Risk Management: Client Termination

How can I turn away a client after I’ve done an intake and feel that a referral is needed?

Aside from initially screening clients out at the first telephone or online contact, the next best time to appropriately decline to provide services is when the provider has completed an intake. At this point, the initial evaluation has been conducted, and the provider usually has enough information on which to base a reasonable judgement about whether the potential client will be a good fit for the provider’s skills, competences, practice composition, and nature of his or her work. However, informing a client (following an intake) that continued treatment or assessment is not a good fit may offend or distress the client. One way to decrease that risk is to specify, prior to beginning treatment, that the first two or three sessions will involve assessment, for both the provider and client. If either believes the fit is not good, or the provider believes the client requires a different kind or level of service, appropriate referrals can be made.

Although this initial structure is recommended, in the event it has not been made explicit, it is nonetheless prudent to refrain from entering an ongoing treatment relationship when the provider has determined that it is inappropriate to do so. Rather, promptly informing the prospective or new client of the provider’s decision, providing a reasonable explanation, making appropriate referrals, and, if warranted, assisting the client in making a transition, is a more prudent course of action. Ethically, at least some termination counseling should occur, though given the length of the intake process, counseling can be brief and to the point.

When is it okay to terminate with an ongoing client and how can I do so ethically?

APA Ethical Standard 10.10 states the following:

  1. Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service.
  2. Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship.
  3. Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pre-termination counseling and suggest alternative service providers as appropriate.

Under some circumstances, it is required that professionals initiate termination of services. Doing so requires a thoughtful approach, and one that normally involves informing the client, providing termination counseling sessions, and when appropriate, referrals.

It is almost always wise, with an ongoing treatment where the provider believes she or he must end before a client wishes to terminate, for the provider to seek consultation before beginning the termination process. This allows the provider to attend to the ethical, interpersonal, technical, clinical, and emotional aspects of the termination, and to develop a plan for the process prior to informing the client. The provider should offer a series of termination counseling sessions and referrals. Depending on the length and complexity of the treatment, termination counseling sessions could be brief or quite extensive. Referrals are also customary. There are, however, exceptions to both typical practices. For example, if a client has threatened the provider with violence, no in-person meetings to conduct termination counseling would be expected. The provider can consider whether a contact via phone or letter would suffice. And, when a client is no longer in need of treatment, referrals need not be provided. For some clients, assisting them in the transition to new providers (e.g., having conference calls with the client and proposed provider, or meeting together for a session) may be productive; for others, it may not be necessary or possible.

We also recommend providing a summary of the treatment to the client (this can be verbal or in writing). It can describe the presenting problems and symptoms with which the client entered treatment, the diagnosis (if any), treatment plan, a summary of the progress that has been made, and any concerns the provider has about risks the client might encounter if she or he failed to follow the provider’s recommendations. For example, clients who have experienced episodic suicidal thoughts and impulses may become more intensely so and ultimately put their lives at risk if they do not seek further therapy.

There is an exception to the provider’s ability to end treatment: if the client goes into crisis — for example, a suicide attempt — the provider should plan to see the client through the crisis before continuing with a termination plan.

Of course, providers should document the termination plan, course of termination counseling, recommendations and referrals, and retain a copy in their own records of the summary they provide to the client. Notwithstanding such plans and documentation and ultimate termination of the relationship, clients may not be willing to participate in the termination counseling process, or may insist on continuing contact via phone, email, or in person after termination. It is important to maintain a compassionate, professional, but firm limit in regards to termination, particularly if there have been boundary tests.

References:

Ethical Principles of Psychologists and Code of Conduct. (2002, with 2010 & 2016 Amendments). In American Psychological Association. Retrieved from http://www.apa.org/ethics/code/index.aspx