What therapists should know about ending treatment with clients

For many therapists, knowing how and when to end the therapeutic relationship with a client can be challenging. The discharge experience is an important part of a client’s treatment journey. And this moment in the client/therapist relationship presents a chance to not only preserve the client’s well-being but also encourage ongoing growth and healing.  

Knowing when discharge is clinically indicated 

In a perfect world, the best time to discharge a client is when they’ve reached their treatment goals and are no longer experiencing the problem or severity of symptoms that originally brought them to therapy. Of course, things don’t always work out this way. There are a few additional scenarios where ending treatment with a client may be clinically indicated.

Lack of medical necessity

For clients who are using commercial insurance to pay for services, a client must have a demonstrated medical necessity for therapy services. Otherwise, the treatment will not be covered by their insurance.  Some clients come to therapy with the expectation that therapy will last forever. Or they might expect therapy to be an ongoing source of support even if they don’t have any functional impairments or a diagnosis that meets the requirements for coverage by their insurance.  In situations where medical necessity can’t be demonstrated, working towards ending the treatment relationship is your best course of action. In the process of ending the relationship, you can help clients understand how they can utilize the skills, knowledge, and growth obtained during treatment to thrive post discharge. 

Poor therapeutic fit

What if you have a client who doesn’t seem to be improving, despite your best efforts to create a treatment plan that meets their needs? If you notice that a client’s symptoms are unchanging or even worsening, sometimes the best thing to do is to end the relationship and refer them to a provider who’s better equipped to meet their needs.  Examples of poor therapeutic fit may include clients who:

• Require a higher level of care
• Would benefit from wrap-around support
• Are a poor interpersonal match
• Might benefit from a different modality (for example, folks who struggle to engage with telehealth if that’s how you provide your services) 

Disengagement 

Sometimes clients stop showing up or become unresponsive for no clear reason. In these situations, a best practice for attempting to reconnect is called “three in three,” where the therapist makes three different outreach attempts over the span of three weeks.  The mode of contact is up to you — it could be a phone call, email, or text — but the idea is to ask the client to confirm if they’d like to continue care or not. If they don’t respond by the third attempt, you can let them know you’ll be closing out care, and point them to who they could contact if they would like to re-engage with services in the future. You can also use the final outreach as an opportunity to reference additional mental health support resources in case of an emergency.

Four tips for an effective discharge

Here are some tips for fostering a supportive and ethical experience when ending treatment with a client.

Prepare for discharge from the start

Informed consent involves educating clients on their treatment plan so that they’re better prepared to make an informed decision about engaging in therapy. This improves the therapeutic relationship by increasing a client’s autonomy, responsibility, and understanding of treatment and the desired outcomes.  As a best practice, therapists should begin laying the groundwork for successful termination during the informed consent conversation. While therapists know that therapy is a time-limited process designed to help people develop the tools and skills to live a more meaningful life, not all clients have the expectation that therapy doesn’t last forever. Educating clients from the start can help. 

Set clear treatment goals 

Setting treatment goals with your client from the start of the relationship will help them see that you’re working towards a “finish line.” Figuring out the steps you and your client will take to reach those goals keeps therapy focused.  One way to support clients in reaching their goals is with a targeted opening question at the beginning of the session. For example, you might say, “How has your anxiety been while out in public lately? I know that’s something we’re working on.” instead of a more general statement like, “What’s new?” Starting with a targeted question helps align the session with a client’s goals. 

Gauge client readiness

In some cases, it’s clear when clients are ready to end treatment. You might be able to observe notable progress or a clear reduction in symptoms. These suggest a client is nearing readiness for discharge.  In cases where you’re not able to observe a clear reduction in symptoms, make sure to check in with your client regularly to learn how they feel about their progress. Some questions to consider include:

• “What’s been the most helpful technique we’ve practiced?” 
• “Can you share any improvements you’ve noticed so far?” 
• “How do you feel now compared with when you started therapy?”

Establish a mental health maintenance plan

Creating a mental health maintenance plan is a great way to help your clients stay healthy after being discharged from treatment.  The mental health maintenance plan can include:

• How to recognize triggers and warning signs
• Strategies for effective coping and self-care
• Knowing when to return to therapy 

Four tips for navigating the discharge conversation

Once you decide that discharge is clinically appropriate, it’s time to talk about it with your client. Know that this conversation may evoke strong emotions for both parties.  Therapists can often be concerned about the idea of abandoning clients, decompensation, and even possible legal risk from discharging a client too soon. And for clients, your counseling relationship may be one of the few times they experienced safety, trust, care, and compassion. Below are several tools you can lean on while working towards ending treatment.

• Co-author a discharge plan: Make it a habit to talk to your clients about discharge early and often in the therapeutic relationship. This directness can support accountability, problem-solving, and foster a shared understanding of next steps.
• Own your expertise: There may be times when a client disagrees with your assessment and wants to continue treatment — even when it’s not medically necessary. It can be tempting to continue working with the client, but always trust your gut and professional assessment. 
• Emphasize the constants: Although you’re terminating your relationship with the client, remind them that they’ll still have access to additional support and resources.
• Lean on measurement-based care: Measurement-based care is an evidence-based practice for improving patient care. You can use it as a tool to support collaborative conversations about what’s working, what’s not, and when a client is ready to end treatment. Being able to point to a patient’s self-reported data to illustrate their improvement can help them feel confident in your decision to end the relationship. 

How Rula helps therapists navigate ending treatment

Sometimes therapy has a clear endpoint: like when a client reaches their treatment goals. But other times, deciding to end or continue the relationship feels like more of a gray zone. For therapists in private practice, it can be incredibly helpful to have clinical support when navigating decisions about discharge.  At Rula, a behavioral health organization that leverages technology to help therapists deliver therapy via telehealth, therapists have access to resources to help them navigate tough issues — such as understanding when discharge is clinically indicated and how to approach that conversation.  Therapists in the Rula network can join biweekly case consultations, collaborate with our clinical team to brainstorm approaches to discharge, and get advice from other therapists on Rula’s private online therapist community.  For more advice on creating a supportive and ethical experience when ending treatment with a client, check out our webinar: What therapists should know about ending treatment with clients. Learn more about joining Rula