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The Personal Impact of Ending Therapy on Speech-Language Pathologists

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The Personal Impact of Ending Therapy on Speech-Language Pathologists Edith Cowan University Research Online ECU Publications Pre. 2011 1-1-2010 I can't sleep at night with discharging this lady: The personal impact of ending therapy on speech-language pathologists Deborah Hersh Edith Cowan University Follow this and additional works at: https://ro.ecu.edu.au/ecuworks Part of the Speech Pathology and Audiology Commons 10.3109/17549501003721072 Hersh, D. J. (2010). I can't sleep at night with discharging this lady: The personal impact of ending therapy on speech-language pathologists. International Journal of Speech-Language Pathology, 12(4), 283-291. Available here This Journal Article is posted at Research Online. https://ro.ecu.edu.au/ecuworks/6421 International Journal of Speech-Language Pathology, 2010; 12(4): 283–291 LEAD ARTICLE I can’t sleep at night with discharging this lady: The personal impact of ending therapy on speech-language pathologists DEBORAH HERSH Edith Cowan University, Perth, Australia Abstract The ending of therapy is a crucial time for speech-language pathologists and can impact on their sense of achievement and satisfaction. Drawing on literature from psychotherapy, social work and rehabilitation as well as from the area of aphasia therapy, this paper explores how speech-language pathologists juggle the tensions of coping with real versus ideal endings, of managing the building of close therapeutic relationships which then have to be broken, and of balancing a respect for client autonomy while retaining control over caseloads and fair allocation of resources. I suggest that the way in which therapy finishes reflects a merger of how clinicians manage these tensions. Clinicians may benefit from a greater recognition of what they do and feel at discharge, not only to further reflective practice, but also to encourage more sensitive involvement with both clients and students. Keywords: Discharge from therapy, aphasia, qualitative research, reflective practice, service delivery, professional issues. therapy? What challenges does discharge pose for Introduction clinicians and why? How does ending therapy impact Ideally, speech-language pathology intervention on therapy itself and how does it colour the nature of For personal use only. should always end in a cure, an experience of the therapeutic relationship? How does the experi- successfully achieving agreed goals, a sense of ence of discharging clients vary within the field of closure and a job well done. Certainly, this ideal will speech-language pathology? be achieved in many situations, although perhaps Chronic aphasia, the key area explored in this with some groups of clients more than others. paper, has particular characteristics which render the However, in reality, there are a range of experiences ideal of a perfect closure unlikely: aphasia is rarely for speech-language pathologists1 at the end of cured, improvement may be slow and prognosis is therapy, whether ideal or not. Intervention usually imprecise. Clinicians know that people with aphasia has to be brought to a close and the evidence we and their families, faced with the considerable have, from both within and outside the profession of disruption of chronic communication disability, speech-language pathology, suggests that the dis- may experience transitions as a time of vulnerability charge process is often a complex negotiation for (Hart, 2001), may have unrealized expectations Int J Speech Lang Pathol Downloaded from informahealthcare.com by Edith Cowan University on 09/05/11 clinicians which involves a great deal of emotional regarding improvement, or may feel a loss of hope energy. While speech-language pathologists are or a sense of abandonment (Hersh, 2009a; Parr, obviously concerned with service level issues, dis- Byng, Gilpin, with Ireland, 1997; Sarno, 1993). But, charge criteria, and discharge planning policies, this in addition, this is an area of practice where the scientific forum examines the personal impact on therapeutic relationship is fundamental. Speech- them of the discharge process, particularly ending language pathologists not only invest a great deal of the therapeutic relationship. This subject, while energy and time into organizing ongoing referrals clinically prominent, has been relatively under- and services but also into ending therapy without explored and infrequently aired in the speech- upsetting their relationship (Hersh, 2003a). language pathology literature. This scientific forum While some of these characteristics are shared with will consider questions such as: What do speech- other aspects of speech-language pathology practice, language pathologists do, think and feel at the end of clinical experiences with, for example, paediatric Correspondence: Deborah Hersh, Speech Pathology, School of Psychology and Social Science, Edith Cowan University, 270 Joondalup Drive, Joondalup,WA 6027, Australia. E-mail: [email protected] ISSN 1754-9507 print/ISSN 1754-9515 online ª The Speech Pathology Association of Australia Limited Published by Informa UK Ltd. DOI: 10.3109/17549501003721072 284 D. Hersh clients, adults with acute rather than chronic com- Williams saw a focus on endings as central in munication difficulties, and those with terminal psychotherapy as much more useful. She pointed illness may yield quite different perspectives. What- out that the word end, as well as meaning something ever the client population, this scientific forum that is over, is also something that is striven towards, emphasizes the importance of the end of our a purpose or an aim. Similarly, Zinkin (1994), intervention since most of the attention in our another psychotherapist, stressed the difference literature and in professional preparation courses is between bringing something to an end and simply on beginnings and middles of therapy. But why focus stopping: ‘‘An end always implies a goal or purpose on how discharge impacts on speech-language having been achieved . but is the end of thera- pathologists? I argue in this paper that there are py . necessarily expressed at the time the therapy three areas of tension for speech-language patholo- actually stops?’’ (p. 18). gists which surface particularly at the end of therapy. The shift from a traditional medical model of The first relates to coping with real versus ideal intervention towards social approaches in aphasia endings, the second to the paradox of building rehabilitation has also stimulated reconsideration of authentic relationships for effective therapy which the terms we use. Simmons-Mackie (1998) saw then have to be broken, and the third to the dilemma discharge as negative and indicative of minimal client of wanting to promote client involvement in deci- input in the process. She preferred reintegration: sions while retaining professional control over the ‘‘Rather than shift from treatment to no treatment, discharge process. the client should experience a gradual transit down a This paper begins with a focus on the terminology continuum towards assisted community reintegra- used to describe treatment endings and then moves tion’’ (p. 236). Similarly, Pound, Parr, Lindsay and to a literature review about the impact of treatment Woolf (2000), reflecting on their work at what is now termination on practitioners from the fields of Connect, the Communication Disability Network, psychotherapy, social work, rehabilitation and then, wrote: specifically, aphasia therapy. The three areas of tension mentioned above can be seen to thread The process of regular goal setting, reviewing change, through this work and I refer to them again in the re-directing therapy and looking to current and future next section, a discussion of a qualitative, grounded needs is, as with all therapy, geared towards addressing theory study (Hersh, 2003b) which explored the timing of ‘discharge’. We are somewhat uncomfor- table with this term, as it suggests medicalisation, aphasia treatment termination experiences more doctor/therapist-driven decisions, and lack of agency broadly and which has already been the subject of a on the part of the client. If possible, we prefer to refer to number of recent papers (Hersh, 2001; 2003a; what is undoubtedly a complex and protracted process For personal use only. 2009a; b). as ‘leaving therapy’. (p. 259) Reconsideration of terminology For clinicians working along the continuum of The complex nature of how therapy draws to a close therapy, discharge may actually be better conceptua- is reflected in the terms we use to describe it such as lized as transition because the emphasis is on a move discharge, treatment termination, endings in therapy or to another phase of rehabilitation. In some situations, closure. At first sight, these terms all imply the same discharge may be understood as a temporary separa- thing but a number of authors have pointed out that tion where clients are formally discharged to satisfy they are value-laden. For example, Dill (1995), a administrative requirements but are invited back for sociologist, talking about the process of leaving review. The subtle meanings imbued in these terms hospital, wrote that the term discharge encompasses are an indication of the importance and complexity a sense of explosive release, but one in which the of the issues they represent including those of Int J Speech Lang Pathol Downloaded from informahealthcare.com by Edith Cowan University on 09/05/11 direction may be uncertain, involving a welcome continuity of care, the degree to which discharge is change but also the potential for danger. Termination shared or negotiated, and expectations
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