The Therapist
(January/February 2009)
(Updated 2012)

Four vignettes are presented below discussing hypothetical situations involving the therapist’s termination of a client. We invite you to provide CALMFT with your written analysis of the legal and ethical issues evident in each of the following four vignettes and the actions taken by the therapist. In an upcoming issue of The Therapist, CALMFT will print the best overall response(s), as judged by Mary Riemersma, David Jensen, Catherine Atkins, Ann Tran, and Michael Griffin. In addition, CALMFT will provide two (2) self-study continuing education units for members who answer all four (4) vignettes.

Vignette No. 1
LMFT has been working with Michelle (age 30), two times a week on issues of depression. Michelle was diagnosed with recurrent major depression. At the onset of treatment, Michelle reported suicidal ideations and one suicide attempt. Over the last three years, Michelle’s symptoms have significantly improved. However, four weeks ago Michelle lost her job and has begun discussing her lack of luster for life. Although Michelle stated she didn’t have a suicide plan, she admitted that she thinks about “ending it all” every few days. Also starting four weeks ago, Michelle’s checks have begun to bounce. Because Michelle is seen twice a week, LMFT is losing hundreds of dollars and is having trouble making the rent payment. LMFT had decided to terminate Michelle due to non-payment and when LMFT told Michelle, Michelle indicated that if she couldn’t see LMFT she would kill herself. LMFT agreed to see Michelle two more times for free, but at the end of the second session Michelle again stated that if she couldn’t continue counseling, she “would end it all tonight.” LMFT suggested other referrals, but Michelle refused to take them. LMFT evaluated Michelle for suicidal ideations, but Michelle would not answer specifically. Michelle stated “I’m afraid of not seeing you anymore. You’re abandoning me.” LMFT decided that based on her financial situation she would have to terminate Michelle and told her so. Michelle ran out of the office crying. LMFT attempted to contact Michelle over the next few hours, with no response. Because LMFT did not have any emergency contact information for Michelle, LMFT called the police to suggest a wellness check. LMFT remains confident in her decision to terminate Michelle.

Vignette No. 2
LMFT and Lili have been working together for six months. LMFT’s working diagnosis for Lili is severe bulimia and borderline personality disorder. Over the last six months, Lili has ignored the treatment plan and has occasionally missed some appointments. LMFT has discussed with Lili, on numerous occasions, the reasons that ignoring the treatment plan can be harmful and is unacceptable. Feeling frustrated, LMFT finally explained to Lili that because she was not following the treatment plan, as well as the missed appointments, LMFT would need to terminate Lili. Lili stormed out of the office stating she hated the LMFT and would make a complaint to the BBS. Over the next two weeks, LMFT received twelve calls from Lili asking to come back and stating she would comply with the treatment plan. LMFT agreed. Almost immediately, Lili again stopped complying with the treatment plan, and reports continued binging and purging. This behavior of non-compliance has continued for another six months, but LMFT has decided to keep seeing Lili stating “some therapy is better than none.”

Vignette No. 3
LMFT has been working with Jimmy (age 14) on a weekly basis for nearly eight years. Although Jimmy had a history of serious behavior problems, he has responded so well to treatment, his parents insist that LMFT keep the relationship going. LMFT doesn’t see any continued behavior problems, but the parents seem reassured by the relationship and LMFT believes terminating Jimmy would upset the parents. Therefore, LMFT decides to keep seeing Jimmy on a weekly basis.

Vignette No. 4
LMFT has been doing couples counseling with Cindy and Bob over the last year. Recently Cindy has been missing sessions on an increasingly frequent basis. Cindy finally called, and left a voicemail that she no longer will be coming to therapy. Bob indicates that he would like to continue with his own individual treatment anyway and LMFT agreed. LMFT and Bob’s sessions tend to revolve around his marriage, his infidelity, and his desire to divorce. In one session, Bob admitted to being attracted to LMFT. Cindy recently called LMFT and demanded that either Cindy be able to return to couples therapy, or LMFT stop seeing Bob as a patient. LMFT decided not to see Cindy since Cindy is no longer LMFT’s patient. LMFT also determined that because Bob’s issues are within her scope of practice, and because the attraction issue is not really a problem, that termination is not necessary.

Instructions
You may analyze as many, or as few, of the vignettes as you wish. Remember, to receive two (2) self-study continuing education units, you must answer all four (4) vignettes. Please address the following questions for each vignette that you choose to analyze:

A. Discuss whether or not, in your opinion, the therapist’s conduct is appropriate in the context of any and all laws, regulations, and ethical standards that may apply.

B. Consider whether or not the therapist’s actions suggest or demonstrate improper termination, issues of abandonment, contraindicated continued therapy, and/ or unclear or inappropriate boundaries between the therapist and his or her patient.

C. Explore any other options that are available to the therapist and any potential consequences of those options. Indicate what you believe to be the best course of action, in light of the applicable laws, regulations, and ethical standards.

We are interested in the specific reasons for any positions that you take. Mailed responses must be typed and submitted to: CALMFT 7901 Raytheon Rd., San Diego, CA, 921. Responses may be submitted as e-mail attachments to: eileen@caLMFT.org. Please type “Vignette Response” in the subject line. In order to be considered, your response must be received by CALMFT on or before March 1, 2009.

*BBS Provider #PCE 50

Catherine L. Atkins, JD, is a Staff Attorney at CALMFT. Cathy is available to answer members’ questions regarding business, legal, and ethical issues.

This article appeared in the January/February 2009 issue of The Therapist, the publication of the California Association of Marriage and Family Therapists, headquartered in San Diego, California. This article is intended to provide guidelines for addressing difficult legal dilemmas. It is not intended to address every situation that could potentially arise, nor is it intended to be a substitute for independent legal 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.