CLINICAL VIGNETTE – Terminating therapy when the client wants to continue but does not require additional treatment

Assignment – Vignette 1 – Ethics & Laws in Psychotherapy: Which clinical, ethical and/or legal issues are presented in the vignette? What provisions are made in the laws, board of psychology rules, and APA ethics code for responding to issues raised in the vignette? What do the authors of the assigned texts have to say? What is your personal position? How does your response to the vignette reflect your own cultural group values? How are your views informed by the assigned reading for the unit. If your values conflict with laws, psychology board rules, APA Ethical Principles or client request/values, state the conflicts and how you might resolve them?

Ethics Vignette

In this ethics vignette, the American Psychological Association’s (APA) Ethical Standards 10.10, Terminating Therapy, 10.01, Informed Consent to Therapy, 3.05, Multiple Relationships, and 3.06, Conflict of Interest, are discussed in relation to resolving ethical and moral dilemmas arising from circumstances in which a client has benefited from therapy and it is determined that treatment should be terminated, but the client wishes to continue, as well as the client’s offer to assist in establishing a financial relationship with the company for which she works.

I chose this case because I have personally experienced similar situations while working as a coach for about five years and then as a therapist for the last fifteen years. During the process of transitioning from coaching to therapy, I realized that I needed to revise my professional ethical code of conduct. One reason for this was that the training for becoming a coach placed little emphasis on ethical and moral concerns; instead, one had to rely on one’s own common sense to resolve the various ethical and moral quandaries that were presented. This put me in a variety of situations, some of which I was able to handle while maintaining my integrity, and others that I believe I would have handled better if I had received adequate training in foreseeing and dealing with the various and sometimes unexpected complexities of therapeutic relationships. In terms of professional boundaries, for example, I could sometimes overextend myself because I wanted to help the client too much, not always finishing a session on time, or simply feeling too responsible for the client’s progress, especially given that they were paying me to assist them. For structural purposes, this vignette is divided into five sections: a case illustration, an ethical dilemma, decision-making factors, decision options, and a concluding discussion about the experience of writing this vignette.

Case Illustration

The following is the case illustration for the clinical vignette chosen for this assignment: You have been seeing a female client for one year. This has been her first therapy experience. Initially, she was withdrawn socially and very unsure of herself. Through therapy, she has sought out and is succeeding in a good career, and has made some new friends. For the past six weeks you notice that this client seems to be doing very well in her life and does not raise many issues to work on during the therapy hour. Instead, she reports the week’s events and then engages in social conversation. She always seems excited to see you and claims at the end of the sessions that she thinks you are great. In fact, she’s referred five good clients to you during the past year, and says she believes she can get you involved in her company’s Employee Assistance Program contract. You believe this client is no longer benefiting from her psychotherapy. When you raise the possibility that perhaps she should be terminating, she tells you that her time with you is very important in her life, and she’s upset that you want to “get rid” of her. Money is no problem, so why can’t she keep coming?

Ethical Dilemmas

The issue, in this case, is that the client wishes to continue seeing the clinician, but the clinician believes she does not require additional treatment. Before delving deeper into the recommendations made in the APA Ethical Principles and Code of Conduct for Psychologists (Ethics Code) regarding such situations, let us briefly discuss the human aspect of this situation. From my personal experience working with clients, it can occasionally be challenging to recognize the various facets of the delicate dynamics of a therapeutic relationship, such as when issues with transference and countertransference arise and the clinician is required to seek supervision. Without a clear structure outlining what the client can expect from the treatment process, the risk of misunderstanding and blurred boundaries increases.

Three ethical dilemmas are particularly apparent in the dynamics depicted in this vignette. While the first dilemma may be considered the central one, the other two are considered sub-dilemmas to the primary one. The central ethical dilemma concerns that the clinician feels compelled to discontinue therapy with the client because he believes she has benefited sufficiently from it, but the client wishes to continue. The second ethical issue concerns the client’s motivations for continuing therapy with the clinician. For instance, the client may wish to continue therapy due to a sense of safety or affection toward the therapist, or both. Finally, the third ethical dilemma considers possible justifications for the clinician to continue therapy, such as the client being an easy client to work with or the clinician wishing to continue therapy for economic reasons.

Decision-Making Factors

In response to the first ethical dilemma, concerning terminating therapy, Ethical Standard 10.10 of the Ethics Code requires psychologists to “terminate therapy when it becomes reasonably clear that the client/patient no longer requires the service” (APA, 2017, p. 15). Additionally, prior to terminating therapy, the psychologist is to “provide pretermination counseling and suggest alternative service providers as appropriate” (APA, 2017, p. 15). Aside from pretermination counseling, it is critical that the client understands what to expect throughout the therapeutic process, from beginning to end, as well as afterwards. Thus, Ethical Standard 10.01, regarding therapeutic relationships, states that when obtaining informed consent to therapy, psychologists must “inform clients/patients about the nature and anticipated course of therapy as early as possible in the therapeutic relationship” (APA, 2017, p. 14), and to “provide sufficient opportunity for the client/patient to ask questions and receive answers” (APA, 2017, p. 14). Establishing a clear structure for the therapeutic process is critical for assisting the client in knowing what to expect and when to expect it. This not only helps the client prepare for the end of the therapeutic relationship, but it also prevents the client from feeling abandoned by the therapist, as stated in the 1992 Code of Ethics (APA, 1992).

In response to the second ethical dilemma, the client’s reason for wanting to continue therapy, according to Principle A of the Ethics Code, concerning Beneficence and Nonmaleficence, psychologists should do their very best to do no harm and to protect the well-being and rights of their clients, as well as, in the event of a conflict, “they attempt to resolve these conflicts in a responsible manner that avoids or minimizes harm” (APA, 2017, p. 3). Additionally, Principle B, regarding Fidelity and Responsibility, emphasizes the importance of a psychologist developing trusting relationships with clients, which can be accomplished by adhering to Principle C, relating to Integrity, by promoting “accuracy, honesty, and truthfulness” (APA, 2017, p. 3) in their activities or communications with the client. Thus, in the spirit of being responsible for the therapeutic relationship, preserving trust between therapist and client, as well as upholding one’s integrity, for example, the therapist needs to gain a clear understanding of the client’s reasons for not wanting to end therapy prior to terminating therapy, something we will discuss a little further ahead.

Lastly, in regard to the third ethical dilemma, possible justifications for the clinician to continue therapy, Ethical Standard 3.05 describe that a psychologist should refrain “from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists” (APA, 2017, p. 6). A multiple relationship exists when a psychologist has another role with the client in addition to their professional relationship, or when he has a relationship with someone close to the client (Corey et al., 2019). There is clearly a risk of conflict of interest in such circumstances, as described in Ethical Standard 3.06, which states that a psychologist should not take on any other professional role that would impair their “objectivity, competence, or effectiveness in performing their functions as psychologists” (APA, 2017, p. 6) and expose the client to harm or exploitation. Additionally, in terms of exploitative relationships, Ethical Standard 3.08 states that “psychologists do not exploit persons over whom they have supervisory, evaluative or other authority such as clients/patients” (APA, 2017, p. 6). Now, in light of the previously described Ethical Standards, which provide the ethical framework within which the clinician can operate, let us discuss a few different decision options available to the clinician.

Decision Options

Concerning the first ethical dilemma, it goes without saying that the clinician must adhere to Standard 10.10(a), as it is unethical to charge clients for treatment that counsellors believe is ineffective or no longer necessary. Nonetheless, if that would be the case, even if the treatment’s initial goals have been met, it is possible to adjust them and establish new ones after reviewing progress and prior goals (Campbell et al., 2010). However, as Campbell et al. (2010) state so plainly, “endless therapy for a client who no longer needs the service is inappropriate” (p. 368), and if the clinician is unable to terminate therapy, “consultation with colleagues, as well as a discussion with the client/patient, may be helpful” (p. 368).

In this case, the client appears to be doing well and is more interested in socializing with the clinician than in therapy, indicating that the client’s initial treatment goals have been met. A relevant issue to consider here is whether or not a mutual agreement for termination was established at the start of therapy, during which the topic of termination was discussed in greater detail. In such cases, it is naturally easier for both the clinician and the client to conclude the therapy and therapeutic relationship satisfactorily. When the therapist decides that therapy should be stopped, he can do so in a clinically sound manner that does not jeopardize the client’s progress or well-being, all while adhering to the definition of termination, which is the “ethically and clinically appropriate process by which a professional relationship is ended” (Younggren & Gottlieb, 2008, p. 500). An inappropriate termination of therapy, on the other hand, risks instilling in the client a sense of abandonment (Barnett & Coffman, 2015; Behnke, 2009), which may have a negative impact on the client’s social ability, which was the initial motivation for seeking therapy.

To ensure a successful termination of therapy, especially concerning not creating a sense of abandonment in the client, the steps taken while providing pre-termination counselling, as explained in Ethical Standard 10.10(c), are critical. Thus, prior to termination, some of the things the clinician may do is to work with the client to agree on a termination date, review therapy progress and what the client has learned, develop an aftercare plan for dealing with future difficulties outside of therapy, determine when referrals may be appropriate in the event the client has ongoing needs, and finally, discuss, grieve, and honor the end of the therapeutic relationship (Campbell et al., 2010; Howes, 2008).

In this case, and more specifically in relation to the second ethical dilemma, which concerns the client’s motivations for continuing therapy, a critical component of successfully terminating therapy would be discussing the client’s reasons for continuing therapy, as well as assisting the client in becoming even more self-sufficient, or recognizing that she already is, without the therapist. One approach to increase the client’s confidence and self-esteem could be for her to practice some of the anticipated difficulties associated with therapy termination. For example, it appears critical for the client to practice developing qualitative relationships with individuals other than the therapist and then discuss the dynamics and difficulty of doing so in therapy, which almost certainly has already occurred. Additionally, it can be beneficial to discuss how the clinician would actually be doing the client a disservice if they continued therapy, as this could create a cycle of dependency and deprive the client of opportunities to grow. Finally, it may be beneficial to allow for some additional time between the final few sessions. This could provide an excellent opportunity for the client to encounter some of the possible post-therapy reactions and then discuss and process them with the clinician.

In relation to addressing the nature and significance of the client’s feelings toward the clinician, the client may gain a better understanding of the various components that contribute to the development of a qualitative relationship, which she can then apply in her personal relationships or when forming new ones. For example, it may be beneficial to discuss and differentiate the similarities and differences between traditional and therapeutic relationships, as well as some of the insights, strategies, and behavior patterns she has acquired as a result of her therapy relationship. Additionally, some of the skills the therapist used to engage the client socially may serve as a model, or guiding mechanism, for the client to learn from, such as establishing rapport, active listening, and being in a mindfulness state.

Lastly, with regard to the third ethical dilemma, possible justifications for the clinician to obtain a contract with the company for which the client works, it is critical to avoid entering into a relationship that could reasonably create a conflict of interest and impair the clinician’s objectivity. If the client assists the clinician in becoming a contractor for her company’s Employee Assistance Program, they have clearly established a new relationship in which she has aided him financially, and thus the clinician is in a different role to the client than her therapist when they discuss those matters. The key question is if this reasonably will impair the clinician’s objectivity and influence the therapeutic relationship? Campbell et al. (2010) explain that a word such as reasonably is used to “offer flexibility so that the Ethics Code simultaneously sets forth clear expectations for behavior and allows psychologists the ability to exercise professional judgment in their own area of expertise” (p. 8).

Therefore, let us examine in greater detail the reasonableness of all of this not affecting the clinician’s objectivity. Both Campbell et al. (2010) and Corey et al. (2019) describe how when psychologists engage in multiple relationships, their self-interests can cloud their judgment in a variety of ways; as a result, they are required to put their own needs aside to meet the professional needs of their patients. Due to the fact that business relationships have significantly different dynamics than therapeutic relationships, for example, in terms of responsibilities, needs, and expectations, having multiple relationships significantly increases the risk of misunderstanding and harm. Multiple relationships not only distort the professional nature of the therapeutic relationship; they may also have an effect on the client’s ”cognitive processes that play a role in the beneficial effects of therapy and that help the patient maintain the benefits of therapy after termination” (Campbell et al., 2010, p. 87), and when a new relationship on an equal footing is entered, the client “often remain vulnerable to exploitation even after termination of therapy” (Campbell et al., 2010, p. 87). Additionally, many clients will require additional therapy, which a multiple relationship is almost certain to impact. To summarize, effective boundaries are critical for minimizing the likelihood that a psychologist will be placed in a position to exploit their clients for personal gain. As a result, it is recommended that you decline the invitation and maintain reasonable boundaries throughout the process, which naturally makes objectivity easier to maintain.

Concluding Discussion

In this vignette, I’ve presented various ethical arguments to consider when deciding whether or not to continue therapy, as illustrated by the chosen case illustration. In essence, I believe that if there are no compelling reasons to redefine or add new goals, therapy should be terminated. Furthermore, while I believe it is best not to allow any business associations with a client, I also believe that nuances may exist in some instances when a client contacts me following the end of therapy. The severity of the client’s problem, the length of time I worked with the client, the time since termination, and whether the client is directly involved or merely referring me to another are all factors that would influence my decision.

I recognize the critical importance of adhering to ethical principles, laws, and rules in order to safeguard both the client and myself as a therapist. To avoid overextending oneself and remaining sustainable in a challenging profession, laws and guidelines help define boundaries and avoid situations that can become unnecessarily complicated. Whichever side of an ethical dilemma is chosen, I believe it is critical to maintaining a therapeutic alliance with the client, in order to act in the client’s best interests, while also being as candid as possible about one’s reasoning when communicating a decision. It is our responsibility to articulate our professional position clearly, even if the client does not always agree. Then, as professionals, we must consider our obligation to act in the client’s best interests, both short and long term.

As a conclusion to myself and to this vignette, I have developed the following “three-stage rocket” to use in the event that I become ethically conflicted following a client session. The first step would be to engage in some reflective introspection in order to ascertain the source of my internal conflict. Hopefully, this will help me better understand the dynamics of the conflict and why I am feeling the way I am. A component of this process would be determining and resolving any issues of transference or countertransference. If this step is insufficient, the next step would be to gather additional relevant information about ethical directives, laws, and regulations, which could be accomplished by speaking with colleagues or conducting an Internet search. Thirdly, I would arrange for supervision to assist in resolving any remaining issues from the previous two stages. These three stages, I hope, will assist me in developing a nuanced and professional approach to the various ethical dilemmas that my future as a psychologist will present me with.

References

American Psychological Association. (1992). Ethical principles of psychologists and code of conduct (effective date December 1, 1992). https://www.apa.org/ethics/code/code-1992

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). http://www.apa.org/ethics/code/index.html

Barnett, J. E., & Coffman, C. (2015, June). Termination and abandonment: A proactive approach to ethical practice. The Society for the Advancement of Psychotherapy. www.societyforpsychotherapy.org/termination-and-abandonment-a-proactive-approach-to-ethical-practice

Behnke, S. (2009, September). Termination and abandonment: A key ethical distinction. Monitor on Psychology, 40(8). http://www.apa.org/monitor/2009/09/ethics

Campbell, L., Vasquez, M., Behnke, S., & Kinscherff, R. (2010). APA ethics code commentary and case illustrations. Washington: American Psychological Association.

Corey, G., Corey, M. S., & Corey, C. (2019). Issues & ethics in the helping professions (10th ed.). Boston, MA: Cengage Learning.

Howes, R. (2008, October 13). Terminating therapy, part IV: How to terminate. How to end therapy. Psychology Today. https://www.psychologytoday.com/us/blog/in-therapy/200810/terminating-therapy-part-iv-how-terminate

Younggren, & Gottlieb, M. C. (2008). Termination and Abandonment: History, Risk, and Risk Management. Professional Psychology, Research and Practice, 39(5), 498–504. https://doi.org/10.1037/0735-7028.39.5.498