Management Of Planned And Unplanned Termination Essay Paper
It’s almost a paradox, but the goal of a successful counselling relationship is to, eventually, come to an end! Sometimes therapists and clients build a rewarding relationship and it may be difficult for both to formalise the end of that bond; but nevertheless, it is a vital step to effectively mark the success of the process and move forward
What IS client abandonment? This is probably one of the most misunderstood or misused terms in the nursing profession. “Abandonment” is defined by the Wyoming State Board of Nursing (“WSBN”) as “the termination of a client relationship, with or without the client’s knowledge, without making arrangements for appropriate continuation of care.”1 The decision to charge a licensee or certificate holder with abandonment will depend on all the circumstances of the particular situation. Because each situation is unique, the general framework for making that determination includes:Management Of Planned And Unplanned Termination Essay Paper
•Did the licensee or certificate holder accept the client assignment; thus, creating a client relationship?
•If so, did the licensee or certificate holder end the client relationship appropriately (i.e., was reasonable notice given that the relationship ended or care properly transferred)?
A “client relationship” begins when the licensee or certificate holder accepts responsibility for providing nursing care. Acceptance of care is usually accompanied by a written or oral report of the client’s needs. The client relationship ends when that responsibility has been transferred to another licensee or certificate holder; again, generally accompanied by communication (i.e., a written or oral report) of the client’s needs.
The following situation(s) would be considered abandonment:
•Accepting a client assignment and later leaving the unit or assigned work area to go home, take a break, etc., without giving the supervisor or other qualified person reasonable notice or reporting the clients’ needs to another qualified person2;
•Accepting a client assignment, completing the shift, but leaving the facility without reporting the clients’ needs to the oncoming shift;
•Sleeping while on duty.
“Reasonable notice” is relative. It also depends on the circumstances of the particular situation. For example, if the licensee or certificate holder was suddenly stricken with illness, which rendered him/her unable to complete the assignment, the amount of notice that would be considered “reasonable” to properly transfer responsibility for care of his/her assigned clients would be different than if the licensee or certificate holder wanted to leave an assignment or shift early to attend a family dinner. Once an assignment has been accepted, it is the responsibility of the licensee or certificate holder to complete the assignment or properly transfer responsibility for that care to another qualified person.Management Of Planned And Unplanned Termination Essay Paper
What IS NOT client abandonment? Both of the above components of the definition of “Abandonment” must be met before a licensee or certificate holder would be subjected to discipline by WSBN. Generally, client abandonment can only occur AFTER the licensee or certificate holder has come on duty AND accepted his/her assignment. In short, no acceptance of client care = no client relationship; no client relationship = no client abandonment.
The following situations are not client abandonment, but are examples of employer-employee issues, which the Board of Nursing has no jurisdiction over:
•Refusing to accept responsibility for a client assignment when the licensee or certificate holder has given reasonable notice to the proper agent that he or she lacks the competence to carry out the assignment (i.e., due to exhaustion from having worked previous shift(s) or the assignment is in an unfamiliar, specialized, “high tech” area where there has been no orientation, educational preparation or experience3). Simply clocking in does not constitute acceptance of an assignment4;
•Refusing the assignment of additional hours beyond the posted work schedule when proper notification has been given5;
•Refusing to come in and cover a shift;
•No Call/No Show to work an assigned shift6;
•Resigning without notice7;
•Giving notice that the employer – employee relationship is being terminated, but only working part of that notice (i.e., giving a 2-week notice, but only working 1 week);
•Not returning from a scheduled leave of absence8;
When a Home Health provider furnishes treatment to a client, the duty to continue providing care to the client is a duty owed by the agency, itself, and NOT by the licensee or certificate holder, who may be employed or contracted by the agency.9 The Home Health agency does not have a duty to provide the same nurse or aide throughout the course of treatment – only the duty to provide competent personnel, who can administer the course of treatment ordered.Management Of Planned And Unplanned Termination Essay Paper
An exception to this general rule may be found when a licensee or certificate holder fails to notify the Home Health provider that he/she is unable to report for a scheduled assignment. In this instance, the licensee or certificate holder could be subject to discipline by WSBN for abandonment because there is a reasonable expectation on the part of the Home Health provider that the licensee or certificate holder accepted care upon acceptance of the assignment, thus creating a client relationship. If the licensee or certificate holder fails to provide reasonable notice of inability to report to the scheduled assignment or to properly transfer care to another qualified individual, then the licensee or certificate holder may have ended the client relationship inappropriately. Each situation would be considered on a case-by-case basis. However, just as with facilitybased care, the licensee or certificate holder would not be considered to have abandoned the client if reasonable notice is given to the appropriate person that he or she is unable to
the purpose of this article was, in part, to differentiate client abandonment from employment abandonment. The term “Client Abandonment” has, on occasion, been reportedly used as a means of intimidation by employers in order to ensure adequate staffing. Providing the appropriate number and type of personnel to provide care is the responsibility of the employer. A threat from an employer to “take away” a nurse’s license or a CNA’s certificate is inappropriate. Only the Board of Nursing can take disciplinary action against an individual’s license or certificate and this decision is based on the facts of each case. Employers can and should; however, report any behavior or instances of suspected abandonment to the Board of Nursing. Each report will be considered on a case by- case basis.
From time to time, the Board of Ethics (hereinafter, the “Board”) determines that members and certificate holders can benefit from additional analysis and instruction concerning a specific issue of ethical conduct. Issues in Ethics statements are intended to heighten sensitivity and increase awareness. They are illustrative of the Code of Ethics (2016) (hereinafter, the “Code”) and are intended to promote thoughtful consideration of ethical issues. They may assist members and certificate holders in engaging in self-guided ethical decision making. These statements do not absolutely prohibit or require specified activity. The facts and circumstances surrounding a matter of concern will determine whether the activity is ethical.
For a variety of reasons, such as leaving a practice to pursue other career opportunities or relocating for family reasons, clinicians may decide to end their relationships with clients. There is nothing unethical about such departures. (Although, given the shortage of professionals in this field, it may be necessary to caution managers of care-giving facilities that it is unethical to try to exert moral pressure on clinicians to continue once they have indicated their plans to leave.) However, professionals must be mindful of the fact that such departures may result in former clients being left without appropriate care. It is therefore imperative that audiologists and speech-language pathologists in such transitional situations maintain their focus on the welfare of the client. They should be careful to uphold the Code so that clients are not harmed by the clinician’s departure.
When clinicians leave a caseload without coverage by an appropriately qualified professional, it is called client abandonment. A professional who abandons their clients without making effective efforts to provide for the clients’ continuing care violates Principle I of the Code, which states that the professional must “honor their responsibility to hold paramount the welfare of persons they serve professionally.”
Examples of misconduct may include the following:
Failing to give sufficient notice to employers when leaving a position may represent misconduct. Sufficient notice will vary depending on factors such as contract of employment terms, location of practice, workplace traditions, employment status, and duration. These factors influence the timing of notification from as short as 2 weeks to several months. This failure violates Principle I, Rule T: “Individuals shall provide reasonable notice and information about alternatives for obtaining care in the event that they can no longer provide professional services.”
Abandoning clients of one employer to see clients of another employer for personal gain or convenience is a detriment to those you serve. For example, a practitioner who is motivated to leave one job for another job that is perceived as more prestigious, better paying, or closer to home must provide sufficient notice prior to making that change. To do otherwise would violate Principle III, Rule B: “Individuals shall avoid engaging in conflicts of interest whereby personal, financial, or other considerations have the potential to influence or compromise professional judgment and objectivity.”Management Of Planned And Unplanned Termination Essay Paper
In all settings, the transition of care must be done properly and in a timely manner so as not to negatively impact those we serve. For example, misconduct in private practice may involve failing to inform clients in a timely manner of plans to terminate treatment. In other employment settings, misconduct may involve failing to develop clear plans with the employer concerning the notification of clients. This violates Principle I, Rule T: “Individuals shall provide reasonable notice and information about alternatives for obtaining care in the event that they can no longer provide professional services.”
When changes in employment occur, failing to provide an interim plan for each client or to provide alternative care options may violate Principle I, Rule B: “Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided.” It may also violate Principle I, Rule T: “Individuals shall provide reasonable notice and information about alternatives for obtaining care in the event that they can no longer provide professional services.”
Any attempt to provide continuing services by correspondence alone is not sufficient to meet the standard of care. For example, a practitioner relocates and is motivated to continue to provide services solely by mail and electronic mail. Such an attempt violates Principle I, Rule N: “Individuals who hold the Certificate of Clinical Competence shall not provide clinical services solely by correspondence, but may provide services via telepractice consistent with professional standards and state and federal regulations.”
When managing one’s caseload during changes in employment, such as closing a practice or moving to a new employment setting, practitioners are obligated to refer clients to other qualified professionals when appropriate. To not do so violates Principle I, Rule B: “Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided.”
When leaving an employment setting, failing to complete all remaining reports, billing, and other required documentation is a violation of Principle I, Rule Q: “Individuals shall maintain timely records and accurately record and bill for services provided and products dispensed and shall not misrepresent services provided, products dispensed, or research and scholarly activities conducted.” This issue highlights the mandatory obligation to complete all clinical/administrative responsibilities when leaving a position.
Upon transitioning from employment, withholding paperwork so that the clinician’s successor does not have access to the client’s entire record is manifestly harmful to clients. Such misconduct is a violation of Principle I, Rule Q: “Individuals shall maintain timely records and accurately record and bill for services provided and products dispensed and shall not misrepresent services provided, products dispensed, or research and scholarly activities conducted.” It is also a violation of Principle IV, Rule A: “Individuals shall work collaboratively, when appropriate, with members of one’s own profession and/or members of other professions to deliver the highest quality of care.”Management Of Planned And Unplanned Termination Essay Paper
Removing materials, records, protocols, and other administrative materials without the consent of the administrator of the facility or organization, even if intended by the clinician to ensure the care of a client, negatively impacts those we serve. This is a violation of Principle I, Rule O: “Individuals shall protect the confidentiality and security of records of professional services provided, research and scholarly activities conducted, and products dispensed. Access to these records shall be allowed only when doing so is necessary to protect the welfare of the person or of the community, is legally authorized, or is otherwise required by law.”
When changes in employment occur, maligning the facility that the professional is leaving and/or its employees while in the presence of clients represents misconduct. Specifically, it violates Principle IV, Rule A: “Individuals shall work collaboratively, when appropriate, with members of one’s own profession and/or members of other professions to deliver the highest quality of care.” This behavior is also a violation of Principle IV, Rule D: “Individuals shall not engage in any form of conduct that adversely reflects on the professions or on the individual’s fitness to serve persons professionally.”
When transitioning to a new job, the potential benefit of recruiting clients from the previous employment setting to the new setting could be considered misconduct. This behavior may violate Principle III, Rule B: “Individuals shall avoid engaging in conflicts of interest whereby personal, financial, or other considerations have the potential to influence or compromise professional judgment and objectivity.”
When there is employment transition or any other change in the relationship with our clients, audiologists and speech-language pathologists should hold paramount their obligations to those being served. Every effort should be made to ensure continuity of care and to accommodate the needs of clients. When good-faith efforts are not sufficient to guarantee that continuity, acceptable alternative plans should be pursued. Such plans might involve developing home programs that could be used during an interim period without professional services, referring clients to appropriately qualified professionals in the surrounding area, and providing clients and their families with troubleshooting techniques and maintenance activities.
A professional who is leaving a facility should, if requested, assist the organization with recruitment of a replacement and should offer to participate in the orientation of replacement personnel as necessary. Audiologists and speech-language pathologists who leave an organization or facility should attempt to sever ties with the employer amicably. Employers should cooperate in every way with departing clinicians in order to safeguard the well-being of clients. Such behavior is consistent with Principle IV: “Individuals shall uphold the dignity and autonomy of the professions, maintain collaborative and harmonious interprofessional and intraprofessional relationships, and accept the professions’ self-imposed standards.”
When the practitioner’s departure has been precipitated by difficulties in workplace relationships or perceived deficiencies in working conditions, there may be increased potential for conduct that violates the Code. Professionals in such situations should avoid engaging in behaviors that might be viewed as retaliatory or slanderous. Employers who are ASHA members are likewise expected to behave in ways that place the highest priority on the needs of the clients. Angry and spiteful words, obstructive actions, and uncooperative or aggressive behavior are potentially harmful to clients and adversely reflect on the professions. It is also a violation of the Code if such behaviors lead to filing a frivolous complaint, as stated in Principle IV, Rule O: “Individuals shall not file or encourage others to file complaints that disregard or ignore facts that would disprove the allegation; the Code of Ethics shall not be used for personal reprisal, as a means of addressing personal animosity, or as a vehicle for retaliation.”Management Of Planned And Unplanned Termination Essay Paper
If a practitioner believes that a facility is not meeting professional standards, they should report the facility to the appropriate oversight organization. If an employer believes that a clinician is unqualified or has behaved unethically, that problem should be reported to the appropriate oversight body. This reporting is required by Principle IV, Rule N: “Individuals shall report members of other professions who they know have violated standards of care to the appropriate professional licensing authority or board, other professional regulatory body, or professional association when such violation compromises the welfare of persons served and/or research participants.”
Some disruptions of clinician–client relationships are involuntary. If a clinician is dismissed for cause, the employee’s responsibility to clients terminates with the dismissal, and the facility assumes all responsibility for seeing that no clients suffer harm as a result of the departure. Clinical relationships may also be interrupted if an organization decides to close a program or when natural disasters occur. It is expected that even in these types of situations, practitioners would hold paramount the welfare of the clients they serve; however, no clinician is ever ethically required to work without pay or to place themselves in physical danger in order to offer client care.
Potential disruptions in clinician–client relationships may also occur as the result of a school strike. If a district makes the decision to close schools because of a strike, this temporary lack of services would not be construed as client/student abandonment by the audiologist or speech-language pathologist (SLP). If schools remain open during a strike, the audiologist or SLP should ensure that parents are notified that their children may not receive services as scheduled. (Whether FAPE [free appropriate public education] has been denied as the result of a missed session is to be decided on a case by case basis. The school district is responsible for addressing parent concerns. For additional guidance, refer to Missed Speech-Language Sessions in Schools and ASHA Guidance on School Walkouts or Strikes on the ASHA website.)
It should be clear from this discussion that whenever it is necessary to terminate a clinical relationship, for whatever reason, there is an unavoidable impact on those we serve. As the welfare of our clients is paramount, practitioners need to effectively eliminate the possibility of client abandonment.
Abandonment fear often stems from childhood loss. This loss could be related to a traumatic event, such as the loss of a parent through death or divorce. It can also come from not getting enough physical or emotional care. These early childhood experiences can lead to a fear of being abandoned by others later in life.Management Of Planned And Unplanned Termination Essay Paper
HOW ABANDONMENT WORKS
Healthy human development requires needs for physical and emotional care to be met. Unmet needs can result in feelings of abandonment. Experiencing abandonment can become a traumatic life event. The death of a parent can be a traumatic event for a child. Feeling unsafe due to a threatening situation like abuse or poverty can also cause trauma.
Some degree of abandonment fear can be normal. But when fear of abandonment is severe and frequent, it can cause trouble. It may impact how a person’s relationships develop. When this is the case, the support of a therapist or counselor may help.
A pattern of emotional abandonment or neglect can also be traumatic. It can qualify as a form of abandonment. Emotional abandonment can occur when parents:
Stifle their children’s emotional expression
Ridicule their children
Hold their children to standards that are too high
Rely too heavily on children for their own sense of worth
Treat their children as peers
People who felt abandoned as children may be more likely to repeat this pattern with their children. But some emotionally abandoned children recognize this pattern. They can go on to nurture their own children and break the cycle of abandonment. Many of these signs of abandonment may also play out between people in a relationship.
Stress or overwhelm can contribute to emotional abandonment. People with unmet needs often have a difficult time meeting the needs of others. Practicing self-care is an important part of making sure one’s own needs are met. The person who practices self-care can then meet the needs of their child or partner in a healthy way.
ABANDONMENT ANXIETY IN RELATIONSHIPS
Adults who did not experience abandonment as children may still have feelings associated with abandonment. These can come from losing an intimate partner to separation, divorce, or death. Abandonment may occur in childhood or adulthood. Either way, the impact can be pervasive. It may negatively affect any other relationships a person develops, whether they are intimate, social, or professional.Management Of Planned And Unplanned Termination Essay Paper
Fear of abandonment can impact an otherwise healthy relationship. People may worry their partner is having an affair. This anxiety can come from experience with previous affairs. It may also come from previous loss or anxiety issues. Adults who are afraid of being abandoned may work to keep their partner from leaving. They may pour hard work and effort into the relationship. Then, they might worry their partner does not appreciate or reciprocate their efforts.
Signs abandonment may be affecting a relationship include:
One partner “gives too much” or is a “people pleaser”
Envy of other people’s relationships
Feelings of insecurity in the relationship
Lack of emotional intimacy
A need for one partner to control the other
Settling in a less-than-satisfactory relationship
People who were abandoned as children may also seek partners that treat them in a similar way. This can lead to a cycle of abandonment. A cycle like that may be difficult to get out of.
FEAR OF ABANDONMENT IN CHILDREN
Children may worry about their parents abandoning them. This can be natural, as children form attachments to their parents from birth. Young children may get anxious about their parents leaving for a short trip. They may get anxious when a parent drops them off at daycare or school. It is possible for children not to be impacted long-term by these worries. This can mean making sure they have a secure caregiver attachment. This will help them learn social skills and have healthy relationships later in life.
Signs a child may have abandonment issues include:
Clinging or separation anxiety
Worrying or panic
Fear of being alone
Getting sick more often due to stress
If your child shows these signs, there are things you can do to help. It is possible to address fear of abandonment early. This can help children form a secure attachment. One way to help children with this fear is to reassure them of your love and role in their life. Parents may also find it helpful to let children know what the “plan” is on any given day. Knowing what to expect may help children feel reassured of their parents’ presence. They may start to feel more secure even when their parent or caregiver is not present.Management Of Planned And Unplanned Termination Essay Paper
Some children experience what is called “abandoned child syndrome.” This may take place after the loss of a parent or caregiver. It can also develop due to physical or emotional abandonment by a parent. Symptoms may show as isolation, low self-worth, and unhealthy coping mechanisms like eating issues or addiction. If not addressed early, symptoms may become severe and make it difficult to form relationships or lead a healthy life.
LONG-TERM EFFECTS OF ABANDONMENT ISSUES
A person who has experienced abandonment may be more likely to have long-term mental health issues. These are often based on the fear that abandonment will recur. A child who was abandoned by a parent or caregiver may have mood swings or anger later in life. These behaviors can alienate potential intimate partners and friends. A child’s self-esteem can also be affected by lack of parental support.
Abandonment fears can impair a person’s ability to trust others. They may make it harder for a person to feel worthy or be intimate. These fears could make a person prone to anxiety, depression, codependence, or other issues. Abandonment issues are also linked to borderline personality (BPD) and attachment anxiety. Someone who lacks self-esteem due to childhood abandonment may seek relationships that reinforce their beliefs.
One important area of practice where this fiduciary responsibility very clearly exists is that of termination and abandonment. As emphasized above, clients entrust their well being to their psychotherapist, trusting that the psychotherapist will act with due consideration of the client’s ongoing needs and best interests.
Ethical Requirements for Psychotherapists
In keeping with these responsibilities to our clients, the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (APA Ethics Code, APA, 2010) provides clear guidance on our responsibilities to our clients regarding termination and abandonment. The enforceable Ethical Standards relevant to termination and abandonment are:Management Of Planned And Unplanned Termination Essay Paper
Standard 10.10, Terminating Therapy, requires that the psychotherapy relationship be ended when the client is not benefiting from treatment, is not likely to benefit from it, or is likely to be harmed from it. Circumstances relevant to this standard include if the psychotherapist no longer possesses the necessary competence to meet the client’s treatment needs and if a potentially inappropriate or exploitative multiple relationship with the client develops or is discovered that holds the potential to adversely impact the psychotherapist’s objectivity and judgment (Vasquez, Bingham, & Barnett, 2008); yet for each of these circumstances an appropriate termination process that addresses the client’s ongoing treatment needs through pretermination counseling and making any needed referrals must occur. This standard also allows psychotherapists to terminate the psychotherapy relationship abruptly (without a termination process) if the psychotherapist is “threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship” (APA, 2010, p. 14).
09, Interruption of Therapy, addresses the need for psychotherapists to make advance arrangements when entering into “employment or contractual relationships” (p. 14) to ensure that client treatment needs are appropriately addressed in the event that the employment or contractual arrangement ends while clients’ treatment is ongoing.
12, Interruption of Psychological Services, highlights the need to anticipate possible circumstances that may interfere with the psychotherapist’s ability to provide ongoing care to clients such as through unavailability, retirement, illness, disability, and even death, and make advance arrangements to ensure that client treatment needs will be addressed and that clients will not be or feel abandoned.
Relevant to Standard 3.12, Interruption of Psychological Services, above, Standards 2.06, Personal Problems and Conflicts, emphasizes the need for each psychotherapist to monitor her or his own wellness, to practice ongoing self-care to minimize the effects of stress and distress in our professional and personal lives, and to seek consultation and assistance from colleagues to ensure that these stressors do not lead to decreased competence and clinical effectiveness.
Standard 10.01, Informed Consent to Therapy, emphasizes the need to share with clients from the outset all relevant information that may impact their decision to enter into and participate in the psychotherapy relationship. It is essential that issues relevant to termination, anticipated and unanticipated absences, and procedures for ensuring that clients’ ongoing treatment needs are met even between treatment sessions, each are addressed in the informed consent process (Davis & Younggren, 2009).
Ending the Psychotherapy Relationship
Termination is defined as the “ethically and clinically appropriate process by which a professional relationship is ended” (Younggren & Gottlieb, 2008, p. 500). This clearly implies that how the termination process is carried out has significant clinical and ethical implications.
In contrast, abandonment occurs when the treatment relationship ends, but this necessary process does not occur, such as by ending a client’s treatment abruptly when the client no longer can afford to pay for treatment. Abandonment can also occur during the course of treatment when the client’s ongoing treatment needs are not met in an ethically and clinically appropriate manner, such as by not being accessible for client crises and emergencies in between sessions and by not making appropriate coverage arrangements during periods of psychotherapist absence or unavailability.Management Of Planned And Unplanned Termination Essay Paper
Ideally, when ending a client’s treatment, a well thought out termination process that has been planned for will occur, with the goal of consolidating the benefits and lessons learned to assist the client to maintain the successes achieved in treatment (Vasquez, Bingham, & Barnett, 2008).
As stated by Joyce, Piper, Ogrodniczuk, and Klein (2007), through termination, the client should be able to “(a) reflect on and acknowledge the effects of the treatment, (b) appreciate the importance of the therapeutic relationship, and (c) look ahead to applying the lessons of therapy” (p. 26). Termination may develop naturally when the client has successfully accomplished all treatment goals and is relieved from previous distress (Joyce et al., 2007).
An appropriately implemented termination process allows clients to “review their goals, describe the changes they have incorporated, and work through feelings in ending the psychotherapy process” (Vasquez, Bingham, Barnett, 2008, p. 654). Abandonment, instead, is when this process does not occur, which can be stressful for both the client and psychotherapist. The clients may feel sadness, loss, confusion, and anxiety, or blame themselves for the termination of psychotherapy (Penn, 1990). The psychotherapist may feel “personal failure” and ending the psychotherapy relationship in this manner may damage the client’s therapeutic growth (Penn, 1990).
Psychotherapy may be terminated for a range of different reasons. It may be initiated by mutual agreement, by the psychotherapist, or by the client.
Termination by Mutual Agreement
Sometimes, due to the nature of the treatment, termination occurs when the treatment process is complete (Joyce et al., 2007). This may occur when the agreed upon treatment goals have been achieved or when treatment is time limited and the agreed upon number of treatment sessions have been provided.
Psychotherapist Initiated Termination
In keeping with Standard 10.10, Terminating Therapy (APA, 2010), the psychotherapist may initiate termination because she or he no longer possesses the necessary competence to be able to assist the client (either due to the client’s changing treatment needs or due to problems of professional competence relevant to stress, distress, burnout, illness, etc.) and/or because the psychotherapist believes that continued treatment would likely be harmful to the client (even if the client wants to continue treatment).
A range of issues may also result in the psychotherapist initiating treatment termination such as a planned retirement from practice or leave of absence, or if the psychotherapist will be at the treatment site for a limited period of time such as a trainee on internship. Additionally, as is highlighted in Standard 10.10, Terminating Therapy (APA, 2010) if the psychotherapist is threatened or otherwise endangered (e.g., stalked, assaulted) she or he may (and most likely should) terminate the psychotherapy relationship.
Client Initiated Termination
The client may lose her or his ability to continue paying for treatment such as due to loss of one’s employment, loss of one’s health insurance, or other changes in the client’s financial situation.
The client may move from the area such as due to a job transfer, retirement, or seeking employment opportunities elsewhere.
The client may not be pleased with the progress being made in treatment, may be displeased with the psychotherapist’s approach, may believe they have made all the progress that can be achieved in working with the psychotherapist, may want to try things on her or his own outside of treatment, or may drop out of treatment without providing any explanation or advance discussion.Management Of Planned And Unplanned Termination Essay Paper
Meeting Our Clinical, Ethical, and Legal Obligations
Psychotherapists may misunderstand our obligations to clients and fear charges of abandonment if we initiate termination, such as for the reasons highlighted above, if the client does not agree with the psychotherapist’s decision (Younggren, Fisher, Foote, & Hjelt, 2011). Yet, it is widely recognized that psychotherapists do not have a duty to treat clients indefinitely and we do not need our clients’ permission to end treatment. Rather, we have an ethical and legal obligation to act consistently with our client’s best interests and ongoing treatment needs.
Landmark legal rulings such as Capps v. Valk (1962) and Collins v. Meeker (1967), and reaffirmed in Sparks v. Hicks (1996), set a legal precedent on termination and abandonment. These rulings make clear that health care professionals are under no obligation to continue a client’s treatment if the clinician’s professional judgment indicates that ongoing treatment is not in the client’s best interests or when ethically obligated to do so, regardless of the client’s opinion on this.
What the clinician must do, however, is to take necessary actions to help ensure that any ongoing treatment needs the client has are adequately met. Thus, this standard of care requires that clients not be abandoned but that any ongoing treatment needs be openly discussed as a part of the treatment process and that relevant referrals are made and adequate time is given so that the client may obtain needed treatment. As is stated in the ruling of Capps v. Valk (1962): “If a [health professional] abandons a case without giving his patient such notice and opportunity to procure the services of another [health professional], his conduct may subject him to the consequences and liability resulting from abandonment of the case….” (p. 290.)Management Of Planned And Unplanned Termination Essay Paper
Recommendations for Ethical Practice
Include discussions of treatment termination and possible interruptions of treatment, to include emergency contact procedures and treatment coverage arrangements in ongoing informed consent discussions. Be sure that ongoing treatment needs can appropriately be met either personally or by those to whom you delegate this responsibility and inform clients of these arrangements in advance.
Include processes and procedures in employment and practice contracts that ensure that client treatment needs will be met should you leave the practice setting or be otherwise unable to provide needed treatment.
Maintain documentation in the client’s treatment record of agreed upon treatment goals and the client’s progress toward achieving them. This will help both psychotherapist and client determine if goals were successfully met. This is also especially important for supporting the psychotherapist’s termination decisions when dealing with clients who do not want to terminate but who have completed all treatment goals and with clients who are not complying with treatment recommendations and who are not making progress in treatment.
Consult with colleagues to obtain a second (or third!) opinion on when termination should occur. Then consult to ensure that the termination process is being implemented appropriately and effectively (Davis & Younggren, 2009).
If treatment needs to be ended when ongoing client needs exist, discuss this openly with the client, offer referral recommendations, and provide some reasonable period of time for the client to make contact with and arrange for treatment with another psychotherapist. Document all these discussions and actions.
If a client drops out of treatment do not tacitly condone this decision to discontinue treatment if in your professional opinion ongoing treatment is indicated (Barnett, MacGlashan, & Clarke, 2000). Make a reasonable good faith effort to contact the client and go on record with your recommendations for any ongoing needed treatment and the reasons why. Sample letters that may be modified by psychotherapists to fit individual situations and then be sent to clients to fulfill this obligation may be found in Barnett, MacGlashan, and Clarke (2000) and in Barnett, Zimmerman, and Walfish (2014).
Remember that ideally, termination should be planned for, discussed openly in treatment, and be an essential aspect of the treatment process that assists the client toward effective independent functioning. It is also important to emphasize that termination is not absolute; it should be made clear that clients may contact you if difficulties are experienced in the future and they would like assistance in addressing them at that time.Management Of Planned And Unplanned Termination Essay Paper
Ending a client relationship can be just as difficult as ending a personal relationship. In fact, while much of the literature addresses when to terminate, a more significant topic is the feelings that surround termination. Depending on the client and the length of treatment, saying goodbye can be hard for both of you. As a result, you should prepare for termination and the feelings surrounding this step of the GIM process early in the client-social worker relationship.
Social workers’ therapeutic relationships with their clients eventually come to an end. However, the way they end and how the social worker handles terminations can have ethical and legal implications.
This article will address some of the more common issues that may arise during termination and ways to enhance client care while avoiding allegations of abandonment.
Social workers should assess a client’s ongoing treatment needs prior to initiating termination. The NASW Social Work Dictionary defines termination as: “The conclusion of the social worker –client intervention process; a systematic procedure for disengaging the working relationship. It occurs when goals are reached, when the specified time for working has ended, or when the client is no longer interested in continuing. Termination often includes evaluating the progress toward goal achievement, working through resistance, denial, and flight into illness. The termination phase also includes discussions about how to anticipate and resolve future problems and how to find additional resources to call on as future needs indicate.”Management Of Planned And Unplanned Termination Essay Paper
There are many reasons why therapy ends. A client may terminate at any time for any reason. Ideally, termination occurs once the client and therapist agree that the treatment goals have been met or sufficient progress has been made and/or the client improves and no longer needs clinical services. However, there are many valid reasons that are discussed below as to why the therapist-client relationship may end the treatment before it is completed. Some of those reasons include:
Client has mental health needs that are beyond the social worker’s area of expertise. For example, the client requires a different level of treatment (e.g., inpatient or crisis intervention) or more specialized treatment (e.g., trauma or substance abuse) than the social worker provides in the practice setting.
Therapist is unable or unwilling, for appropriate reasons, to continue to provide care (e.g., therapist is retiring/closing practice or client threatened therapist with violence).
Conflict of interest is identified after treatment begins.
Client fails to make adequate progress toward treatment goals or fails to comply with treatment recommendations.
Client fails to participate in therapy (e.g., non-compliance, no shows, or cancellations).
Lack of communication/contact from the client.
It is recommended that therapists have a final session with their clients to review the overall progress before ending therapy, but sometimes this cannot happen, e.g., when the client stops communicating with the therapist. It is suggested that therapists create a policy for their practice so that cases are routinely closed after a certain amount of time without any contact from a client, for example: “If I do not have contact or communication from you for a period of xxxx days, I will assume that you no longer intend to remain active in this therapeutic relationship and your case will be closed. You can return to therapy in the future if you decide to continue treatment.”
One way to establish that timeframe is to think about how long you want to be the therapist of record without seeing a client.
Non-payment of agreed upon fees:
Before a social worker terminates for non-payment, the following criteria should be met:Management Of Planned And Unplanned Termination Essay Paper
The financial contractual arrangements have been made clear to the client, preferably in writing.
The client does not pose an imminent danger to self or others.
The clinical and other consequences of the non-payment (i.e., disruption of treatment/interruption of services) have been discussed with the client. NASW Code of Ethics, 1.16c
Certain circumstances may support a delay of the termination. For instance, it is not recommended that a therapist end treatment with a client who is in crisis at the time termination is being considered. A social worker has a responsibility to see that clinical services are made available when a client is in crisis. Postponing termination is preferred, if possible, until steps are in place to handle the crisis.
Abandonment is a specific form of malpractice that can occur in the context of a mental health professional’s termination of services. Abandonment, also referred to as ‘premature termination,’ occurs when a social worker is unavailable or precipitously discontinues service to a client who is in need.
In a malpractice case based on abandonment, the client alleges that the therapist was providing treatment and then unilaterally terminated treatment improperly. The client must show that he was directly harmed by the abandonment and that the harm resulted in a compensable injury. The client’s dissatisfaction with the outcome is not sufficient to establish the therapist’s negligence. The client must also show that the termination was not his fault, e.g., that he kept his appointments, complied with treatment recommendations, and paid his bills.
It is critical to be able to establish both the reason for termination and the manner in which it is carried out. After beginning a therapeutic relationship with a client, a social worker must not terminate therapy abruptly without referring the client to another mental health practitioner. If the social worker does not properly terminate the client-therapist relationship, the social worker exposes himself to allegations of abandonment which could lead to a lawsuit, a complaint to the state licensing board, or a request for professional review by the NASW Ethics Committee. Proper termination that has been documented is a defense to abandonment allegations, and it supports good client care.Management Of Planned And Unplanned Termination Essay Paper
The NASW Code of Ethics addresses the issue of termination of services in 1.16:
1.16 Termination of Services
(a) Social workers should terminate services to clients and professional relationships with them when such services and relationships are no longer required or no longer serve the clients’ needs or interests.
(b) Social workers should take reasonable steps to avoid abandoning clients who are still in need of services. Social workers should withdraw services precipitously only under unusual circumstances, giving careful consideration to all factors in the situation and taking care to minimize possible adverse effects. Social workers should assist in making appropriate arrangements for continuation of services when necessary.
(c) Social workers in fee-for-service settings may terminate services to clients who are not paying an overdue balance if the financial contractual arrangements have been made clear to the client, if the client does not pose an imminent danger to self or others, and if the clinical and other consequences of the current nonpayment have been addressed and discussed with the client.
(d) Social workers should not terminate services to pursue a social, financial, or sexual relationship with a client.
(e) Social workers who anticipate the termination or interruption of services to clients should notify clients promptly and seek the transfer, referral, or continuation of services in relation to the clients’ needs and preferences.
(f) Social workers who are leaving an employment setting should inform clients of appropriate options for the continuation of services and of the benefits and risks of the options.
For more information, see NASW Code of Ethics.Management Of Planned And Unplanned Termination Essay Paper
Tips for Termination
Prepare for termination from the beginning. Termination should be discussed early so both parties can have a number of sessions to discuss ending therapy.
If continued treatment is needed, provide referrals to several mental health professionals, with addresses and phone numbers. Three referrals is the “rule of thumb” minimum. If possible and with the client’s consent, assist in the transition to other health care providers.
Conduct the final session face -to-face, if possible. Avoid ending with a text, in an email or with a voicemail message.
Make sure the client understands when, why and how therapy will be terminated.
Document discussions about termination.
Formalize the termination with a personalized termination letter (not a form letter).
What to include in a termination letter?
It is good practice for a social worker to draft a termination of treatment letter to every client once treatment has ended, regardless of the reason, to formally end the therapeutic relationship. This provides clarity to the client, and it helps avoid any implication that the social worker has an ongoing therapeutic responsibility. The termination letter would be in the form of a business letter and include:Management Of Planned And Unplanned Termination Essay Paper
Date treatment began
Effective date of termination
State the reason(s) for the termination. (e.g., treatment goals have been met, client’s needs are beyond the scope of social’s workers practice or area of expertise, non-compliance with treatment recommendations, therapist is retiring/closing practice)
Summary of treatment, including whether you feel further treatment is recommended
If continued treatment is needed, provide three referrals to mental health professionals, with contact information
Present the letter in person during a session or send it with delivery tracking and confirmation of service and/or certified return receipt
Retain a copy of the letter and delivery documentation in the client’s file
Mark the letter “confidential”
Don’t mention confidential therapeutic treatment information
Addressing the termination of treatment is an important phase of the therapeutic process. For termination to be handled properly, discussions between the social worker and client should occur in advance and be addressed in a thoughtful and sensitive manner. It is best that clients not feel that they have been abandoned, for the sake of the client as well as the social worker. If continued treatment is needed, the social worker must make an effort to assist the client in obtaining ongoing services to ensure that these needs are adequately addressed. Proper documentation of the termination of the therapeutic relationship with the client will provide support for the social workers’ effort to meet the clients’ needs as treatment ends.
Termination is the term typically used when referring to the ending of the psychotherapy relationship. It may occur as an anticipated and well-articulated treatment plan that indicates the next phase of the psychotherapy process or it may occur precipitously or by surprise.Management Of Planned And Unplanned Termination Essay Paper
Abandonment is a term that implies that the psychotherapist either ended the psychotherapy process in an inappropriate manner that does not adequately address the client’s ongoing treatment needs or the psychotherapist did not make necessary arrangements for the client’s treatment during the course of treatment (Younggren & Gottlieb, 2008).
How termination should be seen is both a clinical and ethics issue. These two issues are intertwined and each should be seen as essential for meeting our obligations to our clients. While there is much more to the topic and psychotherapists will hopefully immerse themselves on the literature on termination, this brief article suggests six essential strategies that lay a solid foundation for meeting these obligations to our clients.
1. Address Termination Issues from the Outset. Include in the Informed Consent Discussions and Agreement
The process of informed consent is intended to share all relevant information with clients so that they can make decisions about participation in the treatment services being offered (Barnett, 2015).
Knowing from the outset how treatment will end can be a vital piece of information for clients in making their decisions about participation in the proposed course of treatment (Davis & Younggren, 2009).Management Of Planned And Unplanned Termination Essay Paper
For example, if the length of treatment is open-ended and will be determined by progress made toward treatment goals, this is a very different circumstance than the case where treatment is limited to a specific number of sessions (at times based on limitations on the client’s insurance coverage or in the instance of brief or time-limited psychotherapy).
When psychotherapy is being provided by a trainee this is a crucial issue as trainees typically have an end date to their time at each setting. Clients have the right to know from the outset if their psychotherapist will be there for them for the next five months or for the next five weeks.
Any factors that may have a significant impact on the course of a client’s proposed treatment should be openly discussed as part of informed consent. This enables them to make informed decisions about participation and helps to prepare them for what is to come, helping them to participate more fully in the process, and thus, hopefully to benefit more fully from the experience.
2. Reach Agreement on the Goals of Treatment and the Criteria for Successful Completion of Treatment
The ending of each client’s psychotherapy will hopefully occur when all treatment goals have been achieved. But, in order to know when treatment should end, there must first be an agreement on the goals of treatment. While treatment goals may be modified over the course of treatment as clients make progress and life circumstances change, failure to have an open discussion of goals from the outset and failure to reach agreement on what these goals are impacts the nature, focus, and scope of the treatment offered as well as when and how this treatment will end (Davis, 2008).Management Of Planned And Unplanned Termination Essay Paper
3. Consider and Prepare for Possible Psychotherapist-Initiated Interruptions to Treatment. Have a Professional Will
Psychotherapy can end for a variety of reasons. As is highlighted above, the most desired reason for ending treatment is that the client has achieved the agreed upon goals of treatment. But, psychotherapy may end for a variety of reasons, both client and psychotherapist initiated.
To meet our ethical obligations to clients, psychotherapists may need to end a client’s treatment if the client is not benefitting from treatment, if an inappropriate multiple relationship develops or is discovered, or if the psychotherapist no longer possesses the competence necessary to meet the client’s treatment needs (APA, 2010).
Psychotherapists may also terminate treatment “when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship” (APA, 2010, Standard 10.10).
Psychotherapists may also need to abruptly end or interrupt a client’s ongoing treatment due to psychotherapist factors such as illness, disability, retirement, and even death. In keeping with our focus on each client’s best interests, psychotherapists should plan for these eventualities and make needed advance arrangements to help ensure that clients are not abandoned during the course of treatment.
While some possible interruptions to treatment may be anticipated and planned for (e.g., vacation, taking time off after giving birth or adopting a child, and retirement), others such as illness and death tend not to be anticipated and can be doubly challenging for clients when they occur: the unplanned interruption in their treatment and the impact of the loss of their psychotherapist.Management Of Planned And Unplanned Termination Essay Paper
It is recommended that each psychotherapist make advance arrangements with one or more colleagues to step in and offer assistance to clients when any of these events occur.
Psychotherapists should each have a professional will in which a colleague is identified who has access to client contact information and records, and who will contact clients in the case of psychotherapist death or other incapacitation, assessing ongoing treatment needs and assisting with crisis intervention and referrals to other clinicians (Pope & Vasquez, 2005).
4. Be Mindful of Client and Other-Initiated Interruptions to Treatment
Clients may initiate termination for a variety of reasons. These may include limitations in finances, feeling dissatisfied with the psychotherapist or with how treatment is proceeding, losing one’s job, loss of or changes in their insurance coverage, or moving from the local area. While each of these cannot be anticipated from the outset of treatment, open discussions with clients about their progress in treatment and any issues that may impact their ability to continue should be explored at least periodically.
To fulfill our obligations to clients, even when they initiate termination, we should ensure a reasonable good faith effort to help address any ongoing treatment needs. While we are not required to meet client treatment needs indefinitely, and doing so in some of these situations is not practical, offering assistance in connecting with alternative treatment resources is important to do whenever possible.
When clients discontinue treatment, for any reason, before the agreed upon goals of treatment have been achieved, it is recommended that the client be contacted (either verbally or in writing) to make recommendations for addressing any ongoing treatment needs, offering options and alternatives, and offering assistance in procuring them. Sample letters that may be sent to clients to address these issues may be found in Barnett, MacGlashan, and Clarke (2000) and in Vasquez, Bingham, and Barnett (2009).
5. Be Clear on What Abandonment Is and Is Not (e.g., the Client’s Role in Treatment Discontinuation, the Psychotherapist’s Role)
Abandonment occurs when the psychotherapist does not meet a client’s ongoing treatment needs appropriately. Abandonment may occur when treatment endings are mismanaged as well as when clients’ ongoing treatment needs are not adequately addressed. The latter may include failure to make needed coverage arrangements during periods of anticipated absence such as vacations, attending a conference, or other times when client access to the psychotherapist may be limited.Management Of Planned And Unplanned Termination Essay Paper
Charges of abandonment may even arise from not being sufficiently accessible between regularly scheduled treatment sessions. It is vital that reasonable expectations be established from the outset, with clients being provided with information on how to access the psychotherapist between sessions, when it is or is not appropriate to contact the psychotherapist, and the preferred means of contact. Realistic expectations should be established for the psychotherapist’s responsiveness and when others should be contacted, such as calling 911 in emergency situations.
It is not abandonment when a client drops out of treatment precipitously or when the client does not fulfill treatment obligations. Nor is it abandonment if the client cooperates with treatment recommendations and the treatment is ended appropriately, after discussion, with notice, and with referrals being made; and in fact, these actions may not be necessary in situations where the psychotherapist is threatened or assaulted.
As Younggren, Fisher, Foote, and Hjelt (2011) emphasize, clients have obligations as articulated in the informed consent agreement and/or treatment contract. When continued treatment is not possible or not indicated based on client actions and responses, ending the treatment is not seen as abandonment. Of course, documenting all such situations, discussions, consultations with colleagues, actions taken, and efforts to contact clients, should occur on an ongoing basis.
6. Have Ongoing Discussions with Clients About Progress in Treatment Toward Termination
Plan and prepare for termination. If possible, treatment endings should not come as a surprise. Work collaboratively with clients toward successful treatment endings. Termination should be considered a process and not an event. It should be seen as a phase of each client’s treatment that is worked toward together on an ongoing basis.Management Of Planned And Unplanned Termination Essay Paper
It is recommended that termination be conceptualized as a consolidation phase of treatment that helps prepare the client to build on the gains made in treatment and to move forward positively after treatment ends (Barnett & Coffman, 2015). This important phase of treatment may be conceptualized from a range of perspectives and it may stimulate a number of important themes and issues that are important to work through and address before treatment ends (Hardy & Woodhouse, 2008).
How the psychotherapy relationship and process end has important implications for our clients. It is hoped psychotherapists will consider the guidance provided in this brief article when considering your approach to this essential aspect of psychotherapy. Addressing endings from the beginning, and on an ongoing basis throughout treatment, can help ensure that treatment is provided and ended in an ethical and clinically competent manner.
Efforts to reduce misunderstandings and to be responsive to client needs can help prevent claims of abandonment. We can each institute practices that will help us to fulfill our obligations to clients. Further, keeping up with the literature on termination practices is recommended as part of our ongoing professional development and lifelong learning as psychotherapists.
While you generally anticipate that successful treatment will lead to the eventual termination of the client relationship, there are a variety of other reasons for why this relationship might come to an end. There might be a set number of sessions the client’s insurance will allow, or maybe the end of your internship is quickly approaching. Maybe termination results from the unexpected, like a new job, an illness, or the client leaves without notice. Regardless of the cause, you and your client must be prepared for the end of your working relationship. Not discussing termination can result in uncomfortable feelings, including anger and disappointment for the client. As the social worker, you might feel disappointed about not being able to see the treatment through to completion. Even when termination is a planned event, clients might respond with anger, increased silence, missed sessions, or early termination. If they feel positive about this next step, they might express feelings of satisfaction and pride, with an appropriate amount of sadness about losing this relationship. While you are involved in a purely working relationship, you may be surprised at how many emotions or what types of emotions might surface for both of you when terminating the relationship.Management Of Planned And Unplanned Termination Essay Paper
For this Discussion, review this week’s Learning Resources. Consider potentially positive and negative feelings that you, as a social worker, and the client might feel regarding the termination of a therapeutic relationship. Then, think about how you might assist the client with the potential negative feelings. Finally, reflect on how you might help yourself with your own potentially negative feelings.
By Day 4
Post a brief description of two potential positive and two potential negative feelings that both you, as the social worker, and the client might feel, regarding the termination of a therapeutic relationship. Then, explain a skill you might use to assist a client with the potential negative feelings. Finally, explain how you might help yourself with your own potentially negative feelings.
Let’s overview the formal ending of the client-worker relationship. This formal ending usually falls into two categories: planned or unplanned.
1. Unplanned terminations
Either client or worker may initiate unplanned terminations. Client-initiated terminations may occur as a result of:
the client dropping out of treatment,
an adverse event that has rendered the client unavailable for service, or
the client behaving in a manner that is incompatible with service requirements and is thus withdrawn from the program.
Client-initiated terminations can leave both worker and client with residual feelings of rejection, relief, anger and/or shame due to lack of opportunity for discussion and defusing.
Unplanned worker-initiated terminations can occur as a result of:
an adverse event that has rendered the worker unavailable for service,
the worker being dismissed, or
the worker being laid-off or transferred.
Similar emotional reactions to those that may occur from client-initiated unplanned endings can also occur in response to worker-initiated endings, particularly if the ending is immediate. Some worker-initiated endings, however, whilst unplanned, can accommodate a final session for discussion and handover and this, of course, is best practice.Management Of Planned And Unplanned Termination Essay Paper
2. Planned terminations
Planned terminations can occur with two outcomes:
the unsuccessful achievement of service goals and
the successful achievement of service goals.
Planned Terminations with Unsuccessful Outcomes
Planned terminations with unsuccessful outcomes may occur when:
the worker or client is dissatisfied with the helping relationship,
the client is not progressing, despite continual attempts,
the worker is not competent in addressing the specific needs of the client or
the client does not comply with the requirements of intervention.
Hepworth, Rooney, Rooney, Strom-Gottfried & Larsen (2006) suggest that in situations such as these, the worker should discuss with their client (1) what factors prevented a more favourable result from being achieved and (2) the client’s feelings about seeking help in the future.
Such discussion needs to occur in an environment where the client feels safe and does not feel judged. Additionally, the worker needs to ensure that they do not respond in defence of themselves or the service. This will only serve to distance the client and may initiate a missed opportunity for genuine feedback.
Planned Terminations with Successful Outcomes
The aim of case management and other collaborative practice endeavours is to achieve the goals established with the client in the planning and contracting stage. The achievement of such goals, may not signal that the client won’t need the support of the worker in the future, but it does demonstrate that at this time the client can function sufficiently on his or her own.Management Of Planned And Unplanned Termination Essay Paper
It may therefore be beneficial in situations of planned terminations (with successful outcomes) that client and worker together discuss contingencies should future assistance be required. Additionally, successful outcomes may mark the client’s readiness for further growth and development, thus a referral to an appropriate service that would foster such development may be appropriate. Management Of Planned And Unplanned Termination Essay Paper