The Decision to Terminate Therapy
(November/December 2004)
The Therapist

By Bonnie R. Benitez, Attorney
Previously employed with CAMFT

The decision to terminate the therapeutic relationship can be tricky for both patients and therapists. However, there are steps therapists can take to minimize the ethical and emotional complications that sometimes result from a termination of therapy. Termination of the therapeutic relationship is an issue that should be attended to in the earliest stages of therapy. The possibility of termination, by either the patient or the therapist, should be addressed in writing as a part of the Informed Consent or Agreement for Services process. Finally, the reasons for the termination and the manner in which the termination is handled are by default, very clinical in nature. While legal consultation can be helpful in some circumstances, consultation with another therapist is an important part of the decision-making process.

Dealing with Termination Issues at the Start of Therapy
Including one's termination policy in an Informed Consent or Agreement for Services form is an excellent way to educate new patients about termination. Addressing termination at this stage also provides an opportunity for the therapist and patient to discuss the eventuality of termination prior to the matter arising.

For example, a therapist could include the following statement in his/her Informed Consent or Agreement for Services document:

The therapist reserves the right to terminate therapy at his/her discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, the patient's needs are outside of the therapist's scope of competence or practice, or the patient is not making adequate progress in therapy. The patient has the right to terminate therapy at his/her discretion. Upon either party's decision to terminate therapy, the therapist will generally recommend that the patient participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. The therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to the patient.

Patient Abandonment vs. Proper Termination
There appears to be a great deal of fear, on the part of therapists, regarding patient abandonment. However, therapists are rarely disciplined for having "abandoned" their patients. In fact, most of the licensees who have been disciplined due to "improper termination," terminated with their patients so that they could then engage in a social, romantic, or other type of relationship.

Termination of therapy is addressed in seven sections of the CAMFT Ethical Standards for Marriage and Family Therapists. While the standards make clear that it is unethical for therapists to neglect or abandon their patients, no clear definition of "patient abandonment" is given. However, it appears that what constitutes "abandonment" is not the decision to terminate, but rather the manner in which the termination is handled; specifically, ensuring the availability of undisrupted care through appropriate referrals.

This is an important point, because many members who call for legal consultation seem to be under the misimpression that the decision to terminate is where the risk of patient abandonment lies. "Can I terminate my patient under … circumstance?" "Would I be abandoning my patient if I terminate therapy because of…?" Although some patients may argue that the therapist does not have the authority to unilaterally end therapy, such is not the case.

In fact, the standards make clear that therapists should not maintain therapeutic relationships solely for financial reasons, or when continued treatment is contraindicated. Some of the reasons termination may be appropriate include, but are not limited to, the patient not benefiting from treatment, continuing treatment not being clinically appropriate, the therapist not being able to provide treatment due to physical or mental illness, the treatment is becoming ethically questionable, non-payment of fees, the patient fails to comply with the terms and conditions of therapy, etc.

Are there circumstances in which termination would be inappropriate or unethical? Certainly. Termination may not be appropriate when a patient is hospitalized, in crisis, or actively suicidal. It is difficult to create a bright line rule here because some patients are chronically in crisis, or struggle with suicidal thoughts over long periods of time. Does this mean a therapist can become stuck with such a patient? Perhaps, for a time. On the other hand, skilled therapists should be able to amass a team of professionals, upon which the patient can depend. No therapist should allow him/herself to be the sole support system for a patient. At least not for very long.

So what is the difference between proper termination and patient abandonment? There are two main components to a proper termination: (1) having an appropriate reason for the termination, and (2) proper handling of the termination process. Perhaps the best way to prepare for the possibility of terminating a patient is through clinical consultation. A trusted colleague or mentor can help a therapist determine whether termination is possible, ethical, or perhaps required in a given circumstance. The colleague can also provide guidance with regard to the handling of the termination, and suggest referral sources to the practitioner.

In deciding whether termination is appropriate, you should first ponder the following questions:

  • Why am I considering terminating my therapeutic relationship with this patient?
  • Is there an alternative to termination?
  • Have I sought clinical consultation regarding this patient?
  • Have I discussed the possibility of termination with the patient?
  • What does this patient understand about the process of termination?
  • Is a temporary respite from therapy warranted in this case?
  • Am I experiencing transference that I should address with my therapist or consultant?
  • Is the patient benefiting from therapy?
  • Would the patient benefit from the skillset of another therapist?
  • Should there be other professionals involved in the treatment of this patient?
  • Is continued treatment clinically appropriate?
  • Is the patient not complying with treatment recommendations, (e.g. inconsistent attendance, refusing a psychiatric evaluation, failing to participate in adjunctive care)?
  • Have I made these recommendations clear to the patient?
  • Have I advised the patient that termination may be necessary should he/she decide not to comply with treatment recommendations?
  • Are there reasons (personal or otherwise) that I cannot provide treatment for this patient?
  • Could continuing to treat this patient result in a conflict of interest?
  • Does the patient require a level of care I am unable or unqualified to provide?
  • Are there scheduling or financial issues, between the patient and me, which impede our therapy?
  • Is continued treatment ethically questionable, and why?

The Termination Process
After determining that termination is ethically and clinically indicated, and obtaining clinical and legal consultation, you should then turn to the manner in which termination will occur. For this, you should reflect on the following questions:

  • Is the patient in crisis, and if so, is it in the patient's interest that I see him/her through this crisis before the termination? Or, is this patient always in crisis?
  • What is an appropriate timeline for the termination process with this patient? Is one session sufficient? Two? Three?
  • How will I introduce the need for the termination?
  • How will the patient likely react?
  • How can I best serve the patient's needs while going through the termination process?
  • Do I have any fears or other concerns about terminating with this patient, and how am I addressing those concerns?
  • Would it be helpful to role-play the termination with a consultant or colleague?
  • How will I handle any existing financial or business issues with the patient?
  • Should I inform (with written authorization) any of this patient's other treating professional(s) of my decision to terminate?
  • If continued care is necessary, where will I refer this patient for such care?
  • Is a letter, documenting the termination and referrals, called for in this case?

Before, during and after considering these questions, and discussing the termination with a consultant, you should record the entire process in the patient notes. The most important thing to include in the patient notes is what you are doing and why, especially when considering termination. Should your decision to terminate ever be questioned, the fact that you sought clinical consultation will demonstrate your attention to ethical practice and the standard of care. After documenting the decision to which you have arrived, and the basis for this decision, be sure to record your handling of the termination process, including the patient's response and the referrals provided.

The process of termination, which could take place over several sessions, should be entered into with considerable forethought and planning. It may be helpful to role-play the anticipated reactions of the patient with your consultant in advance of the real thing.

The length of the process and method by which you address the clinical issues will depend upon the patient. Are you terminating therapy because the patient threatened you? Perhaps a telephone call or letter indicating your unwillingness to continue treatment would be appropriate. Are you terminating because you believe the patient is no longer benefiting from treatment? Perhaps a review of the work you have done together over the course of a few sessions would be helpful.

If money is an issue between you and the patient, you may want to consider not charging the patient for the termination session( s). However, be sure to tackle any fee dispute or outstanding balance before concluding the process. If there is an outstanding balance, you should either come to a payment agreement with the patient, preferably in writing, or consider waiving the balance. Hopefully, by the time the termination process has concluded, both you and the patient will be in agreement regarding the patient seeking services elsewhere and have addressed any other business or financial concerns.

How many referrals should be given to a patient? While the standard in the profession appears to be three referrals, each patient's circumstance should dictate the number of referrals given. The patient may be in need of specialized service of which there is only one in your area. The patient may have financial constraints and require a referral to a low-cost counseling agency. If the patient is using his/her insurance, you may want to contact the plan to get a list of other providers in the area. If the patient is also under the care of a psychiatrist, you can contact him/her for suggested referrals. Be sure to contact any potential referrals to determine whether an opening is available.

To what extent must the therapist facilitate the transition to the new therapist? Once again, this depends upon the patient's circumstances. Minimally, one should contact the patient's psychiatrist or treating physician to apprise him/her of the termination, and elicit support in the transition. Also, with the patient's written permission, one could provide the new therapist with records, a treatment summary, or verbal information regarding the previous treatment and possible recommendations.

Sometimes a letter documenting the termination is advisable, particularly when the patient refuses to engage in the termination process or rejects referrals. Such a letter should be brief, professional, reiterate the basis for the termination and include the appropriate referrals. A termination letter is not always warranted, however, and may unfortunately act as salt in an open wound. Your decision to document the termination in a letter should be made on a case-bycase basis. Also, be sure your have obtained permission to contact each patient in writing during the intake process to avoid the possibility of an allegation of breach of confidentiality.

The decision to terminate treatment is a difficult one, for both patient and therapist alike. It is critical that therapists avoid making termination decisions in a vacuum. Clinical consultation should be obtained and documented. Therapists should (whenever possible) be sure to give patients enough notice so that the patient's emotional reactions can be processed, and the need for the termination can be openly discussed. Finally, a suitable referral to another therapist should be made. As always, if you believe legal consultation would be helpful, contact CAMFT for assistance.

This article appeared in the November/December 2004 issue of The Therapist, the publication of the California Association of Marriage and Family Therapists, headquartered in San Diego, California. The information contained in this article is intended to provide guidelines for addressing difficult business and legal dilemmas. It is not intended to address every situation that could possibly arise, nor is it intended to be a substitute for independent advice or consultation. When using such information as a guide, be aware that laws, regulations, and technical standards change over time, and thus one should verify and update any references or information contained herein.

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