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By: Jeffrey E. Barnett, Sherry G. MacGlashan, and Alicia J. Clarke
Ref: Barnett, J.E., MacGlashan, S., & Clarke, A.J. (2000). Termination and abandonment: issues for clinicians. In VandeCreek, L., & Jackson, T. (Eds.), Innovations in Clinical Practice, (pp. 231-246). Sarasota, FL: Professional Resources Exchange.
Copyright 2000 by Professional Resource Exchange, Inc. Reprinted with permission. Further electronic/printed circulation or duplication is strictly prohibited without explicit written authorization from Professional Resource Exchange, Inc.
CASE EXAMPLES*
Case Example A
For several months, you have been providing treatment to a patient for depression. In addition to outpatient psychotherapy with you, she has been treated with antidepressant medication by a colleague, a psychiatrist. The patient cancels and reschedules several appointments and then fails to show up for two consecutive sessions. When you are only able to reach her answering machine, you leave messages to which she makes no response. Several weeks pass and you have no contact with this patient. You are quite concerned because of the difficulties she has experienced with depression, and you have concerns regarding her appropriate use of the medication.
Case Example B
A patient who has been in treatment with you for many months decides that treatment is no longer needed. Toward the end of a session with you, he informs you that he believes he has achieved all of his goals and, therefore, this will be his last session. Although it is clear that he has improved significantly since entering treatment and is no longer in distress, you feel caught off guard and are unsure how to respond.
Case Example C
You and a patient have been working together in outpatient psychotherapy for several months. Despite your best efforts, it is clear that she is not improving. You question if she is actually benefiting from the treatment you are providing. You discuss this with her, and the two of you decide to keep working toward the agreed-upon treatment goals. Additional months pass without any progress being achieved. You become concerned because she is becoming increasingly dependent on you and her condition is worsening.
Case Example D
A patient of yours regularly leaves your office without paying. When you raise the issue for discussion, he makes excuses and promises prompt payment. Despite several small payments, this pattern persists and his outstanding balance continues to grow. When you confront him, he states that he cannot afford to pay his bill. He tells you that he has lost several jobs because of his depression and states that because it has been so serious lately he has been unable to work. Although concerned about him clinically, you are unsure if you should provide any further treatment because of his stated inability to pay for it.
Case Example E
Your patient with a significant anxiety disorder is beginning to achieve some benefits after eight sessions of outpatient treatment. In keeping with her insurer’s requirements, you complete and submit the required treatment plan and request for further authorization. You are quite hopeful due to the progress made thus far and her clear motivation and commitment to treatment. You are alarmed to learn that the utilization review personnel have denied authorization for any further treatment, stating that it is not found to be medically necessary. You are left feeling frustrated, upset, and unsure of what to do.
Case Example F
After many years of clinical practice, you find yourself becoming increasingly distressed by changes in the mental health field. After experiencing mounting frustrations and symptoms of burnout, you decide to close your practice and retire. Having made this difficult decision, you feel relieved and decide to move forward with your plans immediately. You give your patients 2 weeks’ notice and begin moving forward with your life.
INTRODUCTION
As illustrated by the preceding case examples, termination of the psychotherapy relationship has the potential to occur in a variety of ways. It may be initiated by either patient or psychotherapist, by mutual agreement, or in response to external forces or pressures. It may be planned and well thought out or it may come as a surprise. It may leave the patient hurt and abandoned, or may be a solidifying process that facilitates integration of gains made in treatment while serving as the culmination of a successful course of treatment.
Seen in this way, it is evident that how psychotherapists address and conduct the termination process can have far-reaching effects on those they serve. Thus, termination is an important component for the psychotherapy process. Many authors have consistently emphasized its importance for clients and psychotherapists alike for clinical (e.g., Basch, 1980; Goodyear, 1981; Wolberg, 1977), ethical (e.g., Gutheil & Appelbaum, 1982; Simon 1987; Stromberg et al., 1988), and legal (e.g., Ewing, 1990; Macbeth et al., 1994; B. A. Weiner & Wettstein, 1993) reasons.
CLINICAL ISSUES
The appropriate handling of psychotherapy patients’ termination was addressed early by Freud (as cited in Chang, 1977), who stated:
An analysis is ended when analyst and patient cease to meet for the analytic session. . . . There are two criteria . . . that the client is no longer suffering from his former symptoms and that the analyst is satisfied that no repetition of the patient’s specific pathology . . . is to be feared. (p. 18)
These words imply the need for a systematic and orderly manner of appropriately addressing each patient’s treatment needs when ending the psychotherapy relationship. They also suggest that termination is an important part of the psychotherapy process, not an after-thought or surprise. I. B. Weiner (1975) conceptualized termination as one of three phases of each client’s psychotherapy: the initial assessment phase, the middle phase of ongoing psychotherapy, and the final phase of psychotherapy – termination. He states that this final phase of psychotherapy “is exceeded only by the initial phase in its importance for determining the amount of help a patient receives” (p. 263). Most importantly, termination should be considered a mandatory and vital component of the psychotherapy process and, thus, should be given the appropriate level of attention by psychotherapists.
Unfortunately, this final phase of treatment has historically been relatively neglected in training programs and in the professional literature (Bostic, Shadid, & Blotcky, 1996; Brady et al., 1996; Maholick & Turner, 1979; Penn, 1990). It is fortunate that it has received growing attention in recent years, as the manner that psychotherapy is terminated can determine whether or not self-learning during the middle phase of treatment will continue as a life- enriching resource or fade into a nonmeaningful experience (I. B. Weiner, 1975). To effectively bring psychotherapy to a close, the clinician needs to be able to judge when termination is appropriate and how it should best be approached and implemented.
Just as the initial phase of psychotherapy is critical in building rapport, a carefully planned and implemented termination is also critical in securing trust in the comprehensive treatment process while minimizing premature, inappropriate termination, symptom return, and/or feelings of exploitation (Barnett & Sanzone, 1997). Termination should be addressed from the outset of the psychotherapy relationship (Kramer, 1986; Quintana & Holahan, 1992; Strupp & Binder, 1984) and, when relevant, should be included in the informed consent process that is so important for establishing the agreed-upon parameters of the treatment process. When treatment is time limited or when interruptions to the treatment process may be anticipated, addressing these issues from the outset will help to ensure that each patient’s treatment needs are adequately met.
In conceptualizing termination as a discrete phase of each patient’s treatment, it should be pointed out that appropriate termination of psychotherapy involves several important issues and activities. This phase can be viewed as having three distinct purposes: assessment, resolution, and generalization. First, the psychotherapist should conduct an assessment of any ongoing treatment needs and the patient’s readiness for terminating treatment. Secondly, time must be spent working through and hopefully resolving the remaining affective issues and bringing closure to the relationship. Finally, maximizing the generalization of learning and increasing the patient’s self-reliance and confidence are necessary.
Working through termination themes, guided by the needs of each patient, brings about an effective termination process. Some of these major themes include closure, sadness, increased self-efficacy and personal power, ending, growing up, autonomy, individuation, summarizing, consolidating, and saying good-bye (Ward, 1984). At times, patients may experience the perceived end of treatment as a significant loss. Because loss is believed to be inherent in termination, a state of crisis may be expected for some patients. Patients may be expected to react to termination with affective, cognitive, interpersonal, and defense reactions similar to grief reactions (Ward, 1982). Yet, when this phase of treatment is appropriately addressed, termination may be seen as a phase of growth and development (Maholick & Turner, 1979; Quintana, 1993; Ward, 1984). It provides the clinician and patient the opportunity to transform the relationship to incorporate the patient’s growth, reflect on the patient’s involvement and activities in treatment, and show how the patient has learned and contributed. Thus, it may be seen as an opportunity for growth, solidifying the gains made in treatment and helping the patient to move forward independently.
TERMINATION AND BRIEF PSYCHOTHERAPY
In the present age of brief psychotherapy and the influence of managed care, many clinicians do not provide the more long-term treatments described previously. Empirical findings validate the use of specific time-limited treatment protocols for patients with a variety of presenting problems (see Sanderson & Woody, 1995, for a comprehensive review of empirically validated treatments).
Very often, after an initial assessment of a patient’s treatment needs has been completed, a specific course of treatment, which has a clear ending date, can be agreed upon. This approach, when applicable, provides the patient with a very clear expectation of when treatment will end. With such time-limited treatment approaches, the termination phase of psychotherapy is, of necessity, much briefer as well. Typically, this more short-term relationship does not bring with it the previously described issues to be worked through and resolved. Additionally, when patients are aware of the predetermined termination date, they may be preparing themselves for termination throughout the course of treatment. As Shectman (1986) points out, having a predetermined length of treatment set from the outset provides a certain structure which may make separation much less traumatic. Clearly, patient expectations in briefer psychotherapies are different from those in long-term and more open-ended treatments.
Research concerning the termination of short-term psychodynamic psychotherapy has found that many successful psychotherapists tend to spend very short periods of time discussing termination with their patients (Budman & Gurman, 1996). Additionally, Marx and Gelso (1987) reported that the majority of the brief psychodynamic psychotherapy patients they studied tended to report generally positive reactions to the ending of their psychotherapy relationships. Budman and Gurman (1996) further emphasize the importance of assessing each brief psychotherapy patient’s termination needs. For some patients, this phase of treatment will accentuate insecurities and separation and loss issues; for others, these issues are not relevant and a significant focus on and exploration of such issues is unwarranted.
These issues are especially relevant when taking the view of psychotherapy as being an intermittent lifelong endeavor. Kaslow (1992) describes a model in which psychotherapy is returned to at different difficult times in a person’s life. Patients view psychotherapy as a resource to return to when life-cycle issues and stressors arise. When viewed in such a way, brief treatment is provided and then returned to at later dates when needed. Thus, the finality of termination assumed in more traditional psychotherapies typically does not exist for either the patient or psychotherapist. In fact, numerous studies (e.g., Grunebaum, 1983; Hartlaub, Martin, & Rhine, 1986; Kovacs et al., 1981) have found that a majority of psychotherapy patients who successfully complete treatment return later for additional psychotherapy.
Authors such as Pinkerton and Rockwell (1990) recommend that brief psychotherapists take a flexible approach to termination. As previously stated, and articulated further by Wolberg (1980), psychotherapists must assess each patient’s termination needs and respond based upon the patient’s psychodynamics, the nature of presenting problem(s) and the course of treatment, and the quality of the therapy relationship. For some, termination may trigger significant reactions; for others, it creates no significant problems. Pinkerton and Rockwell (1990) describe this later group as including:
VOLUNTARY TERMINATION
Voluntary termination occurs when the patient and psychotherapist mutually agree that it is appropriate for the treatment relationship to end. The initial suggestion for termination may come from either the patient or the psychotherapist.
As illustrated in Case Example B provided previously, a client may propose termination. The psychotherapist’s first response to this expression is to consider whether it reflects an accurate assessment of progress instead of resistance to further work in treatment. If the desire for termination is found to be reflective of significant progress made toward treatment goals, then, in keeping with the initial treatment contract, it is appropriate to move forward through this final phase of treatment. If found to be a reflection of resistance, the psychotherapist can identify that there is unfinished business to address without pressuring or seducing the patient to stay. The psychotherapist should present the information realistically, stating that there may be more to accomplish in terms of meeting the treatment goals with the patient, hopefully agreeing to continue working to achieve them. However, it should be kept in mind that the patient’s stated desire for termination may actually reflect an indication of a readiness for treatment to end.
Termination may also be proposed by the clinician. Some patients may ignore evidence of their progress or avoid calling attention to it. Others may not be improving in treatment. This may be due to resistance to change, some secondary gain being derived from being in psychotherapy, characterologic issues, or psychotherapist inadequacies. As highlighted by Case Example C, the psychotherapist must determine if continued treatment is in the client’s best interest. If not, the psychotherapist is obligated to discuss the discontinuation of treatment in a thoughtful and sensitive manner. Additionally, as treatment goals still remain, the clinician should follow through on the issue of referral to an appropriately trained clinician. It is hoped that termination can be discussed with patients in a supportive manner, avoiding any criticism or comments that may be perceived as signs of failure or rejection. Hopefully, the clinician’s focus is always on the patient’s needs and best interests. Thus, the clinician should be cautious in his or her timing and be alert to countertransference feelings that may be affecting the decision to discuss termination.
The issue of the timing of termination is an important one. It will hopefully be based on the achievement of specific objective criteria such as reaching predetermined treatment goals. The termination phase of treatment may also be initiated when the patient’s coping abilities have improved, maladaptive or dysfunctional behaviors have been reduced, and the ability to apply treatment gains to life situations has been learned. At times, termination may be initiated because of patient noncompliance with treatment requirements or because the patient may be so dysfunctional or disordered that referral to another provider or hospitalization may be appropriate. Additionally, if treatment does not prove to be beneficial, if the patient has progressed as far as possible, or if increases in dysfunctional behavior are seen, the clinician is called upon to address the appropriateness of initiating termination (Maholick & Turner, 1979). As illustrated in Case Example C, a clinician may need to initiate termination when it is clear that a patient is not benefiting from treatment. Continued treatment under such circumstances may not be in the patient’s best interest. Other examples of clinician-initiated termination include a patient being threatening to the clinician or, in group therapy, a patient acting in ways that are consistently destructive to the group.
It is important to note that if the opportunity for considering or initiating termination is ignored, the psychotherapist runs the risk of harming the patient. One possibility is that by ignoring termination indicators the psychotherapist may be encouraging the patient to use the treatment as a “substitute for real living” and blocking the chance for the patient to engage in realistic, effective life experience (Maholick & Turner, 1979, p. 586). In other words, permitting maladaptive behavior to continue is inconsistent with the intent, and an inappropriate use, of psychotherapy. An inappropriate extension of treatment may falsely imply that the clinician condones or supports the patient’s behavior, running the risk of reinforcing or encouraging it. If the psychotherapist cannot act in the best interests of each patient with honesty and appropriate support by modeling real-life consequences and limit setting, the therapist may actually be harming the patient in the long run.
An additional example to consider is when the patient has not made an actual commitment to treatment. Once again, even if the patient does not see a need to end treatment, the psychotherapist may recognize the presence of criteria that imply the need to consider termination. Maholick and Turner (1979) further proposed that “perhaps a successful good-bye would be the most therapeutic thing for a person at that particular nodal point in his living” (p. 587). The next step then becomes the appropriate implementation of termination.
IMPLEMENTING TERMINATION
In working toward closure, the psychotherapist and patient should be cognizant of and avoid pitfalls, allowing enough time for reacting, anticipating, reminiscing, and planning (Penn, 1990). Patient and therapist should have an open discussion of termination issues. As Bennett et al. (1990) recommend, the following points should be discussed and agreed upon:
From the previous discussion, it can be seen that it would not be appropriate to discontinue psychotherapy during the session when termination first comes up for discussion, as was addressed in Case Example B. Clinicians will be well served by adhering to this guideline no matter how appropriate the termination might seem to be. I. B. Weiner (1975) listed the following reasons for this guideline:
Two types of termination are available for the psychotherapist and patient to consider. Time-limited termination involves a fixed duration of time during which treatment sessions continue at their usual frequency and then stop completely. Spaced termination occurs when the time between treatment sessions is gradually extended so that the date of the final session is not set in advance but is approached in measured steps (I. B. Weiner, 1975). Choosing between the two depends upon the nature and goals of the treatment contract. However, as I. B. Weiner (1975) further points out, “Generally speaking, time-limited termination works most effectively in uncovering psychotherapy, whereas spaced termination becomes increasingly appropriate the more supportive the treatment has been” (p. 284).
Additionally, the psychotherapist should work to assist the patient to build on gains made in treatment through a continued process of self-observation (Quintana, 1993). The clinician should reinforce patient self-observational abilities when the client acts as his or her own therapist. The psychotherapist may also help the patient resolve transference feelings by promoting the real relationship between them. This may be accomplished by engaging in increasing amounts of appropriate self-disclosure as the termination nears.
PREMATURE OR FORCED TERMINATION
At times termination must occur before the agreed-upon treatment goals have been achieved. This may occur because external circumstances force the termination of treatment. I. B. Weiner (1975) described the following possibilities: The client or psychotherapist moves out of town; the psychotherapist becomes ill, disabled, or retires; the client can no longer afford treatment or has no more insurance coverage; or psychotherapist rotation or termination of position occurs.
As discussed by Greenspan and Kulish (1985), premature termination can be assumed to be a function of any combination of psychotherapist, patient, and interactional variables within the therapeutic relationship. Patient attributes that can lead to a higher dropout rate include lower socioeconomic class, low motivation, the perception of problems as internal to oneself and not as situational, lack of perseverance, poor social integration, less suggestibility, impulsivity, and the presence of antisocial and authoritarian attitudes. As cited by Greenspan and Kulish (1985), Brandt and Pope (1965) report that psychotherapist variables found to be commonly associated with premature patient termination are interviewer anger, incompetence, inexperience, male gender, and the therapist’s dislike for his or her client.
If events occur that necessitate a forced termination, this does not mean that there are no benefits of treatment and that the termination process should be abrupt, angry, or ignored. A closing phase of psychotherapy should still occur so that patient autonomy and independence may be promoted, gains made in treatment reinforced, reactions to termination processed and worked through, and posttermination recommendations made and implemented.
How much time should be taken to address these issues in the termination phase and when the patient should be informed of a forced termination are not entirely clear. However, in one study of the views of psychologists and psychiatrists (Chang, 1977), 42% of the respondents stated that they would inform their patients 2 weeks before the date of forced termination, 19% 3 weeks before, and 12% 4 weeks before. Interestingly, these clinicians reportedly could not give concrete reasons for their estimates; instead, their responses were intuitive guesses, because they had not received much training on this issue.
Penn (1990) recommended an individualized approach based upon each patient’s personality and treatment needs. Six weeks’ advance notice is recommended for patients who have been in psychotherapy for over 6 months, but this is a flexible guideline dependent on the patient’s presenting difficulties, personality factors, abandonment or loss history, and the length and type of treatment being provided. The dynamic nature of this process is further illustrated by Penn (1990), who stated: “If the topic is broached too early, it may cut off the work in progress; if it is broached too late, there will not be time to work through the feelings and consolidate the gains made” (p. 382). Finally, Brady et al. (1996) suggest that psychotherapists be alert to a variety of both patient and therapist factors that may impact how patients respond to the end of treatment. Therapist attention to their own needs, experiences, attitudes, and feelings is important to promote successful termination.
ETHICAL AND LEGAL GUIDELINES
Ethical standards that address these issues and provide guidance for mental health professionals include the National Association of Social Workers (NASW) Code of Ethics (NASW, 2017), which states:
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. (p. 15)
As was illustrated in Case Examples D, E, and F, the clinician has an obligation to ensure that all treatment needs are appropriately addressed regardless of the reason for a termination. These obligations are mandatory, regardless of whether termination is initiated by the patient or therapist, or in response to some external factors. Once a formal treatment relationship has begun, the clinician maintains responsibility for the patient’s welfare, either until treatment is successfully completed, the clinician is discharged of his or her duty by the patient, or other treatment arrangements are made that appropriately address the patient’s treatment needs. Stated succinctly in the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 1992) is the clear guidance that “Psychologists do not abandon patients or clients” (p. 1606). Similar guidance is provided in the ethics codes of marriage and family therapists, counselors, and psychiatrists (American Association for Marriage and Family Therapy, 1991; American Counseling Association, 1995; American Psychiatric Association, 1993). It is important to note that even if a patient drops out of treatment as was illustrated in Case Example A, the clinician’s responsibility for, and obligation to, the patient has not necessarily ended. As stated by Ewing (1990), “Although patients have an absolute right to terminate treatment unilaterally, their exercising this right does not necessarily relieve the psychotherapist of his or her duty or care” (p. 722). The landmark legal ruling in Collins v. Meeker (1967) illustrates these points well:
It is the settled rule that one who engages a physician . . . to treat his case implicitly engages him to attend throughout the illness or until his services are dispensed with. In other words, once initiated, the relationship of physician and patient continues until it is ended by the consent of the parties, revoked by the dismissal of the physician, and until his services are no longer needed. A physician has a right to withdraw from the case, but if he discontinues his services before the need for them is at an end, he is bound first to give notice to the patient and afford the latter ample opportunity to secure other medical attendance of his own choice. If a physician abandons a case without giving his patient such notice and opportunity to procure the services of another physician, his conduct may subject him to the consequences and liability resulting from abandonment of the case. (p. 493)
Thus, in Case Example A, when the patient discontinues treatment and will not come back to discuss termination, the clinician maintains an obligation to ensure that this patient’s treatment needs are adequately addressed, an obligation that has been repeatedly emphasized in court rulings (e.g., Brandt v. Grubin, 1974; Miller v. Greater Southeast Community Hospital, 1986). Ewing (1990) recommended that clinicians “make a good faith effort to contact the patient, determine the patient’s reasons for terminating, and take appropriate therapeutic steps to deal with the termination” (p. 723). At a minimum, authors (e.g., Macbeth et al., 1994) generally recommend the use of a letter to the patient that communicates the psychotherapist’s concerns about the patient, any recommendations deemed appropriate to include the scheduling of termination sessions, and the offer to be of assistance in arranging for referrals to other health care providers if needed. Sample letters are provided on pages 242 to 243 which may be used as models by clinicians who have had a patient drop out of treatment (Case Example A), when a patient is initiating termination (Case Example B), when treatment must be terminated because of lack of benefit to the patient (Case Example C), or when treatment must be terminated because of other factors (Case Examples D, E, and F). It should be emphasized, however, that these sample letters are general models and will need to be modified based on each patient’s particular circumstances.
One special termination circumstance of importance to consider is that of the patient who is not benefiting from treatment and may possibly be harmed by its continuation. This was illustrated in Case Example C. In keeping with the ethical tenets of beneficence and nonmalefeasance (Thompson, 1990), continuing treatment under these circumstances would be unethical and not in keeping with the commitment to each patient’s welfare. The Code of Ethics of Marriage and Family Therapists (American Association for Marriage and Family Therapy, 1991) states, “marriage and family therapists continue therapeutic relationships only so long as it is reasonably clear that clients are benefiting from the relationship” (p. 2). Similar guidance is provided in the other mental health professions’ ethics codes and is codified into law (Annotated Code of Maryland, 1992) as illustrated for psychologists:
Psychologists shall: (1) make or recommend referral to other professional, technical, or administrative resources when the referral is clearly in the best interest of the client; (2) Terminate the professional relationship in an appropriate manner, notify the client in writing of this termination, and assist the client in obtaining services from another professional: (a) When it is reasonably clear the client is not benefiting from the relationship. (pp. 2-3)
An additional special termination circumstance is the need to terminate treatment because of financial reasons, as illustrated in Case Example D. The NASW Code of Ethics (NASW, 2017) provides clear guidance, stating:
Social workers in fee-for-service settings may terminate services to clients who are not paying an overdue balance if the financial contractual arrangements have been made clear to the client, if the client does not pose an imminent danger to self or others, and if the clinical and other consequences of the current nonpayment have been addressed with the client. (p. 15)
Although it is clear that psychotherapists need not provide treatment indefinitely to patients who cannot or do not pay their bills, certain ethical obligations exist. Advance financial and billing arrangements should be made from the outset of the professional relationship; the psychologists’ ethics code (American Psychological Association, 1992) recommends: “If limitations to services can be anticipated because of limitations in financing, this is discussed with the patient, client, or other appropriate recipient of services as early as is feasible” (pp. 1602-1603). Again, even if the patient can no longer pay for services, one must not abandon him or her. Gutheil and Appelbaum (1982) cite relevant case law stating, “Courts are likely to look less favorably upon therapists who have stopped seeing patients for failure to pay their bills than those who have been terminated for any other cause” (p. 155). Thus, the patient’s treatment needs should be addressed and alternative arrangements made if clinically indicated. If treatment is to be terminated, at least a few sessions should be offered to assist the patient in working through termination issues. When financial hardship exists, this can be done at a reduced rate by using a payment plan, or pro bono. Simultaneously, arrangements can be made for the referral of the patient to an appropriate treatment professional who can meet both the patient’s clinical and financial needs. The use of community clinics, professionals who utilize a sliding fee scale, and pro bono resources may all be helpful.
Although clinicians cannot force patients to follow through with referrals, steps may be taken to help facilitate the transfer to another psychotherapist and to follow-up to encourage the patient’s compliance. Again, follow-up letters such as those provided on pages 242 to 243 may effectively serve such a purpose by communicating the clinician’s recommendations and concerns clearly in a manner that leaves a tangible record of the clinician’s attempts to meet a reasonable standard of care. This final point is important both clinically and as a risk management strategy should questions arise later about how the clinician handled the termination process.
Case Example A illustrates a situation in which treatment is to be terminated because of patient noncompliance. Some courts have ruled that noncooperation in treatment, threats against a psychotherapist, and other conditions can justify clinician-initiated termination (see Eyrich v. Dam, 1989; Herold v. State, 1982). Although it may be appropriate to officially terminate such a patient’s treatment, it must be done according to the legal and ethical guidelines discussed previously. The patient should be contacted in writing and informed of the termination, the reasons it is occurring, and what alternatives exist for the patient’s treatment. If the clinician deems that ongoing treatment is needed, this must be stated clearly, and specific recommendations for continued treatment should be made. The clinician should also suggest possible referral sources and offer to assist in the referral process. It is crucial that the clinician not tacitly condone a patient dropping out of treatment if in his or her professional judgment treatment services are still needed.
When the clinician must initiate termination because of personal reasons as illustrated in Case Example F, procedures used should be sensitive to patient needs as illustrated in psychology’s ethics code (American Psychological Association, 1992), which states: “Psychologists make reasonable efforts to plan for facilitating care in the event that psychological services are interrupted by factors such as the psychologist’s illness, death, unavailability, or relocation” (p. 1606). Similarly, social workers’ ethics code (NASW, 2017) states: “Social workers who anticipate termination or interruption of services of clients should notify clients promptly and seek the transfer, referral, or continuation of services in relation to the client’s needs and preferences” (p. 15). It can be seen that all possible steps should be taken to avoid abandoning patients and to ensure that their treatment needs are adequately addressed. Also implied in these two guidelines is the need to ensure appropriate coverage for patients during periods of therapist absence, whether anticipated or not. Stromberg et al. (1988) emphasized this point, stating: “Claims of abandonment sometimes arise when therapists fail to provide adequate coverage during nights, weekends, or other absences” (p. 495). As Barnett and Sanzone (1997) further pointed out: “Since patients at times experience crises and emergencies between sessions, it is important to ensure accessibility to them and to make appropriate arrangements for coverage by another qualified health care provider during episodes of absence or inaccessibility” (p. 11). But care must be taken to select a colleague who is appropriately trained and qualified to meet the patient’s treatment needs. Utilizing lesser trained personnel such as supervisees or students is clearly not appropriate and leaves the clinician open for charges of negligence (Gutheil & Appelbaum, 1982). These points are emphasized as well in legal rulings such as Johnson v. Ward (1986).
A final termination dilemma of importance concerns the role of managed care and other third-party payors, as illustrated in Case Example E. Clinicians may be tempted to unilaterally terminate treatment because of an adverse utilization review decision. Yet the clinician maintains an ongoing responsibility for the patient’s welfare, even in such situations. The landmark legal decision in Wickline v. State of California (1986) provides guidance for the clinician in such situations:
Patient who requires treatment and is harmed when care which should have been provided is not provided should recover for injuries suffered from all those responsible for deprivation of care, including when appropriate, health care payors.
Third party payors of health care services can be held legally accountable when medically inappropriate decisions result from defects in the design or implementation of cost containment mechanisms, such as when appeals made on behalf of a patient for medical or hospital care are arbitrarily ignored or unreasonably disregarded or overridden.
Physician who complies without protest with limitations on treatment imposed by a third-party payor when physician’s medical judgement dictates otherwise cannot avoid his ultimate responsibility for his patient’s care. (p. 810)
The guidance provided by this and other cases (e.g., Wilson v. Blue Cross of Southern California, 1990) addresses the clinician’s ongoing responsibility for the patient’s welfare, regardless of third-party payor decisions. Terminating treatment because of an adverse utilization review decision would be inappropriate. At a minimum, the clinician must formally appeal this decision in an effort to obtain continued authorization. But clinicians must bear in mind that third-party payors may deny authorization only for payment for treatment. They cannot deny authorization for providing treatment. Only the clinician can make this decision. This highlights the distinction between insurers’ possibly being fiscally motivated in their utilization review decisions and clinicians’ ethical and legal responsibility to make clinically motivated treatment decisions. Thus, should an appeal be denied and the patient be unable to afford treatment that the clinician’s judgment deems necessary, steps should be taken to make alternative financial and/or treatment arrangements as needed. The clinician maintains responsibility for the patient’s welfare and should make sure that the patient is not abandoned.
CONCLUSIONS
Termination is an integral component of the psychotherapy process and can contribute greatly to the patient’s overall success in treatment when handled appropriately. It should be anticipated and planned for as well as discussed actively with the patient over time. Circumstances do arise when treatment must end for reasons other than the patient’s treatment goals being successfully achieved. During these situations it is important to take appropriate care to ensure that any remaining treatment needs are adequately met. A failure to do so may result in harm to the patient and possibly lead to claims of abandonment and malpractice suits. Taking adequate time to work through patient reactions and remaining treatment needs, making referrals to suitable treatment resources if clinically indicated, and assisting in the transition to another health care provider are all important steps to take. Adhering to the underlying ethical tenets of beneficence and nonmalfeasance, along with compliance with the general ethical principle of striving to ensure the welfare of those we serve, will all assist in the decision-making process that leads us to handle each patient’s termination in an ethical and appropriate manner.
Barnett (1998) makes the following specific recommendations for clinicians:
Sample Letters From Clinician to Patient
For Use in the Termination Process
SAMPLE LETTER A: A patient in need of ongoing care drops out of treatment.
Date
Name
Address
Dear __________:
I was sorry to learn that you canceled our most recent scheduled appointments. I have been unable to reach you by telephone and am quite concerned about you. As you know, it is very important that your use of medication be actively monitored by a physician. Dr. __________ informs me that the two of you have not met recently either.
Although you have received some benefit from treatment thus far, it is clear that additional treatment will be needed for you to be able to reach the treatment goals we discussed. If for some reason you decide not to continue your needed treatment with me and Dr. __________, I am hoping you will consider following up elsewhere. Should you need a referral to another health care provider please contact my office and I will be pleased to help you. At a minimum, please keep in mind that the community hotline number is __________. It may be contacted in times of crisis or emergency or you can go to your local hospital’s emergency room.
Again, I am hoping you will follow through with your needed treatment. Please let me know if I can be of further assistance.
Sincerely,
__________________
SAMPLE LETTER B: A patient making progress initiates termination.
Date
Name
Address
Dear __________:
As we discussed at your most recent session, it is my understanding that you have decided to discontinue our work together. As we reviewed during that session, you have made significant progress toward your stated treatment goals. Although not all goals have been fully achieved, I respect your desire to continue this important work on your own. However, I believe it is in your best interest for us to have at least one final meeting to discuss your plans and to review treatment to date. Experience has shown me that individuals who discuss their plans prior to ending treatment tend to be more successful in their posttreatment endeavors. I am hoping that you will contact my office so that these final appointments may be scheduled.
Should you decide not to follow through on this recommendation, I am hoping you will feel free to contact me if any additional difficulties are experienced or if I can be of any additional help in the future. I am also hoping you will give serious consideration to the use of the community support groups on the list of resources I provided you with.
Best wishes for success in your ongoing endeavors.
Sincerely,
___________________
SAMPLE LETTER C: Treatment being terminated due to lack of benefit to the patient
Date
Name
Address
Dear __________ :
As we discussed the last several times we met, it is clear to me that our ongoing work together has not been beneficial to you. Although I understand your desire for your treatment under my care to continue, I strongly believe it to be in your best interest for us to end our work together.
As we reviewed when we met, I am providing you with the names, addresses, and telephone numbers of the following four psychotherapists (__________). Each of these professionals is licensed, has training and experience in __________, and are located in your local area. I am hoping you will contact them and make arrangements to begin treatment. If any difficulties are experienced I will be happy to assist in this transition.
Again, as we agreed I will meet with you up to four more times to assist you during this time of transition. Once arrangements are made with a new psychotherapist, with your written consent, I will be happy to share any information I can to assist in the transfer of your care. Please discuss these or any other issues that concern you during our upcoming meetings.
Sincerely,
___________________
SAMPLE LETTER D: Therapist initiated termination because of an adverse utilization review decision.
Date
Name
Address
Dear __________:
As we discussed during your most recent appointment, your managed care company, ABC, Inc., has rejected the treatment plan we submitted stating that your treatment needs are not found to be medically necessary according to their utilization review criteria. As I explained when we met, this means that ABC, Inc. will not reimburse any additional treatment expenses at this time. This does not mean, however, that additional treatment is not needed or that you would not benefit from it.
To review, this is the plan of action we agreed on: I will file a written appeal of the utilization review decision immediately. While we await the outcome of the appeal process, we will continue your treatment with you paying me the reduced ABC, Inc. rate. If authorization is granted, treatment will continue and any fees due you will be reimbursed. If the appeal is denied, I will provide you with up to four additional sessions at one-half my usual rate and assist you to obtain more economically priced services elsewhere. Or, if desired, we can work out a payment plan so you may continue treatment under my care.
Please rest assured that I am committed to ensuring that your ongoing treatment needs are met regardless of utilization review decisions made by ABC, Inc. I look forward to continuing our work together at our next appointment on __________.
Sincerely,
___________________
CONTRIBUTORS
Jeffrey E. Barnett, PsyD, is a licensed psychologist in private practice in Maryland. He is also an Adjunct Associate Professor in the Department of Psychology at Loyola College in Baltimore, Maryland, where he trains masters and doctoral students in clinical and counseling psychology. Dr. Barnett is a frequent lecturer and author on legal and ethical issues in mental health. He is a past ethics committee chair for the Maryland Psychological Association and a past president of that organization. Dr. Barnett may be contacted at 1511 Ritchie Highway, Suite 201, Arnold, MD 21012.
Sherry G. MacGlashan, MA, is a student in the PsyD program in clinical psychology at Loyola College in Baltimore, Maryland. Her interests in ethics is a product of her active involvement as a parent, educator, and community leader in Maryland. Ms. MacGlashan is a member of Psi Chi and Alpha Sigma Nu, and a student member of the Maryland Psychological Association. She is also the student representative from Loyola College to the Committee on Graduate Studies. Ms. MacGlashan resides with her husband, daughter, and son in Timonium, Maryland.
Alicia J. Clarke, MS, is a student in the PsyD program at Loyola College in Baltimore. She is an active student affiliate of the Maryland Psychological Association, serving as co-chair of this organization’s Graduate Student Committee. Her work with graduate students further extends to her involvement in Psi Chi and in the American Psychological Association for Graduate Students where she acts as campus representative for Loyola College. Her work and interest in ethical issues also include the changing roles of state and provincial psychological association’s ethics committees. Ms. Clarke currently resides in Sparks, Maryland, with her husband and daughter.
RESOURCES
*All case examples are fictitious and do not represent actual patients known to the authors.
Copyright 2000 by Professional Resource Exchange, Inc. and reprinted withpermission. Further electronic/printed circulation or duplication is strictly prohibited without explicit written authorization from Professional Resource Exchange, Inc.