APA article: "Termination and abandonment: A key ethical distinction"

I don't have many issues about a therapist's need to refer clients when there is no other option, but this article makes me sick about the profession. I was actually thinking of writing a complaint about it, but now thinking how it just makes the APA look bad; well worse than they already appear. Not that they haven't already lost their credibility...

It's actually a very bad article regardless, and the author is an attorney. But very troublesome as this seems to belong in the malpractice prevention section under practice management or something similar--not ethics. That in itself is of very poor judgement.

http://nebpsych.org/Resources/Docume...ke%20Broch.pdf

A crucial problem in the case study and much of therapy is the assumption that the therapist knows what is best for the client. This is both ridiculous and dangerous. The article depicts the therapist as god-figure or paternalistic daddy type, handing down a verdict to the infantile client. There needs to be a discussion between two adults (maybe three). Yea i get it, some clients are out of control. Most are not.

And it's not a simple dichotomy. The choices are not continue as before or stop immediately. There are many ways to handle things. Just "referring out" solves nothing and likely creates many new and serious problems. Seems many therapists are so wrapped up in liability concerns, theoretical rubbish, and tending to their own wounded egos around failure that they make terrible decisions around termination. Articles like this only encourage them to diverge further from reality.

For those who have not endured an imposed termination (especially if already in crisis), you have no clue of the potential for damage. It is a surefire way to induce feelings of humiliation, powerlessness, rejection, abandonment, worthlessness, etc etc.

Claiming lack of proper "skills" or "modalities" is largely horses**t and could be a smokescreen for all sorts of things. The only "skill" needed in some cases is just listening and being patient and getting your silly therapist ego out of the way. I understand that things become unworkable, but the ease with which therapists can escape a crisis is just nuts.

Poor writing and word choice aside, after 8 sessions the client was angry to the point of violence and overtly suicidal. There are T's that don't know what to do with this and will need to refer out rather than make a possibly fatal mistake. I see nothing wrong with referring if one is out of their depth. It's the refusal to discuss this that can end up causing pain.

I would rather any healthcare professional tell me they don't know than waste my time and money trying to figure it out. I don't like when a T claims to know what is best for someone, it's patronising and demeaning but I also think they can know that they are not what's best.

Maybe the therapist's incompetence drove her to want to commit suicide. Who knows?

This made me snort. Then it's definitely good for the T to get lost.

You don't think "referring out" a suicidal client could possibly be a fatal mistake?

Originally Posted by puzzle_bug1987 View Post
Maybe the therapist's incompetence drove her to want to commit suicide. Who knows?

JaneTennison1: This made me snort. Then it's definitely good for the T to get lost.

It is amusing with the sad exception that it is totally and very realistically possible and probable. Therapy can trigger suicidal feelings or it can intensify them; if the therapist who triggers them with his techniques, can easily find himself in over his head. Do people who condemn this therapist really think that if the client did follow through with her intentions to suicide feel that they would say, "Oh well, at least he stuck with her and didn't abandon her?" Personally, I think not. I think there would be an uproar of rage that he didn't provide a level of care that kept her safe and got her the therapeutic intervention that she needed considering the possible intense therapeutic needs she was presenting.

There are more than a few therapists out there who truly believe that all they need to do is "listen empathetically", offer some sage advice and walk over to the bank to deposit their session checks. They have no deep understanding or grasp about the power they weld in the therapeutic relationship, and therefore, they are annoyed or scared (but don't let it show because he/she is suppose to be the all knowing therapist) and put the blame for the shaky situation they find themselves stinking into on the client. Some will refer on quickly with no true termination or support and some will stick with the situation in their arrogance that they can "handle things". Personally, either course of action is scary for me and NOT someone I would want working with me.

Someone posted earlier that those who were posting about the referral as being a positive thing as being comparable to women dissing other women for wanting equal pay to males (I think it might have been you, SD, but I'm too lazy to go back to check). In any case, I strongly disagree. I'm sorry, but I do wholeheartedly believe that there are therapists out there who are so poorly equipped to deal with their clients issues that it is vastly less harmful to refer the client than to allow the poorly trained and stupid therapist to continue with his deplorable attempts to meet the needs of his challenging client. . . and I say challenging in the sense that the therapist is too poorly trained to know how to do ANYTHING positive or therapeutic for said client. It has nothing to do with the client and her needs, SHE'S A CLIENT for pity sakes, and she came to therapy to meet with someone who could help her with her needs/mental health issues. The fault does not lie with her! The fault lies with the ill-equipped, poorly trained therapist or with the therapist who does not specialize in the area of concern and therefore does not have the skill set to perform the necessary therapy.

Stopdog, you're a lawyer and from what you have said, I'm guessing that you specialize in medical/psychological malpractice (I apologize if I have that wrong but I'm not a lawyer). Would you not refer someone to another lawyer if they somehow came to you for an appointment and they needed someone who specialized in Contracts or Criminal Defense? Maybe someone referred the client to you and you accepted an appointment thinking he/she needed you special expertise, but when you realize that the person's needs didn't fit into your area of expertise and you referred the person on. That is the right thing to do, right? And please don't tell me it's the arrogance or the belief that they are God's that makes the therapist's refer so egregious. You and I both know that there a LOT of arrogant, God complex lawyers out there who think he/she walks on water.

Look, we all know that eight sessions is a really really brief period of time. I don't know about most of you, but I didn't really and truly see my current therapist as understanding and getting me on a therapeutic level until I was seeing her for six months or more. . . .and even after that, there have been touch and go times when I thought I was sitting across from a total stranger . . . and I'm sure at times, she was feeling the same thing. It wasn't until after I saw her for about three months before I began to think that she had the skill set needed to bring about some positive change with the two of us working together diligently.

I agree that there are a LOT of poorly trained, lame-brained therapists out there. I'd rather see clients focus on ways to bring about changes in the training and vetting of therapists than in trashing the entire profession. Some of us have benefitted from therapy, some have seen no benefit, and some have been hurt and traumatized. I'd like to see those who have been traumatized to get their "day in court" whatever that means for them--filing a grievance, writing a letter of condemnation, confronting the therapist in a termination session with the therapist not able to defend themselves with useless drivel, loss of the therapist's license etc. But I can not and will not agree that the entire profession is useless, arrogant, narcissistic, and should be done away with. I will agree that everyone has the right to speak of their displeasure and disillusionment, but I too have a right to see the value and speak of the value I see in the profession and the therapists I've worked with without feeling as though I am disillusioned or right around the corner from being shafted. Each of us on this board have the right to speak what we believe. I do not dishonor or think those who have been injured are exaggerating or being difficult for voicing their hatred for the profession, but I also know that I am not exaggerating or being unreasonable in my defense of the good, caring and well-trained professionals that I have met with and grown emotionally with over the year. Thanks for letting me vent.

Could be, but honestly I wouldn't see a GP for many years if what I needed was a neurosurgeon. Wastes everyone's time and I would only get sicker in the mean time.

I was terminated at a time when I needed more help than ever. I feel anger, I feel harmed. My T made the choice that was right for her and not for me. It was gross the way I was treated. If she had been honest, sat me down and then supported me through a transition then things would have been different.

I have no issue with a T referring a client on but I have huge issue with the cruel way they often do it.

This is a really interesting and useful conversation, actually. I have been angry lately at the health care industry as a whole after recently being harmed by primary care (less angry with therapy than other areas), so i like to talk about things that need improving and feel it is ok to express anger, too.

The case study was a really stupid example to begin with. But it was posted, so let's look at it from a different angle.

The patient was suicidal, showed excessive anger. The chair really made the case study, didn't it; great that that was thrown in there like that... Anyway, so-this therapist decided he felt so ineffective after just 8 sessions? He couldn't work through this with her under supervision to see if things improved? See if it passed? How can you simply decide the outcome in that amount of time. What if she simply sought help for her first manic episode and simply needed a mood stablizer? He can't really know in just 8 sessions. So the argument is that he is CBT, not positioned for complex clients. Ok, fine.

But then there is this: how many conditions include the possibility of suicidal feelings? Do people think it's ok for therapists to take on clients, but then drop them when they became suicidal? I mean, that would affect many clients. And how can a profession aimed at helping those with mental illness just drop people when they need help the most-when they become suicidal? I mean, how can the profession treat clients with mental illness, most getting paid by insurance to do that, than not treat them for mental illness--suicidal thoughts?

If not, then maybe this guy isn't cut out for treating patients with diagnoses of depression, bipolar, attachment disorders, and many others that might include suicidal feelings. They guy should probably have been a life coach! And if he could only treat the most simplistic of patients, then fine, but then he should have screened for these things up front. So the article should have mentioned at least some of the mistakes this therapist made to begin with. Actually, the article is just a really poor example; unrealistic as someone else said.

It can sometimes take a long time to get an accurate diagnosis, but he should have known sooner that he didn't have the skills simply by asking her a few questions about her history. And therapists do have screenings to decide if they will take a patient or not (psychoanalysts). So that exists, maybe the rest of the profession could look at adopting those methods?

A more real life example would have changed things, and reflected a truly ethical situation that is colored grey and not black and white. That's usually how case studies are done-so people can discuss all the many points to learn ethical decision making. (one reason why i thought the article was very stupid). And again, the biggest issue i have is that the article is framed more from a legal standpoint than an ethical one. If you look at APAs code of ethics, it's to protect the patient. This article and author focus more on the therapist, not the patient's welfare. And that this guy is the Director of Ethics at APA. That's what got me.

I am a lawyer and I do represent clients in the mental health system who have been and those who are being abused by the system, psychiatrists, and therapists.
My objection was to the defense of this example as being an upstanding therapist and statements like the poor therapist who has to put up with a client like this woman being like women who used to be against the Equal Rights Act - I think stands.
I do not say a therapist may not get rid of a client. My problem is how they couch it and approach it and congratulate themselves on their handling of the problem woman.
Please go re-read my comment. You have mischaracterized my position.

I think referring out can (and probably will) cause pain despite a willingness to discuss the issue, but I agree that the willingness is essential. I remember very early on in my own therapy, when I was not super stable, my T talking about referring me out to a bona fide MD Psychiatrist and God knows who else. It was incredibly frightening, and, yes, I felt rejected and worthless. But the fact that this was a discussion--that it was open to debate, that my viewpoint was listened to and his gently and transparently explained--made a big difference.

As for whether a T (or anybody else, really) knows best...This is a sticky, ambivalent issue for me, too. Because, yes, it IS patronizing and paternalistic and all the rest. And I certainly don't think it's true that most (or even many) T's know what's best for most (or even many) clients....But, you know, is it so odious to say that maybe sometimes they do?

Humiliating as it is to admit, there have definitely been times in my life when other people DID know better than I did, and I am, retrospectively, enormously grateful that they stepped in to make decisions for me.

I've gone back to look. I don't see how my (I won't speak for anyone else) support of an ill-equipped therapist's referral of a client is abandonment or justification of his "asshoic ways" when he is clearly and admittedly NOT trained to support or work with effectively with the client. (Is the article written in kind, empathetic, power balance manner? No, but that doesn't change the fact that the referral is most likely correct. Who wants to work with an A hole that is ill-equipped and frightened?)

How is what I have said, "telling other women to get out of the work force so a man can have their job?" I'm sorry, SD, but you are painting with a pretty broad brush here. The clinician in question is unquestionably NOT someone who should be treating a client with the issues the woman brings to therapy. Are you all saying that he should stick with it? Hang in there and practice on her and hope things will get better? She deserves better. Do I think he is blameless or a saint? ABSOLUTELY NOT! That is not what I or anyone else defending the referral is saying. Is termination or referral painful, hurtful and re-traumatizing? Absolutely. But let me say with certainty, I KNOW personally, that getting out of bad therapeutic situation is vastly less painful than staying, even one DAY, with an incompetent, ill-trained, head-in-his arse therapist.

I sure hope that you can see that your hasty comparison of some of us being positive about the referral of the client as equal to advocating for women stepping aside to let men have jobs in the workforce as a bit of a stretch. That's as if you're saying that I'm "selling out the client"; I am a client myself, and let me say, I don't sell out someone who suffers or feels what I feel about mental health issues. I don't want anyone to stuff what they're feeling emotionally or to "suck up the pain" of not being wanted or loved. I want that woman to be with a therapist who cares about her, knows how to treat her and provides her with a boundaried, caring and knowledable therapeutic setting. If my posts on this site have been anything, they have been about how disappointed I am in how poorly supervised and vetted therapists are in the United States. I don't consider my posts or many of the other posts on this forum that support or see the positives of therapy as "protective." I consider my criticism about therapy as direct and pointed as the next guy, but I don't see it as "black and white" as some of you. I see the good and I see the BIG bad. But I'm not willing to throw everything out just to start over. Better to find the bad, weed it out and build on what is good. But I also know that we're not all going to agree, so I'll agree to disagree.

The irony of it, a mental health professional who can only work with the worried well. Not very confidence inspiring.

You have still missed my point. I was referring to the threads about the poor male therapist who had a female client who was not the nicest person on earth to deal with. My comparison was not hasty at all - and was not in reference general posts as to whether a referral was going to be useful to the client or not - that is not for me to determine and I really don't think for anyone else but the client. I have said many times that I don't believe either side need keep on with someone they don't like or want to work with - like in any other business relationship.
I stand by my analogy.

None of the therapists I've seen claimed to be above others or to be saviors. I don't doubt there are therapists who do. There are all kinds of people out there. But I personally wouldn't make generalizations about the entire profession

If you reread my post, you will see that I did not in fact make a generalization about the entire profession. "Many...[but] not all" is what I said.

Sorry, but I don't think I've missed your point at all; I simply view this issue very differently than you do. No big surprise, right? Personally, I don't believe that either of us can claim that one of us is right and the other is wrong. We can only state our own perception, our own experience or belief. We can only disagree and go from there. We both have a different and very contrasting view of what goes into therapeutic situations, and those beliefs or views are flavored by our personal experiences and in both our lives, our "work" experiences. Each of our work and personal experiences are varied and individual. Because of my own work and personal experiences of psychotherapy, I do not and can not buy into your analogy and I view it as inaccurate and flawed, but I accept that you stand by it. We can agree to disagree. I can't say that your view is wrong because I can not say I have experienced what you have gone through, and you can't say that my view is wrong because of the same. In fact, all of our arguments/discussions on this issue on this forum falls into the same category. We are all correct based on our own experiences and beliefs, and we are all incorrect based on the experiences and beliefs of others on this forum.

I do, however, agree with you that neither side (client vs. therapist) "need keep on with someone they don't like or want to work with". How we might differ is that I feel that the therapist has a greater responsibility than the client to make the "transition" from working with to referring out a client easier and less traumatic. Can it be totally non-traumatic to most clients probably not? The exception is those clients who are totally dismissive and could care less what the therapist feels or wants. But it is the responsibility of the therapist to be cautious, open to negative feedback without becoming defensive, skilled in handling their own personal emotions and the emotions of the client's, cooperative, gentle and caring toward the client. When the client wants to leave--it's perfectly okay for her to do nothing other than cancel the appointment . .. and in some cases, I personally think it's okay to just NOT SHOW UP!

My point was not and still is not what you seem think it was. I know what my point is and I know when a characterization of it is off base. It is not that you simply disagree with what the point was - it is a misunderstanding of the point and therefore the disagreement is not with what I was getting at. Certainly one may disagree with me as a matter of principle on how I view therapy - but that is different from misinterpreting what I have said. And the analogy never had anything to do with any of your specific posts.

ROTFLOL And others say that therapists gaslight.
Sorry but your analogy doesn't fit by any shape or form and no amount of you telling me that I've missed the boat is going to convince me otherwise. Look up gaslighting, we all do it and sadly it works on some. I'm not, however, someone who buys that prize package. I like your posts, but in this thread, you and I are NOT going to agree.

And we obviously don't agree on gaslighting either.
I know what I said, I know what posts I was referring to when I posted, I know I was not referring to the idea of therapists not working with clients they dislike, I know I was not referring to any comment made by you, and I meant what I said and it is relevant to those posts that I actually was referring to. How you take it is just not my problem. Disagree all you want and I will rest easily knowing you are not disagreeing with what I actually was getting at in any way that has been demonstrated this far - other than that you simply disagree with how I look at therapy and therapists. I have no problem with those who simply have a different take on therapy from me.

I also know what the definition of gaslighting is. I know what I said. I know what I posted and I know what I am referring to when I post. I meant what I said when I posted and it is relevant to the original post. How you take it is not my problem. We can and will agree to disagree, and I will rest just as easily as you that we are disagreeing and are unable to reach a compromise.

Historically, I have always liked your posts and I get much from them, and I know that our disagreement will not change that, but it will also not make me feel that I have to compromise how I feel, just as I'm pretty sure that it won't make you change how you feel or think. I also know that I don't always agree with your posts, and I often just walk away from them because I don't want to disagree or get into an argument. But in this case, as much as I HATED the language of the stupid therapist in the article and his description of the "client", I hated even more the thought of him sticking with the client and making her feel small, inadequate, sick, violent and unsalvagable. I wanted her to have something better and the only way she could have that is if the stupid arse therapist referred her out. Sure she didn't want that to happen (we abused clients think that whatever scraps are thrown our way is "good enough), but then if you don't feel abused or victimized, you might not feel that but it's a reality for many people who have been traumatized.

Thanks for talking about the issue rationally and without malice and name calling. Take care.

And neither my analogy nor my disagreement with you are in response to what you just wrote. That is not what my analogy went to, nor do I disagree that from what was written, the client was (from the outside looking in) better off without that therapist.

So...

Essentially it's wrong for a therapist to refer a client early in the relationship because therapy "takes a long time" it's wrong to refer a client later in therapy because there has been a relationship established and it would be too painful to break that relationship. It's wrong to be unwilling to work outside of your given skill set (i.e. Expecting straight CBT therapists to delve into psychodynamics. Got it...

Not directed @ you stop dog, but the general theme that I'm seeing on his thread

I agree you didn't say "all". I was thinking more of posts about the entire profession being bogus