[First, can we drop the phrase “termination” when we talk about ending treatment with a client? It sounds like we are ordering a hit!]

Ending treatment may cross your mind in many different situations. Maybe the client is just frustrating, annoying, or in some way, difficult. Maybe their political views or values are at odds with yours. Your client may be missing a lot of sessions, or not paying their balance.

But today’s article focuses on situations when a client isn’t progressing. Perhaps the client has come in for months, saying pretty much the same thing in each session. They don’t do homework, and don’t utilize your advice between sessions. They don’t seem to be getting better. Maybe you feel annoyed at their lack of progress. Or you question if you lack the necessary skills to help, so each week you feel like a failure. You wonder: Can I stop seeing this client if they aren’t improving?

What does your informed consent say about these situations? Attorney Richard Leslie of CPH Insurance asks in a recent issue of Avoiding Liability, “what information, if any, do you share with clients at the start of treatment regarding termination?”

He advises, “perhaps the most helpful provisions regarding termination [in your informed consent] involve the principles that a mental health practitioner may terminate his or her relationship with a patient when it is clear to the practitioner that the patient is not benefitting from the treatment or that the patient’s problem is beyond the ken of the practitioner and that a referral is ethically necessary.”

But, before you rewrite your informed consent, you need to think about your own policies. Under what circumstances should you say that you would end treatment with a client? Perhaps a certain number of missed sessions. Perhaps non-payment of unpaid balances. But what about lack of progress?

What Do the Ethics Codes Say? Professional ethics codes (APA, ACA, AAMFT, NASW and the NBCC) agree that therapists have a duty to end therapy if it is clear the client no longer benefits from it or needs it. The NASW and ACA codes advise referring clients to other professionals when “specialized knowledge or expertise is needed to serve clients fully or when social workers believe that they are not being effective,” and the ACA Codes emphasizes discontinuing client relationships if therapists lack competence or clients refuse referrals.

All Ethics Codes stress that therapists should avoid abandoning clients, and assist in making appropriate arrangements for continued treatment, when necessary. However, the NBCC codes also state that “counselors shall not abruptly terminate counseling services without good cause or significant justification.” And the ACA Codes note that counselors should avoid referring clients based on personal values and must respect client diversity, seeking training to prevent imposing their values, “especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.”

Are there different rules for insurance clients? Not really. You are always free to end with an insurance client for the same reasons as with any other client. It is true that referrals can be more challenging, if you try to help the client to find names of other therapists on their health plan.

With all this said, I am VERY hesitant to end treatment with a client without a great deal of consideration and consultation first. First, most of our clients have experienced a great deal of trauma and abandonment in their lives, and being turned away by a professional they reached out to for help can trigger severe abandonment issues. It may make it more difficult for them to reach out for therapy in the future.

And second, I’m hesitant to impose my definition of “no longer benefiting” or “no longer needs it” on the client. Perhaps a client is benefiting in ways I’m not aware of, but I need to have a conversation with them to hear about it. Or maybe I need to rethink how I’m measuring progress. Or a client may be doing better, or may no longer meet the criteria for a diagnosis or medical necessity for insurance coverage. However, in the conversation, I may find that the client is interested in digging deeper, in addressing a different issue, or in paying out-of-pocket to work on a personal growth issue (since insurance won’t pay for the latter).

So, Before You End Treatment:

1. Ask yourself: Where are YOU stuck with the client? What are you not hearing that the client is trying to say by their behavior? Perhaps they are not ready to change – and maybe that is OK.
2. Before ending, get consultation. You may need practical advice as well as emotional support.
3. Consider – would a different therapy approach help?
4. Do a therapy evaluation with the client. What are they getting out of treatment? Where do they feel they are stuck? What are the barriers to progress? What are they needing from you that they are not getting, if anything?
5. Does your definition of “progress” need to be altered? Were the original treatment goals too ambitious? Consider altering your treatment plan.
6. Consider therapy referrals and adjuncts like adding group support or couples or family therapy that offer new ways to help the client get insight and make progress on their issues

Once You Decide to End Treatment (adapted from NASW Tips For Termination article):

1. Role play with a colleague what you will say, and how you will handle possible client reactions. These may include anger, tears, accusations, or promises to work harder in treatment.
2. Give the client advance warning. Give clients a few sessions to discuss ending therapy, and time to transition to a new therapist, if needed.
3. If possible, tell the client in-person about your decision to end treatment, or at least via video. Avoid ending with a text, email or voicemail.
4. Provide referrals to several mental health professionals, if necessary, and assist in the transition to other health care providers.
5. Predict aloud to the client that they may be tempted not to come to future session, but encourage them to do so for a positive ending – see my article on good goodbyes here.
6. Document each discussion about ending – exactly what you said, the client’s reactions and any referrals given.
7. Follow up with a personalized ending letter (yes, snail mail) which should include referrals given; keep a copy in the client’s chart.