Keep the focus on the interests of the client
Therapy begins with an express or implied contract between clients and therapists, in which therapists agree to provide competent treatment to their clients; and clients, advised of the various ramifications of therapy, give inform consent to the treatment offered. Final or temporary termination of treatment can occur for a variety of reasons. Treatment can end when the client simply stops keeping appointments despite the therapist’s best efforts to continue contact. It can also end by mutual agreement or because the third-party payer declines further payment, and the client is unable to afford additional sessions without such reimbursement. Therapy may also be terminated when clients are transferred or when the therapist retires, becomes ill, moves, or terminates with the current association or agency and another therapist is assigned to the file. Often therapy terminates when the client and therapist mutually agree that the treatment goals have been realized and further treatment is no longer necessary. Finally, therapy can (and ethically must) end when it clearly is no longer benefiting the client, or when the client or therapist, for whatever reason, is no longer comfortable with the treatment plan. Professional ethical guidelines require therapists to terminate their work with clients whenever measurable improvement is not made for a significant period of time and/or when the determination is made that further therapy will not bring significant gains (Bernstein & Hartsell, 2003. Corey, Corey & Callanan, 2003).
When Therapy No Longer Benefits the Client
Kramer (1990) argued that, more than at any other phase of therapy, termination demands that therapists examine and understand their own needs and feelings and separate them from the needs and best interests of the client. Recognizing when a client is not a “good fit” with one’s personality or one’s therapeutic orientation can be a difficult and ego-threatening situation. While it may be relatively clear when to terminate counseling due to successful progression through a therapeutic course, terminating due to a lack of progress is less obvious and straightforward. The determination that the present course of therapy is not operating in the best interests of the client is a difficult judgment call, particularly when it reflects one’s own counseling efforts. In these situations, therapists must struggle with feelings of frustration, uncertainty, failure and inadequacy
Hypothetical Ethical Dilemma
The following scenario is a hypothetical typical dilemma regarding termination of therapy due to lack of progress:
Kevin Jones, 36, has been in treatment for Major Depression for 18 months with only a few sporadic instances of improvement followed by relapse. Although the client denies any addictions, the therapist suspects frequent alcohol and drug abuse which are interfering with therapy. Mt. Jones frequently misses appointments, fails to follow through with treatment recommendations (i.e., participation in a vocational program and/or support group), and is often moody an uncooperative while in sessions. Despite the incorporation of various therapeutic techniques and attempts to break through his resistance, the client cooperates minimally in his therapy and the presenting problem of depression has not shown consistent measurable improvement.
Resolution of Non-Improvement – Ethical Termination
The therapist-client relationship should be terminated when continued therapy is not in the client’s best interest and/or the client is not showing adequate benefit from the course of treatment. Specific steps should be taken to properly terminate an ineffective therapeutic relationship. Specifically, when services to the client are still indicated, as in the scenario above, the therapist should take reasonable steps to facilitate the transfer to an appropriate source of alternate care. Additionally, since termination has ramifications both ethically and as a malpractice risk, the therapist should take certain additional precautions whenever terminating a client-therapist relationship, including consulting with colleagues and thoroughly documenting the rationale for termination and why it represents the client’s best interest (Bernstein & Hartsell, 2003; Bersoff, 2008).
Further recommendations for a thorough and ethical termination include, scheduling an exit session or termination interview to make sure client understands: (1) what is taking place, (2) the reasons for termination, and (3) any recommendations for follow-up or referral treatment; and preparing a termination letter (see Appendix.1 for an example based on the above-mentioned scenario) prior to the final session for review with the client and inclusion in the client file. When further treatment is deemed advisable or necessary it is important to emphasize that recommendation and include viable referrals in the exit interview and in the letter (Bernstein & Hartsell, 2003). Additionally, regarding proper documentation, the clinical case notes must reflect the circumstances of termination, the termination process, and the fact that the client has been advised to seek additional services before the file is officially closed (Bersoff, 2008).
The ethical dilemma of when to terminate therapy with a client who is not making sufficient progress can be particularly challenging for therapists. Having been drilled on the clichés of “Never give up” and “Don’t be a quitter” may challenge them to try harder with a difficult, unresponsive client. It is of utmost importance that therapists remember to keep a focus on the interests of the client and not on their own desire for success – to try harder only so long as it remains in the best interest of the client rather than a measure of one’s own stubborn ego and to let go when perhaps an alternative is better suited to the client’s progress.
REFERENCES
Bernstein, B.E. & Hartsell, T. L. (2003). The portable ethicist for mental health professionals. New York, NY: John Wiley & Sons.
Bersoff, D. N. (2008). Ethical conflicts in psychology, 4e. Washington, D.C.: American Psychological Association.
Corey, G., Corey, M. and Callanan, P. (2003). Issues and ethics in the helping professions (6th ed.). Pacific Grove, CA: Brooks/Cole Publishing Company.
Kramer, S. A. (1990). Positive endings in psychotherapy: Bringing meaningful closure to therapeutic relationships. San Francisco, CA: Jossey-Bass.