Therapy Termination Issues [Ethics and Risk Management]by William W. Deardorff, Ph.D, ABPP.
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“The process of therapy termination begins with the first session.”
Introduction
As the course title implies, this course addresses therapy termination, managing difficult termination issues, and avoiding abandonment. However, in doing that, it covers much more including: when is a treatment relationship actually established, initial and ongoing informed consent, the importance of objectively monitoring a patient’s response to treatment, financial issues and therapy, the patient’s and therapist’s responsibilities in the treatment contract, therapists’ rights relative to terminating therapy, managing transfer of care and referrals, establishing when a therapist’s professional responsibilities actually end, among other things. Actually being sued for malpractice specifically for abandonment in psychotherapy is a rare occurrence (less that 3% of cases according to some sources, Shapiro and Smith, 2011). However, simply looking at claims for abandonment probably hides important information. It is likely that therapy abandonment is a component of malpractice claims and board complaints (to state licensing agencies and ethics committees) that are actually under the rubric of some other category that is much more common: Ineffective treatment, failure to consult; negligent diagnosis; inadequate supervision, etc. In these more common complaints, the issue of abandonment is not mentioned since it is not the most egregious alleged offense.
This course will begin with a presentation of common therapy dilemmas related to therapy termination. It will then proceed with a definition of terms and a discussion of areas of premature therapy termination: appropriate and inappropriate (abandonment). Even though practical guidelines are discussed throughout the course, a summary discussion will be provided at the conclusion. This course will reference the current ethical codes for a number of professional organizations. These can be found in the following Table:
COURSE OUTLINE
Learning Objectives What Would You Do? The Beginning: When is a Treatment Relationship Established? How well do Therapists Terminate Therapy? Definitions Termination (Successful) Premature Termination Abandonment The Ethical Codes Ethics Codes Struggle with the Issue of Abandonment Legal Aspects of Abandonment Factors Influencing Pre-Mature Termination Provider-Therapist Variables Patient Variables Type of Treatment Extra-Therapy Variables Successful Termination Areas of Premature Termination Financial and Reimbursement Issues Reimbursement – Utilization Review Multiple Relationships and Conflicts of Interest Lack of Progress in Treatment Was a Treatment Relationship Established and Duty to Protect Incurred? Nonadherence Therapist-patient Mismatch Boundary Violations (Patient) - Threats Change in Therapist Status (job, moving, illness) Out of area of competence Transfer of Care Resources and References
List of Tables
Table 1. When does the Therapist-Client Relationship Begin? Table 2. Ending Therapy: What Really Happens? Table 3. Successful Therapy Termination Table 4. Starting and Ending Therapy: The Real World Table 5. Premature Termination: What is it? Table 6. Abandonment: Never OK Table 7. Ethical Codes Table 8. Ethical Codes Related to Termination and Abandonment Table 9. Ethical Codes Related to Financial Issues and Treatment Table 10. Ethical Principles Related to Sexual Misconduct Table 11. Dependent Personality Disorder: Termination Issues Table 12. Ethical Codes Related to Change in Therapist Status Table 13. Ethics Codes Related to Competence Table 14. Components of Premature Termination Counseling Table 15. Summary of Practice Recommendations
List of Case Examples
Case Example 1. Collection on a High-Balance Therapy Debt Case Example 2. Sliding Fee Patient Who Can Afford to Pay Case Example 3. Lack of Progress in Treatment Case Example 4. Long Term Treatment; Short-term Termination Case Example 5. Change in Therapist Status Case Example 6. You’re Not an Expert at Everything – Competence
List of Legal Cases Reviewed
Legal Case 1: Lack of Authorization does not Justify Abandonment Legal Case 2: Treatment Relationship Established and Suicide Legal Case 3. Transfer of Care or Abandonment? Legal Case 4. Patient Boundary Violations Legal Case 5. Patient Boundary Violations Legal Case 6. Out of One’s Area of Competence and Transfer of Care
To begin the course, imagine the following not uncommon dilemmas. All of these relate to actual occurrences which will be addressed in the course.
As discussed by Hilliard (1998), the legal concept of abandonment in medical treatment is as follows (See also Reamer, 2015; Shapiro and Smith, 2011):
Abandonment is a legal conclusion reached after examining the process of termination and determining what is substantially departed from the accepted professional standards to the detriment of the patient. In other words, abandonment occurs when a psychiatrist terminates treatment with a patient without regard for the patient’s condition or needs, or without the formulation of an adequate plan for follow-up treatment. Abandonment can occur through neglect (for example the psychiatrist ignores calls from the patient for appointments or misses appointments without appropriate notice) or through intentional conduct (for example, the psychiatrist affirmatively terminates treatment with the patient during the course of therapy and without a proper referral to another psychiatrist (p. 217)
The Beginning: When is a Treatment Relationship Established?
Any discussion of termination, pre-mature termination, and abandonment issues really starts with the beginning of the doctor (therapist) – patient (client) relationship. Since this course is about ending the treatment relationship, we will only briefly discuss the many ways in which a treatment “relationship” may be established. The reader may think that this is an obvious situation – the client calls and schedules an appointment, comes in for the first session, signs the office forms, completes the initial interview, provides payment in some manner, and schedules a follow-up visit before leaving. Although this is likely the process in the vast majority of practices, a treatment relationship may be created (under the law) even when the therapist is not conceptualizing it in that fashion. Being aware of these issues is important for ethical, risk management, and quality of care reasons.
The legal basis for establishing the therapist-client relationship is based upon an agreement of the parties. The law imposes duties when doctors have agreed to treat patients. As such, an understanding of when this has occurred (under the law) is important. Any express or implied agreement to treat a patient creates a relationship with corresponding duties and rights for both parties. It should be noted that legally the doctor’s “duty of care” is not predicated on such things as payment of a fee, the patient signing an office policy form, or “formally” accepting the patient for treatment after two or three evaluation sessions. The duty to treat derives from the “agreement” by the doctor-therapist to render services to the patient-client and the patient-client’s reliance on that expectation. The duty owed by the provider is not that the patient will be cured, but rather that the therapist will exercise reasonable care according to the standard of the profession. The law imposes no duty on therapists to accept a patient for treatment. However, the courts have been quick to recognize a doctor-patient relationship, even when the doctor may assert that no such “formal” treatment relationship had been established. Some of these situations can be found in Table 1:
Some of the possibilities in the Table may seem remote, but one of the critical issues is, “Does the person have the expectation that he or she has been accepted for treatment or is receiving treatment?” Being clear with an individual, prior to him or her being accepted as a patient, and documenting these interactions is important.
A therapist has the right to accept or reject a new patient for treatment and this is usually decided after an initial interview/evaluation. Although some therapists move directly into a treatment role with the first session, it is highly recommended that the provider always complete some type of initial evaluation with the goal of not only conceptualizing the case, but also of making the decision to accept the patient for treatment. The initial evaluation is important for many reasons including case formulation; determining the presence of any immediate, emergent, crisis issues; assessing whether the one has the competence to treat the problem; to complete informed consent procedures, among other things. At the conclusion of the evaluation, the patient should be given some idea of therapist treatment plan, number of session, goals, etc.
In the vast majority of cases, new patients are accepted for treatment. Even so, it is reasonable practice to inform the patient at the beginning of the initial evaluation that no treatment will be provided at that time. Some therapists do not utilize a structured one-hour initial evaluation format; rather, they conceptualize the case in terms of an evaluation “phase” that may extend over several sessions. In either scenario (one session vs. multi-session evaluation), the patient should be explicitly informed about the therapist’s process of evaluation, when the evaluation has been completed, and when a treatment relationship has actually been established. Otherwise, the therapist may believe that a treatment relationship has not been established when the patient has the expectation that treatment has already been initiated. Making this very clear to the patient-client from the very beginning is not only quality practice, but important both ethically and from a risk management standpoint. One important point that should be made is the assessment of emergent or crisis issues during the evaluation. Therapists have no legal obligation to provide emergency care to a person who is not a patient. However, there are certainly situations in which a therapist will be compelled to do so even when a professional relationship is not established. Consider the patient who during the initial evaluation expresses suicidal ideation along with a formulated plan and history of attempts. This situation may not be that unusual given that 8 out of 10 patients who commit suicide have been seen by a physician within 6 months prior to the attempt and 50% have seen a physician within 30 days. Given the patient population presenting to therapists, the initial evaluation should always include a suicide risk assessment. If the risk is high and the therapist must intervene (e.g. initiate emergency treatment of some type), the consequences generally fall under the Good Samaritan laws rather than initiation of a treatment relationship.
The reasons that a patient may not be accepted for treatment are not the focus of this course but the process of “rejecting” (or a better term “not accepting”) a patient for treatment, along with some common scenarios, are as follows. Since many individuals may not realize that therapists have the right to pick and choose who they see and under what conditions, the process of not accepting someone for treatment should be handled professionally and respectfully. Certainly, the therapist does not want the patient to walk away from the experience feeling rejected. Although a therapist is well within his or her ethical and legal rights not to accept a patient for treatment, managing this effectively and successfully is much more satisfying then proving it so in response to an Ethics Board, State Board, or malpractice complaint.
After the evaluation, if a patient is not accepted for treatment, the reasons should be discussed with the patient and appropriate actions taken. If the reason is that the patient’s problems fall outside the scope of the practitioner’s expertise, this can be explained to the patient and appropriate referrals completed. Other issues might be financial, boundary issues, “dual relationships” with other patients, role conflicts, etc.
Once a treatment or professional relationship is established the therapist is legally required, with all of the duties attached, to provide proper treatment until the relationship is appropriately terminated. The therapist should be attending to termination issues from the very beginning, and throughout the course, of treatment. How well do Therapists Terminate Therapy? There is evidence that therapists, in general, may have trouble with completing “successful termination” (or any termination for that matter). In a study whose results still ring true today, 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 (Roe et al., 2006; Bhatia et al., 2017). 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” (Roe et al., 2006). In the study, 82 people who were in psychodynamically-oriented psychotherapy for at least 6 months (an average of 2 years), which had recently ended, were assessed regarding the way they experienced the timing of, reasons for and feelings about their psychotherapy termination. The findings are summarized in Table 2.
In general, clients who reported that termination was on time were more satisfied with their therapy. Factors contributing to positive feelings about termination included perceiving the experience of termination as an expression of independence, reflection of positive aspects of the therapeutic relationship and a reflection of positive gains experienced in therapy.
“Whereas clinical lore has consistently suggested that therapists must help clients focus on the emotionally painful aspects of this period and the difficulty in separating, the emerging data suggest that it is equally important to relate to the clients’ positive feelings” said Professor Roe, “Results suggest that clients find terminating psychotherapy at the right time important and yet difficult to achieve, and that clients experience a wide range of feelings, many positive, during the termination phase, which call for a reconceptualization of the role of the therapist during this important phase of psychotherapy.”
These results are very important to the current discussion. Importantly, they underscore that, in the vast majority of cases, the patient terminates the treatment relationship. This is certainly not consistent with the idea that in most cases therapists assesses their patients, implement a treatment plan, and then bring the process to a successful conclusion with healthy termination. In fact, it appears that this idealized evaluation-treatment-termination process occurred only 16% of the time. One can only speculate as to why this occurred (although the authors do provide some data). First, the researchers investigated psychodynamically-oriented practitioners. It might be assumed that providers who utilize a more structured approach, such as cognitive behavioral interventions, would show different results.
The data are a little difficult to assess relative to possible abandonment. The study states that 37% felt that the therapy ended earlier than it should have but does not discuss how termination was completed in detail (by the therapist, by the patient, reasons across each group). In addition, as we shall see, pre-mature termination (e.g. due to financial issues, boundary issues, etc.) is not the same as abandonment. This differentiation is a critical concept that will be discussed in detail subsequently.
Of the patient-group who terminated treatment, the most common reasons were financial (34.5%) and mismatch with therapist (27.6%). In terms of quality of treatment, one might suppose that these issues could have been managed more effectively by the therapist. For instance, frank and open discussions about the financial commitment to undergo longer term therapy early in the treatment relationship might have helped the therapist plan a more effective and time-limited intervention given the financial resources of the patient. It also seems that the patient feeling mismatched with the therapist might be discovered long before 6 months (the minimum amount of treatment time for inclusion in this study). Therapists can learn a lesson about begin cognizant of these issues since this study suggests they are occurring more frequently than most realize.
As can be seen in the Table, among those clients who experienced therapy as lasting too long, the most frequent reasons were: feeling uncomfortable toward the therapist (26.3%); hope that the treatment would improve (21.1%); and, dependence on the therapist (21.1%). In all of these categories “successful” termination might have been possible if the therapist had been aware of these issues. In the therapeutic relationship, the provider often has a great deal of power and influence over the client. This differential in power has the potential for promoting patient improvement (the way things are supposed to work) or patient abuse. If a patient feels uncomfortable with the therapist, stays in treatment hoping for success when it does not occur, or feels too dependent on the therapist, there is certainly the implication that the therapists missed something in terms of ongoing assessment and intervention. In any of these categories, we can safely assume that if the situation were handled correctly, a more successful outcome might have been obtained in many of the cases. Definitions
Any discussion of therapy termination and abandonment must necessarily include a review of definitions. As the reader shall see, this review will underscore there is no consensus on a definition of “abandonment”. Some of the definitions and concepts of termination, premature termination and abandonment can be found in the following Tables.
Termination (Successful)
Psychotherapy termination may be conceptualized as an intentional process that occurs over time when a client has achieved most of the goals of treatment, and/or when psychotherapy must end for other reasons (Vasquez et al., 2008, p. 653; See also Goode et al., 2017).
Appropriate termination helps to avoid the betrayal of trust and abuse of power, prevents harm, and conveys caring which is critical to ethical treatment. The termination of psychotherapy should be part of the treatment plan from the very beginning. As shall be discussed, the data suggests that actual termination from therapy rarely occurs in a planned fashion, as part of the treatment process. Consider the following which occurs in the real world:
Premature Termination
Premature termination can be appropriate (ethical) or inappropriate (unethical and negligent). In all cases of premature termination, the treatment relationship is ended prior to what was planned and before successful resolution of the problem(s) that were the focus of the intervention. Appropriate and ethical premature termination may be due to such things as reimbursement limitations or a change in the patient’s financial situation, a lack of treatment progress, patient nonadherence (noncompliance), boundary violations on the part of the patient, or a change in the therapist’s employment situation. Inappropriate premature termination always occurs due to the inappropriate actions (or inaction) of the therapist and includes such things as establishment of a dual relationship (e.g. business dealings outside of therapy), romantic involvement, and not managing premature termination, even when indicated, in an appropriate manner. This often constitutes abandonment.
Abandonment
Abandonment is an inappropriate premature termination and/or when a patient’s ongoing treatment needs are not adequately addressed by the psychotherapist, either when treatment ends or during the course of treatment due to unavailability (Reamer, 2015; 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; Younggren et al., 2011). As we will discuss, actual psychotherapy malpractice claims of abandonment are rare. However, the data may not be telling the whole story. First, the frequency of ethics and state board complaints related to abandonment is not clear. Although practitioners are certainly fearful of a malpractice action, a board complaint can be equally as stressful. Both accusations (malpractice, board complaint) require the practitioner to initiate a defense.
The Ethical Codes
All of the ethical codes relating to the provision of mental health treatment address the issues of abandonment. Table 7 lists the links to the full version of the various codes.
Table 8 lists the sections of some of the ethical codes that specifically relate to termination of services and abandonment. Many other sections of these ethical codes also apply both in general (e.g. informed consent) and related to specific situations (e.g. boundaries, competence, etc.). This will be discussed subsequently as they relate to specific situations.
Ethics Codes Struggle with the Issue of Abandonment
As discussed by Younggren and Gottlieb (2008) and Younggren et al. (2011), confusion about psychotherapy termination versus abandonment have been an issue in the field for at least 50 years. Even now, some of the ethics codes do not specifically mention the word “abandonment.” As the authors discuss, this confusion related to these concepts is mirrored in the various APA Ethical Codes. Concern about inappropriate termination of a patient (abandonment) was first addressed in the Ethical Standards of Psychologists in 1953. In those standards, there was the requirement of patient concurrence in the decision to end therapy or to make a referral even when the provider felt s/he was not competent to continue the treatment (presumably to avoid abandonment since patient concurrence was sought). However, unilateral discharge from treatment was allowed if the patient would not accept the referral even after the psychologist “insisted”. As the authors point out, there is an inherent contradiction in having to obtain patient permission for the psychologist to unilaterally terminate the professional relationship. This ambiguity continued in various revisions for 40 years. There was no clear guidance about how to terminate therapy while avoiding abandonment.
In the Ethical Standards Revision in 1992 the term “abandonment” was used specifically. Standard 4.09(a) stated, “Psychologists do not abandon patients or clients” (as cited in Younggren and Gottlieb, 2008, p. 499). The following sections addressed termination of the professional relationship.
In the 2002 Ethical Code Revision, the standard regarding abandonment was removed and a statement added that protected psychologists relative to termination of a patient after being threatened. In the 2002 revision, there are more clear guidelines relative to pre-termination issues including ending a non-productive relationship while providing appropriate referrals (including problems that occur due to insurance managed care plans).
Legal Aspects of Abandonment
Failure to properly withdraw from a professional therapy relationship may expose the therapist to liability. Malpractice cases have established damages including such things as wrongful death, permanent physical incapacity, pain and suffering, mental anguish, an unnecessary hospitalization, and/or excessive hospital bills. Before discussing the specific areas of premature termination, including potential abandonment, it is useful to conceptualize factors that influence this process.
Factors Influencing Pre-Treatment Termination
In the best case scenario, and the goals of a professional therapy relationship from the beginning is completion of the following process:
Evaluation and case formulation
Informed consent in which the patient is “informed” and understands the treatment plan proposed, how it will be implemented, the anticipated course of treatment, the therapist and client’s responsibility in the professional relationship, management of unanticipated issues, and termination
Implementation of the treatment with appropriate monitoring of goals
Completion of the successful termination process
As we have seen, the real-world data suggests that this process rarely goes this smoothly (See Table 2). Although the data relative to these issues may be less than ideal, it has been established that, in many cases, the treatment results in premature termination (either therapist or patient initiated, or by mutual agreement). There are at least four factors that affect termination issues: The therapist, the type of treatment, the client, and extra-therapy variables (See Tsai et al., 2017; Vasquez et al., 2008; Younggren and Gottlieb, 2008; Younggren et al., 2011). Provider-Therapist Variables
Therapist variables that can affect pre-mature termination includes such things as distress/impairment, a lack of competence, dual/multiple relationships, countertransference, crossing boundaries, loss of objectivity, among other things. Patient Variables
Another factor that can affect premature termination is patient behavior. In the most extreme case, that of threatening the therapist, the treatment can be abruptly ended without any type of pre-termination process. This is explicitly addressed in the APA and ACA Ethics and implied in the NASW Code. In this situation, the therapist would certainly not be accused of abandonment.
Aside from this extreme occurrence, there are many other situations in which a therapist is ethically justified in terminating the professional relationship prior to its successful conclusion. Examples include becoming aware of therapist-client mismatch, a lack of patient progress in treatment, nonadherence to the treatment regimen, a lack of expertise in the problem area, financial issues including lack of payment, etc. Therapists are often fearful that any treatment termination prior to the client’s desire to discontinue the therapy, will likely constitute abandonment. As we shall discuss, there are situations in which it is clearly unethical to continue treatment even when the patient desires to do so. Therapists should remember that the treatment is a two-way relationship with contractual responsibilities falling on both parties, the therapist AND the patient. The responsibilities of the patient are usually discussed during the informed consent process early in treatment, including written documentation. The “duties” or responsibility of the patient include such things as paying for the services (either directly or indirectly), compliance with treatment recommendations, maintaining appropriate boundaries, and participating in the therapy.
Type of Treatment
The type of treatment that the parties (therapist and patient) have agreed upon can also influence the termination process. For instance, if the therapist is a cognitive behavioral practitioner specializing in the treatment of phobias, a very specific treatment plan may be proposed at the outset (e.g. 10-20 sessions, homework exercises, established and definable goals, etc.). If the treatment does not progress per plan, the patient continues to attempt to focus on other areas in therapy (e.g. relationship problems), or expresses a dislike for the structure and requests a less structured approach and is longer term, then premature termination may certainly be warranted.
Extra-therapy Variables
These factors include things that occur outside of the actual therapeutic relationship and are usually unpredictable. They might include a sudden change in the patient’s financial situation, a managed care company unexpectedly not approving additional treatment, a change in the patient’s insurance plan due to changing jobs, the therapist changing jobs or moving, etc. A proper informed consent procedure at the beginning of treatment can attempt to predict the possibility of these occurrences and how they might be handled if necessary.
SUCCESSFUL TERMINATION
Our discussion of successful termination will be brief since the focus of the course is “difficult termination issues.” However, if a therapist prepares for a “successful” termination, then problems related to difficult terminations are minimized or prevented. It is also consistent with best-practices (See the special issue of Psychotherapy, Volume 54, No. 1, 2017) devoted entirely to psychotherapy termination issues.
Even though there is a large body of literature related to the psychotherapy termination process, and our graduate training typically covers how to do it properly, the research suggests that it rarely occurs in the real world. It may be more common is a highly structured CBT approach (e.g. 10 sessions for chronic pain whose content is pre-determined) but is less frequent in psychodynamic treatment. As discussed, the research demonstrates that 33% of patients do not return to psychotherapy after 1-2 sessions and only 10% compete more than 20 sessions. This lack of “successful” completion of psychotherapy is likely due to many factors, but the primary of which is financial (lack of reimbursement, approval for only a few sessions, etc.). As reviewed by Fisher (2011), it is recommended that therapists discuss termination at three stages of treatment: the intake, during treatment, when actually ending the intervention (See also Vasquez et al., 2008). The nature and content of these discussions depends on many variables including the therapist, the patient, the type of therapy, and the quality of the treatment process. The responsibility for these discussions lies solely with the therapist. The initial intake process is probably the most important time to review and discuss termination issues, including the patient’s responsibility as a contractual partner in the treatment relationship. As discussed by Younggren and Gottlieb (2008), Younggren (2011), and others (Vasquez et al., 2008), the patient does have responsibilities in the treatment relationship including (but not limited to), showing up for treatment, adherence to recommendation, paying for services, not violating boundary issues, and being involved in the treatment process. These responsibilities, and reasons for premature termination, should be provided in a written format, although this is rarely done (Davis and Younggren, 2009).
I think the most important “take-home” message from this literature is that termination of therapy is an issue that must be addressed and monitored by the therapist throughout treatment (beginning with the first session). This is often either forgotten or ignored by most therapists. Termination issues are typically addressed only at the end of a successful course of treatment (almost as an afterthought), or in response to a “crisis” precipitated by the patient and as part of pre-mature termination (e.g. no-show for one or more sessions, dropping out of therapy, an adverse UR decision, lack of payment, a boundary violation, etc.).
AREAS OF PREMATURE TERMINATION
Financial and Reimbursement Issues
For many therapists, addressing issues related to being paid for services may be uncomfortable and hence either minimized or avoided altogether. As discussed by Koocher and Keith-Spiegel (2016), because we are in a helping profession, there is a sense that discussing or focusing on money issues is “crass or pecuniary” (p. 234). Of course, not addressing money issues in an upfront and clear manner from the beginning of treatment increases the potential for miscommunication, misunderstanding and conflicts. Under the law and ethical codes, therapists have a right to be paid for services. However, conflicts over billing, payment for services, and collections, are thought to be among the most common catalysts for triggering a Board complaint or malpractice suit (even if the complaint is formulated under a different reason). This “sensitive” area is well known to therapists and may induce them to avoid the conflict by continuing to treat even though the patient does not have the financial resources for payment (to avoiding “abandoning” the patient while the amount owed increases week to week).
In general, mental health treatment is paid for (all or part) in one of 4 ways: the patient pays for the services 100%; treatment is covered all or part under health benefits (third party payor) and this usually involves authorization to treat; paid for by some other employee benefit or public funds; and, paid for by another financially responsible party (e.g. parents, grandparents or family member paying for the therapy). Each of these situations comes with its own unique ethical, treatment, and risk-management issues that should be addressed from the beginning of therapy. As documented in the various Ethical Codes, it is not unethical to terminate a patient who cannot pay. This is specifically addressed in the various ethical codes as presented in Table 9.
As can be seen, it is not unethical for a therapist to terminate a patient due to a lack of payment of fees (see also Knapp and VandeCreek, 2006; Treloar, 2010; and the other resources-references). This includes all reasons such as a change in the patient’s ability to pay, loss of insurance coverage, the patient simply choosing to stop paying on an account while continuing to come for treatment, etc. If done in a proper manner, this constitutes an appropriate pre-mature termination. However, there are a couple of important issues relative to termination of therapy for non-payment of fees. First, as with any pre-mature treatment termination, it must not be done if the patient is in a state of crisis. Thus, even if premature termination is appropriate (e.g. inability to pay), the timing and method are important or it could constitute abandonment. Almost regardless of the reason (aside from threatening the therapist), a patient should not be terminated when in a state of crisis. Rather, premature terminations sessions should focus on stabilizing the patient’s condition and setting up appropriate resources (e.g. referral, community based programs, etc.).
Second, all of the ethical codes suggest taking steps to avoid the problem altogether. This includes clearly outlining (in writing) and discussing the financial arrangements at the beginning of treatment. This should be done as part of the informed consent process. If a problem with finances occurs, it should be discussed with the patient relative to options, etc. For instance, if a balance due is getting high, this could be discussed and a payment plan or opportunity to pay offered.
Third, the therapist should be aware of the patient’s insurance plan and take this into account in terms of treatment planning, accepting the patient for treatment, etc. For instance, if the therapist knows that the patient’s plan only allow 10 visits per year, this should be discussed with the patient and taken into account in terms of treatment planning.
It is not technically unethical to use a collection agency, but a therapist is wise to try and avoid allowing the financial situation to reach that point. Collection of past due fees is thought to be one of most common “triggers” for a Board complaint against a therapist. The complaint is not usually related to the payment agreement directly but some other issue is focused on after payment is sought (e.g. breaking confidentiality by involving a collection agency, lack of progress in treatment, etc.). The complaint may be without foundation, but it still must be defended against by the therapist. If the therapist chooses to use a collection services, this must be specifically outlined in the original informed consent paperwork (office policies) signed by the patient. Also, before turning the account over to collection, the patient should be given an opportunity to pay the bill or make some reasonable arrangement for payment. The therapist should release the minimal amount of information to the collection agency (See Case Example 1).
In both of these cases (Case Example 1 and 2), the therapist was clearly trying to be helpful, caring and “nice” in providing services to the patient. However, in doing so, problems occurred which could have been prevented. As discussed throughout this course, termination begins with the first session or even before (scheduling the patient for the first session). Written informed consent (office policy) should be part of this initial process. These materials should obtain clear information about payment for services. If these policies are amended or changed in certain cases (e.g. Case Example 2: sliding fee), the details of the agreed-upon financial arrangement should be carefully documented.
Related to informed consent, it is also recommended that the therapist stand by his or her office policy and implement it on a consistent basis. In the first case example related to reimbursement, the therapist made several poor choices in an attempt to be accommodating to the patient and the referral source. Patients appreciate being given accurate information about reimbursement up front even though the therapist may be uncomfortable with these issues.
Knapp et al. (2006, 2017) and others suggest that a “pay-as-you-go” policy avoids problems related to debt accrual. However, many patients (especially those with insurance) want to pay after insurance has paid its share. If you need to terminate a patient for non-payment of fees, the following important guidelines will help avoid any issue of abandonment.
Written informed consent. Outline all of your financial policies in your initial informed consent and written office policy documents (have the patients sign the agreement and give them a copy). This should include how billing third-party payors will be handled, appealing denial or reductions in third-party payments, policies for carrying a balance, expected payment of co-pay, procedures if the financial situation changes, use of a collection agency, charging interest on past-due balances, use of credit cards, sliding fee scale agreement if appropriate, etc. If you submit insurance for patients consider including in your office policy how many times you will submit a bill for a particular visit, how many times you will appeal an unexpected reduction in payment (if at all), if you charge for your time in submitting appeals, etc.
Terminate patient when not in crisis. If it becomes necessary to discharge a patient from treatment for lack of payment, it must be done at a time when the patient is not in crisis. This is consistent with quality and ethical care. If a patient is terminated while in crisis, it might reasonably be considered abandonment.
Other resources provided to the patient. As part of the pre-mature termination, provide the patient with other resources. This might include therapists or clinics that charge a lower fee (or do pro bono work relative to the case), community resources and support groups, etc. Document that these resources have been provided.
Prevention. Prevention of the situation is the best solution. One should never let a patient accrue a large balance due.
From the beginning of treatment, the therapist’s “money” policies should be clearly outlined as part of completing informed consent. This should include (but not be limited to) the nature of the services offered, the fees charged, the mode of payment used, how insurance or third-party reimbursement will be managed, what will happen if the financial situation changes, charges for missed appointments, the specifics of any sliding fee arrangement, etc. The monetary issues should be reviewed not only at the beginning of therapy but also throughout treatment.
In my practice, I have found it useful to begin the informed consent process even before the first visit. As part of the initial scheduling telephone call, basic demographic information is collected along with insurance coverage. We also discuss the cost of the first visit and treatment sessions. We view the first evaluation session as a time when the provider and the patient are deciding if entering into a treatment relationship is appropriate and agreeable to both parties. As such, there is certainly the chance that I will determine that the patient is not an appropriate candidate for treatment with me (based on a number of issues) or, alternatively, the patient desires to pursue treatment elsewhere. In either case, the patient will be given appropriate resources including referrals, and s/he will not be seen again. Collecting a balance due from a patient who has undergone an initial evaluation (if not done at the time of the visit) and will not be seen again is a high risk situation for problems collecting payment beyond the insurance reimbursement.
To avoid any accrual of debt related to the initial visit that might be a problem, we require that the first session be paid in full at the time of the evaluation. We then bill the insurance for the patient and apply any payment to the future balance (if the patient enters treatment), or refund the money if the patient does not pursue treatment. This process has really solved a lot of problems while also acting as a screening method for patients relative to financial issues. This method is a compromise between a complete pay-as-you-go format as suggested by Knapp and VandeCreek (2006) and the traditional billing arrangement allowing the patient to carry a balance (accounts receivable).
Reimbursement – Utilization Review
A reimbursement issue that occurs frequently is that of a lack of approval for continued treatment. In this common scenario, the therapist has obtained approval to treat for a certain number of sessions (e.g. 6). At the end of the approved number of sessions, the patient requires more treatment but the therapist’s request is denied. If the therapist simply discharges the patient at that time (pre-mature termination), there may be a legitimate case for abandonment. This would especially be the case if the premature termination is handled in an inappropriate manner (e.g. request for additional visits not requested early enough, no transition/termination visits completed, not insuring the patient has other resources, terminating care regardless of “crisis” status, not discussing UR approval issues at the beginning of treatment as part of the informed consent process). In these cases, the therapist should attempt at least an appeal of the denial. If the appeal is not successful, the therapist is justified in terminating therapy due to lack of ability to pay and following appropriate ethical and legal guidelines (provide the patient with other resources, do not terminate if patient in crisis, plan ahead so the UR denial does not come as a complete surprise, etc.).
As illustrated in the Legal Cases (Legal Case 1), the courts will not allow a defense based upon cost containment (e.g. UR) whether it is at the hands of a physician or managed care organization. Economic constraints must not determine what should be done for the patient. When an HMO, PPO, or capitated group denies care, it is the therapist's duty to protest and attempt to change the decision. Verbally and in writing, the therapist should clearly state the reasons for the recommended therapy, the consequences of denial, and provide supporting literature to demonstrate the standard of care. A copy of the letter should be sent to the patient and all protestations documented in the chart.
Multiple Relationships and Conflicts of Interest
Relative to the current discussion is the relationship of multiple relationships, termination of therapy, and abandonment. In many instances of unethical behavior, the case involves abandonment (improper termination of treatment) associated with some other ethical violation such as a dual relationship. Although there is a lack of data in this area, it is the opinion of one previous attorney for CAMFT that, “most licensees who have been disciplined due to ‘improper termination,’ terminated with their patients so that they could engage in a social, romantic, or other type of relationship” (Benitez, The Decision to Terminate, The Therapist, November/December, 2004).
It is not the purpose of this course to address all of the ethical and liability issues related to dual and multiple relationships. As discussed by Koocher and Keith-Spiegel (2016), multiple role relationship can be defined as situations in which the therapist functions in more than one professional relationship, as well as those in which the therapist functions in a professional role and another definitive and intended role, as opposed to a limited and inconsequential role growing out of and limited by chance encounter (p. 171). There are many scenarios of dual and/or improper relationships with patients and much has been written about this ethical area. Multiple role ethics violations might include business dealings, friendships, and romantic/sexual involvement. The multiple roles may be concurrent, as when a therapist hires a patient to provide some task or job. Or, they may be consecutive, as when a therapist and a patient go into business together. Dual relationship also involves romantic encounters with a patient either concurrent with a professional treatment (therapy) or after termination. All ethical codes address multiple relationships and conflicts of interests. Please refer to the various ethical codes related to dual relationships for more information. In this course, we will limit our discussion to dual roles and inappropriate termination.
One of the most common ethical violations and malpractice actions is that of romantic involvement with a patient, either current or past (See Koocher and Keith-Spiegel, 2016 for a review of the ethical issues and Shapiro and Smith, 2011; Reamer, 2003, 2015, for a review of the malpractice data). It is not the focus of this course to review the ethical and malpractice issues related to sexual misconduct with a patient. However, there is evidence that sexual misconduct is often related to premature termination of therapy and abandonment. If the case is ever pursued by the patient as an ethics or malpractice action, the focus is on the sexual misconduct and the abandonment may not be addressed, even though it has certainly occurred. Sexual misconduct was chosen as an example of dual relationship related to premature termination because it might be considered the most serious of the offenses and among the most common. However, all of these principles might apply to abandoning a patient in order to pursue some other non-professional relationship with a patient (business, friendship, etc.).
Romantic and sexual involvement with patients is addressed by the various ethical codes. The statutes, as they might relate to premature termination and possible abandonment can be seen in Table 10. The primary issue here is that a therapist becomes romantically attracted to a patient and desires to pursue a non-professional relationship. In an attempt to avoid an ethical violations and malpractice action (dual role, sex with a patient, etc.), s/he decides to terminate therapy and the professional relationship. In the well thought out cases, the therapist waits the required amount of time and then pursues the romantic relationship. This is usually done with consent and participation of the patient. By outward appearances, there has been appropriate therapy termination by mutual agreement.
Some of the Codes specifically forbid terminating therapy with the goal of pursuing a non-professional relationship (sexual or otherwise):
Psychologists do not engage in sexual intimacies with individuals they know to be close relatives, guardians, or significant others of current clients/patients. Psychologists do not terminate therapy to circumvent this standard.
Social workers should not terminate services to pursue a social, financial, or sexual relationship with a client.
Should therapists engage in sexual intimacy with former clients following two years after termination or last professional contact, the burden shifts to the therapist to demonstrate that there has been no exploitation or injury to the former client or to the client's immediate family.
Other codes address this behavior indirectly, but the spirit of the codes is that it is not to be done. Engaging in this behavior is clearly inappropriate premature therapy termination. This behavior certainly might be conceptualized as abandonment.
In these cases, ethical and/or malpractice actions most often revolve around other violations. However, the actions clearly qualify as abandonment. The therapist, either unilaterally or by mutual agreement with the patient, terminates the therapy in order to start the “clock” counting down for future romantic involvement (e.g. two years after ending therapy). In cases related to business dealings, friendship, or other non-sexual dual relationships, the therapist attempts to circumvent the ethics codes by terminating the therapy to allow for pursuing a non-professional relationship. In these cases, the ethical codes do not address a time frame, and the therapist might pursue the non-professional relationship immediately.
Assertion of abandonment in these cases is likely rare (again, other issues predominate and would be the focus of the complaint). Even so, one can certainly imagine a situation in which a therapist terminates treatment to pursue some non-professional relationship (e.g. a business); the business or relationship goes bad and the patient (ex-patient) pursues action against the previous therapist, including abandonment among other things. Lack of Progress in Treatment
As discussed by Fisher (2011), “Regardless of the underlying reasons, among the most visible signs of psychotherapist discomfort with termination may be the tendency to prolong the therapy relationship inappropriately.” (p. 164). It has been suggested that therapists often defend against the awareness that a patient is failing to progress through various rationalizations (need more time, there actually progress, the treatment is supportive, the patient keeps coming so there must be progress even though I can’t define it). It has been estimated that 36% of psychotherapists in private practice continue to treat patients who are not improving (Stewart and Chambless, 2008). Other research suggests that even when patients are not showing progress, more than 50% of psychotherapists do “more of the same,” rather than revising the treatment plan or considering a referral (Kendall et al., 1992).
“It is difficult to get a man to understand something when his job depends on him not understanding it.”
Upton Sinclair
The various mental health ethics codes universally dictate that a patient who is not making progress should be terminated from care or referred for treatment that has the potential for success. As discussed by Younggren and Gottlieb (2008) this decision is primarily initiated by the therapist but should, ideally, be made mutually by both the therapist and the client. In the best case scenario, the therapist will initiate the conversation and review concerns in detail with the client. In some cases, the client may voice reasons that the therapy is, indeed, progressing and generate new ideas and goals. On the other hand, the client may feel the same way, but did not have the skills to express the issue (possibly one of the hidden reasons in the Roe study that clients state therapy “went on too long”; that of being uncomfortable with the therapist). In these cases, an appropriate termination plan can be developed. One challenge related to this issue is that, aside from fairly structured and objectively defined interventions (e.g. CBT with concrete goals), “progress” is often difficult to define and determine. This makes discussion with the patient all that more important. There are certain personality features that are likely to make patients prone to stay in treatment even when no progress is being made. In these cases, the therapist may consciously or unconsciously collude with the patient to keep things going long after any treatment response has been achieved. This is commonly seen in situations in which a responsible part other than the patient is paying for the treatment. One such common example is that of Dependent Personality Disorder, associated with some other condition. Case Example 3 presents an example of this occurrence and is a case that I evaluated as a consultant to the carrier.
Case Discussion: Chronic Pain with Dependent Personality Disorder. As an overview (See Case Example 3 for a detailed case presentation), the patient presented for treatment of a chronic pain problem associated with a work injury. The psychological treatment was authorized for psychological pain management and concomitant depression. This patient also clearly had a Dependent Personality Disorder which, of course, was non-industrial (not related to the work injury) and was not the focus of treatment. Over the subsequent 12 years of “treatment” provided to this patient by the psychologist (generally twice per week), outside psychiatrists completing periodic Independent Medical Evaluations (IME) related to case frequently commented that the psychologist should focus on fading the treatment and help the patient activate self-management resources (herself, her family, and in the community). The IMEs also correctly pointed out that the extensive and lengthy therapy was creating an unhealthy dependence on the psychologist and actually preventing the patient from making progress. The suggestions were largely ignored by the treating psychologist until the insurance carrier limited the number of visits per month with a fading schedule to basically force the psychologist to appropriately terminate treatment. The psychologist abruptly faded the frequency of visits but did so in a very inappropriate manner. Unfortunately, the psychologist “blamed” the insurance company for not allowing him to continue to “treat” the patient. He rapidly faded the visits from twice per week to every other week to once per month (even though the insurance company was actually allowing more visits for the termination process). Evidently, he was fearful of being deposed about his course of treatment. This increased the patient’s feelings of being “victimized” by the insurance company, increased her feelings of not being provided with treatment she “needed and deserved”, and left her with no skills or benefit in terms of managing her problems (pain or otherwise). This constituted 12 years of wasted treatment resources and left a patient likely iatrogenic issues related to dependency, maintaining the victim role, having no skills related to pain management or other types of self-management, etc.
Since it occurs quite frequently in therapy situations, it is useful to review features of Dependent Personality Disorder (or trends). These patients are certainly prone to develop an unhealthy dependence and reliance on therapy. Providers are also at risk for keeping these patient in treatment far beyond what is appropriate based on ethical guidelines. These patients are easy to “treat” since they never miss an appointment, rarely challenge the therapist, do not complain, pay their bills, and never question the justification for ongoing therapy. To the unethical therapist, these patients “will put your kids through college”.
Although the issue of lack of treatment progress is not directly related to abandonment, it certainly is unethical and has the potential to cause problems. One can certainly imagine a case similar to the one that I outlined, in which the patient pays for therapy over a long term, becomes dependent on the therapist without significant progress, and then at some point realizes they have been “had”. This might occur after an intervention by family members or friends, getting with an ethical and competent therapist, or some other “Ah-Ha” experience. In this situation, the patient is certainly justified in filing a complaint and, possibly, seeking damages (reimbursement for paying for therapy for all those years, and/or damages related to iatrogenically making things worse by fostering dependence). Of course, these claims are likely rare due to the very fact that the patient’s disorder (Dependency) almost precludes taking such action against the therapist.
Case Discussion about Example 4 – Blog Post. The example post on a blog raises interesting issues related to long term therapy, possible lack of progress, and inappropriate management of termination. In the little information we have about the case, we know that the patient has been in therapy for 13 years, which is a long time even by psychoanalytic standards. We also know that the patient is volunteering 20 hours per week and involved in two groups. The volunteer involvement is certainly positive especially if this is a substitute for not being able to work (for some reason). If all of this volunteer activity was a focus of therapy (e.g. moving from a disabled and inactive role to one of volunteering, etc.), that would certainly count as progress. We also know that the patient has been on SSDI for 5 years and likely disabled longer since it takes some time to get approved. If she has Medicare coverage with her SSDI and some type of secondary insurance, then the therapy likely costs the patient nothing out of pocket (if the psychologist is a Medicare provider) and the therapist did not have to concern herself with authorizations for ongoing treatment.
The two issues related to termination and abandonment are: (1) why was treatment necessary for 13 years and (2) why terminate the patient without notice in one session? The justification for the first issue is unknown. We also do not know what “progress” was made during this time. Relative to the termination issue, the therapist on the web site opines that this was handled in an ethical fashion. The treating therapist simply told the patient that “something came up”, she could not remain objective, she consulted with colleagues and someone at the APA ethics committee, and then terminated her.
I think it is reasonable to argue that, after 13 years of therapy, a single “surprise” termination session is not consistent with ethical management of this case. All of the Ethics Codes address these issues and here are just a few examples:
“provide pre-termination counseling and suggest alternative service providers as appropriate (APA Code 10.10.c)
“Social workers should withdraw services precipitously only under unusual circumstances….taking care to minimize possible adverse effects” (NASW Code 1.17.b)
“Counselors provide pre-termination counseling and recommend other service providers when necessary” (ACA, A.11.c.)
It would seem that, short of being threatened (which might have occurred but we don’t know and seems unlikely after 13 years), pre-termination counseling of more than one surprise session would have been appropriate. There is also no mention of providing the patient with alternate resources or referrals, or assisting in the transfer of care. The patient evidently does have a psychiatrist that may have helped relative to these issues. The patient states that her situation is “complex” and there are likely significant personality disorder features involved. Even so, aside from actually being threatened, did the therapist complete an abrupt termination to serve her own needs (e.g. not wanting to go through an uncomfortable pre-termination counseling phase during which the patient is arguing to stay in treatment due to dependency and other needs), or was this method justified? Clearly this abrupt termination resulted in some emotional harm to the patient. After 13 years of being paid for “treating” this patient, it seems that she would be owed more than this type of termination.
None of this discussion should be construed as saying that therapy always has be to successful otherwise ongoing treatment is unethical. Rather, the therapist should constantly be aware of the goals of treatment (short and long-term), the progress towards these goals, etc. In the case of a documented treatment plan with goals, the therapist is on solid ground regardless of the intensity and length of treatment.
The possibility of an accusation of abandonment is certainly present when the therapist attempts to do the “right” thing in this type of case. In general, in these cases, the client is very happy with coming to therapy week and week, year after year, even if there are no goals or progress. The therapist and patient/client often begin to develop more of a friendship as the actual treatment relationship changes. The therapist and the therapy sessions become one of the patient’s primary social contacts and a source of nurturance (often it is a primary relationship for the patient). The patient has no desire to discontinue or modify the therapy relationship in any way. The therapist may also be reluctant to change the situation since the therapy sessions tend to be quite easy (like meeting with a friend) and the remuneration is obviously present. Terminating this type of patient only means a hole in the schedule that must be filled, most likely with a shorter term patient and less comprehensive financial coverage.
Therapy termination with a patient who is ”dependent” on therapy (for the wrong reasons and not making progress) represents a challenge. The patient will almost always disagree with the evaluation of the therapist that termination is indicated. Depending on the length of time the patient has been in therapy, the termination process may take some time (and this is appropriate). Consistent with recommendation for an appropriate termination process, the following should be addressed: reviewing gains made in therapy and how working on these issues can continue; providing the patient with resources outside the therapy situation; making referrals and attempting to insure these have been followed through on by the patient; addressing any concerns the patient might have about termination.
Was a Treatment Relationship Established and Duty to Protect Incurred?
As discussed in the very beginning of this course, establishing when the treatment relationship actually begins can be critical to determining premature termination or abandonment.
As an overview, a malpractice case in 2000 underscores important issues related to ethical, high-quality practice and risk management. These include duty to protect (a patient from harming herself) and alleged abandonment. Briefly, in February 2000, thirty-six year old Ellen Marshall, the patient, hanged herself two days before a scheduled appointment with defendant, Dr. Vladimir Klebanov, a licensed psychiatrist. This would have been the patient’s second visit. Following her death, the patient's husband, Craig Marshall, filed an action against defendant on behalf of himself and his wife's estate for medical malpractice and wrongful death. In simplest terms, he alleged that the psychiatrist deviated from the accepted standards of care in the evaluation, care, and treatment of his wife in at least two ways: (1) the psychiatrist “failed to protect” or prevent a suicide that was imminent and (2) a treatment relationship had been established even though a month had passed since the initial evaluation and the next scheduled visit (which never occurred).
In this case, even though the defendant was not found guilty of deviating from the proper standard of care, avoiding this type of situation altogether is certainly preferred. Even though found not guilty, one wonders if the outcome might have been different if, after the initial evaluation and missed second appointment, the patient might have been contacted by the psychiatrist in some manner to check on her status and possibly reschedule sooner than a month. Of course, this is Monday morning quarterbacking, but the case is certainly worth learning something from.
Nonadherence
Nonadherence or noncompliance with treatment recommendations can be an appropriate reason for premature termination issue. This is decided by the therapist but should be discussed with the patient as a treatment issue. The patient should be given the opportunity to express his or her feelings about the ongoing treatment recommendations (e.g. homework exercises, compliance with a medication regimen being prescribed by a physician treating the patient conjointly, inconsistence attendance to treatment appointments, etc.). The lack of adherence (or acceptance) of the treatment prescriptions should be discussed and the patient given the opportunity to comply with an agreed-upon treatment plan. If, after this process is completed, the patient continues to show nonadherence, then premature termination is appropriate. As part of the termination process, the reasons for the termination should be discussed and other resources/referrals provided to the patient.
The case of Miller v. GSCH might be an example under nonadherence (the patient did not accept the doctor’s treatment recommendation) or transfer of care. Either way, the case underscores that even when a provider appears to follow all accepted procedures, attempts to act in the best interests of patient care, and performs his duties within the accepted standard of care, malpractice action is still a possibility. Of course, informed consent along with proper documentation throughout the process provided a straightforward defense in the case and is consistent with best practice.
This area can be somewhat difficult since often the patient desires to continue therapy “under his or her terms” even though the therapist is not willing to do so. This is similar to the issue with treating a patient who is no longer showing progress. In a common scenario, the patient desires to continue to come in week after week for the sessions without completing any of the home work assignments, not practicing the skills taught in the session, not actually focusing on any important issues, etc. Therefore, this challenging area of premature termination often represents a combination of nonadherence and lack of progress. Since the patient desires to continue in “treatment” as he or she defines it, the termination process has the potential to be challenging. In extreme cases, the claim of abandonment may be suggested even though the therapist has clearly documented that the patient has not fulfilled his/her part of the treatment contract. As with the lack of progress issues, it is easy for the therapist to suspend his or her ethical judgment given the “easy” work for the “easy” money (especially given the patient’s desire to continue the therapy as long as nothing is really required of him/her).
Therapist-patient Mismatch
One type of “mismatch” problem that may occur is related to a patient presenting a problem that is outside the competence of the therapist to treat. The presentation of this problem may occur after the evaluation and may not initially be the focus of treatment (the therapist may not even be aware of it as a problem). This does present a termination issue. This type of mismatch will be discussed in a subsequent section.
Other types of therapist-patient “mismatch” are difficult to define but, generally, both parties know it when it occurs. At some time after the initial evaluation, it becomes clear that, “this is not a match made in Heaven”. On the mild end of the spectrum, the therapist and/or patient may simply not “like” the other person (for whatever reason). Or, the patient may not respond well to the style of the therapist (e.g. confrontive, passive, etc.) or the type of intervention (e.g. CBT with a lot of homework, highly structured and time-limited versus a more psychodynamic approach). At the other end of the continuum, the therapist may develop strong countertransference issues that cannot be overcome no matter how objective he or she attempts to be (e.g. the female therapist who has a personal history of being abused seeing a male client who, during the course of treatment, reveals a history of impulse control problems including abuse directed at women).
No matter what the reason for the mismatch, the therapist should facilitate the termination according to ethical guidelines. If the termination is being initiated by the therapist, the reasons should be discussed (e.g. “It appears that the CBT approach in which…….may not be the best for you.” “What do you think?”). As part of this discussion, the patient can be provided with the names of other practitioners that might be a better “match”.
A mismatch due to other reasons (e.g. lack of treatment progress or lack of therapist competence in an area) can be discussed with the patient relative to those issues and appropriate referrals completed. In some cases, the client-patient desires to continue therapy regardless of the recommendation for premature termination and referral by the therapist. In these cases, the ethical codes mandate that it is incumbent on the therapist to proceed with the termination and referral even though it may be again the patient’s wishes. This can be a difficult discussion and process, but is certainly appropriate. As discussed by Younggren and Gottlieb (2008), “….continued treatment of a problem that is beyond the psychotherapist’s competence is a serious violation of the standard of care” (p. 501). Boundary Violations (Patient) - Threats
As discussed previously, the professional treatment relationship involves responsibilities and contractual obligations on the part of the therapy and the patient. We are all familiar with boundary violations on the part of therapists such as dual relationships, romantic involvement, financial issues, etc. There are also boundary violations on the part of patients and these primarily involve behaviors that become intrusive or dangerous to the therapist (Younggren and Gottlieb, 2008). Therapists have a right to privacy, safety and respect. When these rights are violated by patients, it is grounds for appropriate termination from treatment. The following are some example ethical guides related to being threatened by a patient:
Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship (10.10.b)
Social workers should take reasonable steps to avoid abandoning clients who are still in need of services. Social workers should withdraw services precipitously only under unusual circumstances, giving careful consideration to all factors in the situation and taking care to minimize possible adverse effects. Social workers should assist in making appropriate arrangements for continuation of services when necessary (1.17.b)
Counselors terminate a counseling relationship when it becomes reasonably apparent that the client no longer needs assistance, is not likely to benefit, or is being harmed by continued counseling. Counselors may terminate counseling when in jeopardy of harm by the client, or another person with whom the client has a relationship, or when clients do not pay fees as agreed upon. Counselors provide pre-termination counseling and recommend other service providers when necessary (A.11.c.)
Even though termination for reasons of patient boundary violation issues is ethically and legally justified, it still represents a high risk area for practitioners. Therapists should have a good understanding of what constitutes a boundary violation and how to manage the termination process as effectively as possible. Even though one may be “proven” ethically and legally justified in a premature termination related to a boundary violation, avoiding the very stressful process of proving oneself is certainly a goal. Reviewing cases related to this area can be helpful.
Two of the most frequently cited cases related to alleged abandonment are Ensworth v. Mullvain (1990) and Coddington v Robertson (1987). As can be seen, these cases have firmly established that a therapist is on solid legal ground in terminating a patient that is threatening his or her safety. Reviewing these cases can provide the therapist with some insight in how to manage similar issues – especially in the first case in which the therapist agreed to see the patient after initial termination to address the actual termination and “closure” issues. This was done, in part, at the encouragement of the subsequent therapist. This underscores two issues: In cases of being threatened, therapists may have difficulty switching from a “caring for the patient mode” into one of self-protection. There may be the fantasy that if one could just provide adequate termination and “closure”, the problem would be solved with everyone happy (including the patient). The second is the therapist that encouraged the patient to return to see Dr. Ensworth for a few sessions to address termination and closure. Although the details are unknown, this may not have been the best advice. This case suggests that therapists should be aware of all issues in making recommendations to patients (related to similar issues). Although unknown, some of the problems may have been avoided if Dr. Ensworth stayed with her decision to terminate the patient, transfer care, and not have any further contact.
Ensworth v. Mullvain. As a brief overview, the patient (Ms. Mullvain) engaged in serious boundary violations and threatening behavior against Dr. Ensworth. As a result, Dr. Ensworth referred the patient to another therapist and terminated her from treatment (all very appropriate). However, Ms. Mullvain continued to have a pathological attachment to Dr. Ensworth and the patient’s new therapist encouraged her to schedule some follow-up visits with Dr. Ensworth to gain some “closure”. Dr. Ensworth agreed to the sessions and an escalation in the threatening behavior increased. The patient was again discharged by Dr. Ensworth and a restraining order obtained.
Coddington v Robertson. As a brief overview, Coddington v. Robertson, involved the termination by a psychologist of a relationship with a patient (Ms. Coddington) who routinely communicated death threats to the psychologist (Dr. Robertson). In the psychologist’s professional opinion, a respite from treatment was warranted, although further eventual treatment was not ruled out in the event that the patient ceased making threats. The psychologist provided proper notice to the patient of the cessation of the relationship. Due to the fact that the patient continued to make threatening telephone calls and write threatening letters, the psychologist refused to reinstitute the relationship. Two years after the cessation of the relationship, the patient filed suit against the psychologist, alleging abandonment.
Utilizing the date that the psychologist withdrew from the relationship, the court ruled that Michigan’s two-year statute of limitations for malpractice actions was applicable to bar the patient’s cause of action. Concurrent with this finding was the conclusion that the two-year gap in the relationship could not constitute “treatment” for the purpose of either establishing liability or staving off a defense that the complaint was time-barred. While the court’s reasoning focused on the statute of limitations issue, the opinion it wrote scrutinized and found no fault in the psychologist’s withdrawal in the face of physical threats by his patient. This case underscores a therapist’s absolute right to terminate therapy when threatened (boundary violation by the patient). However, it also brings up interesting issues that the court had to rule on including what constituted treatment (when it started and when it stopped), and this related to our opening discussion of defining when therapy begins. Some of the details of this case are interesting and are as follows (Legal Case Example 5).
Change in Therapist Status (job, moving, illness)
There are a myriad of situations in which a therapist’s situation might necessitate the pre-mature termination of patients. These include such thinks as changing jobs, moving, illness, selling one’s practice, etc. In all of these cases, the therapist cannot simply terminate the patient(s) and transfer care to the “new” provider. Proper and ethical termination, along with transfer of care, is still applicable regardless of the reasons for the therapist’s situation. Some example ethical codes (certainly not a complete list) can be found in Table 12.
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.
In the Case Example, behavior of Dr. Skinner from an ethical and legal standpoint will not be addressed as part of this course. Briefly, the courts have generally not looked favorably on “no-compete” clauses related to a doctor (provider) leaving one practice and setting up another within close proximity. Related to this issue, certainly, changing dentists is quite a bit different from changing psychotherapists. The issues in the Case Example (without the threat from the supervising doctor-therapist) might also occur when an intern finishes his/her training, “rotates” off of one service to start another, changes jobs, etc.
In the Case Example, Dr. Freud can certainly continue to see those patients who desire to continue with him, and defend against the consequences (the lawsuit by Dr. Skinner). However, there are other issues. In all likelihood, Dr. Freud will have been seeing his patients at a reduced fee, since he was an intern. After becoming a fully licensed practitioner in independent practice (with associated overhead costs), Dr. Freud will seek to raise his patients’ fees which may trigger complaints from previous patients since this was not part of the original treatment agreement. Related to reimbursement issues, Dr. Skinner (his previous supervisor) may have belonged to various insurance panels under which many of Sigmund’s patients were being seen. Of course, once Dr. Freud begins seeing them independently, these contracts do not apply. At that time, reimburse rates and even an authorization to treat a patient, may change dramatically. Patients (and Dr. Freud) may not anticipate this occurrence and not realize the problem until the EOB for services is received 30-60 days after each therapy charge. This “surprise” in change of reimbursement does not endear oneself to patients and may result in retaliatory behavior.
The possibility of inappropriate premature termination and/or abandonment is a risk at two points in this Case Example. First, is the situation in which Sigmund decides to comply with Dr. Skinner’s request and abruptly terminates and transfers care to the new intern. Second, is the situation in which Dr. Freud takes many of the patients into his new practice and then abruptly raises his therapy fees. For those patients unwilling or unable to pay the increase and accrued charges (since the patients were unaware of the change until the first billing and reimbursement cycle) he terminates them for “lack of payment” and turns them over to collection. In the second scenario, Dr. Freud (being new to the nuances of independent practice) had failed to obtain new informed consent contracts from the patients carried over from his internship. Of course, Dr. Freud could initiate a complaint against Dr. Skinner related to a possible ethics violation or legal issues.
This Case Example, along with any situation in which a change in therapist (transfer of care or termination) can be reasonably predicted (e.g., internship, moving after training is completed, planning on going into private practice from an agency job, etc.), underscores the importance of informed consent being completed at the very beginning of treatment and throughout the process. This informed consent must include a discussion of termination. This situation, as with any related to supervision or being part of a group practice, should also underscore the necessity of understanding who “owns” the patients when and if the therapist leaves. Of course, patients are free to do as they desire, but there are issues as to whether the therapists would/should accept them into the new practice and dealing with the group’s response to the “patient theft”.
Out of Area of Competence
Every ethics code addresses treatment outside of one’s area of expertise and these issues are primarily covered in Competence (See Table 13). In summary, a therapist is not to provide treatment for a problem outside of his or her competence, expertise or training. Some of the codes make allowances for treatment outside of one’s area of competence under special circumstance if appropriate supervision is obtained.
The focus of this course is therapy termination and abandonment issues. Competence relates to termination in multiple ways. First, the therapist does an evaluation and takes on the patient even though it is clear that the presenting problem is outside the competence of the provider. Once the patient realizes this (or there is a lack of progress), termination is completed. Since the patient has positive feelings about the therapy (albeit accomplishing nothing), s/he resists the suggestion of termination or referral to another practitioner. This becomes a difficult termination issue since the patient questions why s/he was accepted for treatment in the first place (and now insurance benefits have been exhausted for the year). Often, the therapist attempts to “cover his/her tracks” and the patient is never really aware that there was a lack of competence to treat from the beginning.
The second scenario is very similar to the first except the realization on the part of the therapist truly comes after therapy is underway (or a new problem emerges that becomes the focus of treatment). In this case, a discussion with the patient must be completed and referrals to appropriate resources provided. Throughout this course, one of the common elements with difficult terminations is that the therapist has determined that it is the “right” and ethical thing to do, but the patient desires to continue “as-is”. In these cases, there can be a great deal of resistance on the part of the client. Often, especially if money or insurance coverage is not an issue, the patient is more than happy to come in week after week for “supportive” therapy (without any progress or accountability). In the worst case scenario, any attempts at referring the client to treatment that may be more appropriate will result in feelings (and accusations) of “abandonment”. Of course, as these are brought up by the patient, the therapist may be inclined to continue with the status quo.
Examples of difficult termination issues can be found in the following Legal Case Examples (6 and 7). In Case Example 6, a family doctor, Dr. Grubin, was not found liable for abandonment and other issues, after referring a patient for psychiatric care (the patient ultimately committed suicide). After the referral, Dr. Grubin withdrew from the patient’s care. By that time, the patient was already involved in psychiatric treatment. As discussed by the court (See Hilliard, 1998), it was concluded that the patient sought treatment for a specific condition (depression, anxiety, etc.), the doctor (Dr. Grubin) was unable to provide the necessary treatment, he informed the patient that these problems were outside of his area of competence, and he completed referrals for appropriate care (p. 219). The court ruled that once the doctor completed the referral and withdrew from the patient’s care, there was no duty to treat despite the family’s repeated attempts to contact him.
In malpractice actions, like most other negligence cases (accusations), the trial itself may have an adverse effect upon defendant's professional life. Courts should be aware that even allegations of malpractice against physicians and other professionals may have such effect. As noted in this opinion, the application of the principles of negligence law to the facts alleged by plaintiff should not render the defendant liable, and therefore the matter should be terminated at the pre-trial stage insofar as Dr. Grubin is concerned (although this does not always occur). A physician who upon an initial examination determines that he is incapable of helping his patient, and who refers the patient to a source of competent medical assistance, should not be held liable for the actions of subsequent treating professionals or for his refusal to become further involved with the case, and this is what the court found.
In the next case example, the patient was referred for a very specific reason (preparation for surgery). At the initial evaluation, she was given appropriate informed consent along with patient reading-educational materials and homework exercises. It was explicitly explained to her that a typical course of surgery preparation between 3-5 sessions pre-operatively and a few sessions post-operatively. The intervention is fairly highly structured but also flexible taking into account the patient’s presenting biopsychosocial situation (aside from the technical aspects of the surgery) and course of the post-operative recovery.
Arranging Coverage in the Therapist’s Absence
As discussed by Reamer (2003, 2015), a therapist may be liable for abandonment if during the therapist’s temporary absence (e.g. vacation, illness, etc.), a patient does not have instructions about what to do in case of either emergency or the need for interim care. Given the nature of the therapist-client relationship, it is not usual to provide a substitute therapist while the therapist is gone, but is certainly reasonable in appropriate cases. This brings up two issues related to planned absences:
(1) the patient should have a clear understanding of what to do in case of an emergency (e.g. the name and contact information for a colleague who is “covering”, calling 911, etc.). This plan should be in writing and part of the written informed consent process which the patient signs.
(2) The second issue is that of patients in long term therapy who are fairly dependent on the therapist. If the absence is going to be lengthy (e.g. 2-4 weeks and a patient is being seen twice per week and is “fragile”), then the patient will need to be appropriately prepared for the absence during the therapy prior to the absence. Also, in these cases, arranging for the availability of a “substitute therapist” may be appropriate versus just telling the patient to call 911. In these cases, it can be discussed with the patient that the therapist will provide a “substitute therapist” who will have all of the case information so that, if the patient needs to call or schedule an emergency appointment, the therapist will be familiar with the issues and treatment plan (assuming the patient is in agreement with this plan and give consent).
If the absence is not planned, then calling and informing patients about the situation is certainly appropriate (even if previous written informed consent has been completed). This might occur if the therapist has a personal emergency or illness. Ideally, these calls would be made by the therapist with a plan for coverage reiterated. In some cases, it is not possible for the therapist to make the calls (illness). In these cases, the person calling should explain the situation and arrange for coverage. All of this should be documented in the record. In some cases, similar to what was discussed above, arrangement for a substitute therapist might be necessary. Transfer of Care
The very difficult termination issues exemplified by the case example of the surgery preparation treatment underscores that practitioners may be faced with situations in which s/he is fully justified to act in a certain way ethically and legally, but “going the extra mile” (as appropriate) can certainly decrease the risk of having to defend one’s actions.
Most of the ethics codes suggest that pre-termination sessions be completed and that the patient be supported in any process that involves a transfer of care (referral). The spirit of the ethics codes suggests this goes beyond simply handing the patient a list of 3 names for referral and wishing him or her “good luck”. Here are just a few examples (paraphrased from the codes):
Psychologists make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted.
Social workers should take care to minimize possible adverse effects (of termination) and should assist in making appropriate arrangements for continuation of services when necessary.
Counselors provide pre-termination counseling and recommend other service providers when necessary. When counselors transfer or refer clients to other practitioners, they ensure that appropriate clinical and administrative processes are completed and open communication is maintained with both clients and practitioners.
Marriage and family therapists do not abandon or neglect clients in treatment without making reasonable arrangements for the continuation of such treatment. Working with High Risk Patient Populations
We will just briefly mention that there are certain patient populations that represent higher risk for board complaints, ethics complaints, and malpractice actions almost regardless of the therapist’s actions. All of these issues will not be covered in this course since that is not the focus. In summary, any patient population that has:
• a propensity towards forming intense interpersonal relationships with alternating between idealization and devaluation; • has low impulse control; • is very sensitive to feeling abandoned (real or imagined); • shows episodes of intense, and inappropriate anger which the patient cannot control; and • has a pattern of affective instability
will represent a higher risk for difficult termination issues. Aside from meeting the full diagnostic criterion for a Borderline Personality Disorder, any patient who shows some of these features will be a higher risk case (for any type of complaint against the therapist). Although all of the recommendations in this course should be considered for every patient (e.g. implemented as part of one’s general practice), patients’ with the above characteristics require closer attention to detail, making sure one follows his/her usual office policy, being very careful about not making exceptions to the usual office policy (not recommended), and seeking documented consultation.
Practical Guidelines
Issues that should be addressed in terms of therapy termination are derived from the many resources in the references. I am certainly not recommending that a therapist practice so “defensively” that the informed consent, record keeping and termination process become overwhelming. All of these guidelines are consistent with quality treatment and, quite frankly, would be appropriate even without the threat of liability. Informed Consent: The Most Important Issue
As presented at the very outset of this course, and emphasized throughout, termination issues begin with the very first session (or before). Every therapist should have a written informed consent document as part of the usual office forms. The informed consent should include the usual information about the treatment relationship, the bounds of confidentiality, etc. In addition, the informed consent should very clearly outline details of the financial arrangement. This will differ depending upon how a therapist chooses to practice. Some will use the “pay-as-you-go” method recommended by Knapp & VandeCreek (2017). In these cases, the informed consent would outline the cost, expected method of payment (e.g. before or after each session), payment types accepted (e.g. credit cards), what might constitute reasons for termination (including inability to pay), and the termination process if it becomes necessary. This discussion should also include who will submit the insurance if it is available (e.g. therapist, giving the patient a superbill to submit), and whether or not the therapist will do insurance appeals. If the therapist is willing to help the patient appeal an insurance denial (even in the pay-as-you-go method), will there be a charge for the therapist’s time? How many times will the therapist help with appeals? All of these details are important to outline so there will be no incorrect expectations should any of these issues arise.
If the patient has insurance coverage, then the informed consent should discuss how billing will be handled and by whom. It should also cover any information that is available about number of sessions available, how authorization for treatment will be obtained, what will happen if after a certain number of sessions, additional treatment authorization cannot be obtained, etc.
The therapist should have a frank discussion about these issues at the beginning of treatment. For instance, a common scenario might be a patient who has a limited number of sessions available (e.g. 10) and has limited financial resources. This issue must be discussed with the patient especially if the therapist believes that the presenting problem will clearly require more treatment than will be covered by insurance. Patients may not have a good understanding of this issue or the actual ramifications of starting a course of treatment that will clearly be inadequate. This not only creates a situation in which treatment will be inadequate, but also has the potential to actually make the patient’s condition worse (e.g. stopping therapy after just beginning to identify issues could cause iatrogenic problems). In these cases, the therapist might be wise to refuse to begin treatment under the circumstance or negotiate a sliding fee arrangement for the sessions after insurance coverage is gone. Again, all of this should be discussed with the patient as part of the informed consent process BEFORE TREATMENT IS INITIATED. Although many therapists are uncomfortable with this type of discussion, the risk of abandoning the patient in the middle of treatment is heightened if this type of informed consent is not done. It is also consistent with high quality treatment.
As mentioned previously, I begin the informed consent process even before the initial evaluation session. At the time of initial telephone contact, I have a very open discussion with the potential patient about the cost of therapy, the fact that insurance may not cover all of it (or any of it), and that I cannot guarantee coverage. Patients will often want some type of reassurance that insurance will cover a certain amount of the treatment, etc. To make any assurances related to potential coverage is a mistake. The therapist may think he or she is being helpful (e.g., “I will help you get the most reimbursement possible” or “I will fight with your insurance to help you get all of the benefits to which you are entitled”) but this may be communicating a false sense of assurance that the treatment will be covered. At this stage, both the patient and the therapist want to believe that everything will work out; however if after beginning treatment it is determined that no coverage is available and the patient either owes or has spent money s/he doesn’t have, there will be great feelings of animosity towards the therapist since it was implied that “it would all work out”.
I have recently adopted a policy that the initial evaluation visit must be paid in full at the time of service. Requiring this is a great litmus test for a potential patient’s attitude towards paying for therapy (versus having insurance coverage). If the patient has a problem with this, then they will surely have a problem with finding out they have poor insurance reimbursement after 4 or 5 sessions of treatment (and concomitant accumulation of debt). I have had many patients decide not to schedule the evaluation until they check with their insurance company. I am happy to give them the CPT codes so they can complete their own “research”. I also know of several companies that, in my experience, provide terrible coverage for mental health treatment. I will often warn patients, prior to the initial visit, about this issue and recommend that they investigate benefits (if that is an issue and they don’t plan on being a “cash” patient”). I would rather never begin the evaluation and treatment process than have a patient who has to drop out after 4 visits due to insurance reimbursement problems.
Having the patient pay for the initial visit is also consistent with the research in showing that many patients don’t really start treatment - 33% of patients do not return to psychotherapy after 1-2 sessions. Having the patient pay for the initial session solves the problem of a patient who has undergone the initial visit (evaluation) and then, for whatever reason, decided not to come back. Insurance is billed and a balance is remaining. Previously, it is these situations that most commonly resulted in a lack of payment and bad debt. Given the circumstances, these accounts were most often written off as bad debt. I suspect that the patient in this situation was of the opinion that since treatment was not pursued (again, for whatever reason), then they really should be responsible for the evaluation cost beyond insurance coverage. As will all of these termination issues, it is better to avoid problems than have to react to them.
Appropriate Documentation and Record Keeping
Proper record-keeping is important throughout treatment, from the initial informed consent to treatment termination (See the Documentation Course for more details). As discussed by Younggren et al. (2008, 2011), this includes a termination and discharge note. In cases of successful termination (which we have seen actually rarely occurs), the termination note can be fairly brief since the conclusion of treatment is agreed-upon by both parties, goals have been met, and follow-up recommendations discussed (e.g. as-needed, some type of maintenance schedule or other). In cases of premature termination, especially if the patient is not in agreement, then careful and detailed documentation is important. Remember the old adage in legal circles, “if it is not written down, it never happened.”
Managing Pre-mature Termination
Premature Termination that is predicted or planned. The various ethical codes recommend premature termination counseling even if it is just a limited number of sessions. Ideally, the therapist will be aware of the premature termination approaching, and it can be managed in a face-to-face fashion with the patient. An example might be an authorization to treat for 10 sessions and a request for additional sessions (made after the 7th session) is denied. The therapist presumably then has 2-3 sessions to address premature termination. Another situation is the client being unable to continue therapy due to financial out-of-pocket issues. Other examples include a patient who feels s/he is not making progress initiates termination and treatment being terminated by the therapist due to lack of benefit to the client. In all of these cases, termination counseling can be completed even if it is brief. The premature termination counseling should include at the very least:
Some authors recommend writing out the reasons for the termination and request having the patient sign it. In cases where the patient simply drops out of treatment, then it is recommended that a letter be sent. Barnett et al. (2000) and Vasquez et al. (2008) have a number of example “termination” letters for use under various circumstances including:
• A patient in need of ongoing care drops out of treatment, • A patient not making progress initiates termination, • Treatment being terminated due to lack of benefit to the client, and • Psychotherapist-initiated termination following an adverse utilization review decision. Premature termination that is not planned. Premature termination becomes more complicated when it is not planned for and premature counseling cannot be completed. The most common example is a patient who simply drops out of treatment by not re-scheduling or calling and cancelling all future appointments without explanation (or minimal explanation). This presents a dilemma for the therapist since termination issues and “closure” cannot be addressed.
As discussed by Vasquez et al. (2008), if attempts to call and reschedule the patient fail, it might be tempting to assume that the therapist’s obligations have ended. However, this might not be the case (which would be considered abandonment). If efforts to reach the patient by telephone fail, then sending a termination letter as discussed above is recommended. Although some authors recommended providing details about the patient’s course of treatment, current status, etc., it might be argued that a more generic letter is appropriate. The goal is not to continue to attempt to continue the therapy through the letter (especially since the patient’s response cannot be predicted and cannot be managed in therapy). In the spirit of the ethics codes and consistent with best-practices, the letter should serve to protect the client and offer alternatives should s/he choose to utilize them. Issues that might be covered (depending on the circumstances) should include reviewing that the patient has not scheduled further treatment sessions (or cancelled them), that you have unsuccessfully attempted to reach the patient by phone, that you are available if s/he desires to discuss the termination or reschedule in the future, and that you are happy to provide other treatment resources if so desired. Consultation with Colleague and Others
If confronted with any difficult termination issue, you should consult with colleagues. Appropriate consultation with colleagues is recommended in a number of situations and is consistent with all of the ethics codes. Ongoing consultation relative to the termination issues not only helps guide the therapist (by taking into all the relevant factors and points of view) but also establishes that multiple professionals had agreed on your chosen course of action if a problem ultimately occurs (e.g. state board or liability action against you). Consultation in this manner establishes that you acted consistent with the community standard. Of course, you should document the content and result of your discussions with the consultant. You should also request that the colleagues with whom you have consulted also make notes about the process. I can’t say this enough, in a legal case, “if it is not written down, it never happened”. The Termination Process should be Consistent with the Treatment Approach
As discussed in Younggren and Gottlieb (2008; See also the special issue of Psychotherapy, 2017), 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.
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.
Bhatia et al. (2017). The termination phase: Therapists' perspective on the therapeutic relationship and outcome. Psychotherapy, 54, 76-87.
Ensworth v. Mullvain 224 Cal. App. 3d 1105, 274 Cal. Rptr.447(Oct. 1990).
Davis, D. (2008). Terminating Therapy: A Professional Guide to Ending on a Positive Note. Hoboken: NJ: John Wiley and Sons.
Davis, D. and Younggren, J.N. (2009). Ethical competence in psychotherapy termination. Professional Psychology: Research and Practice, 40, 572-578.
Fisher, M.A. (2011). Psychotherapist variables affecting termination. Professional Psychology: Research and Practice, 42,163-165.
Garfield, S.L. (1994). Research on client variables in psychotherapy. In A.E. Bergen and S.L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed, pp.190-228), New York: Wiley.
Goode et al. (2017). A collaborative approach to psychotherapy termination. Psychotherapy, 54, 10-14.
Gutheil, T.G. and Brodsky, A. (2008). Preventing Boundary Violations in Clinical Practice. New York, NY: The Guilford Press.
Hill, C.E. (2005). Therapist techniques, client involvement, and the therapeutic relationship: Inextricably intertwined in the therapy process. Psychotherapy, 42, 431-442.
Hilliare, J. (1998). Termination of treatment with troublesome patients. In L.E. Lifson and R.I. Simon (Eds.) (1998). The Mental Health Practitioner and the Law (p. 216-221). Cambridge, MA: Harvard University Press.
Hjelt, S.E. (2011). Psychotherapy termination: Duty is a two-way street. Professional Psychology: Research and Practice, 42,167-168.
Kendall et al. (1992). When clients don’t progress: Influences on and explanations for lack of therapeutic progress. Cognitive Therapy and Research, 16, 269-281.
Knapp, S.J. & VandeCreek, L.D. (2006). Practical ethics for psychologists: A positive approach (pp. 147-160). Washington, DC: American Psychological Association.
Knapp et al. (2017). Practical ethics for psychologists: A positive approach (3rd Edition). Washington, DC: American Psychological Association.
Koocher, G.P. and Keith-Spiegel, P. (1998; 2008; 2016). Ethics in Psychology: Professional Standards and Cases (2nd ed; 3rd. ed; 4th ed). New York: Oxford University Press.
Lifson, L.E. and Simon, R.I. (1998). The Mental Health Practitioner and the Law: A Comprehensive Handbook. Cambridge, MA: Harvard University Press.
Norcross et al. (2017). Do all therapist do that when saying goodbye? A study of comonalities in termination behaviors. Psychotherapy, 54, 66-75.
Reamer, F.G. (2003). Social Work Malpractice and Liability: Strategies for Prevention (2nd ed.). New York: Columbia University Press.
Reamer, F.G. (2015). Risk Management in Social Work: Preventing Professional Malpractice, Liability, and Disciplinary Action. New York: Columbia University Press.
Roe, D. (2007) The timing of psychodynamically oriented psychotherapy termination and its relation to reasons for termination, feelings about termination, and satisfaction with therapy. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 35:3, 443-453
Shapiro, D.L. and Smith S.R. (2011). Malpractice in Psychology: A Practical Resource for Clinicians. New York: APA Books.
Simon, R.I. and Shuman, D.W. (2007). The doctor-patient relationship. Clinical Manual of Psychiatry and the Law, 17-36.
Stewart, R.E. and Chambless, D.L. (2008). Treatment failures in private practice: How do psychologists proceed? Professional Psychology: Research and Practice, 39, 176-181,
Treloar, H.R. (2010). Financial and ethical considerations for professionals in psychology. Ethics and Behavior, 20, 454-465.
Tsai et al. (2017). Saying good goodbyes to your clients: A functional analytic psychotherapy (FAP) perspective. Psychotherapy, 54, 22-28.
Vasquez, M.J.T. et al. (2008). Psychotherapy termination: Clinical and ethical responsibilities. Journal of Clinical Psychology: In Session, 64, 653-665.
Younggren, J.N. (2011). Psychologist duties, patient responsibilities, and psychotherapy termination. Professional Psychology: Research and Practice, 42,160-163.
Younggren, J.N. and Gottlieb, M.C. (2008). Termination and abandonment: History, risk and risk management. Professional Psychology: Research and Practice, 39, 498-504.
Younggren et al. (2011). Termination: A legal and ethical review of patient responsibilities and therapist duties. Professional Psychology: Research and Practice, 42, 160-168.
Legal Cases Cited
Brandt v. Grubin (1974.) 131 N.J. Super. 182 329 A.2d 82
Coddington v Robertson (1987). 160 Mich. App. 406 407 N.W.2d 666
Ensworth v. Mullvain (1990). 224 Cal. App. 3d 1105 [274 Cal. Rptr. 447]
Hughes v. Blue Cross (1989). 215 Cal.App.3d 832 263 Cal. Rptr. 850
Marshall v. Klebanov (2006). 902 A.2d 873 188 N.J. 23
Miller v. Greater Southern Community Hospital (1986). 508 A.2d 927 (D.C. App 1986)
Wickline v. State of California (1986). 192 Cal.App.3d 1630 (1986) 228 Cal. Rptr. 661
Wilson v. Blue Cross (1990). 222 Cal.App.3d 660 271 Cal. Rptr. 876
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