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Termination Guidelines

By Zur Institute, LLC     2012
 

Zur Institute offers two online courses on Termination for CE Credit, based partly
on this web page:
Termination Issues and Termination in Psychotherapy.

 

  • Clarify expectations and obligations from the outset. The Office Policies are the best way to articulate and discuss such expectations and obligations. (For Zur Institute's Clinical Forms, click here.)
  • Be familiar with the relevant guidelines and standards in your professions' Codes of Ethics with regards to termination and abandonment issues. Summary of the different Codes of Ethics on Termination Psychotherapy and Counseling, available at www.zurinstitute.com/ethicsoftermination.html.
  • Some terminations are short and swift, while others may be long and protracted. Then termination can have different meanings and be just an end of a phase in intermittent-long-term therapy. The form and type of termination depends on the client, setting of therapy, therapeutic orientation, quality and type of therapist-client relationship and the therapist.
  • If necessary, review with patients their insurance coverage, limits to managed care contracts, and how utilization review may impact on termination. Set up arrangements for addressing patient treatment needs if continued authorization is denied.
  • Make adequate arrangements for coverage during any periods of planned or unplanned absences.
  • Provide patients with referrals to other treatment sources, if needed, and work to assist them in their transition to other health care providers.
  • Be cautious in regard to termination of patients who are in crisis. Try to avoid terminating clients who are in acute or temporary crisis due to payment issues.
  • The average number of visits among U.S. patients receiving psychotherapy in 2007 was 8 sessions, according to a study published in the American Journal of Psychiatry.
  • 41 percent of patients in the U.S. quit psychotherapy "prematurely," according to a 2010 study in the journal Psychotherapy Theory, Research, Practice, Training.
  • Many clients unilaterally decide to drop out of therapy. They may do that with a phone message or by simply not showing up to their next scheduled appointment. You must remember that it is the client's prerogative and choice whether to continue in therapy or not. Except in extreme situations, such as when the client poses a danger to self or others, you need to respect their choice. Do not tacitly condone patients dropping out of treatment when your clinical judgment indicates continued care is needed. When clinically and otherwise appropriate, notify the patient of your assessment and recommendations. There is no ethical, clinical or legal mandate to send a registered letter to client. Different clients and situations may require different actions and, at times, lack of action.
  • The question of whether therapists need to send a letter to clients who unilaterally dropped out (i.e., pre-mature termination) was recently addressed by Davis & Younggren in a 2009 PPRP article, where they clearly stated "In ordinary circumstances, however, letters are typically unnecessary and potentially counterproductive to the natural dissolution of the relationship (Davis, 2008). For instance, the client might feel embarrassed or scolded for his or her oblique termination and be less inclined to return. The client might perceive the psychotherapist's actions as controlling and unnecessarily intrusive...It might seem that the psychotherapist is trying to break up with the client or get rid of him or her with such a formal action. Routine letters of closure not only present an unrealistic administrative burden on the provider, they add to the risk of negative client reactions." (p. 575)
  • It is not unusual for therapy to break down rather than go through a smooth, clear or distinct termination process with patients with personality disorders (i.e., BPD) or those who were diagnosed with severe mental illness, such as schizophrenia or Bi-Polar disorders. Termination with these clients can be very abrupt or very long, painful, confusing and tumultuous. Obviously, each case should be handled according to the specific context of therapy. The context of therapy includes client, setting, therapy and therapist factors.
  • You can terminate treatment with clients (or another person with whom the client has a relationship) who threaten or stalk you, your family member or your employees via phone, email, online, in-person or other means. You can also terminate treatment with clients who intrude into your private life via the Internet or in "real" life. You are allowed to protect your privacy and secure your own, your family members' and employee's sense of privacy and safety. (Document, document and document.)
  • You 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. For those patients who have ongoing treatment needs, when appropriate, one should offer to provide them with assistance with referrals to other appropriately trained and accessible professionals (except when we are being threatened, assaulted, stalked, or other relevant situations).
  • Document discussions of termination issues, agreements reached, decisions made and their rationale, and, when relevant, document the recommendations and follow-ups. To purchase a Termination Summary form, click here.
  • Termination of treatment is not always a permanent ending of the professional relationship. Termination is often not relevant during, or an end of phase in, intermittent-long-term psychotherapy. These forms of therapy may continue throughout the life span of individuals and families.
  • Termination is a phase of each patient's treatment. If possible and appropriate, plan for it, prepare for it, process it. Additionally, each clinician should consider termination in light of their theoretical orientation and treatment approach, each patient's/client's diagnosis and treatment needs, and any relevant diversity factors that might impact the process.

 
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