Given the complexity of the therapist-patient relationship, this brief review can only point to particular known trouble spots; it cannot cover the entire issue comprehensively. However, the ubiquity of this problem in leading to trouble for therapists requires at least a warning.
All of us who strive to be good therapists want to be helpful, to stick with the patient through the rough times, to finish a job once begun, and to assist the patient in meeting his or her clinical needs. But we cannot help everyone, and in some cases, we may need to stop. Breaking up is, in fact, hard to do, especially in a field that is largely based on sustained relationships. At certain points, however, it is necessary. Not everyone can treat everyone; not everyone can be treated. Awareness of the issues noted here may be helpful to clinicians struggling with essentially irreconcilable differences with their patients. Section 6 of the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry states10:
A physician shall, in the provision of appropriate care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide care.
Similar provisions are contained in other behavioral health specialties.
One approach has the therapist describe a treatment plan at the outset of therapy that requires such basics as on-time sessions, limited phone calls for emergencies, release of prior records, and a boundary-respecting approach going forward. The patient’s consent to this plan is sought (and usually given). If the plan is violated, the therapist explains that the patient is violating the agreed-on treatment plan, and the therapist cannot continue to provide treatment under those conditions. Such an approach makes informed consent the heart of the contract, as it should be.
The avoidance of consultation is a particular problem. We all have some hesitation in exposing our work to scrutiny, but the importance and clear value of consultation, not only as advice but also as protection, should be stressed for trainees and encouraged for peers among practitioners. Whether or not one consults through fear, one should never fear to consult. A patient who refuses to consult should be strongly urged to follow that advice. (Comparably, a patient should consider terminating with a clinician who refuses to consult.)
A point sometimes lost sight of by clinicians in crisis is this: if you realize you are practicing, by whatever means, below your own standard of care, you cannot defend your practice as being above the needed standard of care. No matter how far you fear you have gone astray, it is never too late to change your ways in the service of the patient’s welfare.
Few things are as valuable in the situations described as advice from an experienced health law attorney—preferably one who is familiar with psychiatric issues. In addition to valuable advice, an attorney can write termination letters to patients and intervene if the patient refuses to stop, threatens, calls excessively, or fills up your answering machine to a degree constituting harassment or other criminal acts.
In sum, clinicians must realize that in some cases, the best therapy is letting go.