University of Pennsylvania ScholarlyCommons Doctorate in Social Work (DSW) Dissertations School of Social Policy and Practice Spring 5-16-2011 Beginnings and Endings: An Inquiry into the Attachment Orientations and Termination Approaches among Clinical Social Workers Katherine C. Ledwith University of Pennsylvania, [email protected] Follow this and additional works at: https://repository.upenn.edu/edissertations_sp2 Part of the Clinical Psychology Commons, Counseling Psychology Commons, and the Social Work Commons Recommended Citation Ledwith, Katherine C., "Beginnings and Endings: An Inquiry into the Attachment Orientations and Termination Approaches among Clinical Social Workers" (2011). Doctorate in Social Work (DSW) Dissertations. 12. https://repository.upenn.edu/edissertations_sp2/12 This paper is posted at ScholarlyCommons. https://repository.upenn.edu/edissertations_sp2/12 For more information, please contact [email protected]. Beginnings and Endings: An Inquiry into the Attachment Orientations and Termination Approaches among Clinical Social Workers Abstract All therapeutic relationships must come to an end. Although there is ample social work literature on the impact of termination on clients, there is a dearth of scholarship on the experiences of clinicians during this phase. This study explored the links between the levels of attachment orientation of a purposive sample (N=49) of clinical social workers and their subjective approaches to termination. The Adult Attachment Questionnaire (AAQ) and the Termination Approaches Questionnaire (TAQ) (created for this study) were instruments used in this online survey design. The results suggested a statistically significant relationship between attachment orientation of clinical social workers and their approaches to termination. Participants with lower scores on the AAQ had higher scores on the engagement subscale of the TAQ indicating that those with higher attachment security were more likely engaging in the process of termination. Likewise, results suggested that the higher the AAQ scores the higher the scores on the avoidance subscale of the TAQ indicating that those with less secure attachment orientation were more likely avoiding the termination process. Qualitative results highlighted the emotional ambivalence, the opportunities, and the need for education about the termination phase. The worker’s role and the therapeutic relationship emerged as key factors in termination approaches. By bringing increased attention to termination and to clinician attachment in this phase of the work, this study strengthens the potential of clinical social workers engaged in outpatient psychotherapy practice to minimize unfavorable effects of termination on clients and on themselves. Degree Type Dissertation Degree Name Doctor of Social Work (DSW) First Advisor Jeffrey Applegate, PhD Second Advisor Joretha Bourjolly, PhD Third Advisor Lani Nelson-Zlupko, PhD Keywords attachment, termination, clinicial social work, psychotherapy, endings Subject Categories Clinical Psychology | Counseling Psychology | Social Work This dissertation is available at ScholarlyCommons: https://repository.upenn.edu/edissertations_sp2/12 BEGINNINGS AND ENDINGS: AN INQUIRY INTO THE ATTACHMENT ORIENTATIONS AND TERMINATION APPROACHES AMONG CLINICAL SOCIAL WORKERS Katherine C. Ledwith A DISSERTATION in Social Work Presented to the Faculties of the University of Pennsylvania In Partial Fulfillment of the Requirements for the Degree of Doctor of Social Work 2010 ____________________________ Jeffrey Applegate, Ph.D. Supervisor of Dissertation ____________________________ Richard J. Gelles, Ph.D. Dean, School of Social Policy and Practice Dissertation Committee Joretha Bourjoly, Ph.D. Lani Nelson-Zlupko, Ph.D. Copyright 2010 by Ledwith, Katherine C. All rights reserved. Dedication This dissertation is dedicated to my clients and teachers – past, present, and future. A special dedication is reserved for Joe McBride, who nurtured me in my early days as a therapist, taught me how to be a clinical social worker, and whose supportive wisdom and humor sustained me. I will always remember him. iii BEGINNINGS AND ENDINGS: AN INQUIRY INTO THE ATTACHMENT ORIENTATION AND TERMINATION APPROACHES AMONG CLINICAL SOCIAL WORKERS Katherine C. Ledwith Jeffrey Applegate, dissertation chair All therapeutic relationships must come to an end. Although there is ample social work literature on the impact of termination on clients, there is a dearth of scholarship on the experiences of clinicians during this phase. This study explored the links between the levels of attachment orientation of a purposive sample (N=49) of clinical social workers and their subjective approaches to termination. The Adult Attachment Questionnaire (AAQ) and the Termination Approaches Questionnaire (TAQ) (created for this study) were instruments used in this online survey design. The results suggested a statistically significant relationship between attachment orientation of clinical social workers and their approaches to termination. Participants with lower scores on the AAQ had higher scores on the engagement subscale of the TAQ indicating that those with higher attachment security were more likely engaging in the process of termination. Likewise, results suggested that the higher the AAQ scores the higher the scores on the avoidance subscale of the TAQ indicating that those with less secure attachment orientation were more likely avoiding the termination process. Qualitative results highlighted the emotional ambivalence, the opportunities, and the need for education about the termination phase. The worker’s role and the therapeutic relationship emerged as key factors in termination approaches. By bringing increased attention to termination and to clinician attachment in this phase of the work, this study strengthens the potential of clinical social workers engaged in outpatient psychotherapy practice to minimize unfavorable effects of termination on clients and on themselves. iv Table of Contents CHAPTER 1: Introduction…………………………………………………. 1 Problem Statement…………………………………………………. 1 Purpose of Study………………………………………………….... 2 Attachment theory and clinical social work practice………………. 3 CHAPTER 2: REVIEW OF THE LITERATURE………………………… 8 Termination Conceptualized……………………………………………….. 8 Characteristics of Termination……………………………………... 8 Missing Elements………………………………………………….. 11 The Setting as a Link……………………………………………… 12 When to Terminate………………………………………………… 15 Attachment: A theoretical framework……………………………………… 17 Patterns of Attachment……………...……………………………… 19 Biospsychosocial basis of attachment………………………….…... 22 Attachment Research………………………………………………………. 24 Termination Research……………………………………………………... 32 CHAPTER 3: METHODS…………………………………………………. 39 Instruments………………………………………………………………… 39 Variables…………………………………………………..………………. 42 Quantitative Data Analysis………………………………….……………… 43 Qualitative Data Analysis………………………………………………….. 46 Hypotheses……………………………………………………….………… 47 Recruitment ………………………………………..………………………. 48 CHAPTER 4: RESULTS………………………………………………….. 51 Quantitative Results…………………………………………………………. 51 v Table of Contents (continued) Sample Descriptive Statistics…………………………………….. 51 Reliability of the Instruments…………………………………… 55 Statistics on Attachment and Termination Constructs……………… 56 AAQ Avoidance……………………………………………. 56 AAQ Ambivalence…………………………………………. 57 TAQ Engagement…………………………………………… 58 TAQ Avoidance…………………………………………….. 59 Intrascale correlations………………………………………………. 60 Interscale correlations………………………………………………. 61 Additional Findings…………………………………………………. 62 Qualitative Results………………………………………………………….. 63 CHAPTER 5: DISCUSSION……………………………………………….. 79 Limitations……………..…….………..………..………..…………………. 79 Conclusions and Implications………………………………………………. 82 Hypotheses……………………………….…………………………. 83 Termination Approaches Questionnaire………………..................... 83 Attachment Orientation and Termination Approaches……………… 84 The Therapeutic Relationship………………………………………. 85 Content of Termination Sessions…………………………………… 87 Termination as Emotionally Ambivalent…………………………… 88 Termination and Opportunities……………………………………… 90 Favorable and Unfavorable Outcomes……………………………... 91 Time………………………………………………………………… 93 Attachment and Termination in Context……………………………. 94 Implications for Practice……………………………………………………. 96 vi Table of Contents (continued) Recommendations for Future Clinical Social Work Research……………… 97 Conclusion………………………………………………………………….. 100 Appendix A……………..………..………..………..…………..………….. 102 Appendix B……..………..………..………..………..………..…………….. 112 References……………………………………………………………………. 114 vii viii List of Tables Table 1: Categorical Placement of TAQ items………………………………. 44 Table 2: Categorical Placement of AAQ items……………..……………… 46 Table 3: Age and Time in the field of participants…………………………. 52 Table 4: Licensure of participants…………………………………………… 52 Table 5: Reliability statistics of TAQ and AAQ subscales…………………. 56 Table 6: Mean and Standard Deviations of AAQ Subscales and total……… 57 Table 7: Feelings list from qualitative data…………………………………. 65 ix List of Figures Figure 1: Gender of participants …………………………………………… 52 Figure 2: Theoretical orientation of participants…………………………… 53 Figure 3: Primary work setting of participants……………………………… 54 Figure 4: Most common reasons for terminating…………………………… 55 Figure 5: AAQ scores histogram…………………………………………… 58 Figure 6: Comparison of Total and Subscale Means of TAQ Subscales…….. 60 x CHAPTER 1: INTRODUCTION Problem Statement According to the Bureau