Decision to Terminate Therapy
Bonnie R. Benitez, Attorney
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
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.
vs. Proper Termination
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:
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.