Michael Griffin, JD, LCSW
Staff Attorney
September/October 2017
Updated November, 2022 by Kristin W. Roscoe, JD (CAMFT Staff Attorney)

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This article is intended to help therapists anticipate, manage, and/or avoid a variety of problems which commonly occur during the termination process with clients. Relevant legal and ethical issues are discussed, including examples of clinical scenarios that are associated with disciplinary actions and ethical complaints against therapists for improper termination.

THE TERMINATION PROCESS

Termination is generally described as a process for ending therapy that takes place over time, rather than a discrete event that marks the end of treatment.¹ Although termination is ordinarily planned to coincide with the client reaching his or her treatment goals, it may also occur in a variety of circumstances, examples of which are discussed below.

It is difficult to overstate the importance of an appropriate and ethical termination. It may help a client to acknowledge and solidify the gains that he or she made during the course of treatment. In some instances, it may even represent the first time that the client was able to experience an appropriate, non-traumatic ending to a relationship. At the very least, the termination process provides a client with his or her final impressions regarding the entire course of therapy.

The termination process varies from client to client. Depending upon the client’s needs and the nature of his or her treatment, it may take place over a few sessions, or it can unfold over the course of several months. For numerous reasons, a therapist who familiarizes him or herself with the relevant clinical, legal and ethical issues is better prepared to anticipate and handle the various challenges which may arise.

The Standard of Care The standard of care that applies to a given circumstance is simply that the therapist exercised the reasonable degree of skill, knowledge, and care that would ordinarily be exercised by other therapists, when practicing under similar circumstances.² Although there is no ideal model for termination with a client, a therapist is expected to manage the termination process with his or her client in a manner that is consistent with the relevant standard of care. In other words, the termination process itself must be conducted with a reasonable degree of skill, knowledge, and care, in view of the client and their circumstances.³

The Importance of a Termination Plan 
Many therapists believe that it is important to begin thinking about termination from the outset of treatment. The rationale for doing so is based on the assumption that it is desirable for a therapist and their client to define the proposed intent of therapy as early as possible. By clarifying the proposed goals and objectives of therapy, it becomes possible to determine the criterion for termination. Whether or not the prediction is perfectly accurate is not as important as the collaboration between therapist and client, and the fact that a treatment plan exists.

It is important to provide clients with the opportunity to prepare for termination. Ordinarily, when the therapist and his or her client have maintained a dialog about the client’s progress in treatment, the timing of termination should be foreseeable to the client. The amount of notice that should be provided to a client regarding termination depends on the needs of that client and the therapist’s clinical judgment. Many therapists believe that it is desirable to provide clients with sixty to ninety days advance notice (if possible), but some clients may require a longer period of time, such as those who are in long-term treatment.^{4 5 6}

SPECIAL CHALLENGES

Regardless of the therapist’s careful planning, the termination process with some clients can prove to be challenging. A therapist should be prepared to encounter and appropriately manage, each of the following issues/scenarios:

Termination Due to a Lack of Continued Benefit 
One of the more difficult circumstances for a therapist to manage is when he or she must consider terminating a client’s treatment due to a lack of continued benefit. When faced with this situation, it may be helpful if the therapist explains to their client/patient that the therapist may continue the therapeutic relationship only so long as it is reasonably clear that the client is benefiting from treatment.^{7 8}

Termination Based Upon Scope of Competency Issues 
A therapist should consider termination with a client if the client’s problems are outside the therapist’s scope of competence.⁹ Although, a therapist will usually become aware of a scope of competency issue at the start of treatment, it is possible for such an issue to emerge at a later date. For example, a therapist may become aware that their client is in need of specialized treatment due to a previously undisclosed drug or alcohol related problem, eating disorder, or other trauma, such as a history of sexual abuse. Depending upon the circumstances and the needs of their client, the therapist may consider the possibility of continuing to provide treatment in collaboration with other, specialized providers,¹⁰ or, they may need to terminate the client’s treatment and provide them with appropriate referrals.

Termination Due to Conflict of Interest 
A therapist has a conflict of interest if they are engaged in some activity or relationship which conflicts with their ability to discharge their duties to a client.11 Ideally, most conflicts of interest are identified at the beginning of treatment. When this occurs, the therapist typically informs the person that they are unable to assume the role of therapist in the given circumstance, due to a conflict of interest. An even less-desired circumstance arises when a therapist discovers that they have a conflict of interest in continuing to provide therapy to an existing client. There are a number of situations where this might occur. For example, a prospective client may have failed to inform the therapist (or may not have known) that they are related to one of the therapist’s other clients; or, a therapist might discover that one of their clients was previously involved in a business venture with the therapist’s spouse or other family member.

Generally speaking, when a conflict of interest is discovered, it is necessary for the therapist to terminate the client’s treatment and to provide an appropriate referral.12 Although the therapist may not be able to offer a detailed explanation to the client (because of confidentiality issues), it is important to provide the client with some explanation about why it became is necessary to terminate their treatment due to a conflict of interest.¹³

Termination Due to Closing a Practice 
When a therapist decides to close their psychotherapy practice, they must plan for the appropriate termination of their clients. A therapist has to decide how far in advance they will provide notice to their clients regarding the closure of the practice, and, whether to communicate the information verbally or in writing. No single method is equally suited to all therapists and/or to all clients, but it is not unusual for a therapist to inform all of their clients at the same approximate time. In view of the sensitivity of termination for many clients, when first discussing this topic, a therapist may decide to ask their clients to refrain from sharing the information with other clients for a period of time, in order to minimize the likelihood that a client will hear the news from another client, rather than from the therapist.¹⁴

When a therapist decides to leave their place of employment, there can be disagreements between the therapist and their employer regarding the disposition of the therapist’s clients. In such circumstances it is important for the therapist (and their employer) to primarily consider the client’s best interests throughout the process.

Terminations Triggered by the Departure of Interns or Trainees 
When an associate, trainee or other pre-licensed therapist provides treatment, termination of treatment to many clients may be triggered by the therapist’s graduation, or completion of training in the setting. Even when the client is aware of the fact that his or her therapist will depart at a specified point in time, the “forced” termination may elicit a strong reaction. In some settings, such as agencies or public mental health clinics which serve as training sites for therapists, there are clients who may have been treated by several associates in a progression that extends over the course of several years. In such settings, a client should be informed at the start of treatment if their therapist is available for a limited period of time, due to a training rotation, or the therapist’s academic schedule.¹⁵

Terminations Triggered by the Departure of an Employee
When the time comes for an individual to leave their place of employment, it is not unusual for disagreements to arise between the employer and the therapist regarding a client’s termination plan. As an example, the employer may ask the employee to arrange for continued treatment of their clients at the present location, or, may even insist that the departing therapist refrain from providing their clients with information about the employee’s future practice location or plans. Although these circumstances can be very stressful for everyone involved, it is important to focus on the client’s best interests and to remember that their treatment needs take priority over other concerns.¹⁶ Note: The client doesn’t belong to any person or entity and generally speaking, they have the right to decide where, and from whom they receive continued treatment. (This topic is discussed at greater length in the article entitled, “Thoughtful Transitions,” by Mike Griffin, JD, LCSW, in the November, 2017 issue of The Therapist, available at www.camft.org.)

Insurance/ Managed Care Issues 
Any therapist who accepts health insurance for the services they provide is aware of the fact that insurance plans often require them to submit clinical justification for authorization of continued treatment of a client. In some situations, in spite of a clinician’s belief that their client would benefit from continued therapy, a client’s insurance plan may decline the therapists’ request for additional visits. In such situations, the therapist may need to consider termination with their client, if that individual is unable, or unwilling to pay for services out of pocket. However, ethical standards require the therapist to consider treatment options that are not limited to the provisions of the client’s insurance plan.¹⁷ It may also be appropriate for the therapist to advocate for, or assist his or her client in seeking authorization for treatment, or in challenging/appealing a denial for authorization or payment, etc.¹⁸

Clients with Delinquent Accounts 
A common question that therapists ask is whether or not it is permissible to discontinue treatment with a client based upon their non-payment of fees.19 Although a therapist is not required to treat someone indefinitely if they are unable or unwilling to pay for services, when considering termination for non-payment of fees, it may be helpful to consider the following questions:

1. At the start of treatment, was the client given clear and specific information about the fees to be charged and did they agree to those terms? ^{20 21}
2. Did the client understand that there was a possibility that their therapy would be terminated for non-payment of fees?
3. What were the reasons given by the client for non-payment? Were they reasonable? 
4. Was the client given an opportunity to rectify the issue? Did they agree to a payment plan and then fail to honor the agreement?
5. Did the therapist contribute to the problem by permitting the client to accumulate a large debt over a long period of time? ²²

The Vulnerable or “At Risk”Client
One of the issues that a therapist must consider during the termination process with a client is whether or not their client is particularly vulnerable or “at risk” at the time. This can be a very difficult issue to manage. As an example, the therapist may find that it is entirely appropriate to refer a client, based upon the client’s lack of progress in treatment, or because of the client’s need for specialized treatment, etc. But the desired treatment resource may or may not agree with the therapist’s recommendation, or the client may lack the necessary insurance or financial resources needed to access the treatment in question.²³

Generally speaking, if a therapist believes that their client would be at risk if treatment was discontinued at the time, the therapist may need to re-evaluate the available treatment options and consider whether it may be prudent to continue to treat the client. In view of the complexity of such situations, it is a good idea for the therapist to seek consultation from an experienced colleague when appropriate and to thoroughly document their actions and the corresponding clinical rational.

The Ambiguous Termination
It is not uncommon to hear a therapist state that their client has failed to appear for several sessions, leaving the therapist uncertain about the client’s intent to continue in treatment. In another common example, a client may inform their therapist that they are “taking a break” from treatment. In these circumstances, a concern is that the therapist may be unable to clearly say whether they are currently serving as the client’s therapist. Unless the therapist can unambiguously say that the client’s treatment has been terminated, there is a distinct possibility that the therapist has a continued responsibility to the individual in question, because the therapist-client relationship never ended. Therefore, it is the responsibility of the therapist to pursue the issue and to clarify with their client(s) whether treatment is or is not continuing. Depending on the circumstance and the therapist’s clinical judgment, this may mean that the therapist calls the client and insists upon having a face to face (or videoconference) meeting or, at the very least, a telephone conversation to discuss the matter. The therapist may recommend that treatment continue or that termination be conducted over the course of several sessions, as appropriate. In the event that the client refuses to contact or cooperate with the therapist, the therapist should clearly communicate, either verbally or in writing if preferred, that the client’s therapy will be considered concluded as of a specified date. Of course, the therapist should carefully document all such communications in the treatment record.

HIGH-RISK SCENARIOS 
It may be helpful to identify and discuss a few examples of clinical scenarios where termination-related legal and ethical problems predictably arise. Variations of these examples are often described in the disciplinary cases reported by licensing boards, in ethics complaints lodged against therapists, and in malpractice (negligence) lawsuits filed against therapists.

Open-Ended Treatment Without a Plan 
Where treatment takes place over a long period of time without identifiable goals, a client may experience the eventual termination of their treatment as a personal rejection by the therapist, rather than a logical end to the therapy.

An example of this situation typically involves long-term treatment (often several years in duration) where the clinical record is sparsely documented regarding the goals of treatment and the client’s progress. When the therapist brings up the issue of termination, the client becomes angry, alleging that the therapist has arbitrarily/unilaterally decided to end the relationship, and that they are unprepared for such an eventuality. In this situation, although there may or may not have been a treatment plan, the lack of clinical documentation makes the therapist vulnerable to accusations of unprofessional conduct.23 24 The therapist may also face a negligence lawsuit, if it were alleged that they provided treatment that failed to meet the expected standard of care.^{26 27}

Lack of Therapist/Client Boundaries 
This situation is similar to the scenario described in the last example. In this example, the client and their therapist often talk about the therapist’s life, and/or they sometimes meet at locations outside of the office without a clear reason for doing so. There is likely to be an excessive (unnecessary) number of phone conversations in between sessions. Here, the therapist’s relationship to the client may seem more like a personal friendship than a therapist-client relationship. In a variation of this example, the client may have become increasingly dependent on the therapist over a long period of time, with the therapist assuming a parental role. Similar to the prior example, when there are few treatment goals in existence, the client may regard the therapist’s attempt to terminate the client’s treatment as a rejection by a friend. The therapist is vulnerable to the same accusations and allegations as described in the prior example.

Don’t Be Reluctant to Seek Consultation 
Although it is possible to encounter some complex and/or difficult issues during termination, most of the issues described can be avoided, or managed, by the therapist who carefully monitors their client’s progress and plans for an appropriate termination process. When problems arise, a therapist should not be reluctant to seek consultation from a trusted colleague who would be willing to offer the benefit of their own experience in managing these situations. CAMFT members are also welcome to phone and ask to speak with one of the staff attorneys regarding any of these issues.²⁸

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Michael Griffin, JD, LCSW, is a staff attorney at CAMFT. Michael is available to answer member calls regarding legal, ethical, and licensure issues.

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References

¹ Vasquez, Melba, J.T., Bingham, Rosie, P., Barnett, Jeffrey, E., “Psychotherapy Termination: Clinical and Ethical Responsibilities,” Journal of Clinical Psychology in Session, Vol. 64(5), 653-665 (2008) Published online by Wiley Periodicals, Inc. (accessible in the EBSCO database, in the Psychology and Behavioral Sciences Collection. The EBSCO database is accessible to CAMFT members in the members-only section of the CAMFT website at www.camft.org.
² Black, H.C. (1990) Black’s Law Dictionary, St. Paul, MN: West.
³ In the event of litigation, in order to determine what the standard of care is, a court will typically seek the opinion of a qualified expert.
⁴ Griffin, Michael, JD, “Closing a Psychotherapy Practice: Further Considerations,” The Therapist, March/April, 2010
⁵ Id.
⁶ Section 1.3 of the CAMFT Code of Ethics provides: “Marriage and family therapists are aware of their professional and clinical responsibilities to provide consistent care to clients/patients and to maintain practices and procedures that are intended to provide undisrupted care. Such practices and procedures may include, but are not limited to, providing contact information and specified procedures in case of emergency or therapist absence, conducting appropriate terminations, and providing for a professional will.”
⁷ When the therapist and their client have consistently monitored and discussed the client’s progress in therapy, the prospect of termination should be foreseeable to everyone involved.
⁸ Section 3.8 of the CAMFT Code of Ethics provides: “Marriage and family therapists continually monitor their effectiveness when working with clients/patients and continue therapeutic relationships only so long as it is reasonably clear that clients/patients are benefiting from treatment.”
⁹ Section 5.11 of the CAMFT Code of Ethics provides: “Marriage and family therapists take care to provide proper diagnoses of psychological disorders or conditions and do not assess, test, diagnose, treat, or advise on issues beyond the level of their competence as determined by their education, training, and experience. While developing new areas of practice, marriage and family therapists take steps to ensure the competence of their work through education, training, consultation, and/or supervision.”
¹⁰ Section 5.12 of the CAMFT Code of Ethics provides: “Marriage and family therapists do not generally duplicate professional services to a prospective client/patient receiving treatment from another psychotherapist. When making a determination to provide services, marriage and family therapists carefully consider the client’s/patient’s needs, presenting treatment issues, and the welfare of the client/patient to minimize potential confusion and/or conflict. Prior to rendering services, marriage and family therapists discuss these issues with the prospective client/patient, including the nature of the client’s/patient’s current relationship with the other treating psychotherapist and whether consultation with the other psychotherapist is appropriate.”
¹¹ Jensen, David, “Unlawful and/or Unethical Dual Relationship? A Word to the Wise,” The Therapist, Sept. /Oct., 2005. A dual-relationship exists when a therapist has a concurrent, non-therapy relationship with a client. A dual-relationship in itself is not unethical, unless there is an associated conflict of interest.
¹² Section 1.4 of the CAMFT Code of Ethics provides: “Marriage and family therapists use sound clinical judgment when terminating therapeutic relationships. Reasons for termination may include, but are not limited to, the client/patient is not benefiting from treatment, continuing treatment is not clinically appropriate, the therapist is unable to provide treatment due to the therapist’s incapacity or extended absence, or due to an otherwise unresolvable ethical conflict or issue.” (See also sections 3.8 Client/Patient Benefit and 5.11 Scope of Competence.)
¹³ It is probably more likely that conflicts of interest may arise when the therapist is practicing in a small geographic community
¹⁴ Griffin, Michael, “Closing Psychotherapy Practice,” Supra.
¹⁵ See also, Bostic, Jeff, Q., M.D., Shadid, Larry, G., M.D., Blotcky, Mark, J., M.D., “Our Time Is Up: Forced Terminations during Psychotherapy Training,” American Journal of Psychotherapy, Vol.50, No.3, Summer, 1996
¹⁶ Section 1.6 of the CAMFT Code of Ethics provides: “When terminating employment or contractual relationships, marriage and family therapists primarily consider the best interests of the client/patient when resolving issues of continued responsibility for client/patient care.”
¹⁷ It should be noted that a therapist should not limit his or her consideration of treatment options to the provisions of an insurance plan. According to Section 3.11 of the CAMFT Code of Ethics: “Marriage and family therapists discuss appropriate treatment alternatives with clients/patients. When appropriate, marriage and family therapists advocate for the mental health care they believe will benefit their clients/patients. Marriage and family therapists do not limit their discussions of treatment alternatives to what is covered by third-party payers.”
¹⁸ Id.
¹⁹ Section 1.5 of the CAMFT Code of Ethics provides: “When terminating client/patient relationships due to non-payment of fees, marriage and family therapists do so in a clinically appropriate manner.”.
²¹ Section 12.3 of the CAMFT Code of Ethics provides: “Prior to the commencement of treatment, marriage and family therapists disclose their fees and the basis upon which they are computed, including, but not limited to, charges for canceled or missed appointments and any interest to be charged on unpaid balances, and give reasonable notice of any changes in fees or other charges.”
²² See also, Section 12.7 of the CAMFT Code of Ethics, which provides: “Marriage and family therapists do not withhold patient records or information solely because the therapist has not been paid for prior professional services.”
²³ Section 1.7 of the CAMFT Code of Ethics provides: “Marriage and family therapists do not abandon or neglect clients/patients in treatment. If a therapist is unable or unwilling to continue to provide professional services, the therapist will assist the client/patient in making clinically appropriate arrangements for continuation of treatment.”
²⁴ “Failure to keep records consistent with sound clinical judgment, the standards of the profession, and the nature of the services being rendered” constitutes unprofessional conduct, per 20 Section 4982(v) of the Business and Professions Code.
²⁵ See also, Section 5.3 of the CAMFT Code of Ethics, which provides: “Marriage and family therapists create and maintain client/patient records consistent with sound clinical judgment, standards of the profession, and the nature of the services being rendered.”
²⁶ Section 4982 (d) of the California Business & Professions Code provides that gross negligence or incompetence in the performance of marriage and family therapy is considered to be unprofessional conduct.
²⁷ A malpractice case is a type of negligence case. In malpractice cases, the standard of care is utilized to measure the competence of the professional.
²⁸ CAMFT members may call (858) 892-2638, to speak to members of the CAMFT legal team regarding questions which concern practice-related legal, ethical and business matters.

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This article is not intended to serve as legal advice and is offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in this article.