Source: https://societyforpsychotherapy.org/termination-and-abandonment-a-proactive-approach-to-ethical-practice/
Timestamp: 2019-04-24 04:33:32+00:00

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One important area of practice where this fiduciary responsibility very clearly exists is that of termination and abandonment. As emphasized above, clients entrust their well being to their psychotherapist, trusting that the psychotherapist will act with due consideration of the client’s ongoing needs and best interests.
Standard 10.10, Terminating Therapy, requires that the psychotherapy relationship be ended when the client is not benefiting from treatment, is not likely to benefit from it, or is likely to be harmed from it. Circumstances relevant to this standard include if the psychotherapist no longer possesses the necessary competence to meet the client’s treatment needs and if a potentially inappropriate or exploitative multiple relationship with the client develops or is discovered that holds the potential to adversely impact the psychotherapist’s objectivity and judgment (Vasquez, Bingham, & Barnett, 2008); yet for each of these circumstances an appropriate termination process that addresses the client’s ongoing treatment needs through pretermination counseling and making any needed referrals must occur. This standard also allows psychotherapists to terminate the psychotherapy relationship abruptly (without a termination process) if the psychotherapist is “threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship” (APA, 2010, p. 14).
09, Interruption of Therapy, addresses the need for psychotherapists to make advance arrangements when entering into “employment or contractual relationships” (p. 14) to ensure that client treatment needs are appropriately addressed in the event that the employment or contractual arrangement ends while clients’ treatment is ongoing.
12, Interruption of Psychological Services, highlights the need to anticipate possible circumstances that may interfere with the psychotherapist’s ability to provide ongoing care to clients such as through unavailability, retirement, illness, disability, and even death, and make advance arrangements to ensure that client treatment needs will be addressed and that clients will not be or feel abandoned.
Relevant to Standard 3.12, Interruption of Psychological Services, above, Standards 2.06, Personal Problems and Conflicts, emphasizes the need for each psychotherapist to monitor her or his own wellness, to practice ongoing self-care to minimize the effects of stress and distress in our professional and personal lives, and to seek consultation and assistance from colleagues to ensure that these stressors do not lead to decreased competence and clinical effectiveness.
Standard 10.01, Informed Consent to Therapy, emphasizes the need to share with clients from the outset all relevant information that may impact their decision to enter into and participate in the psychotherapy relationship. It is essential that issues relevant to termination, anticipated and unanticipated absences, and procedures for ensuring that clients’ ongoing treatment needs are met even between treatment sessions, each are addressed in the informed consent process (Davis & Younggren, 2009).
Termination is defined as the “ethically and clinically appropriate process by which a professional relationship is ended” (Younggren & Gottlieb, 2008, p. 500). This clearly implies that how the termination process is carried out has significant clinical and ethical implications.
In contrast, abandonment occurs when the treatment relationship ends, but this necessary process does not occur, such as by ending a client’s treatment abruptly when the client no longer can afford to pay for treatment. Abandonment can also occur during the course of treatment when the client’s ongoing treatment needs are not met in an ethically and clinically appropriate manner, such as by not being accessible for client crises and emergencies in between sessions and by not making appropriate coverage arrangements during periods of psychotherapist absence or unavailability.
Ideally, when ending a client’s treatment, a well thought out termination process that has been planned for will occur, with the goal of consolidating the benefits and lessons learned to assist the client to maintain the successes achieved in treatment (Vasquez, Bingham, & Barnett, 2008).
As stated by Joyce, Piper, Ogrodniczuk, and Klein (2007), through termination, the client should be able to “(a) reflect on and acknowledge the effects of the treatment, (b) appreciate the importance of the therapeutic relationship, and (c) look ahead to applying the lessons of therapy” (p. 26). Termination may develop naturally when the client has successfully accomplished all treatment goals and is relieved from previous distress (Joyce et al., 2007).
An appropriately implemented termination process allows clients to “review their goals, describe the changes they have incorporated, and work through feelings in ending the psychotherapy process” (Vasquez, Bingham, Barnett, 2008, p. 654). Abandonment, instead, is when this process does not occur, which can be stressful for both the client and psychotherapist. The clients may feel sadness, loss, confusion, and anxiety, or blame themselves for the termination of psychotherapy (Penn, 1990). The psychotherapist may feel “personal failure” and ending the psychotherapy relationship in this manner may damage the client’s therapeutic growth (Penn, 1990).
Psychotherapy may be terminated for a range of different reasons. It may be initiated by mutual agreement, by the psychotherapist, or by the client.
Sometimes, due to the nature of the treatment, termination occurs when the treatment process is complete (Joyce et al., 2007). This may occur when the agreed upon treatment goals have been achieved or when treatment is time limited and the agreed upon number of treatment sessions have been provided.
In keeping with Standard 10.10, Terminating Therapy (APA, 2010), the psychotherapist may initiate termination because she or he no longer possesses the necessary competence to be able to assist the client (either due to the client’s changing treatment needs or due to problems of professional competence relevant to stress, distress, burnout, illness, etc.) and/or because the psychotherapist believes that continued treatment would likely be harmful to the client (even if the client wants to continue treatment).
A range of issues may also result in the psychotherapist initiating treatment termination such as a planned retirement from practice or leave of absence, or if the psychotherapist will be at the treatment site for a limited period of time such as a trainee on internship. Additionally, as is highlighted in Standard 10.10, Terminating Therapy (APA, 2010) if the psychotherapist is threatened or otherwise endangered (e.g., stalked, assaulted) she or he may (and most likely should) terminate the psychotherapy relationship.
The client may lose her or his ability to continue paying for treatment such as due to loss of one’s employment, loss of one’s health insurance, or other changes in the client’s financial situation.
The client may move from the area such as due to a job transfer, retirement, or seeking employment opportunities elsewhere.
The client may not be pleased with the progress being made in treatment, may be displeased with the psychotherapist’s approach, may believe they have made all the progress that can be achieved in working with the psychotherapist, may want to try things on her or his own outside of treatment, or may drop out of treatment without providing any explanation or advance discussion.
Psychotherapists may misunderstand our obligations to clients and fear charges of abandonment if we initiate termination, such as for the reasons highlighted above, if the client does not agree with the psychotherapist’s decision (Younggren, Fisher, Foote, & Hjelt, 2011). Yet, it is widely recognized that psychotherapists do not have a duty to treat clients indefinitely and we do not need our clients’ permission to end treatment. Rather, we have an ethical and legal obligation to act consistently with our client’s best interests and ongoing treatment needs.
Landmark legal rulings such as Capps v. Valk (1962) and Collins v. Meeker (1967), and reaffirmed in Sparks v. Hicks (1996), set a legal precedent on termination and abandonment. These rulings make clear that health care professionals are under no obligation to continue a client’s treatment if the clinician’s professional judgment indicates that ongoing treatment is not in the client’s best interests or when ethically obligated to do so, regardless of the client’s opinion on this.
Include discussions of treatment termination and possible interruptions of treatment, to include emergency contact procedures and treatment coverage arrangements in ongoing informed consent discussions. Be sure that ongoing treatment needs can appropriately be met either personally or by those to whom you delegate this responsibility and inform clients of these arrangements in advance.
Include processes and procedures in employment and practice contracts that ensure that client treatment needs will be met should you leave the practice setting or be otherwise unable to provide needed treatment.
Maintain documentation in the client’s treatment record of agreed upon treatment goals and the client’s progress toward achieving them. This will help both psychotherapist and client determine if goals were successfully met. This is also especially important for supporting the psychotherapist’s termination decisions when dealing with clients who do not want to terminate but who have completed all treatment goals and with clients who are not complying with treatment recommendations and who are not making progress in treatment.
Consult with colleagues to obtain a second (or third!) opinion on when termination should occur. Then consult to ensure that the termination process is being implemented appropriately and effectively (Davis & Younggren, 2009).
If treatment needs to be ended when ongoing client needs exist, discuss this openly with the client, offer referral recommendations, and provide some reasonable period of time for the client to make contact with and arrange for treatment with another psychotherapist. Document all these discussions and actions.
If a client drops out of treatment do not tacitly condone this decision to discontinue treatment if in your professional opinion ongoing treatment is indicated (Barnett, MacGlashan, & Clarke, 2000). Make a reasonable good faith effort to contact the client and go on record with your recommendations for any ongoing needed treatment and the reasons why. Sample letters that may be modified by psychotherapists to fit individual situations and then be sent to clients to fulfill this obligation may be found in Barnett, MacGlashan, and Clarke (2000) and in Barnett, Zimmerman, and Walfish (2014).
Remember that ideally, termination should be planned for, discussed openly in treatment, and be an essential aspect of the treatment process that assists the client toward effective independent functioning. It is also important to emphasize that termination is not absolute; it should be made clear that clients may contact you if difficulties are experienced in the future and they would like assistance in addressing them at that time.
Barnett, J. E., MacGlashan, S., & Clarke, A. J. (2000). Risk management and ethical issues regarding termination and abandonment. In L. VandeCreek & T.
Jackson (Eds.), Innovations in clinical practice (pp. 231-246). Sarasota, FL: Professional Resources Press.
Barnett, J. E., Zimmerman, J., & Walfish, S. (2014). The ethics of private practice: A practical guide for mental health clinicians. New York: Oxford University Press.
Capps v. Valk, 189 Kan. 287, 369 P. 2d 238 (1962 Kan.).
Collins v. Meeker, 198 Kan. 390, 424 P. 2d 488 (1967).
Davis, D. D., & Younggren, J. N. (2009). Ethical competence in psychotherapy termination. Professional Psychology: Research and Practice, 40, 572–578.
Jorgenson, L. M., Hirsch, A. B., & Wahl, K. M. (1997). Fiduciary duty and boundaries: Acting in the client’s best interest. Behavioral Sciences and the Law, 15, 49–62.
Joyce, A. S., Piper, W. E., Ogrodniczuk, J. S., and Klein, R. H. (2007). Termination in psychotherapy: A psychodynamic model of processes and outcomes. Washington, DC: American Psychological Association.
Penn, L. S. (1990). When the therapist must leave: Forced termination of psychodynamic psychotherapy. Professional Psychology: Research and Practice, 21, 379-384.
Sparks v. Hicks, 82203 Ok. 20, 912 P. 2d 331 (1996).
Vasquez, M. J. T., Bingham, R. P., & Barnett, J. E. (2008). Psychotherapy termination: Clinical and ethical responsibilities. Journal of Clinical Psychology: In Session, 64(5), 653-665.
Younggren, J. N., Fisher, M. A., Foote, W. E., & Hjelt, S. E. (2011). A legal and ethical review of patient responsibilities and psychotherapist duties. Professional Psychology: Research and Practice, 42, 160-168.
Younggren, J. N., & Gottlieb, M. C. (2008). Termination and abandonment: History, risk, and risk management. Professional Psychology: Research and Practice, 39, 498-504.
This article is really reassuring. My 9 year old son was receiving weekly thearapy sessions and all of a sudden they ended. There was not any closure or any unpleasant issues that I can recall. My son has server emotional challenges and he looked forward to the theapy. The Thea ray seemed to help bring more balance into his daily routine. The therapist contacted me and left me a message after 2 months. I contacted her to see if we we still going to continue or meeting and were there Changes to please let me know. My call was not returned until another month. My son felt and expressed his sadness and didn’t know why “she just left”. I wasn’t sure if she was injured or had to take some time off. There was no closure and My son and I feel abandoned. It is so very difficult already to build trust in others due to unpleasant experiences. I attempted to make an excuse that she just disappeared; instead I told him I’ll try to see what’s going on.
I am now not sure to continue our relationship with the company. I have sought out other options. I didn’t think we deserved to be abandoned and I am not sure how this has further damaged the image of thearapist to my son.
Let me first apologize for what seems to be a very difficult and trying time for you and your son. I would encourage you to reach out to the organization that the therapist works for and speak to a supervisor, who might be able to shed some light on what happened. I might also suggest reaching out to find another therapist (perhaps through a different organization) to, at the very least, help your son and you process your feelings from the first therapist. It is so very clear that there is pain and hurt there, and I wish you and your family some peace and closure, but also the help for which you originally sought out.
I was recently fired via email, I was not given an opportunity to voice an opinion or wrap up the 2 1/2 year relationship. The feeling of abandonment which as a daily struggle for me have just increased to a level that seems unbearable. I feel at the very least a brief session to end or even a phone session to inform would have been more appropriate.
I was terminated without any notice & it was just after I returned from a family crisis out of state.
There was over a decade of treatment & my psychologist did not provide any referrals.
Has also not responded to any communication including a request for Referal.
I’m overwhelmed with incredible grief & very confused by it all.
I don’t know how to cope with it all.
Is this normal, as I have never been in therapy prior & we had a very good alliance.

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