ONGOING INFORMED CONSENT & CLIENTS WHO LEAVE THERAPY WITHOUT CLOSURE
CLIENTS WHO LEAVE THERAPY WITH NO CLOSURE: Reducing Its Incidence By Continuous Affirmation Therapeutic Objectives
Sometimes a client precipitously leaves therapy with no explanation. They may ghost the therapist, or it may be done with elegant finesse such as suspending therapy for a foreign trip of indeterminate duration from which they seem never to return. Either way an anticipated confrontation involved in going through the exercise of closure is avoided. Such subterfuge is a Pyrrhic transferential victory because the client is taking baggage away from the ruptured relationship, however delicately they engineer their disappearance. The reasons behind such ruptures are wide-ranging, including unstated transference, embarrassment, unstated plateauing in the ability to further confront phobic material, feeling unsafe or insufficiently supported, and so on. These are actually opportunities to advance the therapy if the therapist is quick to recognize what is happening, but in a busy practice, such situations are easily overlooked before the critical moment has passed.
There are clients who leave therapy for less overtly avoidant reasons. Sometimes a client gradually drift away, appointments become less and less frequent, and then the client stops booking, or even fails to show up and doesn’t respond to enquires. Perhaps the therapist closes the file and thinks nothing more of it. “Perhaps their benefits ran out or they weren’t ready for more therapy.” Imagining reasons when there are no explanations is tempting, but the truth may be very different from what we imagine. It is better to tolerate the ambiguity of not knowing than to engage in projection and judgement based on circumstantial evidence.
Simpler territory is the situation where the therapy has achieved its goals, but sessions continue with no mention by either the therapist or the client that the objectives of the therapy need redefinition. Continuing therapy with no explicit reason creates what is sometimes called false alliance—a collusion of motives that do not advance the client’s mental health. Two situations frequently arise:
It is useful to make a distinction between tactical problems and strategic problems. A tactical problem might be recent job loss, recent bereavement, illness or relationship failure. Strategic problems include recurrent job loss, recurrent relationship failure or developmental trauma. If therapy has supported client through a tactical problem which was the stated reason for coming to therapy, and the client continues to want to come to therapy, there needs to be a clarification and redefinition of the reason for continuing the therapy.
While they would actually prefer to quit, the client continues for fear of offending therapist (transference issue) or has insufficient confidence in their capacities to cope without the regular visits with the therapist. Eventually, the sessions feel sufficiently pointless the client quits, and what could have been a good ending is turned into one that leaves a negative feeling that could prevent the client from seeking to resume their therapy at some later date when they may then need it.
What the client may need in both of these situations is encouragement and support to undertake deeper work.
In all of these ambiguous circumstances, it is best to follow up with the client rather than to make assumptions. Better still is to prevent such inconclusive endings. Having clients complete the Miller-Brown brief questionnaires [Scott D. Miller & Duncan, 2000, Outcome Rating Scale (ORS) / Session Rating Scale (SRS)] to bookend each session has the potential to catch misalliances early before other defences of the client are activated. Implicit in the use of the ORS and SRS is the reaffirmation of the consent from the client to receive treatment. If the therapist is not inclined to use questionnaires, explicitly returning to the matter of ongoing informed consent* is another approach.
As part of the intake process, a psychotherapist solicits from the client their objectives for therapy, preferably in writing. A comprehensive history taking, including previous therapy and its outcome, would include goals for the current therapy. Ethically, if the therapy proceeds to address the stated objectives, even if the therapist is aware of other or deeper issues, the client cannot claim to be ill served. Unfortunately, clients sometimes are unhappy with their therapy when their stated reasons for seeking help are at variance with their willingness to follow through. They may have bitten off more than they can chew and are embarrassed to say so. If the therapist doggedly pursues the original objective for therapy, irritation, resistance and dropping out of therapy may result.
There are instances where the client claims to have a particular problem, leaves therapy because their resistance is aroused by the therapy, and then seeks counsel elsewhere for something less triggering. They may not see that their problem is that they set the goal of therapy to be jumping to the top of the mountain. Instead they find another practitioner who will address more superficial issues, and then the client claims that the original therapy was misdirected or mishandled. “You should have known that all I needed was Treatment X.”. The client may not be aware that the vulnerability required to do the deep work they asked of the first therapist may be at odds with their control issues or other psychological defences. For example, a client reports marital breakdown because of a history of childhood sexual abuse by close relatives, leaves therapy with no notice or explanation because the developmental trauma work is too challenging, and then claims better results and takes up umbrage against the original therapist when a subsequent therapist treats only the symptoms of the developmental trauma such as anxiety, addiction or eating disorders. Neither therapist is wrong because both are treating what they were asked to treat, but the client may complain against the first therapist even though they did as they were asked.
In this example, it may seem that a potential malpractice issue is arising—not from improper actions of the therapist who acted on the client’s requests and offered what was requested, but that turned out to be too much for the client, or another therapist who offered them a less challenging treatment—but from the changing perceptions and emotional comfort of the client.
The mistake that the therapist may make is to fail to restate and reconfirm frequently the objectives of the therapy. While it may seem pedantic to periodically repeat back to a client their reason for seeking help, there may be practical and legal reasons for doing so. This revolves around the principle of ongoing informed consent*. Unfortunately, there may be few indicators that the therapist’s understanding of the objectives of the therapy and the client’s emergent desires for the therapy are diverging, especially if the client is inclined toward pleasing others and is therefore hesitant to interrupt the therapist’s approach to treatment.
In summary, it is never a bad time for the therapist to clarify what is going on with the client, and there is never a good time to make assumptions about the shifting dynamics in the therapeutic relationship. It is better for everything to be on the table all the time, which for many clients may be unique experience missing from problematic relationships in their lives.
*Ongoing Informed Consent
Informed consent in the context of a professional service means that nature, purpose and risks of a therapeutic procedure are explained to and understood by the client receiving the service. Having a client sign a document alone may not stand up legally as there is no determination of the client’s understanding unless there is a verbal verification and preferably a discussion with the client.
Regulatory organizations require that mental health practitioners maintain ongoing informed consent from their clients for the treatment they are receiving. It does not mean signing a legal document every time the therapist seeks to reaffirm doing something that has been done before. It does mean asking, are you still OK with (treatment X), or are you up for doing a little more work on problem Y today. For various reasons, the answer may be No, perhaps because the client it too tired today, too anxious, has other present needs or other more urgent matters to discuss. Leading by following is the principle here. While some clients may welcome the therapist leading the therapy and that may accord with the therapist’s personality, it sidesteps ongoing informed consent and may be colluding with client’s issues such as, passivity, pleasing, reticence, unassertiveness, taking personal responsibility or making decisions.
Another take on ongoing informed consent is that it is not so much about consenting as it Is about checking in on refusing. The client may agree in principle about certain activities in therapy, but they may not want them on a particular day. There may be things that the client has done in previous sessions that they do not wish to do today, and checking in may be more about the timeliness of the intervention then it’s overall acceptability. The only way for the therapist to be sure is to ask.
Some may argue that the therapist can sometimes proceed on the basis of implicit consent because of the inter-subjectivity -- essential to any effective psychotherapy -- exists with the client. Has the therapist failed to obtain consent if they proceed on the basis of an intuition based on the therapist knowing the client well enough to sense of what is OK and what is not on a particular day, and doesn’t say anything about this awareness? The lack of explicitness may fail legal metrics, but consent may be there implicitly. The problem is that there is no objective attestation, even though there is attunement between the therapist and the client. Parallels exist in medical situations where a nod of the head, or the blink of an eye may have to substitute for a signature or an affirmative verbalization or refusal.