http://www.apa.org/monitor/2009/09/ethics.aspx
After reading so many stories here about abandonment and if the termination was ethically correct I wanted to learn more.
Above is a link to an article , again I think this article is pretty biased and is more concerned with protecting the therapists ego then protecting the clients best interest. I am apalled at the lack of patience and understanding this therapist shows his disruptive client. I mean really???
The article suggest the therapist terminates because the therapist is upset that he might not be belong the client. I understand all ts have different specialities but an angry suicidal client should give the therapist plenty to work with and it is pretty basic t training too. Really? This makes me very angry

I didn't find the article to be biased. It is simply an explanation of the code of ethics as it concerns terminations. It's point is that if continuing treatment is not in the best interest of the patient, such as the case being beyond the therapists' expertise, then termination is ethical.

[unaluna]

I don't think the point is that "angry suicidal patient" should be easy for any therapist. They were just showing and explaining all the steps to be taken in an ethical decision-making process. That was the point of the article - they just tried to pick an easily relatable situation, I thought. And they showed why termination in this case might not be the best solution - that was 2 or 3 of the possible outcomes, as I read it. Ie don't terminate if there are no other therapists available, or if after consulting he realized he could help her after all.

[Anne2.0]

Originally Posted by monalisasmile

Termination and abandonment: A key ethical distinction
After reading so many stories here about abandonment and if the termination was ethically correct I wanted to learn more.
Above is a link to an article , again I think this article is pretty biased and is more concerned with protecting the therapists ego then protecting the clients best interest. I am apalled at the lack of patience and understanding this therapist shows his disruptive client. I mean really???
The article suggest the therapist terminates because the therapist is upset that he might not be belong the client. I understand all ts have different specialities but an angry suicidal client should give the therapist plenty to work with and it is pretty basic t training too. Really? This makes me very angry

My reading of the article is that there is no hard and fast answer of whether termination is proper in this hypothetical case. The author does not say that the therapist should terminate; he does say that the termination could be ethical, or it might be proper to continue the treatment, especially if there is no other provider available:

"Dr. Berman's consultation will help him decide whether to continue Jessica's treatment or discontinue treatment and refer Jessica to another clinician. Either path may be perfectly acceptable under the Ethics Code. Psychologists in Dr. Berman's position often experience considerable relief upon realizing that terminating treatment may be entirely compatible with our ethics."

My reading of the fake scenario about how this client was pursuing her therapy, I felt sorry for the client because it didn't seem like she was getting what she needed from therapy, and I felt sorry for the T because he felt incompetent to help her. Even if you take the position that terminating a client who doesn't want to terminate (I think that's your definition of "abandonment") is always harmful, this hypothetical suggests that continuing treatment can be harmful to both client and therapist. I don't think a therapist should be forced to "help" a client if they think it's bad for a client and/or bad for themselves. Nobody's entitled to the services of a therapist nor can it be a good situation for a therapist to be forced to work towards something they don't believe in.

But one thing is clear-- it's not a clear cut right or wrong when therapists terminate clients against their will. Even if the therapist is wrong in terminating the client, it seems to me that the client may be better off being away from that particular therapist. If that therapist bungled the termination, then they probably bungled the therapy too.

[ultramar]

Originally Posted by monalisasmile

Termination and abandonment: A key ethical distinction
After reading so many stories here about abandonment and if the termination was ethically correct I wanted to learn more.
Above is a link to an article , again I think this article is pretty biased and is more concerned with protecting the therapists ego then protecting the clients best interest. I am apalled at the lack of patience and understanding this therapist shows his disruptive client. I mean really???
The article suggest the therapist terminates because the therapist is upset that he might not be belong the client. I understand all ts have different specialities but an angry suicidal client should give the therapist plenty to work with and it is pretty basic t training too. Really? This makes me very angry

I disagree. I think this was very thoughtfully written and I think both the best interests of the client and the therapist are explored.

The therapist is CBT. She's getting more and more suicidal and the way this therapist works (the impression I get is that he may be a purist in his modality) is to teach the patient coping mechanisms. He has tried, it makes her even more upset/destabilizes her more. She is clearly not in a place to be helped by this kind of therapy. It's not her fault that she is not in that place, and it is not his fault that he is ill-equipped to help her. The ethical thing for him to do is refer her to someone who *can* help her. I don't see the writer or the hypothetical therapist blaming the client for this at all.

It seems she may have attachment issues (the 'interpersonal issues' mentioned in the referral, her difficulty with the relationship with the therapist) and needs a therapist who can treat this, which, in my opinion, requires more intense, long-term therapy -not CBT.

It is suggested that he seek supervision before making a decision to refer her, which I think is very reasonable. The possible downsides of referring her are explored (i.e. maybe she won't see another therapist, thus being left without treatment) -it takes into account the complexity of the situation. But I think ultimately, in this example, it is a balance between risks and benefits and deciding what would be best in an imperfect situation/a situation without a 'perfect' solution.

What I would fault him for, is since his practice is so limited, is not garnering more information about her (apart from the generalities in the referral listed in the hypothetical) before agreeing to take her on. Maybe it wouldn't have helped (maybe there would have been no way to really know), but I think someone like him should make an effort to find out if a potential client is in a place/is able to participate/benefit from the kind of therapy he offers. Again, this is probably often not possible, though.

Do you really think that a purely CBT therapist is appropriate for this client? I personally really don't think so.

Originally Posted by Anne2.0

If that therapist bungled the termination, then they probably bungled the therapy too.

That is a completely unfair assumption to make. I had EXCELLENT therapy with someone who screwed up my termination royally.
Which he mostly did because his consultant was forcing his hand...I found out much more later on, and the consultant was a complete narcissistic control freak. Consultants for other Ts should have to be certified to be a consultant, period. But there is no "process;" a T just asks (usually) a senior T to be their consultant and trusts them...just like we trust our Ts.

Dr. Berman typically sees clients with difficulties that are more easily resolved by cognitive behavioral approaches. Because he feels that Jessica needs a more intense level of care than what he offers, Dr. Berman feels incompetent to manage her case and to be an effective therapist. He has expressed this concern to Jessica directly and has told her he thinks she would be better suited with another clinician. At this time, he had already begun to make what he considered more appropriate referrals.

The psychologist is not a cbt practitioner alone.
He choses to see patients who benefit from cbt. It didn't mention him giving her any coping skills.
Knowing the client would not benefit from cbt and needs to go deeper with long term therapy. Dr b should never have went any further than a first session. That's where the harm was done, his ego took over and thought he could help but didn't have the nesessary skills.
If he had spoke to her on the phone before seeing her and got an idea of her issues he should have known he could not help her. It is in the code of ethics that you must inform a client of your skills prior to treatment and not mislead them.
I feel the doctor took the easy way out her and got away with malpractice.

You are definitely reading between a lot of lines with that hypothetical scenario.

Originally Posted by 1914sierra

You are definitely reading between a lot of lines with that hypothetical scenario.

That is your opinion and you are welcome to it

[WikidPissah]

yea...I think you are reading too much into it. Maybe she didn't show her "true colors" until several appointments in? He realizes he can't help her, he needs to stop....there is nothing wrong with accepting your limitations.. In this hypothetical situation, the client is attempting to manipulate the T.

[unaluna]

It seems there is something triggering for you in this story. We are told to accept the premise as given, but you aren't able to do that - you see a flaw in the premise. There are a couple of "problems" with that.

One problem is that you don't learn and remember the ethics lessons provided by the example. These will probably be on the test!

The second problem is that it shows you have unaddressed anger towards authority figures. You are not getting recognized for being clever and it is the story of your life! It is the story of MY life. I can see myself having the same reaction. The thing is, your solution requires going back in time. It assumes the doctor can't make a mistake or just be human. Your solution requires perfection, and you are saying you are the sole owner of perfection, and if the world would just listen to you, they wouldn't have these problems. The world has an ego problem. Well, who in your world has an ego problem that is causing you grief? You need to talk about this with a t so it stops hindering your school work and your becoming a t. Because right now I'm afraid it might be. I'm sorry to be so harsh, but this could be a major step forward for you.

[Perna]

I feel the client hires/pays for "buys" from the therapist; the therapist cannot abandon. The client is not the therapist's child, pet, or single sock/closet hanger. It's an "at will" hiring, like any other job; at any time the therapist can terminate the relationship or the client can. Mostly the client does by being ambivalent about the therapy situation.

Inasmuch as it is a human relationship and both sides invest in it; it can hurt like the dickens when one or the other person terminates the relationship. Usually the client has fewer skills and self esteem in dealing with relationship termination so might have a harder time getting over it. That's life, not the therapist's "fault".

[sunrise]

Originally Posted by monalisasmile

If he had spoke to her on the phone before seeing her and got an idea of her issues he should have known he could not help her.

My T has told me he has gotten better at this with experience and now has a good sense of who he can't help from the initial phone call, and he does not accept them as clients. That is a skill in itself. He does feel that he has a good chance of being able to help most people, but there are some he cannot. The phone screen is indeed useful.

I thought this scenario was interesting. I thought that the T handled it OK. I didn't find bias there. I do think it is good for the T to know his scope of practice and refer if the client has problems he is not trained to handle.

[feralkittymom]

Originally Posted by sorta_fairytale

That is a completely unfair assumption to make. I had EXCELLENT therapy with someone who screwed up my termination royally.
Which he mostly did because his consultant was forcing his hand...I found out much more later on, and the consultant was a complete narcissistic control freak. Consultants for other Ts should have to be certified to be a consultant, period. But there is no "process;" a T just asks (usually) a senior T to be their consultant and trusts them...just like we trust our Ts.

In the US, for psychologists, they do have to be certified to conduct supervision: ABPP board certification. There may also be state-level accountability.

[Perna]

They do not have to be certified, there are no laws; it's just that one would want that as it's a value-added feature to offer your clients. One usually has to be state licensed to do therapy (and get protection under the law) but any idiot can get a license, just like any building contractor can and then build cheap crap and get away with it. Licensing requires certain education and maybe time served but you don't have to prove you have common sense, compassion, or "care". We all know there are better and worse T's, just like there are better and worse doctors, lawyers, or any other profession. With T's it's even harder to judge because one has one's own issues, which may have the same title as someone else's issues but how they individually play out, the "devil in the details", can cause all sorts of scenarios that no one, not Super-T him/herself, can be equipped to deal with, especially ahead of time/before they rear their ugly head.

[likelife]

Originally Posted by feralkittymom

In the US, for psychologists, they do have to be certified to conduct supervision: ABPP board certification. There may also be state-level accountability.

I don't think that's true. Supervision isn't a regulated service. At least not that I can find in my state. There are qualifications listed for supervisors for psychologists in training (unlicensed), but ABPP certification isn't one of them. In fact, the only one I can see is that supervisors have a "declared competency" in supervision, and it looks like something they declare themselves.

Well yeah, the guy was a "real" psychologist. But ABPP board certification does not read as being certified to conduct consultation to another therapist on patient issues, and that is what I am referring to.
There are lots of Ts out there who are certified to be Ts based on their degrees and credentials, but we know they suck at it.
In this case I know what my T's consultant told my T re: how to "handle me" and it was not in my best interest, plus he used pressure on my T to do it...I do not wish to get into the details any further as I hate this topic (but felt I had to say something), but any consultant using pressure on a T to follow his or her "advice" has serious issues. My T and I never had that kind client/T relationship where such a thing needed to occur. My T went to him for advice and guidance, period.
And my T was not being supervised (he was way past that)...he hired this guy as a consultant...there is a difference.

[ultramar]

Another way of looking at this, is the potential damage that would have been done if he had *not* referred her out.

There are therapists out there who do not have the skills to treat some patients and yet may have a big fat rescue complex (perhaps with a damaged ego/self-esteem issues to boot) and (try to) treat them anyway. A therapist who is unable to recognize their own limitations can be dangerous to some clients. In this scenario I'm making up here, it is the ego (and perhaps other things) of the therapist getting in the way of ethical practice by choosing to continue to treat the client.

[Miswimmy1]

Can you be both? Have been terminated but feel abandoned? I feel like a therapist can not abandon you because you are paying, and as long as you are paying, then there should be no such thing as termination.

[ultramar]

Originally Posted by Perna

I feel the client hires/pays for "buys" from the therapist; the therapist cannot abandon. The client is not the therapist's child, pet, or single sock/closet hanger. It's an "at will" hiring, like any other job; at any time the therapist can terminate the relationship or the client can. Mostly the client does by being ambivalent about the therapy situation.

Inasmuch as it is a human relationship and both sides invest in it; it can hurt like the dickens when one or the other person terminates the relationship. Usually the client has fewer skills and self esteem in dealing with relationship termination so might have a harder time getting over it. That's life, not the therapist's "fault".

You make an interesting point. I'm not sure I agree with the 'hiring' metaphor (therapy is just different), but I have often been confused by the use of the term 'abandonment' when it comes to therapists referring clients out. Though I think part of the problem is that this word is used pretty loosely and likely means different things to different people.

Where I think I agree with you is the use of the term abandonment when it comes to terminating the therapist-client relationship. When I -personally- hear the word 'abandonment' the first thing that comes to mind is a mother leaving their child on someone's doorstep ('abandoning' the child), and, as you say, the client is not a child (or a pet). (Then again, there's the whole transference thing...).

[unaluna]

Originally Posted by Miswimmy1

Can you be both? Have been terminated but feel abandoned? I feel like a therapist can not abandon you because you are paying, and as long as you are paying, then there should be no such thing as termination.

No - a therapist has to be allowed to quit. If any person cannot quit a job because someone else is paying, that's called slavery! I'm pretty sure you did not read the beginning of this thread to even find out what this discussion is about. But that's okay.

You keep fighting whoever you're in therapy with. It's understandable, but you are wasting time and resources. This could all stop when you're 18. Has anybody told you that? I wanted to leave home and live in an orphanage when I was a kid, just so my parents would stop getting in my way and sabotaging me.

I wasted time and resources too. I think what finally stopped me was just getting tired. I decided no more ts after this one. Whoever dies first! (We're both in our 60's). So I work it out with this one, now. No more second chances. Girl, you can do it. If you can swim, you can do this. We're with you.

[~EnlightenMe~]

There's the intellectual term of abandonment which has a Webster's definition, and then there is the emotional feeling of being abandoned, whether or not it fits the definition. You can absolutely be terminated and feel abandoned due to past issues.

I think that the CBT oriented therapist was in over his head and didn't have the skills to help his patient in the given vignette. His patient maybe needs a higher level of care, or maybe needs a different approach. Either way, terminating the patient so she could see another therapist with a modality that wouldn't escalate her distress, seems like the best choice.

I prefer not to bring ethics and ethical definitions made by a board of professionals into how I felt about being terminated. Terminating a patient against their will, and thus traumatizing them, well, although I see that it needed to be done, I can't process calling being traumatized an ethical act. And I actually don't want to even try as it would be fruitless. These are my issues, no doubt, and my opinion is biased based on my recent and not so recent history.

I would like to see a time when the people who suffer join the therapists as a group to improve therapy, and to be involved in making decisions like the one discussed here. I think that attachment disorders are not really well understood by the profession as a whole (and by me), and I would love to see that change. Getting off my soapbox now. . .

[likelife]

Thanks for saying so well what I didn't know how to voice, antimatter.

[learning1]

I thought that an interesting issue was, why did the therapist have such a low level of skills? Should a therapist with that level of skills be a therapist? I'm not sure.

[feralkittymom]

Originally Posted by likelife

I don't think that's true. Supervision isn't a regulated service. At least not that I can find in my state. There are qualifications listed for supervisors for psychologists in training (unlicensed), but ABPP certification isn't one of them. In fact, the only one I can see is that supervisors have a "declared competency" in supervision, and it looks like something they declare themselves.

My understanding from my T is that if one is a psychologist, which is a protected title unlike "therapist," acc to the guidelines of the APA, there is no mandate for supervision beyond licensing. However, if a psychologist wants to offer their services as a supervisor, they need to have the ABPP certification. In my state, they also have to have an additional state certification to engage as a supervisor.