Here are the readings that need to be incorporated in the assignment.

RITUALS AND TERMINATION PROCEDURES

Irene A. Gutheil, DSW*

ABSTRACT

The author discusses the therapeutic value and use of transition procedures in the ending phase of practice. These procedures can provide a vehicle for reaching the often contradictory and difficult feelings that accompany termination. Knowledge about rituals is used to suggest a framework for understanding termi- nation procedures. The author gives examples of procedures useful during termination and discusses potential pitfalls.

Social workers deal with a variety of clients in an array of settings. Although the modality, goals, and length of the work vary with different clients and settings for practice, certain commonalities transcend these differences. Transition procedures, although they may not be identified as such, are part of our practice with clients. The most common procedure, which occurs during the beginning of the work, is the intake interview. New clients are asked questions for the purpose of gathering prescribed information necessary for assessment and planning. The content and nature of the intake interview varies from one agency to another, but is expected to be consistent within an agency. This initial step in the beginning of the work is frequently anticipated by clients and is often as helpful to them as to their workers. Without this "ritual," initial encounters with clients would lack focus and purpose, and information important to formulating the appropriate next steps might be overlooked. The intake interview is a procedure that marks the beginning and initiates the transition to becoming a client.

The needs served so well by the intake interview demand attention at the end of the work as well. Termination, too, is a transition. It signifies both an ending of the working relationship and the beginning of life without the professional helping person. Focus, purpose, and formulat- ing next steps are important aspects of termination. In contrast to the beginning phase, however, no procedure immediately comes to mind when considering endings. Termination often receives too little attention

•Irene A. Gutheil is Assistant Professor at the Fordham University Graduate School of Social Service in New York, New York. The author is grateful to Raymond Fox, Marilyn Markowitz, and Alice Bobay for their comments during the preparation of this manuscript. Smith College Studies in Social Work, 63(2), March, 1993.

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in practice. Frequently left to chance, it may be unplanned and therefore not well managed. There is real danger in this. As Laird (1984) noted, when transitions "are insufficiently marked and integrated, they may continue to be sources of pain, stress, and dysfunction" (p. 126).

One way to better attend to termination is to incorporate formal procedures into the process. This article addresses procedures, such as evaluation and goal attainment scaUng, for helping clients deal with the transition out of treatment. Knowledge about rituals is used to understand the use and value of these procedures.

ENDINGS Endings are an inherent part of social work practice. Termination with

clients is recognized as a crucial stage and process in the work, which can influence the degree to which clients maintain the gains they have achieved (Fox, 1992; Hepworth & Larsen, 1986). Nonetheless, there is surprisingly little about termination in the social work journals. In 1985, Webb noted that only nine articles in the major social work journals in the preceding 15 years dealt explicitly with the termination process. This averages out to fewer than one article per year. Since that time, only six articles in social work journals are listed in Social Work Research & Abstracts as dealing with the termination process (Barton & Marshall, 1986; Fortune, 1985,1987; Fortune, Pearling, & Rochelle, 1991; Schaffer &Pollak, 1987; Siebold, 1991),aone-per-yearaverage. Although social work texts devote considerable attention to termination (Webb, 1985), the topic is clearly underrepresented in the rest of the social work literature. It has been noted many times in the past that termination is a particularly difficult area (Compton & Galaway, 1989; Germain & Gitterman, 1980). The paucity of journal articles addressing the topic suggests that it remains difficult.

Why do social workers spend relatively little time considering termi- nation? The answers are not surprising and have been noted before. Saying goodbye is hard, often as difficult for the worker as for the client. Termination rekindles feelings around old losses and separations (Germain &Gitterman, 1980; Hepworth & Larsen, 1986; Webb, 1985). In addition, termination may remind us of our failing as helping professionals: We can never "cure" our clients, although they or their environments may function better. Termination may spark feelings of guilt in workers who wish they could have done more for their clients. If our work was not perfect, if we did not do things "just right," how can we terminate?

To add to the problem, termination itself is a powerful construct. The word has many negative connotations in our culture and frequently

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conjures up unpleasant associations. In medical settings, termination suggests images of dying and death. In the business world, terminating employment is a euphemism for firing someone. In Hollywood, the Terminator is a futuristic killing machine. Indeed, it is difficult to conjure up pleasant associations to the word termination.

Endings are complex phenomena. The predominant experience of an ending may be happy (as a college graduation) or sad (as a death). However, these endings are often characterized by mixed emotions. For example, the college graduate, while elated by the achievement and excited about the challenges ahead, may be deeply saddened to leave the secure, familiar world of the college campus and frightened by the responsibilities and unknowns ahead. The bereaved family, mourning a loved one, may also feel relief that his or her suffering and pain are over. It is not surprising, given the complex nature of endings and the predomi- nantly negative associations of terminations, that social workers often struggle with this phase of practice.

RITUALS Like endings, rituals are an integral part of our hves and serve several

important functions. To begin with, these culturally recognized markers endow certain events with a sense of being special and apart from everyday experience (Roberts, 1988a). In addition, rituals provide a connection to both past and future (Rosenthal & Marshall, 1988). With a Bar Mitzvah, for example, tradition passes from one generation to the next; the faith of the past is confirmed and carried on to the future.

Johnson (1988) pointed out that rituals are particularly associated with times of tension, change, and uncertainty. She described them as "system-maintaining" mechanisms. Rituals serve this function during transitions, especially those through which people move from one status to another. Transition rituals serve the important function of symbolizing continuity, therefore providing a sense of a stable social world (Myerhoff, 1984). Transition rituals are complex. They are good illustrations of Roberts' (1988a) observation that "ritual can hold both sides of a contradiction at the same time" (p. 16). While they help people accept a change in another individual' s status and consequently in how that person is perceived, transition rituals also offer reassurance by affirming inter- personal bonds and underscoring the strength of the social structure (Troll, 1988). In this context, they can be understood as efforts to bring part of life into orderly control (Laird, 1984). A wedding celebrates the joining of two people in a relationship that moves them into new roles apart from their families of origin, by bringing these families together in

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celebration. Rituals serve affective or emotional purposes (Rappaport, 1971).

During transitions, rituals provide a means of dealing with powerful emotions. For example, rituals connected to dying, such as wakes and funerals, help people deal with feelings about the deceased and the loss. They provide a "safe framework" for expression ofthe powerful feelings elicited by the loss (Jackson, 1959). These rituals enable the bereaved to move past the shock, put some closure on the early, raw stages of mourning, and move on with the work of letting go. Because rituals may deal with powerful emotions, they have affective consequences (Troll, 1988). Feelings may be heightened by participation with others in rituals. However, rituals can also serve as distancing techniques that enable people to avoid their true feelings (Johnson, 1988).

Useful in dealing with new and challenging circumstances, rituals help make the unfamiliar feel more under control, therefore helping people cope with the demands of new situations by stabilizing them (Cheal, 1988) and providing parameters to guide them. Through rituals, it may be easier to channel pain or to focus attention in an overwhelming situation. For example, rituals associated with dying guide the bereaved through the burial at a time when it may be difficult to think clearly. The ritualized orientation process for new employees used by many large agencies or companies helps integrate new workers into potentially confusing organizations by providing information in a structured way.

Rituals also provide avenues for communication; all rituals have a communication component (Rappaport, 1971; Laird, 1984). Sending cards on birthdays or special holidays keeps people in touch, tells people they have been remembered, and often provides a way of sharing other information. As a part of family life, rituals can serve to enhance communication, as may be the case with the Sunday family dinner, or block it, as when reading the morning paper at breakfast.

Rituals may actually determine the course of conversations. Nydegger and Mitteness (1988) noted that some families rely heavily on ritualization in their conversations. For example, exchange of information may be preceded by a set of stylized questions and answers such as "How was your day?" and "It was fine," enabling the participants to avoid sensitive topics. Ritualization, according to Nydegger and Mitteness "can be a boon to family members wanting to prolong contact, yet anxious to avoid argument or protect their privacy, or simply at a loss for something to say" (p. 714). The same can hold true in social situations outside ofthe family.

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RITUALS AND TERMINATION PROCEDURES The literature examining the use of rituals in treatment, especially

family therapy (Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1978a), demonstrates the power of rituals to produce change. Rituals used in therapy build on what makes sense in the client's world, growing out of the client's meaning system. However, even ritualized procedures defined from the practitioner's perspective can at times carry the power of rituals. Selvini-Palazzoli and her colleagues (1978b) discussed the use of a ritualized prescription to induce change in families with whom they work. Although different from a ritual because it can be used with many different families, the ritualized prescription achieves the same therapeu- tic ends because, like a ritual, it works on several different levels.

In addressing procedures for termination, this article considers one way to apply knowledge about rituals to practice by using the power of evaluation procedures to achieve therapeutic ends. Readers interested in the use of rituals based on the client's meaning system during the termination process are referred to the work of Janine Roberts (1988a; 1988b).

By translating knowledge about rituals to procedures for termination with clients, social workers can improve their practice and ease clients' transition out of treatment. Five characteristics of rituals are particularly relevant to the termination process:

1. The sense of specialness; 2. The connection to both past and future; 3. The ability to hold both sides of the contradiction; 4. The capacity to deal with emotions; and 5. The communication component.

Termination is a transition for both worker and client. Both must move from working together to going their separate ways. The intense emotions that may accompany this can interfere with the therapeutic potential of the termination process, resulting in loss of focus and purpose. When one or more termination procedures are integrated into the process, it can become more focused and purposeful. Such proce- dures, by framing the termination and making it stand out as a special part of the work help underscore the important role of this phase in putting closure on the work and consolidating gains. When this part of the work is clearly identified as special, there is a concomitant demand for attention to and thoughtful examination of the process; the importance of working on termination is underscored.

By connecting past and future, termination procedures can help clients recognize that even though the working relationship is over, the value of

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the work remains and can be drawn upon in the future. The symbolic expression of connection and continuity underscores the inherent con- nections in our clients' lives between the strengths they brought to the work, gained from the work, and will continue to utilize after the work is finished. An example is having a client "showcase" his or her growth in a particular area by role playing a difficult situation that is likely to come up in the future. This leads to a review of how he or she handled such situations in the past compared to now. Together, worker and client can consider ways to hold onto gains made in their work together when future difficulties arise.

Through encompassing both sides of the contradiction, termination procedures can help workers and clients recognize and feel more com- fortable with the confiicting feelings that surface in ending an important helping relationship. Generally associated with feelings of loss, termina- tion also elicits positive feelings (Fortune, 1987; Hepworth & Larsen, 1986). Clients may experience pride about the gains made and relief that the commitment to the work is over. Workers, too, may experience these feelings. For example, a technique to capture the contradiction may be used by a clinician in work with mildly retarded young adults, who compile a list of feelings about termination, with happy feelings on one side of the paper and painful feelings on the other.

As a means of dealing with emotions and as a means of communica- tion, termination procedures help workers and clients first modulate or control and then allow safe expression of their feelings about the ending. In other words, they provide a "safe framework" (Jackson, 1959) within which worker and client can begin to recognize and examine their emotional reactions to the process of termination. Termination proce- dures provide avenues for workers and clients to say both how much they mean to each other and to express negative feelings as well. The communication of negative feelings may be especially difficult at termi- nation. It is much easier for a client to express disappointment in some aspect of the work when this information is initially elicited through an organized process such as the use of an evaluation instrument during termination than when expression of these feelings is left to the client's own initiative.

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TERMINATION PROCEDURES In the following discussion, three termination procedures—evalua-

tion, goal attainment scaling, and the eco-map—are considered.

Evaluation The evaluation of services rendered, a mechanism increasingly used in

our society, has the potential to help clients with the transition out of treatment. With the growing awareness of the importance of customer satisfaction with service, the use of evaluation forms has proliferated in many settings. Examples include hospitals that ask patients to fill out an evaluation prior to discharge, hotels that request that their guests evaluate the service and facilities, and auto dealerships that elicit feedback on quality of service. With increasing frequency, evaluation is becoming associated with the ending of service provision. One day, evaluation may even become an ending ritual, a culturally recognized symbol of ending.

Evaluation of social work practice has received considerable attention in recent years. Social work texts incorporate evaluation into discussions of good practice (Compton & Galaway, 1989; Garvin & Seabury, 1984; Hepworth & Larsen, 1986) and articles on evaluation have proliferated in the social work journals. Much of this literature addresses evaluation by the worker as part of the assessment and intervention processes (Slonim-Nevo & Vosler, 1991). Although evaluation ofthe progress of work with clients is an ongoing process, the finality of termination makes it essential to examine the extent to which gains were or were not achieved and consolidated (Compton & Galaway, 1989), and the client's experi- ence ofthe work together. By recognizing its value in termination rather than just as an indicator that client progress is sufficient to warrant termination, social workers can make conscious and purposeful use of a formalized evaluation, especially one that elicits clients' views, to initiate and enhance the termination process. Evaluation is a vehicle for commu- nication that not only gives feedback about client change, agencies, workers, and services, but also has the potential to open the door to an in- depth discussion ofthe ending of treatment and the associated feelings.

It is crucial that social workers recognize the therapeutic potential in the evaluation process. Evaluation has long been used to assess and justify diversion of resources by demonstrating program effectiveness (Kiersuk & Sherman, 1968). The suggestion here is that it can be used for much more immediate purposes. In asking the client to evaluate in a structured, formalized way the service provided by the agency and the work of the helping relationship, the social worker can help the client move to a discussion of what it was like to receive help, what was positive

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or negative about being a client, and what it will be like to move on without the helping relationship. The objective discussion of the work can be used as a bridge to the subjective discussion of the loss and the gains. If there are fewer gains than the client hoped for, the objective discussion can give permission to move into the expression of anger or frustration as termination approaches.

Workers themselves may at times need help moving into a discussion of termination. The use of a formal evaluation instrument can provide this help. If evaluation is necessary for termination, given the same impor- tance as the intake interview, the worker is obligated to do it. This makes it harder for workers who are experiencing their own struggles with termination to avoid addressing the topic. Although not a guarantee that workers will directly address feelings around termination, evaluation in the ending phase at least ensures that workers will remain cognizant of the importance, the specialness, of that stage of the work and the mandate to deal with it.

Although it may not appear so at first glance, evaluation is well suited to fill the role of a termination procedure geared toward dealing with emotions. This is because the process of evaluation gives clients permission to talk about both positive and negative experiences. Even general instruments such as the Client Satisfaction Questionnaire (Larsen, Attkisson, Hargreaves, & Nguyen, 1979) which measures general satis- faction with services, aims to capture the client's view of the value of the services (Corcoran & Fischer, 1987). Eliciting the client's view is a good beginning step in reaching for feelings. Initially, the process is controlled and relatively free of emotional content. As it moves along, however, and the client begins to sense that the worker is genuinely open to hearing what he or she has to say, emotion may be elicited. When the move from a relatively neutral to more emotionally charged discussion is paced through the evaluation process, the increasing emotional content may be easier to handle and address directly. Evaluation will work most effectively if it is structured like the intake interview, beginning with the gathering of required information which can then be explored as appro- priate. This could include clients' evaluation of agency responsiveness to their needs, service availai)ility, the quality of the physical setting, and so on. The worker and client can then move together from this general foundation to an individualized examination of their own, unique rela- tionship and termination.

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Specific questions, when integrated into the evaluation, can help worker and client move toward the work of termination. Examples of such questions are:

What did it feel like to ask for help? What did you like best about our work together? What did you like least about our work together? What will you miss about our work together? What do you look forward to when we stop working together?

These questions move the client into a discussion of the experience of the work together and the associated feelings, a step toward effective termination.

Goal Attainment Scaling One type of evaluation, goal attainment scaling, enables worker and

client to examine progress toward specific, individualized treatment goals. Because goal attainment scaling links program evaluation and clinical practice, it has particular appeal as a termination procedure.

Goal attainment scaling can be used whenever goal setting is part of the process of the work (Compton & Galaway, 1989). Individualized goals are identified for each client. Goal attainment scaling requires that the goals formulated be clear, objective, and quantifiable (Kiersuk & Sherman, 1968). For each goal, levels of attainment are stated in specific behavioral terms, ranging from most unfavorable to most favorable. At a specified follow-up time, the degree of attainment of each goal is identified by the level achieved. Although goal attainment scaling can be helpful at different times during the treatment process, it has special value during termination.

By starting with an examination of the extent to which mutually agreed upon goals have been achieved, the worker can move toward helping the client express feelings about the achievement, lack of achievement, or going it alone once the working relationship has ended. The worker can also help the client identify strengths that facilitated goal attainment and may help consolidate and maintain these gains in the future, much as rituals connect past and future. The more clients feel they can continue to utilize the strengths enhanced through treatment, the greater confi- dence they will have in the face of termination. At the same time, Umited movement toward goal attainment can be used to help the client identify areas to work on in the future and open the door to a discussion of strategies for doing so. Thus, goal attainment scaling, like a ritual, holds both sides of a contradiction. Client gains and lack of gain can be captured through the same instrument.

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A case illustrates the use of goal attainment scaling during termination. Mr. and Mrs. Martin came for help with their six-year-old daughter, Annie. Two years earlier, Annie started coming into their bed to sleep between them, saying she was frightened. Over time, this became a nightly occurrence. The Martins said their goal was to get Annie back to sleeping in her own bed. They agreed to identify interim outcomes between Annie sleeping with them every night (the current situation and the most unfavorable outcome) and Annie returning voluntarily to her room every night (most favorable outcome). The Martins were seen as a couple weekly for nine weeks. Gradually their talk tumed from their daughter to serious problems in their marriage. When Mr. Martin accepted a job offer in another city, termination was initiated. Review of the original goal and interim outcomes indicated that the problem remained unchanged (the most unfavorable outcome identified). How- ever, Mr. and Mrs. Martin now felt the marriage was the most pressing concern. During termination, they discussed both their disappointment with the lack of movement toward their original goal and their new understanding of the rift between them. They made arrangements with their worker for a referral in the city where they planned to live.

Eco-map The eco-map, a simple diagrammatic assessment of a client's life

space showing the connections with various systems in the environment, makes a fine termination procedure when drawn with the client during termination and compared with an eco-map drawn earlier in the work (see Hartman, 1978, for a complete discussion of the eco-map). Comparisons between early and later eco-maps can open up discussion about changes in the client's social world and potential supports when the helping relationship is ended. Because the worker will be represented as part of the environment in the client's eco-map, this tool can help the worker and client directly identify a change that will occur once the work together is over. This visual representation of the ending can give the client permission to talk about the loss, how it will affect his or her life, and what can be done to facilitate adjustment. The anticipatory planning, prepara- tion for life without the worker, and identification of resources to be tapped (Hartman, 1978) that flow from use of the eco-map in this way are essential parts of the termination process. The eco-map is the communi- cation vehicle for initiating the termination.

Mrs. Roth, a healthy, independent 72-year-old widow, was brought by her daughter for help with the depression she felt since moving from her apartment in a deteriorating neighborhood in the city to an apartment that

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had been added to her daughter's home in the suburbs. Early in treatment, two eco-maps were drawn with Mrs. Roth, one representing her life before moving and the second her current life. Intrigued by the visual representations of the connections in her life, Mrs. Roth observed that there were several "circles" in her earlier eco-map and virtually none other than those representing her family and the social service agency in her current eco-map. Recognizing that the barrenness of her social world left her feeling dependent on her daughter's family, Mrs. Roth deter- mined to look for ways to "add circles to her life." Eventually, she volunteered at the infonnation desk in the local hospital and began to develop a network of acquaintances. On termination, Mrs. Roth re- viewed a new eco-map with her worker, sharing the pleasure of the new circles. The worker observed that the circle representing the agency and worker would soon be empty. Together, worker and client discussed their sadness at parting and the importance of "keeping circles filled."

SOME CAVEATS When integrating termination procedures into the ending process

certain pitfalls must be avoided. Because, like rituals, such procedures can bind the expression of emotion, it is possible to become stuck in the procedure and not deal with feelings. While worker and client may be comfortable dealing with the cognitive component of the procedure, they may have great difficulty dealing with the affective component. In such situations, the termination procedure may actually become a way to bypass expression and examination of feelings.

Fox (1992) noted that termination can become problematic when the worker does not distinguish between task accomplishment and relation- ship ending. Clients may have achieved their goals yet not want to end the relationship. If attention is focused exclusively on goal achievement and the accompanying gains, the pain of the impending separation may be overlooked. Workers must be diligent in their efforts to avoid this pitfall. It is the worker's responsibility to use the termination procedure as a tool to reach for feelings related to the end of the working relationship so that the procedure does not become a barrier to expression of feelings. Techniques specifically geared to addressing the relationship, such as worker and client sharing the one thing that will stand out when they remember each other, help keep feelings in the forefront.

At the same time, practitioners must be careful not to focus only on loss in termination. Van Gennep's (1963) three stages of ritual are helpful in clarifying clients' paths through the helping process. As Roberts (1988a) explained, in the first phase, a level of trust and acceptance is established.

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In the transitional phase, clients leam new information and try on new ways of seeing themselves. The final phase connects people back to their communities, changed and ready to build on their gains. When clients see themselves as moving on to new possibilities and increased opportuni- ties, termination is a time of celebration as well as loss.

The effective integration of procedures in termination will most likely be successful when it is an agency-wide practice. Like the intake interview, procedures associated with the end of practice (such as a formalized evaluation) can become part of an agency's routine, guaran- teeing their use. However, while they should be routinely used, their use should not be perfunctory. Utilized in a rote, sterile fashion, termination procedures lose their power to affect people. Workers bear the respon- sibility for ensuring that the procedure is a means to an end, not an end in itself.

Although the value of using termination procedures spans diverse settings and clients, no one procedure is best for all. Different agencies and clients will often require different procedures. It is essential, therefore, that the techniques and instruments utilized in termination be carefully chosen to suit the type of agency and the needs of individual clients. To be effective, the termination procedure must be relevant to the nature of the work, as the following example demonstrates.

A GROUP'S RITUAL' A social worker in an elementary school developed a ritual for her

work with a group of children dealing with their parents' divorce. On a long roll of white shelving paper, the group members developed an ongoing time line that served two purposes: charting the life ofthe group, and capturing what went on in the outside lives ofthe children. The group members brought in pictures (photographs, magazine pictures, or draw- ings they had made themselves) and pasted them on the time line with brief captions. These pictures showed a child's parents fighting before the divorce, signified "the first time Daddy took me out for the weekend," and so on. Pictures also captured significant events in the life ofthe group such as "the first time we ate lunch together" and "our pizza party."

As the ending of the group approached, worker and group members used the time line to review together where they had started, what they had done over time, and what they had shared together. Through this procedure, the children were able to review their individual and shared experiences, and talk about the role the group had played in their lives.

' This example was provided by Dr, Marilyn Markowitz,

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CONCLUSIONS Termination is an important transition in work with clients. It marks

the ending ofthe helping relationship and the beginning of life without the worker. Transitions in daily life are often marked by rituals. Social workers can improve their practice by applying knowledge about rituals to the use of procedures to deal with transitions in their work.

The beginning of the work is already marked by a procedure associated with transition, the intake interview. Use of termination procedures during the end of the work can provide a vehicle for reaching the often contradictory and difficult feelings that accompany endings. Social workers, who may at times have as much trouble dealing with termination as their clients, can benefit from identifying and utilizing termination procedures. These procedures must be carefully chosen so that they are appropriate to individual agencies and clients. At the same time, social workers need to be wary of certain pitfalls in using termination proce- dures, which may actually impede the work of ending.

Termination, a challenging and vitally important part of social work practice, must be attended to with the same rigor accorded the beginning ofthe work. The use of termination procedures is one way of insuring that termination receives the attention it requires.

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