Ethics Rounds

Distinguishing abandonment from termination can be central to understanding what constitutes ethically responsible client care in difficult cases.

"Ethics Rounds" received this vignette from Janna Koretz and Carrie Murphy, two former practicum students at the Massachusetts Mental Health Center in Boston:

Dr. Berman has been seeing his client Jessica for eight sessions. Jessica was initially referred for complaints of difficulty managing anger, difficulty with interpersonal relationships and depression.

As the sessions progress, Dr. Berman realizes that Jessica has very high suicidal ideation and multiple plans to kill herself, although without apparent intent to carry them out. She has no history of attempts, but the seriousness and frequency of Jessica's suicidal threats have been increasing over time. During sessions, Jessica refuses to focus on anything but her suicidal thoughts and when Dr. Berman begins to suggest tactics for coping, Jessica erupts in tears and has outbursts. On two occasions, Jessica stormed out of the session early, overturning various pieces of furniture on her way out.

Dr. Berman typically sees clients with difficulties that are more easily resolved by cognitive behavioral approaches. Because he feels that Jessica needs a more intense level of care than what he offers, Dr. Berman feels incompetent to manage her case and to be an effective therapist. He has expressed this concern to Jessica directly and has told her he thinks she would be better suited with another clinician. At this time, he had already begun to make what he considered more appropriate referrals.

When Jessica hears this, she initially becomes more compliant and tearfully proclaims that Dr. Berman is a lifesaver and refuses to work with someone else. However, after a session or two, Jessica reverts to her old behavior, reinforcing Dr. Berman's feelings of incompetence.

This vignette captures a dilemma that many psychologists encounter in their work with very challenging clients. Before addressing what Dr. Berman should do, it can be helpful to examine Dr. Berman's experience of the situation, the psychoanalytic "countertransference." This aspect of ethical dilemmas—the psychologist's experience—has received far too little attention. The gap in our literature is unfortunate, because the psychologist's experience can be a window into the nature of the ethical dilemma and can offer important clues on how best to move forward.

According to the vignette, Dr. Berman feels incompetent and ineffective. A reasonable speculation is that he also feels trapped by his client. From the vignette, it is unclear who—Dr. Berman or Jessica—has more control over the treatment. Speaking with a skilled consultant could lead Dr. Berman to new clinical understandings of the situation. A consultation might also help him better manage his undoubtedly complicated feelings about Jessica. Dr. Berman might conclude that his experience mirrors that of his client Jessica; such an understanding could suggest a clinical approach that more explicitly addresses how Jessica feels trapped and unable to bring about change in her own life. The treatment might then continue with a new focus.

A consultation could also lead Dr. Berman to conclude that Jessica requires a more intense level of care than he is able to provide or that she needs a clinician with a different set of skills. Dr. Berman will then need to ask an important question: Does continuing to treat Jessica risk exposing her to greater harm than if he discontinue treatment and refers Jessica to another clinician with the appropriate skills? Clinicians may fall into the "some treatment is better than none" fallacy. These clinicians do not fully appreciate that providing treatment without the proper skills may increase the risk of harm to a client.

Ethical Standards 2.01 and 10.10(a) are helpful in addressing Dr. Berman's situation if he and his consultant conclude that he does not have the appropriate skills to continue Jessica's treatment or that she needs more or different treatment than he can reasonably offer:

2.01 Boundaries of Competence

(a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

10.10 Terminating Therapy

(a) Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service.

These standards provide the ethical context in which Dr. Berman should decide how to move forward based upon sound clinical thinking.

If Dr. Berman decides that he does not have the competence to treat Jessica or that he cannot provide a clinically appropriate level of treatment, and that continuing treatment therefore risks exposing Jessica to greater harm than discontinuing treatment, Dr. Berman might experience himself to be in an ethical dilemma. Dr. Berman may believe that stopping the treatment and referring Jessica to another clinician constitutes abandonment. Jessica may reinforce this belief, intentionally or not, by an intense reaction to the prospective loss of Dr. Berman. A second fallacy among clinicians is that terminating a client against the client's wishes constitutes abandonment. Termination is not the same as abandonment. Abandonment is an inappropriate termination.

The Ethics Code joins good clinical thinking with our values in setting the contours of termination. Principle A in the Code, Beneficence and Nonmaleficence, begins "Psychologists strive to benefit those with whom they work and take care to do no harm." Competence has been called the cornerstone of ethics: A competent psychologist has the skills to benefit a client. A psychologist who is not competent is likely to cause harm. Good clinical thinking may recommend termination as the best way to avoid harming a client.

Although a client may object to ending treatment, the psychologist retains responsibility for making treatment decisions based on sound professional judgments. Behind these judgments are the values in the Ethics Code and clinical experience. Making a decision that a client does not like may be entirely appropriate if the decision is based upon sound clinical reasoning and is in the client's best treatment interest. To do otherwise could be viewed as inconsistent with our ethics.

Dr. Berman's consultation will help him decide whether to continue Jessica's treatment or discontinue treatment and refer Jessica to another clinician. Either path may be perfectly acceptable under the Ethics Code. Psychologists in Dr. Berman's position often experience considerable relief upon realizing that terminating treatment may be entirely compatible with our ethics.

A further ethical dilemma may arise in rural areas where there may not be an available clinician with more appropriate skills, so that the psychologist must continue the treatment or the client receives no treatment at all. In such instances, the question remains whether continuing treatment exposes the client to a greater risk of harm than discontinuing treatment. In this way, good clinical thinking informs sound ethical decision-making.

Few feelings are more distressing to a psychologist than the feeling of being pressured to continue a treatment in which the psychologist feels overwhelmed and ineffective. These feelings undermine a psychologist's sense of well-being and can interfere with a psychologist's ability to provide even minimally acceptable care. The Ethics Code does not require a psychologist to remain in such a treatment. A thoughtful case review may reveal that the Ethics Code recommends precisely the opposite. When termination is appropriate, the psychologist will do so in a clinically sound manner that minimizes the likelihood of harm. Distinguishing termination from abandonment has important clinical and ethical dimensions. The psychologist's own experience—the countertransference—can be a pathway to understanding the clinical situation more deeply and can help a psychologist determine whether termination is clinically and ethically indicated.

Dr. Stephen Behnke directs APA's Ethics Office.

'Ethics Rounds' are now available as CE.