Chapter 19: The Final Phase: Evaluation & Termination

The Kansas Consumer Satisfaction Survey

26-item, Likert-type scale, strongly agree to strongly disagree "If I have an emer- gency at night or on the weekend, I am able to get help from the program" "My opinions and ideas are included in my treatment plan"

Goal attainment scaling (GAS)

A specific type of success measure The social worker and client identify a handful of problem behaviors or targeted changes and related goals Then they assign each item a number corresponding to the likelihood of achievement or success on a scale from -2 to +2 -2 = unfavorable or unlikely, 0 = no expected outcome, +2 = favorable/likely Each scale is made specific to the goal best suited for highly motivated clients that are reliable in reporting results Useful for tracking incremental steps towards service outcomes and can serve as an indicator of readiness for termination

Fidelity assessments

Can address how closely the process and skills used by the program or individual social worker match the design of the intervention Qualitative case study reviews Quantitative fidelity measures Published measures With children and other clients who lack high written or verbal ability Expressive techniques such as collages, paintings, drawing or display of some kind To illustrate "What I liked best about our work together," or "What helped me during my time here"

Managing and Adapting Practices (MAP)

Creates a treatment selection, design, implementation, and evaluation kit that facilitates the search for recommended treatments and a clinical dashboard that organizes data on client progress

Client-initiated Unplanned Termination

Dropping out of treatment Clients who are involuntary or otherwise unmotivated Clients who are dissatisfied with the social worker Clients who feel they have made satisfactory progress and are "done" whether the social worker thinks so or not Clients who decide to quit for pragmatic reasons like a lack of funds or the inconvenience of the service setting An adverse event that renders the client unavailable for service Arrested, running away, committing suicide, dying unexpectedly Client behaving in such a way that services are withdrawn Push out social worker and the client have failed to "click" and the client's discontinuation is prompted or reinforced by the practitioner's disinterest, incompetence, or lack of commitment Client-initiated withdrawal from services are unanticipated and thus allow no opportunity for discussion, processing, or closure, yet the residue of feelings and unfinished business remains Both parties may experience feelings of abandonment, anger, rejection, failure, relief, and shame

Avoiding Premature Termination

Educate clients about what to expect in regard to the duration and process of change Explain the roles that each participant will play in the process of care to dispel inaccurate or stereotyped beliefs about counseling. Incorporate client preferences about the timing, structure, and form of treatment. Instill hope through a focus on strengths, a clear problem formulation and rationale for services, expressions of confidence in the client, and professional compassion, competence, and credibility. Paying attention to pacing and progress, especially early in the helping process, can also encourage hope. Foster the therapeutic alliance by creating a safe environment, expressing empathy, and collaborating with the client in setting goals and tasks for service. Consistently assess and discuss treatment progress.

Follow-Up Sessions

Ensure successful termination and change maintenance Don't set a specific date but rather explain that they will contact the client after a designated interval

4 primary tasks of termination

Evaluating the service provided and the extent to which goals were accomplished Determining when to implement termination Mutually resolving emotional reactions experienced during the process of ending Planning to maintain gains achieved and to achieve continued growth

Published measures

For social workers to evaluate outcomes and processes in their work with groups and families Yalom's Curative Factors Scale Can combine measures (records about sessions, client self-reports, observations)

Formative evaluation methods

Help organizations to determine which elements of their programs were effective in bringing about the desired change Determine whether the techniques used were consistent with standardized agency protocols and delivered as efficiently as possible Capture the nuances of client-social worker interactions that contribute to treatment effectiveness

Process

Identifying the aspects of the helping process that were useful or detrimental Feedback about techniques and incidents that enhanced or blocked progress will help you hone certain skills and eliminate others, and use techniques with greater discrimination Formative evaluation methods Client self-reports about this are subject to the same biases as self-reports about outcomes Fidelity assessments

Avoidance

If clients ignore the SW or fail to appear to appointments, it's critical to reach out to them personally (phone, email, letter)

Hybrid Models

Incorporates measures of outcome, satisfaction, and progress, and can be administered in 2 to 3 minutes Client-oriented, outcome-informed tools capture feedback through brief questions are the outset and conclusion of each session Partners for Change Outcome Management System (PCOMS) The Outcome Rating Scale (ORS) Session Rating Scale (SRS) Available online, there are children's versions, in more than a dozen languages Important to assure that services are appropriate and effective A core competence for social work students involves recognizing the importance of evaluation, selecting proper evaluation measures, critically evaluating findings, and using those findings to improve practice effectiveness

Emotional reactions to termination

Involuntary clients or those with more structured, time-limited services will be less likely to experience a sense of loss at termination than those who have engage in longer, more voluntary relationships with the social worker Be sensitive and be prepared

Partners for Change Outcome Management System (PCOMS)

Scientifically validated and is well-endorsed for practical utility in a variety of services settings

Social Workers' Reactions to Termination

Self-understanding & good supervision are the essential elements to managing emotions

Understanding & Responding to Clients' Termination Reactions

Separation involves mixed feelings for both the SW & client vary in intensity according to the degree of success achieved, the strength of the attachment, the type of termination, the cultural orientation of the client, & his or her previous experiences with separations from significant others Many people experience positive emotions - benefits from the gains outweigh impacts of loss Sadness is a common element impact of termination on SW is shaped by overall well-being (balance in personal & professional lives) Anger Denial Avoidance Reporting Recurrence of Old Problems or Generating New Ones Attempting to Prolong Contact

Quality of Life Self-Assessment

Social life, independence, physical health, mental health

Managing Unplanned Terminations

Some estimates suggest that 50% of the overall client population will drop out of service (may be higher for certain subgroups) Common response to client-initiated unplanned termination is for the social worker to reach out to the client by phone, email, or letter The goals in doing so may be to acknowledge the decision to conclude services, to encourage the client to come in for a closing session, or to achieve the purposes of such a session through the communication itself. Example: social worker sent a letter to client who was arrested in which she reviewed goals he had achieved, the issues he continued to struggle with, conveyed her regard for him and informed him of the availability of resources during his incarceration and following his release When a social worker dies or becomes incapacitated, the colleagues intervene for the care or transfer of clients Client dies unexpectedly Social worker must maintain privacy of client so the social worker's family and friends are unable to address the social worker's grief or may be unaware of the loss Supervisory or collegial support Formal processes for reviewing the case → "postvention" Can take the form of individual or group processing of the case, a psychological autopsy, or critical incident stress debriefing Unplanned terminations of a member of a group Departure due to the group itself - poor fit, discomfort with the leader or other members, a distressing incident Transportation difficulties or time conflicts Cohesion is central to the success of the group, so the loss of a member can threaten that bond, make members question their own achievements or appropriateness for the group, and make them reluctant to continue building trusting relationships with the remaining group members. Social worker should try to encourage closure in some form

Termination Due to Temporal or Structural Limits

Some organizations function by providing services according to fixed time intervals (i.e. hospitals or school settings) Sometimes predictable process where the client progresses through steps or phases leading to termination determined by temporal constraints or agency function rather than by individual factors is that the client's problems may not have been adequately resolved by the time termination occurs SW has dual tasks of working through feelings associated with separation & referring clients for additional services when indicated

Reporting Recurrence of Old Problems or Generating New Ones

Some panic as treatment reaches an end and they experience a return of difficulties that have been under control for some time some may introduce new stresses and problems during the terminal sessions & even during the final scheduled session The severity of the client's revelation, regression, or return of symptoms will dictate how you respond - some instances may have to reconsider a planned ending if it would help the client achieve progress "Sometimes people worry that problems will reemerge once services end, but I'm confident about how far you've come. I trust that even if there are setbacks, they won't affect our ending." the decision should be based on your sense of the client's progress to date, the degree of dependency, & the significance of the issues being raised

Satisfaction

Some settings facilitate the gathering of formal feedback by sending out written evaluation surveys at the termination of services or after a specified follow-up period Questions like: "Would you refer a friend or family member to us for services in the future?" "Were you and the clinician able to meet your goal?" "Do you believe you needed additional services that were not provided?" These surveys also evaluate structural or operational issues such as convenience of parking, time elapsed between the client's request for services and first appointment, the worker's promptness in making a home visit, etc. May inquire about the cultural competence of the staff, openness of the facility to diverse populations, or turnaround time in responding to client calls and requests The Kansas Consumer Satisfaction Survey Quality of Life Self-Assessment Both surveys offer open-ended items to respond with other thoughts or questions

Consolidating Gains and Planning Maintenance Strategies

Task: summarize & stabilize the changes achieved & develop a plan to sustain those changes The failure to maintain gains has been attributed to a variety of factors: 1. A natural tendency to revert to habitual response patterns (e.g., use of alcohol or drugs, aggressive or withdrawn behavior, poor communication patterns) 2. Personal and environmental stressors (e.g., family conflicts, financial pressures, personal rejection, loss of job, health problems, deaths of loved ones) 3. Lack of opportunities in the environment for social and leisure activities 4. Absence of positive support systems (peer or family networks may not have changed in the same way the client has) 5. Inadequate social skills 6. Lack of reinforcement for functional behaviors 7. Inadequate preparation for environmental changes 8. Inability to resist peer pressures 9. Return to dysfunctional or destructive environments 10. Inadequately established new behaviors must anticipate & prepare clients for coping with challenges monitoring phase may be useful for some people- the number & frequency of sessions decrease while support systems are called on to assist the client with new concerns

Planned Terminations with Successful Outcomes

The nature of the setting, intervention method, or funding source can all impose external pressures to terminate within a specific period of time Planned ending can be when clients achieve their goals and move on to independence from the SW Can be called "brief intermittent therapy throughout the life cycle"- individuals who need SW services may come to use them as they do medical and other services—seeking them out in times of need to address acute problems rather than pursuing single episodes of extended treatment

Types of termination

Unplanned Terminations & Planned Terminations

Worker-initiated Unplanned Termination

When the social worker becomes incapaciated, or is dismissed/fired Feelings of abandonment, self-blame, shock Layoffs and job transfers generally allow times for processing and closure

Attempting to Prolong Contact

a person may seek continued contact with SW by suggesting a social or business relationship post-termination Could be inappropriate given the profession's ethical proscriptions against dual relationships In groups, SW could respond "I'll be ending with you after our session next week, but I appreciate your offer to include me."

The Outcome Rating Scale (ORS)

administered at the beginning of each session Clients are instructed to indicate with a mark on a line how well they have been doing over the previous week in regard to personal well-being, family and social relationships, and overall well-being

Session Rating Scale (SRS)

at the end of each session, clients mark their responses on a continuum between two statements (e.g. "I did not feel heard, understood, and respected" and "I did feel heard, understood and respected")

Practice Skills Inventory (PSI)

documents the number of client contacts, the frequency with which particular skills were used, and examples of those skills for the case

Anger

encourage verbal expression of emotions & respond empathically to them - then engage in constructive planning

Planned Terminations with Unsuccessful Outcomes

endings are not marked by successful achievement of service goals: The SW or the client is dissatisfied with the helping relationship: The client is hopelessly stalemated despite vigorous and persistent efforts to overcome his or her difficulties. The social worker is not competent to address the client's needs. The client fails to comply with appropriate treatment requirements. Often not abrupt - chance to achieve the goals of closure When the helping process ends unsuccessfully, termination should include discussion of: 1) factors that prevented achieving more favorable results 2) clients' feelings about seeking additional help in the future. ** create a safe environment & SW needs to be non defensive in hearing feedback SW should be prepared to offer resources

Outcomes

evaluation involves assessing the results achieved against the goals that were formulated during the contracting phase of work. The methods utilized during the assessment and goal-setting phases will help determine which outcomes you measure Changes in the frequency of difficulties E.g. being late for work, getting detention, bingeing, overspending Changes in the frequency of target behaviors E.g. using "I" statements, engaging in safe sex practices Changes in the severity of problems E.g. self-esteem scores, sleep disturbance measured in a journal Achievement of goals or tasks E.g. applying for and getting a job, completing homework, maintaining sobriety, improving parenting Compare to baseline to determine the extent of progress Goal attainment scaling (GAS) Managing and Adapting Practices (MAP) Manualized (guided by manual) or evidence-based interventions often contain measures/instruments as part of the assessment to establish a baseline Standardized scales that can be used repeatedly to measure progress Single-subject designs You can use interviews and questionnaires to determine client's views to evaluate their sense of progress against your own observations Self-report measures are highly selective and may be affected by numerous factors such as the client's desire to please (or punish) the social worker, the client's interest in concluding service, or the hope that the problems are resolved and that further services are not necessary Can reduce biases by asking them to provide examples of recent events that illustrate their attainment of goals, a decline in difficulties, or an increase in capacities Can also get feedback from collateral contacts to compare to self-reports

Denial

helpful to reintroduce the topic of termination & to express your desire to assist them in formulating plans to continue working toward their goals after your departure "I know that being discharged is scary and that makes you wish you didn't have to leave, but not talking about it won't keep it from happening. I want very much to use the time remaining to reflect on our work together so you are prepared to carry all that you've achieved here out into the world."

Other Determinants of Planned Termination

how do the social worker and client know when to end? When services are highly goal directed, the termination point may be clear: it occurs when goals are reached & changes are sustained When goals are amorphous or ongoing determining a proper ending point can be more difficult appropriate to introduce the idea of termination when the client has reached the point of diminishing returns - when the gains from sessions taper off to the point of being minor in significance Simultaneous termination Client death - i.e. hospice cares, nursing homes, hospitals

Evaluation

important to measure client change in satisfaction, assure worker accountability, monitor the effectiveness of services, and evaluate the impact of the intervention themselves The conclusion of services is the final point at which goal attainment and other aspects of change can be assessed prior to termination Clients will be prepared for this at termination if you have systematically obtained baseline measures and tracked progress You can improve cooperation by reviewing the rationale and actively involving the client in the process "An important part of termination is to assess the results we have achieved and to identify what helped you most and least during our work together." Several different methods: Standardized tests, direct observation, goal attainment scaling, and client self reports through logs, journals, and surveys The more sources the better/stronger this is. Focus on 3 dimensions of service: Outcomes, process, and satisfaction

Simultaneous termination

occurs when the client & SW leave the service at the same time- when the end of services aligns with the practitioner's departure from the agency requires SW to have self-awareness to ensure that his or her personal reactions to leaving are not projected onto the client

Unplanned Terminations

or early terminations, occur when clients withdraw prematurely from services or when social workers leave helping relationships due to illness, job change, or other circumstances. Halted suddenly or prematurely Client-initiated Worker-initiated

Termination

refers to the process of formally ending the individual social worker-client relationship All client systems - individuals and families, support groups, coalitions, and communities Occurs regardless of the duration of the helping relationship This can occur when: Goals are met When clients make a transition to other services When time-limited services are concluded When social workers or clients leave the helping relationship The notion of ending is often bought up at the beginning of service when the social worker discusses the duration of care, number of session allotted, or the goals that will guide the helping process Whether in short-term or long-term therapy models, successful this involves preparing clients adequately for separation and accomplishing other tasks that facilitate the transition 4 primary tasks of this The significance of these tasks and the extent to which they can be successfully accomplished are governed by the context in which the helping relationship takes place The type of contact (voluntary or involuntary) The size and characteristics of the client system The nature of the intervention used In crisis or single-session services, the focus of termination is narrower Determining the effectiveness of the encounter in meeting the client's needs and clarifying next steps In crisis work, it also includes an evaluation of the client's safety and stability before the contact is terminated

Quantitative fidelity measures

statistics on type, frequency, duration, and pattern of services, chart reviews and other administrative or quality assurance data, the level of congruence with the intervention model, and inventories that capture the degree to which the social worker employed particular skills Practice Skills Inventory (PSI)

Qualitative case study reviews

supervisory meetings, observation of sessions, audit interviews with clinicians, or focus groups with colleagues are used to examine a particular social worker's actions

Ending Rituals

termination may be concluded by a form of celebration or ritual that symbolically marks the goals achieved and the relationship's conclusion decision should be based on an understanding of the client, the appropriateness of such actions for the agency or setting, and the meaning that the client may attribute to such actions ask the client how they would like to mark the final session & offer options if the person seems unsure what to suggest

Single-subject designs

the client is compared to himself or herself on baseline scores from earlier administrations.

Planned Terminations

when clients' goals are achieved when transfer or referral is anticipated and necessary when service is concluded due to the time-limited nature of the setting (such as hospitals or schools) or the treatment modality used (such as brief treatment or fixed-length groups).