2 APA PRACTICE ORGANIZATION
MARKETPLACE TRENDS AND OPPORTUNITIES
2 APA PRACTICE ORGANIZATION
T
he process of terminating psychotherapy often goes
smoothly and offers an opportunity to review progress
made in treatment, plan for managing any recurrence
of symptoms and gain closure regarding the therapeutic
relationship. Ideally, psychotherapy is discontinued when
treatment goals are met, the psychologist and patient* agree
that it’s time to stop, and the patient knows where to obtain
follow-up services if needed in the future. Factors that may
have a bearing on successful termination include length of
therapy and clinical features such as quality of the
therapeutic relationship and the patient’s personality traits.
Difculties are most likely to arise when transitions are not
mutually agreed upon by both patient and therapist. Sudden
and unforeseen terminations can also be challenging.
Familiarity with legal and ethical duties, a thorough informed
consent procedure and advance planning are all useful in
promoting smooth and effective transitions.
In this article, the term “termination” refers to the
discontinuation of treatment by a particular psychologist.
The term “transition” is used more broadly to refer to all
types of situations that involve discontinuation of
treatment, including transfers to another mental health
professional or setting.
Ethical and legal framework
The APA Ethical Principles of Psychologists and Code of
Conduct (Ethics Code) provides both an excellent
framework and specic guidance for handling treatment
terminations. The Ethics Code Principle A (Benecence
and Nonmalecence) requires psychologists to “strive to
benet those with whom they work and take care to do no
harm.” This principle applies to the course of treatment as
well as its ending. Ethics Standard 10.10 (Terminating
Therapy) specically addresses terminations as follows:
(a) Psychologists terminate therapy when it becomes
reasonably clear that the client/patient no longer needs
the service, is not likely to benet, or is being harmed
by continued service.
(b) Psychologists may terminate therapy when
threatened or otherwise endangered by the client/
patient or another person with whom the client/patient
has a relationship.
(c) Except where precluded by the actions of clients/
patients or third-party payors, prior to termination
psychologists provide pretermination counseling and
suggest alternative service providers as appropriate.
Section (a) implies that clinical judgment is involved in
determining the benets of continued services, a topic
discussed in further detail later in this article. Section (b)
clearly allows psychologists to unilaterally end therapy
when they are threatened by a patient or someone
connected to a patient. Section (c) addresses pretermination
counseling and referrals.
Referral information is preferably given to the patient both
verbally and in writing, with a copy included in the
patient record. Even in circumstances that preclude pre-
termination counseling, such as when a patient suddenly
stops attending therapy appointments, psychologists
Transitions and Terminations: Legal and Ethical Issues
When Discontinuing Treatment
Consider these important factors related to ending treatment.
*The terms “patient” and “client” may be used interchangeably in this article to refer to recipients of psychological services.
LEGAL ISSUES
GOOD PRACTICE Winter 2014 3
should typically provide patients who need additional
treatment with contact information for several appropriate
alternate service providers. A letter to the patient is
generally an appropriate way to convey this information.
Many states have adopted the APA Ethics Code or similar
ethical standards or rules for professional conduct for
psychologists. Furthermore, some states have adopted
specic statutes or regulations prohibiting abandonment of
patients or have case law prohibiting abandonment. In other
words, psychologists are both ethically and legally required
to handle terminations in a way that does not constitute
abandonment of a patient.
For example, the New York Rules of the Board of Regents
§ 29.2 states: “Unprofessional conduct [for psychologists
and other listed health professionals] shall also include…
abandoning or neglecting a patient or client under and in
need of immediate professional care, without making
reasonable arrangements for the continuation of such care, or
abandoning a professional employment… without reasonable
notice and under circumstances which seriously impair the
delivery of professional care to patients or clients.”
According to Younggren & Gottlieb (2008), “Abandonment
represents the failure of the psychologist to take the clinically
indicated and ethically appropriate steps to terminate a
professional relationship” (p. 500). Although psychologists
may become concerned when they need to unilaterally
terminate therapy, legal and/or state board actions against
psychologists for abandonment appear to be rare (Younggren
& Gottlieb, 2008). Usually, the real question is how to handle
transitions in a way that best promotes the patient’s welfare –
whether the transition is complicated or not.
To avoid allegations of abandonment, Knapp et al. (2013)
offer the following advice: “The general risk management
rule is not to terminate against the wishes of patients if they
are in life-endangering crises. If therapists decide to terminate
treatment, they should give adequate notice and provide
referrals for other treatment opportunities if more treatment
is needed” (p. 204). In addition, careful documentation,
obtaining clinical and/or legal consultation as needed, and
advance planning are all helpful in reducing risk. If you are
concerned about a possible allegation of abandonment,
however, you should consult with your malpractice insurer’s
risk management service or a knowledgeable attorney.
Termination as a process
To handle termination as smoothly as possible, it helps to
think of it as a process and begin planning for termination at
the outset of treatment. Topics such as the expected course of
GOOD PRACTICE Spring/Summer 2014 3
REFERENCES AND RESOURCES
American Psychological Association. (2002). Ethical
principles of psychologists and code of conduct.
Available at
www.apa.org/ethics/code/index.aspx.
American Psychological Association Practice
Organization. Are You Prepared for the Unexpected?
Available at
www.apapracticecentral.org/business/
legal/professional/secure/will.aspx.
American Psychological Association Practice
Organization. Checklist for Closing Your Practice.
Available at
www.apapracticecentral.org/business/
management/tips/secure/closing.aspx.
American Psychological Association Practice
Organization. Dealing with threatening client
encounters, Good Practice, Winter 2012, available at
http://apapracticecentral.org/good-practice/index.aspx
American Psychological Association Practice
Organization. Duty to Protect. Good Practice, Fall
2013, available at
apapracticecentral.org/good-
practice/secure/duty-to-protect.pdf
Campbell, L., Vasquez, M., Behnke, S. & Kinsherff,
R.(2010). APA ethics code commentary and
case illustrations. Washington, DC: American
Psychological Association.
Knapp, S., Younggren, J.N., VandeCreek, L., Harris, E.,
& Martin, J.N. (2013). Assessing and managing risk in
psychological practice. Rockville, MD: The Trust.
Sonne, Janet L., (2012). PsycEssentials: A pocket
resource for mental health practitioners, Washington,
DC, US: American Psychological Association.
[Chapter on “Terminations” at pp. 245-249.]
The Trust. Sample Informed Consent Form. Available at
www.apait.org/apait/download.aspx?item=INF.doc;
Vasquez, M. J. T., Bingham, R.P. & Barnett, J. E. (2008).
Psychotherapy termination: Clinical and ethical
responsibilities. Journal of Clinical Psychology, 64(5),
653-665.
Younggren, J. N., & Gottlieb, M. C. (2008). Termination
and abandonment: History, risk, and risk
management. Professional Psychology: Research and
Practice, 39(5), 498-504.
4 APA PRACTICE ORGANIZATION
treatment and policies regarding termination can be included
as part of your informed consent. In fact, Ethics Standard 10.01
(Informed Consent to Therapy) requires that psychologists
inform patients about the anticipated course of therapy. In
addition, clear treatment goals should be established early.
Addressing these issues at the beginning of therapy
helps patients to work in a collaborative manner toward
achieving positive outcomes and to anticipate when
therapy will end. It will also help patients better
understand when termination is needed due to insufcient
progress or inability to meet treatment goals.
Termination by mutual agreement
Typically treatment is terminated by mutual agreement of
patient and therapist, which allows for effective pre-
termination counseling to take place. Pretermination
counseling should usually include the following: planning
for an end date; reviewing progress made and goals
achieved in treatment; discussing strategies for maintaining
treatment gains; and clarifying how to access follow-up
care if needed.
The specic issues that should be addressed and desirable
length of pretermination counseling will depend on a
number of factors, such as overall duration of therapy,
clinical considerations and treatment approach. For
example, a patient who has been in long-term
psychodynamic psychotherapy for chronic depression will
have a longer and more involved termination phase than a
patient who has been in short-term treatment to cope with
anxiety symptoms caused by transitioning to a stressful
new job.
Planned terminations
Planned terminations that are initiated by either the patient
or the therapist also generally allow for thorough pre-
termination counseling and a smooth ending of the
professional relationship. Planned transitions can occur for
many reasons, such as relocation of either party or the
psychologist taking a new job or retiring. Planned
transitions can also occur when the patient’s insurance
benets change or run out.
From the outset of treatment, psychologists should strive to
be aware of any nancial limitations that could interfere
with needed services and plan accordingly, with a focus on
patient welfare. For example, if you are an out-of-network
provider and the patient is under nancial strain but will
likely need long-term treatment, you should consider
referral to an in-network provider.
Planning for the unexpected
Ethics Code 3.12 (Interruption of Psychological Services)
addresses both expected and unexpected reasons for
termination as follows: “Unless otherwise covered by
contract, psychologists make reasonable efforts to plan for
facilitating services in the event that psychological services
are interrupted by factors such as the psychologist’s illness,
death, unavailability, relocation or retirement or by the
client’s/patient’s relocation or nancial limitations.”
Unless you are working for an organization with contracts
in place that address continuity of care, advance planning
is needed in case a psychologist is suddenly unable to
provide services due to unforeseen circumstances such as
an accident, serious illness or death. In addition to meeting
ethical requirements, planning for the unexpected can
facilitate your patients’ transition to a new mental health
professional, simplify access to records, and prevent your
family from being burdened by the complex task of guring
out how to handle your professional affairs if you are
suddenly unable to do so yourself. To put an effective plan
into place, see “Your Professional Will: Why and How to
Create” on page 12.
Other unilateral terminations
Termination is often more difcult when the decision to
stop treatment is made unilaterally by either the patient or
the therapist and is not triggered by a denitive event such
as relocation. For example, sometimes patients will simply
stop paying for therapy or no longer attend scheduled
appointments. Payment issues should be addressed
promptly and referrals to lower-fee or in-network service
providers offered if appropriate. Psychologists should keep
in mind that failure to pay for services may at times reect
a patient’s dissatisfaction with treatment or other
underlying clinical issues that need to be addressed.
If a patient stops attending sessions, it is usually
appropriate to reach out to the patient by phone or mail
to offer continued services or pre-termination counseling,
clarify the status of your professional relationship and/
or offer referrals to alternative service providers if needed.
Further action may be required if you are concerned
that your patient is in crisis or a danger to self or others.
(For additional information on this topic, see “Duty to
Termination is often more difcult when the
decision to stop treatment is made unilaterally
by either the patient or the therapist and is not
triggered by a denitive event such as relocation.
GOOD PRACTICE Spring/Summer 2014 5
Protect” in the Fall 2013 issue of Good Practice magazine
at
apapracticecentral.org/good-practice/secure/duty-to-
protect.pdf
.) If a patient or someone close to a patient
threatens or harasses a psychologist, treatment should
usually be discontinued immediately and appropriate
steps taken to prevent harm (see “Dealing with Threatening
Client Encounters” in the Winter 2012 issue of Good
Practice magazine at
apapracticecentral.org/good-practice/
secure/client-encounters.pdf
).
More complex reasons that psychologists may decide
to unilaterally discontinue treatment or refer patients to
alternative service providers include a lack of progress
and/or a need for services beyond the psychologist’s
professional skills and competence. If you think you may
need to terminate treatment unilaterally, it is often useful
to consult with colleagues about your concerns. Perhaps
the treatment can be modied in order to be more helpful
to your patient? In most cases, if you do decide to stop
treatment, it is important to discuss the situation with the
patient, give adequate notice, provide referrals as needed
and keep careful documentation.
If you are unable to continue to provide needed care due to
a lack of expertise or because treatment is not progressing,
you should give patients the names and contact information
for several mental health professionals or agencies that
can provide appropriate services. Knapp et al. (2013)
note that although giving patients three referrals is often
recommended, doing so is not legally or ethically required.
The goal is to provide some reasonable options for services
(p. 203). If a patient is angry, he or she may at least initially
object to any alternative service providers you suggest.
As mentioned earlier in this article, Knapp et al. (2013)
recommend not terminating against the wishes of patients if
they are in life-endangering crises. Terminating treatment of
a patient with a chronic low level of suicidality can also be
risky and should be handled with particular care. Ideally, the
patient will understand your rationale and agree to a referral,
for example to a more experienced therapist or to a more
structured environment that provides urgent care services. If
the patient is a potential risk to self or others, or if the patient
is angry and disagrees with your decision to end treatment,
you should consider consulting with a colleague. In addition,
you may want to consult with an attorney or your malpractice
insurer’s risk management service.
Although transitions can be difcult to manage when
therapy is not progressing well, it is important to keep in
mind that continuing treatment under these circumstances
may be inadvisable. Knapp et al. (2013) recommend that
psychologists stop treatment “if they are unable to provide
a reasonable level of quality of care” (p. 206). This advice is
consistent with Ethics Standard 10.10(a), as quoted earlier,
which requires psychologists to terminate treatment when
the patient no longer needs the service, is not likely to
benet or is being harmed by continued service. Of course,
the transition itself must still be handled in an ethical and
professional manner.
Vasquez, Bingham & Barnett (2008) offer a detailed discussion
and a list of practice recommendations for ensuring clinically
appropriate terminations consistent with professional
standards and patients’ best interests. Their practice
recommendations cover many of the key issues discussed in
this article. In addition, they provide sample letters for use in
the termination process.
Promoting patient welfare
Maintaining a focus on patient welfare is a good guiding
principle when handling difcult transitions and other
complex practice issues. Even in challenging circumstances,
such as a unilateral termination due to a lack of expertise, the
psychologist may be able to promote a positive outcome, for
example by facilitating a transition to a provider who can
better meet the patient’s needs.
If you have further questions about transitions and
terminations, please contact the American Psychological
Association Practice Directorate’s Legal and Regulatory
Affairs Department at [email protected] or 800-374-2723.
Please note: Legal issues are complex and highly fact
specic and require legal expertise that cannot be provided
by any single article. In addition, laws change over time
and vary by jurisdiction. The information in this article
should not be used as a substitute for obtaining personal
legal advice and consultation prior to making decisions
regarding individual circumstances.
