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REDUCING PREMATURE TERMINATION IN PSYCHOTHERAPY

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


6 Credit Hours - $99
Last revised: 06/28/2016

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. The end should be there from the beginning.”

 

 

COURSE OUTLINE

 

Introduction

Learning Objectives

Definitions

Successful Termination

Premature Termination

Patient-Initiated

Clinician-Initiated

Abandonment

Patient-Initiated Premature Termination

Reasons for Patient-initiated Premature Termination

Reducing Patient-Initiated Premature Termination

Pretherapy Preparation

Patient Selection

Time-limited or Short-term Treatment Contracts

Treatment Negotiation

Case Management

Appointment Reminders

Motivation Enhancement

Facilitation of a Therapeutic Alliance

Facilitation of Affect Expression

Clinician-Initiated Premature Termination

Difficult Termination Situations: What Would You Do?

Factors Influencing Pre-Mature Termination

Provider-Therapist Variables

Patient Variables

Type of Treatment

Extra-Therapy Variables

Areas of Premature Termination by the Therapist

Financial and Reimbursement Issues

Reimbursement – Utilization Review

Multiple Relationships and Conflicts of Interest

Lack of Progress in Treatment

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

 

 Introduction

 

Some of the material in this course overlaps with the course, Difficult Therapy Termination Issues under Ethics and Risk Management.  This course is primarily clinically focused, whereas the other course includes clinical materials with a special focus on ethics and risk management.  As with all of our courses, these can be reviewed prior to purchase to determine which best suites your needs.

 

This course addresses premature psychotherapy termination including patient-initiated and clinician-initiated.  Therapy termination initiated by the patient refers to his or her decision to end therapy contrary to the therapist’s current recommendation and the initial agreement between patient and therapist.  Relative to patient-initiated termination, this course will review such topics as the rate of occurrence, reasons, and strategies for reducing or preventing patient-initiated premature therapy termination.

 

For clinician-initiated premature termination many topics will be reviewed including: 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, avoiding abandonment, among other things. 

 

 

LEARNING OBJECTIVES

 

 

Explain the difference between successful termination, premature termination (patient/clinician-initiated) and abandonment

 

Explain five methods of reducing patient-initiated premature termination

 

Discuss factors influencing pre-mature termination including provider-therapist variables, patient variables, type of treatment and extra-therapy variables

 

List the common areas of clinician-initiated premature therapy termination

 

Discuss practical guides for terminating therapy successfully

 

  

Definitions

 

Any discussion of therapy termination must necessarily include a review of definitions.  These definitions include termination initiated by the patient, by the therapist, as well as the problem of abandonment.      

 

Successful Termination

 

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).  Ideally, clinician and patients agree about when to terminate psychotherapy.  Table 1 includes various definitions of “successful therapy termination”.

 

 

Table 1. 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 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 (See Table 2):

 

 

Table 2. 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 going through the termination process and not due to any specific action on the part of the therapist

 

 

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 in 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% complete 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, and 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 recommendations, 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 premature termination (e.g. no-show for one or more sessions, dropping out of therapy, an adverse UR decision, lack of payment, etc.).

 

Premature Termination

 

Patient-initiated.  Therapy termination initiated by the patient refers to his or her decision to end therapy contrary to the therapist’s current recommendation and the initial agreement between patient and therapist (Ogrodniczuk et al., 2005). These terminations are also referred in the literature as unilateral terminations, discontinuing, or dropping out.  Patient-initiated premature termination typically occurs early in therapy before the patient has experienced any significant benefit or improvement. In the context of this discussion, patient-initiated termination refers to a situation in which there are no extra-therapy reasons justifying the termination (e.g. illness, finances, moving, etc.).

 

Patient-initiated premature therapy termination may or may not represent a treatment failure. In some cases, patients may have received the expected benefit from the intervention, but have simply discontinued treatment without going through a more “formal” termination process. In these cases, at least as assessed by the patient, the treatment has been a “success” even though the termination process was not completed. In other cases, the patient may accurately and appropriately feel that the treatment is providing no benefit even though he or she has been fully involved in the process. Instead of confronting the therapist about the issue and having an open discussion, the decision is made to simply drop out.

 

Clinician-initiated. Premature termination by the clinician 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) on the part 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 3.  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 and can be either patient or clinician-initiated.

 

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

 

 

Abandonment. Abandonment is an inappropriate premature termination 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). 

 

 

Table 4. 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 psychologically 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).

 

 

PATIENT-INITIATED PREMATURE TERMINATION

 

Therapy termination initiated by the patient refers to his or her decision to end therapy contrary to the therapist’s current recommendation and the initial agreement between patient and therapist (Ogrodniczuk et al., 2005). In the context of this discussion, patient-initiated termination refers to a situation in which there are no extra-therapy reasons justifying the termination (e.g. illness, finances, moving, etc.).  This section will focus primarily on patient-initiated premature termination in which the patient is not assessing the treatment as a “success”.  However, even in those cases, there may be reasons that a patient simply stopped treatment rather than discussing with the clinician that he or she felt the problems targeted in treatment had been successfully addressed.

 

As discussed in the literature, patient-initiated premature termination can result in many problems, the most obvious of which is that the patient did not have the opportunity to obtain full benefit from treatment and participate in the appropriate termination process. The patient may experience a sense of failure and a worsening of symptoms. Research has demonstrated that premature terminators are more likely characterized as chronic patients with a tendency to over utilize services (up to twice the rate of appropriate terminators). 

 

Research has demonstrated that the rates of patient-initiated premature termination are typically high. In a meta-analytic study of 125 studies of different forms of psychotherapy, Wierzbicki and Pekarik (1993) reported an average rate of 47% and this is consistent with other studies.  However, rates for short-term, time limited therapy may be lower.  One study found that the dropout rate in a clinic that shifted from a long-term therapy model to a brief intervention orientation went from 62% to 32% (Straker, 1968). In another study, it was found that those involved in brief therapy dropped out at a rate of 13% within the first six months.  For those involved in long term therapy the rate was 41% within the same time period (Reder and Tyson, 1980).  Similar results have been found for more structured approaches such as cognitive behavioral therapy (CBT).  When the CBT is time-limited, the dropout rate is about 17%.  When it is more open-ended, the rate is 50%.  It has also been found that the dropout rate for structured interventions provided within a clinical research setting are much lower than those found for the same treatment approaches in a private practice setting. 

 

More recently, Roe et al. (2006) investigate reasons for unsuccessful termination including those that were premature.  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”.

 

Reasons for Patient-initiated Premature Termination

 

Many reasons have been put forth as to why patients terminate therapy prematurely.  These are mostly based on conjecture and include such things as patient anxiety about self-disclosure, not agreeing with the therapist about problems to address, feeling the therapist is not empathic, feeling criticized by the therapist, perceiving that improvement is not occurring quickly enough, etc. (See Ogrodniczuk et al.,2005; Westmacott & Hunsley, 2010). 

 

Roe et al. (2006) investigated reasons using a more empirical approach.  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 5.   

 

 

Table 5. 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.  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 assess 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 and this seems to be the case based on the previous literature review. 

 

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 being cognizant of these issues since this study suggests they are occurring more frequently than most realize.

 

As can be seen in Table 5, 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 therapist 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. 

 

Reducing Patient-Initiated Premature Termination

 

A recent study by Ogrodniczuk et al. (2005) attempted to identify strategies for reducing patient-initiated premature therapy termination.  The authors identified 39 studies that specifically discussed strategies for preventing or reducing patient-initiated premature termination (PIPT).  These strategies were then grouped into nine sections and these are summarized in Table 6.

 

 

Table 6. Strategies for Preventing/Reducing Premature Termination

 

 

Pretherapy preparation

 

Patient selection

 

Time-limited or short-term treatment contracts

 

Case management

 

Appointment reminders

 

Motivation reminders

 

Facilitation of a therapeutic alliance

 

Facilitation of affect expression

 

 

Pretherapy preparation. One of the most commonly discussed methods for preventing premature termination refers to any procedure prior to therapy that attempts to educate the patient about the process of therapy.  The objective is to provide information about the rationale and nature of the treatment, the roles and obligations of each party (clinician and patient), and about difficulties that can arise during the course of treatment.  Of course, this is all consistent with appropriate informed consent.  Going beyond informed consent, pretherapy preparation will involve such things as clarifying patient expectations, addressing any incongruities between the therapist and patient, and to enhance the patient’s readiness for treatment.  In a real world setting, pretherapy preparation can be done as part of the first session or two.  This is best explicitly stated to the patient. 

 

Patient selection.  Patient selection refers to the process of carefully screening and choosing the most suitable candidates for the type of therapy provided by the clinician, as well as his or her area of expertise (this will also be reviewed in more detailed under the next section).  The rationale behind this approach is that the better the match between the therapist and patient (across all categories), the less likely that premature termination will occur.  One should be cognizant of both a good therapist-patient match and a patient-treatment approach match. After appropriate evaluation, patients who are determined to be at high risk for dropping out, may be offered a different treatment approach, not accepted for treatment, or referred elsewhere with a higher chance of success. The issue of patient selection and matching presenting problems with specific treatment approaches (e.g. CBT) is becoming more and more relevant given the proliferation of evidence-based practice guidelines.

 

Time-limited or short-term treatment contracts.   As discussed in the previous literature review, multiple studies have demonstrated a significantly lower premature termination or dropout rate in shorter term therapies and those with specific time limits.  Making therapy time-limited along with treatment contracts serves several purposes that work against PIPT.  Using these methods, the patient has a clear understanding of what to expect and that treatment will have a definitive endpoint.  This may help patients continue with therapy (even when it is a difficult process) since they know it will end.  Using this method can also help the therapist keep focused on the task at hand since the therapeutic relationship will not go on forever.

 

Using this model does not preclude a longer term therapy approach if indicated.  The clinician can use a short-term contract to begin treatment.  This achieves all of the goals discussed above, along with providing information about the patient’s motivation to participate in treatment.  Once the contracted time has been completed, there is the option of completing another short term contract to continue to address areas in which progress is being made but is not yet complete.

 

Treatment negotiation. A useful strategy that is an extension of many of those previously reviewed is treatment negotiation.  Treatment negotiation is done as part of the pretherapy process. Treatment negotiation involves many features depending on the situation. One common element is that of clearly identifying the problem(s) that are to be the focus of treatment.  This process requires that the therapist be receptive to the patient’s perception of the problems (and solutions), as well as openly discussing the therapist’s viewpoints. At the endpoint, both the patient and therapist should have a concrete understanding of what will be the focus of treatment.

 

Treatment negotiation also involves a discussion of the therapist’s rationale for utilizing a specific type of intervention.  This discussion should include educating the patient about the treatment approach, what will be expected of both parties, and addressing any modifications that will be made based on patient input.  

 

Case management. Investigating the method of case management is relatively new to the area of reducing premature termination.  Case management focuses on addressing stressful life circumstances that are likely to interfere with treatment.  As discussed by Ogrodniczuk et al. (2005), case management might address such things as problems with housing, employment, recreation, and relationships. Case management might involve telephone contact and/or face-to-face meetings. The case manager is not the therapist, but acts more as a “coach” to help the patient deal with difficult circumstances.  Case management to assist in reducing premature termination of psychotherapy treatment is probably most relevant to impoverished social classes where personal resources are limited.  During the initial phases of psychotherapy, if the clinician determines life circumstances may be an issue, helping the patient access community resources that might help with case management may be critical.

 

Appointment reminders.  Other health care providers such as dentists and physicians are now commonly using appointment reminder telephone calls (or email or texts, for that matter), to remind patients of appointments.  This has not commonly been practiced in psychotherapy treatment and this is likely for two reasons: (1) in treatment, appointments are often the same time every week (“a standing time”), and (2) many psychotherapists, particularly psychodynamically oriented, believe that it is the patient’s responsibility to be accountable to attend appointments.  If a patient does not, then that is material for the psychotherapy process.

 

If the therapist’s orientation allows for appointment reminders, this can be an excellent method to reduce premature termination.  In some cases, the reminders are only done in the initial stages of treatment (e.g. the first few sessions) and then may not be necessary if the appointment time is the same from session to session.

 

Motivation enhancement.  Another method of reducing premature termination is to focus specifically on motivation enhancement.  Motivation enhancement is defined as, “increasing a person’s willingness to enter into, continue, and adhere to a specific change strategy” (Ogrodniczuk et al. (2005, p. 66). Motivation enhancement has been shown to not only help patients remain engaged in therapy but also the overall benefit gained.  As discussed by Ogrodniczuk et al. (2005), there has not really been much attention to methods for enhancing motivation for therapy.

 

One model of motivation enhancement for therapy has been developed by Walitzer et al. (1999).  The model is described by the acronym FRAMES (See Table 7).  The FRAMES method has primarily been used in the treatment of substance use and eating disorders but can be adapted for use in psychotherapy. 

 

 

Table 7.  Motivation Enhancement using FRAMES

 

 

Feedback

 

 

Providing and discussing results from pretreatment assessments

 

 

Responsibility

 

 

Making it clear to patients that it is up to them to decide what to do about their problems

 

 

Advice

 

 

Offering professional opinion and guidance

 

 

Menu of Strategies

 

 

Providing options for ways to change

 

Empathy

 

 

Demonstrating concern and understanding of patients’ difficulties

 

 

Self-efficacy

 

 

Stressing that treatment is likely to be successful if patients are committed to change

 

 

As can be seen, the FRAMES model has much in common with what most clinicians attempt to accomplish as part of their treatment.  However, the FRAMES model differs in that it is a “planned effort to engage in these behaviors in an organized manner for the explicit purpose of enhancing the patient’s motivation for, and commitment to engage in, therapy.”  Other suggestions for motivation enhancement include:

 

Correcting patients’ misconceptions about psychotherapy

 

Creating incentives for change

 

Eliciting self-motivational statements

 

Acknowledging and praising the patient’s serious consideration of, and steps toward change

 

Reframing problem behaviors so that they appear less formidable

 

Facilitation of a therapeutic alliance.  Most of the strategies discussed previously for preventing PIPT occur before the clinician and patient begin the formal treatment process.  This is indicative of the widely held conclusion that preventing PIPT involves procedures that are implemented early in the intervention.  However, it is also important to pay attention to other factors during ongoing treatment.  One of the most important areas is the therapeutic alliance.  The specifics of how to develop a strong therapeutic alliance will not be reviewed here but generally involve the Rogerian concepts of warmth, regard, empathy, and genuineness. A strong therapeutic alliance is important not only for a positive treatment outcome, but also to keep the patient involved in the therapy especially during difficult times.  

 

The therapeutic alliance and its relationship to premature termination were investigated directly by Samstag et al. (1998).  The entire article can be viewed here or here.  In the study, patients were scheduled to complete 40 sessions of short term psychotherapy.   All patients (and therapists) completed a number of questionnaires after each session designed to assess in-session therapeutic alliance.  Three groups were investigated: Dropouts from therapy, completed treatment with good outcome, and completed treatment with poor outcome. Although the study investigated many variables, one area was the effect of therapeutic alliance on premature termination.  Some example questions done after each session can be seen in the following.  Each of these questions was rated on a 1 (never) to 7 (always) scale (some are reversed scored).

 

 

Post-Session Therapeutic Alliance Questions

 

 

My therapist and I agreed about the things I need to do in therapy to help improve my situation.

 

What we are doing in therapy gave me new ways of looking at my problem.

 

I believe that my therapist likes me.

 

My therapist did not understand what I am trying to accomplish in therapy.

 

I was confident in my therapist’s ability to help me.

 

My therapist and I worked towards mutually agreed-upon goals.

 

I felt that my therapist appreciates me.

 

We agreed on what is important for me to work on.

 

My therapist and I seemed to trust one another.

 

My therapist and I seemed to have different ideas on what my problems are.

 

We had a good understanding of the kind of changes that would be good for me.

 

I believed the way we were working with my problem was correct.

 

 

As was expected, the researchers found that therapeutic alliance scores of the dropout group were significantly worse than those of the good outcome group, with the poor outcome cases falling in between the two.  This finding was consistent for both therapist and patient ratings, although patients’ ratings were demonstrated to be more sensitive in discriminating dropout from both good and poor outcome cases. 

 

Facilitation of affect expression. As treatment progresses, the likelihood of PIPT may be reduced if the clinician can create a safe atmosphere in which the patient can work through uncomfortable affects. When patients do not feel comfortable enough to express negative feelings about the therapy experience, they will often simply prematurely terminate (usually by dropping out without explanation, etc.).

 

The problems can be addressed (ahead of time) in a number of ways. For instance, therapists should actively encourage patients to express their doubts and questions about therapy.  During these inquiries, and at any other time, the therapist should permit patients to express negative emotions including negative transference. Of course, focusing only on the expression of negative emotions can actually be detrimental to the therapy process.  It is most prudent to facilitate the expression of both negative and positive affect in an effort to keep patients engaged in therapy.

 

CLINICIAN-INITIATED PREMATURE TERMINATION

 

Any discussion of premature termination must include both patient and clinician perspectives. We have just reviewed patient-initiated termination and methods to decrease its occurrence. Equally important are clinician-initiated premature therapy termination situations.  Being aware of these potential “landmines” can help decrease their occurrence.  Clinician-initiated premature termination can occur for many reasons, both appropriate and inappropriate.  Imagine the following not uncommon dilemmas that represent actual occurrences and 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 to pay any more.  He continues to schedule therapy appointments and consistently states that he feels he 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 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”.

 

 

Factors Influencing CLINICIAN-INITIATED PreMATURE Termination

 

The best case scenario 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 clinician-initiated 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 most ethical guides. 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. In these cases, termination is often patient-initiated as he or she gets more and more frustrated with the approach. If the clinician is aware of these issues, they can be discussed in an open fashion and alternative options developed.  This might include clinician-initiated premature termination (appropriate) including some resolution with the patient and provision of resources for treatment elsewhere.

 

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.

 

AREAS OF CLINICIAN-INITIATED 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 and treatment issues that should be addressed from the beginning of therapy. As documented in the various ethical codes, as well as the community standard of care, it is not unethical to terminate a patient who cannot pay. 

 

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 termination 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 (and best practices) 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 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.      

 

 

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…..”

 

 

In both of these cases (Case Examples 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. 

 

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).   

Being very clear about financial issues throughout the treatment process will help prevent the need for clinician-initiated premature termination due to these issues.

 

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.).

 

Preventing premature termination due to UR issues, can be accomplished by being very aware of the number of visits authorized, requesting additional visits well in advance of the final approved visit, and getting the patient involved in the process from the beginning.

 

Multiple Relationships and Conflicts of Interest

 

Relative to the current discussion is the relationship between multiple relationships and termination of therapy or 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 treatment issues (including ethical and liability) related to dual and multiple relationships.  As discussed by Koocher and Keith-Spiegel (1998), multiple role relationships 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 area.  Multiple role 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 relationships also involve romantic encounters with a patient either concurrent with professional treatment (therapy) or after termination.  All ethical codes address multiple relationships and conflicts of interests. 

 

One of the most common violations (ethical, legal, standard of care) 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 clinician-initiated 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.).

 

Romantic and sexual involvement with patients is addressed by the various ethical codes.  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 violation 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).  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 clinician-initiated premature therapy termination.  This behavior certainly might be conceptualized as abandonment.

 

In these cases, 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.       

 

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 to 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 party 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 insurance 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 the 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.     

 

This case could certainly been handled in a different manner resulting in a much high chance for treatment success.    

 

 

Case Example 3.  Lack 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 in 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 patients 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”.   Patients presenting with these features are at high risk for being subjected to inappropriate clinician-initiated termination.  Basically, the therapist will keep seeing the patient until some extra-therapy issues preclude further visits, such as financial problems, loss of insurance, etc.  Then, and only then, does the therapist initiate the termination process, which is often rapid and inappropriate.

 

 

Table 8. 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.

 

 

The issue of lack of treatment progress is certainly 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 clinician-initiated premature 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 appropriate (and ethical) management of this case.  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.

 

Nonadherence

 

Nonadherence or noncompliance with treatment recommendations can be an appropriate reason for clinician-initiated premature termination.  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, inconsistent 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 (treatment negotiation, as discussed earlier).  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.

 

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

 

As discussed previously, one reason for patient-initiated premature termination is therapist-patient mismatch.  From the viewpoint of the therapist, this issue should be addressed and managed before the patient decides to “dropout” of therapy.  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 and certainly before the patient simply drops out (with the possibility of creating a failure experience in the patient; e.g. clinician-initiated rather than patient-initiated termination).  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 against 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

 

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 various ethical codes address the situation of a therapist being threatened by a patient.

 

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.

 

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 things 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. 

 

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, the 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, reimbursement 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”.

 

As with many of the problems we are reviewing, this situation could easily have been a “successful” termination if handled appropriately from the beginning.    

 

Out of Area of Competence

 

Every ethics code (and standards of care) addresses treatment outside of one’s area of expertise and these issues are primarily covered in Competence.  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 premature therapy termination.  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.  In both of these situations, following suggestions to avoid patient-initiated premature termination would be critical.

 

Throughout this section on clinician-initiated premature termination, one of the common elements 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.   Case example 6 illustrates appropriate clinician-initiated premature termination due to area of competence.  

 

 

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

 

 

This was a 42 year old single female with no children who presented for preparation for 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 must arrange for patient coverage during the therapist’s temporary absence (e.g. vacation, illness, etc.) or abandonment (inappropriate clinician-initiated termination) may occur.  The patient must have instructions about what to do in case of emergency and the need for interim care appropriately addressed.  Given the nature of the therapist-client relationship, it is not usual to provide a substitute therapist while the therapist is gone, but it 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 gives 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 clinician-initiated 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 (e.g. 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 and “best practices guides” suggest that pre-termination sessions be completed and that the patient be supported in any process that involves a transfer of care (referral).  This should clearly go 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 problems related to clinician-initiated premature therapy termination almost regardless of the therapist’s actions.  In these cases, all of the procedures for avoiding (or managing appropriately) clinician-initiated premature termination should be implemented throughout treatment.  In summary, any patient population that has:

 

     a propensity towards forming intense interpersonal relationships (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 for Clinician-initiated premature termination

 

Issues that should be addressed in terms of clinician-initiated therapy termination are derived from the many resources in the references.  All of these guidelines are consistent with quality treatment and standards of care.

 

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 that reflects the office policy as well as “negotiated” treatment issues. The informed consent should include the usual information about the treatment relationship, the bounds of confidentiality, the financial arrangement, etc.  In addition, the informed consent should very clearly outline information that developed from the pretherapy phase as discussed in the initial sections of this course.   

 

Documentation

 

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 (of either type), careful and detailed documentation is important.   

 

Managing Pre-mature Termination

 

Premature Termination that is predicted or planned.  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 those components listed in Table 9.

 

 

Table 9.  Components of Premature Termination 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 (patient-initiated), 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.  This is the situation of patient-initiated premature therapy termination.  

 

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” 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 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) 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 (either patient-initiated or clinician-initiated), 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 and community standards of care.  Ongoing consultation relative to the termination issues not only helps guide the therapist (by taking into account all the relevant factors and points of view) but also establishes that multiple professionals agreed on your chosen course of action.  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. 

 

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 10. Summary of Practice Recommendations

 

 

Complete Procedures to Reduce Patient-initiated Premature Termination.  The issue of premature termination is best managed through prevention rather than responding to its occurrence.  As reviewed in this course, take steps to prevent patient-initiated premature termination and be prepared for any type of clinician-initiated premature termination that might be necessary.

 

Informed Consent. Obtain written informed consent at the beginning of treatment and provide reminders to the patient throughout therapy.  The informed consent should include the usual office policy along with any issues agreed upon during the pretherapy treatment negotiation phase.

 

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 after 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 on methods of building and maintaining their practices to the exclusion of treatment termination.  Having a good understanding of reducing patient-initiated premature termination, managing clinician-initiated premature termination, promoting successful termination and avoiding abandonment are important. 

 

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. 

 

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.

 

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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.

 

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

 

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

 

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

 

Reder et al. (1980). Patient dropout from individual psychotherapy. Bulletin of the Menninger Clinic, 44, 229-252.

 

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.

 

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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.

 

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