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    Ending the Therapeutic Relationship: Creative Termination Activities

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    Amy Bucciarelli, MS ATR-BC, LMHC, Board Certified Art Therapist, helped Frank “Dylan” Dinkins make a painting for his parents. Bucciarelli works with pedatrics patients at UF Health Shands Children’s Hospital.

    Termination is a highly important part of every therapeutic relationship that should be addressed throughout each stage of the process.  While many adult clients have the ability to easily think back to their experience in therapy, for youth this is often more difficult.  Because of this I like to provide clients with some sort of physical representation of their time in therapy that will help them reflect on their experiences, highlight their strengths, remind them of what they learned and provide them with tools they can use to help prevent regression, and even continue their progress on their own.

    These activities let you both reflect on their time in therapy and transition out of services in an engaging way. I’ve also found that using metaphors often helps young clients to better understand termination and makes after-care instructions more salient.  Below are some ideas for creative termination activities that are easily adaptable to fit your clients’ needs. I am not sure of the origins of all of them, so please let me know if there is someone that I should be citing.

    Session Trackers

    counter

    I recently spoke to an intern who was confused when a number of her clients seemed surprised when it came time to terminate, despite her verbal reminders.  It is sometimes helpful for young children to be able to have a visual representation of how many sessions are left, and it can help them better prepare for termination.  One way to do this is to create a session-tracking chart.  In the examples above clients color in one image, or choose a sticker, at the end of each session.  The activity is quick and also provides a good opportunity for therapists to check-in with clients and help process any feelings surrounding termination that come up throughout the process.

    Ready to Set Sail: Termination Activity

    By Jodi Smith, LCSW, RPT-S at “Play is Powerful”

    Supplies: Toy boat, paper boat, paper mache boat, box with a boat drawn on it, etc.

    Directions:

    • I’ve found that the use of metaphors increases the amount of information that clients retain and internalize so I use them frequently in termination.  Start by explaining to the client that because of the progress they have made they are ready to sail off on their own.
    • Reflect on what that feels like and process any anxiety, and transition into talking about all the things they will “take” with them to help with their journey.
    • Have the client answer each question and write their response on the back of the cards.  The boat will contain cards related to tools they will take with them (supports, coping skills, etc.), things that may get in their way and strengths (as identified by the client and therapist).  Along with my pre-made cards, I also give them blank ones.

    Treasure Chest Termination Activity

    Supplies: Treasure box (Michaels Crafts has wooden “treasure” boxes  that are cheap and easy to decorate.  A link to directions on how to make a paper one can be found here; Stick-on plastic jewels (found at crafts stores, oriental trading co., etc.); Small note cards (cut to fit the box); Pen.

    Directions: First, have your client decorate a treasure chest.  Then stick a jewel to each card as your client writes down the “task” that is assigned to that specific color (see below).  On the back of the card they include a specific example of how what they identified has helped them in the past and/or how it will help them in the future.  Below are examples of possible color codes, but you should change them to meet your client’s specific age and needs.  In the end the chest will be full with a stack of jeweled cards.

    • Blue: Strengths (Identified by both the client and therapist)
    • Red: Coping skills
    • Green: Supportive people in their life
    • Orange: Resources from therapist (ex. hotline numbers, therapist referrals or directions for reenrolling in services.)
    • Purple: Self-care activities
    • Pink: Inspiration (future goals, motivational quotes, etc.)
    • Yellow: Things they have learned in therapy

     Suitcase Termination Activity

    At termination, your client is finally ready to continue their journey on their own.  Even though they will be leaving you behind, they can pack up everything that they have learned during their time with you to take with them.  This metaphor is easy for most people to identify with and it is a fun activity.

    Supplies: Plastic or cardboard suitcase; Blank sticker labels; Paper luggage tag; String; Cards; Travel stickers.

    Goals: Process termination; Provide transitional object; Help prevent regression; Identify accomplishments, goals, coping tools, etc.

    Directions:

    • Have your client make and/or decorate their suitcase.
    • Then they write something they will “take with them” from their time in therapy on each card provided (I print cards with travel clip-art on the back).  This can be things they have learned, coping skills, supports, resources etc.
    • You can also integrate this with the after-care kit I posted.
    • On the labels they write or draw goals they have accomplished.  (Like the old suitcases in movies that are covered with stickers of past travels).  I also provide additional travel stickers.
    • On the luggage tag they write where they are going next.  This could be a new life stage (ex. my 8th graders usually write “high school”) or a goal they would like to accomplish that the contents of the box will help them achieve on their own.
    • Process feelings about termination throughout the activity.

    Therapeutic Goodbye Cards

    letter

    This is such a simple, yet powerful termination activity.  I got this idea from a client who gave me a very touching thank you note during our last session.  It is something I have kept and reflect back on, and i realized that it could potentially play a similar role for a client.

    • The focus of the content is on the journey through therapy and what has been accomplished.  I highlight strengths, review coping tools and lessons learned, and express my thoughts about termination. At the end I usually include instructions of what to do if they decide to enter therapy again.  You could also have the client write a letter to their future self that they can read when they are struggling.

    Summer Bucket List

    summer

    I put a therapeutic twist on this summer craft.  Most school therapists are unable to see clients throughout the summer but may pick up treatment again during the following school year, which is not ideal.  This activity can help encourage adherence to after-care recommendations.

    Directions: Have your client design a bucket that will help them to continue your work together on their own and prevent regression.  On the back of the paper bucket they can write goals for the summer, self-care activities, etc.  For the 3D buckets these can go on cards placed inside the bucket.  On the shovel they write down “tools” that will help them to accomplish their goals (social supports, coping skills, resources, etc.)

    You’ve Got Mail: Group Termination Activity

    mailbox

    Directions: First, have your clients create their own paper mailbox.  Then, each person, including the therapist, writes a short note to every other member of the group.  You can instruct them to write something that they have gained by knowing that person, a strength they can identify in that person, a motivating message, etc.  The notes are then placed in the mailboxes for the group members to take home.

    Graduation 

    tumblr_mnhh3lPTss1s3e1yro2_1280

    Certificates are very simple to create in programs like Word, Pages, etc. and are a good wrap-up for clients who have worked hard to meet their therapeutic goals.  In my example I left space to write specifics about progress, accomplishments, reflection, etc.  One the last group session we have a “graduation party” where we have fun, reflect on our time together/progress made and process termination.  They are then presented with their certificate.[/emaillocker]

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    The Creative Social Worker is a child and adolescent mental health therapist with special interests in trauma, play therapy and school social work. Her blog is dedicated to sharing interventions, resources, and activities with mental health professionals, as well as raising awareness about the social work field and assisting prospective MSW students with graduate school applications.

    11 Comments

    11 Comments

    1. Beth Crane Palumbo

      November 6, 2014 at 1:49 pm

      Terrific activities! Thanks for sharing!

    2. Dennis Hengstebeck

      Dennis Hengstebeck

      June 20, 2014 at 4:59 pm

      After spending 7.5 years in therapy myself -initially catapulted by crisis, then choosing to remain for personal growth- our closure was great. So, in this respect, I was blessed.

    3. Jamie Dvorak

      June 20, 2014 at 9:24 am

      Lori Anne Lanski Chris Thompson Angie Mk

    4. Travis Lloyd

      Travis Lloyd

      June 20, 2014 at 12:28 am

      Such a great practical tool!

    5. Candace Sims

      June 20, 2014 at 12:00 am

      We talked about this in our clinical meeting brainstorming on ideas due to clients being discharged from court and not having a planned discharge

    6. Daisy Mae

      June 19, 2014 at 7:49 pm

      Daisy Mae

    7. Stacia Barrett, LMSW

      April 2, 2014 at 5:27 pm

      What a great resource!

    8. Renee Fesser

      April 2, 2014 at 9:09 am

      Good lessons the end is just as important as the beginning.

    9. Michelle Lefevre

      April 2, 2014 at 8:56 am

      Really great piece by on creative ways of ending therapeutic relationships with children #socialwork

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    Disability

    Unpacking the Historical Relationship of Racism and Ableism

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    A key part of anti-racist social work practice is engaging in the art of reflection as we consider the person in the environment. This also involves being aware of the larger social context in which we live and practice. The social context can, for some people, include experiences of racism and ableism. Recently, I wrote about the symbiotic relationship between racism and ableism and why social workers should care about it. Now, I want to take a step back and look at the historical context that leads us to where we are today with the relationship for disabled people of color. Through the consideration of history, we can understand how to better move forward with integrity as anti-racist social work practitioners.

    As the poet Maya Angelou said “History, despite its wrenching pain, cannot be unlived, but if faced with courage, need not be lived again.” So what are the historical roots of this relationship between racism and ableism? Let’s explore.

    Historical Roots of Ableism and Racism

    We began to see the interaction between ableism and racism way back in our nation’s history. Let’s look at four examples to make this relationship clear. During slavery times, slaveowners conjured up the idea of drapetomania, the alleged psychosis that was experienced by runaway slaves which in retrospect was emblematic of the interaction of ableism and racism. This is an example of how race is pathologized to create racism. In other words, people of color were treated in specific oppressive ways in order to create barriers and conditions that resulted in the origination of disability categories. In reflecting on drapetomania, Isabella Kres-Nash points out that “the concept of disability has been used to justify discrimination against other groups by attributing disability to them.” Of drapetomania specifically, Kres-Nash says this is an example of a “disability being created by people in power in order to preserve social order” all of which occurred in a racialized context during slavery.

    Moving into the 19th century, we can point to the popularity of phrenology, a pseudoscientific technique originally developed in the late 1700s which purports to determine an individual’s character and abilities (and therefore, alleged superiority). This could be deduced from the size and shape of various bumps on a person’s head. Phrenology, among other things, was used to justify the practice of slavery, as was depicted in the film Django, Unchained. Although this pseudoscience has long been discredited, this technique is considered a precursor to modern neuropsychology and rears its ugly head once in a while in current-day conversations about the use of technology and facial recognition (which is known to be much less accurate for people of color).

    Scientific Racism

    If we look to more recent times, such as the turn of the 20th century, we can see connections between racism and the ableist Eugenics movement which sought to breed a perfect human race through a form of “scientific racism.” This movement often targeted what were known as “feebleminded” people (now known as intellectually and developmentally disabled people), among others, for sterilization, many of whom were people of color. In his discussion on the treatment of African American and Black “feebleminded” people, historian Gregory Dorr says “African Americans had become the targets of extra-institutional and extra-legal sterilizations, reflective of a more general southern racist view that it was necessary to further protect the white race itself from black folks.” Thus, scientific racism is a prime example of the relationship between racism and ableism.

    An Unusual Island in Maine

    In the early 1900s, what transpired with the inhabitants of Malaga Island in Maine is also emblematic of the relationship between racism and ableism. This small coastal island was a multiracial fishing community originally founded by an ex-slave. While inter-racial marriage was illegal, the community apparently allowed people to live and let live in this regard. It is said that many of the inhabitants of the island were “feebleminded” or intellectually and developmentally disabled, as we would now say. Whether this is accurate is unknown. As the Eugenics movement gained popularity and as the value of Maine’s coastal islands became more clear as potential tourist destinations, state government officials issued an eviction order to all of the Malaga residents – of all races and ethnicities. All residents who had no place to go were to be placed in the Maine School for the Feebleminded, where some were eventually sterilized and lived out the rest of their lives. The price of miscegenation was banishment from a happy community due in large part to ableism and racism.

    An Inextricable Link

    These four historical lessons give us some important context for what we may see in social work practice today. So, to put it all together, when we look at how structural racism works, we see the ways in which it has pathologized Black and Brown bodies for the purpose of keeping the White status quo in place. We can see how a society that benefits from structural racism is simultaneously responsible for facilitating environments that promote the development or highlighting of disability. These historical situations set the foundations for present day scenarios in which racism and ableism interact regularly – in our criminal justice system, in our education system, in our health care system, in our child welfare system and beyond.

    Action Steps

    How can you learn from this history and move on in a positive direction? Your job is to reflect on the ways in which the past plays out in the present day, and to identify the ways in which you can disrupt the powerful relationship between ableism and racism in your social work practice. Here are five steps you can consider taking today as an equity-minded social work practitioner:

    1. Become aware of all of your client’s social identities, think about disability as an identity, not just race.
    2. Use data to identify inequitable processes and outcomes based on both race and disability.
    3. Reflect on the differential consequences of social work practices on people and communities based on race and disability.
    4. Exercise agency to produce equity across racial and disability groups.
    5. View the practice context as a potentially oppressive and marginalizing space and self-monitor interactions with clients/patients/constituents of different racial and disability social identities.
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    Disability

    Sexual Education & Disability: Why it Should Matter to Social Workers

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    What do you get when you mix the taboo nature of discussing sexual intimacy with the social stigma surrounding intellectual and developmental disabilities? The answer: a heck of a lot more problems than you might think. Sexual education in the school setting is already a hot-button issue for non-disabled students. But when students with intellectual and developmental disabilities are introduced into the mix, so too are the ableist stigmas we all hold.

    Taboo-Nature

    I would like to start this piece with a brief exercise one of the health teachers at my high school conducted at the beginning of sex ed. Repeat after me: Penis. Vagina. Penis. Vagina. Why do you think she would make a room of teenagers yell these words in school? Isn’t that inappropriate? If you think it is, you proved my point from earlier. Sexual intimacy and anything loosely related to sex are currently incredibly taboo topics. To help break down the air of discomfort surrounding such topics, that health teacher did something many are afraid to do: she spoke openly and encouraged others to follow suit.

    One could argue these topics are not to be spoken about simply because we are taught to not speak about them. A child can ask why their anatomy is different from their siblings, but they will often be met with shushes or roundabout answers. In many cases, there is no reason for this reaction other than traditional values. Those same values are often times what causes conflict in regard to sexual education in public schools.

    My sex ed experience at a public school was mediocre at best. Genitalia, STIs, and contraceptive methods were discussed. Consent was not taught nor were the proper ways to actually engage in sex, just that if we did it we should do it safely. This was not the most educational experience. And if this is what I received, what is the experience of children and adolescents with intellectual and developmental disabilities?

    The Institutional Deficit

    Working in a behavioral school for boys with emotional, developmental, and intellectual disabilities yields an interesting perspective. These students are taught the same subjects most other students in the country are taught just with more academic and therapeutic support. However, they are not always provided with a health class.

    I worry greatly about this institutional deficit, partly due to my own ableism. These students are receiving very little, if any, sexual education during the school year from our faculty and who knows what they see on the Internet and what their families and friends are telling them. As they get older and begin to develop their curiosity, I am worried that they might not always have a reliable source of sexual education. With that, the concept of consent is often discussed but not in the context of intimacy. I don’t know if the connection between consent and sexual activities has been made or if it ever will be in this school setting. I don’t know if some of these students would understand the magnitude of these topics. I’d like to think these kids can do anything, but from what I’ve seen I don’t know if I would feel confident in their understanding. I wish I could feel otherwise.

    Deeper Issues

    Individuals with an intellectual or developmental disability are seven times more likely to experience sexual assault than non-disabled people. In many cases, the perpetrator is another individual with an intellectual or developmental disability. Ableism likely prevents people from thinking this to be possible. Common stereotypes around this population convince the non-disabled community that these individuals can do no wrong and are by default sweet and innocent. Of course, this is not realistic. Another ableist stereotype, as seen above, is the incapability of this population to understand topics related to sexual education and sexual intimacy. Like the non-disabled community, however, individuals with an intellectual or developmental disability prove that idea wrong.

    Why This Matters to Social Workers

    So, if people with intellectual and developmental disabilities are able to learn about sexual education, and learning about sexual education dramatically decreases instances of sexual assault, then what is the reason for this population to not receive sexual education? The signs point towards ableism held by those in helping professions, with social workers being a perfect example. While the social work community prides itself on how educated and accepting they are of different identities, very rarely do social workers take the time to reflect upon identities they may not be as familiar with. Race and sexual orientation are examples of identities social workers study extensively, but disability as an identity and the depths of disability culture are rarely examined. To combat this, social workers need to begin the process of confronting personal ableism.

    Confronting personal ableism is difficult, but doing so will only benefit social workers and others who choose to do so. It is important and necessary to challenge internal biases. Critically examining personal ableist ideas pushes social workers to gain a different perspective. Through this difficult process, one gains clarity in the issues they may not even know they wrestle with. Understanding how ableism impacts perceptions allows social workers to get a firm grasp on the disability community. They may begin to feel empowered to advocate for a change they never once considered, such as a stronger sexual education program for people with an intellectual or developmental disability. The importance of critically examining personal biases should be emphasized throughout the entirety of the social work community and by every social worker.

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    Disability

    Case Study: Reasonable Accommodation in Social Work

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    The social work field is often full of situations that are not straight forward. On a Reddit social media post, a social worker reached out to the social work community for advice on a particularly unclear situation. The social worker runs a solo, private practice in a small town, and recently had a request from one of her clients that she is struggling to navigate. This client has hearing loss and would like to communicate with American Sign Language in therapy sessions moving forward. The social worker identified a potential option for interpreting services, but it comes at a high cost. She knows it is her responsibility to pay for the interpreting service, even though it will cost more than the payment she receives for the sessions. Despite this, she is trying to figure out the best way to serve her client.

    Since her private practice consists solely of her, she does not have coworkers to consult with. She also does not have an agency resource that is already in place. Additionally, there are few options for interpreting services in her small town. She poses a few questions to the reddit community, aimed at gaining a better understanding to serve her client. Responses suggested she try video interpreting services, which can often be a cheaper alternative. In considering the accommodations a social worker should provide, consulting the Americans with Disabilities Act (ADA) is especially useful. Under the effective communication section, it’s outlined that the interpreter service must be provided unless it causes undue financial burden. In a situation where this does happen, the provider must find a suitable alternative. In this instance, an in-person interpreter might cause undue burden, but a video interpreter might not.

    This social worker is being reactive to the needs of this client, and proactive with the needs of future clients. She shared her idea to set aside a specific amount of money each year for interpreting or similar services. She also asked the reddit community if there were any other issues she should be looking at in this scenario. This shows a social worker who is committed to her clients and has their well-being and best interests in mind. With that being said, lets review the National Association of Social Workers Code of Ethics and the Americans with Disabilities Act to better understand how they specifically apply to this scenario.

    The Code of Ethics

    Social workers have an ethical and legal obligation to provide adequate services for their clients. This social worker is trying do to the right thing for her client by following the ADA and the National Association of Social Workers Code of Ethics. In the NASW Code of Ethics, the first standard is the Social Workers’ Ethical Responsibilities to Clients. Within that standard, the first section outlines a social worker’s commitment to their clients. This means that a social worker’s actions should always be in the best interest of the client. There may be instances in which the social worker has to adhere to certain laws or rules that go against what the client wants, but this is necessary in limited circumstances.

    Americans with Disabilities

    In the United States, approximately 15% of adults experience some form of difficulty with hearing. Providing therapy to a Deaf or hard of hearing individual comes with unique circumstances for practitioners. Oftentimes, Deaf or hard of hearing individuals do not experience accurate assessment or diagnostic information due to these circumstances and the shortcomings of practitioners. The NASW has put together a briefing regarding the obligations social workers have when working with individuals who are Deaf or have hearing loss. When working with clients with any type of disability, social workers must provide services that are appropriate and serve the best interests of their clients.

    Approximately 1 in 4 Americans are living with some type of disability. The most common types of disabilities are those relating to mobility, cognition, independent living, hearing, vision, and self-care. Any type of disability may mean that an individual needs accommodations in a therapy setting. One of the first steps in providing adequate care for someone with a disability is to understand what barriers are in place for that person. Awareness and education are key elements to providing competent and adequate services for an individual.

    Wrapping it Up

    A social worker’s role is to act in the best interest of their clients whenever possible. This includes individual therapy sessions, as well as ensuring that future clients receive adequate treatment. Outside of individual therapy sessions, social workers often wear many hats. Social workers are strong advocates, initiators of change, and fierce activists. These are all important roles for social workers to bear when upholding their commitment to clients. Social workers often go above and beyond for their clients, and this is especially evident in cases like the one above.

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