Psychotherapists have numerous obligations to our clients that exist with the intent of ensuring that our clients’ best interests are paramount in our thinking and resulting actions. Jorgenson, Hirsch, and Wahl (1997) describe the responsibilities inherent in the psychotherapy relationship as a fiduciary responsibility to one’s clients. As they explain this relationship and responsibility:
Generally, a fiduciary relationship exists when one party, the fiduciary, accepts the trust and confidence of another party, the entrustor, and agrees to act only in the entrustor’s best interest. The professional, by virtue of his or her status as a fiduciary, has both the power and opportunity to exert undue influence over the client. It is because of this potential for undue influence that the professional is charged with acting only in the best interest of the client. (p. 51)
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.
Ethical Requirements for Psychotherapists
In keeping with these responsibilities to our clients, the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (APA Ethics Code, APA, 2010) provides clear guidance on our responsibilities to our clients regarding termination and abandonment. The enforceable Ethical Standards relevant to termination and abandonment are:
- 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. Circ*mstances 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 circ*mstances 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 circ*mstances 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).
Ending the Psychotherapy Relationship
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.
Termination by Mutual Agreement
- 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.
Psychotherapist Initiated Termination
- 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.
Client Initiated Termination
- 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.
Meeting Our Clinical, Ethical, and Legal Obligations
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.
What the clinician must do, however, is to take necessary actions to help ensure that any ongoing treatment needs the client has are adequately met. Thus, this standard of care requires that clients not be abandoned but that any ongoing treatment needs be openly discussed as a part of the treatment process and that relevant referrals are made and adequate time is given so that the client may obtain needed treatment. As is stated in the ruling of Capps v. Valk (1962): “If a [health professional] abandons a case without giving his patient such notice and opportunity to procure the services of another [health professional], his conduct may subject him to the consequences and liability resulting from abandonment of the case….” (p. 290.)
Recommendations for Ethical Practice
- 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.
