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

Termination and abandonment: A key ethical distinction

For me this article epitomizes the danger faced by vulnerable clients. The client in the vignette is described in language that strikes me as objectifying and remote. Some of the reasoning is sound, but the therapist appears to be making decisions for the client, as if she were a child or a lab specimen. The language is also inordinately clinical and obsessively focused on concepts like "treatment" and "skills", suggesting a level of scientific rigor and control that is a bit delusional (based on my experience).

The central concern seems to be therapist liability. Questions of abandonment are framed as ethical concerns primarily. Whether the client experiences termination as abandonment or not is secondary.

This is relevant for me because my ex T decided unilaterally how termination would be carried out, what additional contact would be allowed, what could or could not be discussed, and finally that all contact would cease. And it was a disaster.

This part says it all:

"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."

It's all about the therapist and their ego and comfort level.

Yeah...I mean, from the last paragraph:

"Few feelings are more distressing to a psychologist than the feeling of being pressured to continue a treatment in which the psychologist feels overwhelmed and ineffective. These feelings undermine a psychologist's sense of well-being and can interfere with a psychologist's ability to provide even minimally acceptable care."

Yes, we must at all costs protect the psychologist's sense of well-being! Sheesh.

I actually think it would be unethical to continue treatment with a client the therapist isn't comfortable with, or doesn't feel competent enough to treat, or similar. It would have a negative effect on the client, and therefore the responsible thing to do is to refer the client to someone else. It is in the best interests of both parties, which is the point that is made in your quote, ATAT.

I recognise that this is a difficult topic, though, because if the client experiences it as abandonment that is very much a problem. But if the alternative is to continue treatment and possibly inflict even more harm that way, what is the therapist supposed to do?

Actually, no, that's not the point of the quote at all as I see it, and it's definitely not the subtext.

Here we have a profession that should be concerned about the well-being of the client. And what strikes me about this scenario is that the psychologist gets to decide everything for the client (with the blessing of the APA ethics board, how nice). Jessica's opinion is not sought; we know she doesn't want to change practitioners. But she is not asked why, nor is she asked how she thinks her treatment with Dr. Berman is going and whether it is helping her. No, it's all about his opinions of the treatment. The client is given no voice.

I have students I feel overwhelmed by just because of the depth of their academic needs. I don't get to refer them out, because it is my job to help them. When you have a profession that is dedicated to the well-being of others, to talk about the well-being of the psychologist while ignoring the (unconsulted) client's thoughts is condescending and rear-covering.

I actually find the article very eye-opening - not about ethics but about the attitude of the profession. And the audience, recall, is fellow mental health workers, not us. The message is, "it's okay to pass on a client in distress, even when they don't want to move on."

Sorry, ATAT, but I have to respectfully disagree with you on this issue. I worked in the educational and mental health system for a looooong time. Believe me when I say that plenty of educators dumped or off-loaded difficult or challenging students all the time, and they could be quite creative in how they did it, not taking any responsibility for getting rid of the student and making the student the one who had the problem. Doctors do this, lawyers do this, mental health professionals do this, businesses do this to difficult or challenging customers, parents do this with their own children . . . the list goes on and on. Does that make it okay? Absolutely not!

But to hold the entire mental health system responsible and the only ones who engage in this behavior does not make sense. I think everyone on this board can pretty much agree that there are some pretty shabby, ill-prepared, stupid, head-up-their-arse, dumb and dull therapists out there and some of them are even charged with training other therapists--almost laughable if it wasn't so sad. BUT, that doesn't make the entire system wrong, corrupt or not workable (In my opinion anyway).

Personally, and I'm only speaking for myself here, if I was seeing a therapist who was feeling "overwhelmed and incompetent" with my situation in therapy, I don't want him continuing to treat me in the hopes that things will improve. Sure getting a referral would sting, but let's be honest, the sooner the ill prepared therapist does this, the better off I'll be. In every situation that I personally sought out therapy, I was overwhelmed and feeling ill-equipped to deal with what was going on in my life, why would I benefit from someone who was feeling the same way as me? And because I was whirling and reeling from the stress, anxiety and pain of my life, how equipped would I be to say to the person who was treating me, "Hey, dude, I think I need a referral. Forget that I just poured my heart out to you and think I'm beginning to trust you, just refer me out!" I think I'd probably stick with the jerk who was doing nothing than agree to trying again somewhere else, even if "trying someone else" might be the best bet for me. No, I don't like anyone making decisions for me, but I sure don't want to be working with someone who doesn't know what the heck he's doing and is going to sink right along with me.

And no, I don't like the attitude of the author who comes across as "covering his a#$" and the a#$ of his colleagues. A good, well-trained therapist who is in over his head accepts responsibility for his incompetency and helps the client make the transition with as much support and ease as humanly possible--but in the end, it will probably still be painful and disruptive to the client, but no more disruptive and painful than if the therapist muddled through with the client for five or six years and no progress was made and he ended up referring her anyway. Just my thoughts on the issue.

ATAT: That is close to my interpretation, and the reason for my post. The actual ethics codes don't say much. To me the article is an elaboration of the thinking behind the cryptic and vague codes, and a glimpse at priorities. Therapist first, client second. Ethics in this context is more about risk management than concern for the client.

Ok to pass on a client in distress… that's the other reason I posted this. Once my T decided we were done, my input was shoved aside. The priority was to maintain the appearance of authority and to avoid breaking the rules, even if it meant I went into total crisis. In the language of the article my T chose to "discontinue treatment and refer me to another clinician with the appropriate skills". She actually spoke like that at one point. It sounds very formal and controlled, but in reality it was just a list of names and an easy escape for her. Smoke and mirrors. Convince me that salvation lay with the hypothetical "next therapist". In plain English it was still abandonment.

In what other job would you want someone to continue to work beyond the level of competence? The notion of that floors me.

I agree that a termination should not occur as an abandonment. The client should be given a measure of control, should be part of the discussion. There should be a time for bringing to a close that former therapy relationship as a new one is established.

But seriously, it goes beyond CYA. There is a point where a person is unable to perform a job, they need to say so. No matter what the job is.

Regarding the language and tone of the report: it was a case study. Case studies present information, they do NOT present emotions, personal details, etc. It doesn't give significant details about the discussion between the client and the psychologist: he could have discussed it with her as a heartless A-hole, or it may have been far more compassionate than it conveyed.

I think if the therapist is willing to blame their own incompetencies and failures and explain to the client that is the reason, then that would at least be something. But really, they are just therapists, not rocket scientists - I think they could suck it more than they are willing to do. And that those guys quite often are trying to make themselves look and feel good and cya.

In the business world, in the '70's, to be promoted beyond your level of competence was called The Peter Principle. Then they started paying techies more money to stay techies rather than having to become managers.

I'm a client whose first clinical psych has to refer out because she was "overwhelmed" and felt "incompetent" about too, though I wanted dearly to stay with her. Like the psychologist in the case study, she primarily worked with clients whose difficulties could be helped with CBT and it became clear that she was beyond her competence level regarding me.

Fortunately I had a relatively good experience with choices to stay with her or her colleague after ex T returned from maternity leave.

I don't like the tone of the article - it doesn't mention anything about the client getting choices or having discussions.

I do however think a T could do harm treating someone clearly beyond their competency. A little beyond could work, but not significantly beyond

It may be worth considering the audience this is written for, therapists working within an ethical framework who need to understand the boundaries of that framework. I wouldn't expect it to be written in client friendly language, more to focus on what is and isn't appropriate under the ethical code while recognising there's a lot of space in the code and different variables that will influence whether a final decision is ultimately ethical.

I suspect that if you read most professional body papers you'd find the same technical, distant language.

Found bad writing to be the article's main issue -- the style / language veer between formal and informal and emotional and distant in a way that seems to induce whiplash.

I do wonder now though if that isn't perhaps symptomatic of how therapists speak / do their work which in turn boggles clients.

This is very nicely put. The vignette reminds me of the toy examples I used to read in epistemology and logic textbooks--it's a very reductive story, all nuances flattened out, intended only to serve one very specific purpose. I'd be very disturbed if every case example looked like this, but that hasn't been my experience reading literature intended for professionals.

In any case, I actually can summon up some concern for the counselor in this vignette. I understand if others don't agree--this is just me--but overturning office furniture on the way out sounds borderline abusive, and it seems awfully unfair to say that Dr. Berman should just put up with it until...when? Jessica just decides to stop coming? If this were Dr. Elderly Lady with 300-pound Linebacker Client overturning furniture, would we feel differently about the right of the therapist to unilaterally terminate (with referral)?

At least, I'd feel pretty bad for my therapist if I walked in one day and found him setting his chairs upright again, and I'd wonder how effectively he could treat me if he left the session before me feeling so helpless and incompetent.

I would not feel bad for the therapist at all if I walked in and found them setting up furniture. I would figure the therapist had done something to provoke it.
And I think feeling helpless and incompetent is good for them - their egos can be over the top. Good to be taken down a peg or two in my opinion.

I am all for no one dealing with another that they don't want to deal with - I just think it better if the therapist admits it clearly and openly that it is their failure and not that of the client. And not go hiding around terms like "in the client's best interest" or couching it in ethical terms that imply they know best.

I have to agree that if a therapist believes they cannot help a given patient, it would be wrong to continue seeing that patient. Termination sounds like the most ethical choice, even if the patient doesn't agree.

The writing isn't great but it's an academic article, I wouldn't expect much.

Yes, it's a case study. But it's a case study chosen deliberately to try to cast a very gray area as black and white.

First of all, how many clients overturn furniture? Odds are this is not the typical client that the scenario of termination/abandonment happens to. The client has been chosen to elicit sympathy for the psychologist in the reader. Easy to identify with him, not so easy to identify with Jessica.

I don't disagree that a therapist who cannot help a client should refer them on. But the case study has other illuminations about the profession:

- they're eight sessions in. We as clients are told therapy takes time, a long time, keep coming back! But a therapist can give up on a client two months in?
- it would have been a much more effective article had Jessica's viewpoint been included more, or if we learned what happened to her (and she's okay). But it is all about the doctor and the reassurance provided him by the ethics board. Which kind of suggests that to the APA establishment it is not about the client - it is about protecting the profession.

Hahaha, maybe Dr. Berman DID provoke it, and that was conveniently left out of the script. And maybe the therapist feels incompetent because they ARE incompetent. I just happen to think even dumbasses reserve the right to unilaterally terminate.

I know I as a client certainly reserve that right. Again - I have no problem with them not working with someone they dislike- but I see it as a somewhat shady business and not medical. If I saw it as medical, I would possibly feel different.

Most certainly well being of a client is the first priority.

But therapist is entitled for some safety on the job. Clients throwing furniture around and acting otherwise violent makes t unsafe. Alone in a room with aggressive client. Does their life have value too or just clientele's?

The way this client is described she might need to be hospitalized plus she isn't getting any better, perhaps talk therapy isn't effective method with clients in distress and she isn't responsive to CBT either.

T is being observant and honestly admits that he is unable to help her he is not competent on treating this particular patient and referral to more appropriate therapist might be the best. Client doesn't want to stop seeing current t despite the fact that she isn't getting any better and in fact remains suicidal. Should t continue seeing her just because she doesn't want to stop or because she cries or throws things around? It doesn't sound like good enough reason. It isn't helping her to keep seeing this t.

Somewhat cold tone of an article might be off putting if it was meant for distressed patients. But it's a case study for professionals. Yeah it is bad writing. But it's not meant to make clients feel better, it's written for professionals not for clients

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The T here is described as practicing CBT, which is supposed to be a short-term therapy focused on improving present coping techniques. The client sounds like she's very troubled and isn't really engaging with CBT. It's sort of like he's prescribing exercise for cancer. It's not going to work and he knows it.
Of course the APA is about protecting the psychologist. It's a professional organization for psychologists. The article might have been more effective for you if it were about the client, but it's written about by, for, and about psychologists, not for clients.

The article is all about taking care of the therapist with absolutely no concern about effect on or continuity to the client. She's merely the threatening beast refusing to be tamed.

We never know how closely these case studies follow the truth, if they're true all. It does however reflect the obliviousness toward clients in almost all the professional literature I've read. The client is an object, a case or a pathology.

I agree the article isn't exactly dripping with empathy for Jessica, that the characterization is flat and one-sided, that it's primarily about the clinician....But I don't know that there's a complete lack of concern for the client here. It's nothing like the reaction Jessica would get in other settings.

I mean, I got into an argument with a self check-out machine once (long, embarrassing story...I wasn't in a good place) and I don't think anybody in that grocery store was thinking "Wow. This makes me feel totally incompetent and helpless. That person must feel trapped and unable to bring about change in her own life. I think she needs more help than I can provide."

I think they were thinking, "Get out of my store, you crazy *****!" You know, because that's what they said.

It is interesting to see the urge to help protect those guys more and justify their assholic ways- particularly when they have it set up so that they already are protected in many ways. I find it like women telling other women to get out of the work force so a man can have their job.