Years ago, when I was in graduate school, there were no discussions on this subject. I don’t know if there are any now, but all of us who have practiced for any length of time have come face to face with situations where we have needed to end therapy without it being a mutual decision. While clients can and do terminate therapy unilaterally without the burden of ethical constructs or constraints, therapists must be guided by ethical justification for doing so.
Just how do we address this issue with ethical decision making in mind? While there are certain specific guidelines that can aid in deciding how best to have therapy come to an ethical end, remember that ethics are almost always a moving target.
As an example of this, many years ago I was seeing a family in therapy with whom I was struggling to make any progress. They had a pattern of not doing any work and I was increasingly frustrated to the point of not wanting to see them any more. I felt I was not helping them and was at a loss for how to proceed with termination without abandoning them, which as we know is a violation of AAMFT’s Code of Ethics (2015). I chose to get a consultation (always a wise choice when stuck) with my partner. He suggested a very provocative approach, stemming from our Whitaker training. His suggestion was for me to act, rather than talk, with them about why they were not doing work, as that had not produced any therapeutic movement.
In the subsequent session, when work was not being done, I chose to turn my chair around so I had my back to the family and began to do some paperwork at my desk. This provoked a question from the mother as to what I was doing. I replied that if they were going to choose to not do any work, I was going to get something done. The mother responded as I guessed she might by becoming quite angry and leading the family out of the room. Two days later, she called to apologize for her overreaction, as I hoped she might. This was the first time she had owned any of her actions. The upshot of all this was that it became a seminal moment in our work together, as any time they struggled to get some traction in therapy, all I had to do was remind them of that time when…
While some would surely question the ethics of turning one’s back (literally and figuratively) on our clients, this maneuver was productive. It most certainly could have gone the other way. In a crazy way, the metaphorical statement of “I am willing to take a risk; will you?” got us unstuck. I risked the possibility of doing harm in order to do some good. Some would surely take me to task for violating the principle of first do no harm. Truly an ethical dilemma!
In determining how to end therapy when a mutual decision cannot be accomplished, we can use both Ethical Rules and Ethical Principles. Ethical Rues include the AAMFT Code of Ethics. Ethical Principles are the five values of autonomy, nonmaleficence, beneficence, fidelity and justice. Autonomy is the right of the clients to make decisions about their involvement in therapy. To some degree, this is also about the right of the therapist to evaluate and implement interventions that promote growth and health of clients.
Nonmaleficence is about doing no harm. Interventions must be weighed with the potential benefit outweighing the potential harm. Beneficence is about decisions that will promote growth and health, keeping in mind that some decisions may be beneficial to some, but not all. Fidelity is about being loyal, keeping confidences and being respectful of each person’s rights. This is an essential ingredient to therapy, as no bonds can be formed without this. Justice is about fairness and treating people as equals. Combined, these five core principles and the Ethical Rules make up the ethical justification for decision making when it comes to termination of therapy.
There are other significant principles to consider, as well as deciding if unilateral termination of therapy is ethical. Theses include non discrimination, informed consent, multiple relationships, non abandonment and dual relationships. Additionally, there may be situations that arise that lead to unilateral termination of therapy, such as practice changes, illness and other unforeseen events. It is important to keep in mind that as a therapist, deciding to end therapy without it being a mutually arrived at decision, one should remember the non abandonment part of the AAMFT Code of Ethics and make a referral whenever possible. Clearly, the decision to end therapy without the client’s agreement is fraught with potential ethical issues.
One very concrete step to take before doing so is to seek and get a consult from a trusted colleague, as well as consult the Code of Ethics. Lastly, review the five values of Ethical Principles.
In determining how to end therapy when a mutual decision cannot be accomplished, we can use both Ethical Rules and Ethical Principles.
Carl F. Greenberg, MS, is an AAMFT Clinical Fellow and Approved Supervisor in Spokane, WA. He is a member of AAMFT’s Ethics Committee and a past board member.
REFERENCES
AAMFT. (2015). Code of ethics. Retrieved from www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx\
ADDITIONAL RESOURCES
Zygmond, M. J., & Boorhem, H. (1989). Ethical decision making in family therapy. Family Process, 28, 269-280.
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