Termination and Unhappy Clients Happen
Last week Lori Nash in Bellingham,
Washington was reading the post titled What Does a Psychotherapist’s Termination Letter Include?
In her comments that followed, she shared concerns about the possibility of retribution from a client.
It’s not an uncommon problem for a therapist to terminate services with a client and have him / her unhappy with that decision.
However, that’s not something most of us had addressed in graduate school, is it?
I wanted to take this conversation into a blog post so that the maximum number of psychotherapists can join in because when it happened to me I was clueless about how to handle it.
Twelve years later, here’s what I can tell you that I’ve learned . . . .
“Good” Reasons for Termination
It can happen for a lot of seemingly good reasons, right?
Your partner / spouse gets a new job and it means relocating to a new state.
(That was my situation.)
Your client has outgrown you and needs a referral to a different professional.
You’re practice is growing and you need to move into a larger office space across town.
You’re making better choices for the health of your business and increasing your fees . . . but that means some of your clients will choose to get their mental health needs met elsewhere.
You’re practicing better boundaries and limiting the number of times you are willing to be stood up by a client.
But, just because you believe you have a good reason to terminate your work with your client and you feel that your decision is justifiable, that doesn’t mean that your clients are going to necessarily understand and appreciate what is ultimately your choice to make.
In fact, your clients (1) may feel gratitude and want to celebrate the decision to terminate with you, (2) may have old triggers tripped and slip into a deeper depression, (3) may need to grieve the losses involved in this transition, (4) may be scared about what comes next, and (5) may feel betrayed and angry that you are leaving them.
These are just a few of the many ways I’ve had clients react to termination over the last 30 years.
Minimizing Retribution
When you believe it is clinically appropriate to terminate therapy or have circumstances arise that result in you needing to terminate therapy – especially when your client is fragile, has difficulty maintaining appropriate boundaries, and / or you have concerns about the response that your termination may trigger – here are the things I have learned can help to reduce the likelihood of client retribution.
- Seek consultation – before, during, and after termination.
The more opinions you gather from therapists more experienced than you, the better able you will be to make a decision that is good for all.
- Document the advice your receive and the thoughts you have including your final position on termination.
- Give verbal notice as much in advance as is possible.
It’s the kind and courteous thing to do. It’s also the responsible thing to do.
- Give written notice after you give verbal notice.
Both your clients and you benefit when you have provided this information in multiple formats.
In doing so, you are giving clients an opportunity to take in the information at their own pace and the ability to review the information as needed.
- Have an attorney review your written notice before you send it to your client – especially if you believe client retribution or stalking is a possibility.
This allows you not only to inform another professional about your concern but also reduces your own risk by providing the necessary information in the right way.
- Review progress made during therapy with the client.
This is basic clinical care.
- Identify and discuss the remaining challenges that the client may encounter so that s/he is aware of your own concerns and that you are aware of his / hers.
- Create a discharge and aftercare plan that your client can pursue after working with you.
Make sure you are addressing any needs for further counseling.
- Offer referrals to other professionals and community resources that can support client as well as any books / literature to support client’s goals.
- Discuss maintenance of and access to your clinical records after termination.
Each state / licensing board stipulates how long you need to keep these records.
- Establish a termination date with your client.
- Send a termination letter. Here’s what I recommend you include in that letter.
When in doubt about your own safety and for your own peace of mind, call your liability insurance company and your local mental health attorney to get additional advice.
While your job is to be of service to others, it should never be at your own expense.
I’m always interested in hearing other therapists’ stories about clients who struggle with termination.
Wondering if you have a story of retribution or something else to add to this discussion . . . .
Well tagged….”Risk Management”. When it comes to drawing the line… there is no humanistic way of doing it unfortunately. Totally agree with the steps above…
Hey, Vinay! Thanks so much for dropping in here! I love hearing from my Aussie community there!
Your choice of words makes me curious . . . . “Humanistic?” I think of Humanistic Psychology as focusing on personal choice and responsibility. Is that what you meant? The reason I ask is that, although I hadn’t thought about this situation in that way . . . terminating (with or against a client’s will) actually does set up a teaching moment in personal choice and responsibility! I’m thinking about the choice to learn from the event or not and the personal responsibility to react in a healthy, appropriate manner – both for the therapist and for the client.
It is “unfortunate,” of course, that we can’t all be happy with life’s circumstances. But, when those diffucult events arise, it’s important as therapists that we act as humanely as possible and still take care of ourselves (as well as our clients) in the process. Perhaps, reframing with finesse unwelcome terminations in humanistic psychology terms of personal choice and responsibility is one way to help create meaning out of less-than-desirable circumstances?
Tamara,
I agree that termination is certainly not my favorite part of the therapeutic process. I also know that sometimes counselors terminate for reasons that are not directly related to client care (such as moving to another state). I also know that a lot of times we terminate with client because of circumstances that are totally beyond our control and in which we had no choice (for example, for those of us who are LPCs, if a client gets Medicare coverage, we can no longer work with them unless they have another funding source that does not require that Medicare is billed first). Just as with the rest of counseling,, I believe that what we say is only part of the story. How we say things makes a big difference. This is also true for termination and I think empowerment is key throughout the entire therapeutic process, including during termination.
Hi, Lauren! Welcome back! I love what you are saying about threading empowerment throughout the work. That’s really a great way to conceptualize how we can work. The only thing I will take exception with is therapists having “no choice” about whether or not to continue working with a client. I think that’s a cop out that many of us have bought into at one time or another. The truth is that unless there is a law dictating otherwise, we always have choices – We just don’t always like the choices that are presented to us.
We have choices about whether or not to work with managed care (assuming we are in private practice); we have choices about what we charge and what we collect for our services; we have choices about every client we decide to work with; we have choices about how to deal with our clients when their own financial circumstances change; we have choices on just about every aspect of our business.
I’m not picking on you, Lauren. However, I’ve met more therapists than not who like to paint themselves as victims of managed care (and you already know that I’m not a fan) or victims of the Affordable Care Act or victims of . . . whatever when all too often, we have made choices with foreseeable consequences. Just because we don’t like the consequences doesn’t mean that we / they don’t have choices.
As counselors, we are quick to urge our clients to take personal responsibility for their lives; I’m ready to create a new groundswell of mental health professionals who are willing to do the same – accept personal responsibility for the choices we make – including those that impact our income and personal welfare. It just seems like the right thing to do, doesn’t it?
You are right that for a therapist who is in private practice, we do have choices. I also heard you say that you weren’t picking on me, and I recognize that.
I’m not in practice right now, so for those of us who are working with managed care, when insurance coverage changes, unless we want to carry a caseload that is half pro bono, we do have limitations. You are right, however, that private practice affords other options. I do pro bono work as well. Most of my clients, however, are concerned about where their next meal is coming from and how they are going to pay their utility bills, so asking for them to pay anything for services that are not covered by their insurance is just not possible.
I agree that most of the time there are other choices. In my particular situation, when someone gets Medicare, since they have no money to pay for services without using their insurance, a transfer of services is pretty much inevitable.
We also have the choice to advocate for Medicare coverage for counselors! There is a bill in the works about that now. I believe the number is HR 3662, but I’m not certain. It was just covered in Counseling Today this month.
Oh, Lauren! Thanks so much for sharing this info on the Medicare bill that is working its way through the legislature.You’re absolutely right to point out that as advocates we should each be involved in the creation and support of laws that affect our clients and our professional practices.
So have you ever had a client that wasn’t happy that you had to terminate with them and transfer services to another provider?
Yes, I have had a few clients who are not happy about having to transfer services. Usually most who do not transfer services because of reasons that are of their own choosing are not happy about it. At that point, I always make sure they are aware of the possibility to pay cash for services (making sure to document that I am not stating that they have to do this) and I also have agencies to which I can transfer them if they have Medicare.
Most of the people who get Medicare where I am working either become old enough to receive it or receive it as part of SSDI. With both, there are typically 3-4 months of lead time between when the clients are told that they will be receiving Medicare and when it actually takes effect. W
e can use this time for the termination process and emphasizing that what they have learned while in counseling with me are all things that travel with them when they go to another therapist and I also offer to speak to the therapist to whom they transfer.
Typically, all the reasons for termination revolve around the client’s choice to go elsewhere or completion of therapeutic goals or some other mutual reason for changing therapists.
I really emphasize empowerment. While they do have choices, if the situation surrounds changing insurance, there are not often feasible choices that also included continuing to receive counseling with me. I do also tell those clients that I am advocating for Medicare coverage for counselors.
So, Lauren, have you ever worried for your own safety when terminating with a client?
Hi Tamara,
I appreciated this and will look at the resources you recommend. I noticed that where you say “Here’s what I recommend you include in the letter.” there is no link and I’m wondering if there should be. I’d love to see a sample letter or a list of points to be included.
Shulamit
Oops! Thanks, Shulamit, for letting me know. I dropped the link somewhere along the way. It’s back in there now.
How are you? I was just thinking about you the other day – wondering what you are doing and if you are still in the same area.
And, here’s the reason Lori Nash and everyone else in the field needs to be thinking about this . . . . I just received an email from a therapist who was too afraid to identify herself here. He wrote back channel to say “I was threatened after termination with a client (it was a number of years ago – s/he threatened to come to my home and said s/he knew that I was moving and where to, and provided evidence of that knowledge).
More recently, I have just terminated, on the advice of my supervisor, with a different client who I am, as a result, afraid will make some kind of trouble, although I don’t fear for my physical safety.”
That’s two clients that one therapist is concerned about. Anonymous went on to say “To protect myself I’m documenting as usual and consulting with my supervisor much more than usual. I am also arranging additional, formal support sessions for myself (paid sessions with professionals and exchanging with peers) because this new event has its own stress and in addition is bringing up fears related to the old one.”
And, that, of course, comes with additional costs – of time and money. It comes with the territory and wise therapists will consider (what sometimes seems like oh-so-remote-) possibilities and prepare accordingly.
Thanks, Anonymous, for sharing these incidents with us! And, I’m wondering if there are others who have / had concerns about client retribution? Care to share?
I am curious to know how long others typically wait before discharging clients. Also, after how many no shows do you discharge?
Hi, Daphne! This is a good question and one every practitioner needs to consider and have a policy for. If I’ve never seen a client, I will typically close out the file immediately. If a client I’ve seen stands me up twice in a row, I typically close out the file and terminate. Even if I reinstate a client after termination for no shows, formally terminating creates a natural opportunity to discuss our professional relationship, expectations, etc.
“Have an attorney review your written notice before you send it to your client – especially if you believe client retribution or stalking is a possibility. This allows you not only to inform another professional about your concern but also reduces your own risk by providing the necessary information in the right way.”
My question here is, should we remove identifying information from the letter to allow for attorney review, or may we share the client’s identity and circumstances with an attorney for the purposes of review, or if we would rather have the attorney send the letter?
Amy, I’m not an attorney so don’t want to be giving you legal advice. In the past, I have asked this question of the attorney before submitting letters for review. The answer that I have gotten consistently is “either way is fine.” However, since the bulk of that letter is likely to be in a template form, I see no reason why you would need to provide identifying information.
Thank you. I just have concerns that sharing even the fact that someone is or was a client with an attorney for the purposes of reviewing or sending a letter is a breach of confidentiality, and if the attorney were to send the letter for me, that I would be opening myself up to a lawsuit or misconduct charges.
Attorney-client privilege is meant to protect attorney-client communications, but it doesn’t negate therapist-client confidentiality. Those are entirely separate issues.
I assume that all the usual rules apply here and that the exceptions remain the same. I am not sure we should be having our own attorneys review anything with identifying information that relates to a client unless that client has provided written consent or has brought a lawsuit.
Amy, it’s always best to ask an attorney rather than assume. I appreciate your conscientiousness and ethical stance. However, there are exceptions, to client confidentiality. I believe one of those may be (again, please verify this with an attorney for yourself) when any type of complaint or litigation is filed against you as a clinician. At that point, it has been my understanding that you are able to freely share ALL info with your attorney. But, again, in the case of a termination letter, you will most likely be using and amending a basic form letter so I see no reason why any identifying information should be shared.
Thank you for this post.
My partner just accepted a job transfer to another state.
I have a private practice and I’m dreading the unnatural terminations that are about to take place.
I am hoping that 6 weeks notice will be enough for my clients.
I could do 8 weeks, but that will leave my spouse and myself living 550 miles apart for 7 weeks.
And our toddler away from her Dad for long stretches between visits.
I am feeling really torn tonight as I prepare to start this process, and I appreciate what you have shared here.
alf,
Thanks for writing here. Transitioning clients can be difficult, especially when it occurs at unnatural times, as you phrased it.
I just went through a transition where I was transferring about 65 clients to different clinicians as I moved from one agency to another (because ethically, none of them could go with me). It was a long process and I did it over about six weeks. Had I been able to do it the way I wanted to, I had composed a letter for all of my clients to mention that the transition would be occurring and encouraging them to keep their appointments so that we could discuss the whole transition. My agency rules were that I could not send the letters to all of them, so I ended up doing it in person with all but about four people, who got letters.
While I will say that it was stressful, they were also aware of the fact that I was moving to an agency closer to home (they knew it was in a different county, but not where).
How can we support you here with this transition?
Best wishes for both your professional and personal transition.
Thank you, Lauren, for always being so supportive in this community!
I wasn’t aware you had changed jobs – I hope that’s a good move for you?!
It sounds as if you did the best you could in transitioning your clients within the parameters of the agencies rules.
I know the agency and your clients will surely miss you!
Hi,Alf! Welcome to Private Practice from the Inside Out!
Unexpected terminations happen for lots of reasons – sometimes yours and sometimes your clients.
In a society as mobile as ours, your situation is certainly one that is not uncommon.
Rather than worrying that 6 weeks might not be enough, put a 6 week discharge / transition plan together for each of your clients and give yourself permission to do the best you can.
The wonderful thing about work as a mental health professional is that we do not have to do it perfectly in order for our clients to get better or benefit from our services; we only have to do it “good enough.”
While you do have a responsibility to each of your clients to do your work “good enough,” you also have a responsibility to yourself, to your toddler, and to your partner to also be “good enough” in those roles, too.
Some of your clients may struggle with the need to terminate earlier than expected; however, you will likely find that others actually find new sources and levels of strength within themselves and are ready to try to “fly” on their own; some will probably take you up on transitioning to another therapist; others may do just fine with a community support group.
You can do this, Alf, and you can do this well enough.
Let your clients know that this timing was not in your control; remind them of their growth and strengths that you see in them; and assure them that you will leave them in good hands, with strong support and ample resources.
And, then trust that you can in good conscience let them go.
If you have particular concerns about an individual client, seek consultation to put both yours and your client’s concerns to rest.
And, once you have stepped away from your practice, take some time to reflect on how you have handled this period of transition and what you might choose to do differently next time around when another “unnatural termination” shows up in your life.
If you stay in this field for very long, illnesses, deaths, relocations, divorces, marriages, and other life events will certainly impact your work.
Giving thought to those possibilities ahead of time will help you be better prepared to deal with them on the next leg of your journey.
In the mean time, blessings to you on your way!
I hope you’ll drop back in often to chat – and to let us know how this transition works for you and your clients!
Yes, Tamara, it was a good move for me. I have been working for two different agencies for years, one of which was more than 30 minutes from home and the other was just 10 minutes. At the beginning of this month, I completed the transition to another agency, so between Thanksgiving and the beginning of this month, I was actually working for three different agencies simultaneously while I was building up a caseload. It’s nice to have so much less travel time and because of that I can also work later, so I can accommodate more clients who want to come in during the evening hours.
Even though the transition was very stressful, I was able to actively transition almost everyone (I think there were only three or four who just received a letter because they were otherwise unreachable).
I’m also lucky that one of my long-time friends and coworkers is still working at that agency and we did a fair amount of our training together and have a relatively similar clinical approach (certainly not identical, but also not opposite ends of the clinical spectrum). I was able to transfer half a dozen clients to her who I thought would really benefit from as much as much similarity as possible (mostly people who had either been transitioned to me from other clinicians years ago and were struggling with being transitioned again or people who were on the lower end of the autism spectrum).
One thing that really helped one of my clients (and also me, I must say) is that with someone who I knew would struggle with the transition and I had been seeing for a long time, I actually did a live transition where there was a session with a brief meeting with the new clinician (five minutes), a couple of sessions with me focused on ways to handle the transition, and a session where the client met with the new clinician with me in the room. I didn’t say much during that session, but it was great to see how well she handled the change and I was there to answer a question or two. I was also at the agency for a couple more weeks after that transition, so I was able to follow up with a couple of five-minute discussions. That made the process as easy as possible on her and I really benefited from seeing that she was able to successfully transition. I was also fortunate to transition her to a clinician that understood why I wanted to be active in the process because of her history and other things that the transition triggered for her.
Oh, Lauren! I’m so happy for you!!!!! And, so appreciate you talking here about your transition in such detail! That information can be so helpful to other therapists who have yet to make their first professional transitions with clients. Thank you!!!!
I want to terminate with a client because I am having difficulty working with him.
I usually find things to like and even love about my clients but . . . . .[Redaction]
I feel I can’t help him . . . . [Redaction]
I made progress with him . . . . [Redaction]
How do I let him go for good?
[All redactions in this comment were made by Tamara.]
Hi, Melissa!
Thank you for taking time to drop in here to discuss this.
As a Licensed Professional Counselor (in Texas and Colorado) and as a professional member of the American Counseling Association, I am ethically mandated to refrain from consulting about clients (yours or mine) in public venues.
For that reason, I have redacted significant portions of your comment.
You may not know that all social media spaces including blogs, email discussion lists, Facebook, Twitter, LinkedIn, Google +, and others are unsecured spaces (yes, even the “private” groups); they do not protect you or clients online.
I don’t know what your professional discipline is but if you are a professional counselor, you are held to that same standard.
Perhaps those of you who are Social Workers, Psychologists, Marriage and Family Therapists, and Addictions Professionals can chime in with your understandings of your own ethical obligations concerning consultation online.
However, Melissa, I do want to address your situation because all of us in the field of mental health have occasion to work with clients that we may dislike, (strongly) disagree with, or have difficulty relating to – situations not dissimilar to your own.
What I have learned is that any time I get stuck in my work with a client, have ongoing or repeated difficulty in working with a client, dislike or am disgusted by a client, it is 100% of the time about me and my history . . . about me and my (unresolved) issues that I need to clean up.
It has never once been about my client . . . even though I have most often initially thought it was about my client.
There are several things therapists can do when these situations arise . . . .
(1) Seek consultation / clinical supervision with a therapist who is more seasoned and experienced than you are.
Peer supervision is great for lots of things, but this is not one of them.
You want fresh and experienced eyes to support you in seeing what’s really going on.
(2) Drop in for a little 1:1 therapy with a therapist who is more seasoned than you are.
S/he can help you float up what might just be getting in your way and is calling to be addressed.
Just as family members can trigger our issues (even before we realize they exist), so can our least favorite clients.
(3) Seek additional training and education about the specific symptoms that your client is exhibiting.
For example, if it’s lousy boundaries and running hot and cold with you, perhaps it would be useful to learn more about Dialectical Behavior Therapy.
(4) And, finally, make sure you are continuing to expand your network of professional therapists to refer to so that when you do need to refer, you can send your client to the very best therapist to handle his particular symptoms and circumstances.
What we cannot do is say “I don’t like him, so I’m referring him” or “He has no morals, so I choose not to work with him.”
Professional Counselors are trained and mandated to be generally competent with whomever walks in the door; if and when we are not generally competent in a given area, then we are mandated to become generally competent in that area.
Melissa, I know this may not be what you were expecting but I hope it helps and I hope you’ll be back often to join the conversation!
And, of course, if you’re here in Colorado and want to consult privately, I’m happy to speak with you about this situation.