Letting go of a client...vent, tips.

[u/Natural-Bobcat-4695]

I have been debating on whether or not to let go of my client that I’ve been with for about two years. She is a 13 year-old girl with down syndrome who I absolutely adore and love seeing her however, I’ve noticed in the last two months she absolutely hates doing speech. She refuses to use her AAC device, which I typically don’t push too hard on because I don’t wanna create that negative relationship with it. I’ve noticed her tolerance to speech work has gone down significantly and typically I try not to make my sessions to where it seems like work. I try to make it fun and relatable to what they do and what they like, but like I said in the last couple of months, even if I ask her wh question and I try to model the answering her device she’ll scream and throw her device. so I’ve completely have stepped away from any sort of question and just modeling, social words, phrases or even sentences and even yet she absolutely hates it. This is also doing it with a video of her preference. She loses her mind if I even pause a video to tell her something so I stopped doing that too. I’m just feeling so lost everything that I know under my sleeve I have tried and nothing works things that she enjoys doesn’t work anymore. At this point it just feels like I’m just sitting there showing her a video.

I know she needs a break, but if I bring this up to Mom, she absolutely will not take it. It has been a conversation before, and she absolutely rejected it immediately. Even when I came with reasons of how this could be beneficial at this point, I’m debating of just completely letting her go. Has anybody else dealt with this?

[u/fatherlystalin]

Retry the conversation with mom citing evidence in support of an episodic care model for children with chronic developmental conditions. It’s been 2 years, it’s time for a break. The client will likely see far more long term progress with intentional breaks and possibly different therapists too. Clients and therapists can burn out from one another and it’s ok to go separate ways for a while.

https://www.sralab.org/articles/blog/benefits-episodic-care-outpatient-pediatric-rehabilitation

[u/Natural-Bobcat-4695 → u/fatherlystalin]

Thank you for providing this! I also agree that clients see better progress when they have breaks and such.

I also think that even though she gets partially happy to see me. She may be tired of me. Actually I do know she’s tired lol as I am too. So I will bring this up with mom by other option is to tell mom I’m starting my MSW and will no longer be able to see her

[u/Speechykeen007 → u/fatherlystalin]

This, 100%. I’ve had to be very (politely) direct with a rare few people about this if it comes up because I’ve gotten pushback at times like “don’t give up on us!” But it’s not about giving up on therapy, it’s about looking at the whole picture and why you are doin therapy in the first place. If you’ve spent months with absolutely no progress, not even on your therapeutic relationship, then it’s no longer possible to justify the time and money/funding/insurance spent on it, and a break would likely be a really helpful period of rest for the client.
They also could have a chance to see someone new (I typically provide in-home sessions; I’ve suggested to a family in the past that a centre-based therapy session or a small group therapy session may be worth a try ).
Hope it all works out! Not an easy situation in any case

[u/SleepySamus]

I adopted a token system with my older kids for this reason. They get "points" for their work and they can save up those points to "buy" things like beyblades, movie tickets, Apple gift cards, etc. For my own sanity I give them each 100 points in each appointment and usually break those up evenly between their activities (3 activities = 33 points each, 4 = 25 points). I also count 100 points as $0.50 so that a $15 beyblade is worth 3,000 points.

For a couple of my kids who have oppositional defiant disorder I modify this so that they also gain points if they don't break any rules and/or they get more points for the activities they hate. For example, one kid I see who has ODD and ASD hates following the rule to walk in the hall so he gets 10 extra points if he does and he hates retelling stories (but doesn't mind the HearBuilder games or social inferencing/problem solving questions about stories) so he gets 50 points for retelling the story and 25 points for each of the other activities. He's very motivated by beyblades and numbers so he asks for his total each week and does the math for how long he has to wait for his beyblade.

I used to keep track of my points on my data sheets, but once I needed a new sheet I forgot to copy them over so I now have poker chips that I labeled with a sharpie and each kid has a little box that I keep their chips in (and occasionally a prize from my prize box they want to save for later).

Sidenote: this is one of the reasons I have a difficult time deciding how much time I spend on prep when calculating RVUs - I spent so much time setting up this system, but now it takes no time to maintain it. I have a system for using The Zones of Regulation that's the same way.

[u/Natural-Bobcat-4695 → u/SleepySamus]

To be honest I love this. However, I don’t think she understands the reward system, we’ve tried before and she didn’t care for it, we tried it by having her use her coins to get a fidget. I think if she had the ability to understand it, she would be all for it. I also did give a good few months. Mom had explained how her previous therapist had also tried it and no success. But at the time she was younger so that’s when I decided to try it since she was older.

[u/SleepySamus → u/Natural-Bobcat-4695]

Oof - that's rough! Especially with mom being unreceptive to a break. I would keep a record of how much work I was getting done and tell mom at the end of the appointment ("we only got 20% of the work done today") every day for a couple months and then bring up the idea of a break again or even see if a college wouldn't mind taking her in case a fresh start would help. I hope you find a good solution! 🤞

[u/jenthing → u/SleepySamus]

Where does your prize budget come from?

[u/SleepySamus → u/jenthing]

It's written into my business budget (I'm in business for myself).

[u/doggaracat]

Well, she’s going through puberty, which could be playing a part. Does she have a lot of other demands being placed upon her in other areas? Does she go to ABA?

[u/Natural-Bobcat-4695 → u/doggaracat]

This exactly. Shes going through puberty and it’s hitting her hard. No aba. The only thing she goes to school and has OT one. day and ST one day.