Termination Revisited: Dispelling Myths - Clarifying Issues
Clinical Update May 2015
By Zur Institute
View a complete list of Clinical Updates.
Some terminations are short and swift, while others are long and protracted. In many situations, the client simply drops out, affording therapists neither the luxury of planning and discussing termination with clients nor the chance to go through a gradual and/or thorough termination process. In fact, in about half of all terminations, clients simply quit therapy and often do not even bother to notify their therapists of their decision to quit.
When clients do not show up, do not call and simply drop out, unlike the common myth, there is no legal mandate for therapists to send a letter to the client, call the client, offer referrals, or offer one more free "closure" session. Each situation is different. Sometimes all the therapist needs to do is to be respectful of the client's implied decision and document the termination process (or lack of) in the patient's records.
- Myth I: Terminations are always initiated by clients. In fact, terminations can be initiated by clients and by therapists. Of course, parents and managed care companies may also initiate or impose termination.
- Myth II: Therapists must always follow up with a letter and give referrals to clients who drop out of therapy. In fact, there is no legal or ethical mandate for therapists to always give referrals, send a letter, or follow up with clients upon premature terminations. Each situation is different. Sometimes following up with a letter and referrals can be highly inappropriate.
- Myth III: Therapists must accept back former clients who seek to re-enter therapy. In fact, therapists do not have an ethical or legal obligation to re-start or re-engage in therapy with former clients (i.e., clients whose treatment was terminated).
- Myth IVa: Therapists must keep clients' records forever after termination. Conversely, Myth IVb: Therapists do not need to keep records after termination. In fact, therapists must keep records for a period of time according to their state laws or professional associations' recommendations. For example, in CA psychologists need to keep records of adult clients for 7 years after termination, and MFTs must keep the records for 10 years.
Our online Termination CE courses debunk many myths and provide guidelines
for handling the various forms of terminations:
Termination in Psychotherapy: Ethical & Clinical Considerations 4 CE Credits
Professional Will 1 CE Credit
NOT ALL TERMINATIONS ARE CREATED EQUAL:
- Ideally, termination is discussed and reviewed by a therapist and client prior to the last session. In reality, however, this often does not take place.
- Therapist-initiated terminations may involve situations in which there has been no progress in therapy, clients no longer benefit from therapy, therapists are not clinically effective due to counter-transference or other reasons, clients are non-compliant, clients require care that is beyond the therapist's scope of practice, or a client threatens or stalks therapists, their family members, or their employees via phone, e-mail, online, texts, or in-person.
- While therapists do not have an obligation to treat clients who cannot pay them, they should be sensitive to clients' clinical needs and proceed with care and caution. Whenever possible, if therapists foresee it coming (such as when insurance coverage runs out), they should prepare clients for that eventuality. Therapists should use caution and patience with clients who are in crisis but can no longer pay for therapy. A few extra sessions and referrals may be necessary to avoid abandonment.
- Office Policies or Informed Consent (given to or shared with clients before or at the start of therapy) should discuss termination issues, including a client's right to terminate therapy at anytime and under what conditions therapists may initiate termination. (Office Policies are available as part of our 60 Essential Clinical Forms.)
- Therapists can also terminate treatment with clients who intrude into their private life or harass them via the Internet or in "real" life.
- Therapists are allowed to terminate intrusive clients in order to protect their privacy and secure their own, their family members' or employees' privacy and safety.
- Generally, therapists must terminate therapy when it becomes reasonably clear that the patient no longer needs the service, is not likely to benefit, or is being harmed by continued service.
- Therapists should be prepared for unexpected termination caused by therapists' illness or death, therapists' need to suddenly relocate to another city or state, or the therapist's unexpected and sudden inability to provide services for a variety of reasons. One way to prepare for such unexpected occurrences is to have a Professional Will. In fact, it is important for all therapists to have such Professional Will on file. (See free Resources or our Online CE course on Professional Will. Professional Will form is also included in our Clinical Forms.)
- Therapists who practice intermittent-long-term therapy view termination differently. In this modality, therapy may continue on-and-off throughout the life span of individuals and families. Rather than a final termination, this modality involves a series of 'end of a phase' of therapy.
- Regardless of how or why therapy is terminated, it is important to document it: document who initiated the termination, why, the termination process (or lack of), treatment summary, and, when applied, referrals and follow-ups.
- In difficult and complex cases, consultation with an expert can be very helpful in determining ways to practice within the standard of care.