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DIFFICULT THERAPY TERMINATION ISSUES [ETHICS & RISK MANAGEMENT]

by William W. Deardorff, Ph.D, ABPP.


9 Credit Hours - $139
Last revised: 08/05/2014

Course content © Copyright 2012 - 2017 by William W. Deardorff, Ph.D, ABPP. All rights reserved.



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“The process of therapy termination begins with the first session.”

 

 

Introduction

 

As the course title implies, this course addresses therapy termination, managing difficult termination issues, and avoiding abandonment.  However, in doing that, it covers much more including: when is a treatment relationship actually established, initial and ongoing informed consent, the importance of objectively monitoring a patient’s response to treatment, financial issues and therapy, the patient’s and therapist’s responsibilities in the treatment contract, therapists’ rights relative to terminating therapy,  managing transfer of care and referrals, establishing when a therapist’s professional responsibilities actually end, among other things. 

 

Actually being sued for malpractice specifically for abandonment in psychotherapy is a rare occurrence (less that 3% of cases according to some sources, Shapiro and Smith, 2011).  However, simply looking at claims for abandonment probably hides important information.  It is likely that therapy abandonment is a component of malpractice claims and board complaints (to state licensing agencies and ethics committees) that are actually under the rubric of some other category that is much more common: Ineffective treatment, failure to consult; negligent diagnosis; inadequate supervision, etc. In these more common complaints, the issue of abandonment is not mentioned since it is not the most egregious alleged offense. 

 

This course will begin with a presentation of common therapy dilemmas related to therapy termination.  It will then proceed with a definition of terms and a discussion of areas of premature therapy termination: appropriate and inappropriate (abandonment).  Even though practical guidelines are discussed throughout the course, a summary discussion will be provided at the conclusion.

 

COURSE OUTLINE

 

Learning Objectives

What Would You Do?

The Beginning: When is a Treatment Relationship Established?

How well do Therapists Terminate Therapy?

Definitions

Termination (Successful)

Premature Termination

Abandonment

The Ethical Codes

Ethics Codes Struggle with the Issue of Abandonment

Legal Aspects of Abandonment

Factors Influencing Pre-Mature Termination

Provider-Therapist Variables

Patient Variables

Type of Treatment

Extra-Therapy Variables

Successful Termination

Areas of Premature Termination

Financial and Reimbursement Issues

Reimbursement – Utilization Review

Multiple Relationships and Conflicts of Interest

Lack of Progress in Treatment

Was a Treatment Relationship Established and Duty to Protect Incurred?

Nonadherence

Therapist-patient Mismatch

Boundary Violations (Patient) - Threats

Change in Therapist Status (job, moving, illness)

Out of area of competence

Transfer of Care

Resources and References

 

List of Tables

 

Table 1. When does the Therapist-Client Relationship Begin?

Table 2. Ending Therapy: What Really Happens?

Table 3. Successful Therapy Termination

Table 4. Starting and Ending Therapy: The Real World

Table 5.  Premature Termination: What is it?

Table 6. Abandonment: Never OK

Table 7. Ethical Codes

Table 8. Ethical Codes Related to Termination and Abandonment

Table 9. Ethical Codes Related to Financial Issues and Treatment

Table 10. Ethical Principles Related to Sexual Misconduct

Table 11. Dependent Personality Disorder: Termination Issues

Table 12. Ethical Codes Related to Change in Therapist Status

Table 13. Ethics Codes Related to Competence

Table 14. Components of Premature Termination Counseling

Table 15. Summary of Practice Recommendations

 

List of Case Examples

 

Case Example 1. Collection on a High-Balance Therapy Debt

Case Example 2. Sliding Fee Patient Who Can Afford to Pay

Case Example 3. Lack of Progress in Treatment

Case Example 4. Long Term Treatment; Short-term Termination

Case Example 5. Change in Therapist Status

Case Example 6. You’re Not an Expert at Everything – Competence

 

List of Legal Cases Reviewed

 

Legal Case 1: Lack of Authorization does not Justify Abandonment 

Legal Case 2: Treatment Relationship Established and Suicide

Legal Case 3. Transfer of Care or Abandonment?

Legal Case 4. Patient Boundary Violations

Legal Case 5. Patient Boundary Violations

Legal Case 6. Out of One’s Area of Competence and Transfer of Care

 

 

LEARNING OBJECTIVES

 

 

Explain the difference between termination, pre-mature termination, and abandonment

 

Discuss the four factors that affect termination issues

 

Explain the difference between appropriate and inappropriate premature termination

 

List the common areas of premature therapy termination

 

Discuss practical guides for terminating therapy successfully

 

 

To begin the course, imagine the following not uncommon dilemmas.  All of these relate to actual occurrences which will be addressed in the course.

 

 

Difficult Termination Situations: What Would You Do?

 

 

Accrual of Debt and Collection

 

 

You are referred a patient who has “excellent” insurance. He, and you, expect that the eventual reimbursement will be generous.  You bill the patient’s insurance but the reimbursement is poor (even after appeals).  Due to a number of factors, the patient’s account balance reaches 3000 dollars.  You finally assert to the patient that he is responsible for the balance and must begin making payments. The patient feels he has been “taken advantage of” even though he has the ability to pay.  He pays on the account what he “expects” his responsibility would have been (about 20% of what he owes), but refuses that pay any more.  He continues to schedule therapy appointments and consistently states that he feels his is making progress.  Due to lack of payment you finally tell the patient you cannot schedule further sessions and the account is sent to collections.  He makes a complaint to the state board alleging abandonment and threatens a malpractice action. He also demands that the balance be written off since he feels he has paid enough.  

 

 

Sliding Fee Scale

 

 

You have been seeing a client for about one year on a sliding fee scale basis.  He is paying significantly less than your full fee.  During a treatment session, he announces his plans to go on a trip to Europe (a cruise) that summer with his family.  You immediately begin to question yourself about the fee arrangement: If he can afford a trip to Europe, why can’t he afford my full fee?  Is it my responsibility to keep my fee low so that he could afford such a trip? Had he been entirely straightforward when discussing his financial situation when he began treatment and we first set the fee?  If his finances had improved since then, should he not have told me so and offered to pay my full fee?

 

 

Continuing Inappropriate Treatment

 

 

The patient presented for treatment of a chronic pain problem associated with a work injury.  The treatment was authorized for psychological pain management and cognitive behavioral therapy for the concomitant depression.  This patient also clearly had a Dependent Personality Disorder which, of course, was non-industrial.  Since the insurance continued to allow treatment (and pay for it), the psychologists ended up “treating” the patient for over the 12 years at a frequency of twice per week.  Over the 12 years of treatment, multiple independent medical evaluations by other doctors questioned the necessity of treatment either for the chronic pain or even the personality disorder.  The therapist justified the treatment in terms of providing “supportive psychotherapy” and not wanting to “abandon” the patient since she was more than willing to continue and subjectively reported “it was helping”.

 

 

Abrupt Termination

 

 

The patient is on social security disability and has been in treatment with a therapist for 13 years.  She attempts to stay active including volunteering 20 hours per week.  She has also been consistent in attending her therapy and it is fully covered by her Medicare-MediCal benefits.  Without warning (in a session the patient believed was to be a regular treatment visit), her counselor abruptly terminates her therapy telling her she (the therapist) can no longer be objective.  The therapist stated she discussed the case with the “ethics committee” and a colleague. 

 

 

Termination due to Lack of Progress

 

 

A patient has been in therapy for assertiveness and mild social anxiety for about 6 months (24 sessions).  She has consistently attended her treatment sessions and payment has not been a problem.  She reports being happy with the treatment.  However, the therapist has assigned a number of “homework” assignments, none of which have been completed.  She has also not followed through on any suggestions made by the therapist to help with the problem being treated such as joining a volunteer group, assertiveness cognitive behavioral therapy (CBT) homework exercises, among other things.  The patient appears perfectly happy coming in week after week, and talking about her week.  She reports the best of intentions but even after being confronted about her lack of follow through, nothing changes.  The therapist finally tells the patient that treatment will be terminated due to lack of progress.  The patient states she wants to continue to come in (for therapy as she is defining it) and that, if you terminate, she will report you for abandoning her.

 

 

Terminating a Threatening Patient

 

 

A therapist in private practice treated a patient who initially engaged in some fairly benign boundary violations that were discussed as part of the treatment (trying to contact the therapist repeatedly outside the treatment setting, giving gifts, etc.).  The behavior resolved temporarily but then returned and escalated.   The patient’s behavior escalated including following (stalking) the therapist, circling around her office building, keeping her house under surveillance, making numerous phone calls and sending her  threatening letters.  She was continuing in treatment during this time and the therapist continued to attempt to deal with the behavior as she had done in the past.  The patient’s behavior did not change and she was discharged from treatment.  The patient threatened “abandonment” since the therapist refused to see her again.

 

 

Abrupt Termination due to Role Change

 

 

A mental health intern who finally accrued enough supervised hours, took the state examination, and became licensed to practice independently.  She opened up her own practice and a number of the patients she had been seeing as an intern desired to continue treatment with her at her new solo practice.  However, her previous supervisor accused her of “stealing” patients and informed her that he had already assigned them to his new intern and was in the process of getting them scheduled.  He instructed her to terminate any ongoing therapy with these patients and tell them that their treatment would be transferred to the new intern.  Many of the patients were upset and implied they would register a complaint of “treatment abandonment”.  On the other hand, her supervisor threatened to sue her for damages stemming from “stealing” the patients.

 

 

Treating Out of Area of Competence

 

 

A woman was referred by her surgeon for psychological preparation for surgery and pain management.  The patient was in long term psychotherapy with another psychologist for dissociative disorder, borderline personality, among other things.  The surgery preparation treatment was coordinated with the other psychologist who was supportive of the intervention.  The surgery preparation and post-operative pain management treatment achieved the agreed-upon goals but was challenging (the patient continually attempted to bring in issues related to her long term therapy). At some point, the patient terminated treatment with her psychologist but did not tell the pain management therapist.  As the pain management treatment was coming to a conclusion (having gone on much longer than expected due to the patient’s continued report of problems), she revealed that she had terminated treatment with her other psychologist quite some time ago and wanted to continue in long term treatment with the pain management therapist.  The therapist discussed with the patient that her other problems were outside of his area of expertise.  She “didn’t care” and expressed that she felt “comfortable” with him and the treatment was covered so “not to worry”.  Appropriate discussion and attempted referrals (back to the original psychologist and others) were not successful.  The pain management therapist decided on a termination date to which the patient responded with threats of reporting treatment “abandonment”.

 

 

As discussed by Hilliard (1998), the legal concept of abandonment in medical treatment is as follows:

 

Abandonment is a legal conclusion reached after examining the process of termination and determining what is substantially departed from the accepted professional standards to the detriment of the patient.  In other words, abandonment occurs when a psychiatrist terminates treatment with a patient without regard for the patient’s condition or needs, or without the formulation of an adequate plan for follow-up treatment.  Abandonment can occur through neglect (for example the psychiatrist ignores calls from the patient for appointments or misses appointments without appropriate notice) or through intentional conduct (for example, the psychiatrist affirmatively terminates treatment with the patient during the course of therapy and without a proper referral to another psychiatrist (p. 217)

 

The Beginning: When is a Treatment Relationship Established?

 

Any discussion of termination, pre-mature termination, and abandonment issues really starts with the beginning of the doctor (therapist) – patient (client) relationship.  Since this course is about ending the treatment relationship, we will only briefly discuss the many ways in which a treatment “relationship” may be established. The reader may think that this is an obvious situation – the client calls and schedules an appointment, comes in for the first session, signs the office forms, completes the initial interview, provides payment in some manner, and schedules a follow-up visit before leaving.  Although this is likely the process in the vast majority of practices, a treatment relationship may be created (under the law) even when the therapist is not conceptualizing it in that fashion.  Being aware of these issues is important for ethical, risk management, and quality of care reasons.      

 

The legal basis for establishing the therapist-client relationship is based upon an agreement of the parties.  The law imposes duties when doctors have agreed to treat patients.  As such, an understanding of when this has occurred (under the law) is important.  Any express or implied agreement to treat a patient creates a relationship with corresponding duties and rights for both parties.  It should be noted that legally the doctor’s “duty of care” is not predicated on such things as payment of a fee, the patient signing an office policy form, or “formally” accepting the patient for treatment after two or three evaluation sessions.  The duty to treat derives from the “agreement” by the doctor-therapist to render services to the patient-client and the patient-client’s reliance on that expectation.  The duty owed by the provider is not that the patient will be cured, but rather that the therapist will exercise reasonable care according to the standard of the profession.

 

The law imposes no duty on therapists to accept a patient for treatment.  However, the courts have been quick to recognize a doctor-patient relationship, even when the doctor may assert that no such “formal” treatment relationship had been established.  Some of these situations can be found in Table 1 (adapted from Simon & Shuman, 2007)

 

 

Table 1. When does the Therapist-Client Relationship Begin?

 

 

Online consultation or treatment

Giving advice to prospective patients, friends, and neighbors

Making psychological interpretations during an independent evaluation

Providing advice during an evaluation for a third party (e.g. pre-employment, medical-legal, workers’ compensation, etc.)

One’s role as a supervisor

Having a lengthy telephone conversation with a prospective client

Correspondence by mail, email, texting that includes advice/treatment

Giving a prospective client an appointment

Telling a walk-in prospective patient that they will be seen

Acting as a substitute therapist

Providing treatment during an evaluation

 

 

Some of the possibilities in the Table may seem remote, but one of the critical issues is, “Does the person have the expectation that he or she has been accepted for treatment or is receiving treatment?”  Being clear with an individual, prior to him or her being accepted as a patient, and documenting these interactions is important.  

 

A therapist has the right to accept or reject a new patient for treatment and this is usually decided after an initial interview/evaluation. Although some therapists move directly into a treatment role with the first session, it is highly recommended that the provider always complete some type of initial evaluation with the goal of not only conceptualizing the case, but also of making the decision to accept the patient for treatment.  The initial evaluation is important for many reasons including case formulation; determining the presence of any immediate, emergent, crisis issues; assessing whether the one has the competence to treat the problem; to complete informed consent procedures, among other things.  At the conclusion of the evaluation, the patient should be given some idea of therapist treatment plan, number of session, goals, etc. 

 

In the vast majority of cases, new patients are accepted for treatment.  Even so, it is reasonable practice to inform the patient at the beginning of the initial evaluation that no treatment will be provided at that time.  Some therapists do not utilize a structured one-hour initial evaluation format; rather, they conceptualize the case in terms of an evaluation “phase” that may extend over several sessions.  In either scenario (one session vs. multi-session evaluation), the patient should be explicitly informed about the therapist’s process of evaluation, when the evaluation has been completed, and when a treatment relationship has actually been established.  Otherwise, the therapist may believe that a treatment relationship has not been established when the patient has the expectation that treatment has already been initiated.  Making this very clear to the patient-client from the very beginning is not only quality practice, but important both ethically and from a risk management standpoint.

 

One important point that should be made is the assessment of emergent or crisis issues during the evaluation.  Therapists have no legal obligation to provide emergency care to a person who is not a patient.  However, there are certainly situations in which a therapist will be compelled to do so even when a professional relationship is not established.  Consider the patient who during the initial evaluation expresses suicidal ideation along with a formulated plan and history of attempts.  This situation may not be that unusual given that 8 out of 10 patients who commit suicide have been seen by a physician within 6 months prior to the attempt and 50% have seen a physician within 30 days.  Given the patient population presenting to therapists, the initial evaluation should always include a suicide risk assessment.  If the risk is high and the therapist must intervene (e.g. initiate emergency treatment of some type), the consequences generally fall under the Good Samaritan laws rather than initiation of a treatment relationship.

 

The reasons that a patient may not be accepted for treatment are not the focus of this course but the process of “rejecting” (or a better term “not accepting”) a patient for treatment, along with some common scenarios, are as follows.  Since many individuals may not realize that therapists have the right to pick and choose who they see and under what conditions, the process of not accepting someone for treatment should be handled professionally and respectfully.  Certainly, the therapist does not want the patient to walk away from the experience feeling rejected.  Although a therapist is well within his or her ethical and legal rights not to accept a patient for treatment, managing this effectively and successfully is much more satisfying then proving it so in response to an Ethics Board, State Board, or malpractice complaint.

 

After the evaluation, if a patient is not accepted for treatment, the reasons should be discussed with the patient and appropriate actions taken.  If the reason is that the patient’s problems fall outside the scope of the practitioner’s expertise, this can be explained to the patient and appropriate referrals completed.  Other issues might be financial, boundary issues, “dual relationships” with other patients, role conflicts, etc.

 

Once a treatment or professional relationship is established the therapist is legally required, with all of the duties attached, to provide proper treatment until the relationship is appropriately terminated. The therapist should be attending to termination issues from the very beginning, and throughout the course, of treatment.

 

How well do Therapists Terminate Therapy?

 

There is evidence that therapists, in general, may have trouble with completing “successful termination” (or any termination for that matter).

   

In a recent study (Roe et al., 2006) it was found that 60% of clients in treatment in psychodynamically-oriented private practice settings felt that their therapy either lasted too long or ended too soon.  The authors concluded that, “While there is widespread agreement that an ideal termination of psychotherapy occurs naturally, with an agreement of the timing between therapist and client, our research reveals that more often than not – this does not happen”.

 

In the study, 82 people who were in psychodynamically-oriented psychotherapy for at least 6 months (an average of 2 years), which had recently ended, were assessed regarding the way they experienced the timing of, reasons for and feelings about their psychotherapy termination.

 

The findings are summarized in Table 2.   

 

 

Table 2. Ending Therapy: What Really Happens?

 

 

84% of patients stated that they initiated the termination

 

16% stated that termination was either by mutual agreement or initiated by the therapist

 

40% of the clients felt that the therapy ended at the appropriate time

 

37% felt that the therapy ended earlier than it should have

 

23% felt that the therapy went on for too long

 

The most frequent reasons for termination among those who experienced it as too early were:

 

Financial constraints (34.5%)

Mismatch with therapist (27.6%).

 

Among those clients who experienced therapy as lasting too long, the most frequent reasons were:

 

Feeling uncomfortable toward the therapist (26.3%)

Hope that the treatment would improve (21.1%)

Dependence on the therapist (21.1%)

 

 

In general, clients who reported that termination was on time were more satisfied with their therapy. Factors contributing to positive feelings about termination included perceiving the experience of termination as an expression of independence, reflection of positive aspects of the therapeutic relationship and a reflection of positive gains experienced in therapy.

 

“Whereas clinical lore has consistently suggested that therapists must help clients focus on the emotionally painful aspects of this period and the difficulty in separating, the emerging data suggest that it is equally important to relate to the clients’ positive feelings” said Professor Roe, “Results suggest that clients find terminating psychotherapy at the right time important and yet difficult to achieve, and that clients experience a wide range of feelings, many positive, during the termination phase, which call for a reconceptualization of the role of the therapist during this important phase of psychotherapy.”

 

These results are very important to the current discussion.  Importantly, they underscore that, in the vast majority of cases, the patient terminates the treatment relationship.  This is certainly not consistent with the idea that in most cases therapists assesses their patients, implement a treatment plan, and then bring the process to a successful conclusion with healthy termination. In fact, it appears that this idealized evaluation-treatment-termination process occurred only 16% of the time.  One can only speculate as to why this occurred (although the authors do provide some data).  First, the researchers investigated psychodynamically-oriented practitioners.  It might be assumed that providers who utilize a more structured approach, such as cognitive behavioral interventions, would show different results. 

 

The data are a little difficult to assess relative to possible abandonment.  The study states that 37% felt that the therapy ended earlier than it should have but does not discuss how termination was completed in detail (by the therapist, by the patient, reasons across each group).  In addition, as we shall see, pre-mature termination (e.g. due to financial issues, boundary issues, etc.) is not the same as abandonment.  This differentiation is a critical concept that will be discussed in detail subsequently.

 

Of the patient-group who terminated treatment, the most common reasons were financial (34.5%) and mismatch with therapist (27.6%).  In terms of quality of treatment, one might suppose that these issues could have been managed more effectively by the therapist.  For instance, frank and open discussions about the financial commitment to undergo longer term therapy early in the treatment relationship might have helped the therapist plan a more effective and time-limited intervention given the financial resources of the patient.  It also seems that the patient feeling mismatched with the therapist might be discovered long before 6 months (the minimum amount of treatment time for inclusion in this study). Therapists can learn a lesson about begin cognizant of these issues since this study suggests they are occurring more frequently than most realize.

 

As can be seen in the Table, among those clients who experienced therapy as lasting too long, the most frequent reasons were: feeling uncomfortable toward the therapist (26.3%); hope that the treatment would improve (21.1%); and, dependence on the therapist (21.1%).  In all of these categories “successful” termination might have been possible if the therapist had been aware of these issues.  In the therapeutic relationship, the provider often has a great deal of power and influence over the client.  This differential in power has the potential for promoting patient improvement (the way things are supposed to work) or patient abuse.  If a patient feels uncomfortable with the therapist, stays in treatment hoping for success when it does not occur, or feels too dependent on the therapist, there is certainly the implication that the therapists missed something in terms of ongoing assessment and intervention.  In any of these categories, we can safely assume that if the situation were handled correctly, a more successful outcome might have been obtained in many of the cases. 

 

Definitions

 

Any discussion of therapy termination and abandonment must necessarily include a review of definitions.  As the reader shall see, this review will underscore there is no consensus on a definition of “abandonment”.  Some of the definitions and concepts of termination, premature termination and abandonment can be found in the following Tables.    

 

Termination (Successful)

 

Psychotherapy termination may be conceptualized as an intentional process that occurs over time when a client has achieved most of the goals of treatment, and/or when psychotherapy must end for other reasons (Vasquez et al., 2008, p. 653).

 

 

Table 3. Successful Therapy Termination

 

 

Termination is the ethically and clinically appropriate process by which a professional relationship has ended (Younggren and Gottlieb, 2008, p. 500).

 

Termination refers to the ending process of psychotherapy.  The termination phase of psychotherapy is the culmination of the psychotherapy experience, one that will build on gains made in treatment and enable patients to function effectively without the active assistance of the psychotherapist (Hill, 2005).

 

Successful termination is determined by mutual agreement among the parties involved that the goals of psychotherapy have been accomplished and/or no longer require attention.  In successful termination, the consumer is a full participant, understands the decision, agrees with the reasons for ending psychotherapy, and is satisfied with the outcome (Younggren & Gottlieb, 2008, p. 501).

 

 

Appropriate termination helps to avoid the betrayal of trust and abuse of power, prevents harm, and conveys caring which is critical to ethical treatment.  The termination of psychotherapy should be part of the treatment plan from the very beginning.  As shall be discussed, the data suggests that actual termination from therapy rarely occurs in a planned fashion, as part of the treatment process.  Consider the following which occurs in the real world:

 

 

Table 4. Starting and Ending Therapy: The Real World

 

 

Many patients don’t really start treatment - 33% of patients do not return to psychotherapy after 1-2 sessions;

 

Only 10% of patients complete more than 20 sessions;

 

30-57% of patients drop out prematurely;

 

In many cases, patients simply leave treatment rather than termination due to any action on the part of the therapist

 

 

Premature Termination

 

Premature termination can be appropriate (ethical) or inappropriate (unethical and negligent).  In all cases of premature termination, the treatment relationship is ended prior to what was planned and before successful resolution of the problem(s) that were the focus of the intervention.  Appropriate and ethical premature termination may be due to such things as reimbursement limitations or a change in the patient’s financial situation, a lack of treatment progress, patient nonadherence (noncompliance), boundary violations on the part of the patient, or a change in the therapist’s employment situation.  Inappropriate premature termination always occurs due to the inappropriate actions (or inaction) of the therapist and includes such things as establishment of a dual relationship (e.g. business dealings outside of therapy), romantic involvement, and not managing premature termination, even when indicated, in an appropriate manner.  This often constitutes abandonment.   

 

 

Table 5.  Premature Termination: What is it?

 

 

Premature termination entails the ending of treatment without the sense of psychological closure that comes with having resolved problems or at least understanding the reasons for ending psychotherapy.  (Younggren and Gottlieb, 2008, p. 501)

 

Premature termination includes many types.  This area represents one of increased risk which varies depending on the type (all of which will be discussed).

 

Depending on the circumstances, premature termination may or may not represent abandonment.

 

 

Abandonment

 

Abandonment is an inappropriate premature termination and/or when a patient’s ongoing treatment needs are not adequately addressed by the psychotherapist, either when treatment ends or during the course of treatment due to unavailability (Vasquez et al., 2008, p. 654).  Whereas termination is the ethically and clinically appropriate process by which a professional relationship has ended, abandonment is the absence of this process (Younggren and Gottlieb, 2008, p. 500).  As we will discuss, actual psychotherapy malpractice claims of abandonment are rare.  However, the data may not be telling the whole story.  First, the frequency of ethics and state board complaints related to abandonment is not clear.  Although practitioners are certainly fearful of a malpractice action, a board complaint can be equally as stressful.  Both accusations (malpractice, board complaint) require the practitioner to initiate a defense.  

 

 

Table 6. Abandonment: Never OK

 

 

Abandonment is an inappropriate termination and/or when a client’s ongoing treatment needs are not adequately addressed by the psychotherapist, either when treatment ends or during the course of treatment due to unavailability (Vasquez et al., 2008, p. 654).

 

Abandonment can occur when treatment is terminated at a time when the patient is psychological vulnerable, at risk, or in a time of crisis (Knapp & VandeCreek, 2006).  In this situation, pre-mature termination may be appropriate, but the timing is not.

 

Inappropriate termination, possibly crossing over to abandonment, often occurs when the unexpected or unplanned happens, ending treatment.  In these cases, the client is willing to continue treatment, but for some reason the therapist cannot or will not continue the professional relationship.

 

Abandonment is a legal conclusion reached after examining the process of termination and determining what is substantially departed from the accepted professional standards to the detriment of the patient (Hillard, 1998, p. 217).

 

 

The Ethical Codes

 

All of the ethical codes relating to the provision of mental health treatment address the issues of abandonment.  Table 7 lists the links to the full version of the various codes.

 

 

Table 7. Ethical Codes

 

 

American Psychological Association (APA)

 

National Association of Social Workers (NASW)

 

Clinical Social Work Association (CSWA)

 

American Association for Marriage and Family Therapy (AAMFT)

 

American Counseling Association (ACA)

 

National Board for Certified Counselors (NBCC)

 

California Association of Marriage and Family Therapists (CAMFT)

 

 

Table 8 lists the sections of some of the ethical codes that specifically relate to termination of services and abandonment.  Many other sections of these ethical codes also apply both in general (e.g. informed consent) and related to specific situations (e.g. boundaries, competence, etc.).  This will be discussed subsequently as they relate to specific situations. 

 

 

Table 8. Ethical Codes Related to Termination and Abandonment

 

 

APA CODE OF ETHICS

 

The primary sections relevant to termination and abandonment are found in the concluding section of the APA ethics code entitled “Terminating Therapy” (Standard 10.10). This standard states the following:

 

(a) Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continuing service.

 

(b) Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship.

 

(c) Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pre-termination counseling and suggest alternative service providers as appropriate.

 

Standard 10.09, Interruption of Therapy, states:

 

When entering into employment or contractual relationships, psychologists make reasonable efforts to provide for orderly and appropriate resolution of responsibility for client/patient care in the event that the employment or contractual relationship ends, with paramount consideration given to the welfare of the client/patient.

 

Standard 3.12, Interruption of Psychological Services:

 

Unless otherwise covered by contract, psychologists make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted by factors such as the psychologist’s illness, death, unavailability, relocation, or retirement or by the client’s/patient’s relocation or financial limitations.

 

Standard 10.06, Sexual Intimacies With Relatives or Significant Others of Current Therapy Clients/Patients: 


Psychologists do not engage in sexual intimacies with individuals they know to be close relatives, guardians, or significant others of current clients/patients. Psychologists do not terminate therapy to circumvent this standard.

 

10.08 Sexual Intimacies with Former Therapy Clients/Patients 


(a) Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy.

 

(b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including (1) the amount of time that has passed since therapy terminated; (2) the nature, duration, and intensity of the therapy; (3) the circumstances of termination; (4) the client's/patient's personal history; (5) the client's/patient's current mental status; (6) the likelihood of adverse impact on the client/patient; and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a posttermination sexual or romantic relationship with the client/patient.

 

Standard 2.06, Personal Problems and Conflicts:

 
(a) Psychologists refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner.

 

(b) When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties.

 

NASW CODE OF ETHICS

 

1.16 Termination of Services

 

(a) Social workers should terminate services to clients and professional relationships with them when such services and relationships are no longer required or no longer serve the clients’ needs or interests.

 

(b) Social workers should take reasonable steps to avoid abandoning clients who are still in need of services. Social workers should withdraw services precipitously only under unusual circumstances, giving careful consideration to all factors in the situation and taking care to minimize possible adverse effects. Social workers should assist in making appropriate arrangements for continuation of services when necessary.

 

(c) Social workers in fee-­for-­service settings may terminate services to clients who are not paying an overdue balance if the financial contractual arrangements have been made clear to the client, if the client does not pose an imminent danger to self or others, and if the clinical and other consequences of the current nonpayment have been addressed and discussed with the client.

 

(d) Social workers should not terminate services to pursue a social, financial, or sexual relationship with a client.

 

(e) Social workers who anticipate the termination or interruption of services to clients should notify clients promptly and seek the transfer, referral, or continuation of services in relation to the clients’ needs and preferences.

 

(f) Social workers who are leaving an employment setting should inform clients of appropriate options for the continuation of services and of the benefits and risks of the options.

 

ACA CODE OF ETHICS

 

A.11. Termination and Referral

 

A.11.a. Abandonment Prohibited

Counselors do not abandon or neglect clients in counseling. Counselors assist in making appropriate arrangements for the continuation of treatment, when necessary, during interruptions such as vacations, illness, and following termination.

 

A.11.b. Inability to Assist Clients

If counselors determine an inability to be of professional assistance to clients, they avoid entering or continuing counseling relationships. Counselors are knowledgeable about culturally and clinically appropriate referral resources and suggest these alternatives. If clients decline the suggested referrals, counselors should discontinue the relationship.

 

A.11.c. Appropriate Termination

Counselors terminate a counseling relationship when it becomes reasonably apparent that the client no longer needs assistance, is not likely to benefit, or is being harmed by continued counseling. Counselors may terminate counseling when in jeopardy of harm by the client, or another person with whom the client has a relationship, or when clients do not pay fees as agreed upon. Counselors provide pre-termination counseling and recommend other service providers when necessary.

 

A.11.d. Appropriate Transfer of Services

When counselors transfer or refer clients to other practitioners, they ensure that appropriate clinical and administrative processes are completed and open communication is maintained with both clients and practitioners.

 

NBCC CODE OF ETHICS 

Section A: General 


10. Sexual intimacy with clients is unethical. Certified counselors will not be sexually, physically, or romantically intimate with clients, and they will not engage in sexual, physical, or romantic intimacy with clients within a minimum of two years after terminating the counseling relationship.

 

Section B: Counseling Relationship 

9. Certified counselors who have an administrative, supervisory and/or evaluative relationship with individuals seeking counseling services must not serve as the counselor and should refer the individuals to other professionals. Exceptions are made only in instances where an individual's situation warrants counseling intervention and another alternative is unavailable. Dual relationships that might impair the certified counselor's objectivity and professional judgment must be avoided and/or the counseling relationship terminated through referral to a competent professional. 


10. When certified counselors determine an inability to be of professional assistance to a potential or existing client, they must, respectively, not initiate the counseling relationship or immediately terminate the relationship. In either event, the certified counselor must suggest appropriate alternatives. Certified counselors must be knowledgeable about referral resources so that a satisfactory referral can be initiated. In the event that the client declines a suggested referral, the certified counselor is not obligated to continue the relationship.

 

AAMFT CODE OF ETHICS

 

1.9 Marriage and family therapists continue therapeutic relationships only so long as it is reasonably clear that clients are benefiting from the relationship.

 

1.10 Marriage and family therapists assist persons in obtaining other therapeutic services if the therapist is unable or unwilling, for appropriate reasons, to provide professional help.

 

1.11 Marriage and family therapists do not abandon or neglect clients in treatment without making reasonable arrangements for the continuation of such treatment.

 

1.5 Sexual intimacy with former clients is likely to be harmful and is therefore prohibited for two years following the termination of therapy or last professional contact. In an effort to avoid exploiting the trust and dependency of clients, marriage and family therapists should not engage in sexual intimacy with former clients after the two years following termination or last professional contact. Should therapists engage in sexual intimacy with former clients following two years after termination or last professional contact, the burden shifts to the therapist to demonstrate that there has been no exploitation or injury to the former client or to the client's immediate family.

 

 

Ethics Codes Struggle with the Issue of Abandonment

 

As discussed by Younggren and Gottlieb (2008), confusion about psychotherapy termination versus abandonment have been an issue in the field for at least 50 years.  Even now, some of the ethics codes do not specifically mention the word “abandonment.”  As the authors discuss, this confusion related to these concepts is mirrored in the various APA Ethical Codes.  Concern about inappropriate termination of a patient (abandonment) was first addressed in the Ethical Standards of Psychologists in 1953.  In those standards, there was the requirement of patient concurrence in the decision to end therapy or to make a referral even when the provider felt s/he was not competent to continue the treatment (presumably to avoid abandonment since patient concurrence was sought).  However, unilateral discharge from treatment was allowed if the patient would not accept the referral even after the psychologist “insisted”.  As the authors point out, there is an inherent contradiction in having to obtain patient permission for the psychologist to unilaterally terminate the professional relationship. This ambiguity continued in various revisions for 40 years.  There was no clear guidance about how to terminate therapy while avoiding abandonment. 

 

In the Ethical Standards Revision in 1992 the term “abandonment” was used specifically.  Standard 4.09(a) stated, “Psychologists do not abandon patients or clients” (as cited in Younggren and Gottlieb, 2008, p. 499).  The following sections addressed termination of the professional relationship.

 

In the 2002 Ethical Code Revision, the standard regarding abandonment was removed and a statement added that protected psychologists relative to termination of a patient after being threatened.  In the 2002 revision, there are more clear guidelines relative to pre-termination issues including ending a non-productive relationship while providing appropriate referrals (including problems that occur due to insurance managed care plans).   

 

Legal Aspects of Abandonment

 

Failure to properly withdraw from a professional therapy relationship may expose the therapist to liability.  Malpractice cases have established damages including such things as wrongful death, permanent physical incapacity, pain and suffering, mental anguish, an unnecessary hospitalization, and/or excessive hospital bills. Before discussing the specific areas of premature termination, including potential abandonment, it is useful to conceptualize factors that influence this process.   

 

Factors Influencing Pre-Treatment Termination

 

In the best case scenario, and the goals of a professional therapy relationship from the beginning is completion of the following process: 

 

Evaluation and case formulation

 

Informed consent in which the patient is “informed” and understands the treatment plan proposed, how it will be implemented, the anticipated course of treatment, the therapist and client’s responsibility in the professional relationship, management of unanticipated issues, and termination

 

Implementation of the treatment with appropriate monitoring of goals

 

Completion of the successful termination process

 

As we have seen, the real-world data suggests that this process rarely goes this smoothly (See Table 2).  Although the data relative to these issues may be less than ideal, it has been established that, in many cases, the treatment results in premature termination (either therapist or patient initiated, or by mutual agreement).  There are at least four factors that affect termination issues:  The therapist, the type of treatment, the client, and extra-therapy variables (See Vasquez et al., 2008; Younggren and Gottlieb, 2008).

 

Provider-Therapist Variables

 

Therapist variables that can affect pre-mature termination includes such things as distress/impairment, a lack of competence, dual/multiple relationships, countertransference, crossing boundaries, loss of objectivity, among other things. 

 

Patient Variables

 

Another factor that can affect premature termination is patient behavior.  In the most extreme case, that of threatening the therapist, the treatment can be abruptly ended without any type of pre-termination process.  This is explicitly addressed in the APA and ACA Ethics and implied in the NASW Code. In this situation, the therapist would certainly not be accused of abandonment.     

 

Aside from this extreme occurrence, there are many other situations in which a therapist is ethically justified in terminating the professional relationship prior to its successful conclusion.  Examples include becoming aware of therapist-client mismatch, a lack of patient progress in treatment, nonadherence to the treatment regimen, a lack of expertise in the problem area, financial issues including lack of payment, etc.

 

Therapists are often fearful that any treatment termination prior to the client’s desire to discontinue the therapy, will likely constitute abandonment.  As we shall discuss, there are situations in which it is clearly unethical to continue treatment even when the patient desires to do so.  Therapists should remember that the treatment is a two-way relationship with contractual responsibilities falling on both parties, the therapist AND the patient.  The responsibilities of the patient are usually discussed during the informed consent process early in treatment, including written documentation.  The “duties” or responsibility of the patient include such things as paying for the services (either directly or indirectly), compliance with treatment recommendations, maintaining appropriate boundaries, and participating in the therapy.      

 

Type of Treatment

 

The type of treatment that the parties (therapist and patient) have agreed upon can also influence the termination process.  For instance, if the therapist is a cognitive behavioral practitioner specializing in the treatment of phobias, a very specific treatment plan may be proposed at the outset (e.g. 10-20 sessions, homework exercises, established and definable goals, etc.).  If the treatment does not progress per plan, the patient continues to attempt to focus on other areas in therapy (e.g. relationship problems), or expresses a dislike for the structure and requests a less structured approach and is longer term, then premature termination may certainly be warranted. 

 

Extra-therapy Variables

 

These factors include things that occur outside of the actual therapeutic relationship and are usually unpredictable.  They might include a sudden change in the patient’s financial situation, a managed care company unexpectedly not approving additional treatment, a change in the patient’s insurance plan due to changing jobs, the therapist changing jobs or moving, etc.  A proper informed consent procedure at the beginning of treatment can attempt to predict the possibility of these occurrences and how they might be handled if necessary.

 

SUCCESSFUL TERMINATION

 

Our discussion of successful termination will be brief since the focus of the course is “difficult termination issues.”  However, if a therapist prepares for a “successful” termination, then problems related to difficult terminations are minimized or prevented.  It is also consistent with best-practices.

 

Even though there is a large body of literature related to the psychotherapy termination process, and our graduate training typically covers how to do it properly, the research suggests that it rarely occurs in the real world.  It may be more common is a highly structured CBT approach (e.g. 10 sessions for chronic pain whose content is pre-determined) but is less frequent in psychodynamic treatment. As discussed, the research demonstrates that 33% of patients do not return to psychotherapy after 1-2 sessions and only 10% compete more than 20 sessions.  This lack of “successful” completion of psychotherapy is likely due to many factors, but the primary of which is financial (lack of reimbursement, approval for only a few sessions, etc.).

 

As reviewed by Fisher (2011), it is recommended that therapists discuss termination at three stages of treatment: the intake, during treatment, when actually ending the intervention (See also Vasquez et al., 2008).  The nature and content of these discussions depends on many variables including the therapist, the patient, the type of therapy, and the quality of the treatment process. The responsibility for these discussions lies solely with the therapist.  The initial intake process is probably the most important time to review and discuss termination issues, including the patient’s responsibility as a contractual partner in the treatment relationship.  As discussed by Younggren and Gottlieb (2008), Younggren (2011), and others (Vasquez et al., 2008), the patient does have responsibilities in the treatment relationship including (but not limited to), showing up for treatment, adherence to recommendation, paying for services, not violating boundary issues, and being involved in the treatment process. These responsibilities, and reasons for premature termination, should be provided in a written format, although this is rarely done (Davis and Younggren, 2009).

 

I think the most important “take-home” message from this literature is that termination of therapy is an issue that must be addressed and monitored by the therapist throughout treatment (beginning with the first session).  This is often either forgotten or ignored by most therapists.  Termination issues are typically addressed only at the end of a successful course of treatment (almost as an afterthought), or in response to a “crisis” precipitated by the patient and as part of pre-mature termination (e.g. no-show for one or more sessions, dropping out of therapy, an adverse UR decision, lack of payment, a boundary violation, etc.).          

 

AREAS OF PREMATURE TERMINATION

 

Financial and Reimbursement Issues

 

For many therapists, addressing issues related to being paid for services may be uncomfortable and hence either minimized or avoided altogether. As discussed by Koocher and Keith-Spiegel (1998), because we are in a helping profession, there is a sense that discussing or focusing on money issues is “crass or pecuniary” (p. 234). Of course, not addressing money issues in an upfront and clear manner from the beginning of treatment increases the potential for miscommunication, misunderstanding and conflicts.    

 

Under the law and ethical codes, therapists have a right to be paid for services.  However, conflicts over billing, payment for services, and collections, are thought to be among the most common catalysts for triggering a Board complaint or malpractice suit (even if the complaint is formulated under a different reason).  This “sensitive” area is well known to therapists and may induce them to avoid the conflict by continuing to treat even though the patient does not have the financial resources for payment (to avoiding “abandoning” the patient while the amount owed increases week to week). 

 

In general, mental health treatment is paid for (all or part) in one of 4 ways: the patient pays for the services 100%; treatment is covered all or part under health benefits (third party payor) and this usually involves authorization to treat; paid for by some other employee benefit or public funds; and, paid for by another financially responsible party (e.g. parents, grandparents or family member paying for the therapy). Each of these situations comes with its own unique ethical, treatment, and risk-management issues that should be addressed from the beginning of therapy.

 

As documented in the various Ethical Codes, it is not unethical to terminate a patient who cannot pay.  This is specifically addressed in the various ethical codes as presented in Table 9.

 

 

Table 9. Example Ethical Codes Related to Financial Issues and Treatment

 

 

APA

 

6.04 Fees and Financial Arrangements

(a) As early as is feasible in a professional or scientific relationship, psychologists and recipients of psychological services reach an agreement specifying compensation and billing arrangements.

 

(b) Psychologists' fee practices are consistent with law.

 

(c) Psychologists do not misrepresent their fees.

 

(d) If limitations to services can be anticipated because of limitations in financing, this is discussed with the recipient of services as early as is feasible. (See also Standards 10.09, Interruption of Therapy, and 10.10, Terminating Therapy.)

 

(e) If the recipient of services does not pay for services as agreed, and if psychologists intend to use collection agencies or legal measures to collect the fees, psychologists first inform the person that such measures will be taken and provide that person an opportunity to make prompt payment. (See also Standards 4.05, Disclosures; 6.03, Withholding Records for Nonpayment; and10.01, Informed Consent to Therapy.)

 

NASW

 

(1.13.a)  When setting fees, social workers should ensure that the fees are fair, reasonable, and commensurate with the services performed. Consideration should be given to clients’ ability to pay.

 

(1.16.c)  Social workers in fee-­for-­service settings may terminate services to clients who are not paying an overdue balance if the financial contractual arrangements have been made clear to the client, if the client does not pose an imminent danger to self or others, and if the clinical and other consequences of the current nonpayment have been addressed and discussed with the client (1.16.c).

 

ACA

 

(A.10.c.)  If counselors intend to use collection agencies or take legal measures to collect fees from clients who do not pay for services as agreed upon, they first inform clients of intended actions and offer clients the opportunity to make payment.

 

(A.11.c.) Counselors may terminate counseling when in jeopardy of harm by the client, or another person with whom the client has a relationship, or when clients do not pay fees as agreed upon. Counselors provide pre-termination counseling and recommend other service providers when necessary.

 

AAMFT

 

Marriage and family therapists make financial arrangements with clients, third-party payors, and supervisees that are reasonably understandable and conform to accepted professional practices.

 

7.2 Prior to entering into the therapeutic or supervisory relationship, marriage and family therapists clearly disclose and explain to clients and supervisees: (a) all financial arrangements and fees related to professional services, including charges for canceled or missed appointments; (b) the use of collection agencies or legal measures for nonpayment; and (c) the procedure for obtaining payment from the client, to the extent allowed by law, if payment is denied by the third-party payor. Once services have begun, therapists provide reasonable notice of any changes in fees or other charges.

 

7.3 Marriage and family therapists give reasonable notice to clients with unpaid balances of their intent to seek collection by agency or legal recourse. When such action is taken, therapists will not disclose clinical information.

 

 

As can be seen, it is not unethical for a therapist to terminate a patient due to a lack of payment of fees (see also Knapp and VandeCreek, 2006; Treloar, 2010; and the other resources-references).  This includes all reasons such as a change in the patient’s ability to pay, loss of insurance coverage, the patient simply choosing to stop paying on an account while continuing to come for treatment, etc.  If done in a proper manner, this constitutes an appropriate pre-mature termination.  However, there are a couple of important issues relative to termination of therapy for non-payment of fees.  First, as with any pre-mature treatment termination, it must not be done if the patient is in a state of crisis.  Thus, even if premature termination is appropriate (e.g. inability to pay), the timing and method are important or it could constitute abandonment.  Almost regardless of the reason (aside from threatening the therapist), a patient should not be terminated when in a state of crisis.  Rather, premature terminations sessions should focus on stabilizing the patient’s condition and setting up appropriate resources (e.g. referral, community based programs, etc.).

 

Second, all of the ethical codes suggest taking steps to avoid the problem altogether.   This includes clearly outlining (in writing) and discussing the financial arrangements at the beginning of treatment. This should be done as part of the informed consent process.  If a problem with finances occurs, it should be discussed with the patient relative to options, etc.  For instance, if a balance due is getting high, this could be discussed and a payment plan or opportunity to pay offered. 

 

Third, the therapist should be aware of the patient’s insurance plan and take this into account in terms of treatment planning, accepting the patient for treatment, etc.  For instance, if the therapist knows that the patient’s plan only allow 10 visits per year, this should be discussed with the patient and taken into account in terms of treatment planning.

 

It is not technically unethical to use a collection agency, but a therapist is wise to try and avoid allowing the financial situation to reach that point.  Collection of past due fees is thought to be one of most common “triggers” for a Board complaint against a therapist.  The complaint is not usually related to the payment agreement directly but some other issue is focused on after payment is sought (e.g. breaking confidentiality by involving a collection agency, lack of progress in treatment, etc.).  The complaint may be without foundation, but it still must be defended against by the therapist.  If the therapist chooses to use a collection services, this must be specifically outlined in the original informed consent paperwork (office policies) signed by the patient.  Also, before turning the account over to collection, the patient should be given an opportunity to pay the bill or make some reasonable arrangement for payment.   The therapist should release the minimal amount of information to the collection agency (See Case Example 1).

 

 

Case Example 1. Collection on a High-Balance Therapy Debt

 

 

As a courtesy to your patients, you bill their insurance, accept credit cards, and send statements each month to collect the co-pay (similar to a traditional medical practice).  You are referred a patient who is an upper management executive with a large corporation.  You are told by the referring physician that this is one of his “VIP patients” and to please “treat him well.” At the initial evaluation, your patient tells you that he has excellent insurance coverage through his company.  He discusses that his medical treatment has always reimbursed at 80% of allowable charges and these are very high (essentially what his doctor charges).  Given his SES status, his high level position with his employer, his “excellent” insurance coverage and the message from the referral source, you expect that this will be one of the few cases in which reimbursement will not be an issue and you can just focus on treatment.  In fact, in some ways, you are hesitant (embarrassed?) to bring up financial issues given all of these factors.  You forego your usual discussion of financial issues and don’t implement your normal payment policies (e.g. payment on account every month, not allowing large balances to accrue, carefully checking insurance coverage prior to initiating treatment, etc.).   

 

You initiate treatment and begin billing his insurance.  The treatment is going well.  The patient is motivated, consistent and follows through on your recommendation.  Working with him is certainly professionally rewarding.   Your statements to patients are sent out monthly.  The patient has not made a payment on the account stating that he will simply pay his share in full once the insurance payments begin.  You submit the insurance billing expecting no problems, especially based on what the patient has discussed with you.  The first EOB (explanation of benefits) is received a little over 60 days from the patient’s first visit.  To your dismay, the claims were actually forwarded to another insurance company that handles mental health benefits for the company (e.g., a “carve-out”).  The allowable is 100 dollars per visit, of which the company pays 50%.  This is far less than what you normally charge (and there is a limit of 15 visits per year).  By this time, the patient has completed the initial evaluation, psychological testing, and 10 treatment sessions.  His total account balance is close to 2,000 dollars.  

 

The reimbursement issue is discussed with the patient and he assures you that it must be some mistake.  He requests that the charge(s) be appealed and re-submitted.  He doesn’t know anything about another company handling mental health claims, but again asserts that he has excellent coverage and it shouldn’t be a problem.  You are not particularly comfortable with “these money issues” and, relative to the treatment, things are going very well.  Due to your reluctance to discuss the money issue, along with his job position and the referral source (one of your best), you decide to appeal and re-bill without addressing the problem directly with the patient.

 

You appeal and re-bill the charges.  The insurance company substantiates that the original payment was correct and no further payment is indicated or will be provided.  By this time, the patient’s account balance is approaching 3,000 dollars (of which you determine the insurance reimbursement will be 600 dollars).  So far, the patient has not made any payments on his account continuing to assert that his insurance will pay a significant portion of the bill and he will cover the co-pay at that time.  At this point, you feel you have to address the issue.

 

The financial discussion with the patient does not go well.  The patient feels that these issues should have been presented to him early in the treatment relationship.  He states that he could have no way of knowing that psychotherapy treatment was covered differently than his medical treatment, and that he should not really be held responsible for the entire amount.  He also tells you that his doctor has always accepted the “allowable” after which he has been consistent in making the co-pay relative to this amount.  He suggests that you should do the same (accept the “allowable” after which he will bring his account current by making the “co-pay”). You discuss with him that you do not participate in the mental health insurance company’s MPN (managed provide network) and you are not obligated to accept the allowable as a charge in full.  You assert to the patient that he is responsible for the balance.

 

Being a business person, the patient feels he is being “taken advantage of” even though he has the ability to pay.  In fact, he asserts that you are pursuing this money because he is affluent and that “with any other patient, you would accept what the insurance company has determined to be a reasonable fee.”  He pays his co-pay based on the allowable and payments made by the carve-out company (his EOBs have a section that shows the patient payment due assuming the doctor accepts their allowable, which you do not).  Aside from the payment issues, he is very pleased with the treatment and desires to continue.  He schedules weekly appointments for the next 6 weeks.  After careful consideration, you have one final visit with the patient outlining that future treatment will be billed at your usual rate.  You will continue to bill insurance, but will not schedule any further sessions until the account is make current.

 

He subsequently cancels all future appointments.  He makes a payment on his account consistent with the co-pay “due” on the allowable and payments made by the carve-out company (from the EOB).  This leaves a significant balance which the patient states he will not pay and is “not responsible for….”  After multiple billing cycles without further payment, the patient is turned over to collection (after being warned, etc.). In response, you receive a letter from the patient’s attorney demanding that the collection proceedings be ceased, the remaining balance “written-off”, and that the patient had actually been abandoned by you, the therapist.  The attorney letter makes a number of threats including reporting you to the ethics board, state board, and possible malpractice action.  The patient also left a message on your answering machine reporting that he has complained to the referring doctor about your “financial” and billing policies, and that he felt “abandoned” by you.      

 

 

In both of these cases (Case Example 1 and 2), the therapist was clearly trying to be helpful, caring and “nice” in providing services to the patient.  However, in doing so, problems occurred which could have been prevented.  As discussed throughout this course, termination begins with the first session or even before (scheduling the patient for the first session).  Written informed consent (office policy) should be part of this initial process.  These materials should obtain clear information about payment for services.  If these policies are amended or changed in certain cases (e.g. Case Example 2: sliding fee), the details of the agreed-upon financial arrangement should be carefully documented. 

 

Related to informed consent, it is also recommended that the therapist stand by his or her office policy and implement it on a consistent basis.  In the first case example related to reimbursement, the therapist made several poor choices in an attempt to be accommodating to the patient and the referral source.  Patients appreciate being given accurate information about reimbursement up front even though the therapist may be uncomfortable with these issues.

 

 

Case Example 2.  Sliding Fee Patient Who Can Afford to Pay

 

 

You have been seeing a client for about one year on a sliding fee scale basis.  He is paying significantly less than your full fee.  During a treatment session, he announces his plans to go on a trip to Europe that summer (on a cruise) with his family.  You immediately begin to question yourself about the fee arrangement: If he can afford a trip to Europe, why can’t he afford my full fee?  Is it my responsibility to keep my fee low so that he could afford such a trip? Had he been entirely straightforward when discussing his financial situation when he began treatment and we first set the fee?  If his finances had improved since then, should he have told me so and offered to pay my full fee?

 

After struggling with the issue for quite some time, you decide to address the issue with the patient.  You express your opinion that, if he is able to afford a trip to Europe with his family, then he should be able to pay your full fee.  You discuss your intention to charge him your full fee for continued treatment.  He states that his financial situation is unchanged, that he still is financially distressed (under the same terms that you accepted him for treatment originally), and he demands to continue to treatment under the same contract.   He reminds you that he has paid the agreed-upon fee at each visit, has complied with your treatment recommendation (e.g. homework assignments, etc.), and feels that he is continuing to make progress. 

 

You decide to stay with your decision to require payment of your full fee for future treatment.  He does not show for his next appointment and you receive notification from your state board that he has filed a complaint of abandonment contending that, due to your change in the fee agreement in violation of the original treatment agreement, you have, in essence, abandoned him.  The patient also contends that if he had known you might change the fee structure later (after he has a positive professional relationship), he would never have started treatment. Rather, he would have found a therapist who would “set a fee I could afford and stick with it….not abandoning me just for money…..”

 

 

Knapp and VandeCreek (2006) and others suggest that a “pay-as-you-go” policy avoids problems related to debt accrual.  However, many patients (especially those with insurance) want to pay after insurance has paid its share.  If you need to terminate a patient for non-payment of fees, the following important guidelines will help avoid any issue of abandonment. 

 

Written informed consent. Outline all of your financial policies in your initial informed consent and written office policy documents (have the patients sign the agreement and give them a copy).  This should include how billing third-party payors will be handled, appealing denial or reductions in third-party payments, policies for carrying a balance, expected payment of co-pay, procedures if the financial situation changes, use of a collection agency, charging interest on past-due balances, use of credit cards, sliding fee scale agreement if appropriate, etc.  If you submit insurance for patients consider including in your office policy how many times you will submit a bill for a particular visit, how many times you will appeal an unexpected reduction in payment (if at all), if you charge for your time in submitting appeals, etc.   

 

Terminate patient when not in crisis. If it becomes necessary to discharge a patient from treatment for lack of payment, it must be done at a time when the patient is not in crisis.  This is consistent with quality and ethical care.  If a patient is terminated while in crisis, it might reasonably be considered abandonment.

 

Other resources provided to the patient. As part of the pre-mature termination, provide the patient with other resources.  This might include therapists or clinics that charge a lower fee (or do pro bono work relative to the case), community resources and support groups, etc.  Document that these resources have been provided.

 

Prevention.  Prevention of the situation is the best solution.  One should never let a patient accrue a large balance due. 

 

From the beginning of treatment, the therapist’s “money” policies should be clearly outlined as part of completing informed consent.  This should include (but not be limited to) the nature of the services offered, the fees charged, the mode of payment used, how insurance or third-party reimbursement will be managed, what will happen if the financial situation changes, charges for missed appointments, the specifics of any sliding fee arrangement, etc.  The monetary issues should be reviewed not only at the beginning of therapy but also throughout treatment. 

 

In my practice, I have found it useful to begin the informed consent process even before the first visit.  As part of the initial scheduling telephone call, basic demographic information is collected along with insurance coverage.  We also discuss the cost of the first visit and treatment sessions.  We view the first evaluation session as a time when the provider and the patient are deciding if entering into a treatment relationship is appropriate and agreeable to both parties.  As such, there is certainly the chance that I will determine that the patient is not an appropriate candidate for treatment with me (based on a number of issues) or, alternatively, the patient desires to pursue treatment elsewhere.  In either case, the patient will be given appropriate resources including referrals, and s/he will not be seen again.  Collecting a balance due from a patient who has undergone an initial evaluation (if not done at the time of the visit) and will not be seen again is a high risk situation for problems collecting payment beyond the insurance reimbursement.     

 

To avoid any accrual of debt related to the initial visit that might be a problem, we require that the first session be paid in full at the time of the evaluation.  We then bill the insurance for the patient and apply any payment to the future balance (if the patient enters treatment), or refund the money if the patient does not pursue treatment. This process has really solved a lot of problems while also acting as a screening method for patients relative to financial issues.  This method is a compromise between a complete pay-as-you-go format as suggested by Knapp and VandeCreek (2006) and the traditional billing arrangement allowing the patient to carry a balance (accounts receivable).   

 

Reimbursement – Utilization Review

 

A reimbursement issue that occurs frequently is that of a lack of approval for continued treatment. In this common scenario, the therapist has obtained approval to treat for a certain number of sessions (e.g. 6).  At the end of the approved number of sessions, the patient requires more treatment but the therapist’s request is denied.  If the therapist simply discharges the patient at that time (pre-mature termination), there may be a legitimate case for abandonment. This would especially be the case if the premature termination is handled in an inappropriate manner (e.g. request for additional visits not requested early enough, no transition/termination visits completed, not insuring the patient has other resources, terminating care regardless of “crisis” status, not discussing UR approval issues at the beginning of treatment as part of the informed consent process).  In these cases, the therapist should attempt at least an appeal of the denial.  If the appeal is not successful, the therapist is justified in terminating therapy due to lack of ability to pay and following appropriate ethical and legal guidelines (provide the patient with other resources, do not terminate if patient in crisis, plan ahead so the UR denial does not come as a complete surprise, etc.).

 

As illustrated in the Legal Cases (Legal Case 1), the courts will not allow a defense based upon cost containment (e.g. UR) whether it is at the hands of a physician or managed care organization. Economic constraints must not determine what should be done for the patient. When an HMO, PPO, or capitated group denies care, it is the therapist's duty to protest and attempt to change the decision. Verbally and in writing, the therapist should clearly state the reasons for the recommended therapy, the consequences of denial, and provide supporting literature to demonstrate the standard of care. A copy of the letter should be sent to the patient and all protestations documented in the chart.

 

 

Legal Example 1. Abandonment not Justified by Lack of Authorization

 

 

Wickline v. State of California – This is an often-cited, landmark case that is relative to abandonment even though an allegation of abandonment was not specifically made against the physician in this case (See Lifson and Simon, 1998).  In this case a Medi-Cal (California Medicaid program) patient was approved for a 10-day hospital stay for vascular surgery. The patient, a diabetic, developed post-surgical complications necessitating additional surgery. The patient's physician and two surgeons filed the appropriate paperwork to request an eight-day extension from Medi-Cal, but only a four-day extension was approved. Although they disagreed with Medi-Cal's decision, the physicians discharged Mrs. Wickline after the approved four-day extension. The patient subsequently lost her leg and sued. Stressing that the ultimate responsibility for medical decisions belongs to the physician, the court stated: "While we recognize, realistically, that cost consciousness has become a permanent feature of the health care system, it is essential that cost limitation programs not be permitted to corrupt medical judgment." Interestingly, the court also stated that third party payers are responsible for defects in cost containment mechanisms, but a physician who does not protest on behalf of a patient cannot avoid ultimate responsibility.

 

Wilson v. Blue Cross – This case tempered some of the ruling of Wickline and places more shared burden on the insurance carrier.  In this case, a physician recommended extended hospitalization for a depressed suicidal drug abuser. When the HMO reviewer certified only three days additional hospitalization, the psychiatrist protested and carefully documented his protest as the patient was being discharged. The patient committed suicide and the family sued the Blue Cross utilization review group and won on appeal when the court accused the group of bad faith benefit denial. Unlike the Wickline case, which placed the burden of responsibility on the physician, in Wilson, the court made it clear that liability is shared by the HMO.

 

Hughes v. Blue Cross - The court found in favor of the family of a 21-year-old hospitalized schizophrenic patient after Blue Cross authorized only $6,500 in coverage toward payment of a hospital bill exceeding $23,000. The court stated that the utilization review was not based upon the standard of care and that Blue Cross was responsible for seeking all relevant information before denying a claim.

 

 

Multiple Relationships and Conflicts of Interest

 

Relative to the current discussion is the relationship of multiple relationships, termination of therapy, and abandonment. In many instances of unethical behavior, the case involves abandonment (improper termination of treatment) associated with some other ethical violation such as a dual relationship.  Although there is a lack of data in this area, it is the opinion of one previous attorney for CAMFT that, “most licensees who have been disciplined due to ‘improper termination,’ terminated with their patients so that they could engage in a social, romantic, or other type of relationship” (Benitez, The Decision to Terminate, The Therapist, November/December, 2004). 

 

It is not the purpose of this course to address all of the ethical and liability issues related to dual and multiple relationships.  As discussed by Koocher and Keith-Spiegel (1998), multiple role relationship can be defined as situations in which the therapist functions in more than one professional relationship, as well as those in which the therapist functions in a professional role and another definitive and intended role, as opposed to a limited and inconsequential role growing out of and limited by chance encounter (p. 171). There are many scenarios of dual and/or improper relationships with patients and much has been written about this ethical area.  Multiple role ethics violations might include business dealings, friendships, and romantic/sexual involvement.  The multiple roles may be concurrent, as when a therapist hires a patient to provide some task or job.  Or, they may be consecutive, as when a therapist and a patient go into business together.  Dual relationship also involves romantic encounters with a patient either concurrent with a professional treatment (therapy) or after termination.  All ethical codes address multiple relationships and conflicts of interests.  Please refer to the various ethical codes related to dual relationships for more information.  In this course, we will limit our discussion to dual roles and inappropriate termination.

 

One of the most common ethical violations and malpractice actions is that of romantic involvement with a patient, either current or past (See Koocher and Keith-Spiegel, 1998 for a review of the ethical issues and Shapiro and Smith, 2011; Reamer, 2003, for a review of the malpractice data).   It is not the focus of this course to review the ethical and malpractice issues related to sexual misconduct with a patient.  However, there is evidence that sexual misconduct is often related to premature termination of therapy and abandonment.  If the case is ever pursued by the patient as an ethics or malpractice action, the focus is on the sexual misconduct and the abandonment may not be addressed, even though it has certainly occurred.  Sexual misconduct was chosen as an example of dual relationship related to premature termination because it might be considered the most serious of the offenses and among the most common.  However, all of these principles might apply to abandoning a patient in order to pursue some other non-professional relationship with a patient (business, friendship, etc.).

 

 

Table 10. Example Ethical Principles Related to Sexual Misconduct

 

 

APA

 

Standard 10.06, Sexual Intimacies With Relatives or Significant Others of Current Therapy Clients/Patients: 


Psychologists do not engage in sexual intimacies with individuals they know to be close relatives, guardians, or significant others of current clients/patients. Psychologists do not terminate therapy to circumvent this standard.

 

10.08 Sexual Intimacies with Former Therapy Clients/Patients 


(b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including:

 

(1) the amount of time that has passed since therapy terminated;

(2) the nature, duration, and intensity of the therapy;

(3) the circumstances of termination;

(4) the client's/patient's personal history;

(5) the client's/patient's current mental status;

(6) the likelihood of adverse impact on the client/patient; and

(7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post-termination sexual or romantic relationship with the client/patient.

 

NASW

 

1.16 Termination of Services

 

(d) Social workers should not terminate services to pursue a social, financial, or sexual relationship with a client.

 

ACA

 

A.5.b. Former Clients


Sexual or romantic counselor–client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact. Counselors, before engaging in sexual or romantic interactions or relationships with clients, their romantic partners, or client family members after 5 years following the last professional contact, demonstrate forethought and document (in written form) whether the interactions or relationship can be viewed as exploitive in some way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering such an interaction or relationship.

 

NBCC CODE OF ETHICS 

Section A: General 


10. Sexual intimacy with clients is unethical. Certified counselors will not be sexually, physically, or romantically intimate with clients, and they will not engage in sexual, physical, or romantic intimacy with clients within a minimum of two years after terminating the counseling relationship.

 

Section B: Counseling Relationship 

9. Certified counselors who have an administrative, supervisory and/or evaluative relationship with individuals seeking counseling services must not serve as the counselor and should refer the individuals to other professionals. Exceptions are made only in instances where an individual's situation warrants counseling intervention and another alternative is unavailable. Dual relationships that might impair the certified counselor's objectivity and professional judgment must be avoided and/or the counseling relationship terminated through referral to a competent professional. 


AAMFT CODE OF ETHICS, 2001

 

1.5 Sexual intimacy with former clients is likely to be harmful and is therefore prohibited for two years following the termination of therapy or last professional contact. In an effort to avoid exploiting the trust and dependency of clients, marriage and family therapists should not engage in sexual intimacy with former clients after the two years following termination or last professional contact. Should therapists engage in sexual intimacy with former clients following two years after termination or last professional contact, the burden shifts to the therapist to demonstrate that there has been no exploitation or injury to the former client or to the client's immediate family.

 

 

Romantic and sexual involvement with patients is addressed by the various ethical codes.  The statutes, as they might relate to premature termination and possible abandonment can be seen in Table 10.  The primary issue here is that a therapist becomes romantically attracted to a patient and desires to pursue a non-professional relationship.  In an attempt to avoid an ethical violations and malpractice action (dual role, sex with a patient, etc.), s/he decides to terminate therapy and the professional relationship.  In the well thought out cases, the therapist waits the required amount of time and then pursues the romantic relationship.  This is usually done with consent and participation of the patient.  By outward appearances, there has been appropriate therapy termination by mutual agreement.   

 

Some of the Codes specifically forbid terminating therapy with the goal of pursuing a non-professional relationship (sexual or otherwise):

 

Psychologists do not engage in sexual intimacies with individuals they know to be close relatives, guardians, or significant others of current clients/patients. Psychologists do not terminate therapy to circumvent this standard.

 

Social workers should not terminate services to pursue a social, financial, or sexual relationship with a client.

 

Should therapists engage in sexual intimacy with former clients following two years after termination or last professional contact, the burden shifts to the therapist to demonstrate that there has been no exploitation or injury to the former client or to the client's immediate family.

 

Other codes address this behavior indirectly, but the spirit of the codes is that it is not to be done.  Engaging in this behavior is clearly inappropriate premature therapy termination.  This behavior certainly might be conceptualized as abandonment.

 

In these cases, ethical and/or malpractice actions most often revolve around other violations.  However, the actions clearly qualify as abandonment.    The therapist, either unilaterally or by mutual agreement with the patient, terminates the therapy in order to start the “clock” counting down for future romantic involvement (e.g. two years after ending therapy).  In cases related to business dealings, friendship, or other non-sexual dual relationships, the therapist attempts to circumvent the ethics codes by terminating the therapy to allow for pursuing a non-professional relationship.  In these cases, the ethical codes do not address a time frame, and the therapist might pursue the non-professional relationship immediately.       

 

Assertion of abandonment in these cases is likely rare (again, other issues predominate and would be the focus of the complaint).  Even so, one can certainly imagine a situation in which a therapist terminates treatment to pursue some non-professional relationship (e.g. a business); the business or relationship goes bad and the patient (ex-patient) pursues action against the previous therapist, including abandonment among other things.

 

Lack of Progress in Treatment

 

As discussed by Fisher (2011), “Regardless of the underlying reasons, among the most visible signs of psychotherapist discomfort with termination may be the tendency to prolong the therapy relationship inappropriately.” (p. 164).  It has been suggested that therapists often defend against the awareness that a patient is failing to progress through various rationalizations (need more time, there actually progress, the treatment is supportive, the patient keeps coming so there must be progress even though I can’t define it).  It has been estimated that 36% of psychotherapists in private practice continue to treat patients who are not improving (Stewart and Chambless, 2008).  Other research suggests that even when patients are not showing progress, more than 50% of psychotherapists do “more of the same,” rather than revising the treatment plan or considering a referral (Kendall et al., 1992).   

 

“It is difficult to get a man to understand something when his job depends on him not understanding it.”

 

Upton Sinclair

 

The various mental health ethics codes universally dictate that a patient who is not making progress should be terminated from care or referred for treatment that has the potential for success.  As discussed by Younggren and Gottlieb (2008) this decision is primarily initiated by the therapist but should, ideally, be made mutually by both the therapist and the client. In the best case scenario, the therapist will initiate the conversation and review concerns in detail with the client.  In some cases, the client may voice reasons that the therapy is, indeed, progressing and generate new ideas and goals.  On the other hand, the client may feel the same way, but did not have the skills to express the issue (possibly one of the hidden reasons in the Roe study that clients state therapy “went on too long”; that of being uncomfortable with the therapist).  In these cases, an appropriate termination plan can be developed.  One challenge related to this issue is that, aside from fairly structured and objectively defined interventions (e.g. CBT with concrete goals), “progress” is often difficult to define and determine.  This makes discussion with the patient all that more important.

 

There are certain personality features that are likely to make patients prone to stay in treatment even when no progress is being made.  In these cases, the therapist may consciously or unconsciously collude with the patient to keep things going long after any treatment response has been achieved.  This is commonly seen in situations in which a responsible part other than the patient is paying for the treatment.  One such common example is that of Dependent Personality Disorder, associated with some other condition.  Case Example 3 presents an example of this occurrence and is a case that I evaluated as a consultant to the carrier. 

 

Case Discussion: Chronic Pain with Dependent Personality Disorder. As an overview (See Case Example 3 for a detailed case presentation), the patient presented for treatment of a chronic pain problem associated with a work injury.  The psychological treatment was authorized for psychological pain management and concomitant depression.  This patient also clearly had a Dependent Personality Disorder which, of course, was non-industrial (not related to the work injury) and was not the focus of treatment.  Over the subsequent 12 years of “treatment” provided to this patient by the psychologist (generally twice per week), outside psychiatrists completing periodic Independent Medical Evaluations (IME) related to case frequently commented that the psychologist should focus on fading the treatment and help the patient activate self-management resources (herself, her family, and in the community).  The IMEs also correctly pointed out that the extensive and lengthy therapy was creating an unhealthy dependence on the psychologist and actually preventing the patient from making progress.   The suggestions were largely ignored by the treating psychologist until the insurance carrier limited the number of visits per month with a fading schedule to basically force the psychologist to appropriately terminate treatment.  The psychologist abruptly faded the frequency of visits but did so in a very inappropriate manner.  Unfortunately, the psychologist “blamed” the insurance company for not allowing him to continue to “treat” the patient. He rapidly faded the visits from twice per week to every other week to once per month (even though the insurance company was actually allowing more visits for the termination process).  Evidently, he was fearful of being deposed about his course of treatment. This increased the patient’s feelings of being “victimized” by the insurance company, increased her feelings of not being provided with treatment she “needed and deserved”, and left her with no skills or benefit in terms of managing her problems (pain or otherwise).  This constituted 12 years of wasted treatment resources and left a patient likely iatrogenic issues related to dependency, maintaining the victim role, having no skills related to pain management or other types of self-management, etc.       

 

 

Case Example 3.  Last of Progress in Treatment

 

 

The patient is a 55-year-old married nurse, who sustained an injury during the course of her employment in 1998.  She was helping to transfer a patient that weighed 275 pounds when he started to fall and “hung on to me.”  The patient experienced a “pop” in her left elbow with immediate onset of pain.  The pain gradually radiated to the left shoulder and upper back region. 

 

The patient underwent a right carpal tunnel release on early 2000.  During this time, the records indicated she was becoming more and more depressed relative to her disability and chronic pain.  She began treating with a psychologist, Dr. Phil in conjunction with a psychiatrist, Dr. Jung. By this time the patient had been diagnosed with fibromyalgia and a chronic pain syndrome.  She underwent a left total knee replacement in October of 2005 that was non-industrial.  Sleep apnea was diagnosed and she was using a CPAP machine.

 

Beginning in 2004, the patient underwent a multiple psychiatric agreed medical evaluations (AME) as part of her work injury case.  In California, these are independent evaluations agreed to by both the insurance carrier and the patient’s attorney to help guide treatment.  These were completed by Dr. Oz, a psychiatrist.  In one of the re-evaluations, in 2010, Dr. Oz reiterated his psychiatric diagnoses including a major depressive disorder, single episode, in partial remission, chronic; anxiety disorder NOS with slight panic-like symptoms; and a pain disorder associated with both psychological factors and general medical condition. On Axis II, Dr. Oz noted that the patient had dependent and hysterical features (“is a person who has both hysterical and dependent personality traits”).  He felt that she tended to over dramatize, to be quite sensitive, and to be dependent on others to solve her problems.  He also stated that such individuals are “quite difficult to treat.”  He stated that these patients have difficulty accepting their level of pain as chronic in nature and trying to maximize their function within the limitations of that pain.  They continue to look to their clinicians to “take the pain away” rather than adopting a pain management philosophy.  He reported that “unless there is an acceptance of the chronicity of the pain and responsibility assumed by the individual to maximize their functioning within the context of the pain, improvement in their condition cannot be obtained.”

 

Dr. Oz addressed the intensive (extensive) psychotherapy being provided by Dr. Phil.  At that time, she was seeing him twice weekly as well as having phone contact with him.  By that time, this had been going on for about ten years.  Dr. Oz felt there was “some inherent danger” in that frequency.  As early as 2004, the patient’s previous psychiatrist, Dr. Smith, discussed the possibility of focusing on psychotherapeutic termination with Dr. Phil, or at least decreasing the frequency of treatment.  Dr. Smith recognized the dangers of increased dependency on the psychotherapy which could lead the patient to not accepting the chronicity of her situation and assuming responsibility for maximizing her level of activity and functioning within the context of the pain.  Dr. Oz again documented that the patient had been seeing Dr. Phil approximately twice weekly for ten years.  He recommended that the visits be initially reduced to once per week with a focus on gradual termination of psychotherapy. 

 

Dr. Oz again evaluated the patient in 2012.  The treatment with Dr. Phil was unchanged, as was the patient’s status.  Dr. Oz again discussed this issue.  He did not feel that it was appropriate to abruptly discontinue the psychotherapy since that could be deleterious to the patient.  However, he reiterated that he had previously recommended fading the frequency of visits to at least once per week in his previous report in January, 2010 (two years earlier).  Dr. Oz again allowed for a very generous treatment termination schedule given the amount of time the patient had been in treatment with Dr. Phil, and the intensity of dependency she had on him. 

 

The insurance company sent these findings to Dr. Phil along with a letter notifying him they would only pay for sessions consistent with the fading schedule suggested by Dr. Oz.  The letter also stated that if Dr. Phil did not comply, they would schedule a deposition to address Dr. Phil’s justification for this ongoing treatment.  Dr. Phil finally faded the patient’s follow up schedule to once per week and told the patient the insurance company was “forcing him” to eventually discontinue her treatment.

 

As discussed by Dr. Oz, Dr. Phil has a critical role and a lot of power in determining how well this patient does with the termination process.  As discussed in the report, and supported in the literature, it is very appropriate to initiate the psychotherapy termination process with emphasis on transferring responsibility to the patient for self-management.  This can be quite successful if done properly.  If Dr. Phil chooses to formulate this process to the patient as one of “the insurance company is taking away the psychotherapy that you need”, or some similar conceptualization, he will be doing a disservice to the patient and risk causing iatrogenic worsening of her psychological condition.   Unfortunately, that is exactly what happened.

 

 

Since it occurs quite frequently in therapy situations, it is useful to review features of Dependent Personality Disorder (or trends).  These patients are certainly prone to develop an unhealthy dependence and reliance on therapy.  Providers are also at risk for keeping these patient in treatment far beyond what is appropriate based on ethical guidelines.  These patients are easy to “treat” since they never miss an appointment, rarely challenge the therapist, do not complain, pay their bills, and never question the justification for ongoing therapy.  To the unethical therapist, these patients “will put your kids through college”.  

 

 

Table 11. Dependent Personality Disorder Treatment and Termination

 

 

Individuals with dependent personality disorder are usually quite needy, for attention, valuation, and social contact. Clients with this disorder usually don't present in a dramatic fashion, but will often make repeated requests for attention to their complaints, whether these complaints are about their lifestyle, social relationships, lack of meaning in life, medical, or education. People who suffer from this disorder are often outwardly compliant with clinicians' suggestion for treatment, and will usually be passive in their overall treatment, no matter what form it takes. However, real gains in therapy may not be made easily, because the client's compliance (due to the disorder) is often only surface-deep. While the individual may be one of the easiest to see week after week or month after month in therapy, they may also be one of the most difficult because of their strong need for constant reassurance and support. Dependency upon the clinician specifically and therapy in general should be carefully monitored and avoided.

 

Clinicians in general should be wary of the therapeutic relationship with a person suffering from dependent personality disorder. The needs of the individual can be great and overwhelming at times, and the patient will often try to test the limits of the frame set for therapy. A clear explanation at the onset of therapy about how treatment is to be conducted, including a discussion of appropriate times and needs for contacting the clinician in-between sessions, is vitally important. While rapport and a close, therapeutic relationship must be established, the boundaries in therapy must also be constantly and clearly delineated.

 

Effective psychotherapy for this disorder focuses on developing effective coping strategies and self-reliant behavior. The therapist should reassure the individual about being available and accessible, within realistic limits. Insight-oriented, cognitive-behavioral, assertiveness training, family therapy, and group therapy have all been used, with successful outcomes in many cases. Long-term psychotherapy may lead to increased dependency. Termination of therapy is often difficult, as the individual often feels dependent on the therapist.

 

As with all personality disorders, psychotherapy is the treatment of choice. Treatment is likely to be sought by individuals suffering from this disorder when stress or other complications within their life have led to decreased efficiency in life functioning. As with all other personality disorders as well, they may present with a clear Axis I diagnosis and the personality disorder may only become apparent after a few sessions of therapy. The most effective psychotherapeutic approach is one which focuses on solutions to specific life problems the patient is presently experiencing.

 

While ideal for many personality disorders, long-term therapy is contraindicated in this instance since it reinforces a dependent relationship upon the therapist. While some form of dependency will exist no matter the length of therapy, the shorter the better in this case. Termination issues will likely be of extreme importance and will virtually be a litmus test of how effective the therapy has been. If the individual cannot end therapy successfully and move on to become more self-reliant, it should not be seen as a therapeutic failure. Rather, the individual was not likely seeking life-changing therapy in the first instance but instead solution-focused therapy.

 

Termination of therapy with a person who has this disorder is an extremely important issue to consider. While termination should always be a joint decision between the clinician and the client, people with this disorder often don't know "how much is enough" therapy. The therapist, therefore, may need to prod the patient toward ending therapy. As the end of therapy approaches, the patient is likely to re-experience feelings of insecurity, lack of self-confidence, increased anxiety and perhaps even depression. This can be typical of individuals with this disorder when terminating therapy and should be treated appropriately. The clinician should not allow the patient to use these new symptoms, though, as a way of prolonging the current therapy. The goal is to end a relationship at an agreed-upon time and way. The client should be reinforced for the positive gains made in therapy and encouraged to explore their new-found autonomy or improved management of their anxious feelings.

 

 

Although the issue of lack of treatment progress is not directly related to abandonment, it certainly is unethical and has the potential to cause problems.  One can certainly imagine a case similar to the one that I outlined, in which the patient pays for therapy over a long term, becomes dependent on the therapist without significant progress, and then at some point realizes they have been “had”.  This might occur after an intervention by family members or friends, getting with an ethical and competent therapist, or some other “Ah-Ha” experience.  In this situation, the patient is certainly justified in filing a complaint and, possibly, seeking damages (reimbursement for paying for therapy for all those years, and/or damages related to iatrogenically making things worse by fostering dependence). Of course, these claims are likely rare due to the very fact that the patient’s disorder (Dependency) almost precludes taking such action against the therapist. 

 

 

Case Example 4. Long Term Treatment; Short-term Termination

 

 

Treatment Length: 13 Years - Termination Length: 1 Session

 

This example was actually found as a post on a blog.  The discussion was on a psychologist’s website about therapy issues.  The person posted the following:

 

Patient’s Post:

 

I’m on SSDI for the past 5 years and don’t work. . . . I devote about 20 hours a week volunteering with 2 groups that advocate for and work to [deleted for confidentiality], and do grassroots organizing. I also volunteer with . . . a group devoted to promoting non-violent dispute resolution; the peace/anti-war movement. Two weeks ago, my psychologist (PhD) abruptly terminated my therapy with her, telling me at what I thought was to be a regular session that she was terminating immediately. I . . . have seen her for about 13 . . . years. . . . The only explanation given to me re: the reason for termination was that she “couldn’t remain objective” in treating me. She spoke of consulting colleagues (including my psychiatrist), and someone with APA ethics. . . . The specific details of my situation are very, very complex and not easily summarized. . . . I am baffled about what is going on here. I think I’m due a more expansive explanation. . . . It feels so adversarial to me. . . . My faith in the mental health field is gone. I plan on . . . dropping my psychiatrist, stopping my meds, not finding a new therapist. . . . How can this happen this way? Sorry for being so long-winded. I’m in quite bad straits over this.

 

Response by the Therapist on the Website: 

 

I can say that, from what you have described, your psychotherapist has handled the case ethically. Something came up between the two of you that she couldn’t handle objectively, she sought outside consultation, and it was decided that termination was the best recourse. So take it as a blessing. Instead of turning your anger against yourself by stopping medications and feeling victimized by psychotherapy, recognize that feeling “violated, abandoned, confused, angry, and terminated” is the very emotional core of your psychotherapeutic work that, in spite of 13 years of treatment, has been missed all along. So rather than try to find political satisfaction for your hurt, find a competent psychologist who’s smarter than you are and can see through all your defenses.

 

 

Case Discussion about Example 4 – Blog Post. The example post on a blog raises interesting issues related to long term therapy, possible lack of progress, and inappropriate management of termination.  In the little information we have about the case, we know that the patient has been in therapy for 13 years, which is a long time even by psychoanalytic standards.  We also know that the patient is volunteering 20 hours per week and involved in two groups.  The volunteer involvement is certainly positive especially if this is a substitute for not being able to work (for some reason).  If all of this volunteer activity was a focus of therapy (e.g. moving from a disabled and inactive role to one of volunteering, etc.), that would certainly count as progress.  We also know that the patient has been on SSDI for 5 years and likely disabled longer since it takes some time to get approved.  If she has Medicare coverage with her SSDI and some type of secondary insurance, then the therapy likely costs the patient nothing out of pocket (if the psychologist is a Medicare provider) and the therapist did not have to concern herself with authorizations for ongoing treatment.

 

The two issues related to termination and abandonment are: (1) why was treatment necessary for 13 years and (2) why terminate the patient without notice in one session?  The justification for the first issue is unknown.  We also do not know what “progress” was made during this time.  Relative to the termination issue, the therapist on the web site opines that this was handled in an ethical fashion. The treating therapist simply told the patient that “something came up”, she could not remain objective, she consulted with colleagues and someone at the APA ethics committee, and then terminated her. 

 

I think it is reasonable to argue that, after 13 years of therapy, a single “surprise” termination session is not consistent with ethical management of this case.  All of the Ethics Codes address these issues and here are just a few examples:

 

“provide pre-termination counseling and suggest alternative service providers as appropriate (APA Code 10.10.c)

 

“Social workers should withdraw services precipitously only under unusual circumstances….taking care to minimize possible adverse effects” (NASW Code 1.16.b)

 

“Counselors provide pre-termination counseling and recommend other service providers when necessary” (ACA, A.11.c.)

 

It would seem that, short of being threatened (which might have occurred but we don’t know and seems unlikely after 13 years), pre-termination counseling of more than one surprise session would have been appropriate.  There is also no mention of providing the patient with alternate resources or referrals, or assisting in the transfer of care.  The patient evidently does have a psychiatrist that may have helped relative to these issues.  The patient states that her situation is “complex” and there are likely significant personality disorder features involved.  Even so, aside from actually being threatened, did the therapist complete an abrupt termination to serve her own needs (e.g. not wanting to go through an uncomfortable pre-termination counseling phase during which the patient is arguing to stay in treatment due to dependency and other needs), or was this method justified?  Clearly this abrupt termination resulted in some emotional harm to the patient.  After 13 years of being paid for “treating” this patient, it seems that she would be owed more than this type of termination.

 

None of this discussion should be construed as saying that therapy always has be to successful otherwise ongoing treatment is unethical.  Rather, the therapist should constantly be aware of the goals of treatment (short and long-term), the progress towards these goals, etc.  In the case of a documented treatment plan with goals, the therapist is on solid ground regardless of the intensity and length of treatment.

 

The possibility of an accusation of abandonment is certainly present when the therapist attempts to do the “right” thing in this type of case.  In general, in these cases, the client is very happy with coming to therapy week and week, year after year, even if there are no goals or progress.  The therapist and patient/client often begin to develop more of a friendship as the actual treatment relationship changes.  The therapist and the therapy sessions become one of the patient’s primary social contacts and a source of nurturance (often it is a primary relationship for the patient).  The patient has no desire to discontinue or modify the therapy relationship in any way.  The therapist may also be reluctant to change the situation since the therapy sessions tend to be quite easy (like meeting with a friend) and the remuneration is obviously present.  Terminating this type of patient only means a hole in the schedule that must be filled, most likely with a shorter term patient and less comprehensive financial coverage. 

 

Therapy termination with a patient who is ”dependent” on therapy (for the wrong reasons and not making progress) represents a challenge.  The patient will almost always disagree with the evaluation of the therapist that termination is indicated.  Depending on the length of time the patient has been in therapy, the termination process may take some time (and this is appropriate).  Consistent with recommendation for an appropriate termination process, the following should be addressed: reviewing gains made in therapy and how working on these issues can continue; providing the patient with resources outside the therapy situation; making referrals and attempting to insure these have been followed through on by the patient; addressing any concerns the patient might have about termination.

 

Was a Treatment Relationship Established and Duty to Protect Incurred?

 

As discussed in the very beginning of this course, establishing when the treatment relationship actually begins can be critical to determining premature termination or abandonment. 

 

As an overview, a malpractice case in 2000 underscores important issues related to ethical, high-quality practice and risk management.  These include duty to protect (a patient from harming herself) and alleged abandonment.  Briefly, in February 2000, thirty-six year old Ellen Marshall, the patient, hanged herself two days before a scheduled appointment with defendant, Dr. Vladimir Klebanov, a licensed psychiatrist.  This would have been the patient’s second visit.  Following her death, the patient's husband, Craig Marshall,filed an action against defendant on behalf of himself and his wife's estate for medical malpractice and wrongful death.  In simplest terms, he alleged that the psychiatrist deviated from the accepted standards of care in the evaluation, care, and treatment of his wife in at least two ways: (1) the psychiatrist “failed to protect” or prevent a suicide that was imminent and (2) a treatment relationship had been established even though a month had passed since the initial evaluation and the next scheduled visit (which never occurred). 

 

 

Legal Case 2. A Question of Treatment Relationship Established and Suicide

 

 

The decedent, Ellen Marshall, was born in 1963 and married plaintiff, Craig Marshall, at age twenty-three.   She gave birth to two sons, one in 1992, and one in 1995.   In 1997, the family moved from their home in Franklin Park to Marlboro.   Around that time, the decedent developed depressive and suicidal thoughts due to financial concerns and other issues.   Although she had been diagnosed with psychiatric problems during high school, her psychiatric history indicates that she felt relatively well for many years until she moved in 1997.   That year, the decedent was admitted to Riverview Medical Center for approximately one week and placed on “suicide watch” after taking an overdose of prescription medication.   Following her release, she was treated with Prozac and Wellbutrin for one year and purportedly felt well until late 1999.

 

In December 1999, the decedent suffered another episode of depression.   According to her sister, around that time the decedent started “slipping.”   She became socially withdrawn, was losing weight, and was depressed.   The decedent's mother states that during that time her daughter was “the worst that [she had] seen her.”   At one point, the decedent told her mother: “If anything ever happens to me, Mom, I want you to know that you were a good mother.”   The decedent also told her sister that her children were better off without her.

 

Because the decedent's mother and sister felt that she needed help, in late December 1999, they went to see defendant, Vladimir Klebanov, a licensed psychiatrist who was opening an office in Old Bridge near the decedent's home.   The decedent's mother informed defendant that she had a “sick daughter” with “suicidal tendencies” and that she was “worried about her.”   Defendant responded that his primary office was in Brooklyn and that the earliest that he could see the decedent would be in the first week of January.   He also informed them that if the decedent was suicidal, she should be taken to a hospital.   The decedent subsequently called defendant and scheduled an appointment for January 7, 2000, the first day that his new office was open to patients.

 

At the January 7 appointment, the decedent noted in an initial questionnaire that her last medical examination was in 1999 and that she was taking Prozac daily.   She further indicated that she had a family history of anxiety attacks, fears or phobias, depression, and suicide attempts.   The decedent listed her current symptoms as including trouble sleeping, fatigue, crying spells, feeling sad or depressed every day, difficulty communicating with others, avoiding social events, difficulty making decisions, suicidal thoughts, periods of tension, and loss of appetite and weight.   The decedent also informed defendant that she had tried to commit suicide in the past.

 

Defendant diagnosed the decedent with “major depression, recurrent, severe.”   He found that she suffered from depressed mood, blunted affect, poor judgment, and poor insight.   He also noted that she had suicidal thoughts but found that “she did not have any plan to commit suicide.”   According to defendant, “[t]o have suicidal thoughts and to commit suicide are not the same things.   There are tons of people who do have suicidal thoughts from time to time at certain points in time but [that does not] mean they commit suicide If the patient would have a plan, I [would] hospitalize her immediately.”   Defendant prescribed Lithium to the decedent to augment the effects of her other medications, increased her dosage of Prozac, maintained her dosage of Wellbutrin, and decided to see her again in one week on January 14, 2000, for follow-up care.   Defendant testified that “therapy is a treatment, and to see the patient who has depression is part of the treatment.”

 

On January 14, 2000, the decedent returned to defendant's office for her scheduled appointment but was not seen by the doctor.   The reason for that is disputed.   Plaintiff contends that, on the day of his wife's appointment, he called his house to check his phone messages and retrieved a message from defendant stating that the decedent failed to attend her appointment.   Plaintiff claims that he became “concerned because it didn't seem that she would intentionally miss the appointment because she was looking very forward to seeing him again.”   As a result, plaintiff called his house again to speak with his wife.   The decedent purportedly informed her husband that she did go to defendant's office but was refused treatment because she did not have a check with her to pay for the visit.   Both parties agree that the decedent offered topay by credit card but that the office was not equipped for such transactions.

 

Defendant asserts that his office would never refuse treatment of a patient who could not pay.   He claims that after the receptionist, defendant's wife, informed the decedent that the office was unable to accept credit cards, the decedent told the receptionist that she did not have confirmation of her insurance and could not afford to pay for the session.   According to defendant, the receptionist stated that the decedent nonetheless should wait to see the doctor because he needed to monitor her medication.   The decedent allegedly refused to wait for defendant and informed the receptionist that she was doing fine with the medication and that she would make a new appointment in a couple of weeks when her insurance was in place.   At some point thereafter, the decedent and defendant scheduled another appointment for February 4, 2000, approximately one month after her first visit.   Tragically, however, the decedent committed suicide two days before the scheduled session.

 

Plaintiff filed an action against defendant for wrongful death and medical malpractice, alleging that defendant deviated from accepted standards of care “[i]n his evaluation, treatment and care of the decedent” and that his deviation was a proximate cause of the decedent's suicide. He contended that the doctor abandoned the patient the patient by not providing adequate monitoring and treatment, and not referring the patient to a different doctor.

 

Plaintiff's expert, Dr. Steven S. Simring, opined that, even assuming defendant's version of the facts, defendant deviated from the appropriate standard of medical care in his treatment of the decedent and “essentially abandoned her.”   Specifically, the expert submitted that although Dr. Klebanov appropriately assessed the high risk of suicide, he did not take appropriate action to deal with that risk.   He failed to provide her with adequate monitoring and treatment and failed to refer her elsewhere.

 

The court basically found that since there was a month between the first visit and the next scheduled visit (since the patient did not have treatment a week after the evaluation as originally scheduled) the various statues (duty to protect, etc.) did not apply because the decedent's family members “did not suspect that [her suicide] was imminent” and defendant “had not [physically] seen the patient since January 7th.”  Thus, there was a question of whether the doctor had actually incurred a “duty to protect” the patient from herself (relative to suicide).

 

The practitioner who has not incurred a duty to “warn and protect” under the statute is not liable for failure to “warn and protect,” but can be liable for other deviations from the accepted standard of care that are proximate causes of a patient's violent act or suicide As a result, the court remanded the matter for a jury to determine whether, under the common law, defendant's conduct met the accepted standard of care and, if not, whether that deviation was the proximate cause of the decedent's suicide.  

Defendant claims that no such duty arose in this matter because there is insufficient evidence in the record to conclude that the decedent's suicide was “imminent.”  

 

Plaintiff further asserts that, applying the common-law standard of care, there is ample evidence in the record to conclude that defendant committed malpractice by abandoning his patient and failing to provide her with appropriate treatment.

 

The New Jersey Supreme Court reviewed the common law on the issue of the duty of care under similar facts, noting that “it is well settled that a physician must act with that degree of care, knowledge, and skill ordinarily possessed and exercised in similar situations by the average member of the profession practicing in the field.” That duty “encompasses, and is shaped by, the plaintiff-patient’s medical condition” and “continues until such time as the physician-patient relationship is terminated.”

 

Based on that background, the court held that the statute did not immunize a mental health practitioner from potential liability if the practitioner abandons a seriously depressed patient and fails to treat the patient in accordance with accepted standards of care in the field. The court concluded that the statute does not bar the plaintiff’s claims against Dr. Klebanov under the common law for abandoning the decedent and failing to treat her in accordance with the applicable standard of care, and remanded the matter for trial.

 

On July 26, 2006, the Supreme Court of New Jersey allowed Marshall v. Klebanov, M.D. to go to trial on the issue of whether a psychiatrist abandoned a seriously depressed patient and negligently failed to provide the patient with adequate medical monitoring despite the statutory immunity provisions [N.J.S.A. 2A:62A-16] which sets forth a mental health practitioner’s duty to warn and protect patients or third parties against a patient’s acts. In under 30 minutes, the jury concluded that Dr. Klebanov had not performed any action that differed at all from proper standards of psychiatric care.

 

 

In this case, even though the defendant was not found guilty of deviating from the proper standard of care, avoiding this type of situation altogether is certainly preferred. Even though found not guilty, one wonders if the outcome might have been different if, after the initial evaluation and missed second appointment, the patient might have been contacted by the psychiatrist in some manner to check on her status and possibly reschedule sooner than a month.  Of course, this is Monday morning quarterbacking, but the case is certainly worth learning something from.

 

Nonadherence

 

Nonadherence or noncompliance with treatment recommendations can be an appropriate reason for premature termination issue.  This is decided by the therapist but should be discussed with the patient as a treatment issue.  The patient should be given the opportunity to express his or her feelings about the ongoing treatment recommendations (e.g. homework exercises, compliance with a medication regimen being prescribed by a physician treating the patient conjointly, inconsistence attendance to treatment appointments, etc.).  The lack of adherence (or acceptance) of the treatment prescriptions should be discussed and the patient given the opportunity to comply with an agreed-upon treatment plan.  If, after this process is completed, the patient continues to show nonadherence, then premature termination is appropriate.  As part of the termination process, the reasons for the termination should be discussed and other resources/referrals provided to the patient.

 

 

Legal Case 3.  Transfer of Care or Abandonment?

 

 

On May 22, 1979, the patient (Ms. Miller) entered the Emergency Room of Greater Southeast Community Hospital (GSCH) complaining of rectal bleeding. She was examined by a physician in the emergency room and subsequently admitted to GSCH as a private patient of her regular attending physician, Dr. Villa-Real. After two diagnostic procedures were completed, Dr. Villa-Real scheduled the patient for a proctosigmoidoscopy, possible polypectomy, and a possible hemorrhoidectomy.

 

On the evening of May 25, 1979, a consent form for these procedures was presented to the patient, but she refused to give her authorization. Dr. Villa-Real was advised of the patient's refusal and he discussed the matter with her that same evening. The patient told the doctor that she did not wish to be anesthetized for the proctosigmoidoscopy, and that she would
not consent to the surgical procedures without knowing what the prior examination revealed. According to patient's deposition testimony, Dr. Villa-Real refused to release her from his services, but told her that she could either sign the consent form or sign herself out of the hospital. Mrs. Owens, a hospital administrator, also spoke with appellant on the evening of May 25. Mrs. Owens told the patient that Dr. Villa-Real had spoken to her about the dispute over the consent form. The patient discussed the problem with Mrs. Owens, but refused to authorize the surgical procedures.

 

The next morning, May 26, Dr. Villa-Real, accompanied by another hospital administrator, Mr. Trefy, spoke with the patient again. Dr. Villa-Real told her that he would release her from his services. She was told that she would be provided with a list of the names of physicians she could contact. On the evening of May 26, another hospital administrator, Mr. Callahan, visited the patient and provided her with the list. The patient selected a name from the list, Dr. Mitchell, and made arrangements for him to come to the hospital. Dr. Mitchell told the patient that he would see her in the hospital the following day. That same evening, one of the hospital nurses told the patient that Dr. Villa-Real had spoken with Dr. Mitchell about her case. The nurse also stated that Dr. Villa-Real was transferring the patient's care to the new doctor.

 

The following day, May 27, the patient was informed that Dr. Mitchell was ill and unable to come to the hospital. On May 28, the patient was again told that Dr. Mitchell was ill and unable to come to the hospital. On both of these days, the patient was seen by Dr. Massimo Righini, Chief of Surgery at GSCH. When Dr. Mitchell failed to appear on May 29, the patient telephoned a physician who had treated her in the past, Dr. Irwin Ardam.

 

Dr. Ardam told the patient that she could discharge herself from GSCH and, depending upon how she felt, admit herself to another hospital or go home for the night and come to his office in the morning. The patient discharged herself from GSCH on May 29 and returned to her home. The next morning, the patient went to Dr. Ardam's office. Dr. Ardam performed a proctoscopic examination on the patient, prescribed rectal suppositories, and advised her to stay off her feet for a week.

 

On May 22, 1982, the patient initiated a medical malpractice action against Dr. Villa-Real and GSCH, alleging that the defendants abandoned her during her stay in the hospital. Specifically, the patient claimed that Dr. Villa-Real withdrew from her case without providing a replacement, and that GSCH failed to provide her with a physician after Dr. Villa-Real terminated his services. The patient alleged that, as a result of defendants' abandonment, she sustained pain and suffering, mental anguish, an unnecessary hospital stay, and an excessive hospital bill. Upon completion of discovery, Dr. Villa-Real and GSCH filed separate motions for summary judgment. Both motions were granted.

 

The record shows that after the patient and Dr. Villa-Real were unable to resolve their conflict over the consent for the surgical procedures, Dr. Villa-Real informed the patient that he would release her from his care. She was provided with a list of the names of physicians that she could contact to arrange for substitute care. She selected a name from the list, a Dr. Mitchell, and arranged for him to come to the hospital. Meanwhile, she was informed that Dr. Villa-Real had spoken with Dr. Mitchell and arranged to transfer her case to the new physician.

 

The sole question raised by the patient's complaint is whether, as a matter of law, Dr. Villa-Real's severance of the physician-patient relationship supports a legal theory of abandonment. Abandonment has been defined as the termination of the professional relationship between the physician and patient at an unreasonable time or without affording the patient the opportunity to procure an equally qualified replacement. Implicit in appellant's claim of abandonment is the notion that if, at the time the professional relationship is terminated, the attending physician is not physically replaced by another physician, then the attending physician has abandoned his patient. The defense disputed this theory of abandonment. Where a patient is not in need of immediate medical attention, supplying the patient with a list of substitute physicians to replace the attending physician is a reasonable means of severing the professional relationship. 

 

In this case, the evidence is uncontroverted that Dr. Villa-Real and GSCH assisted the patient in procuring another physician, and that at no time during her stay at GSCH was she denied medical attention. Indeed, the patient's own medical expert testified at a deposition hearing that the medical care provided her was appropriate, and that the manner in which the doctor and the hospital handled the dispute with the patient complied with accepted standards of medical care. The case was decided in favor of the defendant, Dr. Villa-Real – no abandonment had occurred.

 

 

The case of Miller v. GSCH might be an example under nonadherence (the patient did not accept the doctor’s treatment recommendation) or transfer of care.  Either way, the case underscores that even when a provider appears to follow all accepted procedures, attempts to act in the best interests of patient care, and performs his duties within the accepted standard of care, malpractice action is still a possibility. Of course, informed consent along with proper documentation throughout the process provided a straightforward defense in the case and is consistent with best practice. 

 

This area can be somewhat difficult since often the patient desires to continue therapy “under his or her terms” even though the therapist is not willing to do so.  This is similar to the issue with treating a patient who is no longer showing progress.  In a common scenario, the patient desires to continue to come in week after week for the sessions without completing any of the home work assignments, not practicing the skills taught in the session, not actually focusing on any important issues, etc.  Therefore, this challenging area of premature termination often represents a combination of nonadherence and lack of progress.  Since the patient desires to continue in “treatment” as he or she defines it, the termination process has the potential to be challenging.  In extreme cases, the claim of abandonment may be suggested even though the therapist has clearly documented that the patient has not fulfilled his/her part of the treatment contract.  As with the lack of progress issues, it is easy for the therapist to suspend his or her ethical judgment given the “easy” work for the “easy” money (especially given the patient’s desire to continue the therapy as long as nothing is really required of him/her). 

 

Therapist-patient Mismatch

 

One type of “mismatch” problem that may occur is related to a patient presenting a problem that is outside the competence of the therapist to treat.  The presentation of this problem may occur after the evaluation and may not initially be the focus of treatment (the therapist may not even be aware of it as a problem).  This does present a termination issue.  This type of mismatch will be discussed in a subsequent section.

 

Other types of therapist-patient “mismatch” are difficult to define but, generally, both parties know it when it occurs.  At some time after the initial evaluation, it becomes clear that, “this is not a match made in Heaven”.  On the mild end of the spectrum, the therapist and/or patient may simply not “like” the other person (for whatever reason).  Or, the patient may not respond well to the style of the therapist (e.g. confrontive, passive, etc.) or the type of intervention (e.g. CBT with a lot of homework, highly structured and time-limited versus a more psychodynamic approach).  At the other end of the continuum, the therapist may develop strong countertransference issues that cannot be overcome no matter how objective he or she attempts to be (e.g. the female therapist who has a personal history of being abused seeing a male client who, during the course of treatment, reveals a history of impulse control problems including abuse directed at women).  

 

No matter what the reason for the mismatch, the therapist should facilitate the termination according to ethical guidelines.  If the termination is being initiated by the therapist, the reasons should be discussed (e.g. “It appears that the CBT approach in which…….may not be the best for you.”  “What do you think?”).  As part of this discussion, the patient can be provided with the names of other practitioners that might be a better “match”.   

 

A mismatch due to other reasons (e.g. lack of treatment progress or lack of therapist competence in an area) can be discussed with the patient relative to those issues and appropriate referrals completed.  In some cases, the client-patient desires to continue therapy regardless of the recommendation for premature termination and referral by the therapist. In these cases, the ethical codes mandate that it is incumbent on the therapist to proceed with the termination and referral even though it may be again the patient’s wishes.  This can be a difficult discussion and process, but is certainly appropriate.  As discussed by Younggren and Gottlieb (2008), “….continued treatment of a problem that is beyond the psychotherapist’s competence is a serious violation of the standard of care” (p. 501). 

 

Boundary Violations (Patient) - Threats

 

As discussed previously, the professional treatment relationship involves responsibilities and contractual obligations on the part of the therapy and the patient.  We are all familiar with boundary violations on the part of therapists such as dual relationships, romantic involvement, financial issues, etc.  There are also boundary violations on the part of patients and these primarily involve behaviors that become intrusive or dangerous to the therapist (Younggren and Gottlieb, 2008).  Therapists have a right to privacy, safety and respect.  When these rights are violated by patients, it is grounds for appropriate termination from treatment.  The following are some example ethical guides related to being threatened by a patient:

 

Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship (10.10.b)

 

Social workers should take reasonable steps to avoid abandoning clients who are still in need of services. Social workers should withdraw services precipitously only under unusual circumstances, giving careful consideration to all factors in the situation and taking care to minimize possible adverse effects. Social workers should assist in making appropriate arrangements for continuation of services when necessary (1.16.b)

 

Counselors terminate a counseling relationship when it becomes reasonably apparent that the client no longer needs assistance, is not likely to benefit, or is being harmed by continued counseling. Counselors may terminate counseling when in jeopardy of harm by the client, or another person with whom the client has a relationship, or when clients do not pay fees as agreed upon. Counselors provide pre-termination counseling and recommend other service providers when necessary (A.11.c.)

 

Even though termination for reasons of patient boundary violation issues is ethically and legally justified, it still represents a high risk area for practitioners.  Therapists should have a good understanding of what constitutes a boundary violation and how to manage the termination process as effectively as possible.  Even though one may be “proven” ethically and legally justified in a premature termination related to a boundary violation, avoiding the very stressful process of proving oneself is certainly a goal.  Reviewing cases related to this area can be helpful.

 

Two of the most frequently cited cases related to alleged abandonment are Ensworth v. Mullvain (1990) and Coddington v Robertson (1987).  As can be seen, these cases have firmly established that a therapist is on solid legal ground in terminating a patient that is threatening his or her safety.  Reviewing these cases can provide the therapist with some insight in how to manage similar issues – especially in the first case in which the therapist agreed to see the patient after initial termination to address the actual termination and “closure” issues.  This was done, in part, at the encouragement of the subsequent therapist.  This underscores two issues:  In cases of being threatened, therapists may have difficulty switching from a “caring for the patient mode” into one of self-protection.  There may be the fantasy that if one could just provide adequate termination and “closure”, the problem would be solved with everyone happy (including the patient).  The second is the therapist that encouraged the patient to return to see Dr. Ensworth for a few sessions to address termination and closure.  Although the details are unknown, this may not have been the best advice.  This case suggests that therapists should be aware of all issues in making recommendations to patients (related to similar issues).  Although unknown, some of the problems may have been avoided if Dr. Ensworth stayed with her decision to terminate the patient, transfer care, and not have any further contact.

 

Ensworth v. Mullvain.  As a brief overview, the patient (Ms. Mullvain) engaged in serious boundary violations and threatening behavior against Dr. Ensworth.  As a result, Dr. Ensworth referred the patient to another therapist and terminated her from treatment (all very appropriate).  However, Ms. Mullvain continued to have a pathological attachment to Dr. Ensworth and the patient’s new therapist encouraged her to schedule some follow-up visits with Dr. Ensworth to gain some “closure”.  Dr. Ensworth agreed to the sessions and an escalation in the threatening behavior increased.  The patient was again discharged by Dr. Ensworth and a restraining order obtained. 

 

 

Legal Case Example 4. Patient Boundary Violations

 

 

Ensworth v. Mullvain (1990; 224 Cal. App. 3d 1105 [274 Cal. Rptr. 447]) is considered a landmark legal case in terms of a patient violating boundaries.  Dr. Ensworth was a psychologist practicing in Pasadena, CA. Ms. Mullvain was her patient from November 1982 until September 1984, during which time the patient became very attached to the therapist and, evidently, engaged in some innocuous boundary violations.  Dr. Ensworth terminated the treatment in September, 1984. The patient did not accept the termination in treatment very well.  Mullvain started treatment with a new therapist who recommended that she see Dr. Ensworth briefly to more effectively obtain closure on the termination issue.  In hindsight, Dr. Ensworth made the mistake of seeing the patient again.

 

Apparently, Dr. Ensworth saw the patient again for a period of time to "resolve the termination issues to help [Mullvain] disengage from [Ensworth]." A series of more serious boundary violations occurred including harassing incidents.  Dr. Ensworth was forced to again terminate contact with Mullvain in May 1987 (which escalated the boundary violations). After the second termination, Ensworth sought a restraining order against Mullvain. The restraining order was granted from May 29, 1987 until November 29, 1988.

 

On November 29, 1988, Ensworth filed the petition in the matter before us, in which she sought a second restraining order. In the declaration filed in support of the petition, Ensworth stated that the "ongoing harassment" caused her "significant emotional distress" and was a distraction at work.

 

At the hearing, Ensworth testified that the prior restraining order kept down the incidents of harassment, but incidents did occur. Mullvain followed Ensworth's car, tried to stop her car in the middle of the street, circled around Ensworth's office building, kept her house under surveillance, drove repeatedly around her house, made numerous phone calls, sent threatening letters to Ensworth, and made phone calls to other professionals in the community in an effort to harm Ensworth's reputation. On December 22, 1988, Ensworth received a letter from Mullvain which stated her intention were as follows:

 

Mullvain would repeatedly violate a restraining order, that she would be willing to go to jail, and that she would be willing to do whatever necessary to continue to have contact with Ensworth and to make sure that Ensworth did not forget her. The letter alluded to committing suicide in Ensworth's presence (Ensworth v. Mullvain 1990, p. 449).

 

Nevertheless, the record contains sufficient evidence of Mullvain's harassment [224 Cal. App. 3d 1111] of Ensworth to allow the trial court to draw the conclusion that Ensworth indeed had suffered substantial emotional distress. Dr. Ensworth told of being followed and spied upon, and of receiving repeated phone calls and threatening letters from Mullvain, one of which alluded to committing suicide in Ensworth's presence. Moreover, Ensworth stated in her declaration in support of the petition for the injunction that Mullvain's harassment caused Ensworth "significant emotional distress."

 

The undisputed [224 Cal. App. 3d 1112] evidence demonstrated that Ms. Mullvain, among other things, followed Dr. Ensworth, circled around her office building, kept her house under surveillance, made numerous phone calls and sent threatening letters. These activities are clearly harassment, and the court found as a matter of law, that it was reasonably probable that such harassment would cause anyone emotional distress. Moreover, Ensworth stated in her declaration that Mullvain's activities indeed had caused her "significant emotional distress."  The evidence established that Ensworth needed the protection provided by section 527.6 and there was no error in issuing the injunction.

 

 

Coddington v Robertson.  As a brief overview, Coddington v. Robertson, involved the termination by a psychologist of a relationship with a patient (Ms. Coddington) who routinely communicated death threats to the psychologist (Dr. Robertson).  In the psychologist’s professional opinion, a respite from treatment was warranted, although further eventual treatment was not ruled out in the event that the patient ceased making threats.  The psychologist provided proper notice to the patient of the cessation of the relationship.  Due to the fact that the patient continued to make threatening telephone calls and write threatening letters, the psychologist refused to reinstitute the relationship.  Two years after the cessation of the relationship, the patient filed suit against the psychologist, alleging abandonment.

 

Utilizing the date that the psychologist withdrew from the relationship, the court ruled that Michigan’s two-year statute of limitations for malpractice actions was applicable to bar the patient’s cause of action.  Concurrent with this finding was the conclusion that the two-year gap in the relationship could not constitute “treatment” for the purpose of either establishing liability or staving off a defense that the complaint was time-barred.  While the court’s reasoning focused on the statute of limitations issue, the opinion it wrote scrutinized and found no fault in the psychologist’s withdrawal in the face of physical threats by his patient.  This case underscores a therapist’s absolute right to terminate therapy when threatened (boundary violation by the patient).  However, it also brings up interesting issues that the court had to rule on including what constituted treatment (when it started and when it stopped), and this related to our opening discussion of defining when therapy begins. Some of the details of this case are interesting and are as follows (Legal Case Example 5).

 

 

Legal Case Example 5. Patient Boundary Violations

 

 

Dr. Robertson was the defendant-psychologist from whom Ms. Coddington, the patient-plaintiff received therapy between August of 1979 and March 2, 1981. During this period, Ms. Coddingtgon wrote frequently to Dr. Robertson, causing the letters to be delivered immediately before her scheduled appointments. On March 7, the patient sent the therapist a letter which arrived on March 9, 1981, the day of her next scheduled therapy session. The letter stated in relevant part:

 

What I would really like to do is to hurt or kill.....you and all people like you ... I wish that I could kill you....

 

Dr. Robertson took these statements as a death threat which comported with psychological test results, and the patient's stated fantasies, showing her to be capable of violence. The therapist called the patient's place of employment with the message that he could not make the scheduled appointment that afternoon. When plaintiff went to the session anyway, she found doctor's office locked. 

 

On March 12, 1981, the plaintiff spoke with defendant by telephone. The therapist stated that the patient should take a "respite," "hiatus," or "break" from therapy and in his deposition also stated:

 

I felt that without therapy to stir matters up, that she could gain control. Sometimes the best therapy is none.

 

The patient's understanding from the conversation was that the therapist had discontinued treatment, although in a couple of months he might consider resuming treatment if, in the interval, she would forego therapy and stop writing to him. Instead of terminating therapy, however, the patient on March 20, 1981, sought counsel from a priest. At the end of that month (March, 1981) she began treatment with another therapist, Dr. Romulo Ancog, with whom she continued therapy through the time of her circuit court appeal.

 

On June 23, 1981, plaintiff again telephoned Dr. Robertson, as he had invited her to do in their March 12, 1981, conversation. The patient asserted that the defendant told her he would not resume treatment but the defendant did not remember the call. During 1981 and 1982, the patient continued writing letters to Dr. Robertson and also to her second therapist, expressing anger toward the defendant and threatening to "report" him and his "unprofessional manner."

 

On June 9, 1983, the patient filed a complaint in Oakland Circuit Court. When Dr. Robertson in December, 1983, moved for accelerated judgment due to expiration of the statutory period of limitations, the motion was denied without prejudice pending further discovery.  Finally, in April of 1985, after hearing argument and considering the pleadings, affidavits, depositions and letters written by the patient, the district court granted Dr. Robertson's motion without opinion. Upon appeal, the Oakland Circuit Court affirmed the district court's decision

 

The patient asserted that "failure to treat" was actually treatment. What constitutes "treating or otherwise serving" under the law is a question for the courts. The patient’s assertion that "failure to treat" was actually treatment, and that therefore her treatment did not cease until the telephone conversation of June 23, 1981, is directly contrary to case law. 

 

The patient's last session with defendant was on March 2, 1981. During the telephone conversation of March 12, 1981, defendant told plaintiff that he would not continue treatment and would only consider resuming treatment at a later time if plaintiff during the interim made certain changes. Contrary to plaintiff's present assertions, plaintiff did not make these changes. Instead, she continued in therapy and sent more letters to defendant. In conclusion, the circuit court affirmed and upheld the accelerated judgment granted to Dr. Robertson in district court for the reason that plaintiff failed to meet the two-year limitation period.

 

 

Change in Therapist Status (job, moving, illness)

 

There are a myriad of situations in which a therapist’s situation might necessitate the pre-mature termination of patients.  These include such thinks as changing jobs, moving, illness, selling one’s practice, etc.  In all of these cases, the therapist cannot simply terminate the patient(s) and transfer care to the “new” provider.  Proper and ethical termination, along with transfer of care, is still applicable regardless of the reasons for the therapist’s situation.  Some example ethical codes (certainly not a complete list) can be found in Table 12.

 

 

Table 12. Ethical Codes Related to Change in Therapist Status

 

 

APA

 

Standard 3.12, Interruption of Psychological Services: Unless otherwise covered by contract, psychologists make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted by factors such as the psychologist’s illness, death, unavailability, relocation, or retirement or by the client’s/patient’s relocation or financial limitations.

 

NASW

 

1.16 Termination of Services

 

(e) Social workers who anticipate the termination or interruption of services to clients should notify clients promptly and seek the transfer, referral, or continuation of services in relation to the clients’ needs and preferences.

 

(f) Social workers who are leaving an employment setting should inform clients of appropriate options for the continuation of services and of the benefits and risks of the options.

 

ACA

 

A.11.a. Abandonment Prohibited. Counselors do not abandon or neglect clients in counseling. Counselors assist in making appropriate arrangements for the continuation of treatment, when necessary, during interruptions such as vacations, illness, and following termination.

 

AAMFT CODE OF ETHICS, 2001

 

1.10 Marriage and family therapists assist persons in obtaining other therapeutic services if the therapist is unable or unwilling, for appropriate reasons, to provide professional help.

 

1.11 Marriage and family therapists do not abandon or neglect clients in treatment without making reasonable arrangements for the continuation of such treatment.

 

 

In the vast majority of cases, a change in the therapist’s status due to a change in job, concluding a supervisory relationship, moving, etc., should be anticipated and a plan established.  One common situation is that of training.  This might include a student completing an internship or assistantship (e.g. psychological assistant).  In these cases, it is well known that the therapist’s professional status is going to change at some point in the future (e.g. the therapist will become licensed and approved to treat patients independently).  Please see Case Example 5 that illustrates this point.

 

 

Case Example 5.  Change in Therapist Status

 

 

Sigmund had been a psychological assistant to Dr. Skinner for quite some time.  He had finally accrued enough supervised hours, took the state examination, and became successfully licensed to practice independently.  At that time, Sigmund (now Dr. Freud), opened up his own practice.  During the course of his internship, Dr. Freud treated a number of patients who desired to continue to treat with him at his new practice.  However, Dr. Skinner had a problem with this and told Sigmund that he could not take the patients with him.  He was instructed to terminate the therapy with these patients and transfer care to Dr. Skinner’s new psychological assistant, Anna.  When Dr. Freud (Sigmund) began terminating the patients, he was met with resistance from these patients (appropriately so), and even threatened with treatment abandonment.  Sigmund was in a quandary since he did not want to abandon his patients but was also afraid of the ramifications of “stealing” these patients from the practice of Dr. Skinner.  Dr. Skinner implied that, if Sigmund began seeing these patients in his new practice, he would sue him for damages.

 

 

In the Case Example, behavior of Dr. Skinner from an ethical and legal standpoint will not be addressed as part of this course.  Briefly, the courts have generally not looked favorably on “no-compete” clauses related to a doctor (provider) leaving one practice and setting up another within close proximity.  Related to this issue, certainly, changing dentists is quite a bit different from changing psychotherapists.  The issues in the Case Example (without the threat from the supervising doctor-therapist) might also occur when an intern finishes his/her training, “rotates” off of one service to start another, changes jobs, etc.

 

In the Case Example, Dr. Freud can certainly continue to see those patients who desire to continue with him, and defend against the consequences (the lawsuit by Dr. Skinner).  However, there are other issues.  In all likelihood, Dr. Freud will have been seeing his patients at a reduced fee, since he was an intern.  After becoming a fully licensed practitioner in independent practice (with associated overhead costs), Dr. Freud will seek to raise his patients’ fees which may trigger complaints from previous patients since this was not part of the original treatment agreement. Related to reimbursement issues, Dr. Skinner (his previous supervisor) may have belonged to various insurance panels under which many of Sigmund’s patients were being seen.  Of course, once Dr. Freud begins seeing them independently, these contracts do not apply.  At that time, reimburse rates and even an authorization to treat a patient, may change dramatically.  Patients (and Dr. Freud) may not anticipate this occurrence and not realize the problem until the EOB for services is received 30-60 days after each therapy charge.  This “surprise” in change of reimbursement does not endear oneself to patients and may result in retaliatory behavior.

 

The possibility of inappropriate premature termination and/or abandonment is a risk at two points in this Case Example.  First, is the situation in which Sigmund decides to comply with Dr. Skinner’s request and abruptly terminates and transfers care to the new intern.  Second, is the situation in which Dr. Freud takes many of the patients into his new practice and then abruptly raises his therapy fees.  For those patients unwilling or unable to pay the increase and accrued charges (since the patients were unaware of the change until the first billing and reimbursement cycle) he terminates them for “lack of payment” and turns them over to collection.  In the second scenario, Dr. Freud (being new to the nuances of independent practice) had failed to obtain new informed consent contracts from the patients carried over from his internship.  Of course, Dr. Freud could initiate a complaint against Dr. Skinner related to a possible ethics violation or legal issues.

 

This Case Example, along with any situation in which a change in therapist (transfer of care or termination) can be reasonably predicted (e.g., internship, moving after training is completed, planning on going into private practice from an agency job, etc.), underscores the importance of informed consent being completed at the very beginning of treatment and throughout the process.  This informed consent must include a discussion of termination. This situation, as with any related to supervision or being part of a group practice, should also underscore the necessity of understanding who “owns” the patients when and if the therapist leaves.  Of course, patients are free to do as they desire, but there are issues as to whether the therapists would/should accept them into the new practice and dealing with the group’s response to the “patient theft”.  

 

Out of Area of Competence

 

Every ethics code addresses treatment outside of one’s area of expertise and these issues are primarily covered in Competence (See Table 13).  In summary, a therapist is not to provide treatment for a problem outside of his or her competence, expertise or training.  Some of the codes make allowances for treatment outside of one’s area of competence under special circumstance if appropriate supervision is obtained.

 

The focus of this course is therapy termination and abandonment issues.  Competence relates to termination in multiple ways.  First, the therapist does an evaluation and takes on the patient even though it is clear that the presenting problem is outside the competence of the provider.  Once the patient realizes this (or there is a lack of progress), termination is completed. Since the patient has positive feelings about the therapy (albeit accomplishing nothing), s/he resists the suggestion of termination or referral to another practitioner.  This becomes a difficult termination issue since the patient questions why s/he was accepted for treatment in the first place (and now insurance benefits have been exhausted for the year).  Often, the therapist attempts to “cover his/her tracks” and the patient is never really aware that there was a lack of competence to treat from the beginning.

 

The second scenario is very similar to the first except the realization on the part of the therapist truly comes after therapy is underway (or a new problem emerges that becomes the focus of treatment).  In this case, a discussion with the patient must be completed and referrals to appropriate resources provided. 

 

Throughout this course, one of the common elements with difficult terminations is that the therapist has determined that it is the “right” and ethical thing to do, but the patient desires to continue “as-is”.  In these cases, there can be a great deal of resistance on the part of the client.  Often, especially if money or insurance coverage is not an issue, the patient is more than happy to come in week after week for “supportive” therapy (without any progress or accountability).  In the worst case scenario, any attempts at referring the client to treatment that may be more appropriate will result in feelings (and accusations) of “abandonment”. Of course, as these are brought up by the patient, the therapist may be inclined to continue with the status quo.  

 

 

Table 13. Example Ethics Codes Related to Competence

 

 

APA

 

Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience (2.01a).

 

NASW

 

Social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experiences, other relevant professional experience (1.04a)

 

ACA

 

Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience (C.2.a.)

 

AAMFT

 

Marriage and family counselors pursue knowledge of new developments and maintain competence in marriage and family therapy through education, training, or supervised experience (3.1) and do not diagnose, treat, or advise on problems outside the recognized boundaries of their competency (3.11)

 

NBCC

 

Certified counselors offer only professional services for which they are trained or have supervised experience (A.6) and recognize their limitations and provide services or use techniques for which they are qualified by training and/or supervision (A.7) 

 

 

Examples of difficult termination issues can be found in the following Legal Case Examples (6 and 7).  In Case Example 6, a family doctor, Dr. Grubin, was not found liable for abandonment and other issues, after referring a patient for psychiatric care (the patient ultimately committed suicide).  After the referral, Dr. Grubin withdrew from the patient’s care.  By that time, the patient was already involved in psychiatric treatment.  As discussed by the court (See Hilliard, 1998), it was concluded that the patient sought treatment for a specific condition (depression, anxiety, etc.), the doctor (Dr. Grubin) was unable to provide the necessary treatment, he informed the patient that these problems were outside of his area of competence, and he completed referrals for appropriate care (p. 219).  The court ruled that once the doctor completed the referral and withdrew from the patient’s care, there was no duty to treat despite the family’s repeated attempts to contact him.  

 

In malpractice actions, like most other negligence cases (accusations), the trial itself may have an adverse effect upon defendant's professional life. Courts should be aware that even allegations of malpractice against physicians and other professionals may have such effect. As noted in this opinion, the application of the principles of negligence law to the facts alleged by plaintiff should not render the defendant liable, and therefore the matter should be terminated at the pre-trial stage insofar as Dr. Grubin is concerned (although this does not always occur). A physician who upon an initial examination determines that he is incapable of helping his patient, and who refers the patient to a source of competent medical assistance, should not be held liable for the actions of subsequent treating professionals or for his refusal to become further involved with the case, and this is what the court found.

 

 

Legal Example 6. Out of One’s Area of Competence and Transfer of Care

 

 

In this medical malpractice action, defendant Dr. Grubin (the doctor) is a licensed and practicing physician of the State of New Jersey engaged in the general practice of medicine. The action alleged abandonment by a physician who had referred a patient for specialized services. On October 25, 1971, and for some time prior, decedent, George Brandt, Jr., (the patient) then 21 years of age, was alleged to have experienced periods of anxiety, loneliness and insomnia, as described by Dr. Grubin. On this date (and perhaps one other occasion) decedent consulted Dr. Grubin for examination, care and treatment of these conditions.

 

According to Dr. Grubin, the patient was seen on 10/25/71 and showed symptoms of anxiety, loneliness and insomnia. He presented with an impression of schizophrenia and was referred to the Elizabeth Mental Hygiene Clinic or the Mount Carmel Guild Mental Hygiene Clinic. He was given a prescription for a low dose of thorazine.

 

In the legal proceedings, Dr. Grubin characterized the patient's mental condition on October 25, 1971 as "an anxiety syndrome." He admitted that he was not a psychiatrist, but nevertheless prescribed thorazine to be taken by the patient "to take the edge off his anxiety." He admitted that the principal contraindication for the use or prescription of thorazine is depression, and the second most important contraindication is liver disease. With respect to depression as a contraindication, he noted that "the literature says in the presence of depression thorazine should be used very cautiously.”

 

After this one visit, and perhaps an additional contact a few days later, the patient did not return to Dr. Grubin. A month later, on November 21, 1971, the patient was treated at the Elizabeth General Hospital Emergency Room and was again advised to go to the Union County Psychiatric Clinic for further treatment. Two days later (on November 23, 1971) he was again admitted into the hospital's medical ward, and then placed in the psychiatric ward just prior to his suicide on November 26, 1971.

 

Part of the complaint against Dr. Grubin was his alleged unavailability.  As part of the plaintiff’s case, a plaintiff expert witness opined that there were three separate negligence claims. Set apart, these included:

 

“I think Dr. Grubin is guilty of departing from accepted standards of practice in not adequately assessing the seriousness of the situation when he saw the patient in his office. It was not enough that he merely suggest to the patient that he get psychiatric help. He (the patient) obviously was not competent to make judgments for himself or to follow directions given by a physician. Responsibility for this should have been placed in the hands of the family and they should have been notified about the seriousness of his problem.

 

The treatment that was given was totally inadequate. If there was any question in Dr. Grubin's mind about the severity of the psychiatric problem he should have seen to it that the patient got psychiatric consultation and evaluation before making any recommendations whatsoever. To simply give the patient a small dose of thorazine and tell the patient to get psychiatric help was clearly inadequate for the needs of the situation.”


With respect to his further conduct there apparently is a difference of opinion between the mother of the decedent (patient) and the doctor. She claims she tried to reach him and he did not respond to her calls. The doctor claims he got no calls. This would be a matter obviously for the jury to decide. I can only say that if it can be demonstrated that he did not respond to calls for help from the patient's mother and failed to call her back when she sought his help subsequent to his first examination of the boy, then this too would be a departure from accepted standards of practice. In this case, he failed to meet his obligations toward the patient or failed to be adequately responsive to the needs in this case. In short, the three claims of malpractice are Dr. Grubin's

 

(1) inadequate assessment of the "seriousness of the situation,"

(2) "inadequate" treatment 

(3) abandonment of the patient

 

The adverse physiological consequences of the dose of thorazine and its causal connection with the suicide are nowhere substantiated by competent medical proof.

 

With respect to plaintiff's claim that Dr. Grubin did not adequately assess the situation and should have informed the family of the need for additional treatment and the seriousness of the problem, the deposition of Mrs. Freda is revealing. Where Dr. Grubin has alleged in his interrogatories that he referred the decedent to a competent mental hygiene clinic, it appears that the reference was by means of a written direction which decedent was instructed to bring home to his family, and which they in fact received. The deposition states:

 

Q. You mentioned earlier when you were trying to convince your brother to seek psychiatric help that you did this on Dr. Grubin's advice.


A. Yes. That was only from the form that he sent to my brother. He wrote on it that my brother needed psychiatric help. He wrote exactly what was wrong, that he showed religious orientation and schizophrenia, something about schizophrenia, and something on the bottom he wrote, "needs psychiatric treatment." This is when Dr. Grubin had given this to my brother several days after he saw him. He told him that he would examine, you know, the case to find out just what should be done, and he told my brother to come back and my brother did go back and brought this form home for us.

 

Q. Do you still have that form?

 

A. No. That was to be brought to the Mt. Carmel Guild, which my brother did.

 

The mother, however, gave a different account. She stated:

"[Dr. Grubin] just told me what my boy needed and told him to go to Mount Carmel Guild."

 

Q. In other words, your son had some writing on a slip of paper, is that correct?

 

A. Yes, written down.

 

Q. Do you know what George (decedent) did with the piece of paper?

 

A. He went to Mt. Carmel Guild with it.

Later she also stated with respect to the Mt. Carmel Guild treatment: "He did went there a few times." [sic]

 

Thus we see that over a month before decedent's suicide Dr. Grubin had recommended psychiatric care not only directly to decedent, but in the note brought home to decedent's family; also, decedent entered into the recommended relationship with the mental health clinic. It was not until a month later that decedent went to the emergency room at Elizabeth General Hospital for treatment, and was advised to go to the Union County Psychiatric Clinic for further treatment. Two days after that decedent was admitted to the hospital, placed in a medical ward initially, and then in the psychiatric ward just prior to his death.

 

At these latter dates there was no contact with Dr. Grubin. The treatment by the doctor had terminated with respect to this illness when Dr. Grubin informed the patient and family that the decedent needed psychiatric help and referred decedent to a psychiatric clinic. There is no legal authority to support the expert witness opinion that there is a duty (especially in light of the confidential physician-patient relationship) of a physician to contact an adult patient's family with respect to treatment. But here responsibility was in effect placed in the hands of the patient and his family, who were specifically notified of the seriousness of the problem by the note on which was written (according to the patient's sister) "exactly what was wrong," and when the mother was told (according to her) "what my boy needed."

 

With respect to the treatment that was given, the inadequacy noted in the plaintiff’s expert witness report was that Dr. Grubin should have made sure that the patient obtained a psychiatric consultation and evaluation before making recommendations and administering the small dose of thorazine. But, applying the principles described in other cases, the facts in show that the patient was sent for the very help noted by the expert witness — a psychiatric consultation. To require a physician to obtain a consultation from the same source to which he is about to refer his patient would be meaningless. A general practitioner, when faced with a specialized problem, should not be faulted because he referred his patient to a specialist, or in this case a clinic of specialists, in a situation where the patient presumably could not afford private psychiatric help. The duty of the initial doctor ends upon the patient's undergoing the subsequent treatment. (See the following discussion concerning the abandonment issue.)

 

As noted earlier, no causal connection was supported by the expert's opinion with respect to the administration of thorazine. Even if Dr. Grubin had been negligent in failing to diagnose depression, and therefore should not have administered or prescribed thorazine, there was no demonstration this drug was a factor substantially contributing to the suicide. When this motion was initially argued the court was concerned with whether there could be a causal connection between the administration of thorazine and decedent's death. Consequently, plaintiff's counsel (the patient) was then given the opportunity to supplement his proof by submitting an expert's report. He was specifically directed to the problem of connecting the thorazine to the death. Since no such connection was supplied by the expert witness, the court could not supply this missing medical link in plaintiff's chain of proof. 

 

It is the third allegation that presents the greatest problem in assessing this case (for summary judgment). The first two points involved factual references by the expert which were not borne out by the statements of plaintiff's own witnesses in depositions and interrogatories. The third basis, however, involved a sharp conflict as to the facts and an application of legal principles. The court accepted plaintiff's version of the facts in deciding the motion and assumed that Dr. Grubin was repeatedly called for assistance during the days immediately preceding decedent's hospitalization.

 

The cases bearing on this point are collected in an Annotation, "Liability of Physician Who Abandons Case," 57 A.L.R.2d 432, 439-443. The general statement of the rule concerning a physician's withdrawal from the case is expressed as follows:

 

It is the settled rule that one who engages a physician to treat his case impliedly engages him to attend throughout that illness, or until his services are dispensed with. In other words, the relation of physician and patient, once initiated, continues until it is ended by the consent of the parties or revoked by the dismissal of the physician, or until the latter's services are no longer needed. However, the relationship of physician and patient may also be terminated by the physician's withdrawal from the case. It is well recognized that the physician has a right to withdraw from the case, but only after giving the patient reasonable notice so as to enable him to secure other medical attendance, and such a withdrawal does not constitute abandonment. [at 439, emphasis supplied]


Thus it may be stated as a general rule that a physician who is engaged to attend a patient is liable for any damages caused by his abandoning the patient without due notice to his patient, and without affording the latter an opportunity to procure the attendance of another doctor. Expressed differently, abandonment of a case by a physician without sufficient notice or adequate excuse is a dereliction of duty, and if injury results therefrom, the physician may be held liable in damages.

 

This court is of the opinion that the same rule must apply if a patient is examined by a physician who by reason of his general practice determines that he is unable to provide needed specialized treatment and that the patient must therefore be referred to a specialist. In this case the reference was made to specific clinics where specialized help would be available, and the patient actually underwent care at one of these clinics. The fact that the patient's mother had briefly utilized the doctor's services on an earlier occasion did not render him the patient's physician under any general contract to provide care. The only proofs before the court by way of expert reports, depositions and interrogatory answers show that the patient visited Dr. Grubin for a specific purpose and after this one visit Dr. Grubin found that he was incapable of providing the requested services. This was explained to the patient and the subsequent events cannot be legally ascribed to any abandonment by Dr. Grubin. Whatever efforts were made by the patient’s family to contact Dr. Grubin are of no legal import since no duty then flowed from Dr. Grubin to the patient.

 

 

In the next case example, the patient was referred for a very specific reason (preparation for surgery). At the initial evaluation, she was given appropriate informed consent along with patient reading-educational materials and homework exercises.  It was explicitly explained to her that a typical course of surgery preparation between 3-5 sessions pre-operatively and a few sessions post-operatively.  The intervention is fairly highly structured but also flexible taking into account the patient’s presenting biopsychosocial situation (aside from the technical aspects of the surgery) and course of the post-operative recovery.

 

 

Case Example 6. You’re Not an Expert at Everything – Competence

 

 

This was a 42 year old single female with no children presented by preparation surgery treatment prior to an extensive spine surgery. She was referred by her surgeon.  The initial evaluation was completed including a description of the surgery preparation treatment and informed consent.  Her coverage was Medicare with a secondary, so financial coverage for the treatment was not an issue.  The patient was totally disabled due to the pain, and had been so for quite some time.  During the course of the initial interview, it was determined that the patient was in long term psychotherapy with another psychologist for dissociative disorder, borderline personality, among other things.  The surgery preparation treatment was coordinated with the other psychologist (after proper releases were obtained) who was fully aware and supportive of the intervention.

 

The course of the surgery preparation achieved the agreed-upon goals but was challenging.  The patient continually attempted to bring in material unrelated to the surgery and was more appropriate for the other psychological treatment.  She called and left messages in an effort to make frequent contact outside the surgery preparation program.   She was continually and consistently redirected in terms of the surgery preparation issues, and boundaries were set in terms of contact (telephone calls) outside of the treatment.  For all issues not related to surgery preparation, she was referred back to her long-term psychologist.

 

The patient underwent the surgery and returned for the agreed-upon post-operative recovery sessions.  However, during this time, she did not reveal that she had terminated treatment with her psychologist.  She continued to present with difficulties (physical and pain) related to her post-operative recovery.  As a result, her surgeon recommended that the patient continue to participate in the psychological pain management treatment.  Her treatment continued longer than expected due to these difficulties.

 

At some point in the psychological pain management treatment, she revealed that she had terminated her treatment with her other psychologist (actually quite some time prior) and desired to continue to treat with the pain management psychologist for all of her problems.  Many sessions were spent discussing with the patient that her other problems were outside his area of expertise.  She “didn’t care” and expressed that she felt “comfortable” with him and the treatment was covered so “not to worry”. 

 

In an attempt to complete a reasonable termination from the pain management treatment, she was referred back to her psychologist and a final termination date set (2 more sessions).  It was then discovered that her psychologist was not willing to take her back into treatment.  The case was discussed with the psychologist who reported that the patient had been disruptive, demonstrated a lack of improvement, and difficult to work with, etc (all of the things you would expect from someone carrying these diagnoses).  Unfortunately, the psychologist’s method of termination was to “dump” the patient onto the pain management treatment once the opportunity arose.

 

Although the psychologist completing the pain management treatment may have been within his ethical and legal rights to rapidly terminate the patient (providing her with referrals) since the original treatment contract had been fulfilled (and her problems were outside his area of expertise) this did not seem to be in the best interest of the patient.  It also represented a very high risk area given her impulsivity, personality features, etc.

 

In consulting with colleagues (and documenting everything), it was decided that the patient would be referred but the treatment not terminated after the first meeting with a new provider.  This plan was discussed with the patient, who was in agreement.  Finding a therapist who treated Medicare-MediCal patients with a personality disorder of this nature was no easy task.  Eventually, a practitioner was found and the patient completed her initial evaluation.  The patient still did not want to terminate therapy with the pain management psychologist, but with the new treating psychologist available, termination from pain management was completed.  Two sessions for termination were scheduled and overlapped with the beginning of the other treatment.  Not surprisingly, the patient continued to attempt to continue in treatment with the pain management psychologist.  Due to a mistake by the scheduling desk, she managed to schedule another appointment after the final termination had been completed.  This was discovered and cancelled.  She called and left messages repeatedly making a myriad of threats (non-violent) along with pleading to be taken back into treatment.  She also wrote letters and attempted contact by email.

 

During this time, she was consistently referred back to the new treating psychologist.  She did follow-up with the new psychologist and started treatment. However, she continued to attempt to return to the pain management psychologist’s schedule for about 2 months after the pain management treatment termination and transition.       

 

 

Arranging Coverage in the Therapist’s Absence

 

As discussed by Reamer (2003), a therapist may be liable for abandonment if during the therapist’s temporary absence (e.g. vacation, illness, etc.), a patient does not have instructions about what to do in case of either emergency or the need for interim care.  Given the nature of the therapist-client relationship, it is not usual to provide a substitute therapist while the therapist is gone, but is certainly reasonable in appropriate cases. This brings up two issues related to planned absences:

 

(1) the patient should have a clear understanding of what to do in case of an emergency (e.g. the name and contact information for a colleague who is “covering”, calling 911, etc.).  This plan should be in writing and part of the written informed consent process which the patient signs.

 

(2) The second issue is that of patients in long term therapy who are fairly dependent on the therapist.  If the absence is going to be lengthy (e.g. 2-4 weeks and a patient is being seen twice per week and is “fragile”), then the patient will need to be appropriately prepared for the absence during the therapy prior to the absence.  Also, in these cases, arranging for the availability of a “substitute therapist” may be appropriate versus just telling the patient to call 911.  In these cases, it can be discussed with the patient that the therapist will provide a “substitute therapist” who will have all of the case information so that, if the patient needs to call or schedule an emergency appointment, the therapist will be familiar with the issues and treatment plan (assuming the patient is in agreement with this plan and give consent).

 

If the absence is not planned, then calling and informing patients about the situation is certainly appropriate (even if previous written informed consent has been completed).  This might occur if the therapist has a personal emergency or illness.  Ideally, these calls would be made by the therapist with a plan for coverage reiterated.  In some cases, it is not possible for the therapist to make the calls (illness).  In these cases, the person calling should explain the situation and arrange for coverage.  All of this should be documented in the record.  In some cases, similar to what was discussed above, arrangement for a substitute therapist might be necessary.

 

Transfer of Care

 

The very difficult termination issues exemplified by the case example of the surgery preparation treatment underscores that practitioners may be faced with situations in which s/he is fully justified to act in a certain way ethically and legally, but “going the extra mile” (as appropriate) can certainly decrease the risk of having to defend one’s actions. 

 

Most of the ethics codes suggest that pre-termination sessions be completed and that the patient be supported in any process that involves a transfer of care (referral).  The spirit of the ethics codes suggests this goes beyond simply handing the patient a list of 3 names for referral and wishing him or her “good luck”. Here are just a few examples (paraphrased from the codes): 

 

Psychologists make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted.

 

Social workers should take care to minimize possible adverse effects (of termination) and should assist in making appropriate arrangements for continuation of services when necessary.

 

Counselors provide pre-termination counseling and recommend other service providers when necessary. When counselors transfer or refer clients to other practitioners, they ensure that appropriate clinical and administrative processes are completed and open communication is maintained with both clients and practitioners.

 

Marriage and family therapists do not abandon or neglect clients in treatment without making reasonable arrangements for the continuation of such treatment.

 

Working with High Risk Patient Populations

 

We will just briefly mention that there are certain patient populations that represent higher risk for board complaints, ethics complaints, and malpractice actions almost regardless of the therapist’s actions.  All of these issues will not be covered in this course since that is not the focus.  In summary, any patient population that has:

 

     a propensity towards forming intense interpersonal relationships with alternating between idealization and devaluation;

     has low impulse control; 

     is very sensitive to feeling abandoned (real or imagined); 

     shows episodes of intense, and inappropriate anger which the patient cannot control; and

     has a pattern of affective instability

 

will represent a higher risk for difficult termination issues.  Aside from meeting the full diagnostic criterion for a Borderline Personality Disorder, any patient who shows some of these features will be a higher risk case (for any type of complaint against the therapist).  Although all of the recommendations in this course should be considered for every patient (e.g. implemented as part of one’s general practice), patients’ with the above characteristics require closer attention to detail, making sure one follows his/her usual office policy, being very careful about not making exceptions to the usual office policy (not recommended), and seeking documented consultation.    

 

Practical Guidelines

 

Issues that should be addressed in terms of therapy termination are derived from the many resources in the references.  I am certainly not recommending that a therapist practice so “defensively” that the informed consent, record keeping and termination process become overwhelming.  All of these guidelines are consistent with quality treatment and, quite frankly, would be appropriate even without the threat of liability.

 

Informed Consent: The Most Important Issue

 

As presented at the very outset of this course, and emphasized throughout, termination issues begin with the very first session (or before).  Every therapist should have a written informed consent document as part of the usual office forms.  The informed consent should include the usual information about the treatment relationship, the bounds of confidentiality, etc.  In addition, the informed consent should very clearly outline details of the financial arrangement.  This will differ depending upon how a therapist chooses to practice.  Some will use the “pay-as-you-go” method recommended by Knapp & VandeCreek (2006).  In these cases, the informed consent would outline the cost, expected method of payment (e.g. before or after each session), payment types accepted (e.g. credit cards), what might constitute reasons for termination (including inability to pay), and the termination process if it becomes necessary.  This discussion should also include who will submit the insurance if it is available (e.g. therapist, giving the patient a superbill to submit), and whether or not the therapist will do insurance appeals.  If the therapist is willing to help the patient appeal an insurance denial (even in the pay-as-you-go method), will there be a charge for the therapist’s time?  How many times will the therapist help with appeals?  All of these details are important to outline so there will be no incorrect expectations should any of these issues arise.

 

If the patient has insurance coverage, then the informed consent should discuss how billing will be handled and by whom.  It should also cover any information that is available about number of sessions available, how authorization for treatment will be obtained, what will happen if after a certain number of sessions, additional treatment authorization cannot be obtained, etc.

 

The therapist should have a frank discussion about these issues at the beginning of treatment.  For instance, a common scenario might be a patient who has a limited number of sessions available (e.g. 10) and has limited financial resources. This issue must be discussed with the patient especially if the therapist believes that the presenting problem will clearly require more treatment than will be covered by insurance.  Patients may not have a good understanding of this issue or the actual ramifications of starting a course of treatment that will clearly be inadequate.  This not only creates a situation in which treatment will be inadequate, but also has the potential to actually make the patient’s condition worse (e.g. stopping therapy after just beginning to identify issues could cause iatrogenic problems).  In these cases, the therapist might be wise to refuse to begin treatment under the circumstance or negotiate a sliding fee arrangement for the sessions after insurance coverage is gone.  Again, all of this should be discussed with the patient as part of the informed consent process BEFORE TREATMENT IS INITIATED.  Although many therapists are uncomfortable with this type of discussion, the risk of abandoning the patient in the middle of treatment is heightened if this type of informed consent is not done.  It is also consistent with high quality treatment.

 

As mentioned previously, I begin the informed consent process even before the initial evaluation session.  At the time of initial telephone contact, I have a very open discussion with the potential patient about the cost of therapy, the fact that insurance may not cover all of it (or any of it), and that I cannot guarantee coverage.  Patients will often want some type of reassurance that insurance will cover a certain amount of the treatment, etc.  To make any assurances related to potential coverage is a mistake.  The therapist may think he or she is being helpful (e.g., “I will help you get the most reimbursement possible” or “I will fight with your insurance to help you get all of the benefits to which you are entitled”) but this may be communicating a false sense of assurance that the treatment will be covered.  At this stage, both the patient and the therapist want to believe that everything will work out; however if after beginning treatment it is determined that no coverage is available and the patient either owes or has spent money s/he doesn’t have, there will be great feelings of animosity towards the therapist since it was implied that “it would all work out”.     

 

I have recently adopted a policy that the initial evaluation visit must be paid in full at the time of service.  Requiring this is a great litmus test for a potential patient’s attitude towards paying for therapy (versus having insurance coverage).  If the patient has a problem with this, then they will surely have a problem with finding out they have poor insurance reimbursement after 4 or 5 sessions of treatment (and concomitant accumulation of debt).  I have had many patients decide not to schedule the evaluation until they check with their insurance company.  I am happy to give them the CPT codes so they can complete their own “research”.  I also know of several companies that, in my experience, provide terrible coverage for mental health treatment.  I will often warn patients, prior to the initial visit, about this issue and recommend that they investigate benefits (if that is an issue and they don’t plan on being a “cash” patient”).  I would rather never begin the evaluation and treatment process than have a patient who has to drop out after 4 visits due to insurance reimbursement problems.

 

Having the patient pay for the initial visit is also consistent with the research in showing that many patients don’t really start treatment - 33% of patients do not return to psychotherapy after 1-2 sessions.  Having the patient pay for the initial session solves the problem of a patient who has undergone the initial visit (evaluation) and then, for whatever reason, decided not to come back.  Insurance is billed and a balance is remaining.  Previously, it is these situations that most commonly resulted in a lack of payment and bad debt.  Given the circumstances, these accounts were most often written off as bad debt.  I suspect that the patient in this situation was of the opinion that since treatment was not pursued (again, for whatever reason), then they really should be responsible for the evaluation cost beyond insurance coverage.  As will all of these termination issues, it is better to avoid problems than have to react to them.

 

Appropriate Documentation and Record Keeping

 

Proper record-keeping is important throughout treatment, from the initial informed consent to treatment termination (See the Documentation Course for more details).   As discussed by Younggren and Gottlieb (2008), this includes a termination and discharge note.  In cases of successful termination (which we have seen actually rarely occurs), the termination note can be fairly brief since the conclusion of treatment is agreed-upon by both parties, goals have been met, and follow-up recommendations discussed (e.g. as-needed, some type of maintenance schedule or other).  In cases of premature termination, especially if the patient is not in agreement, then careful and detailed documentation is important.  Remember the old adage in legal circles, “if it is not written down, it never happened.”

 

Managing Pre-mature Termination

 

Premature Termination that is predicted or planned.  The various ethical codes recommend premature termination counseling even if it is just a limited number of sessions.  Ideally, the therapist will be aware of the premature termination approaching, and it can be managed in a face-to-face fashion with the patient. An example might be an authorization to treat for 10 sessions and a request for additional sessions (made after the 7th session) is denied.  The therapist presumably then has 2-3 sessions to address premature termination.  Another situation is the client being unable to continue therapy due to financial out-of-pocket issues.  Other examples include a patient who feels s/he is not making progress initiates termination and treatment being terminated by the therapist due to lack of benefit to the client.  In all of these cases, termination counseling can be completed even if it is brief.  The premature termination counseling should include at the very least:

 

 

Table 14.  Components of Premature Counseling

 

 

A review of the course of treatment and the patient’s response

 

Assessment of current and future treatment needs

 

Recommendations for ongoing treatment (even if the patient does not agree)

 

An offer to see the patient again in the future (if appropriate)

 

Recommendations should emergencies occur

 

An offer to assist with the referral process if appropriate (e.g. the patient wants to continue therapy but with someone else, you are recommending the patient continue with someone else, etc.)

 

Offering the patient any other resources that might be beneficial (e.g. community resources, clinics that provide free or sliding-fee services,  

 

 

Some authors recommend writing out the reasons for the termination and request having the patient sign it.  In cases where the patient simply drops out of treatment, then it is recommended that a letter be sent.  Barnett et al. (2000) and Vasquez et al. (2008) have a number of example “termination” letters for use under various circumstances including:

 

     A patient in need of ongoing care drops out of treatment,

     A patient not making progress initiates termination,

     Treatment being terminated due to lack of benefit to the client, and

     Psychotherapist-initiated termination following an adverse utilization review decision. 

 

Premature termination that is not planned. Premature termination becomes more complicated when it is not planned for and premature counseling cannot be completed.  The most common example is a patient who simply drops out of treatment by not re-scheduling or calling and cancelling all future appointments without explanation (or minimal explanation).  This presents a dilemma for the therapist since termination issues and “closure” cannot be addressed. 

 

As discussed by Vasquez et al. (2008), if attempts to call and reschedule the patient fail, it might be tempting to assume that the therapist’s obligations have ended.  However, this might not be the case (which would be considered abandonment).  If efforts to reach the patient by telephone fail, then sending a termination letter as discussed above is recommended.  Although some authors recommended providing details about the patient’s course of treatment, current status, etc., it might be argued that a more generic letter is appropriate.  The goal is not to continue to attempt to continue the therapy through the letter (especially since the patient’s response cannot be predicted and cannot be managed in therapy).  In the spirit of the ethics codes and consistent with best-practices, the letter should serve to protect the client and offer alternatives should s/he choose to utilize them.  Issues that might be covered (depending on the circumstances) should include reviewing that the patient has not scheduled further treatment sessions (or cancelled them), that you have unsuccessfully attempted to reach the patient by phone, that you are available if s/he desires to discuss the termination or reschedule in the future, and that you are happy to provide other treatment resources if so desired.

 

Consultation with Colleague and Others

 

If confronted with any difficult termination issue, you should consult with colleagues.  Appropriate consultation with colleagues is recommended in a number of situations and is consistent with all of the ethics codes.  Ongoing consultation relative to the termination issues not only helps guide the therapist (by taking into all the relevant factors and points of view) but also establishes that multiple professionals had agreed on your chosen course of action if a problem ultimately occurs (e.g. state board or liability action against you).  Consultation in this manner establishes that you acted consistent with the community standard. Of course, you should document the content and result of your discussions with the consultant.  You should also request that the colleagues with whom you have consulted also make notes about the process.  I can’t say this enough, in a legal case, “if it is not written down, it never happened”.

 

The Termination Process should be Consistent with the Treatment Approach

 

As discussed in Younggren and Gottlieb (2008), your termination process should be consistent with your theoretical orientation and treatment intervention.   If you primarily provide long term, psychodynamically-oriented treatment, terminating a patient in one or two sessions is likely not appropriate.  Even in cases of unplanned, premature termination, allowance should be made for trying to terminate the therapy in a manner consistent with your treatment.  If you have been seeing a patient for 4 or 5 years and termination becomes necessary due to financial issues (e.g. sudden loss of job), allowing for several sessions of termination counseling should be provided.  I take the position that this should be done even if the patient does not have the financial resources to pay for them.  In these cases, I would recommend working out a lowered fee arrangement or doing it pro bono (which, although not required, would be consistent with the various ethics codes).

 

In other situations such as cognitive behavioral therapy for a specific condition (e.g. phobia of driving the freeway), termination may be handled in one session without much complexity.  In these cases, even when the termination is premature (e.g. competed 6 out of the 10 planned sessions), the final session may involve simply reviewing treatment progress and providing the patient with resources to continue to work on the CBT exercises. 

 

 

Table 15. Summary of Practice Recommendations

 

 

Informed Consent. Obtain written informed consent at the beginning of treatment and provide reminders to the patient throughout therapy.

 

Mutual Goals. Be sure that you and the patient agree on the goals for therapy, the process (e.g. frequency, likely length, completion of homework exercises, etc.), and the termination.

 

Document Progress. Complete periodic progress notes documenting the treatment, progress toward goals, adherence issues, and discussion of termination issues.  These should be different than therapy process notes. These progress summary notes also help keep a therapist on important issues such as whether the treatment is “working”, the goals to be attained, etc.  With many longer term patients (especially with good insurance or ability to pay), therapists can be lulled into a comfortable but non-productive process of seeing the patient week and week without any real progress,  accountability for nonadherence, or movement toward treatment termination (successful or otherwise).  

 

Preparation for Post-Therapy Life. Throughout therapy maintain appropriate focus (and discussions) on post-treatment functioning.  This should include such things as utilizing what the patient learned during the treatment, activating psychosocial resources outside of therapy, etc.

 

Be Educated about Termination Issues.  Most therapists are focused methods of building and maintaining their practices to the exclusion of treatment termination.  Having a good understanding of termination, premature termination and abandonment issues is equally important.  Part of this can be documented through taking continuing education courses on the subject.

 

Have a Plan for Patients who Unexpectedly Drop Out of Therapy. Have a plan for managing patients who drop out of therapy unexpectedly (in which premature termination counseling cannot be provided).  Document any attempts to contact the patient, content of the telephone discussions, etc.  Also have a plan in place, as part of your office policy, for managing these occurrences (e.g. sending a termination letter, etc.)

 

Assistance with Guiding Your Behavior.  You should use your ethics codes, consultations with colleagues, and state practice regulations to guide your professional behavior in dealing with termination and premature termination (and avoiding abandonment).

 

Objectively Monitor the Patient’s Response to Treatment.  Consistently monitor your clinical effectiveness with a patient.  Objective assessment of patient progress is probably more common in CBT approaches that target a specific problem than it is in psychodynamic psychotherapy.  Although probably infrequent in real-world practice across all practice types, using appropriate objective measures, regardless of theoretical orientation, to gauge a patient’s response to treatment can be very helpful.  This removes the thorny issue of the therapist subjectively assessing his or her own effectiveness with a specific patient.  The inherent conflict is that no therapist is motivated to create an opening in his or her schedule (especially if it involves terminating a well-paying, “easy” treatment case).  This is also combined with the seductive conclusion on the part of the therapist that since the patient is continuing to attend treatment he or she must be getting something out of it even if it cannot really be measured.  Objective testing, used in a repeated measures format, really forces a therapist to consistently address the issue of treatment effectiveness.

 

 

RESOURCES AND REFERENCES

 

Barnett et al. (2000).  Risk management and ethical issues regarding termination and abandonment.  In L. VandeCreek & T. Jackson (Eds.), Innovation in Clinical Practice (pp. 231-246).  Sarasota, FL: Professional Resources Press.

 

Benitez, B.R. (2004). The decision to terminate therapy. The Therapist, California Association of Marriage and Family Therapist (CAMFT).

 

Bernstein, B.E. and Hartsell, T.L. (2004). The Portable Lawyer for Mental Health Professionals, Second Edition.  Hoboken: NJ: John Wiley and Sons. 

 

Ensworth v. Mullvain 224 Cal. App. 3d 1105, 274 Cal. Rptr.447(Oct. 1990).

 

Davis, D. (2008). Terminating Therapy: A Professional Guide to Ending on a Positive Note.  Hoboken: NJ: John Wiley and Sons. 

 

Davis, D. and Younggren, J.N. (2009). Ethical competence in psychotherapy termination.  Professional Psychology: Research and Practice, 40, 572-578.

 

Fisher, M.A. (2011). Psychotherapist variables affecting termination.  Professional Psychology: Research and Practice, 42,163-165.

 

Garfield, S.L. (1994). Research on client variables in psychotherapy. In A.E. Bergen and S.L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed, pp.190-228), New York: Wiley.

 

Gutheil, T.G. and Brodsky, A. (2008). Preventing Boundary Violations in Clinical Practice.  New York, NY: The Guilford Press.

 

Hill, C.E. (2005). Therapist techniques, client involvement, and the therapeutic relationship: Inextricably intertwined in the therapy process. Psychotherapy, 42, 431-442.

 

Hilliare, J. (1998).  Termination of treatment with troublesome patients.  In L.E. Lifson and R.I. Simon (Eds.) (1998). The Mental Health Practitioner and the Law (p. 216-221). Cambridge, MA: Harvard University Press. 

 

Hjelt, S.E. (2011). Psychotherapy termination: Duty is a two-way street. Professional Psychology: Research and Practice, 42,167-168.

 

Kendall et al. (1992). When clients don’t progress: Influences on and explanations for lack of therapeutic progress.  Cognitive Therapy and Research, 16, 269-281.

 

Knapp, S.J. & VandeCreek, L.D. (2006).  Practical ethics for psychologists: A positive approach (pp. 147-160). Washington, DC: American Psychological Association.

 

Koocher, G.P. and Keith-Spiegel, P. (1998; 2008). Ethics in Psychology: Professional Standards and Cases (2nd ed; 3rd. ed). New York: Oxford

University Press.

 

Lifson, L.E. and Simon, R.I. (1998). The Mental Health Practitioner and the Law: A Comprehensive Handbook.  Cambridge, MA: Harvard University Press.

 

Reamer, F.G. (2003). Social Work Malpractice and Liability: Strategies for Prevention (2nd ed.).  New York: Columbia University Press.

 

Roe, D. (2007) The timing of psychodynamically oriented psychotherapy termination and its relation to reasons for termination, feelings about termination, and satisfaction with therapy. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 35:3, 443-453

Roe, D., Dekel, R., Harel, G., et al.  (2006). Clients' feelings during termination of psychodynamically oriented psychotherapy. Bulletin of the Menninger Clinic, 70 (1), 68-81.

 

Shapiro, D.L. and Smith S.R. (2011).  Malpractice in Psychology: A Practical Resource for Clinicians.  New York: APA Books.

 

Simon, R.I. and Shuman, D.W. (2007). The doctor-patient relationship. Clinical Manual of Psychiatry and the Law, 17-36.

 

Stewart, R.E. and Chambless, D.L. (2008). Treatment failures in private practice: How do psychologists proceed? Professional Psychology: Research and Practice, 39, 176-181,

 

Treloar, H.R. (2010). Financial and ethical considerations for professionals in psychology.  Ethics and Behavior, 20, 454-465.

 

Vasquez, M.J.T. et al. (2008). Psychotherapy termination: Clinical and ethical responsibilities. Journal of Clinical Psychology: In Session, 64, 653-665.

 

Younggren, J.N. (2011). Psychologist duties, patient responsibilities, and psychotherapy termination.  Professional Psychology: Research and Practice, 42,160-163.

 

Younggren, J.N. and Gottlieb, M.C. (2008). Termination and abandonment: History, risk and risk management. Professional Psychology: Research and Practice, 39, 498-504.

 

Legal Cases Cited

 

Brandt v. Grubin (1974.) 131 N.J. Super. 182 329 A.2d 82

 

Coddington v Robertson (1987).  160 Mich. App. 406 407 N.W.2d 666

 

Ensworth v. Mullvain (1990). 224 Cal. App. 3d 1105 [274 Cal. Rptr. 447]

 

Hughes v. Blue Cross (1989). 215 Cal.App.3d 832 263 Cal. Rptr. 850

 

Marshall v. Klebanov (2006). 902 A.2d 873 188 N.J. 23

 

Miller v. Greater Southern Community Hospital (1986). 508 A.2d 927 (D.C. App 1986)

 

Wickline v. State of California (1986). 192 Cal.App.3d 1630 (1986) 228 Cal. Rptr. 661

 

Wilson v. Blue Cross (1990). 222 Cal.App.3d 660 271 Cal. Rptr. 876

 

 

 

 

 

 

 

 

 

 



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