The goal of every client's or patient's psychotherapy is the attainment of treatment goals and a planned successful completion of treatment. Termination is viewed as an important phase of the psychotherapy process that should be planned for in advance (Quintana & Holahan, 1992; Weiner, 1975). When handled appropriately, it contributes to the client's autonomous functioning and long-term success (Barnett & Sanzone, 1997). Weiner (1975) sttes that this final phase of each client's psychotherapy "is exceeded only by the initial phase in its importance for determining the amount of help a patient receives" (p. 263).

Termination should be viewed by practitioners as an essential phase of each client's treatment. It should be planned for, worked toward, and carried out in a thoughtful manner. Doing so helps to ensure each client's long-termsuccess. But, unfortunately, not all clients leave treatment after such an effectively implemented termination phase. Not all treatment terminations are the result of a mutual agreement by practitioner and client that all treatment goals have successfully been achieved.

Other reasons for leaving treatment and their implications include:

1. The psychotherapist initiates termination despite the client's desire for treatment to continue. A clinician may believe that to continue a client's treatment may not be appropriate or in the client's best interest. This could occur when the client is not benefiting from treatment, when the client's treatment needs change and are no longer within the clinician's areas of competence, when a potential conflict of interest arises or multiple relationship is discovered, or when clinician distress or impairment is discovered. In such situations when the client has ongoing treatment needs making arrangements for continued treatment with another appropriately trained clinician would be in the client's best interest.
2. The client initiates termination and the clinician does not view this as in the client's best interest. There are times when clients will initiate termination and the clinician's clinical judgement indicates that this would not be in the client's best interest. To not challenge such an action would in a sense be to endorse the decision. There certainly are times when clients may feel that further treatment is not needed, but the clinician's understanding of the client and of the psychotherapy process would indicate that termination is contraindicated. Addressing these issues with the client is important along with assisting the client to make the best possible decision.
3. The client drops out of treatment without notice and does not respond to the psychotherapist's efforts at contact. Psychotherapy clients may drop out of treatment for a variety of reasons such as initial symptom relief, financial difficulties, or dissatisfaction with the psychotherapist. Again, the clinician will need to make a reasonable effort to contact the client, not appear to agree with discontinuing treatment in this manner if professional judgement indicates that ongoing treatment is needed, and ensure that any ongoing treatment needs are addressed through recommendations and referral. A written letter, with a copy in the client's file, will best address this need. Clearly stating one's concern for the client and the reasons for recommending continued treatment are important to include in such a letter along with possible referral sources and an offer to assist with the referral process.
4. The clinician refuses to continue a client's treatment as a result of certain actions or behaviors on the client's part. Clinicians may want to discontinue work with certain clients due to noncompliance with treatment recommendations, lack of participation in treatment, or the client's refusal or failure to pay for treatment. While clinicians are not required to treat all clients indefinitely, it is important that we comply with the guidelines concerning termination and abandonment providedin the APA Ethics Code (APA, 1992). We must notify them of our plan in advance, make referrals to other practitioners, assist with the referral transition process, and be available for crises until the new clinician takes treatment over. Authors such as Gutheil and Appelbaum (1982) in citing relevant case law, state that we should ensure that termination occurs as the result of clinical need, not as a result of a client's inability to pay for treatment. Options always exist and alternative arrangements can be made such as using a sliding fee scale, a payment plan, pro bono work, or a referral to a community mental health center or other practice that can work within the client's financial constraints. Finally, we must also ensure that clients in crisis are not terminated abruptly, regardless of the circumstance. Their treatment needs are our primary concern regardless of other factors present.
5. Insurance benefits are exhausted or managed care authorization is refused. It is important to keep in mind that insurance and managed care companies can only refuse to authorize reimbursement for services provided. They are not involved in actually authorizing us to provide or not provide treatment. It is important that we do not let their fiscally motivated decisions supercede our clinical judgement. All adverse authorization decisions should immediately be appealed and treatment, if clinically indicated, should continue in the interim (Wickline v. State of California,1986). If an adverse ruling on the appeal is made we may then consider treatment and referral options outside the client's insurance coverage. But, as discussed earlier, we maintain responsibility for our clients' welfare until they agree to end treatment or are in the care of another professional.

General recommendations for addressing termination issues provided by Barnett (1998) include:

1. Clarify expectations and obligations from the outset. The use of a written informed consent agreement at the beginning of treatment that addresses these issues is helpful.
2. Review with clients their insurance coverage, limits to managed care contracts, and how utilization review may impact on treatment. Set up arrangements for addressing client treatment needs if continued authorization is denied
3. Provide clients with other treatment resources if needed and work to assist them in their transition to other health care providers.
4. Do not terminate the treatment of clients who are in crisis regardless of payment issues. Provide needed treatment or help them find it elsewhere.
5. Do not tacitly condone patients dropping out of treatment when your clinical judgement indicates continued care is needed. Notify clients of your assessment and recommendations [click here for sample termination letter].
6. Carefully document all discussions of termination issues, agreements reached, decisions made and their rationale, and client follow-through with recommendations.
7. Termination is a phase of each client's treatment. Plan for it, prepare for it, process it.

References

American Psychological Association. (1992). Ethical principles of psychologists and conduct. American Psychologist, 47, 1597-1611.

Barnett, J.E. (1998). Termination without trepidation. Psychotherapy Bulletin, 33 (2), 20-22.

Barnett, J.E. & Sanzone, M.M. (1997). Termination: Ethical and legal issues. The Clinical Psychologist, 50, 9-13.

Gutheil, T. & Appelbaum, P. (1882). Clinical Handbook of Psychiatry and the Law. New York: McGrqw-Hill.

Quintana, S.M. & Holahan, W. (1992). Termination in short-term counseling: Comparison of successful and unsuccessful cases. Journal of Counseling Psychology,39 299-305.

Weiner, I.B. (1975). Principles of Psychotherapy. New York: Wiley.

Wickline v. Blue Cross of Southern California, No. B040697 (July 27, 1990).