How to ethically discontinue therapy with a client

Staying on with a client after the professional relationship has maxed out its useful lifespan doesn't help anyone. Sometimes, a sense of commitment and unbridled optimism can leave us in situations that aren't working. I struggled with a sense of guilt the first time I needed to discontinue sessions with a client. However, I've since learned that there are ethical, effective ways to discontinue therapy with a client that can make the process far less uncomfortable. It takes support and professional discernment. And that's exactly what I'm going to be covering today!

8 reasons why you might need to terminate a therapy client

There are distinct reasons why therapists sometimes need to discontinue client relationships. It's necessary to acknowledge when a client's care needs exceed our capabilities. We may also need to protect ourselves because we've been threatened or treated with hostility. I want to quickly go through common reasons why you might find yourself in the situation of needing to draft up a patient discharge letter (even when the client doesn’t feel they are ready for discharge).

1. You've been threatened by the client

Did you know that 81 percent of private practitioners have experienced being either verbally harassed or physically attacked by a client during work? Client violence is an occupational hazard that therapists need to talk about more. I often wonder how many of us stay engaged with clients far too long after we've been victimized – perhaps it is simply because as tough as it is, we see it as "part of our job."

If you work in an institutional setting, protocols are in place for addressing client threats. However, independent therapists often feel unprotected against client threats. The APA Ethical Principles of Psychologists and Code of Conduct specifically allows for the termination of therapy in potentially dangerous situations. According to Section 10.10(b), termination caused by a potentially dangerous situation exempts the therapist from the usual requirements of pre-termination counseling and referrals to alternative service providers. 

Depending on the specific circumstances and your comfort level, you may even choose to refer a client to a higher level of care – which can include an inpatient program or day treatment facility.

2. Their needs are outside of your therapy scope

There may come a time when a client's needs don't match your qualifications. One common reason why therapists may need to discontinue therapy with a client is because they are not trained to treat a particular issue. If the client's needs are beyond your scope of expertise or training, the only ethical thing to do is to transfer or refer the client to more appropriate treatment. 

For example, you may discover as time goes on that a client who was referred to you for depression is also suffering from an eating disorder. If you don’t have training in eating disorders, it would be ethical to refer the client to another therapist who specializes in this disorder. 

Additionally, a client may express that they want to move forward with a mode of therapy that you are not trained to offer. A common example would be a client who wants to try EMDR therapy. If you are working with a client who wants to pivot to specialized care you don't offer, work within your power to recommend a local specialist with the proper training and credentialing plus seek ways to continue or combine treatment modalities, if possible, of course.

3. You have a crush on your client 

Don’t fret, this may feel embarrassing, but it happens to many therapists! The first step would be to talk with your clinical supervisor so they can help you work through any countertransference issues. If you are not able to work through this issue in clinical supervision, then it would be appropriate to refer your client to another therapist. (Whether you want to ask them out after that – well, that’s a whole other blog article, but at least you’re now not ethically compromising yourself or their healing.

4. They didn’t pay for your services 

In my experience, this can be one of the most uncomfortable circumstances for terminating a client relationship. It's a tough one because we know better than anyone that late bills can create stress for clients who are already struggling. This is a scenario that we need to be prepared for based on whether we choose to accept insurance or remain out of network.

You may think that you're doing your client a favor by keeping a nonpayment issue "between the two of you." However, you also know as well as I do that you need to keep the lights on at your practice. I'm here to remind you that this is one instance where you really need to keep your business hat on instead of your "compassionate therapist" hat.

Discernment is needed. If a client isn't paying on time, a therapist has the right to suspend or discontinue treatment. You are under no obligation to provide service for free. However, you are required to end the relationship formally with the right channels to avoid allegations of abandonment. Disgruntled clients will sometimes retaliate with phony licensing board complaints when therapists bring up the topic of nonpayment or send accounts to collections. Therefore, make sure the client has the appropriate referrals (including for emergency mental health services) if you have to discharge them for non-payment. 

As therapists, we deserve timely payment. If you're like me, the payment portion of being a therapist can be tricky because we truly wish that everyone could receive the care they need without the cost being an issue. 

5. You’ve decided to change professions 

You’ve made the decision to switch career paths after coming to the realization that the field of mental health just isn’t for you. Or, perhaps you want to pursue research and academics instead. Whatever the reason, it’s important to ethically discharge your clients when you decide to leave the field. Advance planning is the key in this situation. Give adequate notice to all clients and make sure you make the necessary referrals to another provider. 

6. The client isn’t making progress 

Sometimes clients are not making progress in therapy. There could be many reasons for this. They may be resistant to change. Some clients are not ready and are resistant to therapy. It could be that a family member is pressuring them into coming to therapy. Or, it just may not be a good therapeutic fit between you and the client. Whatever the reason, if the client is disengaged in the therapeutic process, they won’t make progress. 

They may say they still want therapy, but if they aren’t following through on recommendations, it might be time to refer them to another therapist or level of care. Whichever the case, make sure you clearly document your reasoning (hint: Upheal is a great tool to help you with this). 

7. You are moving to a different state (or country)

If you are moving to a different state, your client might be able to still do sessions with you if you are licensed in their state. However, they may not want to do online sessions. Perhaps they feel more comfortable in person. This would be an ethical reason to discharge a client. In addition, if you’re moving countries, you’ll have to look into how well your psychology qualifications transfer (or not) to your new place of residence.

8. You're burned out and need to downsize your client list

You’re emotionally exhausted and not functioning at your best professionally or on a personal level. You need more work-life balance but don’t want to stop seeing clients altogether. However, you have realized that you definitely need to reduce the number of clients on your caseload. So how do you decide which clients to keep? One strategy is to discuss this with your clinical supervisor and consider: where each client is in their healing journey, who you feel the most able to help, who is a high-risk case, and who could easily be referred to trusted colleagues of yours. Make sure you follow all the proper avenues to discharge the rest based on the below tips. 

How to terminate a client ethically: 7 tips for making the process easier

I am the last person to advocate for abruptly terminating clients unless we're sure that there's truly no other solution. When you've discerned that discharging a client is the correct choice, it needs to be done right. The first thing we need to talk about is the difference between discharge and abandonment. 

• Discharge is simply the end of the professional therapy relationship. At some point, the client will be discharged from therapy or see that the relationship has naturally come to a close and wish to discontinue it themselves. 
• Abandonment occurs when therapy is ended in an inappropriate manner. An example would be refusing to continue to see a client without justification or preparation.  

As a therapist, the thin line between the two is defined by your ability to make necessary arrangements, such as referring clients to another mental health provider within a reasonable amount of time.  

1. Begin the conversation at the start of therapy

What are the therapy goals? How will you know when treatment is over? 

I learned in my years of practice that talking about discharge from the start made the patient feel more comfortable with the idea that there would be a point when we parted ways. If possible, avoid surprising clients with discharge. 

I would also recommend reassessing where therapy fits in with the patient's overall goals, periodically. Review treatment goals and re-assess them regularly to determine if the client is still benefiting from therapy. Or rather than discharging altogether, you might set new therapy goals once the client has met current ones. 

2. Don't be afraid to refer

Start talking about referrals the moment you realize that your client needs something you don't offer. Ensuring that your client is getting appropriate care is part of your ethical duty. There's also some nuance here. 

One hard pill for me to swallow in my practice was that clients sometimes weren't making the progress they needed even though their needs were within my professional scope. Maybe I just wasn’t the right therapist for them. Have a tough conversation with your client if you feel like you're not the best person to help them. There's a good chance they have been too afraid to risk offending you even though they feel the same way.

Once you've agreed on the referral with your client, there is an ethical process to follow. Don't just choose someone from your network that you deem as best for the job. Seek out different referral prospects based on the needs of your client and then present them to your client so that they can self-determine which therapist is the right fit for them.

3. Emphasize positive growth

Some clients feel intense rejection and blame when a therapist tells them it's time to move on. I always started the conversation by highlighting the positive growth I'd seen. Focusing on the gains reminds clients that there is so much more to be gained.

Go over the treatment goals that have been met and highlight meaningful breakthroughs as you break down your reasons for discharging your client.

4. Consult with colleagues

It can really feel like you have the weight of the world on your shoulders if you know you need to discontinue therapy with a client. I highly recommend consulting with your colleagues or a clinical supervisor to assess the ethics of your situation. This is especially true if the client at hand is either at risk for suicidality or going through a life-endangering crisis. If you don’t have a clinical supervisor, you can find one on Psychology Today. Just type in Psychology Today clinical supervisors for therapists and a list of ones near you will pop up. 

5. Be honest 

It’s extremely important to let your clients know why you need to refer them out to another therapist or a different level of service. If you think that it's time for a discharge because they have met their treatment goals, clearly go over this with them, or renegotiate new therapy goals. If, on the other hand, your reasons are more complicated, such as you have a crush on them or their healing is not progressing, be discerning and careful as you explain to your client you are not the best fit for them anymore. As therapists, we must remember that we’re still speaking from the therapist’s position of power – it is important to model healthy communication and walk our talk in addressing everything to do with the therapy room in a way that is beneficial and mindful of, the client’s healing. 

6. Use a termination note template 

One way of making this difficult situation easier is to use a termination note template. This will ensure a smooth transition for your client. If you’d like an automated AI termination note template, good news! Upheal is working on this as we speak. It will capture all termination-related data from your sessions to create a version of the note that you can adjust as needed. All you have to do is review and approve!

7. Leave the client with resources

During the last session, make sure you provide your clients with plenty of resources and let them know how to access 24-hour crisis emergency support, as well. Provide them with the names of colleagues they might be able to work with, community mental health centers, online videos, and any other resources you find useful. This is incredibly important and if you know that your client has had abandonment issues in the past, provide this information well before the last session. 

Final thoughts: discontinuing therapy doesn't have to feel good to be ethical

I don't know a single therapist who doesn't feel terrible when they need to discontinue therapy due to the issues pointed out above. It can feel like cutting off a person when they are at their most vulnerable. Even situations where it's obvious that both parties are ready to part ways can still feel uncomfortable when you're the one to initiate.

However, try to keep in mind that ultimately, you are attempting to do the best thing for your client or yourself. And sometimes, the realizations that come through this very process are extremely helpful as a continued source of growth in the next phase of your or your client's healing journey.