Termination Challenges and Effective Clinical Practice

 

The goal of every client’s psychotherapy is the attainment of treatment goals and a planned successful completion of treatment. Termination is viewed as an important phase of the psychotherapy process that should be planned for in advance (Quintana & Holahan, 1992; Weiner, 1975). When handled appropriately, it contributes to the client’s autonomous functioning and long-term success (Barnett & Sanzone, 1997), consistent with the underlying ethics virtue of autonomy, the promotion of each client’s independent and autonomous functioning (Beauchamp & Childress, 2001). Weiner (1975) sites that this final phase of each client’s psychotherapy “is exceeded only by the initial phase in its importance for determining the amount of help a patient receives” (p. 263).

Termination should be viewed by practitioners as an essential phase of each client’s treatment. It should be planned for, worked toward, and carried out in a thoughtful manner. Doing so helps to ensure each client’s long-term success. But, unfortunately, not all clients leave treatment after such an effectively implemented termination phase. Not all treatment terminations are the result of a mutual agreement by practitioner and client that all treatment goals have successfully been achieved. As Davis and Younggren (2009) emphasize, successfully and effectively conducting the termination phase of each client’s treatment is an essential clinical competency for each mental health clinician.

It is recommended that the issue of termination be integrated into each phase of the treatment process, beginning with the initial informed consent agreement. The issue of termination should be addressed from the outset of the professional relationship and should never come as a surprise to the client. This is especially salient when the clinician may be at the clinical setting for on a time limited basis. This will be true for all trainees and students who have a specified end date for their clinical experience, but may also be relevant for other clinicians as well. Regardless, clients have the right to know in advance any possible limitations to the treatment to be provided and how the termination process will be handled (Vasquez, Bingham, & Barnett, 2008). Often, clients will enter treatment that has specific goals with the understanding that treatment will end when those goals are achieved. Other times, the treatment to be offered may be time limited in nature, such as for a 12-session treatment group or a 14-session treatment program for a specific disorder. Clients have the right to know of this from the outset of the professional relationship and clinicians have an obligation to ensure that each client understands these parameters of treatment.

Clinicians should also clarify with clients from the outset any likely potential limitations on their ability to participate in treatment. Relevant examples could include limitations to a client’s insurance coverage, financial limitations, plans for travel or a change of residence, and the like. These factors can greatly impact how the clinician and client proceed with treatment. For example, if a client’s insurance coverage only provides for 12 sessions of outpatient psychotherapy per year, beginning long term treatment would likely be inappropriate. Further, failure to address such issues and to confirm the client’s insurance benefits at the beginning of treatment could result in a mishandled termination and possibly even charges of client abandonment. It would not be appropriate to abruptly end a client’s treatment simply because one finds out that they have exhausted their insurance benefits. Again, addressing such issues at the beginning of the professional relationship is most appropriate.

In addition to treatment ending because all agreed upon goals have successfully been achieved, other reasons for leaving treatment and their implications include:

1. The psychotherapist initiates termination despite the client’s desire for treatment to continue. A clinician may believe that to continue a client’s treatment may not be appropriate or in the client’s best interest. This could occur when the client is not benefiting from treatment, when the client’s treatment needs change and are no longer within the clinician’s areas of competence, when a potential conflict of interest arises or multiple relationships is discovered, or when clinician distress or impairment is discovered. In such situations when the client has ongoing treatment needs making arrangements for continued treatment with another appropriately trained clinician would be in the client’s best interest.
2. The client initiates termination and the clinician does not view this as in the client’s best interest. There are times when clients will initiate termination and the clinician’s clinical judgment indicates that this would not be in the client’s best interest. To not challenge such an action would in a sense be to endorse the decision. There certainly are times when clients may feel that further treatment is not needed, but the clinician’s understanding of the client and of the psychotherapy process would indicate that termination is contraindicated. Addressing these issues with the client is important along with assisting the client to make the best possible decision. While of course clinicians should respect each client’s decision should they decide to end treatment, it is still important to share one’s clinical opinion on the matter. If additional treatment is indicated it is important to make such recommendations to the client, explaining the rationale for this recommendation.
3. The client drops out of treatment without notice and does not respond to the psychotherapist’s efforts at contact. Psychotherapy clients may drop out of treatment for a variety of reasons such as initial symptom relief, financial difficulties, or dissatisfaction with the psychotherapist. Again, the clinician will need to make a reasonable effort to contact the client, not appear to agree with discontinuing treatment in this manner if professional judgment indicates that ongoing treatment is needed, and ensure that any ongoing treatment needs are addressed through recommendations and referral. A written letter, with a copy in the client’s file, will best address this need. Clearly stating one’s concern for the client and the reasons for recommending continued treatment are important to include in such a letter along with possible referral sources and an offer to assist with the referral process.
4. The clinician refuses to continue a client’s treatment as a result of certain actions or behaviors on the client’s part. Clinicians may want to discontinue work with certain clients due to noncompliance with treatment recommendations, lack of participation in treatment, or the client’s refusal or failure to pay for treatment. While clinicians are not required to treat all clients indefinitely, it is important that we comply with the standards concerning termination and abandonment provided in their profession’s ethics code. We must notify them of our plan in advance, make referrals to other practitioners, assist with the referral transition process, and be available for crises until the new clinician takes treatment over. Authors such as Vasquez, Bingham and Barnett (2008) in citing relevant case law, state that we should ensure that termination occurs as the result of clinical need, not as a result of a client’s inability to pay for treatment. Options always exist and alternative arrangements can be made such as using a sliding fee scale, a payment plan, pro bono work, or a referral to a community mental health center or other practice that can work within the client’s financial constraints. Finally, we must also ensure that clients in crisis are not terminated abruptly, regardless of the circumstance. Their treatment needs are our primary concern regardless of other factors present.
5. Insurance benefits are exhausted or managed care authorization is refused. It is important to keep in mind that insurance and managed care companies can only refuse to authorize reimbursement for services provided. They are not involved in actually authorizing us to provide or not provide treatment. It is important that we do not let their fiscally motivated decisions supersede our clinical judgment. All adverse authorization decisions should immediately be appealed and treatment, if clinically indicated, should continue in the interim (Wickline v. State of California, 1986). If an adverse ruling on the appeal is made we may then consider treatment and referral options outside the client’s insurance coverage. But, as discussed earlier, we maintain responsibility for our clients’ welfare until they agree to end treatment or are in the care of another professional.

General recommendations for addressing termination issues provided by Barnett (1998) include:

1. Clarify expectations and obligations from the outset. The use of a written informed consent agreement at the beginning of treatment that addresses these issues is helpful.
2. Review with clients their insurance coverage, limits to managed care contracts, and how utilization review may impact on treatment. Set up arrangements for addressing client treatment needs if continued authorization is denied
3. Provide clients with other treatment resources if needed and work to assist them in their transition to other health care providers.
4. Do not terminate the treatment of clients who are in crisis regardless of payment issues. Provide needed treatment or help them find it elsewhere.
5. Do not tacitly condone patients dropping out of treatment when your clinical judgment indicates continued care is needed. Notify clients of your assessment and recommendations [click here for sample termination letters].
6. Carefully document all discussions of termination issues, agreements reached, decisions made and their rationale, and client follow-through with recommendations.
7. Termination is a phase of each client’s treatment. Plan for it, prepare for it, process it.

References

• Barnett, J.E. (1998). Termination without trepidation. Psychotherapy Bulletin, 33 (2), 20-22.
• Barnett, J.E. & Sanzone, M.M. (1997). Termination: Ethical and legal issues. The Clinical Psychologist, 50, 9-13.
• Beauchamp, T. L., & Childress, J. F. (2001). Principles of Biomedical Ethics (5th ed.). New York: Oxford University Press.
• Davis, D. D., & Younggren, J. N. (2009). Ethical competence in psychotherapy termination. Professional Psychology: Research and Practice, 40, 572-578.
• Quintana, S.M. & Holahan, W. (1992). Termination in short-term counseling: Comparison of successful and unsuccessful cases. Journal of Counseling Psychology, 39, 299-305.
• Vasquez, M. J. T., Bingham, R. P., & Barnett, J. E. (2008). Psychotherapy termination: Clinical and ethical responsibilities. Journal of Clinical Psychology, 64, 653-665.
• Weiner, I.B. (1975). Principles of Psychotherapy. New York: Wiley.
• Wickline v. Blue Cross of Southern California, No. B040697 (July 27, 1990).

 
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