplanned endings in clinical
practice.
Although the concept of unplanned endings may not suit the interests of agency
mandates or the requirements of outcome studies (April & Nicholas, 1997; Tweed &
Salter, 2000; Wierzbicki & Pekarik, 1993), in this study they had purpose. They
represented expressions of client self-determination, reflected societal demands for
counselling services to be more consumer-driven, and provided counsellors with an
opportunity to learn and grow in their practice. Given that other research has established
that almost half of the endings in clinical practice are unplanned (Connell et al., 2006;
Pollak et al., 1992; Wierzbicki & Pekarik, 1993), attention must shift from efforts to
minimize these occurrences to understanding what unplanned endings can teach
counsellors about their clinical practice.
The counsellors in the current study appear to be doing this. For the most part,
they accept that unplanned endings are inevitable and, congruent with other research;
they believe they occur for a variety of reasons. Instead of viewing unplanned endings as
unwanted and detrimental clinical experiences, unplanned endings are regarded as
opportunities for reflection, learning and growth as well as expressions of clients’ self-
determination. Adapting to the inevitability of unplanned endings in practice, this
conceptualization appears to provide counsellors with the opportunity for closure.
Closure
Because the current participants mentioned closure and referred to it as important
to their experience of endings, I sought to understand its meaning and also how it may be
connected to the core concept of ‘making room.’ This section of the discussion addresses
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the concept of closure; what is known about this concept from the literature, and how the
core concept ‘making room’ may be further extended to include an opportunity for
closure.
In mainstream language, the concept of closure evolved to suggest an ideal
process of ending. Defined by Merriam-Webster’s Online Dictionary (2010) as, “an
often comforting or satisfying sense of finality”; the term closure originated from a
Gestalt principle. This principle applies when we see complete figures even when part of
the information is missing. For example, as represented in Figure 2, our minds tend to
complete the circle even though the circle is not joined together:
Figure 2: Gestalt Principle: Incomplete Circle (adapted from: Skaalid, B., 2010)
The concept of closure is frequently mentioned in the research and literature on
clinical endings (Craig & Bischof, 2003; Walsh, 2003, 2007). The participants and a
number of authors refer to closure as something to strive towards (Connell et al., 2006;
Lackstrom & MacDonald, 2002; Mirabito, 2006; Ogrodniczuk et al., 2005; Walsh, 2003,
2007) and achieving closure was considered desirable. However, despite this, no
research to date has specifically addressed the concept of closure or sought to understand
the processes involved for endings in general or more specifically for counsellors who
experience unplanned endings.
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Gestalt psychology extended the term ‘closure’ “far beyond its original meaning
as a certain type of perceptual phenomenon” (Schoenfeld, 1941, p. 494). The concept of
closure is now more broadly interpreted to include a process of ending (Walsh, 2007).
Acknowledging the uncertainty and incomplete information often involved in many
endings in life, Allport and Postman (as cited in Wilson, Elkan, & Cox, 2007, p. 446)
believe that closure is important for people to make their “experiences as complete,
coherent and meaningful as possible.” Specifically, Walsh (2007) described closure in
clinical practice as:
A process in which practitioners and clients bring their work to a mutually
understood (not necessarily satisfactory) end, review their work together
(successes and failures), perhaps acknowledge feelings about the relationship, and
acquire an enhanced willingness to invest in future relationships. (p. 5)
Walsh (2007) extended the process of ending work with clients to achieving a
complete, coherent and meaningful experience for both clients and counsellors.
However, he also acknowledged many circumstances in which the process of endings or
closure may feel incomplete.
Unplanned endings are often viewed as an “incomplete” therapy by the
counsellors who experience them. Applying the concept of closure to counsellors’
experiences of unplanned endings; I suggest that the core concept of “making room” and
the sub-processes ‘reflecting, learning and growing’ provide direction for counsellors to
achieve closure when their relationships with clients end unexpectedly.
In unplanned endings, clients leave counselling without advanced notice and, in
most cases, never share their reasons for this decision (Walsh, 2007). Making sense of
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these events is an important step to achieve closure (Wilson et al., 2007). In many
instances, it may be necessary to “fill in the gaps” as to why they left, or what may have
happened during counselling that possibly precipitated the ending. The sub-processes of
‘making room’ or ‘reflecting, learning and growing’ appear to help counsellors do this.
Several authors concur that reflecting, learning and growing are important
processes for counsellors to achieve closure (Pearson, 1998; Tweed & Salter, 2000;
Walsh, 2007; Wilson & Sperlinger, 2004). The most commonly identified strategies
were reflection and seeking professional and personal support (Pearson, 1998; Tweed &
Salter, 2000; Walsh, 2007). Walsh (2007) emphasized that “self awareness and the
utilization of regular clinical supervision are the most important practices for attending to
this (endings) and to other aspects of clinical intervention” (p. 39).
Tweed and Salter’s (2000) grounded theory study of counsellors who experience
‘non-attendance’ found that the, “participants engaged in a variety of internal self-
supervision and action strategies as a means of re-establishing equilibrium” (p. 475).
Similar to the current study, Tweed and Salter reported that the counsellors used their
experiences of unplanned endings as opportunities to learn:
By experiencing disruption to the regular therapy routine, participants gained a
deeper knowledge of the process of therapy and the part both they and their
clients played in this encounter. This seemed to represent a shift from a more
simplistic conceptualization of non-attendance to a more complex appreciation of
the joint nature of this event, involving issues of responsibility of not only
themselves but their clients also. (p. 474)
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When unplanned endings result in no further contact with the counsellor, the
current research and the literature concur that consultation, supervision and self-care are
crucial for counsellors to achieve closure. Vasquez et al. (2008) believes in the
importance of monitoring clinical effectiveness and personal distress: “Psychotherapists
who self-monitor and practice effective self-care are less likely to have inappropriate
terminations or clients who feel abandoned” (p. 662). Pearson (1998) also advocates for
counsellors to access professional and personal support. He believes that, “through
consultation and supervision, colleagues can provide both professional support for the
emotional strain and an objective view regarding potential counter-transference” (p. 3).
The experienced counsellors from the current study also recognized the important
role of clinical supervision and collegial support in addressing unplanned endings.
Mentorship and good clinical supervision helped these counsellors reflect on incidents of
unplanned endings and become better at self-reflection over time, making sense of
unplanned endings and finding closure.
The majority of the counsellors routinely made follow-up phone calls when their
clients did not return. Believing that their clients had every right to end counselling
without having to account for it, they also understood that some clients who “disappear”
may need help or appreciate intervention.
The counsellors described a number of situations in which calling clients not only
demonstrated respect and concern for them, but also allowed the counsellors and their
clients the opportunity to say goodbye, assure the clients that they were welcome to
return in the future, provide additional support, and ensure clients’ safety. In general,
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alleviating concern for their client’s well-being appeared to assist the counsellors achieve
closure to the clinical relationships.
Interestingly, clinical authors are divided on whether following-up with clients is
a good idea. While some believe that follow-up calls should be standard practice
(Mennicke et al., 1988; Vasquez et al., 2008; Ward, 1984), others are more cautious;
especially if there is a risk that the phone call could promote client dependency (Gelman
et al., 2007; Ogrodniczuk et al., 2005). Overall, few authors recommended follow-up
phone calls as strategies for dealing with unplanned endings and no research to date has
explored the value of this practice to achieve closure for clients or counsellors.
Nevertheless, the participants in the current study shed light on the possibility that
follow-up calls may help achieve closure for both themselves and their clients. While
considering the numerous variables involved in clients’ decisions to end counselling, the
clinicians recognized the potential to not only understand their clients’ reasons for
leaving, but, more importantly, to feel reassured that their clients have the necessary
supports, feel empowered to return to counselling, and have the opportunity to say
goodbye.
In summary, the concept of closure has been widely used and interpreted in
clinical practice to reflect an ideal ending. Despite challenges to achieving closure when
faced with unplanned endings, there is potential through the sub-processes of reflecting,
learning and growing. Clinical supervision, collegial support, self-care and following up
with clients are strategies that the counsellors in this study identified to help them achieve
closure and thereby ‘make room’ to continue to practice.
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Unplanned Endings and Social Work Values, Principles and Practice
Another important concept that reflects social work values and principles, self-
determination, is further explored in this section in terms of how it relates to the process
of ‘making room’. Throughout this research, attention has been drawn to the underlying
values and principles of the participants as reflected in their experiences of unplanned
endings. Although four counsellors are not social workers, all of the participants
emphasized a deep appreciation for their clients’ right to self-determination.
The Canadian Association of Social Workers Code of Ethics (2005) holds
“Respect for the inherent dignity and worth of persons” as one of the core primary values
of the profession. Within this, the principle of client self-determination is emphasized:
“Social workers uphold each person’s right to self-determination, consistent with that
person’s capacity and with the rights of others” (p. 4). Further, “Social workers respect
the client’s right to make choices based on voluntary, informed consent” (p. 4).
Unplanned endings were often viewed by the current research participants as
expressions of client’s right to self-determination. However, as noted by Freedberg
(1989) and Rothman (1989), this concept is generally over-simplified and, as such,
requires deeper understanding with respect to how unplanned endings may be
conceptualized as reflections of client self-determination.
According to Rothman (1989), “While self-determination is accorded utmost
esteem in the profession, its meaning and application are clouded” (p. 598). This is
especially true in clinical social work practice. Freedberg (1989) points out that, as
counsellors, social workers are challenged to uphold this important principle within an
environment that has historically defined the role of social work to include social control:
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Day to day contact with clients involves confronting an inherent dilemma in the
philosophy of self-determination: To deliver necessary services to the
community, the agency (an instrument of that community) and its agents (social
workers) must maintain control of the services and to that extent also maintain
control of the clients. (p. 33)
Rothman, Smith, Nakashima, Paterson and Mustin (1996) add that, because
clinicians have increased their knowledge base and are better informed, they are being
held accountable by the community “to deal resolutely with serious and disturbing
problems” (p. 396). As such, social workers are expected to use a ‘firm hand’ to carry
out professional responsibilities. They believe this to be contrary to the ideals of client
self-determination.
Tower (1994) believes that the principle of client self-determination is often
violated “in the real world of human services…in the name of expediency, protection, or
cost containment” (p. 191). Tower (1994), Freedberg (1989) and Rothman et al. (1996)
concur that client self-determination is an “illusive concept” that is difficult to
conceptualize in practice.
However, through defining and interpreting the meaning of unplanned endings,
the study participants appear to have conceptualized unplanned endings as reflections of
client self-determination. They believe that when clients decide to end counselling, they
are asserting their independence and rights as individuals. In this way, client self-
determination is an important foundation on which they understand and experience
unplanned endings.
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Although the majority of the counsellors provide services to fulfill social
mandates, such as in addiction counselling, youth justice, and child welfare, they upheld
their client’s decisions to end counselling as primary. Recognizing the limits of their
control and influence, these counsellors respected their client’s decisions by ensuring that
they were informed of the consequences of ending counselling prematurely. Ultimately,
they accepted that, regardless of the mandates under which they work, clients are
responsible for themselves. In this way, the counsellors established boundaries and
understood the limits of their ability to control unplanned endings.
The majority of the participants view individuals as the experts on their lives. For
the most part, the counsellors trusted that their clients know what they need and how to
manage their lives, including when to end counselling. Many identified the potential for
counsellors to take too much power and responsibility in the clinical relationship, which
could result in feelings of failure and self-blame when clients leave unexpectedly. This
was consistent with Tweed and Salter’s (2000) findings that counsellors who perceive
themselves as ‘super-therapist’ and ‘all-knowing experts’ react to unplanned endings with
strong senses of personal failure. However, Tweed and Salter also recognize that
experienced counsellors have a more balanced perspective than novice counsellors in
taking responsibility for clients’ decisions.
Despite challenges to practice in ways that reflect their core professional values,
the counsellors in this study conceptualized unplanned endings as consistent with their
value of client self-determination. Adopting a consumer-centred approach to practice,
they challenge the dominance of helping professionals of the past. This movement is also
reflected in Tower’s (1994) description of “consumer-centred social work practice”.
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Reflecting the potential to restore client self-determination in clinical social work
practice, she views clients as customers or consumers of a service. She believes that
individuals are more knowledgeable about their own needs and interests than are their
counsellors. Further, she believes that when individuals redefine their role from that of
client to consumer, “their sense of control over their own lives is elevated” (Tower, 1994,
p. 192).
In this way, a consumer-based model of service delivery stresses self-
determination. Further, unplanned endings may reflect what Tower (1994) regards as
“consumer empowerment” with the result being “greater self-determination among
clients and less ethical discord regarding paternalism within the helping professions” (p.
196).
In the current study, a number of the counsellors recognized that unplanned
endings can potentially result in clients feeling more empowered:
If you switch to a consumer perspective they (clients) believe that they have
moved into an empowered position where they can continue to move forward and
deal with what they need to deal with… When people are looking at you going,
“You know, it isn’t working and I’m not satisfied”. If you think of it from a
consumer perspective, the consumer is essentially saying, “You know, I’m buying
a service and it sucks”. (Peter)
However, upholding client self-determination in the context of a consumer-driven
model is not without its challenges. For the majority of the counsellors in this study, to
remain viable in private practice, they need to see clients to generate income. As such,
unplanned endings may hamper their ability to remain in practice. As well, counsellors
employed in for-profit agencies such as employee assistance services, feel pressure to
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maintain their caseloads in ways that are profitable for their employers. This stands in
contrast to the counsellor’s efforts to uphold client self-determination.
Additionally, a consumer-driven counselling model is also concerned with
outcome standards for practice. Attempting to quantify services, the counsellors feel the
pressure of being monitored with statistics. Agency policies, written contracts and
counsellors’ own balance sheets reflect expectations for certain numbers of counselling
hours, sessions and dollars.
Several counsellors in this study felt caught between respecting client’s decisions
to end counselling and meeting agency expectations for certain numbers of direct client
contact hours:
The pressure for me is that I find a lot of clients terminate early but they’re ready
to terminate early. I’m always trying to get clients to come back. I’m always
pushing for follow-up appointments and I’m always writing in my day-timer what
number of session this is. (Sandy)
As evidence-based practice gains momentum, counsellors in all fields are
challenged to quantify and justify their practice. As Ruckdeschel and Balassone, (1994)
suggest, it is not a matter of being accountable so much as it is the method of establishing
accountability that may be at odds with counsellors in current practice. Client self-
determination may include the unilateral decision to end counselling and, according to
Rothman (1989), must be recognized as an “absolute client right and not as a technical or
practical principle for achieving broad goals of the human service professions” (p. 600).
Summary
This study points to new directions for how counsellors could conceptualize
unplanned endings in ways that reflect their core values and principles. In an effort to
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make sense of unplanned endings in their clinical practice, the participants searched back
to the roots of their professions. Unplanned endings were often perceived as evidence of
client self-determination, which provided the counsellors with context for how to
interpret and react to these.
A number of the counsellors are adopting a more consumer-driven practice
perspective in line with current societal demands. Authors from the clinical literature and
the study counsellors appear to recognize the potential for this perspective to empower
clients in their clinical relationships. As such, unplanned endings may be seen as
reflections of clients’ empowerment.
The participants of this study have reconceptualised unplanned endings to reflect
their professional values and offer the opportunity to learn and grow as clinical
practitioners. Unplanned endings are seen to have purpose for both counsellors and their
clients. When viewed in this way, counsellors have the opportunity for closure by
cognitively, emotionally and practically ‘making room’ in their practice for the benefit of
future clients.
Strengths and Limitations of the Study
This section reflects on the strengths and limitations of this research beginning
with the strengths. First, this study addresses an issue relevant to current social work
practice by seeking input from the professionals who have extensive experience in the
area. These professionals have investment in research that aim to advance understanding
of endings in clinical practice. Drawing upon the participants’ years of clinical
experience allowed this researcher to address the topic of unplanned endings broadly and
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deeply. It allowed for substantive theory on counsellors’ experiences of unplanned
endings to emerge.
Second, the research topic and the process of utilizing a constructivist grounded
theory method fit well with my clinical experience and theoretical perspectives. As a
novice researcher, I was able to utilize my skills in interviewing and experience in
clinical counselling and teaching to its fullest. This made the research process and
outcome interesting, exciting and from my perspective, relevant to current clinical social
work practice.
Finally, most qualitative research is interpretive, requiring significant subjective
influences of the researcher. In an effort to be accountable for my influences, I aimed
towards a high level of transparency and reflexivity in the research process. This was
reflected in all aspects of the research, from inception of the research topic to the writing
of the dissertation. Maintaining an open mind to what emerged while seeking new
insights from the participants, supervisors and colleagues captured what I believe to be
the spirit of a constructivist approach to grounded theory.
There were also some important limitations to this study. As mentioned,
developing theory from those who have extensive practice experience is considered a
major strength of this research. However, while benefiting from the participants’ vast
experiences, this research neglected new and student counsellors. Their experiences of
unplanned endings are important and may offer different insights into how unplanned
endings are currently experienced in clinical practice.
Although the study participants practiced in diverse settings and represented the
professions of social work and psychology in mental health clinical counselling, they do
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not represent all practice settings or professional affiliations who counsel in mental
health. Nurse practitioners, psychiatrists, school counsellors and other professionals may
experience unplanned endings differently. As well, although the participants in this study
practiced in diverse settings within clinical counselling, there were many clinical
environments that were not represented.
This research is also limited to geography with all participants practicing in a
large urban Canadian centre. As well, although the participants themselves represented
cultural diversity, the cultural context of the participants in their experiences of
unplanned endings did not emerge and was not forced into the data. However,
consideration of culture and implicit understandings of its impact on this research would
likely be considered important within a constructivist framework.
The study findings were not intended to claim a universal representation of
counsellors’ experiences of unplanned endings but to develop theoretical concepts from
the experience of ten counsellors that could mirror some of the realities of current clinical
practice. Consistent with grounded theory methods for theoretical sampling, the number
of participants reflected when saturation occurred. Although fifteen interviews with ten
participants may appear limited, it is not the intent of a grounded theory to generalize
results. Instead saturation occurred and sampling stopped when I found no new
theoretical insights or properties of the core theoretical categories.
Finally, although counsellors’ experiences of unplanned endings provided an
opportunity to reconceptualise these experiences as reflecting client self-determination,
this study did not explore clients’ understanding or interpretations. This oversight is
important in terms of what these findings suggest and may have given clients more of a
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voice in terms of their own experiences of unplanned endings. However, the focus of this
research was on counsellors’ experiences and therefore accessing clients was not
considered for this particular area of inquiry.
Recommendations and Implications for Further Research
Research and education has historically focused on the engagement, assessment
and intervention phases of counselling. Due to the overall paucity of research addressing
the ending phase of counselling; the common clinical experience of unplanned endings
has been neglected in research and education. Emphasized previously, counsellors are
not talking about endings and especially unplanned endings enough. There is clearly not
enough time or interest devoted to helping professionals and students learn about endings
and to address unplanned endings in practice.
As well, it appears that the development of practice theory is lagging behind
noticeable changes in societal expectations of counselling. Clearly, counsellors are
adapting to changes and making adjustments in their counselling practice to attend to
unplanned endings, however, they are doing this with little guidance from the research,
literature or theory.
Therefore, this study points to new directions for clinical research. Attention
must focus on developing new theory that is based on current expectations of clinical
counselling. Recognizing that counsellors offer a wealth of experience and knowledge
on important clinical issues, they should be given the opportunity to express this in
research. Not only does this validate counsellors’ expertise, it makes clinical research
relevant to their practice.
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Specifically, this research suggests the need for further exploration of what assists
counsellors when they experience unplanned endings. I was struck by the participants’
ability to remain committed and excited about their work despite the numerous
challenges that unplanned endings posed to their practice. The emphasis that these
participants expressed about the importance of reflecting, learning and growing may lead
future researchers to exploring a possible link between the processes of ‘making room’
and preventing burnout.
Additionally, future research exploring the processes involved in finding closure
in the clinical relationships for both counsellors and clients is needed. The concept of
closure is not well understood in terms of how to achieve this in practice, yet the concept
is frequently referred to in the literature on endings. Defining and conceptualizing
closure in clinical practice may add to this research in terms of furthering the core
concept and sub-processes of ‘making room’.
Additionally, this research suggests that the processes of ‘making room’ may be
applicable to many challenging clinical experiences. Reflecting, learning and growing
appear to be fundamental processes to good clinical counselling. Research exploring the
nature and value of these processes to counselling practice in general has the potential to
expand understanding of counselling practice and how new counsellors are educated.
Finally, future research on unplanned endings should also reflect clients’
experiences and understanding. Their insights on clinical practice and in particular,
endings in clinical practice are important in the ongoing efforts of researchers to address
counselling processes.
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As well, the concept of unplanned endings in research and the literature has
subjectively been defined by counsellors and administrators. These interpretations have
historically considered them to be negative and harmful to practice. Research that
explores clients’ experiences of unplanned endings may uncover new ways to
conceptualize this concept and how we language this phenomenon.
Conclusion
How clinical counsellors working in the field of mental health experience
unplanned endings has been explored extensively in this research. A theoretical model
centred on the core concept “making room” was presented. This model delineated
various meanings that the participants of this study provided and offered new ways to
conceptualize unplanned endings in clinical practice.
The challenge for counsellors in clinical practice has been how to interpret and
make sense of this common experience given the limited investment in research and
education on the ending phase in counselling. It has also been a challenge for counsellors
to openly talk about unplanned endings with current emphasis in counselling on
accountability. Although experience has taught the participants of this study that
unplanned endings offer the opportunity for learning and growth, many counsellors
continue to fear reprisals when their clients end counselling unexpectedly.
Grounded theory methods have provided the participants of this study the
opportunity to share their extensive knowledge and insights into unplanned endings for
the benefit of all counsellors. As well, it has provided the opportunity to update and
reconceptualise unplanned endings in ways that are consistent with current clinical
practice. Given the significant challenges that unplanned endings often pose in clinical
159
counselling, this research offers direction to how counsellors may interpret and use
unplanned endings to continually improve their practice.
160
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APPENDIX A: INTERVIEW GUIDE
Research Interview GuideAdapted from Charmaz (2006)
Initial Open-ended Questions
1. Tell me about your experiences with endings in your clinical practice?2. What makes for a good ending?3. What makes for a poor ending?4. When you experienced a poor ending:
a. What was it like? b. What did you think? c. How did you understand it?
5. Please describe events you believe lead up to poor endings.6. What do you think contribute to poor endings?
Intermediate Questions
1. What do you know about unplanned endings?2. Tell me more about your thoughts and feelings when you experience unplanned
endings in practice.3. How do these experiences impact you as a counsellor?4. How do they affect you personally?5. Please describe an example of what you might do when unplanned endings occur.6. How have your responses to unplanned endings changed over time?7. Is this different than when you first started as a counsellor? How so?8. What have you learned about unplanned endings that you think is important?9. What has helped you to come to these understandings?
Ending Questions
1. What do you think are different ways to handle unplanned endings?a. How did you discover this?b. What has helped you to know this?
2. How have your experiences with unplanned endings affected a. Your clinical practice?b. Yourself as a person?
3. After having these experiences, what advice would you give to your students who are experiencing it for the first time? How would you help them?
4. Is there anything that I haven’t asked that might help to understand unplanned endings? Is there anything else I should know or understand better?
5. Is there anything you would like to ask me?
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APPENDIX B: PARTICIPANT RECRUITMENT
Experienced Mental Health Counsellors:Please consider participating in the following research project
exploring the important and common experience of
Unplanned Endings in Clinical Practice
My name is Eva Helpard and I am a PhD student in the Faculty of Social Work at the University of Calgary. I have also been a practicing counsellor (individual, family and group) in mental health programs in Alberta for many years. My Ph.D. dissertation research focuses on the very common clinical experience of unplanned endings. Because so little is known about this experience from counsellors’ perspectives, I am hoping to capture experienced counsellors’ knowledge and insights.
I am seeking counsellors who hold a Masters degree or Ph.D. in the social sciences (social work, nursing, psychology, psychiatry or family therapy) and who have at least five years of direct counselling experience. Participation in this research will involve a face to face, telephone or Skype one to two hour interview at a mutually agreed upon time and place. I may request a follow-up interview for one hour which will be entirely at your discretion.
I will ask you about your experiences of endings in clinical practice and specifically unplanned endings. This will not involve any disclosure of client information. My intent is to gain a better understanding of how counsellors experience unplanned endings and also how unplanned endings may impact counsellors’ practice.
Your participation in this research is completely voluntary. You may refuse to answer certain questions, or withdraw from the study at any time. With your permission, I would like to audiotape the interview to ensure accuracy. No personal information will be collected from you and no identifying information will appear on the audiotape or transcribed interview.
Research that focuses on direct practice issues is vital for the continued development of counsellors in the mental health field. Your participation would contribute to improving clinical competence and knowledge about the ending phase of counselling; ultimately for the benefit of the people we work with.
If you have any questions regarding this research and/or your participation, please contact me via email: [email protected] or phone 403-287-0637. Contacting me does not obligate you to participate in the study.
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APPENDIX C: CONSENT TO PARTICIPATE IN RESEARCH
hi
Name of Researcher, Faculty, Department, Telephone & Email:
Eva Helpard, Ph.D. (candidate), Faculty of Social Work, University of Calgary (telephone: 403-287-0637; email: [email protected])
Supervisor: Dr. Leslie Tutty, Professor, Faculty of Social Work, University of Calgary.(telephone: 403-220-5040; email: [email protected])
Title of Research Project:An Exploration of Counsellors’ Experiences of Unplanned Endings.
This consent form, a copy of which has been given to you, is only part of the process of informed consent. If you want more details about anything mentioned here, or information not included here, you should feel free to ask. Please take the time to read this carefully and to understand any accompanying information.
The University of Calgary Conjoint Faculties Research Ethics Board has approved this research study.
Purpose of the Study:The purpose of this study is to explore experienced mental health counsellors’ subjective understanding, feelings and experiences of unplanned endings. It is hoped that this exploration will contribute to the growing body of knowledge about the processes of the ending phase of counselling; ultimately for the benefit of the people we work with.
The data collected from this study will be used to inform my doctoral research project.
What Will I Be Asked To Do?Participation involves taking part in a one to two hour interview (in person, by telephone or on Skype) with potential for a follow-up 30 minute interview. Your participation is voluntary. You may refuse to participate altogether, refuse to answer certain questions, or withdraw from the study at any time.
174
What Type of Personal Information Will Be Collected?No personal or client information will be collected. However, to ensure accuracy, with your permission, the interview will be audio taped. You will be identified by a pseudonym.
What Happens to the Information I Provide?Participation is completely voluntary and confidential. You are free to discontinue participating at any time during the study. You can then choose whether the information collected to that point can be used, or if your information is destroyed and not used in the study.
No identifying information will appear on the audiotapes or the transcribed interviews. Identifying information will be deleted or disguised if interview quotes are included in the final report or other publications. Only the principal investigator and research assistant will have access to the audiotape. Audiotapes and transcripts will be filed in my locked desk in my personal locked office. The audiotapes will be destroyed after completion of the project and the transcripts will be destroyed five years after completion of the research project, as required by the Faculty of Social Work.
Signatures (written consent)Your signature on this form indicates that you:
1. Understand to your satisfaction the information provided to you about your participation in this research project, and
2. Agree to participate in the research. In no way does this waive your legal rights nor release the investigators, sponsors, or involved institutions from their legal and professional responsibilities. You are free to withdraw from this research project at any time. You should feel free to ask for clarification or new information throughout your participation.
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I wish to choose a pseudonym for myself: Yes No
The pseudonym I choose is: _________________________
Participant’s Name: (please print) ____________________________
Participant’s Signature _____________________________________
Date: ___________
Researcher’s Name: (please print) ____________________________
Researcher’s Signature: ____________________________________
Date: ___________
Questions/ConcernsIf you have any further questions or want clarification regarding this research and/or your participation, please contact:
Eva Helpard, Ph.D. (cand.)Telephone: 403-287-0637Email: [email protected]
If you have any concerns about the way you’ve been treated as a participant, please contact Russell Burrows, Senior Ethics Resource Officer, Research Services Office, University of Calgary at (403) 220-3782; email: [email protected]
A copy of this consent form has been given to you to keep for your records and reference.
The investigator has kept a copy of the consent form.
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APPENDIX D: RESEARCH PARTICIPANTS’ DEMOGRAPHICS
Participant Name: _______________________ ID #:______________________
Age: _______________
Sex: _______________
Professional Affiliation: ___________________________
Clinical Practice: Areas of Practice: ________________________
________________________________________________________________________
Population/client type: ________________________________________________________________________
Total Years of Clinical Practice: __________________
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APPENDIX E: ETHICS APPROVAL