All episodes of clinical practice, regardless of the social worker's agency setting, include the stages of assessment, planning, intervention, and ending (also known as termination). endings may be planned or unplanned, and forced or voluntary. The importance of attending to the ending of an intervention is to ensure that closure is achieved. That is the social worker and client understand why their relationship is ending and can process the experience. They may review the successes and failures of their work, plan for the client's maintenance of gains, and perhaps institute new goals for the client to pursue. Closure also may include the worker and client's acknowledgment of feelings about their relationship and may enhance their mutual confidence in managing future relationships.
Many social workers who have a grasp of practice theory and intervention techniques feel less competent when ending their work with clients (Fortune, 1985), and they receive little instruction on this in their academic and agency training. The topic may receive even less emphasis among practitioners who work with clients with schizophrenia. Such practice is not always considered to be psychotherapeutic, and the chronic nature of the disorder generally requires long-term work. This paper emphasizes multicultural issues and importance of closure with members of this client population and provides guidelines for social workers to incorporate constructive ending processes into their work.
The theory of ego psychology provides a useful perspective from which to address intervention and ending tasks with people with schizophrenia (Goldstein, 1995; Schamess, 1996). ego psychology guides the social worker through a range of task-focused and reflective interventions in short- or long-term clinical relationships. The social worker monitors the client's reality testing, judgment, expression of affect, defenses, relationships, sense of self, ability to manage stimuli, and sense of mastery. Intervention goals include helping the client to develop new adaptive capacities and interpersonal skills. ego psychology also encourages the social worker to monitor developments in the clinical relationship. People with schizophrenia often have few close relationships, and many of these are conflicted. A positive clinical relationship, one that cultivates an attachment between the client and social worker and models a process for examining other relationships, is an essential component of practice with this client population.
Schizophrenia is a disorder of the brain, characterized by abnormal patterns of thought and perception (American Psychiatric Association, 1994). It includes two types of symptoms. Positive symptoms represent exaggerations of normal behavior (such as hallucinations, delusions, disorganized thinking, and tendencies toward agitation); negative symptoms represent a diminishing of what would be considered normal behavior (such as flat or blunted affect, social withdrawal, noncommunication, anhedonia, and ambivalence). Although schizophrenia is widely acknowledged to be biologically based (Gottesman, 1991), there are significant psychological and social factors related to its etiology and course.
A person with schizophrenia experiences ego deficits in reality testing, judgment, the sense of self, impulse control, and integrative processes. The inability of the person to regulate interpersonal boundaries is influenced by many factors, including the symptoms of the illness, its cognitive impairments, and the adverse effects of medication. Many people with schizophrenia experience ambivalence about relationships, which presents their social workers with a major challenge. The defenses of denial and projection keep the client at a distance from others. The lack of a clear sense of self further impairs the client's ability to regulate boundaries. Clients often struggle with conflicting needs for closeness to and distance from others, as both extremes may represent a threat to the sense of self. Still, the client's development of interpersonal skills can help to resolve this ambivalence and facilitate growth. People with schizophrenia may become less isolated if their interpersonal problems are addressed. During the ending process this includes helping the client plan to maintain appropriate boundaries in relationships, to use good judgment in self-disclosure, and to develop greater awareness of his or her reactions to others (Hertz, 1996). ...