Terminating the Therapeutic Relationship
by Nancy Bilello
This article is excerpted from Understanding the Difficult Patient, by Nancy Bilello. Click here to read more about this book.
One of the most difficult crossroads a practitioner can come to is the realization that a therapeutic relationship is no longer therapeutic and should be terminated. There are many reasons why this situation may manifest and, unfortunately, no easy solutions. In most cases your relationship with a client will have a natural beginning, middle and end point. When the patient’s condition improves to the satisfaction of both parties, the patient generally does not schedule future appointments or schedules maintenance appointments appropriate to his/her condition. In some cases, however, the patient demonstrates a need or desire to continue to come for treatments, even when it is apparent to the practitioner that the patient is either not receiving benefits from the treatment or is hanging on for some kind of dysfunctional reason.
Being a healthcare practitioner is an awesome responsibility; the work is rewarding and, most of the time, enjoyable, but you must never forget that you have an ethical, moral and legal obligation to render the best care possible to each and every client. While the majority of these clients will be delightful to work with, it is not a given that you will like all of your patients. It is a given that there will be patients you do not like. Simply not liking a patient, however, is not reason enough to terminate your relationship with them. Your responsibility is to help them heal, not to like them. As Oriental Medicine gains greater acceptance, expectations of Oriental Medicine practitioners will only get higher. We must hold ourselves to the highest standards of patient care.
Reasons NOT to End the Therapeutic Relationship
1. “I can’t stand this person!”
It would be wonderful if we could truly embrace every person on their own terms and accept them completely. But just as we want to acknowledge the humanity of our clients, it is important to realize that we, too, are human! Personality differences abound everywhere, and the clinical setting is no exception. You may encounter clients whose basic personality grates on your nerves. Perhaps you don’t like the sound of their voice, their mannerisms or the way they dress. Nonetheless, you owe them as much time, effort and consideration as any other client. This is a time when a practitioner may need to practice a healthy form of detachment. In other words, provide the necessary service, but not to become emotionally entangled in your feelings for the person. It might be helpful to call on a colleague to vent some of your feelings or to ask for helpful coping strategies. It is always possible to refer the client to another practitioner, but if he or she prefers to stay with you, is compliant, pays and shows up on time, you do not have much legal leg to stand on if you want to end your professional relationship with them.
2. “I can’t figure out what to do!”
It is common for Western-trained practitioners of Oriental Medicine to have little or no clinical experience in dealing with difficult diseases before graduating and going into independent practice. Unfortunately, our Western society is a fertile ground for complex syndromes. Signs and symptoms seem to pile up and contradict each other. Pulse and tongue diagnosis do not match, symptoms do not fit easily into patterns of differentiation, and the practitioner feels like he or she is floundering. It is tempting to throw one’s hands up and say, “I just don’t want to deal with this anymore!” It is encounters such as these, though, that provide some of the best learning experiences. If you are baffled by a client’s presentation, it is time to do research, to hit the books and to confer with others in your field and to decipher the meaning beneath the complexity. With persistence and honest intent, this task is possible, if not always easy. By plowing through the unknown, you will shed light on areas you need to strengthen. If you really get stuck in this type of situation and have truly tried everything you feel is at your disposal, then a referral to someone more experienced may be in order. Most patients will appreciate your honesty in this matter (and so will the other practitioner!) If it is a case of treating a condition you do not feel drawn to or interested in, the simple answer is: do not take the case in the first place! At the beginning of your practice, you will be eager to accept any client that is willing to come to your office and be treated, but it is important to learn discretion and to discern the kinds of cases you really do want to attract.
Reasons to End the Therapeutic Relationship
There are several valid cases in which a practitioner may ethically, legally and morally end a relationship with a patient. It is important to remember that this can never be done lightly. In most cases, a single incident is not enough to warrant termination. Usually, the practitioner must demonstrate that there has been a consistent pattern of unacceptable behavior that has not been amenable to suggestions and/or attempted solutions.
Following are some of them most common reasons a therapeutic relationship may be justifiably terminated:
Noncompliance: A patient who deliberately and repeatedly fails or refuses to comply with practitioner advice and instruction places him or herself in a potentially dangerous situation. A practitioner cannot reasonably be expected to assist a person who will not comply with medical advice. If a patient is showing a pattern of noncompliant behavior and the practitioner begins to feel that the relationship should be terminated, the practitioner should start documenting the specific details of the client’s noncompliance as well as all measures the practitioner has taken to address the problem. The situation should be reviewed with the patient at intervals during the course of the treatment. If the problem continues, the practitioner may well have reason to end the relationship.
Anger/Abuse: As discussed in the chapter on the Angry Patient, anger usually masks a variety of unexpressed emotions. With a little compassion and a lot of patience, a compassionate practitioner can often assist a client to work through feelings of anger, uncover the source of the anger and facilitate emotional as well as physical healing. However, there are those people whose anger is so deep rooted that it may not be possible for the practitioner to assist them. In fact, they may require the help of a mental health expert. This type of anger may involve abusive language or behavior towards the practitioner, staff and even other clients. This type of behavior is not acceptable and the practitioner may have sufficient grounds to terminate the relationship. In this case, it is of the utmost importance to explain fully to the client the reasons he or she cannot continue to be seen in your clinic. You yourself may want to consult with someone in the mental health profession to assist you with finding the best possible way to deal with a dysfunctionally angry client. It is a good idea to have someone else present when you talk to this patient to help diffuse tension if the situation looks like it might escalate or if the client has difficulty accepting what you are conveying.
Seduction: Sexual advances, physical attraction or outright harassment are not appropriate at any time in the health care setting. If the attraction is mutual, the practitioner and client must agree to end their clinical relationship in favor of the personal one, and the client can then seek health care elsewhere. If it is a one-sided attraction initiated by the patient or experienced by the practitioner, the clinical benefits of the relationship are in danger and the relationship cannot continue. This can be a touchy (no pun intended!) subject to broach with a client but temporary embarrassment or discomfort is better than an unhealthy clinical partnership. Your disclosure form should include your policy about sexual relationships in the clinic, and you can refer to this as a starting point if you find yourself in this situation.
Non-payment: You are providing a fee for service. This should be clear and apparent at the outset of every client encounter. Fee schedules must be included in your disclosure form, and it is a good idea to discuss fees with each client in person to avoid misunderstanding. Most practitioners expect full payment at the time of service. If there is third party reimbursement, then payment will be made according to the insurance policy. If a client refuses payment even after a series of bills, reminders, etc. have been sent, the practitioner is not obligated to continue treatments until the bill is paid in full.
There may be other cases in which a practitioner decides it is in the best interests of all concerned to discharge a patient from care. The above list includes the most common cases. Unfortunately, there is no easy formula to guide a practitioner in ending a professional relationship with a client. Remember, though, that each situation is unique and each individual’s characteristics and personal situation must be taken into account. No matter how negative or unpleasant a particular client may be, it is in everyone’s best interest for the practitioner to remain professional, caring and as pleasant as possible during the termination process.
Protecting yourself legally
It is wise to check with your state’s regulatory agency regarding policies about ending a patient/practitioner relationship. In some cases, the practitioner may be charged with patient abandonment if there is not sufficient evidence to warrant termination of a patient. If your state’s regulatory agency does not have a clear policy, it is best to adhere to the standards to which Western Medical practitioners are generally held. This usually includes the following:
1. Documenting a consistent pattern of unacceptable, difficult or problem behavior and all measures the practitioner and staff have taken to resolve the problem.
2. A 30-day written notice sent to the patient’s home outlining the problem and the reason the professional relationship is to be terminated. It should be made clear in this notice that you will continue to assume care of the patient during this 30-day period while he/she seeks out another source of health care. You should also offer to assist the client to this end in any way feasible.
3. A list of other practitioners to whom the patient can be referred. This list can also include any appropriate community resources you feel might benefit the client.
4. Offering to forward the client’s medical records (with proper release, of course!) to the client’s new practitioner.
Hopefully, with your instinctive compassion, personal resources and the suggestions in this book, you will never find yourself in the position of having to terminate a patient relationship. If you do, keep in mind all the legal, ethical and moral ramifications and take every necessary precaution to protect yourself and your client.