Psychotherapist Variables Affecting Termination
Mary Alice Fisher, Center for Ethical Practice, Charlottesville, Virginia
Younggren has provided important ethical and legal information that should dispel some of the misunderstandings about termination. It is not clear how such misunderstandings arose in the first place. If their origins lie in psychotherapists’ clinical training and early supervision experiences, then ultimately the solutions may lie there (Murdock, Edwards, & Murdock, 2010).
But regardless of their origins, it is hard to understand why the misunderstandings have persisted. Practicing psychologists have long had access to detailed advice about managing difficult terminations and about differentiating between psychotherapist-initiated termination and abandonment. (For recent examples see Davis & Younggren, 2009; Shefet & Curtis, 2005; Vasquez, Bingham & Barnett, 2008; Younggren & Gottlieb, 2008). This commentary will focus on possible reasons why such resources have not ended the confusion.
Termination is a complex process that is affected by both patient and psychotherapist variables. Psychotherapists tend to blame problematic or premature terminations on the patient rather than on themselves (Murdock et al., 2010). Undoubtedly, certain categories of patients may complicate the termination process. But perhaps, in focusing on patient variables, we have paid too little attention to psychotherapist variables (Behnke, 2009; Boyer & Hoffman, 1993).
It is recommended that psychologists initiate a discussion of termination at three different stages of psychotherapy: (1) at intake; (2) during treatment, in anticipation of termination; and (3) when the ending actually occurs (Vasquez et al., 2008). The quality of such discussions might depend to some degree on the patient, and on the nature of the patient-psychotherapist relationship. But whether such discussions are actually initiated at each of these stages, and whether they are introduced in a manner conducive to effective interactions, would depend on psychotherapist variables, not patient variables.
Intake is the appropriate time for a psychotherapist to introduce discussion of the patient duties that Younggren describes. In fact, talking about termination during the initial informed consent conversation may be the most important thing one can do to reduce the likelihood of later difficulties with closure (Younggren & Gottlieb, 2008). Written intake materials can provide information about when the psychotherapist might initiate termination, such as “when feasibility or quality of service is compromised; services are not benefitting or harming the client; or when client conduct is inconsistent with the safety or integrity of the work” (Davis & Younggren, 2009, p. 576). Davis (2008) even provides sample paragraphs that psychotherapists can use to describe both their termination policy and patient responsibilities. Yet, reportedly, few psychotherapists include the topic of termination in their informed consent documents or discuss it at intake (Davis & Younggren, 2009).
Failure to initiate that discussion may result as much from a general tendency to shortcut the informed consent conversation as from avoidance of the topic of termination in particular. Obtaining the patient’s informed consent includes (1) providing clear information about what the rules will be and (2) obtaining the informed patient’s consent to accept the conditions described. Many psychotherapists are either reluctant to begin a therapy relationship that way, or are confused about the specifics of the process (Barnett, Wise, Johnson-Greene & Bucky, 2007; Somberg, Stone, & Claiborn, 1993). The APA Ethics Code (Standard 10.01, Informed Consent to Therapy) lists numerous things that psychotherapists are required to inform prospective patients about; and HIPAA has expanded the list. If the item of “termination” is simply added to these ethically- and legally-required intake topics, it is likely to go unnoticed on a crowded handout. Yet, Younggren suggests that patient duties about termination should be emphasized, not ignored.
Once therapy begins, numerous psychotherapist factors might affect whether termination is discussed. Martin & Schurtman (1985) suggested that psychotherapists might experience anxiety about termination because of such things as overconcern about whether it will be a “successful” termination; response to the patient’s termination anxiety; or personal loss at the ending of what has been a meaningful therapy relationship. Others found that dissatisfaction with the results of treatment may be the most frequent psychotherapist hindrance to successful terminations, perhaps because the pending termination brings to the surface feelings of defeat and incompetency about the case (Brady, Guy, Poelstra & Brown, 1996). Conscious or not, such emotions might make it less likely that a psychotherapist would follow the advice to make reference to termination during the therapy or to raise issues of non-payment or non-compliance that might lead to the need to end the relationship. Finally, reluctance to terminate can arise from practical concerns (e.g., financial worries; dwindling caseload) or from psychotherapist fears that the patient will be angry, retaliate, or file a complaint.
Regardless of the underlying reasons, among the most visible signs of psychotherapist discomfort with termination may be the tendency to prolong the therapy relationship inappropriately. Lambert (2000) suggested that clinicians tend to defend against the awareness that a patient is failing to progress. According to Stewart and Chambless (2008), 36 percent of psychotherapists in private practice continue to treat patients who are not improving. Earlier research suggested that, even when the patient showed little or no progress, more than half of psychotherapists tended to continue doing “more of the same” rather than revising the treatment plan or raising the possibility of referring the patient to another provider (Kendall, Kipnis & Otto-Salaj, 1992). Yet, as Younggren notes, this is in direct contradiction to APA Ethical Standards. Although therapy is a bilateral relationship in which patients share responsibility about the termination process, psychotherapists must nevertheless take responsibility for unilaterally ending the relationship in certain circumstances.
The fact that it is sometimes unethical for a psychologist not to end a therapy relationship makes it logically impossible to equate every psychotherapist-initiated termination with an unethical “abandonment” of the patient. Yet psychotherapists who are dealing with unresolved issues of loss or abandonment might so experience it. Boyer & Hoffman (1993) found a correlation between the psychotherapist’s loss history and feelings of anxiety and depression during termination. A psychotherapist with unresolved feelings around loss may fail to be aware when termination is appropriate, or “may respond to the termination phase in a manner that is detrimental not only to ending the therapy but also to progress made up to that point” (p. 276). This suggests that a belated or inept ending can have an “undoing” effect on the progress that was accomplished during the therapy.
Self-Reflection and Consultation
Psychotherapists who are uncomfortable with termination for any reason are less likely to initiate sufficient conversation about it at any stage of the relationship. Davis and Younggren (2009) suggest that a psychotherapist’s competence in conducting a well-executed termination not only requires a strong ethical foundation and good clinical skills, but also taps such things as self-reflection and relationship capabilities.
Questions such as the following might help psychotherapists recognize when they are doing things that unnecessarily complicate or hinder the termination process:
1. At intake, do I discuss patient duties such as responsibility for participating in mutual goal-setting, monitoring progress, or planning for termination? If not, why not?
2. Do my written informed consent documents and patient contracts mention patient responsibilities, including those related to termination? If not, why not?
3. Do I re-open the conversation about termination if the contract needs to change (e.g., patient is making no progress; third party reimbursement is ending)? If not, why not?
4. Do I raise issues of nonpayment or noncompliance when they first arise, and consider the possible need for termination? If not, why not?
5. Do I dread ending particular therapy relationships? If so, which ones, and why?
6. As therapy relationships end, do I spend sufficient time exploring patients’ issues related to the ending, including negative as well as positive feelings about the therapy? If not, why not?
7. Do I remain aware of my possible role in complicating a termination, instead of just blaming the problems on patient variables? If not, why not?
8. Do I obtain consultation in cases involving difficult terminations? If not, why not?
Psychotherapists can use such self-reflection to remain aware of their possible need for ongoing consultation when facing difficult terminations. Psychotherapists who are unwilling to engage in self-examination will not likely benefit from the available resources, even when they come in the form of helpful ethical and legal recommendations such as those provided by Younggren. Finally, we must count on clinical training programs to be alert to issues related to both informed consent and termination, and to use classroom and supervision experiences to monitor trainees’ competence with both beginnings and endings.
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Boyer, S.P. & Hoffman, M.A. (1993) Counselor affective reactions to termination: Impact of counselor loss history and perceived client sensitivity to loss. Journal of Counseling Psychology, 40, 271-277.
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