codes of ethics re: termination

My T was great, but my treatment was challenging and when I had to relocate to another state to take care of a sick relative, there was no talk of what would I do next. It was only later (and though my T helped me a lot), that I realized, what I knew all along, that setting me loose without a follow-up plan was not only uncaring, but unethical.

The harm in my termination occurred long before the termination in the demagoguery the therapists employed, leading me into believing they knew more far more than they did, had far more ability to help my life change than was realistically possible. I needed seasoning and a sense of competence; they lured me into a child-like relationships.

So when my therapist team had a tantrum-throwing meltdown, I had their problems on top of my own topped with the heavy burden the of the delusions we all had created.

I don't think being deceived indicates one is weak or unwell by any means. Highly intelligent people join cults. Highly competent people still can buy the myth of the magic authority figure. I know strong, able, accomplished people who turn childlike talking about their therapists and one who dismantled her life, her marriage other relationships under her therapist's influence.

I question the benefit on a treatment built on delusion. The fairy tale can't last.

Ok, would like to hear the outcome of this. Good luck!

My T and I were also something more than T/C. She gave me special treatment, nothing outrageous but enough to draw me into an intense infatuation and attachment and to make me wonder what on earth was happening and was I in love with her, and was she in love with me. And that made termination and the resulting blame and shame crushing.

musinglizzy, thank you for asking. I guess not (haven't been here very long). I don't know where to post such a thing. I could put it in this thread, but don't want to be self indulgent and off topic.

As to the question of power imbalance, consider the following (quotes and paraphrases of things I've read recently or my own observations). Not saying one should become paranoid, and I think once you become aware of how things are, you are less likely to get into trouble...

- A core assumption is that "the therapist, by virtue of his knowledge, training, and special insight has access to truths above and beyond the capacity of his patients. The therapist interprets the patient's truths and tells him what they really mean."

- "The therapist can question the patient on any topic, but the patient cannot question the therapist."

- The therapist (or the profession) decides the duration of the session, the place of meeting, the cost, the basic rules and code of conduct.

- The therapist often sits in silence while the client speaks. Even when the client becomes emotional the therapist might remain in silent observance. Silence can make one feel "frightened and helpless, the very feelings that which undermine our self confidence".

- Sometimes the therapist will sit in a specially positioned chair, with the client on a couch which is at a lower height. There is a feeling of appearing before a judge in court.

- "In any area of disagreement, it is assumed the therapist is more likely to be right."

I have never, ever, assumed that

Clients don't have to give their power away even if a therapist tries to take it. Just don't give it to them

I think the point of these assumptions is that they hold true in a majority of cases, and are necessary for the system to function the way it does. If nobody bought into this stuff, then wouldn't the system fall apart?

Anyway, no matter how much a client fights for equal power, if you are disclosing difficult or painful stuff and the other person is not, and they are acting as authority or parental figure, and you have a history of abuse or abandonment and are generally vulnerable, and the T is setting most of the rules and controls the apparatus of therapy… then there is a power deficit the moment you walk thru the door.

I have been hurt by therapy, and have done a lot of reading, and I would now challenge much of this, as you describe. And so I agree with the idea that the client should narrow this power gap as much as possible, to protect themselves and to make it more collaboration than hierarchy.

I just have to jump in because this is such a painful subject for many clients who have been terminated in the less than humane and respectful manner, myself included.

I agree with Puzzle. It's not about forcing the therapist to work with someone they no longer wish to work with. Of course, they have the right to terminate the work with someone when they feel they can no longer be useful. Not only they have the right to do so, but it's also their ethical responsibility to do so when they feel they can no longer be of help.

It's about HOW they terminate, and I assert that therapist's position requires them to conduct termination with utmost respect for the client even if they hate the client's guts. They should never communicate to the client in any way, implicitly or explicitly, that the termination is somehow the client's fault. "I no longer feel I am competent enough to work with your specific problems" is one of the appropriate ways to phrase it when break the news to the client and this is the only objectively truthful reason for termination. No matter how difficult the client may be, the difficulty they present only means that the therapist came to his/her limitations and should honestly acknowledge that and refer client to someone more competent to attend to client's unique needs.

In regards to "firing" the client, it is the therapist who, by definition, can be "fired", not the client, because the client pays the therapist for service. Client is the one who hires and who fires therapist because client is the one who pays. It's a fact of business. It may be an uncomfortable fact for some business providers to accept, but it's a fact.

Also, termination for non-payments is a completely separate issue, at least here in CA where I am licensed. Our ethical standards suggest that it's unethical to see clients without collecting payments for a long time because when the balances accumulate, that creates a dual relationship with an additional creditor-debtor dynamic. You, as a therapist, may be pissed that you haven't been paid for some time, but you don't terminate client because you are pissed. You terminate them because it's unethical for you to continue working unpaid for the reason mentioned above, and this is how you explain it to client.

As I said in my previous post, I do agree with you on the point that termination should be done humanely and respectfully. I don't agree that therapists should "suck it up" and continue to work with those who they can't help because of their own unresolved issues, biases etc. Help can't be forced. If it's not sincere, any attempt to force it would result in harm. In that respect, I am a proponent of referring people as soon as the therapist feels even mildly uncomfortable with them and can't resolve this problem through supervision or their own therapy or in any other way. If therapists did it more, less people would get hurt. Unfortunately, they tend to hold on to clients way beyond the point of discomfort mainly for two reasons: a) ego-related (when they are trying to prove to themselves that they "can do it" and to avoid the "shame" of revealing to their colleagues that they couldn't work with someone); b) finance-related (this one is simple - to keep getting paid). Very few of them have guts to be honest with themselves about their limitations and to refer clients in an ethical and timely manner.

I totally agree on the special unique nature of therapy service and that when therapy was going on for a long time and resulted in development of strong attachment to and dependence on the therapist, termination should never be done abruptly and the client should never be left high and dry without an assistance in making a smooth transition to a new therapist.

The problem, however, as I see it, is precisely the strong attachment and dependency that IMO is completely unnecessary and can be avoided if therapy is conducted differently from how it's been conducted from the birth of the field. While many people clearly have strong propensity to get attached to therapists because of their unmet emotional needs, I would argue that therapists' behavior and methods they use contribute greatly into development of strong attachment. Many methods taught in training encourage dependency on a therapist, and I don't think it's helps. Clients are made to believe that somehow through that dependency they would be able to get their emotional cravings satisfied and to compensate for what they weren't given in childhood. This is the grand illusion being sold by therapists and happily bought by many clients because human nature is such that it's easier to believe a beautiful fairy tale than to accept reality as it is.

So, it's not the termination that is a major problem, but the ways in which therapy is done. If it was done differently, terminations wouldn't be so difficult.

As painful as it is for me as a professional to accept this, what you said is largely true unfortunately. I wouldn't say that everything in this field is pseudoscience, but the profession, as a whole, doesn't strive to build a solid scientific foundation for its methods. Most of the current methods are largely based on theories that are more or less speculative, not backed by valid thorough research.

Ironically, while it's become a mainstream habit among professionals and lay people both to arrogantly criticize Freud, he was the only one who made the best effort to back his theories with empirical evidence. No other theories have been backed by any objective empirical data. That doesn't necessarily mean that they don't reflect some realities of human nature or that they are unhelpful, but it means that people are uninformed about the fact that a big chunk of the work their therapist are doing is not based on science, and this lack of informed consent, in and of itself, is unethical.

The thing is that research CAN and MUST be done in psychotherapy and it must be done in large quantities because at this point in history this profession is still largely in its infancy and we know too little to pretend that we are "treating" "disorders" in the same way medical doctors treat physical symptoms.

When it comes to physical ailments, there is a clarity of the cause, the procedures and the expected outcomes. There is no such clarity in psychotherapy. Not even close. So it's time to be honest about it.

You did the right thing. And the courageous one. She should be held accountable.

I agree. The power differential is implied by the situation itself. It has nothing to do with client wanting or not wanting to give it away. When you come to someone for help and spill your guts to them, but they don't have to reveal anything about themselves and their role is to be of help to you and not make it a two-way give-and-take relationship, a certain degree of dependency and vulnerability develops naturally whether you want it or not. If client feels completely equal to therapist, no dependency at all, it simply means they are not talking about a lot of deeply personal things in therapy in order not to reveal their vulnerabilities. But if you don't talk about some intimate personal issues with the therapist, than what's the point of therapy then? Then it's a waste of time and money because it defeats the purpose.

I talk about things I find personal, I do not believe it is more of a waste of my money than I am willing to spend, amd I do not feel dependent or unequal to the therapist. The purpose I use if it for is not defeated.

Agree about how termination is handled being critical. For me it was termination and its aftermath that was most significant part of it all, and most damaging.

But even if termination IS done for valid reasons, IS handled with utmost care, and referrals ARE given, that still leaves the client potentially in a terrible bind if they are destabilized by the rupture.

What if the client ends up in a state of near suicidal despair despite a reasonably well handled termination? Is the T ethically obligated, whether according to ethical codes or not, to reconsider termination or to offer some level of help? Or are they absolved of responsibility? My T seemed to feel that once the termination had been carried out, I was on my own.

Maybe she was not best equipped but is that ALWAYS better than abrupt termination? Maybe continuing in some fashion to a safe point IS better in some cases?

And I think Ts get let off the hook rather easily, by just saying they can't help. Even good intentions and well handled termination can become a smokescreen behind which the T can hide from the fundamental failure of the process, and then just slip away.

Also, what seems to be rarely acknowledged is that if a client is traumatized by therapy or by a painful termination rupture -- even if it is handled with some measure of care -- they might well find it difficult if not impossible to trust the process again and so their ability to get support is now hindered. In my case the whole basis of termination was that I would quickly and easily be rescued by one of ex T's referrals. But the inherent danger and flaws that led to such distress with my previous T were there waiting with other Ts. I have given up for now, and am left to pick up the pieces on my own, though I will likely make another attempt to find someone to talk to.

Your concern is valid and understandable. I've grappled with the same painful questions you've just raised. I myself have been terminated by some of my therapists not in the best way possible and it was painful. At the same time, some other therapists caused me greater damage by not terminating our work when they really should have.

I think, in order to avoid the traumatic effect of termination, the therapist should actively assist the client in finding a suitable replacement instead of just handing them some names without checking if those people can be a good match for the client. Some communication with the therapist should continue until the client gets settled with the new therapist, but it can't continue forever. At some point, the therapist should be able to say "I did what I could" and to be off the hook.

When termination becomes traumatic and client cannot accept it, that tells me that something was wrong with the work itself, and so to me the problem is mainly how therapist conducts the work as opposed to how they terminate it. You said it yourself: "Even good intentions and well handled termination can become a smokescreen behind which the T can hide from the fundamental FAILURE OF THE PROCESS, and then just slip away." It's exactly that, it's the FAILURE OF THE PROCESS rather than the termination that is the problem.

When client is not confused about the nature of the professional relationship and what therapy is and isn't about, termination doesn't become traumatic. In fact, in this case, it's usually the client who calls it quits and leaves. When the therapist projects a clear image of themselves as a professional, not a intimate "friend", not a mother, not a guru, not a teacher/mentor, the client has no problem ending therapy when they feel they no longer get what they need. They quit themselves and they often don't even feel obligated to give the therapist an explanation and they don't have to.

I've never terminated a client. Whoever found me unhelpful left on their own and I had no problem with that.

This is a critical point I think. If there are problems, what is the right point to stop it, or talk about stopping it. I acknowledge that my T was between a rock a hard place -- wanting to help and not give up too easily, then realizing harm was already done and what to do.

I think my T is a fixer and rescuer type, and couldn't face that the process was traumatizing me (the first of your reasons). So she kept going. We ended up in a dangerous middle ground -- well past the point of causing harm but with nothing resolved.

Well said. I never understood this until I went thru it.

Yes, I see what you mean. If therapy goes well and termination comes about naturally then it should be fairly painless assuming it is planned ok. And timing would be another big factor. Even if the work is productive and positive, if termination comes abruptly during a critical period (either in therapy or in the client's life), seems it could still be quite damaging.

Appreciate hearing your insights as a therapist. With all Ts except the problem one, I chose to leave and was no big deal. OTOH, nothing much of consequence happened and it was mainly indifference that caused me to stop. With the problematic T, there was intense emotional involvement that was indeed too intimate. Whole thing induced me to develop overwhelming love/desire feelings for her, and then she basically rejected me in this regard. It was this unrequited love/rejection in the context of therapy and possible maternal link, and when I had placed trust in her and had been extremely vulnerable, that destroyed me, and then termination was another layer of rejection plus abandonment.

This is a classic scenario when the therapist has a rescuer complex and heroically stays on the mission of rescuing the client when not doing so would benefit the client much more as well as spare the therapist much stress. Nothing good comes from the attempts to rescue people. The desire to rescue someone is usually ego-driven. It doesn't come from compassion.

So you put your college age son's car on your name. That's very reasonable and normal thing to do. Your t says it is wrong??? You know what you are better off without this looney wacko therapist

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Even if you did buy him a new car. Plenty of parents purchase their college age kidS cars. So what? She could give you suggestions but what a wacko

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I think she was 2 parts Rescuer and 1 part Narcissist. As to the Rescuer type, this sums up my T well: "Her motivation is pure, and Rescuers are typically good people at heart, but, unfortunately, they are blind to the harm they do."

And the Narcissist part meant she loved the transference and worship and the dependence. But when she finally had to throw in the towel, and I lost my mind because of the traumatic termination and began saying pointed things, she became hostile and defensive. Feel a bit bad for her, though she got off pretty easily...

I think there is certain amount of narcissism in many therapists and some of them have quite a bit of it.

I don't understand what business it is of your T's if you help your son out with a car. Like others said, lots of parents do that. The only way I see it as being an issue for your T is if T is owed money for services and is not getting paid. Why was your T so upset about it?