Termination is the term typically used when referring to the ending of the psychotherapy relationship. It may occur as an anticipated and well-articulated treatment plan that indicates the next phase of the psychotherapy process or it may occur precipitously or by surprise.
Abandonment is a term that implies that the psychotherapist either ended the psychotherapy process in an inappropriate manner that does not adequately address the client’s ongoing treatment needs or the psychotherapist did not make necessary arrangements for the client’s treatment during the course of treatment (Younggren & Gottlieb, 2008).
How termination should be seen is both a clinical and ethics issue. These two issues are intertwined and each should be seen as essential for meeting our obligations to our clients. While there is much more to the topic and psychotherapists will hopefully immerse themselves on the literature on termination, this brief article suggests six essential strategies that lay a solid foundation for meeting these obligations to our clients.
1. Address termination issues from the outset. Include in the informed consent discussions and agreement.
The process of informed consent is intended to share all relevant information with clients so that they can make decisions about participation in the treatment services being offered (Barnett, 2015).
Knowing from the outset how treatment will end can be a vital piece of information for clients in making their decisions about participation in the proposed course of treatment (Davis & Younggren, 2009).
For example, if the length of treatment is open-ended and will be determined by progress made toward treatment goals, this is a very different circumstance than the case where treatment is limited to a specific number of sessions (at times based on limitations on the client’s insurance coverage or in the instance of brief or time-limited psychotherapy).
When psychotherapy is being provided by a trainee this is a crucial issue as trainees typically have an end date to their time at each setting. Clients have the right to know from the outset if their psychotherapist will be there for them for the next five months or for the next five weeks.
Any factors that may have a significant impact on the course of a client’s proposed treatment should be openly discussed as part of informed consent. This enables them to make informed decisions about participation and helps to prepare them for what is to come, helping them to participate more fully in the process, and thus, hopefully to benefit more fully from the experience.
2. Reach agreement on the goals of treatment and the criteria for successful completion of treatment.
The ending of each client’s psychotherapy will hopefully occur when all treatment goals have been achieved. But, in order to know when treatment should end, there must first be an agreement on the goals of treatment. While treatment goals may be modified over the course of treatment as clients make progress and life circumstances change, failure to have an open discussion of goals from the outset and failure to reach agreement on what these goals are impacts the nature, focus, and scope of the treatment offered as well as when and how this treatment will end (Davis, 2008).
3. Consider and prepare for possible psychotherapist-initiated interruptions to treatment. Have a professional will.
Psychotherapy can end for a variety of reasons. As is highlighted above, the most desired reason for ending treatment is that the client has achieved the agreed upon goals of treatment. But, psychotherapy may end for a variety of reasons, both client and psychotherapist initiated.
To meet our ethical obligations to clients, psychotherapists may need to end a client’s treatment if the client is not benefitting from treatment, if an inappropriate multiple relationship develops or is discovered, or if the psychotherapist no longer possesses the competence necessary to meet the client’s treatment needs (APA, 2010).
Psychotherapists may also terminate treatment “when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship” (APA, 2010, Standard 10.10).
Psychotherapists may also need to abruptly end or interrupt a client’s ongoing treatment due to psychotherapist factors such as illness, disability, retirement, and even death. In keeping with our focus on each client’s best interests, psychotherapists should plan for these eventualities and make needed advance arrangements to help ensure that clients are not abandoned during the course of treatment.
While some possible interruptions to treatment may be anticipated and planned for (e.g., vacation, taking time off after giving birth or adopting a child, and retirement), others such as illness and death tend not to be anticipated and can be doubly challenging for clients when they occur: the unplanned interruption in their treatment and the impact of the loss of their psychotherapist.
It is recommended that each psychotherapist make advance arrangements with one or more colleagues to step in and offer assistance to clients when any of these events occur.
Psychotherapists should each have a professional will in which a colleague is identified who has access to client contact information and records, and who will contact clients in the case of psychotherapist death or other incapacitation, assessing ongoing treatment needs and assisting with crisis intervention and referrals to other clinicians (Pope & Vasquez, 2005).
4. Be mindful of client and other-initiated interruptions to treatment.
Clients may initiate termination for a variety of reasons. These may include limitations in finances, feeling dissatisfied with the psychotherapist or with how treatment is proceeding, losing one’s job, loss of or changes in their insurance coverage, or moving from the local area. While each of these cannot be anticipated from the outset of treatment, open discussions with clients about their progress in treatment and any issues that may impact their ability to continue should be explored at least periodically.
To fulfill our obligations to clients, even when they initiate termination, we should ensure a reasonable good faith effort to help address any ongoing treatment needs. While we are not required to meet client treatment needs indefinitely, and doing so in some of these situations is not practical, offering assistance in connecting with alternative treatment resources is important to do whenever possible.
When clients discontinue treatment, for any reason, before the agreed upon goals of treatment have been achieved, it is recommended that the client be contacted (either verbally or in writing) to make recommendations for addressing any ongoing treatment needs, offering options and alternatives, and offering assistance in procuring them. Sample letters that may be sent to clients to address these issues may be found in Barnett, MacGlashan, and Clarke (2000) and in Vasquez, Bingham, and Barnett (2009).
5. Be clear on what abandonment is and is not (e.g., the client’s role in treatment discontinuation, the psychotherapist’s role).
Abandonment occurs when the psychotherapist does not meet a client’s ongoing treatment needs appropriately. Abandonment may occur when treatment endings are mismanaged as well as when clients’ ongoing treatment needs are not adequately addressed. The latter may include failure to make needed coverage arrangements during periods of anticipated absence such as vacations, attending a conference, or other times when client access to the psychotherapist may be limited.
Charges of abandonment may even arise from not being sufficiently accessible between regularly scheduled treatment sessions. It is vital that reasonable expectations be established from the outset, with clients being provided with information on how to access the psychotherapist between sessions, when it is or is not appropriate to contact the psychotherapist, and the preferred means of contact. Realistic expectations should be established for the psychotherapist’s responsiveness and when others should be contacted, such as calling 911 in emergency situations.
It is not abandonment when a client drops out of treatment precipitously or when the client does not fulfill treatment obligations. Nor is it abandonment if the client cooperates with treatment recommendations and the treatment is ended appropriately, after discussion, with notice, and with referrals being made; and in fact, these actions may not be necessary in situations where the psychotherapist is threatened or assaulted.
As Younggren, Fisher, Foote, and Hjelt (2011) emphasize, clients have obligations as articulated in the informed consent agreement and/or treatment contract. When continued treatment is not possible or not indicated based on client actions and responses, ending the treatment is not seen as abandonment. Of course, documenting all such situations, discussions, consultations with colleagues, actions taken, and efforts to contact clients, should occur on an ongoing basis.
6. Have ongoing discussions with clients about progress in treatment toward termination.
Plan and prepare for termination. If possible, treatment endings should not come as a surprise. Work collaboratively with clients toward successful treatment endings. Termination should be considered a process and not an event. It should be seen as a phase of each client’s treatment that is worked toward together on an ongoing basis.
It is recommended that termination be conceptualized as a consolidation phase of treatment that helps prepare the client to build on the gains made in treatment and to move forward positively after treatment ends (Barnett & Coffman, 2015). This important phase of treatment may be conceptualized from a range of perspectives and it may stimulate a number of important themes and issues that are important to work through and address before treatment ends (Hardy & Woodhouse, 2008).
How the psychotherapy relationship and process end has important implications for our clients. It is hoped psychotherapists will consider the guidance provided in this brief article when considering your approach to this essential aspect of psychotherapy. Addressing endings from the beginning, and on an ongoing basis throughout treatment, can help ensure that treatment is provided and ended in an ethical and clinically competent manner.
Efforts to reduce misunderstandings and to be responsive to client needs can help prevent claims of abandonment. We can each institute practices that will help us to fulfill our obligations to clients. Further, keeping up with the literature on termination practices is recommended as part of our ongoing professional development and lifelong learning as psychotherapists.