Vignettes and Comments by Catherine Atkins, JD, Staff Attorney

Responses to Vignettes by Marion Barnett, George Taylor,
Lenore Hunt and Helene Shortwell

The The Therapist
July/August 2009
(Updated October 2012)

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In the January/February 2009 issue of The Therapist, hypothetical situations involving the termination of clients were represented in four vignettes. Members were invited to respond to a set of questions analyzing the potential ethical/legal issues reflected in the vignettes, and to comment on the availability of options for each of the therapists depicted in the vignettes. CALMFT would like to thank all members who provided answers for our consideration. The best overall responses to each vignette are provided here, along with our additional comments.

Vignette No. 1
LMFT has been working with Michelle (age 30), two times a week on issues of depression. Michelle was diagnosed with recurrent major depression. At the onset of treatment, Michelle reported suicidal ideations and one suicide attempt. Over the last three years, Michelle’s symptoms have significantly improved. However, four weeks ago Michelle lost her job and has begun discussing her lack of luster for life. Although Michelle stated she didn’t have a suicide plan, she admitted that she thinks about “ending it all” every few days. Also starting four weeks ago, Michelle’s checks have begun to bounce. Because Michelle is seen twice a week, LMFT is losing hundreds of dollars and is having trouble making the rent payment. LMFT had decided to terminate Michelle due to non-payment and when LMFT told Michelle, Michelle indicated that if she couldn’t see LMFT she would kill herself. LMFT agreed to see Michelle two more times for free, but at the end of the second session Michelle again stated that if she couldn’t continue counseling, she “would end it all tonight.” LMFT suggested other referrals, but Michelle refused to take them. LMFT evaluated Michelle for suicidal ideations, but Michelle would not answer specifically. Michelle stated “I’m afraid of not seeing you anymore. You’re abandoning me.” LMFT decided that based on her financial situation she would have to terminate Michelle and told her so. Michelle ran out of the office crying. LMFT attempted to contact Michelle over the next few hours, with no response. Because LMFT did not have any emergency contact information for Michelle, LMFT called the police to suggest a wellness check. LMFT remains confident in her decision to terminate Michelle.

Vignette No. 1 Answer
Response by: Marion Barnett
The issue of the client’s bounced checks may be a clinical issue that needs to be explored in her sessions. Did LMFT talk about this issue with client? Did LMFT offer community resources that might assist client with financial issues? Did LMFT reassess fees and offer to lower fees temporarily while client was unemployed given the fragility of the client as well as the long term relationship LMFT has with the client? Did LMFT reassess the need to see client twice a week? Did LMFT seek supervision from a colleague for guidance?

It is reasonable for LMFT to be concerned about bounced checks because as a professional, it is reasonable that LMFT be paid for services rendered. While it is ethical and indeed, important to discuss with the client the importance of payment of services, it would not be ethical to terminate purely because of LMFT’s own financial issues.

The vignette stated that the LMFT did attempt to refer client out and client refused to take referrals. I would have also sent client a letter to reiterate this fact and to give client the names in writing. I would keep a copy of the letter as well as document in detail the attempts in session to refer as well as the discussion the LMFT had with client regarding the need to pay for services. It is ethical to refer out and terminate due to non-payment but LMFT did not terminate because of non-payment but because the non-payment was creating her/his own financial issues. The LMFT, it seems was unable to differentiate from her/his own issues and the business issue of a reasonable expectation of payment for services.

The last issue of concern is a legal and ethical one. On the last day that client saw LMFT client stated that she would “end it all tonight” if she could not continue counseling, that she was “afraid of not seeing LMFT again and “(she) was being abandoned.” Because the client’s history of depression, past suicide attempt, and statement that she would “end it all tonight,” it was ethical and legal for LMFT to call police. If LMFT had gotten emergency contact information, though, that call would not have been necessary.

Comment to Vignette No. 1
LMFT’s decision to terminate patient was inappropriate and ill-advised for several reasons.

LMFT had established a very intense relationship with patient, based on the fact that she had been seeing patient for over three years at the rate of twice per week. Given that background, LMFT would be expected to work with the patient according to a more gradual termination plan and to help the patient with the obvious and expected abandonment issues. It was unlikely that the LMFT would have much success referring this patient in so abrupt a manner and she could have and should have, sought clinical consultation if she was uncertain about how to address these difficult issues.

CALMFT Ethical Standard 1.3.4 states that a LMFT should not terminate patient relationships for non-payment of fees except when the termination is handled in a clinically appropriate manner. LMFTs are not expected to work for free, but there will be situations in which the therapist will have to continue treatment (even if it is without payment) until the patient is out of immediate risk, or in a safe environment. This was one of those times. The timing of termination was premature given the facts of this particular client’s case. The motivation for termination appeared exclusively financial, which was especially inappropriate in light of the severity of this patient’s condition.  

Although the patient did not directly state "I'm going to go kill myself" during the last session, based on client’s history and erratic behaviors, it was likely wise that LMFT called the police. With that said, as Marion Barnett pointed out, had LMFT obtained emergency contact information for the client, LMFT could have possibly called the emergency contact rather than the police in this situation. It may have been more clinically appropriate in this situation to call spouse or parent rather than 911.

Vignette No. 2
LMFT and Lili have been working together for six months. LMFT’s working diagnosis for Lili is severe bulimia and borderline personality disorder. Over the last six months, Lili has ignored the treatment plan and has occasionally missed some appointments. LMFT has discussed with Lili, on numerous occasions, the reasons that ignoring the treatment plan can be harmful and is unacceptable. Feeling frustrated, LMFT finally explained to Lili that because she was not following the treatment plan, as well as the missed appointments, LMFT would need to terminate Lili. Lili stormed out of the office stating she hated the LMFT and would make a complaint to the BBS. Over the next two weeks, LMFT received twelve calls from Lili asking to come back and stating she would comply with the treatment plan. LMFT agreed. Almost immediately, Lili again stopped complying with the treatment plan, and reports continued binging and purging. This behavior of non-compliance has continued for another six months, but LMFT has decided to keep seeing Lili stating "some therapy is better than none."

Vignette No. 2 Answer
Response by: George Taylor
Here therapeutic issues overlap with ethical considerations. Borderlines need to be taught how to contain their chaotic feelings, and they need to operate within limits and boundaries. The LMFT has lost control of the therapy.

Theoretically, LMFT made the right move in explaining to Lili the consequences of not following the treatment plan. Unfortunately, LMFT was unable to follow through, because she was intimidated by client's threats. She therefore taught the borderline that threats were a good way to get people to do what she wants. Ethically, LMFT should have followed through on the termination of treatment due to CALMFT Code 1.3.1: “Reasons for termination may include…the patient is not benefiting from treatment.” Individual therapy with this therapist is not working for this client. Her repeated acting out is proof of this statement.

She needs to take a commitment to a deeper form of therapy: inpatient, individual plus group, individual with more sessions, and/or medication. The therapist must make these recommendations and referrals and be able to tolerate her own fear. The LMFT has inappropriate boundaries with the client. Her fear and enmeshment are contaminating the treatment plan.

The vignette doesn’t mention LMFT seeking consultation or legal support for her actions and decisions. One option I have found to be helpful is to consult with other therapists about how they would handle this situation; of course, confidentiality must be maintained. It is important to maintain clear case notes of decisions, treatment plans and consultations and referrals in cases like this.

Comment to Vignette No. 2
First, LMFT needs to learn to explain, follow, and maintain clear boundaries in working with patient. Second, some therapy is not always better than none. The treatment plan is clearly not working. Possibly it is the patient’s trust of the LMFT, the treatment plan itself, possibly the patient’s issue is outside LMFT’s scope of competence, the patient has not made a commitment to therapy, or maybe the patient needs a higher level of care. Regardless of the reason, LMFT should have referred out this patient when it became clear that the patient was unlikely to benefit from the treatment. As George Taylor pointed out, CALMFT Ethical Standard 1.3.1 states that reasons for termination may include…the patient is not benefiting from treatment.

Vignette No. 3
LMFT has been working with Jimmy (age 14) on a weekly basis for nearly eight years. Although Jimmy had a history of serious behavior problems, he has responded so well to treatment, his parents insist that LMFT keep the relationship going. LMFT doesn’t see any continued behavior problems, but the parents seem reassured by the relationship and LMFT believes terminating Jimmy would upset the parents. Therefore, LMFT decides to keep seeing Jimmy on a weekly basis.

Response by: Lenore Hunt

Assuming LMFT is using sound clinical judgment in determining that Jimmy is no longer benefiting from continued therapy, then the LMFT is in violation of Ethical Standards Code 1.3.1 Termination in which it is stated, “Marriage and family therapists use sound clinical judgment when terminating therapeutic relationships and do so in an appropriate manner. Reasons for termination may include, but are not limited to, the patient is not benefiting from treatment; continuing treatment is not clinically appropriate . . . ."LMFT may also be in violation of Ethical Standards Code 1.7 Patient Benefit, in which it is stated “ . . . .Marriage and family therapists continue therapeutic relationships only so long as it is reasonably clear that patients are benefiting from the relationship."

"Appropriate manner" would include incorporating Jimmy and his parents in the termination process rather than just discontinuing therapy with Jimmy or continuing therapy to suit the needs of the parents. The termination process would enable Jimmy to continue his progress and learn to make sound decisions concerning his self-care. Working with his parents would allow them to become accustomed to their relationship with their son without the therapist involved. Referral to a parent support group to help them through this process, or continue sessions on their own with Jimmy’s therapist or another therapist would be both appropriate and beneficial to the parents and Jimmy. LMFT, however, should not continue therapy with Jimmy if he is not benefiting from the therapy.

Comment to Vignette No. 3
It seems that LMFT is continuing treatment solely for financial gain. Clearly continued treatment for the child is not necessary or appropriate, and the therapist’s motivation for continued treatment may be called into question. As Lenore Hunt mentions, giving references to parents for some sort of parent support group or parenting skills may be worthwhile here.

Vignette No. 4
LMFT has been doing couples counseling with Cindy and Bob over the last year. Recently Cindy has been missing sessions on an increasingly frequent basis. Cindy finally called and left a voicemail that she no longer will be coming to therapy. Bob indicates that he would like to continue with his own individual treatment anyway and LMFT agreed. LMFT and Bob’s sessions tend to revolve around his marriage, his infidelity, and his desire to divorce. In one session, Bob admitted to being attracted to LMFT. Cindy recently called LMFT and demanded that either Cindy be able to return to couples therapy, or LMFT stop seeing Bob as a patient. LMFT decided not to see Cindy since Cindy is no longer LMFT’s patient. LMFT also determined that because Bob’s issues are within her scope of practice, and because the attraction issue is not really a problem, that termination is not necessary.

Vignette No. 4 Answer
Response by: Helene Shotwell

At the time of intake, a clear communication on couples in therapy, and the conditions surrounding it would have been appropriate. The communication would have included referral for individual therapy if needed, and this LMFT would work with them as a couple only. LMFT was clearly inappropriate in her dismissal of client’s attraction in light of his history of infidelity. Cindy was still legally and ethically a client as part of the couple and it was inappropriate to abandon her when she wanted to return.

Inappropriate boundaries were set up when individual therapy was agreed upon for Bob when he was still part of the couple as client. The course of action would have been referral for individual therapy to another therapist for Bob. When Cindy asked to return, it would have been appropriate for LMFT to continue to see the couple or refer them both for couple’s and/or individual therapy.

Comment to Vignette No. 4
This is a disciplinary action ready to happen! First, blowing off the husband’s attraction is clinically inappropriate and professionally unwise. Processing the attraction would have been a good next step and then, depending on the conclusion, determining whether termination and referral was in order.

Second, there is no law that states that you cannot switch from husband/wife as “client,” to husband as “client”…but with that said that kind of change in “client” needs to be assessed for risk. What kind of boundary issues does it call into question for husband, wife, and therapist? Will there be loyalty issues that husband or wife throws into the therapist’s face? What about client files? How does therapist separate out what was discussed in couples’ therapy with what is discussed in individual therapy? This kind of change in “client” can be beneficial and accomplished ethically if the therapist is well-trained, has good boundaries, and is cognizant of the law. If not, like in this case, it could lead to a lawsuit, or to a complaint with the Board of Behavioral Sciences or CALMFT’s Ethics Committee.

Third, although wife stated she no longer wanted to come to therapy, she should not be cast aside by therapist so easily. LMFT is not obligated to again see wife, but giving referrals for individual therapy, or processing the reasons for termination may have been clinically appropriate.

This was a model of how not to handle a client situation.

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Catherine Atkins, JD, is a Staff Attorney for CALMFT. She is available to answer member calls regarding business, legal, and ethical issues.

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References

1 Portions of members’ responses were used versus in entirety.