Cases that come to our attention as malpractice claims, ethics claims, or Board of Registration complaints raise the question: why did the treating clinician not terminate the treatment before things got so out of hand?
The answers to this question embrace a wide range of issues, including rescue fantasies; beginners’ errors; transference/countertransference impasses; the drive or need to complete a task once begun; power issues; conflicts around abandonment; and narcissistic, sadistic, or erotic dynamics in the therapist and/or the patient. Often these difficulties play themselves out through boundary violations. Moreover, patients may, in some cases, employ a variety of strategies aimed at resisting termination, including threats of suicide, violence, or litigation and other forms of complaint.
Termination is the appropriate ending of therapy, but also it challenges the emotions of both parties in the dyad.1-5 We focus here on the therapist’s problem, recognizing that the particular chemistry of the dyad may be the wellspring of the issues leading to the impasse. Therefore, although patients may have difficulty in leaving treatment, this analysis addresses the matter from the therapist’s side.
Long-term treatment is not inappropriate, although it is difficult to achieve in today’s environment. The point is that treatment at impasse may be inappropriately prolonged under certain conditions—conditions that may lead to various forms of medicolegal trouble.
The case presented here is a composite of actual cases encountered by the authors. Although the case features a patient who has a personality disorder, termination problems can occur with a broad spectrum of conditions.
The italicized sections in the case are intended to indicate those ideas and postures that were pivotal tothe bad outcome, but the issues, of course, spread far wider than this one example.
Ms J is a 42-year-old married woman with recurring and persistent depression. She tells her psychiatrist, Dr S, that she terminated treatment with her 2 previous therapists out of frustration because they did not give her enough support and did not understand her depression adequately. She refuses to give Dr S permission to contact any previous treater, anxious lest those records “poison” this treatment. Dr S feels there is no patient he cannot treat, records or not, and decides to rescue her from her current depressed state that has apparently been mishandled by previous treaters. He agrees to treat her in his private home office, accessed by a separate entrance in his house. Ms J frequently passes, and interacts with, Dr S’s children as sheuses this entrance.
Early in the therapy, Ms J tells Dr S he is a miracle worker who, she hopes and prays, will never abandon her. Dr S, willingly accepting this description of himself, repeatedly reassures Ms J that he would never think of abandoning her.
Over time, Ms J demands that Dr S run over sessions if she is late, switch her session time to late in the day, and come to her house for a session—later, for every other session. After refusing all these requests at first, Dr S ultimately agrees to all of them, wishing not to be the disappointing therapist like her previous treaters. On one visit, she offers him wine, which he first refuses, then accepts. When she invites him to swim in her pool, he decides he should leave. He considers ending the therapy but feels that he should see it through, especially because of his patient’s obvious sensitivity to abandonment.
Invited in a demanding manner to visit again on a later occasion, he refuses on ethical grounds. The patient, enraged and arguing that she can only be treated in her home environment, states that, after all, he did come over before and if he really cares, he will come over again. When he does not do so, she leaves multiple messages stating that if he does not immediately call back, she will take her own life. Dr S rejects the idea of consultation because he perceives it as a sign of weakness. When he calls, she denies that she meant her threats and states she is “testing his loyalty.” She reminds him pointedly of all the sessions that ended with mutual hugs and of all the letters and e-mails signed “Love,” as though to say, “You’ve come this far . . .” Dr S decides to consult his insurer’s attorney.
Dr S writes the patient a letter indicating that because her calls and harassment have made the therapy unworkable, he believes it will be in her best interest to move on with another therapist. He offers 3 termination sessions and a 30-day supply of medication. The patient’s return letter is filled with recriminations, threats, reports of consultations with other therapists and plaintiffs’ attorneys, and reminders of his promise never to abandon her. Not so subtly, she threatens him with Board of Registration complaints, civil suits, and claims of ethics violations. She begs him to continue treatment, promising changed behavior according to his rules; if he refuses, he can discharge his obligations by a letter of apology and a full refund.
No specialized training is required to recognize how soon the situation in the case presented here spiraled out of control. Clearly, when the decision to terminate comes very late in the game, it often fails to “take.” We repeatedly encounter factors that delay the decision to terminate—even when that response is the only remaining appropriate one.6
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4. Martin ES, Schurtman R. Termination anxiety asit affects the therapist. Psychotherapy. 1985;22:92-96.
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6. Gutheil TG, Brodsky A. Preventing Boundary Violations in Clinical Practice. New York: Guilford Press; 2008
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8. Gutheil TG. Medicolegal pitfalls in the treatmentof borderline patients. Am J Psychiatry. 1985;142:9-14.
9. Norris DM, Gutheil TG, Strasburger LH. This couldn’t happen to me: boundary problems and sexual misconduct in the psychotherapy relationship. Psychiatr Serv. 2003;54:517-522.
10. American Psychiatric Association. The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Arlington, VA: American Psychiatric Publishing; 2010.