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January 2000 The decision to terminate therapy is one of the most difficult issues a psychiatrist confronts in the therapeutic relationship. All too often, psychiatrists have told me that they should have terminated with a patient at an earlier time. When the therapeutic relationship is terminated by mutual agreement that therapy is no longer necessary, there are usually no legal or ethical problems. However, if the psychiatrist unilaterally decides to end the relationship, it must be done carefully. There are many reasons to decide to terminate with a patient including: non-compliance, failure to pay for treatment, threats of harm to the therapist, unsuccessful treatment, and significant negative transference/countertransference. Due to the vulnerability of certain patients and naturally feelings of hurt and rejection, psychiatrists must be very careful in the manner they use to terminate. Once a decision to terminate has been made, the therapist must terminate in a way that will not result in a claim of abandonment and/or lawsuit. Since the patient will usually have continuing psychiatric needs, it is important to terminate appropriately. I always advise my clients that they discuss the termination with the patient and then send a termination letter to the patient. The letter should be sent certified mail, return receipt requested. If the patient refuses to accept or sign for that letter; send another letter via regular mail. Make sure the letter is sent to an address that is authorized by the patient. Place a copy of the letter in the patient’s chart. Whenever possible, tell the patient in advance that you must terminate and the reasons for termination. Usually, an explanation why the therapy is not working will suffice without going into great detail about specific patient issues. Also, if the patient would benefit from further treatment, explain the need for this and provide addresses, phone numbers and contact persons of at least three psychiatrists/facilities/community mental health centers. If possible, try to transfer the care of the patient to a colleague or competent psychiatrist before your final session. Also, set a fixed period of time (usually thirty days) that you will treat the patient and thereby allow the patient the same amount of time to obtain care from another mental health professional. If the patient is on medications, make sure to provide them with detailed instructions regarding each medication. Do not prescribe large amounts of medications around the time of termination to overcompensate if the patient cannot find a subsequent therapist. Be careful not to terminate with patients in acute crisis or in an emergency situation. However, some patients may develop a crisis to prevent termination. One psychiatrist recently told me that he terminated with all his patients due to retirement, but one patient was always in crisis and turned down 17 separate referrals. Her “crisis” continued for more than six months and the therapist felt trapped by the patient and could not fully retire. I would recommend full and complete documentation in the patient’s chart regarding the issues of termination, communications with the patient and steps taken to ensure the patient’s future psychiatric care. A model termination letter can be obtained by contacting our office. Termination with a patient does not have to put the therapist at risk. Documentation, communication and providing alternative sources for continuing treatment are the keys to preventing liability. |
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If you would like more information about the issues in the above article, or about Beranek, Feiereisel & Kasbohm & Hammer, please address your inquiries to Scott Hammer at shammer@bfkhlaw.com. You may
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