Ambiguous Endings - Making sense of the disrupted cycle of care

In ideal clinical and supervision practice, we will have a closure experience at the time of professional separation (final session) that is positive for both parties. However, have you ever had that niggling feeling of not finishing up with a client in a planned or clear manner and been left wondering what your next step is? I have and I must say that it takes away from the important feeling of satisfaction in my work. I have been reading about this and found that it has a name: An Ambiguous Ending as outlined in the book: “The Resilient Practitioner: Burnout and Compassion Fatigue Prevention and Self-Care Strategies for the Helping Professions”.

The authors, Skovholt & Trotter-Mathison, state that having an ambiguous ending is strongly linked with the disruption to the Cycle of Caring which is outlined below. This Cycle of Caring is the cycle that practitioners do over and over again, hundreds or even thousands of times over many years in their career. It has four distinct phases:

Phase 1: Empathetic Attachment Phase – Time is put into establishing rapport by using attachment skills of attending, intense listening, emotional sensitivity and nonverbal understanding. It is this aspect that clients recall when they look back on their experience with a practitioner. More often than not they recall that positive support above anything else.

Phase 2: Active Involvement Phase – This is the work phase for the practitioner and client. This phase demands the continuous attachment of the practitioner to the other person in need of their service. This can be a one-off advising appointment or multiple sessions over months.

Phase 3: Felt Separation Phase – The ability to separate well at the end of the Active Involvement Phase. With the metaphor of landing a plane, Prospective termination consists of a long planning process of the practitioner and client, talking about the trip during the descent and a really smooth landing. When the plane stops (therapy stops) they both get out and go on their ways – this is a positive process for both parties and energises the practitioner to enter the Cycle of Caring again.

Phase 4: Re-Creation Phase – the final phase when the work is completed and the practitioner has a break, time-off, has some fun which allows for repair, restoration of energy levels, rebalancing of the self and preparation for a return to the cycle of care.

When there is an ambiguous ending, such as when a client may suddenly stop coming to appointments and not return communication, it can leave the practitioner with questions such as “Did the client get better? Did they learn anything? Did they think I was a poor practitioner? Did they wish to tell me something?”

With such a situation and many other scenarios, the third phase of the Cycle of caring, Felt Separation, does not occur. The good-bye may be unclear, indefinite or absent. How does the practitioner then move into the next phase of Re-Creation? The Re-Creation phase is very important for the practitioner to have vitality of the next Cycle of Caring with the next person as the Cycle of Caring goes on and prevent depletion of the practitioner or burnout. A recent example of an ambiguous ending I experienced was that I had two quality sessions with a 25-year-old woman regarding anxiety and work-related stress and she cancelled our 3rd session at the last-minute citing physical sickness. I then offered her a number of appointments over the next 3 weeks but did not ever get any reply from her.

Have you experienced an ambiguous ending? How did it feel? In retrospect what might you have done differently (if anything) to reduce the incidence of this ambiguous endings?

I have had some thoughts on how to minimise the incidence and negative impacts of ambiguous endings to sustain the professional self:

Firstly, put some clear procedural aspects into your work. These could include the following:
a. At the outset, clearly communicate the role of the practitioner, the planned intervention and goals, the aims of each session, the likely number of sessions and that this will be revisited regularly to clarify expectations through-out the period of intervention. This way, the client is informed every step of the way and they have significant input into when the intervention will finish up.
b. Clear guidance at outset of how the client would inform the practitioner if they cannot attend the planned session including method of communicating, cost of this if last minute cancelation and how to rebook.
c. Check in with the client at the completion of each session how helpful the session has been on a scale of 1-10 and if anything can be done to increase this for next time. This will help the practitioner to gauge if the client expectations are not being met and give an opportunity to make appropriate changes.
d. Establish at the outset, their preferred means of communication for all appointment making and use this for all communication regarding appointments.
e. If a client does not attend a session and/or does not return communication, have a clear procedure to include the following:
a. If no communication is received at all, inform the referrer and put in clinical notes and offer the client to make contact to reschedule within 10 working days.
b. If no further communication is received within the 10 working days, inform the client that they are on hold and for them to contact practitioner if they wish to reschedule. Provide a further timeframe of 10 working days.
c. If at 10 days (total of 20 working days) there is no further communication, discharge the patient and inform them of this, write up clinical notes and inform the referrer.

Secondly, it is important that the practitioner has some tolerance of some inevitable ambiguous endings and unanswered questions in their work. To assist with this, when an ambiguous ending occurs, spend some time reflecting on the impact it has on you as a practitioner. This may be in the form of reflective writing or symbolic ritual such as sitting with the discomfort of not knowing for a minute and then filing the clinical notes. This is to help complete the disrupted Cycle of Caring so that the Re-Creation Phase can occur. This helps prevent the depletion of practitioner vitality and sustains the professional self so that the practitioner can go on to do the Cycle of Care all over again.

Do you have any other strategies you use or strategies above you would like to trial?

Ambiguous endings are a natural occurrence in the delivery of healthcare, but many clinicians are not aware of the impact they can have on professional satisfaction and wellbeing. Awareness of ambiguous endings and how to manage them is an important aspect of professional self-care, and burnout prevention. Being proactive to avoid ambiguous endings and implementing strategies for optimising the cycle of caring is a skill that all helping professionals could employ.

Skovholt, T.M & Trotter-Mathison, M., 2016. “The Resilient Practitioner: Burnout and Compassion Fatigue Prevention and Self-Care Strategies for the Helping Professions”, 3rd Edition, New York, Routledge.

Written by Louise Tapper, ThriveOT Dated: 17th March 2022

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